Overview of correctional medicine.

Disease-a-Month 60 (2014) 170–195

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Overview of correctional medicine Louis Shicker, MD, CCHP

Introduction As you begin to browse and read through this edition of Disease of the Month, you will undoubtedly raise the question as to why medical care for people in correctional systems requires any special or unique designation in our health care system. Is the care of an offender any different from that of a free citizen in the community? Do offenders as a group have a greater incidence of certain diseases warranting heightened vigilance in screening and workup? Do offenders have any special rights in our system regarding their health care? And finally, do we as a society have any obligation—moral or otherwise—in the care of the incarcerated population? These are the topics that will be addressed in this issue of Disease of the Month. In addition, the issue will take an in-depth look at a tele-medicine program used to treat HIVþ offenders as well as offenders with hepatitis C who are undergoing treatment. With the epidemic levels of hepatitis C amongst people in prison, an article will be devoted to hepatitis C in general. Special sections will deal with mental health and with dental care for the incarcerated. My hope is that after reading this issue, the reader will come away with a clearer understanding of the incidence of diseases such as HIV, hepatitis C, TB, mental illness, and substance abuse in the correctional population. The incidence of routine chronic diseases such as hypertension, asthma, and diabetes will also be addressed. One will also gain an understanding of the challenges and obstacles facing society as a whole and Departments of Corrections in particular to tackle those challenges and obstacles. The reader will also be introduced to novel approaches being employed to address the medical needs of this large and growing population in an age of financial stress and greater demand. The correctional population is made up of offenders in various systems. Jails are County run and comprise those that are arrested and awaiting adjudication. Their lengths of stay are, in general, of a short duration but can run into years under certain circumstances. State prisons are for offenders who have been found guilty and sentenced while they were at the County jail. Their lengths of stay range from a couple of months to life. The populations in these two systems are essentially identical. The types of crime committed are both violent (murder, rape, etc.) and nonviolent (drug possession, theft, prostitution, etc.)

http://dx.doi.org/10.1016/j.disamonth.2014.03.011 0011-5029/ Published by Mosby, Inc.

L. Shicker / Disease-a-Month 60 (2014) 170–195

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Federal Jail and Prison are parallel to the above except that they deal with offenders who have committed Federal crimes (such as mail fraud, kidnaping, bank robbery, tax evasion, etc.). Their population makeup differs to a degree from those in County jails and State prisons. There are also Detention Centers run by Immigration and Customs Enforcement (ICE) for illegals that may be getting deported. Finally, a subset of the above-mentioned designation are youth populations within each category. The authors of this issue have had the majority of their experiences in State prisons and the article will reflect their expertise in that system. The State prisons do house the largest population of incarcerated people in the US—87%. I want to thank my co-authors for their contributions and diligence in assisting me in putting this issue together. They are a diverse group of health professionals who have dedicated much of their careers to serve this often-neglected population.

Epidemiology Much of the data represented below is taken from the US Department of Justice—Bureau of Justice Statistics National Prisoner Statistics Program.1 From 1991 through its peak in 2009, the US prison population has risen. The last 4 years have actually seen some small but steady decline. In 2011, the US prison population was 1,599,000. When you add the jail population of 667,800 you have a total of 2,266,800 (Tables 1–3). This represents approximately 0.7% of adults in the US. Of those incarcerated currently, approximately 93% are male and 7% female. It should be noted, however, that the rate of growth for females has been significantly greater from 1995 to 2005, with male prisoner increase rate at 32% and female prisoner growth rate at 53%. Between 1991 and 2011, new court commitments of females to state prisons for violent offenses increased 83% from 4800 in 1991 to 8700 in 2011.1 Ethnicity makeup is demonstrated in Table 4 for State and Federal systems. In general, the ethnicity makeup of State Prisons across the US is approximately 39% White, 42% AA, and 39% Hispanic. For total prison and jail populations, approximately 39.5% were AA, 20.5% were Hispanic, and 40% White.1 Although aging a bit, the offender population is still a relatively young one. The largest decade cohort was represented by 30–40-year-olds—approximately 37% of those incarcerated. The population is, however, aging. By end of the year 2003, 28% of all inmates were aged 40–54 years (up 22% from 1995). Inmates aged 55 years and older have experienced the largest change—an increase of approximately 85% since 1995.2 This is mainly attributed to increase in life sentences and to new policies of Three Strikes Laws. wherein after being convicted of three felonies, the offender is automatically incarcerated for an extended period of time. State prisoners average lower educational levels and hence less employment skills and opportunities. In the Florida Department of Corrections 2009–2010, the median grade level for males was 6th grade and for females was 7th grade. Overall, 71% were below GED prep level.3 Offenders have a high incidence of mental illness. Approximately 16% of the population are categorized with severe mental illness. It is identified more in women and whites. The problem sky rockets when substance abuse problems are included.4 This issue will devote some key sections to address mental illness in the incarcerated.

Why the focus on the care of the offender There are basically four reasons to warrant a system that is specifically designed to address the medical needs of offenders. They are ethics, socialization, public health, and legal.

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Table 1 Total state and federal prisoners, by sex, December 31, 2011 and 2012.

2011

Percent change, 2011–2012

2012

Jurisdiction

Total

Males

Females

Total

Males

Females

Total

Males

Females

U.S. Total Federala State Alabama Alaskab Arizona Arkansas California Colorado Connecticutb Delawareb Florida Georgia Hawaiib Idaho Illinoisc Indiana lowad Kansasd Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevadac New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Islandb South Carolina South Dakota Tennessee Texas Utah Vermontb Virginia Washington West Virginia Wisconsin Wyoming

1,598,968 216,362 1,382,606 32,270 5,597 40,020 16,108 149,569 21,978 18,324 6739 103,055 55,344 6037 7739 48,427 28,906 9116 9327 21,545 39,710 2145 22,558 11,623 42,940 9800 21,386 30,833 3678 4616 12,778 2614 23,834 6998 55,436 39,440 1423 50,964 25,977 14,510 51,578 3337 22,914 3535 28,479 172,224 6879 2053 38,130 17,847 6826 22,657 21 83

1,487,561 202,462 1285,099 29,696 4932 36,470 14,995 141,382 19,957 17,090 6202 95,913 52,027 5304 6854 45,562 26,406 8378 8647 19,091 37,326 1981 21,576 10,832 41,031 9156 19,808 28,258 3274 4247 11,811 2444 22,762 6366 53,124 36,800 1276 47,061 23,558 13,387 48,795 3158 21,528 3094 26,070 158,036 6266 1905 35,321 16,452 6074 21,472 1944

