Who’s Using and Who’s Doing Time: Incarceration, the War on Drugs, and Public Health

WITHOUT A PERSONAL connection, scientists, researchers, and those who set public policy rarely know the stories of those who are convicted of felony crimes and sentenced to prison: how they came to be convicted, whom they left behind, and what they went home to once released. But the consequences of their imprisonment—social, economic, political, and personal—are evidenced daily in every major city, suburban town, and rural hamlet.

We aim to reframe the growth of the prison industrial complex and the war on drugs from the perspective of those incarcerated for nonviolent, drug-related crimes. By framing the issue this way, we hope to add an often ignored or poorly understood factor to analyses of health disparities. We also hope to highlight an area of public health that has escaped adequate recognition and begin the dialogue necessary to meet the challenges facing people of color in and out of prison while at the same time supporting public health policy changes to meet these challenges.

WAR ON DRUGS

The stories of convicted felons and their families, friends, and communities are shaped by the overreaching arm of the prison industrial complex. The justice system that was designated to “protect and serve” took on the challenge of the war on drugs in 1968 when the Nixon administration decided to redouble efforts against the sale, distribution, and consumption of illicit drugs in the United States. This “war on drugs,” which all subsequent presidents have embraced, has created a behemoth of courts, jails, and prisons that have done little to decrease the use of drugs while doing much to create confusion and hardship in families of color and urban communities.1^,2

Since 1972, the number of people incarcerated has increased 5-fold without a comparable decrease in crime or drug use.1^,3 In fact, the decreased costs of opiates and stimulants and the increased potency of cannabis might lead one to an opposing conclusion.4 Given the politics of the war on drugs, skyrocketing incarceration rates are deemed a sign of success, not failure. Regardless of any analysis of the success or failure of the war on drugs, its impact on lives and communities is much less controversial. The criminal justice system accepts responsibility for making our neighborhoods and cities safe for all. Should it be responsible for the resulting collateral damage to families and communities?5^,6

A broad moral panic about crime fueled by media headlines and political expediency created the need to escalate the war on drugs.7 The outcome has increased incarceration produced by tougher laws and prosecution, less judicial discretion, and greater policing. Because these laws are not enforced equally, most often the poor and people of color who are financially or socially unable to remove themselves from environments that are labeled “drug areas” are persecuted. They inadvertently place themselves directly in the midst of our nation’s war on drugs.

The war becomes a never-ending battle that distorts the face of communities by removing crucial members: parents, spouses, friends, and employees.6^,8 In the eyes of many politicians, police commissioners, community leaders, and affluent citizens, the war on drugs may appear to be a successful one—incarceration rates are on the rise and prisons are built almost as quickly and the threat of drugs is, in theory, being removed from neighborhoods, school playgrounds, and public parks. It would be convenient to consider this the end of the problem, to wash our hands of drugs and felons and move on to something else, something more deserving of attention from both the criminal justice system and public policy.

The consequences of “clean streets” are antithetical to what it takes to build healthy communities; the residual effects of systematic removal and efficient imprisonment of drug users creates a much larger challenge. The repercussions of removing people from their families and communities and then depositing them back later, without any assistance or substantial rehabilitation, are grave.9 Men and women who have served extensive prison sentences for nonviolent drug offenses are not only left with little or no social support but also clearly marked by the criminal justice system as potentially threatening repeat offenders. They are not only taken away from their loved ones but also placed in an impossible situation, one in which they are unable to provide for their families or retain emotional ties with their loved ones. On release, most, as convicted felons, find it difficult to procure gainful, legitimate employment. As with many wars, the collateral damage of the war on drugs is made invisible but is no less destructive.6

WHO’S USING AND WHO’S DOING TIME

There are discrepancies surrounding rates of drug use among the general public and the population serving prison time for nonviolent, drug-related offenses. In addition, social and health policy issues are created by these differences left undetected or unaddressed by those who have created them: the criminal justice system and the current political agenda. Public health as a discipline is now in a prime position to call attention to these discrepancies, design programs to assist both the incarcerated individuals and their families, and create the social environment necessary to change the political climate and social policy surrounding who’s using and who’s doing time.

