The Human Service Role Of Corrections Workers Is Exemplified By Which Of The Following Activities?

Public Health Rep. 2010; 125(Suppl 4): 25–33.

Prisons as Social Determinants of Hepatitis C Virus and Tuberculosis Infections

Niyi Awofeso

^aSchool of Population Health, The University of Western Australia, Perth, Western Australia, Commonwealth of australia

^bSchool of Public Health and Community Medicine, The University of New S Wales, Sydney, New South Wales, Australia

SYNOPSIS

Effects of place or neighborhood—locations where individuals reside, shop, recreate, and work—have been widely studied as sources of environmental influences on individual behaviors, exposures, and physiology, also as reference points for public health interventions. Still, despite modernistic prisons' strong influence on the manual and clinical outcomes of infectious diseases, custodial government and public health officials in many countries have nevertheless to implement credible interventions to minimize the adverse impacts prison settings exert on the epidemiology of catching diseases—particularly with respect to inmates. Among many vulnerable populations, prisons are evolving as one of the social institutions that make up one's mind their wellness status and health outcomes. This article highlights the furnishings of prisons in mediating the risk of hepatitis C virus and tuberculosis infections, as well as viable interventions and policy approaches for limiting the deleterious consequences prisons exert on the transmission and clinical courses of these diseases.

The unremarkably agreed manifest functions of prisons are reformation, incapacitation, retribution, and deterrence.¹ Jeremy Bentham pioneered the modern prison philosophy of incarceration and ocular surveillance (i.eastward., omnipresent, all-seeing custodial authorities) as a component of punishment, thus extending the use of prisons beyond that of a holding state until corporal or capital punishment is inflicted.² In Discipline and Punish, Michel Foucault describes modern prisons as social institutions designed to sequester torture from public view while simultaneously inflicting brutal and unusual penalization on the torso and soul of incarcerated individuals.³ From the early 20th century onward, the role of prisons has evolved from the periphery to the centre of social policy. The Gulag system of the former Soviet Union exemplified this evolution during the get-go half of the 20th century, in which prisons facilitated social control and served as torture centers and sources of cheap labor.⁴

In the past several decades, major transformations of prisons as cadre social-policy instruments take been occurring in the U.S., where the number of inmates rose dramatically from 560,000 in 1978 to ii.3 one thousand thousand in 2008.^five Wacquant viewed mass incarceration in the U.Southward. as evolving from previous social institutions—slavery, Jim Crow laws, and ghettos—for the discipline and command of the underclass.⁶ Authoritarian rule in Prc since Mao's revolution facilitated the exponential growth of People's republic of china's prison house population to at least 1.6 million as of 2007—a substantial contribution to the nine 1000000 incarcerated individuals in the world.⁷

As places or neighborhoods in which individuals are physically confined and deprived of a range of personal freedoms, prisons have been shown to operate equally structural factors that may influence health condition and outcomes independently of individual-level attributes.^viii 3 empiric strategies are commonly utilized to investigate neighborhoods' effects on wellness—ecologic studies, multilevel studies, and comparisons of small numbers of well-defined neighborhoods. Ideally, the impacts of prison neighborhoods on wellness should exist analyzed in relation to upstream social determinants of wellness (SDH) in the larger society,^nine ^, ^x in view of the shut links between prison settings and surrounding communities, as well as the fact that more 95% of inmates will eventually reenter the general community.

Prison settings are ordinarily associated with loftier risk of infectious diseases.^eleven ^, ¹² Such increased risks are attributable to both the likelihood of a loftier proportion of people with infectious diseases coming in contact with the criminal justice system and the increased risk of infectious affliction transmission in prison settings.¹³ ^– ¹⁶ This article explores the roles of prisons equally SDH, as well as prisons' mediating influence on the transmission and clinical course of hepatitis C virus (HCV) and tuberculosis (TB) infections. It also proposes policy approaches for reducing the adverse impact of prisons on morbidity and mortality from infectious diseases.

