Approximately 5% of Americans will be incarcerated at some point in their lives, a number that varies greatly along racial lines. Why don’t we talk about this far-reaching public health issue, and driver of racial disparities in health outcomes, in our medical education?
During the course of my medical education, I listened to countless lectures and took part in many discussions regarding the social determinants of health in the context of marginalized and underserved populations. Unfortunately, incarcerated individuals and other justice-affected persons are often conspicuously underrepresented in the medical school curriculum, research, and discourse. This community is disappointingly large in the United States and despite a downtrend in recent years, the prison population is aging, which means increased comorbidities and complexity (and cost) of care.
Many medical students are seemingly unaware that the topic of correctional health even exists, and I imagine even fewer choose to pursue it as a career. One does not have to choose to work in a carceral facility to be involved in carceral health. In fact, it is likely that every medical student will, over the course of their physician career, treat someone who has been affected by the justice system. Not every justice-affected person will walk into a clinic escorted by correctional officers. Many may not have been incarcerated themselves, but had a parent, spouse, sibling or someone close to them that was. That in and of itself may have implications for their health, perspectives and other factors that color the patient-provider relationship.
Approximately two million Americans are in prison or jail at any given time. Because 95% of incarcerated individuals will eventually be released, correctional health is inherently a matter of public health. Racial disparities within the correctional system have also been described as a driver of racial disparities in health outcomes. Aside from the ethical, public health and health equity considerations, there are legal ones too. In 1976, the Supreme Court ruled in Estelle v Gamble that the deprivation of reasonably adequate medical care was a violation of incarcerated individuals’ rights under the Eighth Amendment. Following this ruling, incarcerated individuals became one of two groups that were constitutionally guaranteed healthcare (the other being Native Americans). Unfortunately, what constitutes “reasonably adequate” is still debated, resulting in wildly varying quality of care among different correctional systems and an overall set of generally worse health outcomes for those who are or have been incarcerated.
Because it is an issue that affects so many people, and has serious implications for individual and public health, it’s time to broaden the discussion surrounding the social determinants of health to include groups less commonly discussed, including the incarcerated and justice-affected persons. In my experience, there has been no shortage of opportunities to have this discussion, and yet, the conversation inevitably returns to the repeatedly discussed topics in lieu of introducing new, unknown topics. Justice affected persons are certainly not the only group that need to be included; for instance, the unhoused and undocumented, among others, take part in the healthcare system with challenges unique to their circumstances and experiences. It’s time for a more inclusive and holistic medical education curriculum that addresses the varied groups of marginalized populations that exist within our communities. Lectures, group discussions, and working directly with these populations where feasible will help foster a more informed and well-rounded group of future physicians.
