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Mass Incarceration, Racial Disparities in Health, and Successful Aging
posted 07.06.2018

By Robynn Cox

Over the past forty years, the United States has taken part in an experiment in mass incarceration. Incarceration rates up until the mid-1970s were relatively stable, after which they began to increase exponentially (see Figure 1, on page 49) due to an increase in the demand for more punitive (versus rehabilitative) crimi­nal justice policies. Over this same time period, there has been a surge in the number of individ­uals with criminal records (it is estimated that more than 100 million individuals in the United States have a criminal record), longer prison sen­tences, and, ultimately, greater rates of incar­ceration. This article explores the impact that mass incarceration might have on successful aging and racial disparities in aging outcomes.
 
Although Americans (influenced by policy makers) demanded harsher punishments for criminal offenses, these policies clearly have had a differential impact by race. Figure 2 (on page 50) shows the imprisonment rate by race and ethnicity. It confirms substantial disparities in imprisonment rates between blacks, Hispan­ics, and whites: the imprisonment rate is 5.6 and 2.6 times the white imprisonment rate for blacks and Hispanics, respectively. This also is shown in Figure 3 (on page 51) by looking at the lifetime likelihood of going to prison over time, which increased from 13.4 percent for a black male born in 1974 to 32.2 percent for a black male born in 2001; for Hispanics, it increased from 4 percent to 17.2 percent during the same time period, with a much less pronounced change for whites.
 
Comparing prison admission rates of blacks and whites from 1926–1993, it is clear that imprisonment has always had a disproportionate impact on the lives of Afri­can Americans compared to whites: the propor­tion of African Americans admitted to prison relative to their proportion in the population has been increasing over time, while that for whites has been decreasing. It is also clear from Figure 4 that, coinciding with the era of mass incarcera­tion, after 1975, the unequal impact of imprison­ment among African Americans increased ex­­­­­­­ponentially. While the threat of exposure to an incarceration has always been greater for Afri­can Americans, this threat has greatly increased within the last forty years.
 
The U.S. experiment in mass incarceration has led scholars from across disciplines to inves­tigate the impact of these policy choices on the lives of all Americans, and in particular Afri­can Americans. These scholars have noted that incarceration has a negative effect on labor-market outcomes through stigma, deteriora­tion of human capital, decreasing access to social capital, and labor-market barriers to employ­ment (Cox, 2010).
 
Spending extended periods in confinement hinders individuals from building social capi­tal, which would otherwise enhance legitimate employment prospects (Cox, 2010). Moreover, confinement may favor developing negative behaviors essential to survival during incar­ceration, but disruptive to economic stability on release. These behaviors can further disrupt social networks, and could lead to the inability to obtain and maintain meaningful employment. 
The impacts of incarceration are not re­­stricted to the imprisoned individual. A pleth­ora of research has identified the deleterious effects of incarceration on the mental and physi­cal health and finances of loved ones exposed to a relative’s incarceration. The well-being of chil­dren is particularly vulnerable to an exposure to parental incarceration and leads to intergenera­tional effects (Cox and Wallace, 2016; Johnson, 2009). There also is evidence that incarceration negatively impacts the identity, stability (Charles and Luoh, 2010; Clear, 2008; Petersilia, 2000), public health (Johnson and Raphael, 2009), civic engagement (Petersilia, 2000), and economic well-being of communities (Clear, 2008; Lynch and Sabol, 2004) having concentrated incarcera­tion rates.
 
Incarceration has consequences at the indi­vidual, family, and community levels; and these are disproportionately borne by communities of color (Wildeman, 2014). Society can no longer address issues of poverty and racial inequality without also addressing the deleterious effects of incarceration.
 
While there has been substantial research investigating the economic consequences of incarceration, less research has focused on iso­lating its effects on health and aging, specifically in the context of prisoner re-entry, even though the prison population has become older over time (Carson and Sabol, 2016). Between 1993 and 2013, the size of the ages 55 and older state prison population has increased by 400 percent. Moreover, 48 percent of state prisoners released are ages 35 and older.
 
