UNITED STATES: SENTENCED TO SICKNESS

The US policy of mass incarceration (with access to inept medical care but
without access to information, prophylactics or disinfectants) has led to a
steep increase in the number of prisoners with communicable diseases.

PEOPLE walking out of jail in the United States usually have up to $200 "gate
money" to get them started in their new lives, to buy some clothes and pay the
Greyhound bus fare to reach the city in which they must live. But they might
also come out with something less helpful and more permanent: 1.3 million of
the 9 million released in 2002 were infected with hepatitis C, 137,000 with
HIV, and 12,000 had tuberculosis. These figures represent 29%, 13-17%, and 35%
respectively of the total number of Americans who have these diseases (1).

As public health researchers have warned for years, the mass incarceration that
has been happening across the country since the early 1980s has been
accompanied by the mass incubation of infectious diseases in correctional
facilities across the US (2).

The figures are dramatic but not really surprising. Much of the behaviour for
which people are sent to jail - such as injecting drugs, sex work, and violence
- - leads to infection with blood-borne or sexually transmitted diseases. So any
police sweep of law-breakers means a round-up of the currently or soon-to-be
ill. Once behind bars, the practices continue, but without the protection that
people might have had on the streets: since homosexual sex, drugs and violence
are illegal in correctional facilities, syringes, needles, bleach, condoms or
latex barriers are considered contraband (and even clean water for rinsing
things is hard to come by).

The result is a make-do policy that results in scarce injection equipment and a
few coveted needles (perhaps actual needles, but what is used are more likely
to be ingeniously transformed ink cartridges, straws, or guitar strings) that
are widely shared. Unprotected sex is routine without access to condoms. And
even activities such as tattooing or skin piercing that are relatively safe
against infection from HIV or hepatitis C when performed in the outside world
become high-risk activities in prison. They are prohibited by law, and their
equipment banned; therefore everything connected with them is concealed and, of
course, shared.

Body decoration is an important and highly ritualised activity among convicts,
for whom "tattooing creates permanent representations of identity that cannot
be taken away by authorities; they represent positive affirmations of self in
an environment full of negatives" as well as a visual means of identifying gang
or group affiliation in a world full of strangers (3). While all needle-related
activities are illegal in prison and therefore go unreported or underreported,
researchers suspect that tattooing involves greater numbers of inmates than
does injection-drug use and could perhaps be the primary means of HIV and
hepatitis C transmission in correctional facilities.

This information surprises many inmates, since untold numbers of them do not
know the crucial facts about the transmission, prevention, or treatment of
infectious diseases; before their arrest they probably did not have access to
medical care. In the US medical care is contingent upon having an employer who
provides benefits (in the form of health insurance) at an affordable premium,
or having personal funds to purchase private insurance, or qualifying for
public aid, which is denied to those who are not impoverished enough and may
anyway specifically exclude medication for drug addiction, mental illness and
other serious conditions. This is a problem.

Paul Farmer and Barbara Rylko-Bauer have written: "The US health system is in
fact a non-system, and what happens is the result of chance and a patchwork of
services: it is splintered, unsystematic, fragmentary and inefficient." So
people entering prison may not know that they are already carrying infectious
diseases if they have not already received treatment for symptoms, or they may
not know they are at risk of acquiring them.

Once inside prison inmates are tested for certain diseases, such as
tuberculosis or syphilis, but institutions do not automatically test for HIV or
hepatitis. But when procedures are not well explained (or when a prisoner does
not speak English) and blood is taken, some inmates think that they are being
tested for these viruses. Budget limitations often mean a no-news-is-good-news
policy, so only those whose results show infection receive a follow-up
appointment - and the rest assume that all is clear.

Inept or illegal medical companies compound the disorder. One California
laboratory faked test results for thousands of prisoners for years during the
1990s. Tipped off by concerned prison medical staff who had noticed spelling
mistakes and other errors in reports, officials from the California State
Department of Health raided the laboratory building in 1996 and "found a jumble
of idle equipment - a laboratory in disarray, with testing equipment that
didn't work, was out-of-calibration or lacked proper reagents for conducting
tests of blood and urine" (4).

By 2000, when the San Francisco Chronicle investigated this affair, there was
little evidence that the California Department of Corrections had made any
efforts to contact or retest inmates who had received wrong information about
their HIV or hepatitis C status, their cervical cancer exams or any other
life-threatening conditions. But in the meantime the manager of the phoney lab
had obtained a state licence to operate a new clinical testing outfit.

