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Impact of Incarceration on Health

As reported by several participants, individuals enter correctional facilities with many health problems; and incarceration has an impact on their health. Evidence was presented that many are released (especially from jails, given the high turnover rate)—and too often are re-incarcerated—with pressing health needs. Participants in the workshop discussed the impact of incarceration on inmate health and the healthcare they receive. Attention was given to possible improvement as well as deterioration in inmates’ health, the legal basis for such care, the provision of it, and the context for delivering healthcare. In particular, the discussion explored the dilemmas that arise in trying to improve health within correctional institutions and the responsibility of healthcare providers to engage in improving the healthcare of incarcerated populations and the health of the communities they come from.

INMATE HEALTH

As observed in the background paper, in the absence of systematic review, perhaps it can simply be said that overall physical health probably improves during incarceration in some ways but deteriorates in others. For people living especially chaotic lives, incarceration can provide a respite and stabilization: available meals, a structured day, and reduced access to alcohol, drugs, and cigarettes, in addition to access to healthcare, especially for black men who on average have lower access than white men outside of prison (Rich, Dumont, and Allen, 2012).



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1 Impact of Incarceration on Health A s reported by several participants, individuals enter correctional facilities with many health problems; and incarceration has an impact on their health. Evidence was presented that many are released (especially from jails, given the high turnover rate)—and too often are re-incarcerated—with pressing health needs. Participants in the workshop discussed the impact of incarceration on inmate health and the healthcare they receive. Attention was given to possible improve- ment as well as deterioration in inmates’ health, the legal basis for such care, the provision of it, and the context for delivering healthcare. In particular, the discussion explored the dilemmas that arise in trying to improve health within correctional institutions and the responsibility of healthcare providers to engage in improving the healthcare of incarcer- ated populations and the health of the communities they come from. INMATE HEALTH As observed in the background paper, in the absence of systematic review, perhaps it can simply be said that overall physical health probably improves during incarceration in some ways but deteriorates in others. For people living especially chaotic lives, incarceration can provide a respite and stabilization: available meals, a structured day, and reduced access to alcohol, drugs, and cigarettes, in addition to access to healthcare, especially for black men who on average have lower access than white men outside of prison (Rich, Dumont, and Allen, 2012). 7

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8 HEALTH AND INCARCERATION Christopher Wildeman (Yale University) suggested that correctional facilities may present “a unique opportunity” to provide these individuals with “at least some medical care that they haven’t gotten otherwise.” Indeed, as Bruce Western (Harvard University) observed in his intro- ductory remarks, “Prisons are coming to function as a massive organ of delivery for public health for people who are involved in the criminal justice system.” Newton Kendig (Federal Bureau of Prisons) outlined the public health opportunities for both jails and prisons. He noted that jails provide a strategic public health opportunity to screen and diagnose infectious diseases among persons who often evade traditional healthcare systems and yet are at high risk for illnesses, such as HIV infection and viral hepatitis, and prisons provide an opportunity to diagnose and treat chronic diseases, such as diabetes, hypertension, addiction, and mental illness among persons who frequently have not sought or had access to treatment prior to incarceration. The structured life of prison provides an opportunity for better compliance with taking prescribed medications and eating a healthy diet as well as engagement in drug treatment ser- vices, frequent recreation, and increasingly a tobacco-free environment. On the other hand, the prison environment may have adverse effects on health as discussed in the background paper (Rich, Dumont, Allen, 2012). The nutritional value of meals is far from ideal, because energy- dense (high-fat, high-calorie) foods are still common in prison meals. Smoking also remains a serious problem, despite the trend toward smoke- free correctional facilities. Poor ventilation, overcrowding, and stress may exacerbate chronic health conditions. More evidence is available regarding the effects of incarceration on mental health. Two conditions are especially associated with a serious degeneration of mental health: overcrowding and isolation units. The association between crowding and suicide or psychiatric commitment has been noted at least since the 1980s. Strains on staffing and facilities have particularly serious repercussions on wait times and holding conditions for the mentally ill. Case studies have also revealed widespread and serious reactions to segregation units, in which inmates are restricted to isolation cells for 23 hours a day. The restriction of movement and deprivation of human contact triggers psychological responses, ranging from anxiety and panic to hallucination. A review of health effects of incarceration also must consider sexual assault and inten- tional injury, either self-inflicted or resulting from assault. Prison health conditions and impacts were further discussed at the workshop. Jamie Fellner (Human Rights Watch) described prisons as “toxic environments” with a negative impact on inmate health. She underscored the damage that can result from isolated confinement: “We know that [solitary confinement] is bad for people who are mentally ill and can cause adverse symptoms for those who didn’t have prior symp-

