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Incarceration – The 51st State (Part 2)

The focus of the following article is what happens when the prison sentence is over. When the prisoner becomes a parolee, ex-con, or ex-felon, the one consistent truth is that the individual was released into a world no one prepared for. Oscar Wilde described prisons as follows: “I know not whether Laws be right, Or whether Laws be wrong; All that we know who be in jail Is that the wall is strong; And that each day is like a year, A year whose days are long.” Let us look at the causes of the long days and what might make the after incarceration time better.

After Incarceration – SDOH

To put it simply, persons released from prison have reduced opportunities for jobs and housing insecurity. For many men, the first healthcare they received was in jail, and now healthcare is less available, if available at all.  The loneliness, absence of social cohesion, and lack of civic participation experienced in jail follow them home. When looking for employment, a study found that employers were reluctant to hire someone with a criminal record, especially when the applicant was black.

In Part 1 of this topic, we discussed the transformation of prisons from rehabilitation to warehouses.  In Part 2, we look at the results of the transformation.  The system to manage the flow of unprepared released prisoners has not kept pace with the flow of released prisoners. The number of parolees assigned to one parole officer has almost doubled in 40 years.  At the same time, the reduction of per capita spending on each prisoner is about 24%.

The SDOH seek to reduce the impact of social inequity on the health of the individual. Yet many persons released from jail suffer from the opposite effect.  One study looked at the risk of death after imprisonment.  The study found that released prisoners had 3.5 times the risk of death as non-incarcerated persons.  The risk of death within two weeks of release was 12.7 times more than other non-incarcerated residents.  In addition, to death by overdose or disease, people released from prison are more likely to commit suicide than in the general population, 3% vs. 0.2%. So if you survived prison, you still faced an increased chance of death on release.

After Incarceration – Recidivism           

Recidivism is the return to crime after release from prison, often resulting in the return to prison.  Previously we have discussed that many newly incarcerated persons were unemployed and had dropped out of school.  If prisons provide no rehabilitation, it is not surprising that almost 2/3s of released prisoners end up back in jail within three years of release. Half of the 2/3s or almost 30% return to prison within six months of release.  Blacks were about 9% more likely to return to jail than whites.

While there are many reasons for recidivism, the failure of jails to deal with mental health issues and substance use disorder are primary factors. Other factors include the economic insecurity that people find when getting out of jail. The unemployment rate for formerly incarcerated persons is five times higher than the unincarcerated population.  The formerly incarcerated also experiences housing insecurity at the rate of 570 out of every 10,000. If we assume the release of 615,000 formerly incarcerated persons, that result is over 35,000 housing insecure related to incarceration. Another result faced by the previously incarcerated is in their community. The stigma felt by the previously incarcerated can lead to social isolation and loneliness. The challenges of community reentry compound the challenges faced by the previously incarcerated. To reduce recidivism, we must address these issues.

Those Left Behind – The Families

Almost 45% of U.S adults have experienced the incarceration of a family member.   Note that the probability of family poverty will increase by 40% due to the father’s incarceration. In addition, family member incarceration and the resulting stress affect family members’ mental health and physical health. The acts of the incarcerated may put at risk family safety and economic well-being.

Upon release, family members need to decide how best to support the previously incarcerated relation. The risk of recidivism and the lack of economic support are all a part of families’ consideration.  The stigma attached to the former inmate may pervade the family, resulting in a possible reduction of the available social supports.

Those Left Behind – Children

To look at the effect on children, you need to look at the incarcerated family member (mother or father) and the record of the children themselves.  There are currently approximately 1.7 million children with a parent in jail. Of these, 1 in 15 is black, 1 in 42 is Latino, and 1 in 111 is white.  In the face of a father’s incarceration, 89% of minor children live with their mother, 13% live with a grandparent, 5% live with another relative, and 2% live in foster care. In the instance of a mother’s incarceration, 37% of minor children live with the father, 45% live with a grandparent, 23% live with another relative, and 11% live in foster care.

As stated above, a father’s incarceration may cause a reduction in family income. The reduction may force the family to move, cause food insecurity, and bring a stigma felt by the child in relation to the community and school. In addition, the father’s incarceration may affect the mother and father relationship, adding the additional risk of stigma.

While a father’s incarceration risks homelessness, a mother’s incarceration adds to the risk of foster care.  As seen above, the child has an 11% chance of ending up in foster care with a mother’s incarceration.  An imprisoned mother suffers from the challenges presented by prison, as discussed in part one of this article. In contrast, children suffer a primal wound caused by the abandonment of their mother. While mothers and children attempt to stay in touch, the cost of phone calls and visits is more than many families can afford.

Youth exposed to parental substance use are more likely to follow in their parents’ footsteps.  If the exposure occurs before the age of 10, youth have a greater likelihood of exhibiting antisocial behavior, drug use, and heavy drinking. The youth have a greater likelihood of ending up in the criminal justice system. Those records will follow them throughout their lives, affecting access to healthcare, employment, housing, and governmental assistance.

