Health Care Ethics in the Prison Setting

June 14, 2021

Information

June 9, 2021

Emily Wang, MD, MAS
Associate Professor of Medicine, Yale School of Medicine
Director, SEICHE Center for Health and Justice
Director, Health Justice Lab

ID6713

To CiteDCA Citation Guide

00:00Good evening everyone.
00:01Welcome to the program for
00:04Biomedical Ethics at Yale School
00:06of Medicine's Final Evening Ethics
00:08seminar of the academic year.
00:10We have the distinct pleasure
00:12of having doctor Emily Wang
00:14come to speak with us tonight.
00:17I will be speaking more about
00:19her expertise in just a minute,
00:22but first, I wanted to just go
00:25over some basic some basics in
00:27terms of the structure of tonight.
00:30First, you may notice I am not Mark Mercurio.
00:35I am taking his his place tonight
00:37but on behalf of him Mark Mercury
00:40or the director of the Program for
00:43Biomedical Ethics Ethics and my Co
00:47associate Director Jack Hughes and
00:49our program manager Karen Kolb.
00:51Again, I'd like to thank everyone
00:54for coming tonight.
00:56We're going to have about 45
00:59minutes of lecture.
01:00And that will be followed
01:02by about 45 minutes of Q&A.
01:04I invite everyone to submit
01:06their questions in the Q&A box
01:08at the bottom of the screen.
01:10I think everyone zoom expert by now,
01:12for better or for worse,
01:14and I will be moderating the session
01:16by asking the questions to Doctor Wang
01:18after she's she's finished presenting.
01:20As always,
01:21we have a hard stop at 6:30,
01:23so I apologize if I don't get
01:26to your question in time,
01:28but I want to make sure that we
01:31respect everyone's time here.
01:32And so I will try to select questions
01:34that get a different aspects of
01:36what we're discussing tonight,
01:38but my again,
01:39my apologies in advance if I
01:41do not get to yours.
01:43So now, without further ado,
01:45I'd like to introduce Doctor Emily Wang.
01:48Doctor Wang is a professor in the
01:50Yale School of Medicine and Public
01:52Health and directs the new Safe
01:54Center for Health and Justice.
01:56The Safe Center is a collaboration
01:58between the Yale School of
02:00Medicine and Yale Law School,
02:02working to stimulate community
02:03transformation by identifying
02:04the legal policy and practice
02:06levers that can improve the health
02:08of individuals and communities
02:09impacted by mass incarceration.
02:11She leads the Health Justice
02:13Lab research program.
02:14Which receives NIH funding to
02:16investigate how incarceration excuse me.
02:18Incarceration influences chronic
02:19health conditions including
02:20cardiovascular disease,
02:21cancer,
02:22and opiate opioid use disorder and
02:24uses a participatory approach to
02:26study interventions which mitigate
02:28the impacts of incarceration.
02:29As an internist she is cared for
02:32thousands of individuals with a
02:34history of incarceration and is
02:36co-founder of the Transitions Clinic Network,
02:39a consortium of 45 community health
02:41centers nationwide dedicated to
02:42caring for individuals recently
02:44released from correctional facilities.
02:46By employing community health workers
02:48with histories of incarceration,
02:49Doctor Wang Co.
02:50Chaired the National Academy
02:51of Sciences consensus report on
02:53Decarceration correctional facilities.
02:55During COVID-19,
02:55the steering committee on improving
02:57collection of indicators of criminal
02:59justice system involvement in
03:01population health data programs and
03:03workshops on health incarceration
03:04and means of violence.
03:05Her work has been published in The Lancet.
03:08JAMA American Journal of Public
03:10Health and Health Affairs and
03:12showcased in national outlets
03:13such as the New York Times,
03:15NPR, and CNN. Doctor Wang is a Navy
03:18from Harvard University and MD from
03:20Duke University and an MA S from the
03:22University of California, San Francisco.
03:24Doctor Wang take it away and
03:26thank you again for being with
03:28us. Thank you so much and thank you
03:30guys for joining on a 5:00 PM where you
03:33know most folks would be having dinner
03:35at home or hustling home, so I really
03:38appreciate the opportunity to be here.
03:40It's a real privilege and to discuss a
03:43little bit of our work and kind of some
03:46ethical issues that were grappling with.
03:48This evening so you know,
03:52I start here and I think you know,
03:55the last year has really shown us
03:57through the deaths of Brianna Taylor,
03:59George Floyd, and the cluster outbreaks
04:02of COVID-19 in prisons and jails.
04:04It's brought into public view,
04:05the serious health risks
04:07of mass incarceration.
04:08This is literally a matter of life and
04:10death for the millions of individuals
04:12in the US who passed through jails
04:15and prisons each and every year.
04:17I say this in all sincerity
04:19that it it's depressing.
04:21It's hard to think about.
04:23And also I think it's here that as
04:25a health system and as a School of
04:27Medicine that we really can exert
04:29our collective powers in dismantling
04:31these health harming structures
04:33through science and clinical care.
04:34And so you know,
04:35before I kick off my more formal remarks,
04:38I thought I would just introduce
04:40the safe center.
04:41What we're up to,
04:43which kicked off in June during the pandemic.
04:46So Sarah described,
04:47you know, the safe center.
04:49It's named after states wave,
04:51and it's illustrated here.
04:52It's a wave that emerges from
04:54stagnant water and I want to be
04:57responsible for this cool name,
04:58but it's actually members of my
05:00center that thought about this
05:02stagnant water and it results from
05:04the interference of two waves that
05:06are traveling in opposite directions,
05:08disrupting the status quo.
05:09So the center, in its conception,
05:11is really aiming to disrupt the status
05:14quo between two systems that the
05:16carceral system in our health system.
05:18With the explicit goal of decarceration
05:22or dismantling that carceral system.
05:25Decarceration and it's kind of
05:27most fundamental term is kind of
05:29the opposite of incarceration,
05:31and involves government policies and
05:33community campaigns to reduce the
05:35number of people held in custody or
05:37under custodial supervision in the US.
05:39And, you know,
05:40currently in the last 15 years
05:43that I've been at it,
05:44we're in a place where there's really
05:47bipartisan support of decarceration
05:48that it's generally acknowledged
05:50that mass incarceration has been
05:53a failed social policy and costs
05:54our society far too much.
05:56So for successful decarceration,
05:58I think the key thing that's you know,
06:01often lost in conversations about this,
06:04is that it requires not just
06:06criminal justice reform,
06:07but a robust social safety net system,
06:10which of course then includes
06:12our Community health system.
06:14So how do health systems?
06:15How does at the healthcare infrastructure
06:19actually take part in decarceration?
06:22And so our mission,
06:23then at the center is really to
06:25advance health and well being for
06:28those impacted by mass incarceration.
06:30We're committed to dismantling
06:32systems of racism enacted through mass
06:34incarceration and other forms of oppression.
06:36Building HealthEquity through four
06:38different domains, clinical care, research,
06:40education and legal scholarship and advocacy.
06:43And so, at the core is our
06:46transitions clinic program.
06:47It's a primary care program that targets
06:50individuals that have returned home from
06:53correctional systems and at its core,
06:55and I like sharing this program.
06:57Doctor Lisa puglisi.
06:58She's leads or transitions
07:00clinic network in Connecticut.
07:02A patient of ours and also community
07:05health worker Jerry Smart,
07:06a longtime friend and colleague.
07:08He's a community health worker who
07:11himself has been incarcerated and.
07:13It's this triumphant,
07:14that kind of dictates.
07:16Care the delivery of care to people
07:18that return home from prison that
07:21acknowledges that oftentimes the
07:23most important person in the room,
07:25in addition to the patient,
07:27is Jerry someone that builds trust
07:30in the system and helps individuals
07:32navigate the health care system
07:35and the social service system.
07:37Through the years, our network has grown.
07:40We are now with 45 programs in 14
07:43States and Puerto Rico have provided
07:45care to release thousands of people
07:47returned home from corrections,
07:49and it's an example at one of few
07:52of health system intervention
07:53that really helps decarceration.
07:56We conducted randomized trials and
07:57have studied kind of how primary care
08:00based intervention reduces people's
08:02future contact into the criminal
08:04justice system and are working
08:06really closely with policymakers
08:07and Community health systems.
08:09Especially payers like Medicaid to
08:11implement and scale the program, and so here.
08:14In Connecticut there's three programs,
08:16one in Bridgeport, one in Hartford,
08:19with plans to scale more.
08:22It's this clinical care then,
08:24that really then informs our education,
08:27our legal scholarship,
08:28and the research we do.
08:29Currently we have a research program
08:32that's really focused on the top
08:34causes of morbidity and mortality
08:36among individuals that are return
08:38home from prisons and jails,
08:39and that's overdose, heart disease,
08:41cancer, gun violence, COVID-19.
08:43We have a robust educational
08:45component that spans across both the
08:48School of Medicine but also other
08:50schools and so at any given day,
08:52this picture here in the corner.
08:54We have students from nursing from
08:56the School of Public Health from the
08:59law school from psychology and are
09:01really trying to think about how it
09:03is that we inform the education of
09:06young learners to learn about the
09:08health impacts of mass incarceration as
09:10well as to take part in mass campaigns
09:13for decarceration and especially to
09:15bring that learning into prisons and jails.
09:17Starting not this year,
09:18but next year we're going to
09:20hopefully partner with the Yellow
09:22Prison Education Initiative to
09:24bring this teaching inside.
09:26And then lastly,
09:27have partnerships with the Justice
09:29Collaboratory and the Solomon Center
09:30to think about how it is that we both
09:33provide individual legal supports to
09:35the patients that we see in clinic.
09:37But also think about what are the
09:39kind of larger structural barriers
09:41that are really impeding the health
09:43of our patients that return home and
09:45how it is that we can support both
09:48state level and federal policies
09:49to create healthier communities.
09:51The center is made up of
09:53primarily Yale faculty,
09:54students and staff have all been
09:56personally impacted by mass incarceration.
