Health Access in Prisons

May 4, 2023

Randolph Riley is a community researcher with Dr. OmiSoore Dryden, James R. Johnston in Black Canadian Studies. He spent the 2022-23 academic year reviewing literature on health access in prisons for Black people - including Black gay, bisexual, queer, and trans men, men who have sex with men, and trans women.

Ten of his article summaries are featured on this page. Randolph provides more of his reflections in his blog post.

Incarceration and the health of the African American community | Schnittker, J. et al. (2011)

This article focuses on the effects that incarceration has on health, specifically for African American men. Patterson (2010) found that the mortality rate among African American men is lower than the rate of mortality in the greater society for this same group. Patterson (2010) suggested the reason for this is the level of access to healthcare that at times can be more difficult for those of African descent when in the general public.

A main reason for the equal access to healthcare prisoners may experience inside as opposed to out in society is the smaller population which may make it easier to access testing, exams, checkups, blood work, all the essential reasons for visits to a healthcare provider (that in some cases in society have long waiting periods or may be unaffordable). We must not confuse this short-term better access to healthcare with the long-term effects that prison has on its population, because the negative impacts far outweigh any assumed benefit.

Prisoners with preexisting health conditions who were formally on Medicaid become ineligible for coverage during their prison sentence and have difficulty reenrolling after release. This is because many are denied based on preexisting health conditions. Although most Black men experience incarceration at an early age, many health issues may not present until later in life once conditions and disparities become known.

In closing it is understood from the above information that incarceration increases the possibility of having poor health.

Schnittker, J., Massoglia, M., & Uggen, C. (2011). Incarceration and the health of the African American community. Du Bois Review, 8(1), 1-9. doi:10.10170S1742058X11000026

Disease prevalence and use of health care among a national sample of Black and white male state prisoners | Rosen, D. et al. (2012)

While searching for information on access to healthcare for Black people facing incarceration, I came across this article regarding disease prevalence examined by race in the Texas Department of Justice. This article reports the diseases that have the largest effect on white and Black male prisoners. For Black men who are incarcerated, hypertension, asthma, and diabetes is higher, and ischemic heart disease rates are lower than that of white prisoners. In the carceral system in Texas Black and white men have similar death rates when compared to white men who are not incarcerated, according to the mortality data Patterson examined from 29 different U.S. states.

The low mortality rates for Black men while incarcerated compared to those who are not is a result of the protection prison offers from incidents folks in society are subject to such as accidents, and gun violence. In an earlier study completed by the Texas prison system, it was determined that Black men had higher rates of tuberculosis and HIV, but lower rates of viral hepatitis, compared to non-incarcerated Black men.

During incarceration, based on data (The 2004 Survey of Inmates in State Correctional Facilities), did an analyses of 16 different health conditions and assessed the access to healthcare for those incarcerated, also. What was also looked into is the availability of healthcare for these conditions, and the varying of services depending on the institution.  

Rosen, D., Hammond, W., Wohl, D., Golin, C. (2012). Disease Prevalence and Use of Health Care among a National Sample of Black and White Male State Prisoners. National Institutes of Health, 23(1): 254–272. doi: 10.1353/hpu.2012.0033 

Health & justice: Framing incarceration as a social determinant of health for Black men in the United States | Nowotny, K. & Kutsevych, A. (2018)

A social determinant of health is not an illness, but social factors that may play a part in contributing to the illness itself. An example of this could be getting cancer or another illness from not drinking filtered water. This would be considered a social determinant because one’s socio-economic place in society as access to clean drinking water may be limited – thus a health disparity,

The U.S. Department of Health and Human Resources stated in 2016 that there have been some serious attempts made to reduce the health disparities but unfortunately high inequalities regarding health remain prevalent in Black communities. The article argues that inequalities in healthcare systems exist, as well as social determinants which contributes to the detrimental experiences of Black people within the carceral system.

The US denying the rise of incarceration for Black people since the eighties has risen concern for researchers and policymakers who have been studying the effects of policy on this specific group and how it reinforces the stigma and mistreatment that 1 in every 3 men of colour will experience in the carceral system within their lifetime.

