What are the greatest health challenges facing people who are incarcerated? We need to ask them

Justin Berk, Josiah D Rich & Lauren Brinkley-Rubinstein

The Lancet | June 08, 2021

In The Lancet Public Health, Paul Simpson and colleagues report their use of a citizens’ jury research method to identify health research priorities directly from people who are incarcerated.1 This type of community-engaged research helps mitigate the disenfranchisement of a systematically marginalised group of individuals to better address their needs. Indeed, as Simpson and colleagues state, “if endeavours in research priority setting are to consider health equity goals, the views of our most health affected citizens need to be included.”

Although people in prison are considered a vulnerable group, rarely are their voices heard in guiding future research. The majority of health-care trials and data have not included incarcerated populations.2 Recent literature has called for their greater participation in research, particularly in the time of COVID-19.3 The USA, in particular, should heed this call and employ similar attempts to understand the primary needs of people in prison from their perspective.

The USA has the highest incarceration rate in the world, but this type of research, that is centred on the voices of incarcerated people themselves, is lacking. Mass incarceration is a public health crisis and is one of the greatest structural drivers for health inequities and racial disparities. Carceral health is community health. Yet the country lacks any direct involvement of incarcerated people in identifying the most important next steps in research, practice, or policy change.

These priorities are particularly important in a time in which the country is reckoning with racial and social injustice. The criminal legal system disproportionately targets individuals of low socioeconomic status, Indigenous communities, and people of colour. As calls against racism echo in protests throughout the country, the racial politics of imprisonment cannot be ignored. How can we best serve this population that is so frequently marginalised from society? Simpson and colleagues have an innovative solution: ask them.

By focusing on the health priorities of people who are incarcerated, we can develop health delivery systems to better address their health needs. Simpson and colleagues’ paper references the WHO and UN guidelines for appropriate care of people who are incarcerated. The US justice system has gone further with a constitutional right to health care, as ruled in the 1976 Supreme Court case of Estelle v Gamble.

Yet despite this mandate, little is known about the quantity, quality, costs, transitions, and outcomes of health care among people who are incarcerated in the USA. The quality of medical care for chronic disorders in correctional settings is also highly variable.4 There is no governmental accreditation for detention facilities as there is among hospitals and other health systems.5 There are no enforced standards of care applied to jails and prisons nationally. Whereas patient satisfaction surveys, Joint Commission audits, and patient services departments are ubiquitous in the health-care system outside of jails and prisons, similar policy initiatives are absent in carceral health settings.

Rather than having a patient-centred focus, many facilities are instead driven by profit motives given the high level of privatisation in the carceral system. Congressional investigations have recently highlighted these concerns.5 In an attempt to address misaligned profit-based incentives, one of the first executive orders issued by President Biden was to eliminate federal contracts with privately operated detention facilities. Focusing on patients over profits could have a dramatic effect on not just incarcerated patients, but also on the neighbouring communities to which they return, as 95% of incarcerated people are ultimately released.6

Regardless of the facility, greater engagement with people who have been caught up in the carceral system offers an opportunity for researchers to identify and address the most crucial consequences of mass incarceration. The health-related and other concerns of people incarcerated in the USA might be similar to those identified in Simpson and colleagues’ study: mental health, substance use disorders, or infectious diseases. Or perhaps in other facilities, priorities might include timely access to care, gender-affirming care, access to pre-exposure prophylaxis medication for HIV, health maintenance screenings, basic exercise and nutrition education, or other issues. Such research could also offer crucial understanding of the challenges faced in correctional facilities during the COVID-19 pandemic or the barriers to increased uptake of immunisation against the SARS-CoV-2 virus. To best provide health care as guaranteed by WHO, the UN, and the US constitution, a more patient-centred focus must be taken. This requires guidance from the voices of people in prisons and jails. When it comes to addressing health inequities brought on by the mass incarceration public health crisis, the people affected must play a greater part. What are the most important issues facing people who are incarcerated? Like Simpson and colleagues, the USA needs to ask.

We declare no competing interests.


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Article Info

Publication History

Published: June 08, 2021


DOI: https://doi.org/10.1016/S2468-2667(21)00074-8


© 2021 The Author(s). Published by Elsevier Ltd.

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