Public Health In Prison
A growing body of evidence shows that incarceration drives further inequities in the health not only of prisoners, but of their families and their communities as well.
Seth Prins, PhD, assistant professor of epidemiology and sociomedical sciences and a Columbia Mailman School alumnus, believes that you can only see how a system truly operates when it is under pressure. Now, as jails and prisons across the country grapple with the pandemic, the pressure is on; and members of the Columbia Mailman School community involved in carceral health are getting a once-in-a-lifetime look at the extreme public health challenges faced by those affected by mass incarceration.
Columbia Mailman School has long worked to address issues surrounding incarceration’s risks and outcomes. In 2014, with support from the Tow Foundation, the School hosted leaders from more than 50 schools of public health for a conference titled A Public Health Approach to Incarceration: Opportunities for Action. The following year, Mark Hatzenbuehler, PhD, former associate professor of sociomedical sciences, published a study in the American Journal of Public Health showing that living in a community with high rates of incarceration is bad for the mental health of all residents regardless of whether or not they spent time in the correctional system.
Yet the pandemic has focused public attention on carceral health to an extent never before seen. The numbers are deeply concerning: According to data collected by the Legal Aid Society, the rate of coronavirus infections in New York City jails in early May was approximately 4.5 times higher than the rate in New York City as a whole. Across the country, mini-epidemics have broken out in correctional facilities. In June, the five largest known clusters of COVID-19 were not in nursing homes but in prisons. By September, The Marshall Project reported that there were at least 132,677 confirmed cases among prisoners.
Columbia Mailman School alumna Ellie Epstein (MPH ’18; Sociomedical Sciences) is seeing firsthand how “the pandemic is exacerbating and revealing tensions and challenges that already existed.” Epstein is director of Reentry and Transition Services at the Correctional Health Services (CHS), a division of New York City Health + Hospitals system that provides medical, mental health, substance use, and reentry support services to individuals in the city’s jails.
A vast body of research, much of it summarized in a recent special supplement to the American Journal of Public Health co-edited by Robert Fullilove, EdD, associate dean for Community and Minority Affairs, documents the health inequalities that confront justice-involved populations, which tend to be disproportionately comprised of already marginalized groups. The challenges range from lack of access to quality healthcare to higher rates of infectious disease, mental illness, and substance abuse. “Any situation that renders a population vulnerable socially also renders it vulnerable from a public health standpoint,” Fullilove says. Yet the health effects of mass incarceration are not limited to those who are caught up in the carceral state; there are collateral effects in the general population as well.
COVID-19 has raised the stakes by introducing a highly transmissible disease into crowded jails and prisons. But the conditions that imperil the health of those who are incarcerated, the communities from which they come, and those to which they will return were in place long before it burst upon the scene.
Glaring health disparities can be found among the currently incarcerated. Patricia Yang, who earned her MPH and DrPH from Columbia Mailman School, is senior vice president of CHS. She notes that rates of syphilis are 140 times higher among those in New York City jails than in the general population; rates of hepatitis C and chlamydia are five times higher; and the rate of serious mental illness is close to 16 percent versus 4.6 percent in the wider population.
Yet that is just the tip of the iceberg. A recent study by Prins and colleagues at Columbia Mailman School and Wayne State University in Detroit suggests that higher incarceration rates are associated with increased rates of premature mortality at a county level. Data also show that counties with higher rates of incarceration show higher mortality rates, especially among teens and young adults. The effect was most pronounced with deaths caused by infectious disease, as Prins and Sandhya Kajeepeta, MSc, a PhD student in Epidemiology, noted in an article they recently co-authored for The Appeal.
Equally troubling, however, was the notion that high levels of incarceration—and the United States has the highest in the world—can compromise the health of community members who have never been involved with the criminal justice system. While jails and prisons may seem isolated, they are in fact highly permeable: Most people who are incarcerated return to their community, and the staff who work with them shuttle back and forth. At last count, there were at least 28,899 cases of COVID-19 among prison staff.
Prins traces the relationship between incarceration and community mortality rates to a constellation of material and psychosocial factors. Mass incarceration removes working-age adults from local labor markets and makes it difficult for them to find jobs when they return. Similarly, it impedes access to education by making it hard to stay in school or complete vocational programs. At the same time, a parent being incarcerated may result in children becoming homeless. It degrades social ties and raises stress levels, affecting the health of adults and children alike.
