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Health Inequities: Gender, Race, and Incarceration in the U.S.

Purpose:

All human beings will, at some point in their lives, find themselves in need of medical care. For many, this experience involves driving to a local clinic or hospital to seek the help of a physician, nurse, or another healthcare worker. However, for prisoners, medical care can often be more difficult to access. Furthermore, the relationship between prisoners and the healthcare system is colored by an oppressive history of systemic marginalization and unethical treatment which is often shaped by discrimination based on race, gender, and sexuality. 

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Source: The New York Times

One way in which we can begin to hold conversations to discuss these issues is through literature. At its core, literature is a means of communication. Thus, it is crucial to examine how text can be used by healthcare workers, patients, and oppressed individuals to advocate for change and draw multidisciplinary connections. This research is aimed at examining how literature can be used to identify, connect, and amplify marginalized voices in discussing and championing reparations of these systemic issues. Additionally, this project seeks to compile a syllabus which will guide students through various texts to build understanding of social determinants of health, the connection between humanities and medicine, and how writing can be used as a form of advocacy in healthcare.

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Methods:

Using databases, I was able to access archived literature — including news articles, theses, and research publications — and longer texts related to prisons, racism, reproductive justice, and LGBTQIA+ rights in healthcare. Through close readings, I identified texts I believed to be most pertinent to the course being constructed. I searched through bibliographies to find related texts which were compiled into an archive of literature which can also be used in lieu of or to support the texts listed in the syllabus. To be included in the syllabus or the archive, the pieces had to discuss (i) the history of the prison system; (ii) the history of medical practice in prisons; (iii) the relationship between the prison and/or healthcare system and discrimination based on race, gender, or sexuality and (iv) racism, LGBTQIA+ rights, and/or reproductive justice generally.

Source: Johns Hopkins Magazine

Results:

Through close readings, I was able to identify a series of texts — and additional related literature — relating to the prison and medical systems, their relationship, and their ability to uphold systems of oppression. These texts encompassed nuanced views of the relationship specifically between healthcare in and outside of penal systems and reproductive justice, racism, and LGBTQIA+ rights. Across these readings, I found that literature composed by healthcare workers, activists, prisoners, and writers about these topics can serve as ways of educating others and advocating for change. In the syllabus included below, I outline the role of each unit and the associated readings, as well as guiding discussion questions. While many of these pieces function as educational tools — and the subsequent questions are designed to provoke critical thinking of biopsychosocial factors — it is also important to examine how the author’s writing impacts the text’s ability to function as a mode for advocacy, personal narrative, or presenting a counterpoint. While many of the readings argue for reform, some older texts listed in the archive highlight older (though possibly racist, homophobic, and misogynist) ways of thinking. While these opinions may be controversial, it is equally important to examine the egregious missteps taken as well as the progress that has been made. Through discussing the literary merits and mistakes made across these various readings, I hope that students will be able to see the utility of literature as a tool for investigating social justice issues in the medical and various intersecting fields.

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Source: The New Jim Crow by Michelle Alexander

Part 1: Overview of the Carceral System

Before examining the role of medicine and its influences in prisons, it is first critical to address the American carceral system itself. The American penal system was first established in the 1800s and became rooted in practice during the 1830s through the advent of the Pennsylvania system. This system was first implemented in two major prisons, Eastern State Penitentiary on the outskirts of Philadelphia and Western State Penitentiary in Pittsburgh. The Pennsylvania system codified the practice of separating inmates, solitary confinement, and even menial job and wage systems. Prisons became vessels for collecting social deviants — alcoholics, the homeless, people with mental illnesses — and housing them separately from the rest of “polite society”. After all, penitentiaries were places for people to seek “penitence” through hard labor. Over the next century, prisons would continue to quietly thrive across the country until the late twentieth century. By the 1970s, with the War on Drugs in full swing, the modern prison industrial complex emerged. Prisons grew explosively across the country. Prisoners were being put to work, doing menial jobs for little to no pay. Some of their work helped run the facility while other work was contracted to prisons, viewing the inmates as a free source of labor. Individuals were given long term sentences for minor and non-violent offenses to fill the jail cells and line the pockets of those who owned the cell blocks. Meanwhile, lack of oversight, poor medical care, cramped living conditions, and abuse from guards ran rampant with little to no control by any regulatory forces. Thus, the modern carceral system was born, solidifying the existence of a state sanctioned machine of oppression.

Suggested Readings:

  1. The New Jim Crow, Michelle Alexander — Michelle Alexander discusses the evolution of the modern prison-industrial complex from its conception in the slave era to its relationship with the War on Drugs and police brutality.

