Ending mass incarceration in the United States is one of the major social, political, civil rights, and economic challenges of our time. Government officials, practitioners, advocates, and philanthropists working in the fields of public health and medicine have important and distinct roles to play.
No other nation on the globe has a criminal justice system that is as bloated and punitive as the United States. With more than 2.2 million people in jails and prisons, the number of people incarcerated in this country has swelled more than six-fold since the 1970s (The Sentencing Project, 2015). The United States rate of incarceration—693 people confined per 100,000 residents—is five to 10 times larger than European countries with comparable crime rates and dwarfs the rates of many nations with greater rates of violent crime and plagued by interstate conflict. For instance, more than 75 percent of states have incarceration rates exceeding El Salvador’s, a country notoriously called a “murder capital of the world.” Nearly one in 33 adults are under some form of control or supervision of the criminal justice system.
Racial inequities pervade our penal system, but they are not the product of a logical response to crime in communities of color. Rather, they are the result of policy decisions throughout the criminal justice system that disproportionately target – and end up dismantling – communities of color. While African Americans comprise 13 percent of the population, about 38 percent of people behind bars are African American (Sabol and Couture, 2008). African American men born in 2001 have a 32 percent chance of spending time in prison in their lives, compared to six percent odds among their white counterparts (Bonczar 2003). Moreover, Blacks represent about 14 percent of people who use drugs, but comprise 35 percent of drug arrests (FBI 2007), 53 percent of all people convicted of drug crimes, and 45 percent of those sent to prison for drug related charges (Sabol et al. 2007).
Why is mass incarceration a public health problem?
We can no longer incarcerate our way out of social problems rooted in poverty, trauma, drug use, and mental illness. Research is demonstrating how the vast expansion of the carceral state has contributed to health inequalities along socioeconomic and racial gradients in profound ways.
For many impoverished, underserved, and uninsured Americans, our institutions of punishment serve as surrogates for accessing mental health and drug treatment, housing, basic education, vocational training, and essential medical services. Nationwide, insufficient investments in community mental health and social services has resulted in warehousing people with serious psychiatric conditions in correctional facilities that are ill-equipped to meet their needs. The vast majority of these individuals are swept into the correctional system for non-violent activities that are symptomatic of a failed community mental health system and an overreliance on police, courts, and correctional agencies to solve public health problems.
By the time most people enter a correctional system, they have already endured years of struggle—intergenerational poverty, failing schools, trauma, inaccessible health services, and violence. For most, incarceration can be detrimental to health. Living conditions, such as overcrowding, poor quality health care, violence, trauma, and solitary confinement are extremely harmful (Cloud, 2014). Epidemiologists are starting to tease out causal linkages between incarceration and disparities in hypertension, asthma, stress-related diseases, and general health functioning (Binswanger et al. 2012). Other studies show that disparate rates of incarceration between African Americans and whites contribute to racial disparities in health functioning in middle stages of the lifespan (Massoglia 2008).
These harms are not isolated to those who spend time behind bars. Exposures to arrest, incarceration, and the stigma of a criminal record can have long-lasting, detrimental effects on the health of entire communities over generations. For instance, about 2.7 million children in the United States have an incarcerated parent. Studies show that the growth in paternal incarceration has contributed to elevated rates of child homelessness by diminishing family finances and placing additional strains on single mothers (Wildeman 2014). Upon release, people cannot escape the stigma of felony records, as they are by design, denied fair opportunities for securing housing, pursuing education, and voting in democratic elections. A retributive criminal justice system perpetuates the very social and economic conditions that underpin international cycles of poverty, despair, and often crime.
What can we do?
What role do those working in the health field have in addressing mass incarceration? Here are a few big picture ideas to consider.
- Making mass incarceration a public health priority. Public health professionals who are committed to abating health inequalities in their communities can adopt initiatives that use a public health lens to address problems such as policing, conditions of confinement, and drug policy as public health priorities. This means asking important questions about the effect of law enforcement, court, and correctional practices on the health of individuals, families, and communities.Those in leadership roles can educate other government leaders and the public on the consequences of criminal justice policies on population health. They can spearhead novel interventions that incorporate principles of health promotion and harm reduction into the culture of public safety agencies. This could mean working with police, courts, and corrections to design strategies that prevent people with serious mental illness and chronic substance use problems from getting ensnared in perpetual cycles of arrest and incarceration.