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IMPACT OF INCARCERATION ON HEALTH 9 toms of mental illness.” Fellner also shared research findings on other aspects of prison experience, including violence (noting that one in ten state prisoners is injured in a fight) and sexual abuse (about 9.6 percent of former prisoners self-report that they were sexually abused by staff or inmates [Bureau of Justice Statistics, 2012]; those abuses were frequently accompanied by physical injuries in addition to any injury that came from penetration itself). Excessive use of force by staff is also a problem, she noted, from “old-fashioned beating” to the use of tasers and pepper sprays that can cause serious injury, particularly depending on inmates’ physical conditions. “Obviously brutality has declined markedly in U.S. prisons in the last 20 years,” Fellner observed, “but it still exists and it still has health consequences.” Fellner also reviewed a range of other conditions in prisons that can be detrimental to inmate physical and mental health, including poor diets, poor sanitation, infestations with bugs and vermin, poor ventilation, tension, noise, lack of privacy, lack of family visits, and cross-gender pat searches (traumatizing especially for the high percentage of women in prison who have been previously sexually abused). Fellner offered these as “just some of the examples of the kinds of conditions, some caused by inattention and poor manage- ment by prison staff, and some caused by prison policies” that can be harmful to inmate health. THE LEGAL BASIS FOR HEALTHCARE FOR INMATES In prisons and jails, according to Robert Greifinger (John Jay College of Criminal Justice, City University of New York), “we have a litigation- driven healthcare system.” Craig Haney (University of California, Santa Cruz) echoed this view, noting that “for better or worse, a lot of the access that I have into prisons has come in the context of litigation. I get called in to look at prison systems, what’s happening to people in them, how those systems are functioning when—in at least someone’s opinion—they’re not functioning very well.” The 1976 Supreme Court decision in Estelle v. Gamble found that deliberate indifference to serious medical needs constitutes a violation of the Eighth Amendment prohibition of cruel and unusual punishment. Estelle v. Gamble led to expanded healthcare services, especially through a series of subsequent lawsuits or threatened litigation. The duty of correc- tional facilities to provide healthcare was recently reinforced in Brown v. Plata (2011), which ordered California to reduce overcrowding in prisons because of the associated failure to provide adequate healthcare to all inmates. Acknowledging that litigation under the U.S. Constitution has driven much of the provision of healthcare services in prisons, Fellner nonethe-

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10 HEALTH AND INCARCERATION less asserted that “the U.S. constitutional floor is so low that it is not one to which the medical profession should limit itself, and nor should government officials limit themselves to that.” She cited elements from a number of international human rights treaties and guidelines addressing prisoners.1 They call for prisoners to be treated with dignity and respect for their humanity; “Starting and ending there would be a huge step for- ward in many prisons, I’m afraid,” she said. International treaties forbid torture or cruel, inhuman, or degrading treatment of prisoners. They also affirm that rehabilitation must be the paramount goal of incarceration and that prisoners have a right to healthcare that is accessible, available, and meets community standards. Feller noted that such standards are not strictly enforceable by U.S. judges. In some instances, the United States has signed but not ratified treaties. The elements of these international treaties are nonetheless available, and Feller urged workshop participants to heed them when generating implications for program and policy. While the Supreme Court decision directs healthcare provision for incarcerated populations in both prisons and jails, it does not extend to those under supervision (on parole, probation, or home confinement) within the criminal justice system. As Faye Taxman (George Mason Uni- versity) underscored, “People in community corrections are the largest population in the justice system, and they don’t have the constitutional mandate for care that people who are incarcerated have.” CONTINUITY OF CARE Some correctional facilities are important public health collaborators in the screening and diagnosis of infectious and other diseases, and many correctional healthcare providers across the country are highly trained and deeply committed to their patients’ wellbeing. Some correctional facilities have sought partnerships with community-based medical and public health practitioners to ensure that care begun during incarceration is continued following release. Overall, however, as discussed and docu- mented in the background paper, a disconnect exists between correctional healthcare and state or local public health departments in planning and delivering care to inmates while incarcerated and upon release (Rich, Dumont, and Allen, 2012). In particular: 1These treaties include the International Covenant on Civil and Political Rights (ICCPR), the Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Pun- ishment (CAT), the International Covenant on Economic and Social Rights (ICESR), and the Convention on the Rights of People with Disabilities.