111,407 13,900 97,507 2574 665 3550 1113 8187 2021 1234 537 7142 3917 733 885 2865 2500 738 680 2454 2384 164 982 791 1909 644 1578 2575 404 369 967 170 1072 632 2312 2640 147 3903 2419 1123 2783 179 1386 441 2409 14,188 613 148 2809 1395 752 1185 239

1,570,397 217,815 1,352,582 32,431 5633 40,080 14,654 134,534 20,462 17,530 6914 101,930 55,457 5831 7985 49,348 28,831 8733 9682 22,110 40,172 2108 21,522 11,308 43,636 9938 22,319 31,247 3609 4705 12,883 2790 23,225 6727 54,210 37,136 1512 50,876 25,225 14,840 51,125 3318 22,388 3650 28,411 166,372 6962 2034 37,044 17,271 7070 22,600 2204

1,461,625 203,766 1,257,859 29,782 4934 36,447 13,594 128,436 18,739 16,312 6348 94,945 51,868 5143 6977 46,599 26,265 7949 8952 19,425 37,783 1944 20,646 10,549 41,647 9228 20,652 28,544 3210 4352 11,845 2583 22,164 6096 51,963 34,675 1341 47,008 22,728 13,609 48,380 3128 21,051 3227 26,048 152,823 6323 1907 34,150 15,934 6265 21,375 1966

108,772 14,049 94,723 2649 699 3633 1060 6098 1723 1218 566 6985 3589 688 1008 2749 2566 784 730 2685 2389 164 876 759 1989 710 1667 2703 399 353 1038 207 1061 631 2247 2461 171 3868 2497 1231 2745 190 1337 423 2363 13,549 639 127 2894 1337 805 1225 238

1.8% 0.7% 2.2% 0.5 0.6 0.1 9.0 10.1 6.9 4.3 2.6 1.1 9.9 3.4 3.2 1.9 0.3 4.2 3.8 2.6 1.2 1.7 4.6 2.7 1.6 1.4 4.4 1.3 1.9 1.9 0.8 6.7 2.6 3.9 2.2 5.8 6.3 0.2 2.9 2.3 0.9 0.6 2.3 3.3 0.2 3.4 1.2 0.9 2.8 3.2 3.6 0.3 1.0

1.7% 0.6% 2.1% 0.3 0.0 0.1 9.3 9.2 6.1 4.6 2.4 1.0 0.3 3.0 1.8 2.3 0.5 5.1 3.5 1.7 1.2 1.9 4.3 2.6 1.5 0.8 4.3 1.0 2.0 2.5 0.3 5.7 2.6 4.2 2.2 5.8 5.1 0.1 3.5 1.7 0.9 0.9 2.2 4.3 0.1 3.3 0.9 0.1 3.3 3.1 3.1 0.5 1.1

2.49% 1.1% 2.9% 2.9 5.1 2.3 4.8 25.5 14.7 1.3 5.4 2.2 8.4 6.1 13.9 4.0 2.6 6.2 7.4 9.4 0.2 0.0 10.8 4.0 4.2 10.2 5.6 5.0 1.2 4.3 7.3 21.8 1.0 0.2 2.8 6.8 16.3 0.9 3.2 9.6 1.4 6.1 3.5 4.1 1.9 4.5 4.2 14.2 3.0 4.2 7.0 3.4 0.4

Note: Jurisdiction refers to the legal authority of state or federal correctional officials over a prisoner, regardless of where the prisoner is held. Counts are based on prisoners of any sentence length under the jurisdiction of state or federal


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correctional officials. As of December 31, 2001, sentenced felons from the District of Columbia are the responsibility of the Federal Bureau of Prisons. Source: Bureau of Justice Statistics, National Prisoner Statistics Program, 2011–2012. a Includes inmates held in nonsecure, privately operated community corrections facilities and juveniles held in contract facilities. b Prisons and jails form one integrated system. Data include total jail and prison populations. c State did not submit 2012 National Prisoner Statistics (NPS) Program data, so population estimates for 2012 are imputed. See Methodology for discussion of imputation strategy. d Change in reporting methods. See National Prisoner Statistics Program jurisdiction notes.

Ethics Prisoners give up most of their autonomy. They do not choose their meals, clothing, housing, or location. In addition, they rely on others to provide any health-related service. They cannot seek out a doctor, dentist, or go to a local emergency department on their own. The Warden of their facility is their custodian. Ethics and moral considerations dictate that because offenders are not free to care for themselves, society must provide humane care, which includes care of acute and chronic illness as well as relief of pain and symptoms.

Socialization The number of releases from US prisons—State and Federal (not jails) in 2012 was 705,966 or 40.5% of those incarcerated (Table 5). In jails, an even higher rate are constantly being released. Health professionals and governmental officials have learned that the costs and consequences to the public are greater when needed health care is withheld.1 The goal of re-entry is reintegration into society. This includes reconnecting with family and friends and finding employment. The recidivism rate has remained high throughout the years. A 2002 study showed a re-arrest rate of 67.5% within 3 years and a 51.8% return-to-prison rate.5 It is believed that unaddressed medical needs hinder the process of re-entry and exacerbate the recidivism problem. Offenders released will spend their initial time out taking care of acute medical issues—certainly those that cause them pain. This may lead to a return to a former drug habit as well. The cost for these services once released would be shifted to governmental programs such as Medicaid and SSI. Providing for preventative and restorative care while incarcerated will in theory better prepare the individual to adapt to society and focus on the task at hand of finding employment and avoiding re-incarceration. The National Advisory Commission has concluded that medical care of offenders is of course a basic human necessity. It also contributes to the success of any correction process. Physical disabilities or abnormalities may contribute to an individual's socially deviant behavior or restrict his employment. In these cases, medical, dental, and mental health treatment is an integral part of the overall rehabilitative program.6

Public health As mentioned earlier, there is a large incidence of severe mental illness within the prison population. Approximately 75% of people with serious mental illnesses in the criminal justice system have a co-occurring substance abuse disorder.7 When you look independently at drug and alcohol abuse, it has been reported that as high as 80% of men and women incarcerated have had drugs and or alcohol implicated in their crimes.8 When one combines this with indigence, homelessness, and poor health care access of those who become incarcerated, one can fully comprehend why the rates of communicable diseases amongst the offenders is so high. In 2002, the National Commission on Correctional Health Care reported that 12–35% of the total number of people with certain communicable diseases in the nation passed through a correctional facility during that same year.9 Approximately 1.6% of the US population has

