1 of 35

Care of Incarcerated Populations

SEMINAL STUDY

14.4

14.3 // Care of LGBTQIA+ Populations

14.5 // Structural Vulnerability

14 APPROACH TO SPECIAL & VULNERABLE POPULATIONS

2 of 35

Care of Incarcerated Populations

Contributors:

Eileen Williams, BA

Caitlin Farrell DO, MPH

Colleen Laurence, MD, MPH

Shama Patel, MD, MPH

3 of 35

Objectives

Define the “incarcerated population”

Define the “justice-involved population”

Discuss factors that make these populations vulnerable before, during, and after incarceration

Describe population-specific barriers to healthcare

Share considerations in caring for this population

Outline additional avenues for education and advocacy

4 of 35

The United States has the highest incarceration rate in the world.�

5 of 35

6 of 35

Who is “incarcerated?”

7 of 35

8 of 35

Who is “justice-involved?”

9 of 35

Individuals who are currently or formerly involved with the criminal justice system.

10 of 35

Beyond the individual

Nearly 2 in 3 families (65%) with an incarcerated member are unable to meet their family’s basic needs
2.7 million children in the US have at least one parent in prison
Children who have an incarcerated parent are 6X more likely to experience incarceration

11 of 35

Jails vs. prisons: What’s the difference?

Prisons are facilities under state or federal control where people who have been convicted (usually of felonies) go to serve their sentences.

Jails are city- or county-run facilities where a majority of people locked up are there awaiting trial (in other words, still legally innocent), many because they can’t afford to post bail.

12 of 35

13 of 35

Context

Currently, there are 2 million people in the nation’s prisons and jails—a 500% increase over the last 40 years
Changes in sentencing law and policy, not changes in crime rates, explain most of this increase

14 of 35

15 of 35

Why do we care?

Incarceration IS a social determinant of health.

16 of 35

Incarcerated populations are sicker.

Rates of HIV infection are four to six times higher, and one in three incarcerated individuals are estimated to have hepatitis C
About 4.2% of all tuberculosis cases occur in correctional facilities while less than 1% of the American population is incarcerated at any given time
Incarcerated individuals have a higher likelihood of experiencing hypertension, asthma, arthritis, and cervical cancer
Each additional year in prison produced a 15.6% increase in the likelihood of death for parolees, translating to a 2-year decline in life expectancy for each year served in prison

17 of 35

Poverty

Incarceration

Poor health

18 of 35

19 of 35

Over half of inmates report mental health problems.

Correctional system now de facto “treatment”

Closure of public mental health facilities

Mental health policy changes

Lack of community support

According to the National Institute of Mental Health (NIMH), 6.3 percent of the population suffers from severe mental illness, defined as longstanding mental illnesses, typically psychosis, that cause moderate-to-severe disability of prolonged duration.

Approximately 14.8 million people have severe mental illness. Experts polled by the Treatment Advocacy Center estimated that about 50 beds per 100,000 people would meet needs for acute and long-term care, but in some states the number of available beds is as low as 5 per 100,000 people. Thus, many who need residential treatment cannot obtain it.

The changes that led to this lack of space, as well as changes to the institutionalization process, have made it impossible for people with severe mental illness to find appropriate care and shelter, resulting in homelessness or “housing” in the criminal justice system’s jails and prisons .

The three biggest mental health centers in America are LA County, Cook County, Ill. (Chicago) and New York City’s Rikers Island jail.

20 of 35

21 of 35

22 of 35

23 of 35

In the two weeks following their release, people who had been incarcerated in state prisons were 129 times more likely to die from an overdose compared to the general public.

24 of 35

DURING incarceration

25 of 35

Healthcare while incarcerated

Incarcerated populations have a constitutional right to healthcare

Denying an incarcerated individual appropriate care is legally considered “cruel and unusual” punishment

BUT access is highly variable

Temporary holding cells may have little to no treatment capacity
Rural jails may be limited in the care provided
Large urban jails and prisons can have extensive medical systems

Correctional health care lacks any standards/monitoring of quality

Patients may present after acute decompensation during temporary confinement (e.g., DKA in a diabetic without access to insulin)

History is critical – find out where the patient is coming from and what medical treatment is available in that setting

Even though access to care is theoretically guaranteed in correctional institutions, a nationally representative study of prisoners showed that many with pre-existing medical conditions did not receive treatment while incarcerated. (Mallik-Kane and Visher, 2008)

Another study showed that only one-fourth of incarcerated populations received treatment for mental health and/or substance use disorders while incarcerated (Petersilia 2008)

Correctional facilities have different ways of providing health care (contract with private groups like Corizon, partnering with academic institutions, hiring their own medical staff).

26 of 35

Infrastructure in correctional facilities often limits access to care.

