Mental health in prisons in Latin America: The effects of COVID-19

Latin America is a vast region of the world. In 2022, it is estimated that nearly 620 million people live in 33 countries spanning almost 20 million km² across North, South and Central America, and the Caribbean. ¹ These countries are united by their common historic cultural origins. ² It is estimated that Spanish is spoken by 400 million, and Portuguese by 200 million people in the region. ² Quechua is the most widely spoken indigenous language in the region, with around 8 million speakers; smaller numbers speak around 560 other indigenous languages such as Mayan, Guarani, and Nahuatl.^2,3 The region was described as having a total gross domestic product (GDP) of almost 4.7 trillion US dollars in 2020, with substantial contributions from the four largest economies—Brazil, Mexico, Argentina, and Chile.^4,5 However, Latin American countries are mainly considered developing nations. ⁵

Meanwhile, it is thought that nearly 12 million people were detained in prisons throughout the world in 2019, of which at least 1.6 million were held in prisons in Latin America (1.163 million in South America, 340,000 in Central America, and 122,000 in the Caribbean).^6,7 These numbers have been increasing throughout the twenty-first century, as the world's prison population has risen by 24% since the year 2000. ⁸ However, the prison population growth in Latin American countries has been extreme, with reported increases of 77% in Central America, and 200% in South America.^8,9 In 2022, prison population rates were 478–605 prisoners per 100,000 people in the Latin American countries with the highest occupancy (El Salvador, Cuba, and Panama). ¹⁰ In Bolivia, with a rate of 175 prisoners per 100,000, the level of overcrowding in some prisons was nonetheless as high as 891% of capacity in 2018. ¹¹

The reasons are linked to multiple factors, including increasing levels of crime and insecurity along with the rise of penal populism and zero tolerance policies, contributing to longer prison sentences.^9,12 Decreases in psychiatric beds have also been found to correlate significantly with increases in the prison population in Latin American countries.^13,14

People in prison present with very high levels of mental ill-health and substance misuse. For example, the global estimated prevalence of psychosis is 3.6% amongst male, and 3.9% amongst female prisoners, while the estimated prevalence of depression is 10.2% amongst male and 14.1% amongst female prisoners. ¹⁵ Neurodevelopmental conditions also feature prominently in this group, with intellectual disabilities said to be present in around 2.9% of prisoners, and attention-deficit hyperactivity disorder in 26.2%.^16,17 Prisoners have a high level of maltreatment in childhood, with almost half reporting four or more adverse childhood experiences. ¹⁸ Unsurprisingly, prisoners therefore present with high reported levels of post-traumatic stress disorder, amongst 6.2% of male and 21.1% of female prisoners, and personality disorder in an estimated 65%.^19,20 Similarly, high levels of drug and alcohol misuse or dependence are described—66.1% and 55.9% respectively in one 2019 UK sample. ²¹

To date, however, most research in this area has been done in high-income countries, reflecting the greater level of resources available. Yet throughout the world, most prisoners are detained in low- and middle-income countries, with different cultural and legal considerations, and resource allocations. ²² In Latin America, some important prevalence studies have been conducted in Brazil, Chile, and Ecuador, but most states have no such estimates available. The available research has confirmed high lifetime and 12-month prevalence rates for all mental disorders, with high rates of depression, personality disorder, and alcohol and drug addiction amongst prisoners in Brazil,^23–25 and very high levels of depression and psychosis—50.2% and 25.9% respectively—in Ecuador. ²⁶ In Chile, very high rates of depression and drug/alcohol use disorders have also been described, with substantial levels of suicide risk—amongst male (28%) and female (15%) prisoners. ²⁷ Substance misuse disorders are the most commonly presenting health issue, with many exhibiting co-morbidities across three domains—the triad of severe mental illness, personality disorder, and substance misuse.^28,29

These high levels of morbidity signify a need for services that are appropriate to the task at hand, both in terms of absolute staff numbers provided and assessments and treatments offered. However, many prisoners in Latin America do not receive these treatments, and even when they do, they are often inadequate, or arrive too late. ³⁰ Further, mental health presentations are often compounded by serious shortcomings in prison systems, with failures to meet agreed international standards—including harsh, over-crowded, and life-threatening conditions, lack of facilities, and low staff-prisoner ratios.^31,32 In some countries, prisoner-led organizations have taken control of resources and daily life, with the formation of groups to meet for collective needs such as cooking, and a variety of gang structures are known to exist. ³² In countries such as Venezuela, gangs have more or less taken over, while in others, they may have wide connections with people in the community, where they may threaten violence to ensure they maintain control inside the prisons.^33,34

