V. Defining Public Health
The World Health Organization’s (1946) broad definition of health, given earlier in this research paper, extends beyond individual risk factors and biological markers to include an assessment of ecological variables that lead to poor community health. The intersection of the criminal justice and public health domains can be explicated through the tripartite scheme of physical health, mental health, and social health.
A. Physical Health
Citizens who regularly interact with the criminal justice system disproportionately share the burden of infectious disease and poor health. Recent evidence identified the presence of an extensive criminal history as a strong predictor of physical illness (Mateyoke-Scrivner, Webster, Hiller, Staton, & Leukefeld, 2003). Furthermore, citizens positioned in the lower socioeconomic strata are more likely to enter the criminal justice process with limited health service utilization and with significant prior exposure to risk factors. As a result, an estimated 44% of state inmates and 39% of federal inmates at any given time have a medical problem other than a cold or virus (Maruschak, 2008). Paradoxically, many inmates discover that the medical services available in prison or jail are superior to the health resources available in the community. This is evident in research that found 80% of all state inmates received medical screening when admitted to prison, with 91% of state inmates seeking further professional care for health problems (Maruschak & Beck, 2001). Addressing physical health through the criminal justice system raises a host of complex issues; therefore, this discussion is limited to two key areas: (1) infectious disease and (2) specialized health needs.
1. Infectious Disease
Criminal populations account for a disproportionately large share of the total population of infectious diseases, in particular HIV/AIDS, sexually transmitted diseases (STDs), hepatitis, and tuberculosis. Infectious disease rates are even higher among incarcerated populations, with state and federal inmates approximately 2.7 times more likely than the mainstream population to have confirmed AIDS status (Maruschak, 2006). Almost all of these inmates will return to the community, and many will continue to engage in high-risk activities. This represents a public health emergency when one considers that prison and jails annually release 25% of all HIV/AIDS cases, 30% of all hepatitis C cases, and 30% of all tuberculosis cases (Hammett, Harmon, & Rhodes, 2002). Despite limitations in resources and the presence of rigid security requirements, the correctional system functions as a crucial intervention point for the identification and treatment of infectious disease.
Sentinel health events highlight that inefficient correctional systems can act as disease incubators that threaten public safety. Sentinel events are preventable and/or treatable diseases that act as a measure of unnecessary disease, disability, and death at the community level. For example, during the early 1990s a combination of prison overcrowding, poor ventilation, inmate predispositions, and minimal health care resources led to an outbreak of drug-resistant tuberculosis in New York City (Schmalleger & Smykla, 2008). Approximately 80% of the confirmed cases were traced back to inmates released from New York jails and prisons. Such lessons reinforce the notion that correctional institutions are not isolated components of society, and infectious diseases left undiagnosed and untreated can generate dangerous contagion effects that resonate to the broader community.
The antecedents of infectious disease within corrections are well known and typically include unsafe sexual behavior, intravenous drug use, and tattooing, yet currently less than 1% of all U.S. correctional facilities provide condoms to inmates, and none distribute clean needles (May & Williams, 2002). These limitations are counterbalanced by the passing of the Prison Rape Elimination Act of 2003 by the U.S. Congress, which aims to reduce rates of sexual violence within prisons and jails. The Prison Rape Elimination Act follows an epidemiological method of surveillance, collection of confidential data, sexual health education, and the development of a risk-assessment model for the early identification of prison rapists. These efforts are supported by innovative collaborations at the state level that rely on both the criminal justice and public health systems to address infectious disease.
2. Specialized Health Needs
The shift experienced by the criminal justice system has been facilitated by the specific health needs of vulnerable populations. In this section, the discussion of health needs is limited to three groups: (1) children/youth, (2) women, and (3) the elderly.
Recent evidence from clinical neuroscience demonstrates that the human brain experiences significant development throughout childhood and adolescence. Using a brain imaging technique known as magnetic resonance imaging, neurologists have found that components of the human brain, the frontal and temporal lobes, are less developed in an adolescent brain when compared with an adult brain. As a result, youth in general are less likely than other age groups to govern impulse control. Criminologists have long known early delinquency to be highly correlated with other risk-taking behaviors, such as underage drinking and binge drinking, drug abuse, unsafe sex, and a propensity for violence. (Violence includes physical fighting, gang membership, bullying, and the use of weapons.)
These behaviors present as a constellation of risk and ultimately lead to comorbidity, or a state in which the individual suffers from multiple chronic diseases or conditions. The Youth Risk Behavior Surveillance System (YRBSS) created by the Centers for Disease Control is a longitudinal data source used to monitor priority healthrisk behaviors in youth. Results from the 2007 YRBSS found that 72% of all deaths among persons aged 10 to 24 years result from four causes: (1) motor vehicle crashes (30%), (2) other unintentional injuries (15%), (3) homicide (15%), and (4) suicide (12%; Centers for Disease Control and Prevention, 2008). Alcohol and drug abuse are strongly associated with this early mortality and represent an early intervention point that the fields of criminal justice and public health have yet to adequately address. The YRBSS also revealed substantial youth morbidity due to teenage pregnancy, STDs, and HIV/AIDS. In addition to these risky behaviors, the majority of youthful offenders who enter the criminal justice system are less likely to have access to preventive medical care, educational programs, and supportive family units. Moreover, adolescence is a period of significant changes, with youth moving from strict attachment to parental figures toward the attainment of social status in accordance with peer standards. These at-risk youth are susceptible to victimization, homelessness, and drug abuse that further deteriorate health status.
