GOVERNMENT, LAW, AND PUBLIC HEALTH PRACTICE

7. Horton HH, Misrahi JJ, Mathews GW, 12. Centers for Disease Control and 2009---2010 influenza season. Avail- surveillance systems. J Public Health
Kocher PL. Critical biological agents: dis- Prevention. Deaths related to 2009 pan- able at: http://www.cdc.gov/h1n1flu/ Manag Pract. 2005;11(3):184---190.
ease reporting as a tool for determining demic influenza A (H1N1) among Amer- childcare/guidance.htm. Accessed
21. Rebmann T, Elliott MB, Swick Z,
bioterrorism preparedness. J Law Med ican Indians/Alaska Natives—12 States, June 11, 2014.
Reddick D. US school morbidity and
Ethics. 2002;30(2):262---266. 2009. MMWR Morb Mortal Wkly Rep. 17. Centers for Disease Control and mortality, mandatory vaccination, institu-
8. Sell TK, Nuzzo JB, Toner E. Where 2009;58(48):1341---1344. Prevention. Updated interim recommen- tional closure, and interventions imple-
does H1N1 influenza information come 13. Turning Point Collaborative. The dations for the use of antiviral medica- mented during the 2009 influenza A
from? An overview of influenza surveil- Turning Point model state public health tions in the treatment and prevention
H1N1 pandemic. Biosecur Bioterror.
lance in the United States. Biosecur act: a tool for assessing public health of influenza for the 2009---2010 sea-
2013;11(1):41---48.
Bioterror. 2010;8(1):55---57. laws. 2003. Available at: http://www. son. Available at: http://www.cdc.gov/
turningpointprogram.org. Accessed H1N1flu/recommendations.htm. 22. Stier DD, Thombley ML, Kohn MA,
9. Lipsitch M, Finelli L, Heffernan RT,
June 11, 2014. Accessed June 11, 2014. Jesada RA. The status of legal authority
Leung GM, Redd SC. Improving the evi-
dence base for decision making during 14. Council of State and Territorial 18. National Center for Immunization for injury prevention practice in state
a pandemic: the example of 2009 in- Epidemiologists. CSTE list of nationally and Respiratory Diseases, Centers for health departments. Am J Public Health.
fluenza A/H1N1. Biosecur Bioterror. notifiable conditions. Available at: Disease Control and Prevention. Use of 2012;102(6):1067---1078.
2011;9(2):89---115. http://www.cste.org. Accessed June 11, influenza A (H1N1) 2009 monovalent 23. Lee LM, Heilig CM, White A. Ethical
10. Balter S, Gupta LS, Lim S, Fu J, 2014. vaccine. Recommendations of the Advi- justification for conducting public health
Perlman SE; New York City 2009 H1N1 15. Centers for Disease Control and sory Committee on Immunization Prac- surveillance without patient consent. Am
Flu Investigation Team. Pandemic Prevention. CDC guidance for state and tices (ACIP), 2009. MMWR Recomm Rep.
J Public Health. 2012;102(1):38---44.
(H1N1) 2009 surveillance for severe local public health officials and school 2009;58(RR-10):1---8.
24. Bayer R, Fairchild AL. Public health.
illness and response, New York, New administrators for school (K---12) re- 19. Association of State and Territorial
surveillance and privacy. Science. 2000;
York, USA, April---July 2009. Emerg Infect sponses to influenza during the 2009--- Health Officials. Assessing policy barriers
290(5498):1898---1909.
Dis. 2010;16(8):1259---1264. 2010 school year. Available at: http:// to effective public health response in the
www.cdc.gov/h1n1flu/schools/ H1N1 influenza pandemic. 2010. Avail- 25. Levy M, Yerardi J, Volz D. In Florida
11. Centers for Disease Control and
Prevention. Prevention and control of schoolguidance.htm. Accessed June 11, able at: http://www.astho.org/Programs/ flawed state reporting raises risks for
seasonal influenza with vaccines. Recom- 2014. Infectious-Disease/H1N1/H1N1- foodborne illness. Florida Center for In-
mendations of the Advisory Committee 16. Centers for Disease Control and Barriers-Project-Report-Final-hi-res. vestigative Reporting. Available at: http://
on Immunization Practices—United States, Prevention. CDC guidance on helping Accessed September 8, 2014. fcir.org/2011/10/05/in-florida-flawed-
2013---2014. MMWR Recomm Rep. child care and early childhood programs 20. Hopkins RS. Design and operation state-reporting-raises-risks-for-foodborne-
2013;62(RR-07):1---43. respond to influenza during the of state and local infectious disease illness. Accessed June 11, 2014.