09:58And I'll tell you that it's through
10:00colleagues at the center and throughout
10:03our transitions clinic network,
10:04most of whom have been incarcerated
10:06that has transformed my view of
10:09healthcare research, the ethics,
10:10morality, and the justice,
10:12really that undergirds our work.
10:15And so you know,
10:16for the remaining kind of 30
10:19minutes what I'm hoping to do
10:21is share with you some of the
10:25epidemiology of incarceration.
10:27Then to discuss health care
10:29in correctional facilities,
10:30health risks of incarceration
10:31and touch on an ethical issue
10:34that we're really struggling with
10:35right now in our state center of
10:38COVID-19 and the ethics of research
10:40in correctional systems and then
10:42end with concluding thoughts.
10:44And I start with this beginning
10:46just to say that we are excited
10:48and interested in partnerships
10:50would really welcome at more folks
10:53really putting kind of our best
10:55brains and efforts forward and so.
10:58Yeah well, this will be brief.
11:00My hope is little tempted enough
11:02to really understand the important
11:04parts of bioethics and ethics
11:06in this work that we're doing.
11:09Alright,
11:09so to start.
11:10So there's currently about 7,000,000
11:12individuals who are under the
11:14jurisdiction of the criminal justice
11:16system in the US and that's about
11:182.2 million that are behind bars at
11:20any given day in jails and prisons
11:22and then about a four million plus
11:24that are under a community system
11:27of supervision of partial control.
11:29And so I'll just start with some
11:31definitions just to make sure that
11:33everyone kind of understands these terms.
11:35Jails house those who are
11:37waiting adjudication of crimes.
11:38And then also those who are have
11:41been sentence and typically serving
11:42sentences of less than a year.
11:45And so while there's like 700,000
11:47individuals in jail at any given time,
11:50there's a huge throughput in
11:51and out of our nations jail.
11:54So about anywhere from 7 to 11 million.
11:56Move through our jails and prisons,
11:59house those who have been
12:00sentence of a crime.
12:02Typically sentence is of greater than a year,
12:05and then the majority of individuals are
12:07in this community system of control so.
12:10After probation,
12:11people that have been sentence of
12:13a crime that serve their sentence
12:15in the community and then parole
12:17constitutes those who've served a
12:19portion of their sentence in prison
12:21and then return home to parole.
12:23All told,
12:24one out of every about 33 adults
12:26in this country are under the
12:28criminal justice systems control.
12:30The correctional population is really
12:32tripled in the last three to four decades,
12:35and there are a number of
12:37reasons that explain this.
12:38This includes mandatory sentence
12:40Ng He is a war on drugs that the
12:43institutionalization of the mentally ill,
12:45and so when you look at
12:47a population standpoint,
12:48it's about 63 million individuals in this
12:52country that have a criminal record.
12:55US incarcerates more people than
12:56any other country in the world.
12:58The rate exceeds that of all
13:00countries in the world,
13:01and so these data come from a paper
13:03that Chris Wildeman and I wrote that
13:05was published in The Lancet and
13:07it's just to point out that here
13:09up in the upper left hand corner,
13:10if you see the United States,
13:12this is the rate of incarceration
13:14over the past three decades,
13:15and this is compared to 20
13:17countries in the EU.
13:18And so you know.
13:19I recently prior to the pandemic had
13:21the opportunity to go to Finland and
13:23there when they talk about Finland.
13:25Finland is like out of control.
13:27Their cultural system is raging
13:28and you can see it's essentially
13:30a flat line compared to the US.
13:37Those who are incarcerated are
13:38disproportionately poor men of color.
13:40These data come from this sentence
13:41Ng project and So what they did
13:44was estimated using life table
13:45measurements among people born in 2001,
13:47what's the lifetime?
13:48Likelihood of imprisonment and they broke
13:51this down by race and as well as gender.
13:53And So what you can see is that
13:55if you look at men born in 2001,
13:58one out of nine men have a
14:00lifetime history lifetime.
14:01Likelihood of being in prison.
14:03So this doesn't even account for
14:05time in jail, just imprisonment.
14:06You break it down by race and you
14:09see that white men have a one in
14:1217 lifetime likelihood for black
14:13men born in this country in 2001,
14:16they have a one out of three lifetime
14:18likelihood of being imprisoned.
14:20And that statistic always kind
14:21of blows my mind for Latino men.
14:24One in six women are far less
14:25likely to be incarcerated,
14:27but again,
14:28you see this racial disparity
14:29in incarceration.
14:30Black women were much more likely to be
14:33incarcerated as compared to white women.
14:37So based on the work of a
14:40sociologist Becky Pettit,
14:41the New York Times ran a headline a
14:44few years back that said that at a
14:47population level, about 1.5 black,
14:491.5 million black men are missing from
14:52daily life between the ages of 25 and 54,
14:56either 'cause they're dead
14:57or they're incarcerated.
14:58This is one of the infographics from that
15:02article showing that in places in yellow,
15:04black men are more likely.
15:06To be disproportionately missing
15:08and in purple that they're more
15:10likely to be overrepresented,
15:12so you can see that there's a predominance
15:15of missing black men really in the South.
15:18While it's long been known that
15:20black men are more likely to
15:22be locked up and die young,
15:24the scale of this combined toll
15:27from a population standpoint is
15:29large more than one out of 6 black
15:31men aren't around to be parents,
15:33husbands working,
15:34citizen's high imprisonment
15:35accounts for black.
15:37The higher imprisonment of black men
15:39accounts for about 600,000 of the men
15:42who are missing and then early death
15:45is thought to account for 900,000.
15:47So Homicide is the leading cause of death
15:51for young black men and heart disease.
15:54For those over 30,
15:55this doesn't just have impact
15:57on the health of black men,
16:00it also has impacts for families.
16:02So it's estimated that about 63%
16:05of black individuals in the US.
16:08Have an immediate family member,
16:10so either spouse,
16:11a child who's ever been incarcerated
16:14and this compares to 45% of
16:16individuals in the US overall.
16:19So all this is to say is that in
16:21that incarceration the experience
16:23of incarceration has an incredibly
16:26wide reach in our country,
16:29especially among poor communities of color.
16:31And while we rarely discuss
16:34incarceration and its intersections
16:35with health and the health system.
16:38I would say that it perhaps has the
16:40largest bearing on our ability to
16:42achieve HealthEquity and racial justice.
16:46And so I'm going to dig into
16:48this a little bit more.
16:50So for this deposition to be true,
16:52you know incarceration must
16:53directly impact patients health,
16:55and you know, I have to say I've been
16:57doing this for a really long time,
16:59and I often get kind of a
17:01doubtful questioning around it.
17:03So from doctors.
17:03And then I get asked all the time,
17:06you know, how is the care of people
17:08that have been incarcerated any
17:09different than those who are homeless?
17:12Those who are poor,
17:13those that have substance use disorder.
17:15From researchers I I get it phrased a
17:18little differently so you know they're
17:20really asking kind of questions of causality.
17:22Is incarceration actually an independent
17:23risk factor for poor health outcomes?
17:25And you know,
17:26I've I've settled out at this point in
17:29my career of saying that, you know,
17:31will really maybe never know.
17:32You know,
17:33you're not going to have a
17:35setting where randomizing folks to
17:36incarceration is as a possibility,
17:38and So what I'm hoping to do is
17:40just share with you a few pictures
17:42to give you an inside look on
17:45what health care looks like.
17:46Behind bars and try to come into on Facebook.
17:50Liberty alone that exposure to
17:52incarceration is a distinctly unique
17:54experience that impacts patients health.
17:58So these pictures all come from within
18:01San Quentin Prison in California.
18:03It's where I had a lanja tude.
18:06No primary care practice as
18:08an internal medicine resident.
18:09So San Quentin is one of the largest and
18:12oldest prison systems in California,
18:15and I had my primary care practice
18:17there for three years among at the 1200
18:21individuals that were on death row,
18:23and what blew my mind really was that,
18:26you know.
18:27It's one of the only places in the
18:30US prior to the Affordable Care
18:32Act where a healthcare primary care
18:36is constitutionally guaranteed.
18:3880% of individuals who are incarcerated
18:40have a chronic health condition that
18:43warrants launched to no primary care.
18:46This includes, you know,
18:47conditions like hypertension,
18:49asthma, diabetes.
18:49That, of course includes communicable
18:52diseases like HIV and hepatitis C.
18:54It also includes substance use
18:56disorders and mental health conditions.
18:59All told,
18:59it's about 80% and about 40% of
19:02individuals are newly diagnosed
19:03with a health condition when their
19:05first incarcerated and so for
19:07young black men in this country.
19:09This often the the prison and jail
19:12system and the health care system in bed.
19:14And that is their first contact with
19:17the health care system as an adult.
19:22But the delivery of care is completely
19:24different, and so this is a photo
19:26of a primary care clinic and I
19:28just want you to take a good look,
19:31especially those of you who haven't
19:33practiced in prisons and jails
19:34at kind of just the construction
19:36of the primary care clinic.
19:38So this guy here,
19:39who's getting his nebulae zehrs waiting
19:41to see the doctor and right next to him,
19:44is another patient who's waiting in a cage.
19:46Correctional officers,
19:47you can see one right there often
19:49accompany incarcerated people to all
19:50medical appointments there often.
19:52In the doctors room with them,
19:54many patients individuals are
19:56woken up by correctional officers
19:58to make the medication in line,
20:00and so the whole healthcare system
20:02behind bars isn't, you know,
20:04it's part and parcel of the
20:07criminal justice system.
20:08In fact,
20:09it's kind of under the correctional system,
20:11and so by and large,
20:13when you think about decisions
20:15that are made about how it's not
20:18healthcare leaders or or physicians
20:20that are making those decisions.
20:22It often, at the sheriffs, the correctional.
20:27The commissioners that are making
20:29decisions about what meds are available,
20:31whether patients can see certain specialists,
20:33how much they're willing to
20:35expend on health care.
20:37And so again,
20:38how care is delivered behind
20:39bars is quite different than
20:41how you might imagine it.
20:43In the how it is in the community.
20:49Of course, while there's a constitutional
20:51guarantee to care that access is
20:53limited by institutional policies,
20:54and so I share with you this photo,
20:57this is a pink slip to kite that patients
21:00have to fill out when they have a complaint.