When it comes to aging, most research has focused on aging while in prison; but 95 per­cent of prisoners are eventually released from prison. Although aging may create unique chal­lenges for re-entry, there is a paucity of research on this topic, particularly on the effect of incar­ceration on racial disparities in health and aging outcomes. This article explores prisoner re-entry in the context of aging by first discussing the relationship between health and incarceration and then discussing how this relationship might impact aging outcomes.
 
The Direct and Indirect Effects of Incarceration on Health
Theoretically, mass incarceration may directly and indirectly place a strain on the immedi­ate family unit and relatives (Cox and Wallace, 2016), as well as the community at large. It is dif­ficult to isolate the direct effect of incarceration on health because those exposed to incarcera­tion typically come from vulnerable populations, which tend to have higher rates of chronic ill­nesses and communicable diseases than the gen­eral population (see Figure 5, on page 53). Even if one could control for this selection bias, the impact of incarceration on health is ambiguous: while confinement often is a traumatic, highly stressful experience, there are opportunities for confined individuals to make human capital investments through social services offered to detained individuals. It is important to note that the quantity and quality of these services can vary depending on whether an individual is con­fined in a jail or a prison, the location of the jail or prison, and by the gender of the individuals housed in the facility.
 
The protective hypothesis suggests that in­­carceration may help to stabilize the health of confined individuals, and possibly even prolong life. Evidence supporting the protective hypoth­esis has been found by researchers who have documented individuals’ higher rates of mor­tality directly after release from prison due to homicide, suicide, disease, and cancer (Rosen, Schoenbach, and Wohl, 2008; Binswanger et al., 2007). Once individuals are released from con­finement, they may have difficulty accessing required medication, or they may find it harder to comply with treatment regimens.
 
According to Patterson (2010), these ben­efits may go beyond being protective, to actu­ally improving the health of imprisoned African American men. She finds that the mortality rate of African American males during incarcera­tion approaches that of white males who are not incarcerated, even after controlling for death from homicide and motor vehicles. Even so, she finds a negative impact of incarceration on the mortality rates of women and whites, suggesting that this effect is specific to African American males (Patterson, 2010).
 
Studies also have documented the negative effects of incarceration. Using administrative data to measure the dose response of an incar­ceration on the life expectancy of New York State parolees, Patterson (2013) finds that for every year in prison, the odds of death increased by 15.6 percent for parolees, which was equiva­lent to a two-year decrease in life expectancy for each additional year in prison. The risk is great­est immediately following release from prison and diminishes over time. While Patterson does not investigate the mechanisms leading to higher mortality rates, prior research suggests (as stated above) that this could be due to an elevated risk of death from suicide, chronic disease, and can­cer immediately following release.
 
Other studies using quasi-experimental designs have found that the formerly incarcer­ated have inferior health outcomes when com­pared to observationally similar individuals who have not been exposed to an incarceration. These studies find that individuals exposed to an incarceration have greater health limitations (Schnittker and John, 2007), an increased likeli­hood of having an infectious disease, and stress-related illnesses (Massoglia, 2008a); in addition, incarceration may exacerbate racial health dis­parities (Massoglia, 2008b).
 
Incarceration not only worsens health out­comes, but also it may lead to additional stigma, stress, and a deterioration of other forms of hu­­man capital (e.g., on-the-job training, motiva­tion, self-esteem) and social capital (e.g., social networks, familial support), which could lead to declines in economic resources and social sup­port, in turn causing prolonged levels of stress post-release, all of which are associated with poorer health outcomes. Incarceration affects labor market outcomes through producing nega­tive stigmas, deterioration of human capital, and decreasing access to social capital (Cox, 2010).
 
