Prisons and Health in the Age of Mass Incarceration
Although the United States correctional population has declined in recent years, the number of people confined to either prisons or jails remains considerable. Across the country, more than 1.2 million people are incarcerated in state or federal prisons, with another 636,000 confined in local jails (Carson & Kluckow, 2023). In Prisons and Health in the Age of Mass Incarceration, authors Jason Schnittker, Michael Massoglia, and Christopher Uggen lay plainly the health related costs that have accumulated following decades of mass incarceration. Given the price, the book serves as a reckoning. Readers are challenged to consider both the role and purpose of prisons in contemporary American society, particularly as “there is no denying that prisons are firmly in the business of providing health care” (p. 33).
The backdrop presented by the authors is compelling. Millions of people filter in and out of jails and prisons each year. The health needs of the carceral population are extensive given that many people are not only vulnerable to poor health outcomes prior to their incarceration, but the prison environment itself is implicated in the erosion of health. This is due to many factors, not least of which include prison violence, the intra-prison transmission of infectious disease, and social isolation. Unlike in community settings, people in prison also cannot select their own medical providers or pursue even basic over the counter remedies for ailments without approval. Problems with overcrowding, an aging prison population, and a secluded landscape are all exacerbated by the legal context of prison health care.
One of the most important contributions of the book is the authors’ writeup of chapter two. In it, they detail the often reactionary nature of the prison health care system. While prisons are required by law to provide health care, the provision of care is situated within the context of Estelle v. Gamble. In this landmark case, the U.S. Supreme Court stipulated that deliberate indifference by prison staff to the serious needs of incarcerated people threatens the constitutional protections of the 8th amendment. The authors point out that although Estelle provides a “crucial safeguard for people in prison,” (17) it leaves troubling ambiguities. This includes a great deal of discretion in determining what needs are considered “serious,” as well as a standard in which medical malpractice itself does not constitute an 8th amendment violation, nor does any medical negligence unless it can be demonstrated that prison staff “knew of and disregarded a substantial risk” (180). Other litigation, including the Prison Litigation Reform Act (1996), requires people in prison to pay filing fees and exhaust prison grievances before bringing claims forward. This combination of factors sets the stage for a largely reactionary prison health care system that is deeply deficient.
Another contribution of this book lies in the authors’ abilities to meaningfully “widen the net” as they present the extensive connections between incarceration and health. To be sure, the authors address the individual level impacts of incarceration. For example, the authors detail the risks of violent victimization among people in prison and highlight the unique vulnerabilities of people with mental health conditions to this victimization. And while people in prison may learn they have an infectious disease because of the routine testing that is offered in prison, people are also exposed to infectious diseases by nature of being incarcerated (e.g., COVID-19). The authors emphasize that incarcerated people face additional challenges upon reentry when any continuity of care they might have received in prison abruptly ends and new stressors associated with release are introduced (e.g., housing insecurity, unemployment, stigma, severed relationships).
Yet, this does not tell the full story. Beyond outlining the health-related costs for those who experience incarceration, the authors importantly confront the costs of incarceration on health for (a) communities; and, by extension, (b) health care systems. Regarding community health, the authors present evidence of incarceration as a pathway to health declines among children with incarcerated parents and mothers and grandmothers with incarcerated adult children. The health impacts of incarceration on families are also evident in examples provided by the authors of diminished mental health among partners of incarcerated people and in the facilitation of income loss via the unemployment or underemployment of the family member during incarceration and post-release. Incarceration can also increase the risk of various infectious diseases in communities, including COVID-19 and sexually transmitted infections. As for health care systems, the authors demonstrate how an overreliance on incarceration places further strain on already overburdened hospital emergency rooms. Because people with incarceration histories are less likely to have health insurance, emergency rooms are more likely to be relied upon by this population as a primary source of medical care. The implications include not only more overwhelmed hospital staff, but increased costs associated with providing so much uninsured care that spills over to people who are insured.
The policy landscape is also importantly described by the authors. This includes issues such as the rise of private prisons, the difficulties of curtailing prison costs even with declines in carceral populations, and the context of living in a society where health care is generally viewed as an individualized (often earned) privilege rather than a basic human right – even in free society. The authors are transparent in noting that the path to reform will be onerous. Although public sentiment towards criminal justice reform is more favorable, policies that could help reduce the health-related burdens of incarceration, including compassionate release and medication assisted treatments for substance use, are still drastically underutilized. The authors note that true health improvements depend upon the pursuit of mechanisms beyond prison downsizing alone. This is because of an “incarceration footprint” that now spans several decades – a landscape where so many have been left vulnerable the volume is staggering. One policy area the authors make the case for is an enhanced liability standard for prison health care, as “there are clear limits to the provision of care based on avoiding cruel and unusual punishment” via Estelle (p. 139). This indeed seems critical.
I was hoping the authors would propose a research agenda to help move the research forward that they so meaningfully summarized in the book. However, this is largely left to the reader. I think the book would have been strengthened if the authors had outlined some health implications of incarceration that are especially underdeveloped or in need of attention. For example, research that documents the rise in environmental disasters and temperatures across the U.S. and their implications for conditions of confinement. Another example could be calls to address the potential long-term health implications of (1) living in a prison during an unprecedented pandemic; (2) living through the pandemic while a loved one was incarcerated; and (3) providing medical care in prisons during the pandemic.
Despite this, Prisons and Health in the Age of Mass Incarceration is a timely, much needed, and welcomed addition to the literature. Those interested in the intersection of incarceration and health, as well as those invested in criminal justice reform, public health, or social inequalities will benefit from reading this text.
Ann Carson & Rich Kluckow, U.S. Dep’t of Just., Bureau of Just. Stat. Correctional Populations in the United States, 2021 – Statistical Tables (Feb. 2023),
Meghan A. Novisky is an Associate Professor at Cleveland State University in Cleveland, OH.