Those Left Behind – Communities

A previous article in this series discussed the importance of communities. The community loses many members to jail and to rearrest upon release. This activity of arrest and rearrest occurs in disadvantaged communities, especially communities of color. Incarceration weakens the community, and a weakened community cannot provide the needed social supports for social cohesion.  It becomes a dangerous circle. The greater the incarceration rate, the more likely it is that the incarceration rate will grow, and the social supports of the community will consistently weaken. It is not surprising that this affects the poorest communities.

Hidden Effect of Criminality – Disenfranchisement

In the United States, only two states allow universal enfranchisement, and two states disenfranchise anyone with a felony conviction. Eighteen states allow everyone to vote except those in prison.  The remaining states have conditions on voting but allow full or partial enfranchisement of persons with completed sentences.  Why is disenfranchisement an issue?

We consider disenfranchisement a collateral consequence of imprisonment.  A consequence that affects communities of color and denies individuals the ability to influence the very laws that put them in jail and the varied consequences of incarceration on the incarcerated and their family.  The urban communities feel the consequences as both civic and economic costs that they will not recover without enfranchisement.

Incarceration also impacts census counts that base residence on current address as opposed to the address before incarceration.  The effect reduces the counts in communities with high incarceration rates, reducing resource allocation and even redistricting.

Hidden Effect of Criminality – The Cost of Prisons

In part one of this article, we discussed the cost of the criminal justice system, approximately $270 billion, of which $88 billion goes towards incarceration.  Much of those dollars go to the prison industrial complex, the private sector. While President Biden signed an executive order on January 26, 2021, directing the Department of Justice to phase out the use of private prisons, it does not mean the phase-out is immediate.  In 2019 8.1 percent of people incarcerated in the United States were held in private prisons.

The private sector currently has the opportunity to profit from both private prisons and mass incarceration. Mass incarceration requires private contracts for healthcare, food services, laundry, maintenance, and related services.  We understand the effect of incarceration on the social determinants of health; we should also take the time to understand the effect the prison industrial complex has on the prison and the prison population.

What Can We Do?

Changes to sentencing laws and the end of private prisons are improving the challenge of addressing the incarcerated and the released prisoners’ needs.  We must look at how we can improve prison’s nature from warehouse to rehabilitation, the specific needs of older inmates, the needs of families, improving the transition from prison to freedom, and policy change.

We need to reconsider the availability of programs in prison to provide rehabilitation services. To support this need, we should open prison services to public scrutiny, not just to the prisoners’ families, but to the public at large as a means to develop standards of care for prisons. An approach to specific services provided within prison is the use of faith-based programs. Operation Starting Line is one such program. It provides entertaining programs to share messages of faith and hope using musicians, comedians, and professional athletes.  Group meetings involving the volunteers followed the day-long programs.  Such programs have increased the participants’ ability to cope with the rigors of jail.  Programs focusing on obtaining a GED, college training, and work and life skills training have also shown positive results.

Older prisoners need programs designed especially for them.  Programs that promote activity and a sense of contribution will fight boredom and increase social interaction. Prisons should provide training for staff on the specific needs of the older prisoner. Nurses should provide health assessments and provide health information to assist the older prisoner in maintaining their health. Such activity will provide needed stimulation while incarcerated and may assist in preparing the inmate for life after prison.

Sesame Street created a program directly aimed at families with incarcerated family members. The Children Big Challenges: Incarceration initiative designed by the Sesame Workshop addressed the needs of children 3-8.  The program includes a DVD and animated and live-action stories, a guide for parents and caregivers, and a children’s storybook, as well as an app designed for cell phone use.  The program has proven successful with both kids and adults.

The healthcare challenges presented in transition from jail to society often mean that individuals while in jail received medical services but no longer have access to services.  We should ensure the availability of Medicaid to all individuals released from jail or prison, and we should provide a warm handoff of care from the prison system to the Medicaid system.  Integrating care from incarceration to post-incarceration will help the ex-prisoner maintain care for the health and behavioral health-related issues and perhaps reduce recidivism.

To impact the numbers of people of color impacted by incarceration, we need to look at the root causes. In Oakland, California, they invested in mixed-income housing and demolished the high-rise public housing.  They did not make the population move; instead, they improved the neighborhood, the availability of services, and the quality of life.  A study in Chicago looks at the displacement of crime or the migration of offenders; Oakland has found the latter is true.

Perhaps these are only bandaids, but it is a start.  The next step requires looking seriously at the underlying causes, including mental health and substance use disorder, and perhaps taking some of the $270 billion and addressing the health and behavioral health needs as an alternative to prison.

Last Comments

Simple comments include supporting legislation that provides Medicaid to all released from prison and provides Medication-Assisted Treatment for those in prison living with Substance Use Disorder.  The more complex issue relates to reducing the number of incarcerated persons in the United States.  We should address the truth incarcerate more people in the United States than any other country. We should look at whom we incarcerate and why, and what we can do to provide more appropriate treatment, sentencing, and rehabilitation. We should take to heart the words of Martin Luther King Jr. “Means we use must be as pure as the ends we seek.”

Thank you and please join my next episode where we rap up the first element of social determinants of health, Social and Community Context, by looking at outcome measures that address how well we are meeting the goals within this element.

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