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TIME ON THEIR HANDS, TIME ON OUR MINDS

136 Farwood Road Wynnewood, PA 19096

Aging Prisoners: Crisis in American Corrections, by Ronald H. Aday. Praeger, Westport, CT, 2003, 229 pp., $24.95 (paper).

Report of the Advisory Committee on Geriatric and Seriously Ill Inmates, by Joint State Government Commission of the Pennsylvania General Assembly. Commonwealth of Pennsylvania, Harrisburg, PA, 2005, 260 pp., free (paper).

The 15 men were volunteers in the 20-bed infirmary of Pennsylvania's Dallas Correctional Institution. Their activities ranged from assisting ill and infirm inmates with basic and instrumental activities of daily living—assisting in making telephone calls, neatening up their living space in the infirmary, helping them eat, getting them ice water, bathing them, helping them generally, talking, and listening—to sitting with them throughout the night during their last hours of life. For the volunteers, this service is an important part of their lives. They bring to the volunteer tasks and the ill and infirm men they help what no one else can—a deep understanding of what it means to be sick and alone and to die in prison. All of the volunteers have thought long and hard about dying in prison, dying alone. Many of them confront that possibility. Most of them are serving life sentences. Some are serving several life sentences. All of them are serving long terms.

These volunteers know about time. They have ideas about aging and aging in prison. They cherish the opportunity to help ill and disabled prisoners get through their illness and disability and to provide special help to those who are completing their sentences, albeit through death.

In the hour and a half we spent together talking about these volunteer inmates' perceptions of time, aging, dying in prison, and their volunteer jobs, they told me about their service being a kind of reparation for terrible crimes committed earlier, about their own fears of dying old and alone in prison, about helping fellow prisoners who do not speak English live through the twin pressures of being sick and in the prison environment, and how work with the ill, infirm, and dying affected the direction of their own lives while they are incarcerated. Some mentioned the death of a parent, grandparent, or child during their time in prison. They could not be with those loved ones, but they were able, instead, to be with dying fellow prisoners.

This group of lifers and other long termers was articulate and thoughtful. They had no hesitation about conversing. Their responses had the ring of candor and reflection. Whatever the subject matter, the overwhelming presence of the prison environment and their days there, measured in thousands of days, never disappeared.

Consideration of matters gerontological in the prison environment cannot occur without an appreciation of long-term incarceration in all its aspects. What they told me brought an otherwise absent color to the customary abstract dialect one ordinarily encounters in the professional literature. I sought out the opportunity to meet with them to better understand what I was really learning from the volumes reviewed in this essay.

Aging Prisoners

Ronald H. Aday's Aging Prisoners: Crisis in American Corrections is an important and provocative addition to a growing literature on the topic. I hope that it provokes and encourages scholars and practitioners to explore the issues of older offenders entering the corrections system, as well as the implications of a growing population of offenders who grow old in prison. And the harder question of whether it is old age that must be dealt with in the corrections system or whether disability (which sometimes, but not always, accompanies old age) is the central issue.

Aday lays out a fact-packed review of a rapidly changing corrections system, criminal populations in prisons, current policies, and implications of how we deal with serious crimes and criminals. His review provides a context for what he characterizes as a crisis engendered by the change in age structure and experience in the justice system. He concludes with a suggestion for "elder justice"—what he sees as future needs and challenges. Each of the discussions, including police discretion, courts and sentencing, age and prison policies, diversion, probation, and parole make good sense. They would make equally good or better sense if cast in terms of individual capacities, disability status, and health needs, rather than in terms of old age. This is not a criticism of the breadth and sweep or excellent referencing of Aging Prisoners. Rather it is no more than a different point of view on the part of this reviewer.

This well-referenced, wide-ranging treatment of an exploding prison system seeks to deal with two disparate issues which appear to have old age in common: (1) criminal activity by older persons and (2) increases in the number of older people in the prison population. The issues are hardly equivalent. As Aday points out through a review of the literature and uniform crime reports:

Overall, crime trends in the 1990s revealed a gradual decline in the number of arrests for most older offender age categories. ... [The fact that] declines of 24 percent in arrests of those aged 55 and over have come as the actual number of older adults in that age category increased ... suggests that it is highly unlikely criminal activity will explode as the aging population continues to increase (p. 53).

