Remarks as prepared; not a transcript

Vice Admiral Richard H. Carmona, M.D., M.P.H, FACS
United States Surgeon General
U.S. Department of Health and Human Services

National Conference on Correctional Health Care
Austin, Texas

Monday, October 6, 2003

"Public Safety is Public Health; Public Health is Public Safety"

Thank you for that kind introduction, Gene. (CAPT Gene Migliaccio, United States Public Health Service Commissioned Corps.)

It’s great to be here with all of you this morning. It is an honor and a privilege to serve as your Surgeon General.

I’ve been in this job a little more than a year, and feel like I’ve aged in dog years. I’ve crisscrossed the country dozens of times, and spoken to Americans in many states about the public health issues of our time. And I love it.

It’s been a long road since the days I worked as a correctional health professional. Like you, I’ve had a great deal of experience providing health care to inmates.

I understand the challenges faced by those who work in corrections and in correctional health care.

Those working in ‘custody’ have a mission; those working in ‘health care’ also have a mission. We don’t always understand the demands those with a different mission face.

That’s why I am so pleased to see the leaders of organizations responsible for both the ‘care’ and ‘custody’ aspects of corrections represented here today.

In addition to the National Commission on Correctional Health Care (NCCHC), we have leaders from the Academy of Correctional Health Professionals, the American Correctional Health Services Association, the American Correctional Association, the National Sheriff’s Association, the American Jail Association, the Texas Department of Criminal Justice, and the Society of Correctional Physicians.

We can overcome the challenges we face in the field of corrections if we work together in partnership.

Let me lead with an idea that’s obvious to everyone in this room, but not so obvious to many outside it: Correctional health is a key to public health.

There is a tendency by some in our field to isolate correctional health from the rest of public health. Perhaps some of you feel that isolation.

But the work you do is tremendously important, not just to the individuals you serve, but to the health of the families and communities they come from and to which they will return.

Some of you here today are part of the uniformed Public Health Service Commissioned Corps, and as your Surgeon General, I am very proud of the work you do.

Even those of you who are not part of the Public Health Service are practicing public health by virtue of your involvement with the incarcerated. It can be a thankless job, I know.

The patients you serve are often the most ‘down and out,’ or ‘at-risk’ individuals in our society. The crimes some of them have committed may give you great pause. You may even have a healthy concern for your safety as you go to work every day.

But the mission of public health practitioners is as important now as it was when the Public Health Service was founded over 200 years ago. A fundamental tenet of that mission is this: you protect the health of the entire country when you address the health concerns of those at greatest risk.

Your work is important to the health of all Americans, even if it is not always appreciated by those in the larger community.

Why should those outside prison walls care about the health of those within them?

As you well know, most inmates will return to their communities. According to the Bureau of Justice Statistics, there were 1.3 million adults confined to a state or federal prison in 2001. More than 4 million living U.S. residents were formerly incarcerated in a state or federal prison.

That means nearly 3 million former prisoners are now living throughout the United States. And that is only a static analysis.

If we include the thru-puts, the number would be much greater, and if we include inmates who spend time in jail and are then released, the numbers are much higher.

So, the man in prison now with HIV/AIDS will one day return to his partner or family. The pregnant inmate will one day return to her community to raise her child, or may even have children at home already.

That makes it imperative to provide the best medical care possible, under the budget constraints we face, to inmates while incarcerated.

More than medical care, we must help them take better care of themselves and practice healthy behavior so that they are as healthy as possible when they return to their communities, whether it is after one night in the county jail, or after 20 years of prison.

For the next few minutes, I would like to speak to you about two of Secretary Thompson’s and my priorities: prevention and eliminating health disparities, and how they relate to correctional health.

But before I delve into this, as you all know, it is important that health policy be driven by science. We are fortunate to work under the leadership of President Bush and Health and Human Services Secretary (HHS) Tommy G. Thompson, who share our passion for science.


Much of my time as Surgeon General is spent talking to Americans about ways they can prevent disease.

Too many Americans — 700,000 each year — are dying from preventable diseases.

