Detail of a cover of a paperback book, with an image of a bed with touseled sheets and text: By the Bureau of Prisons-Public Health Service.

Characterizing Carceral Health at the NLM

Jessica L. Adler ~

While undertaking research for a book on the history of medical care in U.S. carceral facilities, I’ve been searching archives for materials related to a variety of types of institutions—federal prisons, state prisons, local jails.

The approach requires justification. After all, structures of carceral administration vary widely throughout the United States. Broadly, the Bureau of Prisons has historically overseen health care in many federal prisons, whereas state Departments of Corrections, under the auspices of state legislatures, direct services in state prisons. Meanwhile, municipalities generally manage medical care in jails. Beyond the bureaucracy, numerous other particularities influence facilities, such as local culture and the actions of individuals working and detained inside. These dynamics help explain why many seminal studies of the history of incarceration focus on one institution or locale.

Two men in uniform talk to a man in a doorway.
A Public Health Service physician with the Bureau of Prisons talks with an incarcerated person
National Library of Medicine #101446070

But materials in archives reveal that health services in prisons and jails across the country—and how they are perceived or resisted by incarcerated people—are shaped by some overarching (albeit changing) edicts, policies, and social currents. Documents located in more than a dozen collections at the National Library of Medicine (NLM), for example, illustrate that health care professionals and bureaucrats have, for upwards of a century, both embraced and voiced reservations about links between medical authority and punishment. They also highlight connections between shrinking government health care and expanding medicalized incarceration in the late twentieth century. NLM records suggest, too, that stakeholders have long recognized that health services within carceral institutions ranged from non-existent to inhumane. Their proposed solutions—more rigidity, standards, and rules—regularly failed to bring about positive outcomes for incarcerated people. Across time, and in every type of carceral facility, detained people fought against medical neglect and manipulation, and for safety, dignity, and power.

One of the collections at the NLM that reflects some of these realities is that of psychiatrist and public health advocate Bertram S. Brown. Known for supporting community-based rather than institutionalized care for people with mental illnesses and disabilities, Brown worked for the National Institute of Mental Health (NIMH) from 1960 to 1977 and directed the agency between 1970 and 1977.

In 1960, the same year he assumed his post at the NIMH, Brown began advising staff at the Patuxent Institute, a Maryland state facility established in 1955 to house so-called “defective delinquents.” Brown’s records from his time at the Institute are reminiscent of those I’ve viewed in other archives related to similar facilities. They suggest that psychologists and psychiatrists who were called upon to offer medical assessments of jailed and imprisoned people—sometimes by prison staff frustrated by unruly behavior—wielded tremendous power. Rather than opening doors to therapeutic care, diagnoses could lead to harsh treatment and prolonged sentences.

In January 1961, those realities informed Brown’s advice to the Patuxent Parole Board about former prisoners’ morale:

Detail from a typed and mimeographed document.“One can not at this time help but understand the parolees’ attitudes concerning release… because no man has ever been released from parole… one of the therapeutic uses of the indeterminate sentence, namely that one can eventually earn release, has not yet been brought into reality for them.”

1963 writs of habeus corpus and appeals filed by Patuxent detainees, and included in Brown’s records, demonstrate that incarcerated people ardently strove to call attention to their plight. Alleging that psychiatrists’ diagnoses, or “labels,” were both arbitrary and viewed by courts as unquestionable, the imprisoned men and their lawyers proclaimed: “The substantial constitutional questions presented by the petitioner to retain his liberty should not be obscured by a tyranny of labels.” That rationale informed countless lawsuits against Patuxent and other similarly oriented institutions in the 1960s and 1970s.

Handwriting says: Petitioner is presently held, against his will, in actual, immediate, physical custody, in violation of the constitution of the United States. The substantial constitutional questions presented by the practitioner to regain his liberty should not be obscured by a Tyranny of Labels.Brown’s Patuxent-related records underscore the deep impacts of medical authority on incarceration. They also highlight that—as scholars such as Susan Burch, Kylie M. Smith, Liat Ben-Moshe, Ayah Nuriddin, Anne E. Parsons, Jonathan Metzl, and Nancy Tomes have suggested—histories of the detention of people with mental illnesses and disabilities, and of people convicted of crimes, have long overlapped.