Whether and how old age, per se, is relevant to criminal activity by older persons or the number of older persons in prison is unclear. What is clear is the huge increase in prison populations in recent years, rising from 423,898 in 1983 to 1,380,776 in 2003, an increase of over 200% (U.S. Department of Justice, 2005). (These "prison" figures only refer to state and federal correctional institutions that typically house long-term populations, not to municipal and county "jails" that house inmates on a short-term basis, usually less than 1or 2 years.)

The growth of the prison population is a function of sentencing policies, cultural values related to punishment, police arrest policies, application of improved technologies in the medical care of prisoners, and gross changes in the mental health and mental retardation system, which moved substantial numbers of the mentally ill and mentally retarded out of institutions and into the community. It is the consequent pressure to build more and more prisons and the capital and operating costs associated with the increased capacity that has engendered a sense of crisis in corrections systems and the legislatures that must provide the funds for their operation. This underlying fact has driven state corrections systems and legislatures to explore a variety of possible explanations and avenues of relief.

While Aday focuses on "aging prisoners" as a "crisis in American corrections," he is quick to point out that the common definition of old age in correction systems—age 50 and older—may have serious limitations. Furthermore, he acknowledges that issues of health status may have more to do with the underlying socioeconomic characteristics of the prison population than with the characteristics commonly associated with a population in this age range.

Prison populations do not reflect the general population in terms of age, gender, race, or economic status. Although persons aged 50 and older are 29 percent of the general population (U.S. Census Bureau, 2005), Aday notes that they represent 8.2 percent of the total prison population. To be sure, there has been an increase in the percentage of prisoners in this age range. But, clearly, it is not old age that is crowding America's prisons. In fact, Aday does not make a strong case for aging prisoners being a crisis.

Aday's two chapters describing criminal activity among older persons and his theoretical explanations for crime by elderly persons provide an excellent overview and starting point for those concerned with this aspect of criminology. His cautions about understanding the complexities of criminal etiology are careful and appropriate.

The raw figures on commission of "index crimes" (i.e., actual arrests for crimes utilized in the Uniform Crime Reports collected by the U. S. Department of Justice) in no way indicate a geriatric crime wave leading to the massive increases in prison population. Aday acknowledges this. There were 20,332 arrests for violent crimes by those aged 50 and older in 2000, 4.9 percent of the total of such crimes. There were 38,169 arrests for crimes of property that year by this older age group, or 3.5% of the total property crimes.

Although one can take issue with the characterization of aging prisoners representing a "crisis" in the corrections system, Aday's exploration of the graying of the prison population is nonetheless important, particularly for gerontologists. Age creep will ultimately be reflected in corrections programming in preventive medical care, care of the chronically ill and disabled, accessibility issues, and hopefully, in research. This is already evident in prison programs and policies designed to group prisoners with serious chronic illness problems (e.g., Pennsylvania's program for prisoners requiring dialysis, prisoners requiring skilled nursing care grouped at the Laurel Highlands Correctional Institution, accessible bathing and toileting facilities for mobility-impaired inmates, and modified work assignments for those with diminished strength or stamina). However, inmates do not enter those arrangements on the basis of their age status but rather on the basis of their ability to carry out the ordinary activities of daily living.

Is "Aging" the Issue?

Addressing the issue of aging prisoners is a tricky proposition. For instance, characterizing the growth of the population of aging and aged prisoners as a "crisis" is to focus on one manifestation of the underlying issues of prison population growth in the last two decades of the 20th century. The United States incarcerates adults at a higher rate (468/100,000) than all countries reported in Western, Central, and Eastern Europe and North America except for Belarus (550/100,000) and Kazakhstan (546/100,000). By way of comparison, rates of incarceration (per 100,000 inhabitants) in Western Europe and Canada are: Denmark, 43; Italy, 51; France, 56; Ireland, 84; United Kingdom, 90, Spain, 90; and Canada, 282 (United Nations Economic Commission for Europe, 2003). Add to that the U.S. penchant for very long sentences, and it is no wonder that the growth in the U.S. prison population is what it is.

