Is prison healthier, safer than life outside?

Death rates among black male prisoners in North Carolina are lower than the state’s general African-American population, but white inmates are more likely to die from a variety of chronic and infectious diseases than Caucasian men overall, according to a new study. The finding comes from University of North Carolina at Chapel Hill research into male inmates’ health and health-care needs.

The study, published this month in the journal Annals of Epidemiology, was co-written by David Rosen, MD, PhD, epidemiology alumnus of UNC Gillings School of Global Public Health and postdoctoral fellow at UNC’s Cecil G. Sheps Center for Health Services Research; Victor J. Schoenbach, PhD, associate professor of epidemiology at the UNC public health school; and David A. Wohl, MD, associate professor of medicine in the Division of Infectious Diseases in the UNC School of Medicine. The research largely mirrors previous analyses that have shown lower death rates among some inmates, especially disadvantaged groups who tend to be more exposed to hazards and diseases in society in general.

However, researchers cautioned that the findings should not be interpreted as meaning prisons are a healthy environment.

“Beyond the provision of health care, prisons may influence inmates’ health by providing food and shelter as well as opportunities for exercise and health education,” the study’s authors wrote. “For some inmates, prisons also provide a refuge from the substance use and violence endemic in their communities; [but] for others, these threats persist – and in some instances are heightened – in prison.”

The study included about 100,000 men, between 20 and 79 years old, in North Carolina prisons at some point between 1995 and 2005. Sixty percent were black.

Researchers used official health records to determine how many inmates died and of what causes during their time in prison. Then they compared those figures with the number of deaths that would be expected among men of the same age and race in the general population.

Black prisoners in North Carolina were half as likely to die as non-inmates in the state (481 actual deaths, compared to 917 expected deaths). Black inmates also had fewer than expected deaths from accidents, homicides, cardiovascular disease and cancer. The number of deaths among white prisoners was similar to that of white males in the wider community (360 actual deaths, compared to 320 expected deaths), with fewer deaths than expected for accidents and more deaths than expected from viral hepatitis, liver disease, cancer, chronic lower respiratory disease and HIV.

Also, black and white male prisoners’ overall death rates were almost the same. Researchers said the results were in stark contrast to death rates in the general population – both in the U.S. and in North Carolina – in which mortality is approximately 40 percent higher among blacks than whites.

Rosen, the paper’s lead author, said differences in the two racial groups’ incarceration rates and pre-prison health status may explain why they have similar death rates within the penal system.

“Approximately 16 percent of black men are imprisoned during their lifetime, compared to 2 percent of white men,” Rosen said. “It might be that white men who are imprisoned are more disenfranchised and less healthy than white men who are not. This difference is probably less pronounced for black prisoners, due to the higher incarceration rates and wider health disparities gaps faced by the wider African-American community.”

The study noted that prisoners’ mortality rates appear to be linked to three main factors: inmates’ health before they are incarcerated; the prison environment; and the availability of health care and other basic resources in prison. Of these, the effect of the prison environment appeared to have the greatest impact. For instance, among both black and white prisoners, there were far fewer than expected deaths from accidents (26 actual vs. 136 expected deaths for blacks, and 16 actual vs. 61expected deaths for whites).

The new paper follows up on an earlier study published by Rosen and his co-authors in 2008, which looked at inmates’ health after they were released from prison. Its findings included that white ex-inmates were twice as likely to die as the general white population.

“About 95 percent of prisoners are eventually released,” Rosen said. “So the larger story here is not what happens to inmates in prison, but what happens once they are back in the community.”

Study coauthor Wohl said the studies highlight the medical vulnerability of both prisoners and ex-prisoners, and the need to improve correctional and community preventive health services.

“These results turn a spotlight not only on the health of those incarcerated, black and white, but also on the medical care system that exists in the community,” said Wohl. “It would be a sad commentary if it turns out that only with incarceration can some people access and utilize good health care.”


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