J Neurol Res

Journal of Neurology Research, ISSN 1923-2845 print, 1923-2853 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Neurol Res and Elmer Press Inc

Journal website https://www.neurores.org

Review

Volume 12, Number 2, August 2022, pages 34-42

Implicit Bias and Health Disparities in the Incarcerated Population: A Review With a Focus on Neurological Care and the Canadian Perspective

**Table 1.** General Health Status of the Incarcerated Population
	Health status
HIV: human immunodeficiency virus; COVID-19: coronavirus disease 2019.
Psychiatric diseases	Near 1/7 prisoners have a treatable mental illness [48, 49].
	Proportion of individuals with psychiatric disorder is higher amongst incarcerated population compared to the general population [48].
	1/3 of prisoners with a diagnosis of schizophrenia or bipolar disorder were not pharmacologically treated while in prison [50].
	Suicide is the leading cause of death in custody [48, 51].
Infectious diseases	Higher rates of HIV compared to the general population [52, 53].
	Higher risk of viral hepatitis [52, 54, 55].
	High rates of tuberculosis [56, 57].
	Higher rates of COVID-19 infection prior to vaccine distribution, with the inability to safely self-isolate [58-60].
Chronic illness	Higher prevalence of hypertension, asthma, arthritis, diabetes [48].
Oncological diagnoses	One-third of illness-related death in US state prisons is due to oncologic illness [19, 61].

Table 1. General Health Status of the Incarcerated Population

Health status

HIV: human immunodeficiency virus; COVID-19: coronavirus disease 2019.

Psychiatric diseases

Near 1/7 prisoners have a treatable mental illness [48, 49].

Proportion of individuals with psychiatric disorder is higher amongst incarcerated population compared to the general population [48].

1/3 of prisoners with a diagnosis of schizophrenia or bipolar disorder were not pharmacologically treated while in prison [50].

Suicide is the leading cause of death in custody [48, 51].

Infectious diseases

Higher rates of HIV compared to the general population [52, 53].

Higher risk of viral hepatitis [52, 54, 55].

High rates of tuberculosis [56, 57].

Higher rates of COVID-19 infection prior to vaccine distribution, with the inability to safely self-isolate [58-60].

Chronic illness

Higher prevalence of hypertension, asthma, arthritis, diabetes [48].

Oncological diagnoses

One-third of illness-related death in US state prisons is due to oncologic illness [19, 61].

**Table 2.** Case Vignettes
Case 1	Case 2
A 46-year-old male is brought into the emergency department with a new-onset focal to bilateral generalized tonic-clonic seizure. Neurology is consulted and over the phone, the consultant is told the patient is a violent offender. Over the next 24 - 48 h, investigations are performed and both electroencephalography and magnetic resonance imaging (MRI) of the brain are negative. The patient is started on levetiracetam (a reasonable choice) at the typical target dose but is discharged without any further follow-up.	A 34-year-old man is brought in by prison guards after an altercation reporting some left leg weakness. Neurology is consulted for further workup and management. All investigations, including MRI of the brain and full spine come back negative and physical examination indicates functional overlay with a component of anxiety. The patient is discharged without follow-up with reassurances that he will get better.

Table 2. Case Vignettes

Case 1

Case 2

A 46-year-old male is brought into the emergency department with a new-onset focal to bilateral generalized tonic-clonic seizure. Neurology is consulted and over the phone, the consultant is told the patient is a violent offender. Over the next 24 - 48 h, investigations are performed and both electroencephalography and magnetic resonance imaging (MRI) of the brain are negative. The patient is started on levetiracetam (a reasonable choice) at the typical target dose but is discharged without any further follow-up.

A 34-year-old man is brought in by prison guards after an altercation reporting some left leg weakness. Neurology is consulted for further workup and management. All investigations, including MRI of the brain and full spine come back negative and physical examination indicates functional overlay with a component of anxiety. The patient is discharged without follow-up with reassurances that he will get better.

**Table 3.** Factors Affecting Medical Care for Incarcerated Persons
Factors	Explanation
Biases from health care providers	Health care providers may misattribute symptoms to non-organic disorders or substance use disorders given higher prevalence of psychiatric and substance use among incarcerated persons.
	Additive impact of systemic and interpersonal racism may contribute to variable health outcomes and is important given that most of the incarcerated population in Canada is non-White
	Lack of education on cultural safety and humility during medical training which perpetrates these biases.
Safety for health care providers and patients	Perception by physicians that following up with patients may not be safe, particularly applicable to community-based clinics that are less likely to have access to security personnel.
	Patients, particularly Indigenous people, may have had negative experiences with the health care system (lack of cultural safety and humility) and may also have experienced true safety concerns due to previous traumatic experiences.
	General belief held by healthcare providers that prisoners can be incarcerated for violent crimes and stereotypes held that Indigenous and Black individuals tend to demonstrate unprovoked violence may lead them to believe they are at risk for violence while providing care for incarnated patients.
Resource limitations	High resource requirements and logistical challenges to bring people from facilities to appointments and back, with appropriate supervision/security.
Communication	Reduced ability for to communicate changes in health status (medication side effects or worsening condition) to health providers.
	However, continuous surveillance in incarceration can sometimes be advantageous in identifying changes in health status.
Neurologic or psychiatric comorbidities	Individuals have higher prevalence of traumatic brain injuries and mental health disorders which impact medical care.
Non-organic disorders	Malingering and other non-organic presentations may be more prevalent and are associated with the above-mentioned mental health disorders.
Incomplete examinations	Restraints requirement may limit portions of the neurological examination and make reaching the correct diagnosis more challenging.

Table 3. Factors Affecting Medical Care for Incarcerated Persons

Factors

Explanation

Biases from health care providers

Health care providers may misattribute symptoms to non-organic disorders or substance use disorders given higher prevalence of psychiatric and substance use among incarcerated persons.

Additive impact of systemic and interpersonal racism may contribute to variable health outcomes and is important given that most of the incarcerated population in Canada is non-White

Lack of education on cultural safety and humility during medical training which perpetrates these biases.

Safety for health care providers and patients

Perception by physicians that following up with patients may not be safe, particularly applicable to community-based clinics that are less likely to have access to security personnel.

Patients, particularly Indigenous people, may have had negative experiences with the health care system (lack of cultural safety and humility) and may also have experienced true safety concerns due to previous traumatic experiences.

General belief held by healthcare providers that prisoners can be incarcerated for violent crimes and stereotypes held that Indigenous and Black individuals tend to demonstrate unprovoked violence may lead them to believe they are at risk for violence while providing care for incarnated patients.

Resource limitations

High resource requirements and logistical challenges to bring people from facilities to appointments and back, with appropriate supervision/security.

Communication

Reduced ability for to communicate changes in health status (medication side effects or worsening condition) to health providers.

However, continuous surveillance in incarceration can sometimes be advantageous in identifying changes in health status.

Neurologic or psychiatric comorbidities

Individuals have higher prevalence of traumatic brain injuries and mental health disorders which impact medical care.

Non-organic disorders

Malingering and other non-organic presentations may be more prevalent and are associated with the above-mentioned mental health disorders.

Incomplete examinations

Restraints requirement may limit portions of the neurological examination and make reaching the correct diagnosis more challenging.