Social justice and criminal justice go hand in hand

By celebrating the World Day of Social Justice on the 20th February, the international community supports efforts to eradicate poverty and reduce social inequities, promote fair work conditions, gender equality and access to social well-being and justice for all. There is a link that connects poverty, crime, health-related problems, employability, and extreme social disadvantage. Health is often a starting point to study what happens to the people involved in the adult or juvenile justice system, including staff employed by the justice system.

According to the report Drugs in Prison published by The Centre for Social Justice, “social justice and criminal justice go hand in hand. Not only does crime disproportionately affect poorer communities, but also those who have committed crime are also far more likely to suffer from the causes of social breakdown such as drug abuse, poor literacy rates and worklessness”. We explore this topic with Prof. Faye Taxman and Prof. Lior Gideon, Editors-in-Chief of the journal Health & Justice, taking the situation in the USA as an example.

The numbers

Which numbers best describe the current situation of health in criminal justice populations?
Pre-existing health conditions are often linked to other physical and mental conditions. One example is substance abuse and mental health problems; likewise, intravenous methods of self-administration of substances may increase the risk of contracting HIV or hepatitis B or C.

In the USA, approximately 20% of inmates in jails and 15% of inmates in state prisons have a serious mental illness

Based on the total number of inmates, this means that there are approximately 356,000 U.S. inmates with serious mental illness in jails and/or state prisons. Substance abuse among those on probation and/or parole is 7 times greater than the general population with nearly 39 percent of the population suffering for substance use disorders.

What about other physical conditions?
About 40% of all federal, local jail and state inmates have at least one documented chronic illness. Traumatic brain injuries in the jail and prison population range between 25% and 87%. Adults entering jails have much higher prevalence of both chlamydia and gonorrhoea; in particular, chlamydia infection among female jail inmates has been higher than that observed in the general population, and this also happens (about 23-30% higher) among incarcerated juveniles. State and federal prisons held 20,093 inmates diagnosed with HIV or AIDS. Anywhere between 15% and 40% of inmates incarcerated in US jails and prisons are infected with the hepatitis C virus.

Pic by jodylehigh CC0 public domain
Traumatic brain injuries in the jail and prison population in the US range between 25% and 87% (Pic by jodylehigh, CC0 public domain)
© kieferpix / Getty Images / iStock

What are the consequences?
According to a report by the U.S. Bureau of Justice Statistics (BJS), the leading cause of death in local jails is suicide (29%), followed by heart disease (22%), intoxication (7%), and HIV/AIDS—these are 5% of deaths in local jails. However, a newer report from 2016 by the BJS reports the following causes of death as documented by the DCRP (Death in Custody Reporting Program): heart disease – 3,917 (24.5%); AIDs eelated – 471 (3%); cancer – 3,487 (21.8%); liver disease – 1,296 (8.1%); respiratory disease – 943 (5.9%); suicide – 1,816 (11.4%); drug/ alcohol intoxication – 398 (2.5%). Overall, more than 50 different medical conditions were reported by local jail administrators as the causes of death among jail inmates.

The research

What are the real implications of social and policy research in this field?
Providing research protocols, evidence-based research and an overall holistic and multidisciplinary approach for the examination and dissemination of knowledge on the nexus between health and justice improves the health outcomes—both somatic and behavioral health—of affected individuals, community and the entire society.