PRISONS AS SOCIAL DETERMINANTS OF HEALTH

Raphael¹⁷ defines SDH as "the economic and social weather condition that shape the health of individuals, communities, and jurisdictions as a whole. [SDH] are the master determinants of whether individuals stay healthy or become ill (a narrow definition of wellness). [SDH] as well decide the extent to which a person possesses the physical, social, and personal resource to identify and achieve personal aspirations, satisfy needs, and cope with the environment (a broader definition of health). [SDH] are about the quantity and quality of a multifariousness of resources that a society makes available to its members." The Public Health Agency of Canada lists nine SDH: income, employment and working weather, nutrient security, environment and housing, early on childhood development, teaching and literacy, social support and connectedness, health behaviors, and admission to health care.¹⁸

Although several recent manufactures have highlighted prisons as social or structural determinants of health,¹⁵ ^, ¹⁹ limited information currently exists on how prisons socially or structurally influence the wellness status and outcomes of the incarcerated. This article posits that prisons serve as SDH past mediating the vicious cycle of concentration, distension, deterioration, dissemination or overburdening, and mail-release morbidity and bloodshed (Figure).

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Conceptual framework of the primal role of prisons in concentrating, amplifying, and disseminating infectious diseases amid individuals in contact with the criminal justice system

Individuals with inferior wellness status are overrepresented amidst those in contact with the criminal justice system.¹⁵ ^, ¹⁹ Prisons serve as a concentration mechanism for relatively unhealthy individuals, partly considering the behavioral and structural factors that lead to poor health (eastward.g., illicit drug use and alcoholism) are besides associated with increased likelihood of incarceration. This nexus is exemplified by a 2007 national prison entrants' survey in Australia, which revealed that 35% of 740 consecutive prison house entrants were HCV-antibody positive. The documented prevalence of hepatitis C and illicit drug use among the prison entrants studied was almost 40 times the HCV-antibiotic prevalence in the Australian full general customs.¹⁶

Prisons amplify adverse wellness atmospheric condition through a civilization that normalizes behaviors that are deleterious to health, such as tobacco use, injection drug use (IDU), and violence. The disease-amplification function of prisons is reflected in disproportionately high disease incidence and prevalence, which are documented in about inmate health surveys, and in reports of high rates of infectious-disease transmission in prisons.²⁰ ^– ²² In nigh societies, prison settings exacerbate existing health weather of inmates. Indeed, many inmates leave prisons less good for you, physically and mentally, compared with their health condition at incarceration.²¹ ^, ²² Malnutrition, infectious diseases, overcrowding, austere custodial physical infrastructure, limited access to basic health services, and inhumane attitudes and practices of custodial officers toward inmates contribute to the deterioration of the physical and mental health status of individuals following incarceration.²³ ^– ²⁵ An extreme touch of deteriorating health conditions is the increasing number of deaths among inmates in custody—a miracle that is closely linked to inmates' deteriorating physical and mental health, coupled with limited access to basic health care.²⁶ ^, ²⁷

Dissemination of infectious diseases is another mechanism through which prisons serve as SDH. As more than than 95% of incarcerated individuals somewhen reenter the full general customs, amplification of infectious diseases during incarceration poses definite risks to the communities to which infected and untreated inmates return. Patients with chronic, non-communicable diseases too place an increased brunt on the health system, also as their friends and relatives.²² ^, ²³ ^, ²⁸ Increased mortality and morbidity of inmates post-obit release from prison house is another mechanism through which prisons serve as SDH. Studies have shown that inmates are at significantly high risk of suicide post-obit release.²⁹ ^– ³¹ Elevated inmate morbidity post-obit release derives partly from the deterioration of their wellness status following incarceration and partly from express opportunities for employment, social support deficiencies, and inadequate access to mail service-release wellness care. These factors perpetuate the cruel wheel that facilitates the re-incarceration of a large proportion of such individuals or their associates, due, for case, to drug-related crime, poor part models, poverty, and inadequate social back up. In the U.S., approximately two out of every 3 people released from prisons are rearrested within three years of their release; more than than l% are re-incarcerated.³²