Unfortunately, says Prins, while research shows that incarceration has little deterrent effect on crime and violence, resources have been poured into the carceral state at the expense of public health, education, housing, mental health and substance abuse treatment. As a result, the same marginalized groups whose health is most negatively affected by mass incarceration have been deprived of the supports that would mitigate its impact. “The coronavirus epidemic is helping people realize that the way that we do things, even under normal circumstances, is pretty bad,” he says. Prins and Fullilove, who is also a professor of sociomedical sciences, both advocate criminal justice reforms, such as eliminating pretrial detention, implementing bail reform, and choosing not to arrest and prosecute individuals for minor offenses. Prins notes that many of the measures that would protect vulnerable populations from the effects of climate change, such as investing in green jobs, strong public health-led prevention and health promotion, and universal healthcare, would also improve life for those affected by mass incarceration.
Fullilove points to the Bard Prison Initiative (BPI), through which incarcerated persons in New York state can attend college, as an example of how to help address health inequalities created by incarceration. He leads public health trainings and serves as senior advisor to the initiative’s Public Health Program. Since 2001, the initiative has equipped justice-involved individuals to become public health advocates: Incarcerated people can take courses in epidemiology, research methods, and health policy and management, while the BPI Public Health Fellowship offers formerly incarcerated individuals the opportunity to design and conduct original research. Fullilove and other Columbia Mailman School faculty teach in the program; and several of its alumni have earned master’s degrees from the School. “These folks enter public health research with a different view of the world than somebody who’s never been locked up,” Fullilove says. “I think they will amaze us with the ways in which they can shed light on things we only dimly understand.”
For her part, CHS’s Yang emphasizes the urgent need for supportive housing for the formerly incarcerated and for compassionate release programs that can get the most vulnerable, such as older adults with underlying conditions, out of confinement. The pandemic has led to New York City alone releasing thousands of incarcerated individuals from its jails.
But much can be done in the way of clinical interventions, as well. During her time as director of health policy in the mayor’s office, Yang played a pivotal role in transitioning CHS from a private, for-profit contractor to New York City Health + Hospitals, the city’s public healthcare system. That led to the expansion of telehealth services and the creation of therapeutic housing units within jails. “In many respects, the quality of clinical care that we provide in the jails now exceeds that in the community,” says Yang, who adds that CHS employs a number of Columbia Mailman School graduates. Most recently, she won approval to build therapeutic housing units for inmates within city hospitals, potentially eliminating the need for the sickest patients to undertake a nine-hour trip to see a specialist.
Under Yang’s leadership, CHS has also expanded its pre- and post-incarceration services. A program now provides medical and mental health screening for individuals who are awaiting their day in court while in police custody. The results of those screenings help CHS better care for those who ultimately wind up in jail, and participants can also allow their defense attorneys to use the information to argue for alternatives to incarceration.
The Point of Reentry and Transition (PORT) team that Epstein runs offers a helpline that connects formerly incarcerated people with medical and social services. Providers can access patients’ jail-based health records, helping to ensure continuity of care. PORT clinics are staffed by community health workers who have themselves been incarcerated. They help patients navigate the system: scheduling appointments, assisting with prescriptions, and more. “We have folks who are incredibly unwell, for whom care coordination can be challenging under the best of circumstances,” Epstein says. PORT eases their transition back to community-based care.
In the community, many formerly incarcerated people wind up at the Young Men’s Clinic, a partnership between Columbia Mailman School and NewYork-Presbyterian. Medical director David Bell, MD, MPH, estimates that at least 30 percent of his patients have a history of involvement with the justice system. “If attention to a health issue was delayed while they were incarcerated or they desire a second opinion, we address it. We screen for anxiety disorders, depression, and other mental health conditions. Judges and probation officers have referred patients to us,” he says.
Others at Columbia Mailman School are working to build a national effort to examine mass incarceration through a public health lens. The School’s Incarceration and Public Health Action Network, led by Dean Linda P. Fried, MD, MPH, and Patrick A. Wilson, PhD, is working to infuse carceral system reform issues into public health education. One area of focus: “We’re looking at schools as an opportunity for public health intervention,” says Wilson, an associate professor in sociomedical sciences. “So much of the school-to-prison pipeline is about how you discipline kids.” At the root of poor behavior, he points out, you often find layers of issues, such as exposure to trauma. Wilson and colleagues are working to foster partnerships between schools of public health and local organizations to shut off the pipeline at its source.
All of those working in this area recognize that much more needs to be done to redress the health inequities experienced by those ensnared in the criminal justice system and those who are at risk of becoming so. But they also know that the work they do is already making real change in the lives of justice-involved individuals, their families, and their communities. Says Yang, “When you go home at night and look in the mirror, you know that you’ve done a good job.”
Alexander Gelfand lives in New York City. He has written for Columbia Medicine and often covers health and social justice.