In the United States, 1 in 35 adults have been incarcerated and 1 in 43 children have a parent who is currently in prison—each year, more than 650,000 people are released from prisons and more than 7 million individuals are released from jails in the United States. Consequently, as a health-care provider, you are more likely to care for a patient who has been incarcerated or a patient whose parent has a history of involvement with the criminal justice system than you are to care for a patient who has sickle cell disease, cystic fibrosis, or type 1 diabetes (Box 27-1). Yet, health-care providers receive little training about this vulnerable population. Individuals who have been incarcerated disproportionately suffer from chronic illness, live in poverty, and face social marginalization—all of which are risk factors for and result from incarceration. The consequences of incarceration reverberate into patients’ families and neighborhoods, impacting community health and well-being.

This chapter highlights the global prevalence of incarceration and the demographics and health disparities of individuals with a history of incarceration. Additionally, it discusses how criminal justice system involvement can confer vulnerability to an already at-risk population through inadequate medical care and suboptimal living conditions in prisons, barriers to health-care access upon release, and the collateral consequences arising from marginalization of those with a criminal record. Finally, it presents evidence-based interventions to reduce the health impacts of incarceration, and decreases risk of recidivism upon release.

Between 1972 and 2002, the number of adults in US prisons rose by 705%. This rapid increase in the incarceration rate reflects several social and political shifts that began in the 1970s. In 1971, US President Nixon declared a “War on Drugs.” Criminalization of drug offenses was followed by four decades of stricter sentencing and release laws, longer sentences, and court precedents that allowed for more liberal police searches of individuals for contraband (e.g., “stop and frisk”). Concurrently, individuals with mental illness were transferred from permanent psychiatric facilities to community-based mental health programs, debatably resulting in “trans-institutionalization,” or the incarceration of people with mental illness.¹ Notably, rising incarceration rates have not paralleled crime rates. Overall and serious crime rates have declined since 1991, yet incarceration rates increased in the United States until 2009, when many states instituted policies for early release and jail diversion options to nonviolent offenders² that have been shown to reduce costs and re-offense rates more effectively than locking people up.³

Similar patterns of criminalization of drug offenses, increased sentencing duration, urbanization, and growth in incarceration have been noted across the globe. Between 2008 and 2011, 78% of countries saw their prison population grow. The global incarceration rate is outpacing the population growth rate by 5–10%,⁴ and this has significant social impacts on groups that are disproportionately affected by incarceration.

An estimated 10.2 million individuals are held in correctional facilities worldwide, and of these, 2.24 million are detained in the United States. Thirty million people pass through a correctional facility each year with greater than one-third of these being in the United States alone. The United States has the highest prison population rate in the world, 716 per 100,000 people, significantly more than similarly developed countries in Western Europe, such as the United Kingdom (148) and France (98), and even more than Russia (475) and China (121). In more practical terms, in the United States, 1 in 100 adults are presently in jail or prison, and 1 in 45 are on parole, probation, or supervised release.⁵

Globally, most prisoners are young men. Although 95.5% of those in jail or prison are male, the population of women, ranging on average from 2% to 9% of the total incarcerated population, is increasing at a faster rate. Also, prisoners tend to be young. The average age of prisoners in Europe and the United States is in the early 30s. Of note, the number of older prisoners (older than 55 years) in the United States⁶ doubled between 1999 and 2012. At the other end of the spectrum, juveniles (younger than 19 years) account for 5% of the prison population in developed countries.⁷ Juvenile incarceration is the single greatest predictor of recidivating to prison as an adult.

Inmates have low educational attainment and frequently face unemployment and homelessness. In the United States, 68% have no high school degree, and 31–40% scored in the lowest level of literacy on the National Adult Literacy Survey. Prior to incarceration, 28% of US prisoners were unemployed compared with the national rate of 5%. Over half of US prisoners made less than $1000 per month prior to incarceration, and 11% were homeless during the year prior to incarceration. Incarceration is estimated to decrease lifetime earnings by 40%, largely due to an absence of educational and professional development while in prison.⁸

There are large racial disparities in incarceration rates. In the United States, 1 in 17 white men, 1 in 6 Latino men, and 1 in 3 African-American men will have been incarcerated in their lifetimes. Similarly in England and Wales, black people are seven times more likely to be searched by police, and five times more likely to be incarcerated, than white people. Criminal justice involvement is not only highly prevalent but also is more likely to affect racial and ethnic minorities, the poor, and the undereducated, magnifying socioeconomic and health disparities in these groups.

