Reframing Mass Incarceration as a Social-Structural Driver of Health Inequity

With its provocative title, Mass Incarceration Threatens Health Equity in America,¹ a January 2019 Robert Wood Johnson Foundation report highlighted the inextricable link between mass incarceration and health inequity. That report, in combination with this supplement issue, reflects a seismic shift in the conceptualization of incarceration as a fundamental social-structural driver of health inequities. This latest supplement issue aligns with critical theoretical perspectives (e.g., critical race theory, intersectionality, ecosocial theory) making inroads in public health, as well as the Perspectives From the Social Sciences’ mission to “critically engage public health.”^2(p15)

HISTORY OF INCARCERATION AND HEALTH IN AJPH

This supplement issue represents AJPH’s most recent enterprise into the topic of incarceration and health but not its first. The October 2005 issue of AJPH³ that focused on prisons and health deserves that distinction. Moreover, for almost 80 years, AJPH has published research, editorials, and commentaries on the topic of incarceration and health. My keyword search for “incarceration” in AJPH’s archives yielded 830 citations, a number that would likely swell had I added keywords such as “jail,” “prison,” “prisoners,” and “inmates.” Historically, topics such as screening for infections, including gonorrhea (1940), hepatitis B (mid-1980s), and HIV (late 1980s), and the medical care of incarcerated people were common.

My cursory review of these articles found that with a few notable exceptions, most of the articles published before the 2005 issue offered a relatively noncritical view of the topic of incarceration and health. In line with conventional biomedical and epidemiological perspectives, most authors conceptualized incarceration as primarily a demographic variable rather than as a system of structured inequality.

INCARCERATION AS A PUBLIC HEALTH CRISIS

Although the 2005 issue was designed to amass best practices on incarcerated people and health, a handful of the articles (e.g., “Criminal [In]Justice in the City and Its Associated Health Consequences”) and subsequent letters to the editor were harbingers of a shift toward a more critical stance exemplified in this supplement issue. For example, an insightful 2006 letter advocated for the field to “recast incarceration as the public health crisis it is.”^4(p589) Another summoned a “nationwide conversation . . . to challenge correctional practices and legal policies that exacerbate health disparities.”^5(p1148) Echoing these themes, a 2014 editorial sounded a “clarion call” to the field to “address mass incarceration.”⁶ With this supplement issue, AJPH has done so—and done so critically.

Critical perspectives flip conventional biomedical and epidemiological scripts by “interrogating, exposing, and challenging assumptions about policies, institutions, and practices that obscure power relations that foster inequity and oppression and concern how dominant groups construct knowledge, facts, and problems.”^2(p15) A critical take on the topic of mass incarceration and health inequities necessarily begins with criticism of mass incarceration as a system of power relationships designed historically to bolster White supremacy. For example, at the end of the Civil War, southern state legislators relied on the US criminal justice system to sanction the aggressive policing, arrest, and mass incarceration of “freed” Black people. In 1865 and 1866, southern state legislatures passed discriminatory laws—known as Black Codes—that criminalized acts such as vagrancy and loitering for Black people. These laws swiftly increased the ranks of incarcerated Black people, a reality that persists. Oppression is always intersectional, however. Structural racism intersects with ruling socioeconomic class, colonial, and conventional gender and heteronormative interests to ensure that people located at the most marginalized sociodemographic intersections are at increased risk for, or disproportionately represented in, the nation’s carceral systems.

Marking a critical shift in the field’s response to this inequity, this supplement issue breaks new ground in at least three significant ways. First, many of the articles spotlight the collateral effect of mass incarceration on the health of not only incarcerated people but also their children, families, and entire communities. Second, the articles build on the foundation of another article from the 2005 issue—“Coming Home From Jail: The Social and Health Consequences of Community Reentry for Women, Male Adolescents, and Their Families and Communities”⁷—to highlight the deleterious effect of the carceral state on health not just during incarceration but also before and after it. Finally, they highlight the relative dearth of current nationally representative data sets to facilitate the investigation of new or understudied topics relevant to mass incarceration and health.

NEW CONVERSATIONS

This supplement issue arrives at an important juncture in US history, one characterized by momentous transformations in the national conversation about incarceration. Decades of grassroots activism, research, scholarship, and political advocacy have raised awareness that mass incarceration is unjust, financially unsustainable, ineffective, and racist. This work has even managed to penetrate our polarized political climate. To wit, in December 2018, the First Step Act, a bipartisan criminal justice bill designed to reduce the size of the federal prison population, became law. Although it falls far short of what criminal justice reform advocates had hoped, it nonetheless represents a substantial departure from the tough-on-crime sentiments of the War on Drugs, three-strikes law, and mandatory minimum sentencing era. Federal and state initiatives to reduce incarceration have facilitated a reduction in incarceration rates; this good news must be contextualized within the reality that compared with their White counterparts, Black, Latino, and Native American people still bear the disproportionate brunt of incarceration.

The opioid epidemic also has shaped the tonal change about incarceration. Whereas incarceration historically has been the national response of choice for drug offenses perpetrated by Black and Brown people, the opioid epidemic’s greater effect in White US communities has ushered in a markedly more compassionate response from predominantly White policymakers and public health officials who now favor reframing addiction as illness and perceive drug treatment as a more effective remedy than incarceration.

FUTURE DIRECTIONS TO IMPROVE HEALTH EQUITY

The supplement issue is poised to advance important theoretical and empirical knowledge about mass incarceration and health inequity. It also spotlights the gaps for future research, policy, and practice to fill. One is the need to recognize mass incarceration as both a human rights and a health equity issue. Almost three decades ago, the United Nations Human Rights Office of the High Commissioner issued 11 Basic Principles for the Treatment of Prisoners (http://bit.ly/2qOZGeP). Principle 9 addresses health: “prisoners shall have access to the health services available in the country without discrimination on the grounds of their legal situation.” Not surprisingly, people from the communities most affected by mass incarceration in the United States are also those who experience the most disproportionate and stark health inequities regardless of incarceration status. The notion that health is a human right for marginalized people inside and outside of carceral systems should guide how the field responds to political and structural threats to health equity. The supplement issue also signals the path forward for future research, policy, and practice on a host of understudied topics such as how structural interventions to reduce unemployment, poverty, and racism or improve education and access to drug treatment could decrease or eliminate mass incarceration and in turn many health inequities.

The guest editors of the 2005 supplement on incarcerated people and health were prescient in their caution that the field should transcend “simply quantifying or describing the problem.”^3(p10) I echo their admonition. Indeed, the field will have failed if future supplements and articles simply feature more advanced or sophisticated methods of quantifying the effects of mass incarceration and health inequity without working to reduce the policies and practices that bolster mass incarceration and health inequity in the first place.