At an ecological level, prisons as SDH operate through the phenomenon of mass imprisonment. Mass imprisonment implies not just rising numbers of inmates, just also the concentration of social and health furnishings of imprisonment on whole population subgroups, such as young, African American, and Aboriginal Australian males. In Australia, Aboriginal people establish ii.five% of the full general population just more than 22% of the prison population.³³ In the U.S., mass imprisonment is emerging as a new stage in the life class of young, low-skilled African American people. For such disproportionately incarcerated groups, imprisonment becomes i of the social institutions that determines their health condition and outcomes.³⁴ ^, ³⁵

PRISONS AND HCV INFECTION

HCV is a bloodborne pathogen that affects an estimated 130 million to 170 million people, or 2.2%–3.0% of the world's population. Current major take chances factors for infection include IDU (more than 80% of infections) and other procedures requiring skin penetration, such as nonsterile injections, tattooing, and other body art.³⁶ Chronic HCV infection is currently the about common indication for liver transplantation in industrialized nations.³⁷ ^, ³⁸ In the U.Southward., hepatitis C-related mortality overall increased by 123% from 1995 through 2004, with the well-nigh dramatic historic period-specific increment occurring among the economically productive age group of 45- to 54-twelvemonth-olds.³⁹

Socioeconomically vulnerable populations are overrepresented in American hepatitis C morbidity and mortality statistics.³⁸ ^– ⁴⁰ Global estimates bespeak the price of treating decompensated liver cirrhosis and liver transplantation (in the absence of antiviral treatment) is in the range of $24,000 to $39,000 (lifetime disease costs).³⁶ A modeling study estimated the mean cost of achieving sustained virologic clearance for a hepatitis C patient in a U.S. correctional facility at $55,270,⁴¹ excluding costs of infection to the private inmate, such every bit those related to social exclusion, depression, fatigue, and subclinical impairments in cerebral office, which are not hands quantifiable in monetary terms.⁴²

Hepatitis C is known to be transmitted in prison house settings, although probably non as frequently as in the general community of nearly industrialized nations. For example, reported seroconversions in Australian prisons ranged from four.6 to 7.ane per 100 person-years,⁴³ ^, ⁴⁴ compared with 30.8 per 100 person-years in the Australian full general community.⁴⁵ Among inmates in Melbourne, Australia, in the early 1990s, the annual risk of HCV infection with echo testing on reentry to prison was 18%; nonetheless, it was 41% among inmates younger than 30 years of age with reported IDU. Information technology was difficult, nonetheless, to determine whether the studied cohort contracted the infection in prison or in the customs.⁴⁶ It is noteworthy that the apparent effectiveness of injecting-equipment prohibition policies in Australian prisons has not been replicated in other prison house settings, such as in Ireland, where high rates of hepatitis C transmission in prison settings have been reported.⁴⁷ Imprisonment, per se, is considered a major run a risk factor for HCV infection, with the risk of infection straight proportional to the length of incarceration.⁴⁸ ^, ⁴⁹

Prisons socially determine the transmission of HCV infection among inmates in several means. First, a high proportion of inmates are addicted to illicit drugs that are injected, and some of the bedevilled illicit drug users manage to continue with their habit during incarceration.⁴⁴ ^, ⁴⁷ Wellness services for habit direction in most prisons are inadequate to cope with the demand for such treatments. Addicted inmates are less likely to benefit from health-education activities, such as counseling about drug forbearance, without parallel addiction-direction interventions, such every bit methadone or buprenorphine maintenance handling.^l Many drug-addicted inmates turn to tobacco and illicit drug use to satisfy their addictive cravings, as well as to numb the pains of imprisonment, famously classified by Sykes every bit deprivations of liberty, appurtenances and services, heterosexual relationships, autonomy, and security.⁵¹

Second, as a high proportion of individuals in contact with the criminal justice system have already contracted hepatitis C prior to incarceration, prison settings magnify the probability of hepatitis C transmission amidst inmates who engage in IDU. For example, a 2004 survey of 612 Australian prison entrants indicated that 56% had a history of IDU and 39% had injected in the previous month.⁵² Of 81 inmates surveyed as office of a hepatitis C seroconversion study in New South Wales prisons, 29 (36%) gave a history of IDU, and 13 (16%) self-reported drug use in prison house.⁴⁴ Apart from IDU, other risk factors for hepatitis C transmission, such as set on, body piercings, tattooing, and unprotected anal sexual activity with male injection drug users, are also commonly skillful by inmates.⁵³ ^– ⁵⁵

