Jailcare: An Interview with Carolyn Sufrin

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Anita Chary

Anita Chary

Anita Chary, MD PhD, is an anthropologist and resident physician at the Harvard Affiliated Emergency Medicine Residency. She is Research Director of the non-governmental organization Maya Health Alliance | Wuqu' Kawoq, which provides health care and development services in rural indigenous communities of Guatemala.


“My worst day in jail is better than my best day on the street.”
-Kima, a San Francisco woman quoted in Jailcare

I recently read the book Jailcare by Carolyn Sufrin, a physician-anthropologist. This is a timely and important book for anyone interested in mass incarceration, reproductive health, social justice, and health care systems and policy.

 

The book describes Sufrin’s ethnographic research and clinical engagement with a group of poor women–mostly women of color–in the San Francisco women’s jail. At the crux of Sufrin’s work is a paradox: jail offers a safety net for many of these women that does not seem to exist outside its walls. That safety net can provide poor and marginalized women with reproductive health care, shelter, and protection from the types of violence that permeate their daily lives on the street; for some of the women followed through the book, their access to health care is better in jail than in the community. The book also offers insights into the dilemmas health care providers face working with this underserved population.

I had a chance to sit down with the author and chat about the book. Here are the highlights from our interview.


Carolyn Sufrin is an Assistant Professor in the Department of Gynecology/Obstetrics at Johns Hopkins School of Medicine and in the Department of Health Behavior and Society at Johns Hopkins University School of Public Health. She completed her medical residency in OB/GYN at Magee Women’s Hospital, University of Pittsburgh, and her family planning fellowship at UCSF. She obtained her PhD in anthropology at UCSF-Berkeley. She works in advocacy related to improving health care conditions for incarcerated women.

 

To begin, can you tell me how you got started on this project? How did you conceptualize the research for this book?

It all started when I was an OB/GYN resident in my training, and I delivered the baby of a woman who was shackled to the bed. I realized I’d never thought of the fact that there were women who are incarcerated, let alone pregnant women. This opened a whole Pandora’s box for me. It was a deeply troubling moment as a health care provider to feel like I was complicit in this violence, and not to know what I could do or was allowed to do. I’m sure it was of course much more troubling for the woman giving birth. But it really opened up my eyes in a way that made me want to learn more about these women and their health care conditions.

Several years later, when I was a family planning fellow at UCSF, I sought out the opportunity to work at the San Francisco County Jail as an OB/GYN. Within a few months of providing health care in this environment, I was confronted with a lot of complexities and contradictions and things that surprised me. Here I was in a caregiving profession, but having to do this within the constraints of a space of punishment.

I noticed that for many of my patients, the only place where they were accessing health care was in jail.

Also, I had my preconceived notions about the people, especially the correctional officers who work in jails, and thought that they would be uncaring and would categorically mistreat these women, and that’s not what I found. I found a lot of different approaches.

With all of these contradictions and surprising things that I was observing, in the position of a clinical caregiver, I felt there was a larger story that was being told about mass incarceration in our country. There was a larger story about the everyday realities of how mass incarceration unfolds through health care, and especially through reproductive health care and the complex politics of reproduction. I felt like I needed the tools of anthropology to sort through that. That’s what led me to the project and to the research questions of what it means to care in a space of punishment, and what this tells us about health inequalities and society’s role in caring for its most marginalized people more broadly. And anthropology helped me sort through that.

 

I think one of the most provocative points in the book is the discrepancy between how the public tends to imagine jails and prisons—as punitive institutions—and their function as a safety net for the poor. Could you talk a bit about that, and how that plays out in the lives of poor women?