As a result, offenders often are unable to obtain relevant work experience and build pro-social networks that would otherwise enhance legitimate employment prospects. Moreover, behaviors essential to survival during incarcer­ation are disruptive to economic stability after incarceration (Cox, 2010; Petersilia, 2000). Ulti­mately, incarceration may lead to the deterio­ration of social bonds and the development of negative social networks, which could give rise to poorer health because of limited economic resources and a worsening of psychological well-being post-incarceration. For African Americans, incarceration could bring about greater levels of psychological distress if this potentially trau­matic experience causes a deterioration in famil­ial relationships and more negative interactions among family members, as well as greater finan­cial strain (Lincoln, Chatters, and Taylor, 2005).
 
As previously mentioned, incarceration not only impacts the health of the exposed individ­ual, but also has an effect on the health of family, relatives, and children. As in the case of the indi­vidual, the effect of incarceration on the health of family members is ambiguous because on the one hand, incarceration may remove a negative family member and free up additional house­hold resources. On the other hand, incarceration might remove a positive contributing member of the family, which could lead to depleted house­hold resources and social supports for the family members left behind.
Lee and Wildeman (2013) hypothesize mech­anisms through which mass imprisonment may increase hypertension, diabetes, and obesity among non-incarcerated African American wo­­men. They highlight the ways through which social bonds to incarcerated men can compro­mise the health of African American women, and assert that incarceration diminishes socio­economic status, compromises family function­ing, and adversely affects stress levels and mental health (Lee and Wildeman, 2013). Incarceration reduces a man’s potential to earn and damages a woman’s socioeconomic resources by desta­bilizing existing relationships. Stated differ­ently, incarceration acts as an economic shock to the household, with potential long-term ef­­f­­­ects through diminished earnings and in­­creased debt.
 
Grinstead et al. (2001) find evidence that prison is an economic shock to the household, especially to low-income families. They find that to remain in contact with incarcerated African American men, women in the study sample spend roughly $292 per month in 1998, the equivalent of $440 per month in today’s dollars, or between 9 percent and 26 percent of their income.
 
A more recent study by the Ella Baker Center for Human Rights finds that families lose income when a loved one is incarcerated, and often in­­cur, on average, almost $14,000 in debt paying for court-related costs and fines (deVuono-powell et al., 2015). The study also finds that one in three families surveyed went into debt to maintain contact with an incarcerated family member, and incarceration disrupted social ties and familial relationships. Most of the families sur­veyed lost income due to a family member’s confinement, and two out of three families could not afford their day-to-day basic needs. Finally, 83 percent of those left behind were women, and many family members reported negative health problems, such as PTSD, nightmares, anxiety, and chronic stress, due to a loved one’s incarcer­ation (deVuono-powell et al., 2015).
 
Charles and Luoh (2010) find that high levels of incarceration lower the number of men freely interacting in society, leading to lower mar­riage rates and economic well-being, specifically among African American women. Moreover, Lee et al. (2014) find that women with incarcerated relatives have statistically significant increased odds of cardiovascular risk factors and disease as measured by obesity, experiencing a heart attack or stroke, and self-reports of fair or poor health, presumably stemming from the added stress of having an incarcerated family member.
 
There also has been a plethora of research documenting the negative effects of parental in­­carceration on children. Incarcerated children face increased economic (Wildeman, 2014; Cox and Wallace, 2016) and residential insecurity (Wildeman, 2014), as well as developmental and behavioral problems that lead to intergenera­tional transmissions of incarceration (Wildeman and Western, 2010; Johnson, 2009).
 
While some research finds that incarcera­tion has a negative effect on communities and families, other research has found that the con­finement of an unstable family member might improve the well-being of affected family mem­bers (Finlay and Neumark, 2010) and the com­munity at large (Clear, 2008; Lynch and Sabol, 2004). Nonetheless, while removing problem­atic members from a community through in­­carceration may initially lead to benefits, concen­trated levels of incarceration are destabilizing to the community (Clear, 2008; Lynch and Sabol, 2004), and may lead to an array of social prob­lems such as higher crime rates (Clear, 2008) and greater public health concerns (see Johnson and Raphael, 2009, for a discussion on the impact of male incarceration rates on racial disparities in HIV/AIDS).
 
