Globally, the prison population suffers from infectious diseases, including respiratory infections and sexually transmitted diseases, more frequently than the general population. ¹ In countries like India, Ghana, and China, 25% of tuberculosis cases in the country are due to prison-acquired TB. Efforts have been made within the United States to improve these problems, including the work of California Receiver Robert Sillen who has attempted to improve health in the California State prison at San Quentin by building new and larger health care facilities, raising the salaries of medical staff, and increasing the pharmacy’s drug supply. While these enhancements in inmate treatment and rehabilitation are necessary to improve the health of the prison population, they are not sufficient. In order to improve inmates’ health, overcrowding of prisons must be addressed and investments into easing overcrowding should be the priority world-wide.

Remodeling the health care infrastructure of a prison, as was done at San Quentin, will not necessarily improve prisoners’ health. Overcrowding results in the efficient spread of diseases vectors. Even if a diseased inmate is able to be diagnosed and treated, he will have been in contact with many other susceptible inmates and have potentially infected them. ² This is especially true of respiratory and skin infections, which are easily spread by close contact. ² According to a study of prisons in Russia, even with health care professionals able to prescribe and deliver antibiotics, there is no way to guarantee that an infected individual will take the antibiotics regularly or complete the treatment course. ² Assuming that upon diagnosis an infected individual is told the severity of his disease, it then logically follows that for his own benefit he will attempt to make his treatment as effective as possible. ³ However, infected individuals often do not complete antibiotic treatment because their symptoms appear to resolve themselves before the prescription is completed. ² Furthermore, the prison environment may make other options more appealing for an infected inmate than completing his prescribed antibiotic treatment. For example, some infected prisoners fear that a diagnosis will delay their release. In an effort to get treatment without seeing a doctor, inmates may threaten violence against fellow infected inmates, who must then either give up their own treatments or risk injury or death. ³ In an overcrowded prison, the threat of such violence is real, as inmates know that there are too many prisoners for the guards to effectively watch. ³ Direct monitoring of treatment, involving the prisoner taking his daily dose of antibiotic in the presence of a heath care professional, has been shown to be effective in treating TB. In overcrowded prisons, however, the ratio of health care staff to prisoners makes this option unfeasible and instead antibiotics are usually distributed as they are to the general public. ³

Incomplete antibiotic treatment of an infected inmate is not only an issue for the inmate being treated, but poses a health risk for the general prison and sur- rounding community population. Treatment terminated prematurely allows for the selection of strains resistant to that antibiotic, limiting future treatment options. ² Additionally, when an individual does not take antibiotics to completion, he suffers from a prolonged infection. In certain diseases, like tuberculosis, this is particularly dangerous as prolonged infection increases the risk of co-infection with two or more different circulating strains of TB. ¹ This leads to genetic recombination between the strains and the development of multidrug-resistant TB (MDR-TB) which cannot be treated with easily accessible and affordable antibiotics. ¹ Such strains can infect fellow inmates and guards, and, if infected prisoners are released, the general public. ³ Additionally, sexually transmitted diseases develop drug resistance when their treatment is interrupted, as evidenced by the develop- ment of drug resistance in gonorrhea. ² In overcrowded prisons, STD’s, including these drug resistant strains, spread quickly due to the high rate of sexual assaults, ^1,3 which presumably occur because of the lack of guards to effectively monitor inmate behavior.

With a lower ratio of inmates to guards, guards will be able to more effectively police prisoner-to-prisoner violence and sexual assault. This will ease the risk of violence against prisoners receiving treatment and will also decrease the spread of sexually transmitted diseases. ¹ Additionally, with a lower ratio of inmates to health care professionals, doctors and nurses will be able to practice direct monitoring of treatment. This will allow for prisoners who receive treatment to do so safely and will take the burden of monitoring drug related violence off of guards. ³ Efficient diagnosis and effective treatment of disease can elicit positive health benefits, but only if overcrowding can be addressed.

Easing overcrowding can have other positive effects on inmates’ health. In a longitudinal study of one prison in Zaire, a correlation between the population of the prison and both the death rate and the prevalence of mental illnesses was observed; the years when the prison had more inmates, its population suffered from a greater amount of both.4 The study also found that inmates’ blood pressures were positively correlated with the level of overcrowding.4 Relieving overcrowding may therefore reduce the prevalence of mental illness, lower the demand for psychiatric drugs, and create less demand for cardiac care. ⁴ It is important to note that because the health needs of inmates change as overcrowding is relieved, investments made into improving inmate health care before overcrowding is eased will be improperly allocated. Thus, investments should be made into easing overcrowding before investments are made into treatment and rehabilitation services so that resources are properly rationed to provide maximum benefits.

T.herearemeanstorelieveovercrowdingthat are less expensive than building many large, new prisons. Studies in the UK have shown that inmates around the world are often repeat offenders; thus, a cost effective way to decrease prison population overseas is to decrease the rate of reincarceration. ⁵ Reincarceration is strongly correlated with the lack of vocational skills and illiteracy and thus, the inability to find a job, the lack of employment and income drives many criminals to commit another crime. ⁵ To break this cycle, inmates should be given technical jobs while in prison to learn useful skills that will gain them employment upon release. Investments should also be made into improving adult literacy programs in prisons so that upon release each inmate will be functionally literate.

Forcing prisoners to live in overcrowded prisons is inhumane, ¹ as it is known that easing overcrowding decreases death rates, improves inmates’ mental health, and decreases blood pressure. ⁴ Dealing with overcrowded conditions hinders the spread of infectious diseases and allows for easier treatment delivery. Investments to improve the health of prison populations should be aimed at easing overcrowding because as prison commissioner Alexander Paterson said: “Men are sent to prison as punishment, not for punishment.” ³