Breaking the Chains

Eileen: Hi, this is Eileen, one of the writers for the Resonance podcast, and I'm here with Justin and McKenna, who both work with the HEAL initiative. And McKenna, can you tell us a little bit about the HEAL initiative?

McKenna: Yeah. So the full name is the Justice-Involved HEAL Initiative. We're this student org founded here at Baylor and 2021. And our acronym HEAL actually stands for health education, advocacy, and leadership—and specifically, at the intersection of incarceration and health. And so, thinking about educating and advocating for the incarcerated patients we treat, specifically at hospitals in the Harris Health System like Ben Taub.

Eileen: And I know that incarceration has a really profound impact on health. We'll talk about that a little bit more in our interview today. But why do you think that is? If patients are incarcerated, why do they have a higher risk of health conditions?

McKenna: Yeah, I mean so… that is a complicated question just because there are so many, so many factors at play. So people who are less healthy, tend to be the ones who are incarcerated more. But also incarceration itself produces pretty adverse health outcomes. When you think about the conditions of incarceration, the exposure to trauma and violence, infectious diseases, you know, just in terms of like hygiene and the air that you're able to breathe in that space. But then also upon release issues with, you know, health insurance, with employment—especially if your health insurance is tied to your employment, housing. It's a really profound social determinant of health. So that's, that's one answer I would give.

Eileen: Yeah, it's a really big question and I think just like you said that people who are already in poor health and more likely to become incarcerated and then that just in turn worsens the health outcomes for pretty much every condition. And then once you're released, you might not have any resources available to get health insurance or get medications or have stable housing, all of which can contribute to poor health outcomes and I think it's really important to talk about this in the US especially, because we have the highest incarceration rate in the world.

Justin: Yeah, so I think this is something that maybe not everybody is aware of necessarily, or not paying attention to this topic. But, you know, on a per capita basis, the United States has more people in jails and prisons than any other than any other country in the world. And I think that that is a big surprising fact. And a big part of that is because we have a lot of people in jails and prisons for non-violent crime and many of them may not actually be convicted of a crime. They may be pretrial. I think it's something like sixty percent of individuals who are in jails are actually pretrial and have not been convicted yet. They simply can't afford the cost of bail. And so you know, if you can imagine as well, or you know, our population is aging. And so because of that, our jail population is also aging. And so the people in jail are also suffering from a lot of chronic health conditions as well that may or may not be properly managed in the carceral system and that certainly become poorly managed when they leave the carceral system.

Eileen: Yeah and we'll be talking today to Dr. Marc Robinson, who is a hospitalist at Ben Taub and has worked with advocacy for this population. He'll tell us a little bit more about some of the health challenges faced by patients who are in the carceral system and some of the wide variety of health services that are available and the quality of health services that are available depending on if you're in a jail or a prison, if you're pretrial or if you've been convicted—all different kinds of variables that play into those determinants of what kind of healthcare you're getting.

McKenna: I also wanted to jump in and just say, when we're talking about like mass incarceration, these are, you know, factors that are disproportionately targeting specific communities. So, specifically lower-income communities, communities of color, people with disabilities, and also a lot of people who are, you know, fighting issues of substance, use disorders, or mental illness. And so, I just think that's important to note and it definitely is a health equity issue and an issue of injustice.

Justin: And I think that, you know, we'll get to this during the talk, but I think we really have to ask hard questions of ourselves of, you know, do we want this to be a system of punishment or do we want this to be a system of rehabilitation? Particularly considering that so many of the people in our jails and prisons are there for nonviolent offenses, many of which are drug-related, you know. Do we do we truly believe that incarceration is the is the best solution? From many different angles, including a public health standpoint, from a humanistic standpoint, and then also from a financial standpoint. Does it really make sense for society to treat these people this way?

Eileen: Yeah, well you guys bring up some excellent points and I'm really excited to get into this conversation and hear what Dr. Robinson has to say. So without further ado, we'll get to it.

Eileen: And our guest here, Dr. Robinson is pretty incredible. He's an internal medicine doctor at Ban Taub and I'm going to go ahead and ask if he wouldn't mind introducing himself a little bit.

