Perpetual Punishment: Incarceration As a Social Determinant of Health

​Devyn E. Hoopfer
Department of Health Sciences, Carleton University
HLTH 5402: Biological and Social Fundamentals of Health
Dr. Renate Ysseldyk
April 7, 2025 

​Artificial Intelligence Declaration
This paper was written by the author. ChatGPT 4o was used for the purposes of idea generation, outlining, and/or language refinement. All content, arguments, and references have been independently evaluated by the author. The use of AI complies with the academic integrity policies of Carleton University and the HLTH 5402 instructor’s policy for this assignment.

Position Statement
I was previously employed by Correctional Services Canada. The stories I heard were nothing short of atrocities. These experiences profoundly changed the way I see the world. While this paper presents facts, figures, and statistics to build its case, it’s crucial to remember that behind every number is a human being shaped by circumstances. Each data point is a son or daughter that deserves dignity and respect.

Perpetual Punishment: Incarceration As a Social Determinant of Health
In Canada, approximately 38,570 people are held in federal, provincial or territorial custody (Statistics Canada, 2024), yet only 53.3% of them have been tried and sentenced (Public Safety Canada, 2023). For many incarcerated Canadians, a prison sentence marks the beginning of a vicious cycle fueled by stigma and systematic neglect. Indeed, of those sentenced, the average two-year recidivism rate was 23.4%  (Stewart et al., 2019) with incarceration impacting nearly every facet of life, including accessibility to housing, income, and, as discussed in more detail in this blog, health.
Social determinants of health (SDoH) are systemic social factors that drive differences in health across groups and are closely tied to structural inequities (Raphael et al., 2020). Incarceration is a profound but often overlooked SDoH. It disproportionately affects marginalized communities, worsening existing health disparities, and creating new ones. Incarceration is not just a legal issue or a moral failing, it reflects deeper societal failures, including those related to health equity and public health.

Colonization & Incarceration
The Canadian criminal justice system is deeply intertwined with the legacy of colonialism. Indigenous inmates account for 28% of the prison population, despite representing just 5% of the national population (Department of Justice, 2023). The forced relocation of indigenous communities to reserves, the repressive measures of the Indian Act, and the denial of treaty rights have contributed to socio-economic marginalization, setting the conditions for crime and victimization (Department of Justice, 2023). Additionally, the intergenerational trauma caused by residential schools and the foster care system has further disrupted family and community structures. Consequently, Indigenous people are more likely to suffer from poorer mental health and substance use disorders compared to non-Indigenous people (Cameron et al., 2021). Similarly, Black Canadians are overrepresented in correctional institutions due to racial profiling, socio-economic disadvantages, and systematic inequalities within the criminal justice system (Department of Justice, 2022).

