A/HRC/38/36 International cooperation and assistance 29. International human rights treaties recognize the obligation of international cooperation, which includes cooperation regarding the right to health. International cooperation linked to the realization of a wide range of rights is also recognized in Sustainable Development Goal 17. Higher-income States have a particular responsibility to provide assistance in the area of the right to health, including as it relates to adequate access to health care in prisons and other settings of detention and confinement. International assistance should not support prison and health systems that are discriminatory or where violence, torture and other human rights violations occur. This is particularly so in the cases of drug detention centres, large psychiatric institutions and other long-term segregated care institutions.19 30. Through international cooperation, support for community-based health interventions should be scaled up to effectively safeguard individuals from discriminatory, arbitrary, excessive or inappropriate deprivation of liberty and confinement. It is worrying to see the continued imbalance between multilateral and bilateral assistance provided for the administration of justice and that provided for rights-based community investment. More work is needed to better understand the full scope of projects that continue to fund closed settings and impede community-based investment in health and social welfare. Underlying determinants of health 31. Various factors affect the physical environment of persons who are deprived of liberty or confined. Adverse conditions can include poor sanitation and poor access to nutritional food, fresh air and potable drinking water. Some facilities were constructed on land contaminated with carcinogens. 20 32. In these settings, including but not restricted to prisons, violence is common and takes many forms, including physical and sexual abuse by staff and peers, the use of physical and chemical restraints, forced medical treatment and solitary confinement. Furthermore, sexual violence against women has shown in multiple cases to be systematic and widespread. The most silent forms of adverse conditions of detention and confinement, including boredom and powerlessness, can often prove to be the most severe, notably affecting mental health while giving rise to feelings of hopelessness and despair and suicide attempts. 33. Overall, centres of detention or confinement are not therapeutic environments. In a previous report, the Special Rapporteur identified the underlying determinants of the right to mental health, including the creation and maintenance of non-violent, respectful and healthy relationships in families, communities and society at large. 21 In detention or confinement, where the person is surrounded by staff tasked with restricting freedom, it is difficult to establish these type of relationships, which hinder the full and effective realization of the right to mental health. 22 Even with noble efforts to establish a strong culture of respect and care, violence and humiliation usually prevails, adversely affecting the development of healthy relationships. Health care 34. As elsewhere, for the right to health to be enjoyed in detention centres, health-care facilities, goods and services must be available, accessible, acceptable and of good quality. 35. Even with the most comprehensive health system in place, structural barriers may impede the full and effective realization of the right to health. Centres of detention and 19 20 21 22 8 A/65/255, A/HRC/35/21. Judah Schept, “Sunk capital, sinking prisons, stinking landfills: landscape, ideology and the carceral state in Central Appalachia”, in Michelle Brown and Eamonn Carrabine (eds.), Routledge Handbook of Visual Criminology (New York, Routledge, 2017). A/HRC/35/21. Peter Stastny, “Involuntary psychiatric interventions: a breach of the Hippocratic oath?” Ethical Human Sciences and Services, vol. 2, No. 1 (spring, 2000).