There is no question that changes occur within a prison population that is aging. But that does not mean that looking at prisons through an "aging lens" and focusing on "aging prisoners" is the most productive way of examining prison services and programs that deal with issues that often, but not always, accompany old age—no matter how we define it.

Louisiana's Angola State Prison is a penitentiary with 5,000 inmates, half of whom are serving life sentences and 85% of them are estimated to die in the prison. The search for additional cemetery space led the warden to think about inmates dying, where they died, and how they died. And a hospice program came to flower in this improbable setting (Open Society Institute, 1998). It is not that hospice is there for old inmates. It serves dying inmates, many of whom are not old by conventional markers, most of whom will have spent a long time in prison by any measure.

It is not aging that is overcrowding our prisons. And it is not aging prisoners who are generating requirements for health care in accordance with standards of common decency, a constitutional standard (Estelle v. Gamble, 1976), and legislative standards dictated by the Americans with Disabilities Act (U.S. Code). This review essay argues that the "problems" associated with the issues of rising census, rising costs, and the rising need for more and better health care for inmates of jails and prisons are less a function of aging, and more and more a function of disability. In any event, and despite a number of special prison arrangements that Aday describes that use chronological age as a discriminator—segregated housing, "retirement" from work, work assignment modifications, and others—there is a legitimate question to be raised as to whether chronological age markers should be used in structuring prison programs.

Knowledge Gaps

As Aday points out, the complexity of this issue is compounded by our limited knowledge and confusion about aging prisoners and health-related matters. For openers, there is virtually no definition or accepted standard of convenience for the term aged or aging prisoner. In terms of chronological measures Aday finds age 50 commonly used, with ages 55 and 60 used less frequently. There is no particular evidence-based reasoning behind these categorizations. Virtually none of the prison data on aging persons or programmatic parameters utilize age 65. We have no idea of how, why, or even if the passage of time in a prison affects the aging process. Are mortality and morbidity experiences in and out of prison comparable, even holding constant factors such as socioeconomic status, preprison health history and known risk factors, race, and ethnicity?

Exploring these issues and questions systematically is extremely difficult. Health and disability data regarding prison populations are severely limited. Scharff (2004) points out that the sources of morbidity and mortality data typically relied upon outside the correctional systems are simply not available within them. Billing systems, a rich source of data customarily collected in the community regarding what diagnostic and treatment interventions are ordered and charged, and aggregated laboratory and pharmaceutical data reflecting similar aspects are not collected because prisons don't "need" them.

Surveys are expensive and are not viewed as important to the central function of correctional facilities. To be sure, there have been reports of some surveys of inmates but they are more often than not targeted on narrow issues, confined to a single institution involving a small number of inmates, and frequently undertaken without typical controls for exogenous factors affecting the issue examined.

Mortality data are not generally collected for correctional institutions, and where they are collected the quality of data is, at best, mixed. Statistics collected on cause of death and contributing causes are too limited for practical analysis. Medical histories are incomplete and contributing causes of death are not often noted. Data on disabilities are even more limited.

All of the above notwithstanding, Aday's general review of demographics and specific health concerns of aging prisoners is helpful in identifying what source material is available. He is appropriately cautious in the conclusions and inferences he draws from the admittedly limited studies and data available.

Whatever the issue, exploring aging (or disability) and prisons is confounded by two related pervasive factors. One is the nature of the prison environment and its impact on every aspect of an inmate's life. A second is the increasing definition embodied in law of the relationship between the inmate and the government that incarcerates him or her. Aday devotes two chapters to adjustment to prison life and housing and programming for aging inmates. These chapters cover a remarkable amount of territory. Their intent, I believe, is to convey what the prison environment is like, what its impact must be on various elements of the inmate's life, how his days and nights are spent, his relationships, and his work, religion, and pastimes. The attempt is a worthy one. In the context of the overall content and style of the book it is not only appropriate, but it is a good fit. That said, however, prison life and the prison environment is so far and distinct from the experience of most readers that the imagination cannot fill in the blanks or conjure up the images which Aday knows well from his long interest and explorations in prisons and encounters with hundreds of inmates around the country.

