AbstractThe United States incarcerates more people than any other country in the world. The scale of mass incarceration ensures that almost all practicing physicians will treat formerly incarcerated patients. Yet the majority of physicians receive little training on this topic. In this paper, we will outline the need for expanded education on the interface between incarceration and health, describe initiatives taking place within the New York City jail system and nationally, and describe future directions for curriculum development. We conclude by highlighting the important role health care workers can play in transforming our criminal justice system and ending mass incarceration.
The United States incarcerates more people than any other country in the world , with 10.9 million people passing through its jails  and an estimated 6.7 million under correctional supervision in 2015 . The scale of this mass incarceration—historically high rates of imprisonment, especially among young men of color —along with the fact that the vast majority of incarcerated patients will return to their communities, ensures that almost all practicing physicians will treat justice-involved patients . While innovators like the Transitions Clinic Network  have modeled comprehensive care for patients with a history of incarceration, most returning citizens will find themselves in a health care system that might not appreciate the harms of incarceration or the challenges of reentry.
Furthermore, incarcerated patients are disproportionately burdened by chronic medical problems and are exposed to health risks inherent to incarceration itself. Substance use disorders and severe mental illness are especially common [7, 8], and even short jail incarcerations can confer new morbidity due to violence, forced detoxification, medication interruption, and worsening mental health or self-harm during solitary confinement .
While Estelle v Gamble established the legal right to health care for incarcerated patients in 1976 , this right has not guaranteed access to clinicians with the knowledge, attitudes, and skills necessary to care for a vulnerable population in a complicated environment. Recruiting and retaining mission-driven health care professionals to work in correctional settings remains a challenge .
We believe that concerted education of medical trainees in criminal justice and health can benefit patients and communities by improving community care for formerly incarcerated citizens, attracting talented clinicians to the correctional health workforce, and engaging medical professionals in criminal justice reform efforts.
Unfortunately, the majority of health care workers receive little training on this topic despite the high prevalence of criminal justice exposure in many communities [12, 13]. While select academic health centers have partnered with correctional systems, providing educational experiences in correctional health to nursing, social work, pharmacy and physician trainees, most academic health centers do not maintain such a relationship . One survey found that only 14 percent of residency programs offered lectures or conferences on the care of incarcerated persons, and only 22 percent offered clinical experiences in a correctional facility . Most experiences are offered as electives and not as required rotations .
In the Division of Correctional Health Services (CHS) of the New York City (NYC) public hospital system, Health + Hospitals, we have sought to foster an academic approach to the provision of medical care in the NYC jail system. These efforts included the hiring of a director of clinical education to manage the engagement of trainees with the jail system and to improve partnerships with academic health centers. This position has formalized CHS’s commitment to public education on criminal justice and health and has led to the creation of new educational initiatives within the NYC jail system.
In this paper, we will review the harms of criminal justice exposure for patients and communities in connection with educational initiatives taking place within the NYC jail system, with a focus on CHS’s two-week medical student and resident elective in correctional health. We will then discuss barriers to implementation of such programs and the need for expanded clinician education on the interface between incarceration and health. We conclude by highlighting the important role health care workers can play in transforming our criminal justice system and ending mass incarceration.
Curricular Themes and Implementation
Health risks of incarceration and reentry. Incarceration can have long-lasting effects on health and health-seeking behavior, with the immediate postrelease period considered to be a time of particularly increased health risk . Forced detoxification from heroin during incarceration has been shown to increase overdose risk on reentry, and rapid methadone tapers while incarcerated can lead to subsequent aversion to medication-assisted treatment . The Medicaid Inmate Exclusion Policy (MIEP), which suspends patients’ Medicaid coverage while they are incarcerated, can leave patients uninsured during the transition to the community , and clinicians’ stigmatization of justice-involved patients can limit patients’ engagement with medical care . Discrimination in the labor market, where potential employers screen out persons with a criminal record, can make employment difficult to secure . Many patients struggle to find housing, often unable to return to their families or public housing due to restrictions stemming from their conviction . Last, many patients convicted of a felony—including those on parole—are unable to vote in certain states such as New York , leading to disenfranchisement and civic disengagement. Collectively, these social determinants of health directly and indirectly confer health risks on justice-involved patients [24, 25], and an awareness of these factors by clinicians can influence clinical care and advocacy efforts.