This study focuses on unique experiences of Black men and the consequences on their families and communities. This article outlines several types of effects incarceration has on Black people including exposure to infectious diseases, depression, loss of income and ability to provide for their families.

Nowotny, K. &Kutsevych, A. (2018). Health & Justice: Framing Incarceration as a Social Determinant of Health for Black Men in the United States. Sociology Compass, 12, e12566. doi: 10.1111/soc4.12566

Health implications of incarceration and reentry on returning citizens: A qualitative examination of Black men’s experiences in a Northeastern City | Williams, J. et al. (2020)

The health disparities among Black men are explained in this article as structural, historical, and systemic. This project demonstrates that more research needs to engage with and focus on the intersectionality of Black male identities and imprisonment. Researchers see the health disparities within this population as a national crisis because of the effect it has on Black communities. Health and wellness are also examined in this study because the disparities experienced subject these men to a lower quality of life, decreased life expectancy, increased rates of mental illness, increased drug dependency and/or abuse, reduced physical health (due to poor nutrition and confinement), and social exclusion.

Due to healthcare disparities and discrimination, Black men – and the Black community in general – have an elevated level of distrust for the healthcare system, making them less likely to seek medical attention for serious illnesses. Paired with poorer health care services in prison, this exacerbates existing health conditions for Black men. Additionally, the authors found that Black men reentering society struggle because not only are they unable to get stable and adequate paying jobs (if at all), but the severe trauma experienced in prison (and the coping mechanism to survive) impacts their connections, especially with family. Upon reentry, they often return to unsupportive environments that do not have the resources to support them.

This study applies Critical Race Theory (CRT) to contextualize and interpret the experiences of the participants. CRT is a framework initiated by Black scholars in the 1980’s to critique how law operates to systematically disadvantage non-white people. CRT specifically enables the identities of participants (Black, male, American) – particularly their masculinity – to be understood in relation to structural and historical racism. In this way, the deleterious impacts of prison on health and quality of life (upon reentry into society) are explained by the social, legal, and political factors – and it is very clear why Black men face the harshest outcomes when no institution prior to, during or after their incarceration favours their life.

Williams, J., Wilson, S., Bergeson, C. (2020). Health implications of incarceration and reentry on returning citizens: A qualitative examination of Black men’s experiences in a Northeastern City. Promoting Men’s Health Equity. 1–16. DOI: 10.1177/1557988320937211

Health care reform in Canadian corrections facilities | Lee, A. et al. (2021)

In this study Ontario health officials raise concerns regarding how many provinces and territories exclude prisoners from the Canada Health Act, meaning the province has no responsibility to assure a certain level of care for those incarcerated. Correctional Services Canada manages the prisons in Canada and therefore manages the healthcare one receives within institutions rather than health authorities.

Of all the provinces and territories in Canada, Alberta, British Columbia, and Nova Scotia are the only provinces where healthcare is provided by the health authority as opposed to Corrections Canada. Although available statistics demonstrate that between 2013 and 2018 incarceration rates have been on the decline, overrepresentation of Indigenous populations and people of African descent consistently rise annually. Even though the numbers, compared with the general population, are staggeringly lower, they make up the majority of the prison population. Health in Prisons, a program developed by the World Health Organization, calls for healthcare in the prison system to be provided by public health officials, and not the department of justice.

If the government wanted to truly better society, it would ensure equal healthcare to those inside – giving folks the opportunity to better their health inside will also make for a healthier environment for all inside and outside. Studies have shown that those incarcerated face serious health issues when inside whether it be respiratory illnesses, hypertension, diabetes, or hepatitis C. The level of care expected to be met in institutions is not made clear in the Corrections and Conditional Release Act by medical professionals. If Corrections would turn over care of prisoners to healthcare professionals, it is believed the system and level of care would increase. Therefore, medical physicians would then be able to better advocate for improved treatment of prisoners with regards to punishment/isolation, diet and exercise, and overcrowding issues.

Lee, A., Ross, A., & Saad, M. (2021). Health Care Reform in Canadian Corrections Facilities. Ontario Medical Students Association.

