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Edition 87 - Global Health

Unraveling the Public Health Crisis of Mass Incarceration

By Alice Liu

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Liu A. Unraveling the public health crisis of mass incarceration. HPHR. 2024. 87. https://doi.org/10.54111/0001/IIII3

Unraveling the Public Health Crisis of Mass Incarceration

For decades, the United States has consistently incarcerated a larger proportion of its population than any other nation. The intersection of the carceral system and public health has become increasingly prominent due to the disproportionate impact of incarceration rates on marginalized groups and their role in exacerbating health disparities. Mass incarceration not only adversely impacts the health of those directly involved but also poses risks to the health of communities.

 

The article first explores the historical and structural factors contributing to mass incarceration in the United States. It then delves into the multifaceted impact of incarceration on societal well-being. Recent studies, for example, reveal links between exposure to incarceration and adverse health outcomes, including increased vulnerabilities to mental illness, suicide, substance use disorder, infectious diseases, and non-communicable diseases. The article proposes several policy recommendations. Key endeavors involve ensuring adequate access to healthcare and preventive measures, such as vaccinations, mental health support, and substance abuse treatments, for individuals within the carceral system. Additionally, the article advocates for actions addressing racial disparities in bail practices, enacting sentencing reforms, commuting sentences for nonviolent drug offenders, and simplifying health insurance enrollment procedures post- release.

Introduction

Over several decades, the U.S. has consistently incarcerated a larger proportion of its population than most other nations.1 Despite representing less than 5% of the global population the U.S. incarcerates 20% of the world’s prisoners.2 Crime rates in the U.S. have generally been stable or decreasing over the past few decades. However, the country has seen a dramatic increase in incarceration rates due to tougher sentencing laws and policies.3

 

Mass incarceration poses significant ramifications for public health and medicine. Mass incarceration not only adversely affects the health of those directly experiencing it but also jeopardizes the health of communities, especially impacting Black, Indigenous, and People of Color (BIPOC). Recent studies reveal links between exposure to incarceration and adverse health outcomes. 4,5,6,7,8

 

This article explores the profound public health implications of mass incarceration in the U.S. It will first examine the historical roots and socio-political factors contributing to mass incarceration, and how it perpetuates health disparities among BIPOC communities. The article will then delve into the specific health challenges faced by incarcerated individuals, including mental illness, suicide, substance use disorder, infectious diseases, and non-communicable diseases. Finally, the article will highlight the urgent need for comprehensive public health interventions and structural reforms to mitigate these impacts. It will advocate for decarceration and abolition as critical steps toward addressing systemic injustices within the criminal legal system.

History Behind Mass Incarceration

Mass incarceration in the U.S. is deeply rooted in centuries of the enslavement of people of African descent and the genocide and displacement of Indigenous people, and is also linked to labor exploitation, racial discrimination, criminalization of immigration, and inadequacies in systems of care for behavioral health problems.9 Mass incarceration did not emerge as a rational response to crime but rather as a recalibration of legalized racism in response to the social, economic, and political progress of the civil rights movement in the 1960s. With a disproportionately adverse impact on BIPOC communities, mass incarceration is often referred to as the new Jim Crow.10

 

Outside the criminal legal system, policies have contributed to America’s excessive reliance on police, courts, jails, and prisons for addressing social problems. In the 1960s, a movement towards deinstitutionalization of people with mental illness, coupled with advances in psychotropic medications and Medicaid, aimed to enhance community-based care. However, while people were deinstitutionalized, the promise of community mental health centers fell short, leading to the expansion of jails and prisons becoming de facto institutions for those with chronic mental illness and substance use disorders.11

 

In the 1970s, federal programs designed to address intergenerational poverty and social inequalities in disenfranchised communities were diverted toward a “War on Crime” and later a “War on Drugs.” Law criminalizing drug use and imposing lengthy prison terms disproportionately affected BIPOC communities and contributed to mass incarceration. The 1980s and 1990s witnessed the growth of the “prison-industrial complex,” with huge cuts to funding for public education, housing, early education, food assistance, and community mental health resources while witnessing massive investments in private prisons.12

 

In 1960, there were 346,015 people incarcerated in the U.S., representing an incarceration rate of 193 per 100,000 population. By 1970, this number slightly decreased to 328,020, with a rate of 161 per 100,000. The 1980s saw a substantial rise, with 503,586 incarcerated and a rate of 220 per 100,000. This trend continued into the 1990s, reaching 1,148,702 incarcerated individuals and a rate of 457 per 100,000. By 2000, the incarcerated population had soared to 1,937,482, with a rate of 683 per 100,000. The numbers peaked in 2010 at 2,270,142, with an incarceration rate of 731 per 100,000, before slightly declining to 1,675,400 in 2020, with a rate of 505 per 100,000. Today, 31% of those incarcerated are White (non-Hispanic), 24% are Hispanic, and a disproportionately high 33% are Black, despite Black individuals making up only about 13% of the overall U.S. population.13

