August, 2003 - Le Monde Diplomatique (France)

United States: Sentenced To Sickness

The US policy of mass incarceration (with access to inept medical care but without access to information, prophylactics or disinfectants) has led to a steep increase in the number of prisoners with communicable diseases.

By Megan Comfort, sociologist at the London School of Economics

PEOPLE walking out of jail in the United States usually have up to $200 "gate money" to get them started in their new lives, to buy some clothes and pay the Greyhound bus fare to reach the city in which they must live. But they might also come out with something less helpful and more permanent: 1.3 million of the 9 million released in 2002 were infected with hepatitis C, 137,000 with HIV, and 12,000 had tuberculosis. These figures represent 29%, 13-17%, and 35% respectively of the total number of Americans who have these diseases (1).

As public health researchers have warned for years, the mass incarceration that has been happening across the country since the early 1980s has been accompanied by the mass incubation of infectious diseases in correctional facilities across the US (2).

The figures are dramatic but not really surprising. Much of the behaviour for which people are sent to jail - such as injecting drugs, sex work. and violence - leads to infection with bloodborne or sexually transmitted diseases. So any police sweep of law-breakers means a round-up of the currently or soon-to-be ill. Once behind bars, the practices continue, but without the protection that people might have had on the streets: since homosexual sex, drugs and violence are illegal in correctional facilities, syringes, needles, bleach, condoms or latex barriers are considered contraband (and even clean water for rinsing things is hard to come by).

The result is a make-do policy that results in scarce injection equipment and a few coveted needles (perhaps actual needles, but what is used are more likely to be ingeniously transformed ink cartridges, straws, or guitar strings) that are widely shared.

Unprotected sex is routine without access to condoms. And even activities such as tattooing or skin piercing that are relatively safe against infection from HIV or hepatitis C when performed in the outside world become high-risk activities in prison. They are prohibited by law, and their equipment banned; therefore everything connected with them is concealed and, of course, shared.

Body decoration is an important and highly ritualised activity among convicts, for whom tattooing creates permanent representations of identity that cannot be taken away by authorities; they represent positive affirmations of self in an environment full of negatives" as well as a visual means of identifying gang or group affiliation in a world full of strangers (3). While all needle-related activities are illegal in prison and therefore go unreported or underreported, researchers suspect that tattooing involves greater numbers of inmates than does injection drug use and could perhaps be the primary means of HIV and hepatitis C transmission in correctional facilities.

This information surprises many inmates, since untold numbers of them do not know the crucial facts about the transmission, prevention, or treatment of infectious diseases; before their arrest they probably did not have access to medical care. In the US medical care is contingent upon having an employer who provides benefits (in the form of health insurance) at an affordable premium, or having personal funds to purchase private insurance, or qualifying for public aid, which is denied to those who are not impoverished enough and may anyway specifically exclude medication for drug addiction, mental illness and other serious conditions. This is a problem.

Paul Farmer and Barbara Rylko-Bauer have written: "The US health system is in fact a non-system, and what happens is the result of chance and a patchwork of services: it is splintered, unsystematic, fragmentary and inefficient." So people entering prison may not know that they are already carrying infectious diseases if they have not already received treatment for symptoms, or they may not know they are at risk of acquiring them.

Once inside prison inmates are tested for certain diseases, such as tuberculosis or syphilis, but institutions do not automatically test for HIV or hepatitis. But when procedures are not well explained (or when a prisoner does not speak English) and blood is taken, some inmates think that they are being tested for these viruses. Budget limitations often mean a no-news-is-good-news policy, so only those whose results show infection receive a follow-up appointment - and the rest assume that all is clear.

Inept or illegal medical companies compound the disorder. One California laboratory faked test results for thousands of prisoners for years during the 1990s. Tipped off by concerned prison medical staff who had noticed spelling mistakes and other errors in reports, officials from the California State Department of Health raided the laboratory building in 1996 and "found a jumble of idle equipment, a laboratory in disarray, with testing equipment that didn't work, was out-of-calibration, or lacked proper reagents for conducting tests of blood and urine." (4).

By 2000, when the San Francisco Chronicle investigated this affair, there was little evidence that the California Department of Corrections had made any efforts to contact or retest inmates who had received wrong information about their HIV or hepatitis C status, their cervical cancer exams or any other life-threatening condition. But in the meantime the manager of the phony lab had obtained a state licence to operate a new clinical testing outfit.

