The prison system and its relation to communicable disease presence in the United States.

Katie Nolan, Associate Editor

The prison system in this country is nothing short of problematic and broken. At year’s end in 2010, there were 1,612,395 prisoners in both state and federal correctional facilities; this worked out to be a rate of about 1 prisoner in every 200 residents.[i] These are some of the highest rates of imprisoned people in the world, and they come at a cost for the prisoners, the community and the criminal justice system itself.

“Offenders sent to prison enter a complex social world of values, rules and rituals designed to observe, control, disempower and render them subservient to the system,” and often this “subhuman” ideology portrayed onto the prisoners results in maltreatment to a cruel and inhumane extent [ii]. As the Stanford experiment of 1971 describes, there is a natural tendency for prison guards to treat prisoners in an inhumane manner, and the system of checks and balances to protect inmates are virtually non-existent. In the United States, it is not uncommon to find prison facilities overcrowded and scant of basic hygienic necessities, creating the perfect breeding ground for infectious diseases to prosper. Many detention facilities have become so overcrowded, in fact, that they have resorted to a process known as “cell doubling,” where inmates are placed in cells with twice the occupancy as the prison capacity suggests. Although this process may seem to constitute as a “cruel and unusual punishment” that should be obstructed by the Eighth Amendment, the Supreme Court voted to uphold these detention facilities’ decision to overcrowd the already small living quarters of inmates in 1981 [iii]. Currently, there is no federal requirement that controls the density of inmates in correctional facilities. With so many inmates occupying so little space, there comes an increased chance of activities that could result in the spread of many infectious diseases, such as razor sharing, exposure to used needles (through illegal tattoos, drug use, etc.) or sexual contact, whether consensual or non-consensual.

The Center for Disease Control and Prevention (2003) finds that the hepatitis B virus is of great significance when considering the spread of infectious diseases and the role the U.S. prison system plays in it. The hepatitis virus is transmitted through blood, semen and vaginal secretion. Thus it is a virus that is easily spread through sharing instruments that may have contact with blood such as razors, tattoo equipment, and needles used by injection drug users, or through sex—all activities that can be found in correctional facilities, especially those with such a high density of inmates. It is estimated that a staggering 1.0-3.7% of U.S. inmates are chronically infected with the virus—which is a prevalence rate two to six times higher than the national prevalence [iv]. This high prevalence of hepatitis B is particularly troubling due to the increased risk of liver disease, damage and scarring, and subsequently, mortality and morbidity.

Even more troubling, perhaps, is the high rate of tuberculosis in American prison systems. Tuberculosis is an airborne disease caused by the M. tuberculosis bacterium that usually targets the lungs, causing such symptoms as fatigue and coughing up blood, among other things. If TB is left untreated, it can be fatal. It is suggested that the correctional facilities in the U.S. have an alarmingly high prevalence of TB due to the infectious nature of the bacterium. Because it is spread through the air, one highly infectious person can infect any other person that occupies the same air space, which may be a drastically large number due to our problem of cell overcrowding. The CDC estimates that although only 0.7% of the total U.S. population was incarcerated, inmates accounted for 3.2% of all TB cases nationwide [v].

It can be inferred that this high prevalence as well as the high prevalence of HIV/AIDS in the nation’s prisons can actually be due to the vicious cycle in which the victims of either of these diseases are placed. HIV/AIDS and TB are co-morbidities, meaning that patients who test HIV+ are far more susceptible to contracting TB. And with HIV rates so high in inmate populations due to activities associated with high densities of people such as increased sexual contact and the exchange of dirty needles, we can be absolutely certain that these are of a huge concern to public health. It was estimated that in 2005, 1.7% of the federal inmate population was diagnosed with HIV/AIDS and .4% were confirmed cases of AIDS, compared to the national averages of .31% and .15%, respectively [vi].

These health issues that inmates are facing within our country’s correctional system are far from isolated. The high rates of communicable diseases in these environments impacts the entire country, all communities and families.  Recidivism rates in the U.S. are also extremely high, and most inmates at any given time can expect to lead a life that entails living between prisons and the free world. During 2007, it is estimated that over a million persons that were on parole were also at risk of reincarcaration.[vii] The continuous exchange of people from prisons to their communities at such high rates can be detrimental if they are carriers of a communicable disease, and worse, if they are highly infectious. Parolees risk infecting family, friends and any person or body that may come into contact with their direct social network. Thus, the high rates of these diseases in prison systems may threaten the health of an entire unknowing community.

Rather than preventing inmates from returning to their lives and families, I suggest that we put into place a two-tier system that prevents the spread of infectious diseases, namely HIV, TB and hepatitis, throughout the prison system and throughout communities. As a type of primary prevention, we should attempt to bring down the number of people that are sentenced to incarceration in this country. As the U.S. has some of the highest levels of incarcerated persons in the world, we need to begin to consider ways to lower the amount of people that are put into jails to begin with. Perhaps we may find that many people who are being placed into prisons could actually be better served through social services, such as counseling, or through milder punishments such as community service. The other advantage of this idea is that by allowing criminals to retain their autonomy, the social and financial implications to the community and familial structures will be highly diminished. Once incarceration rates are lowered, this may also help to alleviate the issue of overcrowding in prisons. Thus, there would be less contact with other prisoners that may lead to the spread of disease.

The second tier would focus on a secondary preventative action to avoid the spread of infectious disease. Preventative efforts need to be enforced in our prison systems. Knowing what we know about the disease burden of this community, we need to act and respond to this emergency. Prison systems need to not only offer counseling for disease prevention, but adequate treatment and medical attention to those who are infected. By incentivizing inmates to seek medical attention and get tested regularly for these conditions, we could treat them and thus render them less infective, alleviating the spread of disease among the population. Simply because the incarcerated population in this country seems to be distant and secluded from the country as a whole, it is important to also consider their burden as our own.



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