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Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
00;00;00;04 - 00;00;32;20
Alan Weil
Hello and welcome to “A Health Podyssey”. I'm your host, Alan Weil. There are approximately 3000 jails in the United States and millions of Americans cycle through those jails every year. Jails are where people serve short sentences, but most are there detained, awaiting trial, often because they can't afford to post bail. People in jail face many health barriers. They often arrive with significant medical conditions.
00;00;32;20 - 00;01;01;01
Alan Weil
They have difficulty obtaining treatment when they're in jail and they're often released back into the community with limited guidance on how to care for themselves or to receive the care they need. And we've learned that deaths of people in jail have increased over the past couple of decades, even before the COVID pandemic took hold. What do we know about deaths in jail and more particularly, how death rates vary across jail characteristics?
00;01;01;08 - 00;01;29;18
Alan Weil
That's the topic of today's episode of “A Health Podyssey”. I'm here with Jessica Adler, associate professor in the Department of History at Florida International University. Dr. Adler and Weiwei Chen were coauthors of a paper in the June 2023 issue of Health Affairs, examining the relationship between jail conditions and characteristics and death rates. They found an association between certain conditions and these mortality rates.
00;01;29;18 - 00;01;35;13
Alan Weil
We'll discuss those findings in today's episode. Dr. Adler, welcome to the program.
00;01;35;15 - 00;01;37;01
Jessica Adler
Thanks for having me.
00;01;37;04 - 00;02;01;13
Alan Weil
This is a really important topic and one that if you haven't looked into before, there's sort of some basic terminology and understanding that's probably helpful to make sense of your findings. So I think we should probably begin by setting the stage. Who is in jail? Why are they there? How long are they there? Just give us some of the basic sense of what population it is that you studied in this paper.
00;02;01;18 - 00;02;25;07
Jessica Adler
Okay. So this is a great place to start. And as you suggested, each strand of this question is actually more complex than it might seem. So I'm going to take the first part of the question about who is in jails in terms of raw numbers. There were about 10 million admissions to more than 3000 jails in 2019, which was the final year of our study.
00;02;25;10 - 00;02;50;04
Jessica Adler
A recent report on people in jails indicates that the majority of people, about 52%, are between the ages of 18 and 34, 8% are 65 or older. The great majority of people in jails, around 70%, are un-convicted. They're awaiting trial. Certain populations we know face a heightened risk of being jailed and of being detained while awaiting trial.
00;02;50;04 - 00;03;29;13
Jessica Adler
So those are two separate things, of course. So studies show that those who are incarcerated in jails are significantly poorer, economically poorer than people on the outside. And as of 2019, black people were jailed at a rate more than three times higher than whites. And black and Hispanic people were disproportionately likely to face pretrial detention. In terms of that that issue of pretrial detention, I think it's worth noting here that more than 30% of people who are jailed and un-convicted remain incarcerated because they can't afford to pay their bail. Between 2008 and 2019, according to the Bureau of Justice Statistics,
00;03;29;14 - 00;03;54;13
Jessica Adler
I want to just talk a little bit about women in jails because they're population increased by 11% in those years. A very recent report from the Sentencing Project shows that racial and ethnic disparities that I discussed in the overall jail population just now also exist even more pronounced among incarcerated women. So black and Latinx women are much more likely to be detained than white women.
00;03;54;16 - 00;04;17;08
Jessica Adler
So that's just some basic information about demographics and conviction status. But just briefly to mention that another way to think about who is in jails relates to the agency that is overseeing their incarceration. Now, so here this gives us an opportunity to think pretty broadly about systems of incarceration in the U.S. States, we know, have their own prison systems.
00;04;17;11 - 00;04;50;21
Jessica Adler
Also, federal agencies like the Bureau of Prisons, the U.S. Marshal Service, Immigration and Customs Enforcement, or ICE, have systems for detaining people. Now, these are really complex arrangements. They vary by agency, by locale, but generally, when we think about who's in jails, we have to consider that some are being held for federal agencies. Now, the last thing I'll say about this sort of bureaucratic diversity of the jail population is just that I bring it up here to underscore that incarceration in the United States is massive.
00;04;50;22 - 00;05;09;25
Jessica Adler
This is a massive system and it's also really messy and really convoluted. And even though we tend to think about jails and prisons and ICE facilities as separate, we have to see that different carceral systems are actually really entangled. So that's just a few ways to think about who is in jail.
00;05;09;27 - 00;05;36;21
Alan Weil
Let me turn to the health dimension of what you've just described about who is in jail, because on the one hand, you describe some characteristics of significant vulnerability, low income, disproportionately black people and people of Hispanic origin. You these are we know that these are correlated with some poor health outcomes. At the same time, you mentioned that it's a it's a young population.
