We have a problem, you know, and it's only getting worse. It doesn't strike us equally - it's a problem that mostly affects young men, minorities, and people without high school diplomas. It's worse in the US than anywhere else in the world - and five times as bad in the state of Louisiana than it is in Iran. Its survivors usually don't make good advocates - not while they fight for employment, hold onto their families, and, in some states, lose the right to vote. The problem of mass incarceration is a problem some don't want to address, because the felon class represents those who must have known they would trade for their crimes a piece of their lives. But the health risk of prison doesn't end when their sentences do. In some cases, it has only just begun - and not just for them.
It is one of the great ironies of American society: prisoners are constitutionally guaranteed healthcare, but former prisoners are not. The prison health paradox is one dramatic way to think about the health disparities of impoverished minorities in the United States. In 2010, Evelyn Patterson found that "prison appears to be a healthier place than the typical environment of the nonincarcerated black male population." Indeed, during incarceration, black-white mortality differences vanish. But once released, we see something else entirely. The mortality rate skyrockets. The deadliest time is the first two weeks after release, when former inmates have a 12.7 times higher risk of death than the general population and a 129 times higher risk of drug overdose.
One explanation is that prisoners are often returned to their old neighborhoods - and returned to their old risk factors for homicide and drug overdose. This cycling to and from prison has been called "coercive mobility," as it concentrates people with fewer and fewer resources into smaller and smaller areas. But another explanation is poor transitional planning. For example, poor transitional planning for prisoners with mental illness translates into an excess risk of suicide within the first weeks that follow release. But this is not only a short term problem. Because there is a long term health problem that former prisoners face that is not infectious, mental, or violent: the problem of being former prisoners.
Former prisoners pay a social penalty for incarceration - and it affects their health and their community. Former prisoners are doubly disadvantaged as they struggle for employment and they are eliminated from welfare. In a recent Annual Review of Public Health article, we learn that "a prison record eliminates eligibility for public assistance such as food stamps, public housing, and student loans." A prison record also reduces the ability of former prisoners to find employment - especially employment that provides suitable health care coverage. Medicaid may not be an option for them, or at least not an easy one, since 90% of states withdraw Medicaid coverage once an inmate's sentence begins. Not only does incarceration disrupt employment, which we know affects health status, but also marriage, which is another indicator of physical health. Marriage and employment are "two key tenets of adult health," Michael Massoglia writes, which disproportionately impact African Americans.
In the Du Bois Review's special issue on "Racial Inequality and Health," three sociologists discuss the 'spillover effect' of incarceration. That is, parental incarceration harms children, especially those who live in areas highly concentrated with former prisoners. In her article, "Punishment Beyond the Offender," Megan Comfort shows how children may be collateral damage in the exercise of the state's punishment. Beyond the offender, their children become exposed to risky behaviors that decrease their life chances and increase their risk for mental illness. These children often end up funneled into the criminal justice system themselves.
The people most likely to suffer the negative health effects of incarceration are also the people most likely to already suffer from health disparities. Because African Americans are incarcerated at a rate higher than whites, racial health disparities are ultimately worsened by the effects of incarceration. In their Du Bois Review piece, Schnittker, Massolgia, and Uggen remind us that the mass in mass incarceration "is indeed 'mass' in the sense that it is now large enough to affect an entire demographic group." In Michelle Alexander's The New Jim Crow: Mass Incarceration in the Age of Color Blindness, we learn that more African American men are imprisoned today than enslaved in 1850. Incarceration does not only threaten the long-term health of individuals, but entire communities. In a justice system plagued by racial bias, incarceration threatens the health of an entire race.
Incarceration has become a feature of American life. We are told incarceration creates a barrier between the criminal class and innocent civilians. Incarceration keeps us safe. Why should we help those who threaten us? But inflicting social, civic, and political penalties on former prisoners does not reduce criminal behavior; it only encourages it. We should focus on strengthening transitional services to facilitate reintegration - in both our prisons and jails - and release the punitive grip on healthcare, welfare, housing, voting rights, and student loans. Or else we risk cementing health disparities in the name of a questionable justice.
This blog originally appeared on January 22, 2013 at PLOS Blogs Public Health Perspectives.