21:03An urgent complaint that needs
21:05to be addressed, and at the time
21:07when I was practicing California,
21:09this doesn't happen there now,
21:11but it happens.
21:12Another correctional systems.
21:13This slip is filled out by a
21:15person who's incarcerated.
21:17Then it's next evaluated by.
21:18A correctional officer,
21:19the correctional officer thank you know,
21:21evaluates to see if
21:22there's medical necessity.
21:22Then it goes to a nurse and
21:24then it goes to a provider and
21:26so you can see that while there
21:27is a constitutional guarantee,
21:29access is really different.
21:30So in the community,
21:31if you have to see the doctor
21:33and you need to see the doctor,
21:35he can always roll up into the
21:37emergency department and you know
21:38you'll be seeing it might be a wait,
21:40but you'll be seeing here.
21:41You can't decide the doctor you wanna see.
21:43You can't even decide when you
21:45wanna see and it's filtered
21:46through a correctional officer.
21:47The other thing that's important
21:49to note is that.
21:50For instance,
21:51in Connecticut there's about a
21:53$3 copay to see a physician,
21:55and you know you might be thinking like,
21:58well, what's 3 bucks?
22:00Well,
22:003 bucks is equivalent to
22:02about four days worth of work
22:04within the prison system here,
22:06and so you know if you're
22:09lucky enough to have a job,
22:11and so it's a significant
22:13barrier to see a provider,
22:15especially when you have
22:16to pay the $3 copayment.
22:22And the very conditions of confinement,
22:25of course, can then promote ill health.
22:27And so this picture is taken in the
22:30reception center at San Quentin and
22:32you know they were so overcrowded
22:35at the time that people were
22:37triple bunking in the gymnasium.
22:39So about, you know if you look at
22:41Bureau of Justice statistics right now,
22:44about 40% of correctional systems are,
22:46you know, technically over capacity, right?
22:48So which of course then can lead
22:51to the transmission of infectious
22:53diseases like COVID.
22:54But also sparked tensions and violence.
22:57When you have this,
22:58many young folks crowded together.
23:01It's not just the overcrowding either,
23:03it's that many,
23:04many of these prisons and jails.
23:07There's 5000 across the country
23:09really utilized congregate space,
23:11and so again, you know,
23:13even if a prison or jail isn't over capacity,
23:16oftentimes the living conditions,
23:18the eating where they shower or are
23:21all congregate an again can lead to
23:24the transmission of other diseases.
23:29This photo here is of a patient with COPD,
23:33whose ox independent and he's being
23:35held at in Solitaire E confinement,
23:37so he spends his 23 hours a day without
23:41any human contact in an 8 by 6 foot cell.
23:45This patient I can remember you
23:47would hear as you walk by his
23:50self and damning on the door.
23:52Every single you know sometimes it
23:54be minutes, sometimes it be ours,
23:57but every single time.
23:59The oxygen tubing got kinked and
24:01he no longer could breathe and
24:03I think you know this for me.
24:06This photo is really telling of
24:08how healthy individuals health are
24:10prioritized that you know in carceral
24:13systems its safety, its control,
24:15it's punishment that are the values
24:17that really go before a person's health,
24:20and what I often, you know,
24:22think about,
24:23and I think it's important to think
24:26about is that if this is the only way.
24:30That this patient has seen doctors
24:32like doctors and nurses were
24:33passing by this cell all the time.
24:35How much trust can a person
24:37have in the healthcare system?
24:39How much trust you know when they come home?
24:41Will they be willing to engage in care?
24:47And so you know, given this and I've
24:50described both kind of the delivery
24:51of care and then also the physical
24:54environment of Corrections really should
24:56be no surprise that COVID-19 wreaked
24:58havoc in our nation's prisons and jails.
25:0090 out of 100 of the largest outbreaks
25:03took place in correctional facilities.
25:05And again, these are the largest
25:07until college is opened.
25:09But as a result of this,
25:11hundreds of thousands of people
25:13who are incarcerated and those that
25:15work in corrections dot COVID.
25:17So here are data from earlier
25:19on in the pandemic.
25:21Sorry, the figure legend went away,
25:23but the blue here is incarcerated people.
25:25The red here staff and then the
25:28green is the general population
25:29and what you can see here is that
25:32incarcerated people in staff had
25:34about a three to five times higher
25:37rates of contracting COVID-19
25:39compared with the general population.
25:41In a published study that was
25:43published in JAMA and last year,
25:45they found that the COVID-19 adjusted
25:47death rate in the prison population
25:49was about three times higher
25:51than in the general population.
25:53And so you know, you might expect then,
25:56of course,
25:57that the risk for transmission is
25:58quite high in correctional systems.
26:00We worked with colleagues at Stanford
26:02to design an SCR model to really look at
26:05kind of transmission transmissibility,
26:07in a large urban jail.
26:09So calculating you know what we all
26:11talked a lot about in the last year
26:13is the basic reproduction ratio,
26:15and on the Y axis is just the incident
26:18COVID-19 infections from this urban jail,
26:20the X is the day since the outbreak,
26:23and just a whole new in.
26:25But we did find was that the beginning of
26:28the pandemic within this large urban jail.
26:32They are not the basic reproduction
26:34ratio was 8.3,
26:35so for every one person infected,
26:38eight others got infected and this is
26:40a rate that's higher than the cruise
26:44ships or any other congregate setting
26:47in the country that's been described.
26:50And so while the health care delivery
26:52system and the conditions of
26:54confinement certainly played a large
26:56role in these cluster outbreaks,
26:59COVID-19 I think also is a story
27:01of how correctional health systems
27:03really fall entirely out of our
27:06public health system infrastructure.
27:08So this is a picture of an incarcerated
27:11woman sewing her facilities masks
27:13during COVID-19.
27:14Most correctional systems were
27:16strapped to provide care they didn't
27:18have the personnel.
27:20They didn't have the budget for
27:22additional testing or equipment
27:23or personal protective equipment.
27:25They didn't have guidance from our
27:27our national centers of Disease
27:28Control on how best to protect
27:31incarcerated people are workers.
27:32Given the constraints of their facilities,
27:34many correctional systems contract
27:36out their diagnostic testing to
27:38outside vendors or community health
27:40systems and their source code.
27:41V2 testing was deprioritized so oftentimes,
27:43even if they had testing available,
27:45they had to wait 14 days to get
27:49the results back.
27:50And I just want us to think about
27:53this contrast ING list to what
27:55happened in nursing homes and long
27:57term care facilities which were also
27:59the sites of large cluster outbreaks.
28:02Nursing homes, of course,
28:03were prioritized for testing their
28:05prioritized for vaccinations.
28:06Of course, correctional systems were
28:08not guidance was also forthcoming
28:10and centers the Medicare and Medicaid
28:13services compelled data capture from
28:15all of these nursing homes early
28:16in the pandemic to better drive
28:19response to the spread of disease.
28:21Within those facilities,
28:22so we knew about what was going
28:26on in those facilities.
28:28But not in correctional systems,
28:30and so for us, this raised all sorts
28:33of questions within our center.
28:36How best we could protect our patients,
28:39families and their communities from COVID-19,
28:41we quickly turned to the literature and what
28:44you find is that for incarcerated settings,
28:48there's almost nothing about pandemics.
28:50Past very limited research on H1N1,
28:53for instance.
28:54Very little into research on an
28:56even vaccine vaccine uptake.
28:59And from my vantage point
29:01at this is a deep injustice,
29:04and so where our team started at
29:06to shift was really trying to
29:09interrogate the ethics of conducting
29:11research in correctional systems.
29:14And especially what this meant during COVID.
29:18And So what I wanted to do is kind of
29:21take you through a work in progress.
29:24Some work that we're working on
29:26as some work that we're thinking
29:28through about the ethics of research,
29:31but especially the ethics of
29:33clinical trials during COVID and
29:34correctional systems to start at,
29:36just say that you know probably
29:38most of you are familiar with this,
29:41but there is a real long and brutal
29:43history of conducting research in
29:45commercial systems in our modern history,
29:48so.
29:48More than 90% of phase one clinical
29:51trial studies of you know new drug
29:54safety in the US were conducted
29:56in commercial systems in night
29:58and before the 1960s.
30:00At that time,
30:01incarcerated individuals were enrolled
30:03without any informed consent.
30:04In any federal oversight of the studies,
30:07and so in the 1970s,
30:09then,
30:09this changed the National Commission for
30:12the Protection of Human Subjects in Bio
30:14Medical and Behavioral Research Institute.
30:16A moratorium on research that
30:18involved the testing of drugs and
30:21vaccines with impartial systems.
30:23The Commission then recommended that
30:25research involving prisoners that pose
30:27more than a minimal risk that wasn't
30:30studying the process of incarceration
30:32that didn't directly improve the
30:33health or well being of individuals.
30:36Prisoners shouldn't be
30:37conducted unless there was,
30:39you know,
30:39a really compelling reason.
30:41Further,
30:41they stated that the federal research
30:44had to begin overseeing such research
30:46through a Subpart C common rule.
30:48There were now prisoner,
30:50IRB stipulations,
30:51and what this essentially meant was
30:53that individual researchers who wanted
30:55to conduct research among pop you.
30:58Nations that have criminal justice
31:00contact even for minimal research
31:03had to get additional approvals.
31:05Around that time,
31:06as you can see and I just present
31:09this figure at the bottom,
31:11the rates of incarceration were
31:13starting to climb and over like I said,
31:16the past three decades to four decades
31:18there's been a disproportionate
31:19incarceration of black people,
31:21here represented in the Orange
31:23Latinos and LeBron and then non
31:26Hispanic whites in the blue.
31:27Now of course this wouldn't be a
31:29problem if the health impacts of
31:32incarceration if there weren't any
31:34health impacts of incarceration.
31:36But there are and so you know
31:39what this means then is that.
31:42We are not as able to understand the
31:45health of black men or really kind of
31:48better understand health disparities,
31:49our country and so to prove this point.
31:52We did a study to explore how
31:55mass incarceration has impacted
31:56the study of heart disease.