Dr. Robinson: Sure, my name is Marc Robinson. I'm an internal medicine physician at Baylor. I work just at Ben Taub. I'm a hospitalist, so meaning I just work in the hospital. I don't have a clinic. My main job is teaching residents, so running a teaching team in the hospital. I'm also one of the associate program directors in the Internal Medicine Residency. And I have a strong interest in improving the care and education about patients who are incarcerated.

Eileen: Can you tell us a little bit how you first got started working with an incarcerated population?

Dr. Robiinson: Yeah, so my background is originally in global health. I did a Global Health Fellowship. I worked in Haiti for about a year and we were debating whether to come back to the US or work abroad. And I was a medical student at Baylor, and I just really missed Ben Taub. It was my favorite hospital that I'd ever worked at and it was really the only place I wanted to work in the US. And so, I was fortunate enough to get a job back at Ben Taub. And then the original plan was to to continue doing global health work, but some of my global health contacts kind of dried up. And starting to look for avenues to work with underserved populations here in the US. And my boss at the time, Dave Heineman, we had talked for a little while about what to do and I just read the book Just Mercy by Bryan Stevenson and I told him, "Oh you know, I'm thinking of doing some work, you know, around incarcerated patients" and he just said to run with it. And so I started picking up moonlighting shifts for a couple years in the Harris County Jail just to get a better sense of what goes on there. And we—Ben Taub—being one of the largest county hospitals in Houston, we receive a lot of the patients that come from the Harris County Jail. So if somebody has a medical emergency and needs to come in, we're the ones that take care of them. So we take care of a lot of incarcerated patients in our day-to-day practice. So that's kind of what got me into it in the first place.

Eileen: And just for quick clarification. I know this is confusing a lot of times, but what is the difference between a jail and a prison?

Dr. Robinson: Yeah. A really good question and something that even I still mess up sometimes. So prisons tend to be long-term incarceration. So prisons are for people who have been found guilty of a crime and then are sentenced to a sentence usually greater than a year. And they're run by the state or they're run by federal jurisdictions. Most people in the United States are incarcerated in state prisons. Especially here in Texas, we have an incredibly large state prison population. Jails, on the other hand, tend to take care… tend to incarcerate three different types of people: people who are pretrial and who don't have enough money to afford bail to get out while they wait for their trial, people who are awaiting transfer to a prison facility after being found guilty, or people who are serving sentences less than a year. So, short term incarceration. The vast majority of people in jails in the United States are in because they're pretrial and can't afford bail. And so that's about, right now, in Harris County—it's about 80% of the 10,000 people in the Harris County Jail who are there pretrial, meaning that they have not been found guilty of a crime and they just don't have enough money to afford bail.

Eileen: And you also mentioned that you've worked some shifts at the jail. Can you tell us a little bit about the health care delivery system in the jail? I know you mentioned patients sometimes have to come to Ben Taub, the county hospital, if they need hospital care but what do they have available, sort of, at the Harris County Jail?

Dr. Robinson: Yeah so at the jail and in most jails that's usually a very simple clinic. You know, very often we in the hospital think that they're a lot more resourced than they actually are. But you know, the story of jails in the United States is there's actually no federal requirement for quality of healthcare. There is a constitutional mandate that people have to deliver healthcare in jails, but in terms of what you need to have, there's just some voluntary certifications that jails have to get. There's nothing that's actually required. So it usually tends to be very simple. Typically, like an urgent care and sometimes even less under resourced, or sorry, more under resourced than some urgent care facilities that you'd find in the facility. The care in the jails, in especially the Harris County Jail is in improving somewhat now that Harris Health has taken over. For a while, it was just run independently by the sheriff's office. But I still think there's a long way to go. It's usually very under resourced and that's why a lot of patients do get referred to Ben Taub or LBJ, the other county hospital, for urgent conditions.

Eileen: Yeah, you mentioned that there is a constitutional right to receive health care for incarcerated persons which is pretty interesting because I'm not sure there are many other classes of people in the US who have a constitutional right to health care.

