Public Health Implications of Substandard Correctional Health Care

Abstract

US citizens face a growing threat of contracting communicable diseases owing to the high recidivism rate in state and federal prisons, poor screening and treatment of prisoners, and inferior follow-up health care upon their release.

Insufficient education about communicable diseases—for prisoners and citizens alike—and other problems, such as prejudice against prisoners, escalating costs, and an unreliable correctional health care delivery system for inmates, all contribute to a public health problem that requires careful examination and correction for the protection of everyone involved.

“The United States has the highest incarceration rate in the developed world.”1 Many enter prisons on relatively short sentences. Others are trapped in the revolving door of recidivism.

Prisons are surrounded by large loops of razor wire atop impenetrable walls and secured inside by lock upon lock; heavy doors slam shut, securing criminals from the surrounding community. But prisons are open, not closed, societies. People come and go: administrators, staff, guards, inmates. And according to a Department of Justice report, entering prisoners bring with them “infectious diseases from impoverished home environments that are breeding grounds for HIV/AIDS, hepatitis C, and tuberculosis, the three most prevalent communicable diseases in America’s prisons today.”2

Owing to crowded conditions, prisoners pass on their infections to other prisoners, staff, and their own friends and families who visit them. Or they contract communicable diseases themselves and slip through shoddy screening and substandard treatment programs. Left untreated inside prison, inmates eventually leave, usually returning to the communities in which they were sentenced. Back home, they risk infecting families, friends, and—if they engage in violent crime—complete strangers.

The public health implications of substandard health care in our nation’s prisons continue to grow as correction institutions, educators, and community leaders fail to properly address health care issues involving prisoners. Prejudice plays a key role in erecting barriers that prevent prisoners from receiving the same quality of health care that is afforded to free members of society. Politicians, with their “lock ’em up and throw away the key” attitudes, further exacerbate the problem.

PRISONER PROFILE

Most of America’s 2 million or more prisoners are male, aged between 18 and 44 years, and deprived of the educational and employment advantages enjoyed by the general population. They come from predominantly minority and migrant communities, living on the margins of social existence, where there is the highest risk for disease and infection and the least opportunity for early diagnosis and proper treatment.3

Prisons are microcosms of society in the free world. They are filled with people who are there for having victimized others and who are themselves often victims of racism and poverty.4

Statistics

In 2000, the United States incarcerated 2071686 individuals, or 478 per 100000 US residents.5 The number of male inmates has increased by 77% since 1990, and the number of female inmates has increased by 108% during the same time. Most alarming is the fact that nearly 600000 inmates are released each year, many with communicable diseases.5

Eighty-four percent of new prison admissions in 2000 were for nonviolent crimes, typically for drug abuse.4 Contrary to the common public perception, most inmates are not hardened criminals. They come from the underbelly of society, where drug and alcohol abuse runs rampant. These nonviolent prisoners lack direction and, given the chance, could become productive citizens instead of wasting space in prison.

According to Bureau of Justice statistics, 24000 inmates nationwide were HIV positive in 1996, but more recent studies suggest the number is as high as 47000, a rate 10 times higher than among nonprisoners.6 One in 4 inmates is infected with tuberculosis (TB), compared with less than 1 per 10000 in the general population; hepatitis C infects more than 41% of California inmates alone, compared with less than 2% of the state’s general population.6

Living Conditions

Since the end of 2000, state and federal prisons have operated at full capacity or significantly above capacity. Crowded or overcrowded state prisons can be optimum breeding grounds for infectious diseases. The practice of “double celling”—doubling the standard number of inmates to a cell—puts inmates at risk through the use of shared razor blades for shaving. One of the greatest threats to good health comes through consensual and noncon-sensual sex, including anal sex, which is common in prisons.7

Rights

There is a general misconception that when a person commits a crime and goes to prison, he or she surrenders all rights. In fact, while being held in custody, judged, and sentenced, the individual maintains certain rights—to be protected, to be represented by legal counsel, and to have access to health care services.3