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Table 2 Prisoners held in the cursor of private prisons and local jails, December 31, 2011 and 2012. Inmates held in private prisonsa

Jurisdiction

2011

2012

Percentage of total Percent jurisdiction, change 2011–2012 2012

U.S. Total 130,972 137,220 4.8% Federalb 38,546 40,446 4.9 State 92,426 96,774 4.7% Alabama 545 538 1.3 Alaskac 1688 1733 2.7 Arizona 6457 6435 0.3 Arkansas 0 0 0.0 California 697 608 12.8 Colorado 4303 3939 8.5 Connecticutc 855 817 4.4 0 0 0.0 Delawarec Florida 11,827 11,701 1.1 Georgia 5615 7900 40.7 c Hawaii 1767 1636 7.4 Idaho 2332 2725 16.9 Iliinoisd 0 / / Indiana 2952 4251 44.0 Iowa 0 0 0.0 Kansas 74 83 12.2 Kentucky 2050 812 60.4 Louisiana 2951 2956 0.2 Maine 0 0 0.0 Maryland 78 27 65.4 Massachusetts 0 0 0.0 Michigan 0 0 0.0 Minnesota 0 0 0.0 Mississippi 4669 4334 7.2 Missouri 0 0 0.0 Montana 1418 1418 0.0 Nebraska 0 0 0.0 Nevadad 0 / / New 0 0 0.0 Hampshire New Jersey 2887 2717 5.9 New Mexico 2853 2999 5.1 New York 0 0 0.0 North 30 30 0.0 Carolina North Dakota 0 0 0.0 Ohio 3004 5343 77.9 Oklahoma 6026 6423 6.6 Oregon 0 0 0.0 Pennsylvania 1195 1219 2.0 Rhode lslandc 0 0 0.0 South 20 16 20.0 Carolina South Dakota 11 15 36.4 Tennessee 5147 5165 0.3 Texas 18,603 18617 0.1 Utah 0 0 0.0 Vermontc 522 504 3.4 Virginia 1569 1559 0.6 Washington 0 0 0.0 West Virginia 0 0 0.0 Wisconsin 36 18 50.0

8.7% 18.6 7.1% 1.7 30.8 16.1 0.0 0.5 19.3 4.7 0.0 11.5 14.2 28.1 34.1 / 14.7 0.0 0.9 3.7 7.4 0.0 0.1 0.0 0.0 0.0 19.4 0.0 39.3 0.0 / 0.0

Inmates held in local jails

2011

2012

Percentage of total Percent jurisdiction, change 2011–2012 2012

82,053 83,603 1.9% 1439 795 44.8 80,614 82,808 2.7% 2148 2382 10.9 0 0 0.0 0 0 0.0 883 584 33.9 57 0 100.0 116 134 15.5 0 0 0.0 0 0 0.0 1.267 1197 5.5 3100 4896 57.9 0 0 0.0 588 467 20.6 0 / / 1504 797 47.0 0 0 0.0 1 0 100.0 7190 8487 18.0 20,866 21,571 3.4 110 72 34.5 151 178 17.9 163 196 20.2 36 42 16.7 562 614 9.3 5996 6528 8.9 0 0 0.0 523 488 6.7 56 32 42.9 100 102 2.0 20 43 115.0 109 45.5 0 0.0 0 100.0 0 0.0

5.3% 0.4 6.1%: 7.3 0.0 0.0 4.0 0.0 0.7 0.0 0.0 1.2 8.8 0.0 5.8 / 2.8 00 0.0 38.4 53.7 3.4 0.8 1.7 0.1 6.2 29.2 0.0 13.5 0.7 0.8 1.5

11.7 44.6 0.0 0.1

200 0 14 0

0.5 0.0 0.0 0.0

0.0 10.5 25.5 0.0 2.4 0.0 0.1

55 0 2088 0 609 0 366

106 0 2373 0 489 0 374

92.7 0.0 13.6 0.0 19.7 0.0 2.2

7.0 0.0 9.4 0.0 1.0 0.0 1.7

0.4 18.2 11.2 0.0 24.8 4.2 0.0 0.0 0.1

73 8660 11,906 1529 0 7474 386 1677 149

64 8618 10,814 1574 0 7389 279 1735 70

12.3 0.5 9.2 2.9 0.0 1.1 27.7 3.5 53.0

1.8 30.3 6.5 22.6 0.0 19.9 1.6 24.5 0.3


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Table 2 (continued ) Inmates held in private prisonsa

Jurisdiction Wyoming

2011 245

2012 236

Percentage of Percent total change jurisdiction, 2011–2012 2012 3.7

10.7

Inmates held in local jails

2011

Percentage of Percent total change jurisdiction, 2011–2012 2012

2012 9

4

55.6

0.2

Note: As of December 31, 2001, sentenced felons from the District of Columbia are the responsibility of the federal Bureau of Prisons/not reported. Source: Bureau of Justice Statistics, National Prisoner Statistics Program, 2011, 2012. a Includes prisoners held in the jurisdiction's own private facilities, as well as private facilities in another state. b Includes federal prisoners held in nonsecure, privately operated facilities (8932), as well as prisoners on home confinement (2659). c Prisons and jails form one integrated system. Data include total jail and prison populations. d State did not submit 2012 National Prisoner Statistics (NPS) Program data. Local jail value for Nevada estimated based on 2011 data.

hepatitis C while studies have demonstrated that in some states (California, Virginia, Connecticut, Maryland, and Texas), there is an incidence of hepatitis C between 29% and 42%.10 Across the country, the incidence for those incarcerated is approximately 15–30%. The prevalence of hepatitis B infection ranges between 8% and 43% vs. 4.9% for the general population.11 HIV has been reported by the CDC to have an incidence of 1.9% of male inmates and 2.8% of female inmates—an approximately 4–7 fold increase over the general population.12 Tuberculosis—an airborne disease that will thrive amongst people who live in close quarters—is also significantly more common in the incarcerated population. About 12,000 people who had active TB during 1996 served time in a correctional facility during that year. More than 130,000 inmates tested positive for latent TB in 1997.13 This trend has continued over the years. Other communicable diseases, such as influenza and varicella, also present in the prison population as they would in the public at large. Failure to appropriately screen and treat contagious disease can lead to secondary complications of the disease including death. Additionally, staff and visitors are placed at risk for contracting certain diseases. Transmitting disease to families and friends after release is a major public health concern and risk to society at large.