00;05;36;21 - 00;06;03;11
Alan Weil
And when we think generally about health care, you think of people in those aged categories as having fewer health conditions and health barriers than people as they get older. So if we're trying to look at health outcomes and of course the mortality that you study, how should we think about the vulnerabilities that people in jail have relative to the population as a whole?
00;06;03;13 - 00;06;29;08
Jessica Adler
So there are no shortage of health vulnerabilities that people in jails face. Some of those are from the jail side and the services side, and some are from the side of just their personal health status. So when we think about the jail population, we have to think about the fact that people in jails are just generally much less healthy than people in the free world.
00;06;29;10 - 00;06;59;25
Jessica Adler
And breaking that down, we can think in terms of physical conditions, infectious disease, drug dependance, mental health. As of at least the last data we really have on this is from 2011, 2012, when 40% of people in jails reported having a chronic noninfectious medical condition and 45% reported ever having had one. And that's a hugely disproportionate amount based on what the general population is, which is about 27% of people who are who are not jailed report ever having had a chronic condition.
00;06;59;26 - 00;07;27;12
Jessica Adler
So we're talking about things like hypertension, asthma, arthritis, diabetes. Then when we look into infectious diseases, the same is true. Tuberculosis, hepatitis B and C, STDs like HIV/AIDS, all much more common among people in jails. The same with drug dependance. One report that that focused on data from 2007 to 2009 showed that more than 60% of people serving a jail sentence met the criteria for drug dependance or abuse.
00;07;27;14 - 00;07;43;10
Jessica Adler
And then the last category of stuff we need to think about has to do with mental health conditions, which again follows that same trend. Nearly half of all people in jails report that a mental health professional has told them that they have or had a mental disorder.
00;07;43;12 - 00;08;18;16
Alan Weil
So despite the relative youth, it sounds like the risk factors are profound. And that means that this is very, from a health perspective, this very vulnerable population when they come in and it sounds like, given the prevalence of chronic conditions, one of the key questions is whether people are getting those chronic conditions managed when they come in to jail because they can quickly deteriorate and turn into very serious acute problems that can have lasting implications, including death.
00;08;18;19 - 00;08;43;12
Alan Weil
So I want to return to sort of the health system question. But let's get out on the table the primary findings of your study, because I think in some ways it'll be more interesting to think about health care delivery in the context of those findings. Can we spend a minute just getting a sense of how common deaths are in jail and what the causes are?
00;08;43;15 - 00;08;47;23
Alan Weil
And we can begin talking about sort of the findings from your paper.
00;08;47;25 - 00;09;14;23
Jessica Adler
As I mentioned, we looked at the year 2008 to 2019, and we know from the Bureau of Justice Statistics that between 2000 and 2019, mortality rate increased by 11% in jails. And that's, of course, what drew us to this period of time. And when we talk about commonality of deaths, of course, we need to think about the problems with comparing overall jail mortality with death rates in broader society.
00;09;14;24 - 00;09;41;27
Jessica Adler
Of course, some common causes of death like car accidents, are not going to occur in jails. But even correcting for that sort of factor, we know that that jail mortality is higher than prison mortality and that even though reported in jail, mortality is lower than that of the adjusted general population. Life expectancy is reduced overall for those who are exposed to incarceration at all.
00;09;41;29 - 00;10;09;26
Jessica Adler
In 2019, there were about 1200 deaths in local jails and that was about a 167 deaths per 100,000 people who were jailed. So that's again an increase of about 11% since 2000. Suicide is the leading cause of death in jails by far, represents about 49 per 100,000 fatalities. Drug and alcohol deaths were also the highest they'd ever been.
00;10;09;26 - 00;10;28;04
Jessica Adler
In 2019, it was about 184 deaths per 100,000 people. And that was again, a quintupling of drug and alcohol related deaths since 2000. So huge increases in this period. So I can go into now what we looked at in our study.
00;10;28;06 - 00;10;29;29
Alan Weil
Yes, please do.
00;10;30;01 - 00;10;56;28
Jessica Adler
Okay. So we looked at mortality rates and jail conditions in approximately 450 U.S. jails between 2008 and 2019. And our most robust findings had to do with turnover rates and the demographics of populations. So what we found was that high turnover rates and this is a term that indicates the numbers of people cycling in and out of a jail in a week.
00;10;57;01 - 00;11;24;20
Jessica Adler
High turnover rates were associated with higher death rates overall, as well as higher deaths due to suicide, drugs and alcohol, and homicide. So the only cause of death that wasn't significantly impacted, according to our study by turnover was illness. The second most robust finding has to do with the presence of greater proportions of non-Hispanic black people in jail populations, which too was associated with more deaths due specifically to illness.
