Incarceration and Cancer Care: A Key Focus for Health Justice Efforts

Transcript

• 00:00Good morning, everyone.
• 00:01We're going to go ahead and get
• 00:03started with today's grand rounds,
• 00:05so I would like to introduce
• 00:08Emily Wong and Carrie Gross,
• 00:10who will be our speakers today.
• 00:12Emily Wong is a professor of Yale
• 00:14School of Medicine and directs the
• 00:15SAFE Center for Health and Justice.
• 00:17She leads the Center's research program,
• 00:19the Health Justice Lab,
• 00:21which receives NIH funding to
• 00:22investigate how incarceration
• 00:24influences chronic health conditions
• 00:26including cardiovascular disease,
• 00:28cancer, and opioid use disorder,
• 00:30and uses a participatory approach to
• 00:33study interventions which mitigate
• 00:35the impacts of incarceration.
• 00:37She received her medical degree from
• 00:38Duke University Medical Center and her
• 00:40MAS from the University of California,
• 00:42San Francisco.
• 00:43As an internist,
• 00:45she has cared for thousands of
• 00:47individuals with a history of
• 00:48incarceration and is Co founder of
• 00:50the Transitions Clinic Network,
• 00:51a consortium of 40 community health
• 00:54centers nationwide dedicated to caring
• 00:56for individuals recently released
• 00:58from correctional facilities by
• 01:00employing community health workers
• 01:01with histories of incarceration.
• 01:03Doctor Kerry Gross is a professor
• 01:05of medicine and public health
• 01:06and founding director of the
• 01:08Cancer Outcomes Public Policy and
• 01:10Effectiveness Research Center.
• 01:11His research addresses
• 01:13comparative effectiveness,
• 01:14quality,
• 01:15and HealthEquity with a focus on
• 01:17cancer prevention and treatment.
• 01:19He received his medical degree
• 01:20from New York University School of
• 01:22Medicine and completed his residency
• 01:24in internal medicine at New York
• 01:26Hospital Cornell Medical Center.
• 01:27His research has been supported by
• 01:29the National Cancer Institute and the
• 01:31American Cancer Society, among others.
• 01:32As a former Robert Wood Johnson
• 01:34Foundation Clinical Scholar,
• 01:35Doctor Gross has advanced
• 01:37training in Biostatistics,
• 01:38epidemiology, research,
• 01:39ethics and outcomes research.
• 01:41Please join me in welcoming
• 01:43them for their talk about
• 01:45incarceration and cancer care,
• 01:46a key focus for health justice efforts.
• 01:48Thank you.
• 01:54It's a real, real pleasure to be here,
• 01:56to be speaking with my friend and
• 01:58colleague Carrie Gross on a topic
• 01:59probably that hasn't been covered
• 02:01at the Cancer Center before.
• 02:02And so we just wanted to thank you
• 02:05for the opportunity to be here.
• 02:07This year marks the 50th
• 02:08anniversary of mass incarceration,
• 02:10a term that's used to describe
• 02:12legal and policy decisions that
• 02:14have led to a massive explosion
• 02:16and expansion of incarcerationist
• 02:17punishment and restrictions on public
• 02:20social services like food, housing,
• 02:23and employment, and civic life,
• 02:25including voting following incarceration.
• 02:27By almost all accounts,
• 02:29and also among bipartisan leadership,
• 02:31it's been seen as largely ineffective
• 02:33in reducing crime,
• 02:34keeping our community safe and
• 02:36much too costly.
• 02:38And its effects have been largest
• 02:40among black people, poor people,
• 02:41and has left in its way poor health for
• 02:44individuals who've been incarcerated,
• 02:46but also their families and our communities.
• 02:49While there are lots of questions
• 02:50about how to undo this harm,
• 02:51I'm certain of two things.
• 02:53As physicians, as researchers,
• 02:55as health system leaders,
• 02:56we've been complicit in creating the
• 02:59circumstances by which mass incarceration
• 03:01and the healthcare system behind
• 03:03bars is virtually invisible to us.
• 03:05I'm also confident that we're
• 03:07responsible for finding these solutions.
• 03:09And so for the next 45 minutes or so,
• 03:12we'd like for you to entertain how
• 03:15extraordinarily wide the reaches
• 03:16of the criminal justice system,
• 03:18how it impacts our work to
• 03:20create healthier communities.
• 03:21And hope that at the end you'll
• 03:23start considering how cancer
• 03:25equity must necessarily attend
• 03:27to the injustices in the criminal
• 03:29legal system in the ways that we
• 03:31all might individually proceed.
• 03:36We have no disclosures.
• 03:37And so I went to start in a grand
• 03:40rounds fashion with a patient to
• 03:42ground our conversation for today.
• 03:44One of the first patients that I saw
• 03:46when I began my career was a 40 year
• 03:48old man who was incarcerated just for a
• 03:50few years who during his incarceration
• 03:52was diagnosed with the leukemia.
• 03:54He was scared out of his mind.
• 03:55It was the first time that he
• 03:57had any sort of health condition
• 03:59and of course he was behind bars,
• 04:01away from his family,
• 04:03away from his social support,
• 04:04and when he was introduced to the care
• 04:07team prepared for his first chemotherapy,
• 04:09he was shackled in the hospital while
• 04:12receiving intrathecal chemotherapy
• 04:14and this was chilling to him.
• 04:15He, of course,
• 04:16refused to continue treatment and
• 04:18ended up dying from his cancer.
• 04:20And I want to begin our conversation
• 04:22this morning about thinking about
• 04:24what our role is as providers to
• 04:26advocate for patients like him and
• 04:27others so that the patient treatment
• 04:29experience is different and humane,
• 04:32honoring him as a person first.
• 04:34From an outside perspective,
• 04:35if you didn't know the story and maybe
• 04:37you're just looking at the charts,
• 04:38you might think that the patient's
• 04:40not compliant.
• 04:41You might think that they're
• 04:43refusing treatment,
• 04:44but framed a different way,
• 04:45how might the health system do
• 04:48differently by those who are most vulnerable?
• 04:50And today,
• 04:51today,
• 04:51we're going to start by defining
• 04:53mass incarceration,
• 04:54so to give kind of real terms and
• 04:57concrete descriptions about what this is.
• 04:58Then we'll discuss the healthcare
• 05:01system behind bars in carceral systems
• 05:04and the experience post release.
• 05:06We'll then shift to presenting
• 05:08some of our own research on mass
• 05:10incarceration and its impacts on health
• 05:13outcomes using data from across the
• 05:15Yale Cancer Center catchment area.
• 05:18And lastly,
• 05:18end with some concluding thoughts.
• 05:22And so just to start,
• 05:23and maybe this isn't news to all,
• 05:25but I think it's important for us just to
• 05:27land here that the US incarcerates more
• 05:30people than any country in the world.
• 05:32And there are a number of reasons for this,
• 05:35but one is just that we've
• 05:37criminalized substance use,
• 05:38mental health conditions and poverty.
• 05:41And so much of what we do is take
• 05:43care of health system issues
• 05:45within the criminal legal system.
• 05:48There are 7 million individuals that
• 05:50are currently under the jurisdiction
• 05:52of the criminal justice system on
• 05:54any given day and this breaks down,
• 05:56and this is slightly an old slide
• 05:58so post COVID.
• 05:59This means that about 1.9 million
• 06:02individuals are behind bars and
• 06:04closer to five millionaire being
• 06:06supervised in the community.
• 06:08And just to break it down to,
• 06:09jails are facilities that house those
• 06:12that are awaiting judication of crime
• 06:14or serving sentences of less than a year.
• 06:17Prisons are those facilities that
• 06:19house those that have been sentenced
• 06:21serving sentences of more than a year.
• 06:23And so while the population behind
• 06:24jails in any given day is smaller,
• 06:26there's a huge throughput.
• 06:27So we actually don't know how many it is,
• 06:29but it's over 7 to 10 million move
• 06:31in and out of these jail facilities.