Dr. Robinson: There is actually no other class of people. It's the only class that people in the United States that has a constitutional mandate for healthcare, are people who are incarcerated. It was actually a Texas… a person who was incarcerated in Texas, back in the 70s—JW Gamble—he was injured on a prison work assignment and he said that the healthcare he got for his… the back injury that he sustained led to cruel and unusual suffering. That he didn't get good enough health care and so he suffered needlessly. And actually went all the way to the Supreme Court. The Supreme Court actually ruled against him said that no you got health care but they said, "Now even though we were ruling against you, from now on, every single person who's incarcerated has a right to health care." Because they have no other choice, right? And they have no other choice. They can't just, you know, walk out of the house and go to the emergency room, or go to clinic, or go to a hospital. They, you know, they only have the providers that the jail or prison provides to them and so it's yeah… Again they're the only class of people with the constitutional mandate. And that's why I find the work important, right? So, when you're taking care of, when we take care of someone who's incarcerated at Ben Taub, we're it, right? They don't have any other choice. They can't, you know, go across the street to Methodist or Herman or St. Luke's. We're the only people that are taking care of them and we're their only choice for care. And so we got to do a really good job.

Eileen: And like you mentioned these patients don't really have an opportunity to shop around, so to speak. They don't have a choice in where they're receiving their care. Does that mean the care is free for them?

Dr. Robinson: It depends. It's been a lot of work around, especially during the pandemic, around in jails—making people not have any payment to seek healthcare. That's not the case though in a lot of jurisdictions, people do have to pay some money to go see the jail clinic. In Harris County Jail, I don't know the exact rules right now, but usually they get several free visits before they have to start paying. If they're referred to clinic, they don't have to pay. So, most of the time they don't have to pay. That's not to say that there aren't significant hurdles and burdens for people to get care in jails and prisons. So let's say you're in a jail that you're lucky enough where you don't have to pay to get the clinic. Well, you still have to usually put in a request to go to clinic. Somebody has to read that request. Somebody has to approve that request. Somebody has to schedule that request. You know, that's not to say… it's hard to see doctors in the US anyways, but it's especially hard to see someone if you're in a jail or prison and you have a medical complaint.

Eileen: Especially if it means you have to miss a meal or miss time outside.

Dr. Robinson: No, that's exactly right. I mean, you know, let's say you have just a tiny bit of money in your bank account or, you know, to spend at the commissary or, you know, buy snacks—buy little things that make you feel a little bit more human while you're incarcerated. You know, the last thing you want to do is blow a lot of that money to go see a clinic visit that you might not, you know, get good care anyways. And so a lot of people kind of let conditions fester.

Eileen: So in terms of letting conditions fester, do people generally experience worst health once they're in jail or prison? I kind of hear sometimes in the news or just sort of the popular media that, "Oh these people go to jail or they go to prison and all of a sudden they have access to healthcare that they didn't have before and so they do much better." Is that true?

Dr. Robinson: In terms of jails, no. Prisons are a little bit different story and depend state to state. So in terms of jails, I mean, the incarcerative event, being the act of incarceration, is going to make your health worse. I mean, there's, you know, some survey data showing that people, you know, over 40% of people that are taking medications entering a jail will stop taking it whenever they leave the jail. Repeated incarceration events make people have worse control of their HIV AIDS. The… just having a history of incarceration is going to raise your chance of having cervical cancer. If you're diagnosed with cancer while you're incarcerated, you're going to have a higher cancer-related mortality than if you were diagnosed in the community. So just the act of incarceration is going to make your health a lot worse. And so there's this perception that you know, jails are full of young healthy men you know, working out in the yard, playing basketball. That's not the case. I mean, when you look at the health of people in jails, it's significantly worse than the health of people who are out in the community across all disease processes—heart disease, lung disease, liver disease, infectious disease. They're just going to be sicker when you match for age, sex, gender, everything—they're going to be sicker than a cohort in the community. Prisons are a little bit different, you know. Prisons are long-term facilities. And you do have some prison systems that actually provide fairly good longitudinal care because they have somewhat of a financial incentive to do so, right? They want people to control their chronic illnesses so that they're not expensive. And so, there is some data that in Texas, especially out of the UTMB system, which controls a large portion of the state prison systems health care, that controls of asthma HIV/AIDS, at least in the early 2000s, was better as compared to the general population. They're still terrible places to be, right? Prisons and jails are awful places to be. And so, you know, I don't think it's a good argument that, "Oh these people didn't have health care. Let's you know throw them in jail or prison and get them healthcare." I think we should just provide them, good health care regardless of where they are.