00;11;24;22 - 00;11;51;14
Jessica Adler
So to us, these findings suggest that it's a heavy reliance on incarceration and the prevalence of free world health disparities, you know, just wide ranging health disparities that help to shape mortality risks inside of jails. You know, we tend to think about jails as these kind of standalone entities. But our findings are encouraging researchers to think about broader contexts.
00;11;51;16 - 00;11;54;06
Jessica Adler
And I think that's important to consider.
00;11;54;10 - 00;12;41;18
Alan Weil
Yeah. So I actually want to get into sort of how you map those differences in mortality rates with some of the characteristics that we talked about. We'll dive into some of those questions after we take a short break. And we're back. I'm speaking with Dr. Jessica Adler about jail conditions and mortality. What I was hoping we could do in the next portion of our conversation is to map a little bit those characteristics onto some of the risk factors that we were discussing earlier.
00;12;41;18 - 00;13;07;26
Alan Weil
So the notion that someone who dies in jail, it's a combination of a few things. It's a combination of the risks they brought into the jail and the treatment or lack thereof they received in the jail. They could be there for a very short time, but for some of the conditions you discussed, a very short time can be ample time for a condition to get much worse.
00;13;07;26 - 00;13;28;14
Alan Weil
Or, as you note, with suicide as the top cause of death to change someone's attitudes towards life. So I wonder if you could say maybe to introduce a subject we talked earlier a lot about the characteristics of people coming in. What is the availability of health care services when people are inside the jail?
00;13;28;16 - 00;13;56;04
Jessica Adler
Yeah, this is a really important question with, again, a very convoluted possible answer because there is again, tremendous variability across the 3000 facilities throughout the country. So we do have a 2018 report from the Pew Charitable Trusts as very helpful in this respect. And what they point out is that at the time of the report, around 80% of jails contracted out services to some private company in some way.
00;13;56;04 - 00;14;21;20
Jessica Adler
That doesn't mean all health services were under the oversight of a private company, but at least some. The payment models, the contracts vary tremendously across these relationships between the jails and the private companies. This Pew report also points out that that even within one state, there are tremendous differences between what jails spend on medical care, the resources that they devote to medical care.
00;14;21;20 - 00;14;43;09
Jessica Adler
So the example that they provide is that in Virginia, jails spent between two and a half and 33% of their budgets on health care. In terms of on the ground realities, though, this Pew report is really helpful. They talk about the fact that many jails lack medical staff during some intake hours, which of course, leads to delays in diagnosis and treatment.
00;14;43;11 - 00;15;12;05
Jessica Adler
And of course, suggests that even basic medical care is missing, let alone things like access to a specialist, access to something like drug or alcohol treatments, prescription drugs, etc.. And, you know, I just want to point out that when we think about this problem, we cannot rely solely on peer reviewed literature. I mean, we have to we have to open our eyes and see that there is no shortage of news reports, lawsuits, every single day that talk about the consequences of these conditions.
00;15;12;08 - 00;15;23;18
Jessica Adler
The results of these conditions are very real. And I hope that we can remember that some of the numbers in the data that we're talking about are people and actual stories that involve sons, daughters, brothers, mothers, etc..
00;15;23;20 - 00;15;54;12
Alan Weil
When I read your paper and I listen to how you discuss it, I see two distinct but related elements that point to these differences we see in mortality rates. One has to do with the care inside the facility and the potential interruptions or lack of availability that can lead to a horrible outcome.
00;15;54;14 - 00;16;17;25
Alan Weil
The other is who's coming in the door in the first place, how many people are coming in and the vulnerabilities they face when they enter, which can't be addressed by spending another giving them an extra doctor's visit. So I wonder if in thinking about the implications of the paper, you could sort of help me with both of those.
00;16;17;25 - 00;16;28;29
Alan Weil
How does it what does it lead you to think about in terms of care inside? And what does it lead you to think about in terms of the characteristics of people and the numbers of people coming in the door?
00;16;28;29 - 00;16;52;28
Jessica Adler
I think this question gets at the important idea that that people are coming in to jails, like you said, sometimes for a very short period, and their broader health and social status really need to be considered when we think about jail based health outcomes and mortality. So this is not to say or suggest that jail administrators or jail staff have no role to play.
00;16;52;28 - 00;17;21;18
Jessica Adler
Like you said, the jail health care system has a role to play in keeping people safe. But it is to say that broader contexts matter. So, in our paper, we cite a 2022 study from Cain and Ellison that examined some of the connections that you're talking about here and this broader possibility that jail incarceration may actually be more dangerous for some people than others, particularly dangerous for some people.