 

Mass incarceration in the U.S. is deeply rooted in centuries of the enslavement of people of African descent and the genocide and displacement of Indigenous people, and is also linked to labor exploitation, racial discrimination, criminalization of immigration, and inadequacies in systems of care for behavioral health problems.9 Mass incarceration did not emerge as a rational response to crime but rather as a recalibration of legalized racism in response to the social, economic, and political progress of the civil rights movement in the 1960s. With a disproportionately adverse impact on BIPOC communities, mass incarceration is often referred to as the new Jim Crow.10

 

Outside the criminal legal system, policies have contributed to America’s excessive reliance on police, courts, jails, and prisons for addressing social problems. In the 1960s, a movement towards deinstitutionalization of people with mental illness, coupled with advances in psychotropic medications and Medicaid, aimed to enhance community-based care. However, while people were deinstitutionalized, the promise of community mental health centers fell short, leading to the expansion of jails and prisons becoming de facto institutions for those with chronic mental illness and substance use disorders.11

 

In the 1970s, federal programs designed to address intergenerational poverty and social inequalities in disenfranchised communities were diverted toward a “War on Crime” and later a “War on Drugs.” Law criminalizing drug use and imposing lengthy prison terms disproportionately affected BIPOC communities and contributed to mass incarceration. The 1980s and 1990s witnessed the growth of the “prison-industrial complex,” with huge cuts to funding for public education, housing, early education, food assistance, and community mental health resources while witnessing massive investments in private prisons.12

 

In 1960, there were 346,015 people incarcerated in the U.S., representing an incarceration rate of 193 per 100,000 population. By 1970, this number slightly decreased to 328,020, with a rate of 161 per 100,000. The 1980s saw a substantial rise, with 503,586 incarcerated and a rate of 220 per 100,000. This trend continued into the 1990s, reaching 1,148,702 incarcerated individuals and a rate of 457 per 100,000. By 2000, the incarcerated population had soared to 1,937,482, with a rate of 683 per 100,000. The numbers peaked in 2010 at 2,270,142, with an incarceration rate of 731 per 100,000, before slightly declining to 1,675,400 in 2020, with a rate of 505 per 100,000. Today, 31% of those incarcerated are White (non-Hispanic), 24% are Hispanic, and a disproportionately high 33% are Black, despite Black individuals making up only about 13% of the overall U.S. population.13

Recognition of Public Health Challenges Associated with Prisons

Since 1980, the U.S. Department of Health and Human Services (DHHS) has released reports as part of the Healthy People Initiative, outlining national policy priorities to enhance population health. In 2010, following the peak of the U.S. prison population, DHHS acknowledged incarceration as a determinant of health disparities and a priority policy area for reform.14 Subsequently, public health practitioners have increasingly advocated for structural and policy-level changes to mitigate the health impacts of mass incarceration.15 These calls have gained momentum through social movements against police violence, increased awareness of the public health crisis in jails and prisons during the pandemic, and a surge in research unveiling connections between incarceration and health inequalities.

 

The public health crisis within prisons stems from various factors. Inmates entering correctional facilities often present with a myriad of pre-existing health issues, including chronic conditions like diabetes, hypertension, and HIV/AIDS, as well as mental health disorders such as depression, anxiety, and schizophrenia.1 These complex health needs demand comprehensive and specialized care, which may not always be readily available or adequately provided within the prison environment. Moreover, substance abuse disorders, including addiction to drugs and alcohol, further complicate the healthcare landscape within prisons.1

 

Additionally, the infrastructure and resources allocated to healthcare in prisons often fall short of meeting the diverse and demanding medical needs of the incarcerated population. Budget constraints, understaffing, and limited access to medical facilities and equipment contribute to substandard care and missed opportunities for intervention. Overcrowded conditions in prisons, exacerbated by tough-on-crime policies and mass incarceration, strain the capacity of healthcare facilities and personnel to provide adequate care.

