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Episode 18 – Remedying Health Inequities Driven by the Carceral System

Learning Objectives
1. Understand the history of mass incarceration and its effect on health
2. Recognize how cultures of punishment and control within carceral spaces and within clinical settings impact health
3. Learn how to best care for and support those experiencing violence at the hands of the carceral system
4. Consider how we enact carceral structures and act as agents of the state in our clinical practices
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The Clinical Problem Solvers Antiracism in Medicine Podcast Series aims to equip listeners with the consciousness and tools to practice antiracism in their health professions careers. Learn more.

Audio Transcript

Sudarshan Krishnamurthy: [00:01] Hey, y'all. Wanted to give you a heads up that this episode includes some sensitive content around the topics of racism and sexual violence.

[00:19] [music] Hi, y'all. Welcome back to another episode of the Anti-Racism and Medicine series of the Clinical Problem Solvers podcast. As always, our goal on this podcast is to equip our listeners at all levels of training with the consciousness and tools to practice anti-racism in their health professions careers. On our team with us today, we have Alec and Ashley. Ashley is brand new to our team and this is her first time on the pod. So I have the honor of introducing her today. So Ashley Cooper is currently a student at Harvard Medical School pursuing a master's in media, medicine and health. She recently graduated from Harvard College in 2021 with highest honors in neuroscience and anthropology. She also holds an MPhil in health, medicine and society from the University of Cambridge, where she served as the Lionel de Jersey Harvard Scholar as a recipient of the prestigious Harvard Cambridge Scholarship. A Mellon Mays Fellow and John Harvard Scholar, Ashley aims to increase equity in mental health care dispersal and especially to foster increased accessibility to mental health care for the Black community. Welcome, Ashley. We're so excited to have you on the team. So, on this episode, we hope to discuss the history and roots of the carceral system and its far reaching impacts on the health of women and children today. With that, I'd love to begin with introducing our guests. Their bios absolutely don't do their prolific careers and lives justice, but I'm going to let Ashley and Alec take it away in introducing our amazing guests for today.

Ashley Cooper: [01:54] Thank you so much, Sud. So to introduce Dr. Jennifer James. Dr. James is an assistant professor in the Institute for Health and Aging, the Department of Social and Behavioral Sciences, and the Bioethics Program at the University of California, San Francisco. She is a qualitative researcher and Black feminist scholar whose research lies at the intersection of race, gender, and health with a specific focus on experiences of cancer and chronic illness. Dr. James received her BA. in Political science from Yale University, attended the University of Pennsylvania for her masters in social work and masters of science and social policy and received her PhD in sociology from the University of California, San Francisco. Welcome, Dr. James.

Alec J. Calac: [02:38] Wonderful and welcome, Ashley. Hi, everyone. Alec here. Glad to be back on the pod. Introducing Dr. Nia Heard-Garris. She is a pediatrician and a researcher in the Department of Pediatrics at the Feinburgh School of Medicine at Northwestern University. Also serving in the Division of Academic General Pediatrics and Mary Anne and Jay Milbird Smith Child Health Research Outreach and Advocacy Center at the Anne and Robert H. Lurie Children's Hospital, Chicago. Dr. Heard-Garris recently completed a prestigious Robert Wood Johnson Foundation Clinical Scholars Fellowship at the University of Michigan. She earned her masters of science in health and health care research. Dr. Heard-Garris trained at Children's National Medical Center in Washington, DC for her pediatrics residency. She received her medical degree from Howard University and helped to launch their student round of free clinic serving DC residents. Dr. Heard-Garris earned her bachelors of science and biology at Spelman College in Atlanta, Georgia. Welcome. Dr. Heard-Garris.

Nia Heard-Garris, MD, MSc: [03:38] Thank you so much. So happy to be here. I heard all those bios, and I'm like, “What am I doing with my life right now?” You guys are so impressive. It's amazing.

Krishnamurthy: [03:48] Thank you so much for taking the time to be with us over here today and imparting the wisdom. I think I speak for everyone when I say we're very excited to have this conversation with you. So to kind of really just jump into it, when discussing any system, it's important to understand the historical context surrounding the origins to better understand its role in society today. So similarly, to better understand the functioning and profound impacts of the criminal legal system today, we thought that it would be appropriate to properly understand its history. I was recently reading Mariame Kaba's new book, No More Police, and in that book, she said it refers to policing at its root as anti-Black, anti-indigenous, patriarchal, and ableist, while upholding all other forms of supremacy in the service of racial capitalism. And for listeners who are just beginning to learn about the historical context of mass incarceration, I was wondering if both of you could provide a brief background on the history of mass incarceration, its relationship with health, and add your unique academic lenses to the topics.

Heard-Garris: [05:04] Jen, you want to go first?

