Since 2004, I have had the privilege of serving as a member of the National Advisory Committee of the Robert Wood Johnson Foundation (RWJF) for its Community Health Leaders Program. This role gives me the opportunity to learn about community health leaders from across the country who are making a difference in their local communities in innovative and unique ways.
From time to time, I also get to see this leadership in action through participating in site visits. This work recently took me to San Quentin State Prison in California. Opened in July 1852, it is the oldest prison in the state and is the only death row for male inmates in California, which, incidentally, has the largest number of male death row inmates in the United States. And with a population of over 5,000 – 159% of capacity – it is also overcrowded.
My visit included a tour of the medical facilities and conversations with inmates. The purpose was to learn about the work of a young doctor, Shira Shavit, who directs a prisoner re-entry program called Transitions Clinic. An article in the New York Times, “Clinic Works to Include Ex-Inmates in Health Care’s Embrace,” characterized Transitions as “the first in the country specifically for parolees, combining aggressive outreach — like recruiting prisoners before their release — with a nonjudgmental approach.” The program provides recently released inmates who are chronically ill with a medical home, care management, and referral to social services needed upon their release from prison. The goal is to successfully integrate these individuals into their communities.
At the heart of Transitions’ success is a cadre of trained peer community health workers who also have a history of being incarcerated. Chronically ill inmates are first identified while in prison, then the peer community health workers meet them at parole meetings upon their release. They accompany the patients to their appointments and check in with them by phone. In addition to connecting them to housing, employment, education, and other benefits, peer community health workers also help the patients navigate the complex processes that go along with accessing the benefits of fragmented systems.
During our visit to the community clinic in the Bayview neighborhood of San Francisco which houses the Transitions program, we listened to the peer community health workers and recently released patients talk about how much they appreciate the program and the critical health and social support services it provides. One patient drives several hundred miles round trip just to maintain his relationship with the program, and one of the community health workers is now working to complete her education. We also learned about how the community clinic is working to integrate the Transitions patients into its broader practice.
It also was interesting to learn the other ways in which Transitions’ work extends beyond the clinic’s walls and into the community at large. For example, the clinic is one of three partners participating in the Post Release Wellness Project which focuses on:
- Providing culturally competent primary care health services and case management for formerly incarcerated individuals.
- Advocating for policies that support equal access to quality health services on the state and local level.
- Providing training for front-line providers including community health workers.
Other Project participants include a nonprofit advocacy organization, and the City College of San Francisco’s (CCSF) Health Education Department. CCSF is the home of the nation’s first community health worker certificate program, which led to it becoming the first college-based, vocational education certificate program that trains front-line public health providers to specifically work with formerly incarcerated individuals.
While participating in the site visit, I could not help but relate all of what I had learned in San Francisco to our community and the Foundation’s work “back home.” There were several lessons I took away from the experience:
- Peer involvement and empowerment—as educators and navigators—is critical for success.
- Listening is a powerful tool for developing and implementing this kind of program. Continuous references to the value of “knowledge as power” and “each one, teach one” kept creeping into many conversations with the patients.
- Health care is only one piece of the network of services essential for successful reintegration and that, in fact, housing, employment, and support systems often precede health care in a prioritized list of essential services as articulated by the consumers.
- The importance of extending the reach of the program beyond providing critical health care services to establishing partnerships with others who work in multiple arenas, including advocacy, policy, education, and multiple social services.
- The value of shared leadership at multiple levels – the medical staff (both inside and outside the prison), the community health workers and peer educators, and the volunteers.
- The importance of focusing on outcomes, particularly in an environment where there is demand to replicate a successful program.
According to 2008 report by the Pew Charitable Trusts, more than 1 in 100 American adults are incarcerated. As the report notes, “For some groups, the incarceration numbers are especially startling. While one in 30 men between the ages of 20 and 34 is behind bars, for black males in that age group the figure is one in nine. Gender adds another dimension to the picture. Men still are roughly 10 times more likely to be in jail or prison, but the female population is burgeoning at a far brisker pace. For black women in their mid- to late-30s, the incarceration rate also has hit the 1-in-100 mark. Growing older, meanwhile, continues to have a dramatic chilling effect on criminal behavior. While one in every 53 people in their 20s is behind bars, the rate for those over 55 falls to one in 837.” When their sentences are served and these individuals are released into the community, there are often no community supports or safety net. Health and other needs can go unchecked. These individuals become some of the most marginalized and disenfranchised members of a community.
In the District of Columbia, Unity Health Care and a set of community partners have joined forces to design and deliver a prisoner re-entry program for individuals returning from federal penitentiaries outside of the city. According to the Court Supervision and Services Agency, over 2,000 men and women return to the District each year from federal prisons. This is in addition to the thousands that cycle through our local jail. That program is in its early stages. CHF and other local foundations have provided funding support through a Local Funding Partnership with the Robert Wood Johnson Foundation. The work is complex and very tough. But, it’s an issue that our community cannot afford to neglect. The good news is that there are other communities and models across the country to help guide our way.
Dina Gebrehiwot joined CHF in June. She provides administrative support to both the Foundation and the 
Carissa Lewis is CHF’s 2010 Summer MPH Fellow. During the academic year, Carissa attends the University of Michigan, where she is pursuing two master’s degrees, one in public health with a concentration in health policy and management, and the other in social work with a focus on social policy and evaluation. After graduation, in December 2010, she hopes to focus on mental health and/or women’s health issues and work in policy advocacy or lobbying for a non-profit organization. Carissa will be with CHF until mid-August.