The sevenfold increase in female incarceration rates between 1980 and 2000 means that there are now over 950,000 women in the United States under some form of criminal justice supervision (Chesney-Lind & Pasko, 2004). The majority of these incarcerated women (55% in state facilities and 63% in federal facilities) report having a child under the age of 18, which equates to 1,498,800 children who are directly impacted by incarceration (Mumola, 2000). The effect of the mass incarceration of women has been disproportionately experienced by communities of color and in low socioeconomic areas.
Women who interact with the criminal justice system have discrete needs that differ from male populations. First, typical female offenders are more likely than their male counterparts to be convicted of a crime involving alcohol, drugs, or property, and they are more likely to have histories of sexual victimization. Typical juvenile female offenders are between 14 and 16 years of age, of a racial or ethnic minority, and likely to have significant academic problems (Boyd, 2008). These deficiencies are further compounded by a history of negative interactions with social institutions, such as the family, school, and work, that promote noncompliance with health directives.
Second, higher rates of HIV/AIDs and STDs are reported in women who interact with the criminal justice system on a regular basis. The sequelae of HIV/AIDS include victimization due to intimate partner violence and/or a history of sex work. As such, at-risk women may draw the attention of law enforcement systems that can intervene to address public health issues. Within incarcerated populations female inmates are more likely than their male counterparts to request medical services; however, gynecological examinations are frequently conducted by nonspecialized providers, and preventive services, such as Pap smears and breast examinations, are not routinely provided in many institutions. This represents an underutilized intervention that could be altered to improve the sexual health of female offenders, most of whom are returning to families and children.
The third relevant need of female inmates relates to maternity and jail/prison visitation. Approximately 3% to 4% of female inmates enter the criminal justice system pregnant, and many will give birth while under correctional supervision (Maruschak, 2006). A lack of prenatal care places many of these women at increased risk for a complicated and/or high-risk pregnancy, which in turn increases the cost of health care for the institution and, eventually, the broader society. In general, women experience more guilt, anxiety, and worry about their children when compared with men. Jail visitation policies that balance the needs of incarcerated mothers with the need for institutional security will greatly benefit the emotional health of these women.
Fourth, women who interact with the criminal justice system are at increased risk of intimate partner violence. Feminist scholars posit that patriarchal societies relegate women and girls to subordinate social positions in order to maximize the power and status of men. As such, the oftencyclical pattern of partner violence continues over the life course and requires gender-based programming to restore self-efficacy and address issues of drug dependency and learned helplessness. Interestingly, the classic Minneapolis Domestic Violence Experiment conducted by criminologists Lawrence Sherman and Richard Berk (1984) addressed the health needs of women by using a medical model. This research viewed law enforcement as an intervention and randomized the treatment effect in order to identify an evidence-based policy outcome that supported mandatory arrest protocols in cases of domestic violence.
c. The Elderly.
The term baby boomer signifies the rapid increase of birth rates following the second world war. In the year 2000, this boomer generation constituted between 22% to 32% of state populations, with the 50-to-54 age group exhibiting a 55% growth rate between 1990 and 2000 (Meyer, 2001). In addition, the national life expectancy of the elderly increased in part because of medical developments but also because the notion of “age” was reconceptualized and a greater proportion of elderly people have benefited from active and healthy lifestyles. These demographic changes have impacted the country’s social structure and the criminal justice system.
Studies routinely demonstrate that elderly populations fear crime more than other groups despite the fact that they have a lower risk of being victimized. In San Francisco, a survey of elderly people residing in a crime-ridden area found that fear of crime was the most important health problem in their lives, supporting an association between low self-perceptions of public safety and reduced physical activity (Robert, 1999). Stated differently, fear of crime directly impacts the health of the elderly as they are forced to restrict daily activities, and fear of crime indirectly harms the community by reducing the level of collective efficacy its citizens can muster.
The health needs of an increasingly graying population have also impacted correctional facilities, where it is estimated that 83% of elderly prisoners have a long-standing disability and an average of three chronic illnesses (Fazel, Hope, O’Donnell, Piper, & Jacoby, 2001; McCarthy, 1983). Elderly health concerns can be separated into topics of morbidity and mortality. Elderly inmates experience morbidity due to incontinence; arthritis; and the potential need for corrective aids and prosthetic devices, including eyeglasses, dentures, hearing aids, ambulatory equipment, and special shoes. Early mortality, or early death, is usually the result of advanced medical conditions such as dementia and kidney, liver, or prostate disease. The resources needed to provide specialized health services to the elderly can overwhelm correctional facilities. Small jails have experienced difficulties in meeting the expense of constructing disability-friendly facilities, which is a component of the Americans with Disabilities Act. One cost-saving measure involves compassionate release of the sick. Elderly inmates who are terminally ill are provided palliative care services and can apply for a compassionate release; however, this is granted on the basis of poor physical health rather than consideration of age.