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Dear Decaturish,

It was recently announced that Dekalb County Jail has a new medical contractor, Armor Health. Armor will replace Wellpath and Centurion, contractors previously responsible for medical care and mental health services respectively. This follows a horrifying year for those incarcerated in Dekalb County Jail that saw nine people die in 2022, including the highly publicized deaths of two people related to hypothermia.

Armor has been presented as the primary solution to the chronic issues of neglect and preventable death that have long plagued the jail. Sheriff Melody Maddox has framed the change in contractor as one focused on the well-being of incarcerated individuals, saying, “Armor addresses a priority area of inmate care in today’s jail environment: a collaborative, holistic approach to medical and behavioral/mental health needs.” Unfortunately, as a physician who frequently cares for incarcerated individuals who are hospitalized and studies the health impacts of incarceration on health, I have little hope that conditions for incarcerated people in Dekalb will markedly improve.

The scapegoating of medical contractors is a common refrain for local jails which frequently face lawsuits relating to medical neglect. This attempts to distract the public from the true driver of preventable suffering and death behind bars, the carceral environment itself. It also works to absolve the sheriff’s department of any responsibility for a system that devalues, abuses, and neglects the lives of incarcerated individuals. This care-centered rhetoric from the sheriff’s department exemplifies carceral humanism, or the building of a more humane cage. It amounts to public relations work to assure you that your tax dollars are not spent inflicting human rights violations and allows us to collectively avert our eyes from the harms of incarceration, albeit temporarily, until the next preventable death.

Unlike the general public, incarcerated individuals have a constitutional right to healthcare stemming from a 1976 Supreme Court ruling that stated, “deliberate indifference to serious medical needs…” was inconsistent with the eighth amendment right to no cruel and unusual punishment. In 1987, that right to care was further defined as care being “reasonably commensurate with modern medical science.” Unfortunately, in practice, this legal standard has proven unattainable. While Dekalb residents may breathe a sigh of relief that Wellpath is no longer at the helm, given their concerning track record, it is hard to say that Armor’s recent history is much better.

Wellpath, for its part, continues to fail upwards and is taking over medical care in Georgia prisons. Calls to improve medical care alone are not enough as carceral facilities are built to punish and once someone is criminalized, they are systematically dehumanized. The function of carceral facilities stands antithetical to a mission of care.

While the majority of local jails medical providers are for-profit, private companies, introducing a clear conflict of interest and contributing to the undertreatment of certain diseases, health outcomes have been similarly poor with publicly contracted providers. This is perhaps unsurprising given that the vast majority of health is not driven by explicit clinical care but by environmental, social, and political factors known as the social determinants of health. Incarcerated individuals come overwhelmingly from poorly resourced communities struggling with significant divestment, are often impoverished, and have a high burden of disease. This includes undertreated chronic diseases such as hypertension, diabetes, kidney disease, as well as higher rates of infectious diseases like hepatitis C, tuberculosis, and HIV. Nearly one half have a diagnosed mental health disorder with roughly one in five considered severe. The majority also have a substance use disorder, which jails overwhelmingly fail to treat, resulting in extremely high risk of overdose on release.

What we see in local jails are people who are highly medically complex, who lack access to appropriate and comprehensive care in their community before incarceration, and who are then placed into an incredibly traumatizing and destabilizing environment. It is not surprising, then, that incarceration dramatically lowers one’s life expectancy, if they survive the experience at all. A jail’s primary purpose remains security over health and medical providers often face what has been described as dual loyalty, their obligations to both employer and patient that at times conflict. This creates an environment that even well-trained, well-meaning physicians can struggle tremendously in.

It is foolish to pretend adequate care can take place in a cell, and it is cruel to continue to offer resources only after criminalizing people. Incarceration remains an expensive and ineffective public safety intervention. For at least 40% of those incarcerated, it is serving no justifiable public safety benefit. In our local jails, the majority are not convicted, awaiting trial, and many are simply unable to afford their bail. A system like this does not resemble justice in any meaningful way yet inflicts immeasurable harm disproportionately on those already made vulnerable by threadbare social systems.

If elected officials are serious about improving both public safety and health, they must urgently move away from incarceration altogether. To start, it is arrest through interactions with the police that drives incarceration. Many current offenses should be decriminalized, including drug offenses. This would allow us to take an evidence-based, public health approach to increase linkage to care and reduce overdose deaths. With over 90% of 911 calls unrelated to violence, police as a default one-size-fits-all response remain expensive, dangerous, and inefficient.

We need various alternative responses, including mental health responses like that of CAHOOTS in Oregon, where less than 2% of their tens of thousands of responses required calling an armed officer for backup. For those who end up in jail, cash bail must be eliminated. Incarceration must become a last resort. It is clear that resource provision is the best crime prevention. It was prison abolitionist and Professor Angela Davis who stated over twenty years ago, “Prisons don’t disappear social problems, they disappear human beings.” We all stand to benefit if only our collective investments would begin to address the root causes of trauma, despair, and harm. Care in a cage is far from therapeutic and often comes too little, too late.

— Mark Spencer, MD is an Internal Medicine Physician in Atlanta and lives in DeKalb County, GA.

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