• 06:33And then the larger proportion again
• 06:35that's living in the community with us
• 06:38is on a community system of supervision.
• 06:40And this is broken down into
• 06:41parole and probation.
• 06:42So parole,
• 06:43you've been sentenced the crime
• 06:44released from prison and you're
• 06:46released into the community.
• 06:47And probation are those that are
• 06:49sentenced of a crime and now serving
• 06:52their whole sentence in the community.
• 06:54And so, all told, and again,
• 06:56the estimates aren't perfect,
• 06:58But about 7 million adults have a
• 07:01criminal record in this country,
• 07:03and each of these individuals confront
• 07:05a myriad of collateral consequences.
• 07:07They've served their time and still,
• 07:09because of their criminal record,
• 07:11face barriers to getting food,
• 07:13housing, employment,
• 07:14even voting in this country.
• 07:16Which,
• 07:17all told,
• 07:17constitutes the large toll and
• 07:20tale of mass incarceration.
• 07:23Those who are incarcerated are
• 07:25disproportionately poor men of color
• 07:27using life table measurements.
• 07:29In 2021,
• 07:30when you look at the lifetime
• 07:34likelihood of imprisonment for all men,
• 07:36it's one out of 10 men in this country
• 07:38will spend some time in prison.
• 07:40When you break it down by racial categories,
• 07:42again, white men, it's one out of 20.
• 07:45Black men it's one in five.
• 07:47And when I started residency,
• 07:48that number was one in three.
• 07:51And so now we're narrowing the disparity,
• 07:53but it's still extraordinarily large.
• 07:55And for Latino men, it's one in eight.
• 07:58Similarly,
• 07:58incarceration is far less likely for women,
• 08:01but black women are far more likely
• 08:03to be incarcerated in their lifetime
• 08:06compared to white female counterparts.
• 08:08And So what
• 08:11the question I guess that we're presenting
• 08:14today is as follows that by doctors,
• 08:16they often get asked,
• 08:17you know what's different among those
• 08:19with the history of incarceration?
• 08:20Aren't they just like any
• 08:22patients who are poor,
• 08:23that have many social needs that we're not
• 08:25attending to or those that are homeless
• 08:27or those that have substance use disorder?
• 08:30What is it that uniquely defines
• 08:32them as being at poor risk?
• 08:34And by researchers we get asked
• 08:36the questions of causality.
• 08:37Again, is this really,
• 08:39truly an independent risk factor?
• 08:41And, you know, I'm not sure we're
• 08:42ever going to know there isn't a,
• 08:44you know, an ethical basis by which you
• 08:46randomize individuals to incarceration.
• 08:48But in the next few slides,
• 08:49what I wanted to do was give you
• 08:51an inside look into pictures.
• 08:53How many of Y'all have stepped
• 08:54foot into a prison or jail before?
• 08:56OK, so some, but not all.
• 08:59And how many have provided
• 09:02healthcare behind bars?
• 09:03Great, again a few fewer,
• 09:06but not everyone.
• 09:06And So what I wanted to do is
• 09:09give you an inside look on what
• 09:11healthcare looks like behind bars
• 09:12and just to try to convince you on
• 09:15face validity alone that exposure to
• 09:18incarceration is a unique experience
• 09:20that definitely impacts health.
• 09:25And so to start, and I think what drew
• 09:28me to this field and kind of area is
• 09:32the following fact that Healthcare is
• 09:35constitutionally guaranteed in prison.
• 09:37It's one of the only places in
• 09:38the United States where we have a
• 09:41constitutional guarantee in care.
• 09:42And so just give a pause to that.
• 09:45And what this means is that there's
• 09:48a large group of young black men,
• 09:51poor folks that first access
• 09:53healthcare as adults behind bars.
• 09:55In fact, our data and others show that
• 09:58about 40% of individuals are newly
• 10:00diagnosed with the chronic health
• 10:02condition while they're behind bars.
• 10:04And to me as a primary care physician,
• 10:05this blew my mind.
• 10:07But this also was something that
• 10:10really drew me into this work.
• 10:12After 50 years of this policy,
• 10:14what we've been seeing is the aging
• 10:17of whole generations behind bars,
• 10:19the media, if you'll watch,
• 10:20you know, Netflix,
• 10:22it gives us the impression that
• 10:25folks that are in prison are
• 10:27actually this young healthy lot.
• 10:28And the reality of it is,
• 10:29is like this gentleman who has COPD,
• 10:33they many individuals are aging behind bars.
• 10:3685% of those that are incarcerated
• 10:39have chronic medical condition that
• 10:41warrants longitudinal primary care.
• 10:43This includes physical health conditions
• 10:45like diabetes, hypertension, asthma,
• 10:47infectious diseases like hepatitis,
• 10:50CHIV, of course, substance use disorder,
• 10:52mental health disorders.
• 10:53And then of course because the aging
• 10:55behind bars have higher rates of cancer.
• 10:58And you know,
• 10:58just to take a look at each
• 10:59of these pictures,
• 11:00I want you to ground this photo again.
• 11:02This was taken in San Quentin.
• 11:05And of course I have permission
• 11:07from the prison and these patients
• 11:09to be sharing these photos,
• 11:11but they're just waiting to see a doctor.
• 11:13And so I just want you to Orient
• 11:14your attention to, like, again,
• 11:16to the correctional officers
• 11:17overseeing this delivery of care.
• 11:18And there's a patient that's waiting there
• 11:20to see a Doctor Who's held in a cage.
• 11:22And so this is how Healthcare
• 11:25is delivered behind bars.
• 11:27Of course,
• 11:27there's a constitutional guarantee to care,
• 11:29but access is limited by
• 11:31institutional policies.
• 11:32And this picture,
• 11:33I want you to look at that pink slip.
• 11:35So that pink slip is a kite,
• 11:37and it's a form that at the time this
• 11:39doesn't happen in California anymore
• 11:41because it's under federal receivership.
• 11:42But it happens still across the US
• 11:45Individuals who need to see a doctor
• 11:47have to fill out that pink form.
• 11:50They fill out the pink form,
• 11:51the kite,
• 11:51and then first person that evaluates
• 11:53it is a correctional officer.
• 11:55If there's medical need deemed by
• 11:57a correctional officer and think
• 11:59about the power kind of hierarchies
• 12:00that exists with incarceral systems,
• 12:02then it goes to a nurse.
• 12:04And after it goes to a nurse,
• 12:05then it goes to a physician for a view,
• 12:07and then the person can see a physician.
• 12:08And so you know,
• 12:09it's not like in the in the
• 12:11community you need to see a doctor,
• 12:13there's a long wait.
• 12:14You can always roll up to an emergency
• 12:16department and you'll be seen.
• 12:18It might be ours, you know,
• 12:20but you'll be seen and you'll
• 12:21be seen by a physician.
• 12:22It isn't the case behind bars.
• 12:26And then of course the self management
• 12:28of chronic conditions is difficult and
• 12:30it's just wholly different than how we,
• 12:32our expectations are within
• 12:33the community health system.
• 12:34And so this is a picture of a patient
• 12:37and again, who was first diagnosed
• 12:40with hypertension behind bars,
• 12:42had hypertensive emergency sent to the
• 12:44outside hospital with this diagnosis
• 12:46coming back and we're doing rounds on
• 12:48those that have come back, you know,
• 12:50and kind of a discharge planning rounds.
• 12:52And I just want to Orient you to the picture.
• 12:54Again, there's no privacy.
• 12:55He's in a typical cell block,
• 12:57and you can see that we've thrown the
• 13:00blood pressure cuff through the hole.
• 13:02The gentleman is strapping it up
• 13:03around his arm. He's not seated.
• 13:05This is not probably a very accurate
• 13:06blood pressure medication, right?
• 13:08Blood pressure measurement.
• 13:09Each morning this person is called by a
• 13:12correctional officer to go get his meds,
• 13:15and so his amlodipine,
• 13:17his lisinopril, is doled out.