These adventure factors are more mutual in custodial settings, primarily because of the structure and function of prisons. For case, limited access to harm-reduction interventions, such as needle- and syringe-exchange programs or condoms, makes it more likely that inmates volition contract HCV infection. The finding that hepatitis C prevalence amongst custodial officers is higher compared with the general community⁵³ suggests that prison environments may as well mediate infection risks for prison workers—either directly, through occupational hazards associated with concrete assaults, or through the stress of prison house duties putting custodial workers at higher risk of engaging in activities such equally illicit drug use, and consequently contracting HCV infection. However, proof of such a trajectory is defective from systematic reviews.⁵⁶

3rd, custodial policies and practices influence the likelihood of inmates contracting HCV infection. Prisons with lax or poorly implemented policies in relation to illicit drug use make inmates more vulnerable to contracting HCV infection. Lax policies include weak surveillance of drug and injecting-equipment trafficking, and inadequate sanctions meted to inmates or custodial workers found to be involved with drug trafficking. A report in Australia in the 1990s indicated that about one-half of all imprisoned injection drug users injected drugs in prison, and non-random urine drug tests may reinforce and perpetuate the original reasons for drug use in prison.⁵⁷

Custodial environments in which inmates are -tortured, not provided with productive outlets for their motivations, or not accorded bones human being nobility are more than likely to be characterized past inmates who develop ingenious or irrational means to adapt to stressful prison government, such as gang-affiliation tattooing and unprotected anal sexual activity, as well as increased trafficking and use of illicit drugs. Such high-gamble activities magnify their hazard of contracting HCV infection in custody.⁵⁸ ^– ⁶⁰

Prisons mediate the dissemination of HCV infection beyond the period of incarceration. History of recent incarceration is significantly associated with contracting HCV infection in community settings.⁴⁵ ^, ⁴⁸ Amongst claret donors in community settings, history of incarceration, as well as being HCV-antibiotic positive, is strongly associated with IDU.⁶¹ ^, ⁶² History of incarceration has deleterious consequences on employment and earning prospects of released inmates, in function due to adverse employment implications of criminal records checks. Released inmates with HCV infection carry a double burden of stigma related to both imprisonment and HCV infection. A 2001 American written report on the labor market place consequences of incarceration adamant that the earnings penalty of imprisonment ranges from 10% to 30%.⁶³ Morbidity from HCV infection stigmatizes sufferers and impairs physical and mental fitness, thus contributing directly to reduced earnings potential. Income level is i of the established SDH through which imprisonment adversely impacts the health and welfare of released HCV-infected inmates. Individuals with HCV infection are more probable to be incarcerated, or re-incarcerated, mainly due to increased likelihood of involvement in drug-related criminal activeness, homelessness, and unemployment, thus perpetuating the barbarous cycle of health deterioration among HCV-infected individuals, in which prisons play a key mediating part.¹⁹ ^, ⁶⁴ ^, ⁶⁵

PRISONS AND TB INFECTION

TB ranks amongst the 10 chief causes of death and inability worldwide. In 2007, there were an estimated 9.3 million incident cases of TB and 1.8 million deaths from TB globally.⁶⁶ TB causes $13 billion annually in reject in workforce productivity, its treatment using standard World Wellness Organization (WHO) regimens is highly toll effective in the nigh TB-afflicted countries,⁶⁷ and information technology's one of merely several diseases for which specific control strategies were set in the United Nations' 2000 Millennium Evolution Goals.⁶⁸ Globally, prisons take been shown to have a college prevalence of TB morbidity and bloodshed compared with other population cohorts.⁶⁹ A 2008 WHO-supported literature review of TB in prisons⁷⁰ revealed the post-obit:

Prisons in countries of the former Soviet Union have some of the highest chief TB (e.one thousand., prevalence of 4,560/100,000 in 1 Russian study) and multidrug-resistant TB (MDR-TB) prevalence rates in the world. MDR-TB rates for previously treated inmates ranged from 12% to 55%.
In an English written report, one.5% of prison staff had TB.
Spanish inmates were plant to exist co-infected with TB and homo immunodeficiency virus (HIV) 17.9% of the time.
TB prevalence in a sample of Thailand's prisons was 568/100,000, with 19% of the patients confirmed with MDR-TB.
In a report of Tanzania's prisons, 41% of inmates had active TB. Rates of TB-HIV co-infection ranged from 26% in Tanzania to 74% in Malawi.