Even his descriptions of four state programs in North Carolina, South Carolina, Ohio, and Pennsylvania cannot provide the picture. These programs are remarkable. They may come as a surprise to most readers better schooled in "prison flicks" (Prison Flicks, 2005) and other sources of misinformation than in major changes in late-20th century prison programming. Aday's descriptions report on expanded medical programs, chronic illness units, personal care and skilled nursing facilities, special exercise and walking programs, hospice programs, and others. However, participation in these is grounded in inmate characteristics other than age. Some of the most substantial changes that have come about in prison programming are the result of legal challenges addressing boundaries of prison life dictated by the U.S. Constitution (Estelle v. Gamble, 1976) and the Americans with Disabilities Act (Goodman v. State of Georgia et al., 2005; Pennsylvania Department of Corrections et al. v. Yeskey, 1998).

Law and Life in Prison

Aday does not explore either the nature of the relationship law has carved out in defining what happens to prison inmates nor the extraordinary ongoing historical development of that relationship.

The plaintiff's brief in a U.S. Supreme Court case (Goodman v. State of Georgia et al., 2005) provides a useful overview and discussion of the legal relationship:

[The] Court has repeatedly held that affirmative constitutional obligations arise from the State's total domination of an inmate's life. Prisons are places in which "the government exerts a degree of control unparalleled in civilian society," and inmates are dependent on the government's permission and accommodation to satisfy virtually all of their basic human needs. Cutter v Wilkinson 125 S. Ct. 2113, 2121–2122 (2005). (p. 8)

Within that general overarching framework, the U.S. Constitution imposes upon the state duties to assume responsibility for the safety and well-being of prisoners (DeShaney v. Winnebago County Department of Social Services, 1989). Those duties have been elaborated in U.S. Supreme Court decisions (Estelle v. Gamble, 1976; Farmer v. Brennan, 1994; Robinson v. California, 1962) and in scores of lower court decisions dealing with cases arising in more than a score of states (Goodman v. State of Georgia et al., 2005).

Perhaps even more effective in terms of producing wide-ranging changes in corrections policies and operating procedures are detailed settlement agreements between states and plaintiffs seeking changes that take into account a wide range of issues. For example, the 87-page settlement agreement in Steven Austin et al. v. Pennsylvania Department of Corrections et al. (1994) sets out policies, standards, time limits, and monitoring provisions for medical care, mental health care, and corrections issues dealing with HIV and AIDS and environmental and fire safety issues. This settlement agreement did effect major changes which were instituted over time in Pennsylvania, and without any refiling of complaints in the original pleadings.

The prison environment continues to evolve. What does not and cannot change is its character of confinement and control. Security trumps everything. However, this does not mean that decent care and accommodation to the needs of ill, infirm, and/or disabled people in prison need be necessarily compromised or diminished thereby. Aday's three final chapters—"Housing and Programming," "Older Women in Prison," and "Responding to Aging Offenders,"—provide a catalog of examples of responsive programming to the wide range of life and health circumstances of prison inmates. Although many of the advances in prison reform came about in response to litigation, the most substantial and lasting changes are the result of synergies achieved through joint action and cooperative program development by security-oriented prison leadership and their security officers with medical, psychological, and social service personnel. Both groups have been focused on the joint goals of security, stability, and social, mental, and physical health.

Finding Legislative Answers

Aging Prisoners provides us with an excellent overview of the issues, problems and considerations confronting prison operations with growing populations and increasing health, psychological and social problems among elderly and disabled prisoners. A parallel perspective is laid out in the Report of the Advisory Committee on Geriatric and Seriously Ill Inmates to the Pennsylvania General Assembly. It offers an excellent example of policy options for the state legislature on a number of the most salient issues: health and hospice care, mental health, geriatric and life-sentenced inmates, and a victim wrap-around program. The first three areas are accompanied by draft legislation. The last is a group of confidential services offered to support victims at the time of the offender's reentry into the community. These services may include a safety plan providing geographic parameters addressing the needs of the offender and the safety needs of the victim, assistance in securing information on the offender's status and on obtaining restitution, and linking the victim to other services.

