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The U.S. has two separate health care systems: one for people who aren’t incarcerated, and one for people behind bars. Since 2006, physician and researcher Emily Wang has been working to integrate the two.

“There’s really no glue, no connection between these health care systems,” Wang said. “When you have two million individuals cycling in and out of two disparate health care systems, your first thought — and I was a young physician at the time — is, how do you create a program to bridge that transition of care?”

To find out, Wang, along with internist Clemens Hong and formerly incarcerated civil rights leaders in San Francisco, spoke with incarcerated and formerly incarcerated health advocates and their families. Those interviews prompted Wang to co-found the first of many clinics under the Transitions Clinic Network, which hires formerly incarcerated people as community health care workers who help those newly released from prison navigate new health care and social service systems. The community health workers serve as trusted guides, “someone where there wouldn’t be any issues of explaining what had gone on inside, any issues of understanding how hard it is to transition home,” Wang said.

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That clinic was the first of what are now 48 community-based primary care programs across 14 states and Puerto Rico. Last month, Wang was awarded one of 25 MacArthur “genius” grants in recognition of her work. STAT spoke with Wang over Zoom about the biggest barriers to health care access for people who’ve been in prison and how these issues affect a lot more people than those who have been incarcerated.

Excerpts from the conversation are below, lightly edited for clarity.

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Was there a particular moment when your interests in racial disparities and the U.S. criminal justice system coalesced for you? 

I have a very vivid memory of my first time walking into a correctional system in Botswana. In the middle of that correctional facility was what appeared to be a correction officer, sitting in the middle with a person who is incarcerated, with large shears, cutting his hair. People were walking in and out of the correctional facility with large bowls of food, in open air. There was music playing.

And that, juxtaposed to what was my experience in the North Carolina Correctional Institute for Women, struck me as profoundly shocking. This was [Botswana’s] maximum security prison, and the primary function that a prison serves there is the deprivation of one’s liberties, but not the deprivation of one’s humanity. You have food. There’s air. There’s music. You’re interacting with correctional officers there.

In this women’s prison [in North Carolina], you go through gates after gates. All visitors are screened. There’s metal detectors. The noise — it’s just shocking. It’s jarring. Of course, there’s restrictions on food. There’s restrictions on exercise. There’s certainly restrictions on music [and] entertainment. The officers interact with incarcerated people in totally different ways. Families are restricted from entering. And so, in contrast, the correctional systems in the United States are not just for the deprivation of liberty after having committed a civil or criminal crime, but really about exerting a certain level of punishment that inevitably, as we have seen in our studies, is health-harming.

You often speak about the lack of agency people who are incarcerated face. Could you speak to the role of agency and control when these folks are released from prison, and how that plays into health inequities?

So much of pre-incarceration is largely dictated by conditions of poverty … Once they come home, it’s that much harder. Now you have a criminal record, so you can’t get food stamps. You can’t support your kids. It’s hard to get a job. Getting into an educational system to increase your opportunities or abilities to get a job is that much harder. You’re turning to the same communities in which you were living before. It’s not like miraculously your circumstances have changed.

The hope would be that once you’ve served your time, you have the ability to then rejoin the workforce, rejoin your family, make amends, repair one’s community, repair one’s family. And instead there are so many laws, policies, and practices that really constrict what men and women can do post-release, what families can actually do, what communities can do, that it’s incredibly hard to then get back onto a road.

What are some of those laws and policies?

In certain states, depending on where you live and if you’ve been convicted of a drug felony, then you have a lifetime ban of getting food stamps, getting access to housing. Those laws are still on the books in a few states. They are residual … under the Clinton welfare act [The Personal Responsibility and Work Opportunity Reconciliation Act of 1996]. Most states have eliminated those restrictions.

“Fifty percent of all Americans have had an immediate family member who has been incarcerated.”

Even where the laws don’t exist in practice, many communities still kind of enforce those restrictions. It’s just an example of how arbitrary, how punitive the laws are — even after you’ve served your time, of not being able to get food or housing.

There’s long-term health consequences and economic consequences for families and communities that have been impacted by mass incarceration. There was a huge study led by researchers at Cornell, a national population-based study, that showed that 50% of all Americans have had an immediate family member who has been incarcerated. And so it has a huge effect, and not just on those individuals that have been incarcerated, but also on their loved ones, their kids, who also experience these health harms.

What particular policies are you focused on at the Transitions Clinic Network?

Depending on where one lives and the health system’s policy, there’s real restrictions to having individuals that have criminal records work in health systems. Our work shows that people with a history of incarceration can be real benefits to their communities, be real assets to the health systems. When you have community health workers that are integrated within primary care […] it builds new alliances between patients and providers like myself.

