The ‘paradox’ of receiving health care in prison

The following is an excerpt from “Prisons and health in the age of mass incarcerationby Jason Schnittker, Michael Massoglia and Christopher Uggen (©2022 Oxford University Press).

At the heart of the relationship between prisons and healthcare is a paradox. Prisons are accused of being punitive and therapeutic, of denying freedom and providing treatment. Common corrective concepts are full of ironies. Protective custody, for example, is a type of confinement in which the intent is to protect inmates from harm, especially from other people in prison.

But the idea is a contradiction if the custody itself is harmful. And, indeed, incarceration is often harmful. The language of protective custody, for example, is often used synonymously with isolation, which is particularly harmful to well-being.

The paradoxes are evident in other ways as well. In the spring and summer of 2020, more than 900 imprisoned Americans died of COVID-19 and thousands more will die of other causes. Prisons are also implicated in the spread of other infectious diseases, including, at least historically, HIV and tuberculosis. Physical and sexual abuse are not uncommon in prison settings, leading to emotional and physical harm.

At the same time, however, many people in prison are receiving urgent medical attention and receive care they probably would not have received before their incarceration. For many, incarceration increases their access to medical care, leading to significant improvements in their health and risk profile, from more accurate diagnoses of long-standing problems to better blood sugar control and lower blood pressure. For black youth, mortality in prison is lower than outside prison.

The paradox at the heart of prison healthcare has, if anything, become more acute over time.

While medicine has broadened the range of therapeutic technologies and concepts of appropriate punishment have evolved, the legal system has failed to provide guidance on what prisons are obligated to provide in relation to health care, exacerbating the tension. at the heart of the irto system. The tension is further heightened by the seemingly sharp but actually porous boundaries of the prison system’s mandate. Whatever assistance prisons are able to provide to those in their custody ends abruptly on their release, even as the health of those previously incarcerated deteriorates and better access to treatment would aid their rehabilitation.

Understanding the connection between prisons and health requires us to hold both of these ideas at the same time: prisons can undermine health and deliver meaningful health care services, and they operate in an environment that insists on both. Understanding the connection also requires us to understand the prison system as a complex institution, operating under a diverse set of legal, cultural and political mandates.

As an institution, the prison system ostensibly serves the interests of criminal justice. As with many other institutions, however, prisons are increasingly tied to a variety of coexisting and often incompatible goals. Prisons are simultaneously required to supervise, punish, correct and maintain the health of those entrusted to them. The same staff often performs all of these functions simultaneously.

Given these mandates, there are important distinctions between what prisons are required to do, are permitted to do, and actually do. Furthermore, prisons intersect with other institutions responsible for the care of similar populations, albeit with different responsibilities and operating principles. Currently, for example, the US prison system provides a good deal of assistance to those who, in an earlier era, might have been treated in a mental hospital. By some accounts, the prisons can now be considered the largest mental hospital system in America.

But the legal mandate that supports health care in prisons distinguishes prisons from other institutions that provide care. At its root, prisons are hostile to health. The law stipulates that US prisons must provide health care, in line with the Eighth Amendment’s prohibition against cruel and unusual punishment. But the constitutional mandate that upholds prison healthcare is very different from the care ethic that governs ordinary healthcare encounters.

Understanding the connection between prisons and health requires us to hold both of these ideas at the same time: prisons can undermine health and deliver meaningful health care services, and they operate in an environment that insists on both.

From “Prisons and Health in the Age of Mass Incarceration”

Unlike hospitals or clinics, prisons are largely defined by punishment. This, of course, goes without saying. Punishment is what most people associate with prisons. Prisons come with cells, restrictions, supervision, and service time. And prisons are sometimes involved in state-sanctioned killings, as in the case of capital punishment.

Health is the antithesis of punishment. To punish is to harm and injure, while to care is to heal and cure. To discipline is to despoil, while to treat is to build. Guards enforce passivity, while medics step in to allow activity. It’s hard to imagine respecting an oath not to harm first when the institutional prerogative is to sanction.

When judges sentence people to prison, they do so on the assumption that the experience will be painful. Some judges go one step further: they believe that the prison sentence should not only be painful in itself – as if the forced separation from loved ones and the severe restrictions on freedom were insufficient – ​​but also extremely painful, so much so that the material and social conditions of prison life should by no means be conducive to well-being. Some jail and jail officials even brag about the pain they inflict, such as when they have no air conditioning in the summer heat, no pay for work, and food costs pennies a day.

To be sure, the philosophy behind incarceration has changed over time. Severe punishment has not always been the guiding philosophy. It is possible, for example, to view a prison sentence as an opportunity to rehabilitate people, as we have done much earlier in our nation’s history. It is also possible to look at prisons as a place to equip people with the skills needed for reentry, as we did until the end of the 20th century.

Yet the current era has been defined primarily in terms of a tough approach, as well as a reluctance to extend to people in prison anything that might be considered an amenity. Significantly, the shared concept of “rehabilitation” is also fundamentally different in prisons and hospitals. In corrections, rehabilitation denotes the elimination of the injury, while in medicine it denotes the improvement and restoration of ability. In hospitals, rehabilitation is expansive, while in prisons, it is restrictive. Rehabilitation becomes reduction of recidivism or, even more reductively, reduction of the cost to society once someone is released.

Yet the fact remains: the prison system is clearly about providing care.

Jason Schnittker is a professor at Department of Sociology in the School of Arts and Sciences to the University of Pennsylvania. The co-authors of him are Michael Massoglia of the University of Wisconsin-Madison And Christopher Uggen of the University of Minnesota.

The text above is an excerpt from “Prisons and health in the age of mass incarceration” (©2022 Oxford University Press). Used with the permission of the publisher.

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