It is well-known that the United States incarcerates more people and at a higher rate than any other country in the world. Moreover, we do so unequally, with low-income people of color—particularly poor Black men—bearing the brunt of disproportionate hyperincarceration.1Loïc Wacquant, “Class, Race, & Hyperincarceration in Revanchist America,” Daedalus 139, no. 3 (2010): 74–90. Yet the nation’s exceptional focus on the apprehension, containment, and surveillance of impoverished black and brown bodies in the legal system contrasts sharply with lack of attention to these same individuals in the public health arena, where people in prison are largely excluded from national population health surveys.2Dora Dumont et al., “Public Health and the Epidemic of Incarceration,” Annual Review of Public Health 33 (April 2012): 325–339.
This absence of data has contributed to the popular misconception that people in prison (and men in particular, who make up 94 percent of state and federal prisoners)3E. Ann Carson, Prisoners in 2016 (Bureau of Justice Statistics, 2018). are optimal physical “specimens”—young, healthy, and muscled from hours spent in the prison weight yard. Justice Antonin Scalia invoked just such an image in his dissent to the Supreme Court’s 2011 Brown v. Plata decision. The case was a lawsuit filed on behalf of mentally and physically ill people incarcerated in California’s prison system, which at the time was nearly 200 percent over capacity. The Court ruled that overcrowding and inadequate medical care violated the Eighth Amendment, and ordered California to release over 30,000 people from the state’s prisons within two years. In his strenuous oral dissent, Scalia argued that most of the people released under the court’s order would not be those suffering from medical or psychiatric issues, but rather “fine physical specimens who have developed intimidating muscles pumping iron in the prison gym.”4Brown v. Plata, 563 U.S. 493 (Scalia, J., dissenting; 2011). Bracketing the fact that free weights had been banned from California and many other prison systems decades previously, the associate justice’s stereotype reflected a common misconception about incarceration and health. Evidence shows people in prison are generally sicker and experience the effects of aging more rapidly than their nonincarcerated peers.5Brief for the APA as Amicus Curiae, Brown v. Plata, 563 U.S. 493 (2011).
Assessing the health of the incarcerated
More than half of people in US jails and prisons have a mental health problem; the majority of those with mental illness are dually diagnosed with drug or alcohol dependency.6Doris J. James and Lauren E. Glaze, Mental Health Problems of Prison and Jail Inmates (Bureau of Justice Statistics, 2006). People in US correctional facilities also have higher rates of both infectious and chronic disease than do people who are not incarcerated. For example, the prevalence of HIV, hepatitis B and C, tuberculosis, and sexually transmitted infections is consistently higher within than outside prisons. The number of incarcerated people over the age of 55 has increased by over 500 percent in recent years,7Brie A. Williams et al., “Addressing the Aging Crisis in US Criminal Justice Health Care,” Journal of the American Geriatrics Society 60, no. 6 (2012): 1150–1156. and chronic health conditions, many associated with the aging, are also common in correctional facilities. A 2012 survey by the Bureau of Justice Statistics found that 40 percent of people in prison and jail reported at least one chronic medical condition—most often hypertension, asthma, or arthritis. The same survey found sharp increases in high blood pressure and diabetes among incarcerated people since 2004, with rates of diabetes nearly doubling.8Laura M. Maruschak, Marcus Berzofsky, and Jennifer Unangst, Medical Problems of State and Federal Prisoners and Jail Inmates, 2011–12 (Bureau of Justice Statistics, 2015). Moreover, 74 percent of people in state and federal prisons (62 percent in jails) are overweight, obese, or morbidly obese according to BMI measures.9Maruschak, Berzofsky, and Unangst, Medical Problems of State.
There are multiple reasons why incarcerated people have so many health problems. The deinstitutionalization of the mentally ill and the underfunding of community-based mental health care put jails and prisons on the frontlines of dealing with mental illness. The “War on Drugs” criminalized addictive disorders, sending many people to jail and prison rather than to drug treatment. The hyperincarceration of the poor, who often receive inadequate access to health care, means that disproportionate numbers of people enter prison with untreated or undertreated infections and chronic conditions.10→Timothy P. Flanigan et al., “HIV and Infectious Disease Care in Jails and Prisons: Breaking Down the Walls with the Help of Academic Medicine,” Transactions of the American Clinical and Climatological Association 120 (2009): 73–83.
