Incarceration as a catalyst for worsening health

The primary aim of this paper is to explicate the mechanisms through which incarceration affects health. Guided by theories that emphasize the compounding nature of inequality and with a focus on those that are disproportionately impacted by the drastic increase of incarceration over the last three decades, an exploration of these mechanisms is undertaken. This investigation provides a better understanding of the issues that are faced by incarcerated individuals in the incarceration environment, after release, and via macro-level policy. Finally, a hypothetical heuristic framework is presented that illustrates the ways in which incarceration affects individual, family and community level health. Implications for policy intervention programs and future research that serve to address diminished health among incarcerated populations are discussed. The incarceration rate has risen steeply in the United States over the last several decades, increasing by 397% between 1980 and 2011 (Carson and Sabol 2012; National Institute of Justice 1984). In 2011, there were a total of 6.98 million people in the criminal justice system, including 2.17 million in jails or prisons and 4.81 million on probation or parole (Glaze 2012). Drucker (2011) suggests that if the population of incarcerated individuals were likened to a city, this city would be the second largest in the United States. In addition to these staggering statistics, each year, on average for the last 25 years, more than 10 million people are arrested. In 2009 alone, there were more than 13,687,000 people arrested leading to over 600,000 new prison inmates (Federal Bureau of Investigation 2010). The causes of this extreme increase in the incarceration rate have been explored extensively across a number of disciplines. However, the factors that have led to the colossal rise in the number of incarcerated individuals are difficult to isolate. Importantly, the social context, both at the policy-level and micro-individual-level, has been widely cited as contributing to the surge in the incarcerated population (Alexander 2010; Drucker 2011; Mauer and Chesney 2002). Intersecting categories of disadvantage accounts for much of the relationship between mental health and incarceration (Draine et al. 2002). Mental health policy shifts, the closure of public mental health hospitals and a lack of political will to create alternative community support Correspondence: [email protected] Department of Human and Organizational Development, Vanderbilt University, 230 Appleton Place, Peabody #90, Nashville, TN 37203, USA © 2013 Brinkley-Rubinstein; licensee Springer. T Commons Attribution License (http://creativeco reproduction in any medium, provided the orig systems created a drastic reduction in available psychiatric inpatient beds and prohibition of admission to private hospitals for mental health patients (Lamb and Weinberger 2005). This resulted in an increased population of individuals living with untreated mental illness who are also increasingly likely to engage in “illegal behaviors” and, thus, become incarcerated. Additionally, policies related to substance abuse, such as those that culminated in the War on Drugs, led directly to an increase in drug-related arrests and the creation of harsher, more punitive laws regarding drug use (Boutwell and Rich 2004; Lurigio and Swartz 2000; Drucker 2011). Research demonstrates nearly twothirds of the increase in the federal prison population was due to stricter, more mandatory and determinant sentencing for drug offenses rather than an actual increase in crime (Mauer and Chesney 2002; Wacqant 2010). Concomitant with the War on Drugs was what Wacqant (2010) refers to as the “workfare revolution” that culminated in the Personal Responsibility and Work Opportunity Act (PRWOA) in 1996. These two simultaneous seismic policy shifts resulted in “hyperincarceration” that has disproportionately impacted low-income African Americans (Wacqant 2010). Incarceration rates among African Americans are much higher than their White counterparts. African American men specifically are incarcerated at a rate that is 650% greater (Sabol and Couture 2008). Strikingly, African Americans and Whites have nearly the exact same rate of drug use (7.4% for African Americans and 7.2% for Whites), but African Americans constitute almost 63% of drug arrests and more than 80% of drug possession arrests despite constituting only 13% of the total population his is an Open Access article distributed under the terms of the Creative mmons.org/licenses/by/2.0), which permits unrestricted use, distribution, and inal work is properly cited. Brinkley-Rubinstein Health and Justice 2013, 1:3 Page 2 of 17 http://www.healthandjustice.com/content/1/1/3 (Fellner 2008, 2009). Subsequently, the Bureau of Justice Statistics has projected that one in every three African American males is likely to go to jail or prison in his lifetime (Bonczar 2003). This disproportionate rate of incarceration, thus, affects many areas of one’s life including employment, education, and, most relevant herein, overall well being and health (Alexander 2010; Drucker 2011). Those who are most likely to experience incarceration, such as African Americans, often have pre-existing disproportionately high