Jennifer James, PhD, MS, MSW: [05:06] Sure, I'm happy to. Yeah. And that was a great book recommendation that everyone should check out. I think that this history has been pretty well documented over the last decade or so in both academic and popular media. Things like Michelle Alexander's book, the New Jim Crow, the documentary 13th that's on Netflix. And a lot of folks, including those, have theorized that as a society, we sort of went from slavery to Jim Crow to mass incarceration in this really linear fashion. And there's this quote that came out several years ago from a staffer in the Nixon administration who is basically— I'm paraphrasing this, but barely. He was like, “We had two enemies, the anti-war left and Black people. We couldn't make it illegal to be against the war or to be Black. So instead, we could make the public associate the hippies with marijuana, associate Black people with heroin, criminalize them both and then we could disrupt them, and we could raid their communities and their houses and traumatize them, and everyone would be okay with it. We could vilify them every night on the news.” And that's what they did. It was really overt racism, and it was really successful. And we still have this idea that there are these bad people who need to be incarcerated who are different than us in this distinct way. And we lock up millions of people because of this sort of ideology that's only expanded and it continues to permeate. And it looks different in different eras and times, but it's been a really successful campaign. And just in terms of health, for a long time, we don't know that much about what prison health care looked like in the early days of prisons in the US. But everything we know, is it was bad. Often, it was delivered by other people who were incarcerated, if there was health care happening, who did not have medical training. Then it expanded to there were doctors who couldn't get jobs other places, they didn't have board licensing to practice and they went to practice in prison. And a lot of that has changed in a lot of places because of a lot of advocacy and lawsuits.

JJ 07:04 So there is more access to health care. But that took a really, really long time. There was a lot of medical experimentation that went on, both voluntary and not so voluntary, really poor quality food, really things that are hard on the body, like walking on concrete all day. There are a lot of things about being in prison that are really bad for your health, which we'll get into more. But I also just want to note taking people out of society because of our fragmented health care really disrupts your ability to access health care afterward. It's hard to get employer-sponsored health care if I can legally discriminate against you and not give you a job because you've been incarcerated, which we can do. It's hard to access social services like Medicaid and Medicare if you haven't been paying into them or if you're not seen as the deserving poor who deserves access to services. So throughout the life course, outside of when you're incarcerated, having that history of incarceration deeply impacts your health in many ways.

Heard-Garris: [07:54] Yeah, I don't feel like I can add anything to what Jen said. I mean, it was pretty comprehensive. And I echo all of the things that Jen said, specifically this idea that there are these bad people in the world and we feel like we need to lock them up. People have been made to be marginalized and been made to be poor and made to be Black and made to be minoritized in those ways. And so we have created this system where it's like an enemy system that we have to lock people up that look differently or that threaten us, threaten our power, threaten anything, and have to try to take their power away. I think of the 1960s and the war on poverty. It was also associated with the war on crime and this criminalization, really, of Black poor people, especially when it comes to police surveillance and who is even policed in what neighborhoods they are policed in. And so thinking about those different wars and the fact that we've even had to term them that way shows you who were meant to be the criminals in those different spaces. The war on drugs in the 1980s and the 1990s and the racial profiling that came with that, excessive arrest and sentencing and incarceration, as well as thinking about the penalty. So for crack cocaine versus pure forms of cocaine and how the sentencing was different depending on who held that drug in their possession, and specifically the different racial groups that gravitate it towards one drug versus the other. And then just thinking about the health implications. And I think Jen said this so well. It starts before incarceration.

Heard-Garris: [09:50] It starts with how communities are prioritized or not, like what spaces are available in those communities. Fresh fruits and vegetables and sidewalks or not. And then schools, what opportunities exist for kids to grow up and thrive, and what sort of opportunities exist or don't exist that shuttle them to or away from the carceral system. And when we think about just mass incarceration today, we mostly talk about the people that are incarcerated, but we have to also think about people that are on surveillance in other ways. So they're on probation, they're on parole, or their family is impacted by the carceral system. So even though they themselves are not behind bars or serving time or whatever, they are serving time, the families, the grandmothers, the moms, the kids are also serving those sentences. So I think that's important to remember, especially as we continue this conversation about health and why the health of those who are not incarcerated, but our loved ones of those incarcerated are important and should be a part of the conversation.

Calac: [10:59] Certainly. And I think hearing both of your responses, it reminds me of Isabel Wilkerson's book Caste that is used to visualize racial hierarchies in the United States. And it's unfortunately not surprising for many of us here on the podcast how these implicit and frankly, explicit biases, prejudices, and assumptions come out and manifest towards Black and Brown individuals. And it's just tragic. But unfortunately, it's what we still experience today. It's not something of the past. And I think this also leads us nicely into our next segment with Jen, which is that Dr. James, you've described your work as focused on understanding the individual experiences of health care decision making in carceral spaces among women formally or currently experiencing incarceration from a bioethics perspective. Can you tell us a little bit about what you found from your work so far and speak about some of the experiences or kind of interactions that these women have had to make regarding critical reproductive health care decisions?