• 13:19The nurse gives him a cup,
• 13:21that he takes the cup,
• 13:22he takes the medications.
• 13:23She checks to see if he's cheeked it.
• 13:26I mean, these are blood pressure medications.
• 13:28And then he rolls back to his cell.
• 13:30And so adherence is almost perfect,
• 13:34but it's incredibly passive.
• 13:36And again,
• 13:37it's at the behest of a correctional officer.
• 13:40Cancer care is similar that they rely
• 13:43on correctional officers and workers to
• 13:44get people to go to their mammograms,
• 13:47get people to go to pap smears.
• 13:48And so you can see that there's
• 13:50a whole different layer by which
• 13:52chronic conditions are managed that's
• 13:54different than in the community.
• 13:55Similarly, this patient rarely,
• 13:57if ever most correctional facilities
• 13:59keeps that medication on his person.
• 14:02So it doesn't have to be like today.
• 14:04I got to eat this after my meal,
• 14:06it's always in the morning.
• 14:07He's always called up at the same darn time,
• 14:09right?
• 14:09Never draws up his insulin for chemo,
• 14:13for if he's newly diabetic,
• 14:16never draws up his own insulin,
• 14:17never uses a glucometer.
• 14:19And so kind of what we ask of
• 14:21our patients in the community
• 14:23is horribly different than,
• 14:24again,
• 14:25what the carceral system asks
• 14:27of patients behind bars.
• 14:31Lastly, if this patient needed
• 14:33to see a physician, often,
• 14:35he has to put it down at a $3 Co
• 14:38payment to see the physician.
• 14:40Oh, there's a little swelling in his legs.
• 14:43Having started on Norvasc wants to
• 14:44see the doctor and you're asking,
• 14:46well 3 bucks, what's 3 bucks?
• 14:49Well, 3 bucks is essentially equivalent
• 14:52to four, four days of salary.
• 14:54So if you're lucky enough to have a
• 14:57job at $0.75 is your daily salary.
• 14:59And so again,
• 15:00to be able to see a physician is
• 15:03a real challenge and especially in
• 15:05navigating these chronic health conditions.
• 15:08And lastly,
• 15:08I share this that the conditions of
• 15:11confinement impact disease management.
• 15:14This is a patient with COPD
• 15:16who's oxygen dependent.
• 15:17But you could think about him
• 15:18as also a patient with lung
• 15:20cancer who's oxygen dependent,
• 15:21who's being held in solitary confinement.
• 15:24A solitary confinement is is a
• 15:26place where you stay in kind of an
• 15:288 by 6 foot cell 23 hours a day,
• 15:31and often when.
• 15:32And you'll notice of course that
• 15:34the tank is held outside the cell.
• 15:37And as providers walking by
• 15:40this person's cell,
• 15:41you would hear him intermittently,
• 15:43bam, on the door.
• 15:44And this was his kind of way of
• 15:47letting us know that the tubing was
• 15:50kinked and he could no longer breathe.
• 15:53The rationale being that the tank it's
• 15:56too dangerous to have inside, right?
• 15:58That health is secondary to punishment,
• 16:01to control, to safety.
• 16:02And what I want you to think about is
• 16:05putting yourself in the place of the patient.
• 16:09He's seeing physicians,
• 16:10healthcare providers walk on by him
• 16:13complicit in these health harming behaviors.
• 16:16And the question is how could you
• 16:18actually treat a system that trust,
• 16:19a system that treats you in this way?
• 16:23And so, you know,
• 16:24when I get asked the question often like,
• 16:27well, this is, you know,
• 16:29horrifying, worrisome,
• 16:30but what does this have to do with me?
• 16:34You know,
• 16:35I practice in the community,
• 16:36almost everyone comes home,
• 16:38is released from these carceral systems.
• 16:4095% of individuals that are
• 16:42incarcerated ends up back into the
• 16:45community and then over three years
• 16:47time and then again five year times,
• 16:49almost 2/3 go back into the carceral
• 16:51system and over five years time,
• 16:5375%.
• 16:53And So what we have is a large
• 16:56population here in the United States,
• 16:58but in New Haven,
• 16:59even that cycle in and out of
• 17:01these two health systems,
• 17:03ours in the community and
• 17:05the carceral system,
• 17:07what happens when he walks out the door?
• 17:09So y'all know that if you have a patient
• 17:11that's being discharged from Smilo,
• 17:13even if they're here for an obstay,
• 17:15you've at least arranged the medications,
• 17:18a primary care follow up,
• 17:19a Cancer Center follow up,
• 17:21you've faxed the medications over,
• 17:23you've arranged for an appropriate discharge.
• 17:26Many individuals that are released
• 17:28from carceral systems have hardly
• 17:31any discharge planning set up.
• 17:34And what this means is that they're
• 17:36given a short supply of medications.
• 17:39Here in Connecticut, it's about 28 days.
• 17:41But in lots of carceral systems around
• 17:42the country, it's no medications,
• 17:44and they have to find their
• 17:45own primary care appointment,
• 17:47mental health substance use treatment.
• 17:49I've had patients released without
• 17:52chemotherapy arranged in the community,
• 17:54and so they're coming back into
• 17:55a community health system,
• 17:56which we already know.
• 17:58It's fragmented.
• 17:59It's hard to coordinate all these
• 18:01health care appointments,
• 18:02You know, as a person in the
• 18:04community right now for me,
• 18:05much less you've been incarcerated for two,
• 18:09520 years. When people come home,
• 18:11they also often have significant barriers
• 18:14to maintaining their basic needs.
• 18:16Our patients often are coming
• 18:18home without a dime to them.
• 18:20They do not have a place to find.
• 18:22They do not have housing,
• 18:23There's no food, there's no employment.
• 18:25And primary among their minds is
• 18:27trying to reunify with their families.
• 18:29And so, not surprisingly,
• 18:30there's a worsening of health outcomes,
• 18:33risk of hospitalizations and of course,
• 18:35a high risk of death.
• 18:38And so during residency almost 20 years ago,
• 18:42I became obsessed with what I thought was
• 18:44going to be a real easy questions like
• 18:46we do transitions of care all the time.
• 18:48We're going to transition folks from.
• 18:50And again,
• 18:50I did residency in San Francisco
• 18:52from the California Department of
• 18:55Corrections back into San Francisco.
• 18:57And because in San Francisco there's a
• 19:00large robust civil rights community,
• 19:03a formerly incarcerated individuals
• 19:04leaned on them to to convene them
• 19:07to say what are the components of
• 19:09healthcare that you want to see
• 19:11in a transitions care program.
• 19:12And they wanted early access.
• 19:14They wanted physicians,
• 19:15healthcare providers that knew
• 19:17about the risks,
• 19:18incarceration could even say welcome home.
• 19:20We know what it was like inside.
• 19:21We're going to help you come home.
• 19:23But most importantly,
• 19:24they wanted a community health worker
• 19:26person with a history of incarceration
• 19:28to be centered in primary care.
• 19:30That person would help them
• 19:32navigate the healthcare system,
• 19:33which is hard to navigate
• 19:35the social services system.
• 19:36So again, housing, food, employment.
• 19:39But also to say, like, I've been there,
• 19:42I've been incarcerated,
• 19:44I've been successful coming home.
• 19:47And that experience then builds
• 19:48trust in the healthcare system,
• 19:50rebuilds or builds 'cause it never was there.
• 19:53Trust in the healthcare system
• 19:54so a person can return home.
• 19:56And so here's a picture of
• 19:58our late colleague and friend,
• 19:59community health worker Jerry Smart,
• 20:01with doctor Lisa Puglisi,
• 20:03A colleague here in Yale,
• 20:06in our Transitions Clinic program,
• 20:09in the room with the patient
• 20:11helping navigate that care.
• 20:13Since that time in residency,
• 20:15we've studied the program and of
• 20:16course reduces acute care utilization,
• 20:18reduces actually any future
• 20:20criminal justice interaction.
