"Health-care services should be organized
in close relationship to the general public health administration and in a way that ensures continuity of treatment and care, including for HIV, tuberculosis and other infectious diseases, as well as for drug dependence."
UN Nelson Mandela Rules

Overcrowding is a crisis in prisons throughout the globe. According to Penal Reform International’s 2017 Report, prison occupancy levels in 79 countries (40 percent of the world’s states) were above 120 per cent capacity and as many as 51 countries (26 percent) had a problem of extreme overcrowding, with occupancy levels above 150 per cent. Of the 198 countries for which data was available, 58 percent were operating at over 100 percent capacity.

Overcrowding leads to conditions that sit well below safe or humane levels. The UN Special Rapporteur on Torture reported as much in his 2011 global report: “Police and prison authorities simply do not regard it as their responsibility to provide detainees with the most basic services necessary for survival, let alone for a dignified existence or what human rights instruments call an ‘adequate standard of living’.”

Brazil’s prison population is the fastest-growing in the Americas, having nearly quadrupled in the last twenty years. This has led to overcrowding that has been declared a “human rights disaster” by Human Rights Watch; prison capacity currently  sits at 157 percent over the official occupancy rate.

In South Africa, a 2011 UN report stated, “The committee is concerned at poor conditions of detention in some of the state's prisons, particularly with respect to overcrowding, dilapidated infrastructures, unsanitary conditions, inadequate food, lack of exercise, poor ventilation, and limited access to health services.” According to the 2012-13 Department of Correctional Services report, the country’s correctional facilities housed 150,609 prisoners in facilities designed to hold 119,890; many prisoners had less than 13 square feet in which to eat, sleep, and spend 23 hours per day.

In the Bahamas in 2015 the maximum-security block of the prison held 625 men in spaces designed to hold approximately 375; in 2016 the overall prison, built to hold 1,000 prisoners, held 1,727.

Few African countries have maintained or added prison capacity post-independence, with the result that most prisons are now beyond repair and fail to meet minimum requirements generally accepted today. Luzira Prison in Uganda, for instance, was built for 600 and currently contains 6000 men, women and children.

In Ghana, 28 of the country’s 43 prison facilities were overcrowded by as much as 358 percent. Occupancy rate is the highest in the world in El Salvador, with 310 percent in 2015. Honduras’s prison system, designed to hold 8,000 people, holds more than 17,000. Cambodia’s prisons and correctional centers operate at 179 percent of their official capacity.

The solution for overcrowding is not to build more prisons but to: reduce the amount of time people spend in pre-trial detention by providing access to legal services and enacting legal aid reform (guided by the 2016 Global State on Legal Aid report published by the UN Development Program and the UN Office on Drugs and Crime); amend the judicial system so that it treats drug use as a public health issue, not a criminal justice one; create policy change that stops penalizing the poor for petty offenses and inability to afford bail payments; provide proper services inside prisons that address health crises across all spectrums.
Pre-trial detention is a global crisis, described 
in a recent Open Society Foundation survey as “one of the most overlooked human rights crises of our time.” One third of the over 10 million people in prisons around the world are in pre-trial detention: potentially innocent people subjected to barbaric, crime-producing conditions.

Pre-trial detention disproportionately affects the world’s poor, who cannot afford bail or bribes; according to a study cited in a report by the Open Society Justice Initiative, those entering pretrial detention come from “the poorest and most marginalized echelons of society, who are least equipped to deal with the criminal justice process and the experiences of detention.”

In South Africa, the government spends $300,000 a day imprisoning people who have been granted bail but are unable to afford it. Money spent on imprisoning pre-trial detainees could be better spent on an array of public services, including police officers, prosecutors, schools and hospitals.

In many countries, suspects can spend decades awaiting trial, a life lost in limbo. In Trinidad, for instance, pre-trial detainees make up 63 percent of the prison population, waiting on average between six and 11 years for trial. Thailand faces a backlog of over a million cases.

In India, 68 percent of the prison population were on remand in 2016, around 22 million cases were pending in the country’s district courts, six million of them having lasted longer than five years, and another 4.5 million were waiting to be heard in the high courts. India has one of the world’s lowest ratios of judges to population in the world (13 judges for every million people, compared to 50 in other nations), and one of the lowest proportions of allocated governmental budget to the law ministry.

In Central and South America, pre-trial detainees make up over 40 percent of the entire prison population. In Central and West Africa, the number sits at over 50 percent; in South Asia over 65 percent; in some countries (Nigeria, Liberia) pre-trial detainees make upwards of 70 percent of prisoners.