James: [12:11] Sure. Yeah, I'm happy to. So I'm not a criminologist, I'm not a lawyer. I have not had any training in actually studying the criminal legal system. I'm a medical sociologist. What I've always studied is decision making. It's been mostly Black women or other women of color learning about how they form relationships with their providers, how they make decisions about their health. And a lot of that work is focused on things like family, on accessing second opinions, on participation in clinical trials, on who you bring in and how you support or navigate biomedicine. And in doing that work, I met a lot of people who they've been incarcerated or they had loved ones who are incarcerated and I wanted to learn more. What is it like if you're facing something like cancer or like a pregnancy, these big things in your life while you're incarcerated? What does that look like? So many of the resources, the tools, the ways we try to empower patients in these circumstances are not available to you anymore. And so yeah, I could spend all day answering this question. But I think what it really comes down to fundamentally, and what I've seen and learned through my research, is that prisons and jails are not healing spaces. They're just not. And we could talk about if they could be or should be or there's different models in different locations in different contexts and if we ended racism or something, I don't know. But right now, in the US, they are not spaces that are designed for healing or care. They're designed for punishment and control. There's a lot of really fantastic and really passionate health care providers who choose to work in these spaces more and more. As I said, it used to be not the best providers who were choosing to work there. I think there's more people who are doing it because they really want to help the people who've been most marginalized and oppressed in our society. But they're still working within this context of punishment and control and violence and trauma, which is not an easy space to give or receive care.

[14:01] And some of the big things that come up in my work often are, first, just the way that security concerns and corrections operations disrupt care, the ways that it overrides health care needs and priorities, the way that the assumptions and presumptions about people who are incarcerated disrupt their ability to seek care. Often, correctional officers serve as gatekeepers to health. So you have to sort of prove to a correctional officer that you're sick enough to need to go to medical, or in some cases, to need to go to the hospital. And they have been taught that they should not believe you. That you, being someone who's incarcerated, are going to manipulate them, you're going to lie to them, you're going to deceive them to do something bad because you're this bad, evil person, who's incarcerated. Which means I heard so many stories of people being told, “There's nothing wrong with you, there's nothing wrong with you.” People being kicked or abused or accused of being drugseeking and then ending up things with like an appendix ruptures and someone dies on something totally preventable. Or somebody is having foot pain for years and they end up having to have their foot amputated because they weren't getting treatment soon enough. And these are, unfortunately, really common stories. Someone told me a story once, they collapsed on the floor. Their legs weren't working. They couldn't walk. They urinated on themselves. And they were told, “There's nothing wrong with you. What are you doing?” So these really horrific examples. And I think what this comes down to in so many ways is, as we said, one of the big things mass incarceration has done, our criminal legal system has done, is created this mechanism to dehumanize people. In order to justify locking someone in a cage for decades at a time often, we have to believe they're different than us. We can't think of them as being like us, being human. They're this dangerous other, and that translates to health. So what patients tell me all the time is that they aren't being treated as patients. They're being treated as inmates, which what they mean is they're not being treated with human dignity. They often use language of, “We're lined up like cattle.”

[15:56] Just the way that the dehumanization of the carceral environment translates to all their health care interactions, including when they're most vulnerable. And what's been really challenging around reproductive health, or one thing I've been studying right now is reproductive health in California prisons. It was originally focused specifically on the forced sterilizations that occurred. To folks that may not be familiar with this, it came out about a decade ago that between 2006 and 2010, at least 144 women who were incarcerated in California prisons have received tubal ligations without proper consent, which was illegal. It was not supposed to be happening at the time. There's been additional laws passed. And through our research and through advocacy work, I mean, there's many hundreds more who had other types of sterilizing procedures during that time. So people who were told, “You need to have a hysterectomy. That's the only thing we can do.” And they said okay, but it turns out, maybe they didn't actually need to have a hysterectomy. It was to treat a condition that could have been left untreated or could have been treated with birth control, and they weren't offered that option. So people don't have resources to look things up on the internet or to go seek a second opinion or to find out if there's other things they can do. You can only trust your doctor. And some of the things these doctors were saying at the time were talking about the expense of, “These people are going to keep having babies. It's going to cost us on welfare. We should just stop that right now.” Which is horrific, right? And so people are being asked to continue to go see those doctors, to make medical decisions within this context, knowing that the people who are caring for you potentially believe that you shouldn't have the right to have children. So I've also met a lot of people who described not seeking care, having horrific symptoms, and for decades, refusing to go seek care because they fundamentally do not trust that the system will do anything but harm them and dehumanize them further, which is just dangerous and bad for health across the life course.