Cover of a paperback book with an image of a patient with an IV in a bed and a man in a suit leaning over him.
A study of the Federal prisons health services
by the Bureau of Prisons-Public Health Service Program Study Group, 1966
National Library of Medicine #101527221

While Brown’s records focus heavily on mental health, they also hint at connections between health policy, the welfare state, and imprisonment. A 1971 meeting with the staff of a Public Health Service (PHS) Hospital in Fort Worth, Texas, which had been established three decades earlier to offer treatment to people with substance use disorders, is revealing. Within months, Brown told attendees, the PHS would be handing over the property to the Bureau of Prisons (BoP). The closure of the PHS hospital, he noted, indicated a federal commitment to a “community approach” rather than “direct care in far-away institutions.”

Although Brown emphasized the merits of deinstitutionalization, the Fort Worth facility did not simply close; it transitioned. And the nature of its transition is crucial. Elsewhere at the NLM, in the Public Health Service Hospitals Historical Collection, for example, lists of hospital closures from the 1940s through the 1970s show that Fort Worth was hardly unique. The federal government appears to have increasingly rescinded the role of providing care in its own hospitals during the same years it (like state governments) began devoting more resources to imprisonment.

The Fort Worth story hints at a larger context, illuminated by NLM records: as access to public health services, entitlements, and health insurance became increasingly precarious in the free world in the final decades of the twentieth century, higher numbers of people—especially from marginalized groups—were criminalized and incarcerated. And activists and practitioners called attention to both prisons and jails as sites of public health catastrophe. For example, the 1977 Proceedings of the 1st National Conference on Improved Medical Care and Health Services in Jails, reveal that, in the wake of a rash of prison uprisings in the early 1970s, groups like the American Medical Association (AMA), the American Bar Association, the National Jail Association, and the American Correctional Association studied, acknowledged, and centered “the poor quality of medical services in institutions, particularly in jails.” The AMA’s survey of more than 2,000 jails nationwide revealed that many featured “outmoded facilities, inadequate staffs, limited funds and uninterested doctors.” Findings like those justified the establishment in the 1970s and 1980s of health-related rules and standards for correctional institutions. The latter, often flouted by prison and jail administrators who prized local control, failed to alleviate the varied and dire health threats of incarceration.

Four decades ago, John Lewis Gaddis in Strategies of Containment, juxtaposed historians who prioritize making broad generalizations and finding patterns (“lumpers”) with those who search out and analyze the exceptional (“splitters”). Both approaches have their peril and promise, Gaddis surmised, and both are “indispensable.” While the dichotomy might be overstated—after all, historians need to lump to effectively split, and they need to split to effectively lump—the general point is useful. The expansive resources at the NLM enable those wishing to tell national stories to both “split” and “lump”—to consider not just divides, but also ties, between federal, state, and local practices.

Jessica L. Adler, PhD, is an Associate Professor at Florida International University and a 2021 NLM Michael E. DeBakey Fellow in the History of Medicine.


  1. Ms. Adler, this is an engaging commentary as it enlightens the lay person about former treatment of incarcerated persons in the USA’s penal system which, as you note, is variegated by federal, state, and local regulations and individual practices, regrettably (since they are supported by unwilling taxpayers as well as proponents of reform). However, by reflecting on past failures and strengthening successes, reform advocates help to promote necessary changes that propose policies that punish, when necessary and/or rehabilitate, when adventitious so that the general social welfare is improved by implementation of model innovative carceral structures in the United States and across the globe. One segment of the incarcerated population that has been unaddressed here is that of political prisoners; the other, focused on but also in continued need of stressing, is the mentally challenged inmate. These two groups should not lose their dignity but, to my mind, require special training to meet the challenges they make to the prison system and its ancillary method of confinement or parole (i.e., restricted freedoms).

    1. Thank you for reading, and thank you for your comment. Your points about “unaddressed” incarcerated populations highlight the importance of recognizing that people in jails and prisons have multi-faceted identities. A variety of characteristics – for example, demographic background, social and political beliefs, and health status – can make some individuals particularly vulnerable to criminalization and deeply impact how they are treated in carceral institutions and systems.

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