The Structural Violence of Hyperincarceration - A 44-Year-Old Man with Back Pain

Challenging Health Inequities in Incarceration: a Call for Equitable Care for Kidney Disease and Hypertension

PURPOSE OF REVIEW

To review the current literature on care of hypertension and chronic kidney disease for people who are currently and formerly incarcerated, and to make recommendations for improving outcomes.

RECENT FINDINGS

There is a growing body of literature describing care for kidney disease and hypertension for incarcerated and formerly incarcerated individuals that documents the provision of care itself, notably that many jails contract with private companies; the system is not designed to provide sustained, chronic disease care; and the transition from incarceration to community is fraught with gaps in care. However, deficiencies in data collection and regulation still limit our understanding of the quality of care provided in jails and prisons. Furthermore, more data is needed to understand the impact of structural racism in the criminal legal system on overall disparities in care for hypertension and kidney disease. Insurance coverage rates for people who were formerly incarcerated continue to be lower than the general population despite Medicaid expansion in many states. There is little recent data regarding kidney replacement therapy for this population despite known variation in dialysis modalities and transplant programs by state. Transitions clinics, which connect people who were formerly incarcerated with care in the community upon release, are growing and are important avenues by which to deliver care. People who are incarcerated are disproportionately affected by hypertension and kidney disease, yet data regarding the extent of these inequities and availability of quality care is lacking. More work is needed to understand the care of individuals with kidney disease and hypertension in prisons and to improve outcomes for these common chronic conditions. Both providing effective treatment of kidney disease and hypertension in prisons and jails and providing coordinated, quality transition to community care upon release represents an important opportunity for reform in care for a marginalized population.

Ideological assumptions of Chile's international migrant healthcare policy: A critical discourse analysis

In the current historical moment of rewriting the Chilean Constitution, there are new hopes for producing a different socio-legal, political-economic and public health order. The Chilean case holds important implications for global health practitioners, researchers and policy-makers because it clearly shows both the impacts of neoliberal processes on a worldwide scale and neoliberal policy responses. This article contributes to the field of global health policy critical analysis by offering scrutiny of Chile's international migrant healthcare policy from the perspective of its ideological assumptions. We apply Fairclough's analytical perspective to the Chilean migrant healthcare policy, identifying its components, argumentative premises and ideological assumptions that contribute to the reproduction of the processes of social determination. It allows us to identify bias mobilisation, exclusion, and subordinate inclusion processes that systematically lead to the omission of structural processes in the social determination of migrants' healthcare, contributing to their reproduction. We conclude by problematising the place of academia in said reproduction to the extent that the concepts and premises they use remain in the ideological territory of exclusion of the structural defined by the policy, disconnecting reflection and action in the health field from collective demands.

Planetary Health and Hospitals' Contribution-A Scoping Review

Climate change is one of the greatest global threats for planetary and human health. This leads to new challenges for public health. Hospitals emit large amounts of greenhouse gases (GHG) in their healthcare delivery through transportation, waste and other resources and are considered as key players in reducing healthcare's environmental footprint. The aim of this scoping review is to provide the state of research on hospitals' carbon footprint and to determine their contribution to mitigating emissions. We conducted a systematic literature search in three databases for studies related to measurement and actions to reduce GHG emissions in hospitals. We identified 21 studies, the oldest being published in 2012, and the most recent study in 2021. Eight studies focused on GHG emissions hospital-wide, while thirteen studies addressed hospital-based departments. Climate actions in the areas of waste and transportation lead to significant reductions in GHG emissions. Digital transformation is a key factor in implementing climate actions and promoting equity in healthcare. The increasing number of studies published over time indicates the importance of the topic. The results suggest a need for standardization of measurement and performance indicators on climate actions to mitigate GHG emissions.

"It's a revolving door": Ego-depletion among prisoners with injecting drug use histories as a barrier to post-release success

BACKGROUND

People who inject drugs (PWID) are overrepresented among prisoner populations worldwide. This qualitative study used the psychological concept of "ego-depletion" as an exploratory framework to better understand the disproportionate rates of reincarceration among people with injecting drug use histories. The aim was to illuminate mechanisms by which prospects for positive post-release outcomes for PWID are enhanced or constricted.

