IN NEED OF
CORRECTION:
THE PRISON CYCLE
OF HEALTH CARE
A FORUM HELD ON
SEPTEMBER 28, 2005
TO HIGHLIGHT RESEARCH
FROM THE

OCTOBER

2005 AMERICAN
JOURNAL OF PUBLIC
HEALTH

SPONSORED BY
THE AMERICAN PUBLIC HEALTH
ASSOCIATION IN COLLABORATION
WITH THE COMMUNITY VOICES
INITIATIVE OF THE NATIONAL
CENTER FOR PRIMARY CARE
AT THE MOREHOUSE SCHOOL
OF MEDICINE

HEALTHCARE FOR

THE UNDERSERVED

C

ommunity Voices: HealthCare for the Underserved has chosen to highlight the issues surrounding individuals in re-entry
from jails and prisons as a part of our overall work to improve the
health of underserved communities. We believe this work is essential because ignoring the fate of poor men and women who
have lost their legal voice and place in our communities will make
things worse on all utilizing our nation’s health care system.
As the debt accrues for delivering care to those without a payment system so does the levels of incarceration. The foundation
of Community Voices is rooted in listening to the voices of those in
communities nationwide and responding with action and policy options. Our work, within the National Center for Primary Care at the
Morehouse School of Medicine represents a new endeavor for us.
Our goal is to design a system that serves all Americans, including
those that have an involvement with the corrections industry.

Executive Summary of

In Need of Correction:
The Prison Cycle of Health Care
A forum held on September 28, 2005 to highlight research from the
October 2005 American Journal of Public Health

Sponsored by
The American Public Health Association
in collaboration with
The Community Voices Initiative of the
National Center for Primary Care at the Morehouse School of Medicine

O

On September 28th Dr. George Benjamin, executive director of the American Public Health Association,
welcomed and introduced keynote speaker Dr. David Satcher, 16th Surgeon General and interim president
of Morehouse School of Medicine; Marguerite Johnson, vice president for Programs in Health at the W.K.
Kellogg Foundation, and Henrie Treadwell, guest editor for the American Journal of Public Health and senior
social scientist at the National Center for Primary Care. Following opening remarks, Judge Greg Mathis,
of Michigan’s 36th District Court and the host of a nationally-syndicated reality-based courtroom television
show, moderated a distinguished panel of forum participants including Nicholas Freudenberg, professor and
director of Urban Public Health at Hunter College in New York, Judge Steven Leifman of the Miami-Dade
County Court in Florida; and Dr. Lester Wright, commissioner and chief medical officer of the Department of
Correction Services for the State of New York.
Together the speakers trained the spotlight on the growing body of evidence about the health of people
in prisons, the relationship between our nation’s health care system and the prison population, and the
implications and opportunities for community health. In their remarks and exchange, participants offered data,
experience, and models for public health, corrections, communities, and the judiciary to begin to redirect and
reorient society’s resources to improve health.
Root Causes for Prison Population Growth
In his keynote address, Dr. Satcher called the health care system “a major culprit” in the explosive growth
in the number of people incarcerated in prisons and jails across the country. “We as a nation have perhaps
inadvertently used the prison system to deal with our mental health burden,” he said. “People often say that
the Los Angeles County Jail is the largest mental health system in this country. There’s a lot of truth to that,”
Satcher continued, “because so many of the people there are mentally ill and wouldn’t be there if they were not
mentally ill.”
In his remarks, Judge Leifman of Miami-Dade County Court explained how a U.S. Supreme Court ruling 40
years ago resulted in “the parade of misery” visible in every criminal court. “Deinstitutionalization” was the
first part of the High Court’s ruling made “with the best of intentions,” Leifman said. “The second half of the
opinion says if you’re going to deinstitutionalize, you must provide community-based treatment,” he added.
“Unfortunately, the states only read the first part.” Before deinstitutionalization, some 560,000 people were
living in state psychiatric institutions. “Last year more than 700,000 people with serious mental illnesses were
arrested,” Leifman noted. “Another 500,000 people with severe mental illness are out on probation.”
Untreated or inadequately treated mental illness, the role of violence and trauma in fueling mental illness
– especially among children and young people who witness violence – panelists spoke frankly about these and

