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Join us as we explore the critical issue of carceral censorship and its impact on incarcerated individuals’ access to health information. Our guest is Brian Tuohy, an assistant professor of bioethics, who shares his perspectives on the challenges and ethical considerations surrounding this issue. We’ll discuss real-life stories like that of Kwaneta Harris, who faced severe health challenges while in solitary confinement due to the lack of accessible health education. Together, we’ll examine the reasons behind the censorship of health literature in prisons, its detrimental effects, and what medical professionals and advocates can do to bring about change.

Brian Tuohy is an assistant professor of bioethics.

They discuss the KevinMD article, “Left in the dark: the censorship of health literature in prisons.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Brian Tuohy. He’s an assistant professor of bioethics, and we’re going to talk about the KevinMD article “Left in the dark: the censorship of health literature in prisons.” Brian, welcome to the show.

Brian Tuohy: Thank you so much. I’m really excited to be here with you.

Kevin Pho: So let’s talk about this article in a little bit. First off, briefly share your story and journey.

Brian Tuohy: Great. Yeah, I think I probably have a bit of an atypical journey for someone being interviewed here. I’m a sociologist by training, so I finished my PhD in 2018, and I’ve been teaching at Temple Medical School for the last three years. So my research is interested in the social determinants of health, and thinking about the relationship of communities and health systems. And yeah, excited to be here.

Kevin Pho: So in terms of medical education, sociology is such an important part, as you mentioned, social determinants of health. For those who may not be familiar with that intersection, talk more about that sociology, health care intersection, and why that impacts patients so much.

Brian Tuohy: Yeah, I think over the last 10 or 15 years there’s been a bit of an explosion within medicine of thinking about and understanding the role that the social plays. So it’s really important to memorize all the parts of a body and anatomy, and to understand the forces in physics for heart rate and cardiology, but it’s also equally as important to understand the role that legal status plays in experiences with health, the role that housing plays, the role that food security plays.

And so it’s trying to improve the knowledge and understanding of context that our future physicians have when interacting with the patients in front of them, to better understand who they are, what they’re experiencing. If our mutual goal is to improve health, having an understanding of the context, having an understanding of the social, is something that is also as important as understanding some of these key body processes that you learn about in med school.

Kevin Pho: All right. So let’s talk about this KevinMD article that you co-wrote with Hannah Celli and Olivia Duffield. It’s titled “Left in the dark: the censorship of health literature in prisons.” For those that didn’t get a chance to read this article, tell us what it’s about.

Brian Tuohy: OK. And first I just want to give a shout out to my two co-authors, students Hannah Celli and Olivia Duffield, who have currently just started their residency training. Hannah’s residency is in general surgery at Penn, and Olivia’s in internal medicine.

And so this paper, it started from, we have a relationship with an organization called Prison Health News, which is the only national organization that responds to letters from people who are incarcerated around health related concerns. And so I formed a partnership with this organization. I teach a class at Temple Medical School called community engagement, and we have relationships with different community partners which our med students interact with, and so Hannah and Olivia became leaders in this organization.

And so one thing that Prison Health News does is respond to letters from people who are incarcerated. It also produces a newsletter that is sent out quarterly to different prisons throughout the United States. And so we recognized that some of these newsletters were being censored and banned at random prisons, and so the question was, why was it the case that letters were being banned, what was the reason?

And looking into it, there’s sort of a surprising level of discretion that prison systems have for banning literature that they see as problematic. And so we begin with a story about Kwaneta Harris, who’s on the Prison Health News board, who’s been in solitary confinement for a really long time, trying to understand what was wrong with her, and she didn’t know if she was going crazy. It turned out she had menopause, but she didn’t have the ability to read health textbooks and things to try and understand what was going on in her life.

So it’s about thinking about what people in prison should have access to in terms of understanding their health, and thinking about what role society should play, in terms of, people are being punished, and is this an excessive level of punishment, keeping them from information? So how do we make decisions about the information that they should or shouldn’t have access to? And we’re trying to raise questions about that, essentially.

Kevin Pho: So you mentioned that this newsletter was being censored. So typically what would be some of the content in this newsletter that would be so sensitive for these prisons to censor?

Brian Tuohy: Yeah, I think an example would be like a diagram of doing a prostate screening. It would be seen as nudity. There are examples in the article, diagrams that would be seen as something that could be problematic in terms of sexual gratification. And so just being banned not from the content itself, but just from a very punitive angle in which the prison, and the different health systems or different carceral systems, are viewing information.

And so the goal really for us is just to raise awareness that this is happening, that there’s not really federal oversight for how information is decided upon, in terms of what can and can’t get into the hands of people that are incarcerated. And so just trying to raise awareness of that is a key issue for us.

Kevin Pho: To your knowledge, is this happening in prisons across the country, or are there certain select prisons that may have a more stringent standard of censorship? So what’s it like nationally?

Brian Tuohy: Yeah, I think it kind of tracks maybe with what you would expect in terms of the red state, blue state issue. But the key issue is that there isn’t this federal oversight, and that it is one that varies significantly across place. And so some prisons are a bit more lenient, or some are extraordinarily restrictive. So the one that Kwaneta is in, that we report, the vignette that opens the article in terms of how she’s trying to understand menopause, is in Texas, which is an extraordinarily restrictive state in terms of the things that people do and don’t have access to.

And so I think the key issue is that it varies significantly, that we’re trying to raise awareness that this is even a thing and that’s happening. And maybe I’m jumping ahead a little bit here, but I think it’s important for the listeners of this podcast, we have higher levels of social capital, and just being aware that this is happening throughout the country and can hopefully lead to generating some pushback against it, is sort of the key idea for us.

Kevin Pho: Now, have there been any studies that show the health outcomes of people with the lack of access to health information that they have? What kind of health outcomes can this have on the population?

