The Intersection Of Innovation, Social Theory, and Care Delivery in Carceral Environments
Introduction to Telemedicine and Structural Unwellness Behind Bars
This paper will examine issues of healthcare access within the US prison system, specifically the application of telemedicine services as a means to increase access to care, and by effect, health outcomes at San Quentin State Penitentiary in Northern California.
Outside of prison, telemedicine has been shown to be an effective tool to create more efficient means of delivering care by reducing wait times and increasing access to care across geographical boundaries. Delays in care cause irreparable damage, leading to infection, exacerbation of chronic illnesses, or death. Telemedicine offers the opportunity to reduce delays, connect resources such as relevant data or specialist care, conduct remote diagnostics, and reduce the costs associated with physical transport to outside clinics (Nash, 2021). The COVID-19 pandemic played a significant role in accelerating the adoption of telemedicine, both in consumer uptake and in financial reimbursement models. A 2021 report from McKinsey notes a 38x increase in telemedicine adoption compared to pre-pandemic baseline levels (Bestsennyy et al., 2022). Telemedicine’s most effective manifestation is when it operates as part of a larger ecosystem in which the technology is defined primarily by its form-factor and operates in conjunction with real human interactions, real-time data, access to information, social support, and behavior change modalities, acting in interoperable harmony with other tech-based platforms such as electronic medical records, wearable devices, and digital health tools. In this ecosystem, telemedicine in and of itself is not the solution, but rather is a tool, a mechanism, used to augment care delivery and the experience of care. This is telemedicine in its most idealized form. Telemedicine is not a silver bullet. It cannot perform surgery or take an x-ray or MRI. It cannot replace real-life human connection or have bedside manner. But it can be especially effective at managing chronic conditions like diabetes, asthma, and hypertension—conditions which affect 6.6%, 11.7%, and 22.1%, respectively, as of 2016, of America’s incarcerated population (Wang, 2022). In a carceral environment, specifically within San Quentin, whether telemedicine can—by this definition—be effective or not is at the heart of tension between system administrators and the people who purportedly benefit from it. Can prison, a place of systemic subjugation, a system which benefits from inequities of power, facilitate telemedicine services in such a way as intended: to increase efficiencies and access to care, and by effect, health outcomes?
Prisons are not a care-based industry. They are a “punishment industry” (Bauer, 2019). They are in the business of maintaining—or possibly even growing—their power and influence. Whether public or private, a vast constellation of businesses operate in support of such an institution. “Corporations producing all kinds of goods—from buildings to electronic devices and hygiene products—and providing all kinds of services—from meals to therapy and healthcare—are now directly involved in the punishment business. That is to say, companies that one would assume are far removed from the work of state punishment have developed major stakes in the perpetuation of a prison system whose historical obsolescence is therefore that more more difficult to recognize (Davis, 2003). Corporations make profit from the existence of prisons, a relationship which perpetuates mutual benefit at the expense of a group of people under its control. In this respect, prisons and the “prison industrial complex” are forms of biopower.
The delivery of healthcare services is one expression of biopower. In prison, healthcare services are legally mandated, as stated by the “cruel and unusual” protection clause of the Eighth Amendment (U.S. Const. amend. viii). The amendment also qualifies that the quality of care be of a certain caliber in order to be deemed humane and sufficient. But the reality is quite different. Prisons are not medical facilities and do not come equipped with the requisite machinery, diagnostics, testing, imaging technology, or specialized staffing to deliver comprehensive or properly preventative care. It is well documented in the press and in legal proceedings that, as a result, unwellness, pain, illness, and even death, festers behind bars.