Legal The US Legal system has had a significant impact on the trajectory that prisoner health care has taken over the years. In a landmark case in 1976, the US Supreme Court in Estelle vs. Gamble established that prison health care is guaranteed under the US Constitution. Failure to provide care would constitute cruel and unusual punishment prohibited by the Eighth Amendment to the Constitution. Thus prisoners became the only Americans with a constitutional right to health care. In that case, the Court established three basic rights for prisoners: (1) The right to access care. (2) The right to the care that is ordered. (3) The right to a professional medical judgment.

Violation of any of the above can lead to a claim of “Deliberate Indifference” to serious health care needs of the offender. This is the claim most often used against health care providers by prisoners, and it if it proceeds to trial, it is tried in Federal Court.

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Table 3 Sentenced state and federal prisoners released, by age, sex, race, and Hispanic origin, 2012. Male

Female

Totala

All malea,b

Whitec

Blackc

Hispanic

Otherb,c

All femalea,b

Whitec

Blackc

Hispanic

Otherb,c

Totald 18–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65 or older Number of released prisoners

100% 1.3% 14.0 19.0 17.6 13.3 12.0 10.3 6.9 3.2 1.4 0.9 637,411

100% 1.2% 14.2 19.0 17.5 13.2 11.8 10.2 7.0 3.3 1.5 1.0 568,556

100% 0.8% 12.0 17.5 16.6 12.8 13.0 11.6 8.2 3.8 1.8 1.5 181,841

100% 1.6% 15.1 18.5 17.0 12.3 11.4 10.5 7.4 3.7 1.5 0.7 208,415

100% 1.3% 15.5 21.4 19.3 14.5 11.0 8.1 4.9 2.2 1.0 0.7 130,107

100% 1.1% 14.4 20.6 18.0 14.6 11.2 9.3 6.1 2.5 1.2 0.8 48,193

100% 2.1% 12.6 19.1 18.2 14.5 13.1 10.7 6.0 2.2 0.9 0.4 68,855

100% 0.4% 10.9 19.5 18.8 14.9 13.9 11.4 6.2 2.3 1.0 0.5 33,758

100% 0.7% 10.7 16.7 17.4 14.3 14.1 13.6 8.2 2.7 1.0 0.4 15,934

100% 10.3% 20.6 20.2 15.7 13.6 9.6 5.7 2.2 0.8 0.4 0.1 11,038

100% 0.5% 12.1 20.7 20.3 14.4 12.8 9.3 5.6 2.4 0.8 0.3 8125

Note: Counts based on prisoners admitted to serve a sentence of more than 1 year under the jurisdiction of state or federal correctional officials. Excludes transfers, escapes, and those absent without leave (AWOL). Totals for all admissions include other conditional release violators, returns from appeal or bond, and other admissions. Missing data were imputed for Illinois and Nevada. See Methodology. Sources: Bureau of Justice Statistics, National Prisoner Statistics Program, 2012; Federal Justice Statistics Program, 2011–2012; National Corrections Reporting Program, 2011; and Survey of Inmates in State and Local Correctional Facilities, 2004. a Detail may not sum to total due to rounding, inmates age 17 years or younger, and missing race/Hispanic origin data. b Includes American Indians, Alaska Natives, Asians, Native Hawaiians, other Pacific Islanders, and persons identifying two or more races. c Excludes persons of Hispanic or Latino origin. d Includes persons aged 17 years or younger.


Age group


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Table 4 Imprisonment rate of sentenced state and federal prisoners per 100,000 U.S. residents, by sex, race, Hispanic origin, and age, December 31, 2012 Males Age group

Females

a b b a,b All femalea Whiteb Blackb Hispanic Othera,b Totala All male White Black Hispanic Other

Totalc 480 18–19 228 20–24 805 25–29 1113 30–34 1198 35–39 1060 40–44 902 45–49 722 50–54 539 55–59 326 60–64 193 65 or older 66

909 428 1426 2032 2213 1975 1682 1451 1031 636 386 146

463 148 654 998 1098 992 922 814 581 360 238 99

2841 1393 4284 6138 6932 6258 5148 4433 3219 2016 1144 423

1158 485 1226 2412 2594 2338 1986 1231 1352 983 687 280

972 417 1480 2245 2304 2042 1623 1458 1144 689 456 193

63 18 100 166 175 149 130 107 65 34 16 4

49 11 78 138 147 128 108 82 49 24 12 3

115 35 163 263 287 251 230 204 128 71 32 6

64 22 101 165 163 130 113 97 66 42 22 7

90 14 141 242 237 165 148 130 100 52 16 8

Note: Counts based on prisoners with sentences of more than 1 year under the jurisdiction of state or federal correctional officials. Imprisonment rate is the number of prisoners under state or federal jurisdiction with a sentence of more than 1 year per 100,000 U.S. residents of corresponding sex, age, and race/ethnicity. Resident population estimates are from the U.S. Census Bureau for January 1 of the following year. Illinois and Nevada did not submit 2012 data to the National Prisoner Statistics Program, so their jurisdiction counts are imputed. See Methodology. Sources: Bureau of Justice Statistics, National Prisoner Statistics Program, 2012; Federal Justice Statistics Program, 2012; National Corrections Reporting Program, 2011; and Survey of Inmates in State and Loral Correctional Facilities, 2004. a Includes American Indians, Alaska Natives, Asians, Native Hawaiians, other Pacific Islanders, and persons identifying two or more races. b Excludes persons of Hispanic or Latino origin. c Includes persons aged 17 years or younger.

In Carlson vs. Green 446 US 14 (1980), the US Supreme Court extended a prior ruling under Biven vs. Six Unknown Federal Narcotic Agents 403 US 388 that damages can be sought and recovered when there are Eighth Amendment violations by prison officials. In Farmer vs. Brennan 511 US 825, the US Supreme Court ruled that a prison official's “deliberate indifference” to a substantial risk of serious harm to an inmate violates the cruel and unusual punishment clause of the Eighth Amendment. This was to address the harms from prisoner rape. It extended to areas where any substantial medical risk exists that was known about but reasonable measures to address it were not taken. Recently in Brown vs. Plata No 09-1233, the US Supreme Court held that a Court-mandated population limit was necessary to remedy a violation of prisoners Eight Amendment Constitutional Rights. The California prison system was mandated to reduce its population to 137.5% of design. The violation of constitutional rights included the inability to provide adequate medical and mental health services to the overcrowded prison population. Finally in January 2014, a Federal Appeals Court upheld a district Court's decision in Massachusetts ordering transgender reassignment surgery to offender Kosilek who is serving a life sentence for murder. The Court stated that receiving “medically necessary” treatment is one of those rights a prisoner is entitled to even if the treatment “strikes some as odd or unorthodox.” To address prisoner health care needs in a constitutional manner, Correctional systems—both State and Federal have set up elaborate Health Care Systems for their population. They include the following: (1) Adequate access to health care for the offenders. Sick call—where inmates can notify providers about symptoms they are having, are triaged, and are seen within defined periods of time. It must be set up to handle emergent, urgent, and routine types of requests.

