Dora M. Dumont

Public Health and the Epidemic of Incarceration

An unprecedented number of Americans have been incarcerated in the past generation. In addition, arrests are concentrated in low-income, predominantly nonwhite communities where people are more likely to be medically underserved. As a result, rates of physical and mental illnesses are far higher among prison and jail inmates than among the general public. We review the health profiles of the incarcerated; health care in correctional facilities; and incarcerations repercussions for public health in the communities to which inmates return upon release. The review concludes with recommendations that public health and medical practitioners capitalize on the public health opportunities provided by correctional settings to reach medically underserved communities, while simultaneously advocating for fundamental system change to reduce unnecessary incarceration.

Incarceration, Community Health, and Racial Disparities

Several recent studies have shown that the racial disparities in U.S. mortality nearly disappear in prisons. We review the social determinants of the recent epidemic of incarceration, especially the war on drugs, and describe inmate morbidity and mortality within the context of U.S. health disparities. Incarceration provides an important public health opportunity to address health disparities by accessing a high-need, medically-underserved, largely non-White population, but it has also been associated with poor long-term health outcomes. Viewing incarceration within the context of community health and community life shows that the more equitable mortality rates among inmates are not evidence of the beneficial effects of incarceration so much as an indictment of disparities in the community at large. Because people of color are incarcerated far more frequently than Whites, the experience may ultimately exacerbate rather than mitigate health disparities.

Medication assisted treatment in US drug courts: Results from a nationwide survey of availability, barriers and attitudes

Drug treatment courts are an increasingly important tool in reducing the census of those incarcerated for non-violent drug offenses; medication assisted treatment (MAT) is proven to be an effective treatment for opioid addiction. However, little is known about the availability of and barriers to MAT provision for opioid-addicted people under drug court jurisdiction. Using an online survey, we assessed availability, barriers, and need for MAT (especially agonist medication) for opioid addiction in drug courts. Ninety-eight percent reported opioid-addicted participants, and 47% offered agonist medication (56% for all MAT including naltrexone). Barriers included cost and court policy. Responses revealed significant uncertainty, especially among non-MAT providing courts. Political, judicial and administrative opposition appear to affect MATs inconsistent use and availability in drug court settings. These data suggest that a substantial, targeted educational initiative is needed to increase awareness of the treatment and criminal justice benefits of MAT in the drug courts.

How Health Care Reform Can Transform The Health Of Criminal Justice–Involved Individuals

Provisions of the Affordable Care Act offer new opportunities to apply a public health and medical perspective to the complex relationship between involvement in the criminal justice system and the existence of fundamental health disparities. Incarceration can cause harm to individual and community health, but prisons and jails also hold enormous potential to play an active and beneficial role in the health care system and, ultimately, to improving health. Traditionally, incarcerated populations have been incorrectly viewed as isolated and self-contained communities with only peripheral importance to the public health at large. This misconception has resulted in missed opportunities to positively affect the health of both the individuals and the imprisoned community as a whole and potentially to mitigate risk behaviors that may contribute to incarceration. Both community and correctional health care professionals can capitalize on these opportunities by working together to advocate for the health of the criminal justice-involved population and their communities. We present a set of recommendations for the improvement of both correctional health care, such as improving systems of external oversight and quality management, and access to community-based care, including establishing strategies for postrelease care and medical record transfers.

Survey Finds That Many Prisons And Jails Have Room To Improve HIV Testing And Coordination Of Postrelease Treatment

Early diagnosis of HIV and effective antiretroviral treatment are key elements in efforts to reduce the morbidity and mortality associated with HIV. Incarcerated populations are disproportionately affected by HIV, with the diseases prevalence among inmates estimated to be three to five times higher than among the general population. Correctional institutions offer important opportunities to test for HIV and link infected people to postrelease treatment services. To examine HIV testing and policies that help HIV-positive people obtain treatment in the community after release, we administered a survey to the medical directors of the fifty state prison systems and of forty of the largest jails in the United States. We found that 19 percent of prison systems and 35 percent of jails provide opt-out HIV testing, which is recommended by the Centers for Disease Control and Prevention (CDC). Additionally, fewer than 20 percent of prisons and jails conform to the CDCs recommendations regarding discharge planning services for inmates transitioning to the community: making an appointment with a community health care provider, assisting with enrollment in an entitlement program, and providing a copy of the medical record and a supply of HIV medications. These findings suggest that opportunities for HIV diagnosis and linking HIV-positive inmates to community care after release are being missed in the majority of prison systems and jails.

