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. 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, data on mortality during and after incarceration are lacking.Methods and FindingsWe linked incarceration and mortality databases for the Brazilian state of Mato Grosso do Sul to obtain a cohort of 114,751 individuals with recent incarceration. Between January 1, 2009 and December 31, 2018, we identified 3127 deaths of individuals with recent incarceration (705 in detention; 2422 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. 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% CI, 2.0-2.8), police stations (3.1; 95% CI, 2.5-3.9), and youth detention (8.1; 95% CI, 5.9-10.8). Incarcerated women had increased mortality from suicide (IRR = 6.0, 95% CI 1.2-17.7) and communicable diseases (IRR = 2.5, 95% CI 1.1-5.0). We additionally modeled mortality rates over time during and after incarceration from all causes, violence, or suicide. Following release from prison, mortality was markedly elevated for men (IRR=3.0; 95% CI, 2.8-3.1) and women (IRR=2.4; 95% CI, 2.1-2.9). The risk of violent death and suicide was highest immediately post-release and declined over time; however, all-cause mortality remained elevated eight 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 eight years post-release. These disparities may have been under-recognized in Brazil due to underreporting and insufficient data.Author SummaryWhy Was This Study Done?The global prison population is growing rapidly, particularly in Latin AmericaIncarcerated and formerly incarcerated individuals may be at high risk of death from illness and external causes (i.e. homicide, suicide)Mortality during and after incarceration has been described in high-income countries but is poorly understood in low- and middle-income countries, including those in Latin AmericaIn Brazil, deaths during incarceration may be underreported, and there are no data on deaths after incarcerationWhat 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 occurring during or after incarcerationWe calculated rates of death from all causes and specific causes among incarcerated and formerly incarcerated individuals, and we compared them to those in the general populationWe found elevated mortality from violence, suicide, and communicable diseases during incarceration, which was underreported by national and state sourcesFollowing 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 two years post-releaseWhat 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 environmentThe exorbitant rates of violent deaths during and after incarceration point to deep-rooted social problems that cannot be solved by incarcerationAccurate and comprehensive data on mortality during and after incarceration are needed in Brazil and other low- and middle-income countries where this issue remains poorly understoodStructural 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