The proportion of mental and physical health disorders in America’s prisons far surpasses that of the general population by up to 10 times. In this article, I hope to examine some causes of this discrepancy, compare and contrast the various prison systems across different countries, understand the shortcomings of America’s prison system in addressing these issues and shed light on how prison systems can provide better health care services. I particularly focus on mental health disparities, infectious disease spread and control, gaps in women’s health and advancements over the years in prison health.
Once we establish that prisoners have a fundamental human right to health care, we then must consider the traits or life circumstances which made them vulnerable to incarceration as well as the inequality in care which they receive while serving their sentence. Therefore, it is vital to distinguish between the mental health disparities which preceded imprisonment and those which were precipitated by life in the prison system. This framework also encourages us to consider the broader question of how society should treat prisoners — should prisoners be justly punished for their sins or rehabilitated for their mistakes?
Sweden has a unique perspective on the prison system which focuses on rehabilitation rather than punishment. With the lowest rate of recidivism of all European nations, Sweden’s prison model is now beginning to attract worldwide attention. Sweden’s “rehabilitation-focused” model is multi-faceted and comprehensive, beginning with the physical prison facilities themselves, which are superior to the living conditions of some non-incarcerated populations worldwide. As a result, Swedish prisoners are housed in an environment which encourages growth, not punishment.
Moreover, prisoners are given free access to the prison library, encouraged to partake in university courses and provided access to other life-skills programs that enhance their education and life experiences, with the ultimate goal of reintroducing prisoners to society prepared to pursue new jobs and fruitful opportunities. These aspects of care improve prisoners’ quality of life both within, and subsequently, after prison, consequently improving their overall mental health.
Therefore, the Swedish prison system at the very least maintains the mental health of prisoners, substituting years ‘lost’ to the prison system with years ‘gained’ in self-improvement. In contrast, inmates in most nations lose years of their lives with no academic, career or skills advancements, thus complicating their opportunities in finding a job upon return to society. In fact, 58% of female inmates in the United States who committed another offense upon release reported the reason for their recidivism was unemployment or lack of skills to get a job.
Improving prisoners’ mental health can have cost benefits, too. Incarcerated individuals with mental health conditions are far costlier with additional staffing, psychiatric medications and lawsuits accounting for the extra expenditure. In Texas, for example, supporting the average prisoner costs $22,000 annually, whereas a prisoner with mental illness can cost up to $50,000 per year.
What’s more, prisoners with mental illnesses tend to have longer sentences, thus further burdening both taxpayers and the prison system. Accordingly, I believe that it’s worth investigating if treating their mental illness properly through rehabilitation and proper psychiatric attention would reduce the burden on both the prisoner and the system, especially considering the funds of re-incarceration if the individual commits a second crime upon release.
Another health care concern in prisons is the high incidence and spread of infectious diseases. In 2013, WHO and the United Nations Office on Drugs and Crime (UNODC) published Good Governance for Prison Health in the 21st Century, a set of recommendations which established several major recommendations: prisoners share the same right to health care as others, prisoners generally come from a socioeconomically disadvantaged background and carry a high incidence of both communicable and noncommunicable diseases as compared to the general population. Prisons are high risk environments for infectious and communicable diseases like HIV/AIDS or TB due to prison-specific factors such as overcrowding, limited water access, frequent transfers of personnel and delayed diagnoses of communicable conditions.
Further priming prisoners’ vulnerability to communicable disease is their poor baseline levels of health — a consequence of many factors including poor nutrition, substance use disorders and the presence of pre-existing chronic illnesses. Among these existing illnesses, HIV is the strongest risk factor, which offers a 20-37 fold increased chance of acquiring TB, the opportunistic infection which accounts for 25% of deaths among those living with HIV. HIV transmission is especially amplified in prisons with the highest incidence of shared-needle drug use, unprotected sex (potentially with multiple partners) and unhygienic tattoos and piercings. In fact, as many as one in four HIV-infected individuals and one out of three with Hepatitis C infection in the United States passes through correctional facilities every year.
United States prisons have the highest number of female inmates in comparison to any other country worldwide. 81% of incarcerated females are imprisoned for nonviolent crimes such as theft. Of these, 83% have reported long-standing mental illness or self-harm. This holds true in most other nations as well, as 90% of incarcerated women in England and Wales, for example, had a diagnosis of a mental disorder, substance use disorder or both.