The report is work product of a 46-member advisory committee to a bipartisan 8-member task force of Senate and House members established by the Joint State Government Commission, the research arm of the Pennsylvania General Assembly. The committee had its first meeting in early 2003.

The enormous growth in prison populations and the attendant costs of construction and programming have focused attention on state correctional programs throughout the United States. Similar inquiries have generated reports for other state legislatures and corrections agencies throughout the country (Anno, Graham, Lawrence, & Shansky, 2004; Southern Legislative Conference Special Series Report, 1998).

The interest of the Pennsylvania General Assembly initially was broader than the impact of and response to geriatric and seriously ill inmates. By the turn of the century it became apparent that "getting tough on crime," extending sentences, "three strikes and you're out" policies, and similar constraints on judicial discretion were not having the hoped-for effect of reducing crime. Furthermore, locking up more and more people for longer and longer terms led to building and operating more and more prisons. Political competition about who was tougher on crime contributed to the increases in length of sentences, particularly in eliminating the possibility of parole from life sentences. Prosecuting attorneys and victims' rights groups vigorously opposed serious examination of sentencing policies, review of "compassionate release" programs, pardon and sentence commutation practices, revisitation of arrest policies, and similar issues affecting the increases in prison populations. Nonetheless, continuing budgetary pressures required some response that would withstand popular political commitments to being tough on crime.

A focus on elderly prisoners would have looked at all inmates growing old in prison. A focus on geriatric and seriously ill inmates became an acceptable purpose that would not run afoul of "get tough on crime" proponents. Thus, the Pennsylvania report concluded that broader criminal justice issues such as revision of the Post-Conviction Relief Act, discharge planning, mandatory impact statements, prison camps, determinate versus indeterminate sentencing, mandatory sentences, and consecutive or concurrent sentencing either exceeded the scope of the advisory committee's charge or presented issues which it could not profitably explore.

The Advisory Committee was broadly representative of a wide range of interests: civil liberties and prison reform advocates, police, corrections officials, prosecutors, victims rights representative, clergy, academics, judges, attorneys, corrections officers, and state officials dealing with parole, pardons, health, corrections, aging, welfare, and mental health. Not surprisingly, the report is not unanimous on all points. On some issues it was not possible to develop policy options acceptable to all interests. What makes this volume important to scholars, planners, policy makers, and practitioners alike is its focus on policy and practice with starting points and objectives for changing what isn't working.

The report is organized into three main parts dealing respectively with "Health/Hospice," "Mental Health," and "Geriatric and Life-sentenced Inmates." These sections include background issue statements, statistics and other information related to current practices, related programs in state and local agencies, and examples of program elements in other states. In addition, the volume includes an extensive bibliography of books, reports, government publications, journal articles and materials from magazines, newspapers, and the Internet. Appendices include statistical materials on the prison population, mental health, miscellaneous survey results and summaries of correspondence from the public and inmates, and a summary of Advisory Committee members' visits to three state correctional institutions.

Although the report is specific to Pennsylvania, it has value elsewhere as a model of inquiries that need to be made. Its specific proposals, however useful in Pennsylvania, may or may not be relevant in other jurisdictions governed by particular state statutes and constitutional provisions. Yet, this report is straightforward, written for consideration by legislators and policy makers, offering current knowledge, current conditions, and possible remedies through draft legislation, where appropriate, and describing exemplary programs that might be replicated. It includes correspondence from the public and from inmates that provides the human component—the facts that impinge on the lives of victims' families and on the lives of people condemned to decades in prison.

The report is a good fit with the Aday volume. Both will be useful to scholars and practitioners concerned with old age, infirmity, and disability in American prisons. Both volumes should stimulate systematic inquiry.