Racial Disparities in Health, Incarceration, and Aging
In 2015, the National Institute of Aging proposed a new framework to research health disparities. Criminalization was included in this framework as one of the environmental factors to be consid­ered by health disparities researchers (Hill et al., 2015). However, there has been little research investigating the role of the criminal justice sys­tem and criminal justice policies on health, aging, and racial disparities in aging. Most research has focused on the role of other environmental, socioeconomic, sociocultural, behavioral, and biological factors in racial health disparities. This research has provided insight into some of the possible mechanisms of racial disparities in aging. There is, however, a paucity of literature focusing on the relationship between aging, the criminal justice system, and prisoner re-entry (see Williams and Abraldes, 2007, for a brief dis­cussion of aging and re-entry).
 
But, given the pervasiveness of the crimi­nal justice system in the lives of minorities, it is impossible to completely understand racial dif­ferences in aging without incorporating how pol­icies and institutions, such as mass incarceration and the criminal justice system, impact minority health and racial disparities in health.
 
Non-communicable, generally preventable diseases such as cardiovascular diseases, can­cer, chronic respiratory diseases, and diabetes are the leading causes of death across the world. This is true for the United States: even though largely avoidable, chronic illnesses continue to be widespread and very costly to society; they also are the leading causes of death among Afri­can Americans. While there is some overlap in the ranking of these diseases across racial and ethnic groups, minorities tend to experience greater morbidity and mortality from chronic illnesses than do non-Hispanic whites (Shuey and Willson, 2008).
Prior research has focused on three main explanations of racial health disparities: 1) bio­logical; 2) race as a proxy for socioeconomic sta­tus; and 3) race and socioeconomic status as separate constructs (Kawachi, Daniels, and Rob­inson, 2010). The belief that racial disparities result from biological differences is largely dis­credited. There is, however, some debate about whether racial health disparities are solely at­­tributable to class, or if race is actually a separate construct from socioeconomic status.
 
Nonetheless, research demonstrates that racial health disparities cannot be explained by class alone, and therefore race should be consid­ered a separate construct from class (Kawachi, Daniels, and Robinson, 2010; Brondolo, Gallo, and Myers, 2009; Shuey and Willson, 2008). One hypothesized mechanism through which race affects health outcomes is through the psychoso­cial stressors resulting from cultural, structural, or interpersonal discrimination. Psychosocial stressors also are associated with greater eco­nomic barriers and changes in behavior and psy­chobiological processes, which could impact future generations (Brondolo, Gallo, and Myers, 2009). For example, while certain minorities may participate at greater rates in behavioral risk fac­tors (leading to greater racial health disparities), these behaviors may have developed as coping mechanisms to deal with greater life-stressors (see Jackson, Knight, and Rafferty, 2010).
Of particular importance to this article is the effect of discrimination on structural barriers that may lead to inferior health. As previously discussed, minorities in general, and African Americans in particular, are more likely to be exposed to an incarceration. Therefore, they are also more likely to suffer from the health conse­quences of an incarceration. If these disadvan­tages compound over time, the portion of the racial health gap attributable to incarceration should widen over time.
 
Given the magnitude of the incarceration cri­sis in minority communities, and the direct and indirect effects of incarceration on health, it is no longer possible to discuss racial health dispari­ties or successful aging without considering the impact of the criminal justice system in general, and the carceral institution in particular, on the health outcomes of minorities. Moreover, given the indirect effects of concentrated incarceration on children, families, and communities, we must take an intergenerational life-course approach, one that not only focuses on individuals but also on their families and communities, to under­stand how these policies might impact the aging outcomes of certain communities across time and space.
 
Robynn Cox, Ph.D., is an assistant professor at the USC Suzanne Dworak-Peck School of Social Work and Schaeffer Center for Health Policy and Economics, in Los Angeles. She can be contacted at robynnco@usc.edu.
 
This article is taken from the Summer 2018 issue of ASA’s quarterly journal, Generations, an issue devoted to the topic of economic & social inequality in an aging America. ASA members receive Generations as a membership benefit; non-members may purchase subscriptions or single copies of issues at our online store.
 
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