Prisoners who arrive at a prison in ill health are often released by the courts to allow the jail to avoid incurring medical costs. A corrections officer then takes them to the community general hospital; after treatment there, they are rearrested.8

The general public, including correctional staff and health care professionals, tend to view prisoners as subhuman, as those who have surrendered their rights by being convicted of crimes. This mentality, fueled by political rhetoric, leads to the erection of barriers that affect the delivery of health care to prisoners.9

Ethical and Legal Considerations

Doctors, who take the Hippocratic Oath upon graduating from medical school, vow to use all measures required for the benefit of the sick. Those who take the classical version of the oath repeat, “Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice.”10

The negative view of prisoners adopted by the public and by health care professionals ignores the spiritual laws of compassion, forgiveness, reconciliation, and responsibility. The price of this attitude has been an endless recycling of crime and violence, all stemming from hatred. Teens, especially, are affected by this attitude. The effects can be felt across the board—teen murders have doubled and murders of children by children have increased. At the same time, the general population’s attitudes are also being skewed: people of all ages have grown comfortable celebrating the executions of criminals.11

From a legal perspective, incarcerating nonviolent offenders for having used illegal drugs has been a hotly debated issue for years. Many people consider drug abuse a public health problem, not a criminal offense. In most cases, drug abuse does not lead to violent criminal activity, yet some nonviolent offenders learn violence as a way of life in prison, further endangering the public upon their release.6

COMMUNICABLE DISEASES

The alarming prevalence of communicable diseases like hepatitis C, TB, and HIV/AIDS among prisoners poses a serious public health problem. Overcrowded conditions and poor health education in prisons, as well as weak community-based public health programs for infected people, exacerbate the problem. Also, since condoms and bleach are illegal in prisons, many inmates who are victims of rape or engage in consensual sex are at risk of transmitting diseases in prison and after they are released back to their communities.

Even those with short-term sentences can become infected in prison with a communicable disease, which can mean a virtual death sentence. The links between intravenous drug use, hepatitis C and HIV/AIDS, and incarceration help explain the rise in infectious diseases in our nation’s prisons.7

Hepatitis C

The Association of State and Territorial Health Officials reported in 2000 that “an estimated 1.4 million HepC [hepatitis C]-infected people pass through the US correctional system each year.”8 Today, 20% to 40% of prison inmates are infected with hepatitis C, a rate due in large part to the prevalence of injected drugs in prison. Released prisoners spread the infection in the community through sex, blood transfusions, needle sharing, and street fighting.8

As Phyllis Beck, director of the Hepatitis C Awareness Project and cofounder of the Hepatitis C Prison Coalition, reports, “all of the risk factors [of hepatitis C] multiply exponentially when they are confined to a small space with crowded conditions such as a prison.” She adds, “In essence, our state prisons have become a state-sponsored incubator for HepC, by default.”7

Tuberculosis

TB has seen a rapid rise in recent years in state and federal prisons, owing in part to inadequate screening on admission and poor treatment if TB is diagnosed. Because TB is an airborne disease, it thrives among people who live in close quarters with poor ventilation. Prisons offer the optimum environment for the growth of TB.

Controlling TB requires a joint effort on the part of health care professionals to diagnose the disease, isolate infected individuals, give proper medical treatment, track reactivation of the disease, and educate both prisoners and the general population.

TB spreads from prisons to the outside community through releases, prison transfers, and regular contact between prisoners and prison staff and visitors. The impact on the community can be considerable.12 For example, in one Arkansas community, 800 males aged 16 to 61 years were diagnosed with TB between 1972 and 1977; 9.6% had spent time in prison.13 The incidence in Arkansas today has increased considerably.