San Quentin—California’s oldest prison—is one such institution which has been subject to allegations of healthcare mismanagement and inhumane treatment over the years. As is the case when such allegations are taken to court and the prison is found in violation of their constitutional obligation, the prison must correct course. If this does not occur to the court’s liking, the prison is placed under a receivership—a third-party method of holding accountable a large institution responsible for the health and wellbeing of a vulnerable population. San Quentin was placed under a receivership (Associated Press, 2017). Rikers Island in New York is facing a receivership (Stroud, 2022). Alabama prisons went through a receivership in the 1970s (Jenkins, 1979)—it is not uncommon. For San Quentin, the receivership was the result of a 2001 lawsuit, the Plata v. Schwarzenegger case. In it, enhanced IT infrastructure was mandated, thus laying the groundwork for a tech-enabled future in which telemedicine and other connected health modalities will continue to play a prominent role. This investment represents an acknowledgement that tech infrastructure has become a central tenet of meeting the constitutional definition of protection against cruel and unusual punishment regarding healthcare.
In order to understand the true value of telemedicine within the carceral system, the conditions and ramifications of health and wellness behind bars must be examined. Acknowledging the social, structural, economic, historic, and political factors that convene to make the modern prison is a prerequisite to understanding how health care interventions, such as telemedicine, might play out. This paper will look at telemedicine through (1) the lens of social theory and suffering, in which the structural forces and physical environment informs the experience of disease; (2) abolition versus reformist approaches to healthcare, in which investments and innovations may still have abolitionist aims; and (3) the accompaniment principle and whether telemedicine provides a unique avenue to understand the conditions of prison or whether its form factor disqualifies it from being truly accompanying.
Social Theories and Suffering as Applied to Care Delivery in a Carceral Environment
Social suffering, a phrase coined by Arthur Kleinman and colleagues (Kleinman, 2010), to provide a framework for global health practices, is everywhere—including the carceral environment for which its inherent constraints make social suffering all the more palpable to those under its effect. Social suffering exists within a realm of social theories aimed at understanding the intersecting forces of power. The social theories, including the four pillars of social suffering, as applied to health care delivery in the carceral environment as follows:
(1) Unintended Consequences
“All social interventions have unintended consequences, some of which can be foreseen and prevented, whereas others cannot be predicted,” said Kleinman in a 2010 Lancet article (Kleinman, 2010). Prisons exist to function as a social intervention (to house people who’ve broken the law) with both intended and unintended consequences, foreseen and unforeseen. Prisons in the US were always intended to be a punishment (Davis, 2003), but the failing health of people incarcerated in those prisons could be seen as one of the institution's unforeseen consequences. The more that is discovered about the effects of the carceral environment on the human body, mind, and spirit, the more society has to reckon with the system's intended purpose and its consequential effects. Kleinman suggests that social interventions must be continually examined for their potential harmfulness and if enough harm is found, the intervention should be terminated. The question of ‘how much [harm] is enough?’ is one society has wrestled with in public spheres for generations. In prisons, enormous harm is being done. Diabetic prisoners die without their insulin (Levin & Sitthivong, 2022). Colon cancer screenings are delayed due to a rationing of resources (Brooks, 2022). Solitary confinement damages the brain and spirit forever (James & Vanko, 2021). Mothers give birth alone, their cries ignored by prison guards, bleeding out, to stillborn babies (Roh, 2022). And while there are efforts to terminate specific prisons, such as the shutting down of California prisons whose closures are cited as being due to overcrowding and exorbitant costs (Ahumada, 2022), while laudable for their outcome, aren’t pointing directly to the inhumanity of the social suffering associated with being locked up in the first place. A Pew Charitable Trust report from 2015 shows that California spent more than any other US state per prisoner on healthcare at $19,796 (Prison Health Care Costs and Quality, 2017), a figure that increased year over year prompting Governor Newsom to take action to close prisons because the state simply couldn’t afford to operate them at such a scale. Within a more reformist sphere, healthcare interventions within prisons are met with mixed results. Telemedicine, which has had such success on the outside and had good intentions on the inside, is not the preferred medium for provider visits among prisoners at San Quentin, according to Steve Brooks, a prisoner serving a life sentence. The pandemic green-lit “tele-everything,” he said, from court hearings to visits with his physician, the consequence of which are feelings of isolation and disconnection from other humans, especially from those whose role it is to be healers and foster connection in deeply personal matters related to health. Brooks said in his six years at San Quentin, he has never seen a doctor face-to-face—only nurses—and during video consultations, he is discouraged from seeking the routine screenings recommended for his race (Black) and age group (over 50). The combined effect, the consequences, of telemedicine implemented in a silo in a resource-poor setting, is a void of human connection and a feeling that the institution does not care about him. The antithesis to this consequence isn’t to terminate telemedicine necessarily, as Kleinman’s theory would suggest. Instead, it would be to seek opportunities for in-person visits and even models of accompaniment.