• 20:22And the program has grown to
• 20:24the largest national network of
• 20:25programs in the country,
• 20:26almost 48 programs in 14 different
• 20:29states in Puerto Rico.
• 20:30And here again just to highlight this,
• 20:33we have a network of programs in
• 20:35Connecticut in the Yale Cancer
• 20:37Center catchment area.
• 20:38We've provided primary care to
• 20:391000 patients that have left
• 20:41correctional facilities,
• 20:42again each with a community health
• 20:44worker with histories of incarceration.
• 20:46And we currently have three
• 20:47statewide programs here in New Haven.
• 20:49This, this network in
• 20:52Connecticut's led by Lisa Puglisi,
• 20:53who was in the picture before in New Haven,
• 20:57Bridgeport and Hartford.
• 20:58And we've been working closely with
• 21:00state policy makers and the Department
• 21:03of Corrections and payers to really
• 21:05think about how we implement the
• 21:07model and how we scale it so that
• 21:10there's more than just three programs.
• 21:12And so it's in the delivery of primary care.
• 21:15Again, having been here for 15 years
• 21:17that we've seen a ton of folks
• 21:20that have come home either at with
• 21:22cancer or really kind of having not
• 21:26accessed cancer prevention treatment
• 21:28and have turned of course the
• 21:30literature to see well what's known
• 21:32about these higher rates of cancer.
• 21:34And so and so doing what I'll indicate
• 21:39is that we've had the literature
• 21:42prior to Carrie and I starting our
• 21:45investigation were single side studies
• 21:47that either studied incarceration
• 21:50outcomes rather cancer outcomes when
• 21:52people are incarcerated or cancer
• 21:54outcomes when people were released.
• 21:56And so but none that combined kind
• 21:58of the full story of how people move
• 22:00in and out of these two systems.
• 22:03So what we know is that individuals
• 22:05with a history of incarceration had
• 22:07higher rates of cancer risk factors,
• 22:09smoking, alcohol use,
• 22:11HIV and Hepatitis C Our team did
• 22:15a study again using what was
• 22:18available national data showing
• 22:20that the prevalence of lung cancer,
• 22:23cervical cancer and alcohol related
• 22:25cancers were higher among those that
• 22:27were just as involved compared to
• 22:28those that didn't have any exposure
• 22:30to the criminal legal system.
• 22:32And then one study again existed in Ontario,
• 22:35Canada found that individuals with
• 22:37a history of incarceration have
• 22:40higher incidence of cervical head
• 22:42and neck liver lung cancer compared
• 22:44with the general population.
• 22:47Of course incarceration was also found
• 22:48to be associated with worst cancer
• 22:50survival and there have been two
• 22:52studies that really highlight this.
• 22:54We bring this up,
• 22:56one that's showing that in prison
• 22:59there's worse survival rates.
• 23:00So these data come from Texas,
• 23:02my home state,
• 23:03and where you see the kind of solid
• 23:07dotted lines is the incarcerated individuals.
• 23:10These data come from those that were
• 23:12in the Department of Corrections
• 23:14in Texas with cancer,
• 23:15and they compared it to data from SEAR
• 23:18and then they compared it to SEAR data,
• 23:20individuals that are matched demographically.
• 23:22As you can see,
• 23:24there's decreased survival among
• 23:25those who have cancer behind bars.
• 23:29And then similarly following release,
• 23:33my friend and colleague Ingrid
• 23:34Binzwanger published a study in
• 23:35the New England Journal.
• 23:37Again,
• 23:37these data come from Washington State
• 23:39and found that there's a significantly
• 23:42increased risk of dying in the
• 23:44first weeks to months post release.
• 23:46You can see how high the bar is.
• 23:48One to two weeks falling release.
• 23:51I do not have a pointer.
• 23:53And again,
• 23:53cancer was one of the primary causes of
• 23:56death in that study.
• 23:58So again, high rates of mortality,
• 24:01both incarceration during
• 24:03incarceration and falling release.
• 24:05But no studies really combine
• 24:07them and no studies have really
• 24:09kind of gotten that mechanism.
• 24:10So, you know, a lot of people,
• 24:12a lot of anecdotal evidence
• 24:13showing poor quality of care.
• 24:15When you turn to the literature,
• 24:16there hasn't been a lot of work looking at
• 24:19the quality of care of cancer outcomes.
• 24:22Again, two studies,
• 24:23multiple studies and done looking
• 24:25at the access to palliative care,
• 24:27only one study looking at cervical care,
• 24:30cervical cancer care.
• 24:31And so again, this is a hypothesis,
• 24:34but not really borne out in
• 24:36the literature as of yet.
• 24:38And then some discussion about,
• 24:39of course, what are the social
• 24:42determinants of cancer outcomes.
• 24:43And again, people don't have transportation,
• 24:45food, housing, a job.
• 24:47They often lack insurance,
• 24:49healthcare, access.
• 24:50They have these competing priorities,
• 24:52again with family trying to meet
• 24:53the terms of parole, probation.
• 24:55And then there's the real stigma
• 24:57having been incarcerated.
• 24:58And all these may play a role in how
• 25:01they access cancer care coming home.
• 25:04And so this was a something that was
• 25:08important to both myself and Doctor Gross.
• 25:11And so we started thinking about,
• 25:13well,
• 25:13how can we together and with the
• 25:17amazing resources within the state,
• 25:19think about how it is that we can start
• 25:22informing what is driving the higher
• 25:25rates of poor health outcomes among
• 25:27those that are just as involved care.
• 25:39Thank you, Emily, and thank you to
• 25:41the Cancer Center for inviting us
• 25:43to to have a discussion with you
• 25:47today about this issue of, frankly,
• 25:49if we're thinking about health justice,
• 25:51unfortunately, as Emily points out,
• 25:53we need to be thinking
• 25:55about criminal justice,
• 25:56and we're thinking about HealthEquity.
• 25:58We need to be thinking about systemic
• 26:01racism and structural factors such as
• 26:03mass incarceration that are affecting
• 26:05all of our patients and all of our
• 26:07populations here in the state of
• 26:10Connecticut as well as here at Smilow.
• 26:12Our collaboration with between the
• 26:14Copper Center and Emily's wonderful
• 26:17group has really been personally
• 26:19an inspiration for me seeing this,
• 26:21this mission driven group of people
• 26:23who are not only doing research but
• 26:26are also advocating for change.
• 26:28And I think this is a testament to
• 26:31the amazing environment here at Yale
• 26:33and that our offices were next door
• 26:35to each other for like 10 years.
• 26:37And we kept thinking, oh,
• 26:38you're thinking of cancer outcomes
• 26:40and you're thinking of improving
• 26:43HealthEquity and health justice for
• 26:46the current formerly incarcerated
• 26:48patients and people.
• 26:49Why don't we collaborate?
• 26:51It took us a while to figure it,
• 26:52figure it out, but it worked well.
• 26:55And I think I would just use this as
• 26:57a brief pause to encourage all of you
• 26:59to look outside of your primary domain,
• 27:02your primary area of focus.
• 27:03Find people who share your values
• 27:05in your mission. Reach out to them,
• 27:07because those are often the most fruitful,
• 27:10fruitful collaborations.
• 27:12What do I do?
• 27:14This.
• 27:14OK, so Emily has done an excellent
• 27:17job of cultivating the intuition.
• 27:20There are three distinct risk
• 27:23strata that we should think about
• 27:26as we shift over to talking about
• 27:28our particular research endeavor,
• 27:30so that there are people who
• 27:32are never incarcerated,
• 27:33people who are currently incarcerated,
• 27:35and then there's third risk group or
• 27:37people who were recently released.
• 27:39That Bin Swagger article highlighted
• 27:41in the first one to two weeks
• 27:43after release is what is it,
• 27:45a four fold increase in risk of death.