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Table 5 Admissions and releases of sentenced prisoners by jurisdiction, 2011 and 2012 Admission duringa

Releases duringb

2011 Total

2012 Total

Percent change, 2012 New court 2011–2012 commitmentsc

2012 Parole violationsc,d

2011 Total

2012 Total

Percent change, 2012 2011–2012 Unconditionalc,e

2012 Conditionalc,f

U.S. Total Federal State Alabama Alaskac,g,h Arizona Arkansas California Colorado Connecticutg Delawareg Florida Georgia Hawaiig Idaho Illinoisi Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusettsj Michigan Minnesota Mississippi Missouri Montana Nebraska Nevadai New Hampshire New Jersey New Mexico

671,551 60,634 610,917 11,387 3789 13,030 7059 96,669 9455 5881 3031 33,399 14,877 1366 3531 31,167 18,389 4709 4954 15,479 16,161 921 9811 2856 13,165 7214 8410 17,979 2063 2410 5545 1616 10,110 3491

609,781 55,938 553,843 11,203 3906 12,970 5782 34,294 9409 5659 3017 32,265 15,743 1524 4568 30,877 18,694 4877 5060 15399 17,325 846 9396 2635 13,888 7412 8559 18,216 2020 2761 5336 1696 9976 3580

9.2% 7.7 9.3 1.6 3.1 0.5 18.1 64.5 0.5 3.8 0.5 3.4 5.8 11.6 29.4 0.9 1.7 3.6 2.1 0.5 7.2 8.1 4.2 7.7 5.5 2,7 1.8 1.3 2.1 14.6 3.8 5.0 1.3 2.5

152,780 4696 148,084 1116 / 2394 1182 8017 4396 800 389 119 1794 670 262 10,807 3014 1114 1300 4137 5104 283 3534 250 4100 2677 2108 8465 501 459 930 813 2472 1355

691,072 55,239 635,833 11,052 3599 13,149 7252 109,467 936? 6379 3600 34,673 15,309 1404 4079 31,155 18,422 5105 4671 14,571 16,580 1049 9829 2484 14,374 7734 8197 17,823 2101 2391 5910 1881 11,485 3529

637,411 56,037 581,374 11,253 3774 13,000 6298 47,454 10,919 6014 4012 33,661 14,021 1631 4617 30408 18,555 5221 4795 16,215 17,404 1108 10,347 2871 13,199 7730 7725 17,957 2089 2688 5399 1555 10,817 3371

7.8% 1.4 8.6 1.8 4.9 1.1 13.2 56.6 16.6 5.7 11.4 2.9 8.4 16.2 13.2 3.4 0.7 2.3 2.7 11.3 3.2 5.6 5.3 15.6 8.2 0.1 5.8 0.8 0.6 12.4 8.6 17.3 5.8 4.5

408,186 591 407,595 7358 / 10,146 5940 17,756 9426 2634 3651 11,879 9388 654 3644 24,381 16,608 3810 3614 12,852 15,419 405 8974 574 9972 6666 6239 16,238 1789 1950 3374 1440 4618 2322

444,591 51,241 393,350 9201 / 10,469 4588 26,277 5009 4,711 2610 31,129 13,940 854 4306 19,881 15,377 3754 3701 11,262 12,197 563 5859 2385 7477 4735 6412 9748 1519 2162 4335 868 7504 2225

213,204 55,079 158,125 3740 / 2119 313 29,485 1315 3355 304 21,426 4510 315 958 5602 1888 1330 1159 3272 1511 703 1303 2266 961 1049 1370 1625 284 722 1989 98 6040 1034


Jurisdiction

Table 5 (continued ) Admission duringa

Jurisdiction

23,257 11,523 950 22,150 7456 5313 18,175 850 7323 2820 14,283 73,444 3258 2044 11,140 16,335 3404 6411 857

2012 Total 23,065 12,098 1160 21,529 7697 5376 18,492 868 6802 2918 13,922 75,378 3142 1912 11,727 18,232 3525 6200 907

Percent change, 2012 New court 2011–2012 commitmentsc 0.8 5.0 22.1 2.8 3.2 1.2 1.7 2.1 7.1 3.5 2.5 2.6 3.6 6.5 5.3 11.6 3.6 3.3 5.8

13,853 11,469 640 18,939 5235 3729 10,758 697 5205 1180 8577 50,071 1945 597 11.507 7622 1724 3774 770

2012 Parole violationsc,d 9158 629 520 2579 2462 1443 7259 170 1572 835 5337 24,331 1197 1315 220 10,605 1327 2426 137

2011 Total 24,460 11,878 1013 22,899 7694 4567 17,698 960 7912 2732 14,961 74,544 3206 2062 12,345 16,412 3257 7825 787

2012 Total 24,224 12,327 1069 21,628 6947 5023 18,805 967 7309 2812 15,955 82,130 3063 1963 11,568 18,181 3293 7724 878

Percent change, 2012 2011–2012 Unconditionalc,e 1.0 3.8 5.5 5.6 9.7 10.0 6.3 0.7 7.6 2.9 6.6 10.2 4.5 4.8 6.3 10.8 1.1 1.3 11.6

2696 8119 188 10,008 3884 17 3933 617 3160 399 4878 11,280 1262 306 1276 2285 1086 467 213

2012 Conditionalc,f 21,261 4132 874 11,478 2978 4745 14,702 346 4066 2402 10,997 66,820 1786 1655 10,168 15,848 1744 7213 659

