I was nervous and excited to start my palliative care elective in my fourth year of medical school. I knew it would be emotional and that I would be faced with ethical dilemmas and issues of life and death. My most vivid memory is of a patient — a quiet, frail, emaciated gentleman in his 60s who was dying of cancer. What made him different was that he was shackled to the bed, one arm and one leg bound to the bed of a barren room, lit only by the pale blue light from the window that cast the silhouette of bars on the floor.

This was the prison unit.

This patient and the majority of inmates I met during my clinical rotations were either Black or Hispanic. I knew that minorities were overrepresented behind bars, but it was not until I saw those wasted arms shackled, even in death, that I began to appreciate the reach of our racialized political culture.

More than two million Americans are incarcerated, of whom over half are either Black or Hispanic. How could we have let his happen? Or was this the goal all along?

How We Got Here

America’s racialized criminal justice system is a symptom of our national disease — the latest iteration of a long tradition of subjugation and discrimination. Michelle Alexander’s The New Jim Crow is perhaps the most definitive chronicle of this history. Her book lays out a timeline — from the era of slavery to the Jim Crow laws of the 20th century to the modern era’s War on Drugs. Uniting these events are the common threads of systematic oppression of racial minorities and the incitement of division among vulnerable groups, all to the social and economic benefit of a privileged white elite. Alexander’s book offers a more comprehensive argument that I can provide here, so I’ll focus this discussion on the current embodiment of American racism — mass incarceration.

The incarcerated population in America is defined by its marked racial disparities. Evidence repeatedly shows virtually identical rates of use and sale of illegal drugs across racial groups, yet the majority of those entering the prison system are Black or Hispanic. According to the Human Rights Watch, “Nationwide, black men are incarcerated at 9.6 times the rate of white men. In eleven states, black men are incarcerated at rates that are twelve to twenty-six times greater than those of white men … In the District of Columbia, black men are incarcerated at 49 times the rate of white men.”

These outcomes are largely attributable to the War on Drugs and a regime of racialized enforcement procedures. One infamous and controversial tactic is “stop and frisk,” a practice that allows law enforcement to conduct searches based on “reasonable suspicion,” an ambiguous standard that has been applied in a discriminatory fashion, and often in otherwise minor settings such as a routine traffic stop. According to David Harris in Factors for Reasonable Suspicion: When Black and Poor Means Stopped and Frisked, stop and frisk encounters disproportionately impact the poor, Blacks, and Hispanics because these groups are more likely to live in “high crime areas” with reasons to avoid the police.

Equally important are the long-term consequences that follow incarceration. Once labeled as a felon, an individual can legally be discriminated against for employment, housing, voting rights, education, and public benefits such as food stamps. And, since the felon population is disproportionally comprised of African-Americans and Hispanics, the result is the institution of a new Jim Crow regime — one that socially, economically, and politically disenfranchises racial minorities.

The Juvenile Justice System

What is perhaps more disturbing is that these racial disparities start with our youth, at the level of juvenile justice. The remainder of this discussion will focus on this population. According to the National Criminal Justice Reference Service, racial and ethnic minorities are overrepresented in juvenile justice systems in nearly every state. Although Blacks, Hispanics, Asians, Pacific Islanders and Native Americans only make up a third of the country’s youth, they account for over two-thirds of the youth in juvenile facilities. Research shows that minority youth are treated more harshly than their white counterparts; they are confined and sentenced for longer and are less likely to get probation or alternate forms of sentencing.

According to analysis of several studies over a 12-year period conducted by the Office of Juvenile Justice and Delinquency Prevention, there are several factors that contribute to increased minority contact with the system including police practices that target low-income urban areas. Additionally, minority youth are more likely to use and sell drugs in public areas whereas their white counterparts use and sell in their homes. This research also found in a majority of the studies, race explained why minority youth remained in the system due to negative race effects  at multiple stages in the juvenile process. Research has also shown that juveniles that are automatically transferred to adult prisons are minority youth, a majority African-American, due to automatic transfer laws in certain states. These laws permit youths aged 14 and older who meet certain criteria to be automatically tried and sentenced as adults, thus subjecting them to more severe sentences.