31:58So it's a real focus of my initial work.
32:03What we did was really wanted to
32:05understand how incarceration might
32:07impact loss to follow up in these
32:09large cohort studies that have
32:11been funded by the National Heart,
32:13lung and Blood Institute.
32:14We identified all studies that
32:16followed participants for more than
32:18two years that enrolled both black
32:20and white participants followed them
32:22for two years and at a very bare
32:24minimum just wanted to see did they
32:27enroll any incarcerated people OK
32:28and so none of these studies did.
32:31Then we wanted to see that among
32:34those participants that.
32:35That were enrolled within the community,
32:37did they just follow them into
32:39car stration so you could at least
32:41see what happens when they go in
32:44and then follow them back out?
32:46None of them did,
32:47and then among these studies,
32:49only one study axed about exposure
32:51to incarceration at the very
32:53beginning of this study at the very
32:55beginning of their cohort study.
32:57And so because none of the studies
32:59measured any incarceration exposure,
33:01we had to estimate the possible
33:03incarceration rates based on
33:04participant demographics.
33:05And location of study and then looked
33:08at the proportion of the lost a
33:10follow up at that could be due to
33:13incarceration and so this figure
33:15here shows the data just for black
33:17male participants that are missing
33:19from health cohort studies and so on.
33:22the Y axis are the cohort studies
33:24and you know there's some that
33:26maybe all know the Mesa Jackson
33:28Heart study Cardia Eric.
33:30These are the ones that are really
33:33informing our understanding that the
33:35genealogy of heart disease, right?
33:36And in red you see the loss to
33:39follow up over time among black male
33:42participants and in the blue it's the
33:45estimated loss to follow up due to
33:47incarceration and what we found was
33:50that among black male participants
33:51at the last default Doodle Corporation
33:54ranged anywhere from 15 to 65%,
33:56with the largest in cardiac and
33:58the point that I want to make
34:01here is just one single study.
34:03Is that the scale that we've
34:06incarcerated in this country?
34:07At that,
34:08we've incarcerated over the last three
34:10to four decades has to be impacting
34:13our knowledge of racial health disparities.
34:15As most studies in this country don't
34:17follow people into prisons and jails
34:20and don't include institutionalized
34:21participants and don't include
34:23measures of incarceration so
34:24that we can even understand
34:26how exposure to the commercial
34:29system changes health outcomes.
34:32In 2003, the Institute of Medicine
34:34then was asked to revisit this issue,
34:37especially given the increase in the
34:40and the prison and jail population,
34:42and also the disproportionate incarceration
34:45of poor people of color and also the
34:48over representation of lots of diseases,
34:51including HIV and hepatitis C,
34:53behind bars, and so they had a number
34:56of recommendations and hearing list.
34:59Some of them is that.
35:02That instead of these categorical
35:04exclusions to research that there
35:06ought to be more considerations of
35:08the risks and participation versus
35:10the benefits of participation in
35:12any sort of health research studies.
35:15Secondly,
35:15they suggested that incarcerated
35:17people and Ann correctional leaders
35:19should be included in decision making,
35:21so there should be this notion or
35:24understanding of collaborative
35:25responsibility around these decisions.
35:27Another recommendation they made
35:28was to expand the Office of Human
35:31Research protections oversight.
35:33So there should be more federal.
35:35Boarding of where studies are
35:37being conducted,
35:38which studies are conducted in which
35:41you know correctional facilities
35:43and how many are being enrolled,
35:45so it may not be a surprise to
35:47any of you that none of these
35:51recommendations have taken hold,
35:53and there's still very little research
35:55that really is examining both exposure
35:57to incarceration nor including
35:59incarcerated people into studies.
36:04And so during the early part of
36:07the pandemic as vaccines had made
36:09their way through kind of phase
36:11one and phase two clinical trials,
36:14we were really motivated by
36:16members of our team who had,
36:19you know, some of whom there's Mr.
36:21Tina grown, who spent 30 years
36:24incarcerated to put forward a
36:25thought piece of perspective piece
36:27in JAMA looking at the ethical
36:30considerations for COVID-19 vaccine
36:32trials in correctional facilities.
36:34And we saw this at least as a need
36:35to start the conversation about the
36:37inclusion of incarcerated people and
36:39made a few recommendations again
36:41that incarcerated people ought to
36:43be in these decision making bodies.
36:45And, you know,
36:46pandemics will push us to kind of
36:48making urgent and fast decisions.
36:49And of course, that's a necessity.
36:51But it also should, you know,
36:53if you look back at history,
36:55know that another one is going to come,
36:58and so we should be having this
37:00conversation now.
37:00We also make the recommendation to
37:02really have a racial equity lens.
37:04I'm kind of clinical trials and
37:07correctional systems and clinical
37:09trials in general and turn to the
37:12literature on how rarely black
37:14people are included in clinical
37:16trials of cancer therapies,
37:18especially salvage care,
37:19cancer therapies,
37:20and how this too is an equity in
37:23our access to medications that do,
37:26preserve or could preserve life,
37:29we talk about ensuring the
37:31applications receipt of of vaccines,
37:33and ensuring the receipt of
37:35applications vaccines.
37:36You know,
37:37once a vaccine,
37:38if if a Correctional Facility or individuals
37:40to participate in a vaccine trial,
37:42then they should at least be able
37:44to get vaccines regardless if
37:46you participated after the trial,
37:48they should have aftercare after
37:50the Trump convenes.
37:51That certainly there should be a
37:53convening of a federal oversight board
37:55to oversee these vaccine trials,
37:56and then also the importance
37:58of studying implementation of
37:59vaccines and correctional system.
38:01So it shouldn't just be a trials of advocacy,
38:04but also how best to do it.
38:06How do you increase?
38:08Uptake.
38:11And then very quickly I
38:13received countless emails,
38:15really objecting to that
38:17perspective in a really well
38:19written piece by professor writer,
38:22she published, you know,
38:24and questioned whether or not a
38:27public health crisis justifies more
38:30research with incarcerated people
38:32and specifically laying out which
38:35I think is quite important that you
38:38can't truly have informed consent.
38:41In systems with deep structural coercion,
38:44her piece ends, you know, and I quote.
38:47But if the car show institution itself
38:49imposes extreme social deprivations,
38:52research participation among those
38:54incarcerated might never be ethical,
38:56and I think it's important you know I
38:58spent a good deal of this evening's
39:01talk talking about the deep social
39:04deprivations within the carceral system.
39:07But this end conclusion really
39:09gives me pause,
39:10especially because I'm surrounded.
39:12By people that have been incarcerated
39:15that know first-hand the structural
39:17coercion and that disagree with her
39:19statement that who feel strongly that
39:21the decisions that have made them
39:24by others who aren't incarcerated,
39:26strip them of their autonomy
39:28and their humanity.
39:29And so this letter has come in from
39:32an incarcerated student who listened
39:34to one of our station webinars on this
39:37issue and he writes describing an idea
39:40that he has for his own study and I quote.
39:44Another suggestion I have would
39:46follow my question, Idea,
39:48questionnaire, idea.
39:49Of course after gleaning data
39:52from it would be.
39:54To set up a pilot program of inmate
39:56volunteers who would either participate
39:58in ongoing clinical trials for
40:01COVID-19 or any virus of that matter,
40:03and it goes on and you know,
40:06I know that this is kind of a
40:08contentious issue of including
40:10incarcerated people clinical trials.
40:12But this letter and the voices
40:14incarcerated people really raised
40:16important questions of who is
40:18being excluded from research who
40:20reaps the benefits of research and
40:22why they haven't been included.
40:24Decisions about scientific governance.
40:27So we currently have a NIH grants
40:30looking at COVID-19 testing and
40:33prevention and correctional systems.
40:35A specific aim is really to identify
40:38ethical concerns and potential solutions
40:40to testing and vaccine strategies
40:43using a Community engaged strategy.
40:45And it's a real mixed group of researchers,
40:49physicians,
40:50historians.
40:50Legal scholars will note an ethicist
40:53in their psychologists,
40:54never incarcerated and formerly
40:56incarcerated individuals.
40:57Who constitute at the research team
41:00and together we've been really
41:02trying to grapple with this idea,
41:04which isn't new of expanding the
41:06frame of voluntariness in informed
41:08consent to include an acknowledgment
41:10of structural coercion.
41:11And, you know,
41:12we've gone so far as to really
41:15think about kind of, you know.
41:18You know, of course,
41:20consent is the legal term is it?
41:22Should it be a set like is is
41:25a cent more appropriate and of
41:27course ascent doesn't make sense.
41:30These are adults.
41:31There's no other legal authority
41:33that can stand in and then sign
41:35an consent and so had turned two
41:38decades worth of legal scholarship
41:40looking at consent and.
41:43In a police search for vehicles so you know,
41:46of course,
41:47when a police stop ****
41:49they've got a gun and they're asking
41:51for permission to search your vehicle.
41:53You have to consent.
41:55But of course this there's all
41:56sorts of structural coercion
41:58embedded in that voluntary consent,
42:00and so you know in the in many
42:03localities what they're now doing is
42:05an acknowledgment of that consent,
42:07like the police officer has to
42:09give the person a piece of paper
42:12saying that these are your rights.
42:14And you can choose not to consent.
42:17Professor Tracy mirrors that.
42:18The Yellow School has been doing much of
42:21this work for the last now two decades,
42:24and we thought that maybe that this
42:26would be a place that can inform our own
42:29notions of voluntariness in informed
42:31consent within health research forward.
42:33And So what we've tried
42:35to do is think through.
42:37And this is a real preliminary draft
42:40of a kind of social ecological model.
42:44Conceptualising the determinants of
42:45structural coercion within correctional
42:47systems and and how coercion would play
42:50out in health research and in particular,
42:52you can see these multiple different levels.
42:55Individual interpersonal, social,
42:56community and structural structure,
42:57of which there are many,
42:59many kind of coercive factors.
43:01But even at the individual level right now,
43:04or Arby's of course,
43:06have us think through mental health,
43:08cognitive impairment,
43:09health literacy, but length of them.