“

“

We must see how we can
address the issue in a
way where the poor don’t
automatically go to jail
while the privileged get
counseling and treatment

— Judge Greg Mathis
Michigan’s 36th District Court
Host of a Nationally-syndicated Reality-Based
Courtroom Television Show,

other factors draining vulnerable communities of their health, youth, and manpower.
“We lose more men every year to gun violence in America than we’ve lost in Iraq,” Judge Greg Mathis said.
“In many communities, it’s like a war zone. So the question becomes, if soldiers can return home with posttraumatic stress syndrome after 18 months on the front line, what do you think a young person who deals with
it for 10, 15, or 20 years in the inner cities of America is going to be like?”
The connections between mental health, drugs, poverty, and disease show up in the courtroom as rage,
hopelessness, and despair. According to Judge Mathis, young people who grow up in impoverished
neighborhoods have two choices: to become a member of a street gang or a victim of one. “Ninety percent of
those young black males are forced to either participate as predator or prey,” according to Judge Mathis. “We
must see how we can approach the root causes of the reactions that we see in many who encounter the criminal
justice system. We must see how we can address the issue in a way where the poor don’t automatically go to jail
while the privileged get counseling and treatment.”
Marguerite Johnson echoed the concerns of Judge Mathis. “Truly this population of individuals in the
criminal justice system is invisible and forgotten. They enter the system with a myriad of complex physical and
emotional issues and they emerge with even more.” And the experience of incarceration – like any other trauma
– further threatens the health of those imprisoned. As Dr.. Satcher commented, research continues to show that
traumatic experiences change people. “We can no longer separate environment and biology,” Satcher explained.
“Environmental experiences lead to changes in the brain.” And as more and more men and women are locked
up – whether for a few days, a few weeks, or years on end – the health effects and potential impact on society
are staggering.
In the course of his remarks, researcher Nicholas Freudenberg provided this stunning statistic: “Each year more
than 10 million people are locked up in our municipal and county jails,” he said – an increase of 265 percent in
two decades. “In the last 20 years, police, drug, mental health, and employment policies have become a funnel
into jail for our nation’s least healthy populations.”

“

People often say that the Los
Angeles County Jail is the
largest mental health system
in this country. There’s a lot
of truth to that, because so
many of the people there are
mentally ill and wouldn’t
be there if they were not
mentally ill.

“

— Dr. David Satcher
Interim President
Morehouse School of Medicine
16th U.S. Surgeon General

Opportunities for Public Health Collaboration
Dr. Lester Wright spoke directly to colleagues in public health when he said, “If I were again a county or
state public health administrator, one of the first things that I’d look at would be the jails and prisons in
my jurisdiction.” Why? Because “prison is far more a sentinel of health problems in the community than
an incubator of ill health,” he suggested. Yet the culture of public health and perceptions about corrections
often present barriers to collaboration. “We [in public health] tend to think of ourselves as knights on white
horses riding out to save the victims of the system,” said Wright. But if public health practitioners can begin
“cross-cultural interface” with corrections, the opportunities to improve health – both for prisoners and for
the community – are great. “We take the position that offering hepatitis B vaccine to all inmates who need it
protects [prisoners] not only while they are inside, but the community afterward,” he said. “It’s much easier to
find those who need hepatitis B vaccine while they’re in Sing-Sing than it is in the South Bronx.”
The first step for public health, Wright believes, is to acknowledge “the importance of understanding something
about another culture and working within it.” As he says, “Corrections health is one of the few settings in
health care where health professionals are not working on our own turf . . . Unless we understand how security
operates and why it has the rules and patterns that it does, unless we actively cultivate collaboration with
security, we will spend inordinate amounts of our time and effort battling.” It’s the same as working in any
unfamiliar culture; respect must come first. But Wright added, “Respect between health professionals and
security professionals does not happen by chance. It takes proactive effort.”
But with collaboration between public health and corrections, gains in tackling infectious diseases, such as