Public Health and Solitary Confinement in the United States

David H. Cloud, JD, MPH, Ernest Drucker, PhD, Angela Browne, PhD, and Jim Parsons, MsC

The history of solitary con- and prisons in accordance WITH 2.3 MILLION PEOPLE IN suggest that about 84 000 indi-
finement in the United States with established public health its jails and prisons, the United viduals endure extreme conditions
stretches from the silent functions (e.g., violence pre- States incarcerates more people of isolation, sensory deprivation,
prisons of 200 years ago to vention, health equity, sur-
than any other nation. At 716 per and idleness in US correctional
today’s supermax prisons, veillance, and minimizing of
occupational and psychologi-
100 000 people, the US per capita facilities.2 Federal data indicate
mechanized panopticons that
isolate tens of thousands, cal hazards for correctional incarceration rate is more than that from 1995 to 2005, the
sometimes for decades. We staff). 7 times the average in European number of people held in solitary
examined the living condi- Public health professionals Union countries. With only 5% confinement increased by 40%,
tions and characteristics of should lead efforts to replace of the world’s population, the from 57 591 to 81 622 people.3
the populations in solitary reliance on this overly punitive United States now accounts for Even in jurisdictions where the
confinement. correctional policy with models
one quarter of its prisoners.1 The prison population has declined in
As part of the growing based on rehabilitation and
United States not only incarcerates recent years, the number of people
movement for reform, public restorative justice. (Am J Public
Health. 2015;105:18–26. doi: the most people, but also exposes in solitary has grown. For instance,
health agencies have an eth-
ical obligation to help ad- 10.2105/AJPH.2014.302205) more of its citizenry to solitary from 2008 through 2013, the
dress the excessive use of confinement than any other na- number of people in solitary con-
solitary confinement in jails tion. The best available data finement in federal prisons grew