Prison systems serve as social determinants of TB infection in several ways. Get-go, prison house entrants more often than not have disproportionately college prevalence of TB compared with their respective civil communities. The concentration function of prisons in relation to TB is attributable to homelessness, poverty, malnutrition, high rates of TB-predisposing diseases such as HIV, and marginal social condition, such as unemployed, foreign-born cohorts.⁷¹ ^, ⁷²

Second, as TB is an airborne disease, the architecture of prisons and the population of prison house residents increase the chance of TB infection. For instance, South Africa's prisons have a total capacity to conform 115,327 inmates, just recorded a mean daily count of 163,049 in 2007—a 42% excess capacity.⁷³ Overcrowding is a demonstrated risk factor for TB transmission and a particularly mutual risk factor in prisons situated in developing countries with a high TB burden.⁷⁴ Prison construction plans invariably accordance college priority to security than to acceptable ventilation. In situations where inmates with active TB alive in poorly ventilated custodial settings (equally is usually the case in most developing countries), the potential for rapid transmission of TB is high.⁷⁵ ^, ⁷⁶ Malnutrition and bloodborne virus transmission—common health hazards associated with most prisons—too contribute to an increased risk of TB infection.⁷⁷ ^, ⁷⁸ The amplification role of prisons in relation to TB infection extends to custodial workers, with upward to ane-3rd of new TB infections among custodial staff in some prisons attributable to occupational exposure.⁷⁹ ^, ⁸⁰

3rd, the quality of prison house health services for TB surveillance and treatment remains inadequate in almost prisons. For example, few prisons consistently undertake peel testing of new prison house entrants (and annual testing thereafter) and correctional health staff, despite evidence that such surveillance activities have a strong potential to detect new TB cases early on.⁸¹ ^, ⁸² Some of the consequences of TB surveillance and treatment failures in prison settings were highlighted during a TB outbreak in New York's prisons. A report related to this outbreak institute that just ix (23%) of 39 inmates with MDR-TB received treatment prior to outbreak investigation.¹⁴ In Kyrgyz republic, as of 2006, TB prevalence in prisons exceeded 5,000/100,000 inmates—at least 40 times that of the general community—and MDR-TB rates were at least xv%. As of January 2007, less than half of all inmates with active TB had been diagnosed and had begun treatment.⁸⁰

Prisons are directly linked to post-release morbidity and mortality of TB infection amid inmates. The follow-up of released inmates who contract TB in custody is suboptimal, and failures to follow up imply that those with agile TB are at increased gamble of premature death from TB or serious TB-related morbidity. These former inmates may also endanger the health of close contacts in the customs by posing serious infection risks. Increased morbidity and stigma of TB increase the risk of unemployment, homelessness, malnutrition, and drug use for released inmates. Unemployment and poverty limit the ability of TB sufferers to access constructive handling, and increase the likelihood of recidivism, thus perpetuating the brutal wheel in which prisons constitute a focal point.¹⁹ ^, ⁷²

Give-and-take

Documentation of the place or neighborhood furnishings of prison house settings on the wellness of the incarcerated equally well as elucidation of the mechanisms through which they are mediated have of import policy implications for health-care commitment, health promotion, and the reduction of health inequities.⁹ This article adds to current literature on the part of custodial settings in determining the health of the incarcerated by positing that prisons institute important SDH and that their impacts on the health of the incarcerated are particularly pregnant in relation to HCV and TB infections. Prisons exacerbate health inequities between individuals in contact with the criminal justice system and the general community. In the U.S., since 2008, one in 100 adult Americans is imprisoned at any point in fourth dimension.⁵ Imprisonment is not an equal-opportunity punishment—every bit of June 2006, the adult imprisonment rates were 134/100,000 for females, 736/100,000 for white males, and 4,789/100,000 for African American males. Mass incarceration of poor, young African American males adversely influences their health outcomes for several decades following incarceration.^v ^, ^{half dozen} ^, ³⁵