(2) Social Construction of Reality
The social construction of reality “holds that the real world, no matter its material basis, is also made over into socially and culturally legitimated ideas, practices, and things,” according to Kleinman (Kleinman, 2010). This theory plays out heavily as cultural relativism and as it relates to prisons, can fuel divisive attitudes on the outside about whether prisoners “deserve” the treatment they get while incarcerated. Should a serial rapist get access to a community support and education group to help manage his diabetes? Not everybody agrees that he should, citing the cause of his imprisonment as a metric for what kind of life he deserves once behind bars. “You go to prison as punishment, not for punishment,” said Dr. Salmaan Keshavjee in a Harvard College lecture (2022). The Norwegians, like Keshavjee, believe the removal from society is the punishment and no further punishing circumstances are inflicted on the prisoners. They call it the “Normality Principle” (Høidal, 2018). By contrast, the US, where prisons are the direct descendents of slavery (Davis, 2003), punishment is embedded into every aspect of the carceral experience. It is believed by many that prisoners do not deserve proper healthcare. If they are in prison, then they must have done something wrong, and they don’t deserve cancer screenings, healthy meals, or mental health treatment; they don’t deserve to be treated humanely, the logic goes. In reality, this form of judgment and subsequent behavior and policy is a social construction rather than a truth with material basis.
(3) Social Suffering
(a) Socioeconomic and sociopolitical conditions can cause disease (Kleinman 2010). Prisons, as environments of socioeconomic and sociopolitical strife, cause disease because prisons are, broadly speaking, stressful. The most recent example of this condition is from the COVID-19 pandemic, in which the overcrowding in San Quentin that long predated the pandemic got worse and contributed to the swift and deadly spread of the disease. Incarcerated people were five times more likely to contract COVID-19 than a non-incarcerated person (Saloner et al., 2020). In San Quentin, in the summer of 2020, men from another prison—the California Institution for Men, the institution with the highest COVID-19 cases nationally—were moved to San Quentin without proper testing or quarantining protocols, mixing housing accommodations of the new men with the existing men. COVID-19 hadn’t spread in San Quentin until this change, but after the new men arrived, the virus affected 2,600 prisoners and staff. Twenty-nine people died, making it the worst outbreak in the country at the time (Haines, 2022). This institutional mismanagement of housing protocol resulted in a lawsuit citing the violation of the eighth amendment protecting against cruel and unusual punishment and unlawful imprisonment (CBS San Francisco, 2021). Another example is the unintended consequence associated with telemedicine implementation. The vacuum left by the lack of real life human connection creates feelings of isolation and a culture in which prisoners believe nobody cares for them, nobody is looking out for them. Feelings of loneliness—in this manifestation or others commonly associated with being removed from society and known community networks—are extremely dangerous to a person’s health. A National Institute of Aging study found that loneliness affects the body in similar ways as would smoking fifteen cigarettes per day. Furthermore, studies report that stress acts on cells by shortening telomeres, resulting in “cellular aging and risk for heart disease, diabetes, and cancer” (Lu, 2014). The more stressful the condition, the more dangerous to a person’s health—and prisons are extremely stressful places to live.