Jails are definitely spaces of punishment. Punitive measures certainly play a role in the everyday routines of the jail. But at the same time, there are also aspects of caregiving that happen behind bars. Part of this actually has a constitutional basis. Since 1976 and the supreme court case of Estelle v. Gamble, prisons and jails and other institutions of incarceration have been constitutionally mandated to provide health care for people inside. The language is that prisons and jails have to tend to people’s “serious medical needs.” There’s a legal constitutional basis for caregiving, but of course that doesn’t have meaning until you examine what happens on the ground and the everyday realities.

“Serious medical needs” is a very vague and nondescript phrase. There’s tremendous variability in how that constitutional standard is applied. There are some prisons and jails where there is profound medical neglect, and “serious medical needs” are basically understood as: Is this person dying? And how can I make sure this person doesn’t die while in my prison or jail?

But there are other places, including the San Francisco jail where I did my research, and where I worked as a physician, where they have a different approach to health care–where they see their role as providing health care services that are equivalent to community standards, and where they recognize that the people cycling in and out of jail are largely medically marginalized. And they understand that for some people, this is the only place where they get health care. There’s a strong sense to make sure that they tend not just to people’s very acute medical needs, but their chronic conditions and preventative health care as well.

What this can look like, especially for women and women’s health care, is that for many of the women I studied and took care of, jail became the only place where they could access health care.

This is true for some of the pregnant women I took care of, as well. The only place they got prenatal care during their pregnancy was in jail. What I began to see was that the jail was not only filling in this role as a medical safety net, but also a broader social safety net.

I acknowledge and talk about this in more detail in the book, but the meaning of the safety net is polyvalent. It has many different meanings. But in addition to the necessary medical services that the jail provides people with–services that the community is lacking–there are also things like housing, and providing what the women told me was a relatively safe space. If you think about it, that’s a bit disconcerting, because jail is still jail. It’s still a place of punishment. There is violence that happens among the incarcerated people, between the guards and incarcerated people. There’s more subtle violence in the regimented ways that just being in jail affects people’s sense of autonomy and sense of self. Yet for the women I met, their lives on the street were characterized by so much uncertainty and so much violence—from not having a place to live, to being trafficked in sex, to being coerced into commercial sex work, from being involved in the drug trade that they sometimes felt exposed them to violence. There were all sorts of violence that they weren’t experiencing in jail. So for some of them, the jail sort of filled in for the safety net in many ways beyond just medical care.

What all of this amounts to—and this is the main argument of the book—is that although jail was an essential part of the safety net for certain poor women on the margins of society, what that really diagnoses is not any kind of success, per se, of jail, but the failures of broader society to take care of those marginalized people.

 

Could you say a bit more about the population of women that you were working with?

Although all the women I met were unique and had their own stories, they also were representative of the broader population of women in our nation’s jails.

I want to pause for just a moment and recognize that jails and prisons are very different spaces. This is important to recognize especially when thinking about the connections with the safety net. Jails are short-term state facilities. When people are are arrested, they go to jail first. The majority of people going to jails have not been convicted of a crime, but are pre-trial, and awaiting a trial. For those pre-trial people who are in jail, most of them are there not because they’ve committed a violent crime or been arrested for a violent crime, but because they can’t afford their bail.

When it comes to thinking about the population specifically of women whom I interacted with, the majority of them were black, which is out of proportion to the 6% of the population that’s black in San Francisco. Most of them had histories of trauma and sexual, physical, and/or emotional abuse. Most of them also had histories of substance use disorder, of marginal housing, poverty, unemployment, limited access to education. Many of them were children of parents who had also been incarcerated. These are people who even as children, were already along a pathway through being involved in the criminal legal system, both because of the inadequacies of our mental health care system and because of their race, and the ways that our criminal legal system disproportionately incarcerates people of color. This is true nationally for incarcerated women and for the women I took care of.