Brian Tuohy: Yeah, I think the data overwhelmingly shows that prisons and carceral institutions lead to negative health outcomes, even though it’s the case that this is one of the only places that people are constitutionally guaranteed to receive health care. It’s one that’s done in an extraordinarily haphazard way.

And I think that some listeners might be like, well, why does this matter to us? And I think that our key goal that we want to stress is, prison health is a public health issue. Many people that are in prisons, or that are affected by prisons, will come out of prisons. And so I think that a lot of MDs that are working with folks, not just like at Temple, in North Philadelphia, which is highly impacted by mass incarceration, I think a lot of folks will interact with people who either themselves or family members have been involved with carceral institutions. And so it’s important just to understand sort of the impacts that this could have on physical and mental health.

But to answer your question, I think it’s one in which we know that it leads to premature aging, chronic illness, long-lasting trauma, mental illness. And there’s also the issue, some prisons are privatized, in which the way in which they handle the health system is, it’s not necessarily about improving the health of populations within carceral institutions, but it’s often about saving money.

There’s issues around, we know, around co-pays, in terms of, you might have to pay $5 to see a physician or a nurse when you’re in a carceral institution. And $5 might not sound like a lot, but if you’re making 19 cents an hour, these things can be exorbitant.

So I think the key aspect is that these institutions have negative health effects both whenever people are within them and then later, in terms of thinking about mental health issues. And I think we as a society have to think about what our role is as a society in terms of how much punishment is necessary, and what is and isn’t morally acceptable, I think, is another key ethical question that’s associated with this. And so these are just some of the bigger issues we’re trying to get at by raising awareness around this stuff.

Kevin Pho: So in general, what kind of information does the prison population have access to? And I understand that it can vary, but just give us a general sense of what they have access to today.

Brian Tuohy: I think that’s a great question. And I think a key aspect is, when we’re thinking about health nowadays, I don’t know what the age of the audience listening to this is, but a lot of us will go on to Google. Actually, this audience, you guys have all went to med school. But a lot of us, if we’re thinking about health related questions, we can go on the internet. And the internet is severely restricted within jails and prisons in the United States. So it’s something which most folks don’t have access to.

And when we’re thinking about whether or not people have access to medical textbooks, it’s one in which, again, it varies significantly across place. So in terms of what people have access to, it’s extraordinarily limited, it’s extraordinarily constrained. Oftentimes either folks are waiting a long time to get appointments, they have to pay these high co-pays to speak to a nurse, or, for those that contact and communicate with us in Prison Health News, it’s literally the mail, what do they call it, snail mail, the paper mail.

Someone might ask a question about, like, I’ve been told that I have diabetes and I’m just wondering if I can have a better understanding of what that is. They might not get a response for four, five, six, seven weeks.

Kevin Pho: Wow.

Brian Tuohy: Or if someone is thinking about, like, I have this condition and I’m trying to think about what I should and shouldn’t eat, we have to take into account not only the constrained level of information, but also the constrained system in which people don’t have access to any kind of food. So there’s a lot of unique aspects of what health is like and how it’s experienced.

And I think the challenge is, and why I’m really excited that you publish this article and a lot of folks are interacting with it and reading it, is that this is a hidden population, in the sense that I think it’s extraordinarily stigmatized. There’s a lot of the population feels like, if you’re in prison you might have done something to deserve to be there. But the question is, what should life be like when you’re in prison, and what should we as a society find to be morally and ethically acceptable?

And I think what we do now is not morally and ethically acceptable. I think the level of punishment is too high, the negative health implications are too high. And so again, it’s just raising awareness.

Kevin Pho: Yeah. So tell me, in terms of other than raising awareness, let’s say in your ideal world, what would you like to see happen? What would be your ideal scenario?

Brian Tuohy: I think the ideal scenario, I think that there should be federal oversight for information that should be and shouldn’t be allowed within prisons. That should be decided by folks that are on this call or that are listening to this podcast, medical experts. It shouldn’t be decided by random prison wardens who might not have the medical knowledge to know what is and isn’t literature versus what is and isn’t nudity, and things like that.

So federal oversight that says what people should and shouldn’t have access to. I think increasing access to information, it shouldn’t be so constrained. People in prison are being punished by being in prison, and the level of punishment, I don’t think, should extend to creating a situation in which people are ignorant about their existence and about their health and about their lives. I think it’s a level that goes too far.

So federal oversight, I think, would be a wonderful aspect if it was done in consultation with medical experts. I think improving the conditions in general of people that are incarcerated would be like a first step. I think we have to, as a society, think about the cost benefit of prisons in terms of the incredibly negative implications they have on people’s lives.

Kevin Pho: We’re talking to Brian Tuohy. He’s an assistant professor of bioethics. We’re talking about the KevinMD article “Left in the dark: the censorship of health literature in prisons.” Brian, as always, we’ll end with some of your take-home messages that you want to leave with the KevinMD audience.

Brian Tuohy: Great. So again, I appreciate the opportunity to be on this call. And I think that prison health is a public health issue that medical professionals should care about, regardless of whether or not they’re involved directly in carceral settings, in the sense that people that are in prisons will get out of prisons, and people that are in prisons are socially connected to folks that are in communities and societies in which doctors are interacting with these folks.

It’s an important area in which we should become more knowledgeable. I would love for more of us to become advocates and try to make changes at the federal and state levels in terms of what people do and don’t have access to. But what we could do at the bare minimum is just have a better understanding of what’s happening in the world around us and what’s happening within these prison systems.

I think that generally the censorship of health literature is detrimental and unjust to patients who lack access to the means to information, and so we need to think about some of the bigger ethical questions around this, and what people should and shouldn’t have access to.

Kevin Pho: Brian, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.