tuberculosis, can be significant. “In the past two years, the rate of new cases of TB diagnosed in our prison
system has been lower than the rate of tuberculosis in New York City,” Wright explained. “We haven’t had
any cases of multiple-drug-resistant TB for the last several years. We’ve done this in partnership with the State
Department of Health.”
Collaboration generates opportunities for improvements in substance abuse treatment, and in treatment for
sexually-transmitted diseases as well. And mental health treatment during incarceration and referral upon
release is another collaborative opportunity that benefits individuals, their families, and communities as a
whole. “If we’ve developed our partnerships between corrections and the rest of public health, we will have
established referral mechanisms for those we identify with HIV or any other infectious or chronic disease so
that they can continue to receive care,” Wright concluded. “All of us in society can benefit from that.”
Opportunities for Judicial Leadership
“Our jails have become the largest psychiatric warehouses,” Judge Leifman stated. “Since conditions are not
conducive for treatment, people with mental illnesses stay in jail on average eight times longer than someone
without mental illness,” he explained – even if they were imprisoned for the exact same reason. “The sad irony
is that we did not de-institutionalize; we allowed for the trans-institutionalization of this population,” said
Leifman. “We have made our jails the asylum of the new millennium.”
Judge Leifman listed the consequences to a society of trans-institutionalization: “Increased homelessness,
increased police injuries, increased police shootings of people with mental illnesses, [and] wasted critical tax
dollars,” are some of the nation’s symptoms. In one recent analysis, a Miami-Dade task force looked at the costs
associated with 31 people with frequent arrests. “Thirty-one people cost $540,000 in one year” for acute care

“

Since conditions
are not conducive
for treatment,
people with mental
illnesses stay in jail
on average eight
times longer than
someone without
mental illness

“

— Judge Steven Leifman
Miami-Dade County Court
Miami, Florida

alone, said Leifman. “Acute care is “jail, crisis stabilization, and emergency room care,” he explained. “It would
cost about a quarter of that to provide them with actual treatment and keep them out of our system.”
We as judges, corrections officers, police, mental health professionals are “so busy doing our jobs; no one
was looking at the big picture,” he admits. That’s why Leifman convened a two-day summit five years ago to
bring together mental health providers and what he called “us non-traditional stakeholders – the judiciary,
corrections, the police, the state attorney, the public defenders . . . It was really a melding of the mental health
community with the criminal justice system.”
The result was a concerted effort in Miami-Dade on “pre-arrest diversion programs,” teaching police “how to
identify people who have mental illness, de-escalate situations, and divert people into treatment,” Leifman said.
Many people are in jail for what he called “avoidable charges,” such as resisting arrest. “What had happened is
the officer wasn’t trained to appropriately deal with someone who had a mental illness. The situation escalated
because the officers are trained to become aggressive when someone’s aggressive – which is a good thing if
they’re dealing with someone who is not paranoid but it’s a dangerous thing if they are,” Leifman explained.
Rather than be arrested on a felony, diversion into treatment keeps the public safer and saves time and money.
“In Miami-Dade County alone we were able to reduce our misdemeanor recidivism rate from over 70 percent
to 18 percent last year,” he said. “We have improved public safety; we have significantly reduced police injuries.
We’re saving our county over $2.5 million a year by keeping people in the mental health system rather than
the correction system.” Judge Leifman is encouraged by the numbers, but he considers the benefits in human
terms more significant. “We’re saving lives and more importantly we are decriminalizing mental illness.” He
urged members of the judiciary to take the lead in pulling together both mental health and criminal justice
stakeholders to address community issues. “You would build a political coalition that is extremely powerful,”
Leifman said. “Between the judiciary and law enforcement, [such a coalition] can have a larger impact on policy
makers because it’s a different set of people approaching them on an issue that certain brands of conservatism
have made more difficult to address.”

“

“

Each year more than 10 million
people are locked up in our municipal
and county jails. In the last 20 years,
police, drug, mental health, and
employment policies have become a
funnel into jail for our nation’s least
healthy populations.
— Nicholas Freudenberg,
Professor and Director of Urban Public Health
Hunter College

“

“

Truly this population of individuals in the
criminal justice system is invisible and
forgotten. They enter the system with a
myriad of complex physical and emotional
issues and they emerge with even more.

— Marguerite Johnson
Vice President, Programs in Health
W.K. Kellogg Foundation

Redirecting Resources & Removing Policy Barriers for Reentry to Society
“In 2002, the New York City Independent Budget Office found that the full cost for one year of incarceration
in New York City jails for one individual was $92,500,” Nicholas Freudenberg told the forum participants.
Contrast those figures with the much more modest costs of providing needed health and social services when
they return to their communities “to enable them to turn their lives around,” he said.
Freudenberg reported on findings from research gathered while following 491 adolescent men and 476 adult
women who were released from New York City jails between 1997 and 2002. “What we found shows the
difficult life circumstances people leaving jail face and the extent to which local, state, and federal policies
complicate rather than facilitate successful reentry from jail,” he explained. “Our study also shows that people
leaving jail can make positive changes in their lives and that modifying Medicaid, employment, and housing
policies could contribute to significant reductions in recidivism.”
Young men who had a job after release were two-thirds less likely to be arrested again, for example. But
other factors held the same power and promise for successful reentry into community life, the study found.
“Unexpectedly we found that having health insurance – which for this population was primarily Medicaid
– reduced the likelihood of arrest [in young men] by more than two-thirds,” Freudenberg noted. “And for the
women, having health insurance in the year after release lowered the risk of re-arrest by more than 80 percent.”

Yet current federal and state policies allow for terminating Medicaid when a person is incarcerated. “Leaving
jail without health insurance makes it more difficult for people to get prescription drugs for psychiatric
conditions, HIV and other sexually-transmitted illnesses, and chronic conditions like asthma and diabetes,”
said Freudenberg. “It also makes it harder for people returning from jail to get the basic health care that can
manage and prevent health problems and avoid expensive hospitalizations and emergency room visits.” In the
question-and-answer portion of the forum, Judge Leifman concurred with the study’s findings by adding: “We
really need to address some of these issues with policy makers because there are a lot of ridiculous systems in
place that don’t work.”
Employment policies are another barrier, Freudenberg noted. “We need to discuss a legislative proposal that
would remove the requirement for seeking employment [that the applicant] disclose a felony conviction. Not
every job requires disclosing,” he said. “Dozens of occupations” could be opened up to individuals returning
to their communities, Freudenberg suggested – and he used working as a barber as an example. “Many people
learn how to be a barber in prison and can’t practice,” he said.
A record can be a barrier in many professions, Judge Mathis told participants. Arrested as a juvenile himself,
Mathis told how he spent eight months in prison – “ at a cost of $35,000,” he said – compared to a year in
college, which at the time was $6,000. “Upon completing college, completing law school, passing the bar exam,
I was not allowed to practice for three years because of my juvenile record,” Mathis told the group.
For every one person like Judge Mathis who surmounts barriers, communities lose the talents and energy of
many dozens who cannot. But Freudenberg’s data suggest that reducing barriers to employment could generate
many more success stories. He advocated “rethinking national goals for people leaving jail” and “redirecting
the wave of money now being spent” on job training and placement and health care. “To sustain improvements
in public safety over the long term and to make more money available for other pressing needs – like public
education, health care, and rebuilding our infrastructures,” Freudenberg concluded, “it’s time for public health
to go to jail.”
At the conclusion of the session, panelists urged their audience to use
the data, examples, and stories from the forum and the October 2005
American Journal of Public Health to bring prison health to the forefront of
community concerns and collaborative efforts. In thanking the panelists,
writers, and editors that made the forum possible, Henrie Treadwell
charged listeners to build on their combined knowledge. “We are
hoping that with the shoulders of so many of you to stand upon that
today we will have more support to speak on this important issue,”
she said. “The people displaced by Katrina pale in comparison to
the people displaced by our criminal justice system. We hope that
from this day forward the topic of prison health and working with
those who have been in prison will no longer be one we fear to talk
about,” Treadwell concluded, “but in fact one we must talk about
because we are all Americans whether we have been in prison or
not.”

Richard. A. Gooden
Director of Communications
National Center for Primary Care
Morehouse School of Medicine
720 Westview Drive,
SW Room 204
Atlanta, GA., 30310
Office: 404-756-8807
Fax: 404-756-5767

HEALTHCARE FOR

THE UNDERSERVED