Promoting Health Equity and Criminal Justice Reform: The Louisiana Experience

Currently, 2.3 million people are incarcerated in the United States, and people of color are disproportionately represented.¹ Incarcerated people face significant health disparities, including higher rates of chronic diseases, infectious diseases, addiction, and mental illness compared with the general population.^2,3 Until 2018, Louisiana led the world in incarceration rates, and it remains the least healthy state in the nation. Despite this, we have made progress. We, a Louisiana-based group of medical and public health practitioners, advocates, and lawyers, provide examples of successful, cross-disciplinary, grassroots efforts to reduce incarceration and improve health. We also provide recommendations to further work in this area.

MASS INCARCERATION IN LOUISIANA

Louisiana’s history of mass incarceration is deeply rooted in institutionalized and thinly veiled racism. Upon abolition of slavery, many plantations became prison labor camps. The 1898 Louisiana constitution explicitly aimed to reinforce the “supremacy of the White race.” People of color became systematically disenfranchised through literacy tests, poll taxes, and revoking the voting rights of people with convictions. As recently as 1974, Louisiana reinforced a law requiring only 10 of 12 jurors to reach a guilty verdict, making it easier for already disproportionately White juries to convict people of color.⁴ Since the 1980s, sentences have steadily grown longer, whereas parole opportunities have been lengthened or repealed. Today, Louisiana’s largest prison, a former slave plantation known as Angola, still forces people to work the fields for two cents per hour.

Louisiana has the second highest rate of exoneration per capita,⁵ raising the question of whether district attorneys seeking reelection may be incentivized to prosecute regardless of guilt. In 2011, the US Supreme Court acknowledged that a New Orleans prosecutor’s suppression of evidence led to a death sentence for John Thompson but ruled that the state was not liable.⁶ After Glenn Ford’s 2014 release from 30 years on death row, another district attorney refused to acknowledge Ford’s false imprisonment and insisted, “I think we need to kill more people” through use of the death penalty.⁷ Like much of the nation, Louisiana struggles with lack of appropriate funding for indigent defense and a bail system and supervision fees that target the poor. It has also faced legal challenges for its prison conditions, including the use of long-term solitary confinement, excessive temperatures in poorly ventilated cells, and inadequate health care.

COMMUNITY-DRIVEN REFORM EFFORTS

Amid these circumstances, we created the Prisoner to Patient (P2P) initiative to address health disparities driven by incarceration. Specifically, we aimed to develop community-informed health services for formerly incarcerated people, conduct participatory research, and engage in policy reform. Using the principles of community-partnered participatory research, our group assessed the health needs of formerly incarcerated individuals in Louisiana, and under the leadership of a university-based physician, we created the Formerly Incarcerated Transition Clinic, which provides care for acute and chronic illnesses for those transitioning out of incarceration.

Through collaborative efforts with the Louisiana Department of Corrections and community partners, the Formerly Incarcerated Transition Clinic, now a member of the national Transitions Clinic Network, identifies persons being released to mitigate lapses in treatment and avoid unnecessary utilization of costly health resources. This is crucial particularly for those released without medications or who receive prescriptions that cannot be filled because of lack of insurance or physician licensure issues (some Louisiana Department of Corrections physicians are allowed to practice on restricted licenses). A formerly incarcerated community health worker supports Formerly Incarcerated Transition Clinic patients in accessing health and social services for themselves and their families. A formerly incarcerated volunteer hosts a bimonthly peer-support group, which harnesses experience from those who have successfully reentered society to assist those who are newly released.

Voice of the Experienced (VOTE), a nonprofit organization originally started inside Angola prison, has been critical to these efforts. Half of the organization’s staff, including both directors, have been incarcerated, and their participation has been vital to understanding the unique needs of people leaving confinement and gaining their trust.

Independently of the P2P initiative, VOTE has led the charge on criminal justice reform in Louisiana by strategic coalition building and shifting common narratives about incarceration from public safety to public health. VOTE spearheaded a three-year campaign to create the nation’s most permissive public housing admissions policy in 2016. The following year, coalitions that VOTE created helped Louisiana become the first state to “ban the box” on college applications, enabling people with convictions to obtain higher education. VOTE also advocated for a justice reinvestment initiative in 2017 that included a slate of new laws addressing a range of issues, including parole opportunities, reducing fines and fees, expanding medical parole, and reducing probation time. These new policies led to an immediate release of roughly 3000 people and a sustained reduction in the prison census of about 5000 people. In 2018, VOTE, along with a growing group of diverse advocates, won the restoration of voting rights for nearly 40 000 people under community supervision and won a ballot amendment to eliminate the nonunanimous jury.

RECOMMENDATIONS

Given the links between mass incarceration and health disparities, achieving health equity in the United States will require a systematic, community-informed approach to decarceration, promoting reentry, and policy change. Based on our experiences with developing services and implementing broad reform amid an incredibly challenging backdrop, we recommend that the public health community direct its efforts in several ways.

Primary Prevention

First, recognize the policies that lead to mass incarceration as drivers of health inequity, and focus on preventing incarceration by supporting diversion, community policing, harm reduction programs, substance use treatment, and community-based mental health services. Public health practitioners can also collaborate with criminal justice advocates on sentencing reform, elimination of cash bail, and abolition of private prisons. All efforts to develop research, interventions, and policy addressing mass incarceration must involve directly affected people and operate within an antiracist framework.

Improving Conditions of Confinement

Although primary prevention of incarceration must be prioritized, the public health community should also support improvements in conditions of confinement, including appropriate medical triage on entry into jails and prisons, improved access to substance use treatment, reduction in the use of solitary confinement (particularly for punitive purposes), access to healthy food, and sufficient outdoor exercise. Triage for sick calls should be performed exclusively by licensed health care professionals, and lack of significant findings from medical visits should never be grounds for punishment for perceived malingering. Copays for medical visits should be eliminated. We recommend the development of policy to require additional state and federal oversight of correctional health care.

Training

Additional fellowships and training programs in correctional medicine, informed by currently and formerly incarcerated people and antiracist principles, are needed. Public health curricula should address mass incarceration, and students should be encouraged to interact with people who are currently or formerly incarcerated through practicum experiences at carceral facilities or reentry organizations. Schools of public health should admit and support people with histories of incarceration.

Improved Coordination

Community-based health providers conducting social needs assessments should include questions about incarceration history and offer additional health services or referrals to community-based organizations, as needed. States should support shared health records between prisons and public health and health care facilities to promote continuity of care. State Medicaid and carceral facilities should use common formularies to ensure consistent medication access, and exposure to incarceration should be included in analysis of population health data.

Although addressing health inequities caused by incarceration is complex, there are reasonable steps that the public health community can, and must, take in partnership with affected populations. Doing so is not merely a moral imperative—it is a matter of life and death.