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INTRODUCTIONDownload PDF 390 KB - File format PDF In 1997 more than 1.75 million people were incarcerated in jails or prison in the United States—almost 1 percent of the Nation’s population.1 This dramatic increase in the number of prisoners has been fueled since the 1980s by the “War on Drugs.” By 1998, nearly 60 percent of incarcerated people were drug offenders, compared with only 29 percent in the mid-1980s.2 By early 1999, an estimated 2 million people were incarcerated, an increase of about 500 percent over the 325,400 who were incarcerated in 1970.3 During the 1990s, the United States experienced its highest incarceration rate ever, which created a strain on the resources of corrections systems, particularly in the area of health care.4 Inmates suffer disproportionately from infectious diseases, substance abuse, and a constellation of problems related to socioeconomic status.5 Most people who are incarcerated come from impoverished, medically underserved environments; they have engaged in a variety of high-risk and often violent behaviors. Those behaviors and high-risk lifestyles make them vulnerable to serious health problems and increase the prevalence of infectious diseases, such as HIV/AIDS, tuberculosis (TB), sexually transmitted infections (STIs), and hepatitis. Factors such as drug addiction, lack of access to health care, poverty, substandard nutrition, poor housing conditions, and homelessness contribute to increased risk for not only infectious diseases but also chronic conditions such as hypertension, cardiovascular disease, skin conditions, gastrointestinal disease, diabetes, and asthma. For many people, incarceration may be their first contact with health care. It is estimated that up to 80 percent of chronically ill inmates have not received medical care prior to incarceration and may have been using the local hospital emergency room as their primary care provider.6-8 As a group, inmates report higher rates of disabling conditions, have poorer perceptions of their health status, and have lower utilization of primary health care services than the general population. In the United States, 20 to 26 percent of people living with HIV/AIDS (PLWHA), 29 to 43 percent of those infected with the hepatitis C virus, and 40 percent of those who have TB passed through correctional facilities during 1997.9 Physical and mental illness and the range of psychosocial problems encountered in correctional facilities reflect the health disparities within the larger community. The correctional population is most in need of care, as outlined in the Surgeon General’s list of priorities for the Nation’s health care.10 Although the focus of correctional health care is generally on the people who are incarcerated, benefits accrue to corrections staff, their families, and the neighborhoods from which inmates come and to which they return. In this way, correctional settings, although self-contained, are linked to our Nation’s communities.11,12 The huge growth in incarceration over the past two decades has led to similar growth in the numbers of people released. Nearly 700,000 people from State and Federal prisons were released to return to their communities in 2005, more than four times the 170,000 released in 1980.13 This figure, however, does not include the additional 12 million who are incarcerated in local or county jails for short periods, ranging from only a few hours to up to a year, and are subsequently released. Local officials and community leaders are starting to ask questions about how the flow of inmates back into communities affects public safety, how corrections systems prepare prisoners for release, and what communities can do to successfully absorb and reintegrate inmates into community life.14-16 Because most inmates are eventually released back to their communities, public health officials have begun to recognize the tremendous public health opportunity within corrections and the potential to benefit the community through reduced illness rates, financial savings, improved public safety, and better use of the existing health care system and resources. More inmates are returning home, having spent longer and more frequent terms behind bars; they are less prepared for life on the outside and have less help and fewer resources available to assist in their reintegration. They will have difficulty reconnecting with jobs, housing, and families when they return and will have to deal with substance abuse and health problems. Many will be rearrested, and many will be returned to prison or jail for new crimes or parole violations. This cycle of removal and return, which is occurring mostly among men, is increasingly concentrated in communities that are already disproportionately affected by social and economic disparities.17 From a policy perspective, inmates’ health care and reintegration back into the community began to take on new importance with the increasing number of HIV/AIDS cases identified in correctional settings. By the late 1990s, public health and corrections officials had begun to recognize that a comprehensive approach, including early detection and assessment, health education, prevention and treatment, and continuity of care, was critical to reducing the incidence and prevalence of disease in correctional facilities and communities.18 Given this realization, collaborations among corrections, community, and public health programs at both the Federal and State levels have increasingly been developed to take advantage of the incarceration episode to decrease the burden of illness on inmates and the greater community.19,20 Although the costs of prisoner reintegration are great, opportunities to enhance the health and safety of the community are gaining in importance. By the mid-1990s, public health workers in communities with high rates of HIV and STIs had begun to recognize the strong relationship among disease, drug use, and periods of incarceration in jails and prison among PLWHA. Those relationships were especially pronounced among injection drug users (IDUs). Despite high disease rates and risk behaviors among prisoners and releasees, initial Centers for Disease Control and Prevention (CDC) studies documented that correctional health and community-based primary health care systems had not forged the relationships to link and deliver surveillance, prevention, and treatment, including substance abuse treatment and social services. This lack of comprehensive approaches and the poor organizational framework to support continuity of care were contributing to significant, preventable disease and morbidity among people at high risk for HIV/AIDS, TB, STIs, hepatitis, and other health problems.21,22 People moving into or out of incarceration must negotiate differences in access as well as structural and procedural differences between correctional and community-based case systems. The barriers also may make it more difficult for clients to benefit from public health efforts to promote behaviors that aid in prevention and treatment.23,24 The Health Resources and Services Administration’s (HRSA’s) Special Projects of National Significance (SPNS) initiatives, which targeted incarcerated populations during the mid-1990s, found that continuity of care was a significant problem for recently released inmates with HIV disease for whom effective clinical management and ongoing treatment were essential to prevent further HIV transmission. SPNS also found that program models that integrate correctional and community-based prevention, primary care, and other supportive services were effective at helping clients maintain continuity of care and reduce risk behaviors.25 Better coordination of services for returning inmates can reduce criminal behavior, which in turn can translate into fewer crimes committed and fewer returns to jail or prison. This approach has potential benefits for the families and communities most affected by prisoner reentry as well as for the former prisoner. The costs and opportunities associated with reentry and long-term reintegration of former prisoners raise important questions that need to be addressed:
Collaborations between public health and correctional agencies have evolved and are now an important venue for addressing gaps in health care services for inmates. Public health departments are mandated to prevent illness—particularly environmental and communicable diseases—in the general population. Public health departments have the funds, staff, expertise, and other resources to help correctional facilities address the serious health needs of inmates and thereby advance the cause of public health in their communities.31,32 The same can be said for public health’s interactions with community-based organizations (CBOs). Corrections agencies and CBOs, in turn, need to collaborate because they share the same clients (although traditionally at different times) and families and because each entity has the necessary expertise and experience to address the issues. Many types of collaborations exist between corrections and public health at Federal, State, and local levels, although State departments of corrections collaborate most often with State-level public health agencies. Most collaborations at all levels are limited and focus only on correctional populations that are HIV infected or mentally ill. Although correctional systems value the collaborations, vast areas for improvement remain.33,34 Recognizing this need and opportunity, HRSA and the CDC developed a partnership in 1999 to provide funding “to support demonstration projects within correctional facilities and communities that develop models of comprehensive surveillance, prevention, and health care activities for HIV, STIs, TB, substance abuse, and hepatitis.”35 This report describes the initiative; its intent, development, and implementation; and lessons learned. NOTES
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