All-Cause And Cause-Specific Mortality During And Following Incarceration In Brazil: A Retrospective Cohort Study

BackgroundMortality during and after incarceration is poorly understood in low- and middle-income countries (LMICs). The need to address this knowledge gap is especially urgent in South America, which has the fastest growing prison population in the world. In Brazil, insufficient data have precluded our understanding of all-cause and cause-specific mortality during and after incarceration.

Methods and findingsWe linked incarceration and mortality databases for the Brazilian state of Mato Grosso do Sul to obtain a retrospective cohort of 114,751 individuals with recent incarceration. Between January 1, 2009 and December 31, 2018, we identified 3,127 deaths of individuals with recent incarceration (705 in detention and 2,422 following release). We analyzed age-standardized, all-cause, and cause-specific mortality rates among individuals detained in different facility types and following release, compared to non-incarcerated residents. We additionally modeled mortality rates over time during and after incarceration for all causes of death, violence, or suicide. Deaths in custody were 2.2 times the number reported by the national prison administration (n = 317). Incarcerated men and boys experienced elevated mortality, compared with the non-incarcerated population, due to increased risk of death from violence, suicide, and communicable diseases, with the highest standardized incidence rate ratio (IRR) in semi-open prisons (2.4; 95% confidence interval [CI]: 2.0 to 2.8), police stations (3.1; 95% CI: 2.5 to 3.9), and youth detention (8.1; 95% CI: 5.9 to 10.8). Incarcerated women experienced increased mortality from suicide (IRR = 6.0, 95% CI: 1.2 to 17.7) and communicable diseases (IRR = 2.5, 95% CI: 1.1 to 5.0). Following release from prison, mortality was markedly elevated for men (IRR = 3.0; 95% CI: 2.8 to 3.1) and women (IRR = 2.4; 95% CI: 2.1 to 2.9). The risk of violent death and suicide was highest immediately post-release and declined over time; however, all-cause mortality remained elevated 8 years post-release. The limitations of this study include inability to establish causality, uncertain reliability of data during incarceration, and underestimation of mortality rates due to imperfect database linkage.

ConclusionsIncarcerated individuals in Brazil experienced increased mortality from violence, suicide, and communicable diseases. Mortality was heightened following release for all leading causes of death, with particularly high risk of early violent death and elevated all-cause mortality up to 8 years post-release. These disparities may have been underrecognized in Brazil due to underreporting and insufficient data.

Author summary Why was this study done?The global prison population is growing rapidly, particularly in Latin America.

Incarcerated and formerly incarcerated individuals may be at high risk of death from illness and external causes (i.e., homicide and suicide).

Mortality during and after incarceration has been described in high-income countries but is poorly understood in low- and middle-income countries (LMICs), including those in Latin America.

In Brazil, deaths during incarceration may be underreported, and there are no data on deaths after incarceration.

What did the researchers do and find?We retrospectively followed over 114,000 individuals with recent incarceration in a Brazilian state and used database linkage to identify deaths between 2009 and 2018 that occurred during or after incarceration.

We calculated rates of death from all causes and specific causes among incarcerated and formerly incarcerated individuals, and we compared them to rates of death in the general population.

We found elevated mortality from violence, suicide, and communicable diseases during incarceration, which was underreported by national and state sources.

Following release, individuals were at increased risk of mortality from nearly all leading causes of death, with particularly high risk of violent death and suicide among men in the first 2 years post-release.

What do these findings mean?While we could not establish causality between incarceration and mortality, many of our findings indicate increased mortality risk associated with exposure to the carceral environment.

Accurate and comprehensive data on mortality during and after incarceration are needed in Brazil and other LMICs where this issue remains poorly understood.

Structural interventions are needed to reduce the mortality risk in this population, including immediate improvement of conditions and healthcare within carceral facilities, supportive programs and services for the early transition period post-release, and implementation of alternatives to incarceration.