Intended for healthcare professionals


Prisons and pandemic preparedness

BMJ 2023; 381 doi: (Published 24 April 2023) Cite this as: BMJ 2023;381:p860
  1. Paul Leslie Simpson, research fellow1,
  2. Tony Butler, programme head1
  1. 1Justice Health Research Program, School of Population Health, University of New South Wales, Sydney, Australia
  1. Correspondence to: P L Simpson p.simpson{at}

The pandemic treaty should oblige governments to report data on imprisoned people

Historically, prisons have been incubators for infectious diseases1 because of overcrowding in confined spaces,23 poor ventilation, under-resourced healthcare, and the poor physical and mental health of those incarcerated.4 Such conditions placed prisoners at a high risk of covid-19 and increased the threat of outbreaks among the communities to which they returned.5

Early in the pandemic, public health experts advocated for “strategic decarceration” in prisons with high population densities to prevent outbreaks and deaths.67 More than a dozen countries released people from prison in response, but globally such efforts were haphazard.8 Instead, many prison health services opted to increase testing and use of personal protective equipment, quarantines, and, once available, vaccinations.

Correctional services typically introduced measures to reduce the movement of prisoners, including long term “lockdowns” and stopping in-person visits.910 The mortality and morbidity associated with these measures remains unknown for most countries. However, emerging evidence suggests that the effects are likely to have been grim, particularly in prisons in areas where community transmission was high.

In February 2023 the New York Times reported that deaths in US prisons increased by almost 50% during the first year of the pandemic, and by over 100% in six states.11 During the first six months of the pandemic, the covid-19 death rate in US prisons was reported to be 39 deaths per100 000 prisoners, compared with 29 per100 000 people in the general population.12 Furthermore, WHO European Region data on prisoner health from a survey of 36 European countries, shows that in 2020 covid-19 was the second most common cause of death for people in prisons (31.2 per100 000), after suicide (103 per100 000).13 The covid-19 death rate among prisoners in England and Wales between March 2020 and February 2021 was 3.3 times the rate among people of the same sex and age in the general population.14

Patchy and unreliable data

In many other parts of the world, information on the physical and mental health effects of covid-19 on prisoners is either difficult to obtain or unavailable. The reliability of data on cases and deaths in Latin American prisons, for example, varies greatly between countries: some governments provide up-to-date data on cases, deaths, and vaccination rates (for example, Brazil, Chile, Colombia, and Mexico), but in other countries estimates are derived from press releases or media articles.15

In some Australian jurisdictions, reporting is limited to vaccination rates and active and new cases in the previous seven days (New South Wales and Victoria); others have stopped reporting on covid-19 altogether. Deaths from covid-19 are not reported by Australia’s national deaths in custody programme.16 Compounding this poor transparency is the lack of access for the UN subcommittee on prevention of torture, which, having been denied access to numerous Australian prisons in late 2022 while carrying out its mandate under the Optional Protocol to the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment, abandoned its visit.17

The effects of the pandemic are likely to have exacerbated the poor mental health of people in prison and their families.1819 One qualitative study that interviewed key informants and 43 people who had been in prison from Kenya, South Africa, Brazil, US, India, Thailand, England and Wales, Hungary, Netherlands, and Australia documented that protests, violence, and riots in prison were common after covid-19 restrictions were introduced. Interviewees reported anxiety, sadness, and depression because of lack of in-person contact with loved ones.19

Pandemic treaty

In response to the failure of the international community to respond to the covid-19 pandemic collectively and effectively, particularly among disadvantaged populations, WHO member states are negotiating a new international instrument—a pandemic treaty. The treaty aims to establish new global mechanisms for future pandemics and is likely to include legally binding obligations between countries.20 The draft treaty, released in February 2023,21 recognises the underlying principles of equity, transparency, and accountability and acknowledges that nationally determined priorities must “take into account the rights of individuals and groups at higher risk and in vulnerable situations.”21 However, while refugees, migrants, and asylum seekers are acknowledged as being in vulnerable situations, prisoners have been forgotten.21

A clear understanding of the nature and extent of risks associated with imprisonment during infectious disease outbreaks and pandemics is a crucial first step towards ensuring that prison health systems are resourced appropriately and held accountable for the physical and mental health of people in their care.22 As the pandemic treaty develops, discussions should consider placing legally binding obligations on states to collect and report data related to vulnerable populations, including those in prisons.