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 GOVERNMENT, LAW, AND PUBLIC HEALTH PRACTICE

by 17%—from 10 659 to 12 460 and without pity; it does not re- ultimately setting free a man measure to separate only the most
form, it kills.8(p311)
prisoners------almost triple the 6% convicted of murder.14 As it be- dangerous individuals, but instead
rise in the total prison population Dickens condemned silent came clear to legal, medical, as a more routinely applied puni-
for that same period.4 prisons in his travel diaries as “a and correctional authorities that tive tactic to control overcrowded
secret punishment which slum- solitary confinement had failed jails and prisons.18,19
FROM SILENCE TO bering humanity is not roused up to achieve its intended purposes Nowadays, solitary confinement
SUPERMAX to stay.”9(p69) and caused unnecessary mental is typically used either to punish
Mid-19th-century physicians in anguish and suffering, jails and prisoners for violating rules (known
The United States began exper- the United States and Europe prisons gradually stopped using as disciplinary segregation), remove
imenting with solitary confinement echoed these concerns, reporting on it with any regularity.15 prisoners from the general prison
more than 200 years ago, when the distinct patterns of symptoms------ This shift away from solitary population who are thought to pose
American penology was undergo- labeled prison psychosis and solitary confinement was short lived. The a safety risk (known as administra-
ing a philosophical transformation, confinement psychosis------caused federal government opened Alca- tive segregation), or protect vulnera-
influenced by the Enlightenment, by prolonged isolation with a lack traz Prison in 1934 and, in 1963, ble individuals believed to be at risk
which sought to distance itself of natural light, poor ventilation, a penitentiary in Marion, Illinois, in the general prison population.20
from the brutality of corporal and lack of meaningful human that included segregation blocks to Pelican Bay, the first high-
punishment.5 The pioneers of contact.10,11 In Prison Discipline in house those who were considered security (supermax) prison built
solitary confinement were activist America (1848), Francis Gray, who a significant risk to the safety of solely to house prisoners in seg-
reformers who believed that silence other prisoners or staff. States regation, opened in California in
observed more than 4000 people
and solitude would induce repen- soon followed suit, establishing 1989. In supermax prisons, all
in US silent prisons, concluded,
tance and motivate prisoners to live designated cellblocks to separate prisoners are held in high levels of
a devout, socially responsible life.6 [T]he system of constant separa- the most threatening prisoners. confinement in cells designed to
tion . . . even when administered
This theory served as the basis In the 1970s a philosophical restrict visual and tactile contact
with the utmost humanity pro-
for the establishment of the United duces so many cases of insanity sea change occurred in US penol- with others, typically for long pe-
States’ first silent prisons: peniten- and of death as to indicate most ogy. Deontological philosophies riods. By 2004, 40 states had built
clearly, that its general tendency
tiaries where every prisoner was of retribution and deterrence or repurposed prisons as super-
is to enfeeble the body and the
placed in solitary confinement. mind.12(p181) replaced rehabilitation as the max facilities, like Pelican Bay,
The penological premise of operational purpose of correc- while hundreds of other prisons
In 1843, B. H. Coates reported tions. Courts and law enforcement established segregation units in-
silent prisons intrigued prominent
to the Philadelphia College of increasingly attributed crime to side existing facilities.21 Most state
19th-century thinkers, including
Physicians that African Americans the moral failings of the individual, departments of correction do not
political theorist Alexis de Toc-
were disproportionately subjected largely ignoring the social deter- keep reliable data about or report
queville and literary icon Charles
to solitary confinement in Eastern minants of criminal behavior, such on the average duration of pris-
Dickens, who traveled to the
State Penitentiary “without air, ex- as poverty, substandard educa- oners’ segregation. Depending on
United States to observe what
was being publicized as a revolu- ercise, or sunshine,” and had twice tion, addiction, and inequities in the reasons an individual is placed
tionary system for rehabilitating the relative mortality rate of other access to health care.16 Respond- in isolation and whether the cor-
individuals convicted of crimes.7 racial and ethnic groups in the ing to a burgeoning fear of crime, rectional facility imposes indeter-
After observing people isolated prison.13(p406) the United States instituted long, minate sanctions, the length of
in dark cells in Pennsylvania’s As the evidence accumulated in mandatory prison sentences, built stay can range from days to
Eastern Penitentiary, however, the medical community, the legal more prisons, and (in some cases) months to decades.22
both men revised their views community followed in noting abolished parole. From 1972 to
about the rehabilitative potential the inhumanity and detrimental 2012, the nation’s prison popula- LIFE IN SOLITARY
of silent prisons. de Tocqueville psychological impacts of solitary tion grew by 706%.17 It was in the
remarked, confinement. In 1890, the US sociopolitical context of this large- Living conditions in solitary
Supreme Court was so appalled scale prison growth that solitary confinement are physically un-
This absolute solitude, if nothing by the effects of solitary confine- confinement rapidly expanded------ healthy, extremely stressful, and
interrupts it, is beyond the
strength of man; it destroys the ment on a habeas corpus peti- not as an idealized system for in- psychologically traumatizing. The
criminal without intermission tioner that it issued a ruling ducing repentance or a necessary typical cell is 60 to 80 square feet,

