Extensive literature has documented racial and ethnic differences and disparities across the continuum of medical care in disease prevalence, prevention, management, and outcomes,1–5
but little is known about how these population health disparities relate to the criminal justice system. In general, racial and ethnic minority groups, including African-Americans, Latinos, and American Indians, receive poorer care and have worse outcomes than non-Hispanic whites. They also experience more criminal justice involvement than whites. Epidemiologic studies have confirmed that jail and prison inmates have a higher burden of chronic diseases such as hypertension, asthma, and cervical cancer than the general population, even after adjustment for known confounders such as age.6–12
Furthermore, inmates are particularly at risk for substance use disorders, psychiatric disorders, victimization, and infectious diseases, including hepatitis C, HIV, and tuberculosis.8,9,13–21
Despite the prevalence of poor health status among both minorities and inmates, the effect of criminal justice involvement on population health disparities has been largely overlooked in research on population health disparities.
The criminal justice system includes a large and high-disparity population. Over seven million people in the USA were under the supervision of the criminal justice system in 2008, including individuals incarcerated in prisons and jails and those on probation or parole.22
However, these numbers only reflect the population under supervision at a given point in time during the year. There is tremendous flux through the correctional system, with 23.9 million people handled by the criminal justice system a year, of which 15.9 million were handled by the prison and jail system (may not represent unique individuals).23
Racial and ethnic disparities in incarceration rates are striking. An estimated 33% of African-American men will serve time in prison during their lifetimes, in contrast to 17% of Latino men and 6% of white men.24
Over 3,000 per 100,000 African-American men were in prison at year-end 2008, in contrast to 1,200 Latino men and 487 white men per 100,000.25
African-American and Latino women, American Indians, and Alaska Natives are also disproportionately likely to be incarcerated.24,26
Despite the large scale and health care costs associated with the criminal justice system,27,28
the potential of this system to either mitigate or exacerbate health disparities is not yet fully understood.
Criminal justice involvement may be associated with health outcomes through direct or indirect effects. Because individuals engaged with the criminal justice system are already at risk for poor health outcomes,25
the health screening and care provided by jails and prisons could have an important impact on racial/ethnic health care disparities. While jails and prisons may provide access to care due to constitutional mandate, the quality of care in correctional facilities is variable and has been poorly measured. Probationers and parolees, who represent the largest proportion of criminal justice involved populations, suffer from inadequate access to care29
and risk deterioration in health status and death.30,31
The health status of parolees and probationers is particularly important now that states are attempting to reduce budgets through early release and diversion programs from prisons. Increasing numbers of inmates are being released into their home communities,32
where they may not have access to health care.
Individuals involved in the criminal justice system often experience multiple health care transitions. An individual with diabetes placed on chronic medications by their community physician can be detained in a jail upon arrest, after which they may transition to a prison, transferred to another facility, released to a half-way house, and discharged back to the community on parole, while remaining at risk for re-incarceration. In each new setting, a new medical provider should continue the individual’s diabetes medications and obtain medical records to ensure adequate continuity of care. Each of these medical transitions involves a complex system of information transfer process which poses risk to the patient, as shown by data on the poor adherence to HIV medications after release from prison.33
While transitions in care are problematic in the non-incarcerated population, they are likely to have exaggerated effects in the criminal justice system due to poor transfer of medical, laboratory and pharmacy records, poor communication among providers, variable access to care, limited family involvement, and inability to afford treatment.
In addition to health effects on criminal justice involved individuals, the system is likely to impact the health of families and communities, predominantly in urban areas.34–37
Iguchi and colleagues described the adverse effects of criminalization of drug users on health through decreased access to health benefits, housing, and employment, as well as subsequent impacts on families and communities.38
In 2001, Freudenberg extensively reviewed the mechanisms by which the criminal justice system adversely impacted health in urban communities.34
Notably, over 2% of the nation’s population under the age of 18 and 6.7% of African-American children had a parent in prison at year-end 2007.39
Rates of sexually transmitted diseases and teenage pregnancy have been shown to be associated with community incarceration rates.35
Urban neighborhoods whose inhabitants have high rates of incarceration and many returning inmates40
experience a phenomenon similar to “forced migration” which disrupts social, family, and sexual networks and has secondary effects on the health of the community.36
For instance, community members find new sexual partners when prior partners go to prison. Former inmates may have multiple partners on return to the community after release, putting themselves and others at risk for acquiring HIV.35
Despite these potentially detrimental effects of criminal justice involvement, interventions with criminal justice involved populations could play a pivotal role in the identification and reduction of racial/ethnic disparities in health care and outcomes. Alternatively, if the health problems of individuals in the criminal justice system are neglected, disparities could be perpetuated or worsened. We examine the interplay of criminal justice involvement and racial and ethnic health disparities and propose an agenda for research and action on health disparities related to the criminal justice system.