rates of many chronic and infectious diseases due to the many other social determinants of health that differentially affect at-risk populations (Williams et al. 2010; Adler 2007). Extant scholarship has explored the multiple mechanisms of incarceration that may also have a detrimental effect on health (de Viggiani 2007). However, whereas previous research has explored and identified a link between social conditions and health, a clear and extensive model theorizing the mechanisms of incarceration, their connection to worsened health, and exacerbation of health disparities among the most impacted populations is missing from the literature (Link et al. 2010; Williams et al. 2010; Adler and Stewart 2010). In fact, most frameworks elucidating the social determinants that negatively effect health omit incarceration altogether. Only the World Health Organization’s Model of the Impact of the Social Determinants of Health mentions social exclusion, but it does not fully elaborate or define this facet of the model (Commission on Social Determinants of Health (CSDH). 2008). Thus, this paper’s overall goal is to present the mechanisms through which incarceration exacerbates the conditions of an already medically disenfranchised population and contributes to a diminished health status of individuals, families and entire communities most impacted by hyperincarceration. Therefore, this paper’s specific aims are to: 1) present a theory that underpins the relationship between health and incarceration via a heuristic framework that hypothesizes how incarceration affects community, family and individual health, and thus, exacerbates health disparities; 2) elaborate on the specific mechanisms through which incarceration directly and indirectly deteriorates and impacts health via stress-producing circumstances that are imposed, enforced, and reinforced through the present day paradigm of criminal justice, and 3) to elucidate the policy, programmatic, intervention and future research implications that are necessary to address the effects of incarceration on health, and thus, address health disparities among those who are most likely to experience incarceration. However, first, a review of the research that examines the impact of incarceration on health is presented. This is necessary in order to better understand the relationship between health and incarceration. Literature review The extant literature that explores the link between health and incarceration can be classified into three distinct categories. The first examines the incarcerated experience and health. This category explores the relationship between mental and physical health and incarceration and the provision of healthcare in correctional facilities. Related is the second category that includes research that explores the link between incarceration and actions that may also influence health, such as risky sexual behavior and substance use. The third and final category includes scholarship that investigates the post-release transition and well being. This research focuses on post-release barriers to community reintegration and the sustained effects that they may have on health. The incarcerated experience and health Research has established a connection between incarceration and health. This is due, at least in part, to the potential for prisons and jails to amass individuals who are most at risk for accumulated disparities such as a high prevalence of experiencing violence, substance abuse, mental health issues and infectious and chronic diseases (Heron et al. 2009). Rates of HIV infection are four to six times higher, and one in three incarcerated individuals are estimated to have hepatitis C (Centers for Disease Control 2012; Maruschak 2006). About 4.2% of all tuberculosis cases occur in correctional facilities while less than 1% of the American population is incarcerated at any given time (Centers for Disease Control 2010; Schmitt et al. 2010). Additionally, Binswanger et al. (2009) found that those incarcerated in jails and/or prisons have a higher likelihood of experiencing hypertension, asthma, arthritis, and cervical cancer than their non-incarcerated counterparts. Prince (2006) analyzed hospital and prison administrative records and found that individuals who were diagnosed with schizophrenia who had a history of incarceration in New York City were more likely than their non-incarcerated peers to have a higher number of previous hospital stays, visits to the emergency room and re-hospitalization within three months of being discharged from the hospital. Research has been conducted that investigates the mortality rates of inmates compared to those in the general population. Studies have shown that the mortality gap narrows for some populations, in incarceration settings demonstrating the importance of routinized healthcare provision. African American inmates’ rate of mortality is lower compared to the general African American population, whereas Whites either have a higher or an unchanged mortality rate compared to their non-incarcerated White counterparts (Patterson 2010; Rosen et al. 2011; Spaulding et al. 2011). However, several studies have shown that incarceration is associated with decreased mortality among individuals Brinkley-Rubinstein Health and Justice 2013, 1:3 Page 3 of 17 