Noncommunicable diseases (NCDs) cause 71% of deaths globally and present a challenge to healthcare systems. [1] NCDs disproportionately affect poorer and marginalised groups across the world. One of the universal values of the 2030 Agenda for Sustainable Development is to “leave no one behind.” [2,3] However, NCDs are poorly recognised as an important health issue for the 30 million people moving annually between prisons and communities, most of whom experience multiple disadvantage. [4] 

Health systems need strengthening to effectively respond to the challenges posed by NCDs, and prisons must be part of these developments. There is scarce research into NCDs in prisons or robust surveillance data from prisons. Imprisoned people are at high risk of NCDs, but information on measures to protect them from NCDs and their risk factors is poor. [5] Only 2% of the WHO EURO Region Member States have data on the proportion of overweight people in prison and only 15% know the prevalence of hypertension—both risk factors for NCDs. [6] The underinvestment in NCDs witnessed in society at large is magnified in prison settings where NCDs are not considered a priority. Barriers in governance and financing, health workforce, and in care transitions lead imprisoned people affected by NCDs to see their health needs ignored despite international standards stipulating equivalence of care. [7]

Paradoxically, it is an infectious disease that has focused our attention on NCDs in the most marginalised. The dangers of covid-19 and NCDs are increasingly recognised in wider society. [8,9] Imprisoned people face multiple, intersecting risks. The crowded, poorly ventilated, and unhygienic conditions in prisons amplify the transmission of infectious diseases, putting imprisoned people at a higher risk of infection. [10] Existing NCDs put those affected at increased risk of serious illness or death. Over 90% of imprisoned people are male, of increasing age with an overrepresentation of black and ethnic minority groups. [11-13]  As with NCDs, the most marginalised groups are worst affected by covid-19. [8]      

The response measures to covid-19 imposed on communities have been even more severe in closed settings. Key issues affecting those living with NCDs in prisons include the interruption of prevention and screening services, reduced physical activity by time spent in cell, decreased access to health services, and disrupted supply of essential medicines. [14] Although service provision in prison should be equivalent to that in the community, it is likely that problems are instead magnified. [15] For example, staff needing to take time off sick or to self isolate, leads to shortages of custodial and healthcare staff which diminishes the care provided.  Restrictions have been imposed on access to external health providers as a result of the pandemic. [16]

Solutions to overcome covid-19-related disruptions in the community include the use of telemedicine, online prescription renewal, home delivery of medicines, and remote support to physical activity. These could also apply to prisons. [9] There are, however, barriers to their implementation, e.g. medical records are often inaccessible online, electronic devices enabling risk factor monitoring or virtually observed therapy are unlikely to be permitted, and Wi-Fi access is often limited, even for prison staff. 

Although “building back better” is challenging in prisons, it is not impossible and must be grasped as an opportunity to improve the lives of vulnerable people and to transform healthcare delivery. Covid-19 has shown that many of the tools required for fighting a pandemic are those required to fight NCDs: disease surveillance, strong civil society, robust public health and social measures, and equitable access to resilient universal health care systems. Prisons must be an integral part of national covid-19 recovery plans. The pandemic has exposed the “fault lines” in societies and recovery that ensures the most vulnerable are not left behind must include imprisoned people. [17] Creating effective solutions for prisons will result in benefits for the community and decreased societal inequalities. This will mean:     

• ensuring universal healthcare access for imprisoned people including programmes of prevention and treatment for NCDs risk factors
• investments to transform prisons into health-promoting and rehabilitation-driven environments; and enable the development of digital solutions
• providing a competence-based career pathway for prison healthcare staff 
• developing strategic intelligence on inequalities in health and well being by generating data and investing in research for NCDs in prisons to enable evidence-based policies 
• improving prison health governance, through better coordination between different sectors (health, justice, and social) 

Although the pandemic has been a major disruptor, it has highlighted that “business as usual” falls very short when it comes to addressing the unmet needs of marginalized groups. Investment in prisons now will reap a community dividend. [18] This must be an opportunity for resetting our societal moral compass to ensure that historical inequities are reduced and that the right to health for all is delivered and no one is left behind. [3]

Filipa Alves da Costa, health policy expert. Alcohol, Illicit Drugs & Prison Health Programme, WHO European Office for Prevention and Control of Noncommunicable Diseases. Twitter @Filipa_a_c

Carina Ferreira-Borges, programme manager, Alcohol, Illicit Drugs & Prison Health Programme, WHO European Office for Prevention and Control of Noncommunicable Diseases (NCD Office). Twitter @FerreiraBorgesC

Nino Berdzuli, divisional director. WHO Regional Office for Europe, UN City, Copenhagen 2100, Denmark. twitter @NinaBerdzulli

Hans Kluge, regional director. WHO Regional Office for Europe, UN City, Copenhagen. Twitter @hans_kluge

Elizabeth Davies, group lead, Cancer Epidemiology and Cancer Services Research and Head, Cancer Epidemiology, Population and Global Health Programme, School of Cancer and Pharmaceutical Sciences, King’s College London, Guy’s Hospital.

Mohamed Hamad, public health expert, Alcohol, Illicit Drugs & Prison Health Programme, WHO European Office for Prevention and Control of Noncommunicable Diseases (NCD Office)

Maria Neufeld, public health expert, Alcohol, Illicit Drugs & Prison Health Programme, WHO European Office for Prevention and Control of Noncommunicable Diseases (NCD Office). Twitter @NeufeldM

Kremlin Wickramasinghe, technical officer, Noncommunicable Diseases, WHO European Office for Prevention and Control of Noncommunicable Diseases. Twitter @KremlinKW

Emma Plugge, Public Health England, Primary Care, Population Sciences and Medical Education, University of Southampton.

Conflict of Interest: The authors declare the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding: The Ministry of Social Affairs and Health Finland is the donor for the Health in Prison Programme (annually), although no specific funding was requested for this publication.

Disclaimer: HK, NB, CF-B and KW are staff members of the WHO, FAC, MN and MH are WHO consultants. The authors alone are responsible for the views expressed in this publication and these do not necessarily represent the decisions or the stated policy of the World Health Organization.

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