Man in orange uniform standing beside gray metal gate. Photo by RDNE Stock project/Pexels.
Isa Montes is a double major in Ethnic Studies and Political Science, and is a 2023-24 health care ethics intern with the Markkula Center for Applied Ethics at Santa Clara University. Views are her own.
Incarceration
The United States criminal legal system includes thousands of federal, state, local, and tribal systems. As of January 2024, the Prison Policy Initiative reported over 1.9 million currently incarcerated persons in 1,566 state prisons, 98 federal prisons, 3,116 local jails, 1,323 juvenile correctional facilities, 142 immigration detention facilities, and 80 Indian country jails, as well as in military prisons, civil commitment centers, state psychiatric hospitals, and prisons in the U.S. territories. For those currently incarcerated, those with a history of incarceration, and their families and communities, incarceration leaves a lasting effect on health and well-being.
Incarceration as a Social Determinant of Health
Studies have shown that people who are incarcerated are more likely than the general population to have high blood pressure, asthma, cancer, arthritis, and infectious diseases, such as tuberculosis, hepatitis C, and HIV. Men and women with a history of incarceration have worse mental and physical health when compared to the general population. Further, as the number of older adults (aged 50 and above) in U.S. prisons increases, many correctional facilities fail to adequately respond to the special health needs of these individuals. Only 18 percent of older incarcerated adults were prescribed medication to treat their mental health conditions.
When it comes to release from prison, the process of reintegrating prisoners into society proposes unique adversity for older adults who have spent significant amounts of time in prison. For many, life after prison is just as detrimental because of the stressors and struggles posed when adjusting to changes in society and specific communities after social seclusion and isolation. The effects of incarceration reach even the family of those incarcerated. For example, children of incarcerated parents are at higher risk of poverty and homelessness and may be more likely to witness domestic violence or substance abuse by a parent, and more likely to reside with a person who has a mental illness or suicidal thoughts.
Generally, carceral practices are associated with both mental and physical health problems. It must be recognized that carceral practices are disproportionately employed for Black, Indigenous, People of Color (BIPOC), thereby creating disparate health outcomes not only along carceral status, but along racial lines as well. These issues are intersectional and compounding.
Incarceration as a Public Health Crisis
The adverse impacts of the prison environment are abundant and undeniable. Prison meals are commonly energy-dense (high-fat, high calorie) foods that lack nutritional value. Though smoke-free correctional facilities are on the rise, smoking continues to be a persistent issue. Poor ventilation, overcrowding, and stress have the potential to exacerbate chronic health conditions. But perhaps most notable, and certainly the most studied, is the repercussions of incarceration on mental health in particular.
Overcrowding and isolation units are the two conditions most associated with the severe degradation of mental health. Case studies have unveiled the prevalence of segregation units, in which a person is restricted to an isolation cell for 23 hours a day. This restriction—deprivation of both movement physically and human contact socially—triggers psychological responses, resulting in anxiety and panic to hallucination. Moreover, the prison environment lends itself to cases of sexual assault and intentional injury, either self-inflicted or resulting from assault. With these factors and more at play, the increased likelihood of an early death may not come as a surprise for those affected by incarceration.
Incarceration is a clear and abhorrent disregard for beneficence. Solitary confinement, exposure to violence, and other harsh conditions inflicted by prison are manifestations of complete neglect for nonmaleficence, let alone beneficence and respect for autonomy. While it is relatively well known that the United States incarcerates its citizens at a rate greater than any other country, the effect that this has on our national health is an understated issue. In 2014, the life expectancy at birth in the U.S. was 78.8 years. Meanwhile, comparable countries (Spain, Sweden, Switzerland, Netherlands, New Zealand, Norway, Italy, Japan, France, Germany, Canada, Australia, Austria) had life expectancies above 81 years. Incarceration is a public health crisis. For every one year in prison, two years are taken off an individual's life expectancy. With millions of people locked up, a 2017 report found that mass incarceration has shortened the overall U.S. life expectancy by almost 2 years. Moreover, a 2020 study concluded that incarceration caused excess adult mortality—a loss of between 4 to 5 years of life expectancy at the age of 40.
Incarceration as both an issue and an opportunity
All things considered, when we think about the dire implications of mass incarceration, we are left with two central questions:
- Should prisons be abolished?
- If prisons are not abolished, what can be changed?
