Dr. Emily Wang: Mass Incarceration and Health

Harlan Krumholz: Welcome to Health & Veritas. I’m Harlan Krumholz.

Howard Forman: And I’m Howie Forman. We are physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. Harlan, what’s caught your attention this week in healthcare?

Harlan Krumholz: Well, one of the biggest stories of this week was that Joe Biden’s top science advisor, Eric Lander, stepped down from the Office of Science and Technology Policy. So this is a big deal because science has always been important in most administrations, but in this administration that was elevated to a cabinet position, and Lander was brought in to much fanfare. A renowned scientist, he’d run the Broad Institute. He’d had a little bit of controversy about him along the way, ruffled some feathers, but he seemed committed to digging in and focusing on the administration priorities. What happened was that there was reports of bullying within the office, and especially from the general counsel, who was then demoted, and that led to an internal audit by the White House. And then the report comes out and affirms! And it’s not just one person, but it’s many people, and so that leads to a White House that had committed to having zero tolerance for bullying to say like, “Yeah, we’ve sat down and talked to him.” He issued a response; it was kind of a tepid apology. And they said, “We’re going to check back and forth to explain. He’s going to have a bunch of brown bag lunches with people who’ve been complaining and seeing if we can tamp this down.” And then it wasn’t until Politico broke the story that actually it put the administration in a position, I think, where they had to act. And he ultimately resigned, and he owned it all. By the way, I mean, his people said they were afraid of him. He was screaming, yelling, humiliating.

This bothers me for a whole bunch of reasons. One is that it ever got to this point. There’s no... there’s nothing about this that makes me feel good. I feel bad for Eric Lander, who obviously has issues around control. It’s sort of like the old-time coaches who used to throw chairs. This kind of behavior has no place in our world today and in the workplace, for sure. A slow response by the White House. What it means for science, derailing it. He was going to testify to Congress about the new federal agency devoted to science. He was running the cancer moonshot. All of that work, preparing him, his leadership now unraveled, and now [you] have to find a new leader who has to be approved by Congress. By the way, that’ll slow things down, too.

And I’m also disheartened by all this behavior by men. The University of Michigan president resigned. You’ve got this obstetrician gynecologist in the University of California system who’s on trial for bad behavior with... and when I say “bad behavior with patients,” that’s an understatement, I mean, but you saw this in Michigan, too, and you’re seeing all these places. It’s demoralizing. It’s just demoralizing at best and horrific at worst. And we have to change normative behavior and standards. And we also have to empower people with the ability to speak out when there are issues and protect them when they do.

Howard Forman: Yeah, no, I agree. And I think we need to have workplaces where people feel safe to be able to speak, to be able to work, and not to be bullied verbally, physically, and so on. And great leaders are never bad actors like this. And I’m glad to see that the White House responded appropriately to this.

Harlan Krumholz: Eventually—just to be honest—eventually. Anyway, it’s enough said. Okay. How about you, Howie, what’s on your mind?

Howard Forman: Yeah. I saw a study earlier this week on…a large study on veterans looking at cardiovascular outcomes, seeing that there’s significantly more frequent negative adverse cardiovascular outcomes in patients who have had recent COVID infection. And it’s not like we hadn’t understood this anecdotally, but they found strokes, atrial fibrillation, other arrhythmias, pericarditis, myocarditis, heart failure, clot formation to be substantially elevated in these patients more than 30 days after infection, and, quote, “the risks were evident regardless of age, race, sex, and other cardiovascular risk factors, including obesity, hypertension, diabetes, chronic kidney disease, and hyperlipidemia; they were also evident in people without any cardiovascular disease before exposure to COVID-19, providing evidence that these risks might manifest even in people at low risk of cardiovascular disease.”

So this is a large study, but it still has some limitations, including a limited time to follow up and the nature of the population being in the Veterans Administration hospitals, but it does align with anecdotal evidence. It represents yet another counterargument to those who are either eager to get COVID in order to get it over with or those who have avoided vaccines due to perceived side effects. And taken together with much of your research and others on long COVID, this paper should be yet another reminder of how little we know and how much work we still have to do to get answers to key questions. I know—you must have thoughts about this paper too, particularly as it’s at the intersection of your clinical specialty in your area of scholarly expertise. And I’m curious to know what you think.

