Correctional Populations

The purpose of this section of Public Health Behind Bars is to provide a backdrop for later chapters. This section is about the effect of law and public policy on correctional health care and public health. The chapters offer new and different public policy options to consider, focusing on the health of our communities and what the legal bases are for inmates' rights to medical care. The chapters help us ask and answer questions about what can be done through laws themselves, for example laws about sentencing, and what can be done to improve health care through litigation. This section provides a basis for dealing with the puzzles of prevention and reentry.

During the past few decades, the growth in imprisonment in the United States has been startling, both for its volume and for its concentration of poor, young men, disproportionately African-American. Todd Clear is a social scientist who looks at communities and the impact of incarceration on the people who live in them. His chapter on the impact of incarceration on community public safety and public health describes the characteristics of the home communities of prisoners and the impact of incarceration on the families and communities to which prisoners return. Professor Clear makes a compelling argument that the high incarceration rate is a direct impediment to public health and public safety. In effect, he makes a compelling argument that the imprisonment of a high proportion of community residents is a punishment for the home community as well as for the individuals.

Jon Wool, an attorney working in public policy, explains the current status of litigation as a driving force for improving health and health care for inmates. He describes the vehicles for this litigation including constitutional entitlements through the Eighth and Fourteenth Amendments, the Americans with Disabilities Act, and the Constitutional Rights of Institutionalized Persons Act. Mr. Wool also describes the barriers to legal enforcement created by the Prisoner Litigation Reform Act. Behind bars, litigation has driven constructive change for more than 30 years, yet it has been frustrating for correctional administrators and policy makers when they are the objects of these lawsuits. The author posits the value of litigation for improving medical care in prisoners.

Likewise, Sam Paz, a civil rights attorney, writes about accommodating disabilities behind bars and the legal protections that Congress awarded the disabled, including prisoners, with the passage of the Americans with Disabilities Act

12 Section 1 Impact of Law and Public Policy

(ADA). The ADA is being used increasingly in inmate litigation, for patients with either physical or mental disabilities. Mr. Paz clearly describes the rights of disabled people and the responsibilities of correctional administrators to accommodate these people.

And there will be more disabled people behind bars unless public policy changes. Brie Williams, a geriatrician, researcher, and correctional health practitioner, elucidates the elements of managing disabled inmates. Because of high incarceration rates and long sentences, the proportion of elderly inmates is increasing. Dr. Williams addresses the numbers and the potential costs for care for a larger elderly population. The cost implications for public policy makers are mind-boggling. These data scream for some sound economic analysis of the implications of the aging inmate population.

In his chapter on international public health models, Michael Levy, a public health physician who works with correctional systems, provides us with a view that we often miss, i.e., there are other ways to do things. With descriptions of harm minimization programs in jails and prisons around the world, Dr. Levy offers us a lot of ideas on how we might craft improved prevention programs behind bars and for reentry.

Mark Heath, a professor of anesthesiology, writes about the implications of the medicalization of lethal injection, currently the dominant mode of capital punishment in the United States. He explains the horror of the pain and suffering of the condemned that is caused by botched executions. Dr. Heath describes the spectacle of lethal injection and asks the reader why we are "witnessing the foreseeable and gratuitous suffering of condemned prisoners?" This is both a practical question and a moral one, so long as the execution process is medi-calized with pharmaceuticals and intravenous delivery methods.

Section 2

The Polarity Path

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