Why This Matters

None of this information is particularly revolutionary — racial discrimination in criminal justice has been well studied for decades, and grassroots political movements such as Black Lives Matter have thrust it into the public consciousness. It’s tempting to think of these issues as social and economic phenomena to be addressed by policymakers and activities — but they also have profound effects on health.

Racial and ethnic minorities face a significant number of adverse health outcomes from early in childhood that are often made worse by encounters with juvenile justice and what follows. Many of these minority youth have a significant number of Adverse Childhood Events, or ACEs, such as abuse and trauma that have a significant effect on their health later in life and can compound their chances of engaging in risky behaviors. One source cited as many as 93% of youth entering juvenile justice having at least 1 ACE. Once in juvenile incarceration, minority youth have been shown to have poorer adult health outcomes including worse general health, higher rates of limited functionality, earlier mortality (the highest mortality rate among black male youth of 887 deaths per 100,000 person-years), higher exposure to infectious disease, trauma in detention centers, and a number of social barriers, stigma, and social isolation after release. Since many minority youth have poorer health status prior to entering juvenile justice, it can be extrapolated that the stress and unmet healthcare needs in prison systems exacerbate those pre-existing risk factors.

Incarcerated youth in general often have more health needs than the general population, with higher rates of sickle cell disease, diabetes, PTSD, pregnancy, asthma, and sexually transmitted infections, among other conditions. The chronic diseases are particularly challenging, because they require a certain standard of medical attention for diagnosis and management. In one national survey of incarcerated youth, two-thirds reported physical health care needs and 46% had at least one diagnosable condition that required management.

Furthermore, there are special populations even within minority youth that further increase their risk of morbidity and mortality. These groups include girls who may be pregnant or have children and have reproductive health needs, and youth who are lesbian, gay, bisexual, or transgender, as well as sex-trafficking victims who are still detained despite being victims. One source cited 12.5% of LGBT youth in juvenile detention reported sexual assault compared to 1.3% of their heterosexual counterparts. All of these groups are at greater risk of poorer health outcomes and unmet health needs.

Another particularly vulnerable group is “crossover youth, ” who are youth involved in both the child welfare system (which has its own set of risk factors) and the juvenile justice system. Youth in foster care or living in group homes may be more likely to be referred to juvenile justice then those who are not in child welfare systems for a variety of reasons including being treated more harshly for normal adolescent risk-taking behaviors.

What You Can Do About It

Clearly, we cannot operate in a bubble. Mass incarceration is a public health crisis that demands our attention and action, and there are roles for physicians of every type to effect change in clinical, academic, and public advocacy spheres.

Clinically, providers can screen for risk factors for among youth who have not been detained and help prevent that trajectory when possible, and can directly provide care for youth in detention facilities or who have been detained and may require much closer follow-up and specific screenings. One particularly important screen tool is the child’s ACE score as mentioned above, as this can help identify youth who are at higher risk and anticipate their physical and mental health needs. This article also suggests that providers can research how best to deliver care for this populations and explore the relationship between juvenile incarceration and later health outcomes, as well as researching strategies for health after release and re-integration.

A critical time for improvement is during the training of medical providers. Medical students and residents should be exposed to juvenile and adult incarceration, their social determinants, and their consequences for health and wellness. Additionally, providers can lobby for improved legislation and policy change that can address risk factors for youth incarceration and specifically minority overrepresentation. Providers can always advocate for the health of youth at-risk or in contact with the juvenile justice system. The American Academy of Pediatrics offers training modules specifically geared towards advocacy for providers.

Where We Are Now

America’s forward momentum has never been more threatened than it is today. Donald Trump’s election to the presidency made our country’s racial divisions painfully obvious — his ascent was predicated on the exploitation of long-simmering resentments, anti-immigrant rhetoric, and dog-whistle politics. Our society has no hope of becoming whole unless we all do our part to bend its arc back toward justice. That means we, as physicians, have to get engaged — are we willing to join the fight?

Image credit: Alcatraz Prison by Alexander C. Kafka licensed under CC BY-ND 2.0.