Eileen: And how has covid played into all of this?

Dr. Robinson: I mean, yeah, if you were to design a place where covid would be—to have the worst covid outcomes possible, what you would eventually come up with is a jail or a prison. So you know, we had just lots of and lots of deaths, lots and lots of covid in jails and prisons. In Texas, we've had, you know, hundreds and hundreds of people die in Texas prisons and jails. Many of these people were pretrial, meaning that they had not yet been found guilty of a crime. They're not even gone to trial yet, you know, they ended up getting a life sentence. You know, many people in prison who were actually awaiting release on parole but you know, their paperwork hadn't been filed, they ended up dying of covid. And then there's some really good studies out of Chicago showing that people cycling in and out of the jail accounted for a large portion of the racial disparities of covid. And that, you know, so tracking covid in communities was a really good metric for what… how jailing affected a community.

Eileen: And you still take care of patients who are incarcerated here at Ben Taub. Do you still work at the jail at all?

Dr. Robinson: No, it's been some time. You know, I'm trying to get back in. Just with some of the changes… the credentialing is a lot different and stuff. So I'm working on getting back in, but I do love taking care of the population when they come to Ben Taub.

Eileen: Are there any specific patient encounters—obviously without breaking confidentiality—but anything you can tell us about a… something that's been meaningful to you working with an incarcerated patient, either at the jail or at Ben Taub?

Dr. Robinson: Yeah, you know, we had this guy at Ben Taub who was really sick. He had a chronic condition that was very uncontrolled. And you know, he was just an interesting guy. And you know, taking care of him… had some affiliations that you know, were really, you know, nefarious. And you know, if you just looked at a picture of him, you would be, you know. You wouldn't want to take care of him, right? And then the second you started talking to him, he was just like the loveliest guy. And he would take these Styrofoam trays that they are served their lunch on and he would draw these pictures on the trays. So I have one up in my office of a hummingbird and a flower. And it's just a… just a really good reminder that you know, don't judge a book by their cover and you know, we should just approach everyone, you know, as a blank slate.

Eileen: And I'm actually going into emergency medicine, so we a lot of incarcerated patients in the ER. And when we see those patients, they're usually wearing bright orange to mark that they are incarcerated patients and more often than not will be restrained, handcuffed to the bed quite frequently. Which makes it much more difficult to do a full exam. We often have to ask the law enforcement officer who is present if they can release the patient so that we can do all of the testing that we need to do. is that something that continues on the inpatient side or do they have a little bit more, sort of, flexibility in how they're treated?

Dr. Robinson: No, I mean it absolutely continues on the inpatient side. So, a couple things, you know, one, you know, everyone that comes into the hospital from the jail, is shackled to the bed. So with a leg shackle, a leg cuff, or an arm cuff. And usually, this is done is, you know, for safety, right? And although there's not a lot of evidence that it's needed to be done universally to every single person, but we do do it to every single person. Also everyone's put in an orange jumpsuit and identified as somebody from jail. And very often in the hospital, they're identified as a "prisoner." And you got to remember, 80% of the people in the jail are there pretrial, right? So they have not yet been found guilty of the crime that for which they are accused. So in the eyes of the law, I mean, they're really not too different than you or I. If we were falsely accused of a crime and all of a sudden, we had a medical emergency, we'd be exactly like these people. And so, we, I think we should treat them with a lot more grace than they often are. And regarding the shackling. I mean, when you talk about universal application of shackling, which is done here in the US, meaning every single person from a jail or prison is shackled, that was actually in the European Court of Human Rights seen as a human rights violation. That if you were to apply the shackles on every single person regardless of their risk of flight, or their risk of danger, you're actually violating their human rights. And I see that, you know. I see elderly people coming from the jail. I had his elderly patient who's blind, and who was shackled to the bed, right? Like the danger of this person, escaping the hospital was 0. The danger of them hurting anyone was 0. Yet, they still had a leg cuff, right? And then that limits physical exams. It limits mobility, so puts them at risk for all the different things that restraints put people at risk for: risk of dying in the hospital, risk of getting injured in the hospital, risk of getting blood clots. And so it's a terrible practice. We haven't found great solutions for it. I think it's just going to… we're just going to have to slowly change the culture of how we view these patients before it gets changed.