27 of 35

POST incarceration

The final category of incarceration and health includes research that focuses on the post-release experience of former inmates and how reintegration into their home community affects access to healthcare and successful reintegration. They include issues related to micro, individual factors and macro-level policy such as inability to find a job or job training, issues related to medications (for those who are already ill), finding housing and shelter, administrative or bureaucratic barriers in obtaining services, lack of emotional support from both peers and professionals, issues with medical care including obtaining insurance such as Medicaid, transportation, and lack of availability of social services (Petersilia 2008; Sowell et al. 2001).

These issues related to access and standards of care can compound to further exacerbate health disparities. Incarceration’s impact on health begins with the incarceration experience itself, is followed by post-release setbacks and has foundations in policy that restricts access to various rights, including employment and housing.

For and women who received treatment for physical or mental health conditions during their incarceration, treatment rates drop dramatically within 8-10 months after their release.

The absence of continuity of care after incarceration leads to increased morbidity for patients who have chronic conditions, particularly those who are HIV-positive.

28 of 35

The adjusted relative risk of all-cause mortality within the first two weeks after release from prison is 12.7 times the risk of non-incarcerated individuals.

Drug overdose, cardiovascular disease, homicide, and suicide are the leading causes of death.

29 of 35

The big picture

Mass incarceration disproportionately impacts lower-income communities, communities of color, and persons with disabilities, creating a barrier to achieving health equity. People who are incarcerated face greater chances for chronic health conditions, both while confined and long after their release. Incarceration exposes people to a wide range of conditions, such as poor sanitation and ventilation and solitary confinement, that are detrimental to long-term physical and mental health. After release, previously incarcerated individuals often face higher mortality rates and experience limited opportunities for gainful employment, stable housing, education, and other conditions needed for good health.

30 of 35

Next steps

Educate yourself

Advocate for your patients

Understand that incarcerated patients may require more resources and support

31 of 35

Considerations for providers

Emergency physicians are likely to care for patients who are under arrest or being sent to booking

Patients needing "medical clearance” or “fit for confinement”

May also care for patients who are currently incarcerated and need acute care

Especially common at public hospitals where patients are often sent from county jails

Both situations require careful consideration of available follow-up

Might consider having a lower threshold to admit patients could otherwise be discharged "with close PCP follow up”

32 of 35

Resources

Corrections in Ink - Keri Blakinger (memoir)

The Prison Industrial Complex for Beginners - James Braxton Peterson

The New Jim Crow - Michelle Alexander

Locking Up Our Own: Crime and Punishment in Black America - James Forman

American Prison: A Reporter's Undercover Journey into the Business of Punishment - Shane Baue

Locked In: The True Causes of Mass Incarceration—And How to Achieve Real Reform - John Pfaff

13th (Documentary)

33 of 35

Get involved

34 of 35

References

Prison Policy Initiative. Mass Incarceration: The Whole Pie 2022. March 2022. https://www.prisonpolicy.org/reports/pie2022.html Accessed September 4, 2022.
The Sentencing Project. Criminal Justice Facts. May 2021. https://www.sentencingproject.org/criminal-justice-facts/ Accessed September 4, 2022.
Fair, H. and Walmsley, R. (2021) World Prison Population List (13th edition). London, ICPR.
U.S. Department of Justice, Bureau of Justice Statistics. (n.d.). Glossary. Retrieved March 9, 2022, from https://bjs.ojp.gov/glossary
Dumont, D. M., Brockmann, B., Dickman, S., Alexander, N., & Rich, J. D. (2012). Public health and the epidemic of incarceration. Annual Review of Public Health, 33, 325–339.
Binswanger IA, Stern MF, Deyo RA, et al. Release from prison--a high risk of death for former inmates. N Engl J Med. 2007;356(2):157-165.
National Research Council and Institute of Medicine. Health and incarceration: a workshop summary. Washington, D.C.: The National Academies Press; 2013.
Wang EA, Wang Y, Krumholz HM. A high risk of hospitalization following release from correctional facilities in Medicare beneficiaries: a retrospective matched cohort study, 2002 to 2010. JAMA Intern Med. 2013;173(17):1621-1628.
Brinkley-Rubinstein L. Incarceration as a catalyst for worsening health. Health & Justice. 2013;1(1):3.
Colbert AM, Sekula LK, Zoucha R, et al. Health care needs of women immediately post-incarceration: a mixed methods study. Public Health Nurs. 2013;30(5):409-419.
Robert Wood Johnson Foundation. Mass Incarceration Threatens Health Equity in America. December 2018. https://www.rwjf.org/en/library/research/2019/01/mass-incarceration-threatens-health-equity-in-america.html Accessed September 5, 2022.
Brinkley-Rubinstein, L. Incarceration as a catalyst for worsening health. Health Justice 1, 3 (2013). https://doi.org/10.1186/2194-7899-1-3
Saneta deVuono-powell, Chris Schweidler, Alicia Walters, and Azadeh Zohrabi. Who Pays? The True Cost of Incarceration on Families. Oakland, CA: Ella Baker Center, Forward Together, Research Action Design, 2015

35 of 35

SEMINAL STUDY

Structural Vulnerability

14.5

15.1 // Community Violence

15.2 // Firearm Violence

Up next: