The health impact of incarceration


“Doc, I’m tired.”

This is a refrain that we hear from many of our patients who have been incarcerated in California’s prisons for decades. Now past the midway points of their lives, our patients describe how the absence of autonomy — what they eat, how they dress, how frequently they bathe, how they spend their day, and when they communicate with their families — has taken its toll, making them weary and despondent. For most of them, the fatigue is inextricably linked to the realization that they are serving a sentence that is disproportionate to their crime.

As physicians, we have no prescription for this type of suffering. The etiology of the problem is political (and financial), embedded in the draconian laws of the tough-on-crime era. Due to these laws, thousands like our patients are currently spending an outsize portion of their lives behind bars.

During his first term, California Governor Jerry Brown signed a law requiring fixed sentences for most crimes, effectively abolishing the possibility of parole. Driven largely by fear, and disproportionately affecting people of color, this was the first of the series of tough-on-crime laws, including the notorious three-strikes law, which produced California’s severely overcrowded prisons. To keep up with the surge in population, California has built 23 new prisons since 1980, bringing the total to 33. In comparison, just one additional campus has been added to the University of California system over this period.

Nearing the end of his tenure, Brown now acknowledges that the criminal justice legislation he supported in the 1970s has had “unintended consequences.” As physicians, the consequence that we see most clearly is poor health.

In 2001, the health care system in California’s prisons was ruled unconstitutional, and ultimately placed under federal receivership, based on evidence that on average one prisoner died weekly from malpractice or negligence. Although the quality of medical care improved following this decision, the U.S. Supreme Court in 2011 found that health care remained inadequate due to overcrowding. In other words, although the intention of the tough-on-crime era was incarceration as punishment, a further consequence has been poor health among those incarcerated.

This is the historical context out of which Proposition 57 has emerged. Intended to reduce overcrowding, and backed by Brown, the state ballot measure would expand the possibility of parole to thousands of people who have served their base sentence for a non-violent felony. It comes on the heels of Propositions 36 and 47, under which thousands of people have been released from California’s prisons. The recidivism rates under these measures are in the single digits, far below the state and national averages.

Although improving the health care system by way of lowering the prison population is a major driving force behind Proposition 57, we cannot help but reflect on the significant health benefits that our qualifying patients stand to gain if the measure passes. No matter how much the health care system in California’s prisons improves, there are less visible health consequences of living in prison that are independent of health care access and quality, but rather related to confinement itself.

There is a large body of research demonstrating that people in lower social classes have higher mortality rates than people in higher classes, despite equal access to health care. These findings stand even after accounting for differences, including smoking, obesity, activity, and baseline illness.

The key question raised by this research is why people who are less well off experience more disease and live shorter lives. According to Dr. Michael Marmot, principal investigator for the Whitehall Studies and a leader in the field of the social determinants of health, the answer lies in two factors: autonomy and social participation. These are key features missing in the lives of our patients. By virtue of their confinement, they have little control over their lives, feel disempowered by their circumstances and lack support networks, resulting in a higher burden of disease and death.

We are not naïve to the health risks facing those who are re-integrating into the community. More attention and resources need to be invested in the health and safety of people during the re-entry period. However, there is no question that the net health (and other) benefits of freeing an individual from confinement far outweigh the risks.

With this in mind, we call on health care providers in California and other states facing ballot measures on the criminal justice system (e.g., Oklahoma’s State Questions 780 and 781) in November to consider how their vote will impact the health of human beings living behind bars. For us personally, Proposition 57 presents an opportunity to finally do more than simply bear witness to our patients’ suffering. We will have the opportunity to improve their health by voting in favor of a measure that would start the process of restoring the autonomy and sense of social belonging needed for a healthy life.

Rahul Vanjani and M. Catherine Trimbur are physicians.

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