Introduction to Public Health and Incarceration: Social Justice Matters

Overview

Providing health care in jails, prisons, half-way houses, and community-supervised correctional programs, correctional facilities, and community systems has a direct effect on health outcomes of incarcerated populations. Moreover, effective linkages to a myriad of services upon release and assistance with community reintegration are key components for reducing recidivism. In an effort to highlight some of the disparity issues and challenges in corrections, we offer this issue, titled, Public Health and Incarceration: Social Justice Matters.

In 2012, U.S. state prison systems, comprising 50 independent entities, incarcerated over 1.3 million people, of whom a disproportionate share were minorities, primarily African Americans and Hispanics.¹ Despite recent reports that 2012 marked a decrease in the number of imprisonments of males and females, the U.S. continues to lead the world in incarceration of its residents. The reported decrease in incarceration may be attributed to alternative sentences, such as probation, which maintains individuals under correctional supervision. Mass incarceration disrupts families and affects health status and the quality of life within families. Prisoners are more likely than the general population to have chronic health conditions and infectious diseases. In 2012, 43.9% of offenders reported a chronic condition, relative to 31.0% of the general population; 21.0% of offenders had had an infectious disease, relative to 4.8% of the general population. The disparities in mental health and substance abuse are equally troubling.² These health risks are not proportionately distributed across populations.

African American males have an imprisonment rate of 2,841 per 100,000; Hispanic males have a rate of 1,158 per 100,000; and White males have a rate of 463 per 100,000. There are similar disparities for African American and Hispanic females relative to Whites.¹ Although some of the health problems experienced by offenders are addressed during their incarceration, many are not addressed upon their release, which poses serious health risks for the former offenders and for the local communities to which they return. Health problems of former offenders become those of the local community, where there may be little knowledge and discussion related to the intersections of corrections, public health, and reentry for this subset of a vulnerable population. This special issue of the JHCPU—with a focus on disparities related to racial and ethnic minorities, reentry, and public health—explores innovative research, services, and programs that deal with the health of the offender population.

The social justice system is burdened with imperfections deleterious to health equity. The system disproportionately lessens the life opportunities of African Americans, Latinos, and other disadvantaged ethnic minority groups. Eliminating such imperfections is a formidable task, but nevertheless one that must be accomplished if the nation is to achieve true health equity. The articles in this issue of the JHCPU report on strategies for change.

In the commentary by Ferguson, et al., a strong case is made that systems change is the “order of the day”; this case is eloquently presented as a “Call for Action.” While there have been many other such appeals, this call offers recommendations for clinical practice, criminal justice studies, health science institutions, and communities. Much like the compelling call for action in Michelle Alexander’s book, The New Jim Crow: Mass Incarceration in the Age of Colorblindness, a stage is set for sector stakeholders to move in a new direction, one involving sector accountability without compromise. We must change the mass incarceration practices and eliminate their catastrophic effects on racial and ethnic minorities, in the U.S.

In the manuscript by Coughlin, Lewis, and Smith, developments in ethics in the context of the racial/ethnic disparities that exist in corrections, are discussed. Ethical considerations in clinical and public health research on HIV in prison and jail settings are considered. Factors in mental health research are summarized, along with issues pertaining to research involving female inmates. The ethics of research involving incarcerated people extends beyond traditional ethical concerns related to human subjects to include issues in the domains of bioethics and public health ethics. Tamburello and Ferguson present a commentary on marginalized individuals diagnosed with mental health conditions and the medication-prescribing practices in correctional facilities.