RIGHT TO HEALTH CARE IN PRISONS

Following the atrocities that prisoners suffered during World War II, the United Nations adopted the Standard Minimum for the Treatment of Prisoners, which lays out basic legal and medical rights. In 1990, the United Nations recommended that prisoners “have access to health services available in the country.” The US Supreme Court decision, Estelle v. Gamble (1976), in advance of the recommendation, already guaranteed a constitutional right to health care in prisons. These precedents have interesting implications for prisoner health care. First, incarcerated individuals may have guaranteed access to care in countries, including the United States, where there is no universal mandate for health care. Second, because these mandates require equivalence of care, prisoners, who often have greater medical needs than community members, may actually need greater health care than that provided. Prisons have long been thought of as unique settings for screening, treatment, and prevention of communicable diseases in “hard-to-reach” and high-risk populations.⁹ Screening and treatment of prisoners for both communicable and noncommunicable diseases (NCDs) may have a positive effect not only on the health of the individuals but on the health of their families and communities as well, thereby constituting an investment in general public health.

HEALTH PROMOTION IN PRISONS

Providing universal and equivalent health care for prisoners is not just a human rights issue, but many scholars point out that it is also a matter of public health. The prevalence of many conditions is greater in prisoners than in the general population and other high-risk groups. Therefore, in jail settings, where the average length of stay is 48 hours, prompt screening and treatment of infectious diseases directly prevents transmission in communities. Prisons, on the other hand, where longer stays are the norm, offer opportunities for continuity of care, initiation of long-term therapeutic regimens, substance use and mental health treatment, and screening and lifestyle factor modification to prevent NCDs. Settings-based approaches that not only focus on medical care provision but also create an environment that fosters wellness, through opportunities for fitness, nutrition, and peer education, have been advocated and applied largely in the United Kingdom. The goal of these health promoting prisons is to improve “health resilience” of individuals with a history of incarceration by reducing health disparities and recidivism risk.⁶ The success of these programs may be limited by the inherent differences between the roles of the health-care system, to promote health, and correctional system, to punish or promote security.

CHALLENGES TO HEALTH-CARE DELIVERY IN PRISONS

In addition to the ideological incongruence between the health care and correctional missions, there are many barriers to providing quality care to inmates. While organizations, such as the World Health Organization (WHO) and National Commission on Correctional Health Care, disseminate recommendations for health-care provision in prisons, no organizations are tasked with evaluation or enforcement, and as a result, these recommendations can go unimplemented.

At an institutional level, cost of care, access to medical specialists, distance to medical facilities, and sheer patient volume limit care delivery. In the United States, health care accounts for 20% of the overall prison budget, and this share is growing with an aging prison population.⁶ These older prisoners have more complex medical needs that may require specialists at an outside hospital or clinic. The cost of transportation to and from these facilities, as well as providing security escorts, can also be substantial.⁶ These issues are compounded by high incarceration rates, which contribute to patient volumes that overwhelm the capacity of medical staff and facilities and to long wait times for medical care.

At the individual level, short stays in jails and confidentiality concerns can thwart effective care provision. Many jail detainees are held for a few days until they can post bail. Thus, inmates who are screened and/or diagnosed may be released prior to treatment being initiated or completed. Confidentiality is difficult to achieve in correctional settings, and fear that other prisoners and correctional officers may find out about medical conditions may prompt a prisoner to refuse screening or treatment for known infectious or chronic conditions.

Several studies have corroborated that management of chronic conditions is improved in correctional facilities and mortality rates for African-American men due to chronic disease are lower in prison than in the community.^10,11 Researchers have posited that stable housing, adequate nutrition, guaranteed access to care, and decreased access to alcohol and illicit substances contribute to these gains.¹⁰ These studies suggest that enhanced access to care and the salutatory environment in prison have the potential to reduce health disparities.

The health status of incarcerated individuals is complicated by the same risk factors that may have contributed to their being incarcerated in the first place—addiction, mental illness, poverty, low educational attainment, and racial and sexual discrimination. High rates of injection drug use (IDU) and risky sexual behaviors strongly predispose incarcerated individuals to HIV, HCV, and sexually transmitted infections (STIs). However, studies have demonstrated that incarceration is an independent risk factor for disease, suggesting that the correctional setting may directly promote disease.^12,13 Correctional settings also influence the risk of disease in more nuanced ways, through a process of social marginalization, disruption of social networks via “forced migration” in and out of prisons, and decreased choice in care and other health-promoting resources.

