In public health terms, the prison population represents one of the highest risk groups in society. Nationwide, HIV incidence is ten times higher among inmates than in the general population, with mental illness occurring at a five times higher rate. In addition, inmates will often have a history of untreated chronic illness, substance abuse, and high-risk sexual behavior. Despite these alarming statistics, prisoners are often among the most medically under-served in society, posing a major health risk not only to themselves but also to the broader community into which they are eventually released.
Hampden County Correctional Center (HCCC), in the state of Massachusetts, has successfully addressed these problems through its Public Health Model for Corrections (PHMC). Underpinned by a philosophy of "the jail is part of the community, the community must be part of the jail," the PHMC is an innovative program that not only deals with specific health issues but is also an integral component of the HCCC's approach to rehabilitation: each inmate must have every opportunity to succeed upon return to the community.
Upon entry to HCCC, each new inmate receives a comprehensive medical and psychiatric assessment including blood and urine analysis, and testing for sexually transmitted diseases, tuberculosis, and diabetes. A voluntary HIV test is also offered upon entry and at regular intervals during the inmate's term. At this time, prisoners are also assigned a physician and caseworker from one of four community health facilities contracted by the HCCC to provide services. Assignment of a health facility is done on the basis of the prisoner's home zip code thus facilitating continuity of care on release from prison. Research has shown that upon release, 88 percent of inmates keep medical appointments with their assigned health care provider, thus demonstrating the program's success at linking prisoners to the health care system.
Treatment of chronic illnesses and substance abuse continues for the duration of an inmate's prison term. This includes medical treatment for chronic medical diseases (e.g., asthma, hypertension, and heart disease), health education programs for HIV and other communicable diseases, and counseling and 12-step treatment programs for alcohol and other substance abuse. There is an array of benefits arising from this approach including a reduction in the spread of disease, early identification and treatment of disease, and a decline in high-risk behavior. Aside from the public health benefits to both the prisoner and the broader community, this proactive approach results in financial savings through the timely treatment of disease.
The PHMC is also promoting cultural change within the prison system. Training is given to all non-medical corrections officers to enable them to recognize disease and patterns of mental health, and they are encouraged to refer patients for treatment. This approach has improved the relationship between health staff and corrections officers. Furthermore, prisoners have reported that they feel more motivated to take control over their lives and their health. The recidivism rate of HCCC inmates is only 9 percent compared to a rate of 25 percent or more for other correction facilities in the Massachusetts.
The focus on proactive testing, prevention, and early treatment of disease contributes to the overall cost effectiveness of the PHMC. The health care budget represents 10 percent of the HCCC's overall operating budget which is consistent with health spending in other prisons. Though not quantified, the downstream savings to the community arising from improved prisoner health adds to the overall benefits derived from the program.
This program reflects a significant step forward in corrections health. Accordingly, the PHMC has received awards from the National Commission on Correctional Health Care (NCCHC) and the Centers for Disease Control (CDC). Financial sponsorship has been provided by the CDC, the National Institute of Justice, the Soros Foundation, and the NCCHC to undertake a three-year demonstration and evaluation research program. In practical terms there is significant scope for replication of this program. The most difficult element in replication will be overcoming the views of critics who consider the prison population undeserving of medical services. Communication of the community benefits arising from the PHMC is likely to be the best strategy in challenging these perceptions.