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IMPACT OF INCARCERATION ON HEALTH 11 • Testing policies and procedures remain inconsistent across states and facilities. Even wide-scale screening does not ensure that appropriate treatment is being provided once conditions have been diagnosed. In jails, where many people remain for under 48 hours, testing follow-through (delivery of results and establishment of a treatment regime) is especially challenging. • Limited resources and resultant understaffing appear widespread across correctional facilities. However, there is a lack of data and appropriate measures sufficient to determine the extent of shortcomings in correctional healthcare. Health outcomes associated with staffing shortages were highlighted in testimony in Brown v. Plata, which specifically linked overcrowding and insufficient healthcare provider staffing. Brown v. Plata further noted that the conditions of care created by overcrowding had created a staff culture of “cynicism and fear,” which made it even more difficult to attract competent clinicians, and presumably affected the care provided by existing staff. • Treatment for substance dependence is consistently insufficient to meet prisoner need. Despite a body of evidence demonstrating that addiction is a chronic brain disease that can be effectively treated, surveys have found that few correctional facilities have adopted evidence-based treatments, relying more frequently upon less- effective drug education services (Chandler, Fletcher, and Volkow, 2009; McCarty and Chandler, 2009). Moreover, detoxification and symptoms of withdrawal are most often treated with analgesics. This does not address the underlying addiction and leaves prisoners vulnerable to relapse and overdose upon release. As workshop participants discussed healthcare provided in different settings and to different populations, transitions were a recurring shared concern. Haney declared transitions to be “the weakest points,” as “the very best intentions flounder at the point at which there is a pass off.” Haney noted this weakness at every stage: when the inmate enters the system, then “when somebody moves from one facility to another, or even within a facility to another part of the institution, and certainly when somebody moves from the general [prison] population to a segre- gated housing unit.” Release is a further highly vulnerable transition. In Haney’s assessment, “No matter how good the care was, no matter how much information and intelligence was gathered about the patient, even in [well] functioning systems, there is a tremendous falloff in terms of the quality of care” at transition points. As “sometimes those transitional moments are the moments of greatest vulnerability,” Haney asserted “that

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12 HEALTH AND INCARCERATION drop-off in care occurs at exactly the moment at which the patient needs the most care or the most attention.” QUALITY OF CORRECTIONAL HEALTHCARE A recurrent and sustained theme throughout the workshop concerned the dilemma inherent in providing healthcare within environments that may in many ways undermine inmate health. Haney offered a blunt statement of “the elephant in the room: prisons are not just hospitals with electrified fences around them.” As he elab- orated, correctional facilities are for the most part characterized by a culture that tends to create limited communication and collaboration between healthcare providers and the custody staff who operate the facility. In this setting, healthcare providers have less authority, unlike in any other setting in which they are accustomed to practicing. This affects both their ability to do their job and patients’ confidence in healthcare providers. And that, observed Haney, “cycles back oftentimes even in the best trained and most well-intentioned care providers to a change in attitude about the patient.” However, it should be noted that the health- care providers at the workshop welcomed the incarcerated population as patients in need of care. Furthermore, in Haney’s view, some prison environments “are so inhospitable that it is impossible to deliver effective medical and mental health care.” Citing particularly the “two extremes of confinement: hope- lessly overcrowded prison systems and conditions of long-term seg- regation or isolation,” Haney argued that the norms, policies, culture, and even architecture of prisons can worsen health problems among the ill, and even generate problems among the healthy. Thus, it simply “becomes impossible to effectively deliver treatment in those kinds of environments.” Fellner offered a similar account of the environment and culture within correctional facilities, and the resulting dilemma for doctors. In her view, “prisons are ill-equipped by virtue of [a broad] mission, their cul- ture, their training, their reward systems, their bureaucracies” to under- take the delivery of healthcare services to all prisoners who need them. Therefore, while correctional facilities aim to provide adequate healthcare and may even recognize their interests are served by having a healthier inmate population, other purposes, environments complicated by the rise in incarceration rates, and limited resources compromise reaching that end.

