More than two million people are incarcerated in the United States, the highest incarceration rate in the world. So perhaps it comes as no surprise that last year the popular children's television series Sesame Street introduced a character that has an incarcerated father.

With incarceration having found a home even on Sesame Street, public health practitioners, policymakers, and health care providers ought to pay closer attention to incarceration's impact on health inequality in the country, argue a team of two physicians and a medical researcher in an article published today (Oct. 6) in Annals of Internal Medicine.

Scott A. Allen, MD, a professor of medicine in the School of Medicine at the University of California, Riverside, and his colleagues report that while many people need to be in prison for the safety of society, a majority are incarcerated due to behaviors linked to treatable diseases such as mental illness and addiction.

"In such cases, incarceration will improve neither the imprisoned person nor the social problem without medical intervention," Allen writes, along with coauthors Dora M. Dumont, Ph.D., MPH, at the Rhode Island Department of Health and Josiah D. Rich, MD, MPH, at Brown University, RI.

Allen, Dumont and Rich recommend policy changes that would allow doctors to steer eligible defendants into treatment programs rather than correctional facilities, when appropriate. When incarceration is necessary, doctors and correctional facilities should coordinate transfer of patient care upon release so that gains made during incarceration are not lost, they write.

The authors also note that incarceration reduces prisoners' access to social resources such as health programs. Incarcerated persons have a higher chance of being unmarried and unemployed. They tend to lack access to nonemergency health care as well as health insurance. Frequently, they are excluded from antipoverty programs. Many are even banned from receiving food stamps and are deemed ineligible to receive federal student financial aid.

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"Physicians should join ongoing efforts to end policies banning former prisoners from the antipoverty programs designed to promote citizenship, productive participation in society, and along the way, health," Allen and his colleagues write.

"Incarceration affects also the well-being of the incarcerated's family members," Allen said. "This is especially true of children, whose health could be adversely affected by unhealthy stress-coping behaviors that the incarcerated persons' partners often choose -- smoking and drinking, for example."

More than half of federal and state prisoners are parents of nearly 1.5 million minor children, and one-fifth of prisoners have children under the age of five. Children of incarcerated parents are more likely to have witnessed criminal activity and/or the arrest of the parent, both of which have been shown by researchers to have unique effects undermining children's socio-emotional and behavioral adjustment.

"The long-term impact of parental incarceration has been best documented among boys," said Tuppett Yates, an associate professor of psychology at UC Riverside. "Compared both to boys who had not experienced parental absence and to boys whose fathers were absent due to hospitalization, divorce, death, or other reasons, boys who experienced parental incarceration before age 10 reported more co-occurring internalizing and anti-social problems at ages 18, 32, and 48, more delinquent behavior at age 32, and were more likely to have been convicted of a crime by age 25. Likewise, among both boys and girls, parental incarceration has been associated with concurrent social and academic problems, and prospective substance abuse."

Allen, Dumont and Rich urge all physicians to be more aware of social issues such as education, housing, race and poverty -- social determinants of health that can increase incarceration risk.

"These factors have been demonstrated to have effect on health," Allen said. "There are the obvious things that affect health like genetics, nutrition and access to preventive and disease oriented healthcare, but social determinants of health have also been shown to have a significant impact on health. Numerous investigators have demonstrated that factors like poverty, lack of access to good education, poor or no housing, and being in certain racial groups are associated with poor health and poor outcomes.

"We make two important points in our paper," Allen added. "One, the same social determinants that have been associated with poor health are also the same social factors that have been associated with higher risk of incarceration. Two, a history of incarceration becomes, in and of itself, another negative social determinant of health. Individuals who have a history of incarceration have more difficulty achieving good health outcomes."

The overall incarceration rate in the United States is 492 per 100,000 persons. Among black men, the incarceration rate is 3074 per 100,000 persons.

"Consequences of parental incarceration thereby become concentrated among black children," Allen, Dumont and Rich write.