METHODS

Participants were recruited from a longitudinal cohort study, SuperMIX, in Victoria, Australia. Eligible participants were invited to participate in an in-depth interview. Inclusion criteria were: aged 18+; lifetime history of injecting drug use; incarcerated for >three months and released from custody <12 months previously. Analysis of 48 interviews examined how concepts relevant to the ego-depletion framework (self-regulation; standards; consequences and mitigators of ego-depletion) manifested in participants' narratives.

RESULTS

Predominantly, participants aimed to avoid a return to problematic drug use and recidivism, and engaged in effortful self-regulation to pursue their post-release goals. Post-release environments were found to diminish self-regulation resources, leading to states of ego-depletion and compromising the capacity to self-regulate according to their ideals. Fatalism, stress, and fatigue associated with the transition period exacerbated ego-depletion. Strategies that mitigated ego-depletion included avoidance of triggering environments; reducing stress through opioid agonist therapy; and fostering positive affect through supportive relationships.

CONCLUSIONS

Post-release environments are ego-depleting and inconducive to sustaining behavioural changes for PWID leaving prison. Corrections' behaviourist paradigms take insufficient account of the socio-structural factors impacting on an individual's self-regulation capacities in the context of drug dependence and desistance processes. Breaking the cycles of reincarceration among PWID requires new approaches that moderate ego-depletion and facilitate long-term goal-pursuit.

Association of Incarceration With Mortality by Race From a National Longitudinal Cohort Study

IMPORTANCE

The association between incarceration and long-term mortality risk is unknown and may contribute to racial disparities in overall life expectancy.

OBJECTIVE

To determine whether incarceration in the US is associated with an increase in mortality risk and whether this association is different for Black compared with non-Black populations.

DESIGN, SETTING, AND PARTICIPANTS

This generational retrospective cohort study used data from the National Longitudinal Survey of Youth 1979, a nationally representative cohort of noninstitutionalized youths aged 15 to 22 years, from January 1 to December 31, 1979, with follow-up through December 31, 2018. A total of 7974 non-Hispanic Black and non-Hispanic non-Black participants were included. Statistical analysis was performed from October 26, 2019, to August 31, 2021.

EXPOSURES

Time-varying exposure of having experienced incarceration during follow-up.

MAIN OUTCOMES AND MEASURES

The main outcome was time to death. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% CIs, adjusted for baseline sociodemographic, economic, and behavioral risk factors. Models were evaluated for the full cohort and stratified by race.

RESULTS

Of the 7974 individuals included in our sample, 4023 (50.5%) were male, and 2992 (37.5%) identified as Black (median age, 18 [IQR, 17-20] years). During a median follow-up of 35 years (IQR, 33-37 years), 478 participants were incarcerated and 818 died. Unadjusted exposure to at least 1 incarceration between 22 and 50 years of age was 11.5% (95% CI, 10.4%-12.7%) for Black participants compared with 2.5% (95% CI, 2.1%-2.9%) for non-Black participants. In the multivariable Cox proportional hazards model with the full cohort, time-varying exposure to incarceration was associated with an increased mortality rate (adjusted HR [aHR], 1.35; 95% CI, 0.97-1.88), a result that was not statistically significant. In the models stratified by race, incarceration was significantly associated with increased mortality among Black participants (aHR, 1.65; 95% CI, 1.18-2.31) but not among non-Black participants (aHR, 1.17; 95% CI, 0.68-2.03).

CONCLUSIONS AND RELEVANCE

In this cohort study with 4 decades of follow-up, incarceration was associated with a higher mortality rate among Black participants but not among non-Black participants. These findings suggest that incarceration, which was prevalent and unevenly distributed, may have contributed to the lower life expectancy of the non-Hispanic Black population in the US.

Association of Individual and Familial History of Correctional Control With Health Outcomes of Patients in a Primary Care Center

IMPORTANCE

Research has shown that experiences of incarceration, probation, and parole are associated with worse health outcomes for incarcerated individuals and their families.

OBJECTIVES

To quantify the proportion of patients in an urban primary care clinic with an individual or family history of incarceration, probation, and/or parole and to evaluate how correctional control is associated with subjective and objective health outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional, mixed-methods study used patient surveys and retrospective medical record review to assess the experience of correctional control among 200 English-speaking adult patients presenting for care at the Rhode Island Hospital Center for Primary Care between July 9, 2019, and January 10, 2020.

