Two speakers at the workshop presented overviews of incarceration in the United States and its effects on health. In his keynote address, Jim Parsons, vice president and research director at the Vera Institute of Justice, drew largely on data collected by the Vera Institute to examine the consequences of incarceration for the incarcerated, their families, and the broader society.1 Later in the workshop, Kathleen Brown, practice associate professor of nursing at the University of Pennsylvania, connected some of the broad features of incarceration in the United States to Pennsylvania and Philadelphia—with a particular focus on women who are incarcerated, which is the subject of Chapter 4—using figures drawn largely from the National Institute of Justice.2
INCARCERATION AND HEALTH
“The criminal justice system is a driver of health inequity that impacts the well-being of communities around the country,” said Parsons in his overview of incarceration in the United States. It directly and indirectly affects the health of individuals and communities, increasing rates of illness while simultaneously undermining the supports that contribute to community health and well-being. As such, incarceration is a critical social determinant of health. “Mass incarceration is one of the most significant drivers of public health in our time,” Parsons stated.
Prisons house many people with very poor health, and the correctional environment makes those conditions worse, Parsons observed. Rates of substance use disorders are between five and seven times higher among people who are incarcerated than in the general population, though less than 15 percent of the people with diagnosable substance use disorders in jails and prisons receive appropriate treatment. Similarly, rates of mental illness are much higher among incarcerated populations as compared to the general population. Of prison and jail inmates, 44 percent have been told in the past by a mental health professional that they have a mental health disorder.
Brown pointed out that, in state prisons nationwide, females have a higher rate of mental health problems, 73 percent, as compared with 55 percent among males. Only about one-third of those women experiencing prison receive treatment. Of those with mental illness, 68 percent report that they had been physically or sexually abused in the past compared with 36 percent of those without mental illness. Of the women with
mental illness who are in prison, nearly three-quarters met the criteria for substance dependency or abuse, and almost 64 percent had used drugs in the month before their arrest.
Within 3 years of being released, 37 percent of incarcerated individuals who leave state prisons with mental illnesses are reincarcerated, compared with 30 percent of those who do not have mental health problems, Brown observed. Inmates battling addiction fare worse: about half are convicted of a new crime within 3 years. And inmates with a dual diagnosis of addiction and mental illness do worst of all. Yet, many people with mental health issues use street drugs as a form of treatment rather than going to a health care provider, Brown stated.
In Pennsylvania’s Cook County, which houses an average of 9,000 inmates daily in jail, 25 to 35 percent suffer from mental illness. Brown said that the treatment options available for people with mental illness vary greatly from jail to jail but that mental health care is “quite good in Philadelphia,” with psychiatrists and psychologists who try to help everyone who needs treatment. However, treatments are not always up to date, financial resources are limited, and treatment does not follow people once they leave jail. “When their court case is heard, they’re back in their community and they’re not getting care again,” she said. “Then they come back again.” Brown also noted that people in prisons have a longer time to undergo treatment, which can result in fewer mental health problems in prisons than in jails.
Beyond mental health, between 39 and 43 percent of people in custody have at least one chronic health condition, Parsons stated. HIV/ AIDS is two to seven times more prevalent than in the general population, and an estimated 17 percent of all people with HIV in the United States pass through prison or jail each year. Rates of hepatitis C in correctional settings are 8 to 21 times those seen in the community, and tuberculosis is more than 4 times as prevalent.
With regard to violence, suicide, and self-harm, suicide accounted for 30 percent of deaths in jails between 2000 and 2013, Parsons observed. Fifteen percent of individuals experiencing state-level incarceration reported violence-related injuries. He added that about one in five people who pass through prison or jail have been in solitary confinement in the past year, and a study in New York City jails found elevated rates of self-harm among people held in solitary confinement. For these and many other reasons, said Parsons, “Jails and prisons are an important place for us to be focusing in targeting public health interventions.”
EFFECTS ON COMMUNITIES AND FAMILIES
In addition to personal health, mass incarceration has a major effect on community health and well-being, Parsons said. People leaving jail and prison typically return to communities characterized by poor health outcomes and limited access to primary care. Controlling for a range of factors that affect health, counties with higher incarceration rates have 3 percent higher mortality rates compared with communities with low incarceration rates, he said.
Parsons described a study of New York City neighborhoods; neighborhoods with high rates of incarceration had high rates of diabetes, psychiatric hospitalizations, people who go without needed medical care, infant mortality, and premature mortality. These neighborhoods also have much higher percentages of nonwhite populations.
The effect of incarceration on families is similarly dire. One in 25 white children born in 1990 had an incarcerated parent at some point during childhood, compared with one in four black children. Children exposed to parental incarceration have an increased likelihood of long-term negative outcomes, including depression, anxiety, withdrawal, difficulties forming healthy relationships, aggressive behaviors, substance use, developmental delays, and academic difficulties. In addition, women with incarcerated family members were less healthy and reported higher rates of obesity, stroke, and heart disease. The health effects of mass incarceration “are not limited to the prison walls,” Parsons said.