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IMPACT OF INCARCERATION ON HEALTH 13 HEALTHCARE PROVIDERS The workshop discussion sharpened to focus on providers’ profes- sional and ethical responsibilities to advance the quality of correctional healthcare. Greifinger added two factors to the difficulty of providing healthcare effectively within correctional facilities. One is the lack of lead- ership, as “the commissioners, secretaries, and wardens often are not providing the leadership to allow the modern innovative value-driven physicians and other healthcare practitioners to do their jobs.” Another is the pronounced isolation of healthcare providers in prison and jail set- tings, as they are often separated from their peers practicing in the general public. Above all, however, Greifinger underscored the adverse effects of the culture of correctional facilities, particularly the “stereotyping and cyni- cism that results in distrust.” As Greifinger reflected, “I’ve been involved in a lot of litigation over the years, class-action suits and individual cases. I can tell you that in the individual cases, 99 percent of the time the rea- sons there was unconstitutional care was because there was mistrust and cynicism of what the patient was saying. So I think we have a real danger of a lot of harm continuing unless we change the system of care.” Scott Allen (University of California, Riverside) directly addressed the medical profession’s responsibility in establishing the current system. Declaring that the system was created “on our watch,” Allen explained that historically doctors were involved in the initiation of both prisons and asylums, and that “doctors remain essential, and even we would argue foundational, to the continued existence of jails and prisons.” Allen described the crux of the dilemma as the effort to provide care with and within institutions with practices that can be more punitive rather than therapeutic. As the system became established, “the medical profession went along for the ride.” Indeed, declared Allen, “I see this as a failure of the medical profession as a whole.” Specifically, Allen reviewed four aspects of medical professionalism and how they are tested by the prison system: (1) altruism and commit- ment to patient interest; (2) physician self-regulation; (3) maintenance of technical competence; and (4) civic engagement. In Allen’s view, within correctional institutions, “altruism and loyalty to the patient’s interest is fine as long as they don’t come into conflict with the institutional mis- sion.” There is some support for physicians’ self-regulation, and a good deal of emphasis on technical competence. Civic engagement, however, is “the first to go,” as doctors providing healthcare within correctional facili- ties are “often reminded whether directly or indirectly to stay in our lane, that we’re not there to make policy suggestions, just treat the patients, just take care of them.” In Allen’s view, to accept that constriction of civil engagement is to forgo both the moral authority and the legal authority

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14 HEALTH AND INCARCERATION of the medical profession within the criminal justice system. To Allen’s dismay, “I don’t think historically we have leveraged that or asserted that [authority].” Haney puzzled over this situation, calling for “help figuring out how to operate effectively” in such adverse environments. Fellner agreed, noting that this is “something which medical professionals have to work on.” She articulated a challenge to healthcare providers: “You’re no longer guests in the house of corrections, you have as much right to be there as the guards, you’re constitutionally required, and it means speaking up more.” Healthcare professionals working within correctional facilities and those observing the situation from the outside have, in her view, “an obligation to inform themselves and speak out” on conditions of confine- ment and impediments to appropriate healthcare delivery. Speaking from the vantage point of a medical professional seeking to provide healthcare within correctional facilities, Allen affirmed “it’s important we take ownership of our role. We went along for the ride, we were always integrated as a profession, and we need to take ownership and acknowledge that.” The next step is to “assert our medical leader- ship,” including exercising both moral and legal authority. Noting the medical profession’s past “failure to civically engage on both the policy and political level,” Allen called for doctors to become engaged “in greater number, with greater emphasis, and greater authority, so that we move forward and promote policies that are in the interest of our patients.” Such policies, Allen asserted, will address not only conditions of confinement and delivery of healthcare within correctional facilities, but also transition of care for those released back to the community, and above all, “all the things that lead to the risk of incarceration in the first place.”