MAIN OUTCOMES AND MEASURES

Patient surveys included closed and open-ended questions pertaining to personal or familial experiences of incarceration, probation, and parole, as well as health outcomes associated with these experiences. Medical record review abstracted key health indicators and health care use data.

RESULTS

In this cross-sectional study of 200 adult patients (1 participant was removed from the full analytic sample owing to missing ethnicity data; 113 of 199 men [56.8%]; mean [SD] age, 51.2 [14.0] years) presenting for primary care, 78 of 199 (39.2%) had a history of incarceration, 32 of 199 (16.1%) were on probation or parole at the time of the study, and 92 of 199 (46.2%) reported having a family member with a history of incarceration. Of the 199 patients, 62 (31.2%) identified as non-Hispanic Black, 93 (46.7%) identified as non-Hispanic White, and 44 (22.1%) identified as belonging to another race (American Indian and Alaska Native, Asian, Native Hawaiian and Other Pacific Islander, or other nonspecified). Compared with participants without a history of correctional control, those with a personal history of incarceration were at greater odds of having an emergency department visit that did not result in hospitalization in models adjusted for age, sex, and race and ethnicity (odds ratio, 2.87; 95% CI, 1.47-5.75).

CONCLUSIONS AND RELEVANCE

This cross-sectional study suggests that primary care clinicians should screen for correctional control as a prevalent social determinant of health.

Prevalence and predictors of recent temporary psychiatric hold among a cohort of people who inject drugs in Los Angeles and San Francisco, California

California's Welfare and Institutions code 5150 allows for a temporary psychiatric hold (TPH) of individuals who present a danger to themselves or others and/or may be gravely disabled due to mental illness. Little is known about the frequency and predictors of involuntary holds among people who inject drugs (PWID).

METHODS

We sought to identify the prevalence and predictors of recent TPHs (within the past 12 months) among a community-recruited sample of PWID in Los Angeles and San Francisco, California during 2017-2018 (N = 531). Multivariable logistic regression modeling was used to evaluate demographic (e.g., age), economic (e.g., homelessness), drug use (e.g., types of drugs used), incarceration (e.g., recent arrest history) and mental health (e.g., lifetime mental health diagnosis) variables associated with recent TPH.

RESULTS

Age (40-49 years old vs age 50 or older: AOR = 5.85; 95 % CI = 2.18, 15.67), current homelessness (AOR = 3.75; 95 % CI = 1.28, 11.0), lifetime mental health history (AOR = 6.23; 95 % CI = 2.08, 18.66), and frequency of methamphetamine use (AOR = 1.01; 95 % CI = 1.00, 1.01) were statistically associated with increased odds of having experienced a TPH, while frequency of past month heroin/opioid use was associated with decreased odds of reporting a TPH (AOR = 0.99; 95 % CI = 0.99, 1.00) in multivariable analysis.

CONCLUSIONS

Diverse factors were associated with TPH among PWID. Our analysis underscores the need for research on PWID with co-occurring substance-use and mental illness disorders and homelessness. There is urgent need for expanding access to lower barrier publicly funded mental health treatment from a harm-reduction approach.

Healthcare-induced trauma in correctional facilities: a qualitative exploration

BACKGROUND

While incarcerated people are known to experience trauma at higher rates than the general population, little is known about how the correctional health system contributes to trauma rates.

METHODS

We conducted 20 semi-structured qualitative interviews with men who were recently released from a correctional system to understand their experiences with healthcare systems and medical staff during incarceration. Using reflexive thematic analysis within a critical realist framework, we coded and analyzed the data iteratively to refine and unify emerging themes.

RESULTS

The unanticipated concept of healthcare-induced trauma emerged and was revealed in three overall themes: (1) healthcare leading to fear of serious illness or death, (2) healthcare leading to fear of people, including healthcare providers, correctional staff, and other incarcerated people, and (3) the correctional institutional, social, and physical environment leads to fear of place.

CONCLUSIONS

Healthcare in correctional settings has the potential to induce trauma, even when the medical conditions addressed are not life-threatening. Future research should examine the factors contributing to the development of healthcare-induced trauma in correctional settings and develop interventions to prevent and address this phenomenon.

