Book Review

Prisons and AIDS: A public health challenge

N Engl J Med 1997; 337:284-285July 24, 1997

Article

Prisons and AIDS: A public health challenge
(The Jossey–Bass Health Series.) By Ronald L. Braithwaite, Theodore M. Hammett, and Robert M. Mayberry. 247 pp. San Francisco, Jossey–Bass, 1996. $32.95. ISBN: 0-7879-0308-6

Justice and injustice are the twin leitmotifs that run through discussions of American prisons and jails. AIDS has merely heightened the negative consequences of self-deceiving correctional policies and further reduced the distance between “them” and “us.” Prisons and AIDS provides the following statistics: by the end of 1994, 5 million people were in jail, in prison, on probation, or on parole, and 1.5 million of them were incarcerated; blacks, who make up 12 percent of the overall population, account for 50.8 percent of inmates in state and federal prisons; and federal sentencing guidelines require that someone possessing 5 g of crack cocaine must receive the same sentence as someone possessing 500 g of cocaine in powder form.

Corrections is one of the nation's major growth industries. It is also an industry that disproportionately targets the poor and people of color, many of whom have histories of drug abuse that enmeshed them in criminal behavior in the first place. The AIDS epidemic exploded into the prison system, affecting many people who were already seropositive for the human immunodeficiency virus (HIV) and creating an ideal medium in which the virus could spread — a setting in which same-sex encounters are common and drug use widespread, both of which the corrections authorities must deny. The 1994 report of about 5000 AIDS cases in state and federal prisons reflects an increase of 59 percent over the 1992–1993 data and describes the “highest concentration found anywhere in the United States of persons already infected with HIV.” Moreover, experts agree that these numbers represent an underreporting of the problem.

Although there are other factors that increase mortality in prisons, the escalation of AIDS-related disability and death among inmates is particularly striking. Determinate sentences and “three strikes and you're out” laws have increased the probability of life without parole, contributing to the “graying” of the prisons and making death the final and inevitable stage of confinement for many. But with injection-drug use now the most common risk factor, AIDS is the leading cause of death among inmates, one of whom observed, “Somehow they should not have to get the death sentence just because they have the habit.”

Against the troubling backdrop of disproportionate punishment for persons of color, the authors attempt to explain patterns of institutional, bureaucratic, and professional inaction. While they agree that it is not reasonable to subscribe to “a major myth in the African American community that black males are sent to prison in large numbers to contract HIV,” it is harder to avoid the conclusion that callous disregard for people at risk, both inside and outside prison, underlies the misguided policies that govern AIDS prevention and risk reduction in prisons. The authors document that consensual sex, rape, needle sharing, tattooing, and the subsequent transmission of HIV infection occur in jails and prisons. Yet they note that only two states permit even the limited distribution of condoms or bleach kits. Inmates who might heed the prevention message and reduce the risk of transmitting AIDS are thus denied that opportunity, thereby justifying the authors' comment that “the ineffectiveness of correctional systems' policy responses to the HIV/AIDS epidemic presents not only a missed public health opportunity but also a failure in ethics and human rights.” Given the locus of the epidemic in communities of color — AIDS is now the leading cause of death among black men between the ages of 25 and 44 — and the fact that one of every three black men between the ages of 19 and 29 is under the jurisdiction of the criminal-justice system, the lack of focused programs of education and prevention bolsters the authors' position that only “institutionalized racism” could account for such a level of disregard.

But not all HIV-positive persons remain behind bars. In 1991, the revolving doors of the state correctional institutions in New York discharged 4000 of their 8000 HIV-infected inmates back into the community. It might be expected that simple self-regard would compel citizens to lobby on behalf of programs to promote awareness of risk reduction and help inmates avoid infection to themselves and transmission of HIV to others. Unfortunately, missed opportunities for individual and public health prevention characterize the operation of correctional institutions and the social policies that govern them.

This book comprehensively reviews the literature on corrections and AIDS. The authors combine national survey, demographic, and epidemiologic data to create a meta-analysis of existing information on incidence and prevalence among adults and adolescents. They supplement these data with their own findings, based on interviews and focus groups in four representative correctional facilities, augmenting this discussion with a comprehensive list of resources for education and prevention. This wealth of information is enriched by descriptions of inmate behavior that provide excellent bases for program development. This book contains all the material that an educator might need to design a program of risk reduction or prevention.

Medicine is committed to diagnosis, care, cure, and comfort; prisons and jails, increasingly abandoning their recent efforts at education and reform, are designed to confine and punish. These goals have always been mutually incompatible, and medicine and corrections have worked together because humanity and, more important, the federal courts have insisted they do so. This is not always a comfortable or successful partnership, as is demonstrated by the hundreds of cases challenging the constitutionality of the care provided. The principles of public health demand that the epidemic of HIV and AIDS be addressed inside prisons and jails and that inmates be educated about risk reduction and permitted to protect themselves from harm. Decency, concern for ourselves, and regard for others so demand. This timely, well-written, comprehensively documented, and compellingly argued book provides the template for action.

Nancy Neveloff Dubler, LL.B.
Montefiore Medical Center, Bronx, NY 10467