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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

    

Adverse Effects of US Jail and Prison Policies on the Health and Well-Being of Women of Color

Nicholas Freudenberg, DrPH

December 2002, Vol 92, No. 12 | American Journal of Public Health 1895-1899
© 2002

Nicholas Freudenberg is with the Program in Urban Public Health, Hunter College, City University of New York.

Correspondence: Requests for reprints should be sent to Nicholas Freudenberg, DrPH, Box 609, Hunter College, 425 East 25th St, New York, NY 10010 (e-mail: nfreuden@hunter.cuny.edu).


ABSTRACT


In the past few decades, US policies have led to an unprecedented increase in the number of people behind bars. While more men than women are incarcerated, the rate of increase for women has been higher.

Evidence of the negative impact of incarceration on the health of women of color suggests strategies to reduce these adverse effects. Correctional policies contribute to disparities in health between White women and women of color, providing a public health rationale for policy change.

Specific roles for health professionals include becoming involved in alliances addressing alternatives to incarceration, creating programs that address the needs of women in correctional facilities, and identifying the pathways by which correctional policies damage health.


   INTRODUCTION

 
NATIONAL DEBATES ON CRIME, race, and incarceration have usually focused on men rather than women and on justice and public safety rather than health. Yet, high rates of incarceration affect the well-being of women of color directly, in that incarcerated women are removed from their communities, they are placed in close proximity to a population of women with high rates of infectious and chronic diseases, and opportunities to link them to needed services are missed. Incarceration also affects families by separating women from their children, often forcing children into foster care and leaving them vulnerable to psychological, educational, and social problems. Prison eliminates current income and reduces future earnings by diminishing women’s prospects for postrelease employment. Moreover, even a short stay in jail can lead to homelessness.

Equally important and less addressed in the literature, criminal justice policies aimed at men can also harm women. The disproportionate incarceration rates among Black and Latino men affect women by reducing the pool of male partners who can contribute to family income, reducing overall employment rates in low-income communities, and diminishing men’s ability to be consistent and present fathers. For some women, the incarceration of an abusive or criminally involved partner can offer safety. However, the vast majority of men return to their homes from jail or prison, and thus the failure of correctional facilities to provide most incarcerated men with substance abuse, mental health, or domestic violence services forces many women to make an unpalatable choice. They can either separate from a male partner who returns from jail or prison, thus reducing financial and emotional support, or take back a man with drug, violence, or psychological problems that may jeopardize the family’s health and safety.

Here I review evidence of the impact of current incarceration policies on the health of women of color and suggest public health programs, policies, and research to reduce adverse effects. I also argue that current correctional policies contribute to health status disparities between White women and women of color, providing a public health rationale for policy change.

GROWTH OF THE POPULATION BEHIND BARS
 
In the past 2 decades, US criminal justice, drug, and other social policies have led to an unprecedented increase in the number and proportion of people behind bars. These increasing rates of incarceration have had a disproportionate impact on people of color. Moreover, although the vast majority of inmates are male, the proportion of women who are in jails and prisons has grown at almost twice the proportion of men since 1990.

Between 1980 and 1997, the number of women in state and federal prisons increased nearly sevenfold. In 1998, there were an estimated 3.2 million arrests of women, accounting for 22% of all arrests that year. More than 950 000 women were under correctional supervision in 1998, about 1% of the US female population. In the past decade, the numbers and proportions of women have increased in terms of all components of the system: jail, probation, parole, and prison. Each component has unique influences on health, but the focus here is on the cumulative impact of the correctional system as a whole.


CORRECTIONAL FACILITIES AND WOMEN OF COLOR

 
The Bureau of Justice Statistics estimates that 11 of every 1000 women in the United States will be incarcerated at some point in their lives. Reflecting the disproportionate representation of women of color in jails and prisons, lifetime risks per 1000 women are 5 for Whites, 15 for Latinas, and 36 for Blacks. In other words, a Black woman is more than 7 times as likely as a White woman to spend time behind bars.