Harlan Krumholz: Yeah. I think it’s great paper by Ziyad Al-Aly and colleagues at the St. Louis VA. I also just want to do a shout-out to them for posting their code. So they do this kind of work, and they’re also posting the code. So there’s full transparency with regard to this. And they’ve done another great paper in Nature that was on high-dimensional characterization of post-acute sequela of COVID. I think the only question I had about this, which I also posed on Twitter, was whether this is specific to COVID or whether after major infections, which leads to systemic inflammation in the body, that people are susceptible to increased risk of cardiovascular events. We know after, for example, pneumonia, that people are often at higher risk for cardiovascular events. Flu, influenza. I mean, one of the reasons the American Heart Association pushes so hard on flu vaccine is because we know that getting the flu is a risk factor for cardiovascular disease.

And so it’s not just for people who have heart disease that get in trouble when they get the flu, but it also can cause problems subsequently, we think. So there’s lots to disentangle here, but the truth is, lots of people have been infected with COVID. If this is true, then there’s lots of people at risk, and we need to pay attention to it and know if it is a risk factor. I agree with you.

Howard Forman: So Harlan, let’s move on to our guest.

Harlan Krumholz: Howie, guess what? Today we’re here with another superstar faculty member, but this one is so dear to me. She is amazing. Emily Wang. She’s a professor at the Yale School of Medicine. She directs the new SEICHE Center for Health and Justice. And I got to ask her what “SEICHE” means, because I’m not really sure. It’s a collaboration, I know, between the Yale School of Medicine and the Yale Law School that’s working to stimulate community transformation by identifying legal policy and practice levers that can improve health of individuals and communities impacted by mass incarceration, which by the way, she’s done research that shows that this isn’t really an isolated thing. This is something that affects so many families throughout the country.

But she to me is the quintessential scholar and activist, someone who’s producing new knowledge that is actionable, important to society, and working to see that knowledge actually translated into benefit for people. And she goes really where few other scholars have been willing to go, to work with populations that are often ignored at best and disparaged at worst. And anyway, she’s an immense inspiration to me, and I’m so happy to have her on the program today. So, welcome, Emily. Thanks for joining us.

Emily Wang: I’m super excited to be here. Thank you for the invitation.

Harlan Krumholz: So Emily, just to start off, what is the SEICHE Center for Health and Justice and how did you come up with that name?

Emily Wang: It’s an esoteric word. It’s something that I didn’t know before. In naming the center, we really wanted it to be something that emerged from all the folks on our team and convened in a real participatory fashion, a group just to think through what would be symbolic of us. And so a seiche wave is one that emerges out of stagnant waters, right? Just out of nothing. And it really is one where there’s two competing waves that pop up, intersect, and collide and create this enormous wave. And there’re some examples of it on YouTube where you can see kind of waves coming out of Lake Michigan or even swim pools. And so our team really envisioned that it was like the health system on one side and the criminal justice system. So, that’s where the name comes from. SEICHE Center.

Harlan Krumholz: And what would success be for the center if you really make the impact that you want to make?

Emily Wang: For me, it means a system where we haven’t made huge investments in a criminal justice system that isn’t functioning for the whole of us. And what it means for me is, is a world where, when you talk about abolition, it’s a deeper investment in the social safety systems, in healthcare, in education, in our wellbeing that brings people home and keeps them home.

Howard Forman: And the work that you’re doing right now and have done over the last decades really is a reflection also of sort of the systemic racism that is also built into our healthcare system. Because one of the things I noticed in the papers that you’ve written is that it affects our ability to do clinical trials on Black men. It affects Black men having healthcare after leaving prison. I’m just wondering, when you’re dealing with something that is so deeply rooted in our justice system, in social determinants of health, where do you target interventions to fix this? Are you really targeting the justice system or are you looking at ways to interact with our healthcare system and our providers to enact change?

