United States: addressing the structural inequalities underlying a failing prison health system

The consequences of, and alternatives to, mass incarceration are part of policy discussions throughout much of the United States. However, the impact of incarceration on health remains largely hidden. The criminal justice system is often used to respond to health problems in the U.S., such as substance use and mental illness. This affects particularly people of color and those who are poor. This approach blocks evidence-based policy in healthcare provision, in a way that reinforces racial and economic disparities.

In addition, incarceration itself brings new health risks that drive disparities in morbidity and mortality and impart tremendous, unmeasured and untreated trauma. These new health risks include medical neglect, physical and sexual abuse and, more recently, infection with COVID-19.

Efforts to correct these disparities include eliminating the criminalization of substance use and mental illness, as well as increasing transparency and quality of health outcomes during incarceration. Major barriers to these reform efforts include the state-by-state variations in justice reform, the financial incentives linked to mass incarceration and punishment, a reluctance to address structural racism, and the lack of involvement of public health organizations in the health of incarcerated people.

The ‘war on drugs’ and other policies have resulted in disproportionate incarceration of people of color and people with behavioral and other mental health problems. The 3,000 jail (pre-trial) and 2,000 prison settings in the U.S. hold disproportionate numbers of people who have substance use disorders and mental health problems but who rarely receive adequate care. The leading cause of death in America’s jails is suicide. In addition, few jails or prisons offer evidence-based treatments for opiate use disorders, which are at epidemic levels in the US today.

When a person experiences a mental health crisis, the response in prisons is too often simply to lock them into isolation.

Many local and state governments have developed special courts to divert people into a treatment pathway. However, these programs are implemented in the context of law enforcement and often lack the full range of evidence-based care that people need. They also come with numerous triggers to continue the cycle of incarceration in response to health problems.

People who have a behavioral health crisis in some communities will receive treatment, while those in communities of color or heavily policed communities will be met with armed law enforcement officers. This is a stark example of structural racism in healthcare provision in the US.

The disparity in healthcare drives many immediate adverse outcomes, including injury and death during law enforcement contact. It also has significant downstream implications in terms of reduced prospects for treatment and recovery, and greater chances of (repeat) incarceration. Some communities are creating mental health response teams that are independent of law enforcement. These can respond to people in crisis and provide a treatment approach where one does not currently exist.

Another important reform movement is targeting excessive, mandatory prison sentences.

These sentences have resulted in a rapidly increasing geriatric population in US prisons, bearing a large and growing burden of complex health problems and inadequate care. COVID-19 has helped many people who were previously unaware of this issue to understand just how devastating incarceration can be for health, especially for the 2.3 million incarcerated people who are aging. In Florida, COVID-19 deaths reduced the overall lifespan of state prisoners by 4 years..

Making pre-trial release more common allows people to continue receiving community treatment for physical and behavioral health problems. Inside carceral settings, there is now appreciation (if not yet implementation) of the need for evidence-based substance use treatment. The drivers of this change include growing public support for addressing the nation’s opiate overdose deaths as well as successful lawsuits against carceral systems that fail to provide this treatment.

It is imperative for the Centers for Disease Control (CDC), our national public health agency, to create an office of detention health to monitor healthcare and health outcomes in jails, prisons and immigration detention settings. It is also essential that every State Department of Health do the same.

The US currently has no national plan of oversight or health monitoring in places of detention.

Even the data on the number of deaths behind bars dates back to 2016. The CDC and our State Departments of Health have made commitments to addressing racism as a public health problem. They must become involved in the health of incarcerated people.

In its most recent recommendations to President Biden, the Task Force has advocated for including people who are incarcerated in a national connection of data on health outcomes from COVID-19.

If we can achieve this, then we can build a system of health surveillance that includes, rather than omits, people in these settings. This step, tracking the healthcare and outcomes of people who are incarcerated, is not only about improving care behind bars. It is also crucial to showing the public, our community health systems, and even insurance companies, how incarceration harms health. It will also demonstrate how treatment-based responses to health problems are at the core of addressing racism in health.