Although these questions cannot be easily answered here, I implore you to interrogate the history of carceral practices and reverberations of systemic oppression. I invite you to explore radical reimaginations of justice through a comprehensive review of abolitionist literature and visual works. A few examples can be found below:
- Are Prisons Obsolete? by Angela Y. Davis
- The New Jim Crow by Michelle Alexander
- 13th available on Netflix
- Time: The Kalief Browder Story available on Netflix
In seeking answers to the second question, some arguments made for overall physical health improvements during carceral confinement should be acknowledged. For people who would otherwise be living chaotic or unstable lives, incarceration provides regular meals, a structured schedule, reduced access to alcohol, drugs, and cigarettes, and access to healthcare. Black men on average have lower access to health care than white men outside of prison. Thus, correctional facilities may be in a novel position to provide some level of health care that would otherwise never be accessible to people. Newton Kendig, Medical Director for the Federal Bureau of Prisons from 1999-2015, firmly believes that in addressing justice-involved patients’ health needs, we can reduce healthcare disparities and ultimately strive for healthier and safer communities. He advocates for a strategic public health opportunity in which jails and prisons screen and diagnose infectious diseases among persons who do not have contact with traditional healthcare systems and are also at high risk for illnesses. A system of diagnosis could lead to treatment of chronic disease like diabetes, hypertension, addiction, and mental illness among individuals who have not sought or had access to treatment prior to incarceration. It is believed that the prison environment could lend itself to better compliance with taking prescribed medications, healthy eating, engagement with drug treatment services, frequent recreation, and a tobacco-free environment.
However, even with the potential of these positive impacts, we return to inherent harms. There remains a disconnect between healthcare and state and local public health departments when it comes to actually delivering care to incarcerated persons and upon their release. The disconnect is evident in three main ways:
- Inconsistent policies and procedures for medical testing across states and facilities. The wide-scale screening that does exist does not ensure that appropriate treatment is provided after diagnosis.
- Limited resources and understaffing. Conditions of overcrowding create a culture where staff who are meant to provide care operate with “cynicism and fear.”
- Substance dependence. Treatment for addiction—a chronic brain disease that can be effectively treated—is consistently insufficient for the needs of those incarcerated. During incarceration, detoxification and symptoms of withdrawal are frequently treated with analgesics, in turn failing to address the underlying addiction and only advances vulnerability to relapse and overdose upon release from jail or prison.
In their current state, prison environments are inhospitable and ill-equipped to properly deliver medical and mental health care because of “their mission, their culture, their training, their reward systems, their bureaucracies.” So what can be changed? What can we do?
Compassionate care for the health of the incarcerated
Early on in the Health Care Ethics Internship, our cohort discussed a framework for ethical decision making through six ethical lenses. In this case, I want to hone in on the Care Ethics Lens. With Care Ethics, our actions and decision making are founded on the belief that there is a universal interdependence between humans. This invaluable interconnectedness is born from relationships with one another, appreciation for emotions and the body, and “the context-sensitive nature of ethical deliberation that does not merely follow abstract moral rules.”
Admittedly, correctional facilities cannot easily be converted to carry the same functions of a hospital. Jails and prisons tend to limit communication and collaboration, thwarting a relationship between health care providers and facility staff. Unlike a standard health care setting, healthcare providers have less authority; incarceration thereby hinders health care providers’ ability to do their job and patients’ confidence in the health care providers. It has been observed that even the most well-trained, well-intentioned care providers require a change in attitude about the patient—the incarcerated person.
Care ethics places an emphasis on duties and motivations to act derived from one’s relationship with friends or family. Our capacity to care is based on shared history, kinship, or the knowing of another person—not simply because that person is good or useful for other interests. This is not exclusively applicable to relationships that we consider personal or intimate. Care pours into our professional settings, relationality to fellow citizens, and even to global connections that exist oceans away. Care stands on revolutionary empathy that relieves burdens of bias and fear and empowers us to respond more attentively and holistically to the needs of others.
Health care providers may not share personal relationships with those incarcerated. Nonetheless, health care should recognize the ways in which mere adherence to moral rules and normative relationships ignores the critical complexities of our caring relationships. When incarceration ensures seclusion and results in early death, who will care for incarcerated persons? Through a care ethics lens, I ask that we picture ourselves in the position of an incarcerated person. We are interconnected and overlapping. We—healthcare providers and community members alike—must expand our care for one another.