3. Damage to health caused by imprisonment In this chapter, we consider some of the ways in which being in prison can worsen existing mental and physical health problems and create new ones. This comes about because of poor material conditions, a lack of healthcare, the availability of illicit drugs, social and psychological stresses, violence and mistreatment. As part of this, we look at the scale of overcrowding in prisons around the world. We describe how overcrowded, underresourced prisons present particular risks to the health of prisoners, prison staff and wider communities. There are no words to describe how crowded it is in the cell… It is not enough food and I am hungry all the time. I have lost a lot of weight. Male remand prisoner 2, South Africa (This and all other South African prisoner accounts are taken from affidavit evidence in the case of Sonke Gender Justice v. the Government of South Africa, 2016 Western Cape High Court, no. 24087/15 (unreported).) 3.1 Conditions of custody As the previous chapter showed, people entering custody are more likely to have mental and physical health problems and to be at greater risk of ill health than people who do not experience imprisonment. Once in the prison environment, people often experience a worsening of these problems – and may develop new health problems – as a result of the conditions and regime. This can include a general lack of access to treatment and a failure to conduct routine screening or to employ harm reduction methods, often simply because there are insufficient staff to provide these measures. The typical physical conditions and regime of a prison are not conducive to physical or mental wellbeing either of prisoners or of staff (World Health Organization, 2014). Incarceration in much of the world usually involves: • reduced access to natural light and fresh air • poor diet • limited opportunities for exercise • reduced access to medical treatment • the availability of illicit drugs and the presence of drug users • lack of contact with family members or other support network • limited activity and interaction with others • the risk of intimidation or violence • high levels of boredom, tension and despair. These aspects of incarceration heighten the risk of disease, violence and mistreatment and can lead to psychological stress, self-harm and even suicide. 3.1.1 Equal rights to health and healthcare These conditions and their effects on health are in stark contrast to the rights to health and healthcare enshrined in law, including for people in any form of detention. Whatever the nature of their offence, prisoners retain the fundamental rights to which they are entitled as human beings, including those relating to health. International treaties and standards (often reflected in regional and national rules and guidance) make this clear. For example, the International Covenant on Economic, Social and Cultural Rights enshrines every person’s equal right to enjoy the ‘facilities, goods, services and conditions necessary for the realisation of the highest attainable standards 7