(b) “Social institutions that are developed to respond to suffering can make suffering worse” (Kleinman, 2010). Prisons are designed to, under the promise of public safety, alleviate suffering for the society at large by removing certain people from free society. But this social intervention has in effect transferred the perceived suffering of society to the creation of actual suffering in prisons. The question of who suffers “worse” —society or the prisoners—is answered easily by acknowledging that the removal of a person’s agency, whether through social, economic, or political means, is always the most harmful form of power extraction (Farmer, 2006).
(c) Pain and suffering are not solely held by the person faced with the conditions of social suffering, but extends into the family and social network as well (Kleinman, 2010). Prisons are out of sight, out of mind, by design, often built and operated away from populated areas and often far from family members. This distance both enhances the isolation prisoners experience as well as reinforces the notion that carceral institutions are a separate entity—rather than a part of and product of—society. As such, it’s easy for society, especially those immediately unaffected by criminal justice, to lose sight of the goings on of both prison and the prison industrial complex. The feeling of being forgotten by the world contributes to a stressful living condition, which as noted earlier, affects the body on a cellular level, aging it prematurely and making it vulnerable to disease states it might not otherwise be. In the absence of in-person visits due to geographical distances or a global pandemic, telecommunication services play a role in helping to fill the void. As is the case with telemedicine, tele-based services are, in an idealized manifestation, not meant as a replacement for in-person, human connection, but to augment it under special circumstances.
For the vast majority of people, prison is not forever. Ninety-five percent of incarcerated people will get out of prison and become part of the general population again. In doing so, they will bring with them lived experiences, disease, and illness that affect the mind, body, and spirit. In this way, prisons and the conditions they endorse are society’s collective responsibility, if not on ethical grounds then surely on financial. Tax payers bear the cost of a carceral system that sends people home sicker than when they arrived, facing medical conditions that will again become the public’s responsibility through public health systems like Medicare and Medicaid. It is in the collective interest to care for people in prison, and yet it isn’t done.
(d) “The theory of social suffering collapses the historical distinction between what is a health problem and what is a social problem, by framing conditions that are both and that require both health and social policies'' (Kleinman, 2010). When the health outcomes of a social condition are so deeply determined by that social condition, the solution must be both specific and holistic, addressing the health and the social simultaneously. This is how investments in prison healthcare services can serve abolitionist aims, rather than perpetuating continual harm by upholding an exploitative system.
(4) Biopower
Biopower is a term used to explain the exploitation of power over other humans for financial profitability. In order to exist, prisons must exercise biopower; it is inherent to their operations. As noted earlier, prisons—even public ones—contract with private businesses in order to run their operations. Everything from meal service, to medical staffing, email communications, and laundry. This is the “prison industrial complex” and it runs on the fuel of biopower. An extension of this exploitation is the association people have with the experience, such as people who become biologically—meaning, medically—defined by the experiences—usually traumatic ones—in their lives. Imprisonment is newly being referred to as a Social Determinant of Health (Peterson & Brinkley-Rubinstein, 2021). And while this is apt—people often leave prison sicker than when they arrived—Social Determinants of Health are also conditions that affect the likelihood a person will become incarcerated in the first place.
Innovation and Investment in the Context of Abolition and Reform
One of the aims of this paper is to explore the gray zone between abolitionist and reformist approaches to health care delivery in prison and how telemedicine, as a reformist solution in its most perfect form, could have abolitionist aims. Abolition and reform—or incrementalism—are not necessarily in opposition. In fact, for many people, they are part of the same solution, in which abolition is the long-term goal and reform occurs in the interim. Modern day abolitionists seek a dramatic reduction in the number of prisons, a feat only possible if it occurs within a system of other changes related to policing and criminal justice that removes power from these institutions and places it in the hands of citizens or nonprofits instead (Keller, 2019). There is precedence for this. New York City has a model in which nonprofit groups augment the role of keeping the community safe and receive financial subsidies from the city to do so. While New York has successfully—arrests are down, safety is up—replaced traditional policing with a replacement model that works for them, there is not yet consensus about what a prison alternative looks like. Generally speaking though, prison alternatives include places for rehabilitation, healing, purpose in the truest sense of the words. One architecture firm in Oakland, California called Designing Justice + Designing Spaces is working to make this a reality. Their Center for Equity is a collaboration with the city of Atlanta to reimagine a central city jail into a healing center, and serves as an example of abolition in action (DJDS, 2021).