• 27:48But also as Emily pointed out the
• 27:50whole point of the Transitions
• 27:52Clinic is during that very initial
• 27:54transition that's it's a very
• 27:55fraught time with increased risk.
• 27:57So anyway that's why we have
• 27:59three groups here and we'll go
• 28:00through these in greater detail.
• 28:02For our study based upon
• 28:04the prior literature,
• 28:05we looked at the relation between
• 28:09these three risk strata and and
• 28:12the incidents or a detection of
• 28:14an imprompt diagnosis of cancer.
• 28:16The second outcome of interest was
• 28:19cancer care and third was cancer survival.
• 28:23Anybody want to hazard a guess
• 28:25for people who are incarcerated,
• 28:27what is the most common cause of death?
• 28:40We're in Cancer Center Grand Round
• 28:42Cancer I know you all like it's too
• 28:46easy so that's one of the motivating
• 28:48factors for for for our work is cancer
• 28:51is highly relevant to the incarcerated
• 28:53current and former population
• 28:55call out to our amazing study team
• 29:00we include people from both the
• 29:03site center copper but also
• 29:06people who work within the state
• 29:09Department of Corrections that the
• 29:11state Department of Public health.
• 29:14It's really been a wonderful
• 29:15and diverse group.
• 29:17Again mission driven being that I
• 29:18would say that the buzzwords people
• 29:21that are really wanted to not only
• 29:23do research but use the evidence
• 29:25to drive change and it's been an
• 29:27honor to be a part of this group.
• 29:28So first let's talk about
• 29:31cancer incidence and diagnosis.
• 29:34Our first study that I'll highlight
• 29:37was led by a Genereus Aminowa
• 29:40looking at cancer incidence,
• 29:42addressing the questions what
• 29:43is the cancer incidence in the
• 29:46incarcerated and post incarcerated
• 29:48population compared to the general
• 29:50population and how does this differ
• 29:53across race and ethnic groups.
• 29:57So this slide is incredibly over simplistic.
• 30:01These arrows make these these
• 30:04linkages look very easy.
• 30:07This collaboration between the state
• 30:09Department of Health tumor registry,
• 30:11the Department of Corrections would not
• 30:14have been possible without years of prior
• 30:17collaboration with these different groups.
• 30:19And anyway, so the arrows kind
• 30:21of like oh it's just easy.
• 30:24So the tumor registry data was linked with
• 30:27the state Department of Corrections data,
• 30:31their master file as well as the
• 30:33movement file which which tracks
• 30:35when people are released and
• 30:38and readmitted if that happens.
• 30:41So looking at cancer incidents there
• 30:44are some chat methodologic challenges.
• 30:46We don't have all the data that
• 30:48you traditionally would have when
• 30:49looking at the denominator.
• 30:50So for the incarcerated population,
• 30:52because people are going in and out,
• 30:54we just we looked at the the mid,
• 30:57mid year inmate population.
• 31:00For the post incarcerated population
• 31:02for our denominator we discharge,
• 31:05we basically looked summed the
• 31:07number of people who are discharged
• 31:10every year discounted by about
• 31:11a third because of recidivism.
• 31:14So it's just an estimate of how
• 31:16many people were released and and
• 31:18in the community at any given time.
• 31:20And then the Connecticut general
• 31:22population cancer types,
• 31:24we like to excuse me,
• 31:25all invasive cancers as well as
• 31:28screen detectable defined as such.
• 31:31So what we found overall cancer
• 31:34incidence on the left side of this
• 31:37figure is the general Connecticut
• 31:39population people who were incarcerated.
• 31:42You see, there's a dramatically
• 31:45lower cancer incidence rate,
• 31:47but in that post incarceration period,
• 31:50defined as one within one year after release,
• 31:54there's then a substantial bump up,
• 31:56substantial increase,
• 31:57which raises the concern that maybe there's
• 32:00under diagnosis while incarcerated and
• 32:02then there's a catch up period afterward.
• 32:05We then looked at strata by whether
• 32:10the cancers were screen detectable
• 32:12such as you know, colorectal,
• 32:14cervical, etcetera.
• 32:14Again for the if you look at the Gray bars,
• 32:18these are the screen detectable bars.
• 32:21So it's cancers.
• 32:22There's a dramatic dramatic decrease
• 32:24in the incarcerated population If
• 32:25you look at the relative change and
• 32:28then there was a slight bump after
• 32:30release for the non screen detectable
• 32:32cancers for which they were not
• 32:35routinely recommended screening tests.
• 32:37There's less of a substantial
• 32:39decrease when you go from general
• 32:41population to incarcerated and then
• 32:43still there's a bump afterward.
• 32:45So this suggests that maybe
• 32:47the screen detectable cancers.
• 32:49The reason why there's such a huge
• 32:51drop is that there's less screening
• 32:54in the incarcerated population.
• 32:55However, we don't have screening data.
• 32:57That's next one of our next
• 33:00studies we'll be addressing.
• 33:03Alana Richmond here in general
• 33:04medicine LED the next study,
• 33:06incarceration and cancer stage of diagnosis.
• 33:10So here this is looking at the Y axis,
• 33:13is the percent of people in each group whose
• 33:17cancer was diagnosed at an early early stage.
• 33:21The incarcerated group,
• 33:23roughly 45%,
• 33:24recently released a little more,
• 33:2655% and this is,
• 33:27but these are both lower than the
• 33:30general Connecticut populations.
• 33:32So we show show this to our collaborators in
• 33:34the Department of Corrections and they said,
• 33:36well,
• 33:36hold on,
• 33:37it's not really fair because the
• 33:40full state of Connecticut has
• 33:42different demographics than people
• 33:43who are at risk of incarceration.
• 33:46Maybe you could choose a different comparison
• 33:48group to kind of level the playing field.
• 33:50So maybe just looking at people
• 33:52who have Medicaid statewide,
• 33:54Connecticut,
• 33:54maybe they're a little more similar to
• 33:56the population that's incarcerated.
• 33:58And this is again for us the beauty
• 34:01of having these collaborations with
• 34:04stakeholders who can call us out on
• 34:06our initial plan that we're going to publish.
• 34:08They're like wait,
• 34:08hold on guys,
• 34:09that's that's not a good idea.
• 34:10Let's try something a little different.
• 34:11So we added a state of Connecticut
• 34:16Medicaid population and still we
• 34:18we basically the percent early
• 34:20diagnosis as you can see was
• 34:22Medicaid is definitely lower than
• 34:24the full state of Connecticut,
• 34:26but still is a little bit higher
• 34:28than the incarcerated population.
• 34:30We then looked at colorectal cancer.
• 34:33Now here are the stories,
• 34:33a little bit different.
• 34:35The full state of Connecticut did
• 34:38have more early stage of diagnosis,
• 34:40but all the other groups were roughly equal.
• 34:42So maybe the incarcerated people
• 34:45in this case,
• 34:46where they were pretty much
• 34:48equally likely of being diagnosed
• 34:50with the early stages of the full
• 34:52state of Connecticut prostate cancer.
• 34:54A slightly different story in
• 34:57that the state of Connecticut
• 34:59Medicaid was substantially better,
• 35:01more likely to be early diagnosed
• 35:03than the incarcerated into a degree
• 35:05of the recently released population.
• 35:07So take home points here,
• 35:10which will be reiterated by looking at
• 35:13the adjusted standardized incidence rates
• 35:16are the if you look at the left side,
• 35:18so this is the Sir.
• 35:19So the incarcerated group is the center
• 35:22column there and basically 0.28.
• 35:25That means compared to people
• 35:26in the general population,
• 35:28people who are incarcerated have
• 35:3028 percent of the risk of being
• 35:33diagnosed at an early stage and then
• 35:35recently released compared to the
• 35:37general population also is lower,
• 35:39but not as lower.
• 35:40So I'm not going to go through
• 35:41these numbers in great detail
• 35:42because they show the same thing.