Front-cease policy choices that may facilitate reductions in the numbers of incarcerated individuals include alternatives to imprisonment for less serious offenders, as well as targeted use of drug courts to break the cycle of addiction, crime, and incarceration.⁸³ ^, ⁸⁴ Back-stop policy options to reduce prison population growth include accountability for parole violations that practise not necessarily imply imprisonment as the first penalty option. Noncustodial sanctions, such equally well-managed day-reporting centers, constitute a viable noncustodial option, particularly for minor offenders or released inmates guilty of technical violation of their parole conditions, such equally missing a counseling session.⁸⁵

Europe's initiatives in working toward harmonizing penal and public wellness policies to promote the health of inmates through the Health In Prisons Project are commendable, as are the guidelines and policy positions of the National Commission for Correctional Health Care in the U.South.²² ^, ⁸⁶ Advocacy for prison health-service quality equivalent to that of health care available in the respective general community is an important component of the "Prison house Health as Part of Public Wellness" Moscow Declaration of October 2003.⁸⁷ ^, ⁸⁸ The implementation of the declaration'due south measures implies a demand for adequate resources to fund health-intendance provision in prison settings, including optimal quality, quantity, and distribution of prison wellness workers. General and health-related prison policies and practices in virtually countries may crave revision to ensure compatibility with human rights of inmates. Furthermore, inmate copayment policies demand to exist closely monitored, to reduce the chance of this cost-saving policy serving as an obstacle to sick merely poor inmates receiving treatment.²⁷

In relation to HCV and TB infections, acceptable interventions to limit transmission and to promptly treat infected inmates constitute a public health opportunity to reduce the burden of these diseases. To facilitate control, information technology is important for prison health advocates and policy makers to ensure that treatment of inmates' TB and HCV infections is provided at nominal or no cost to inmates. Constructive implementation of surveillance and prevention of drug and drug-equipment trafficking may minimize HCV-infection risks in prisons, as appears to exist the case in many Australian prisons.⁴³ ^– ⁴⁵

Policies related to facilitating improved health of released inmates include pre-release screening to find new health bug, documentation of existing health bug, and arrangement for community-based treatment, as well equally social inclusion strategies, such every bit access to unemployment benefits, housing, and skills training. An inmate-reentry partnership that does non involve former inmates or members of the communities most affected by incarceration and reentry will likely find itself defective expertise and legitimacy.⁸⁸ ^– ⁹¹

Reducing the adverse impact of prisons on the health of the incarcerated and the general community requires a cooperative endeavour among all stakeholders. Development of quality benchmarks for core aspects of prison health intendance is an important component of this effort. Socio-politically, more equitable societies accept a significantly greater capacity to address the upstream factors that pb individuals to prison, ensure acceptable care for the incarcerated, and provide enough assist to facilitate inmate reintegration.⁹² ^, ⁹³

CONCLUSION

As social determinants, prisons exert a especially strong influence on the epidemiology of HCV and TB infections. The threat posed by the high prevalence of hepatitis C and TB in prison settings represents both a difficult claiming and a unique opportunity. Custodial health workers have access to vulnerable populations that otherwise would be difficult to reach in the customs. For some inmates whose lives prior to incarceration have been chaotic, their prison house term represents an opportunity to assist them in developing an ordered approach to assessing and addressing their health needs. Each prison has a potential to be a healthy setting, provided there is political will and technical competence on the part of governments and custodial authorities to address the social, physical, spiritual, and mental well-being of inmates. Funding for prison house health care is a major impediment; nevertheless, the stress on prison house budgets may be reduced by penal systems being more than selective near criminals who receive custodial punishment. Prison house reforms have a strong potential to benefit non but inmates, but also the wider community, into which nearly inmates will render in the fullness of time.⁹⁴

Acknowledgments

The author thanks Kim Brooklyn for assist with proofreading.

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