Study finds strong connection between incarceration and early death

Journal: JAMA Network Open

Title: Elevated death rates associated with incarceration emphasize the need for health care interventions both during and after incarceration

Author: Utsha Khatri, MD, Assistant Professor of Emergency Medicine, Population Health Science and Policy, and Global Health and Health System Design, at the Icahn School of Medicine at Mount Sinai

Bottom line: This study shows individual incarceration rates and rates at the county level (the number of incarcerated individuals per 100,000 residents) are strongly associated with increased mortality in the United States. Additionally, people who weren't incarcerated but live in counties where a higher number of their fellow residents are in jail or prison were also linked to increased all-cause mortality.

Why the study is important: Elevated death rates associated with incarceration emphasize the need for health care interventions both during and after incarceration, especially as the United States faces the ongoing overdose crisis.

Why the study is unique: This is the first national study to jointly examine both individual and area-level incarceration in relation to all-cause and overdose mortality. It is also one of the largest studies that is representative of the U.S. population, analyzing more than 3 million people with 11 years of follow-up data.

How the research was conducted: Researchers did a retrospective analysis on data from the American Community Survey, a government survey that collects detailed information about people's lives, such as age, race, income, and living situation. They analyzed more than 3.2 million adults in the United States for more than a decade (2008-2019). Researchers linked those survey responses to official death records from the National Death Index to track who died and what they died from. They also analyzed county-level jail incarceration rates using data from the Vera Institute of Justice to study how personal incarceration affects health-and how living in communities whose residents experience high incarceration rates influences mortality even among people who weren't incarcerated. The team classified people as "incarcerated" if they were living in jail or prison at the time of the survey; everyone else was considered "not incarcerated," and adjusted for many factors that influence health and mortality, including age, gender, income, education, race/ethnicity, and the poverty level of each county. They then determined how individual incarceration status and high incarceration rates in each county were associated with death from any cause and death from drug overdose. 

Study results: Incarcerated individuals were 39 percent more likely to die from any cause than those who were not incarcerated. They were also three times more likely to die from a drug overdose. People living in counties with higher incarceration rates faced higher overall death rates, even if they themselves weren't incarcerated. For every 10 percent increase in a county's jail population, there were approximately 5 additional deaths per 100,000 people.

Incarcerated individuals were more likely to be younger, male, Black, or Hispanic, and to have lower levels of education and income. They also tended to live in communities with higher poverty rates and higher percentages of Black residents, which are linked to worse health outcomes.

Many counties in the Southeast had some of the highest jail incarceration rates in the country and also experienced elevated rates of all-cause mortality. Individual counties were not identified in the paper, but the regional pattern highlights the overlap between high incarceration and poor health outcomes in this area.

Main takeaways: People who experience incarceration face substantially elevated risks of premature death, especially from drug overdose. This underscores the urgent need for patients to be provided quality and evidence-based health care access before, during, and after incarceration, including medications for opioid use disorder. Clinicians should be aware that incarceration history is a major risk factor for mortality, particularly from overdose, and should screen for incarceration history as a social determinant of health.

Quotes: 
"Incarceration increases mortality at both the individual and community levels, highlighting its significance as a critical public health issue," says Dr. Khatri. "Strengthening health care services in communities with high incarceration rates-such as expanding access to community-based primary care, a strategy shown to reduce population-level mortality-may help address the structural factors contributing to poor health in these areas and mitigate the associated elevated risks."