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 GOVERNMENT, LAW, AND PUBLIC HEALTH PRACTICE

with a cot, a toilet, a sink, a narrow 19 states, policies permit locking segregation to protect or control a coalition of advocates and state
slit for a window, and sometimes people into solitary confinement them. Nearly a third of people legislators introduced what poten-
a small molded desk bolted to the indefinitely.28 housed in segregation units have 1 tially represents the most compre-
wall. In many facilities, cells have or more preexisting psychiatric hensive legislative effort to date
a steel door with a small slot for THE PEOPLE IN SOLITARY conditions.31---33 to curb the use of solitary con-
delivering meals. Because of housing policies and finement.38 In California, multiple
Inmates have little exposure to It is commonly thought that inadequate programming, lesbian, hunger strikes involving 30 000
natural sunlight; bright fluorescent solitary confinement is reserved gay, bisexual, transgender, and prisoners resulted in a certified,
lights illuminate each cell, often for incorrigibly violent, dangerous queer individuals; pregnant class action lawsuit challenging the
through the night, disrupting nat- people------the worst of the worst. In women; and people with infec- constitutionality of administrative
ural sleep cycles and circadian fact, only a small percentage of tious diseases may find themselves segregation policies and prompted
rhythms. Some solitary confine- people held in isolation need to be in solitary confinement solely be- congressional hearings to examine
ment units are nearly silent except continuously separated from the cause of their identity or medical California’s use of solitary con-
for sudden outbursts; others sub- general population. In some juris- condition.34 Finally, tens of thou- finement.39 Other states are rec-
ject prisoners to an incessant ca- dictions, the majority of people sands of people are assigned to ognizing that, at 2 to 3 times the
cophony of clanking metal doors, in disciplinary segregation do not administrative segregation be- cost of housing in the general jail
jingling keys, booted footsteps, pose a threat to staff or other cause of perceived gang affiliation. or prison population, solitary con-
and distressed voices reverberat- prisoners, but are placed in segre- In some jurisdictions, assignment finement provides a poor return
ing off thick walls. In more modern gation for minor rule infractions, to administrative segregation is on investment. In 2013, decisions
units, electronic doors, search such as talking back (insolence), based solely on a point system that to close 2 supermax units, the
cameras, and intercoms create smoking, failing to report to includes factors such as tattoos, Tamms Correctional Center in
a mechanized environment that work or school, refusing to return known associates, and possessions Illinois and the Centennial Cor-
minimizes face-to-face interaction. a food tray, or possessing an suggesting gang affiliation, without rectional Facility in Colorado,
Prisoners are typically taken out excess quantity of postage regard to individual behaviors.35 cited fiscal pressures.40 Several
of their cells for only 1 hour on stamps.29 states are working with nonprofit
weekdays for recreation or a Segregation units also hold a A GROWING MOVEMENT organizations to curb segregation
shower, or, in some systems, once disproportionate number of indi- FOR REFORM practices. The Segregation Re-
a week for 5 hours. Before being viduals who are especially vulner- duction Project, led by the Vera
moved from their cells, prisoners able in correctional settings, such Civil rights lawsuits, prisoner- Institute of Justice, has been
are cuffed and often shackled at as people with a serious mental led hunger strikes, scrutiny from working with corrections officials
the waist and placed in leg irons. illness or who are developmen- international human rights author- in Illinois, Washington State,
Recreation usually occurs in either tally delayed, very young, or ities, increased media attention, and New Mexico, and Pennsylvania
an open cage outdoors or an in- considered especially sexually mounting fiscal pressures have to develop more humane and
door area, sometimes with an vulnerable. These individuals are prompted some jurisdictions to effective alternatives to solitary
open, barred top. Some prisons often particularly sensitive to the rethink the place of solitary con- confinement.22
offer group therapy sessions, but, detrimental impacts of isolation. finement in their criminal justice The US Congress is also in-
in many facilities, participants are Many of the 95 000 adolescents system. At the state and local level, creasingly active on this issue. The
chained to metal chairs that are in adult jails and prisons are a combination of tireless grassroots Senate Judiciary Subcommittee
mounted to the floor of a cage. housed in segregation cells, ei- advocacy and timely litigation has on the Constitution, Civil Rights,
Many people live in these con- ther to protect them from being already spurred dramatic reduc- and Human Rights has held 2
ditions for years without the op- victimized by adults or as a re- tions in the use of solitary confine- hearings on the overuse of solitary
portunity to engage in the types of sult of often minor disruptive ment in some state prison systems, confinement (in June 2012 and
human interaction, treatment, job behavior.30 With an abundance of such as Ohio, Mississippi, and February 2014); an exonerated
training, and educational experi- rules, but a shortage of quality Maine, and others are showing former death row inmate, clinical
ences that would help them adjust treatment, prisons route people signs of meaningful reform.36,37 psychologists, and corrections
when reentering the general with psychiatric conditions to dis- In early 2014, following a administrators were among those
prison population or society.23---27 ciplinary segregation for minor rule federal lawsuit brought by the who testified in favor of measures
In the federal system and in at least infractions or to administrative New York Civil Liberties Union, to reduce segregation in the prison