Several articles in this issue concern incarcerated women specifically. Mahaffey et al. highlight the disproportionate numbers of imprisoned Black women, relative to other women, and survey psychological determinants of health by reviewing findings from 19 studies. In the literature review, mental health, sexual behavior, and dysfunctional negative relationships are addressed. The Robillard et al. article is qualitative and explores the relationships among incarcerated mothers, their children, and their children’s caregivers from the point of view of the children and the caregivers. This article bears on the important and widely ignored issue of the negative effect of the large and increasing number of women in prison who leave children behind. The caregivers for these adolescent children of incarcerated mothers become primary supporters by providing all forms of guidance (sexual risk behavior, substance use, delinquency) for these left-behind children. The nature and tone of such guidance should be considered in assisting these youth to feel connected to the larger community and the world. Oser and colleagues employ the Gelberg-Andersen Behavioral model for vulnerable populations to predict African American women’s use of traditional and alternative health systems during an 18-month post-release period. They report that use of alternative health services were predicted by ethnic community membership, higher religiosity, and HIV/hepatitis C (HCV) infections. Hospitalizations were predicted by the lack of barriers to health care and lack of disability. Ambulatory office visits were predicted by more experiences of gender-based racism, greater numbers of physical health problems, and HIV/HCV infections. These findings highlight the importance of cultural factors and HIV/HCV in obtaining both alternative and formal care during community re-entry. They advance the idea that clinicians and policymakers should consider the salient function of the vulnerable domain in offender’s accessing health services. Noska and colleagues look at a history of sex exchange among women with a history of incarceration and discuss factors associated with sex exchange among a sample of incarcerated women. Of 257 women surveyed, 68 (26.5%) reported a history of sex exchange. In multivariate logistic regression analyses, a history of physical abuse (p=.05, OR 2.20), a history of two or more sexually transmitted infections (p=.01, or 2.90), use of intrauterine devices (p=.04 or 2.46), and use of crack-cocaine (p<.01, OR 3.42) were associated with prior sex exchange.

The Wallace et al. study employed a mixed-methods design to assess health risks at community re-entry. They examined perceived health status and health care utilization among recently released Black men of ages 18–25 years. Qualitative interviews (n=20) and quantitative surveys (n=170) were conducted. Qualitative findings identified several health concerns, including chronic conditions. Quantitative results indicated that most survey respondents rated their health status as excellent or good, despite reporting having a health issue within the past year. Health status ranking was chosen by how men felt in comparison with an objective measure such as a medical report. The subjects indicated having problems finding health care since their release. Holliday and colleagues draw attention to the high rate of African American men in the criminal justice system and target substance-use correlates of depressive symptoms among these men. Of this study population, 90% manifested symptoms of depression, ranging from mild to severe. The results are discussed in the context of planning for transition of jail inmates. McGregor and colleagues examine the prevalence of mental health and substance abuse in corrections. For those with alcohol and drug abuse challenges, they offer Day Reporting Centers (DRC) as an alternative approach to incarceration. They provide results from a study of 258 DRC participants in regard to their attitude and behaviors related to substance abuse and mental illness.

The Gates et al. article draws attention to the risk of sexually transmitted infections, especially among African Americans with a juvenile justice history. These authors propose that consideration of a set of interrelated factors (mental health, substance use, trauma, and intimate relationships) can decrease risk and increase protective behaviors for detained young adults (ages 16– 21), who are most at risk. Zeller et al. discuss the increasing prevalence of HCV and the disproportionate burden borne by correctional populations. They posit that this disease has been largely ignored by correctional facilities and, for this high-risk, underserved population, make the case for increasing HCV testing in these facilities and in community-supervised corrections, for prevention education, and for linking affected individuals to care services. Elkington and associates present a systematic literature review on implementation issues and outcome studies of programs that promote HIV testing or that promote linkage to community HIV treatment post-release. Meeting the researchers’ inclusion criteria were 35 articles, including nine HIV testing initiatives and four linkage programs. Uptake rates for HIV testing were between 22% and 98%, and rates of linkage to community treatment were between 79% and 84%. The findings indicate that some programs are effective in reducing HIV transmission within the communities to which inmates return. However, attention to implementation factors, such as organizational culture and staff collaborations, appears necessary for the success of these programs.

This issue of the JHCPU seeks to draw attention to correctional health disparities and health equity concerns. Obtaining social justice equity will undoubtedly continue as a litmus test for advancing correctional parity in the U.S. As the struggle continues, progressive and forward-thinking practices, policies, and legislation must be implemented.