The Case for Improving the Health of Ex-Prisoners

Abstract

The global prison population exceeds 10 million and continues to grow; more than 30 million people are released from custody annually. These individuals are disproportionately poor, disenfranchised, and chronically ill.

There are compelling, evidence-based arguments for improving health outcomes for ex-prisoners on human rights, public health, criminal justice, and economic grounds. These arguments stand in stark contrast to current policy and practice in most settings.

There is also a dearth of evidence to guide clinicians and policymakers on how best to care for this large and growing population during and after their transition from custody to community. Well-designed longitudinal studies, clinical trials, and burden of disease studies are pivotal to closing this evidence gap.

The world prison population is more than 10.75 million and is growing at a rate in excess of population growth.¹ Although in the United States there is a distinction between prisoners (felony offenders incarcerated in state and federal prisons) and jail detainees (mostly misdemeanor offenders), this distinction is not made in most countries. Here we use the term prisoner to refer to both prisoners and jail detainees. Because of the rapid turnover of custodial populations, it has been estimated that globally, more than 30 million people move through prisons each year.² Incarceration rates vary markedly within and between countries, and are heavily influenced by public policy decisions, such as the criminalization of drug users³ and the de-institutionalization of the mentally ill.⁴ The United States has the highest incarceration rate in the world (743 per 100 000 population) and accounts for more than one fifth of the world’s prisoners, with approximately 2.2 million people in custody on any one day.¹ Of these, 1.5 million are held in state and federal prisons, and spend on average three years in custody before returning to the community; more than 700 000 are held in local jails, where the average stay is less than seven days. Given the large incarcerated population and rapid turnover of jail detainees, in excess of 11 million persons pass through US correctional facilities each year—more than in any other country.^5–7

Prisoners globally are characterized by complex and multifaceted health problems.⁸ Although imprisonment confers its own unique health risks,^9,10 health usually improves in custody, where stable accommodation and regular meals are provided at little or no cost, illicit drugs are less readily available, and high-intensity health services are routinely provided.^11,12 Unfortunately, these health gains are often rapidly lost after return to the community, where many ex-prisoners experience poor health-related outcomes, including poorly controlled disease,¹³ elevated rates of life-threatening drug overdose,^14,15 preventable hospitalization,^16,17 and mortality.^18,19 Key to improving these outcomes is increased access to health care for ex-prisoners,²⁰ but this has proven difficult to achieve. Despite recent encouraging research findings,²¹ the greater challenge has been translating promising pilot programs into policy, at scale and in a sustainable way. Here we make the case for improving the health of ex-prisoners, in the hope that this will provide a platform for evidence-based advocacy to improve the health of this profoundly marginalized, challenging, and underserved population.

MAKING THE CASE

We believe that there are at least four compelling reasons to improve the health of ex-prisoners.

Human Rights and Equivalence

The United Nations Basic Principles for the Treatment of Prisoners make specific reference to health services for prisoners. According to Principle 9, “Prisoners shall have access to the health services available in the country without discrimination on the grounds of their legal situation.”²² This is sometimes referred to as the principle of equivalence, and given the disproportionate burden of disease among prisoners, health services for prisoners should be, and in some respects are, similarly disproportionate.²³ Unfortunately, this high intensity of care typically unravels as prisoners approach their release date, with transitional arrangements often ad hoc, underfunded, and of unknown effectiveness.²⁴ After return to the community, while health and social circumstances are rapidly declining,²⁵ access to health services is typically poor because of a combination of individual, social, structural, and economic factors. This situation is in stark contrast to Principle 10 of the Basic Principles, which states that

with the participation and help of the community and social institutions . . . favourable conditions shall be created for the reintegration of the ex-prisoner into society under the best possible conditions.²²

Therefore, there is a compelling human rights argument for improving the health of ex-prisoners, but at present, there is a stark contrast between the high intensity of health care in prison and the predictably poor health outcomes after release.

Prisoner Health Is Public Health

The prevalence of communicable diseases, including HIV, hepatitis C, tuberculosis, and sexually transmitted infections is greatly elevated in offending populations^26–28; prisons are increasingly recognized as presenting a pivotal opportunity to screen and initiate treatment of infected individuals.^28,29 However, even when treatment is provided in custody, release from custody often precipitates a breakdown in treatment adherence, increased infectivity, and an escalation of risky behaviors including unprotected sex and sharing of injecting equipment, which has a direct and measurable impact on the health of the broader community.³⁰ For example, among HIV-infected illicit drug users, recent incarceration has been associated with reduced adherence to antiretroviral therapy and virologic failure.^31,32 Release from incarceration has also been associated with HIV risk behaviors, including syringe sharing^33,34 and unprotected sex.³⁵ Given the high prevalence of communicable disease in prisoners, prisons therefore represent a public health opportunity. However, a corollary of this is that release from prison constitutes a public health risk, and proper management of this risk hinges on minimizing risk behavior and infectivity among those released. Findings from recent randomized controlled trials suggest that appropriately designed and implemented programs can reduce risk behavior³⁶ and increase treatment adherence³⁷ among recently released prisoners with infectious disease; however, scale-up of these and similar programs at a population level have been patchy at best.