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 GOVERNMENT, LAW, AND PUBLIC HEALTH PRACTICE

system. The subcommittee also transportation, business, commu- Addressing solitary confine- incidence of violence; to empiri-
received written statements from nity planning, and agriculture in ment undoubtedly requires gov- cally determine which individual,
advocacy groups; human rights determining outcomes.44 Increas- ernment action from corrections relationship, community, and so-
authorities; professional societies; ingly, population health researchers agencies, state legislatures, and cietal factors affect the risk for
religious organizations; family and policymakers see incarceration executive leaders, but public violence; to evaluate violence
members with loved ones being as a major social determinant of health professionals also have an prevention initiatives; and to push
held in solitary; correctional phy- health, opening the way for a more important role to play. In November for the adoption of evidence-based
sicians; immigration think tanks; assertive public health role in 2013, the American Public Health prevention approaches. As a mat-
advocates for lesbian, gay, bisex- addressing conditions inside cor- Association issued an official ter of violence prevention, public
ual, and transgender persons; law rectional facilities.45 policy statement recognizing health agencies should work in
professors; philosophers; and Nearly every scientific inquiry solitary confinement as a public collaboration with correctional
criminologists. These hearings into the effects of solitary con- health issue and issuing a set of systems to reduce the use of soli-
resulted in the Bureau of Prisons finement over the past 150 years recommendations (see the box on tary confinement in jails and
agreeing to an independent as- has concluded that subjecting an page e4).46 Public health agencies prisons.
sessment of its use of solitary individual to more than 10 days can apply approaches rooted in Violence is endemic in correc-
confinement.41,42 of involuntary segregation results violence prevention, health equity, tional environments. Suicide is
in a distinct set of emotional, surveillance, occupational health, a leading cause of death, account-
A PUBLIC HEALTH cognitive, social, and physical pa- social justice, and human rights to ing for one third of deaths in jails
ETHICAL FRAMEWORK thologies. This is not solely a cor- address the overuse of segregation. between 2000 and 2009.49 The
rections issue; the overwhelming incidence of self-harm, injuries
The duty of public health pro- majority of people incarcerated A Matter of Violence inflicted on correctional staff, and
fessionals is to prevent disease will be released, and the impact of Prevention suicide among prisoners is signifi-
morbidity and premature mortal- long periods of isolation on their Public health agencies have cantly higher in segregation units
ity in all populations by maximiz- health, employability, and future a duty to prevent violence in than in the general prison or jail
ing social, environmental, and life chances will be felt in the society by identifying its causes population.50 For example, in New
structural conditions required for families and communities to which and correlates and implement- York, suicide rates are 5 times as
healthy living and abating harmful they return. It is important to un- ing interventions to reduce its high among prisoners in solitary
conditions.43 The social determi- derstand the health impacts of the occurrence.47,48 For instance, the confinement as among those in the
nants of health perspective ac- widespread use of segregation at Division of Violence Prevention of general prison population.51 More
knowledges the need to shift the the population level, in addition the Centers for Disease Control than 60% of the suicides commit-
focus of public health beyond to assessing the effect of time spent and Prevention follows a social- ted by youths while in correctional
the medical treatment of cases to in solitary confinement on indi- ecological model in describing its facilities take place in solitary
the role of education, housing, vidual health outcomes. role: to monitor and track the confinement.52

American Public Health Association Action Steps to Address Solitary Confinement

Eliminate the use of solitary confinement as a punishment and create alternative disciplinary measures tailored to individuals with serious mental illnesses.
Eliminate the use of solitary confinement as a tactic to promote institutional security, except when there is no less restrictive option available to address a serious, imminent, and ongoing
safety threat.
If an individual must be segregated, then he or she should be confined in the least restrictive conditions possible, and protocols must be in place to return the individual to the general
population once there is no longer a pressing threat.
Individuals with serious mental illness must never be placed in solitary confinement.
Juveniles must never be placed in solitary confinement, regardless of whether they are in adult or juvenile facilities.
Segregating people for medical reasons should only take place upon direction of a physician and must take place in the least restrictive environment for the shortest duration possible.
People who must be separated from the general population for their own protection must be placed in the least restrictive conditions possible.

January 2015, Vol 105, No. 1 | American Journal of Public Health Cloud et al. | Peer Reviewed | Government, Law, and Public Health Practice | 21
 GOVERNMENT, LAW, AND PUBLIC HEALTH PRACTICE