Also, our studies have shown that it actually reduces unnecessary use of the emergency department, long stays at hospitals, and actually reduces the cost to the state. It reduces cost to the criminal justice system by preventing future interactions with [the system]. So the policy arena that we’ve made significant strides in across our network, led by Shira Shavit, is really trying to interrogate why it is that there are large barriers to people with criminal records working in the health system.

The Equal Employment Opportunity Commission federally has found that having people with criminal records encounter barriers to working in certain industries, especially the health system, is discriminatory, given the disproportionate incarceration of people of color. This is a place where health systems, because they’re the largest employers, often anchor institutions and communities. It’s important to think about what are these barriers to hiring capable individuals, who’ve long served their time, into our health system to work alongside physicians like myself.

Your research, in part, looks into whether there’s something about incarceration itself that leads to worse health outcomes in individuals. What have been your most important or surprising findings so far?

Our research program here at the SEICHE Center [at the Yale School of Medicine] has focused on incarceration’s health impacts on cancer, heart disease, opioid use disorder, you name it. What we have found was that the transition home from a carceral system to the community is where the risks are the highest. There’s a high risk of dying. There’s a high risk of hospitalizations, a high risk of worsening of these chronic health conditions.

Post-release, those that cycle in and out of the carceral system have worse health outcomes. And that’s not a huge surprise. But much of the work [being done] is focused on what happens behind bars, and our work is really saying that, in fact, these systems are very interconnected, and people are placed at risk, especially when they return home from a correctional system. What we’re seeing in the clinic is that, as community physicians, we need to be doing better, far better.

Could you give a concrete example of why that’s the case, particularly for individuals with chronic disease?

Let me give you an example, and this isn’t from our work, but a study that was done among [approximately] 2,000 individuals with HIV in the Texas Department of Correctional System. People are released from a carceral system back into the community, and they don’t get their meds. They don’t have a doctor’s appointment. There’s not smooth communication between the health care providers. The transition in care between two health systems, even when there are certain systems set up, isn’t good. And there are all sorts of reasons. One, again, there’s barriers to people finding housing, food, employment. So their chronic health conditions — even something as important as taking care of their HIV disease — is lower on their priorities if they don’t have a place to stay.

Secondly, about 40 percent of individuals are newly diagnosed with a chronic condition while they’re incarcerated. So their experience of that chronic health condition is really affected by how they took care of their disease behind bars, and there it’s incredibly passive. Every morning a correctional officer is waking you up for the med line. The nurse is giving you the medication. You have to pop it in your mouth in front of her or him. They check to see if you chewed it. You never have to go to a pharmacy. You don’t need to present your ID card. You don’t need to figure out how to call a refill. You don’t have to do anything, so adherence is much better when you’re incarcerated, and then you haven’t learned the skills.

“If you are a person that lives in a community where the rates of incarceration are high, you have a higher risk of poor health outcomes.”

So you’re unable to make that transition home, and it’s in those settings that people have worsening of their chronic health conditions like HIV, where their CD4 [white blood cell] counts get worse. Or worse yet, they miss their insulin. They don’t know how to inject it, they don’t know how to pull it up, and they’re in the emergency department with a diabetic emergency or hypertensive emergency, or even worse yet, have died. These are the sorts of conditions that we see post-release, and some of the structural explanations for why people don’t do well coming out.

The other surprising thing is that this story of how mass incarceration has impacted health is one that, of course, affects individual patients. But increasingly what we’re seeing is also [that] its impact is pervasive, and its health harms are experienced not just by those that are incarcerated, but by family members and communities. If you are a person that lives in a community where the rates of incarceration are high — even if you’ve never been incarcerated yourself —  you have a higher risk of poor health outcomes. Through that lens, you can see that mass incarceration is one of the greatest health challenges of our time, if not the greatest.

You’ve said that “to achieve health equity, we have to attend to health inequities within the criminal justice system.” Why?

At the family level, you can imagine that if your loved one has been incarcerated, it can lead to fewer resources in the home. If the primary bread earner has left, the cost of visitation, the cost of calling is so exorbitant that it depletes your family home. And the stress of having a loved one incarcerated. All those are paths by which women in particular have a higher rates of heart disease, higher rates of obesity — independent of their own behaviors, how they eat, [whether they] smoke. Studies have shown that they have a higher risk of reporting poor health, and higher rates of cardiovascular risk factors.

For community members that live in heavily policed, really surveilled communities, stress is a reported pathway by which living in those communities, independent of your own risk of incarceration, is associated with higher rates of death, higher rates of perinatal mortality.

It’s not just about over-policing. It’s about the depletion of resources. These same communities are ones where — because of the laws, policies, and practices that are tied to mass incarceration — where there aren’t strong neighborhood ties, where there aren’t strong community resources that create parks, safe schools. And these pathways really affect these large health outcomes of whole communities.

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