Improving Mental Health Care in Prisons

Jails and prisons frequently function as primary providers of mental healthcare, but the treatment they offer often falls short of addressing the needs of individuals with mental illnesses. The prevalence of mental illness in state prisons is two to four times higher than in the community.16 Despite this, prisons often lack adequate clinical resources for this population, leaving individuals vulnerable to exploitation, mistreatment, and violence. Correctional officers often lack the necessary training to identify mental health symptoms, leading to punitive measures for behaviors stemming from psychiatric conditions.17

 

Moreover, individuals with mental illness are at a heightened risk of placement in long-term solitary confinement, where they face additional harm. Mental health treatment is frequently administered at the cell front, compromising confidentiality and the therapeutic relationship.18 This lack of privacy can discourage individuals from openly discussing their issues, thereby undermining the effectiveness of treatments. Prisons should increase access to qualified mental health professionals within their facilities and implement confidential treatment spaces to enhance the quality of care for individuals with mental illness.

 

The Stepping Up Initiative in Miami-Dade County, Florida, is a successful example of mental health care in prisons, featuring comprehensive mental health screenings upon intake, specialized units staffed with trained professionals, and collaboration with mental health courts to divert eligible individuals to community-based treatment.19 The program includes extensive Crisis Intervention Training for law enforcement, ensuring safer handling of incidents involving mentally ill individuals, and emphasizes continuity of care post-release, linking former inmates to community services and support networks. This data-driven approach has significantly reduced recidivism, saved millions in incarceration costs, and improved mental health outcomes, demonstrating an effective strategy in addressing the needs of incarcerated individuals with mental health disorders.19

 

Calls to Action:

 

  • Increase access to qualified mental health professionals within jails and prisons.
  • Implement confidential treatment spaces to enhance the quality of mental health care.
  • Provide comprehensive training for correctional officers to identify and appropriately respond to mental health symptoms.
  • Ensure mental health treatment is conducted in private settings, not at the cell front, to maintain confidentiality and the therapeutic relationship.
  • Develop and enforce policies to prevent the placement of individuals with mental illness in long-term solitary confinement.
  • Implement measures to protect individuals with mental illness from exploitation, mistreatment, and violence within correctional facilities.

Addressing the Rising Suicide Rates and Self-Harm in Prisons

Suicide rates in U.S. prisons rose by 85% between 2001 and 2018, surpassing community rates.14 This increase is linked to the prevalence of adverse childhood experiences, economic instability, and mental health and substance use disorders among incarcerated individuals.20 Nonsuicidal self-harm incidents, occurring nearly daily, involve 5-18% of men and 5-24% of women in prisons.21

 

Prisons inadequately address suicide and self-harm, with institutional policies exacerbating vulnerabilities. Punishments like solitary confinement and lack of family visits intensify social isolation and contribute to self-injury and suicidality. States such as Missouri, Texas, and Georgia criminalize self-harm among prisoners, responding with punishment instead of health care and compassion.21

 

Educating and training prison staff on suicide prevention, trauma-informed responses, and emergency clinical services is crucial. Furthermore, increasing access to mental health care, restricting solitary confinement, and reevaluating punitive responses to self-harm and suicide attempts are essential.

 

The “Samaritans Listener Scheme” in UK prisons effectively addresses suicide rates and self-harm through a peer support model where trained inmates, known as Listeners, provide confidential emotional support to fellow prisoners experiencing distress.22 These Listeners, who undergo extensive training from the Samaritans charity, are accessible 24/7 and work closely with prison staff, integrating into the prison’s mental health strategy. The program’s emphasis on confidentiality, regular monitoring, and ongoing support has fostered a supportive environment, significantly reducing suicide rates and self-harm incidents. The Listener Scheme’s success demonstrates its effectiveness as a model for mental health intervention in correctional facilities.

 

Calls to Action:

 

  • Educate and train prison staff on suicide prevention, trauma-informed responses, and emergency clinical services.
  • Restrict the use of solitary confinement, especially for those at risk of suicide and self-harm.
  • Reevaluate and reform punitive responses to self-harm and suicide attempts, replacing them with healthcare and compassion.
  • Adopt a program like the Samaritans Listener Scheme.
  • Develop and implement policies to reduce social isolation, such as maintaining family visits and other social connections.

Combating Substance Use and Overdose in Prisons

Substance users are disproportionately represented in prisons, with approximately 58% of individuals in state prisons having a substance use disorder.23 Drug markets operate within prisons, contributing to a high prevalence of drug-related issues.21 Overdose, a leading cause of death among incarcerated and formerly incarcerated individuals, has increased by over 600% from 2001 to 2018 within prison settings.11 Individuals are 12.7 times more likely to die from an overdose during the first two weeks following prison release.24

 

Prisons lack strategies to reduce fatal overdoses, with inadequate access to medications for opioid use disorder and underutilized overdose education and naloxone distribution programs.25 Individuals suspected or found to be using drugs in prison may face strip searches, forced detoxification, and even new criminal charges, while lacking access to harm reduction strategies and fentanyl testing.26 The punitive approach in prison, including solitary confinement, also increases the risk of overdose.