The violence induced by con- put groups of people who are divert people with serious mental human interaction. Participation
ditions of solitary confinement is already socially disadvantaged illness from incarceration and in such a system is a stressful and
not limited to the prison environ- or disenfranchised at further develop sufficiently funded, demoralizing experience that can
ment. Studies show that prisoners disadvantage with respect to their community-based alternatives. breed distrust, frustration, anger,
who are released from segregation health.”43(p254) People with serious Several components of the psychological damage, and some-
directly to the community reof- psychiatric conditions are among Affordable Care Act, including times violence on the part of both
fend more quickly and at higher society’s most vulnerable and stig- the expansion of Medicaid eligi- prisoners and officers.
rates than prisoners who spent matized populations. The grave bility and stronger parity for be- Reflecting on what it is like to
at least 3 months back in the overrepresentation of people with havioral health coverage, create work in an isolation unit, a New
general prison population before serious mental illnesses in the na- new opportunities for criminal Jersey prison officer noted,
their return to the community.53 tion’s prisons and jails------and within justice and public health agencies
When I see a human being who is
Releasing people directly from segregation units in particular------is to develop programmatic solu- reduced to throwing feces and
solitary confinement to communi- a public health crisis that demands tions to the problem of correc- urine, it wears me down. . . . I am
ties without any rehabilitative a response. tional facilities serving as de facto breathing the same canned air,
sitting under the same fluorescent
programming to help them transi- A recent survey found that in behavioral health providers. At lights, listening to the same noises.
tion is a perilous but common 44 states, more people with seri- the same time, public health au- I don’t believe this is good for
practice. For instance, in 2011, ous mental illness are confined in thorities should play a larger role officers or good for the pris-
oners.57
Texas released 1347 individuals the jails and prisons throughout in overseeing health care services
directly from administrative seg- each state than in the largest and formulating standards for Staff members of the Mississippi
regation to the streets without any remaining state psychiatric hospi- the quality of medical and behav- Department of Correction re-
rehabilitative programming.54 tal.55 Members of this population ioral health care in correctional ported dramatic improvements
This can have a direct impact on are significantly more likely than facilities. Regulations should be in their work environments con-
the occurrence of violence in other prisoners to end up in solitary issued to fund sufficient staffing, nected to lower levels of stress
community settings. confinement, for several reasons. medication formularies, and treat- and violence after the prison
Decreasing the use of segrega- People with psychiatric conditions ment options to allow health care implemented major reductions
tion has also been shown to protect or developmental delays may ex- professionals working in correc- in solitary confinement.36
against future violence. Mississippi’s perience difficulties complying with tional facilities to uphold their Clinicians who deliver medical
prison system, which reduced the facility rules and may be placed ethical obligations. and mental health treatment to
use of solitary confinement by in disciplinary segregation as a re- people in solitary confinement
more than 80% and moved pris- sult. Correctional officers often lack Occupational Health Hazards also experience occupational haz-
oners with serious psychiatric sufficient training and may inter- Mitigating occupational health ards. In the face of the monotony,
problems to an alternative setting, pret the symptoms of psychiatric hazards is another classic role of deprivation, and punitive environ-
realized a 70% decrease in the distress as willful noncompliance public health agencies.56 Working ment of segregation units, many
incidence of violence.36 More pub- with facility rules and respond conditions in segregation units are prisoners resort to feigning illness
lic health agencies should view punitively. Persons with psychiatric psychologically stressful and can or engaging in self-harm in an
violence that results from condi- conditions are also more likely to be physically harmful. Correc- attempt to be removed to a medical
tions of confinement as a public be victimized by other prisoners tional officers are at risk for injury, setting. Correctional health pro-
health issue and partner with cor- and are often placed in adminis- and they endure some of the same viders are routinely required to
rections officials to develop more trative segregation for protection. conditions as the prisoners. Pris- determine whether adaptive be-
humane housing and incentive Access to quality psychiatric care oners held in isolation have no havior to avoid anguish caused by
structures to reduce segregation in most correctional facilities is social contact with other prisoners solitary confinement is connected
and curtail violence. severely limited, and segregation is and struggle with the lack of phys- to a “legitimate” health concern.
too commonly used in systems that ical activity, effects of sensory dep- This places providers in an ethical
Health Equity lack sufficient behavioral health rivation, and sense of extreme bind: labeling prisoners’ behavior
Public health authorities also services to meet the needs of their powerlessness. Correctional officers as malingering typically means that
have an ethical duty to narrow inmates. Health departments must responsible for enforcing rules, ap- they will continue to be held in
health inequities attributable to continue to work in partnership plying shackles, and controlling solitary and may receive additional
social factors that “systematically with criminal justice agencies to behavior are their main source of punishment.