• 35:43Basically there is a decreased likelihood
• 35:46while you're incarcerated of being
• 35:47diagnosed at an early stage and this
• 35:49seems like there may be a bounce
• 35:52back after after you're released.
• 35:53And that also applies to late stage cancer.
• 35:57Moving on to mortality outcomes among
• 36:00people who were diagnosed with cancer.
• 36:03This is led by Damalola Oladeru.
• 36:07Here we compared these three groups,
• 36:10people who were diagnosed with
• 36:12cancer while they were incarcerated
• 36:14as about 200 people.
• 36:16People who were diagnosed after
• 36:18release and then the large
• 36:20never incarcerated population.
• 36:22As you can see,
• 36:23people who were diagnosed while
• 36:25incarcerated or post release
• 36:27or substantially younger than
• 36:29the general population,
• 36:31again more likely to be black or Hispanic.
• 36:35And the most common cancer types are
• 36:37slightly different between these groups,
• 36:40largely reflecting probably differences
• 36:41in risk factors as well as age,
• 36:43age, distribution of the different
• 36:46populations with GI,
• 36:48mainly colon and liver,
• 36:51long male reproductive and leukemia
• 36:53and lymphoma particularly common
• 36:55in the incarcerated population.
• 36:58But to cut to the chase,
• 37:00what we found when you look
• 37:03at ALL 'cause mortality,
• 37:05these are survival models that are based
• 37:07on our Cox proportional hazards model.
• 37:10The never incarcerated group has a much
• 37:15better survival outcome than either the
• 37:18incarcerated or post release group.
• 37:19This means you were diagnosed after
• 37:22released or diagnosed incarcerated
• 37:24and the hazard ratio is basically two,
• 37:28SO twofold greater risk of death if
• 37:30you're in either of these groups.
• 37:32We then added a stage of diagnosis
• 37:35to the model to see because as you
• 37:37saw from the prior studies that
• 37:40there there was a distribution,
• 37:41a difference in stage of diagnosis.
• 37:43With incarceration it didn't really
• 37:45change the hazard ratio hardly at
• 37:47all the like the the risk of death
• 37:49went from like 2.1 to 1.9 after you
• 37:51account for stage of diagnosis.
• 37:53So,
• 37:54so there are other factors that are
• 37:56causing this difference in risk of death.
• 37:59You want to look at cancer related mortality.
• 38:03This was interesting.
• 38:04So I wanted to pause here because
• 38:06we were just talking earlier about
• 38:08transitions being a fraught time
• 38:10after after being released to the community.
• 38:12Here you see again the never
• 38:14incarcerated folks have the
• 38:15best cancer mortality,
• 38:17but the incarcerated people are
• 38:18in the middle and the post release
• 38:20actually have the worst cancer
• 38:22survival really making us worried
• 38:24about what's happening after release
• 38:25with regard to being people connect,
• 38:27being connected to care.
• 38:33OK. So then our third outcome of
• 38:36interest is looking at the quality
• 38:38of cancer care, addressing how
• 38:40does incarceration affect quality.
• 38:42We have an ongoing study that
• 38:45we're not going to be presenting
• 38:46today doing chart review,
• 38:47looking at specific quality measures
• 38:50and comparing incarcerated with non
• 38:52incarcerated individuals is care
• 38:54different for individuals diagnosed
• 38:56during incarceration versus post release.
• 38:59And we set out to identify perceptions
• 39:02regarding accessing high quality
• 39:04cancer care in the correctional system.
• 39:07And in the immediate post release period.
• 39:09Let me turn the microphone back
• 39:11over to Doctor Wong.
• 39:14All
• 39:18right. And so our last part of our study
• 39:20is really trying to center this work again
• 39:23in the voice and perspective patients.
• 39:26And so we have a a last name focused on kind
• 39:29of what are patient perceptions regarding
• 39:31quality of cancer care in the correctional
• 39:34system and immediately post release.
• 39:36This is being led by Alana Rosenberg
• 39:38and our team as well as doctor
• 39:40Dina Schulman Green at NYU now.
• 39:42And in this study we're conducting in
• 39:45depth interviews with purposeful sample
• 39:48of people just released from prison or
• 39:52jail within two years who have cancer.
• 39:54And so either they were diagnosed
• 39:56while they're incarcerated or
• 39:58diagnosed in the community.
• 39:59And again, these are preliminary themes.
• 40:01We still haven't quite
• 40:03finished up recruitment,
• 40:04but the themes are the access,
• 40:07so access to care, timeliness,
• 40:09which I think is going to
• 40:11be of critical importance.
• 40:13But also fragmentation of care.
• 40:14And not just, again,
• 40:15in the transition from the
• 40:17carceral system to the community,
• 40:19but even in communications that are
• 40:21bidirectional from the community back
• 40:23to the carceral system or transitions
• 40:26between different carceral facilities.
• 40:28Again,
• 40:28each individual facility has a
• 40:30different kind of structure.
• 40:32And once you transition from one
• 40:34Correctional Facility to another,
• 40:36that often creates different
• 40:38barriers to care.
• 40:39There were conversations and
• 40:42a theme of communication,
• 40:43wanting more transparency in the care plan,
• 40:46wanting availability of records.
• 40:48And so patients would often report that
• 40:50they had no idea what was going on,
• 40:52didn't have medical records,
• 40:53they have to pay for their medical records.
• 40:56And so this was a a real issue
• 40:58of of knowing kind of centering
• 41:00the care plan around the patient.
• 41:03Of course trust in healthcare writ large,
• 41:06but especially with within the
• 41:08Department of Corrections was an issue.
• 41:10There were questions about the
• 41:11competence of care and the commitment
• 41:13to actually patient centered care
• 41:15again both in the community as
• 41:17well as in the carceral system.
• 41:19Not surprisingly there were was a
• 41:21theme of kind of the correctional
• 41:23system and correctional officer
• 41:24role that as I'd indicated before
• 41:27that often times correctional
• 41:28officers were the arbiter of care.
• 41:31They were kind of in charge of
• 41:34triage that they also could detect
• 41:37that the criminal justice system
• 41:39was primary before healthcare.
• 41:40And so they would comment on shackling
• 41:42and also the presence of correctional
• 41:45officers in the healthcare space as
• 41:47they were getting their treatment.
• 41:49And then importantly,
• 41:50as we all know as primary care providers,
• 41:53as cancer providers, the themes of family,
• 41:57family supports came up both
• 41:59as advocates from the outside,
• 42:01but also the importance of of
• 42:03supporting a person through a,
• 42:05you know,
• 42:06again life shaking experience like
• 42:07being diagnosed with cancer and getting
• 42:10treatment and and clarifying the care plan.
• 42:12And so usually we like to have their voices.
• 42:15We couldn't get this prepared in time,
• 42:16but I'll just read these out loud that in
• 42:19terms of trust in the healthcare system,
• 42:22one person comments,
• 42:23medical care is so expensive now that
• 42:26when you're inside, when you're an inmate,
• 42:28you're really not looked upon,
• 42:30you're a liability.
• 42:31Now they're not going to really treat you.
• 42:33This guy's got 30 years,
• 42:34he's going to die in prison
• 42:35anyway or he's getting released,
• 42:37so we'll let them deal
• 42:38with it when he gets out.
• 42:39And so this is both the commitment
• 42:41but also really signaling that,
• 42:43hey, because there's fragmentation
• 42:45in the healthcare system,
• 42:47the care isn't going to be delivered in
• 42:49the way that's central to the patient.
• 42:52The importance of family was mentioned
• 42:56and this participant notes you got
• 42:58to go a whole lot of things for
• 43:01them to get you an appointment.
• 43:02I got two sisters that are in my corner.
• 43:05I call them and tell them and they would
• 43:08call the prison and keep complaining.
• 43:10And so who doesn't love a sister?
• 43:12But that's the sisters that are
• 43:14calling in to make certain that
• 43:15cancer care is is being arranged.
