American Prisons: Where Public Health is Most at Risk

by Leslie Kumler

When Ryan Thompson was released from a Nashville jail after a 4-month stay on a drug charge, she had been infected with lice, methicillin-resistant Staphylococcus aureus (MRSA), and scabies.¹ The scabies infestation made headlines in June 2017 when over 300 inmates had to be treated for an outbreak that was diagnosed in 33 inmates and sent 16 courthouse workers in search of treatment.²  Thompson said an infected inmate was put in the same POD (living area) with other prisoners. “They washed her clothes with ours and that’s when the entire Alpha 1 POD became infested with the scabies,” she said. “Now, we didn’t know it was scabies. It was a mysterious bug or a fungus from the shower is what they were saying.” Desperate for help after medical staff seemed unable to diagnose them, inmates contacted family. In the end, Thompson left the jail untreated.

American prisons are constructed with one primary concern: public safety. This is often diametrically opposed to a physician’s greatest concern: public health. Inmates are at much greater risk for contracting and spreading infectious diseases than the outside population because of the risky behavior they may engage in prior to and during their incarceration, the conditions in prison, the difficulty in accessing health care while incarcerated, and the lack of support in transitioning to any form of health care when they leave prison. The risk of spread of disease (including blood-borne pathogens such as hepatitis C virus [HCV], sexually transmitted diseases [STDs], MRSA, airborne pathogens such as Mycobacterium tuberculosis, influenza virus, varicella-zoster virus,³ measles, infections like scabies and ringworm, and more) is much greater in local jails and prison systems, which house over 2.2 million adults⁴ across the United States, than among the population at large. Once inmates are released, they may bring infectious diseases back into their communities, increasing the risk for their family, friends, and other contacts, some of whom may be particularly vulnerable to sickness due to extremes of age or immune status. Changing some basic aspects of prison health care by following the recommendations of the US Centers for Disease Control and Prevention (CDC) and other health care organizations would significantly improve the short-term health of inmates and the long-term health of the public.

Prevention Failure?

When inmates first arrive in prison, they are tested for some communicable diseases. For instance, human immunodeficiency virus (HIV) testing is approved if requested by an inmate, and is mandatory for inmates with certain risk factors or surveillance requirements, or who have had an exposure incident. Tuberculosis is also routinely screened for with a skin test or an x-ray. However, for two illnesses on the rise, HCV and MRSA, screening is rarely performed. In 2003, the CDC issued guidelines urging correctional facilities to “become part of prevention and control efforts in the broader community”⁵ for HCV, which is carried in the blood. It is most often transmitted by sharing needles but can also be transmitted via personal care items (eg, razors, toothbrushes) and sexual contact. Since many people who are infected have no symptoms for a long time, it is easily transmitted to others without anyone’s knowledge. HCV infection rates among inmates are estimated to be as high as 35% compared with about 1% of Americans who are not incarcerated.⁶ Between 2001 and 2012, only 12 states have instituted routine HCV testing for entering inmates.

High-Risk Behavior Brings Tough Consequences

Two realities of prison life that leave inmates vulnerable to STDs and blood-borne pathogens are unprotected sex and sharing needles (either for drug use or for prison tattoos). Many inmates enter prison with HIV or other diseases that are then passed on to other inmates, in part because most prisons do not provide clean needles (needles are deemed too dangerous) or condoms. Only three states – Vermont, Mississippi, and, starting in 2016, California – provide condoms for prisoners upon request. Other states continue to be concerned that condoms will be melted down into weapons or filled with human waste and thrown at guards, so they don’t want to give condoms out.⁷

Infectious Diseases Thrive in Prison Conditions

Diseases that are easily passed from person to person love an environment where people live closely together, where soap is not always readily available, where laundry is rationed, where bleach is contraband, where there are not enough toilets, and where common areas are infrequently cleaned.⁸ One of the diseases that has thrived in recent years is methicillin-resistant Staphylococcus aureus (MRSA). Additional risk factors for MRSA in correctional populations were identified in a paper by Bianca Malcolm, MPH, as “prolonged incarceration, outdoor work assignment, previous antibiotic use, self-draining of boils, sharing soap, washing clothes by hand, close contact with persons known to have MRSA, comorbidities, history of antimicrobial use, factors associated with crowding and inadequate hygiene, and (possibly) gender.”⁹ Once an inmate is infected, MRSA may not be accurately diagnosed during the first examination by medical staff because it presents as a skin infection and does not always seem serious. However, MRSA can quickly progress to a serious infection requiring hospitalization and can result in amputation or death. MRSA can also be passed from inmates to visitors and prison employees, starting its spread outside of the facility.