00;17;21;20 - 00;17;50;05
Jessica Adler
They evaluate how individuals health and social status could impact jail based suicide mortality risk just in one jail. And they find that people who are homeless, who were incarcerated for the first time, people who were in psychological distress, and people who had substance dependance were more likely than others to threaten or attempt suicide or self-harm. And so there we have only one cause of death being examined, only one facility.
00;17;50;08 - 00;18;12;20
Jessica Adler
But we have a suggestion of exactly what you're implying, which is that we cannot just look at only jail conditions, only jail health care, or for that matter only pre incarceration status. We have to look at all these things in concert and try to figure out really the existential question is whether jails are the best places for some of the people who are ending up there.
00;18;12;27 - 00;18;36;02
Alan Weil
Well, I think it's really important that you help build out that dimension of the discussion. So one way to read the paper is death rates vary by jail characteristics, and we ought to look at the characteristics of jails that have lower death rates and maybe try to make jails more like that. And I suppose numerically, that's a reasonable approach.
00;18;36;05 - 00;19;00;22
Alan Weil
But you're describing something quite different, which is thinking of arrival at jail as a health risk factor. If from a public health perspective, asking the question, is it safe to expose a vulnerable population to this risk factor, you use the example of suicide. You said it's one facility, it's one cause of death, but it's the leading cause of death inside jails.
00;19;00;22 - 00;19;40;20
Alan Weil
So it's not as exactly as if you've taken some marginal issue. And it does seem that if you're looking at this purely from a health perspective, not a criminal justice perspective, you would be right to ask the question, is it appropriate to expose this vulnerable population to something that we know can lead to very poor health outcomes? And if not, I mean, obviously there's a reason people are there, but if there is an undue risk associated with that, are there alternative approaches that could achieve the reasons why they're there that don't create those kinds of health risks?
00;19;40;20 - 00;19;51;06
Alan Weil
And I hope that that opens up a whole other way of thinking about the findings of this paper that that I'm glad you brought into the conversation.
00;19;51;09 - 00;20;15;24
Jessica Adler
Yeah, thank you. I mean, that's where we end up in our conclusion is just that, you know, we realize that revelations about inhumane conditions and overcrowding in jails, which, by the way, overcrowding we did examine and there showed there was no significant association between overcrowding and mortality. That's not to say that ours is the end all be all final word on that.
00;20;15;24 - 00;20;51;01
Jessica Adler
But it is just it's worth mentioning. So these revelations have led to calls for more better, more modern, more regimented jails, more, and more plentiful prisons. And we know from more than a century of experience that these things have not worked and are that the results in this paper, in our view, suggest that there's actual now quantitative proof, as you suggested, that that we are actually putting people at risk of death by merely exposing them to jail incarceration.
00;20;51;01 - 00;21;31;20
Jessica Adler
And then when you think about the fact that there are 100,000 people in jail for public order offenses, things like traffic violations, failing to pay fees, etc., then it really becomes imperative to say, what are we accomplishing here when we have 100,000 of our population in jails is incarcerated for public order offenses? Should we be revisiting this idea of whether there are better approaches than jailing people for things that when there are alternative approaches that can have much deeper individual and societal benefits?
00;21;31;26 - 00;22;02;27
Jessica Adler
So that's our conclusion. We're highlighting the need for a different approach with this finding. I think that policymakers, stakeholders need to resist devoting more funding to incarceration. They need to focus on decreasing the use of incarceration, expand ongoing efforts to limit the use of cash bail, enhance community based services that are specifically intended to address mental illness, drug use, homelessness so that jails don't become the site of first resort anymore for people who are in need of social support and health care.
00;22;03;00 - 00;22;35;25
Alan Weil
Well, Dr. Adler, I think that's a great place for us to bring the conversation to a close. It's really interesting to me in the conversation with you two to think of my own evolution of starting to take your findings as really about health care in jails, but convert it as we discussed in more depth to a real understanding about the health implications of having so many people in jail and some of those implications cannot be reversed by providing better health care services in jail.
00;22;35;25 - 00;22;58;09
Alan Weil
That's just not what they're about. I don't pretend to be an expert on what the next steps are here, but you've certainly opened my eyes and I think our listeners hopefully have heard as well the need to take a more expansive view of what this study is about. So for that and for the work itself, I really appreciate what you've done here and I thank you for being my guest on “A Health Podyssey”.
00;22;58;16 - 00;23;01;20
Jessica Adler
It's been a pleasure. Thanks for having me.
00;23;01;23 - 00;23;06;04
Alan Weil
And thanks for listening. If you enjoyed today's episode, I hope you'll tell a friend
00;23;06;07 - 00;23;07;16
Alan Weil
about “A Health Podyssey”.