A report is sitting at the Justice Department, unpublished. It has been there for two years. Titled The Health Status of Soon-to-be-Released Inmates, it was compiled by experts who sat on three panels: one on communicable diseases, one on chronic diseases and a third on mental illness. Their findings are, to say the least, somewhat startling. Estimating that 11.5 million Americans cycle in and out of jail or prison each year (the great majority of them short-term jail inmates), the report suggests that more than 18 percent of hepatitis C virus (HCV) carriers in the country pass through the jail or prison system annually, as do 8 percent of those with HIV and one-third of those with active tuberculosis (TB). Six percent of incoming inmates, according to the report, show evidence of recent syphilis infection, 6 percent have chlamydia and up to 4 percent have gonorrhea. Experts believe that for these diseases, the infection rates (the number of cases per 100,000) among prisoners are upward of ten times those found in the American population as a whole.

"It's clearly a public health issue," says Ted Hammett of the Boston-based research group Abt Associates. "These people find themselves in prisons and jails; therefore there's a tremendous opportunity for intervention."

Intervening would be a smart economic move, too. In tandem with the medical report, economists affiliated with the Centers for Disease Control were commissioned to write three background papers positing economic models for treatment and screening protocols inside prisons. Although their data also remain unpublished, one of the authors, CDC health economist Dr. Beena Varghese, reports that their models predict that for such a disease as HIV, offering screening to an additional 10,000 inmates will likely detect fifty new cases; counseling those who test positive will, their model estimates, prevent the disease from being passed on to four more people than would be the case absent such a program. Since the additional screening and counseling (minus the fixed costs already incurred for starting up a blood-testing program) runs to approximately $125,000, while the cost of treating four more cases of HIV/AIDS over the patients' lifetime is estimated to be $800,000, Varghese's team believes such screening to be extremely cost-effective.

The economists also predicted that universal screening of inmates for STDs and treatment for those who test positive would curb transmission of diseases like syphilis when inmates return to the community and thus save the public health system tens of millions of dollars per year. "You get a bigger bang for the buck," says one doctor involved in compiling the report. "If there's only one in a thousand, it's not very cost-effective" to screen all inmates. "But if you have a prevalence rate of more than one in twenty and you're able to cure the disease, you have tremendous costs saved."

In response to these dramatic statistics, The Health Status of Soon-to-be-Released Inmates, according to those with access to its contents, recommends a massively expanded data collection system that would allow public health authorities to track and treat infectious diseases among this population group (that is, of cons and ex-cons) and their friends and lovers out in the community. It also endorses a policy of universal hepatitis B (HBV) immunization for incoming inmates--as a way to limit the amount of liver disease in an at-risk group already deeply vulnerable to the often-untreatable HCV. And it urges a far greater degree of coordination between correctional health systems and public health authorities, so as to provide continuous medical treatment and adherence to treatment regimens, for patients both inside jail or prison and those recently released.

In interviews, recently released inmates describe a patchwork health system with gaping holes. At the Fortune Society in New York, ex-inmates with HIV gather in peer education groups, where their stories reveal widely varying degrees of access to medical care. Rochelle, for example, left New York State's Bedford Hills Correctional Facility in 1995 with an AIDS Drug Assistance Program (ADAP) card that gave her immediate access to the medications she needed for her HIV infection, and with contacts at a residential therapeutic community where she went to wean herself off drugs. Hector, by contrast, left his prison in 2000 with no ADAP card and only one month's supply of HIV medication. Carol, a resident of Bedford-Stuyvesant with a string of convictions behind her, took no medication for her HIV while in prison, and only began taking these lifesaving drugs when she was sent to Phoenix House upon her release. None of those in the room also infected with HCV had received treatment for it while behind bars.

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