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 GOVERNMENT, LAW, AND PUBLIC HEALTH PRACTICE

The conditions of solitary con- fails to detect the health effects outcomes or evaluate measures unit of New York City’s Depart-
finement also impinge on medical that segregation and other condi- designed to reduce the use of iso- ment of Health and Mental Hy-
providers’ autonomy and jeopar- tions of confinement have on the lation. Public health researchers giene responsible for overseeing
dize their ability to meet their communities most affected by in- can use their expertise and the provision of health services at
ethical obligations as clinicians. carceration.59 Health departments methods in the service of commit- the city’s jails, adopted an elec-
For example, health care pro- can assist in unveiling the curtain tees commissioned by legislatures tronic health record in 2011. This
viders are frequently asked to of secrecy that cloaks most prison to study the impacts of solitary allows the bureau to record and
conduct mental health consulta- and jail environments from public confinement or to explore alterna- categorize all injuries that occur in
tions through a slit in a cell’s steel (and public health) scrutiny. tive housing policies. the city’s jails according to Centers
door or on an open tier with Most research on the effects Reliable data collection is es- for Disease Control and Preven-
barred cell fronts that offer no of solitary confinement on health sential for public health research tion criteria. For each injury, in-
privacy and no ability to develop has involved clinical case studies and policymaking. To advocate cluding injuries that occur in
trust and patient rapport. Health and surveys with relatively small changes in the use of solitary segregation units, information
care professionals working in samples. Most state and local confinement, it will be important is collected on intentionality, re-
prisons routinely encounter the systems, as well as the Federal to empirically describe the rela- ported cause, type of injury, and
detrimental impact that solitary Bureau of Prisons, have not tionship between environmental location in the jail where it oc-
confinement has on a person’s independently evaluated the factors associated with segregation curred. The bureau used data
physical and mental health. Yet long-term health impacts of segre- and clinical outcomes, including produced by the electronic record
mental health providers lack the gation. The limited capacity of suicide attempts, violent incidents, to reveal a significant increase in
authority to remove individuals corrections systems to study the and mental health crises. The acts of self-harm in the jail system
from these settings or to authorize issue and the lack of reliable data National Institute of Corrections between 2009 and 2012, despite
better health services. Thus, clini- highlight the need for public reported that only a few states a 9% drop in the average daily
cians can become extremely frus- health researchers to initiate more used data systems that could ac- population. Over the same pe-
trated trying to deliver care in and better investigations, and the curately aggregate descriptive in- riod, the use of solitary confine-
these settings, under environmen- theory, methods, and metrics of formation about the population in ment in city jails increased by
tal conditions and systems of rules epidemiology can provide a com- their custody, and state correc- approximately 60%.
that undermine their ability to pelling, data-driven approach to tions departments could not easily Electronic health record data
uphold their obligations as medi- understanding the health impacts produce data on the number of also allowed the city’s epidemiol-
cal professionals to pursue benef- of corrections policies. people held in administrative seg- ogists to contrast the characteristics
icence and alleviate malfeasance In analogous contexts, epidemi- regation, punitive segregation, or of groups within the jail population
for their patients.58 ologists have documented the protective custody or on the who inflicted self-harm with a com-
health impacts of widespread ex- prevalence of mental health and parison group who did not engage
Surveillance posure to traumatic experiences other health issues for those kept in self-harm. They found that pris-
Surveillance of health outcomes associated with human rights in isolation.65 Increased capacity oners with records of self-harm had
is a core function of public health abuses.60 Similar approaches could and commitment to collecting substantially higher rates of recidi-
and critical for identifying risk be used to assess the incidence of basic health data will play an vism, serious mental illness, and
factors, causal pathways, and pro- psychopathologies associated with essential role in evaluating segre- exposure to solitary confinement
tective factors against disease as segregation and the relationships gation policies. than patients who did not engage in
a basis for allocating resources and between solitary confinement and The increasing numbers of self-harm.66
informing targeted interventions. disease trajectories over time. Psy- correctional systems that have Increasingly, European coun-
Despite the high prevalence of chiatric epidemiologists might electronic health records offer a par- tries are creating independent,
health conditions among pris- adopt models from studies of the ticularly promising opportunity to nonprofit agencies to monitor
oners, most health departments do impact of political imprisonment on facilitate epidemiological analysis the health of incarcerated popula-
not track the prevalence of dis- populations in conflict settings.61---64 of the health impacts of such cor- tions.67 Independent monitoring
eases or the incidence of violence For example, research might focus rectional policies as disciplinary or boards in correctional facilities can
in correctional settings. This leads on the relationship between time long-term administrative segrega- improve the treatment of pris-
to underestimation of the actual spent in solitary confinement and tion. For example, the Bureau of oners and help protect them from
burden of disease in society and the incidence of negative health Correctional Health Services, the abuse.68 With a few exceptions,

