INTRODUCTION

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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:

• How can corrections and communities work together to build a successful framework for reentry that addresses both the needs of the prisoner and those of the community to prepare for the return home?26-28
• How can public resources be allocated to improve public safety and reduce or prevent reoffending?
• How can corrections and communities work together to develop strategies and programs to support successful reentry into society?
• And, most important, what types of policies can be realistically implemented to make a difference using current resources?29,30

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

1. Gilliard DK, Beck AJ. Prison and jail inmates at midyear 1997. NCJ 167247. Washington, DC: Bureau of Justice Statistics; 1998.
2. Belenko S. Behind bars: substance abuse and America’s prison population. New York: Columbia University, National Center on Addiction and Substance Abuse; 1998.
3. Beck AJ. Prisoners in 1999. NCJ 183476. Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics; 2000.
4. Federal Bureau of Prisons. Quick facts. Available at: www.bop.gov/news/quick.jsp. Retrieved July 2005.
5. National Commission on Correctional Health Care. The health status of soon-to-be-released inmates: a report to Congress. Vol. 1. Chicago: National Commission on Correctional Health Care; 2002.
6. Hammett TM. Public health/corrections collaborations: Prevention and treatment of HIV/AIDS, STDs and TB. Washington, DC: US Department of Justice, Office of Justice Programs, National Institute of Justice; 1998
7. National Commission on Correctional Health Care. The health status of soon-to-be-released inmates: a report to Congress. Vol. 1. Chicago: National Commission on Correctional Health Care; 2002.
8. Hammett TM, Maruschak L, Harmon P. 1996-1997 Update: HIV/AIDS, STDs, and TB in correctional facilities. Washington, DC: National Institute of Justice, Bureau of Justice Statistics, and Centers for Disease Control and Prevention; 1999.
9. Hammett TM, Harmon MP, Rhodes W. The burden of infectious disease among inmates of and releasees from US correctional facilities, 1997. Am J Public Health 2002;92(11):1789-94.
10. Office of the Surgeon General, U.S. Department of Health and Human Services. Pubic health priorities. Available at: www.surgeongeneral.gov/publichealthpriorities.html.
11. Travis J, Solomon AL, Waul M. From prison to home: the dimensions and consequences of prisoner reentry. Washington, DC: Urban Institute Justice Policy Center; 2001.
12. Re-Entry Policy Council. Report of the Re-Entry Policy Council: charting the safe and successful return of prisoners to the community. New York: Re-Entry Policy Council; 2004.
13. Sabol WJ, Minton TD, Harrison PM. Prison and jail inmates at midyear 2006. NCJ 217675. Washington, DC: Bureau of Justice Statistics; 2007. Available at: www.ojp.usdoj.gov/bjs/abstract/pjim06.htm.
14. Harrison PM, Beck AJ. Prisoners in 2003. NCJ 205335. Washington, DC: Bureau of Justice Statistics; 2004.
15. Harrison PM, Beck AJ. Prisoners in 2002. NCJ 200248. Washington, DC: Bureau of Justice Statistics; 2003.
16. Davis LM, Pacchiana S. Health profile of the state prison population and returning offenders: public health challenges. J Correctional Health Care 2004;10(3):325-6.
17. Travis J, Solomon AL, Waul M. From prison to home: the dimensions and consequences of prisoner reentry. Washington, DC: Urban Institute Justice Policy Center; 2001.
18. Conklin TJ, Lincoln T, Flanigan TP. A public health model to connect correctional health care with communities. Am J Public Health 1998;88(8):1249-50.
19. Klein SJ, O’Connell DA, Devore BS, Wright LN, Birkhead GS. Building an HIV continuum for inmates: New York State’s criminal justice initiative. AIDS Educ Prev 2002;14(5 Suppl B):114-23.
20. Roberts CA, Kennedy S, Hammett TM. Linkages between in-prison and community-based health services. J Correctional Health Care 2004;10(3):333-68.
21. Hammett, 1998.
22. Kennedy S, Roberts CA, Hammett T. Discharge planning and continuity of care for HIV-infected inmates as they return to the community: a study of ten States. Study prepared for the Centers for Disease Control and Prevention by Abt Associates. Cambridge, MA; 2001
23. Legal Action Center. After prison: roadblock to reentry: a report on State legal barriers facing people with criminal records. New York: Legal Action Center; 2004.
24. Freudenberg N. Community health services for returning jail and prison inmates. J Correctional Health Care 2004;10(3):369-97.
25. Health Resources and Services Administration, HIV/AIDS Bureau. Lessons learned: innovations in the delivery of HIV/AIDS services. Washington, DC: Health Resources and Services Administration, HIV/AIDS Bureau; 2001.
26. Health Resources and Services Administration, HIV/AIDS Bureau. Plan for providing medical case management and support services to individuals with HIV disease being released from Federal or State prison-report to Congress. Washington, DC: Health Resources and Services Administration, HIV/AIDS Bureau; 2002.
27. Hammett TM, Roberts C, Kennedy S. Health-related issues in prisoner reentry. Crime Delinquency 2001;47(3):390-409.
28. Freudenberg N. Community health services for returning jail and prison inmates. J Correctional Health Care 2004;10(3):369-97.
29. Travis et al., 2001.
30. Davis LM, Pacchiana S. Health profile of the State prison population and returning offenders: public health challenges. J Correctional Health Care 2004;10(3):325-6.
31. Hammett, 1998.
32. Conklin TJ, Lincoln T, Flanigan TP. A public health model to connect correctional health care with communities. Am J Public Health 1998;88(8):1249-50.
33. Conklin TJ, Lincoln T, Wilson R, Gramarossa G. A public health model for corrections health care. Ludlow, MA: Hampden County Correctional Center; 2002.
34. National Institute of Corrections Information Center. Corrections agency collaborations with public health: special issue in corrections. Longmont, CO: National Institute of Corrections Information Center, US Department of Justice; 2003.
35. Centers for Disease Control and Prevention. CDC/HRSA cooperative agreements for HIV/AIDS intervention, prevention, and continuity of care demonstration projects for incarcerated individuals within correctional settings and the community (Program Announcement 99099). 1999. Available at: www.cdc.gov/od/pgo/funding/99099.htm. Retrieved May 20, 1999.