Eileen: And that applies even to women who are in labor, correct?

Dr. Robinson: Yeah, I mean, there's, so there's a couple of laws… so just to go back. Yeah, many women were shackled during active labor for a long, long time. Many states have outlawed this practice, but it's really not well defined. And so you know, they are there's laws on the books saying that they can't be shackled during the peripartum period. Well what does that mean, right? Is it when the baby's coming out you can't have a shackle on? When you're holding your child skin to skin after delivering can you not have a shackle on? When you can you put it back on? And so the application of these laws are quite variable. There is a federal law on the books saying that for people who are in federal prison, they can't be shackled during delivery. But this is a really small part of the population. The vast majority of, you know, pregnant people who are incarcerated are going to be in jails. And they're still you know, I can't remember the exact number—might be a dozen—states that don't have laws on the books, where people can still be shackled during delivery. So it's a big problem, you know. We need… the problem is, you need… all these laws are written by men who really have no idea what's going on, right? And so I… this is not totally related to pregnancy, but kind of paints the picture. I have a friend who's a—Krish Gundu with Texas Jail Project. Wonderful person, wonderful organization. And she talks about how, you know, they there was a law written where they… women who are incarcerated, no longer had to pay for sanitary products during their menstrual cycle. And it was seen as a big win. But she said, well, you need to provide underwear, you know, for a lot of these products and, you know… people on the Texas Jail Commission were wondering, "What are you talking about? Why would we need to do that?" And it was, she was just flabbergasted. And so, the problem is a lot of these people that write these laws one, are never affected by incarceration or two, really, you know, just can't get in the in the shoes of somebody who might be impacted by some of these policies. So, I'd really… anyone who's interested and who might fill those gaps, like really get interested in. So that's what we'll talk about later, HEAL Initiative. I love seeing students active in it because I think they have perspectives that a lot of people don't.

Eileen: You mentioned the Texas Jail Project as well. Could you tell us a little bit more about that?

Dr. Robinson: Yeah, Texas Jail Project. I mean, it's just an incredible organization. They fight passionately for people who are incarcerated in jails. So they get calls all the time from family members, who think that a family… someone who's incarcerated is being mistreated. And they just have no idea what to do. Because it's incredibly hard to figure out what's going on with your loved one who's incarcerated. And so I work with them on a number of things. Very often they call just to kind of talk through a medical issue that somebody's having in a jail to see if it makes sense. Oftentimes, it doesn't. Right now… so last year, in almost two decades, was the deadliest year in the Harris County Jail. And so we are, you know, currently collecting all the autopsy records from people that died in the jail, since they're a public record. And so kind of going through those and seeing what we find. And, you know, we found people who died of fentanyl overdoses who have been incarcerated for two months. And so they just do incredible work. So I really just can't speak highly enough of their organization.

Eileen: And as future doctors—hopefully—future residents, medical students. What else can we do to advocate for these patients and for this population?

Dr. Robinson: Yeah, I mean, the thing about it is, you know, as doctors you're always going to have a voice that, you know, for better or for worse is gonna… politicians are going to listen to you, right? And so you know, staying on top of legislative sessions, staying on top of the news around bills coming out. You know right now there's a current, a bill that's in the Texas legislature that has been proposed that any natural cause death in a jail doesn't need to be investigated. That if a crime has not occurred, then they probably don't need to investigate it. And so, this means all suicides, all deaths from people not getting their medications promptly, basically anything—those would not be investigated and I think that would be a huge loss. And so, just staying on top of things is probably the number one thing that a medical student and future doctor could do. And then calling your legislator when something it doesn't make sense or you don't like something. Because they'll listen to you. If you call and say, "Hey, I'm a medical student" or "I'm a physician and I'm in your district and I don't like this bill," they're going to listen to that, one because you're a voter; two, because you're a doctor who's, you know, potentially a donor to their campaign. So they're going to listen to you. So I… take advantage of that. Because you're going to see a side of society as a physician that many people don't see at all. Ricardo Nuila has a wonderful book out right now called "The People's Hospital" about Ben Taub and his experiences with people at Ben Taub. And I'm just… I love seeing things like that. Because you as a physician, especially in a… with a marginalized population, are going to see things that the general public has no idea about nobody. I mean, nobody who… nobody knows about shackling, right? Like, nobody knows that if you're incarcerated, you're going to be shackled to the bed the entire time. Nobody knows about that. And so, just talking about your experiences, telling people about your experiences, and then advocating for the for people who you see, I think is the number one thing you can do.