→Michael Massoglia and William Alex Pridemore, “Incarceration and Health,” Annual Review of Sociology 41 (August 2015): 291–310. Sentencing policies such as mandatory minimums and “three strikes” laws mean people stay in prison for much longer than before, and consequently diseases of middle and old age are increasingly common among incarcerated people.
Prison-induced death“The incarcerated people we spoke with described a slow erosion of their physical, mental, and/or social well-being over the course of their imprisonment.”
In addition to all the factors listed above, there is also the possibility—many would argue the reality—that incarceration itself harms health. This was the view of some of the incarcerated individuals that my colleague and I interviewed for a research project on health and incarceration in Washington State.11Johanna Crane and Kelsey Hirsch, “Incarceration as a Chronic Condition” (unpublished manuscript). The incarcerated people we spoke with described a slow erosion of their physical, mental, and/or social well-being over the course of their imprisonment. Some interviewees directly linked incarceration to disabling levels of anxiety, depression, or PTSD—particularly following solitary confinement.12See Lorna A. Rhodes, Total Confinement: Madness and Reason in the Maximum Security Prison (Berkeley, CA: University of California Press, 2004). But even those who had not been subject to extreme isolation saw incarceration as eroding their well-being. They described everyday life in a correctional facility as stressful in ways both big and small, including the “helplessness of no control,” separation from family, and what one man described as “the daily grind” of “being subjugated to a lesser human.” Those we interviewed had a name for what they described: “institutionalization” or “becoming institutionalized.”
In their usage, this term referred to more than the simple physical fact that they were housed within a correctional institution, and it did not imply “madness” or mental institutionalization as it often does in common parlance. Rather, they described “institutionalization” as a chronic biopsychosocial state brought on by incarceration and characterized by anxiety, depression, hypervigilance, and a disabling combination of social withdrawal and/or aggression. The process of “becoming institutionalized” reflected their experience of incarceration itself as corrosive to physical, mental, and social well-being. Moreover, they described this state of “institutionalization” as remaining with them even after release, adding to the already numerous challenges of re-entry after prison. As one man put it, “it’s difficult to emerge back into regular society and be a normal-operating person.”
Sociologist Joshua Price has characterized incarceration as a form of “social death.”13New Brunswick, NJ: Rutgers University Press, 2015More Info → But “institutionalization,” as described by my interviewees, is perhaps better understood as “slow death.”14Lauren Berlant, “Slow Death (Sovereignty, Obesity, Lateral Agency),” Critical Inquiry 33, no.4 (2007): 754–780. For Berlant, “slow death refers to the physical wearing out of a population and the deterioration of people in that population that is very nearly a defining characteristic of their experience and historical existence.”15Berlant, “Slow Death,” 754. Slow death, she writes, “prospers not in traumatic events…but in temporal environments.”16Berlant, “Slow Death.” Carceral facilities—“doing time”—constitute just such a temporal environment. Incarcerated people and their advocates have long argued that lengthy sentences, in particular life sentences without parole, constitute a form of death by incarceration. But the erosive nature of “institutionalization” and “slow death” suggests that even those who are released may suffer the after-effects of years spent behind bars. In other words, even those who don’t die in prison may die because of prison.“There are a few existing studies that strongly suggest a causal link between incarceration and harm to health.”
The Department of Justice’s recent damning report on conditions in Alabama’s state prisons is an important reminder that violence is the most immediate threat to health within many prisons. My focus on “slow death” is not intended to overlook this grim reality. But prisons also harm the body in less overt ways that rarely make headlines. While it is fairly easy to show a correlation between incarceration and poor health, empirically documenting a causal relationship—that incarceration causes health deterioration, or that “becoming institutionalized” leads to “slow death”—is not straightforward. There are a few existing studies that strongly suggest a causal link between incarceration and harm to health. A 2013 study of parolees in New York used a dose-response analysis to examine the relationship between time served and life expectancy, and found that those on parole lost approximately two years of life for each year of incarceration.17A dose-response analysis measures the relationship between the level of exposure to a phenomenon (“dose”) and its impact or effect (“response”). Evelyn J. Patterson, “The Dose–Response of Time Served in Prison on Mortality: New York State, 1989–2003,” American Journal of Public Health 103, no. 3 (2013): 523–528. Another study found that women in prison gained an average of one pound a week over the course of their incarceration, meaning that a year in prison potentially correlates with 50 pounds of gained weight.18Jennifer G. Clarke and Molly E. Waring, “Overweight, Obesity, and Weight Change Among Incarcerated Women,” Journal of Correctional Health Care 18, no. 4 (2012): 285–292. Additionally, a recent review of the literature found that formerly incarcerated people suffer ongoing health problems associated with their imprisonment even after their release, and that incarceration harms the health not only of people in prison but their family members as well.19Christopher Wildeman and Emily A. Wang, “Mass Incarceration, Public Health, and Widening Inequality in the USA,” Lancet 389, no. 10077 (2017), 1464–1474.