Race and incarceration: The representation and characteristics of Black people in provincial correctional facilities in Ontario, Canada | Owusu-Bempah, A. et al (2021)

Throughout this study data presented is dissecting the racial disparities between different ethnic groups within Canada and how incarceration is heavily concentrated among young Black men coming from disenfranchised communities. Throughout this Canadian study it is detailing how incarceration rates with an overrepresentation of men of color, including Black men, not only in the provincial prisons within Ontario but also the substantial number of Black men who experience incarceration during their lifetime.

It is important to recognize that the socio-economic barriers and the criminogenic factors that are keeping Black and Indigenous people overly represented and highly oppressed. In 2013, the National Correctional Investigator highlighted in his annual report that Black people are overrepresented with disproportionate numbers in the carceral system.

Statistics Canada stated that the only racial data being documented is that of the Indigenous population. To date, there is still no population data on Black people. I believe the very fact alone that government agencies keep data on how many Canadians identify as Indigenous yet do not keep the same data about people of African descent is a direct symptom of systemic anti-Black racism, showing the total disregard for such important data.

The data is contextualized by describing the historical and social circumstances of Black people in Canada, and although it does not discuss the issues of access to healthcare, we can draw the conclusion that it is more difficult for Black people in all aspects of life here in Canada. 

Prime minister of 1911 of Canada signed an order prohibiting the immigration of Black people to Canada (Shepard,1997). From the end of slavery to the Virginia Slave Codes (the first institution of policing), to segregation, to now mass incarceration, I would argue that it is safe to say Black people are targeted by anti-Black racism in Canada and that this is experienced in all government institutions and agencies. Whether it is education, public services, medical, media, child welfare, employment etc.

Owusu-Bempah, A., Jung, M., Sbaı, F., Wilton, A., Kouyoumdjian, F. (2021). Race and Incarceration: The Representation and Characteristics of Black People in Provincial Correctional Facilities in Ontario, Canada. Race and Justice, DOI: 10.1177/21533687211006461

‘I just wanted them to see me’: Intersectional stigma and the health consequences of segregating Black, HIV+ transwomen in prison in the US state of Georgia | Kilty, M. (2021)

This study breaks down the intersectional stigma experienced by Black LGBTQ+ and HIV positive populations in the carceral system. Due to the mistreatment Black queer and trans individuals receive from staff, they are pushed further away from the available testing programs. When in the carceral system Black trans and HIV positive individuals often feel the need to suppress their gender identity due to the mistreatment they may receive if they are their full selves, expressing themselves freely. Trans people are often segregated due to transphobia in the prison system.

In the US although the total population of trans people facing incarceration is not known, an LGBTQ+ organization has estimated that one in every six trans Americans and one in every two Black trans people experience incarceration in their lifetime. This an alarming stat to come across, especially knowing that it is a reality for some folks daily.

Research has confirmed what trans communities have been stating – the biomedicalization of gender dysphoria, which is the diagnosis of the disconnect between one’s gender with the sex assigned at birth – is damaging to trans people. It is necessary to move away from pathologizing trans identities.

Black trans individuals report the trauma of incarceration and being misgendered in this process. The refusal to recognize their gender and provide gender affirming care, such as clothing, and body maintenance, furthers this harm. In addition, barriers to gender affirming medication and surgeries increases harm – psychological and physical. The amount of peer and psychological pressure on this group, and in light of the statistic above, Black trans people are highly impacted by these systemic transphobic barriers.

Kilty, J. (2021). I just wanted them to see me’: Intersectional stigma and the health consequences of segregating Black, HIV+ transwomen in prison in the US state of Georgia. Gender, Place & Culture A Journal of Feminist Geography, 28(7), 1019-1039. DOI: 10.1080/0966369X.2020.1781795

Do prisoners trust the healthcare system? | Vandergrift, L. & Christopher, P. (2021)

According to this study there are prisoners more susceptible to higher levels of distrust in the prison healthcare system. The study conducted with 200 people who were incarcerated by using the Revised Health Care System Distrust Scale. The poor healthcare system and health status of prisoners makes it increasingly difficult to provide an equitable level of care based on the disproportionately high number of Black and Indigenous people, and people of colour in prison.

