There are 2.3 million people incarcerated in the United States, a number that dwarfs the prison population of any other country, and one that has grown at a staggering rate since the ‘70s, when there were just over 350,000 inmates. Mass incarceration is now widely acknowledged as a major problem in our society — and one that professionals in law enforcement, education, public policy, and government are working to address. In New York City, where some 10,000 inmates are housed in the city’s dozen jails on any given day — and 55,000 inmates are admitted each year — Dr. Ross MacDonald ’03, MD ’08, chief of medicine for the Division of Correctional Health Services, is tackling this issue from a public health perspective.
On most days, Dr. MacDonald drives from his Manhattan home to his office on Rikers Island, across the East River from LaGuardia Airport, where nine city jails are grouped in a massive complex. Tasked with overseeing medical care for inmates in one of the nation’s biggest municipal jail systems — which provides roughly 800,000 patient appointments per year — Dr. MacDonald has a primary goal of ensuring that detainees receive the care to which the law entitles them. But on a broader scale, he is part of what he describes as a complicated, generations-long, multi-disciplinary effort to roll back mass incarceration — a staggering public health issue in which prisoners and the recently jailed are among the unhealthiest members of society, dealing with high rates of substance use disorders, mental illness, and homelessness that are only exacerbated by imprisonment.
“I believe that physicians have a particular role to play in helping society find alternative ways of dealing with mass incarceration,” says Dr. MacDonald, who notes that contributing to the scientific literature is part of that role, as is promoting what he calls a human rights approach to medicine that acknowledges the ethical complexities inherent to providing healthcare in a jail setting. But, Dr. MacDonald stresses, that isn’t enough. He also uses data from his studies on drug treatment and solitary confinement in New York City jails to influence policy makers, police officers, drug enforcement agents and others to respond to substance use and mental illness with a public health — rather than a criminal justice — approach. “I want to be part of the conversation about how we can help citizens who have been impacted by mass incarceration come back to society, and about how we can minimize the harms of substance use disorders and violence in our communities without resorting to incarceration so quickly,” he says.
Dr. MacDonald, who is also an attending physician at the Bronx’s Montefiore Medical Center and an assistant professor at Albert Einstein College of Medicine, became interested in working with incarcerated people more than a decade ago, when he was a Cornell sophomore. Having decided to major in English rather than pre-med, he volunteered once a week at the maximum-security Auburn Correctional Facility an hour north of Ithaca, helping inmates improve their writing skills. Participating in what’s now known as the Cornell Prison Education Program was a transformative experience for Dr. MacDonald, opening his eyes to the realities of how mass incarceration disproportionately affects people of color and the poor. At the same time, he found himself gratified by the one-on-one relationships he developed with the inmates. “It felt like what I’d hoped to experience in a patient-doctor relationship, and as a result, sort of drew me back toward medicine,” says Dr. MacDonald, who ended up fulfilling his premed requirements before graduation.
With a goal of treating underserved, vulnerable populations, Dr. MacDonald earned his medical degree from Weill Cornell Medicine and completed a residency in social internal medicine at Albert Einstein College of Medicine/Montefiore Medical Center. In 2009, he helped found the Bronx Transitions Clinic, which continues to provide primary medical care to people who were recently released from jail or prison; in 2011, he was named deputy medical director — and promoted a year later to medical director — of the Bureau of Correctional Health Services under the New York City Department of Health and Mental Hygiene.
In January 2016, New York City’s correctional healthcare system transitioned from its previous model — in which medical services were contracted out to a for-profit company — to its current one, in which care is integrated into the city’s public hospital network and overseen by NYC Health + Hospitals. This distinction is important, Dr. MacDonald says, in part because it means that the control over inmates’ healthcare delivery is now in the hands of physicians who can think about where inmates are receiving care over the long term. “Having jail healthcare under the same public hospital system that our patients use in their communities removes some of the disruption inherent to imprisonment,” he says.
Medical care is now more streamlined, coordinated and continuous for inmates, Dr. MacDonald says. But this change is also important because it’s allowed him to recruit mission-driven, academic physicians, who are able to practice the kind of patient-centered and proactive medicine that the complicated jail environment demands. These new hires have assumed important roles, like overseeing clinical education for the staff, handling geriatric patients and issues of palliative care, and treating inmates with substance use disorders. The latter issue is especially significant, given that 75 percent of inmates enter Rikers with recent substance use — nearly 20 percent of them withdrawing from heroin or opioid painkillers.
While Dr. MacDonald says that making New York City’s jail health system the best in the world is his primary focus, contributing to a larger policy discussion is an important parallel goal. In 2014, he co-authored a paper in the American Journal of Public Health that showed that inmates who were assigned to solitary confinement were almost seven times more likely to self-harm than those who were not. The data showed that being diagnosed with a serious mental illness or being 18 or younger were also predictive of self-harm, leading the investigators to conclude that solitary guidelines should be reconsidered. The paper won the Most Impactful Journal Article award from the New York City Department of Health and was cited by Justice Anthony Kennedy in a 2015 Supreme Court opinion. In addition, it contributed to dramatic changes in how solitary confinement is used in New York City, as today, inmates who are under 21 or have a serious mental illness are now excluded from being placed in solitary. “These types of changes are the product of many different forces and weren’t a direct result of our study, but when you’re dealing with controversial topics, data is often the least controversial way to approach and spark these conversations about how to reform criminal justice,” Dr. MacDonald says.
Dr. MacDonald has also studied other issues that affect inmates on the local and national level — like how the trifecta of mental illness, substance use disorders and homelessness often plague the frequently incarcerated, and how incarceration and release from jail represent a huge risk for drug overdose. And to reach a larger audience, Dr. MacDonald has for the past four years been working with a New York City-based multi-disciplinary group that brings together prosecutors, Drug Enforcement Agency officers, and others to collaborate on innovative solutions to drug use. He has also spoken to local and federal policy makers at national conferences, like the National Rx Drug Abuse & Heroin Summit, about how sending drug users to jail to “get clean” can actually increase their risk for death from overdose. “Presenting to these audiences allows me to reach people who have much more impact on criminal justice policy than doctors or the public health community do,” he says. “In many cases, no physicians have ever spoken to them about the effects that jail and incarceration can have on problems like drug use and homelessness. What they believe might intuitively be helping can actually be causing harm.”
— Anne Machalinski
This story first appeared in Weill Cornell Medicine, Vol. 16. No. 2