In the CHS two-week medical student and resident elective in the NYC jail system—which includes guided readings, lectures, jail-based clinical shadowing, and experiences with community-based organizations providing services or advocacy to formerly incarcerated patients—learners develop an appreciation for the health risks of incarceration and reentry while also learning about ongoing efforts to minimize these risks. Such efforts include comprehensive reentry support services; overdose prevention through counseling, initiation of methadone or buprenorphine, and naloxone training for families; development of transitions clinics ; and promotion of justice-friendly hiring .
Social determinants of health. Not all communities are affected equally by the harms of criminal justice exposure . Social determinants of health, such as race and class, also affect one’s risk of arrest and incarceration by way of specific criminal justice policies. For example, the use of monetary bail increases the likelihood of pretrial detention and its associated health risks, such as infectious disease, violence, or interruption in medical care, for low-income people [28-30]. Certain law enforcement activities, such as the New York City Police Department’s “stop, question, and frisk” policy, are associated with mental health risks for those targeted  and, along with schools’ zero tolerance policies , increase criminal justice exposure for communities of color [31-33]. Lastly, the criminalization of addiction  increases the likelihood that patients with substance use disorders will experience incarceration and its associated health risks.
To better understand these risks, we connect learners participating in the CHS correctional health elective to organizations engaged in related organizing and advocacy work. Educational partners include Voices of Community Activists and Leaders (VOCAL-NY), Drug Policy Alliance, the Bronx Defenders, and the Osborne Association. Our trainees learn how interventions such as bail reform (e.g., reducing use of pretrial detention, elimination of cash bail), drug policy reform (e.g., decriminalization of substance use or possession), Law Enforcement Assisted Diversion (LEAD®) , and assisted outpatient treatment  can mitigate harms of criminal justice exposure for low-income patients with substance use disorders or mental illness. During one elective, medical students observed arraignments at Kings County Criminal Court, met with the Brooklyn Community Bail Fund (a nonprofit organization that pays bail for low-income people), and then observed medical intakes in the jail system. These experiences allowed learners to observe the relationship between poverty and pretrial detention, with its attendant health risks, while highlighting the potential for community bail funds (or, ultimately, bail reform) to mitigate those risks. Community partners are critical to educational efforts, as they help trainees see connections between criminal justice policy and their patients’ health, potentially informing trainees’ subsequent advocacy.
CHS offers trainees the opportunity to rotate through its jail-based clinics on Rikers Island, either for a one-time visit or as part of a longer elective in correctional health. During these experiences, learners review the triple aims of correctional health: patient safety, population health, and human rights . They observe as clinician educators provide patient care, including medical intakes; chronic care visits; and specialized addiction, mental health, and HIV care. Dual loyalty—the impact of the security setting on health care delivery—and efforts to mitigate its impact are explored . Efforts to reduce the harms of incarceration, including prearraignment health screening, medication-assisted treatment for patients with opioid use disorders, clinical alternatives to punitive segregation, and the use of electronic health records to track violence and injuries are essential topics. The relationship between jail and community is also emphasized. Jails represent part of the institutional circuit [8, 39]—along with inpatient drug treatment programs, emergency rooms, and psychiatric hospitals—for patients with substance use disorders and unstable housing. As such, CHS has hosted addiction specialists and emergency room physicians from community hospitals so that learners might better understand the jail experience and its impact on patients’ health.