The abolition of prisons—meaning a divestment in existing systems and investment in reimagined systems—cannot happen overnight. It is, what Dr. Robert Lustig, would call a “generational shift,” in which a generation of people who hold certain ideas about how the world should operate die off, and a new generation with revised ideas, come into positions of influence. In the meantime, people in prison today are suffering. People in prison today need help, they need change, and they need it now. Critics argue that investing in health care services and innovations are antithetical to abolitionist endeavors. The real world does not operate in a binary state of moral absolutes. There are people suffering from disease in prison today and those people need pathways for care today (Farmer, 2013). Dr. Paul Farmer was famous for his steadfast commitment to healing when and where he could heal, for helping the person in front of him regardless of bureaucratic protocols. Steve Brooks needs a colonoscopy. He needs meals that don’t feature so many simple carbohydrates so he has a chance of eating his way out of the prediabetes danger zone. He needs to feel seen and heard by his doctors, and less alone in the care experience in San Quentin. Abolition may be ideal, but it is not practical in the short term. The barriers Steve Brooks faces on a daily basis are the barriers that can be addressed by reforms. Furthermore, the delays, healthcare and otherwise, associated with abolition could be considered a violation of the “do no harm” oath that physicians take. This is when reform can fill in the gaps. There are reforms which incrementally dismantle and there are reforms which will never take on the eventual destruction of prison as its aim. It’s not always obvious which reforms will function as aligned with abolitionist ideals and which will perpetuate the same system until they are already in play and outcomes begin to become available. This is the case with telemedicine in San Quentin and how the promise of telemedicine does not match its reality.
In 2001, a lawsuit was brought against the 33 adult prisons within the California’s Department of Corrections and Rehabilitations citing a violation of the eighth amendment for subpar medical screenings, failure to provide in medical care, insufficient access to specialists, delays in response times to emergencies, incomplete medical records, incompetent medical staff, including a failure to recruit, and a deficiency in providing care management for chronic conditions such as diabetes, asthma, hypertension, copd, and heart disease—all told, a very serious collection of grievances. Thirty-four people died under these conditions from preventable circumstances (Plata V. Schwarzenegger, n.d.). In 2002, the courts agreed to allow the state to make changes they deemed necessary to improve conditions, but a report three years later showed that conditions were as grim as ever. Among the changes the state was making during this period included increased staffing, the innovation equivalent of a “faster horse.” By this time, while not mainstream in society yet, other prisons were already being equipped with telemedicine infrastructure (Nash, 2021) —but not San Quentin. When, in 2006, a receivership was put in place, removing the state from control of fixing the problem, San Quentin had endured many years of medical services that were actually harmful. It was now the receiver's job to hold the institution accountable as well as implement the changes they weren’t making on their own. The most significant change made by the receiver was to invest in telehealth services. An influx of financial and structural investment of this kind is seemingly anti-abolitionist, and perhaps it was. Its stated intent, however, was to modernize existing systems for maximum efficient use of resources. The outcomes being reduced delays in access to physicians including specialists, interoperability between telemedicine consultations and electronic medical records, increased ability to manage chronic conditions, and access to medical staffing from around the country because professionals wouldn’t have to be geographically tethered to the Bay Area necessarily. This was its promise, and in this way it did seem to increase access to care and by effect, health outcomes. But there were unintended and unforeseen consequences, namely that telemedicine investments without investments in holistic solutioning was always doomed to fail. As Steve Brooks recounts, in prison, the pandemic green-lit the adoption of tele-everything from court hearings to doctors visits, an experience he describes as dehumanizing. As a result, telemedicine services as they’re operating in San Quentin today do not serve abolitionist or reformist aims—the latter least of which with the prisoner, the patient, in mind. It can be considered true that telemedicine has provided reform to staffing issues and financial bottom lines, but not so with patient experience. Telemedicine cannot function in its idealized form if forced to operate independent of a robust ecosystem.
