THERE HAS BEEN A TREMENDOUS increase in the correctional population over the last 25 years. Today, more than 2 million individuals are incarcerated in our nation’s jails and prisons, as compared to 500,000 in 1980.1 Much of this growth can be attributed to changes in sentencing law and policy, resulting in a dramatic increase in the number of inmates convicted of drug offenses and in lengthier sentences. In addition, as public health and social service programs are being reduced, more and more homeless individuals and those with mental health problems are ending up in correctional facilities.2 A disproportionate number of the incarcerated are poor3 and come from racial and ethnic minority groups.4 Their lifestyles often include drug and/or alcohol abuse,5 poverty,3 homelessness,5,6 under education,7 unemployment,8 and unsafe sex.9 Given these factors, it is not surprising that the inmate population is 1 in which problems such as tuberculosis, HIV, hepatitis, STD’s, and the consequences of violence and trauma are much more prevalent than in the general population.10–16 Many of these illnesses can affect not only the individuals themselves, but also other inmates, staff, and the community at large. Overcrowding, the frequent movement of inmates both between and within correctional facilities, and the short length of time some of these individuals spend in a facility often make it difficult to identify, treat, and prevent the spread of these diseases.
Despite the high prevalence of these problems in the prisoner population, the majority of prisoners have been medically underserved before their incarceration. This is due to a number of factors, including limited access to medical care in the community, lack of insurance, distrust of the medical establishment, competing priorities, and unpredictable lifestyles. Thus, for the majority of those who pass through correctional facilities each year, the jail medical staff functions as their primary provider, and is often the first contact with the health care system. For those inmates who suffer from chronic illnesses, drug or alcohol dependencies, communicable diseases, mental illnesses, or the various other ravages of poverty and violence, this contact with the public health care system is central to their health, the health of their families, and the health of the overall community. The opportunity to provide health care services in correctional facilities makes it possible to not only manage the treatment and prevent the spread of disease, but also to draw many inmates and their families into the public health care system.
Many people think of jail or prison as a life time sentence. In reality, the overwhelming number of incarcerated individuals will be returning to their communities. The average length of stay in a jail is approximately 2 to 3 months,17 whereas for prison, it is approximately 3 years.18 This means that efforts of correctional health care staff aimed at identification, treatment, continuity of care, and prevention of health problems are critical not only in reducing the incidence and prevalence of disease in correctional facilities, but also in the community at large. In its landmark 2002 report to Congress on The Health Status of Soon-to-be-Released Inmates, the National Commission on Correctional Health Care19 found that the failure to treat these problems is likely to have significant adverse effects on society. The report noted that released inmates who are not treated for communicable diseases may transmit these diseases to members of the general community and that many inmates who are released with untreated communicable or chronic diseases, or with mental illness, are likely to become a much greater financial burden on their local health care system than if they had been treated while still incarcerated and in an earlier stage of their disease. The report concluded that: by providing comprehensive prevention, screening, and treatment services in prisons and jails, communities can take advantage of a tremendous opportunity to improve public health by reducing the problems associated with untreated inmates returning to the community.
Many correctional systems do not have the necessary knowledge, skills, or resources to adequately address these problems. Collaborations between public health programs and correctional systems are an effective means of filling this gap. Public health departments have the staff, expertise, and other resources to assist correctional medical programs in developing and implementing necessary screening, surveillance, prevention, education, and transitional services. There are a variety of methods by which this can occur, including direct health department funding of health care programs; the presence of health department staff in correctional facilities to provide specific services, such as STD screening; the presence of a health department liaison; or regular meetings between public health and correctional staff to discuss public health issues. In San Francisco, the health care services are directly provided by the Department of Public Health Department. In addition, staff from other programs within the Health Department, such as STD Control and TB control, are assigned to the jail to assist in providing services such as STD screening, TB surveillance, partner notification, and contact investigations. This collaboration has also assisted in the development and implementation of comprehensive HIV education, prevention and treatment services (including the distribution of condoms), and in the successful transition of many of our patients with chronic medical and mental health problems into community care when they are released from jail.20
In summary, given the nature of the health problems seen in the correctional setting and the public health implications of these illnesses, correctional health care must serve a broader community than just the individual inmate patient. Because many prisoners do not normally access the health care system when not incarcerated,21,22 the period of their confinement provides a significant opportunity to address problems of concern to the general public. In addition to the treatment of specific medical problems, correctional health systems must also devote time and resources to screening, early detection and intervention, prevention, and health promotion. Problems such as substance abuse and mental illness, which are traditionally public health concerns, should be treated in a public health setting. Correctional institutions and health care programs should serve as conduits into the necessary community-based services. Finally, other public health problems, such as violence and the special needs of women need to be addressed within correctional facilities.23 By following such a course, the health and well-being of the community-at-large will benefit.