  2. “A National Survey of Medical and Health Facilities in Prisons, 1970", Glen A. Aker — In his Master’s Thesis, Glen A. Aker examines the emerging role of medicine in the prison system during the 1970’s, a time when the penal system was seen as a mode of reforming and rehabilitating prisoners.

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Guiding Questions:

  1. How has the carceral system changed over the past century? How has it changed since the beginning of slavery?

  2. What might be the connection between the carceral system and medicine in a general sense?

  3. Why does understanding this system matter for all healthcare workers, even those who don’t work in prisons?

  4. How do these texts serve as a mode for advocacy and education? What are their limitations?

  5. How do the authors structure their arguments and research to more effectively communicate their beliefs? 

  6. What is the role of foregrounding these texts in historical context?

  7. Glen Aker’s thesis was written in 1970. What are some of the merits and limitations of his writing?

Part 2: Racism in the Carceral System

While discussing any type of social institution — such as medicine or prisons — it is important to recognize the inevitable roles that race and racism will play. Although medicine is often thought of as a noble profession focused on healing, there are many instances where doctors are unprepared to handle the impacts that race and racism have on healthcare delivery. Thus, discussions about the medical system can never be separated from discussions of race and racism. As Michelle Alexander discusses in her text, The New Jim Crow, racism within the carceral system — through factors such as Stop and Frisk or the War on Drugs — has led to the imprisonment and death of many Black and Brown people in the U.S.. Therefore, one cannot discuss the prison system without accounting for race or racism either. When focusing on medical care in prisons, we must account for the compounding effects of racism within both of these institutions. This is especially important considering the history of medical experimentation on prisoners. Additionally, we must consider how race impacts medical care after someone is released from prison to assess if our society has proper safety nets to provide for those attempting to exit the carceral system.

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Source: Medical Apartheid by Harriet A. Washington

Suggested Readings:

  1. Medical Apartheid, Harriet A. Washington — Harriet A. Washington discusses how the medical system has systematically oppressed and abused Black people through unethical experimentation and neglect of care. She tells this story in order to generate recognition of this dark history and the necessary steps that need to be taken to face racism in medicine.

  2. Homeward: Life in the Year After Prison, Bruce Western — In this text, Bruce Western examines how inmate’s lives are shaped by prison even after they have been released, and how factors such as abuse, addiction, and mental illness can make it harder for inmates to reintegrate in society.

  3. “Discrimination based on criminal record and healthcare utilization among men recently released from prison: a descriptive study”, Joseph W. Frank et. al — This study examined the role of discrimination based on criminal status in healthcare settings.

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Guiding Questions:

  1. How might COVID affect prison populations, specifically Black and Brown prisoners?

  2. Does locking people up for things like minor drug offenses play a role in the medicalization of illnesses?

  3. How does our medical system fail people who are leaving prisons? Is there a safety net for them? Does race play a role?

  4. What are the consequences of discriminating based on criminal record? How might that show itself in our interactions with patients?

  5. What are some good/bad aspects of this study?

  6. How do the authors’ positionality (i.e. race, class, gender, etc.) affect their telling of the stories in their respective texts? How does this impact their ability to advocate for their subjects?

  7. How does the author’s use of POV affect the merits of their writing?

  8. What tools do the authors utilize to convey their arguments? Is it convincing?

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Part 3: Reproductive Care in the Carceral System

Reproductive rights and healthcare have always been, and still remain, a tenuous issue. Broadly, reproductive care encompasses any healthcare involving reproductive systems and people who have uteruses; this includes transgender folks and does not depend on one’s fertility. As a result, reproductive healthcare also intersects with many social determinants of health including environmental factors, education about maintaining safe relationships, gender inclusivity, and racism. Thus, it is also important to consider how delivery of reproductive care and rights is altered in the carceral system. From parenting classes to pregnancy visits, reproducing bodies face altered, and sometimes harmful, conditions when kept in prisons. It is important, as healthcare workers and citizens, to understand how the medical system can better advocate for safe reproductive care within the penal system.

Source: University of California Press

Suggested Readings:

  1. Medical Bondage: Race, Gender, and the Origins of American Gynecology, Deirdre Cooper Owens — In this text, Cooper Owens guides the reader through the stories of exploited black enslaved and Irish immigrant women to examine the horrors behind the development of modern gynecological procedures, instruments, and techniques.

