Societies Sickened by Punishment? An Examination of the Relationship Between Incarceration and Population Health Across Nations

Abstract

Research, primarily based out of the United States, has shown that incarceration is related to a variety of negative outcomes for individuals, families, communities, and even broader populations. For example, studies have highlighted primarily negative physical and mental health effects of incarceration at multiple levels. However, we know little about societal consequences of incarceration, even as the global imprisoned population reaches its highest number yet. This dissertation aims to add to the small existing body of cross-national research on nation-level outcomes of imprisonment by examining the effect of incarceration rates on population health. To do so, I have collected, cleaned, and compiled longitudinal data from 1990-2019 from a range of sources, including datasets from the United Nations’ Office on Drugs and Crime and the World Bank. Using multilevel models with repeated measures within countries, this dissertation examines the overall relationship between incarceration and five population health outcomes – life expectancy, infant mortality, suicide rate, HIV prevalence, and TB incidence – for over 100 nations. In addition, models explore factors suggested by the literature to moderate or mediate these relationships, including prison conditions, welfare support, and racial diversity for the former and social capital for the latter.The findings from this research partially support hypotheses that incarceration levels relate to negative health outcomes at the population level. Bivariate and simple multivariate analyses of around 200 countries show that incarceration can be protective, especially at lower levels of country wealth, but high-income countries are often negatively affected by high levels of incarceration. When looking at a smaller sample of around 130 countries with available data for a range of relevant variables in this 30-year time period, most of these overarching relationships between incarceration and health do show negative effects – the one consistent outlier is infant mortality rate. Moderation analyses showed many of the direct effects to be moderated by country contexts such as racial diversity and exclusion, social protection expenditure, and prison conditions. Adding in these interactions revealed some relationships that were obscured in the direct effect models; sometimes, these were relationships that supported the narrative suggested by the literature, such as infectious disease outcomes being exacerbated by high racial diversity (HIV prevalence) or harsh prison conditions (TB incidence), but other times these were in the opposite, or an unexpected, direction. Subsample analyses allowed examination of subgroups of countries that were driving overall effects. For example, the negative effect of incarceration on life expectancy over time was found to be present only in the subsample of countries with above average racial diversity and/or exclusion, below average social protection expenditure, and worse than average prison conditions. Mediation analyses within a smaller sample of countries and years (2007-19) showed some evidence of partial mediation through civic participation and social networks, but also evidence of a suppressive effect of social capital variables on the relationship between incarceration and both infant mortality rates and HIV prevalence. While there are limitations to this research due mainly to characteristics and availability of comparative international data, there are also implications for theory, research, policy, and practice. Hopefully this work will promote more theory and research on the effects of incarceration at the country level, as negative consequences are not confined to the U.S., and encourage policymakers and practitioners to better understand how incarceration levels are affecting the health of the whole population.