Towards a health-informed approach to penal reform? Evidence from ten countries among prisoners and staff and, from them, to their families and wider communities, are one aspect of this. Another is the heightened risk presented by the release of prisoners suffering from mental health conditions that have arisen (or worsened) as a result of a harmful custodial environment. From a criminal justice perspective, when imprisonment leaves people in worse health than when they entered custody, the prison system fails to tackle crime other than through the brute fact of incapacitation. Most penal systems, including several of those in our ten country project, rank the rehabilitation of offenders highly among the purposes of imprisonment: in some countries, such as the Netherlands, it is expressly prioritised.23 An essential pre-condition of rehabilitation is an environment that guarantees adequate care and protection for the health and wellbeing of prisoners and staff alike. In reality, effective healthcare, rehabilitation and resettlement services will be hard to find in the under-resourced or overcrowded prison. When people leave prison without having accessed the support they need, or in poor health, their prospects of finding and keeping a job and a home and of avoiding the misuse of drugs and alcohol will be reduced. This in turn can increase the risk of reoffending and returning to prison, perhaps in worse health – the ‘revolving door’. Tackling these challenges requires a health-informed approach to penal reform that has two major components. The first is reducing numbers in custody. The second is improving conditions and health provision in prisons. We deal with each in turn below. So many are left by their husbands during time in prison – then their families won’t take them back. Women are expected to be with their husband till they die. So once you’ve been criminalised you’re beyond help and society doesn’t care. You end up on the street or back in prison. Female ex-prisoner 1, Kenya 4.2 Reducing numbers in custody We approach this in two stages. First, we briefly discuss the need to reduce the size of prison populations overall (including pre-trial/remand and sentenced prisoners); we then focus on options for reducing numbers of prisoners with mental health conditions. 4.2.1 Reducing overall numbers in custody In 2000 the world’s prison population was around 8.7 million: in less than two decades, it has increased to its present level of at least 11 million (Walmsley, 2018). Many countries have seen particularly rapid and unsustainable rises in their prisoner populations in just a few decades. America’s total prison population more than quadrupled between 1980 and its peak in 2008. In Brazil, prisoner numbers increased twenty-fold from around 30,000 in 1973 to nearly 720,000 today.24 See Figure 7 for the percentage change in total prisoner numbers in each of the ten countries. The growth of some prison population groups is all the more concerning in view of their specific health needs and vulnerabilities. The global female prison population has risen far more steeply than the male, having grown by more than 50 per cent since 2000 (whereas male prisoner numbers grew by around 20 per cent in the same period) (Walmsley, 2017). Numbers of women prisoners have risen in all five continents, but by larger margins in the Americas, Asia and Oceania than in Europe and Africa. There have also been significant increases in the numbers of foreign and ethnic minority prisoners over recent decades, particularly in western European countries.25 23 Netherlands Penitentiary Principles Act 1998 (Penitentiaire beginselenwet) 24 For a more detailed account of each of the ten countries’ recent imprisonment trends within a global context, see Jacobson et al, 2017, http://www.prisonstudies.org/sites/default/files/resources/downloads/global_imprisonment_web2c.pdf. 25 See for example Aebi et al, 2018. 20