Barriers to Implementation
Implementing educational experiences in correctional health presents unique challenges. Security concerns inherent to correctional settings can present logistical barriers to access for trainees. During a rotation with CHS, the student coauthor needed to meet his preceptor near public transit, drive onto the grounds of the jail complex, wait for daily security clearance, and be escorted through facilities by a corrections officer. Such restrictions to access and movement create a barrier to entry for trainees interested in correctional health.
A shortage of mentors represents another barrier. The student coauthor on this paper came to New York City—where CHS has a faculty member dedicated to education—in part because he had difficulty finding faculty mentors at his home institution. These challenges have been described previously and are likely to be experienced at other institutions implementing similar programs . Higher requisite faculty-to-student ratios, coupled with the shortage of faculty mentors, can leave systems struggling to support student interest.
The need for unique systems knowledge represents another barrier. Providing care for justice-involved patients requires navigating the intersection of two complex systems: the health care system and the criminal justice system. Doing so effectively requires knowledge and skills that can take years to learn. This learning process is further complicated by criminal justice policy that varies from one city or state to another. One must be familiar with Medicaid policy to participate in discharge planning, and a basic knowledge of criminal procedure (e.g., timing of court dates, implications of charges or parole for drug treatment) is often necessary to make a treatment plan for jail-incarcerated patients . Without a foundation of such knowledge, trainees can find themselves overwhelmed in justice-related training environments.
Three key elements are rapidly converging in this field: a critical mass of students interested in the health effects of mass incarceration, the development of novel curricula to meet this need, and digital technologies enabling rapid dissemination of educational material. While experiential learning remains at the center of these educational initiatives, technology allows for the expanded reach of educational efforts to more learners without stretching scarce faculty resources.
In addition to his being a participant in the CHS curriculum, the student coauthoring this paper is the co-creator of a separate correctional health curriculum for medical students. This online student curriculum features a collection of curated didactic videos by nationally renowned faculty on salient topics related to criminal justice and health , and it has served as a foundation for students nationwide to create similar electives. Already, this digital curriculum has inspired two similar curricula that we know of for medical residents at the University of Washington and Brown University and has generated partnerships with institutions across the country.
As our country wrestles with its response to complex social problems like poverty, institutional racism, and structural violence, there is growing bipartisan consensus (with the exception of some from within the Trump administration ) that mass incarceration is a failed experiment and that an alternative path must be pursued. In New York, the governor, the mayor of New York City, and an independent commission convened by the New York City Council and the advocacy community have called for the closure of Rikers Island and the transformation of our city jail system . As this process unfolds, it will be critical for mission-driven health care workers to remain involved, both as providers of compassionate clinical care for patients wherever they might be, and as advocates calling for public health approaches to community problems. Expanding education for medical trainees on criminal justice and health will be critical to this important effort.
Walmsley R. World prison population list (fifth edition). London, UK: Home Office Research, Development and Statistics Directorate; 2003. http://www.apcca.org/uploads/5th_Edition_2004.pdf. Accessed June 8, 2017.
Minton TD, Zeng Z. Jail inmates 2015. US Department of Justice Office of Justice Programs Bureau of Justice Statistics; December 2016. https://www.bjs.gov/content/pub/pdf/ji15.pdf. Accessed June 7, 2017.
Kaeble D, Glaze L. Correctional populations in the United States, 2015. US Department of Justice Office of Justice Programs Bureau of Justice Statistics; December 2016. https://www.bjs.gov/content/pub/pdf/cpus15.pdf. Accessed May 30, 2017.
Wildeman C. Mass incarceration. Oxford Bibliographies. http://www.oxfordbibliographies.com/view/document/obo-9780195396607/obo-9780195396607-0033.xml. Updated April 24, 2012. Accessed July 24, 2017.
Hughes T, Wilson DJ. Reentry trends in the US. US Department of Justice Office of Justice Programs Bureau of Justice Statistics. https://www.bjs.gov/content/reentry/reentry.cfm. Updated July 31, 2017. Accessed July 31, 2017.