In additional to the lack of regard for mental health, 70% of prison guards are male, a factor likely contributing to the notorious sexual harassment and assault, which has been reported by 72% of female inmates. Neglect is another commonly experienced issue among female inmates. In August 2019, video footage was released of 26-year-old Diana Sanchez giving birth alone, with no medical assistance, in her cell in Denver, Colorado, after her pleas for help during labor were ignored by the guards. Unfortunately, such events are not unique; many states lack official standards for medical care for pregnant incarcerated women and as a result, 46% of pregnant women failed to receive any form of prenatal care while incarcerated.
Additionally, twelve states in the United States practice restraining women while giving birth, a practice condemned by national standards, as it has been associated with missed diagnoses of complications, worsened pain and limited movement during birthing. Lastly, 20% of female inmates’ pregnancies end in miscarriages, about twice the national average, and 10% are preterm births, 10 times higher than the national average. Further complicating matters, one-third of female prisoners have no home or possessions for support upon completion of their prison sentence, minimizing the chance that they will receive adequate medical care even upon release, with no financial stability.
Female health in prison is a unique problem because it not only affects individual health, but also generational health through the negative impact that maternal incarceration has on children. Fewer than 10% of children are cared for by their fathers in their mother’s absence and 40% of young women in prison are mothers. The emotional trauma inflicted on children who have been separated from their mothers and raised in foster homes has been well documented and has resulted in a vicious cycle of generational imprisonment, with the children of incarcerated mothers having a 60% higher chance of future imprisonment themselves. Many countries provide mother and baby units in special facilities for very young children to stay with their incarcerated mothers, however, the consequences of raising a child in a nonstandard prison environment have not been studied.
Advancements in Prison Health
Several countries have begun to pave the way for advanced care in their prison systems with various improvements in addressing physical and mental health concerns. Despite these improvements, we are still lightyears away from bridging the gap in the various discrepancies between the health care of the general population and inmates. Fortunately, there are several small and attainable measures that can affect short-term progress towards the greater goal of health equity.
The World Health Organization’s Mental Gap Action Program is designed to improve the mental, neurological and substance use disorders seen in the general population of low and middle-income countries. Ethiopia is the first country to implement this system to improve the training of health care providers in the prison system. Acknowledging that this is a beneficial program for not only low and middle-income countries, but all prisons across the world, would be an effective first step in improving health care access for prisoners worldwide.
Recently, the Texas Prison system has demonstrated improvements in the care of chronic illnesses, including diabetes and hypertension. One way to improve mental health and reduce the spread of infectious diseases would be to apply the same principles to additional chronic illnesses such as substance use disorders and psychiatric illnesses.
The Texas system has also shown, for example, that HBV vaccinations reduce the risk of further disease spread to partners of unprotected sexual intercourse and shared needle drug users, saving thousands of dollars per case of HBV prevented. Such interventions can even benefit the non-incarcerated population as well. In San Francisco, for example, STI rates in the local community significantly decreased after universal testing for chlamydia was implemented in the prison population.
Despite evidence that needle exchange programs reduce the spread of infectious disease without increasing rates of drug use, clean needle distributions are underutilized in prisons around the world. The first needle exchange program in a prison was initiated in Switzerland in 1994, but since then, only 60 prisons have taken up this practice worldwide. Currently, most prisoners sterilize needles for re-use using dispensed bleach.
This, however, comes with several shortcomings. Bleach does not eliminate Hepatitis C completely and the bleach dispensers are commonly emptied or discouraged by prison staff as evidence of forbidden drug use. Importantly, these efforts to reduce needle availability do not effectively discourage drug abuse, as inmates often resort instead to using other materials such as “markers, light bulb filaments [or] the inside of a pen tube,” to inject.
The majority of health disparities for the incarcerated population arise from society’s tendency to view prisoners as outcasts rather than fellow human beings and to emphasize punishment over rehabilitation. Acknowledging first and foremost that prisoners deserve health care, a human right, would shed light on the inadequate provision of care demonstrated by most prisons around the world. Providing an environment of nurture, equal access to health care resources, reducing harm and setting minimum standards of care, especially for vulnerable populations, are all important steps in addressing the inadequacy of health care services currently being provided to the world’s incarcerated population.