http://www.healthandjustice.com/content/1/1/3 post-release (Binswanger et al. 2011; Binswanger et al. 2007; Calcaterra et al. 2012). New findings from Patterson (2013) illustrate that each additional year in prison produced a 15.6% increase in the likelihood of death for parolees, translating to a 2-year decline in life expectancy for each year served in prison (Patterson 2013). In addition to impacting physical health, research has also been conducted that illustrates incarceration’s impact on mental health. Previous findings indicate that imprisonment is independently associated with emotional reactions, such as anxiety, and that multiple incarcerations seem to elicit even stronger detrimental emotional reactions (Blanc et al. 2001; Schnittker et al. 2012). Incarcerated populations also have disproportionately high levels of various mental health issues such as depression and antisocial personality disorders (Fazel and Danesh 2002; Wilper et al. 2009) and post-release many inmates have a high rate of psychiatric disorders that may have gone undiagnosed (Mallik-Kane and Visher 2008). Finally, based on in-depth life interviews with individuals who served an average 19 years in a correctional institution, Liem and Kunst (2013) theorize that those who experience long-term incarceration may suffer from post-incarceration syndrome, which they likened to post traumatic stress disorder. Compounding the health issues already faced by many inmates is the fact that healthcare infrastructure in correctional facilities can create barriers that limit access to medical care (Magee et al. 2005). Hatton et al. (2007) investigated the specific issues related to healthcare access in jails and found that errors caused by the facility itself, hygiene issues, mandatory requirement of co-payment, delay in obtaining needed medications, side effects from medications, administration of wrong medications, medications stopped by mistake and allergic reactions to medications were common and often influenced the health of inmates negatively. Thus, existing research repeatedly demonstrates the compounding impact of the incarceration on the physical and mental health of prisoners, both while serving their sentence and following release. The link between incarceration and engagement in risk behavior Research has also explored the risk behavior of individuals who are prone to experience incarceration and how it influences the likelihood of re-incarceration and health status. A large focus of this literature examines the role of drug use, the nature of drug use for incarcerated populations, and the relationship between drug use and infectious diseases, such as HIV (Horton 2011). Studies have examined post–release sexual risk behavior and found that those who have a steady, long-term partner prior to incarceration are less likely to be inconsistent condom users, have sex while high on drugs and/or using alcohol, use marijuana daily or carry weapons during illegal activity immediately after release (Ramaswamy and Freudenberg 2010). Catz et al. (2012) also found that partners’ perceptions that being released from prison increases sexual desirability, partners’ negative condom attitudes, depression, strong desires for sex and/or substance use and HIV disclosure-related fears of rejection act as barriers to risk reduction after release from prison. Post-release transition and reintegration into the community The final category of incarceration and health includes research that focuses on the post-release experience of former inmates and how reintegration into their home community affects access to healthcare and successful reintegration. They include issues related to micro, individual factors and macro-level policy such as inability to find a job or job training, issues related to medications (for those who are already ill), finding housing and shelter, administrative or bureaucratic barriers in obtaining services, lack of emotional support from both peers and professionals, issues with medical care including obtaining insurance such as Medicaid, transportation, and lack of availability of social services (Petersilia 2008; Sowell et al. 2001). Additionally, Rotter et al. (2005) posit that the experience of incarceration may force inmates to adapt to the prison environment by adopting a hyper masculine “inmate code.” This adaptation includes rules and values such as not reporting violations and not appearing weak within the prison walls. These attitudes, however, manifest and persist even after release and can cause confrontational behavior that may hinder successful reintegration and lead to re-incarceration. The mechanisms through which incarceration impacts health The remainder of this paper will explore ways in which incarceration directly and indirectly affects health. Figure 1 is a visual depiction of the crosscutting nature of incarceration on communities, families and individuals and serves as the conceptual grounding for the heuristic framework that is proposed. As such, it illustrates that incarceration has a multi-level impact that affects all realms of one’s life. Figure 2, then, is a heuristic path model elucidating how incarceration acts as a catalyst for worsening health. More specifically, this model presents a hypothetical path via which incarceration deleteriously affects multiple levels