Despite their relative youth, prisoners are also disproportionately affected by noncommunicable diseases, including hypertension and diabetes.^38–40 This elevated risk remains after adjustment for traditional risk factors, including socioeconomic disadvantage, obesity, and tobacco, alcohol, and illicit drug use.⁴¹ Similarly, the prevalence of mental illness is markedly elevated in prisoners^42,43 and is associated with impaired physical health.⁴⁴ After return to the community, these complex health problems become public health problems, and if poorly managed, can adversely impact the well-being of wider society.⁴⁵

The health status and health behaviors of ex-prisoners also have a direct impact on the health of another large and disadvantaged segment of the population: the families of prisoners and ex-prisoners.⁴⁶ Parental incarceration has been associated with a range of poor health-related, behavioral, economic, and criminal justice outcomes in children.^47–51 Incarceration also adversely affects intimate relationships, both directly through the transmission of infectious disease³⁰ and indirectly through the disintegration of emotional bonds.⁵²

The Argument for Public Safety

An emerging literature is beginning to document links between poor health outcomes in ex-prisoners and risk of recidivism. The association between substance use and recidivism is well documented,^53,54 and there is growing evidence that poorly treated mental illness can also increase the risk of offending, particularly in the context of co-occurring substance use disorders.^55,56 In the United States, two studies of people returning from jail to the community found that health insurance was protective against recidivism^20,57—a significant finding given the recent expansions to health coverage for former prisoners in the United States.⁵⁸ Improving the health of ex-prisoners may therefore have flow-on effects of reduced crime, although to date few studies have been able to examine this empirically; the limited evidence from trials has been equivocal.²⁴

The Economic Argument

There is emerging evidence that ex-prisoners underutilize preventive health care but are overrepresented in acute care settings (e.g., hospitals and emergency departments), often presenting with preventable or poorly managed conditions. One study from Western Australia followed a cohort of 7414 adults after release from custody and found that within one year of release, 20% had been hospitalized, at a total cost of AU$10.4 million. More than one third (37%) of bed days were the result of mental and behavioral disorders, and a further 22% were caused by injury and poisoning.¹⁶ Similarly, in a study of 110 419 Medicare beneficiaries released from a correctional facility in the United States from 2002 to 2010, the rate of hospitalization for acute conditions was significantly higher than among matched community controls, with approximately one in 12 former inmates hospitalized within 90 days of release.¹⁷

Other studies have estimated the costs of crime, incarceration, substance misuse, and mental illness in the population at large; the proportion of these costs attributable to ex-prisoners is unknown but likely to be substantial. There is an urgent need for health economic studies to estimate the avoidable economic costs associated with poor health outcomes in ex-prisoners, both directly through utilization of high-cost acute health services and indirectly through collateral costs (e.g., unemployment, crime) associated with poor health outcomes. To enable this, we strongly urge those undertaking evaluation studies in this area to include economic costs among their outcomes.

FUTURE DIRECTIONS

There is a growing literature documenting a range of adverse health outcomes in ex-prisoners, but important knowledge gaps remain. To further strengthen the case for improving the health of ex-prisoners, we urge researchers to consider the following:

1. Longitudinal and record linkage studies of individuals transitioning into and out of prison settings, including examination of the natural history of key health conditions to quantify the long-term health impacts (good and bad) of incarceration. In addition to studies of high-risk populations (e.g., HIV-infected prisoners), we urge our colleagues to consider whole-of-population studies and to measure a range of outcomes, including direct health and social outcomes, health service outcomes, offending outcomes, and economic outcomes.

2. Attempts to quantify the burden of disease in prisoners globally. The world prison population exceeds 10 million,¹ and it is estimated that more than 30 million adults move through prisons each year.² This large and unwell group is typically excluded from the population surveys that inform burden of disease estimates. A key limitation in this regard is the dearth of high-quality studies estimating the (prisoner) population prevalence of key health conditions and quantifying the health impact of incarceration on the individual, family, and community.

3. Rigorous evaluation of reentry interventions. Only a handful of reentry interventions globally have been subjected to rigorous evaluation, and some have produced null or even adverse findings. None has been implemented at a (prisoner) population level.^24,59 Rigorous evaluation studies in this field that focus on individual health, public health, public safety, and economic cost are challenging, but possible, and urgently required.

CONCLUSIONS

In a context in which human rights and criminal justice priorities often suggest conflicting courses of action, we have identified a rare alignment of human rights, public health, public safety, and economic imperatives. This is at odds with a remarkable inertia in the policy arena.^57,60 We have identified key areas for future research, but in addition to the continued pursuit of high-quality evidence to guide future decision-making, we encourage researchers and clinicians to engage in evidence-based advocacy for improving the health of ex-prisoners. We have offered some arguments that may assist in this endeavor.