• 43:18And what happens again when
• 43:19you're aging behind bars,
• 43:21when you don't have sisters,
• 43:22you don't have family members that
• 43:25can advocate that even know to
• 43:27advocate for your cancer care and
• 43:29then importantly access this patient.
• 43:33This participant is a New Haven resident
• 43:35just released with advanced cancer
• 43:37and he says a Co worker just tried
• 43:40to hook me up with a medical cap,
• 43:42but they said something that
• 43:43I wasn't eligible.
• 43:44I forgot the exact reason we had to
• 43:46jump through a hoops to try to give
• 43:47me that one time, that medical van.
• 43:49I had no way to get to my chemo.
• 43:51I was hoping that they could
• 43:52at least put me in Smilo here.
• 43:53That's right here.
• 43:54It had been a whole lot easier instead
• 43:57of going all the way out to New Haven.
• 43:59And I I think it's important
• 44:01here just to frame that,
• 44:02as Doctor Gross presented,
• 44:04we have work here in the community
• 44:07to be kind of tackling to improve the
• 44:11care for this vulnerable population.
• 44:13Of course there's work in the
• 44:14carceral system,
• 44:15but thinking about what it is that
• 44:16we can do right here, right now,
• 44:18I think it's a central focus of
• 44:20the work that lies ahead for us.
• 44:22And so in summary,
• 44:23we hope that you take away these
• 44:25key points that incarceration has a
• 44:28substantial impact on overall health.
• 44:30It's a profound mediator of
• 44:32health disparities and you know,
• 44:34I think it's often overlooked.
• 44:36We don't measure it in our
• 44:38large population based,
• 44:39national population based studies.
• 44:41We don't often understand that
• 44:43it it may be a key mediator in
• 44:45looking at black white disparities
• 44:47and socio economic disparities.
• 44:49And and it needs more attention.
• 44:52Incarceration is associated
• 44:54with increased risk of cancer
• 44:56incidence later stage of diagnosis,
• 44:58higher cancer mortality rate.
• 44:59And this is both for those who
• 45:01are incarcerated and those who are
• 45:03returning home to the community
• 45:05and patient experience with cancer
• 45:07care while incarcerated and falling
• 45:09release shows multiple domains
• 45:11in need of improvement.
• 45:12And so you know,
• 45:13often when we give these talks,
• 45:14we're left with like, well,
• 45:16what can we do, you know,
• 45:17And so I just wanted to present some
• 45:20ideas that Carrie and I had and perhaps
• 45:22there are many others in the room.
• 45:24But for those that have you that
• 45:26are involved in clinical care is
• 45:28to focus on centering care around
• 45:30the patient and not the inmate.
• 45:32So remove those shackles.
• 45:34We have the ability to also ask correction
• 45:37officers to leave the room in certain ways.
• 45:40Over the last 50 years,
• 45:41we've ceded power to a carceral
• 45:43system in our own healthcare system
• 45:46and there are ways that we can do so.
• 45:47And again, if you're looking for
• 45:49guidance on the Safe Center website,
• 45:50there are kind of guidance about what we
• 45:53can and can't do within a healthcare system.
• 45:56Secondly,
• 45:56consider compassionate release.
• 45:58There's policies,
• 45:59statutes in Connecticut now that
• 46:02enable you especially as oncologists
• 46:04to write for compassionate release.
• 46:06In 2019, prior to COVID,
• 46:09when we did a FOIA of our records,
• 46:13only three people in the state of
• 46:15Connecticut were released under
• 46:17compassionate release.
• 46:19How do you do this?
• 46:20The best way that we found,
• 46:22and we've been able to do
• 46:24this for certain patients,
• 46:26is to engage with the medical
• 46:29provider behind bars.
• 46:31Often times they too are advocating
• 46:33and often feel like it's easier for a
• 46:36community provider to be in partnership.
• 46:38These requests have to go through
• 46:40the Connecticut Parole board,
• 46:42but letters from outside physicians
• 46:44saying we've got this person coming home,
• 46:46they're in our care will do better,
• 46:49the patient will do better if they
• 46:51come home is the kind of deciding
• 46:53factor in in moving forward
• 46:55with compassionate release.
• 46:57And then of course,
• 46:58if you practice within Bridgeport,
• 47:00New Haven and Hartford,
• 47:02refer your patients that you're
• 47:03seeing that have just been released
• 47:05from a carceral system to our
• 47:06Transitions Clinic programs.
• 47:08Again on the Safe Center website,
• 47:09you'll see the contacts for
• 47:11community health workers.
• 47:12Again,
• 47:12y'all do everything for your patients
• 47:15and we know often times primary
• 47:17care can shift over to oncologists.
• 47:19But what's additional about Transitions
• 47:21is having a community health worker.
• 47:23That's how the history of incarceration.
• 47:25Having real specific knowledge,
• 47:27research resources and expertise
• 47:29to attend to,
• 47:30especially the social determinants of
• 47:32health for when people return home.
• 47:34Here.
• 47:34Unique to our Transitions Clinic
• 47:36in New Haven,
• 47:37we have a partnership with the
• 47:39Yale Law Schools Medical Legal
• 47:41Partnership where we have Yale Law
• 47:42School students and staff lawyer
• 47:44that are attending to the civil legal
• 47:46needs of individuals that come home.
• 47:48And so there's additional benefit
• 47:50to having primary care rooted
• 47:51within Transitions Clinic.
• 47:53If you're a researcher,
• 47:54I think you will know especially those
• 47:56of you that run clinical trials.
• 47:58Rarely do clinical trials include
• 48:00incarcerated people.
• 48:01And I think that this is,
• 48:03as we all know,
• 48:04clinical trials are real beacon
• 48:06of hope for certain patients with
• 48:09certain cancers
• 48:09and it is possible to include them.
• 48:12It takes a lot of advocacy.
• 48:13We've been working at the safe center
• 48:16nationally trying to think about
• 48:17how it is that we can have more
• 48:19individuals that are incarcerated
• 48:21participate in clinical trials.
• 48:23But if those of you that are running
• 48:25trials please reach out to us,
• 48:26we would love to be in conversation,
• 48:28advocate for the linkage of CR
• 48:31data or cancer registries that
• 48:32are linked to correctional data.
• 48:34Again, you can see the from the work
• 48:36that we've been able to do with the
• 48:38tumor registry in the Department of
• 48:40Corrections that this is how we can
• 48:42illuminate the actual disparities
• 48:43that exist within our state.
• 48:45To then be able to identify
• 48:48meaningful places of change,
• 48:50if you run the health system here at SMILO,
• 48:52creating partnerships of the
• 48:54Department of Corrections to improve
• 48:56prevention and treatment efforts both
• 48:58in reach into the carceral system.
• 49:00But also thinking about how do
• 49:02the outreach efforts that the L
• 49:04Cancer Center is already making
• 49:05really target this population,
• 49:07those individuals that have just
• 49:08been released and their families.
• 49:10And lastly,
• 49:11concentrating our efforts on eliminating
• 49:14the social barriers to care.
• 49:16And so I'll end here,
• 49:17which is to say that these
• 49:19patients here and every day remind
• 49:22us that this work is urgent.
• 49:24That even as we forge forward with
• 49:26the science that we need solutions
• 49:27now that there are really things
• 49:29that each and every day that
• 49:30you can do in clinical care,
• 49:32in research and in your work leading
• 49:34at the Cancer Center that will make
• 49:37a difference for these patients.
• 49:39So with that,
• 49:39we thank you for your attention and
• 49:41really appreciate the opportunity to be here.
• 49:49Thank you so
• 49:50much for that fantastic talk. We have
• 49:51time for questions.
• 50:01The cost benefit of early screening
• 50:06and diagnosis is well known to us
• 50:10with a fairly substantial literature,
• 50:12not for every cancer but for most cancers.
• 50:16So you actually save money if you have a
• 50:19Primary Health care system that does a good
• 50:22job with screening and early diagnosis.
• 50:24Is this an argument that that has been
• 50:27made in the carceral setting with
• 50:30the research that you're describing?
