Stuckler D, Basu S, McKee M, King L. Mass incarceration can explain population increases in TB and multidrug-resistant TB in European and central Asian countries. Proceedings of the National Academy of Sciences. 2008; 105(36):13280–5.
Thomas JC, Torrone E. Incarceration as Forced Migration: Effects on Selected Community Health Outcomes. Prisons and Health. 2008; 98(9 Suppl): S181–4.
These two articles both describe detrimental effects of increasing incarceration rates on population health. The Stuckler article evaluated the effect of increasing rates of incarceration on tuberculosis (TB) in Eastern European and Central Asian countries. They found that each percentage rise in the sentencing rate was associated with a 0.34% increase in TB incidence. The sentencing rates rose 60% from 1991 to 2002 in the countries surveyed. The net effect of this increase, after controlling for multiple variables, was a 20% rise in TB incidence, which accounted for three-fifths of the total 35% increase in TB incidence during that time frame. The authors conclude that more than the absolute number of prisoners, the rate of prison growth is the largest determinant of TB infection.
The Thomas article examined the correlation between rates of incarceration and rates of sexually transmitted diseases (STDs) and teen pregnancies in North Carolina from 1995 to 2002. They found that even after controlling for age, race, and poverty, STDs and teen pregnancies consistently increased with rising incarceration rates. Most notably, a county with a prison population rate in the 75th percentile had a 32% increase in teen pregnancies when compared to a county with a prison population rate in the 25th percentile. The authors argue that high rates of incarceration destabilize communities. With men ten times as likely to be imprisoned, incarceration lowers the ratio of men to women which has been shown to increase rates of teen pregnancy, syphilis, and gonorrhea in other studies.
Commentary
As the USA continues to promote policies that lead to ever increasing mass incarceration, unintended consequences are inevitable. These papers highlight such effects, showing that expanding incarceration rates contribute to increasing rates of TB, sexually transmitted diseases, and teen pregnancies. These diseases are a tremendous public health concern not only for the individual inmates, but for the entire community. The findings of these studies are particularly concerning as the USA leads the world in rates of imprisonment, incarcerating 702 per 100,000 people. HIV will only augment this problem, as one in four of all Americans infected with HIV pass through a correctional facility each year. The implication of these studies has a racially disproportionate effect in the US where 60% of black males who drop out of high school have served time in jail, and at any given time 29% of black males aged 25 to 29 are incarcerated. Not surprisingly, in the USA blacks are eight times more likely than whites to be infected with TB and seven times as likely as whites to be infected with HIV. Until the policies promoting mass incarceration in the USA are revised and incarceration rates are reduced, we will continue to have the unintended consequences of destabilizing communities and increasing rates of infectious diseases.
Maru DS, Bruce RD, Basu S, Altice FL. Clinical Outcomes of Hepatitis C Treatment in a Prison Setting: Feasibility and Effectiveness for Challenging Treatment Populations. Clin Infect Dis. 2008; 47:952-961.
This study examined the efficacy of combination pegylated IFN and ribavirin (PEG-RBV) treatment for HCV among prisoners within the Connecticut Department of Corrections. More than one-third of all HCV infected Americans are said to pass through a correctional facility each year, yet the combination of cost, the necessity of long-term and closely monitored treatment, and the high rates of comorbidity with mental health and substance use disorders among inmates has hindered widespread treatment. This study analyzed data from 138 treatment-naïve HCV-infected inmates referred for treatment, 68 of whom were approved. Of the study population, 28% were co-infected with HIV and 75% were infected with genotype 1. Forty-seven percent of the patients achieved a sustained virological response (SVR). Based on multiple regression analyses of SVR, the only two factors that predicted not attaining SVR were the presence of genotype 1 with cirrhosis or major depressive disorder at baseline. These results were comparable to results from treatment within community settings. During the course of treatment, only four patients required hospitalization, and only two of those were for conditions related to treatment. The authors argue that this low hospitalization rate further demonstrates the safety of HCV treatment within prisons.
Commentary
With over 7,000 of the 22,000 individuals incarcerated in Connecticut infected with HCV, it is remarkable that only 138 were referred for possible treatment. Of course, most of these infected individuals are not aware of their infection. If they were made aware of their infection, told to avoid alcohol and transmission to others, and vaccinated against hepatitis A and B, it is likely that this relatively low-cost intervention would have a tremendous public health impact.
This article makes a substantial contribution in corroborating the findings of others that HCV treatment of prisoners is feasible and as effective and safe as treatment in the community “despite the high prevalence of alcohol and substance use disorders, high prevalence of psychiatric co-morbidities, and the large proportion of ethnic minorities.” Given that many of these patients would have not have received treatment in community settings because of these and other factors, this demonstration is crucial. This study also further supports the now well-known fact that treatment of HCV is effective and important among HIV-infected individuals, which is crucial as those co-infected individuals are much more likely to have their HCV disease progress.