摘要：Over the past 25 years, incarceration rates in the United States have more than tripled. Providing health care services for this growing number of inmates poses immense medical and public health challenges. Focusing on the administrative and financial shifts in health care delivery, I examined the history of medical services in one of the nation's largest correctional facilities, Rikers Island in New York City. Over time, medical services at Rikers have become increasingly privatized. This trend toward privatization is mirrored nationwide and coincides with the rising prevalence of incarceration. OVER THE PAST 25 YEARS, incarceration rates in the United States have increased dramatically ( Figure 1 ). At midyear 2006, 2.2 million people were held in jails and prisons nationwide, yielding an incarceration rate of 750 inmates per 100 000 residents. 1 At present, the Unites States has the highest rate of incarceration in the world; it is between 4 and 10 times higher than that of other industrialized nations. 2 According to the US Bureau of Justice Statistics, rates of incarceration in federal and state prisons doubled between 1980 and 1990 and increased by more than 50% between 1990 and 2005. 3 , 4 The rates of imprisonment in 1985, 1995, and 2005 were 313, 601, and 737 per 100 000 residents, respectively. 5 , 6 This unprecedented rise in imprisonment has been described in the social science literature as a phenomenon of “mass incarceration.” 7 , 8 Open in a separate window FIGURE 1 Incarceration rate and number of persons in prisons and jails: United States, 1980-–2006. Source. Bureau of Justice Statistics 3 and Pastore and Magure. 4 In 2006, 92% of US prison inmates and 87% of jail inmates were men. 1 Black men were 6.5 times more likely than were White men to be incarcerated; Black women were 3.8 times more likely to be incarcerated than were White women 3 ( Figure 2 ). More than 10% of Black men aged 25 to 29 years were incarcerated at midyear 2006. 1 About half of the nation's jail inmates have less than a high school education, and 14% lived in an institution or in foster care as children. 9 Open in a separate window FIGURE 2 Jail incarceration rates by race and ethnicity: United States, 1990–2006. Source. Bureau of Justice Statistics. 3 In addition to these socioeconomic markers, prisoners bear a disproportionately high burden of chronic and infectious disease. Human immunodeficiency virus (HIV) seroprevalence in prison populations is estimated at 1.8%, about four times higher than in the general population. 10 Prevalence of hepatitis C infection in prisons is estimated to be between 15% and 25%. 11 In jail inmates, rates of substance use disorders in the year before incarceration are approximately 70%. 12 Thus, the prisoner population is composed predominantly of poor men from minority groups, who have complex medical and mental health needs. Delivering medical care to this population poses immense medical and public health challenges. I performed a historical case study of the evolution of medical services in one of the nation's largest correctional facilities, Rikers Island in New York City. My objective was to describe the trajectory of medical services at Rikers Island and thus elucidate key issues in the intersection between criminal justice policy and health care delivery. I used ethnographic methods, including archival review, qualitative key informant interviews, and media content analysis. I obtained primary sources from the New York city hall library, municipal archive, and the Montefiore Medical Center archive. These materials include reports from the Department of Health (DOH), Department of Correction (DOC), mayor's correspondence, and city budgets and contracts. Policy papers, health statistics, and administrative records served as secondary sources. The New York Times database provided a source of media coverage. I conducted semistructured qualitative interviews with directors of the Montefiore Rikers Island Health Service.
