The incarcerated remain one of the most disenfranchised populations in America. While recent trends in criminal justice reform have made progress in reversing historic increases in the incarceration rate, the US prison population remains higher per capita than in any other country.1 Additionally, while sentencing reforms and early release policies reduce the overall prison population, the number of individuals in the community with criminal legal involvement (CLI) continues to grow. The prison population is unique from the lens of racial disparities in healthcare. It is the only civilian population that has an explicit constitutional right to healthcare where a “deliberate indifference to serious medical needs” constitutes cruel and unusual punishment.2 The prison population has also been increasingly limited in its ability to advocate for themselves through the courts. The Prison Litigation Reform Act enacted significant barriers for prisoners to file suits against the federal government.3 Furthermore, racial identity plays a significant role in prison sub-culture and has been correlated to health outcomes.4, 5 As the impact the correctional system has on the social determinants of health of these individuals persists long after they reenter the community,6 research that focuses on community-dwelling individuals with CLI is important to bridge the gap between the incarcerated and the population at large.
Research on disparities in CLI has been limited by the absence of datasets and by ethical considerations in conducting research in incarcerated individuals, those with CLI, and adolescents. In “Associations Between Incarceration History and Risk of Hypertension and Hyperglycemia: Consideration of Differences among Black, Hispanic, Asian, and White Subgroups,” the authors used a unique longitudinal data set to examine the crossroads between race and a history of incarceration, and the prevalence and incidence of diabetes and hypertension.7 A significant finding in the study was that among Asian participants, a history of incarceration was independently associated with a threefold risk of having SBP ≥ 130 mmHg compared with never incarcerated peers.
While many conclusions could be extrapolated in concert with prior research, the authors were limited in their interpretation of the results for a number of reasons. Black, Hispanic, and Asian individuals are known to have a high prevalence of diabetes in the general population as a result of socially determined precipitants, which may be expected to be mirrored in the population with CLI.8 However, the study found no significant relationship between non-Hispanic ethnicity, CLI, and hyperglycemia. This might be partly due to a multitude of reasons, including a small subgroup population, patients with CLI being still incarcerated and thus not included in the follow-up population, the heterogeneity of non-Hispanic ethnic groups, and sampling bias within this specific cohort. There was also significant attrition from individuals lost to follow-up and missing clinical data between successive waves. This might have also contributed to the study’s non-significant findings among Hispanic and Black individuals with CLI and highlights additional barriers to conducting research in this population.
A more foundational limitation of the study was that it relied on a data set that carried forward ethnic and racial subgroup comparisons that are inherently difficult to directly compare. For example, Asian as a racial identifier oversimplifies the heterogeneity of this population. However, further subdivision of this racial group would serve to additionally limit the authors’ statistical findings with regard to Asian individuals with CLI, as the Asian racial group was the smallest racial or ethnic subgroup. While the utilization of Asian racial and Hispanic ethnic groups in comparison with White and Black racial groups is a widely accepted and historical means to examine racial and ethnic disparities, this aspect of the study’s limitations further questions how the stratification of racial and ethnic data should be incorporated into health disparity research. Conducting racial disparities research is in and of itself difficult for this reason. How can investigators utilize race in an intersectional means that avoids oversimplification of identities but takes into account cultural and social variations while maintaining discrete populations as comparable variables? Although redefining the social constructionist paradigm of racial and ethnic identity is far beyond the scope of this study, a closer look into how race and ethnicity are categorized can benefit the field of health disparity research. Future studies may provide a more accurate approach to categorizing what is commonly known as Asian and Hispanic subgroups in a way that preserves the utility of past research on racial disparities.
The inherent understanding of racial health disparities is evolving, specifically with regard to how disparities research can be more inclusive, as well as the importance of conceptualizing race as a social construct. This study sheds light on a patient population that has historically been neglected due to ethical challenges, societal stigma, and discrimination. Furthermore, this study serves to elaborate on the social edifices that contribute to racial disparities, shifting the lens of race and medicine toward race as a societal construct. A history of CLI should be recognized as a distinct social determinant of health that contributes to racial health disparities. The authors touch upon issues of social networks, stigma, discrimination, and access as examples of how CLI may affect health and how this intersects with race. Further work on elucidating these distinct factors can be a potential sequel to this work in helping advance efforts to address these specific issues.
The complexity of the intersection of race, ethnicity, and the criminal justice system presents challenges to addressing health disparities in this context. Class-action lawsuits directed toward the state or federal government have been the predominant approach to health equity advocacy for incarcerated people. For instance, a 2004 settlement in an Alabama district court resulted in mandated access to fundamental components of diabetes care such as insulin, blood sugar checks, and screening for complications of diabetes.9 However, the litigatory approach toward improving prison health often hinges on arguments based on Eighth and Fourteenth Amendment rights, namely the prohibition of cruel and unusual punishment and the equal protection clause, respectively. This has historically been challenging, as the courts have interpreted these protections narrowly within the scope of the incarcerated individuals. Health reform for the incarcerated through comprehensive legislation at the state and federal level would be a more proactive and preventative means of addressing these disparities. The incarcerated and individuals with CLI represent a traditionally neglected population that forms a significant proportion of our community. To improve the health of the incarcerated and people with CLI, comprehensive prison healthcare reform can serve as a means of addressing a component of racial health disparities in our community. Research and scientific evidence in concert with public advocacy can serve as a powerful means of building sufficient public will and the collective action necessary to accomplish this goal.
Health Equity, JGIM, Social Determinants of Health, Vulnerable Populations
Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
John Hon MD, Joseph Conigliaro MD, MPH & Eun Ji Kim MD, MS, MS
Institute of Health System Science, Feinstein Institutes for Medical Research, Manhasset, NY, USA
Joseph Conigliaro MD, MPH & Eun Ji Kim MD, MS, MS
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