Surveillance, System Avoidance, and the Health of People Formerly Incarcerated

Recent attempts to merge disconnected data systems within agencies reveal the government’s capacity for surveillance and population control, and highlight critical data privacy concerns. This trend of building a bigger and stronger surveillance system can increase “system avoidance” behavior, by pushing people with criminal records away from health care services.

Contact with the criminal legal system leaves many symbolic and formal traces on people’s lives – having a “record” often means internalizing what’s been called a “carceral citizenship,” wherein state and social expectations that formerly incarcerated will re-offend are internalized by individuals and communities affected by the criminal legal system. They will, in turn, often isolate themselves from broader segments of the population and fear exposing themselves to state institutions that engage in surveillance and control.

Sarah Brayne calls this behavior “system avoidance.” Looking at a nationally representative sample of the U.S. population, the author found that people who had been stopped by police, arrested, convicted, or incarcerated were less likely to interact with institutions that collect information and keep records such as banks, formal employment, schools, and medical facilities. This behavior, in turn, may lead to important health consequences. Research has shown that even police contact led to social isolation and avoidance of formal health care, which in turn worsens general health and depression. Others have shown that system avoidance behavior might persist even as people age and their health needs become more acute.

Exposure to the criminal legal system, moreover, is a common event to many people living in the United States. Research shows that between 1948 and 2010, 3 percent of the American adult population and 15 percent of its African American population had been incarcerated. By 2021, data indicated that around 5.4 million people (or 2 percent of the country) were under some form of correctional supervision.

This routine exposure to the criminal legal system has been shown to systematically affect the health and well-being of individuals and communities, making it a social determinant of health in the United States. People who enter prisons and jails might have access to health care for the very first time, because in the United States, counties, states, and the federal government have the constitutional mandate to provide health care to their correctional populations, a right largely absent when people are in the “free world.” However, incarceration may expose people to stressful and traumatic conditions of confinement and infectious diseases, effects which may continue throughout their life course. Post-release efforts to find housing and employment, and reconnect with family and friends might worsen or lead to the development of new health conditions.

But even if formerly incarcerated people are more likely to have higher than average needs for health care, that does not mean they will seek it. For one, research has shown that formerly incarcerated people are more likely to live with lower levels of health insurance than the rest of the population. Coverage under Medicaid is normally discontinued during incarceration due to the Medicaid Inmate Exclusion Policy and many states do not offer assistance for re-enrollment upon release. Moreover, upon release, people often struggle to gain access to their medical records, a clear care plan, and referrals. But even if all these resources are available, individuals might still avoid seeking healthcare for fear of surveillance and state control.

And they might be right. The use of the criminal legal system surveillance apparatus within the provision of health care services has become more frequent in recent years. Research has documented how, through prescription monitoring programs, pharmacists make use of big data surveillance to determine whether patients should be prescribed opioids or not, often interpreting their behavior in terms of likelihood of crime. A recent study documented information sharing between mental health facilities and criminal legal system agents on patients with serious mental illness. More recently, states have approved laws that authorize hospitals to create and manage their own police forces, despite research indicating that the presence of law enforcement often impedes proper care and affects the health privacy of patients or their trust in health care workers. The most recent numbers show that in 2024, at least 2 million people were incarcerated in American prisons, jails, juvenile correctional facilities, and immigration detention centers, 671,000 people were on parole, and 2.9 million on probation. Added to these 5.5 million people under direct contact with the criminal legal system are all the other people with past criminal records, their family members and immediate communities. Considering the massive size of the American population who had or still have contact with the criminal legal system, it is concerning that health surveillance has been often equated to or taken inspiration from criminal law surveillance. The study shows that, contrary to what one might expect, a surveilled population does not necessarily mean a healthier population, especially when the type of surveillance implemented might not only push people away from health care services or be seen as one more door toward criminal punishment.