According to the International Centre for Prison Studies, on average 41 percent of Africa’s prison population is awaiting trial, compared with Asia (38 percent), the Americas (27.8 percent), Oceania (24.3 percent) and Europe (20.3 percent). Africa produces half of the world’s top 15 pretrial detainee countries, where this average hits at least 68 percent: Libya, Liberia, Democratic Republic of Congo, Congo Brazzaville, Benin Republic, Central Africa Republic, Cameroon, and Nigeria.

The number of prisoners in Australia has soared by nearly 40 percent since 2012, driven by a huge increase in the number of unsentenced prisoners.

In detention people cannot work to support their families and will likely lose their jobs. In Sierra Leone, for example, research showed that for every four detainees in pre-trial detention, there were five family members who no longer had the support of a main breadwinner.

A number of US states have been radically changing bail regulations, to strong results. In 2017 New Jersey passed legislation that eliminated bail for minor crimes and instituted the use of a risk assessment tool to determine pretrial supervision conditions. Kentucky instituted the same risk assessment tool in 2013 and will automatically release people determined to be low-risk. Washington, D.C., releases 90 percent of those arrested with conditions to report to a pretrial agency and comply with drug testing and other requirements.

A number of countries’ legal systems contain outdated, colonial-era petty offenses that criminalize actions that pose no threat to public safety and are exploited by law enforcement to target people based on their socio-economic status and race. The vague, disproportionate, and arbitrary nature of these offenses enable law enforcement to use petty offenses to target street children, the poor, the homeless, LGBTQ people, sex workers, hawkers, people with substance use problems, and people with disabilities.

Racial discrimination is thus rife in criminal justice systems throughout the world, as evidenced by the disproportionate number of minorities that populate prisons. In New Zealand 1 in 2 of the prison population is indigenous Maori, even though they account for just 15 percent of the population.

In Australia, the UN's Special Rapporteur on the Rights of Indigenous Peoples condemned the "incredibly high" incarceration rate of Aboriginal people as a "major human rights concern" and was most concerned about the arrest and imprisonment of young Aboriginal people for petty offences. In the Northern Territory, 95 percent of youth detainees and 86 percent of the total prison population are Indigenous.

Petty offenses is an issue that persists across Africa, where laws against “loitering” or being seen as “ideal and disorderly” are routinely used by police officers to detain people. In Malawi, one of the key petty offenses, the “rogue and vagabond” law, was successfully challenged in January of 2017, setting a hopeful precedent for the rest of the continent.

In Indonesia a whopping 1,154 crimes come with prison sentences.

A major contributing factor to rising prison populations is the punitive rather than rehabilitative response to drug crime—a nefarious export of the United States. The US-style war on drugs that has been waged across the world, from Thailand to the Philippines to Norway, has resulted in prison populations multiplying. Jails have been swamped by people convicted of drug offenses, mostly from disadvantaged backgrounds.

A 2013 UNODC study suggests that offences related to drug possession currently comprise more than eight out of ten of global drug-related offences.

In at least 33 countries and territories, the death penalty is still applicable for drug-related offences, including 10 where the death penalty was mandatory.

In Tunisia 70 per cent of drug-sentenced prisoners are convicted for marijuana possession.

Thailand replicated the American approach to drug crime, to a devastating effect. Waging a 15-year-long war on drugs since the former Prime Minister Thaksin Shinawatra launched it in 2003 fast led Thailand to the highest incarceration rate in Southeast Asia. This produced drastic overcrowding and brutal conditions; there are more than 260,000 people in 148 Thai prisons designed for 120,000.

Some 33,500 of the 59,600 convicted people in prisons in Malaysia are there due to drug offences. In Sri Lanka in 2015 nearly half of convicted prisoners—11,171 people—went to prison for narcotics crimes, but the number of users entering rehabilitation and reintegrating into society was abysmal: Just 2,355 people with substance abuse issues registered with the official Drug Abuse Monitoring System, and the government’s rehabilitation centers can accommodate only 40 to 50 patients at a time.

A 2016 bill proposed in Ghana reduces sanctions for possession of drugs and funds harm reduction services. The Seychelles abolished mandatory drug sentences and allowed for remission of drug sentences. In the United Arab Emirates, judicial officials recommended an overhaul of mandatory prison terms for low-level drug offences in favor of judicial discretion.

The consequence of overcrowded and cramped conditions goes beyond the daily dehumanizing trauma of existing like confined cattle; it also enables the spread of disease and causes death.

The prevalence of infectious diseases such as HIV, other sexually transmitted infections, viral hepatitis
B and C, and tuberculosis among prison populations tends to be much higher (up to 50 times) than in the community.

