Health and Health Promotion in Prisons

Michael Ross

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781136183775
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

The impact of the United Nations "Healthy Prisons" initiative has highlighted the importance of health and health promotion in incarcerated populations. This invaluable book discusses the many health and medical issues that arise or are introduced into prisons from the perspective of both inmates and prison staff.

Health and Health Promotion in Prison places key issues in prison healthcare into a historical perspective and investigates contemporary policy drivers. It then addresses the significant legal issues relating to health in prison settings and the human rights implications and questions that arise. The book presents a useful framework for health education in prison and a model for introducing structural, policy and health-related changes based on the UN Health in Prisons model, and also includes a special chapter on mental health issues.

Providing a comprehensive and thought-provoking overview of health promotion issues in correctional environments, this is an essential reference for all those involved in prison healthcare.

1 The need for correctional public health and health promotion

Prisons, jails and other correctional settings are a part of the community. They also serve to focus risk for many diseases, either by concentrating people with elevated risks, or by providing the conditions for exacerbation or transmission of some diseases. And, as part of the community, they return the vast majority of inmates back into the community. Thus, correctional public health and health promotion is arguably of as much, if not more, significance than “free world” community health. In correctional settings, people with actual or potentially elevated risks are concentrated and probably easier to screen, treat and educate than those in the community. This introduction is not intended to be an exhaustive review of health in prisons: for that, there are excellent texts available (for example, Greifinger, 2010). Its purpose is to introduce the significance of health and disease in prisons and the opportunities it provides for interventions. I have chosen to emphasize data for one US state, Texas, as an example, in addition to wider US data, simply to make the point that even in a single statewide community, there are major issues with prison and jail health and major opportunities to address them. If, as former Speaker of the US House of Representatives Tip O'Neill once said, “All politics is local,” then ultimately all health is local – and personal – too.

Public health risks and social disadvantage

Disease in society follows a process of social sedimentation. Poor health and disease, whether communicable or chronic, is more prevalent in those with lower income, education and occupation, and this relationship holds in the United States within racial/ethnic groups, as well as between them. Further, this relationship is compounded by Hart's (1971) Inverse Care Law, which notes that those with the greatest burden of disease have the least access to health services (including preventive health programs), and vice versa. However, the sedimentation of disease, where the highest rates are found in the lowest levels of society, is not solely a function of availability and utilization of services. If issues of disease, particularly communicable diseases, are to be dealt with in those “core transmission groups” in the community where rates are highest and where utilization of services is lowest, then correctional institutions (jails, prisons, juvenile and other detention facilities) and their populations are central to disease reduction efforts. Core groups are those responsible for most of the transmission of STDs: it has been estimated that more than 80 percent of STDs are transmitted by less than 20 percent of the population (Yorke et al., 1978). Further, Okie (2007) estimates that each year, 25 percent of people with HIV in the United States will spend time in a correctional facility, as will 33 percent of people with Hepatitis C.

Health risks and social disadvantage among correctional populations

The population who circulate through correctional institutions (prisons, jails, juvenile detention centers and other specialist correctional units such as substance abuse felony punishment units) form a significant part of an “underclass” (a sociological term for those who are frequently marginalized, unemployed, on welfare or other assistance, in persistent poverty, have significant barriers to health care and may have a family history of more than one generation in this situation), who are difficult to access and who rarely use available health facilities except in emergencies. Reduction or elimination of most communicable diseases is not possible without a focus on the lowest levels of society in terms of income, education and occupation, and correctional institutions are a key to accessing, treating and preventing disease transmission in this population. In this context, as Virchow (1941) noted, “The physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction.” Preventive innovations may diffuse from inmates to their families and associates, both in terms of preventive behaviors and of lowered disease transmission rates, making diffusion of information to other at-risk members of the community a positive additional impact, as well as making those treated de facto peer educators in their communities.

Medical conditions among incarcerated populations

In 2009, Binswanger et al. looked at nationally representative data from surveys of inmates in the United States. Even with adjustment for important sociodemographic differences including sex, age, race, education, employment, US birth, marital status and alcohol consumption, jail and prison inmates had a higher burden of most chronic conditions. Binswanger et al. report that compared with the general population, prison and jail inmates had higher rates (odds ratios [ORs] given for jail first and prison second) for hypertension (OR = 1.19, 1.17); asthma (OR = 1.41, 1.34); arthritis (OR = 1.65, 1.66); cervical cancer (OR = 4.16, 4.82); and Hepatitis (OR = 2.57, 4.23). There was no increased risk for diabetes, angina or myocardial infarction, and lower odds of obesity. These data were based on self-report and so may be underestimates of conditions which were not clinically obvious or had not been diagnosed. These data emphasize the chronic, as well as infectious, conditions that are over-represented in correctional populations.