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Note: As of December 31, 2001, sentenced felons from the District of Columbia are the responsibility of the Federal Bureau of Prisons/not reported. Source: Bureau of Justice Statistics, National Prisoner Statistics Program, 2011–2012. a Counts based on prisoners with a sentence of more than 1 year. Counts exclude transfers, escapes, and those absent without leave (AWOL). Totals include other conditional release violators, returns from appeal or bond), and other admissions. See Methodology. b Counts based on prisoners with a sentence of more than 1 year. Counts exclude transfers, escapes, and those absent without leave (AWOL). Totals Include deaths, releases to appeal or bond, and other releases. See Methodology. c Alaska did not report type of admission or release Total admissions and releases include Alaskan reported values, but state and national totals by type of admission and release do not. d Includes all conditional release violators returned to prison for either violations of conditions of release or for new crimes. e Includes releases to probation, supervised mandatory releases, and other unspecified conditional releases. f Includes expirations of sentence, commutations, and other unconditional releases. g Prisons and jails form one integrated system. Data include total jail and prison populations. h State updated 2011 admission and release totals. i State did not report 2012 NPS data. Total number of admissions and releases imputed, and types of admission and release based on 2011 distribution, See Methodology. j Changes made in the legislature to reduce discretionary paroles in 2011 are reflected in a higher parole rate in 2012.


New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Islandg South Carolina South Dakota Tennessee Texas Utah Vermontg Virginia Washington West Virginia Wisconsin Wyoming

2011 Total

Releases duringb

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(2) Personnel ratios that adequately cover the health care needs of each facility. (3) Maintenance of Health Records. (4) Continuing Quality Assessment Programs for ongoing monitoring and evaluation of the adequacy/appropriateness of the care provided. Some States have required accreditation, which can be obtained through one of three ways for health care. The National Commission of Correctional Health Care (NCCHC) focuses exclusively on health care delivery. The American Correctional Association (ACA) offers accreditation to the entire operation of the facility but has standards for health care services as well. Occasionally the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) now known as The Joint Commission (TJC) accredits health care services at Correctional institutions.

Litigation and legal decisions have caused and continue to cause reform of health care practices and inmate services in jails and prisons. Increased demands on States where resources have become more scarce is certainly straining the system. Major litigation against States often cause diversion of needed funds. Prisons and jails are continuously challenged with finding more cost-efficient methods to care for their population. Tele-medicine and use of designated centers for acute and specialized care are a couple of methods that allow for pooling of resources and are beginning to show dividends. Careful management of pharmaceuticals and active utilization of management programs are also critical. Working with State legislators and other governmental officials to seek out innovations and acceptable options to care for the correctional population is crucial. This is especially true in dealing with specific Prisoner subgroups—those with severe dementia, those who are incapacitated, and those who have a terminal disease. They present an enormous manpower and cost strain on Correctional systems and if they present no danger to the public at large, alternative care outside of corrections is likely a better option.

Chronic disease in the prison population The National Health Interview Survey conducts studies to determine the incidence of chronic disease in the general population. Unfortunately, offenders, as some other groups—the military, institutionalized individuals, and nursing home residents—are not included in these surveys. Therefore, getting an accurate assessment of the burden of chronic disease amongst prisoners is a bit of a challenge. The Bureau of Justice Statistics does include some health-related questions in their national surveys of jails and prison inmates. In addition, there have been some researchers in public health who have done independent surveys. Most prisons across the country set up their medical care with a chronic clinic care system to track those offenders with chronic disease and monitor their progress while incarcerated. They are seen at defined intervals throughout the year. In the Illinois Department of Corrections, the clinics are Hypertension/Cardiac, Asthma/Pulmonary, Diabetes, and Seizure Clinic. Offenders enrolled in these clinics are seen every 4 months at a minimum. In addition, offenders with HIV are seen in the tele-medicine clinic every 3 months. With the increased stability of these patients, we are considering extending the interval to 4 months in line with the other clinics. Offenders with Hepatitis C are seen every 6 months unless they are in treatment where they follow the treatment protocol schedules. Finally, there is a General Medical Clinic to cover the spectrum of other illnesses for which chronic monitoring is necessary. They include such illnesses as thyroid disease, rheumatoid arthritis, inflammatory bowel disease, malignancies, etc. These offenders are generally seen every 6 months and often their care is coordinated with offsite specialty consultants. As mentioned earlier, the prison population age is a relatively young one. Despite that, there is a high incidence of reported chronic disease. Wilper et al.14 have reported that in Federal prisoners, 39% reported having a chronic disease, in State prisoner 43%, and in local jails 39%. In comparison, the CDC reports that in 2005, 133 million Americans, approximately 45%, had at


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least one chronic illness. In addition 7 of every 10 deaths among Americans each year are from chronic diseases. Heart disease, cancer, and CVAs account for greater than 50% of death each year. Broken down further, about 80% of older Americans (those 65 years and older) have one chronic condition, and 50% have at least two. In middle-aged Americans (45–65 years), the percentage with a chronic illness is significantly less—just above 20%.15 Looking at more specific disease states, we find that in prisons approximately 25% have hypertension, 14% have asthma, 1.9% have HIV, 15–40% have hepatitis C, and approximately 2.5% have seizure disorder.16,17 Reports of the incidence of diabetes vary from less than the general population (4.2% reported in Texas) to comparable to the general population of 8.3%, to reports of approximately 11.1% reported in Federal prisoners.18 Overall cancer incidence at any given time is approximately 3.1%.19 It is beyond the scope of this issue to go through all the specific cancers. In the population at large, the following prevalence rates are reported—hypertension: 31% overall, levels vary significantly by age (20–34 year-old men, 11.1%; 35–44-year-old men, 25.15%); asthma: 8.2%; HIV: 0.3%; hepatitis C: 1.6%; seizures: 0.6%; diabetes: 8.3%; and cancer: 4.3%.20 In the study by Binswanger,16 she concluded that jail and prison inmates have a disproportionate burden of many chronic medical illnesses compared to the general population, including hypertension, asthma, arthritis, cervical cancer, and hepatitis. She found no difference in diabetes. Others have shown that seizure disorder and HIV also disproportionately affect people incarcerated and that cardiovascular disease (MI and angina, CVA) occurs less in the incarcerated population.19 Hepatocellular cancer is also significantly greater amongst prisoners, given the epidemic levels of Hepatitis C and secondary cirrhosis. The means to have a reliable program to care for offender medical needs starts with effective screening of all inmates entering prison. The screening is for communicable disease, chronic disease, targeted cancers, and mental health, followed by appropriate referral to chronic care clinics and monitoring. in the following pages, you will find the IDOC intake screening forms as well as chronic disease management forms from the National Commission for Correctional Health Care (Figs. 1–4).