Structural competency in the post-prison period for people who inject drugs: A qualitative case study

INTRODUCTION

Access to services is key to successful community (re-)integration following release from prison. But many people experience disengagement from services, including people who inject drugs (PWID). We use a case study approach and the notion of structural competency to examine influences on access to services among a group of PWID recently released from prison.

METHODS

This qualitative study recruited participants from SuperMIX, (a longitudinal cohort study in Victoria, Australia).

INCLUSION CRITERIA

aged 18+; lifetime history of injecting drug use; incarcerated for > three months and released from custody < 12 months previously. From 48 participants, five case studies were selected as emblematic of the complex and intersecting factors occurring at the time participants missed an appointment at a service.

RESULTS

Numerous, concurrent, and interdependent structural influences in participants' lives coincided with their difficulty accessing and maintaining contact with services and resulted in missed appointments. The key factors involved in the cases presented here include policies around opioid agonist treatment, inadequate, unsuitable and unsafe housing, the management of mental health and side effects of treatment, the lack of social support or estrangement from family, and economic hardship. The support available from service workers to navigate these structural issues was inconsistent. One dissenting case is examined in which missing appointments is anticipated and accommodated.

CONCLUSIONS

A case study approach enabled a holistic and in-depth examination of upstream structural elements that intersect with limited social and economic resources to exacerbate the challenges of community re-entry. These results highlight structural issues that have a disproportionate impact on the choices and opportunities for PWID. The incorporation of a structural competency framework in design of services and in staff training could support person-centred and coordinated service provision that take into account PWID's experiences post-release to overcome structural barriers to service engagement.

Structural competency and global health education

Structural competency is a new curricular framework for training health professionals to recognise and respond to disease and its unequal distribution as the outcome of social structures, such as economic and legal systems, healthcare and taxation policies, and international institutions. While extensive global health research has linked social structures to the disproportionate burden of disease in the Global South, formal attempts to incorporate the structural competency framework into US-based global health education have not been described in the literature. This paper fills this gap by articulating five sub-competencies for structurally competent global health instruction. Authors drew on their experiences developing global health and structural competency curricula-and consulted relevant structural competency, global health, social science, social theory, and social determinants of health literatures. The five sub-competencies include: (1) Describe the role of social structures in producing and maintaining health inequities globally, (2) Identify the ways that structural inequalities are naturalised within the field of global health, (3) Discuss the impact of structures on the practice of global health, (4) Recognise structural interventions for addressing global health inequities, and (5) Apply the concept of structural humility in the context of global health.

Structural Competency in Conflict Zones: Challenging Depoliticization in Israel

Structural competency is the trained ability to discern and acknowledge how health care outcomes are shaped by larger political, social, economic, policy, and legal forces and structures. Although structural competency has become an increasingly known framework for training and teaching, especially in the United States, it has usually not been used in nursing and nursing education. Moreover, very little is known about how to implement structural competency programs in conflict zones. Due to depoliticization that often prevails in both the higher education system and the health care system, the political conflict and the structural violence that significantly impact people's health are rarely discussed in these systems. This article examines the potential contribution of structural competency training programs for nurses and nursing students in conflict areas by analyzing a program that has emphasized the impact of the Israeli-Palestinian conflict on the health of Jerusalem's Palestinian residents. The article explains how this program has challenged the denial and silencing of conflict-related sociopolitical issues. At the same time, this program has created heated disagreements and friction. We suggest that structural competency training programs that are adapted to the political context in question may help nurses become organic intellectual leaders and agents of social change for those whose voices are not heard.

Decarceration and community re-entry in the COVID-19 era

Jails and prisons are exceptionally susceptible to viral outbreaks, such as severe acute respiratory syndrome coronavirus 2. The USA has extremely high rates of incarceration and COVID-19 is causing an urgent health crisis in correctional facilities and detention centres. Epidemics happening in prisons are compounding the elevated risks that COVID-19 poses to people of colour, older people, and those with comorbidities. Intersectoral community re-entry efforts in the USA and other countries have shown that releasing people from correctional facilities as a pandemic-era public health intervention is safe and can support both public safety and community rebuilding. Therefore, substantial decarceration in the USA should be initiated. A point of focus for such efforts is that many people in prison are serving excessively long sentences and pose acceptable safety risks for release. Properly managed, correctional depopulation will prevent considerable COVID-19 morbidity and mortality and reduce prevailing socioeconomic and health inequities.