Intersecting Inequities
There is significant overlap between risk factors associated with criminal behaviour and SDoH such as poverty, housing instability, racism, level of education, unemployment, and mental illness (Department of Justice, 2024). Most of the prison population report some history of family violence, family separation, physical or sexual abuse (Ulzen & Hamilton, 1998). Additionally, substance-use is also highly prevalent in this population compared to the general public (Kouyoumdjian et al., 2016).  
The intersection of these social determinants is often clustered in communities that are marginalized and under-resourced, where chronic stress and limited access to opportunity create vulnerability (Department of Justice, 2024). In such settings, individuals may adopt coping or survival strategies, such as substance use, petty theft, or informal economic activities, that are more likely to be criminalized than treated with social or health-based interventions. Rather than addressing the root causes of these behaviors, the criminal justice system often responds with punishment, reinforcing cycles of disadvantage.
For instance, homelessness or mental illness may lead to minor legal infractions like loitering or public intoxication, resulting in arrest rather than connection with housing services or mental health care. These punitive responses reveal the structural inequities in how different populations are policed and punished. Recognizing the overlap between SDoH and incarceration is essential for shifting toward a public health approach that treats these behaviors as symptoms of systemic failure rather than individual moral weakness.
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Barriers to Services Behind Bars
Once incarcerated, these individuals face further harm within the correctional system, particularly when in need of medical and/or mental health services. ​ Adequate health care remains a persistent challenge in Canada’s correctional facilities, with health care issues being among the most frequently reported inmate complaint (Office of the Correctional Investigator, 2023). Incarcerated individuals often face barriers to receiving timely and adequate care in prison (Canada et al., 2022), leading to poorer health outcomes than the general population (Kouyoumdjian et al., 2016).
Mental health services are particularly inadequate. There is strict control of medications within prisons and jails, where institutional concerns over drug misuse or diversion often override medical necessity (Fazel et al., 2004). This is extremely problematic given the disproportionately high rates of mental illness among inmates (Fazel et al., 2016). Fazel et al (2004) found that a mere 18% of participants with diagnosed mental illness were prescribed appropriate medication. Shortages of mental health professionals have left many struggling with mental illness, who were already failed by outside community supports (Mental Health Commission of Canada, 2017).
Those with mental illness may be written-up for being disruptive or aggressive, which could be caused by untreated mental health problems. Unfortunately, penalties may extend their sentences leaving them vulnerable longer. In many cases, individuals feel they have no escape other than to self-harm to receive medical attention or commit suicide, with much higher rates of both compared to the public (Kouyoumdjian et al., 2016).
Chronic and communicable diseases are more common in prisons and are often poorly managed (Stewart et al., 2015). Delays in care from prolonged waiting times, inadequate staffing, and limited access to specialized services further burden an already strained and underfunded system (Kouyoumdjian et al., 2016). For those with pre-existing issues or emerging health conditions, poor nutrition, inadequate ventilation, and overcrowding can worsen their health and enable the spread of communicable diseases (National Research Council, 2013). Diseases such as tuberculosis thrive in such conditions, where it remains a persistent concern (Kouyoumdjian et al., 2016). COVID-19 further exposed these vulnerabilities, with incarcerated populations experiencing higher infection and hospitalization rates (Zygmunt et al., 2024). Additionally, the prevalence of HIV, Hepatitis C, and syphilis is significantly higher among incarcerated individuals (Kouyoumdjian et al., 2016).
Despite the high prevalence of substance use (Correctional Service Canada, 2024) and associated health risks among incarcerated individuals, there is a notable lack of harm reduction programs within the provincial correctional system (Sander et al., 2019). Most facilities do not offer supervised consumption services, needle exchange programs, or tailored educational materials (Sander et al., 2019). This gap increases the risk of disease transmission through the sharing of needles, unprotected sex, and reusing tattoo needles.
Taken together, these conditions reflect a broader failure to uphold the health and rights of incarcerated individuals who fall under the purview of the government. Addressing these systemic gaps is not only a matter of health care reform but also one of social justice and public accountability.

The Lingering Impacts of Incarceration
The health challenges of incarcerated individuals persist long after they are released. While there is no available Canadian data on post-release outcomes, international research consistently shows elevated mortality rates among the formerly incarcerated (Kinner et al., 2013), most often from preventable causes such as drug overdoses or chronic illnesses (Kinner et al., 2013). Additionally, many individuals experience traumatic events during their internment that contribute to long-term mental health problems such as post-traumatic stress disorder (Hammock et al., 2024).
Furthermore, stigma and restrictions may prevent individuals from acquiring adequate social support. Released individuals are more likely to be underemployed, earn lower incomes, lack social support, and have difficulty securing stable housing (Babchishin et al., 2022). These factors all negatively impact health (Raphael et al., 2020) and increase recidivism (Augustine & Kushel, 2022) further perpetuating the cycle.

The Need for Systemic Reform
Health issues in the criminal justice system are deeply rooted in structural inequities. Incarceration undermines physical, mental, and social well-being, far past the initial sentence, impacting health long after their debt to society has been paid. Without systemic reform, the correctional system will continue to function as both a consequence and a driver of poor health, particularly for marginalized communities. True justice cannot be achieved until the health, well-being, and dignity of every Canadian is recognized, prioritized and addressed. Until then, vulnerable individuals will continue to bear the cost of our inaction.

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