43:11Confinement might be a unique dimension too.
43:14Whether or not it the risks outweigh
43:17the benefits for certain individuals.
43:19Again, at the interpersonal level,
43:21thinking bout the researcher,
43:23participant,
43:23DYAD,
43:23the researchers understanding
43:25of structural coercion,
43:26there two might be a place of having
43:28kind of more bolstered supports that
43:32really acknowledging the structural
43:34coercion going all the way to the structural.
43:38Domains again,
43:38you know,
43:39really kind of being able to understand
43:41what is the quality of an access
43:44to health care within correctional
43:46systems before you start a health
43:49service health research trial?
43:50Do they have copayments?
43:52What's accreditation and governance
43:53look like?
43:54What are the conditions of confinement
43:57where the abilities to communicate
43:59with trusted people or even the
44:02ability to get access to information?
44:05And So what we've started thinking
44:07through is how a research plan,
44:10putting the onus on the researcher
44:12to address structural coercion,
44:14like even a checklist that you
44:16have to submit before an IRB or an
44:20acknowledgment of that structural coercion,
44:22and so at the individual level.
44:24For instance,
44:25perhaps that for certain trials there
44:27might be additional considerations
44:29of if a person, for instance,
44:32is right now convicted to serve.
44:34A lifetime behind bars their risk
44:37benefit ratio for participating in a
44:40clinical trial for a COVID-19 vaccine
44:42might be really different than the
44:44person that's just in and out of jails,
44:47and will be scheduled to be
44:50released within days, weeks,
44:52or even a year.
44:53We were thinking about kind of
44:55at the interpersonal level that
44:57maybe participants would sign an
45:00acknowledgement of the structural coercion,
45:02but researchers might maybe should
45:04complete a standardized training.
45:06Find structural coercion,
45:07acknowledging the different
45:08ways and how they've
45:10thought through this.
45:11Similarly, maybe, correctional officers
45:13should be thinking through this before,
45:16and it could be standardized training
45:18for correctional facilities that
45:20engage in research and then for the
45:23more structural issues you know.
45:25Again, going to COVID-19 vaccine trials,
45:28you couldn't, for instance,
45:30do a trial unless you could assure that
45:33you know no one would be doing a trial
45:37just to get access to COVID-19 testing.
45:40As a researcher,
45:41you would have to provide access to care,
45:44so access to COVID-19 testing for all,
45:47regardless of participation.
45:48Similarly,
45:48you know participation in COVID-19
45:50tiles shouldn't be your only way of
45:53getting information about COVID-19,
45:54and so you would as a researcher would
45:57be responsible for making certain
45:59that people had access to iPads,
46:01libraries,
46:01phone calls so that they could
46:03get information about COVID-19 or
46:05make decisions about participation
46:07with more information.
46:12But you know, I think our where we're
46:15landing and where we consistently
46:17land is that the critical importance
46:20of including currently and
46:22formerly incarcerated people in
46:24the governance of health research.
46:27We do this. We have a, you know,
46:30a representative within our IRB's.
46:33But really, thinking about kind
46:35of larger forms of governance and
46:39certainly in the decision making
46:41of whether or not individuals.
46:44As whether or not studies should be
46:46going on in correctional systems.
46:49I mean we turn to the 2003 IOM
46:51report and really kind of strike and
46:53land on the importance of having
46:56incarcerated people at the table
46:58discussing these broader policy's.
47:01You know, it's been in my process of,
47:04you know, me of working alongside
47:06my colleagues and friends,
47:08and this is a picture of our Community
47:10health workers within transitions clinic.
47:13That I've started to see this
47:14important view of that by not including
47:16incarcerated people in our data
47:18infrastructure and our public health
47:20data infrastructure in our systems.
47:21In our science, it too is a way of
47:23saying that their lives don't matter,
47:26and so you know.
47:29It's here though,
47:30that I think we're really kind
47:32of interested in having further
47:34conversation about what this would look
47:37like and how this would look like.
47:39Really.
47:39Recognizing and certain truth,
47:41which is that, of course,
47:43health care in most correctional
47:44systems is a form of structural violence,
47:47but you know.
47:49The bioethics of health research
47:51in correctional systems,
47:52I think should acknowledge,
47:53and really doesn't right now,
47:55deeply.
47:55But it should acknowledge and should
47:57attend to structural coercion.
47:59But I would argue that it shouldn't
48:01preclude incarcerated people's
48:02participation in research,
48:03and this is kind of the question at
48:05hand that the pandemic presents to us.
48:08And then lastly,
48:09I think if you're taking anything
48:10away from this talk is that including
48:13incarcerated people and the governance
48:14and the decision making of research
48:17is really critical to ensuring justice.
48:20I'm in it end with this photo
48:23and state this that you know I.
48:25I think like while for most of you
48:28I'd imagine on the web and are today,
48:32you don't practice in corrections,
48:33you don't conduct trials in
48:35prisons and jails.
48:37We can categorically look at the
48:39healthcare delivery behind bars
48:40and recognize that it's coercive,
48:42violent, and deeply unethical.
48:44But you know,
48:46I want to expand our thoughts
48:47about how our own practice in
48:49our community is compromised by
48:50the reach of the carceral system.
48:53And so you know,
48:53when I see a picture like this and
48:56the patient to shackle 2 rolls
48:57into our emergency department or
48:59in our clinical offices,
49:01why is it that we as a Community
49:03permit the shackling?
49:04See the power to correctional officers?
49:06Let them stay in the room.
49:08Why is it that we're not holding
49:10ourselves to the highest standards of care,
49:12honoring patients rights to privacy,
49:13or not autonomy, and so?
49:15You know,
49:16my hope is that our conversation
49:18today what we're engaging with the
49:20massage center you know which is
49:22largely focused today on clinical trials.
49:24Hopefully can open up conversations
49:27about how our practice as a whole.
49:30I want to change really recognizing
49:32the humanity and the millions of
49:34individuals that have been incarcerated
49:36and recognize the complicity that we
49:39have in a system that's health harming.
49:41So I'm going to stop here and take questions.
49:45I really appreciate the opportunity
49:46to talk this evening.
49:51Thank you so much Emily.
49:53That was a really eye opening
49:56talk that that you gave and you
49:59brought up a lot of really,
50:01really critical questions that that.
50:03I think many of us may not have
50:06asked ourselves because we are
50:08pretty insulated from the realities
50:11of the carceral system that
50:13you've really nicely illustrated.
50:16Would encourage participants to
50:18submit questions in the Q&A.
50:20I'm I'm going to start with with
50:23a question which is that you know
50:26it's it's clear that that as you've
50:28stated that the delivery of health
50:31care within the carceral system
50:33is is unethical in several ways,
50:36and I think you know this this idea
50:39what what you're proposing is that you know,
50:42in fact,
50:43while the idea of excluding prisoners
50:46from research is a way of protecting them,
50:49that in some ways that.
50:51That's a paternalistic.
50:55Impulse that actually strips them
50:56even more of dignity and autonomy
50:58than than they already are.
51:00And recognizing that there's
51:02structural coercion,
51:03but finding some way to sort of
51:05balance that with with prisoners
51:07seeking more autonomy and dignity,
51:09perhaps through contribution
51:10to research that may give them
51:12a sense of purpose,
51:13which often is linked to dignity,
51:16is really is really compelling.
51:17And just this idea that you're advancing
51:20that that prisoners should really,
51:22or that people who have been
51:24incarcerated in the past.
51:26In particular, should be greater
51:27stakeholders in these discussions.
51:29Yeah, go ahead,
51:29you know.
51:30I mean,
51:31I think like
51:32I just there's so many kind of
51:34conversations that I've been in through
51:36these years and you know, to me it's.
51:40I I think you hit the nail on
51:42the head that it's course we
51:45look at the commercial system.
51:46We look at health care delivery
51:48behind bars and you know there's
51:50parts that are just deeply grotesque,
51:52like there's just no other way to say it,
51:55right? It is a deep form,
51:57deep form of violence and and people
51:59that are incarcerated are are,
52:01you know, there's so many levels
52:03of deprivation and one is through
52:05the the delivery of health care.
52:07But I will say this is that you
52:09have been in conversations with.
52:12Colleagues that have been
52:13incarcerated where people who are
52:16incarcerated can't donate a kidney.
52:17To a loved one.
52:19You know, so they their ability,
52:21but but you know have kind of the
52:23ability to consent to like wave
52:25wave an attorney at trial, right?
52:27And so we're willing to kind of
52:29extend consent and voluntariness,
52:31and these notions of autonomy
52:32and personhood in one domain,
52:34and then totally unwilling
52:35to do so in another.
52:36And I think that that strikes at the core
52:39for me as like it's worthy of interrogation.
52:42Like, I don't know where it
52:44ought to settle and sit, I,
52:46I'm not even stating that I think I mean,
52:48I, I personally do think like.
52:50Course I sit on the side of we
52:52just have to too little knowledge.
52:54I wish I could figure out the best
52:56way to kind of administer vaccines
52:58and correctional facilities.
52:59There aren't good trials that there's just.
53:01You know, there's no knowledge there,
53:03but we have to start with saying like
53:05we just have to tackle the beer.
53:08Easy,
53:08like the question that's been there
53:10since 2003 of like what are we gonna do?
53:13We just don't have any
53:14data right? Yeah right this is.
53:16This is a tough question that I'm going
53:19to ask but I'm going to ask it anyway only
53:22because it's so broad and and you know,
53:25it's not just an ethical question,
53:27but a legal one as well.
53:29What do you think?
53:30You know we're talking about the realities
53:32within a carceral system of health care.
53:34That that are again as you pointed out,
53:37deeply problematic in many ways.
53:39But what about sort of upstream of that
53:41reform of the criminal justice and system
53:44to prevent so many incarcerations what?
53:46What if you were sort of in charge?
53:49What do you think would be the top
53:52priorities for criminal justice reform?
53:54And again,
53:55I know that's a really big fraud question,
53:58but I'd love to hear your
54:00thoughts on that. Yeah, so I I.
54:04There are so many energies right now
54:06towards kind of decarceration right?
54:08Then it comes from all.