  2. Jailcare, Carolyn Sufrin — Sufrin takes an anthropological perspective when examining the lives and medical care of pregnant inmates and mothers living in a San Francisco jail. 

  3. “Reproductive Justice Disrupted: Mass Incarceration as a Driver of Reproductive Oppression,” Crystal M. Hayes — This paper examines how prisons deny women, particularly women of color, access to reproductive care such as abortion, contraception, and the ability to parent their own children.

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Guiding Questions:

  1. How does being imprisoned limit reproductive autonomy?

  2. How is the experience of parenthood disrupted by the carceral system?

  3. Why is the carceral system seen as a “rehabilitation” center for “bad parents”? How does this affect parenting decisions made outside of prisons?

  4. Do the authors make their discussions about reproductive justice accessible to those who do not have uteruses or can’t reproduce? If yes, how do they do this?

  5. How does race factor into reproductive justice in prisons?

  6. What is the utility of writing about these subjects as an author (ex: Carolyn Sufrin writing Jailcare)?

  7. What do the authors do to center their subjects in their stories? Are they successful in doing this?

  8. How do the authors’ positionality (i.e. race, class, gender, etc.) affect their telling of the stories in their respective texts? How does this impact their ability to advocate for their subjects?

Part 4: LGBTQIA+ Care in the Carceral System

LGBTQIA+ folk are exposed to many negative social determinants of health outside of prisons — including misgendering, homelessness, assault, and addiction. Current medical systems are just beginning to listen to and reform based on the dire concerns and needs of the LGBTQIA+ community. However, within prisons, this type of care is rarely provided and often trans and nonbinary inmates face disporportionate levels of violence and harm. Additionally, because many members of the community have mental health conditions or struggle with addiction (often caused by incredibly harmful social conditions), prison has often been used as a means to isolate and control LGBTQIA+ folk. LGBTQIA+ health and rights encompass issues of race, class, and reproductive care, placing these issues at the epicenter of social justice, the medical system, and carceral institutions.

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Source: Queer (In)Justice: The Criminalization of  LGBT People in the United States by Joey L. Mogul, Andrea J. Ritchie, & Kay Whitlock

Suggested Readings:

  1. Captive Genders, Eric Stanley & Nat Smith — This is a collection of essays by transgender, gender-variant, and queer authors and activists discussing liberation from the prison-industrial complex.

  2. Queer (In)Justice: The Criminalization of LGBT people in the United States, Andrea Ritchie, Joey L. Mogul, and Kay Whitlock — Whitlock examines records of queer criminals, defendants, and prisoners to identify how stereotypes influence and harm LGBTQIA+ folk in prisons whether a crime was committed or not.

  3. “Psychiatric Facilities in Prisons and Correctional Institutions in the U.S.,” Warren S. Wille — Though mental illness intersects with gender, sexuality, race and racism collectively I chose to include this article here since students will have learned about all of these factors by this point in the course. Additionally, because LGBTQIA+ folk disproportionately suffer from mental illnesses (again, not because of their queer identity, but because of negative environmental and social factors) I feel that this article could be interesting to examine through a queer lens.

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Guiding Questions:

  1. How does race factor into LGBTQIA+ care in prisons?

  2. How does reproductive justice factor into LGBTQIA+ care in prisons?

  3. What topics or questions do you think still need to be investigated?

  4. How are prisons used as a form of social control?

  5. How do the authors make these experiences accessible to their audience who may or may not be members of the LGBTQIA+ community?

  6. How do the authors’ positionality (i.e. race, class, gender, etc.) affect their telling of the stories in their respective texts? How does this impact their ability to advocate for their subjects?

  7. What do the authors do to center their subjects in their stories? Are they successful in doing this?

  8. Many of the essays in Captive Genders are personal narratives. Compared to the previous sections, why is it especially important to center personal narratives when discussing LGBTQIA+ marginalization in prisons?

Conclusion:

Hippocrates writes that, “No one can understand the science of medicine unless he knows what man is”. Literature is just one of many ways through which one can investigate medicine through a humanistic lens. This project has found extensive literature that attempts to tackle issues of injustice in healthcare present in carceral institutions from a variety of angles. As described in the syllabus, each text selected is designed to educate students about these various perspectives. By examining the literary and rhetorical devices utilized in these texts, students will gain a deeper understanding of the humanistic values and social justice issues that arise in medicine. Additionally, I hope that they will gain an appreciation for the role of the humanities in medical education and practice. While understanding the science behind healthcare delivery is important, I hope that this course and its associated texts will shed a light on the valuable role writing and communication plays in medicine.

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