A Political Declaration on HIV/AIDS adopted by UN Member States in 2016 noted that prisoners are five times more likely to be living with HIV than adults in the general population.

The number of prisoners infected with TB is estimated to be 4,500 in every 100,000. The World Health Organization considers 250 cases per 100,000 an epidemic.

In Ugandan prisons, poor sanitation and the ongoing use of the bucket system for sewage leads to frequent outbreaks of cholera and diarrhoea, a major cause of death among prisoners.

In prisons unsterile injection equipment is often shared in the absence of needles and syringes—which are estimated to be available in just 60 of 10,000 prisons worldwide.

The TB transmission risk in Cape Town, South Africa’s Pollsmoor Prison, Africa’s largest prison, is estimated at 90 percent.

In South Africa lack of trained healthcare staff exacerbates the situation; some 32 percent of prisons there lack a doctor or nurse. The country’s Department of Correctional Services 2012-2013 annual report details shortages of prison doctors and inadequate investigation and documentation of prisoner deaths.

In Brazil, tuberculosis is 100 times more prevalent among the state of Pernambuco’s prisons than in the outside world, while the rate of HIV infection is 42 times higher.

In Colombia, where occupancy levels are around 150 percent, the Justice Minister declared the state of prison healthcare an emergency, signing a decree permitting prisons to take emergency measures to address the lack of medicine and healthcare staff.

According to Penal Reform International, the mortality rate in prison settings (which includes both deaths from natural causes and those resulting from external causes) is consistently significantly higher than the rate for the general population.

In the seven countries 
in the Americas for which data was collected by UNODC in 2014, the homicide rate among prisoners
 (56.7 per 100,000 prisoners) is three times higher than the homicide rate
for the general population (on average 19.1 per 100,000 population).

In 2011 there were 47 suicides and murders behind South African bars, and the corrections department owed billions in damages to prisoners and former prisoners, mostly for assault and rape. Some detainees awaiting trial reportedly contracted HIV/AIDS through rape. The South African government has no policy on the prevention of sexual violence in prisons.

In Brazil, overcrowding is widely acknowledged as the root cause of the prison violence because overpopulated prisons allow rival gang members to exist in dangerous proximity to one another. This, coupled with shortages of prison guards, has helped fuel deadly prison riots: More than 130 people have been killed in prisons in Brazil in the first few months of 2017 alone.

The Brazilian federal government announced in December 2016 that it would disburse $380,000 to fix the penal system—yet $253,000 of that will go towards simply building new prisons. The population is likely to increase given moves to reduce the age of criminal responsibility for violent crimes from 18 to16 years.

In Australia in 2015, a prison officer was assaulted every three days in the state of Victoria. The union representing prison officers said the rise in violence was linked to prison overcrowding and recommended increasing community sanctions.

Prison riots led to deaths in several countries during 2017, including the Philippines, Indonesia, Nigeria, Congo, South Africa, Guatemala, the Dominican Republic, Mexico, Venezuela and Colombia.

The prevalence of poor mental health among prisoners has been found
 to be considerably higher than in 
the community, often exacerbated 
by overcrowding, violence, isolation, lack of privacy and meaningful activity and inadequate health services, especially mental health services.

Studies worldwide have shown that suicide rates in prisons are up to ten times higher than those in the general population.

In a prison in Colombia, there was one doctor for every 496 prisoners. In France, prisoners reported being on a waiting list for one to two years to have an initial appointment with a psychologist.

A study of Latin American prisoners in six countries revealed 
the prevalence of broken homes
 and abandonment in prisoners’ family histories.

A study of prisoners in South Africa—a country that saw 47 suicides and murders within its prison walls in 2011—found pitiful levels of mental health problems; 23.3 percent of prisoners in Durban were suffering from psychotic, bipolar, depressive and anxiety disorders, all of them for the most part undetected and untreated.

In Australia, mentally ill individuals make up almost half of prisoners, according to the country’s Chair of the National Mental Health Commission, who said that the management of such people in prison is costing taxpayers millions of dollars per year and the failure of the country’s mental health services to cope with demand is absorbing as much as 50 percent of police time, with police estimated to detain one mentally ill person every two hours. One in three prisoners with a mental illness in Australia has been in prison five times or more.

The causal link between overcrowding and mental health of incarcerated people is seen in the success story of Cyprus, a country that in 2014 had the highest suicide rate of any European nation and yet, following major reforms to reduce overcrowding, this year announced that no one has committed suicide within a Cyprian prison and that there has been a 99.9 percent drop in cases of self-harm.