Emily Wang: Yeah. You know, Howie, I think your question raises kind of two process issues for me. So one of the places where I’ve always come to this work is really recognizing, I personally haven’t been incarcerated, very few of my family members, immediate communities have ever had experiences, even real deep experiences with the police or certainly a criminal justice system, and early on have felt it was important, critical really, to bring in people that have histories of incarcerations, that have been incarcerated, proximate, to work with us, alongside us in the healthcare system, to work with us, alongside us in our research. And so within the SEICHE Center, one of the things I’m most proud of is the fact that the vast majority of folks that we employ—and it kind of pushes up against Yale’s hiring system—but the vast majority of people we employ have been directly impacted by incarceration, from the faculty level on down to kind of the staff that really emboldens our work.

And it’s in those conversations that the interventions that we’ll take on are ones that are asset-driven and then ones that are structural, that there’s too many interventions, and there aren’t a ton, but there’s too many interventions that are really focused on individual-level kind of risk factors, right? It’s like, how is it that we make these bad apples better without really acknowledging the structures, and as you say, that there’s structural racism that are historical that are present, that are persistent, that are kind of causing these worse health outcomes. And so we really focus on assets like, hey, let’s look into these communities where there’s people that have been incarcerated that are kicking ass. Where are they... Where are things going well? Communities that in spite of these structural forces, where there are kind of thriving groups, organizations, and study kind of in a positive deviance way, and thinking about Harlan and Leslie Curry’s work, you know, like, where can we learn from where it works and how do we scale and study?

And so I think that in those ways, by bringing folks that have been incarcerated near us, it shifts the work into really interesting scientific places, right? To like places where people haven’t looked before, like what works in these communities, how do we scale those interventions, and how do we focus on what is working? As opposed to kind of just saying, like, “These criminals, what’s wrong, and how do we fix them?” And so, our interventions right now are ones that are squarely focused on the healthcare system where we’re studying transitions, clinic networks, these programs, primary care–based programs as alluded to where my primary practices are, and how it is that you kind of transform the transitions between the criminal justice system and the healthcare system. And then, trying to study, for instance, home loans, down payments to people whose families have been incarcerated in a randomized control trial, how is it that that may improve kind of community wellbeing, exposure to health and even heart disease.

Harlan Krumholz: So one of the points you made was about how people think of these people as other, and one of the things that you have to do in order to galvanize action and to bring about investment is to generate compassion about the plight of people who are on this road. And how have you bridged that? I mean, one of the things you’ve written about is actually how many families in the U.S. have had somebody who’s been incarcerated, and the degree to which it’s sort of a widespread phenomenon when you start considering the network of people who are connected in some ways. I’m just wondering how you think about that and what kind of strategies you’ve used to try to get people to take a moment to really think deeply about this group.

Emily Wang: Yeah. I think that my thinking on that has probably evolved. Earlier on in my training, I think I was... I am a primary care provider at heart and, in my own practice, see kind of how it is that mass incarceration, but even exposure to kind of being incarcerated really affects the individual level, and felt maybe naively that, should we get people that have been incarcerated to work as community health workers? Should we really focus in on this, that the community healthcare providers, you know, us as a health system would see this, realize kind of, they’re people, it’s inefficient to deliver care, and let’s do it, let’s get in there and kind of fix this inefficiency. And over time, I’ve realized that it’s far more complicated than that, right? And it also is really this deep issue of othering, that our health system actually doesn’t give two craps about this inefficiency. This inefficiency exists for a reason. It’s baked into how, when in 1965 Medicaid was born. Right? And I think slowly, iteratively, is really now starting to make the argument that it isn’t just individuals. It certainly is an individual issue, but it also is about families. And it also is about whole communities. It’s also about our health system. It’s also about kind of how it is that we practice writ large as a system. And, I think that that family question that you raise, Harlan, is right on. It blew my brains out, kind of, to think that when we did that study and Chris Wildeman and his team at Cornell led it, 50% of all Americans have had an immediate family member ever imprisoned. Mass incarceration reaches way beyond just the individual level and kind of touches us all. And those arguments are really compelling and kind of start making people think about kind of other ways that the system really impacts us all.

The other thing I would say is that I do think it is critical, also we’ve started in our work SEICHE Center, really trying to think about folks that work in correctional systems, right? That it’s not just health-harming to family members, but it’s health-harming to those that work within corrections. And nothing has been more telling than COVID-19 of showing kind of how these are ecosystems in our five thousand prisons and jails all over the country, there are men and women that go to work each and every day that have to work and make a gainful living, supporting their families in a correctional system that puts them at increased risk for COVID-19; actually kind of probably the stressors increases their risk for heart disease. And so the whole ways of kind of understanding how mass incarceration impacts health, I think is beyond those that have been convicted of a crime.