Importantly, the women of the women in prisons and jails in this country are young women of childbearing age. Seventy-five percent are younger than 45. We also have to think about their roles as mothers and their reproductive capacity. In fact, two thirds of the women who are incarcerated in this country not only have had children before but are the primary caregivers to young children. When they come incarcerated, that leaves millions of children orphaned because of incarceration. We also don’t know how many women are pregnant when they enter prison or jail, and we don’t know how many give birth, but we know from prior research that the majority of incarcerated women have been sexually active with men in the months prior to incarceration and that most of them are not using a form of contraception. So we know that some of the women who visit jail will be pregnant, and for many of them, getting into prison or jail is the first time when they learn about their pregnancy.

 

I think a point that’s really important is that it actually seems easier for the women in your book to get prenatal care and family planning services in jail.

I would be hesitant to summarize it that way. That was true in the jail where I worked, and in some other jails, but there’s tremendous variability. Because the Estelle vs. Gamble decision did not come with any mandatory standards of what services need to be provided, or mandatory oversight, what happens in prisons and jails is completely variable. Many places around the country have abysmal neglectful prenatal care. It may be just seeing a nurse every week or so and getting your blood pressure checked, but never seeing a qualified prenatal care provider. Most jails and prisons do not allow women to initiate a method of contraception. Many jails and prisons deny pregnant people the right to abortion if that’s what they want. Although I describe a medical system in the San Francisco jail that is relatively robust, especially with regard to reproductive health care, it’s certainly not universally the case.

 

That’s a very important point. In the particular institution you were working in, which did have a more robust reproductive health care system, how did the women understand the disconnect in the safety net inside versus outside of the jail? You write that the safety net inside of jail encouraged motherhood, and as some of the women said, created a “safe space” for it. On the other hand, outside of jail a safety net essentially didn’t seem to exist for these women, and that makes motherhood very challenging.

Many of the women acknowledged the contradiction and the paradox. One woman, when she told me about how she experienced health care in the jail, said [paraphrasing], “You know, I’m really grateful for it. When I come back to jail, that’s where I get my rest. That’s where I get back on my thyroid medication. I know I’m going to get a chance to refuel here.” They would sometimes even comment [paraphrasing], “I know I should be getting health care outside of jail too, but this is a place where I know I can access it.”

I think this is nicely summarized by a woman whom I call Kima [pseudonym]. She said to me on a number of occasions [direct quote], “My worst day in jail is better than my best day on the street.”

She went on to qualify [paraphrasing], “It’s still jail and we hate it here, but we also know that to some degree, this is safer, because it’s hard out there. You never know when you’re going to get hurt. You never know when stealing someone’s car is going to get you killed.”

There was a recognition of the fact that jail plays some role of giving people comfort, but they still hated jail and recognized the predicament they were in.

With regards to motherhood, what I describe in more detail in the book is the ways that jail actually cultivated motherhood. Jail cultivated a very particular version of motherhood, but enabled many of these women to be mothers in ways they couldn’t outside of jail. Again, this wasn’t true for everybody, but for many of the women who were cycling in and out of jail, their lives on the street were relatively unstable. It did not permit them to have a home and a place where they could raise their own children.

The jail went to great lengths to enable visits between parents and children.  This included between women who gave birth while in jail and allowing their newborns to come to jail and visit them several times a week. Again, this is not universal. There are many jails where there are no visits, or where the visits consist of a video conference call. But at this particular jail, they did promote visits. Sometimes people would see their children more often in jail than they did on the streets.

In addition, the jail has parenting classes. Some women attended these classes even if they weren’t pregnant, but were interested in learning about parenting, or if they had children already.  There was one woman who said to me [direct quote], “Jail brings me back to what being a mother is.”

That is kind of an unusual thing to reflect on, but jail had parenting classes, enabled visits, had mothers’ day celebrations, and around the holidays would have letter writing sessions for women to write to their children over Christmas. And–this was true for Kiva–in jail, they had walls in which they could hang photographs of their children. In the streets, many of these women did not have  place to live. They did not have a wall where they could hang a picture of their child. These conditions enabled women to imagine motherhood in jail in different ways than they experienced it on the street.

