The growth of the incarcerated population in the US over the past 40 years has been so large and unprecedented that it has been referred to as “mass incarceration.” 1 in every 35 people in the United States is under criminal justice supervision—in prison, jail, or on probation or parole. This explosion in our incarcerated population led the New York Times to refer to our country as “prison nation.” Mass incarceration also means mass reentry from prison, as 95% of the prison population will return to general society.
This mass reentry poses a serious public health risk. In the first 2 weeks after coming home from prison, people have a 12x higher risk of death than the rest of American society. This increased morbidity is the result of a tornado of factors: more chronic disease, fewer health resources, more social and economic instability. Health needs of previously incarcerated people are embedded in a set of social issues that makes addressing them difficult.
The Cultural Humility Curriculum is based on the work, commitment and values of the staff of the Transitions Clinics. It reflects the choices of these staff to serve people returning from incarceration who need healthcare and to learn about their particular experience and needs. In this curriculum, we’ll explore the ways that the laws, policies, and practices that create mass incarceration affect the health of those inside prison and jail and those who have come home, as well as the health of their families and communities.
Education for Healthcare Providers
Around the country, Transitions Clinics are developing to meet the complex needs of previously incarcerated people, and to help ease their reentry by providing informed, specialized care. The delivery of this high-quality primary care requires an understanding of the social determinants of previously incarcerated patients—that is, the sociocultural background of patients, their families and the environments in which they live. For previously incarcerated people, often this means unstable housing and family situations, unemployment, and inadequate education. To provide patient centered care, educating clinical staff on the experience of incarceration is absolutely vital. It is also critical to become aware of how one’s own cultural assumptions are shaped by the social contexts in which we work and live, and how these assumptions influence the provision of clinical care.
There is little or no mention in standard healthcare curricula about the impact of criminal justice involvement on patients. This failure to educate providers, combined with the underrepresentation of formerly incarcerated people among healthcare staff, means that a patient’s history with criminal justice system is rarely discussed openly in a clinical setting. Staff education on these topics will create both knowledge and commitment to working with a population that is often stigmatized and devalued within our society. Staff education will contribute both to staff growth and to the clinic development.
Cultural Humility & Structural Competence
Many forms of training have developed to educate health care providers on the impact of cultural differences on health behavior. While cultural competency training is achieved through the accumulation of knowledge about other cultures and their impact on health behavior, cultural humility is developed through critical self-reflection and acknowledgement of differences between the provider and patient in terms of perspectives, goals, and priorities. From this place of humility, a provider is taught to meet patients where they are.
This curriculum draws upon the tradition of cultural humility training, in that it encourages clinic staff to be critically self-aware of their assumptions and beliefs about previously incarcerated patients and to meet each patient on his/her individual health goals.
However, the impact of incarceration on health is not simply a cultural problem. Incarceration-related stigma and its impact on health exist in a context of structural inequality and systemic oppression of marginalized populations. A good-faith effort to confront healthcare issues related to incarceration requires an investigation of the upstream policies, institutional actions, and economic realities driving the phenomenon of mass incarceration. Thus, this curriculum also draws from a new tradition of training—structural competency.
Structural competency begins by looking beyond the patient-provider encounter, acknowledging that health disparities flow from social determinants of health such as poverty and homelessness. Then, in turn, it stresses identifying the institutional, political and economic forces underlying these social determinants of health. To care for patients returning from prison and jail, we must develop a structural competency of the societal forces that drive mass incarceration and create barriers to accessing and engaging in care upon release.
Thus, this curriculum pulls from both cultural humility and structural competency—encouraging critical self-reflection as well as raising awareness of the structural underpinnings of incarceration-related health disparities. Both are vitally important in order to provide quality care.
Historic Comparisons
The emergence of a new clinic model to meet changing needs is not new. Rather, the development of Transitions Clinics follows in the footsteps of the emergence of HIV/AIDS clinics during the 1990’s and women’s health clinics during the 1970’s. As with the Transitions Clinics, each of these two types of clinics emerged in response to a health and broader social issue. The very people most affected by that social issue—people with HIV/AIDS, women and now people with criminal justice histories—played a critical role in bringing that issue to the attention of society. In each case, a patient centered approach to healthcare was needed, involving the interrelation of medical skills, social skills and knowledge of the cultural environment that impact the patients. In all three examples—HIV/AIDS clinics, the women’s clinics and the Transitions Clinics—a focused effort was needed to train staff committed to a population that was not valued within the larger society. In each instance, people from within those communities played a critical role in developing and implementing patient-centered services.
Previously incarcerated individuals working in healthcare were invaluable in all steps of this curriculum’s development. From consultation, to authorship, to editing, those most impacted by incarceration have been at the heart of this project.
Supreme Court Mandates Adequate Care
In 2011, the Supreme Court issued a landmark decision in Brown v. Plata when they ruled that the physical and mental health conditions of California prisons were below constitutional standards, and that the California prison system had to release people from the overcrowded prison system in order to meet those standards. The majority opinion, written by Justice Kennedy, made a critical statement that affirmed the right of prisoners to be treated with human dignity and respect:
Just as a prisoner may starve if not fed, he or she may suffer or die if not provided adequate medical care. A prison that deprives prisoners of basic sustenance, including adequate medical care, is incompatible with the concept of human dignity and has no place in civilized society. (Brown v. Plata, 131 S.Ct. 1910, 1928)
The central role of the Transitions Clinics is precisely to treat patients with dignity and to provide healthcare with respect, knowledge and understanding. The goal of the Cultural Humility Curriculum is to train healthcare providers to provide care for persons returning from incarceration—that is, providing care for returning citizens.