Tobacco use is still the single biggest killer, causing more than 440,000 deaths each year and resulting in annual cost of more than $75 billion in direct medical costs.

After tobacco-related diseases, obesity-related illness is the leading, and fastest-growing killer of Americans. Nearly 2 out of 3 of all Americans are overweight and obese; that’s a 50% increase from just a decade ago.

More than 300,000 Americans will die this year alone from heart disease, diabetes, and other illnesses related to overweight and obesity.

Both tobacco-related and obesity-related diseases are preventable by relatively simple steps: eating right, being active and not smoking.

The numbers alone tell us there is no greater imperative in American health care than switching from a treatment-oriented society, to a prevention-oriented society.

Of course, for those of you in correctional health care, the notion of ‘prevention’ takes on an even more urgent imperative, in the treatment and control of infectious disease, mental illness, and substance abuse.

As we all know, incarcerated men and women have a higher prevalence of health problems than the general population.

As the Health Status of Soon to be Released Inmates report notes, 17% of all AIDS cases, 35% of all tuberculosis cases, and 29% of all hepatitis C cases pass through our correctional facilities at some point.

Those who are incarcerated have a higher concentration of substance abuse and mental illness than the general population.

And, while men make up the majority of the prison population, the female prisoner population has more than doubled since 1990 and is growing at a faster rate than for men.

More than 1 million minor children have a mother who is under criminal justice supervision.

One in four women in state prisons are receiving medication for psychological disorders. Most of these women have co-occurring substance abuse disorders.

Without effective interventions, the high prevalence of disease and the movement of inmates into and out of correctional facilities can spread communicable diseases.

But turn that statement upside down, screening for sexually-transmitted diseases and tuberculosis and appropriate medical interventions can help decrease the likelihood that infectious diseases will be transmitted by an inmate to an uninfected person, either during incarceration or after release back into the community.

Quite literally, each time you treat an inmate with tuberculosis, or hepatitis, you are preventing the spread of a serious contagious disease into the community at large.

You also have the opportunity, by virtue of the ‘custody’ relationship with inmates, to ensure that those with a diagnosed mental illness stay on their medications.

As health care professionals and administrators, each of you has the opportunity to spread the prevention message each and every time you see a patient.

Both for the urgent and time-sensitive infectious diseases they may be subject to, as well as to the longer-term chronic illnesses their behaviors may cause them to face one day.

Eliminating Health Care Disparities

In addition to taking part in a shift toward prevention, correctional health providers also have the opportunity to help in another priority of the President, the Secretary and mine: eliminating health disparities.

Simply put: America suffers from racial and ethnic disparities in health.

To put a new twist on something that a great man — Dr. Martin Luther King, Jr. — once said: the inseparable twin of racial injustice is health injustice.

A Hispanic American has three times the risk of developing type 2 diabetes as a white American, and also has a higher risk of complications.

Heart disease is the #1 killer of women in this country. And African-American women are 40 percent more likely to die from cardiovascular disease than white women.

And then there is HIV/AIDS. The Centers for Disease Control and Prevention (CDC) estimates that there are approximately 40,000 new HIV infections in the United States each year. Close to one million Americans are infected with HIV. And in the past few years, more than 70% of new AIDS cases were among minority groups: Hispanic-Americans, African-Americans, Asian Americans, American Indians and Alaska Natives.

President Bush and Secretary Thompson have made strengthening the health care safety net a fundamental goal of the Department of Health and Human Services.

HHS is working in many ways to close the gap in the larger community. There is also a great deal you can do in the corrections environment.

The President has committed to increasing the number of community health centers by 1,200 over the next five years; eventually doubling the number of people they serve to reach at least 22 million low-income Americans … from inner cities to rural communities.

Many inmates will return to communities served by community health centers.

On the domestic HIV/AIDS front, President Bush has requested $16 billion in next year’s budget for domestic HIV prevention, care, and treatment — a 7% increase over last year.

HHS also offers a comprehensive database with HIV/AIDS information and medical practice guidelines for providers,

And just last week, Secretary Thompson announced nearly $9 million in grants to 52 organizations to train adult volunteers as mentors to children whose parents are incarcerated.