 

Public health solutions include expanding evidence-based drug treatment in prisons, such as medications for opioid use disorder, overdose education and naloxone distribution, and syringe service programs. Prisons should prioritize harm reduction programs, and such organizations can connect incarcerated individuals to services upon reentry. Ultimately, advocacy for racial equity in drug policies is necessary to dismantle the current carceral structures.

 

The Medication-Assisted Treatment (MAT) program implemented by the Rhode Island Department of Corrections (RIDOC) is a successful example of combating substance use and overdose in prisons.27 This comprehensive approach provides FDA-approved medications, such as methadone, buprenorphine, and naltrexone, to manage withdrawal symptoms and reduce cravings for inmates with opioid use disorder. The program ensures continuity of care post-release by connecting inmates with community-based MAT providers, offers extensive support services including counseling and peer groups, and provides training for prison staff and education for inmates. Using a data-driven approach to monitor and adjust the program, RIDOC has achieved significant positive outcomes, including a dramatic reduction in overdose deaths among recently released inmates.27 This program serves as a model for other correctional facilities, demonstrating the effectiveness of MAT in improving health outcomes and reducing overdose deaths in prisons.

 

Calls to Action:

 

  • Expand evidence-based drug treatment programs in prisons, including medications for opioid use disorder.
  • Implement and increase access to overdose education and naloxone distribution programs within prisons.
  • Establish syringe service programs in prison settings.
  • Improve connection to community-based services for incarcerated individuals upon reentry.
  • Develop strategies to reduce fatal overdoses in prison and post-release, including better access to medications and harm reduction resources.
  • Eliminate punitive measures like strip searches, forced detoxification, and new criminal charges for drug use in prison.

Mitigating Infectious Disease Risks in Prisons

Incarcerated individuals have an increased risk of infectious diseases due to factors like overcrowding and substance use. Hepatitis C is over ten times more prevalent in prisons than in the general population.28 Sexually transmitted infections and HIV are also more common in prison populations, with HIV incidence highest among individuals with multiple incarcerations.29 Transmissible respiratory infections, including tuberculosis (TB), are amplified in prisons due to inadequate ventilation. TB prevalence is 12 times higher in prisons than in the general population.28 The COVID-19 pandemic further highlighted the vulnerability of prisons to outbreaks, with significantly higher infection and death rates among incarcerated individuals compared to the public.30

 

Preventing the spread of infectious diseases in prisons requires comprehensive public health interventions, including screening, prevention, and treatment. Opt-out testing strategies for infectious diseases should be encouraged upon entry to increase testing rates. Prisons should also provide prevention measures, such as syringe-service programs and pre-exposure prophylaxis for HIV. To mitigate the risk of respiratory-borne illnesses, prisons should implement widespread vaccination, optimize ventilation, conduct surveillance testing, and reduce crowding to enable social distancing. Such measures not only protect incarcerated individuals but also prevent the transmission of diseases from prisons to surrounding communities.

 

The comprehensive HIV/AIDS program at the San Francisco County Jail effectively mitigates infectious disease risks through routine voluntary testing, early detection, and consistent antiretroviral therapy (ART) for inmates diagnosed with HIV.31 The program includes extensive education on disease transmission and prevention, harm reduction strategies such as condom provision and needle exchange, and ensures continuity of care post-release by linking inmates to community health services. Collaborating with community organizations and using a data-driven approach to monitor and adjust interventions, the jail has achieved significant reductions in HIV transmission rates.31 This multifaceted strategy demonstrates the effectiveness of routine testing, effective treatment, education, harm reduction, and post-release care in managing infectious diseases in correctional settings.

 

Calls to Action:

 

  • Encourage opt-out testing strategies for infectious diseases upon entry to increase testing rates among incarcerated individuals.
  • Provide prevention measures such as syringe-service programs and pre-exposure prophylaxis for HIV to reduce the transmission of sexually transmitted infections and HIV within prisons.
  • Implement widespread vaccination against transmissible respiratory infections like tuberculosis to mitigate the risk of outbreaks in prison settings.
  • Optimize ventilation systems in prisons to reduce the transmission of respiratory-borne illnesses.
  • Conduct surveillance testing for infectious diseases to identify and control outbreaks promptly.
  • Reduce overcrowding in prisons to enable social distancing and decrease the risk of infectious disease transmission.
  • Develop protocols for managing outbreaks of infectious diseases within prisons to minimize the spread to surrounding communities.

