By Rachel Crumpler
On any given day, about 20,000 people are incarcerated inside North Carolina’s county jails. These individuals are more likely than the general population to have substance use disorders, mental health problems, chronic diseases and infectious diseases, according to years of research.
Despite the large health care needs of this population, there is limited information on how that care is delivered and by whom. That’s why a group of local researchers set out to measure the amount and type of health care staffing in jails in North Carolina, South Carolina, Georgia and Alabama.
Researchers conducted 45-minute phone surveys with jail personnel from 254 of the 346 jails identified in the four states from October 2020 to May 2021; North Carolina’s 95 jails had the highest response rate at 90 percent.
The survey, which was published last month, found that nearly 30 percent of jails routinely lacked on-site providers, and 50 percent lacked registered nurses. Additionally, in about half of the jails surveyed, neither a provider nor a registered nurse worked on site for more than two days per week — even as jails operate around the clock, every day.
“When you don’t have a lot of health care staff on site, you can’t provide a lot of health care,” said Jessica Carda-Auten, a researcher at UNC’s Institute for Global Health and Infectious Diseases who helped conduct the research. “We know that folks in jails have many health issues. The implications are, they might not be getting care as fast or as much care as they might need while they’re incarcerated.”
David Rosen, another researcher at the Institute for Global Health and Infectious Diseases leading the staffing assessment, said the survey findings indicate that jail health care likely falls short of community health care standards, resulting in missed opportunities for care and potentially endangering incarcerated people.
“I think this is a cause for concern,” Rosen said. “These aren’t necessarily new issues, but … by quantifying what’s actually there, we can begin to have a conversation about how could these services be improved.”
Role of detention officers
Due to the infrequent on-site hours of health care staff, researchers found that many jails relied heavily on licensed practical nurses and detention officers to perform various medical responsibilities — even performing tasks that may exceed their training.
Licensed practical nurses train for one year and are often skilled in taking vital signs and following nursing care plans. But they’re not trained in independent nursing assessments and creating care plans.
Detention officers have even less training. In North Carolina, the state training program required to become a detention officer includes less than four days of health-related instruction. Despite this minimal training, detention officers can have a wide range of medical responsibilities. Among surveyed jails, 67 percent reported that detention officers determine if an arrested person is healthy enough to be jailed, 83 percent conduct a medical questionnaire at intake and 58 percent assess the urgency of medical requests.
Findings showed officer responsibilities decreased when there were greater nursing coverage hours in a week.
Carda-Auten said relying on detention officers for a host of health care duties likely results in poorer care. There’s also a bigger chance that incarcerated people have health conditions that are not fully recognized or detected. She explained that people may not feel comfortable disclosing personal health conditions, such as mental illness or substance use disorder, to a security official, as they could perceive that it might get them in more trouble.
That can become a problem, because failing to identify health issues can lead to serious problems during incarceration, such as suicides and other in-custody deaths.
In March 2022, Disability Rights NC released a report reviewing the 56 jail deaths that occurred in 2020. According to the report, Disability Rights staff found that, in many of the deaths, jails failed to recognize serious health concerns, failed to react appropriately to serious medical emergencies and failed to transfer patients to facilities with better medical coverage when necessary to save lives.
Although a formal report has not yet been released by the organization, Luke Woollard, an attorney at Disability Rights who is tracking jail deaths, told NC Health News that Disability Rights counted 67 in-custody deaths in 2021 and 77 in 2022.
Putting health care responsibilities on detention officers is also problematic for staff and increases liability concerns for jails that are run by county sheriffs’ departments, Rosen said.
“They don’t want to be in these situations where they are being asked to make decisions that they don’t have the training or background to make,” Rosen said. “I don’t think anyone wants to be in that type of situation.”
more coverage of prison and jail health
Falling short of community standards
Based on the survey’s findings, Rosen said jail health care also lags community standards in terms of staffing norms.
Rosen said he can’t think of another setting in which nonmedical personnel have as many health care responsibilities as detention officers can have.
For example, jails in the study were less likely to staff registered nurses than U.S. public primary and secondary schools, the researchers wrote in their paper.
The American College of Physicians affirmed its position in November 2022 that jails and prisons should provide “timely access to necessary healthcare services” that meet “prevailing community standards.”
While Rosen acknowledges that comparing jail health care to community health care settings is imperfect because of the patients’ wide range of severity of illness and varied lengths of stay, he said it’s important for care to be on a similar level.
“You really can’t create this dichotomy between health in carceral settings and community health,” Rosen said, explaining that people frequently cycle between jail and the community. “It’s really kind of this dynamic flow between the two, and so it’s really vital to community health as well that we be providing adequate care.”
Working with limited resources
Jails are required by law to provide medical care for individuals in their custody — most of whom have not yet been convicted of a crime — but health care access and personnel vary largely because jails are operated and funded by individual counties, and local sheriffs primarily direct their management.
Funding for these services is all over the map.
“Care completely differs depending, often, on which side of the county line you’re on,” Woollard from Disability Rights said.
Carda-Auten acknowledges that it’s complex to provide health care for this continuously rotating population, and she has spoken with many jail staff who recognize the limitations to the available health care.
“Simply like many government entities, they’re trying to do the best they can with very limited resources,” Carda-Auten said.
To increase health care staffing, Rosen said jails should consider using telemedicine more frequently. The survey found relatively low telemedicine use, with 13 percent of jails using it at least once per month for primary care and 55 percent for mental health care.
Rosen said other potential pathways to improved jail health care are new models of funding, greater accountability of private health care contractors and policies that could safely reduce the size of jail populations.
“What happens to these folks in the jails does not stay in the jails,” Woollard said. “It’s going to sort of echo in the communities.”
That can be a problem when people are released into the community sicker than they were when they went to jail, he said. That can drive recidivism rates higher, which comes at the expense of taxpayers who pay to fund jails.
“If people go in and are not given health care, not given treatment they need, not provided programs — you get people going back to the community worse off,” Woollard said. “And that’s going to lead to more community health problems.”
But if care is good, he added, “that can be a positive thing. If we have good programs to rehabilitate folks in jails, and we have good health care, … that maybe could even diagnose something the person didn’t know they had and provide them care for that.”
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