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The lower death rate for black male prisoners was largely, but not entirely accounted for by protections from external causes of death. It is important to note, however, that any mortality benefit may be outweighed by long-term consequences.

For example, Patterson used mortality data from New York State and found a dose-response effect. Each additional year of incarceration produced a 16 percent increase in the odds of death and a 2-year decrease in life expectancy.

Similarly, Houle found that the exclusion of inmates from national obesity estimates leads to an overestimation in obesity prevalence particularly for disadvantaged white and black men. Collectively, the results of previous research highlight the differential selection among racial and ethnic minorities into the prison system.

This research supports the hypothesis that racial health disparities in morbidity and mortality among prisoners are muted. In fact, the health of black prisoners may be more likely to reflect the health of the noninstitutionalized black population whereas white prisoners may be drawn from some of the unhealthiest whites in the population. As such, noninstitutionalized disparities may be smaller, nonexistent, or reversed among prisoners.

To date, no existing work has explicitly compared estimates of health disparities among incarcerated adults with comparable estimates from the general population of adults in the United States. The objective of this paper is to determine the patterns of black-white health disparities within prisons, and how they differ from noninstitutionalized community settings. If there is no health bias in the selection of individuals into prison, then the race disparities documented for the noninstitutionalized population will be comparable to the disparities in the prison setting so that black prisoners have worse health than white prisoners.

But given what we know about the racialized and gendered selection of adults into prison, we expect health disparities to be either neutralized or significantly reduced. Specifically, disparities will be smaller within prisons due to the selection of the least healthy whites into prison but very little health selection among black prisoners.

Due to the social processes associated with incarceration Beckett et al. Therefore, we expect that whites will represent a highly select group of individuals and they will have worse health than their noninstitutionalized counterparts. We examine comparable indicators of physical health using two large and nationally representative cross-sectional samples of adults within and outside of prisons Binswanger et al.

The sample design for state inmates employed a stratified, two-stage selection: Prisoners were then randomly selected for participation.

A total of 14, prisoners participated, for an overall response rate of The sampling design for federal inmates includes a universe of male prisons and 17 female prisons. In total, 32 male and 8 female facilities were selected for inclusion. Nondrug offenders were oversampled to ensure large enough numbers to be analyzed.

The final sample size was The survey asks respondents about their incarceration history, offense characteristics, family and background characteristics, drug and alcohol use and abuse, prison activities, and self-reported health, mental health, and treatment history. We pooled two waves from — and — time periods roughly comparable to the data collection period for the SPI to create a similar sample size to the SPI.

The interview includes demographic, socioeconomic, dietary, and self-reported health as well as the results of medical and laboratory examinations. The final pooled sample of respondents aged 18 to 65 who identified as non-Hispanic white or black is 18,, including 12, incarcerated and noninstitutionalized adults. Age is measured as a continuous variable ranging from 18 to Three age categories are also assessed: Dichotomous variables include sex 0 female, 1 male , race 0 non-Hispanic white, 1 non-Hispanic black , and inmate status.

Education is included as a control given its strong association with health Link and Phelan, , Phelan et al. GED attainment is coded for degree obtained inside or outside of the correctional facility. Incarcerated adults are younger and are overrepresented by men and blacks.

The prison sample has a mean age of The prisoners in the study also have lower levels of education than the general population. We assess 10 health conditions. In both data sets, respondents were asked to self-report lifetime diagnosis with health conditions.

The remaining conditions include asthma, kidney problems, stroke, arthritis, all-cause cancer, and sexually transmitted infections STI. Missing values were imputed using chained equations. The first analysis reports the disparity between black and white adults for each physical health problem across age strata using predicted probabilities. Accordingly, the sampling weights were mean centered with respect to each population. Second, we estimate models separately for incarcerated and noninstitutionalized populations using logistic regression with the respective mean centered weights controlling for age and education.

To examine statistical significance for the differences between incarcerated and noninstitutionalized populations, we combine the data sets and include an interaction term race X incarcerated status to test whether incarceration modifies race disparities in health.

We mean centered the full distribution of sampling weights. In this manner, the relatively smaller population of prisoners and the design effects of each respective study are accounted for when characterizing the standard errors for the interaction term between race and incarceration status for each health problem.

Only the p-value associated with the interaction term is reported. We estimated the same models using linear probability models as a sensitivity test and found similar results. In the third analysis, frequency weights are used to estimate the number of adults in the population with each morbidity. We first estimate the noninstitutionalized population at risk for black and white women and men. We then estimate the populations to see how the prevalence of health conditions would change if the adult prison population was included.

All analyses are conducted using Stata 13 StataCorp, Table 1 provides the prevalence for each health condition across age strata and stratified by sex, race, and incarceration status. For most health conditions prisoners report worse health than their noninstitutionalized counterparts, and the differences are larger for whites than blacks. White women experience an even more dramatic increase in the prison sample The largest disparity among the incarcerated populations is the risk of sexually transmitted infection STI , in which there is no significant race difference among non-institutionalized men and a 3.

Table 2 presents the odds-ratios for health disparities within the incarcerated and noninstitutionalized adult samples. The corresponding p-value denotes whether the health disparity OR 1 vs. OR 2 differs significantly for incarcerated and noninstitutionalized adults. These findings are also presented graphically in Fig. Among men, disparities are significantly lower in prison for three health conditions: In the general population, black men 2. This relationship is shown graphically in Fig.