THE CHANGING PROFILE OF THE INCARCERATED POPULATION
Jails and prisons perform different functions and have different effects, Parsons observed. People tend to stay in jails for much shorter periods—an average of 24 days—than they do in prisons. As a result, many more people churn through the jail system than through prisons, which causes jails to have an oversized effect on communities. In an average year, almost 11 million admissions to jails are made, compared with about 600,000 to prisons. That represents more than 3 percent of the population of the United States and more than the population of New York City.
One reason that jail churn is particularly high, Brown noted, is because most people in jails have not been convicted. Some have just been arrested and will make bail in the next few hours or days, while others are too poor to make bail and must remain behind bars until their trials. Only a small number (150,000 on any given day) have been convicted, generally serving misdemeanor sentences under 1 year.
Nonviolent drug convictions are a defining characteristic of the federal prison system, with almost half of those convicted individuals
incarcerated because of a drug offense (Federal Bureau of Prisons, 2018). However, such convictions play only a supporting role at the state and local levels, Brown said. While most people in state and local facilities are not incarcerated for drug offenses, most states’ continued practice of arresting people for drug possession destabilizes individuals’ lives and their communities. Drug arrests give residents of overpoliced communities’ criminal records, which reduces employment prospects and increases the likelihood of longer sentences for any future offenses.
The backgrounds and characteristics of the people who are incarcerated has been changing over time. In the year 2000, the local jail rate per 100,000 population was between 200 and 240 for all sizes of cities and rural areas. Since then, the rate for rural areas, where people may have less access to supports and treatments, has grown to more than 330 per 100,000 population, while the rate for large metropolitan areas has fallen below 200 per 100,000. “We often think of criminal justice as being an urban phenomenon,” said Parsons, “but more than half the people who pass through jails return to small towns and rural America. Mass incarceration is increasingly a rural phenomenon.”
Mass incarceration is marked by huge racial disparities (see Figure 3-1). African Americans are 3.6 times as likely to be incarcerated as whites, Parsons pointed out. As an example of how these disparities play out, he noted that African Americans and white Americans self-report using drugs at about the same rate. But a disproportionate number of
African Americans are arrested for drug possession and distribution; they are also sentenced to federal prison for drug offenses at a much higher rate than whites.
On the topic of racial disparities, Brown observed that 1 in 17 black men between the ages of 30 and 34 was in prison in 2015, compared with 1 in 42 Hispanic males and 1 in 91 white males. In 2015 the rate of prison incarceration for black women was double the rate for white women; the rate for Hispanic women was 1.2 times higher than the rate for white women. She spoke of her experience:
The first time I went to Graterford, I was warned I was going to be shocked by the gates slamming and opening and closing. That part didn’t really bother me. What almost knocked me over at the first gate was the racial disparity. So many people of color incarcerated, way out of whack with what the numbers are in the general population. It was stunning to me.
Of the people in prison, 93 percent are men and 7 percent are women, Brown noted. However, as Parsons pointed out, since the year 2000, the number of females entering jails has risen by 20 percent while the number of males has fallen by 20 percent. The prison and jail populations are also getting older, with an increase of 55 percent in the number of people behind bars over the age of 55.
The relationship between poverty and incarceration is as predictable as it is disturbing, said Brown. The American prison system is filled with people who have been shut out of the economy and who had neither a quality education nor access to good jobs. In 2014 dollars, incarcerated people had a median annual income of $19,185 prior to their incarceration, which is 41 percent less than nonincarcerated people of similar ages. People living in poverty cannot hire attorneys, afford bail, or take the other steps available to people from stronger economic backgrounds.
THE DRIVERS OF MASS INCARCERATION
Mass incarceration is not a function of the crime rate, Parsons observed. The crime rate has been continuously falling since 1990, while the incarceration rate increased through 2008 and then fell slightly. “The best available evidence shows that increasing the number of people behind bars will not reduce crime,” said Parsons. “Incarceration is not about making communities safer, and the number of people who are in jails and prison is not determined by the crime rate.” Instead, he said, the driver of mass incarceration has been policy making, often at the local level, which has led to increases in the incarcerated population.
Brown agreed that the massive increase in the number of people in the nation’s prisons and jails is largely the result of changes in laws and poli-
cies, not changes in crime rates. The consequence for states and localities, she added, has been overcrowding in prisons and fiscal burdens, despite increasing evidence that large-scale incarceration is not an effective means of achieving public safety.
The operation of the criminal justice system can seem to have a kind of inevitability, Parsons noted, as if it has to operate that way. In fact, the operation of the system is the result of deliberate decisions made over the past 40 years. In the 1970s, the justice systems in the United States and in Western Europe were similar, “but we have taken steps over this period to create a system that looks the way it does,” he said. The contrast is obvious in comparison with a country like Germany, Parsons said. There, incarceration is founded on the idea of human dignity. The system operates on the premise that the best way to prepare people to return home is to have them remain healthy, wear their own clothes, and cook their own meals. “Being held in prison or jail is what is supposed to be the punishment,” Parsons said. In the United States, the system is based on the premise that punishment requires inhumane treatment. Then, when people leave prison, they face many barriers to finding housing, employment, education, and health care, including mental health care. “We need to get away from the idea of prisons and jails being places of punishment,” Parsons said.
