4.  Developing a health-informed approach to penal reform 4.3.2 Physical health Communicable diseases The risks of contracting life-threatening diseases are greatly increased by prison overcrowding and poor living conditions, as discussed in Chapter 3 with reference to Brazil and South Africa. This demonstrates the importance of reducing overcrowding and improving conditions as an essential precondition to limiting these risks. Good prison healthcare practices are also essential. This includes screening on reception into prison, vaccination programmes and speedy access to treatment, medicines, education and advice, including through effective collaboration with community health services. The use of harm reduction methods in prisons (for example, supplying condoms and syringes and establishing opioid substitution programmes) is also essential for controlling risk of disease transmission. The global take-up of harm reduction recommendations has been limited in prisons compared to wider communities, especially in low- and middle- income countries (Stone & Shirley-Beavan, 2018), despite the elevated risks of infection in and through prison populations. When I arrived… I told them that I was HIV positive. They never gave me my antiretroviral treatment even though I had told them my status and asked them for medication. … As a result of my detention… my viral load has increased. Male remand exprisoner 3, South Africa Lack of funding and of political support is often the main obstacle to prison-based healthcare provision. This is exemplified by the fate of recent plans to improve prison healthcare in Brazil. In 2014, a new national plan was adopted to tackle tuberculosis, HIV/AIDS and other communicable diseases.34 The underlying principle was that prisoners should have access to the same level of healthcare services as those available for the general public. This was to be achieved by means of extra budget provision and greater integration of local health services and prisons. Unfortunately, the federal budget crisis of 2015 prevented the reforms from being implemented. They are now unlikely to take effect for the foreseeable future, following the change of government in 2018 and the new administration’s pledges to increase the use of imprisonment, create harsher regimes and lower the age of criminal responsibility.35 Non-communicable diseases Significant extra demands fall on prison administrations if they are to make appropriate healthcare provision for the increasing numbers of prisoners suffering from chronic illnesses. Most prisons have been designed to hold a younger, fitter population. There are challenges in safely housing prisoners who are physically infirm as a result of hypertension, diabetes, obesity, asthma or other respiratory diseases. The humane management of prisoners with chronic conditions or physical I have type 1 diabetes so I have to have insulin 4 times a day, taken at meal times. But in prison, I’d have to do [the final injection] much earlier than I normally would, 4.30 or 5pm, when they bang you up. They couldn’t bring it to your cell later cause of staff shortages. I’d have to go from 5pm to 8am with no access to testing equipment or insulin. It was scary. You can feel really anxious if you don’t have access to your kit or insulin.… You have nightmares – ‘might I slip into a hypoglycaemic coma?’ I felt so anxious I stole a testing kit and hid it in my mattress. Ex-prisoner, England 34 The plan can be found here: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2014/pri0001_02_01_2014.html. For additional resources: http://dab.saude.gov.br/portaldab/biblioteca.php?conteudo=legislacoes/pnaisp 35 All candidates for presidency are required to submit to Brazil’s electoral authority a ‘programme for government’. Candidate Bolsonaro’s was contained in a Powerpoint presentation (http://www.tse.jus.br/arquivos/jair-bolsonaro-proposta-de-governo-1o-turno), which proposed: ‘zero tolerance for crime and corruption’ (slide 10); ‘to arrest, incarcerate and keep incarcerated’; and to ‘end temporary leave and progression [from higher to lower security regimes]’ (slide 32). 27