In Black and Indigenous communities and communities of color, the level of distrust in the healthcare system may explain exacerbates health disparities. Mistrust leads to delays in seeking out health care.  In seeing this severe lack of trust in the healthcare system, it may serve as an indicator of the policies and practices needed to address gaps in the provision of the healthcare system for these populations.

Currently, not much is known about the level of trust prisoners have in the healthcare system, in addition, it is important to keep in mind that the prison system’s priorities do not necessarily include healthcare, compete with the concerns of punishment, rehabilitation, and public safety, which at times obstructs the aims of healthcare.

Institutional priorities and conditions may contribute to the reluctance of prisoners to seek care. For those who go through the criminal justice system, they may perceive healthcare within as inferior to healthcare outside of prisons, thus, furthering the levels of distrust, and also keeping people from seeking help while incarcerated.

Vandergrift, L. & Christopher, P., (2021). Do Prisoners Trust the Healthcare System. Health and Justice, 9, 15.

Factors associated with HIV testing and treatment among young Black MSM and trans women in three jail systems | Antos, N. et al (2022)

In America, Black trans women are disproportionately affected by HIV and incarceration. In the prison system the number of undiagnosed HIV patients is alarming [include the alarming rate for those in prison here if it is available]. A recent meta-analysis found that the prevalence of HIV was 44% for Black trans women.

In the USA, it is estimated that 14% of people living with HIV are not aware that they are infected, (CDC, 2019). It is also estimated that 40% of all new infections are mostly transmitted by folks who are unaware that they are carrying the virus (Patel et al., 2020).

A study was completed in which 178 Black men who have sex with men (MSM) and Black trans women were surveyed, all participants were incarcerated at three of the four largest jails in the United States. This is one of the very first studies published regarding access to HIV testing within the carceral system, based on this study alone it has been determined that Black detainees face barriers to receiving testing and treatment, and are more likely to be further along in disease progression once it has been detected.

Considering the overrepresentation of Black people and sexual and gender minorities in the justice system, more research needs to be conducted to better identify needed accommodations needed while in the carceral setting.

Antos, N., Flores, R., Harawa, N., Vecchio, N., Issema, R., Fujimoto, K., Khanna, A., Paola, A., Schneider, J., & Hotton, A. (2022). Factors associated with HIV testing and treatment among young Black MSM and trans women in three jail systems. AIDS Care, 35(1), 123 -130. DOI: 10.1080/09540121.2022.2094312

Inequities in life course criminal legal system sanctions: Measuring cumulative involvement | LeMasters et al. (2022)

This article details the effects legal sanctions have on youth and adults that go through the criminal and legal system, and how it contributes to poor health throughout the rest of their lives. Given that Black communities are disproportionately overpoliced and surveilled, and Black men overall have a higher incarceration rate, thus making the welfare of this population vulnerable to lack of proper healthcare access.

The mass incarceration of Black men has compromised the health of everyone who becomes involved with the criminal and legal system, from the lack of access to healthcare while incarcerated, to the mental health of children who are left behind at home, and the health and social dynamic of the community is heavily impacted by the mass removal of male influence and guidance. Every part of the criminal legal process needs to be analyzed more carefully, from arrests and charges, to the probation or incarceration of an individual, each part of the process has a detrimental effect on overall health.

Previous research has discovered that each part of the criminal legal process causes stress, worsening the health of those who come in contact with the law. Interestingly, this article mentions that the criminal legal system has a large but highly unequal presence in society when looking at sociodemographic lines, and that this unequal presence lasts throughout the lifespan of these communities. 

Throughout this study it was found that while 14% of white participants had experienced time in juvenile detention and 18% of the Black participants had experienced juvenile detention, the Black participants had a higher rate of adult arrests and time incarcerated.

LeMasters, K., Renson, A., Edwards, J., Robinson, W., Rubinstein, L., Delamater, P., &Pence, B. (2022). Inequities in life course criminal legal system sanctions: Measuring cumulative involvement. Annals of Epidemiology, 76, 83–90.