54:10All you know, both parties
54:11people that are from the Koch
54:13brothers all the way to kind of,
54:15you know, abolitionists like many,
54:17many people are in agreement that
54:18mass incarceration hasn't worked.
54:20And for me, I think where I spend
54:22most of my energies is really thinking
54:24about where it is that our health
54:26system where it is that you know our
54:29privileges in our powers has health care.
54:31Providers can really move the
54:33needle and so undoubtedly.
54:34In looking that you know substance
54:36use people with substance use
54:37disorders shouldn't be incarcerated.
54:39People with mental health conditions
54:40shouldn't be incarcerated.
54:41Things that are kind of social needs like
54:44homelessness shouldn't be criminalised.
54:45So that's the first.
54:47But you know I'm just going to caveat this.
54:50But just like those are the low,
54:52easy hanging fruit,
54:53the reality of it is Sir,
54:55are the system of mass incarceration
54:57is been going on and it's a system
55:00right that it's been going on
55:01for four decades that even those
55:03that were picked up for you know.
55:06Three strikes and selling cocaine
55:09or using etc.
55:10Once you've gone and rolled through
55:13the carceral system inevitably,
55:15because if there's it's violent,
55:17there's trauma.
55:18You know, that creates kind of more.
55:24Kind of difficulties within
55:25individuals you come home on,
55:26parole and probation, right?
55:27Like it breeds violence, right?
55:29You come home on parole and probation.
55:31And then there's all sorts of other rules
55:33that are parole and probation violations.
55:35And you know, just to kind of label a few.
55:38It's like you go a certain block.
55:40If you go, you know, like there's just.
55:42So if you don't show up to your parole or
55:45probation officer, that's a violation.
55:47You end up back in your sentence is lengthen,
55:49and so the process kind of just continues.
55:52And So what I would say is.
55:54Much of what I think it has to happen is
55:57that it's not just a criminal justice issue.
56:00You know it is really an issue.
56:02It's not just about eliminate ING,
56:03you know mandatory sentence things,
56:05which of course should happen.
56:06The length of sentence is all of
56:09that judicial reform, all of that.
56:10All of that is true and needs to happen.
56:13We arrest how we arrest, etc.
56:15But I think what really that the
56:17harder conversation, I think,
56:18is that in order for at the prison
56:21and jail system to come down.
56:23Even if we stop,
56:24even if we stop incarcerating people
56:26based on their substance use disorder,
56:28mental health conditions
56:30in their homelessness.
56:32There are people that have been
56:34convicted of violent offenses.
56:35There are people that have,
56:37you know, never did anything violent,
56:39then got incarcerated,
56:40then started kind of getting in the mix.
56:42Then you know,
56:43like you get charged with violence.
56:45And that's the conversation that
56:47we have to have as a nation is.
56:50We have incarcerated far,
56:51far too many people.
56:52I mean, you step out in any other country.
56:56It in the world, right?
56:58And so again,
56:59I gave the example of Finland just because
57:02it's how where I visited most recently,
57:05the longest longest time behind bars
57:08of any single person is 14 years.
57:11We have sentences.
57:12Right now there's like 3 lifetimes, you know.
57:15So we have to kind of really
57:18interrogate our values like where,
57:20where did they start?
57:21We also have no minimum age
57:23for children to be incarcerate.
57:25The youngest person that's incarcerated
57:27in this country spot California.
57:29So our system when I get asked that question,
57:32I'm like,
57:33I think that there's much to be done,
57:35you know,
57:36and certainly from a health system
57:37like we can be advocating for the
57:39decriminalization of things that
57:40we know to be health conditions.
57:42We also, as a health system,
57:44can get everyone home start transitions,
57:46clinic programs, hire people with histories,
57:47incarceration of work in the House system.
57:49But there's this larger issue,
57:51you know, eliminate in Connecticut.
57:52We have a bill right now that's up,
57:55which is once you've been convicted.
57:56You've served your time.
57:58There should be a clean slate.
57:59You no longer are.
58:00Kind of prohibited from getting a
58:02job you're no longer prohibited
58:04from getting food stamps etc based
58:06on a criminal record.
58:07Your slates wiped clean.
58:08If served your time,
58:10why should you have to serve more?
58:12So those are obvious easy ones,
58:13but the deeper part where we have to go,
58:16I think, is the part that I'm itching for.
58:18People to go is to really think about like,
58:21you know, we're all comfortable
58:22with those kinds of conversations.
58:24Not comfortable with is that because
58:25we've been doing this for four decades,
58:27we have to go to the harder
58:29place of what our values.
58:31How long do we think what?
58:33What should a system of justice look like?
58:35You know, are we looking for punishment?
58:37Are we looking for accountability?
58:39Are we looking for justice?
58:40And so anyhow,
58:41you opened up a bag of words I
58:43could talk about this for, really.
58:47Well, thank you so much.
58:49I'm going to turn to some of
58:52the audience questions now.
58:54We have a question in cases when
58:56people who are incarcerated receive
58:58care that falls below the standard
59:00of care to the point that it meets
59:03the definition of malpractice.
59:04Do they have access to malpractice
59:06suits to compensate them
59:07financially and otherwise?
59:09Is this different
59:10in theory versus in practice so they?
59:13I, I think that the issue is like you know,
59:18in theory I suppose they do.
59:21In practice it's about you know
59:23getting a lawyer, getting a person,
59:26getting the evidence etc.
59:28And that is far, far harder to do,
59:32you know, so you know.
59:34There are of course cases against
59:37correctional officers, facilities,
59:38health care providers behind bars.
59:40You know we've we've seen malpractice,
59:43I would say.
59:44Among our patients that have
59:46returned home that received care
59:48post release and transitions,
59:49you know, bad bad care.
59:51But I would say that that's not
59:53the primary avenue of reform
59:55and most do not kind of end
59:56up getting a malpractice suit
59:58and getting a big settlement.
01:00:02OK. Our next question is,
01:00:05what can healthcare workers in
01:00:07the carceral system possibly do to
01:00:09improve health care for the prisoners?
01:00:11Do they have any power
01:00:13to affect changes? Yeah,
01:00:14I really appreciate this question.
01:00:16'cause I think one of the things that I
01:00:19think is really important is to 1st state,
01:00:22which I didn't state here is that
01:00:23there's a real heterogeneity across
01:00:25correctional system, so there's 5000
01:00:28jails and prisons across the country,
01:00:30and you know each of them are governed
01:00:32and overseen in different ways, right?
01:00:34And so kind of. We've seen one gel.
01:00:37You've seen one jail, right?
01:00:39And I think what is important to
01:00:42note there is that and let me just
01:00:45give you an example of Rikers so.
01:00:48Good friend of mine used to be the
01:00:50medical director Homer Venters.
01:00:52He no longer is.
01:00:53He serves now on Biden's task force
01:00:55for equity right at and when he
01:00:58was the medical director of Rikers,
01:01:00which is a large jail system
01:01:02in New York City.
01:01:03The many different ways that you
01:01:05can advocate for the health care
01:01:07of people that are behind bars,
01:01:10some of which we'll talk a lot about,
01:01:12is using an electronic health record
01:01:14to document kind of correctional
01:01:16officer infractions right of like
01:01:18starting to look at the rates of.
01:01:20Self harm looking at the rates of
01:01:22traumatic brain injury and recognizing
01:01:24that if the rates are so much higher
01:01:27among those that are incarcerated in
01:01:29Rikers and obviously there's an issue,
01:01:31and so he'll often talk about
01:01:33the electronic health record
01:01:34as a human rights tool.
01:01:36But I think the other thing
01:01:38is that it is important.
01:01:40Like look because there's a
01:01:41constitutional guarantee for health care.
01:01:43It means that that place needs us,
01:01:45needs people that are health care providers.
01:01:48And of course there are health
01:01:51care providers that are.
01:01:53Trained social justice minded individuals
01:01:55that are practicing in correctional systems.
01:01:57And so I think that there are just many,
01:02:01many examples of how having
01:02:03providers inside is important.
01:02:05I mean I,
01:02:06I think good providers providers
01:02:09that are willing to kind of.
01:02:12Practice medicine,
01:02:12good quality samaesan and think about
01:02:15systems changes for correctional systems.
01:02:17I mean I,
01:02:18I can also give another example of the Rhode
01:02:21Island Department of Corrections right now.
01:02:24Their vaccine rate is at 70%.
01:02:26They've thought really deeply about how
01:02:28to engage those who are incarcerated.
01:02:31People that work within correctional
01:02:33systems and have gotten really
01:02:35high rates of vaccine uptake.
01:02:37Compared to, you know,
01:02:38better than many, many communities.
01:02:40Even in Connecticut, right?
01:02:41And so there are examples of
01:02:43how to do it and how to do it.
01:02:46Well.
01:02:46It's just that it's not the norm,
01:02:49and I would say,
01:02:50and also that there's no way of of
01:02:52there's no state or federal regulation.
01:02:54And So what I mean by that is like
01:02:56if you think about Dzeko that comes
01:02:59into our hospital system and at
01:03:01least has some bare bones, you know,
01:03:03kind of metric of quality care
01:03:05before you're going to receive your.
01:03:07Funds from CMS.
01:03:09There's no such thing,
01:03:10so the state gives the Connecticut
01:03:12Department of Corrections the
01:03:14cash. There's no transparent reporting.
01:03:15We don't know how we're doing.
01:03:17You don't Ding, you know,
01:03:19get dinged by Jacob for an infraction.
01:03:21And so that's what I mean by that.
01:03:25One that there is heterogeneity
01:03:27across all systems, but two.
01:03:28We really don't know how good
01:03:30or bad they are, and three,
01:03:32there just isn't oversight,
01:03:33and so that's what's problematic.
01:03:35But I do want to say that there's
01:03:38many health care providers
01:03:39that are behind bars that.
01:03:42Practice amazing medicine.
01:03:45Thank you. The next question I think
01:03:49you've touched upon this a bit,
01:03:51but just I will read it.
01:03:53Can you clarify if state or
01:03:55federal guidelines mandate
01:03:56prison healthcare standards?