A growing body of research is documenting the ways in which chronic vigilance and stress erode health through the phenomenon of “weathering.”20Arline T. Geronimus, “The Weathering Hypothesis and the Health of African-American Women and Infants: evidence and speculations,” Ethnicity and Disease 2, no. 3 (1992): 207–221. “Weathering” refers to the ways in which social inequalities, political marginalization, and racial discrimination have a bodily impact, and has been used to explain why African Americans consistently have higher morbidity and mortality than Whites even when controlling for all other factors.21Arline T. Geronimus et al., “‘Weathering’ and Age Patterns of Allostatic Load Scores among Blacks and Whites in the United States,” American Journal of Public Health 96, no. 5 (2006): 826–883. Although this framework has not, to my knowledge, been applied to incarceration, the authors’ assertion that “on a physiological level, persistent, high-effort coping with acute and chronic stressors can have a profound impact on health” seems particularly relevant to the high-stress, ultravigilant, and race-conscious environment found in many prisons. Indeed, it is already widely accepted that people in prison are physiologically older than their chronological years.22→American Civil Liberties Union (ACLU), At America’s Expense: The Mass Incarceration of the Elderly (New York: ACLU, 2012).
→Tina Maschi et al., “Forget Me Not: Dementia in Prison,” The Gerontologist 52, no. 4 (2012): 441–451.
→Joann B. Morton, An Administrative Overview of the Older Inmate (National Institute of Corrections, 1992). Might “institutionalization” infer a form of “weathering,” and might “weathering” be empirical evidence of “slow death” by incarceration?
Social science studies of death and prison
There are a number of ways social science might approach such a research question, but it is important to pause first and ask why. Incarceration is not a medical problem, it is a political problem. There is a risk that if we frame incarceration in health terms we will sideline the much more dire human rights and racial justice problems raised by US incarceration practices. We should not need to show that incarceration harms health in order to fight incarceration—we already have abundant social, moral, and ethical reasons to do so.“The goal is massive structural change toward an equitable and humane society.”
This said, there are pragmatic reasons to study the impact of incarceration on health. Scientific evidence can be a powerful tool in advocating for change. For example, the authority and persuasive power of medical science played a role in recent Supreme Court decisions regarding juvenile sentencing, where evidence on adolescent brain development was “central” to rulings that effectively ended life-without-parole sentences for those under the age of 18.23Josh Rovner, Juvenile Life without Parole: An Overview (The Sentencing Project, October 22, 2018). Again, we should not need to rely upon medical arguments to show that life sentences for children are wrong, and the fact that we did is frankly disturbing. Nonetheless, it is a useful example of how medical research can provide a useful leverage in the broader fight against US carceral norms. It is possible that studies demonstrating the harmful health impacts of incarceration could benefit currently incarcerated people, both by encouraging more humane prison conditions (for example, outlawing solitary confinement) and by supporting policies that would reduce time spent in prison. Of course, this alone is not enough. The goal is not to tinker with an inhumane system in order to make it somewhat less so; the goal is massive structural change toward an equitable and humane society. Documenting and reducing health harms for currently incarcerated people is an important step along the way.
→Michael Massoglia and William Alex Pridemore, “Incarceration and Health,” Annual Review of Sociology 41 (August 2015): 291–310.
→Tina Maschi et al., “Forget Me Not: Dementia in Prison,” The Gerontologist 52, no. 4 (2012): 441–451.
→Joann B. Morton, An Administrative Overview of the Older Inmate (National Institute of Corrections, 1992).