Women in the correctional system are typically young, poor, and of limited formal educational attainment. The median age of incarcerated women is 35 years; about 70% of these women are mothers of children younger than 18 years, and fewer than 40% have a high school diploma or its equivalent. Results derived from a national sample showed that 48% of jailed women reported having been physically or sexually abused before admission, and 27% had been raped.Studies conducted in urban jails have shown that rates of recent homelessness among incarcerated women are as high as 40%.

Women behind bars face an assortment of intersecting health and social problems. In comparison with other low-income women, they have higher rates of (1) recent and chronic substance use problems; (2) HIV/AIDS, hepatitis C, and other sexually transmitted diseases; and (3) mental health problems. In some jails and prisons, there are extraordinary concentrations of women with illnesses. For example, a study conducted among the New York City jail population in 1997 revealed that the rate of early syphilis in women in jail exceeded that year’s rate among all women in New York City by more than 1000-fold. Also, a study of the Chicago jail system showed that more than a third of incarcerated women had been diagnosed with posttraumatic stress disorder. In comparison with the overall population of women residing in the Chicago area, Black and Hispanic women entering the system were about 10 times more likely to have a psychiatric disorder.

Even though women behind bars have high rates of health and social problems, few receive help while they are incarcerated. It is estimated that no more than 10% of drug-abusing women are offered drug treatment in jail or prison, and most jails lack comprehensive discharge planning or aftercare programs. According to a 1998 national survey, only two fifths of male and female jail inmates with mental health problems received any help while incarcerated, and when help was offered it usually involved limited services such as 12-step groups. Although health care is a constitutional right for prisoners, many women behind bars receive inadequate or incompetent care.

In addition, most women leaving correctional facilities return to communities that present inadequate educational, housing, and employment opportunities. Despite the recent period of national prosperity, low-income communities of color continue to have the worst schools, the fewest job opportunities, and the least affordable housing. All poor families suffer from these conditions, but people of color returning from correctional facilities face the triple jeopardy of poverty, racism, and stigma toward ex-offenders. The incarceration experience often contributes to a downward cycle of economic dependence, social isolation, substance abuse, and other physical and mental health problems. Because they have more parental responsibilities than men leaving correctional facilities, along with lower wages and higher rates of psychiatric symptoms and victimization in the form of violence, women ex-offenders face unique reentry challenges.

    

Recent policy changes may have unintentionally made successful community reintegration of inmates even more difficult. For example, as a consequence of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, help is less readily available to many women, especially those with substance abuse or mental health problems. The programs associated with this act often involve punitive behavioral expectations—for example, abstinence from substance use as a condition for receipt of benefits—and women with drug problems may have troubling meeting such criteria, especially when high-quality drug treatment is scarce and few programs address the special needs of women. Current regulations of the US Department of Housing and Urban Development require public housing projects to evict families with whom a convicted felon resides, forcing some women leaving prison to abandon their children or partners or become homeless.

Advocates of current criminal justice policies argue that the most important benefit of these policies has been the dramatic reduction in crime and violence in the past decade. African American and Latino communities have benefited significantly from these lower rates, both directly (through reduced numbers of deaths and injuries) and indirectly (through the contributions of lower crime rates to improved economic development). While many experts question whether higher incarceration rates (rather than national prosperity) lead to reduced crime rates, elected officials continue to advocate for more prison cells and more aggressive policing to further reduce crime.

African American and Latino communities have borne a disproportionate burden of the adverse effects of aggressive policing and "zero tolerance" policies. Moreover, as a result of prison expansion, correctional budgets in many states now equal or exceed those for education and health care. This shift of resources has a disproportionate adverse effect on communities of color, which rely on publicly funded health care and education, and on women, who are often responsible for managing family health and education.

CAN INTERVENTIONS MAKE A DIFFERENCE?
 