Heard-Garris: [17:48] Can I add to this? Because I just see so many intersections right now. Jen, you speaking, it's beautiful. Thank you for enlightening all of us, really. As you talked about the provision of care within institutions, within the carceral system in this case, there's just so many parallels between hospitals. You're talking about essentially people being gatekeepers. People believing you if you're sick enough, people treating you like a human. And spaces that should be healing or not. And I want to talk about this now. I know it might be better to talk about it later, but just because it came up. For all the people that are listening to this, and they're going to go into hospitals or go into clinics and care for patients and think that this issue is over here and it may not touch them or it may not impact their medical decision making or any of that. I'm just here to tell you that that's a lie. Hospitals also are supposed to be these places of healing and clinics are similarly supposed to be these places of healing. But often, you have security. You have armed guards, you have police that are in hospital spaces, are in spaces that are supposed to be healing. And so I just— I want to make that connection because I think that we often, because of our privilege of being educated or being physicians or nurses or whatever, often walk past that and don't even realize the impact of those presence, that presence of security, policing, guns have on health and healing. And that that policing that we're talking about in the carceral system, that's what people are saying is over there, is right here. It's right here in our clinics.

[19:46] My clinic, we have security. In hospitals, we have security, we have police, we have people patrolling. And when people get out of line or they behave in a way that is contrary to what we think is normal, we have those people step in, we have the security, the people that are here to impose control. And so when you were talking Jen, I was like, “Yes.” There are so many intersections here with incarceration and health that don't even have to happen within prisons or happen within jails or wherever, because it happens in places that people don't necessarily think of as police or a surveillance type of system. So when you said that, I was like, “We got to talk about hospitals and the problematic nature of supervision and control and policing within hospitals.” And then the other thing that you said with respect to the trust. So people are needing care and are not being believed. And finally, when they finally get care, it's things that could have been prevented or they could have gotten a different sort of care, something that was better for their health. We see that too for people that even though they, themselves have not been involved with the carceral system, having a mother or a father involved in the carceral system in some way also makes it more likely that they're going to forgo care. And we don't know why that is, but we imagine it's for the reasons you mentioned. It's like there's already the confidence that's lost. Like, “People didn't treat me with humanity and respect when I needed them the most. And when I was the sickest and they didn't believe me, and I had to prove and prove and prove myself.”

Heard-Garris: [21:38] And so this kind of distancing from seeking care because you're not going to be believed and you have to wait till you're damn near dead to actually be taken seriously. So we see that reverberated in generations post incarceration too. So I think those are important things to kind of say out loud for all the health care providers and clinicians to be and the ones that are out there practicing now. It doesn't stop just because we are not practicing within jails and prisons. That control and that belief in other people, we need to be showing up right now.

Calac: [22:15] Okay, I will be rewatching, relistening to that bit and that back and forth for a long time. Nia and Jen, I wonder, given that we're talking about intersections, also this intersection with substance use and parenthood. We know that the number of cases of children entering foster care due to parental drug use has more than doubled since the year 2004. Incarcerated women who give birth in an incarcerated setting, many go on to lose their parental right. So I wonder, and I wonder, but I feel like we all know the answer, why do we focus so much on incarceration, punishment, taking away children rather than treatment, diversion and healing?

James: [23:12] Nia, do you want to start us off?

Heard-Garris: [23:14] I don't know how much time we have today. Why do we start with that? There are so many reasons why. I think there's some profit motives to lock people up. There are the election and political motives like, “I've put more people away that were going to harm you or harm your neighborhood.” Like, “These scary people out there that are just going to take all your things and kidnap your children.” And there's this fear element, right? But then also, it just is easier. It's easier to lock people up and throw away the key and be done than actually invest in substance use treatment facilities and counselors and facilities and mental health, like psychologists and therapists and all of those things. That takes time, that takes money, significant investment and that also takes you caring about that population so that they can get help that they need. So I think in general, the answer is capitalism. Is capitalism and profit and White supremacy and all of the things that we've kind of been talking about before. But I think the harder answer is that it takes infrastructure. We have to realign incentives. When we think about health care specifically and how we're paid and how things are reimbursed, you don't get really reimbursed for preventative care and counseling and helping and referring people to therapy and doing all of those things. They're not aligned with how health care continues to operate.

[25:02] But specifically, when we think about foster care and kinship care, taking kids away or taking people out of families instead of giving the families the support they need in place, it's a much harder thing. And that means totally dismantling many of our systems and how they operate and restructuring into something totally new and totally that may not exist yet. So it's a hard answer and easy at the same time, but I think there's just so, so many layers to it. There's so many layers from the politics to the policies to the capitalism and the people who stand to benefit and profit.