Transparency is critical for exposing the degree of human suffering that takes place in many overcrowded correctional institutions. Epidemiologists can push for laws that establish surveillance systems for tracking the prevalence of disease among correctional populations, monitoring living conditions in correctional facilities, and creating publicly available datasets for investigating how incarceration levels shape health outcomes.
- Make shrinking the criminal justice system a goal of health care reform.
Public health leaders can advocate for increased resources in their communities for housing, psychiatric services, and substance use treatments informed by the science of harm reduction, so that police and jails no longer serve as the surrogate points of access. Decarceration will inevitably require legislative changes that drastically expand the capacity of the public health and social service infrastructure.While not enough, the Affordable Care Act creates important opportunities for extending health insurance and vital health services to historically underserved groups by expanding Medicaid eligibility to childless adults and strengthening parity requirements for behavioral health services. Public health leaders can pursue interventions that enroll newly eligible individuals into Medicaid in courts, correctional facilities, and probation offices. State Medicaid officials can develop plans that provide reimbursements for establishing and sustaining interagency programs that are designed to divert people from arrest and incarceration and into community-based care.
- Engaging academic institutions. The pursuit of social justice is foundational in public health practice. Academic institutions educating future public health leaders and practitioners committed to social equality, can develop curriculum, coursework, and practicum experiences to inform students on the intersection of mass incarceration and public health and inspire them to devote their careers to addressing these problems. Vera’s “Pathways to Postsecondary Education Project” has helped successfully expand opportunities for higher education for incarcerated people across the country (Delaney, Subramanian, and Patrick). Public health schools can also work with government officials to create free college and graduate degrees that prepare incarcerated people to join the public health workforce upon release.
- Increasing funding. The U.S. Department of Health and Human Services and philanthropic institutions with public health priorities can increase resources devoted to supporting research, programs, public education, and advocacy efforts that seek to improve the health of people whose lives have been impacted by the criminal justice system.
- Empowering those most affected. Glenn Martin, founder of JustLeadership USA, a non-profit organization that employs formerly incarcerated individuals to lead reforms and is one of the most influential forces working to fix our broken justice system, frequently states that, “those closest to the problem are closest to the solution, but the furthest from the resources and power.” Health care institutions can abate health inequities in communities afflicted by mass incarceration by training and recruiting individuals who have experienced incarceration first-hand into their workforces as clinicians, service providers, and policymakers.
Binswanger, I. A., N. Redmond, J.F. Steine., and L.S. Hicks. “Health disparities and the criminal justice system: an agenda for further research and action.” Journal of Urban Health: 89(1) (2012): 98-107.
Bonczar, T. P. “Prevalence of Imprisonment in the U.S. Population, 1974–2001.” Washington, D.C.: Bureau of Justice Statistics. (2003).
David Cloud. On Life Support: Public Health in the Age of Mass Incarceration. New York, NY: Vera Institute of Justice, 2014.
Ruth Delaney, Ram Subramanian, and Fred Patrick. Making the Grade: Developing Quality Postsecondary Education Programs in Prison. New York: Vera Institute of Justice, 2016.
Federal Bureau of Investigation. Crime in the United States, 2006. Washington, D.C. (2007).
Massoglia, M. “Incarceration, health, and racial disparities in health.” Law & Society Review: 42(2) (2008): 275-306.
Sabol, W. J., and H. Couture. “Prison Inmates at Mid-year 2007.” Washington, D.C.: Bureau of Justice Statistics. (2008).
Sabol, W. J., H. Couture, and P. Harrison. “Prisoners in 2006.” Washington, D.C.: Bureau of Justice Statistics. (2007).
The Sentencing Project. “Trends in U.S. Corrections.” (2015)
Wildeman, C. “Parental incarceration, child homelessness, and the invisible consequences of mass imprisonment.” The ANNALS of the American Academy of Political and Social Science, 651(1) (2014): 74-96.