While women of color returning home from correctional facilities face daunting challenges, a significant body of evidence describes promising approaches to reducing drug use, HIV risk, and rearrest and promoting links to health and social services and successful community reintegration. A few examples illustrate some of these models. In Hampden County, Massachusetts, for instance, a partnership between a health department and a county jail offers coordinated jail and community health and social services, assistance in obtaining Medicaid benefits, and ongoing postrelease case management and primary health care services. A program aimed toward women leaving Bedford Hills prison in New York State offers educational opportunities and HIV prevention, health education, and postrelease counseling services. Health Link, a program for women leaving New York City jails, provides health education, social support, and case management during incarceration as well as a year of postrelease services to help women reduce their drug use, HIV risk behavior, and risk of rearrest.

These brief examples, and a number of recent reviews, illustrate that it is possible to address the health and social needs of incarcerated women and to reduce the adverse health consequences of incarceration. Common characteristics of such interventions include the following: prerelease as well as postrelease services; integration of drug treatment, health care, employment and vocational training, social services, mental health, and housing; activities conducted at the client, community, and policy levels; and strong partnerships among correctional and public health agencies and community organizations. Unfortunately, few women leaving jail/prison have actually received services that can be expected to make a difference.


CORRECTIONAL POLICIES AND DISPARITIES IN HEALTH

 
The growing interest in racial and gender disparities in health promises new insights into the causes of these differences and their possible solutions. Too often, however, researchers have focused on the specific causes of a particular disparity in health conditions, thus losing sight of the more fundamental causes underlying disparities in multiple conditions. An alternative approach would be to consider the social processes that underlie multiple disparities and then develop programmatic and policy interventions designed to reverse or mitigate the adverse effects of these processes. Social processes are defined here as the dynamic historical forces that move people to different positions within the social structure. The high incarceration rates of women of color, and the failure to focus on their reintegration after release, represent one such process.

Correctional policies can contribute to adverse health outcomes through various pathways. Incarceration itself can increase the risk of infection, sexual assault, and improper medical care or contribute to posttraumatic stress disorder. Reduced income as a result of incarceration-related job loss or employment discrimination compromises a woman’s ability to provide adequate housing, nutrition, and health care for her family. Stigmatization of returning offenders can lead to social isolation, which has been linked to various physical and mental illnesses.

At the community level, evidence suggests that flooding low-income urban communities with ex-offenders without providing adequate aftercare services can lead to community disruption and higher crime rates, damaging social cohesion and its healthenhancing effects. More broadly, the racial dimensions of current criminal justice policies contribute to the growing racial/ethnic and income inequalities in the United States, inequalities that have been associated with poor health outcomes. The gendered character of these policies reinforces women’s lower socioeconomic status and fails to address gender-specific needs related to violence, reproduction, and mental health.

If incarceration policies exacerbate health disparities, the Healthy People 2010 goal of eliminating these disparities provides public health professionals with a clear rationale for research, practice, and advocacy in the area of alternative programs and policies. Because the health effects of incarceration operate through multiple pathways, no single strategy will reverse these adverse effects. Table 1 summarizes some of the potential goals for policy changes designed to improve the well-being of people involved in the correctional system; all of these changes will benefit both men and women, although each has gender-specific dimensions. Some address "upstream" determinants (e.g., reducing the number of people who enter prison by improving economic opportunities and access to drug treatment); others seek to reduce rearrest rates by emphasizing rehabilitation rather than punishment alone.



TABLE 1 —Policy Goals Aimed at Reducing the Adverse Health Effects of Incarceration

Policy Goal

Desired Health, Public Safety, and Economic Outcomes


Increase alternatives to incarceration

Less family and community disruption; fewer foster care placements; reductions in drug use; lower correctional costs

Improve quality of health, mental health, and substance abuse services in correctional facilities and develop gender-specific programs

Early identification and treatment of infectious diseases; higher levels of adherence to prescribed medications, leading to less drug resistance; lower rates of postrelease transmission; improved readiness for postrelease drug treatment; lower rates of recidivism

Improve discharge planning and linkages with community service providers

Improved access to health care postrelease; improved control and management of infectious and chronic diseases; lower rates of recidivism

Expand and improve vocational and employment programs for inmates and ex-offenders

Improved capacity for postrelease employment and less dependency; higher postrelease legal income; reduced involvement in drug trade

Reduce stigmatization of ex-offenders

Less social isolation; improved community reintegration; improved social cohesion.