Brown also noted that other nations take a very different approach to criminal justice. As an example, she observed that she has worked in the past with individuals who were given life sentences for crimes they committed when they were juveniles, a population known as “juvenile lifers” (though Brown said that she dislikes the term). When she was working with this population, Pennsylvania had more juvenile lifers than the rest of the world combined. “We’re doing something very different from everyone else,” she said. “We need to look at what other countries are doing and get some ideas about how we might be able to do it differently.”
Brown explained that researchers have studied the role of presidents, national politicians, governors, state legislatures, law enforcement agencies, prosecutors, and correctional unions in shaping the legislation that has contributed to mass incarceration. Other accounts have emphasized the importance of local actors, especially county-level prosecutors, who have seen a great expansion of their authority over the past several decades. The war on drugs, the strength of a correctional industrial complex, a backlash to the victories of the civil rights movement, a response to the increasing sense of moral fragmentation in society, fear of crime, and a crisis of legitimacy and trust in government also have contributed to mass incarceration. Other factors Brown listed are
- knowledge and power in penal decision making
- right-wing party domination and party competition
- proximity of government to the reality of crime
- sentencing and parole
- racialized threat and animus
- politics of crime control
“No one group is responsible” for mass incarceration, said Brown. Many factors have caused it.
PREVENTION, DIVERSION, AND REENTRY
Opportunities to reform the criminal justice system are abundant, Brown pointed out. They include literacy programs, formal education, job training, reentry classes, and work programs. “It’s called the department of corrections. They should be correcting something,” she said. Again, the opportunities vary greatly from prison to prison and jail to jail. Opportunities also vary between men and women. Men tend to have many more opportunities for exercise. Women tend to get the same food as men, which is unhealthy for them, and programs suited for men, such as substance abuse programs, that may not be as effective for women, Brown noted.
Much of what is offered to incarcerated individuals, especially in jails, is a function of how many volunteers can work in an institution. Through a program called Breaking the Cycle, Brown and a group of students spend 3 hours per week at the women’s jail in Philadelphia. One thing they work on is mindfulness, so the women are better able to handle the situations in which they are living. She explained:
It’s very difficult. It’s loud all the time. The lights are on all the time. There are fights erupting on the blocks all the time. We try to help them find some peaceful place to go through mindfulness, and the warden has been very pleased with the changes in their behavior.
Breaking the Cycle also encourages discussions of health issues, including nutrition, exercise, and intimate partner violence. The women in the jail choose the things they want to talk about each week. The challenge for the students is to figure out ways to help the women engage. “It’s fun once you’ve figured out how you can get them to engage,” Brown explained. At the same time, students learn about the lives of the women both before and during their time in jail.
The program includes women who have left prison and are living in transition houses, which are places where women can work on health-related issues, job skills, and social skills so they get the training, education, and experience they need to leave an entry-level job. “No one wants to work at McDonald’s or washing people’s hair in a beauty salon for the rest of their life,” said Brown. “You have to move on to something that makes more money.”
Parsons noted that people who completed a survey while they were held in the main New York City jail reported employment, housing, substance use treatment, help with relationships, and staying out of trouble as their greatest needs when returning home. Surprisingly, relatively few interviewees cited health and mental health. Parsons explained, “What this illustrates is that we need to think holistically about providing services to this population.” Employment, housing, and substance use treatment need to “go hand in hand” with health care, he said.
Reflecting this holistic view, the Sequential Intercept Model that Parsons described highlights opportunities to provide services at different points in the process of incarceration and reentry.3 Typically, the emphasis of services is on reentry, but interventions can also occur before people are incarcerated, including at the stages of law enforcement contact, initial detention, and court appearances. He said:
By the time someone has gotten to the point of reentering from prison or jail, they’ve experienced so much harm, so much damage, and so much health impact from being in the criminal justice system that much of the damage has already been done, and trying to repair that damage is usually difficult.
A much better option, Parsons said, is to try to keep people out of the system in the first place through such means as diversion programs.
Other interventions are also possible. Jails are largely untapped resources to provide quick interventions for drug abuse, such as naloxone and overdose prevention. In the first 2 weeks after returning home from incarceration, people are 12 times as likely to die, partly from opioid overdoses. “We should be equipping people not to overdose when they leave prison and jail,” Parsons said.
Many people are unaware of the lack of support for people released from prison and their communities, Parsons pointed out. People in health care are often astounded when they hear one of Parsons’s presentations. Law students rarely study the mental health issues of the people they will be representing if they serve as public defenders. In addition, considerable misunderstanding and stigma continues to surround issues of drug use and health. Medical schools and associations (including mental health associations), nursing associations, public health groups, legal organizations, and others need to be brought into the conversation, he said. “We need to shout this message from the rooftops, because the message is not being heard,” Parsons concluded.
3 The Sequential Intercept Model is a conceptual framework for communities to use in considering the intersection between the criminal justice and mental health systems.
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