Drug use in suburban areas goes unchecked and underreported, while people of color are profiled in urban areas as potential drug users and dealers. Although there is a serious drug problem in urban, minority communities, the problem also exists in every other community. Profiling is more difficult to conduct in suburban areas; therefore, cities are most often the locations in which minorities are arrested for nonviolent drug-related offenses.

Who’s Using

Although the current rates of illicit drug use are roughly the same between Blacks and Whites (7.4% and 7.2%, respectively) and lower for Lations (6.4%), the number of White drug users is vastly greater than that of drug users of color because White people are a larger share of the population.10 In 1998, Whites composed 72% of all illicit drug users compared with the 15% share contributed by Blacks. Whites were nearly 5 times more likely than are Blacks to use marijuana and were 3 times more likely than Blacks to have ever used crack.7

The communities reporting drug use are not the only ones typically considered to be high

“Public health as a discipline is now in a prime position to call attention to these discrepancies, design programs to assist both the incarcerated individuals and their families, and create the social environment necessary to change the political climate and social policy surrounding who’s using and who’s doing time.”

drug traffic areas: drug use is prevalent in suburban, middle-class areas around the country as well as in rural settings and in cities. However, suburban police presence is largely concerned with the residents’ desire to keep the “bad element” out rather than turn attention to its own citizens. From a public health perspective, this is probably a good thing, because the middle class and affluent are more likely to use drug treatment, counseling, and simple maturation as solutions to problematic drug use.11^,12

Who’s Doing Time

Persons of color compose 60% of the incarcerated population.13 In 1996, Blacks constituted 62.6% of drug offenders in state prisons. Nationwide, the rate of persons admitted to prison on drug charges for Black men is 13 times that for White men, and in 10 states, the rates are 26 to 57 times those for White men.8 People of color are not more likely to do drugs; Black men do not have an abnormal predilection for intoxication. They are, however, more likely to be arrested and prosecuted for their use.

The prison system is designed to remove a criminal from society, but it leaves an inadequate system to cope with what is left behind. A vital member of both a family and community is gone, weakening emotional family and community ties. Prisons are typically located far away from the cities in which most inmates live.14 For a family, the cost of transportation and accommodations, not to mention time to visit their incarcerated relative, will typically discourage frequent visits. Children lose vital contact with parents and other caregivers.6^,15 Incarceration also bleeds the broader community of men and women who would otherwise contribute to the workforce and to community life.

From a broader political perspective, this has led to systematic disenfranchisement of the poor and of people of color, particularly in the South. Persons who are incarcerated lose their right to vote, in some states for the rest of their lives.16^,17 Because the US Census and other population surveys base residence on where one currently lives, as opposed to where one customarily lives, population counts in rural communities that house prisons are artificially bloated, whereas urban populations shrink proportionately.18 This has negative implications for cities in regards to the allocation of resources and political redistricting. Taken as a whole, the latter 3 points ultimately result in the erosion of representative democracy nationwide.

The impact of the criminal justice system is evident in the Black and Latino communities in major cities who often suffer from underserved state and government assistance for education, health, and employment. Services that might prevent drug use are underfunded, and the budget for the war on drugs increases. More than $11 billion was spent on the war against drugs in 2003. That budget has steadily increased, with more than $12 billion in funding for 2006.19 State and local governments are spending another $30 billion on the offensive against drugs.20 There are more than 2 million men and women serving sentences in United States prisons, nearly three quarters for nonviolent offenses.8^,13 The unequal enforcement of the war on drugs serves to fuel our spiraling incarceration rates and the removal of men, women, and children from our communities.

HEALTH ON THE INSIDE

Prisons are not healthy places. Ironically, although medical care is neither mandated nor considered to be a right for the general population, it is mandated for prison inmates. In spite of this, prison medical care is substandard in many states. The California prison health system’s entrance into federal receivership is an extreme example of the crisis.21 Prison inmates suffer from high rates of mental illness, HIV, tuberculosis and other infectious diseases, and of course, violence.22^–24

Although prisons are mandated to treat infectious diseases and other conditions, they are in no way required to support controversial programs such as condom distribution and needle exchanges for HIV and hepatitis C prevention. Prisons often house inmates from communities disproportionately affected by health inequities and, in turn, return sick people to those same communities.

