Incarceration linked to deaths from infectious/respiratory disease, substance abuse, and suicide over following year

U.S. county jail incarceration rates have a major impact on several causes of premature death in surrounding communities, leading to increased mortality from infectious and respiratory disease, substance use, and suicide, researchers found.

Previous research showed that increases in rates of county jail incarceration are associated with increases in county all-cause mortality rates, Sandhya Kajeepeta, MS, of the Department of Epidemiology at Columbia University Mailman School of Public Health in New York City, and colleagues explained in The Lancet Public Health. For their analysis, the researchers built on the existing evidence to identify the short-, medium-, long-term consequences (1-year, 5-year, and 10-year, respectively) of increases in local jail population on specific causes of death.

They found that jail incarceration “can be harmful not only to the health of individuals who are incarcerated, but also to public health more broadly,” with every one new incarceration per 1,000 county residents leading to a 6.5% increase in deaths from infectious disease, a 4.9% increase in deaths from chronic lower respiratory disease, a 2.6% increase in substance abuse deaths, and a 2.5% increase in suicide deaths after one year — and mortality rates also increased for heart disease, unintentional injury, malignant neoplasm, diabetes, and cerebrovascular disease.

Kajeepeta and colleagues argued that their findings highlight the need for interventions designed to reduce county-level incarceration rates — and, moreover, “responses to the current most pressing public health challenges, including the Covid-19 pandemic, overdose epidemic, and their physical and mental health sequelae, require a reckoning with the effects of carceral systems.

“Given the ongoing Covid-19 pandemic, these findings highlight the immediate need to account for jails as drivers of infectious disease spread in the community,” they added. “In the longer term, the conceptual model we introduce can guide future research and intervention planning, including substance use disorder treatment, social service invest­ments, and ultimately decarceration.”

For their retrospective, longitudinal analysis, Kajeepeta and colleagues evaluated county-level jail incarceration rates and county-level cause-specific mortality using county incarceration data (1987-2017) for 1,094 U.S. counties from the Vera Institute of Justice, as well as cause-specific mortality data for individuals 75 years of age or younger in the total county population (1988-2018) from the U.S. National Vital Statistics System. They modelled nine common causes of premature death, consisting of the seven most common causes of death for individuals <75 years of age (cerebrovascular disease, chronic lower respiratory disease, diabetes, heart disease, malignant neoplasm, suicide, and unintentional injury) and deaths due to infectious disease and substance use, which were included due to their analyses’ relevance to the ongoing Covid-19 pandemic and the U.S. opioid epidemic.

“We lagged county jail incarceration rates by 1 year to assess the short-term, by 5 years to assess the medium-term, and by 10 years to assess the long-term associations of jail incarceration with premature mortality.” the study authors noted.

“A 1 per 1,000 within-county increase in jail incarceration rate was associated with a 6.5% increase in mortality from infectious diseases (risk ratio 1.065, 95% CI 1.061-1.070), a 4.9% increase in mortality from chronic lower respiratory disease (1.049, 1.045-1.052), a 2.6% increase in mortality induced from substance use (1.026, 1.020-1.032), a 2.5% increase in suicide mortality (1.025, 1.020-1.029), and smaller increases in mortality from heart disease (1.021, 1.019-1.023), unintentional injury (1.015, 1.011-1.018), malignant neoplasm (1.014, 1.013-1.016), diabetes (1.013, 1.009-1.018), and cerebrovascular disease (1.010, 1.007-1.013) after 1 year,” they wrote. “Associations between jail incarceration and cause-specific mortality rates weakened as time lags increased, but to a greater extent for causes of death with generally shorter latency periods (infectious disease and suicide) than for those with generally longer latency periods (heart disease, malignant neoplasm, and cerebrovascular disease).”

The study authors noted that the dramatic associations between increased incarceration rates and increased mortality for infectious disease, chronic lower respiratory disease, substance use, and suicide conform with the “substantial epidemiological evidence linking mass incarceration with community infectious disease spread and acute psychosocial and economic resource deprivation.” Likewise, they added that the association between incarceration and deaths from chronic lower respiratory disease is likely directly influenced by incarceration conditions, including overcrowding and poor ventilation, as well as resource deprivation.

Kajeepeta and colleagues laid out the direct and indirect pathways that they believed underlies these associations:

  1. The direct pathogenic effects of jail incarceration: “Not only do jails have disproportionately high rates of infectious disease and expose people to contaminated water and air, but incarceration itself is also a traumatic and often violent experience. Despite having higher rates of infectious disease and co-­occurring substance use and psychiatric disorders, prisoners have reduced access to testing and treatment and face substantial barriers to care… As the rates of jail incarceration increase, the health of an increasing number of individuals is likely to be affected, which in turn might be reflected in a county’s overall mortality rate.”
  2. The racialized psychosocial pathway: “[T]his pathway describes the psychosocial public health consequences of community destruction… High community rates of jail incarceration disrupt social ties and support networks, which are protective for community health. Additionally, there are psychosocial harms for the family members of incarcerated people: divorce rates are higher among formerly incarcerated people, and the stress of separation for parents and children has long-­lasting effects.”
  3. The racialized material or economic pathway: “[S]usceptibility to death because of infectious disease, chronic lower respiratory disease, substance use, and suicide is also driven by economic resource deprivation. Increased jail incarceration rates lead to large ­scale material investments in the criminal legal system, restricting the funding available for investment in social services, including those tied to public health… Exposure to the criminal legal system also has clear disenfranchising and depoliticizing effects, is a driver of job loss and wage inequality, and harms local economies because of the removal of working ­age individuals from the labor force. As a result, standard labor force data underestimate U.S. unemployment rates, particularly among Black men.”

“Notably, all three pathways described here might produce feedback loops that in turn lead to increased rates of jail incarceration, given the ways in which the criminal legal system disproportionately criminalizes poor and marginalized communities,” they noted — and, they added, these pathways are racialized “because substantial empirical evidence shows that, at each point along these pathways, racist structures and institutions produce differential effects across different racialized groups.”

Kajeepeta and colleagues noted several limitations to their analysis, including the study’s observational design, missing administrative data for some county-years, the use of mortality as the study outcome at the expense of other potential community health impacts of mass incarceration, variations in validity of administrative data by jurisdiction, and the inability to make “individual-level inferences” based on county-level data.

  1. Results from a retrospective, longitudinal analysis suggest that increases in county jail incarceration rates are potential drivers of mortality from infectious diseases, chronic lower respiratory disease, substance abuse, and suicide within one year, with smaller mortality increases seen for heart disease, unintentional injury, malignant neoplasm, diabetes, and cerebrovascular disease.

  2. These results suggest that mass incarceration has substantial public health consequences, highlighting the need for interventions designed to reduce county-level incarceration rates.

John McKenna, Associate Editor, BreakingMED™

Coauthor Keyes reported personal fees related to consultation with plaintiff representatives in ongoing opioid product litigation. No other conflicts of interest were disclosed.

Cat ID: 151

Topic ID: 88,151,730,192,151,587,590,925