HIV/AIDS

When the HIV/AIDS epidemic peaked in the 1980s, there was an explosion of cases in US prisons. The prison health care system reacted slowly, but it eventually developed treatment programs for HIV-infected inmates. The problem now, however, is inconsistency in administering these programs and in helping prisoners overcome the stigma attached to HIV. To receive medications, prisoners must wait in long lines. Medications for treating HIV are uniquely packaged, allowing other prisoners to identify them and their recipients. These conditions make many prisoners reluctant to request diagnostic tests and receive needed treatment.4

Public Health Concerns

Prison screening programs and treatment initiatives are inadequate and inconsistent. Prisoners are sometimes not notified that they have an infection. When they are released, they become free carriers of the infection. Because prisoners constantly come in contact with other prisoners, staff, guards, health care professionals, and the general public through visits, the rampant spread of communicable diseases throughout the nation’s prisons affects society as a whole.

PRISON HEALTH CARE DELIVERY

Many of the problems in prison health care delivery stem from myths about prisoner patients. Concern about violent behavior may cause health care professionals to use excessive force, such as shackling hospitalized prisoners to beds. Such activity perpetuates the notion that all prisoners are violent.

In an attempt to remedy the delivery of health care, many states have retained private health care providers or correctional health maintenance organizations (HMOs), such as Correctional Medical Services (CMS), purportedly to save the state money. While CMS is the nation’s largest provider of prison medicine, it is also the cheapest. Unlike conventional HMOs, however, which risk malpractice suits, CMS and similar companies have little reason to protect themselves because juries are reluctant to decide on behalf of convicts or award them damages.

Health Care Professionals

The husband of Josephine Williams has been incarcerated in an Indiana prison for 33 years. He currently suffers from a number of serious medical problems. In an interview with the author, Mrs Williams described the shoddy treatment given to her husband and to other inmates at the prison.

In one episode, a friend of her husband suffered chest pains while on the job. He went to the infirmary and, after waiting a long time, was given an aspirin and told to return to work. A while later, weakened by progressively greater chest pains, he was assisted to the infirmary by another inmate. He was told to get on a gurney and wait. He waited for an hour, until he died, completely unattended.

The primary barrier to health care that prisoners face is being seen by a prison physician. They must fill out a form and then wait for approval. Even then they cannot be assured of seeing a physician. Some states require that a prisoner must be able to afford the copayment portion of the care received. If a prisoner arrives at the clinic after it closes, he or she must wait for another appointment. A long wait to see a doctor could mean time lost from work; in some state prison systems, every missed day of work adds another day to the prisoner’s sentence.

Prison nurses in Illinois have voiced concerns over a variety of problems in 19 correctional facilities, including deteriorating care, lack of medical supplies, and weak accountability from state officials and contractors. In short, the health of Illinois prison inmates has been sacrificed to boost the profits of private companies administering health care.4

Ethical and Legal Questions

Doctors and nurses working in jails and prisons face ethical conflicts that are unfamiliar in a community context. Prisons are designed primarily to carry out court instructions and protect society from those who have committed crimes. Reformation is secondary to detention. Although prisons are not normal health care settings, prisoners undeniably have health care needs that must be addressed.

Although Skubel v Fuoroli, as detailed by Wing,14 pertained to home nursing services, he states that there is a “consensus among health care professionals that community access is not only possible but desirable for disabled individuals.” Prisoners, by virtue of their incarceration and high risk for contracting infectious diseases, should be considered disabled and therefore have access to health care, just as do all members of society.

SUMMARY

Two million men and women are incarcerated in US prisons. Many contract chronic, life-threatening contagious diseases while in prison. The impoverished environments of prisons are breeding grounds for hepatitis C, TB, and HIV/AIDS; drug abuse; and violence. If these diseases go undetected in prison, people emerge infected. The “diseases” flourish and spread in the outside communities, becoming epidemics affecting the general population. Society pays the price, in the high cost of both private health care providers—who often fail to deliver adequate care—and of public health care for released inmates receiving treatment and for their families and friends who become infected and cannot afford private care.

If society is to diminish the risk of contracting infectious diseases from prisoners, it must insist on education, preventive measures, proper screening and treatment, continuity of care, and accountability on the part of those agencies and officials in charge of prisoners in jails, state prisons, and federal correctional facilities.