Prison health, public health: obligations and opportunities.

I. INTRODUCTION We don't care enough about prisoners' welfare. We should care deeply because, as two prominent commentators on the history of prisons have said, "Prisoners are ourselves writ large or small. And, as such, they should not be subjected to suffering exceeding fair expiation for the crimes for which they have been convicted."1 Well over two million persons are imprisoned in America today.2 We imprison a higher percentage of our population than any other country.3 Those we imprison are disproportionately poor, of color, uneducated, and sick.4 They have chronic conditions, mental illnesses, sexually transmitted diseases and other infectious diseases.5 They usually receive inadequate health care-and sometimes shockingly poor care.6 It has always been so. Prison reformers have argued for decent prison care based on humanitarian principles since the founding of the Republic, and, notwithstanding some notable achievements, have failed to achieve decent conditions. In the last fifty years, reformers shifted to individual rights arguments based on prisoners' constitutional rights.7 Substantial progress in the early years of that era has given way to reaction from courts and legislatures, throwing this strategy of prison reform into doubt. This article seeks to identify a third vision of prison reform to supplement the historic humanitarian and more recent individual rights efforts. This third vision of prison reform argues for decent prison health care on the basis of equally selfless and selfish motivations. Reform failures of the past notwithstanding, Americans retain some fellow-feeling for prisoners. The power of this fellow-feeling should not be overstated, as such feelings have proven too diffuse in the past to permit reform traction. The selfish motive for prison health reform therefore takes on great importance. The selfish motive springs from public health effects-the harm to communities that flows from mismanagement of prison health care. The harm that flows from mismanagement of chronic conditions and mental illness comprises severe strain on community health facilities, harm to the communities flowing from the inability of sick ex-prisoners to reintegrate into society, and the costs of recidivism when failure to reintegrate contributes to ex-prisoners' return to crime. The harm that flows from mismanagement of sexually transmitted diseases and other infectious diseases is more direct. Almost all of the two million prisoners now in prisons and jails will return to their communities one day.8 If, due to poor prison health care, they return with uncontrolled syphilis, tuberculosis, HIV, and other infectious conditions, they will likely infect many around them. In these circumstances, prisons and jails serve as "epidemiological pumps,"9 amplifying infectious conditions, perhaps even transforming them into treatment-resistant strains, and then sending them out into society for distribution. It is in the interest of all in society to prevent the population health effects that demonstrably flow from mistreatment of the health conditions of prisoners. The following pages describe the sorry state of health care services for an enormous prison and jail population, the serious harm poor health care inflicts on the prisoners and the communities to which they return upon release, and the steps that should be taken to protect them and the communities they will reenter. Part II discusses the demographics and health status of the American prison population and the health services provided them while imprisoned, with particular attention to communicable diseases, chronic illness, and mental illness. It grounds this discussion in modern-day realities in which one of every one hundred Americans is behind bars on any particular day.10 Part III describes the ebb and flow of prison conditions and health care reforms, focusing on the humanitarian movements of the 19th Century and the prisoners' rights movement of the mid-20th Century. …