Transitions Clinic Network website. http://transitionsclinic.org/. Accessed May 30, 2017.
Maruschak LM. Medical problems of prisoners. US Department of Justice Office of Justice Programs Bureau of Justice Statistics; April 2008. https://www.bjs.gov/content/pub/pdf/mpp.pdf. Accessed May 30, 2017.
- MacDonald R, Kaba F, Rosner Z, et al. The Rikers Island hot spotters: defining the needs of the most frequently incarcerated. Am J Public Health. 2015;105(11):2262-2268.
- Kaba F, Lewis A, Glowa-Kollisch S, et al. Solitary confinement and risk of self-harm among jail inmates. Am J Public Health. 2014;104(3):442-447.
Estelle v Gamble, 429 US 97 (1976).
- Venters H. A three-dimensional action plan to raise the quality of care of US correctional health and promote alternatives to incarceration. Am J Public Health. 2016;106(4):613-614.
- Shah MP, Edmonds-Myles S, Anderson M, Shapiro ME, Chu C. The impact of mass incarceration on outpatients in the Bronx: a card study. J Health Care Poor Underserved. 2009;20(4):1049-1059.
New York City Department of Health and Mental Hygiene. NYC community health profiles. https://www1.nyc.gov/site/doh/data/data-publications/profiles.page. Accessed June 8, 2017.
- Trestman RL, Ferguson W, Dickert J. Behind bars: the compelling case for academic health centers partnering with correctional facilities. Acad Med. 2015;90(1):16-19.
- Kraus ML, Isaacson JH, Kahn R, Mundt MP, Manwell LB. Medical education about the care of addicted incarcerated persons: a national survey of residency programs. Subst Abus. 2001;22(2):97-104.
- Min I, Schonberg D, Anderson M. A review of primary care training programs in correctional health for physicians. Teach Learn Med. 2012;24(1):81-89.
- Binswanger IA, Stern MF, Deyo RA, et al. Release from prison—a high risk of death for former inmates. N Engl J Med. 2007;356(2):157-165.
Maradiaga JA, Nahvi S, Cunningham CO, Sanchez J, Fox AD. “I kicked the hard way. I got incarcerated.” Withdrawal from methadone during incarceration and subsequent aversion to medication assisted treatments. J Subst Abuse Treat. 2016;62:49-54.
- Morrissey JP, Dalton KM, Steadman HJ, Cuddeback GS, Haynes D, Cuellar A. Assessing gaps between policy and practice in Medicaid disenrollment of jail detainees with severe mental illness. Psychiatr Serv. 2006;57(6):803-808.
- Marlow E, White MC, Chesla CA. Barriers and facilitators: parolees’ perceptions of community health care. J Correct Health Care. 2010;16(1):17-26.
- Stoll MA, Bushway SD. The effect of criminal background checks on hiring ex-offenders. Criminol Public Policy. 2008;7(3):371-404.
Baptiste N. After incarceration, what next? American Prospect. January 26, 2016. http://prospect.org/article/after-incarceration-what-next. Accessed July 2017.
Chung J. Felony disenfranchisement: a primer. The Sentencing Project. May 10, 2016. http://www.sentencingproject.org/publications/felony-disenfranchisement-a-primer/. Accessed July 2017.
- Schnittker J, John A. Enduring stigma: the long-term effects of incarceration on health. J Health Soc Behav. 2007;48(2):115-130.
- Marmot MG, Stansfeld S, Patel C, et al. Health inequalities among British civil servants: the Whitehall II study. Lancet. 1991;337(8754):1387-1393.
- Wang EA, Hong CS, Samuels L, Shavit S, Sanders R, Kushel M. Transitions Clinic: creating a community-based model of health care for recently released California prisoners. Public Health Rep. 2010;125(2):171-177.