James: [25:49] Yeah, I agree with all that. I think my summary of what you said is, it's capitalism, it's racism, and it's complicated, but also simple at the same time. And I think you all have had Dorothy Roberts on the pod before, and she has a new book out called Torn Apart, which if you haven't read it, you have to. It extends the work that she did, gosh, 20 years ago. Was that when Shattered Bonds came out? I don't know. A long time ago. And it's really phenomenal look at the system that she calls the family policing system, which we often think of as the CPS, Child Protective Services. And what I've been thinking about, this is like a preview of a preview of a thought I'm trying to create in the future. It's very much like I'm in my head still trying to think about this right now. So I talked a little bit at the start about sort of this slavery to Jim Crow to prisons. And what I've been thinking about a lot is the same sort of linearish trajectory around family and reproductive control. And if we think of sort of slavery to the eugenics area to incarceration as doing a similar thing. And if you look back historically at slavery, if you look at what we did to Native Americans, if you look at so many immigrant things, the right to family, what we think about as reproductive justice, to birth your children, to choose if you want to have children, to give birth to them and to raise them has never been a thing that's existed for people of color and poor people in this country. We changed the rules and the laws about how paternity was passed on in slavery. It used to always be it's like a paternal lineage. And then we were like, “Nope. Actually, if you're a slave and you're a woman, your baby is a slave, doesn't matter who fathered it.” We changed the entire rules of how we did it to make sure that who had control over these children were slave owners. There's never been a guarantee that people of color and poor people should have a right to raise their children, let alone support from society to raise their children. And that continues today.

[27:43] We problematize, we make assumptions, we interrogate what families, poor families and families of color are doing and their parenting in ways that we do not for other families. And incarceration is both a symptom of that. You can be incarcerated for your involvement in the system or for assumptions about things like drug use during pregnancy or other things that say that you're a dangerous parent. But also being incarcerated can prevent you from raising the kids you have. In a lot of states, if your kids are in foster care for a certain amount of time, your rights are automatically terminated, even if what you're incarcerated for had nothing to do with your parenting. You can lose rights to your children forever. And if you're incarcerated, if you incarcerate someone from the time they're 20 to the time they're 50, they are not having more babies. You have essentially, whether or not you forcibly sterilize them in a medical procedure, you have created a world in which they can not have children. So the incarceration system plays just a pivotal role in the formation of families. And then we blame people for it. We're like, “Where are all the fathers? Where are all the Black fathers?” Well, we locked them up. We took them away. We made it so they couldn't get jobs. We made it so they couldn't live in these houses because you lose access to public housing if your partner is there with you. We've done this really quite intentionally. And then we continue to blame families and criminalize and surveil even more. So I think we must really center the role of incarceration sort of in our modern day eugenics project, in our modern day reproductive and family control, and thinking about who has a right to children. And I think, anyway, I could go on. I could get into Roe v. Wade and all this stuff. But yeah.

Cooper: [29:17] Thank you both so much for really elucidating how slavery has informed current day from the other structures and how really we're seeing the impact the carceral system having on families today is really vested of slavery. And Dr. Heard-Garris, I know your work has studied adverse childhood experiences and the mental health impacts of parental incarceration and juvenile justice involvement on young adults. Additionally, along with Dr. Rachel Hardeman, who we had on our podcast series the very first episode, you've written about the harmful effects of policing on health and rediscusing its role in medicine. I was wondering if you could speak to the effects of structural racism and early exposure to the criminal legal system inflicting worse health outcomes later in life.

Heard-Garris: [29:56] Yeah. So we talked a little bit earlier about how one person involved in a carceral system and it sets them up, from losing their insurance to not being believed to very severe health outcomes. So when children and adolescents have parents that are involved in the carceral system in some way, those health impacts don't necessarily skip over them. And so similarly, we see that kids and young adults that have had a parent incarcerated, usually it's a father, but now actually, the rate of maternal incarceration is rising because of the rate of women that are being incarcerated is rising. But we're seeing that those that have had a family member, a mom or dad in some of the studies that I've done, we're more likely to smoke cigarettes, are more likely to have substance use issues, prescription drug abuse issues, as well as mental health, PTSD, anxiety and depression. And so I don't want to leave it there because that's not everybody, right? And I don't want to paint it as like, “If you have a parent that's incarcerated, then you are doomed.” Like, “These are things that are going to happen to you.” Especially when we're talking about this in the framework of adverse childhood experiences, I really got into thinking about adverse childhood experiences because of resilience and because of the people who have experienced these sorts of adversities and traumas, really, and still go on and still are able to do amazing things and are able to help other people. With that being said, I think the system needs to be changed so people don't have to weather these storms.