There are no guarantees that incarcerated persons will be healthier on their return home. Incarceration increases the risk of exposure to HIV and other preventable conditions; families and sexual partners reunited with their loved ones in turn find themselves at an increased risk of infection. Partners and children of incarcerated persons and the wider communities of color bear the burden of morbidity and mortality.25

LIFE AFTER PRISON?

The challenges that lead a person to prison—drug addition, alcoholism, untreated mental illnesses, lack of employment opportunities—are not abated by incarceration; they are often worsened. Former inmates may have lost family and social ties. They are certainly less employable than before, because many employers do not hire convicted felons. Zero tolerance laws prohibit people with drug-related felonies from using government assistance such as public housing and federal financial aid to attend college. However, violent felons are not excluded from these programs.26 The trend away from rehabilitation in the past 20 years means that fewer people are able to get college degrees or transferable job skills while in prison.27 Three quarters of state prison inmates lack a high school diploma, and less-educated inmates are more likely than their educated peers to be recidivists.28 Policymakers discuss the need for increasing the technological skills of the country’s workforce by offering education for meaningful employment, yet we have a massive and growing population of formerly incarcerated persons that may never be able to participate in the legitimate job market aside from unskilled, minimum-wage labor.

The popular war on drugs translates to a war on people of color in terms of their overall health and well-being. It is unlikely that an ex-felon will navigate with success the hurdles constructed by the criminal justice system during imprisonment and then tackle additional barriers set up by both the government and society once released. These consequences are the byproduct of a double standard that gives treatment to the rich and prison to the poor. They are also a result of the politics of fear, which compels politicians to fund prisons over schools and punishment over health.

EMERGENCY CALL AS A PERSONAL CONNECTION

Communities of color face an escalating public health problem created by our society’s solution to imprison those arrested for nonviolent drug offenses. Challenges that plague inner cities—from poverty and hopelessness to substance use and increased morbidity and mortality—are exacerbated by high incarceration rates; suburban communities are not “harmed” when nonviolent drug offenders are given treatment and second chances. Public health practitioners and policymakers should work in collaboration to treat this as a public health problem, one that deserves prevention and treatment rather than punishment. Primary prevention includes the creation of strong, viable communities in which members have employment and other options besides drugs. Substance use treatment can be more effective only in places where the conditions of primary prevention are established.

Public health professionals should advocate for the families of incarcerated people. Family separation is a likely cause of recidivism and can contribute to the risk of children joining their parents in the system. Everyone should be able to access quality health care and education inside and out of prison. We should support ex-felons after their prison terms in their attempts to find meaningful employment, housing, and education. Discriminating against those who have served prison sentences does nothing but propagate the perception that persons in poor communities are limited to illegal and high-risk employment and ensures their individual futures as unemployable, unsafe, and unwanted by society.29^,30

Recent years have seen changes in what was once a monolithic drive to incarcerate drug users. States have increasingly accepted drug courts as a more humane answer to drug problems.31 People within and outside the criminal justice community are recognizing the need for educational programs within prisons and viable reentry programs for release. Some judges are reasserting their discretion with sentencing.32 Jurisdictions are even being forced to cap inmate populations and institute early releases.33 It would reflect a vast improvement if coherent treatment and prevention policies guided their early releases; early releases work best when prompted by coherent prevention and treatment policies, not prison overcrowding. Activists have struggled to change punitive zero tolerance and disenfranchisement laws.

The circular pattern of prison and eventual release with limited rights has presented health risks that have gone unchecked by the public health system, creating a public health issue with no system to handle the outcome. There is no program in place to address the consequences created by the imprisonment and subsequent life-altering progress of whole populations. The issues created by incarceration must be systematically addressed through public health policy set forth by our state and federal governments. Calling these issues to the attention of our government is the overall responsibility of public health professionals because these are our communities and their stories are our stories.