Eileen: And you are also the faculty mentor for the HEAL Initiative. So, students here at Baylor College of Medicine can get involved a little bit more directly in some education with these patients and with incarcerated persons. Can you tell us a little bit about the initiative?

Dr. Robinson: I mean, I'll let the wonderful students who run the initiative say the most about it. I will say that, you know, they've done incredible work, right? I mean, I… when you say faculty advisor. I mean, I just like kind of sign my name and say "You're doing a great job." They do all the work and… but I'm happy to take some of the credit. They do an amazing job, you know, teaching people about what a healthy life looks like whenever they get out of jail. I think the number one thing that they do is, you know, when you… they give people in jail break, right? I mean, because your day in jail is incredibly monotonous and you have no control over anything. And so, if you can sit and listen to really passionate wonderful, lovely medical student, you know, tell you about what it means to have a healthy life when you get out. I mean, that's a nice break and that's treating you like a little bit more of a human in a setting that really does its best to strip away your humanity. So I… you know, I think that's the best thing that they do, but I'll let them explain a little bit more about the nitty gritty of the… of the initiative.

McKenna: Yeah. So this is McKenna, also a third-year medical student here at Baylor, and we reached out a couple years back to get Dr. Robinson to be our faculty mentor for this HEAL Initiative organization. I think it was originally inspired by Dr. Robinson's, like, lecture given to this Care of the Underserved elective that I attended. Because I think realizing that there were incarcerated patients at Ben Taub that we're interacting with but then, you know, nothing necessarily specifically organized within the Baylor College of Medicine community to kind of engage with these populations. It just seemed like a good kind of space to get involved in and so we started the organization, I think like fall 2021, really hoping to teach some classes at the Harris County Jail. And then it's kind of blossomed into this beautiful community where students can engage with topics of incarceration and thinking about incarceration as a social determinant of health, kind of like what we've been talking about so far.

Justin: Yeah, so our organization now, we try to do two main things. So as McKenna said—and I'm Justin, I'm also a third-year medical student—the first thing that we try to do is we try to have these health literacy classes at the Harris County Jail, where we teach people at the jail, about a variety of health topics, including infectious diseases, general health, mental health, and healthy relationships. And our intention is sort of to present the information in a way that is, you know, usable. We're not trying to be very, like, overly scientific or overly formal in our presentation of the information. We really want to make them feel like this is information that they can apply on a day-to-day basis. And let's say, if somebody in their family or friend or they themselves develop some symptoms of a certain disease, well maybe they, you know, we can give them some information to equip them with the idea of they maybe know what's going on and they maybe know what resources they can pursue. So that's the first thing that we try to do as our organization. The second thing that we try to do is more focused on, you know, just the Baylor College of Medicine and the healthcare community at large, you know: medical students, residents, physicians—just raising awareness about some of the barriers to adequate healthcare experienced by people who are incarcerated. And this takes the form of, you know, we have like talking sessions where we just have a roundtable discussion. We've done film screenings where we watch documentaries that are very informative about these issues. And then we also do things like journal clubs where we try to take… or, we're planning to do these journal clubs where we were try to take like a very quantitative and sort of scientific approach to explaining, you know, exactly what these barriers look like in the incarcerated population. And then also how it affects the community at large, right? It doesn't just affect people who are in jail or prison. It also affects… just everybody in the community. And so, we just want to raise awareness so that we know, as a healthcare community, how to address some of these problems and maybe we can improve some things at the smallest level.

Eileen: And I am lucky enough also to be a member of this group, so I've gotten to teach some classes. And it's really pretty incredible, the range of knowledge that people come in with and the curiosity that they have about these different topics. I'm wondering if either of you could speak to a certain question or story of an experience that you had when you were teaching that really stands out.