Prevention and public health for communicable diseases in correctional institutions involves reducing staff risk as well as inmate risk

Correctional institutions need to be targeted in terms of both inmates and staff, since for communicable diseases such as meningococcal infections, influenza, pneumococcal infections, tuberculosis (TB), and Hepatitis A, B/D and C, among others, spread between inmates and staff, and from staff to their families and the outside community, is not limited. In this sense, the concept of inmates as being part of a closed community for disease transmission is inappropriate. A recent study in Texas found that over one-quarter of men and nearly half of women entering the Texas Department of Criminal Justice system were infected with Hepatitis C (Baillargeon et al., 2003). Attention needs to be equally given to the health of correctional staff and service providers. While correctional institutions are designed, among other purposes, to provide protection to society from those incarcerated, they do this only physically. From the point of infectious diseases, they provide almost no protection, with staff and the community almost as much at risk as if the offenders were in the wider community. Indeed, the level of risk may be greater because of the concentration of “at risk” groups in incarcerated settings. Prevention, including immunization where available, thus becomes a matter of occupational as well as public safety.

Endpoints for interventions with the incarcerated might include risk reduction among “high risk” groups, reducing risk for correctional staff and their families (including vaccination where appropriate) and reducing risk between inmates and their social networks post-release. All of these endpoints can be addressed in prison- or jail-based health programs.

An important component of public health surveillance and screening

For communicable diseases, correctional facilities are a key – but often neglected – component of surveillance, screening, treatment and prevention. The burden of disease is extremely high in the correctional population: 35 percent of TB, over 50 percent of Hepatitis C, and in 1996, 17 percent of HIV cases were detected in people passing through correctional facilities. Over one-quarter of new syphilis cases and very significant numbers of cases of gonorrhea and chlamydia are identified in correctional facilities. There are up to 45,000 cases of HIV infection currently in US correctional facilities. Core transmitters for many of the most significant communicable diseases pass through prisons and jails, and any attempt to reduce disease burden thus needs to focus on correctional populations. Risser et al. (2001) found that 10 percent of males and 18 percent of females in a juvenile detention center in Houston were infected with chlamydia, and 88 percent of these were treated while incarcerated. Prisons and jails get many of the disease prevention failures from the wider community, but can then function as a safety net to treat or prevent transmission if there are adequate public health programs developed for correctional populations. It is likely that adequate prevention efforts in the correctional setting would have a disproportionately large impact on the free world community's health and communicable disease prevalence. Binswanger et al. (2005) found that jail could also be an appropriate venue in which to provide cancer screening for a high-risk population, especially for African American and other minority populations, and for breast and colon cancer screening.

High health and death risks on immediate release from prison

In recent evidence, Binswanger et al. (2007) conducted a comprehensive study on deaths of released inmates in Washington State and found that risk of death in the 1.9 years after release was 3.5 times higher than in other state residents, after adjusting for age, race/ethnicity and sex. In the first two weeks after release, the death of former inmates was over 12 times that of other state residents! The most elevated risk (129 times that of state residents) was of death from drug overdose. Binswanger et al. report that in addition to high vulnerability to drug overdose, in the two weeks following release, risk of death from violence, unintended injury, and a lapse in treatment of chronic health conditions is also high (and significantly higher for females than males). In Houston, Harzke et al. (2006) studied prisoners receiving HIV treatment in state prisons, and despite post-release incentives, half of the inmates were lost to follow-up and did not access or maintain their antiretroviral medications following release. This has serious implications not only for the former inmates, but for the development (and transmission from those former inmates) of drug-resistant forms of HIV. Former inmates with stable housing and who did not use alcohol post-release were most likely to access primary care. Risser and Smith (2005) similarly note for TB in incarcerated youth in Texas that less than 10 percent kept follow-up appointments or continued their treatment. Transitional medical care post-release for many infectious or chronic conditions may be critical, not only for the former inmate, but also for transmission to the public of infectious conditions (possibly drug-resistant) such as HIV, TB, and Hepatitis B and C. Good public and community health involves managing the transition from prison to community as seamlessly as possible to ensure that any gains from prison interventions are not lost by lack of maintenance or treatment on return to the community or in fact by higher risk of death or relapse.

