Another Kind of Safety Threat

The Health-Related Consequences of Releasing Prisoners

By Lois M. Davis

Lois Davis is a health policy researcher at RAND.

Photo: Lois M. DavisAs states struggle to make budget ends meet in the current fiscal climate, many are considering the early release of state prisoners as one answer to the problem. When prisoners are released back into communities, some people worry about public safety, concerned primarily about becoming victims of crime. While these concerns are legitimate, another public safety threat is just as real, if not as obvious: the threat to people's health and to the public health system itself.

Research has shown that much disease goes undetected by the correctional health care system. Existing estimates of disease prevalence among the prison population have had to rely on multiple data sources outside of the system because of serious limitations in the data available from state prisons.

Our best estimates indicate that prisoners who are awaiting release tend, on average, to be sicker—in many cases, much sicker—than the population as a whole. This is true across the spectrum of disease categories. When it comes to the prevalence of infectious, or communicable, diseases, prison inmates are 4 times more likely to have active tuberculosis (TB), 9-10 times more likely to have hepatitis C, 5 times more likely to have AIDS, and 8-9 times more likely to have HIV infection.

Among chronic diseases, the prevalence of asthma is higher in prison inmates. Although the prevalences of diabetes and hypertension are lower than for the population as a whole, they are relatively high given that the prison population is generally younger. These conditions are typically associated with older people. The prison population is growing older, however, which means these prevalences are likely to increase over time.

Inmates also have higher prevalences of mental illness—they are 3-5 times more likely to have schizophrenia or other psychotic disorders and 1.5-3 times more likely to have bipolar disorder—and are more likely to suffer from substance abuse and dependence problems.

What can be done to reduce the potential risks to the health of the communities to which prisoners are returning? What can be done to reduce the potential strain on the public health system itself?

First, state prisons need to improve the data systems they use to track and assess the health status of prisoners. For example, we know little about the prevalence of co-occurring disorders (e.g., mental illness and substance abuse, HIV and hepatitis B or C), both because of inaccurate or missing data and because of variations in screening and discharge planning of soon-to-be-released offenders. This hinders our ability both to understand the true disease burden that prisoners will impose on the communities they are reentering and to decide how to ensure the continuity of their care upon release.

Second, there is a need for improved screening, prevention, and treatment programs for state prison inmates. Third, prisons could improve the discharge and transitional planning for ex-offenders with special health care needs. Such improvements can help protect the public's health, since without them, ex-offenders with unknown and untreated infections—TB, for example—may contribute to the spread of disease in a community and to the development of drug-resistant strains.

Finally, the system will need to address the structural problem of who pays for improved screening and more treatment. Improved screening could be expensive for prison systems, because it is likely to increase the number of inmates identified as requiring treatment services and whose care will need to be transferred to community health care providers upon release. Moreover, improved screening could lead to greater liability for the prison system. For example, screening could demonstrate that some inmates were infected with HIV while incarcerated and therefore might have been subjected to a cruel or unsafe environment.

There are no simple solutions to the problem, but the problem is pressing. Ex-offenders rely heavily on the public sector for health care services and will be returning to communities and neighborhoods with limited health care resources at a time when the public health system and America's "safety net" are severely strained. Unless we take actions now, we may be facing a looming health crisis just over the horizon.