McKenna: Yeah. I mean, I think every session… like I know I'm going to have a good day when I have a session in coming up. A lot of them have been over Zoom just because of some of the challenges like logistically with onboarding and coordinating with a jail system, but I also was lucky enough to go to some in-person classes as well. And just like, I remember walking in and there's a room of like 40 men in a tank all at tables and like really ready to engage with the material. I personally, I think the class I've taught the most was the infectious diseases course which Justin and Eileen both designed. And I love the conversations around covid and vaccines that we get into every time we lead this class, just because people are so curious. And also it really is a conversation just, you know, about health misinformation and just different questions that maybe people were not given the opportunity to ask to a physician or healthcare provider. And I think it's really kind of gratifying to, like, talk about these things in a way that's free of judgment and just learn what people's conceptions are about covid, especially people who experienced covid, you know, in the carceral setting.

Justin: Yeah, so for me, the class that I've taught the most as well is also the infectious disease course. I really do love being able to share that information. For me, you know, when I start the lectures, I like to say that, you know, yes, I'm here to, you know, provide this information you but I'm also here to learn from you as much as you're here to learn from me. And I find that very true. I often find myself asking them questions, what their perceptions of things are. And also, it's a great way for me as a student to learn what sort of healthcare resources they actually have access to. I can ask things like about how often they get TB testing and whether or not they have access to certain vaccines. And you know, what their colleagues or their friends, think about getting vaccinated. And we're able to sort of, you know, address some of their concerns or their questions in a very non-judgmental way, in a way that's… because the thing to keep in mind about this, this population of people is that they have historically been taken advantage of by the healthcare system in our country. And so, you know, it's really incorrect for us to blame them for any sort of skepticism or any sort of misunderstanding they may have about even the most trivial of healthcare issues. But the thing you'll find is that just through simple conversation, asking questions back and forth, you'll find that, you know, you… even as just a medical student, you can make a big difference in people's perceptions. And then your perception about things yourself can be completely changed as well, and you're able to see things from their shoes from, you know, from their side, much more effectively. And I think that makes, you know, that will make me a better doctors... that will make us better doctors in the future. Because we have a, you know, we have a different understanding or maybe a deeper understanding of the things that they've gone through and their perception.

Eileen: So, and McKenna, if someone wants to get involved with the initiative, if they're here at Baylor, who should they get in touch with?

McKenna: Yeah, I think any of us three, we I try to kind of put my phone number and email out there and… Lucky enough, a lot of people I think recently, I think have been forwarding people my way and I always, you know, put them on our email list serve for the organization. But also, you know, we try to advertise pretty broadly. I've been putting our… like, a couple weeks ago we had a film screening and kind of putting it on the greater, like, Baylor student affairs calendar. Just so that everyone's kind of aware of these opportunities. In terms of service opportunities, we're constantly setting them up and creating like a schedule of weekly classes each month and recruiting volunteers. It is challenging because we're all busy medical students, and especially the clinical students with their busy schedules, but somehow we always make it work with a team of like, you know, three, four, five students teaching an afternoon class. So yeah, I would say just, you know, reach out to me, Justin or Eileen. Or hopefully, people have started to realize, kind of, our names in this community and sending people our way to get involved.

Eileen: And what's your email first?

McKenna: My first name… so, McKenna.Gessner@bcm.edu.  

Eileen: And spell please…

McKenna: Yeah. M-C-K-E-N-N-A dot G-E-S-S-N-E-R @bcm.edu

Eileen: Wonderful. Thank you so much. Thank you guys for speaking about the initiative. I know it's something that we're all really excited about and really passionate about. I was wondering if Dr. Robinson could let us know, if there's anywhere that a student is looking to get more information about this topic, or become involved with any other organization, do more research or some reading perhaps in the academic literature, where should they look for those sorts of resources?