In another case a Michigan prisoner was accidentally shown medical records from his previous incarceration and was stunned to learn that he had tested positive for hepatitis C two years earlier and had never been told. His girlfriend, with whom he had lived between his arrests, discovered that she too had the disease (probably acquired between her partner's detentions).

This raises a little-known issue: a sizeable percentage of the 9 million people released from jail each year in the US carry infectious diseases back into their communities and risk transmitting them to their sexual and needle-sharing partners - and anyone else who comes into contact with their bodily fluids.

People do not see prisons as particularly risky to their health and so do not avoid unprotected sex or needle-sharing with someone who has recently rejoined society (5). In fact, since the correctional facilities do provide regular meals, sheltered housing and some degree of health care (however inadequate), the poor and homeless in the outside world may view prisons as quite healthy environments, especially when they see someone return to the streets well rested, nourished and even buffed up from long hours of exercise in the gym.

The decline in the US welfare state to the point where the penal situation "has increasingly become America's social agency of first resort" (6) means that, for the most marginalised, the harsh grip of the punitive state also functions as the steadying hand that keeps their heads above water.

Even so, errors, neglect and incompetence can prevent adequate medical care for detainees and prisoners. Doctors and other medical personnel who have been sanctioned for poor standards of practice may have their general licences revoked but can continue to be allowed to work in correctional facilities.

Inmates who requite medication for HIV or hepatitis C may receive out-dated treatments that are modified according to correctional policies (for instance, inmates may be required to prove compliance with single-drug regimens before being allowed to receive more advanced multi-drug therapies) or improperly administered, as in, the case of a Florida prisoner who was routinely given his pills with his meals, despite the interdiction on eating two hours before and one hour after taking his HIV medication. Such blunders endanger lives and well-being, and they also help create drug-resistant strains of viruses.

But whatever health care someone receives in a correctional facility may be better than that which he or she can scrounge when not behind bars. The US Census Bureau reports that, in a nation that still rejects implementing a system of universal coverage for its citizens, 41 million people found themselves uninsured in 2001, meaning that they were responsible for paying in full any medical costs they incur. Meanwhile the price of malpractice insurance for doctors and hospitals translates into bills that are three to five times higher than in Europe; prices for prescription drugs are prohibitive, and bills for prolonged stays in hospital can cost hundreds of thousands of dollars.

Those who cannot afford these costs must rely on unpredictable and bureaucratic state aid, under-funded and often shoddy public services (free or low-cost), or the hospital emergency room, which the poor often use for primary health-care, since hospitals are required to treat people if they arrive in bad enough shape.

Ironically, prisoners are the only group in the US who are entitled to medical treatment, for as long as they remain under state supervision. No wonder some people "deliberately return to incarceration because they feel that they can obtain better care there than in the community" (7).

The alarming prevalence of infectious diseases among the incarcerated ratchets up the costs: sky-high rates of illness and infection translate into equally high prison medical costs. which is a difficult issue to pitch to taxpayers who already have seen engorged correctional budgets dwarf allotments for education and social welfare spending during the past decade.

The combined policies of hypertrophic incarceration for the poor and commercially based laissez-faire medical coverage for citizens are causing a public health nightmare in the US.

(Original text in English)

Footnotes:

(1) The Health Status of Soon-to-Be Released Inmates, National Commission on Correctional Health Care, 2002.

(2) This situation is not confined to the US: for information about healthcare in French prisons, see Claude Veil et Dorninique Lhuilier, La prison en changement, Editions Eres. Ramonville Saint-Agne, 2002. For Spanish prisons, see "Sida y Carcel" in PANPTICO, No 1, Nueva Epoca, 2001, Virus Publications. For Russian prisons, see Paul Farmer, Pathologies of Power, University of California Press, 2003.

(3) Susan A Phillips: "Gallo's body: decoration and damnation in the life of a Chicano gang member", Ethnography 2:357-388,2001.

(4) Farmer Sabin Russell, "State Fumbles Prison Lab Testing Company's Fake Results May Never Have Been Corrected. San Francisco Chronicle 6 July 2000.

(5) See Megan Comfort, Olga instead Bonnie Faigeles, and Barry Zack, Reducing HIV Risk Among Women Visiting Their Incarcerated Male Partners", Criminal Justice and Behaviour, Thousand Oaks, California, 2000.

(6) Elliott Currie, Crime and Punishment in America, Henry Holt and Company, New York, 1998.

(7) Theodore M Hammett, "Health-Related Issues in Prisoner Reentry to the Community", in Reentry Roundtable, The Urban Institute, Justice Policy Centre. Washington, 2000.