US mass incarceration as a public health problem

post by Bill Gardner

The US imprisons more of its citizens on a per-capita basis than any other country in the world. The Bureau of Justice Statistics reported that in 2008 there were about 1.6 million US prisoners.

Consider incarceration as a health risk exposure, in the epidemiological sense. What are the consequences?

Dora Dumont and her colleagues review the evidence about how this affects the health of the imprisoned, and the rest of us. It was not a surprise to discover that inmates have substantially worse health than age and gender-matched persons who are not incarcerated. They are five times more likely to be HIV+ and nine times more likely to be infected with hepatitis C than the rest of us. They have far higher rates of mental disorders. Many inmates suffer injuries or death from physical or sexual assaults.

What was a surprise is that, despite this,

At first sight, incarceration appears to provide a protective health influence to many of the underserved who enter the criminal justice system, particularly those from violent or homeless backgrounds. However substandard, the system provides shelter and meals; it also enforces supervision and highly-structured routines, a stabilizing force for some. Moreover, several recent studies of inmate mortality rates appear to indicate that the black-white mortality gap shrinks within correctional facilities because black male inmates’ mortality rate is lower than that of the general black male population but white male inmates’ mortality rate is either the same or slightly higher than that of the general white male population (emphasis added). 

Think this through. The implication is that the population being incarerated lives under such dangerous circumstances in their communities that they suffer little or no additional risk while they are behind bars. And it's not okay if a preventable health problem is acquired in prison even if the person was equally likely to suffer outside of prison.

More importantly, as the authors note, the apparent 'benefit' of being incarcerated disappears when you include the health effects of imprisonment that manifest themselves following release. The effects of HIV, hepatitis C, other infections, or the chronic stress of confinement will affect former prisoners for their entire lives. I was stunned, however, to learn about the health risks suffered by prisoners in the days immediately following their release:

Each year, more than 600,000 inmates leave prison and more than 7 million leave jail... The weeks following release from a correctional facility present extraordinary risks to releasees and others. Former prisoners are 12 times more likely than the general public to die of any cause in the 2 weeks following release and 129 times more likely to die of a drug overdose. Some of this postrelease mortality is due to “compassionate release” of the dying, but much of it reflects the instability of circumstances in the days following release and the concomitant return to high-risk behaviors.  

Again, think this through: It is not just that we are failing to rehabilitate persons in prison, we are setting them up for immediate and catastrophic life failure.

There's lots to do to improve the health care of prisoners (my wife and I have made a small contribution here to the literature on health care for youths in juvenile justice). The most important thing we can do, however, is to find methods to control felons that avoid prolonged incarceration. Read Mark Kleiman's superb When Brute Force Fails: How to Have Less Crime and Less Punishment, for an argument about why and how to do this.

And, Canadians, think very carefully about whether you want to follow US policies of mass incarceration. 

 

Comments

[Brendan Saloner]

Very interesting, Bill. Thanks for calling attention to this article.

Three quick comments:
1. In addition to increased transmission of infectious diseases, incarceration also has an impact on the mental health of inmate's partners and children. It's generally thought that children will fare worse, for example, if their father is locked up, but it may also be the case that some children will be better off if a man is aggressive or abusive in the home. I think the literature here is mixed.

2. It seems like a no-brainer that we could get the greatest bang for our public health dollar by intensively focusing resources on returning offenders in the first month of release, yet post-release resources (such as transitional housing and substance treatment) are woefully lacking in many states.

3. Economists worry about unobserved risk factors that make it difficult to statistically match inmates to people in the general population, but we now have a very plausible natural experiment -- the court-ordered release of thousands of inmates from over-crowded California prisons. We will see what happens to the health of this fragile population once they rejoin the general population. (Ironically, the original litigation sued the state for failure to provide health care, yet many of these prisoners will leave prison uninsured and without any treatment options).

[Bill Gardner]

Thanks for such a thoughtful comment, Brendan.

With respect to #1, I agree, and agree with your caveat. Clinicians will tell you about cases where getting a TERRIBLE dad out of the family's life benefits mom and kids. W.r.t. #2, Kleiman's model requires that transitional resources be available -- his tightly monitored parole is in effect a behavior change program using the resources of the court to reinforce engagement and compliance. And of course you are right about #3, and it will be great to see the data you mention.

[Will]

This argument combines very well with Kleinman's point about incapacitation. While it may intuitively make sense that "well, we've put the dangerous person in prison so it can't do any more harm", these prisoners are eventually released. Unless we have changed the behavioral propensity of someone significantly between time A and time B all we have done is DELAY the costs once they are released.

His astute point is that simple incapacitation (without concomitant deterrence/rehabilitation) is literally just locking someone up for their eventual failed release back into society. Meanwhile, those 10 years of resources spent keeping this one prisoner locked up was not used on the hundreds of new adolescents graduating into a world where they may develop the impression that crime is their most viable path.

[Bill Gardner]

Hi Will,
Again, another great comment. However, I didn't read Kleiman as proposing an incapacitation program. I thought that the idea was that small but quick and near-certain punishments actually promoted self-control better than huge punishments that were delayed and uncertain.