Dr. Robinson: Yeah, that's a good question. So, as I mentioned before, Texas Jail Project—really good. And so I know a lot of the Texas resources. So Texas Jail Project has a good website. Texas Justice Initiative, TJI, they collect all of the custodial death or deaths for people who are in custody in the state of Texas and, kind of… you can get all of the data since it's all publicly reported from their website. It's a really, really great resource. There's a couple good review articles over the past few years. So there's one in JAMA Internal Medicine, couple years ago for care for incarcerated people in hospitals. To view, just Google that, it should show up. That was a good resource that I use. There's a really good book called "Death in Rikers Island" by Homer Venters. He's the former chief medical officer of the New York City jail systems and he kind of goes through all of the different problems in healthcare in jails and does it through the lens of patients, who, unfortunately it, you know, passed away or had bad outcomes in the New York City jail system. So "Death in Rikers Island" is a really powerful book. You know, I think just getting involved or reading more about how the justice system works or that, you know, the punishment system to put it more accurately. And so I… there's a couple, you know, classic books that people everyone should read. "The New Jim Crow" by Michelle Alexander is required reading. "Just Mercy" by Bryan Stevenson is another good, kind of through the death penalty lens. Those are two that really impacted me before I got into this work. So those are the three books, I'd recommend: "Death in Rikers Island," "Just Mercy," "The New Jim Crow." There's another really good organization called the Civil Rights Corps. You can look at them. Alec Karakatsanis runs it, and they do a lot of work in kind of bail reform law suits. And so, arguing the constitutionality of bail laws and the implementation of bail laws. So, those are some things that have really impacted me and so I encourage people to go look at them.

Eileen: Great, thank you so much. Is there anything else that you would like to share with us about this population or your experience just in general? It's okay if the answer is no...

Dr. Robinson: No, I mean, just, you know, to put a cap on it. One of the reasons I do this work is just spreading the word, right? And so anything you learn, tell your family about any amazing impacting experience, you have. You know talk to it in a protected, you know—patient history protected—way about your experiences, right? Because the more we can kind of talk about how bad things are in our carceral settings in United States and how it impacts people's lives, the more the word spreads, right? And so, if all you do is learn a lot and talk about it, like that's something that's really good, right? And so I really encourage people. You don't have to, you know, change the world with it. But if you could spread the word and talk to people about it, I mean, that's doing quite a bit of good.

Eileen: And Justin, McKenna... Do you guys have any final thoughts?

McKenna: I would just say like taking incarceration seriously as a social determinant of health. Like recognizing when we talk about ACES, like Adverse Childhood Experiences, one of those is having a family member who is incarcerated and it's a really really profound adverse childhood experience. And so I think you know, recognizing the seriousness of that and bringing it up and conversations about public health and about, you know, medical outcomes. That's just something I've been trying to get people to do more in our community and just like in our profession at large.

Justin: Yeah. And I think that the way that our society sees incarceration really speaks to our values. And so, I think it's… that's why it's so important to really raise awareness about many of these issues. Because I really do think that if more people know about them, more people would be quite upset about the way that we treat the, you know, incarcerated populations in this country and the way that we handle their healthcare, And I think that we could get a lot of people on board. And so, I think it's just a matter of, you know, as Dr. Robinson was saying, just increasing awareness about these things.

Eileen: Yeah, yeah, I completely agree. We are lucky enough here at Baylor to have courses that talk about social determinants of health and often times that ends up being related to income level or race or where a person is living, if they have access to insurance. And I think that by sort of spreading the word about this, we're getting that incarceration aspect to be a part of the conversation, because people don't, obviously think about it. It's not the first thing that springs to mind when you think of risk factors for diseases. I think the other thing that's really just stuck out to me, is how profoundly this impacts all of us in the healthcare system. As I mentioned before, I am going into emergency medicine and we see a tremendous number of incarcerated patients. But we also have students in the group who are interested in all different fields. McKenna is very interested in obstetrics and gynecology. And so she has a unique interest in women's health in the jails and prisons and reproductive healthcare, especially in the state of Texas with all of the changing legislation right now. We have people who are interested like Justin in internal medicine. We have people who are interested in psychiatry and how profoundly incarceration impacts mental health and what it means to be mentally ill in America. And people who are struggling with mental illness, how much more likely they are to become incarcerated or to become homeless. So I think all of these systems really play together and I'm really excited that we've been able to start building this. I want to say thank you so much to Dr. Robinson, and to the incredible student leaders for this group. I am very grateful that you guys have been able to take the time to come speak with us today, and I wish you the best of luck.