- Thill Z, Abare M, Fox A. Thinking outside the box: hospitals promoting employment for formerly incarcerated persons. Ann Intern Med. 2014;161(7):524-525.
Stevenson M. Distortion of justice: how the inability to pay bail affects case outcomes.
https://www.law.upenn.edu/cf/faculty/mstevens/workingpapers/Stevenson%20Job%20Market%20Paper%20Jan%202016.pdf. Published January 2016. Accessed July 27, 2017.
Pinto N. The bail trap. New York Times Magazine. August 13, 2015. https://www.nytimes.com/2015/08/16/magazine/the-bail-trap.html. Accessed July 2017.
Open Society Foundations. Pretrial Detention and Health: Unintended Consequences, Deadly Results.https://www.opensocietyfoundations.org/sites/default/files/ptd-health-20111103.pdf. Published 2011. Accessed July 2017.
- Geller A, Fagan J, Tyler T, Link BG. Aggressive policing and the mental health of young urban men. Am J Public Health. 2014;104(12):2321-2327.
Heitzeg NA. Education or incarceration: zero tolerance policies and the school to prison pipeline. Forum Public Policy. 2009(2). http://files.eric.ed.gov/fulltext/EJ870076.pdf. Accessed June 8, 2017.
- Gelman A, Fagan J, Kiss A. An analysis of the New York City police department’s “stop-and-frisk” policy in the context of claims of racial bias. J Am Stat Assoc. 2007;102(479):813-823.
Mollman M, Mehta C. Neither justice nor treatment: drug courts in the United States. Physicians for Human Rights; June 2017.http://physiciansforhumanrights.org/assets/misc/phr_drugcourts_report_singlepages.pdf. Accessed July 31, 2017.
Beckett K. Seattle’s law enforcement assisted diversion program: lessons learned from the first two years. Ford Foundation; March 21, 2014. https://fordfoundcontent.blob.core.windows.net/media/2543/2014-lead-process-evaluation.pdf. Accessed June 8, 2017.
- Swartz MS, Wilder CM, Swanson JW, et al. Assessing outcomes for consumers in New York’s assisted outpatient treatment program. Psychiatr Serv. 2010;61(10):976-981.
- MacDonald R, Parsons A, Venters HD. The triple aims of correctional health: patient safety, population health, and human rights. J Health Care Poor Underserved. 2013;24(3):1226-1234.
- Glowa-Kollisch S, Graves J, Dickey N, et al. Data-driven human rights: using dual loyalty trainings to promote the care of vulnerable patients in jail. Health Hum Rights. 2015;17(1):e124-e135.
- Hopper K, Jost J, Hay T, Welber S, Haugland G. Homelessness, severe mental illness, and the institutional circuit. Psychiatr Serv. 1997;48(5):659-665.
- Haley HL, Ferguson W, Brewer A, Hale J. Correctional health curriculum enhancement through focus groups. Teach Learn Med. 2009;21(4):310-317.
- Tomasino V, Swanson AJ, Nolan J, Shuman HI. The Key Extended Entry Program (KEEP): a methadone treatment program for opioid-dependent inmates. Mt Sinai J Med. 2001;68(1):14-20.
Mitchell A, Randall J, Aziz-Bose R, Reichberg T, Stern M, Ferguson W. Criminal justice health digital curriculum: lessons at one year. Poster presented at: 10th Academic and Health Policy Conference on Correctional Health; March 16-17, 2017; Atlanta, GA.
Ford M. Jeff Sessions reinvigorates the drug war. Atlantic. May 12, 2017. https://www.theatlantic.com/politics/archive/2017/05/sessions-sentencing-memo/526029/. Accessed July 2017.
Independent Commission on New York City Criminal Justice and Incarceration Reform. A More Just New York City. https://assets.documentcloud.org/documents/3533809/Independent-Commission-on-New-York-City-Criminal.pdf. Accessed June 8, 2017.