• 50:32Is there a signature paper,
• 50:35a series of papers that we could cite
• 50:38as as we as we argue these cases?
• 50:41Because I mean, we know Byron Kennedy well,
• 50:44the medical director of the of
• 50:45the Department of Correction.
• 50:48He used to be, of course,
• 50:49the health director here in New Haven
• 50:52before that health director in Rochester,
• 50:54an enlightened MDPHDAA graduate of,
• 50:57you know, an alumnus of Yale.
• 51:00So it's a window of opportunity,
• 51:02but he has to make the economic arguments.
• 51:05And if you can actually improve
• 51:08cancer care and save money,
• 51:11that argument might work better
• 51:13than the humanitarian argument.
• 51:16Well, I appreciate this question.
• 51:18And, you know,
• 51:19I think what's interesting is twofold.
• 51:21So in fact, of course,
• 51:22we're partnering with Doctor Kennedy
• 51:24right now and Doctor Richardson who
• 51:26run the medical services behind bars.
• 51:28And let me just give you an example
• 51:31of kind of what they're up against.
• 51:33So I I think that they plainly know and I
• 51:35don't want to put words into their mouth,
• 51:37plainly know the cost savings and the like
• 51:40larger health benefits of early screening.
• 51:43But to give an example,
• 51:45it's been nearly impossible prior
• 51:47to kind of FIT tests etcetera to
• 51:50actually get colonoscopies arranged.
• 51:53And what it means is that,
• 51:54you know there wasn't access within
• 51:56the healthcare system in the community
• 51:58where they could do it or they feel like
• 52:00mammograms or getting a diagnostic biopsy,
• 52:02we're deprioritized.
• 52:03And so it really is more of an
• 52:06indictment I think of kind of our
• 52:09statewide community healthcare systems
• 52:11and the ability for our cultural system
• 52:14providers to be able to access the screening.
• 52:17It's so much so that of
• 52:19course now that for instance,
• 52:21colorectal screening has transitioned
• 52:23from colonoscopies etcetera,
• 52:25that they now have instituted.
• 52:27Again,
• 52:28trying to think about how you
• 52:29scale up fit testing etcetera
• 52:31within the carceral system,
• 52:32knowing the value of early screening
• 52:36and knowing that again rates of colon
• 52:39cancer are climbing among black men
• 52:42in particular and that this is an
• 52:45important issue to really lean in on.
• 52:49I would just also add briefly that first of
• 52:53all for the patients with cancer who were
• 52:55in our study that who are incarcerated,
• 52:57the average length of stay was, I mean
• 53:00time incarcerated was four to five years.
• 53:02So there was plenty of time to
• 53:05potentially diagnose them early.
• 53:06The challenge is that these cancer
• 53:08screening tests, they're cost effective,
• 53:09they're usually not cost saving, right.
• 53:11So it's like $50,000 per quality.
• 53:13So it's an it's an investment or
• 53:15quality investment per survival.
• 53:17So part of it comes down to,
• 53:20it comes down to the cost argument,
• 53:21but also comes down to the
• 53:23moral and ethical argument too.
• 53:25The, the other thing I just wanted
• 53:27to highlight now that you bring this
• 53:28up is these data that we present
• 53:29are from 2006 to 2016. And so
• 53:32again there's an opportunity now to see how
• 53:34screenings change given different modalities.
• 53:37So, but thank you for your question.
• 53:40Thanks so much for this talk. It has made
• 53:42me think so much. My name is Jen Capo.
• 53:44I serve as the Chief of Palliative Care
• 53:46here at Smilo and across the hospital.
• 53:48And our team has been thinking about these
• 53:51issues over the last couple of years.
• 53:52We've just encountered a lot of moral
• 53:54distress about how several patients
• 53:56have been treated at the end of life.
• 53:58And we noticed the suffering that's
• 54:00not only physical with access
• 54:01to adequate symptom management,
• 54:03but also just a tremendous suffering
• 54:05that comes from all the psychosocial
• 54:07distress that accompanies not
• 54:09only a cancer diagnosis but
• 54:10this history of incarceration.
• 54:12And so, you know, there is some
• 54:15data looking at the integration
• 54:16of palliative care into the care
• 54:18of patients who are incarcerated.
• 54:21As a team in Connecticut,
• 54:23what would you want us to
• 54:24advocate for? How could we best
• 54:26affect the patients in our state?
• 54:29What would be the best next steps
• 54:30to care, to provide better care,
• 54:33you know? So I appreciate that.
• 54:34It's lovely to meet you in person
• 54:36in this way. And I think the first
• 54:39I would say first and foremost and
• 54:41without a doubt is get people home.
• 54:44So you know, it, it blows
• 54:46my brains that like really.
• 54:48And it's not that only three people
• 54:50applied and got compassionate release.
• 54:52Many people have applied and only
• 54:55three got it. And so you know,
• 54:58when you're seeing people in
• 54:59care within the Cancer Center,
• 55:02when you're seeing a person that's
• 55:04shackled getting care to when
• 55:05you're seeing a person that has
• 55:07criminal justice involvement in
• 55:08clinic and you know that they're at.
• 55:11And again,
• 55:11of course physicians were notoriously
• 55:13bad at predicting kind of when
• 55:14the end of your days are,
• 55:15but you know what I mean?
• 55:17One to start investigating how
• 55:20compassionate release can be used.
• 55:22And and again,
• 55:24it's always with patient permission
• 55:26that either you're reaching out
• 55:28to also and I'll just not just
• 55:30those that are incarcerated,
• 55:32but for those that are on parole too.
• 55:34So you know, just to give you an example,
• 55:37just because you're at the end
• 55:38of your days doesn't mean you're
• 55:40parole and probation terms end.
• 55:41And it is incredibly freeing at the
• 55:44end of your days to not have to
• 55:46report back to parole and probation.
• 55:48And these are ways that we can again
• 55:51get people out of the large reach
• 55:54of the criminal justice system.
• 55:55Reporting means that every week you're
• 55:57going in, you're ******* you know,
• 55:59in a cup to to provide your urine.
• 56:01It's deeply dehumanizing.
• 56:02And for some of these individuals,
• 56:04it could have been 5-10,
• 56:06fifty years where they've been doing so.
• 56:09We've had patients 50 years who've
• 56:11been under the crucial system.
• 56:13And so that's one.
• 56:14Secondly,
• 56:15I would say you know to me some
• 56:18of the questions I mean I think
• 56:20that you're raising and again I
• 56:22would have lots to say about this,
• 56:24but is the really important role of family.
• 56:27And again trying to think about how
• 56:31the policies again in the carceral
• 56:33system can include advanced directive
• 56:36planning that includes family.
• 56:38It's, you know again at the end of our days,
• 56:41the regrets that I've seen patients
• 56:42have are ones where they haven't
• 56:44been able to collect with family
• 56:46and family members.
• 56:47Also again,
• 56:47we didn't touch on this in this talk
• 56:50that 50% of Americans in the United
• 56:51States have an immediate family member
• 56:53that's had a history of incarceration,
• 56:5550%.
• 56:56And so there's healing and important
• 56:58healing that comes from the family
• 57:00members being able to reintegrate with
• 57:02their loved ones that are behind bars,
• 57:04being able to have these conversations.
• 57:06And if you think about patients
• 57:08that are behind bars for them
• 57:09to come up with their advanced
• 57:14advanced care directed thank you.
• 57:16I'm going to set a advance directives
• 57:21without family members in the room,
• 57:23which currently they're often not.
• 57:25There was this paper that was recently
• 57:27published where if you don't have
• 57:29a family member sometimes it's the
• 57:31carceral system that that is your,
• 57:32you know, proxy.
• 57:33These are the places I think that
• 57:35from a policy standpoint, you know,
• 57:38clinically and then policy need advocacy.
• 57:43Thank you so
• 57:43much again to Doctors Wong and Gross
• 57:45for your talk today. We appreciate.