Research, Research, Research

For scholars, the field of corrections is a relatively unworked mine in the areas of gerontology, public health, mental health, and the impact of correctional systems and practice on incidence of crime. For policy makers, planners and administrators concerned with aging and disabled prisoners there is a driving need for exploration of creative budgeting, the possibility of applying new payment mechanisms including Medicare, Medicaid, and private insurance, the impact of sentencing policies and long-term imprisonment, and the nature of community in the prison context.

For prisoner-rights advocates it is, as always, essential to explore the proper balance between humane, ethical practice for old, disabled or infirm prisoners and the state's interest in assuring safety, security, punishment, and deterrence.

For gerontology, in particular, it is hard to imagine another setting in which one can learn so much from aging in a controlled environment surrounding a, literally, captive group, about which it is possible to capture data over an adult lifetime or much of it. To be sure, the fact of imprisonment itself creates a sui generis data set, generating the problem of ecological fallacies in any attempts to generalize interpretively to life in the broader community. But this is a constraint about which the facts are readily available. Here is a singular opportunity for scholars and practitioners to pursue further research.

Acknowledgments

Thanks to Dr. Nicholas Scharff, University of Pennsylvania Medical School, for providing background information and advice, Patricia Ginocchetti, Corrections Health Care Administrator, and the Dallas Correctional Institution of Pennsylvania and volunteers of the infirmary for sharing their views on time, aging, and volunteer work with infirm and elderly prison inmates.

References

• Anno, B. J., Graham, C., Lawrence, J. E., & Shansky, R., (2004). Correctional health care: Addressing the needs of elderly, chronically ill, and terminally ill inmates. Middletown, CT: Criminal Justice Institute, Inc.
• DeShaney v. Winnebago County Department of Social Services. (1989) 489 U.S. 189, 199–200.
• Estelle v. Gamble. (1976) 429 U.S. 97.
• Farmer v. Brennan. (1994) 511 U.S. 825.
• Goodman v. State of Georgia et al. (2005) Brief for Petitioner Goodman, U.S. Supreme Court No. 04-1236.
• Open Society Institute & The Center on Crime, Communities and Culture (producer). (1998). Opening the door: Angola prison hospice [Motion picture]. (Available from The Center on Crime, Communities and Culture and the Project on Death in America, 400 W. 59^th St., New York, NY 10019).
• Pennsylvania Department of Corrections et al. v. Yeskey. (1998) 524 U.S. 206.
• Prison Flicks. (2005). All reviews (77 reviews of movies about prisons 1930–2004). Retrieved August 18, 2005, from http://www.prisonflicks.com/genres.php?filmGenreID+0&sortVar+filmReviewDate&sortdir=down.
• Robinson v. California. (1962) 370 U.S. 660.
• Scharff, N., (2004). Corrections and correctional health (PowerPoint presentation). Philadelphia: University of Pennsylvania School of Medicine.
• Southern Legislative Conference Special Series Report. (1998). The aging inmate population. Atlanta: Council of State Governments Southern Office.
• Steven Austin et al. v. Pennsylvania Department of Corrections et al., Settlement Agreement. (1994) E.D. Pa. No. 90-7497.
• United Nations Economic Commission for Europe. (2003). Crime and safety. In Trends in Europe and North America: The statistical yearbook of the Economic Commission for Europe (chap. 13, table 13.7). Retrieved August 21, 2005, from http://www.unece.org/stats/trends/ch13/13.7.xls.
• U.S. Census Bureau. (2005). Annual estimates of population by sex and 5-year age groups for the United States April 1, 2000–July 1, 2004. Retrieved September 1, 2005, from http://www.census.gov/popest/national.asrh/NC-EST2004-01.xls.
• () U.S. Code, 42 U.S.C 12101 et seq..
• U.S. Department of Justice. (2005). Correctional populations. Bureau of Justice Statistics Correctional Surveys (The National Probation Survey, National Prisoner Statistics, Survey of Jails, and The National Parole Survey). Retrieved August 20, 2005, from www.ojp.gov/bjs/glance/tables/corr2tab.htm.

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Cohen, E. S. Search for Related Content PubMed Articles by Cohen, E. S.