Comprehensive care Prison providers also address the acute medical problems that arise during incarceration whether they be fever, rash, diarrhea, flu symptoms, pains, injuries, etc. This is accomplished through a sick call system. The most important part of this system is access. Daily access to providers by submission and collection of sick call requests is critical. Nurses triage these requests on a daily basis and can deal with the vast majority of them via detailed nursing protocols that include clear directions as when to get the physicians involved. The system needs to also include the ability to deal with emergent and urgent situations and the ability to transport offenders securely to outside hospitals when necessary. Most State prison facilities have infirmaries on site. They have 24-hour nursing coverage and allow for a higher level of care such as treatment for an acute asthmatic attack, IV fluids, parenteral antibiotics, parenteral pain medication, and the ability to monitor/observe prisoners who present with potentially serious conditions. Cardiac monitoring is rarely undertaken. Prisons struggle to bring specialty consultants on site. This cuts down on security expenses when taking a prisoner off grounds—which usually requires two correctional officers. In addition, prison and State officials are always keenly aware of the increased security risk to the public when an offender goes off site. Consultants/Services that are done on site are general dentistry, often radiology (plain films), optometry, physical therapy, and gynecology. Occasionally, general surgeons, podiatrists, and orthopedists come on site as well. It is more rare for other specialists to do their consults at the facilities. As pharmaceutical options continue to expand and prices rise, States, Counties, and Federal systems struggle to keep costs down without compromising care. Formularies are scrupulously

182


Fig. 1.


Fig. 2a.

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Fig. 2b.


Fig. 3a.

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186


Fig. 3b.


Fig. 3c.

187

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Fig. 3d.


Fig. 3e.

189

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Fig. 4a.


Fig. 4b.

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Table 6 2008 Definitions of disease control and clinical status Good control

Fair controla

Poor controla

Improved status

Cardiac/HTNc HTN þ Diabetesc,d

Systolic o140 mmHg Diastolic o90 mmHg Systolic o130 mmHg Diastolic o80 mmHg

Systolic 140–160 mmHg Diastolic 90–100 mmHg Systolic 130–150 mmHg Diastolic 80–95 mmHg

Systolic 4160 mmHg Diastolic 4100 mmHg Systolic 4150 mmHg Diastolic 495 mmHg

Blood pressure reading is Blood pressure, weight, and/or baseline lower than at the laboratory values have previous CIC visit not changed since the previous CIC

Dyslipidemiac

LDLC at goal

HbAlC ¼ 7% or less

Based on Coronary Equivalents AND Risk FactorsSee Table on “Assignment of Risk Status in Relation to Medication Treatment Initiation and Definition of Good Control”e HbAlC ¼ 9.1% or higher

Lipid levels have improved or reached goal level since the previous CIC visit

Diabetesc

Based on Coronary Equivalents AND Risk Factors See Table on “Assignment of Risk Status in Relation to Medication Treatment Initiation and Definition of Good Control”e HbAlC ¼ 7.1–9.0%

HIV Infectionc,f,g (on ART 4 90 days)

HIV viral load is undetectable CD4 is rising

HIV viral load is o 5000 copies CD4 is unchanged

Weight is 4 90% of ideal body weight No active OI’s or malignancies Patient is asymptomatic

Weight is 4 85% of ideal body weight No active OI’s or malignancies Patient is asymptomatic

HIV viral load is o50,0000 copies

HIV viral load is o100,0000 copies

HIV viral load is 4 5000 copies CD4 is o50 or declining Weight is o 85% of ideal body weight New active OI’s or malignancies Patient is symptomatic (wasting, thrush, unexplained fever for 4 2 weeks) HIV viral load is o100,000 copies

HIV Infectionc,f,g (not on ART o 90 days)

Unchanged status

Lipid levels have not changed since the previous CIC visit

Worsened statusb An increase in blood pressure, weight, baseline laboratory values; nondherence to treatment plan; or development of more acute symptoms Lipid levels have worsened or nonadherence with the treatment plan

Increase in HbAlC or the HbAlC and the average of Reduction in HbAlC or average of finger stick finger-stick levels are the the average of fingerlevels; or for type same as previousaly stick levels; or for type 2 diabetes, a weight recorded, and the weight 2 diabetes, intenational gain of 5% or more is relatively unchanged weight loss of 5% or more due to diet and excercise Clinical status and Clinical status and Clinical status and adherence has adherence has not adherence has worsened since the changed since the improved since the previous CIC visit previous CIC visit previous CIC visit

Clinical status and adherence has improved since the previous CIC visit

Clinical status and adherence has not changed since the previous CIC visit

Clinical status and adherence has worsened since the previous CIC visit


Clinic

Table 6 (continued )

Seizurec

CD4 count is o200 mm3 Weight is o85% of ideal body weight New active OI’s or malignancies o1 beta-agonist MDI refill per month 42 on-site ER visit for asthma in past month No nighttime awakening o2 weekly nighttime 42 weekly nighttime with asthma symptoms awakening with awakening with asthma symptoms asthma symptoms No seizure activity since One seizure activity since More than one seizure previous CIC visit previous CIC visit activity since previous CIC visit

Less use of beta-agonist Both the use of betaMDIs and less frequent agonist and frequency of symptom presentation symptoms are unchanged

Number of seizures has diminished since previous CIC visit

Greater use of betaagonist, more acute sympotoms, or an increase in emergency department visits

Number of seizures has Number of seizure has increased since remained the same since previous CIC visit previous CIC visit

To be assessed in Good disease control, the patients must meet ALL criteria with in the given disease category. For example, a hypertensive patient with a blood pressure of 132/84 should be assessed as Good disease control. If a patient does not meet all criteria, the clinician should select the category of lowest disease. For example, if a pulmonary patients has required only 1 beta-agonist MDI refill and has had no visits to the on-site ER, but has had 5 weekly nighttime awakenings with asthma symptoms, the clinician should asses this as Poor disease control. An HIV patient on ART who has an undetectable viral load but is at 85% of ideal body weight should be assessed as Fair disease control. a For patients determined to be Fair or Poor disease control, the clinician (MD, DO, NP, PA) must document treatment plans for getting the patient’s condition under GOOD control. b For patients whose disease status since the last CIC has WORSENED, the clinician (MD, DO, NP, PA) must document treatment strategies in an attempt to improve patients status. c National Commission on Correctional Health Care. Recommended Correctional Clinical Guideline on Diabetes Chronic Care. Journal of Correctional Health Care (Fall 2001), Vol. 8, Issue 2, pp. 97–156. d American Diabetes Association. Standards of Medical Care for Patients With Diabetes Mellitus. Diabetes Care (January 2002), Vol. 25, Suppl. 1, pp. S33–S89. e NCCHC’s clinical guideline for the treatment of high blood cholestrol. f Centers for Disease Control and Prevention. Guidelines for Using Antiretroviral Agents Among HIV-infected Adults and Adolescents. MMWR (May 17, 2002), Vol. 51, No. RR-7. g American Medical Association. Consensus Statement; Antiretroviral Recommendations of the International AIDS Society-USA Panel. JAMA (July 10, 2002), Vol 288, No. 2, pp. 222–235.