2. Greenberg GA, Rosenheck RA. Jail incarceration, homelessness, and mental health: A national study. Psychiatr Serv 2008; 59:170–177.
4. Bureau of Justice Statistics. Additional corrections facts at a glance: Correctional populations by race, 1986–1997. Available at: www.ojp.usdoj.gov/bjs/gcorpop/htm
. Accessed May 19, 2008.
5. McClelland GM, Teplin LA, Abram KM, et al. HIV and AIDS risk behaviors among female jail detainees: Implications for public health policy. Am J Public Health 2002; 92:818–825.
6. Weiser SD, Riley ED, Ragland K, et al. Brief report: Factors associated with depression among homeless and marginally housed HIV-infected men in San Francisco. J Gen Intern Med 2006; 21:61–64.
7. White MC, Marlow E, Tulsky JP, et al. Recidivism in HIV-infected incarcerated adults: Influence of the lack of a high school education. J Urban Health 2008; 85:585–595.
8. Stoner BP, Whittington WL, Hughes JP, et al. Comparative epidemiology of heterosexual gonococcal and chlamydial networks: Implications for transmission patterns. Sex Transm Dis 2000; 27:215–223.
9. Chen JL, Bovee MC, Kerndt PR. Sexually transmitted diseases surveillance among incarcerated men who have sex with men–an opportunity for HIV prevention. AIDS Educ Prev 2003; 15(suppl A):117–126.
10. Bick JA. Infection control in jails and prisons. Clin Infect Dis 2007; 45:1047–1055.
11. Roberts CA, Lobato MN, Bazerman LB, et al. Tuberculosis prevention and control in large jails: A challenge to tuberculosis elimination. Am J Prev Med 2006; 30:125–130.
12. Centers for Disease Control. Prevention and control of tuberculosis in correctional and detention facilities: Recommendations from CDC. Endorsed by the Advisory Council for the Elimination of Tuberculosis, the National Commission on Correctional Health Care, and the Am Correctional Association. MMWR Recomm Rep 2006; 55(RR-9):1–44.
13. Wohl DA, Rosen D, Kaplan AH. HIV and incarceration: Dual epidemics. AIDS Read 2006; 16:247–250, 257–260.
14. Vong S, Fiore AE, Haight DO, et al. Vaccination in the county jail as a strategy to reach high risk adults during a community-based hepatitis A outbreak among methamphetamine drug users. Vaccine 2005; 23:1021–1028.
15. Neighbors CJ, O’Leary A, Labouvie E. Domestically violent and nonviolent male inmates’ responses to their partners’ requests for condom use: Testing a social-information processing model. Health Psychol 1999; 18:427–431.
16. Hammett TM, Drachman-Jones A. HIV/AIDS, sexually transmitted diseases, and incarceration among women: National and southern perspectives. Sex Transm Dis 2006; 33(suppl 7):S17–S22.
20. Freudenberg N, Daniels J, Crum M, et al. Coming home from jail: The social and health consequences of community reentry for women, male adolescents, and their families and communities. Am J Public Health 2005; 95:1725–1736.
21. Lee J, Vlahov D, Freudenberg N. Primary care and health insurance among women released from New York City jails. J Health Care Poor Underserved 2006; 17:200–217.
22. McGuire J, Rosenheck RA, Kasprow WJ. Health status, service use, and costs among veterans receiving outreach services in jail or community settings. Psychiatr Serv 2003; 54:201–207.
23. Hatton DC, Kleffel D, Fisher AA. Prisoners’ perspectives of health problems and healthcare in a US women’s jail. Women Health 2006; 44:119–136.