Health risk interventions with correctional populations

One of the major goals of the “Healthy People 2010” ten-year health objectives of the US Federal Government (US Department of Health and Human Services, 2000) was the reduction of racial and ethnic disparities in health, particularly including those in HIV/AIDS, STDs and immunizations. Correctional institutions provide an important venue for education, screening and prevention activities in the United States and should be a focus of these aspects of the ten-year plan. Conklin et al. (1998) note that in a large northeastern correctional facility, for example, 82 percent of inmates reported no history of a regular medical provider at time of incarceration, and 93 percent had no form of medical insurance. Clearly, inmates are not likely to be served by traditional medical and public health services. Correctional facilities, therefore, can play a significant role in reducing both disease burden and risk behaviors. Further, as emergency rooms in large metropolitan areas are overburdened with walk-in non-emergency care cases from the under-served and “underclass” populations, an emphasis on screening and prevention in correctional facilities could have a cost-effective impact on inappropriate use of expensive emergency room services. However, as Harzke et al. (2006) noted for released inmates with HIV, only half in their Texas sample were in primary care three weeks after release, and thus half were not continuing medication.

Preventing disease transmission within correctional environments

In addition to holding inmates with communicable diseases, some correctional environments also provide opportunities for activities that transmit disease. Wolfe et al. (2001) describe a major outbreak of syphilis in three prisons in the south of the United States, and they note that in most institutions, inmates are not isolated but are inescapably, from the perspective of infectious diseases, part of the American community. This is inevitable, they argue, given the movement of detainees through jail, prison and the community, and most inmates return to the community, bringing with them infectious diseases harbored or acquired through correctional facilities. HIV has also been recorded as spreading in correctional facilities (Mutter et al., 1994). Despite intentions of staff, and state laws notwithstanding, risk behavior exists at high levels in correctional facilities, whether sexual activity, use of smuggled drugs or “home brew” alcohol, injecting or tattooing, or poor diet or opportunities for exercise.

Correctional populations comprise a significant proportion of the US population, particularly young African American males (Osemene et al., 2001), and an even more significant proportion of the population that carries the greatest burden of preventable and treatable communicable diseases. In 2000, the total estimated US correctional population (prison, jail, probation, parole) was 6,467,200, plus an additional 105,790 juveniles in detention. In Texas, as an example of one of the largest states, the figure at the same time was slightly over 150,000, or 1 in 20 adults in the state. This constitutes nearly 4 percent of the adult population of the country, and 5 percent in Texas. The Texas Department of Criminal Justice is the second largest correctional service in the United States, and one of the largest in the world. As of August 31, 2006, total receives were over 74,000 (62,804 males and 11,366 females), with nearly 26,000 African American and 26,000 White inmates, and over 22,000 Hispanic inmates. These were divided between prison (43,138) and state jail (25,690), with the remainder in youth programs. The majority (34,871) were in minimum custody, and mean sentence length was 8.5 years (of which average time served was 4.5 years) for the prison inmates (0.8 years is the mean sentence length for state jail inmates) (Texas Department of Criminal Justice, 2006). Two in three prison inmates will return to prison within three years of first release (Sourcebook of Criminal Justice Statistics, 2001).

Effective evaluation of correctional health promotion programs

Some correctional systems have innovative programs set in correctional environments that deserve evaluation and wider dissemination. For example, the Texas HIV prevention curriculum uses peer educators to teach and disseminate information about HIV prevention and reaches a large population including not just inmates, but their families and other contacts in the “free world.” Ross et al. (2006) evaluated this program and found it to be highly effective across inmates of varying educational and socioeconomic backgrounds, and to result in increased HIV testing in inmates who had been exposed to it. Mullen et al. (2003) have described many of the constraints in carrying out public health interventions, such as their alcohol-exposed pregnancy prevention program in a women's county jail in Texas, which make it clear that conducting public health interventions in a correctional setting requires modifications to adapt them to jail operational needs and policies, staff limitations and inmate perceptions, as well as follow-up difficulties post-release. Understanding and adapting to setting and target group constraints in correctional contexts requires careful design, preparation and evaluation, and public health specialists familiar with these constraints (Mullen et al., 2003). It also requires appropriate buy-in, and a joint collaboration, including joint planning, between correctional staff, health care staff and public health specialists. Without a shared commitment and interest from all sectors (including administration, inmates and staff), health-related programs in correctional settings are predestined to failure.

