Incarceration Medicine: Problems and Potential
As the incarcerated population in America continues to rise, parts of the incarcerated healthcare system continue to fail to provide consistent, basic care. But because this system touches so many lives, it has the potential to do a great deal of good. The incarceration healthcare system can use its reach to screen for and treat common diseases such as Hepatitis, tuberculosis and HIV in individuals who would have never accessed the healthcare system on their own. It could also help them register for and access the Medicaid system for healthcare while incarcerated as well as after they leave the justice system. Finally, it can provide health education and literacy to help the incarcerated manage their health for the rest of their lives. These interventions, both big and small, require a commitment and a sincere interest in those working with the justice system. This is perhaps the biggest determinant to the success or failure of correctional system healthcare. But for those willing to make that commitment, they will be able to affect positive change for the lives of incarcerated persons.
Over the past 40 years, the number of incarcerated individuals has increased by 600% in the United States, which now has the highest rate of imprisonment in the world. 1 Unfortunately, this population has historically had significantly worse health outcome both before being incarcerated and after release.2 While inmates suffer all of the same health problems of the general population, they additionally shoulder a heavier disease burden of both infectious illnesses, like hepatitis B and C, HIV and tuberculosis, and non-infectious diseases such as coronary artery disease, diabetes, and asthma.1,3.4 This makes correctional facilitates an ideal place for public health initiatives. It may seem odd to talk about prisons as a potential public health boon, as these facilities have become infamous for providing inconsistent access to basic health care.5 But by taking advantage of the time and resources available to correctional facilities, we can better equip those involved in the justice system to take charge of their health.
Each year, 33% of all hepatitis C infected persons pass through the correctional system, as do 25% of HIV-positive Americans and 40% of active tuberculosis cases.1 Many of these individuals were not previously aware of their disease.6 This disproportional health burden comes in part due to the risky behaviors that this demographic statistically participates in, from getting tattoos to using needle-based drugs.7 It can then also spread within prisons through unprotected sex and the continued sharing of needles.7
All new inmates go through a health screening when entering the national prison system, as do many, but not all, those who are jailed for shorter periods.6 In light of this, the Center for Disease Control (CDC) recommends that all jails and prisons conduct opt out HIV testing during these screening.6 But only 19% of the prison systems and 35% of the jails currently do.6 Where these tests have been implemented, they have seen an effect. In Atlanta, GA, a county jail system enacted rapid test HIV kits.6 Even though most of the county’s inmates do not stay long enough to begin treatment, they reported that those individuals with positive rapid tests were more likely to give authorities their real address for follow-up.6 Unfortunately, diagnosing HIV in a long-term prison setting does no good if it is not treated. In Rhode Island jails, it was found that two-thirds of newly diagnosed inmates learned of their positive confirmatory test results while detained, but only 9% began antiretroviral therapy before their release due to delays in filling prescriptions and lack of financial resources.6
While finding the finances to pay for these interventions might be difficult in America, there could be an easy fix. In Norway, prisons are able to provide top of the line health care by billing the national healthcare system for medications and services.8 In the United States, 90% of states choose to terminate Medicaid benefits when an individual enters the justice system because Medicaid benefits cannot be accessed by jails and prisons.5 This applies not only to sentenced inmates, but also those awaiting trial.5 By making use of a system that is already in place, the jail or prison would not have to pay for medical serivces.8 If Medicaid could be billed and utilized in the United States, like it is in Norway, it might provide some much needed financial support and oversight of the prison medical system. But in order to do this, the Medicaid Federal law would have to be changed. While this is possible, it would take time and effort on a national scale.
Maintaining healthcare benefits helps newly released inmates as well. Upon release, there is a minimum 45-day delay in resuming benefits of Medicaid after reenrolling.9 This lag time is not benign. Former inmates have a 12-fold increased risk of death in the first 2 weeks after release, with the leading causes of death being drug overdose, cardiovascular disease, homicide, and suicide.10 This is attributed to the increased stress that comes from reintegration, and the significantly lower drug tolerance that many former inmates develop from drug abstinence in prison.10 Even if a former inmate intends to continue to abstain from drugs when released, being back in a drug filled environment, paired with the stress of reintegration, can be enough to cause someone to start using again.10 Having Medicaid at the time of release is a notable advantage, increasing access to and utilization of services, leading to decreased drug use and re-incarceration.5
Changing the way that correctional facilities pay for health care is not going to happen overnight. In the meantime, there may be easier interventions: providing prisoners ways to reduce risks and improve health literacy. One example: providing condoms. In an interview, Catherine Hanssens, executive director of the Center for HIV Law and Policy, states that “The notion that we’re going to lock up young people… and expect that there will absolutely be no sexual expression—it’s this wild ‘emperor with no clothes’ thing that we always do around sex.”6 Since we know that diseases like HIV, Hep B and Hep C all are spread through sexual contact, and that all of them can be prevented through the use of condoms, it makes sense to provide access to them. Additionally, making condoms widely available is a relatively cheaper alternative to treating newly developed disease in prison.6 Other relatively easy interventions include hepatitis A and hepatitis B vaccination programs, needle exchange programs, methadone maintenance programs, risk education programs, and hepatitis C virus antiviral programs.7 These small interventions have the potential to save individuals from developing chronic diseases and ultimately save lives.
Additionally, basic health literacy programs in correctional facilities can make a world of difference. In surveys of female inmates, participants frequently said they felt that they lacked basic health care knowledge, such as how to do a self-breast exam or what foods were considered healthy.11 Health literacy and understanding modifiable risk factors for common diseases, which many people take for granted, can dramatically increase the life expectancy of inmates once they leave the justice system. To address this gap in knowledge, students at Rush University visit a local women’s prison monthly to teach classes on various health care topics. The hope is that these women can use this knowledge not only to take control of their own health, but also to help educate others in their community when they leave the justice system. Through this volunteer work, students are able to work towards closing the gap in life expectancy that these individuals and their community face.
These interventions, both big and small, require a commitment and a sincere interest in those working with the justice system. This is perhaps the biggest determinant to the success or failure of correctional system healthcare. There is a long way to go before the justice system can use its unique position and demographics to make a positive difference in the healthcare world. But with dedication of its staff to preventing, testing for and treating diseases, and with resources to lessen the burden of healthcare, medicine in these environments has huge potential to help those who really need it.
Acknowledgments: I would like to thank Dr. Cynthia Boyd, my capstone mentor and Rush University for providing the education and resources that made this possible.
Other Disclosures: None
Previous Presentations: None
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