January 2015, Vol 105, No. 1 | American Journal of Public Health Cloud et al. | Peer Reviewed | Government, Law, and Public Health Practice | 23
 GOVERNMENT, LAW, AND PUBLIC HEALTH PRACTICE

equivalent agencies do not exist in for the protection of prisoners solitary confinement and are resis- Correspondence should be sent to David H.
Cloud, 233 Broadway, 12th floor, New
the United States. A lack of inde- and detainees. For example, the tant to change.
York, NY (e-mail: dcloud@vera.org). Re-
pendent mechanisms for holding United Nations has declared that Momentum is growing nation- prints can be ordered at http://www.ajph.
correctional agencies and legisla- more than 15 days in solitary ally to reduce solitary confinement org by clicking the “Reprints” link.
This article was accepted June 30,
tors accountable for health out- confinement violates human rights in jails and prisons, motivated by
2014.
comes in corrections facilities standards. The Committee Against the realization that it is overused,
means that serious problems in jails Torture, the governing body of the causes severe and lasting mental
Contributors
and prisons typically only come to Convention Against Torture, to health consequences for prisoners D. H. Cloud conceptualized and wrote
light if legislators, advocates, litiga- which the United States is a party, and staff, costs much more than the article. All other authors provided
valuable additions, insights, and editing.
tors, family members, or the media has recommended that solitary other modes of incarceration, and
raise concerns. To ensure improved confinement be abolished entirely makes our prisons and our com-
health surveillance, public health because of its harmful effects on munities less safe. To bring about Acknowledgments
We thank Linda Cushman, Joseph L.
leaders should urge state and city prisoners’ mental and physical significant and lasting change, we Mailman School of Public Health, Columbia
legislative bodies to create indepen- health.70 The US courts and legal must acknowledge that disciplin- University, for her feedback on earlier
versions of this article.
dent health authorities to monitor system have not been receptive ary and administrative segregation
conditions, policies, and practices to international norms in this are not simply an unintended
in jails and prisons and should press area. Public health agencies, re- consequence of overstretched Human Participant Protection
No protocol approval was needed because
for funding for needed medical and searchers, corrections professionals, correctional budgets and over- no human participants were involved.
mental health care. and advocates must push for action, crowding. The United States’
providing the leadership to increase overuse of isolation has become References
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Assessing the Expected Impact of Global Health Treaties:

Evidence From 90 Quantitative Evaluations
Steven J. Hoffman, BHSc, MA, JD, and John-Arne Røttingen, MD, PhD, MSc, MPA

We assessed what impact adoption, ratification, and do- global health broadly.9 These calls new regulations can automatically
can be expected from global mestic implementation. follow the perceived success of enter into force for all member
health treaties on the basis of Experimental and quasiexper- past global health treaties—most states on communicable disease
90 quantitative evaluations of imental evaluations of treaties
notably the Framework Conven- control, medical nomenclature,
existing treaties on trade, fi- would provide more informa-
tion on Tobacco Control (2002) diagnostic standards, health prod-
nance, human rights, conflict, tion about what can be expected
from this type of global interven- and the revised International uct safety, labeling, and adver-
and the environment.
It appears treaties consis- tion. (Am J Public Health. 2015; Health Regulations (2005)—and tising unless states specifically
tently succeed in shaping 105:26–40. doi:10.2105/AJPH. perceived potential for future im- opt out (article 21). Treaties in
economic matters and con- 2014.302085) pact.10 The World Health Organi- other health areas can be adopted
sistently fail in achieving so- zation’s unusually expansive yet by a two thirds vote of the
cial progress. There are at largely dormant powers for mak- World Health Organization’s
least 3 differences between THERE HAVE BEEN MANY ing new international treaties un- membership, with nonaccepting
these domains that point to calls over the past few years der its constitution’s articles 19 states legally required to take the
design characteristics that for new international treaties and 21 are also cited as a reason unusual step of justifying their
new global health treaties can addressing health issues, including for using them.11---13 Although nonacceptance (article 19).14
incorporate to achieve positive
alcohol,1 chronic diseases,2 few multilateral institutions are The effect that can be expected
impact: (1) incentives for those
falsified/substandard medicines,3 empowered to enact new treaties, from any new global health treaty,
with power to act on them; (2)
institutions designed to bring health system corruption,4 impact in the World Health Organiza- however, is as yet largely un-
edicts into effect; and (3) interests evaluations,5 nutrition,6 obesity,7 tion’s case, with just a majority known. Negotiation, adoption, rat-
advocating their negotiation, research and development,8 and vote of its governing assembly, ification, and even domestic

26 | Government, Law, and Public Health Practice | Peer Reviewed | Hoffman and Røttingen American Journal of Public Health | January 2015, Vol 105, No. 1