 
Achieving the policy changes listed in Table 1 will require public health workers to join or create new alliances. For example, the growing international interest in the links between health and human rights may provide a forum for discussion and action. In recent years, both Amnesty International and Human Rights Watch have issued reports documenting the abuse of women in US prisons and called on this country to abide by international standards regarding the treatment of this vulnerable population. The women’s movement is another possible partner, especially in terms of its focus on the special needs of women of color. A recent US Supreme Court decision that banned South Carolina from incarcerating pregnant drug-using women on the basis of a positive drug test illustrates the potential for linking public health, feminist, and social justice issues.

The increasingly vocal critics of the war on drugs are also possible allies. The dissatisfaction with the results of this war, the high costs of incarceration, and the renewed interest in harm reduction approaches to substance abuse may help in efforts to gain public and political support for policy changes. Recent reports on the specific impact of the war on drugs on women suggest areas for collective action. In the past 5 years, the prisoners’ rights movement has also grown in strength and sophistication. Its grass roots campaigns aimed at halting prison construction, encouraging dialogue on incarceration policies, and eliminating capital punishment have created opportunities for public education and mobilization.

Finally, in a potentially important reversal of earlier trends, it appears that local and state political officials may be open to new approaches. For the first time in almost a quarter century, incarceration rates have stabilized or declined in the past 2 years, creating opportunities for reconfiguration of services. Because the costs of incarceration have increased over the past decade, and because public revenues targeted toward state governments are now declining, some public officials are looking for new, more effective and economical correctional policies and better links with public health agencies.

What role can public health professionals play in changing criminal justice policies and reducing their adverse health impact on women? First, we can develop partnerships with correctional agencies and community service providers to strengthen health and social services in jails and prisons and to create community reintegration services that link women to needed services and ease the transition into the "free world." Programs that meet the specific needs of returning female inmates with regard to housing, substance use, mental health, reproductive health, parenting, and employment are especially important. Other urgent needs are for systematic evaluation of the many small programs that seem promising and for additional attention to the issue of bringing successful models to scale.

On the research front, investigators need to understand better the specific pathways by which various aspects of correctional policy or practice contribute to adverse health outcomes. For example, do women leaving prison with untreated posttraumatic stress disorder fare worse than other released women? Does participation in correctional literacy or college programs reduce postrelease health problems? Do women returning to communities with high proportions of ex-offenders have higher rates of recidivism or illness than those returning to low-prevalence areas? The goal of such research would be to identify opportunities for intervention.


   CONCLUSIONS

 
Eliminating the health disparities that burden women of color in the United States has been identified as a national health goal for the next decade, providing the public health community with a mandate to join the effort to change criminal justice policies. However, achieving this objective will require more than documenting disparities or analyzing their causes. It will necessitate ongoing action to modify the social processes that so consistently produce these differential health outcomes. Current incarceration policies represent one such process. By working with public officials, correctional agencies, women’s rights and criminal justice advocacy groups, and citizens to change health-damaging correctional policies, public health professionals can help to improve the health and well-being of women of color and their families and communities, protect public safety, and promote social justice.


   Acknowledgments

 
This work was supported by the Robert Wood Johnson Foundation and the New York City and New York State health departments.

The comments of Beth E. Richie, Wendy Chavkin, Bea Krauss, and 3 anonymous reviewers are gratefully acknowledged.


Footnotes

 
The views expressed herein are those of the author and do not necessarily represent those of the funding agencies.

Peer Reviewed

    

Accepted for publication August 21, 2002.

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