01:03:57Oh OK, because I know you talked about,
01:04:00you know, from a constitutional standpoint,
01:04:02but from a more direct standpoint.
01:04:04And then do all states have copays?
01:04:06So can you comment a little
01:04:08bit more about that?
01:04:09Yeah, I
01:04:10wish I knew there's just a paper that
01:04:13was published about this so I I do
01:04:15know that not all states have it,
01:04:17but most states. Too, and they do it.
01:04:20Same for kind of it is both
01:04:22a way of raising capital.
01:04:24But it's also a way of reducing
01:04:26kind of what they see are like
01:04:28specious requests for healthcare.
01:04:30OK.
01:04:33So I'm I'm going to ask just because I I
01:04:36know you said you wanted to sort of spur
01:04:39some debate and so I'll ask a question
01:04:42that that I don't think is contentious.
01:04:44But is something that that maybe some people
01:04:47think you know with with respect to sort of.
01:04:50Balancing different different
01:04:51rights and obligations. So how?
01:04:54How might one balance respecting the
01:04:56dignity and autonomy of prisoners?
01:04:59Versus, for example, you know,
01:05:01shackling prisoners like like you showed
01:05:03us that example versus protecting
01:05:06the safety of clinicians because
01:05:08actually violence against clinicians,
01:05:10and I don't mean just from from
01:05:14incarcerated individuals across the board,
01:05:16violence against clinicians and healthcare
01:05:18providers actually is a huge problem.
01:05:21And you know whether whether it's right,
01:05:24whether it's actually evidence based to
01:05:26have more fear of prisoners versus just
01:05:28a prejudicial fear that's not found in
01:05:31evidence across the board of violence
01:05:33against health care providers is an issue.
01:05:36So could you comment a little bit about that?
01:05:39And in terms of balancing rights,
01:05:41balancing autonomy versus safety,
01:05:43and speaking a little bit
01:05:45more about that topic totally?
01:05:47I appreciate that question, you know,
01:05:49and I think that part of for me.
01:05:52Is that I wish I had kind of an
01:05:55easy off the cuff answer I and
01:05:58you know I I had mentioned to you.
01:06:01I recently had the opportunity to
01:06:03speak at one of the departments in at
01:06:07Yale talking explicitly about this and
01:06:09so really recognize that this is it,
01:06:12just a place of conversation,
01:06:14but also strikes a lot of concerns
01:06:16and there really valid concerns
01:06:18of concern for clinicians.
01:06:20Safety of running kind of clinical spaces so.
01:06:23To me, I think some of the issues are
01:06:26the concerns that I have is that.
01:06:30The way that policies are made rarely include
01:06:33patients or others perspectives rights like
01:06:35they rarely include those that are shackled.
01:06:37They rarely include those that are, you know,
01:06:39even you know if you look at the C-Suite,
01:06:42they rarely include people of racial
01:06:44and ethnic minority groups, right?
01:06:46And so to me, I think the first and foremost
01:06:49is to have a kind of community conversation
01:06:51about what it feels like to have.
01:06:54For instance,
01:06:54a police officer in a clinic like,
01:06:57is that necessary?
01:06:58Do they have to be armed?
01:07:00Are there other ways to create
01:07:02safety that don't require this?
01:07:03Because I think that what is a common
01:07:07conception is that we would all agree that we
01:07:10would want the police officer to be there.
01:07:14But you can also imagine a environment
01:07:16where you know some providers wouldn't feel
01:07:19safe with a police officer there, right?
01:07:22And so to me, I just think we haven't
01:07:26created a space like again where we've
01:07:28talked about this honestly and openly.
01:07:31You know, I again think that.
01:07:34Oftentimes we create kind
01:07:35of notions of what happens,
01:07:36or it is the status quo, and there it is.
01:07:39Like there's police officer,
01:07:40the person shackled.
01:07:41We don't know what to do.
01:07:42You know I get to ask this question
01:07:44all the time from students and
01:07:46residents that that work with us and.
01:07:49Why it has to be and so I you know,
01:07:52I frequently in my own clinical care.
01:07:54I mean, I do when I walk into the room,
01:07:57acknowledged patient first,
01:07:58then turn ask the correctional
01:08:00officer to leave,
01:08:01then ask if they can be unshackled.
01:08:03I need to do an exam etc and but I I
01:08:06recognize that most don't feel many,
01:08:08don't feel comfortable or don't
01:08:10have the language,
01:08:11and I think the most important piece of that
01:08:13is that we have to have this conversation.
01:08:16You know,
01:08:17I've never been in a setting
01:08:18where we talk explicitly.
01:08:20And about what it feels like or how it
01:08:23feels like or what the policy should be.
01:08:27An after that conversation,
01:08:28then create policies that are living,
01:08:30breathing policies that reflect
01:08:32kind of the whole of our community.
01:08:34Recognizing that I,
01:08:35I do think that it is a place where
01:08:39there's cause for concern and you know,
01:08:42I'll say this is that for incarcerated
01:08:44patients they are shackled in many states
01:08:47when they give birth their shackled.
01:08:49When they get intrathecal chemotherapy.
01:08:52And so I,
01:08:53I just can't imagine you know that there's
01:08:56a provider at the other end of that.
01:08:58There's a oncologist that's given
01:09:00the intrathecal therapy, you know.
01:09:02And so.
01:09:03It warrants conversation that
01:09:04we just haven't had.
01:09:06Yeah,
01:09:07I, I think that's that's
01:09:08a really nuanced answer.
01:09:10And and that I think that that's a I
01:09:13think you're absolutely right that it
01:09:15isn't going to be an easy off the cuff.
01:09:19One size fits all.
01:09:20Oh well, this will just be our policy,
01:09:23and I think it does.
01:09:25Certainly as a non expert
01:09:27in carceral healthcare,
01:09:28but it seems to me like certainly
01:09:31at least two salient factors
01:09:32emerge based on what you said,
01:09:35one of them being.
01:09:36What's the nature of the care being
01:09:39given and so certain things that
01:09:41are particularly either important
01:09:43in someone's life like giving
01:09:45birth or potentially very stressful
01:09:48or distressing or uncomfortable
01:09:49like receiving chemotherapy.
01:09:50It seems you know just just our
01:09:53moral intuition is it's maybe
01:09:55more problematic for someone to be
01:09:58shackled during something like that,
01:10:00as opposed to.
01:10:02Having an Abscess drained,
01:10:03although many may argue, well,
01:10:05that's a very stressful thing too,
01:10:07and we shouldn't ever have people shackled,
01:10:08and I think you're right that
01:10:10we we need to have sort of a an
01:10:12intentional debate about that rather
01:10:14than just sort of accepting the
01:10:16status quo and the other factor
01:10:17that that seems to me that would
01:10:19be very salient in this discussion,
01:10:21is is what is the nature of the
01:10:23offense for which the person is incarcerated?
01:10:26No,
01:10:27that's not again necessarily to
01:10:28say this should be the the beyond
01:10:30and all in determining.
01:10:32But you know, is it.
01:10:33Is it reasonable?
01:10:34Is there a difference between shackling
01:10:35of completely nonviolent offender
01:10:37versus shackling an offender with
01:10:38a history of significant violence,
01:10:40and is there a spectrum there?
01:10:42Some people may argue that
01:10:44nonviolent offenders shouldn't
01:10:45be incarcerated in the 1st place,
01:10:46which sort of gets back to
01:10:48the initial discussion,
01:10:49but it seems like those are at
01:10:51least two very salient factors.
01:10:53Nature of the offense,
01:10:54whether it's violent or
01:10:55nonviolent and nature of the.
01:10:57The treatment that might be starting
01:10:59points for that discussion.
01:11:00If you think that that's
01:11:02I'm completely off base,
01:11:03suggesting that I certainly welcome
01:11:05your input as to other things
01:11:07that you that you would take into
01:11:10consideration more in in in having
01:11:12that discussion and drafting a living
01:11:13policy with iterative revisions.
01:11:15As as we
01:11:16learn more, I think both of those
01:11:18are domains worthy of consideration,
01:11:20so certainly I will say,
01:11:22you know, again, I think again,
01:11:24thinking about the very many different ways
01:11:26and places where we practice medicine,
01:11:28I think that that's.
01:11:29Critical importance, right like?
01:11:32Is Emily shackling is for
01:11:34safety reasons right?
01:11:35And for those of us that
01:11:36have delivered a child,
01:11:38there's that persons on absconding
01:11:39they're delivering a child, right?
01:11:41Have a needle in your back?
01:11:43You're not gonna abscond, right?
01:11:44So I think that that's
01:11:46one kind of conversation,
01:11:47but it's worth having the second
01:11:49point that I think many people do.
01:11:51Think about I,
01:11:52I probably I do disagree with and,
01:11:54but I do think it's important for
01:11:56that conversation 'cause that's
01:11:57naturally where your mind goes.
01:11:59You're like,
01:12:00you know they've been convicted
01:12:01of blah blah blah.
01:12:02Bands that you really violent,
01:12:04really terrible,
01:12:05but I contend that there are
01:12:08so many people in our mix that
01:12:10have done terrible things.
01:12:14That have are not caught up in the
01:12:17carshall system and those are people
01:12:19that are more likely to be well off with
01:12:22means and just haven't been caught right.
01:12:24So I I just always to me
01:12:27the conversation you know.
01:12:28And this is maybe more new ones,
01:12:30but just to say that you know again.
01:12:34I'm I work closely and dear friends with
01:12:38people that have been incarcerated have
01:12:41even done, you know, terrible things.
01:12:44And shouldn't be known for the terrible
01:12:47thing they've done 30 years ago.
01:12:49There's people that are in, like I said,
01:12:52for life, afterlife, afterlife,
01:12:53and so it's real hard for us to kind of be
01:12:56discriminating as healthcare providers.
01:12:57So in this case we would.
01:12:59In this case, we wouldn't you know,
01:13:01and because the system is so like,
01:13:04it just is created in ways that
01:13:06I don't think are sensible.
01:13:07So to me.
01:13:08That conversation should be LED with.
