In an article published in the June issue of Health Affairs, my colleague, Weiwei Chen and I analyze relationships between jail conditions and jail mortality. How do facility characteristics, we ask, relate to death rates?

Although the question may appear relatively simple, data on the health of the justice-involved population is notoriously inaccessible, so researchers aiming to study care and outcomes in jails must be creative about marshaling information and statistics.

Some conduct examinations of one facility with particularly detailed available records. Studies focused on COVID-19 have relied on data made publicly available by clinicians, lawyers, and advocates working to shed light on conditions inside.

Informed by this pathbreaking work, and aware that in the two decades before the onset of COVID-19 (2000—2019), mortality in jails increased 11 percent, we were eager to draw conclusions about numerous facilities across the country.

As we note in the paper, we wanted to conduct what one scholar called an "apples-to-apples comparison" of circumstances and deaths in multiple jails—to examine how "environmental and personal risk factors" could relate to mortality.

To do so, we relied on a combination of data sets.

One was compiled by Reuters reporters, who placed a Freedom of Information Act request to access mortality information from the largest jails in the United States; others came from the Bureau of Justice Statistics, which is charged with gathering and disseminating data related to jails and prisons.

Ultimately, we assessed mortality rates and conditions in approximately 450 US jails between 2008 and 2019 and found that certain facility characteristics were associated with more deaths.

Our most robust findings: high turnover rates — relatively large numbers of people cycling in and out of a jail weekly — were associated with higher death rates overall, as well as due to suicide, drugs and alcohol, and homicide.

Also, the presence of greater proportions of non-Hispanic Black people in jail populations was associated with more deaths due to illness.

Heavy reliance on incarceration and the prevalence of free world health disparities, these results suggest, shape mortality risks inside jails.

We also found an association between higher death rates due to accidents and large shares of juveniles (children under 18 years old) in jail populations, as well as a marginally significant association between higher proportions of women and higher mortality.

While the presence of large shares of non-US citizens in jail populations was associated with lower overall mortality rates, we found that in relatively small jails (with capacities of less than 365 people), higher proportions of non-US citizens was related to more deaths.

We examined, too, mortality rates related to facility health care management and found that oversight by a public provider, as opposed to a private provider or a hybrid of the two, was related to lower mortality due to suicide.

In our paper, we offer perspective on individual findings, but here, it’s worth recapping perhaps the broadest takeaway point: risks related to jail mortality are rooted in policies and practices of the free world.

The complex factors undergirding the United States’ heavy reliance on incarceration — and high jail turnover rates — include structural racism, decades’ worth of cuts in social welfare programs, local and national political trends, policing practices, and an over-reliance on cash bail.

These points help explain why the US continues to have the highest incarceration rate of any country for which data is available; why jail detainees are disproportionately likely to be impoverished, from marginalized groups, and physically and/or mentally ill; and why approximately two-thirds of the 700,000 people confined in jails each day are unconvicted and awaiting trial.

Ongoing programs geared at reducing incarceration rates focus on these complex forces.

Some limit the use of cash bail. Others enhance community-based services intended to address mental illness, drug use, and homelessness, so jails are less likely to be sites of first resort for people in need of social support and health care.

An additional means of addressing deeply rooted health disparities and improving outcomes among people who may be vulnerable to incarceration, scholars note, is to expand access to Medicaid and eliminate the program’s "inmate exception."

Our results suggest that stakeholders aiming to reduce mortality in jails should likewise focus on broad contexts, including alleviating conditions that lead to the facilities’ over-use, as well as the inequities shaping what happens inside them.

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Jessica Adler

About Health Affairs

Health Affairs is the leading peer-reviewed journal at the intersection of health, health care, and policy. Published monthly by Project HOPE, the journal is available in print and online. Late-breaking content is also found through healthaffairs.org, Health Affairs Today, and Health Affairs Sunday Update.

Project HOPE is a global health and humanitarian relief organization that places power in the hands of local health care workers to save lives across the globe. Project HOPE has published Health Affairs since 1981.

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