HIV Prevention for Adults With Criminal Justice Involvement: A Systematic Review of HIV Risk-Reduction Interventions in Incarceration and Community Settings

We summarized and appraised evidence regarding HIV prevention interventions for adults with criminal justice involvement. We included randomized and quasi-randomized controlled trials that evaluated an HIV prevention intervention, enrolled participants with histories of criminal justice involvement, and reported biological or behavioral outcomes. We used Cochrane methods to screen 32,271 citations from 16 databases and gray literature. We included 37 trials enrolling n = 12,629 participants. Interventions were 27 psychosocial, 7 opioid substitution therapy, and 3 HIV-testing programs. Eleven programs significantly reduced sexual risk taking, 4 reduced injection drug risks, and 4 increased testing. Numerous interventions may reduce HIV-related risks among adults with criminal justice involvement. Future research should consider process evaluations, programs involving partners or families, and interventions integrating biomedical, psychosocial, and structural approaches.

Correctional facilities as partners in reducing HIV disparities.

Abstract:The United States now has the highest incarceration rate in the world. The majority of prison and jail inmates come from predominantly nonwhite and medically underserved communities. Although incarceration has adverse effects on both individual and community health, prisons and jails have also been used successfully as venues to provide health services to people with HIV who frequently lack stable health care. We review demographic trends shaping the difficulties in providing care to incarcerated people with HIV and recommend the Centers for AIDS Research Collaboration on HIV in Corrections as a model of interdisciplinary collaboration in addressing those difficulties.

Medicaid Policies and Practices in US State Prison Systems

Medicaid is an important source of health care coverage for prison-involved populations. From 2011 to 2012, we surveyed state prison system (SPS) policies affecting Medicaid enrollment during incarceration and upon release; 42 of 50 SPSs participated. Upon incarceration, Medicaid benefits were suspended in 9 (21.4%) SPSs and terminated in 28 (66.7%); 27 (64.3%) SPSs screened prisoners for potential Medicaid eligibility. Although many states supported Medicaid enrollment upon release, several did not. We have considered implications for Medicaid expansion.

Incarceration of a Household Member and Hispanic Health Disparities: Childhood Exposure and Adult Chronic Disease Risk Behaviors

Introduction Incarceration of a household member has been linked to poor mental and behavioral health outcomes in children, but less is known about the health behaviors of these children once they reach adulthood. Methods We analyzed data from 81,910 respondents to the 2009–2010 Behavioral Risk Factor Surveillance System to identify associations between the childhood experience of having a household member incarcerated and adult smoking status, weight status, physical activity, and drinking patterns. We used multivariable logistic regression to control for sex, age, education, and additional adverse childhood events in the whole population and in separate models for Hispanic, non-Hispanic white, and non-Hispanic black adults. We also assessed for having multiple risk behaviors. Results People who lived with an incarcerated household member during childhood were more likely as adults than those who did not to engage in smoking (adjusted odds ratio [AOR] 1.50; 95% confidence interval [CI], 1.27–1.77) and heavy drinking (AOR 1.39; 95% CI, 1.03–1.87), after controlling for demographics and additional adverse childhood events. Exposure to incarceration in the household as a child among Hispanic adults was associated with being a smoker, being a heavy drinker, and having multiple risk behaviors and among white adults was associated with being a smoker and having multiple risk behaviors; among black adults there were no significant associations. Conclusion Incarceration of a household member during childhood is associated with adult risk behaviors, and race/ethnicity may be a factor in this association.

Adverse childhood events: Incarceration of household members and health-related quality of life in adulthood

Background. Incarceration of a household member has been associated with adverse outcomes for child well-being. Methods. We assessed the association between childhood exposure to the incarceration of a household member and adult health-related quality of life (HRQOL) in the 2009/2010 Behavioral Risk Factor Surveillance System controlling for age, race/ethnicity, education, and additional adverse childhood experiences. Results. Adults who lived in childhood with an incarcerated household member had higher risk of poor HRQOL compared with adults who had not (adjusted relative risk [ARR] 1.18; 95% CI 1.07, 1.31). Among Black adults the association was strongest with the physical health component of HRQOL (ARR 1.58 [95% CI 1.18, 2.12]); among White adults, the association was strongest with the mental health component of HRQOL (ARR 1.29, [95% CI 1.07–1.54]). Conclusions. Living with an incarcerated household member during childhood is associated with higher risk of poor HRQOL during adulthood, suggesting that the collateral damages of incarceration for children are long-term.