[31:52] And having a parent incarcerated, having a loved one incarcerated, influences your physical health, your mental health, as well as your access to care. And again, we don't know exactly what's happening with the access to care. If people are like— their confidence in these systems, like the carceral system, the foster care, child welfare system, and the medical health care systems are just shattered because of what they've seen and what they've lived through, or if there's something else fundamentally happening, because not having a parent there, having that parent there growing up has changed how you interact or you think about caring for yourself. We don't know. So we're still trying to figure those things out. But ultimately, long term, as these children grow up and become young adults, we continue to see these issues. And the shocking thing for me is we looked at— some of my studies, we looked at having a mother incarcerated versus a father incarcerated. And my initial hypotheses around these issues were that if a person had a mother incarcerated, the health impacts would be worse. And at least the early studies we've done, we have not found that to be true. People that have had fathers incarcerated, the impacts were greater, especially around behavioral health stuff. And a lot we can guess and hypothesize why that may be. It could just be the numbers. More people have fathers incarcerated when we looked at these studies. But again, it's changing and it's rising and it's becoming different. And the other reason why I got into this is because when I was seeing patients, one of my colleagues was asking me, “Well, do you ask?” And I'm like, “Do I ask what?” And they're like, “Well, if they're there just with one parent or with a grandmother or so and so, do you ask where the parents are?” And I frequently did not ask.

[33:44] And as we started to ask more, you start to hear more and hear more stories about parents being incarcerated. And sometimes, grandmother is caring for these children and saying, “Well, they don't know. They don't know where their dad is. We said that dad has gone away or is on business.” And so that's brought up a whole bunch of other issues about how to talk to kids and how to talk to adolescents about incarceration and prison and the things that their parents are living through. So there's a whole bunch of things that have come from this work, and I don't want it to end on their health outcomes are so much worse and this is a really sad story. It is a sad story. And that incarceration needs to be— in this country, needs to be totally changed. And actually, we would argue that people shouldn't be incarcerated. And I don't want to end it there. But I do want to say that this population, these kids and these young adults that have experienced incarceration, either directly because then they're more likely to go and be incarcerated themselves in the juvenile systems or the adult systems, or indirectly experienced incarceration just because of their loved ones being gone, we need to support this group and we need to think about ways to provide them the mental health care that they need, the physical health care and the access that they need, the insurance that they need, the school and education supports that they need, because it's wrapped around and taking one family member out of the unit impacts all of the family.

Cooper: [35:21] Absolutely. Thank you so much for sharing that. Dr. Heard-Garris and Dr. James, I know that both of you have conducted extensive research on the impact of the criminal legal system on health of women and children. And from your research, I'm wondering what are your perspectives on interventions we could undertake to remedy health inequities experienced by women and children impacted by the carceral system?

James: [35:41] I mean, it's hard to start any place other than incarcerating fewer people. I think we incarcerate a lot of people for reasons that are not clear to me and don't make sense when sort of we think about any rationale for what the role of incarceration is. We shouldn't be incarcerating as many people who we're incarcerating. But I think if we're thinking about what changes need to be made while people are incarcerated, or if we make the assumption that prisons and jails are going to continue to exist in some way, I think there's a lot of different models and a lot of ways we can think about getting people better care. I mean, first is just thinking about who's doing the health care. In a lot of states, in a lot of places, there is for profit companies who are running a health care system in a way that is maximizing profits over patients, which is true across our health care system, right? You find that a lot of hospitals too, but it speaks to we don't have a strong single payer health care system in general, and that extends to our prisons. We don't have a system that people can easily access care as they go inside and out of prisons and jails and in the community. People should have consistent and equitable access to high quality care, and they do not. Before, during and after incarceration is a huge problem. I think we think about things, I think it's what Dr. Heard-Garris was talking about, is access to children, access to family. That's not something that has been prioritized and it's something that's harder, actually, for incarcerated women. And so most states have fewer women's prisons than men's prisons, which means women are more likely to be incarcerated somewhere very far from home, hard for their children to visit them. It's very, very expensive to do phone calls in prison. And so it's hard for people to be in communication. A lot of people talk about a reason people have illegal cell phones in prison is so they can have regular communication with their families, which is really good if we're thinking about a child-centered model of people should have easy access between parents and children to maintain their relationships, to help with homework, to talk about problems, to talk to teachers. And that's not something that's allowable right now. And people should have easier visits. It's interesting, you might not think this, but when men are incarcerated, the people who— it's women who are taking care of their children.