A Structural Competency Curriculum for Primary Care Providers to Address the Opioid Use Disorder, HIV, and Hepatitis C Syndemic

The interrelated epidemics of opioid use disorder (OUD) and HIV and hepatitis C virus (HCV) infection have been identified as one of the most pressing syndemics facing the United States today. Research studies and interventions have begun to address the structural factors that promote the inter-relations between these conditions and a number of training programs to improve structural awareness have targeted physician trainees (e.g., residents and medical students). However, a significant limitation in these programs is the failure to include practicing primary care providers (PCPs). Over the past 5 years, there have been increasing calls for PCPs to develop structural competency as a way to provide a more integrated and patient-centered approach to prevention and care in the syndemic. This paper applies Metzel and Hansen's (1) framework for improved structural competency to describe an educational curriculum that can be delivered to practicing PCPs. Skill 1 involves reviewing the historical precedents (particularly stigma) that created the siloed systems of care for OUD, HIV, and HCV and examines how recent biomedical advances allow for greater care integration. To help clinicians develop a more multidisciplinary understanding of structure (Skill 2), trainees will discuss ways to assess structural vulnerability. Next, providers will review case studies to better understand how structural foundations are usually seen as cultural representations (Skill 3). Developing structural interventions (Skill 4) involves identifying ways to create a more integrated system of care that can overcome clinical inertia. Finally, the training will emphasize cultural humility (Skill 5) through empathetic and non-judgmental patient interactions. Demonstrating understanding of the structural barriers that patients face is expected to enhance patient trust and increase retention in care. The immediate objective is to pilot test the feasibility of the curriculum in a small sample of primary care sites and develop metrics for future evaluation. While the short-term goal is to test the model among practicing PCPs, the long-term goal is to implement the training practice-wide to ensure structural competence throughout the clinical setting.

Structural vulnerability to narcotics-driven firearm violence: An ethnographic and epidemiological study of Philadelphia's Puerto Rican inner-city

BACKGROUND

The United States is experiencing a continuing crisis of gun violence, and economically marginalized and racially segregated inner-city areas are among the most affected. To decrease this violence, public health interventions must engage with the complex social factors and structural drivers-especially with regard to the clandestine sale of narcotics-that have turned the neighborhood streets of specific vulnerable subgroups into concrete killing fields. Here we present a mixed-methods ethnographic and epidemiological assessment of narcotics-driven firearm violence in Philadelphia's impoverished, majority Puerto Rican neighborhoods.

METHODS

Using an exploratory sequential study design, we formulated hypotheses about ethnic/racial vulnerability to violence, based on half a dozen years of intensive participant-observation ethnographic fieldwork. We subsequently tested them statistically, by combining geo-referenced incidents of narcotics- and firearm-related crime from the Philadelphia police department with census information representing race and poverty levels. We explored the racialized relationships between poverty, narcotics, and violence, melding ethnography, graphing, and Poisson regression.

FINDINGS

Even controlling for poverty levels, impoverished majority-Puerto Rican areas in Philadelphia are exposed to significantly higher levels of gun violence than majority-white or black neighborhoods. Our mixed methods data suggest that this reflects the unique social position of these neighborhoods as a racial meeting ground in deeply segregated Philadelphia, which has converted them into a retail endpoint for the sale of astronomical levels of narcotics.

IMPLICATIONS

We document racial/ethnic and economic disparities in exposure to firearm violence and contextualize them ethnographically in the lived experience of community members. The exceptionally concentrated and high-volume retail narcotics trade, and the violence it generates in Philadelphia's poor Puerto Rican neighborhoods, reflect unique structural vulnerability and cultural factors. For most young people in these areas, the narcotics economy is the most readily accessible form of employment and social mobility. The performance of violence is an implicit part of survival in these lucrative, illegal narcotics markets, as well as in the overcrowded jails and prisons through which entry-level sellers cycle chronically. To address the structural drivers of violence, an inner-city Marshall Plan is needed that should include well-funded formal employment programs, gun control, re-training police officers to curb the routinization of brutality, reform of criminal justice to prioritize rehabilitation over punishment, and decriminalization of narcotics possession and low-level sales.