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 num-
ber 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 ve percent of the
worlds population, yet accounts
for about one quarter of its pris-
oners, and at 756 per 100 000,
the per capita incarceration
rate far exceeds that of other
industrialized democracies.
1
Peo-
ple in correctional facilities are
among the unhealthiest and most
medically underserved in society.
Compared with the general
population, they have signi-
cantly higher rates of infectious
and chronic diseases. People with
addiction and serious mental
illness are gravely overrepre-
sented 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 consti-
tutionally mandated, the quality
of health care services in these
settings lags far behind the stan-
dard of care in the community.
Furthermore, correctional facili-
ties are unhealthy environments,
where individuals are exposed to
a range of conditions that are
detrimental to physical and
mental healthovercrowding,
violence, poor nutrition, unsani-
tary conditions, and solitary con-
nement. As the US Supreme
Court afrmed in the landmark
case Plata v. Brown (2011)
addressing overcrowding in
Californian prisons, such condi-
tions can result in an uncon-
scionable degree of suffering
and death.
3
The cycling of people between
jails, prisons, and poor communi-
ties is a likely contributor to pop-
ulation 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 dispro-
portionate 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 relation-
ship between mass incarceration
and population health, existing
research illustrates how punitive
criminal justice policies can affect
the social ecology of communi-
ties in ways that are known to
negatively inuence mortality
and morbidity. High concentra-
tions of incarceration in a geo-
graphic area can impact the so-
cial determinants of health by
criminalizing and stigmatizing
the medically underserved,
6
ex-
acerbating education achieve-
ment gaps, crippling the social
mobility of young men of color,
disenfranchising millions from
During a visit to San Quentin State Prison in California, Sunshine, aged
7 years, makes a Fathers Day card for her father Kinney who said he
was serving a life sentence for murder. An annual Fathers 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-prot
organization that runs the program. Photograph by Lucy Nicholson.
Printed with permission of Creative Professionals.
March 2014, Vol 104, No. 3 | American Journal of Public Health Editorial | 389
the democratic process,
7
depriv-
ing children with incarcerated
parents of economic and familial
support, undermining the collec-
tive efcacy of urban neighbor-
hoods, and stymieing the eco-
nomic progress of historically
oppressed groups.
8
EXISTING ON AN ISLAND
Historically, public health and
corrections systems have oper-
ated in silos with different phi-
losophies, funding streams and
priorities. The long-standing cul-
tural and organizational divide
between these systems disrupts
continuity in care, breeds inef-
ciency, and results in preventable
morbidity and mortality. Despite
high levels of need, people
entangled in the US criminal jus-
tice system have been largely
absent from strategies intended
to improve the health and lon-
gevity of populations by target-
ing the disadvantaged. Even
though the quantity of health
services delivered in large met-
ropolitan jails can mirror that
of a medium-sized hospital, cor-
rectional health providers are
detached from services, stan-
dards, technologies, and ethics
of mainstream health systems.
Health departments do not col-
lect sufcient information on
the health proles of people in
their jails and prisons and often
play a minimal role in planning,
monitoring, or delivering correc-
tional health services, leaving
corrections departments responsi-
ble for developing and managing
health services for a high-need
population. Despite epidemiologi-
cal evidence of excess mortality
risks during the initial weeks of
reentry, most states release peo-
ple from custody without health
insurance, a treatment referral,
or a meaningful plan to continue
care in the community.
9
At a crit-
ical 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 ap-
proach to reforming the criminal
justice system. The Affordable
Care Act (ACA) will change the
landscape of the US health sys-
tem.
10
The law will extend cov-
erage and services to medically
underserved groups that have
historically been excluded from
public health benets including
young, impoverished adults who
often rely on emergency rooms
and the criminal justice system
to access health services. The
laws regulatory requirements,
which include mental health and
substance use treatment as es-
sential health benets, 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 scal ramications of
criminal justice policies that have
fueled forty years of prison
growth. Attorney General Eric
Holders 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 initia-
tives.
11
At the state level, a growth
in therapeutic jurisprudence
the application of treatment phi-
losophies to the justice systemhas
led to a proliferation of programs
intended to divert people with
serious mental illness, addiction,
and trauma histories away from
incarceration in favor of community-
based 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 condi-
tions 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 chal-
lenges of our time. It will require
leadership, interagency col-
laboration, education, and cul-
tural change. Policymakers,
researchers, and community ad-
vocates can take a number of
steps to bridge the divide be-
tween correctional and commu-
nity health.
Forming New Partnerships
Public health agencies must
play a more active role in out-
reach, health education, and
Medicaid enrollment for incar-
cerated populations with chronic
health conditions. Not having
health insurance creates struc-
tural barriers to accessing
community-based services and
can lead to preventable morbid-
ity, mortality, and recidivism.
Especially in states expanding
Medicaid eligibility, health de-
partments should partner with
criminal justice agencies to de-
velop strategies for facilitating
enrollment into health plans
inside jails and prisons. Agen-
cies should consider partnering
with community health organi-
zations to employ formerly in-
carcerated community health
workers to help people leaving
correctional settings navigate and
engage with community health
services.
The Power of Data
New forms of health informa-
tion technology (HIT) are revolu-
tionizing the ability of community
health organizations to provide
coordinated treatment services to
patients as they move between
various treatment settings. Invest-
ment in HIT is essential to im-
proving coordination between
providers in correctional systems
and community health systems,
leading to far-reaching benets
for personal health, public health,
and public safety. An increasing
number of states and city gov-
ernments are actively working to
develop bidirectional information
ow between community health
and justice systems through
electronic health records (EHRs)
and health information exchanges
(HIEs). Utilizing HIEs allows
justice and community health sys-
tems to access data necessary to
improve continuity of care as in-
dividuals 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 depart-
ments 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 ep-
idemiology lens. This means ask-
ing not only whether the justice
systems approach to drug addic-
tion reduces future arrests but
also determining what impact
390 | Editorial 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 communi-
ties 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 prose-
cution practices on public health.
CONCLUSIONS
For the last 40 years, an
overreliance on the criminal jus-
tice system to respond to the
related social problems of pov-
erty, 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 so-
lutions that prioritize access to
health care, education, and eco-
nomic opportunity to prevent
crime. The current alignment of
funding opportunities, political
will, and technical capacity to
provide coordinated services across
systems creates a momentous op-
portunity for public health to rein-
vigorate its core values in social
justice to improve the health of
poor, underserved communities
aficted 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
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.
Correspondence should be sent to David
H. Cloud, 233 Broadway, 12
th
Floor, New
York, NY 10279 (e-mail: dcloud@vera.org,
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
Contributors
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 initia-
tive (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.
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