The odds ratio for kidney problems for noninstitutionalized men is on the right side of the 1. Similar patterns emerged for stroke and arthritis. Disparities among men are significantly larger in prisons for obesity and STI. A more pronounced pattern is found among women, especially at older ages. Disparities are significantly smaller among incarcerated women compared to women in the general population for a number of health conditions including hypertension, diabetes, heart problems, kidney problems, and stroke.

Thus, the race disparity gap is largely closed among incarcerated women due to the increasingly worse health of white women who are incarcerated.

Examining the prevalence of these health conditions by age group shows an even more pronounced effect among the 50 years of age and older group. For example, overall rates of diabetes show that white women in the community report a prevalence rate of 3. In the oldest age group, the reported prevalence is 8. However, in prisons, white women report an overall rate of 7.

Comparable patterns are present for hypertension, heart problems, kidney problems, and stroke. Similar to men, black-white disparities in STI are larger among women in prison. In the general population, black women report an overall STI prevalence of In the prison population, black women report much higher rates These findings are particularly important when you take into account the health selection process with respect to the incarcerated and noninstitutionalized populations for each group.

Consider the values presented in Table 1 that describe the prevalence of each health problem for black and white men and women. The prevalence for each in the general population can be used to derive the standard deviation for each health problem. One can then compare the prevalence in the incarcerated population to the prevalence and standard deviation in the general population as a standardized level. The average of these for the 10 health problems that we consider provides an estimate of 0.

That is, the average health burden in the prison population is representative of the 59 th percentile of the non-institutionalized white male population. This number nicely characterizes the magnitude of the health differences between prisoners and non-prisoners. Importantly, this number is somewhat lower 54 th percentile among black male prisoners and black female prisoners 53 th percentile , suggesting that the health selection mechanisms related to incarceration are less pronounced among black adults compared to white men.

The health burden among incarcerated white women places them in the 62 th percentile of poor health among the noninstitutionalized white female population providing, again, strong evidence that the selection mechanisms of poor health among prisoners is the most pronounced among white women. Finally, we more closely examine the selective process of incarceration with a descriptive exercise shown in Table 3 and Fig.

Here, we examine the number of adults with each specific morbidity in the U. The results show important increases in the population of unhealthy adults for all of the morbidities and they detail the anticipated change in health disparities among U.

For example, if all of these inmates were included in population health estimates, the number of adults with hypertension would increase by 78, for white men, , for black men, 12, for white women, and 12, for black women Table 3. Even though black men account for a much smaller percentage of the U. Thus, given the overrepresentation of black men in prison, the population estimates for this group would be most affected. One of the goals for Health People is to reduce health disparities for people of color.

Moreover, incarcerated persons are excluded from national health surveys and correctional facilities often have an inadequate surveillance system for providing valid and reliable data on the health status of inmates. The National Commission on Correctional Health Care report on the health status of inmates that was presented to the U. Congress concludes that there is a tremendous and largely unexploited opportunity to benefit public health by illuminating health disparities among inmates and improving correctional health care practices.

Understanding the health profile and healthcare needs of the incarcerated population is imperative for achieving health equity and maintaining the public health of the local communities from which inmates are drawn. To better understand why Americans fare so poorly relative to individuals in other high-income countries in terms of health, we argue that incarceration rates should be considered when comparing health within and among countries see Wildeman, In this paper, we show that prisoners report worse health than their noninstitutionalized counterparts.

Incarceration is associated with a higher prevalence of hypertension, diabetes, heart problems, asthma, kidney problems, stroke, arthritis, and STI, with differences larger for whites than blacks, especially among women. Some support is found for the main hypothesis that race disparities are muted in prisons than the general community.

After adjusting for age and education, we find that male prisons have smaller black-white disparities for kidney problems, stroke, and arthritis compared to men in the general population. For women the hypothesis is supported for hypertension, diabetes, heart problems, kidney problems, and stroke. Black-white disparities are actually larger in prisons for obesity among both men and women and for STI for men. Overall, these findings are consistent with previous studies Binswanger et al.

This study demonstrates that the poor health documented among prisoners is not necessarily due to the overrepresentation of people of color within prisons. These results provide evidence that the selection of more unhealthy persons into prisons is only moderately stronger among white compared to black men but noteworthy among white compared to black women.

At the beginning of the paper we noted several mechanisms that contribute to health disparities. Specific morbidities, however, are more likely than others to respond to these mechanisms. While the mechanisms for health disparities are not directly tested in this paper, we can discuss the findings in light of current knowledge.

For instance, neighborhood environmental exposures are best characterized by cancer and asthma and we see that patterns of disparities are nearly identical in and out of prison. The only exception is disparities in cancer among female inmates in which the gap between white and black women is wider in prisons, with white women having higher odds of cancer.

Similarly, arthritis—a leading cause of disability in the United States CDC, —is likely unrelated to imprisonment per se and the only significant difference found in patterns of disparities is among male prisoners. On the other hand, hypertension, heart problems, and stroke are the most proximate morbidities linked to stress and discrimination. Changes in the links between race and health in this domain would shed light on health disparities. The findings show that among women in the noninstitutionalized population, blacks have significantly higher odds of reporting hypertension, heart problems, and stroke compared to whites on the order of 1.

Among women in the prison population, however, the black-white disparity is significantly reduced for hypertension and reversed for heart problems and stroke so that white women have significantly higher odds of reporting these conditions compared to black women. Among men, only the black-white disparities for stroke is reversed in prisons.

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