Pulmonaryc

CD4 count is 4 350 mm3 CD4 count is 200–350 mm3 Weight is 4 90% of ideal Weight is 4 85% of ideal body weight body weight No active OI’s or No active OI’s or malignancies malignancies o1 beta-agonist MDI o1 beta-agonist MDI refill per month refill per month No visits to on-site ER o2 on-site ER visit for asthma in past month

193

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maintained with non-formulary requests requiring prior authorization. Generic medication is preferred, and cheaper non-combination formulations will be chosen even if the pill burden may be higher when there are significant cost-savings. At times, halving scored medication is less expensive than having the lower-dose whole-pill ordered. New medications that become FDA approved need to show evidence-based improved outcomes before they are added to the Formularies. The newer Biologicals for treating auto-immune diseases and malignancies are emerging to be quite challenging financially. The same is true regarding the treatment of hepatitis C and mental illness. Prisoners essentially live in their own communities, apart from the general population. They rely on others to provide all of life's basic necessities of which health care is certainly a substantial part. Is the health care provided effective? In a study by Dr. Anne Spaulding that looked at prisoner mortality both inside and outside the institutions in the State of Georgia, she found the following: Mortality during incarceration was low, with standardized mortality ratios (SMRs) of 0.85, 95% CI. Post-release mortality was high, with an SMR of 1.54, 95% CI. African-American men were the only demographic group to have significant lower mortality while incarcerated, with SMR of 0.66, 95% CI. White men experienced elevated mortality while incarcerated, with SMR of 1.28, 95% CI. Homicide, vehicular accidents, accidental poisonings or ODs, and suicides accounted for 74% of the decreased mortality during incarceration. HIV, cancer, cirrhosis, homicide, vehicular accidents, and accidental poisoning accounted for 62% of the excess mortality following release.21

It appears that prisons do have a positive health impact on the lives of prisoners by offering protection and by treatment of illness. Exactly how well correctional health care providers do in managing long-term illness and preventative health care needs further study. Certainly releasing prisoners into an environment where they will be completely self-reliant for health care does not seem to be effective and may ultimately have a significant impact on the over 50% reported recidivism rates. The recently passed Affordable Care Act may translate into getting more prisoners signed up for insurance either through Medicaid or through the Exchanges and allow for a smoother transition for continued health care postrelease. Time will tell (Table 6). References 1. Bureau of Justice Statistics. National Prisoner Statistics Program. Trends in admissions and releases 1991–2012. 〈http://www.bjs.gov〉. 2. Bureau of Justice Statistics. National Prisoner Statistics. 〈http://www.bjs.gov/index.cfm?ty=pbdetail&lid=915〉. 3. Education levels—inmate admissions, 2009–2010 agency statistics. 〈http://www.dc.state.fl.us/pub/annual0910,stats/ 1a_grade_level_html〉. 4. American Correctional Association: Government and Public Affairs. 〈http://www.aca.org/government/healthcare. asp〉. 5. Langam Patrick A, Levin David J. (June 2, 2002) Recidivism of prisoners released in 1994. 〈http://bjs.ojp.usdoj.gov/ content/pub/pdf/rpr94.pdfBJS〉. 6. United States. National Advisory Commission on Criminal Justice Standards and Goals—National Institute of Law Enforcement and Criminal Justice (1973:37). 7. The Presidents New Freedom Commission on Mental Health; 2004 (Goal 2 p. 43). 8. BJS—Special report—Drug use and dependence, state and federal prisons, 2004 October 2006 NCJ 213530. New Freedom Commission on mental health; 2004. 9. The National Commission on Correctional Health Care. Health care of soon to be released inmates; March 2002. 10. Hammett TM. HIV/AIDS and other infectious diseases among correctional inmates: transmission, burden and an appropriate response. Am J Public Health. 2006. 〈ncbi.nlm.nih.gov〉. 11. Khan Amy J, et al. Ongoing transmission of hepatitis B virus infection among inmates at a state correctional facility. Am J Public Health. 2005;95(10):1793–1799. 〈ncbi.nlm.nih.gov〉. 12. Maruschak L.M. HIV in prisons, 2001–2010. BJS 〈http://wwwbjs.gov/index.cfm?ty=pbdetail&iid=4452〉. 13. MacNeil Jessica R. Jails, a neglected opportunity for tuberculosis prevention. Am J Prev Med. 2005;28(2):225–228.


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14. Wilper AP, et al. The health and care of US prisoners: results of a nationwide survey. Am J Public Health. 2009;99: 666–672. 15. Kung HC, et al. Deaths: final data for 2005. Natl Vital Stat Rep. 2008;56(10). 〈http://www.cdc.gov/nchs/data/nvsr/ nvsr56/nvsr5610.pdf〉. 16. Binswanger Ingrid A. Chronic medical diseases among jail and prison inmates Society of correctional medicine. 〈http://www.societyofcorrectionalphysicians.org/corrdocs/corrdocs-archives/winter-2010〉; March 2010. 17. King Lambert N, et al. Epilepsy in prison. J Am Acad Neurol. 1984;34(6):775. 18. Harzke Amy J. Prevalence of chronic medical conditions among inmates in the Texas prison system. J Urban Health. 2010;87(3):486–503. 〈http://www.ncbi.nlm.gov/pmc/articles/PMC2871081〉. 19. Binswanger Ingrid A, et al. Prevalence of chronic medical conditions among jail and prison inmates in the USA compared with the general population. J Epidemiol Community Health. 2009;63(11):912–919. 20. Center for managing chronic disease—putting people at the Center of Solutions University of Michigan. 〈http://www. cmcd.sph.umich.edu/statistics.html〉; 2011. 21. Spaulding Anne C, et al. Prisoner survival inside and outside of the institution: implication for health care planning. Am J Epidemiol. 2011;173(5):479–487.

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