High through-flow and opportunity for public health interventions in correctional facilities

Contrary to popular perception, most stays in correctional facilities are relatively short. For example, in Houston (Harris County Jail), Texas, the mean stay is 34 days, and over 7,000 inmates are released each month. This pattern is typical of urban areas in the United States. For the Texas Department of Criminal Justice, the average prison inmate serves 4.5 years of an average 8.5-year sentence and has an eighth-grade education; the prison population turnover is about one-third per year. In the United States there are approximately 12.5 million adult correctional facility entries and 12 million exits per year, approaching 10 percent of the adult population. About 45 percent of those released return to prison within five months, and thus there is a cycling between correctional institutions and the community comprising people who are not only at the highest risk for communicable diseases, but also are not usually seeking or accessing care in any place. Public health programs in correctional facilities could have a very significant impact on the communicable disease burden in the United States by accessing the population where the attributable risk is extremely high. Further, this population is commonly not accessible through other health care programs, and are accessible, sober and without competing interests while in correctional facilities. Correctional institutions, for many of their population, are a “revolving door” to the community, with jail inmates returning faster and in larger numbers and thus having more of an impact on community health (Mullen et al., 2003). Correctional health in the field of communicable diseases is thus clearly not only a matter of considerable significance for community health, but also of public safety: for communicable diseases, incarceration is not, and cannot be considered, quarantine from the wider population.

Organizational and health interactions

There is a close relationship between health in prisons and prison organization and facilities. In a review of the Greek prison system, Cheliotis (2012) reports that prison establishments are vastly overcrowded and conditions of detainment are deplorable, with minimal health care provision and high prevalence of serious transmissible diseases, mental disorders, deliberate self-harm and suicide and death. He notes that the harms of imprisonment are typically centered upon two central issues: physical conditions and prisoner health. In Greece, the rise of the prison population is largely accounted for by an increase in drug-related offences (over 30 percent of convicted prisoners) and non-Greek offenders (over 40 percent of convicted prisoners, the majority of whom are Albanian). One consequence of this overcrowding is that over one-third of prisoners reported deliberate self-harm in prison, including hitting one's own head, wrist-cutting and self-burning, all correlated with overcrowded conditions. Suicides were highest in overcrowded facilities and dropped dramatically in semi-open and agricultural prisons. Creation of poor health through prison conditions can and does occur.

Gross overcrowding in Greek prisons is exacerbated by most of the health-related posts being unfilled, by the criterion of the number of health care posts provided by the relevant Act (a number arguably itself too meager for prisoner needs and based on lower numbers of inmates). Only 39 percent of needed health care staff are in place, including only 22 percent of medical staff and the same proportion of dentists; only half of the nursing positions are filled. This is in a country with an oversupply of medical and dental specialists and pharmacists! Staffing is so low that most health care centers in prisons are run by prison officers and prisoners themselves, Cheliotis notes. There was one prisoner death every ten days (including sui...

Table of contents

• Front Cover
• Health and Health Promotion in Prisons
• Routledge Studies in Public Health
• Title Page
• Copyright
• Contents
• Foreword
• Acknowledgments
• 1 The need for correctional public health and health promotion
• 2 Health in prisons: A historical perspective
• 3 Approaching health and human rights in prison: Comparing England and Wales and the European Court of Human Rights, and the United States
• 4 The resurrection of the body in penology: Prison health care as physical punishment in a twentieth-century US correctional system
• 5 On giving good care to bad people: Examining the principles of prison health care
• 6 Pedagogy for prisoners: An approach to peer health education for inmates
• 7 Prison staff occupational health and safety and its relationship with inmate health
• 8 Ensuring health in prison and achieving healthy prisons: The TECH model
• 9 Mental health and treatment in prisons: Hospitals of last resort or rehabilitation?
• 10 Conclusions: Some principles of public health and health in prisons
• Notes
• References
• Index