EDITORIAL Addressing Mass Incarceration: A Clarion Call for Public Health

The United States has the highest incarceration rate in the world with 2.2 million people in jails and prisons. The growth in the number of people behind bars over the last four decades is staggering; since the mid-1970s, it has swelled by more than 500%. The United States constitutes less than five percent of the world’s population, yet accounts for about one quarter of its prisoners, and at 756 per 100 000, the per capita incarceration rate far exceeds that of other industrialized democracies.1 People in correctional facilities are among the unhealthiest and most medically underserved in society. Compared with the general population, they have significantly higher rates of infectious and chronic diseases. People with addiction and serious mental illness are gravely overrepresented in the criminal justice system: an estimated 16% of men and 31% of women in jail have a serious psychiatric condition, compared with 5% in the general population and at least 50% experience problems related to drug or alcohol use.2 Although access to health care within jails and prisons is constitutionally mandated, the quality of health care services in these settings lags far behind the standard of care in the community. Furthermore, correctional facilities are unhealthy environments, where individuals are exposed to a range of conditions that are detrimental to physical and mental health—overcrowding, violence, poor nutrition, unsanitary conditions, and solitary confinement. As the US Supreme

March 2014, Vol 104, No. 3 | American Journal of Public Health

During a visit to San Quentin State Prison in California, Sunshine, aged 7 years, makes a Father’s Day card for her father Kinney who said he was serving a life sentence for murder. An annual Father’s Day event, Get On The Bus, brings children in California to visit their fathers in prison (see http://www.getonthebus.us/index.php). Sixty percent of parents in state prison report being held more than 100 miles from their children. Regular prison visits lower rates of recidivism for the parent and make the child better emotionally adjusted and less likely to become delinquent, according to The Center for Restorative Justice Works, the non-profit organization that runs the program. Photograph by Lucy Nicholson. Printed with permission of Creative Professionals. Court affirmed in the landmark case Plata v. Brown (2011) addressing overcrowding in Californian prisons, such conditions can result in an “unconscionable degree of suffering and death.”3 The cycling of people between jails, prisons, and poor communities is a likely contributor to population health disparities. Each year, roughly seven million people cycle between jail systems and the community, while about 700 000 are released from prisons.4 People returning home bring with them the negative health consequences of incarceration and a disproportionate percentage return to impoverished communities of color, further exacerbating

existing health disparities and social inequalities. 5 While there is much still to learn about the complex relationship between mass incarceration and population health, existing research illustrates how punitive criminal justice policies can affect the social ecology of communities in ways that are known to negatively influence mortality and morbidity. High concentrations of incarceration in a geographic area can impact the social determinants of health by criminalizing and stigmatizing the medically underserved,6 exacerbating education achievement gaps, crippling the social mobility of young men of color, disenfranchising millions from

Editorial | 389

EDITORIAL

the democratic process,7 depriving children with incarcerated parents of economic and familial support, undermining the collective efficacy of urban neighborhoods, and stymieing the economic progress of historically oppressed groups.8

EXISTING ON AN ISLAND Historically, public health and corrections systems have operated in silos with different philosophies, funding streams and priorities. The long-standing cultural and organizational divide between these systems disrupts continuity in care, breeds inefficiency, and results in preventable morbidity and mortality. Despite high levels of need, people entangled in the US criminal justice system have been largely absent from strategies intended to improve the health and longevity of populations by targeting the disadvantaged. Even though the quantity of health services delivered in large metropolitan jails can mirror that of a medium-sized hospital, correctional health providers are detached from services, standards, technologies, and ethics of mainstream health systems. Health departments do not collect sufficient information on the health profiles of people in their jails and prisons and often play a minimal role in planning, monitoring, or delivering correctional health services, leaving corrections departments responsible for developing and managing health services for a high-need population. Despite epidemiological evidence of excess mortality risks during the initial weeks of reentry, most states release people from custody without health insurance, a treatment referral, or a meaningful plan to continue

390 | Editorial

care in the community.9 At a critical juncture for intervention, most health departments are absent.

A POLICY CLIMATE FOR CHANGE Fortunately, even amid the currently polarized state of US politics, there are opportunities to promote a public health approach to reforming the criminal justice system. The Affordable Care Act (ACA) will change the landscape of the US health system.10 The law will extend coverage and services to medically underserved groups that have historically been excluded from public health benefits— including young, impoverished adults who often rely on emergency rooms and the criminal justice system to access health services. The law’s regulatory requirements, which include mental health and substance use treatment as “essential health benefits,” promise to radically increase access to community-based behavioral health services. Additionally, lawmakers on both sides of the aisle increasingly acknowledge the unsustainable social and fiscal ramifications of criminal justice policies that have fueled forty years of prison growth. Attorney General Eric Holder’s speech delivered before the American Bar Association in August 2013, called for major reforms to laws mandating prison time for drug crimes and greater investment in rehabilitation initiatives.11 At the state level, a growth in “therapeutic jurisprudence”— the application of treatment philosophies to the justice system—has led to a proliferation of programs intended to divert people with serious mental illness, addiction, and trauma histories away from

incarceration in favor of communitybased treatment services. The stage is set for a shift away from a punitive paradigm to a public health approach that conceives addiction, mental illness, and chronic illness as health conditions requiring treatment rather than punishable symptoms of moral failure.

A CALL TO ACTION Addressing the consequences of mass incarceration is one of the great public health challenges of our time. It will require leadership, interagency collaboration, education, and cultural change. Policymakers, researchers, and community advocates can take a number of steps to bridge the divide between correctional and community health.