Harlan Krumholz: Let me, I just want to make sure the listeners just know the central take-home of your piece, because I was shocked when I read it, that almost half of Americans have a family member who’s been incarcerated. But that was such a big number. I don’t know if you were surprised to learn that also, but that was a big number.

Emily Wang: Yeah. I was—

Harlan Krumholz: And goes by.... And we’re what, the country with the largest incarceration rate in the world, except maybe, I think there’s... . We’re second or something. I don’t....

Emily Wang: Yeah. We’ve incarcerated, and those numbers have fluctuated during COVID, but in the last three decades by far we’ve become the country that incarcerates the highest number of its citizens, so we account for 25% of all prisoners in the world.

Howard Forman: And when you’re looking at healthcare within prisons, a lot of the work you’ve done has been adjacent to prison population healthcare, people who have been discharged or family members and so on. But I’m curious about—you worked on a paper with one of my former students on hepatitis treatment in, you know, on hepatitis virus eradication among prison populations with hepatitis C, and that was one of the most striking things, that we have a system that basically allows us to allow people to get worse and worse, to spread more and more disease and probably to contribute to worse community spread when they’re let out of prison. And yet we perpetuate that. And now six years later, after you wrote that paper, I’m not sure much has changed. And how do we get to a point where we realize that we have an obligation to these individuals, not just for themselves but for the communities that they’ll return to. Have you seen any progress since that paper?

Emily Wang: Yeah. I haven’t seen much. I mean, and again, the practice of healthcare behind bars is really heterogeneous. So there five thousand prisons and jails, and there isn’t necessarily a state or federal oversight agency that kind of oversees the care. I mean, I think it’s important for listeners to kind of just note this, and I always like to say it, is that healthcare behind bars is constitutionally guaranteed. And it’s one of the only places in the country where there is a constitutional guarantee by Estelle v. Gamble, the Supreme Court case in the 1970s. And what is, I think, really important to note is that even though there is the guarantee, that that doesn’t mean that the care is quality, that doesn’t mean that the there’s equal access or access the way that we think about access to healthcare, and nor does it mean that there is kind of, even though the Supreme Court case dictates this, that the community standards of care necessarily pertain to those that exist in the community. And so hepatitis C is a perfect example.

When we wrote that paper, and it’s with Adam Beckman and a good group of people, we really wanted to just understand what the landscape was for hepatitis C treatment. You think, my gosh, there’s DART [anti-retroviral therapy] now, it’s available, it can treat folks. Who are they treating, how are they screening? And this is just in the fifty state prisons, did a great survey and found that there’s lots of heterogeneity in who’s getting treatment; very few places that are systematically delivering treatment, much less testing. Right? And this doesn’t include all the jails, the nation’s jails. And so, the take-home issue is that there just isn’t the oversight for healthcare behind bars, nor are there often the resources to deliver kind of quality care, and also that this hasn’t changed. And it only changes when there’s court cases involved. And so part of the reasons why we’ve really thought about, kind of hard about partnerships via law schools, to really think about how culture changes is oftentimes through court cases, legal cases that really push the needle forward.

Harlan Krumholz: You make me think that a lot about how we treat people in this circumstance says a lot about who we are as a people, as a country. And sometimes that reflection right now is not so strong. Even, we’re talking about how people care and to go out, but it does strike me that the work that you’re doing is so important, but like I said, just come back to it, it’s like we have to recognize it as a problem in our society. And the work you’re doing to show how many people are affected and that there are interventions in the transitions, but this really needs to be from the beginning to the end, right? Including kind of the trauma in the incarceration itself has dire consequences to anyone’s ability to succeed afterwards, too. So, many of these people are being put in positions where they’re... it’s very hard to succeed post-incarceration because of all the things that are lined up against them, including the withdrawal of full medical insurance.

I mean, just what you’re saying. I mean, that’s one of the things that happens is they’ve been in a system now with full medical insurance and now they’re left to their own devices, largely.