Children whose parents are incarcerated rarely have contact with that parent, and face seven times the risk of the general population of becoming incarcerated themselves.

We must reach out to them to ensure they have the adult role models they need to finish school and stay out of trouble. Connecting these at-risk kids whose parents are in prison with mentors at this critical time in their lives should help ‘close the gap’ and make a lasting positive difference.

As I mentioned earlier, inmates have a higher prevalence of health problems than the general population, both acute and chronic. For instance, the overall rate of confirmed AIDS cases among the nation’s prison population is five times the rate of the general population. This stems in part from the communities inmates come from.

More than 60% of incarcerated individuals are African American or Latino. Typically they are from an underserved urban community.

By screening and treating inmates for various diseases, we take the important first step of preventing their spread into the larger community, as I mentioned earlier.

But I believe it is also possible to make progress on eliminating disparities through corrections-based interventions.

For many inmates, the corrections system may be only contact they have with a health care provider for years, if not for their lifetimes.

When an individual is released from a prison or jail setting, the corrections system no longer has responsibility, or authority, for his or her care. Many times the inmate is released without much money or support, right back into the old neighborhood without linkages back to the health care community.

To ‘close the gap,’ those who are released need continuity of care to maintain the good treatment and care started in the correctional facility. The corrections and local public health systems need to work together to ensure that those who are released continue their treatment and care once they go back to their communities.

We need better linkages between corrections and community health centers and local public health agencies to ensure that those who are released do not ‘fall through the system’ once again.

The Substance Abuse and Mental Health Services Administration (SAMHSA) is funding grant programs to enable communities to provide effective substance abuse prevention and treatment services to those returning to their families and communities after incarceration.

Providing re-entry linkages is easier said than done, I know.

And yet, many of you are positioned to be that type of linkage yourselves.

You may serve in your local public health department or community health center already, and see patients in the corrections system as well. You may be able to provide linkages on the practitioner level.

As correctional health care providers, you take many important steps to eliminate health disparities.

You identify those who are infected with disease through early testing and screening in prison or jail; you begin or continue treatment; you conduct appropriate discharge planning; and you make connections for the continuity of care.

Through each of these steps you are improving the health of the inmate, the correctional institution, the community, and the nation as a whole.

Eliminating health disparities within the correctional institution will have a positive effect on the community; and vice versa. Let’s keep working together.


Where do we go from here? We have limited resources to solve the many health challenges we face in corrections. Deciding how to spend those limited resources is not always an appealing process to participate in, or to watch!

But, we can take heart from the many different organizations and viewpoints represented in this room. We know a lot more today about correctional health and the relationship of community health and correctional health.

As we continue to work on challenges in the field of correctional health care, we will be drawing from your collective knowledge and experience, from all segments of corrections: administration, security, and health.

That is why I am so gratified to see such a representation here today from all sectors of corrections: the NCCHC, the Academy of Correctional Health Professionals, the American Correctional Health Services Association, American Correctional Association, the National Sheriff’s Association, the American Jail Association, the Texas Department of Criminal Justice and the Society of Correctional Physicians.

Because no one of us can solve these issues alone. We need to collaborate, we need to communicate, we need to understand better the requirements and constraints each of us face, for us to collectively move this forward.

We need to find ways, within the limited resources we all have, to honor the custody mandate and to advance the health mandate.

Public safety is public health; public health is public safety.

Our goal: to find that elusive balance between the ‘care’ and ‘custodial’ aspects of correctional health and to develop an integrated strategy of responding to the health care needs of inmates to protect them — and the many people they will encounter when they are released back into their communities.


  • People in prison come from a family, and a community, and will return to that family, and that community.
  • When you address the health concerns of those at greatest risk, you protect the health of the entire country.
  • You have a unique and powerful opportunity to make a difference, for those who are in your custody, for our communities and our nation.
  • I look forward to working with all of you as we move ahead on these challenges.


    Last revised: January 9, 2007