The Supreme Court recently declined to hear the of a man held in long-term solitary confinement. While his case pertained to specific issues involving a lack of exercise and access to the outside, it is a broader reminder that around the nation, we have jails, prisons, and detention centers where more than are locked in a cell for most or all of their day. This practice, termed solitary confinement, creates of morbidity and mortality, and in carceral institutions or when people return home.
Despite years of reform efforts, some detention facilities continue to rely on widespread solitary confinement. In other settings, reform efforts have led to solitary being used under a different name. There are two things we can do as health professionals to push for more humane treatment: speak with our patients about their experiences and connect with groups that already work in this space.
Changes in Solitary Confinement
While solitary confinement has been a large part of U.S. incarceration since the 1980's, there are a couple of recent shifts behind bars that are increasing the use and harms of this practice. One trend in the wrong direction is that worsening staffing shortages of correctional officers results in people being locked in their cells under unofficial "." Rather than subjecting people to confinement in their cells for no official punishable reason, short staffing should instead catalyze a movement toward decreasing rates of incarceration.
Another worrisome trend involves expanded use of solitary under the guise of a "mental health watch" or other health pretense. A harmful and common scenario is that a person is identified as having a mental health or other health crisis, and the facility response is to lock the patient in a . There, an acutely ill patient is often kept naked except for a filthy "suicide smock" and periodically checked in on and asked perfunctory health questions through a locked cell door. Not surprisingly, the of death in U.S. jails is suicide, and the rates of death from intoxication/withdrawal have increased more than 300% in the past 20 years.
"Clearing" Patients for Punishment
As solitary persists and morphs, health staff working behind bars are ill-equipped to advocate for their patients. Health professionals are often asked to "clear" their own patients for this punishment, a practice that is both unethical and common. Because the health services behind bars are often under the control of security leadership, health staff are under considerable pressure to satisfy the requests and demands of custody staff who they rely on for security. One health professional in the New York City (NYC) jail system how this feels better than I ever could: "This is very personally distressing to me, and situations like this leave me with a negative impression of the work I do and my workplace."
Clearing patients for punishment may lead to the identification of a few people that health staff think are too vulnerable to be placed in a locked cell all day, but this rarely occurs. Furthermore, doing this work transforms the entire health service from being patient-focused to being agents of the security service. When solitary comes in the guise of a staffing-related lockdown, health staff may not even know when their patients are locked into cells. When solitary is directly used by the health service as a response to a health crisis, like suicidality or withdrawal, the health staff themselves may unknowingly increase the likelihood of death. In these cases, they should instead initiate transfer to a hospital.
For health staff working behind bars, this problem of -- security pressures on patient care -- is omnipresent. Yet, few carceral health systems discuss this problem, let alone train their health staff on possible mitigation steps.
Promoting Humane Treatment
For community-facing health professionals, there are two things we can do to promote more humane and less harmful treatment of people behind bars. First, many of our patients may have experienced incarceration, and they bear physical and psychological scars that few physicians, nurses, or mental health professionals ever look for. Solitary units are often characterized by physical and sexual violence, and assessing physical and psychological impacts of these experiences is not part of most health encounters after release. Asking patients about incarceration and solitary confinement is not only a way for us to become educated as health providers, but it's also a basic element of evidence-based care. Solitary is a harmful and traumatizing experience for our patients, and learning about how they were harmed is important for engaging with them in future clinical care.
A second thing we can all do is connect with groups that work in this space, either tracking or trying to incarcerated people and their families. These groups often link of incarcerated people to resources for re-entry and support, and they know the truth of what happens in local jails, prisons, and detention settings, including how solitary confinement is used. These groups can benefit from the support of health professionals to eliminate solitary confinement and to address other harmful parts of our criminal justice system.
A few examples of discrete policy reforms that health professionals can help with include:
- Eliminating solitary confinement in local jails, ICE [Immigration and Customs Enforcement] detention, and state and federal prisons.
- Increasing community mental health and substance use resources, and diverting people into treatment instead of incarceration.
- Promoting independent oversight of carceral facilities, including health services.
- Ensuring access to medications for opiate use disorder during incarceration.
These steps by health professionals won't directly end solitary confinement. But they can make a meaningful difference by connecting our training and expertise to the real experiences of people who have experienced solitary confinement and the other harms to health that come with incarceration.
Homer Venters, MD, is a physician and the former Chief Medical Officer of the NYC Jail System. He currently works as a court-appointed monitor and inspector of health services in jails and prisons, is the author of , and is part of the adjunct faculty at the NYU School of Global Public Health.