Moving to the Bay Area from the Midwest was a culture shock in many ways. I was amazed by the diversity, the food, the openness of opinions. And I was struck by the traffic, the stark differences driving from one community to another and the homelessness — you could see signs of it everywhere. As time went on, I acclimated to these changes. Working in the hospital, I got used to the “frequent flyers” in the emergency department looking for shelter. Living on Mission in San Francisco, I was used to the encampments around the Civic Center BART Station every time I went to and from work. However, it was when I was visiting the San Francisco Juvenile Justice Center (JCC) that I learned more about homelessness and youths in the JCC, and I wanted to know more.
This started with an understanding of California’s history with mental health services. The Short Doyle Act in 1957 had defunded state mental health hospitals and Lanterman-Petris-Short Act of 1966 restricted involuntary hospitalization for mentally ill. Both of these acts in California were actually supported by many activists’ groups in the midst of unjust use of state-funded mental institutions to systematically disenfranchised groups of people starting from the dark history of the Age of the Imbecile. The Short Doyle Act was meant to shift to community-centered care of mentally ill patients, and the LPS Act was meant to establish due process rights of individuals for whom commitment was being sought. However, the shortcoming arose when the funding for community mental health programs was vetoed during Governor Reagan’s term leading the poor mental health access to many Plata v. Brown alleging that the California Department of Corrections and Rehabilitation (CDCR) medical services are inadequate and violate the Eighth Amendment leading to awareness of severe over-crowding and poor mental health services for mentally ill, insufficient medical staff, incomplete medical records and lack of quality control measures in correctional health service departments.
Currently, 1 out of 31 people in the United States is in correctional services of some kind. The profiles of the correctional population are made of people coming from lower socio-economic background, poor education, lack of parental support, adverse childhood events, mental health illnesses and men of color have much higher rates of being incarcerated than white men. Once again, similarly to the unjust and underfunding of mental health services in California, we now see similar treatment of marginalized populations within the legal system. We have many reasons for the rising prison population including drug laws, mandatory minimums and the three-strike system, “tough on crime” policies, longer sentencing, high recidivism rates, discriminatory and poor re-entry support with lack of community support especially in substance abuse and mental health services. The impact of imprisonment itself on mental health is worsened by conditions of confinement, solitary confinement and separation from family support with less visitation as people are moved to different prisons far from their hometowns.
We also have a new problem arising, the aging population in the prisons. Currently, 46 percent of male inmates are 50 years or older, and 82 percent of the inmates that are 65 and older have chronic physical problems. In California, the inmates that are 55 and older (7 percent of the prison population) consume 38 percent of prison medical beds and requires a range of medical staff and facilities offering different levels of care. In Vallejo’s correctional facilities, they have opened to skilled nursing facilities and a hospice facility to help serve this aging population. This 17-bed palliative care hospice center allows prisoners to die with some dignity while minimizing harm and pain. The impact of age on health care costs nationally concluded that the average annual cost per prisoner was $5,482, but for older prisoners, that figure rises to $11,00 for ages 50-59 and $40,000 for prisoners 80 years and older.
There are examples across the country and globe that have shown that investing in mental health and improving our prison systems can improve the productivity of our communities and decrease costs. For example, in saves taxpayers $7. The Norwegian prison system, with one of the lowest recidivism rates in the world, has been held as the new standard for how to shape the future of our prison systems.
Norway’s prisons are designed with three core values: normality, humanity, and rehabilitation. The prison is set up as a progression where all offenders start at the highest level of security and work their way towards “becoming a neighbor” again. This includes working daily, first on prison grounds to working in the community. They are given normal clothing, ability to see family regularly, more furloughs and are paid decent wages for their work. The security is dynamic, and the “guards” have interpersonal relationships more as coaches and mentors and role models for the prison population. This system provides gradual reintegration into society and mental health support along the way.
These systems show how the U.S. can adopt health policies to redistribute state and national budget to improve community mental health services that save money by decreasing the homeless and prison population, improve prison conditions to reduce its harm on mental health of the individual but also to reintegrate back into society and save health care costs. This would include providing funding for Mental Services, similar to Mental Health Systems Act of 1980 to provide grants to create robust community mental health centers and specialty courts in every state for mental health and substance abuse courts to provide treatment programs and close support during the probationary period. Thirdly, there needs to be a restructuring of prison systems, with the first step to reduce solitary confinement and then to create a reintegration program to ensure reduced recidivism rates. The journey to the current state of our mental health services was long and fraught with underfunding and poor awareness; it will take time to create a space for improved mental health services to see the cost-saving benefits of investing in the mental wellness of our citizens.
Deepika Parmar is a pediatrician and public health student.
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