Understanding how social inequities and poor health conditions affect justice involvement is a hot topic (Pic by United Workers on Flickr, CC BY 2.0)
Understanding how social inequities and poor health conditions affect justice involvement is a hot topic (Pic by United Workers on Flickr, CC BY 2.0)
What are the latest breakthroughs and challenges in migraine treatment? It is a great moment for migraine treatment because we have new drugs for the prevention of acute attacks. The first of those new drugs, erenumab, is already available in the USA and hopefully it will soon become available in other countries. Other drugs such as fremanezumab, galcanezumab and eptinezumab are on the way. The new drugs are monoclonal antibodies which act on the calcitonin gene-related peptide pathway. Available studies indicated that those drugs are effective for migraine prevention. Additionally, they have a good tolerability profile and ease of use because they can be administered via subcutaneous injections once a month or even quarterly. They will offer a substantial improvement to the treatment of the disease as currently available drugs are associated with poor adherence to treatment because of side-effects, lack of the expected benefits from patients, and poor compliance with the daily intake. The shortcoming of the new drugs is represented by the costs which will be high limiting the number of patients who will benefit from them. What is the aim of the consensus article and what are you hoping to achieve for patients and physicians? Migraine mostly affects women in their reproductive age and the issue of hormonal contraception in women with migraine is very common in the daily clinical practice. A joint group of experts in headache, hormonal contraception, and stroke developed two consensus documents [LINK TO NEW ARTICLE ON 'documents'] on the use of hormonal contraception in women with migraine. The documents were supported by the European Headache Federation (EHF) and the European Society of Hormonal Contraception and Reproductive Health. The aim of the documents was to provide suggestions useful for the everyday clinical practice. On one side, there are the headache specialists who treat migraine patients but who do not have in some instances sufficient knowledge of the benefits and harms of all the possible contraceptive options. On the other side, we have the gynecologists who know hormonal contraceptives but may pay not enough attention to the presence of migraine. In the two consensus papers, we pooled together the knowledge in the two areas in order to improve the use of hormonal contraceptives in women with migraine. Would you like to pick out relevant examples to illustrate the importance of the findings from the consensus article? I can give you two examples each referring to one of the two consensus documents. The first consensus article was about safety as the use of hormonal contraceptive containing estrogens increases the risk of ischemic stroke in women with migraine and especially in those with migraine with aura. I’ve recently admitted to my hospital a woman aged 37 years who developed a left hemispheric ischemic stroke. After extensive investigations, the only evident factors which could have triggered the stroke were a history of migraine with aura and the recent initiation of an oral combined hormonal contraceptive containing 30 mcg of ethinylestradiol. This young woman was left with a serious disability. By applying our guidelines this stroke would probably have been prevented as the use of the combined hormonal contraceptive was contraindicated because the woman had migraine with aura. The second consensus article was about the impact of exogenous sexual hormones on the course of migraine. I can provide the example of a 24 years old woman with polycystic ovary syndrome and dysmenorrhea who started treatment with a 24/7 combined hormonal pill following the suggestion of her gynecologist. The woman experienced worsening of her previous migraine without aura attacks soon after the first cycle of treatment. The pain was particularly severe and occurred during the pill-free week. In this case the replacement of the 24/7 pill with an oral extended combined hormonal contraceptive regimen led to improvement of the attacks. The two examples point out the two main points of our documents: safe use of hormonal contraception in women with migraine and impact of hormones on the course of migraine. Applying the guidelines, we can prevent ischemic stroke, improve migraine, and avoid worsening related to the use of hormonal contraception. Tell us more about the process and efforts of getting this document together, how long did it take and what challenges did you encounter? It took about a year each to develop the documents. Both were developed according to a standardized methodology which implied systematic review to get evidence-based recommendations. The major challenge was that in this field the quality of scientific evidence is low and recommendations were mostly based on experts’ opinions. As you can imagine, it is not easy to agree about something when evidence is limited. The discussion on some recommendations was very animated and several rounds of revisions were needed to agree on a shared recommendation. We cannot guarantee that some of our recommendations won’t change in the next years as new evidence becomes available. In your view what are the most important goals? I think that there are two important goals of our documents. The first is to provide guidelines which can be easily applied in the everyday clinical practice by those who are involved in the care of women with migraine and in the prescription of hormonal contraceptives. Hopefully, the consensus documents will be valuable also for the general practitioners who are the main care providers for many women. Secondly, we hope that the documents may foster further research on this topic to provide evidences to further improve current knowledge.

Which are the most debated and urgent topics at the moment, in your opinion?
We think there are some pressing topics:

  • Expanding the mission of justice organizations to include behavioral and somatic health;
  • Understanding how social inequities and poor health conditions affect justice involvement;
  • Identifying effective re-entry and seamless systems of care;
  • In the US, implication of the Affordable Care Act on underprivileged populations who are also involved in the criminal justice system;
  • Special needs populations pose a unique challenge to the criminal justice system, and in particular to probation and parole agencies and correctional facilities that are not adequately prepared to deal with such needs;
  • Increasing elderly and geriatric population in jails and prison system;
  • Health impediments of released prisoners during their reintegration process and community readiness and response to such needs;
  • Community-based treatment modalities that are designed and designated to absorb released prisoners with substance abuse problems, health and mental health problems, as well as connecting care providers in the community with those in correctional facilities for better tailored discharge planning; and finally,
  • Legal issues that revolve around health care for criminal justice-involved populations.

Special needs populations pose a unique challenge to the criminal justice system, and in particular to probation and parole agencies and correctional facilities

Aside from the above, we would also like to see studies on nutrition and diet management and education in correctional facilities and its effect on quality of life.

What led you to start Health & Justice back in 2013? Why were you interested in studying this particular topic?
There was a pressing need to have a clear publication outlet that would overcome the fragmented existing literature for multidisciplinary research on the nexus between health and justice, and the criminological discipline.

There is a pressing need for multidisciplinary research on the nexus between health, justice and criminology

In other words, most journals up to this point were discipline specific—criminology, substance abuse, pediatrics, internal medicine, and so on. As a result, interdisciplinary studies that address special populations or special processes were often difficult to publish because they did not fit within a single discipline. Health & Justice was conceived as fitting a need to have a place to examine the impact of health and functioning of individuals that are affected by the justice system—this includes those that are justice-involved, workers in the system, and citizens that are impacted by law enforcement, judiciary, corrections and other justice processes.

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