Accessing Health Care Behind Bars

Health care in prison is often at odds with the mission of prison. The cost of health care, privacy worries, and concerns about consent all add additional levels of complication for inmates who need to access to health care while in prison. Prisoners are entitled to medical care, but they may be required to pay $3, $5, or up to $100 for a visit to the medical staff.¹⁰ Commissary accounts, usually refilled by family members on the outside or by small amounts earned in prison jobs, are the only source of money for these co-pays, extra food, phone calls, and personal items. For many inmates, co-pays are a prohibitive fee, so they forgo medical visits for minor concerns. This might lead, for example, to inmates lancing boils themselves without taking actions to prevent MRSA.  “Charging prisoners for health care is yet another way of kicking them when they’re down,” says Dr. Josiah Rich, professor of medicine and epidemiology at Brown University, who holds a weekly clinic at the Rhode Island Department of Corrections in Cranston, RI.¹¹

In some cases, treatment may be available, but the cost and/or the length of treatment make it unlikely to be given to all inmates. This is the case with HCV. Although the rate of infection for HCV is very high in the incarcerated population and testing is relatively inexpensive, treatment itself can be expensive and lengthy. Some argue that inmates will simply re-infect themselves, rendering the treatment useless.¹² Even if treatment for HIV and other chronic illnesses is covered, some inmates may refuse testing because of lingering stigma associated with diagnosis. Although inmates who are patients are entitled to doctor-patient confidentiality, the reality is that, for example, once an inmate goes to the HIV clinic hours, everyone knows they have HIV. Prisons have tried to remedy some privacy issues, but there are still problems with consent. Issues have arisen in which inmates might wish to participate in research trials for new drugs, but with a terrible history in which inmates have been forced to participate in drug trials without proper consent, there has been concern that prisoners shouldn’t be allowed to participate in trials at all even if they might benefit. Additionally, “courts have held that [an inmate’s] right to refuse care might create confusion and discord in the prison if it is interpreted by other inmates as an institutional refusal of care.”¹³

The Transition Back to Society

In 2015, 641,100 prisoners were released from federal and state prisons, with 70% released into some form of required post-custody community supervision. It stands to reason that a significant number of those prisoners carried infectious diseases with them into the community at large. There is no formal structure in place to assist released prisoners with ongoing post-custody health care needs, especially for chronic or urgent health conditions like HIV, HCV, STDs, and MRSA. For example, while in prison, inmates with HIV can maintain a regular treatment regimen because of the access to medication and structure provided by the institution. When they are released, the treatment is necessarily interrupted and it may be some time before they can pick up with treatment again, if ever. Their viral load often rises and they are more infectious than ever. Any sexual partners or people with whom they share needles during this time are at risk.

Recommendations from Experts

Health care in prisons is a complex problem, but the threat to public health inside and outside of prisons means it should not be ignored. Infectious disease experts and medical researchers from a number of fields have been researching how to improve the way health care is delivered to inmates. Some of their recommendations include:

• Screening and precautionary measures should be taken to prevent inmates who carry infectious diseases from spreading them to others.
• Information technology can be employed both to share patient information between facilities when inmates are transferred, which happens frequently and sometimes with very little notice, and also to assist with accurate diagnosis.
• Employees and inmates should be better educated about communicable diseases – how to recognize symptoms and prevent their spread.
• Inmates who have jobs in culinary services, laundry, and barbering should learn proper procedures to prevent the spread of disease, and supervision of these activities should include inspections.
• More liberal access to medical care should be provided with vaccinations for influenza for all inmates and employees.
• Soap, showers, and clean clothing and linens should be readily available to all inmates regardless of status (i.e., solitary confinement should not mean an inmate isn’t allowed a fresh set of clothes).
• Condoms should be provided upon request.
• The United Nations Office on Drugs and Crime and the World Health Organization (WHO) both advocate for needle and syringe exchanges for inmates. 60 prisons, 55 in Europe, allow needle exchange and “found no reported increase in drug use and no negative unintended consequences. No needles were used as weapons, for example.”¹⁴
• Funding should be made available for HCV treatment for inmates incarcerated long enough to receive treatment, which should be offered in conjunction with substance abuse diversion programs to decrease the likelihood that patients will re-infect themselves.
• More programs should be put in place to aid inmates with chronic health problems such as HIV as they transition back into society to obtain health care. If some or all of these improvements were put into place, they would not only aid the inmates themselves, but also protect their families and public health as a whole, saving valuable time and money for an already strained health care system.

