By Scott A. Allen, MD
Posted on June 13, 2008 – It is often said that physicians working in correctional facilities have felt like guests in someone else’s house. Prisons and jails serve punitive and security missions primarily, and medical missions only secondarily. Accordingly, physicians have historically focused on the delivery of health care while remaining relatively silent about the nature of the institutions themselves. But in a country with a booming prison population, with increasing numbers of inmates with addiction, mental illness and chronic medical disease, that paradigm is ripe for rethinking.
In the United States the quality of health care for prisoners has improved over the past several decades with the professionalization of correctional medicine. In part, this stems from the 1976 Supreme Court decision (Estelle v. Gamble) that found that lack of adequate health care for prisoners is cruel and unusual punishment. With that ruling, it became clear that medical care is both an integral and necessary component of a correctional facility and legally recognized as a fundamental component of a constitutionally sound prison or jail.
An often unrecognized consequence of that decision is that physicians share in the responsibility for the legitimacy and constitutionality of the institutions themselves. To some degree, physicians have some responsibility for any adverse health effects of the institution on their patients beyond the effects of direct medical services. Since a prison cannot constitutionally function without the support of physicians, physicians assume some ownership for the effects the institutions have on their patients.
Since the Supreme Court ruling, there has also been a dramatic change in the population behind bars in the U.S. Two trends have contributed to this surge: the so-called war on drugs and the de-institutionalization of the mentally ill. As a result, correctional institutions are frequently overburdened with individuals with two overlapping medical conditions: addiction and mental illness. The natural history of these conditions, if left untreated, often causes behaviors that result in incarceration. Thus, much of the dramatic increase in incarceration over the last three decades can be viewed as the failure of society to appropriately treat addiction and mental illness. In addition, persistent racial disparities in jails and prisons represent a failure of society to address institutional racism that profoundly harms communities of color and society as a whole.
This is not to say that the current correctional model should be replaced by a medical model. As many correctional health professionals are keenly aware, mental illness, addiction and other chronic illnesses are not excuses for criminal conduct. But physicians, both those working in correctional facilities and those working in the community, can no longer afford to be passive in the policy arena as the country continues to mount an unprecedented human subjects experiment based on a rather crude model of punishment and isolation. As a matter of medical professionalism, physicians will need to assert a leadership role in reform of a system that is increasingly at odds with the health and welfare of their patients.
Physicians have an often overlooked responsibility to lobby for change in institutions that may harm their patients. While correctional health professionals often remain overwhelmed by simply trying to meet the immediate medical and psychiatric needs of their patients, it is clear that the current system of mass incarceration is unsustainable. It is inefficient and costly to society, in both dollars and in human terms. Across the political spectrum there is growing unity in the call for significant reform; however, for optimal reform to succeed, physicians and other health professionals must assert their right and responsibility to have a leadership role in the political and policy driven process that will determine the future of jails and prisons in this country.
Dr. Allen, MD, is Co-Director of the Center for Prisoner Health and Human Rights at The Miriam Hospital, Alpert Medical School, Brown University, and former Medical Program Director of the Rhode Island Department of Corrections. Readers may contact him at docallen@aol.com.