COMMUNICABLE DISEASES

HIV/AIDS

Globally, prisoners, especially female prisoners, are much more likely to be infected with HIV as compared with those without a history of incarceration.¹⁴ Accessible, low-cost antiretroviral therapy (ART) in the community and prisons has decreased the burden and mortality associated with HIV in correctional settings.¹⁵ In the United States, between 1992 and 2008, rates of HIV+ prisoners decreased from 2.5% to 1.5% and AIDS-associated mortality decreased from 34.2% to 4.6%.^7,16

Despite the gains in HIV-associated outcomes, several key issues undermine the implementation of HIV care in correctional settings. Discharge practices for HIV care vary substantially by region and correctional setting in the United States.¹⁷ Evidence suggests that even when inmates are released with prescriptions for ART, few actually fill these prescriptions in time to avoid treatment interruption.¹⁸ Discontinuity in care likely contributes to high rates of resistance and poor viral suppression in individuals with a history of incarceration, and these outcomes are magnified by recidivism. In a Canadian study of HIV+ IDUs, the number of incarceration events predicted poor adherence to ARTs in a dose-dependent fashion.¹⁹ Interventions to improve discharge planning and transitional care for inmates with HIV will be discussed at the end of this chapter.

Hepatitis B and C

Hepatitis B and C infections represent a growing epidemic in incarcerated populations. Chronic Hepatitis B virus (HBV) infection is 7.4, 4, and 50 times higher in prisoners in the United States, the Netherlands, and Brazil than in the overall populations.²⁰ In light of these marked disparities, the WHO and Centers for Disease Control and Prevention (CDC) recommend universal hepatitis B vaccination for unvaccinated individuals in prisons.

The burden of HCV infection is even greater, with a prevalence of 30–40% in prisoners worldwide. It is estimated that one in three individuals with chronic HCV in the United States pass through a correctional facility each year and that 12–35% of US inmates have chronic HCV. Although the CDC recommends opt-out screening (screening everyone, except those that decline) for HCV in prisoners born between 1945 and 1965, many experts, citing incarceration itself as a high risk, recommend universal opt-out screening as more efficient and potentially cost-effective.²¹

Two major limitations to initiating HCV treatment in prisoners are the cost of therapy and duration of incarceration. To initiate treatment, one study stipulated that inmates stay in prison for the duration of treatment (up to 15 months), defer parole, and accept transfer to a 24-hour nursing facility. Despite these additional criteria and the high rates of psychiatric and HIV comorbidity, 49% of prisoners met eligibility criteria, 61% completed treatment, and 47% of those who initiated treatment had a sustained virologic response.²² HCV treatment initiation in prisons is complicated, yet feasible; expensive with the potential to be cost-effective; and has the potential to shrink the burden of HCV in incarcerated individuals.²¹ Newer treatments for HCV could simplify the logistics for treatment and provide great health benefits but, at current prices, would overwhelm correctional budgets.²³

Sexually Transmitted Infections

High-risk sexual behaviors, sexual victimization, poverty, and substance use likely influence STI risk in prisoners. Rates of chlamydia, gonorrhea, and syphilis are much greater in prisoners than in the community or other high-risk settings, although comparisons are difficult owing to the absence of universal screening in the general population. Globally, women and juveniles have higher rates of STIs, with estimates in incarcerated juveniles of 2–10 times higher than peers in the community.⁷ The CDC recommends universal screening for syphilis, gonorrhea, and chlamydia in jails and prisons, yet these practices have not been universally adopted. In areas where screening and treatment have been adopted in local jail populations, prevalence of STIs in the surrounding community has been shown to decline, revealing the interconnections between jail populations and their surrounding communities and offering one perspective of prison health care as a public health opportunity.²⁴

Tuberculosis

Common risk factors for TB—homelessness, poor nutrition, IDU, HIV, and poor access to health care—track those of incarceration and contribute to rates of TB in prisoners that are 18 and 33 times greater than in the populations of high and low-to-middle income countries, respectively.²⁵ Coinfection with HIV, estimated at 13.2% in prisons, has contributed to an international resurgence in TB rates.²⁶ A study of incarceration growth and rising TB incidence in Eastern Europe and Central Asia demonstrated that mass incarceration magnifies community TB transmission.²⁷

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The Hidden Poor: Care of the Older Adult The Family as the Context for Care Community Engagement and Partnership Health-Care Disparities: An Overview Dental Care: The Forgotten Need Trauma and Trauma-Informed Care

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