Upon my arrival, I felt like I was walking into a sort of playground, except the children were adults—and some could only move with the assistance of a cane. Instead of sandboxes and slides, there were pull-up machines and basketball hoops with nets made of rusted chains. Everyone wore a uniform, not unlike the scrubs I had on, except theirs was a light tan, darkened by dirt and wear-and-tear. But between me and them stood a rigid steel fence taller than four humans standing on each other’s shoulders. While playing, they—not unlike children—occasionally acquired boo-boos in need of medical attention, though their insult was on the order of broken jaws and contorted limbs. They would come into the clinic, where I would sit with the rest of the team on worn-out chairs on un-mopped floors. We would dig through paper medical records as healthcare staff in the 1900s might have done, rummaging for crumpled bandages in a paltry stack of medical supplies, before starting a negotiation with prison security about how to transport them to the ER. Usually, the patients would have to wait for hours, sometimes overnight, sitting in their cell, injury unhealed and mind unwell.

Origin of the Carceral System

We often view incarceration as a necessary evil, a system that must exist to “handle” people who cannot function outside of their cells. Although there are instances of people being put in the royal jails of historic kingdoms and imprisoned by past empires, rates of incarceration have never been this high, nor has the carceral system ever been this profitable. How did we end up in this position?

In the past, many societies (e.g., Indigenous tribes on the land currently known as the United States) had a different approach. Offenders were sent to an area separate from the rest of the community (without being locked into a cell) and supplied with ample resources before a timely reintegration. Other societies, such as the ancient kingdoms and empires, did have a concept of imprisonment, but this approach became more prominent in the 17th and 18th centuries, with the rise of profit-based economies (i.e., capitalism). Suddenly, incarceration could be done privately for monetary gain.

This pursuit of profit that continues into the present day, makes it unsurprising that one of the missions of prisons has been to find people to incarcerate to fill the prison. It would be easier to find people to fill the cells if generalizations could be made using race, ethnicity, socioeconomic status, etc. For example, in 19th-century United States and Britain, the poor were viewed as being predisposed to both wrongdoing and disease, and it was thought that prisons (not medical care) could control both.1 At the same time in history, colonialism was running rampant, and many enslaved Black and Indigenous people in the United States were incarcerated for resisting slavery and colonialist expansion, respectively.

Today, according to the Prison Policy Initiative, a disproportionate number of incarcerated people are Black/Brown, low-income, unhoused, and unemployed.2 Relative to the general population, incarcerated people are at least three times more likely to have moderate/severe mental illness, substance use disorder, and no health insurance.2 Based on these statistics, it has been suggested by advocates in and out of health care that both medical attention and social services could (1) improve the quality of life of incarcerated people and (2) potentially decrease the need for incarceration altogether.

Quality of Life of Incarcerated People

According to the Centers for Disease Control and Prevention (CDC), the percentage of incarcerated people living with either HIV or Hepatitis B is three times higher, tuberculosis six times higher, and Hepatitis C 10 times higher than in the general population. This pattern is also present for other sexually transmitted infections, such as gonorrhea or chlamydia, and, more recently, diseases such as COVID-19.3 The increased incidence and prevalence of certain diseases might be considered acceptable if a proportionately higher number of resources were present for diagnosis and treatment, but the actual situation is the opposite.

In New York State, for example, more than 20% of incarcerated people have a chronic medical condition and are not provided any health care.4 And when services are provided, co-pays are two to five dollars. Based on the $0.14-0.63 per hour wage for incarcerated individuals, this is equivalent to a minimum-wage worker having a co-pay of hundreds of dollars.4 Funding for health care in prisons is significantly lower, per person, than in non-carceral settings. Equipment is obsolete, medical records are often outdated, and wait times are even worse than in many emergency rooms around the country. A case could be made that infectious diseases could be more easily handled in carceral settings, as the environment—for better or for worse—allows for effective quarantine and contact-tracing, yet many diseases (such as COVID-19) have run rampant in jails and prisons. Perhaps most damning of all is the consensus among incarcerated populations that carceral health care does not seem to care about their well-being; as a result, incarcerated patients do not trust their providers.4

Incarceration versus Medical Care

Not only do incarcerated people have a decreased quality of medical care but also a case could be made for many (who were uninsured, unemployed, food-insecure, or had mental/physical health issues) that medical care could have played a role in keeping them out of prison in the first place.

This is not surprising given that the number of psychiatric beds has decreased from 339 to 22 per 100,000 people in the United States from 1955 to 2000. A recent study investigated this phenomenon by matching hospital referral regions (HRRs) with nearby jails/prisons and found that decreases in psychiatric bed capacity (by about 80-90 beds) were associated with an increase of 256 inmates.5 Similar increases in psychiatric bed capacity were associated with a decrease of 199 inmates. And this does not even consider the effect that other forms of medical care and social services could have on decreasing the number of people who are incarcerated.

Why Is This Important for Clinicians and SGIM Members?

We, as healthcare professionals and SGIM members, should always provide and advocate for compassionate and effective patient care. We should also ensure that people in need of medical care are provided with medical care, not a profit-driven substitute like incarceration. And we should not ignore the fact that incarceration disproportionately affects people who are Black/Brown, low-income, unhoused, and unemployed—disparities that significantly contribute to health outcomes.

Our current system that features (1) decreased quality of patient care for incarcerated people and (2) the incarceration of people who would be better rehabilitated with medical care indicates that significant gaps remain in the compassionate and effective treatment of this population. Education about and advocacy for proper carceral health care—in medical school, residency, fellowship, and continuing medical education—are essential for the adequate medical care of incarcerated people. It is this education and advocacy that we, as SGIM members, can and should contribute to our healthcare system daily.

References

  1. Lindenauer MR, Harness JK. Care as part of the cure: A historical overview of correctional health care. J Prison Health. 1:56-64. LIS, Inc. 1997. NCJRS Virtual Library.
  2. Jones A, Sawyer W. Arrest, release, repeat: How police and jails are misused to respond to social problems. Prison Policy Initiative. https://www.prisonpolicy.org/reports/repeatarrests.html. Published August 2019. Accessed May 15, 2024.
  3. Data and statistics about correctional health. CDC. https://www.cdc.gov/correctionalhealth/health-data.html. Accessed May 15, 2024.
  4. McCann S. Health care behind bars: Missed appointments, no standards, and high costs. Vera Institute of Justice. https://www.vera.org/news/health-care-behind-bars-missed-appointments-no-standards-and-high-costs. Published June 29, 2022. Accessed May 15, 2024.
  5. Gao YN. Relationship between psychiatric inpatient beds and jail populations in the United States. J Psychiatr Pract. 2021 Jan 21;27(1):33-42. doi:10.1097/PRA.0000000000000524.

Issue

Topic

SGIM

Author Descriptions

Aprotim Bhowmik (abhowmik1@pride.hofstra.edu) is a fourth-year medical student at the Zucker School of Medicine at Hofstra/Northwell in New York City.

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