The COVID-19 pandemic placed considerable additional strain and exposed existing weaknesses in prison systems across Latin America, leading to a major humanitarian and healthcare crisis.^35,36 The existing overcrowded and unsanitary conditions within prisons resulted in an inability to provide effective social distancing measures or protective equipment to prisoners, increasing infection and death among the prison population.^35–37 Infections in prisons in the region grew more than 200% in just two months in 2020, and both cases and deaths are likely highly under-reported, particularly since the testing capacity was typically low.^35–37 In Argentina, although the infection rate was relatively low in the prison system, the mortality rate from COVID-19 (4.4%) was over double that in the general population (2.1%). ³⁸ Over 5% of the total prison population in more than 13 Latin American countries have at least one risk factor for severe COVID-19, including age and medical conditions. ³⁶

Infection inside the prison also increases the risk of spread in the population at large from the generally high turnover rates of the population, visitors, and prison staff.^35–37 In many Latin American countries, prisoners are dependent on family and friends to provide food, medicines, clothing, and blankets.^35,38 The general approach to the pandemic in Latin America was to put prisons on lockdown, banning visits from families and others including defense lawyers, social workers, non-governmental organization staff, and those providing physical and mental healthcare and educational activities.^36–38 This resulted in additional emotional and physical hardships for the affected populations from hunger, cold, increased segregation from families and societies, more exposure to violence of peers, and higher thresholds to receive appropriate medical and legal support. The lockdowns also restricted the ability to provide oversight of prison conditions and treatment of prisoners. ³⁸ Some prison administrations did allow video or phone calls for family connections and educational or outreach services, ³⁹ and many systems prepared special areas to treat those infected with COVID-19, though these were often deficient.^36,38

In several countries, including Colombia, Venezuela, Bolivia, Argentina, Peru, and Brazil, conflicts and riots broke out in response to the prison lockdowns, the lack of protective measures for prisoners against COVID-19, and the poor living conditions inside prisons.^36–38 This led to additional deaths, which, like COVID-19 deaths, were likely underreported. ³⁶ The sense many prisoners in the region have of being “disposable” and invisible in life and death was heightened by the pandemic, the official response to it, and the response to the ensuing riots. ⁴⁰

Approximately 17 countries within Latin America adopted pre-release or house arrest measures for inmates to reduce overcrowding, based on factors including age, remaining time in sentence, pregnancy, and pre-existing health conditions.^36,38 In several countries, there was concern from the public that those with serious crime convictions, including crimes against humanity and human rights abuses, were being released, leading to limitation of releases by higher courts.^36,38,39 Only 3 of 26 systems reporting on whether these measures were used made serious efforts to release more than 5% of inmates; overall, less than 2% of prisoners were released under these measures, with a minimal effect on overcrowding.^36,38

After a slow start, by the beginning of 2022, parts of Latin America were leading the world with COVID-19 vaccination rates, likely due to the high mortality rates from the virus in the region. ⁴¹ However, prison populations are often omitted from vaccine priority plans, or implementation is uneven, even for prisoners with increased risk factors such as age or health. ⁴²

The pandemic has demonstrated many of the problems within Latin American prison systems, but may serve as a learning opportunity to improve prison conditions going forward. ³⁹ Improving prison healthcare, including mental health, can also help with infection prevention and control.^39,43 Other measures against infection include appropriate use of personal protective equipment, improved hygiene, priority vaccination of staff and prisoners, improved testing, and using isolation and quarantine protocols where needed.^39,43 Measures to reduce overcrowding in prisons are a key part of strategies against COVID-19, but can also significantly improve prison conditions in general, including directly addressing the health of those remaining incarcerated.^39,43,44 These measures include limited use of pretrial detention, and releasing vulnerable prisoners and those sentenced for minor and non-violent crimes. ⁴⁴

These measures should also be considered as part of a longer-term strategy to address overcrowding and health problems in prisons, alongside approaches including reducing sentence length, using custodial sentences as a last resort, and reducing the incarceration of juveniles, caretakers of children, mentally ill people, and those with drug addiction.^39,44 Those in this category could be kept out of prison, where appropriate, by means including education, restorative noncustodial measures, and appropriate medical or other care.^39,44

This is an area in which research is urgently needed to inform service improvements and address the most urgent problems highlighted and exacerbated by the pandemic. ³⁹