The Role of Academic Public Health in Reducing Incarceration

In 2018, there were 2.3 million people¹ in the US state and federal prison population. The US incarceration rate (716 per 100 000 people) is higher than that of any other country in the world² and about five times higher than the median worldwide (144 per 100 000).³

There is little doubt that incarceration affects health. The disability-adjusted life year rate linked to incarceration is more than double⁴ that attributed to other conditions commonly experienced in the general population. Much of this disability arises from the disenfranchisement of the formerly incarcerated,⁴ including bans on employment and social welfare benefits such as housing and public assistance. Prison enhances the transmission of infectious diseases,⁴ such as tuberculosis and viral hepatitis, because of the cramped spaces, high rates of injection drug use, and unprotected sexual relations endemic in incarceration populations. Annually, approximately one in seven Americans with HIV/AIDS⁴ passes through the prison system, reflecting a convergence of increases in drug-related incarceration and the emergence of this blood-borne virus and concentrating infection risk in this setting.

Another convergence—that of incarceration and mental illness—is the cause of substantial morbidity and, in the case of suicides, mortality among those who are incarcerated. A review of the evidence suggests that the prevalence of mental illness⁵ among those incarcerated is substantially higher than estimates from community samples. Importantly, the burdens and consequences of incarceration are borne unevenly across US society, with minority populations—particularly Black and Latinx populations—being vastly and disproportionately affected by incarceration. By way of illustration, among children born in 1990, 1 in 25 Whites and 1 in 4 Blacks had a parent imprisoned by age 14 years,⁶ an increase in magnitude and racial disparity compared with those born in 1978.

Therefore, incarceration is a prevalent challenge to the health of the US population and contributes in innumerable ways to health gaps. This suggests that the field of public health should be concerned with incarceration as a cause of health inequities and overall poor population health. With this understanding, incarceration fits squarely within the remit of schools and programs of public health, which are near uniformly motivated by a goal of improving population health and addressing health disparities.⁷ What role could academic public health then play in reducing incarceration and mitigating its consequences? At core, schools and programs have a responsibility to generate scholarship that can help us understand the health of populations, train the next generation of public health scholars, and translate their scholarship as evidence for advocacy and policymaking for generating meaningful change. We suggest that “academic public health,” the term we use here to refer to schools and programs of public health, can play a role in reducing incarceration and mitigating its consequences along each of these core functions.

First, it falls to academic public health to generate the science and scholarship for informing the health conversation. This is far less straightforward than it may seem at first glance. The research endeavor in most academic institutions is funded extramurally; it depends on donor imperatives. Incarceration is seldom a priority topic for federal funders or a focus of private foundations, suggesting that scholars interested in the question need to be creative in their approach to funding this work. Academic public health has an opportunity to elevate the visibility of the issue by being clear and unequivocal that incarceration is a core public health concern in the field’s remit. In some respects, funding becomes available when scholars articulate areas of research priority. A contemporaneous example is the historic paucity of funding for firearms and their consequences, which is now changing in no small part because of pressure in academic public health, which increasingly makes it clear that gun violence is a public health issue. The same should be true of incarceration and health, and this special issue of AJPH is an important step in this regard.

Second, academic public health is entrusted with training the next generation of scholars and developing the public health workforce. Although public health curricula now broadly recognize a social determinants perspective, the pervasive influence of incarceration and the criminal justice system stands out from this framework. Academic public health is uniquely positioned to investigate this public health problem and equip students with the knowledge, tools, and analytic lenses to address it. For example, applying epidemiologic methods to examine the scale and impact of incarceration can expose its population health influences and angles for meaningful intervention. Considering historical developments in mental health and substance use disorder treatment can explicate the criminal justice intersection and sharpen the focus on health-based alternatives. Highlighting the contribution of incarceration to health inequities can prepare the next generation of public health scholars for applying the knowledge and tools to interrupt the harmful cycle. Developing the capacity and perspective of students could strengthen a coordinated public health response, just as past cohorts have advanced the role of public health to improve labor practices and environmental protections. Certainly, the sheer scale and population specificity of US incarceration patterns warrant explicit attention from academic public health.

Third, academic public health aspires—or should aspire—to translate their knowledge and make their scholarship accessible to those who are producing change. As the United States reckons with the human costs and consequences of incarceration, the public health articulation of this relationship should be emphasized. Civil rights advocates and scholars have amplified the issue to join the popular discourse, and some policymakers and providers are engaged in efforts to address it. In the health care sector, clinics are orienting to a broader, community-based perspective, which demands recognition and response for the health impact of incarceration in burdened communities. In the social service sector, focus on the economic, housing, and employment needs of criminal justice–involved populations reflects the critical role of the social determinants of health. And in the criminal justice sector, some are pursuing reforms for the sustainable reduction of incarcerated populations. Work across these sectors is happening in governmental and community settings and through diverse coalitions. Academic public health can make an important contribution to these movements.

The wide-reaching impacts of incarceration are a distinct and critical challenge for population health in the United States, and academic public health is uniquely equipped to address it. This disciplinary perspective obliges us to invest in generating the scholarship, training the professionals, and translating the knowledge to shine a light on and to share what we learn. Academic public health ought to be playing a central role in the work to reduce incarceration and mitigate its consequences in the United States.