Addressing Noncommunicable Disease Disparities in Prisons

Individuals who are incarcerated experience elevated rates of noncommunicable diseases, including hypertension, kidney disease, and cancer.32 Preexisting factors such as diet, and activity levels, along with limited healthcare access, housing and food insecurity, and racism, contribute to these health disparities. Additionally, incarceration itself introduces risk factors, including acute and chronic stress, dehumanizing conditions, exposure to trauma and violence, poor diet, and variable access to physical activity and quality healthcare.33

 

In comparison to many European nations, where correctional systems provide nutritious and diverse food options, the U.S. lacks such provisions. Scandinavian prisons, for instance, offer incarcerated individuals regular access to onsite grocery stores, allowing them to shop, prepare meals, and dine communally.34 Scandinavian countries often report lower rates of recidivism compared to the U.S.35 This could be attributed to practices promoting health and nutritional benefits,35 and nutrition experts should advocate for similar access to higher-quality and more substantial food options for incarcerated individuals.

 

Calls to Action:

 

  • Advocate for providing nutritious and diverse food options in correctional facilities.
  • Implement programs promoting physical activity within correctional facilities.

Decarceration and Abolition

Structural-level changes are needed to address the health impacts of mass incarceration. Calls for decarceration, ranging from reforms to large-scale depopulation and even abolition of police, jails, and prisons, have gained momentum. The murder of George Floyd and subsequent civil unrest heightened public awareness of systemic injustices within the criminal legal system. Professional organizations, such as the American Public Health Association, explicitly recognize and condemn police brutality as a manifestation of structural racism, urging reform and abolition.15

 

Decarceration, acknowledging that both individual and community health improve with fewer people in prisons, involves interventions to slow admissions, reevaluate crimes requiring incarceration, shorten sentences, and expedite releases. The pandemic prompted the urgent need for decarceration as a public health imperative, prompting some jurisdictions to implement changes, such as moratoriums on low-level arrests and temporary releases.36 Insights from the fight for decarceration during the pandemic highlight the effectiveness of policies focused on reducing arrests and admissions at the front end of the criminal legal system in reducing prison populations.3

 

Addressing the issue of mass incarceration necessitates collective engagement from policymakers, practitioners, and activists. Policymakers play a pivotal role in enacting legislation that reevaluates incarceration criteria, shortens sentences for non-violent offenses, and emphasizes rehabilitation over punishment. By supporting community-based alternatives and ending low-level arrests, policymakers can redirect resources towards prevention and rehabilitation, fostering healthier communities and reducing recidivism rates.

 

Practitioners within the criminal justice system and healthcare sector also have a critical role to play. By providing comprehensive health services, advocating for decarceration, and developing effective reentry programs, practitioners can improve the well-being of incarcerated individuals and support their successful integration into society upon release. Additionally, offering training to law enforcement and correctional staff on alternatives to incarceration can shift perspectives and practices towards more holistic and restorative approaches.

 

Activists play a vital role in raising awareness, mobilizing public support, and amplifying the voices of affected communities. Through public awareness campaigns, grassroots movements, and community support initiatives, activists can apply pressure on policymakers to enact meaningful reform and address systemic issues such as structural racism within the criminal justice system. Collaborating with other organizations and stakeholders further strengthens advocacy efforts, creating a unified front for comprehensive criminal justice reform and public health improvements.

Conclusion

Mass incarceration in the U.S. has far-reaching implications for public health, exacerbating health disparities among marginalized communities and undermining the well-being of incarcerated individuals. Rooted in historical injustices and fueled by punitive policies, mass incarceration disproportionately impacts BIPOC communities, perpetuating systemic racism within the criminal legal system. This article has shed light on the myriad health challenges faced by incarcerated individuals, including mental illness, suicide, substance use disorders, infectious diseases, and non-communicable diseases, all of which are exacerbated by inadequate healthcare and punitive institutional practices.

 

However, there is hope in the growing recognition of mass incarceration as a public health crisis and the increasing momentum behind calls for decarceration and abolition. By shifting away from punitive approaches and towards community-based solutions, such as investing in mental health and substance use treatment, promoting harm reduction strategies, and addressing social determinants of health, the systems that perpetuate mass incarceration and its associated health harms can begin to be dismantled. It is imperative that policymakers, practitioners, and activists work together to enact structural reforms that prioritize the health and dignity of all individuals, creating a more just and equitable society.

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  38. A

About the Author

Alice Liu

Alice Liu is a medical student at Dartmouth College. Her interests include health equity and improving healthcare outcomes for marginalized communities. She received her MPH from Harvard University and her undergraduate degree from the University of Pennsylvania.

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