[37:39] It's women who are coming to visit them and bringing their children to them. Often, when women are incarcerated, it's very high likelihood that the father may also be incarcerated. It's often other women who are taking care of the children. It's an incredible economic burden having a family member who's incarcerated. And people feel like they can't ask as much for visits, they can't ask for support they need inside. So women actually struggle in some ways more to have the resources they need to have while incarcerated, which has effects on health too, what food can you afford to buy. Usually, the amount of food you're getting from the prison is not sufficient and you need more. How are you doing that? What skills and programs are available to you really varies really widely across prisons. And I live in San Francisco, California. We're near San Quentin. There's a lot of resources and a lot of programming at San Quentin that is not nearly equitable to a lot of facilities that women are housed in and to many facilities in general. So it's a very unequal landscape. But really, I think we need to prioritize believing people about their health, getting them access to health care. And really, I think something I've heard from some of the doctors who work inside, who seem like the most passionate and the best doctors and they're like, “The care I give is exactly the same. I give exactly the same care inside as I do outside.” And I think that's really interesting. Should that be the goal or should we think this is the most vulnerable, marginalized, oppressed community, they need an extra heightened level of care. They need to be getting care beyond what other people are getting, just like the people in Safety [inaudible] care beyond what the people who go to the UCSFs and the Harvard Medical Centers are getting care, right? And the other thing I think about is trauma. That's something that comes up. 90% to 98% of people who are incarcerated in women's prisons are survivors of physical, sexual, or emotional abuse. It's a universal experiences of trauma. Often, that is what led to their incarceration, is relationships or traumatic events. And that is not prioritized in health care.

[39:31] So people go into situations where they're told, “Do you want to do this?” And people have said to me like, “I just got to prison. In my experience, when I say no to a man, that becomes a violent encounter. So if a male doctor is telling me to do something, I'm going to do it no matter what.” So how do we think about bringing a trauma-informed lens into care, which needs to be in every scenario, but especially in a place where you know every single person there has experienced trauma?

Heard-Garris: [39:55] I would agree. Snaps with everything Jen said, because, yeah, for me, I also start at a place with respect to locking up fewer people. To me, that is a good next step. For all the people that are currently incarcerated, decarcerating those people, especially people are really scared that the jails and prisons are going to open up and it's going to be all these people. But a lot of people, the non-violent folks that are in prison and drug offenses. If you just even think about the legalization of marijuana and how many people were serving time for marijuana, and now marijuana is legal and there's dispensaries on every corner and the like. So I think there should be efforts to decarcerate people as a whole and think about how do you decarcerate people and then offer support. We can't decarcerate rate people and just expect— like Jen said, it's harder for them to get a job and provide for their family and get health care, all of those things. So how do we help people actually survive on the outside and do the things that they need to do, feed themselves, educate themselves and their families and be able to live a life outside of prison? So I think those are places to start. As a pediatrician, my slant, my bias always will be to invest in communities, prevent incarceration from even being a thing. Because we have communities that have amazing school systems and that people have jobs and people have transportation to the things that they need to get to, and people have the health care needs met, and that prisons and jails aren't necessary. First of all, I know they're not necessary now, but just ever.

[41:51] There is no need because everybody in this society has everything they need to thrive, especially those that have been marginalized, especially those that have been taken advantage of and exploited. So I'm saying, namely the people that help to build our country and build the systems in which they're now subjected to. They built America and yet, now are still serving time or still serving all these sentences. And the other thing that I would also like to think about is how individuals are punished because they're poor and how many people are sitting in jails awaiting trials just because they can't post bail. And how do we think about those people? Just because they can't afford to post bail, do they need to be sitting in jail and just wasting their life and wasting their time there? So there's so many angles and there's so many things that need to be done. I just want us to start somewhere.

James: [42:55] I just want to echo all of that and just add one thing, which is, I think so much of what Dr. Heard-Garris is describing, I think falls under the umbrella of sort of the A word, the scarlet A, which is abolition. And I think people have this idea that abolition means like, “Okay, at 12:00, noon, we're unlocking, and that people are running out of prisons and that's it.” And no, that's not what abolition is, right? Abolition is, “Let's make investments in community. Let's make investments in education and health care and mental health and substance use and capitalism and all these things.” Not in capitalism, in giving people money so they can afford to meet their basic needs so that we don't need prisons and jails. It's making sure we have the resources available before what would have been incarceration and when people are returning home to the community. And I'll just say we did a project looking— at the beginning of COVID in San Francisco, where I live, we had a very sudden decarceration in our jail population. It dropped 40% due to both local policies, state policies, partially because of the pandemic and partially because, at the time, we had a very progressive DA, who was unfortunately recalled and is no longer in office. But what we found is for people with mental illness and substance use disorders, there was actually a lot that was really challenging. We have built and designed so many of our systems to be reliant on incarceration. We have all these ways that you can access services, all these social supports, but a lot of them were like, “You have to get arrested first and then get diverted to mental health court or drug court, or you have to be arrested, spend 24 hours in the detox cell, and then you can get a bed.” We don't have ways for people to access care if they aren't engaging with these systems. That is a fundamental problem. Your entree point to resources and care shouldn't be via incarceration, via the legal system. We need to imagine ways where we can invest in community that are totally divorced from this system.