Tensions Between Whether Accompaniment and Prison can Coexist
“To accompany someone is to go somewhere with him or her, to break bread together, to be present on a journey with a beginning and an end” (Farmer, 2011). In a prison environment, proven models of intervention, such as accompaniment, are, except for within the prison population itself, not possible. The segregated nature of prisons from the outside world means that the folks best equipped to deliver care are locked out. If telemedicine, as an innovation designed to reach across distances both literal and tk, is considered to be a way into the lived experience of patients, then it fails to function as such in a carceral environment, due to the limitations associated with only seeing the version of events presented through a fixed-point camera. But consider the role of the prison nurse, who delivers care in-person, in real time. Even they are not capable of acting in accompaniment, despite their proximity. They may share space during the appointment, but the appointment is time-bound and their shared space does not extend into mealtimes, recreation times, or downtime. They are limited by their working hours, as by the fact that nurses do not live in prison as prisoners do. And so alternative methods of reaching people in the carceral setting are sought after, often from the outside as is necessary, and often through the form of virtual connection. It may be better than nothing, as the 2006 San Quentin receivership indicates, but it is not accompaniment.
The dehumanization affect Steve Brooks recounts, is a function of the physical distance between him and his provider. Instead of air, there are screens. Instead of eye contact, there is a camera. Instead of body language and nuance, there is a frame. While telemedicine creates opportunities for, potentially, more visits, it does not increase the depth or meaningfulness of those visits necessarily.
In unique instances, accompaniment behind bars can occur. It is really only possible between a prisoner and another prisoner, two people who are sharing not only living space, culture, and conditions, but also systemic subjugation, in which one is in a caregiving role to the other. Cellmates might care for one another if one is ill, coming off addiction, suffers a chronic condition, or is even recovering from COVID-19. It’s a special relationship that is fueled by trust, compassion, and also necessity. The California Medical Facility in Vacaville houses the only prison hospice care program in the state in which a specialized medical unit trains prisoners as caregivers for the dying (Jaouad, 2018). Fernando Murillo spent the last five years of his sentence as a hospice caregiver, often spending hours well beyond the scope of his assigned shift with people, especially if he could sense they were near their end. He described the experience of accompanying people on their way out of this world and into the next as “transformational” (Murillo, 2023). As far as accompaniment behind bars goes, this is as close as it gets.
Concluding Thoughts on How Innovation, Social Theory,
and Care Delivery Intersect in a Correctional Setting
Scholarly review of the topic of telemedicine in a carceral setting to date has taken a quantified approach indicating the cost-benefit models associated with augmenting at least some in-person prison care with a virtual visit option (Khairat et al., 2021). This approach is furthermore glaringly institutionally-centric as it focuses exclusively on the system rather than on the experiences of prisoners themselves. The fact that most academic research to date has focused on the ROI of telemedicine in prison and what a time- and money-saver it is, meanwhile the people for whom telemedicine visits behind bars is a lived experience report inadequate experiences, indicates that the research is incomplete. In an under-resourced setting such as prison, it is not uncommon for experiences and conditions to also go under-reported. As Dr. Anne Becker indicated in a Harvard College lecture, just because the data isn’t present, does not mean the condition isn’t. The parameters for data collection are not necessarily appropriate to the culture of prison and thus does not capture the truth of the situation.
Telemedicine may be an efficient method for delivering care in terms of cost in the immediate billing cycle, but not in terms of the downstream costs of caring for someone with a chronic illness inside prison, nor the downstream effects of the costs associated with someone's illness once they are released back into society. These efficiencies come at the cost of human experience, dignity, and connection. An environment in which so much else has been taken, so much else stripped away, is reason to treat healthcare interactions with more empathy, more compassion, more connection—not less.
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