Emily Wang: It’s interesting, Harlan, I was reflecting on that a little bit. And it brings to me, thinking about the physicians that practice inside, kind of the example that you gave of Rikers, right? That there was literally an exposé, literally physicians online, on Twitter, writing off, that saying that the conditions are deplorable. We could all see them as a public witnessing, people commenting. New York City and New York State are one of the few places in the country that has a governance oversight board, and yet—it’s like an independent oversight board—and yet the conditions haven’t changed. Even the commissioner was saying, “We need more, we need more oversight, we need more help.”

And so that’s a place where there’s transparency and still no accountability. And for me, so much of what we need to do, you bring up Medicaid, is that we have to hold policymakers accountable, we have to hold our citizenry accountable. That we are seeing this, we’re seeing our colleagues who are practicing behind bars suffer and have to take care of patients in that condition. And still, even when it’s like the most egregious, I mean, people were sitting in their own feces, fourteen in a cell, right? We’ve seen in Alabama over and over, but there’s no way to change the system. And so—

Harlan Krumholz: Well, you raise the issue of Medicaid. Do you want to just explain that a little bit more? What’s the issue with Medicaid?

Emily Wang: Yeah, I think it’s an important one. It’s one that is a place that gives me a little bit of hope these days. So as you know, there’s a—Medicaid, they an made exclusion policy, so at the birth of Medicaid folks that are incarcerated can no longer benefit from Medicaid. So if you were a Medicaid beneficiary, once you’re in a carceral setting, you no longer receive those benefits, states can suspend and not terminate Medicaid, but at the individual level, once you’ve been incarcerated, this is in broad strokes, you’d lose those Medicaid benefits. And then you have to either reapply or it pops on, but there’s usually a big delay. What’s happening now is given the delay, is given the suspension, and given kind of what we’ve seen are poor transitions in care, the increases of kind of overdose deaths. Again, COVID-19 brought out the real inefficiencies between that transition between a constitutional-guaranteed healthcare and a community healthcare system post-release that there is now bipartisan interest in at least trying to bridge that gap with Medicaid.

So in certain states, there’s state exemption plans saying that the thirty days prior to release, Medicaid will kick on, in other states the state waivers are ninety days. And then other people are calling for, for instance, Massachusetts is asking to be able to test, to eliminate the policy altogether in Massachusetts and have Medicaid continue when people are in a jail or prison and post-release.

And the promise of that, which is, I think, complicated given our history and given problems with Medicaid, but the issues with that are as follows, is that once Medicaid is covering care within correctional systems, then there will be more federal oversight, presumably. Then there will be at least a minimum standard of care that have to be delivered. Then there’s conversations about accreditation of providers, then there’s conversations about what does quality look like. And again, the three of us know that that’s murky, what oversight looks like. And again, there’s lots of variance in community practices, but it’ll be the first time in this country where there is conversation about a state- or federal-level oversight and hopefully accountability. And I think that that’s what’s critical, is that it’s not just transparency, it’s literally holding policymakers, holding us all as healthcare providers accountable to the people that are incarcerated and the providers that have to work there.

Howard Forman: And is it a federal solution that we need, or is this going to happen state by state to get Medicaid expansion to these populations? Because that is, as much as you’re downplaying it and saying there’s a lot of challenges to it, that is, to me, the main solution, to at least treat them as though they’re human beings, because they are.

Emily Wang: A hundred percent. I don’t mean to downplay it. I feel like I’m now in the weeds. I think that actually the expansion of Medicaid and it, through the [Affordable] Care Act, was the biggest criminal justice reform policy there was, it is profoundly impactful. And so expansion of Medicaid certainly is part of this. And I certainly think that repeal of the Medicaid inmate exclusion policy is also an important piece.

I also think that it’s important to see kind of that there’s competing priorities among criminal justice agencies, where now sheriffs are excited about the revenue that will come in. What does that mean when you grow the carceral system? And so these forces, I think, are important to kind of consider. It also is important to really dig down into kind of the practical issues of providing healthcare behind bars. Most systems don’t have an electronic health record, so how do you even enforce quality? How do you even see it? It’s a paper record, right? And so there’s lots of kinds of stuff that you have to get into the weeds and get at. But overall there is a real promise in the Medicaid Reentry Act right now that was up twice, and also these estate exemption waivers.