In another case a Michigan prisoner was accidentally shown medical records from
his previous incarceration and was stunned to learn that he had tested positive
for hepatitis C two years earlier and had never been told. His girlfriend, with
whom he had lived between his arrests, discovered that she too had the disease
(probably acquired between her partner's detentions).

This raises a little-known issue: a sizeable percentage of the 9 million people
released from jail each year in the US carry infectious diseases back into
their communities and risk transmitting them to their sexual and needle-sharing
partners - and anyone else who comes into contact with their bodily fluids.

People do not see prisons as particularly risky to their health and so do not
avoid unprotected sex or needle-sharing with someone who has recently rejoined
society (5). In fact, since the correctional facilities do provide regular
meals, sheltered housing and some degree of health care (however inadequate),
the poor and homeless in the outside world may view prisons as quite healthy
environments, especially when they see someone return to the streets well
rested, nourished and even buffed up from long hours of exercise in the gym.
The decline in the US welfare state to the point where the penal institution
"has increasingly become America's social agency of first resort" (6) means
that, for the most marginalised, the harsh grip of the punitive state also
functions as the steadying hand that keeps their heads above water.

Even so, errors, neglect and incompetence can prevent adequate medical care for
detainees and prisoners. Doctors and other medical personnel who have been
sanctioned for poor standards of practice may have their general licences
revoked but can continue to be allowed to work in correctional facilities.
Inmates who require medication for HIV or hepatitis C may receive out-dated
treatments that are modified according to correctional policies (for instance,
inmates may be required to prove compliance with single-drug regimens before
being allowed to receive more advanced multi-drug therapies) or improperly
administered, as in the case of a Florida prisoner who was routinely given his
pills with his meals, despite the interdiction on eating two hours before and
one hour after taking his HIV medication. Such blunders endanger lives and
well- being, and they also help create drug-resistant strains of viruses.

But whatever health care someone receives in a correctional facility may be
better than that which he or she can scrounge when not behind bars. The US
Census Bureau reports that, in a nation that still rejects implementing a
system of universal coverage for its citizens, 41 million people found
themselves uninsured in 2001, meaning that they were responsible for paying in
full any medical costs they incur. Meanwhile the price of malpractice insurance
for doctors and hospitals translates into bills that are three to five times
higher than in Europe; prices for prescription drugs are prohibitive; and bills
for prolonged stays in hospital can cost hundreds of thousands of dollars.

Those who cannot afford these costs must rely on unpredictable and bureaucratic
state aid, underfunded and often shoddy public services (free or low-cost), or
the hospital emergency room - which the poor often use for primary health-care
since hospitals are required to treat people if they arrive in bad enough
shape. Ironic ally, prisoners are the only group in the US who are entitled to
medical treatment, for as long as they remain under state supervision. No
wonder some people "deliberately return to incarceration because they feel that
they can obtain better care there than in the community" (7).

The alarming prevalence of infectious diseases among the incarcerated ratchets
up the costs: sky-high rates of illness and infection translate into equally
high prison medical costs, which is a difficult issue to pitch to taxpayers who
already have seen engorged correctional budgets dwarf allotments for education
and social welfare spending during the past decade. The combined policies of
hypertrophic incarceration for the poor and commercially based laissez-faire
medical coverage for citizens are causing a public health nightmare in the US.

(1) The Health Status of Soon-to-Be Released Inmates, National Commission on
Correctional Health Care, 2002.

(2) This situation is not confined to the US: for information about healthcare
in French prisons, see Claude Veil et Dominique Lhuilier, La prison en
changement, Editions Eres, Ramonville Saint-Agne, 2002. For Spanish prisons,
see "Sida y Carcel" in PANPTICO, No 1, Nueva Epoca, 2001, Virus Publications.
For Russian prisons, see Paul Farmer, Pathologies of Power, University of
California Press, 2003.

(3) Susan A Phillips, "Gallo's body: decoration and damnation in the life of a
Chicano gang member", Ethnography 2:357-388, 2001.

(4) Farmer Sabin Russell, "State Fumbles Prison Lab Testing: Company's Fake
Results May Never Have Been Corrected," San Francisco Chronicle, 6 July 2000.

(5) See Megan Comfort, Olga Grinstead, Bonnie Faigeles, and Barry Zack,
"Reducing HIV Risk Among Women Visiting Their Incarcerated Male Partners",
Criminal Justice and Behaviour, Thousand Oaks, California, 2000.

(6) Elliott Currie, Crime and Punishment in America, Henry Holt and Company,
New York, 1998.

(7) Theodore M Hammett, "Health-Related Issues in Prisoner Reentry to the
Community", in Reentry Roundtable, The Urban Institute, Justice Policy Centre,
Washington, 2000.