01:13:11You know,
01:13:11if we're trying to think about the
01:13:13health and well being of those that
01:13:15work in our healthcare settings and the
01:13:17health and well being of our patients,
01:13:19that should be the guiding principle and we
01:13:21really promote safety like safety meeting.
01:13:23We should have more buzzers for when
01:13:25we feel unsafe, but how do we come,
01:13:28you know, create safety.
01:13:29What are the ways that we deescalate
01:13:30etc versus thinking about kind
01:13:32of that individual?
01:13:33The crime he committed a police officer?
01:13:35The timber round, right?
01:13:36That makes a lot of sense.
01:13:38Thank you. We have another question.
01:13:41You mentioned that for many
01:13:43prisoners the carceral system
01:13:45is the first opportunity for
01:13:46them to access health care.
01:13:48What happens upon release from prison?
01:13:50Is there any transition
01:13:51to healthcare out of jail?
01:13:55So in most prisons and jails in the system,
01:13:57and you know I didn't go too into it,
01:14:00but I appreciate that questions.
01:14:01That's the kind of the focus of what
01:14:04we do in our primary care practice.
01:14:0895% of people that are incarcerated
01:14:10will return back into the
01:14:11community and as I mentioned,
01:14:13it's about like 10 million.
01:14:15But it move in and out of jails
01:14:17and prisons and most return home to
01:14:19settings where you know if you think
01:14:22about like the day you had person
01:14:24for 24 hour OPS in our hospital.
01:14:26At the very least,
01:14:27they're getting the discharge summary.
01:14:29Their medications are called to
01:14:30their primary care provider,
01:14:32like all set up and tidied up.
01:14:34Most folks will return home
01:14:35with no medical records.
01:14:37A very limited supply of medications.
01:14:39And no primary care appointment,
01:14:40and you know where is trying to
01:14:42describe is like if you think about
01:14:44those 40% that are newly diagnosed
01:14:46with their chronic health condition.
01:14:48Let's say it's high blood pressure inside,
01:14:50right?
01:14:50They've never had a call pharmacy.
01:14:52They don't know when to take
01:14:53their medication.
01:14:54They were called to a medication line, right?
01:14:56The correctional officer gets in the Medline.
01:14:58The nurse you know delivers it.
01:15:00She checks to see if you CHEAT SHEET,
01:15:03it's right,
01:15:03and then he swallows it so they don't have
01:15:06kind of the skills and the experience of
01:15:08kind of managing their own medication.
01:15:10And they come home to our communal system,
01:15:13where we expect all of that like.
01:15:15We're like, I'll just get your refill,
01:15:17call the pharmacy,
01:15:18take your medications, you know etc etc.
01:15:21And on top of that people,
01:15:23when they come home,
01:15:24face additional barriers to
01:15:25meeting their basic basic needs.
01:15:27So I mentioned this really quickly,
01:15:29but I I shouldn't.
01:15:30That you know,
01:15:31if you have a criminal record,
01:15:33depending on the state you return home to,
01:15:36you have lifetime bans on food stamps.
01:15:38You have lifetime ban on Section 8 housing.
01:15:41You have perhaps in certain states.
01:15:43Of course, this you even have prohibitions
01:15:46certainly on where you can work,
01:15:48what trade you can practice, right?
01:15:50These are all called collateral consequences,
01:15:53and so when you come home,
01:15:55you have bears to meeting your
01:15:57basic names right of like just food,
01:16:00housing, shelter, food,
01:16:01housing and employment like what your income.
01:16:04And then you now have these new kind
01:16:06of health care priorities help you
01:16:09know chronic condition priorities.
01:16:11That you don't know how to attend to and so.
01:16:14Yeah,
01:16:14most people come home without a
01:16:16primary care appointment without
01:16:18kind of this appropriate transition
01:16:20into primary care and the data from
01:16:22our team and then other show that
01:16:24there's an incredibly high risk of
01:16:26dying immediately post release,
01:16:27like a 12 times increased risk
01:16:29of dying in the first two weeks.
01:16:32Post release.
01:16:34An increased risk of possible caitians
01:16:36increase use of emergency permanent
01:16:38actually worsening of your chronic
01:16:39health conditions and so you know,
01:16:41I think that that is an important
01:16:44point to bring up.
01:16:45Is that even though it looks terrible inside,
01:16:47in fact people do worse once
01:16:50they return home.
01:16:52It is speaking about kind
01:16:53of the population at large.
01:16:56Are there any kind of programs
01:16:58that are specifically aimed
01:16:59at helping that transition?
01:17:01Just like there are at perhaps educational
01:17:03or employment related programs?
01:17:05And could you speak a bit
01:17:07about that? Sure, so
01:17:08you know, I mentioned our
01:17:10transitions clinic program,
01:17:11and that's probably the largest one
01:17:14in national and kind of to attend
01:17:16to the transition of health care.
01:17:18And there are, you know,
01:17:20employment programs here in New Haven.
01:17:22There are organizations that both tend to,
01:17:25let's say financial literacy
01:17:27and getting people.
01:17:28Some supports for housing.
01:17:34So there's some additional programs
01:17:35for housing people once they
01:17:37are released from incarceration.
01:17:39There are programs that provide
01:17:41vocational training and then
01:17:42some employment programs,
01:17:43but I would say that the the truth
01:17:46of it is is that they still feel
01:17:49really scattered and they're not
01:17:51really coordinated and so it's still
01:17:53largely is an individual level kind
01:17:56of fixing an individual level solution
01:17:58like it asks of the person who is already,
01:18:01you know,
01:18:02just came back from a commercial system.
01:18:05So then navigate all these systems versus it,
01:18:07being kind of all the structures
01:18:08and the policies are in place.
01:18:10You know you can imagine a different
01:18:12structure program is that when you come home,
01:18:14your Medicaid is already activated.
01:18:15Your food stamps are on your disabilities.
01:18:17Here.
01:18:17Here are the things that we
01:18:19should have been teaching you in
01:18:21prison or jail when you're inside.
01:18:24To support your health.
01:18:25But now we gotta do it on the outside.
01:18:28Right?
01:18:30Well, thank you so much for
01:18:32sharing all of that really
01:18:34important information with us.
01:18:37I think I don't believe there any
01:18:40further questions and were coming
01:18:42up or only 8 minutes off of 6:30,
01:18:45so I think we'll adjourn a few
01:18:48minutes early tonight.
01:18:49We have one more question.
01:18:53There are programs that provide about
01:18:55one month supply of medications,
01:18:57but it does not work 100% of the time.
01:19:00My patients with HIV sometimes are
01:19:01able to continue their meds on release
01:19:03from the Department of Corrections,
01:19:05but this does not always happen.
01:19:07I'm not sure about other chronic conditions.
01:19:09I don't know if you
01:19:11want to comment a bit about that.
01:19:13Yeah, I I. It's interesting.
01:19:15So for HIV and I think in particular
01:19:17through Ryan White funding,
01:19:18there's been a longer history of
01:19:20kind of transitioning people safely.
01:19:22To home, but there's a really good study
01:19:25that's out of Texas looking at kind
01:19:27of a program where they provided the
01:19:29medication to people post release in a
01:19:32pharmacy accessible and what they found
01:19:34was that even if the meds are there, right?
01:19:37Like literally there,
01:19:38and these are HIV medications.
01:19:39You don't want to drop a day of it, right?
01:19:43That it was within seven days, 60%.
01:19:45Haven't picked them up within 30 days.
01:19:47It was like you know,
01:19:4950% I've picked up, up, etc.
01:19:51And so I think that that's exactly right,
01:19:53is that?
01:19:54Even kind of programs where
01:19:56that are established,
01:19:57the short kind of duration
01:19:58you know of medications.
01:20:00Even for HIV.
01:20:01The issue,
01:20:01I think that's really important to contend
01:20:04with is that there's so many competing
01:20:06priorities for people that returned
01:20:08home that even at you set up a program,
01:20:11it really has to be kind of teaching
01:20:13them again how to use the pharmacy,
01:20:15why this is important, you know,
01:20:17like even a day lapse,
01:20:19and so not everyone is going to use the
01:20:22program that you set it up like it.
01:20:25Again, it requires kind of more handholding
01:20:28than May may otherwise be thought.
01:20:31And for the other chronic
01:20:33conditions to her point,
01:20:34I mean no.
01:20:35So in Connecticut 30 days and it goes to CVS.
01:20:38So we have 30 days of medications,
01:20:40and it's exactly what you said.
01:20:41It's a little variable.
01:20:44But much better here than in other states.
01:20:48Thank you we have one kind of pointed
01:20:50as well specific question that may be
01:20:53a quick answer if the answer is no,
01:20:56but someone is asking if you have seen
01:21:00the documentary belly of the beast.
01:21:02Sorry, I'm not familiar with
01:21:04that documentary either, so.
01:21:06And we have several comments.
01:21:08Thank you for a great talk.
01:21:11Thank you for this program and I would
01:21:14just like to echo that that I, I,
01:21:17and the the program for Biomedical ethics.
01:21:19We're very grateful for your
01:21:21sharing this information with us,
01:21:23because like I said,
01:21:25I think a lot of us are very,
01:21:28very privileged and very blind to
01:21:30what's actually going on behind
01:21:33prison doors and the really the many
01:21:36practices that really present a lot of.
01:21:38Of of.
01:21:39Ethical conflicts with with principles
01:21:42of medical ethics and you know,
01:21:44we as as the medical profession
01:21:46need to do a better job.
01:21:49First of all,
01:21:50acknowledging what's going on,
01:21:51and secondly,
01:21:52advocating for for reform to ensure
01:21:54that that high standard of care is
01:21:57delivered really to to everyone,
01:21:59regardless of carceral status.
01:22:00Do you have any final comments you
01:22:03want to make before we wrap up?
01:22:05No,
01:22:06I think this has been
01:22:08great. I really appreciate the opportunity,
01:22:10which we're kind of in person.
01:22:12Or there was more opportunity for
01:22:14conversation, but I really it's
01:22:16been great to be here so thank you.
01:22:20Thank you. And everyone have a
01:22:22good night and have a wonderful
01:22:25summer and we will see you in the
01:22:29next academic year. Goodnight