Harlan Krumholz: Look, I just want to thank you for taking the time. I know you’re so busy, actually, lots of things in the air, exciting sabbatical and lots of ideas for when you come back and, anyway, deep gratitude for all the work you do, for how you inspire all of us and for taking the time to be with us today. Thanks so much, Emily.

Howard Forman: Thanks very much, Emily.

Emily Wang: Thank you both for the opportunity to be here. Really appreciate it.

Howard Forman: Harlan, what’s something that inspires you or keeps you up at night?

Harlan Krumholz: One of the topics that has really been talked about a lot in the last week or two has been this issue of Joe Rogan, the radio talk show host, and his placement on Spotify, and some of the artists like Joni Mitchell and Neil Young deciding to pull off their music from the Spotify platform. And I find it an interesting debate. It’s a lot about free speech and tolerance of allowing different points of view to be aired and whether or not Rogan is beyond the pale, and if they’re going to promote Rogan, I mean, when does speech become hateful to the point that really people should be not supporting a platform like Spotify, who would... And by the way, it’s not just that they have Rogan’s podcast on, but they cut, what was it, a $100 million con— I mean, he is intensely popular and they’re paying him a ton of money to be on the Spotify platform. And I said to you, like, are we on Spotify? Should we pull off?

And the thing that really disturbed me was that Spotify had to remove eighty episodes because of hate speech, including the use of the N-word and other things on his thing. And you and I both know that he’s also pushed a lot of misinformation during the pandemic, information that I believe has caused harm, caused harm to people who may believe that he was a credible and trustworthy source of health information. And so to me, this is where it crosses the line, where it becomes not just a former comic or current comic making jokes, but somebody really... I saw, Trevor Noah said that this wasn’t about somebody making, in a comic routine, leveraging racism, but someone using racism to try to be funny. And that really, to me, crosses the line. If they had to pull off those episodes because they were so heinous, that’s a big problem. There has to be a line somewhere, right? And then the misinformation.

Howard Forman: Yeah, these are private platforms. They have every right to either keep him or not. They have every right to set terms of service that encourage this or discourage this. And for the moment they’re making money off of him, and so all is good. If that were to change, they might change their rules a little bit. And I’m a very, very big believer in free speech, but I do think that when a private platform is supporting dangerous speech, and by dangerous speech I mean misinformation that results in harm to individuals, they have some responsibility.

Harlan Krumholz: Which includes racist speech, right? Correct?

Howard Forman: That’s correct. Yeah.

Harlan Krumholz: Correct. So anyway, that was on my mind. How about you, what’s on your mind this week?

Howard Forman: So I’m going to go in the other direction and just say that it’s hard, for me at least, not to be inspired by our Olympians, and by the way, so many other Olympians from many other countries far and wide. The Olympics are such a great example of how we can simultaneously compete with one another but also be inspired by the stories from allies and non-allied nations alike. There are many individual competitors from Connecticut. And while Nathan Chan is from Utah, he’s currently matriculated at Yale and reportedly premed. I can momentarily ignore the crises in the United States and abroad, and I can cheer for individuals of many countries, even as I’m also saddened to see the systematic repression and abuse of the Uyghurs by the Chinese government.

And by the way, I think the Olympics shine a light on this. So I think there is a small silver lining about an issue too many people are unaware of. I admit that I’m a little conflicted about the Olympics themselves. We’re participating in the aggrandizement of a nation that is acting badly, but I also believe we gain much more from engagement, from shining light and from getting the truth out, than we can from isolation.

Harlan Krumholz: So you’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

Howard Forman: So how did we do? To give us your feedback or to keep the conversation going, you can find this on Twitter.

Harlan Krumholz: I’m @H-M-K-Y-A-L-E, that’s hmkyale.

Howard Forman: And I’m @thehowie, that’s @T-H-E-H-O-W-I-E.

Harlan Krumholz: Health & Veritas is produced with the Yale School of Management. Thanks to our researcher, Sherrie Wang, and to our producer, Miranda Shafer. Talk to you soon, Howie.

Howard Forman: Thanks, Harlan. Talk to you soon.