In the end, physicians practicing in the correctional setting, like Rahul Vanjani, MD, just want to do the best for their patients. “So why are conditions of confinement rarely considered in our approach to the health of marginalized populations? The answer is rooted in a complex history and the way we are socialized to think about incarceration. The crux of the problem is the belief that inmates are different from the rest of us — that they are, and should be, second-class citizens… The resulting approach to health care is diametrically opposed to the medical ethos, in which the emphasis is on the person first and the necessity of building relationships in order to humanize and individualize care.”¹⁵ Dr. Vanjani detailed an interaction with an inmate that was just like one with any sick patient anywhere:

“I reached out, taking Mr. P.’s calloused hand in my own.

“‘Your mother must be worried about you,’ I said. ‘Do you want me to give her a call?’

“He nodded. ‘Please tell her I love her,’ he said.”¹⁶

References

1. Flowers, L. Inmate who says she got scabies in Nashville jail blames medical staff. WKRN. June 23, 2017. http://wkrn.com/2017/06/23/inmate-contracted-scabies-at-nashville-jail/. Accessed August 1, 2017.

2. Barchenger, S. Emails: Scabies at Nashville jail treated in January; doctors blame mold. Tennessean. June 14, 2017. http://www.tennessean.com/story/news/2017/06/14/emails-scabies-nashville-jail-treated-january-doctors-blame-mold/391866001/. Accessed August 1, 2017.

3, 8. Bick, JA. Infection control in jails and prisons. Clinical Infectious Diseases 2007; 45(8): 1047-1055. https://academic.oup.com/cid/article/45/8/1047/344842/Infection-Control-in-Jails-and-Prisons. Accessed August 1, 2017.

4. Bureau of Justice Statistics. Correctional populations in the United States, 2015. https://www.bjs.gov/index.cfm?ty=pbdetail&iid=5870. Published December 29, 2016. Accessed August 1, 2017.

5. Prevention and control of infections with hepatitis viruses in correctional settings. US CDC Morbidity and Mortality Weekly Report. January 24, 2003.  https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5201a1.htm. Accessed August 1, 2017.

6. An overview of hepatitis C in prisons and jails. National Hepatitis Corrections Network. February 22, 2016. http://www.hcvinprison.org/resources/71-main-content/content/191-hepcprison#_edn4. Accessed August 1, 2017.

7. Watson, J. Condoms now available to prisoners in three states. Prison Legal News. September 2, 2016. https://www.prisonlegalnews.org/news/2016/sep/2/condoms-now-available-prisoners-three-states/. Accessed August 1, 2017.

9. Malcolm, B. The rise of methicillin-resistant Staphylococcus aureus in U.S. correctional populations. J Correct Health Care. 2001 Jul;17 (3): 254-265. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3116074/. Accessed August 1, 2017.

10, 11. Andrews, M. Even in prison, health care often comes with a copay. Shots: Health News from NPR. September 30, 2015. http://www.npr.org/sections/health-shots/2015/09/30/444451967/even-in-prison-health-care-often-comes-with-a-copay. Accessed August 1, 2017.

12. Associated Press. Prison’s deadliest inmate, hepatitis C, escaping. NBC News. Updated March 14, 2007. http://www.nbcnews.com/id/17615346/ns/health-infectious_diseases/t/prisons-deadliest-inmate-hepatitis-c-escaping/. Accessed August 1, 2017.

13. Dubler, N. Ethical dilemmas in prison and jail health care. HealthAffairs Blog. March 10, 2014. http://healthaffairs.org/blog/2014/03/10/ethical-dilemmas-in-prison-and-jail-health-care/. Accessed August 1, 2017.

14. Glauser, W. Prison needle exchange programs rare despite evidence. CMAJ. 2013 Dec 10; 185(18) 1563. http://www.cmaj.ca/content/185/18/1563. Accessed August 1, 2017.

15, 16. Vanjani, R. On incarceration and health – reframing the discussion. N Engl J Med. 2017 Jun 22;376(25): 2411-2413. http://www.nejm.org/doi/full/10.1056/NEJMp1702373. Accessed August 1, 2017.