Forming New Partnerships Public health agencies must play a more active role in outreach, health education, and Medicaid enrollment for incarcerated populations with chronic health conditions. Not having health insurance creates structural barriers to accessing community-based services and can lead to preventable morbidity, mortality, and recidivism. Especially in states expanding Medicaid eligibility, health departments should partner with criminal justice agencies to develop strategies for facilitating enrollment into health plans inside jails and prisons. Agencies should consider partnering with community health organizations to employ formerly incarcerated community health workers to help people leaving correctional settings navigate and engage with community health services.

The Power of Data New forms of health information technology (HIT) are revolutionizing the ability of community health organizations to provide coordinated treatment services to patients as they move between various treatment settings. Investment in HIT is essential to improving coordination between providers in correctional systems and community health systems, leading to far-reaching benefits for personal health, public health, and public safety. An increasing number of states and city governments are actively working to develop bidirectional information flow between community health and justice systems through electronic health records (EHRs) and health information exchanges (HIEs). Utilizing HIEs allows justice and community health systems to access data necessary to improve continuity of care as individuals transition between systems. Providing courts with carefully regulated access to this information can also help identify people with behavioral health problems who are better suited for treatment in the community as an alternative to incarceration. EHRs and HIEs can also provide rich data sources for health departments interested in the incidence of disease in correctional settings and the effects of correctional environments and policies on health outcomes.

Rethinking Drug Policy Public health researchers and policymakers must continue to reassess the impact of the laws and policies that have fueled mass incarceration through a social epidemiology lens. This means asking not only whether the justice system’s approach to drug addiction reduces future arrests but also determining what impact

American Journal of Public Health | March 2014, Vol 104, No. 3

EDITORIAL

these laws and policies have on the health of individuals and the social ecology of the communities where they live. Metrics that capture the years of life lost from premature death and disability, such as disability adjusted life years, can be useful to quantify the impact of drug law reform, diversion programs, and prosecution practices on public health.

CONCLUSIONS For the last 40 years, an overreliance on the criminal justice system to respond to the related social problems of poverty, homelessness, addiction, and chronic mental illness has resulted in an epidemic of mass incarceration. Policymakers are waking up to the unsustainable social and economic failures of this overly punitive approach, and increasingly turning to solutions that prioritize access to health care, education, and economic opportunity to prevent crime. The current alignment of funding opportunities, political will, and technical capacity to provide coordinated services across systems creates a momentous opportunity for public health to reinvigorate its core values in social justice to improve the health of poor, underserved communities afflicted by mass incarceration. For those committed to abating gross health disparities, the sad fact is that there is no other institutional setting where so many people with such poor health can be reached. j

Correspondence should be sent to David H. Cloud, 233 Broadway, 12th Floor, New York, NY 10279 (e-mail: [email protected], 212-376-3053). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This editorial was accepted October 18, 2013. doi:10.2105/AJPH.2013.301741

References

Contributors

3. Brown v. Plata, 131 S. Ct. 1910 (2011).

D. H. Cloud conceptualized and authored the content of this editorial. J. Parsons and A. Delany-Brumsey provided valuable insights and editing.

Acknowledgments The Justice and Health Connect initiative (http://www.jhconnect.org) at the Vera Institute of Justice is federally supported by the Bureau of Justice Assistance with additional support from Community-Oriented Correctional Health Services.

1. Drucker E. A Plague of Prisons: The Epidemiology of Mass Incarceration in America. New York, NY: The New Press; 2011:37---47. 2. Dumont DM, Brockmann B, Dickman S, et al. Public health and the epidemic of incarceration. Annu Rev Public Health. 2012;33:325---339.

4. Freudenberg N, Daniels J, Crum M, et al. Coming home from jail: the social and health consequences of community reentry for women, male adolescents, and their families and communities. Am J Public Health. 2005;95(10):1725---1736. 5. Iguchi MY, Bell J, Ramchand RN, et al. How criminal system racial disparities may translate into health disparities. J Health Care Poor Underserved. 2005;16(4):48---56. 6. Draine J, Salzer MS, Culhane D, et al. Role of social disadvantage in

crime, joblessness, and homelessness among persons with serious mental illness. Psychiatr Serv. 2002;53(5): 565---573. 7. Western B, Pettit B. Incarceration and social inequality. Daedalus. 2010; 139:8---19. 8. Wilderman C & Muller C. Mass Imprisonment and Inequality in Family Life. Annu Rev Law Soc Sci. 2012; (8): 11---30. 9. Binswanger IA, Stern MF, Deyo RA, et al. Release from prison —a high risk of death for former inmates. N Engl J Med. 2007;356(2):157---165. 10. Patient Protection and Affordable Care Act. Pub. L. No. 111---148 (2010). 11. Attorney General Eric Holder. Remarks at the Annual Meeting of the American Bar Association’s House of Delegates; August 2013; San Francisco, CA.

David H. Cloud, JD Jim Parsons, MSc Ayesha Delany-Brumsey, PhD

About the Authors All authors are members of the Substance Use and Mental Health program, Vera Institute of Justice, New York, NY.

March 2014, Vol 104, No. 3 | American Journal of Public Health

Editorial | 391

Addressing mass incarceration: a clarion call for public health.

Addressing mass incarceration: a clarion call for public health. - PDF Download Free
721KB Sizes 0 Downloads 0 Views