 

You also write about the jail staff and health care providers in the book. How did jail staff and health care providers grapple with the disconnect between the safety net inside and outside of the jail?

They grapple with it everyday. They grapple with it especially through triaging the limited medical resources in the jail and deciding on what level of care to provide. There are some conditions where it’s very clear cut that they should address them, like someone who comes in diabetes whose blood sugar is in the 500s. Yes, they should get insulin and get treated acutely. But there were other times with managing chronic conditions or situations where people didn’t pose as much of an acute risk, and that made them wonder [paraphrasing], “You didn’t take care of it on the street, so why it is our responsibility to take care of it here in jail?”

As the health care providers are thinking through that, what they’re really doing is asking the questions: what is the jail’s obligation, and by proxy the state’s, to provide health care to these people? Are they deserving of this health care service?

They work through that tension daily of what is the jail’s role in the health care system. They work through that every day in how they triage people’s medical requests.

In the book, I describe an example of a woman who constantly would request Boost nutritional shakes from medical staff, because she felt she was too thin and that she needed to gain weight. By body mass index (BMI), she was not underweight. She certainly appears thin, but technically by BMIs, she was not underweight at all. So the medical staff did not prescribe her boost shakes. Part of that was also thinking: Well, when she was out on the street, does she consume boost shakes? The medical staff made this comparison to what they access and what their lives are like on the street. And you know, no, she doesn’t buy Boost [outside of jail], she can’t afford it, she can’t afford to eat every meal. Yet jail staff still make these reckonings of balancing resources against what they perceive their role and the jail’s role to be, and also the deservingness of the person they are taking care of in front of them. It’s a really tricky process that they’re enacting moment to moment with every patient. What is the jail’s role in the safety net? Without consciously thinking about it, they are enacting that role every time they’re making decisions about what health care an incarcerated person is to receive.

 

That’s very interesting. Thanks so much for sharing that. What messages would you want health care providers and public health practitioners to take away from your book?

First is to recognize there are women behind bars, and they have tremendous health care needs that are neglected. We need to advocate for improved health care services for all incarcerated people, but especially for women’s health care and pregnancy health care.

At the same time we work to improve systems inside, we have to recognize that mass incarceration is a public health issue. It is harmful to people’s health. Prison or jail health care systems may play a temporizing role for people. It has potential to be what some people might call a “public health opportunity.” However, seeing incarceration in that opportunistic way fails to see the bigger problem of the deficiencies of our broader health care system. If people can experience health care as better in jail than health care in the community, that diagnoses the failure of our broader health care system. We need to recognize that mass incarceration itself is a public health care issue, both because of the effects it has on people’s bodies, but also because of the broader deficiencies of our health care system and safety net.

 

Finally, from a public health policy perspective—and I realize this is a broad question—what actions do you think can be taken to improve these women’s lives and health? And particularly in this era, where there are constant political assaults against care for the underserved?

That’s a good question. I think it’s a dual strategy of criminal legal system reform and health care system reform. I think that changes to federal laws that would help depopulate our prisons and get people out who are not threats to society would help. That would mean fewer people who are getting sick in jail and prison because they’re not able to access quality health care. Also, comprehensive bail reform will help depopulate our jails. So many of the people in jails are there because they’re poor and can’t afford bail for very minor offenses.

From the health care perspective, we need to strengthen our investment in the medical and mental health care safety net. That’s not only a question of material resources but also the quality of the services. This is a point that’s harder to intervene on at a policy level, but still needs to be considered. Even when there are safety net services that exist, there are so many people that access them and feel judged. It’s a deterrent to them seeking out services that are designed to help them. That’s one aspect–making our safety net more robust, not only materially but also  qualitatively. And then there’s another point that I previously mentioned: while we are working on these broader systems changes, we need to standardize health care in prisons and jails and have a mandatory oversight system.

Check out Carolyn Sufrin’s book, Jailcare, here.