[44:41] And instead, I think very, very well-meaning people who want to have fewer people incarcerated have built interventions on our system, which only sort of further entrenches and meshes health care and social services with the criminal legal system.

Krishnamurthy: [44:59] Wow. Yeah. This discussion has just been so, so rich and genuinely has just kind of left me like—like Alec, I will be going back and listening to this over and over, and I wish that we could kind of keep this just going. Unfortunately, we have to wrap up for the sake of manufacturing this into a podcast. I think that we've kind of started all the way back with context around the history of the carceral system, gone on to talk about how to best support and care for those experiencing the most violence at the hands of the carceral system, and then gone all the way to how we might prioritize decarceration and talking about abolition and ways forward. So this has been an unbelievable discussion. I'm wondering for our listeners who will don their White coats, get back in the clinic, go back in the hospital tomorrow, what are some practical applications or practices that they can incorporate into their clinical practice to help reduce the impacts of mass incarceration on their patients?

James: [46:14] Yeah. I think Dr. Heard-Garris really spoke to a lot of this earlier where she talked about the overlap and the intersection of carcerality and medicine. So I think both on— if we're thinking specifically about incarceration, and I think just remembering that we have 2 million people incarcerated in our country on any given day, millions more on probation and parole or pre-trial, not to mention immigration. I mean, we have so many forms and ways that we incarcerate people in this country. In some communities, I think it's among Black women, 50% have a loved one who is or has been incarcerated. So no matter almost any specialty, almost any way you're practicing medicine, you are interacting with incarceration, right? We spend a lot of time— I didn't go to medical school. But you spend a lot of time learning really minute things about diseases you may never see in clinical practice if you go into a different specialty, unless maybe you're like, I don't know, a Beverly Hills plastic surgeon. And then I think you probably are still seeing people who are incarcerated almost every place you're working. And probably if you're listening to this podcast and wanting to work with people who are vulnerable and marginalized, this is going to be a part of your care. And I think that's important to think about and remember and think about how has this come up? Are you asking about things? Are you asking people about their histories of trauma? Are you asking about incarceration or how should you ask about incarceration or about where's dad today? Where's mom today? When your patients come in, how are you understanding this? But then I think the critical piece is also remembering, no matter who your patience is, what are the ways in which you as a provider are enacting a carceral framework? Are there security guards in your ER, and what are they doing and who are they threatening and who are they making it who does not want to seek care or who leaves early? Are you chemically or physically restraining your patients, and why and who is it? Are you ordering tests or are you doing drug screening or cavity searches on behalf of police and what are your implications of that? Who are you assuming might have a substance use disorder? Or when are you calling CPS, or when are you engaging with all these systems that surveil?

[48:12] And are you doing that in a way that is necessary, that is protecting your patients or not? And are you thinking critically about it? And that's not to say that any of those behaviors or practices are necessarily always bad or always unwarranted, but I think we need to remember that this is carceral. This is the doctors acting as agents of the state. It's doctors acting in partnership with police. And I think we need to think critically about that and about the implications of that instead of just presuming it's what is done. So I think that's my advice, is think carefully, think critically, read a lot, learn a lot about both your patients and about these systems that impact your patients life and the way you give care.

Heard-Garris: [48:53] I mean, I think you can just end it there. Done. Dr. James said literally everything. I mean, I think as a pediatrician, I was blown away that 5 million children have had a parent that they've lived with go to jail or prison, and that's just that they've lived with. So we know it's an underestimate. 5 million. That is wild to me. So I was missing them. Before my colleague asked like, “Do you know where mom or dad or whoever it is, is today?” And I didn't. It was a miss. It was a miss because that is an opportunity, as Dr. James said, to provide better care, to go above and beyond. And you know the disparities, you know the health implications and impacts. So you don't use that to marginalize people. You use that to go above and beyond and say, “You know what? I have other patients that have experienced the same thing, and they found these programs that have been helpful, or I personally volunteer there, and I can say for sure, they do great work and would you like a referral or how can I best help you today? What do you need today? How are you doing?” Those supports, I think, go a long way. And I think, like Dr. James said, we sometimes do act as agents of the state. And the power and the privilege that we have, I think acknowledging that and understanding and not walking in and saying, “I treat everybody the same.” Because there are many studies that say that you don't. There are many studies that say that you don't. So the sooner that you can understand that and recognize that and try to do better, you're going to do better for your patients. You're going to do better for your families and communities and society. And those are the type of doctors we need. That's the type of health care that I want my kids to grow up in. Not the health care it is today.

Krishnamurthy: [50:45] I think it's appropriate only to end right there. Thank you so much both of you for joining us today and really just imparting so much wisdom. It was amazing to talk to you all. [music]

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If applicable, all relevant financial relationships have been mitigated.

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