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

January 19, 2024

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Yale Cancer Center Grand Rounds | January 19, 2024

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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.