of health. More specifically it theorizes that incarceration affects the health of individuals, families and communities via the incarceration experience, worsening social conditions post-release and macro-level policy. Figure 1 Conceptual model of incarceration’s multi-level impact. Brinkley-Rubinstein Health and Justice 2013, 1:3 Page 4 of 17 http://www.healthandjustice.com/content/1/1/3 Theoretical underpinnings The conceptual and heuristic framework for the current study is guided by a number of inter-related theories that illustrate the cumulative effects of stressful and negative life events imposed via incarceration. They include intersectionality theory (Andersen and Collins 1998; Collins 2000; McCall 2005), which seeks to explain how social and cultural classifications (such as gender, race, class, ability and other axes upon which individuals build their identity) interact simultaneously to contribute to inequality; life course theory (Berkman 2009), relevant Figure 2 Incarceration as a catalyst for worsening health. to exploring the longitudinal and continual impact of the incarceration experience; weathering (Geronimus and Thompson 2006), a conceptualization of aging in which vulnerable and at risk populations experience depreciated health because they have more severe and more recurrent experiences with societal and economic hardship than that experienced by other groups; and the social ecological model (Bronfenbrenner 1979; Rappaport 1981) which has a focus extending beyond individuals, taking a crucial stance that shifts responsibility for reducing health inequalities away from individuals onto the environmental factors and systems in which they are situated. Critical to each of these frameworks is the need to focus on the societal, policy, community, family and individual level rather than just micro-level behaviors. To date, the focus of most policies and research related to incarceration has been on the outcomes affiliated with behaviors, absent of considerations of the sociopolitical contexts that may impact individual decision-making. Thus, attention must be paid to the influence of macroscale variables (e.g. drug law policies) and how societal conceptualizations of behavior affect an individual’s construction of attitudes and behavior over the life course. Furthermore, the interaction between individual and societal norms must be better understood in order to more comprehensively address the means through which incarceration intensifies health disparities longitudinally. A long-term approach that takes into account the multidimensional nature of disparity is necessary to exploring the sustained and continual effect of the incarceration experience. A nuanced view of incarceration’s impact extends the existing literature because it assumes Brinkley-Rubinstein Health and Justice 2013, 1:3 Page 5 of 17 http://www.healthandjustice.com/content/1/1/3 that the effect of incarceration is not temporary and limited to the time of imprisonment. Instead, incarceration has the ability to cascade into each area of one’s life and, as such, can affect individuals and communities on multiple levels (e.g. individual, family, community) and for extended durations. Additionally, those who are most likely to be incarcerated are also more likely to come from impoverished backgrounds, to have been victims of crime, live in violent, low-resource neighborhoods, and to have lower levels of educational attainment (Travis and Crayton 2009). Therefore, individuals who are most at risk of incarceration are already more likely to have lower levels of self-rated health, less access to medical care and health insurance, and lower quality of care (Veenstra 2011). These issues related to access and standards of care can compound to further exacerbate health disparities. Incarceration’s impact on health begins with the incarceration experience itself, is followed by postrelease setbacks and has foundations in policy that restricts access to various rights, including employment and housing. Incarceration as a catalyst for worsening health In this section, the ways in which incarceration negatively impacts health are explained in more detail by focusing on the specific mechanisms of incarceration that affect health via the incarceration environment, after release, and on the policy level. Although each of these mechanisms has a separate and distinct influence on health, it is essential to develop an understanding of the cumulative, continual and intersectional impact of the stressors and inequalities that are first experienced inside the walls of a prison or jail. It is also particularly important to explain the mechanisms through which incarceration negatively affects health not only for individuals but also for families and, eventually, communities. Table 1 identifies the main variables of interest—each of which acts individually and in combination with other factors to deleteriously affect the health of incarcerated populations. Incarceration environment In the correctional setting, individuals are faced with a number of circumstances, each of which affects health. These include experiencing various forms of deprivation, exposure to the “prison code”, existing in a coercive and controlling environment, poor prison conditions, and the mandatory provision of healthcare.