According to the Centers for Disease Control and Prevention, individuals entering correctional facilities have higher rates of infectious diseases, including HIV, tuberculosis and hepatitis C, than the general population of the United States (1). Former inmates make up 17% of people in the United States with AIDs, between 13 and 19% of people with HIV, 20 to 32% of those with hepatitis C and 35% of the US population with tuberculosis. There is significant overlap between populations that are at high risk for imprisonment, populations that are at high risk for infectious disease and populations that have limited access to medical care, and for this reason many have argued that prisons offer a site for potentially wide-reaching health interventions (2). In offering treatment to individuals entering prison with a communicable disease and taking measures to prevent the spread of such diseases, correctional departments could extend their mission of protecting public safety to include fortifying public health.
Perhaps a first step prisons may take towards treatment and prevention of infectious diseases is conducting health screenings. The CDC suggests that screenings for infectious diseases can increase the overall health and safety of incarcerated populations by providing correctional facilities with the information they need to take treatment and prevention measures (1). Missouri has taken steps to ensure this practice by codifying it: Missouri law mandates that “all individuals who are delivered to the department of corrections and all individuals who are released or discharged from any correctional facility operated by the department of corrections, before such individuals are released or discharged, shall undergo HIV and tuberculosis testing without the right of refusal. In addition, the department of corrections may perform or conduct infectious disease testing on offenders without the right of refusal” (3).
In addition to screenings and treatments for infectious diseases like HIV and TB, prisons offer an opportunity to update adult populations that may not otherwise have access to medical care on vaccine regimens. In their article “Vaccinations in prisons: A shot in the arm for community health,” author Víctor-Guillermo Sequera and colleagues argue that vaccines should become a priority health intervention in prison. Prison populations face higher risks of contracting many infectious diseases than the general population due to crowded living conditions, certain risk behaviors like intravenous drug use and unprotected sex and the transient nature of the population. According to Sequerra, not only would vaccination help prevent the spread of disease inside prison, but also that every vaccinated prisoner returning home would bolster the immunization coverage of their communities. As many formerly incarcerated individuals return to communities that have limited access to health care themselves, vaccination in prison would be one way to target public health interventions to at-risk communities (2).
Failures of these types of vaccination interventions can have serious consequences. In March of this year, an inmate at Coffee Creek Correctional Facility in Oregon died of influenza. She had not been vaccinated. This case is striking not because it is certain the woman would have survived had she been vaccinated, but because of the vaccination rate in the Oregon Department of Corrections this year: only about 4, 550 vaccines were administered to a prison population totaling around 14,550. This rate is nowhere near the 70 percent coverage needed to effectively prevent the spread of the influenza virus through a population.
There are numerous prevention measures that may be taken in addition to vaccination, many of them significantly more controversial. For example, in 2014 California passed a law that requires condoms be made available to all inmates, despite sex between inmates being illegal in California prisons (4). And this May, two federal prisons in Canada launched a needle exchange program in which prisoners can exchange used needles for clean ones in an attempt to prevent the spread of disease during intravenous drug use (5). Both of these programs exemplify the situation when public health and the law collide. It may seem odd that correctional institutions offer tools to facilitate a safer performance of illegal activities within its walls, but perhaps these types of programs should be considered on larger scales when they are shown to decrease HIV and hepatitis C contraction.
With all the benefits of the health interventions proposed above, there are also legitimate issues to be taken with them and legitimate obstacles to overcome. For example, there are serious concerns regarding legally required disease screenings, particularly for HIV given the stigma surrounding the disease and the persistent challenge of protecting the HIPPA rights of individuals in a setting where utter lack of privacy is virtually a guarantee (6). Furthermore, the argument in favor of making prisons institutions of public health as well as public safety relies on a system of adequate health care in correctional facilities that often does not yet exist. Finally, and perhaps most importantly, there is a fear that this focus on prisons as sites of public health intervention will not address the deeper structural problem that many of the arguments in favor of such interventions rest on: the fact that for many disadvantaged and at-risk populations, prison may be the first time they have access to medical care. While this fact highlights the importance of having adequate health care in prisons, it also highlights the importance of expanding health care to these populations before incarceration. All that being said, correctional facilities can have a significant impact on public health both inside and outside their walls if we expand our definition of safety to include protecting inmates from infectious diseases.
Edited by: Rachel Brace
Illustrated by: Lily Xu