The Prison Industrial Complex as a Commercial Determinant of Health

Researchers and the public alike increasingly recognize that elements of modern capitalism and poor health outcomes are fundamentally intertwined. A small number of industries, including tobacco, alcohol, and food and beverage, now contribute to the major causes of poor health and premature deaths in the United States and globally.¹ The commercial determinants of health (CDOH) provide a framework to systematically analyze the strategies that corporate interests employ to boost consumption of their unhealthful products and behaviors. In laying out both the strategies that corporate interests employ and the mechanisms to counteract these strategies, the CDOH provides a set of tools to address corporate practices, an important determinant of health.

Many research fields that focus on corporate impacts on health are not in communication with each other, yet they can all learn from each other in both mapping and analyzing the strategies that industries use and the methods researchers have developed to analyze industry practices’ impacts on health. Despite selling very different unhealthy products, corporations frequently follow a similar playbook and operate through parallel channels, including control over decision-making and agenda-setting, continual political lobbying, campaign and party donations, participation in governmental agencies, deployment of public relations committees, reduced legal liability, and greenwashing strategies to reduce attention on companies’ broader deleterious actions.²

To date, CDOH researchers have predominantly focused on corporate strategies within tobacco, alcohol, and unhealthy food and beverages. These areas are all vital to an improved understanding of epidemiological patterns, but the frameworks and methodological approaches of CDOH can greatly contribute to other fields as well. As the CDOH field has grown, recent scholarly attention has been aimed at the firearm industry, gambling, and more. Little attention to date, however, has been paid to the prison industrial complex (PIC).

THE PRISON INDUSTRIAL COMPLEX

The United States is the world leader in incarceration, with about 2.1 million Americans currently incarcerated and one in three African American men incarcerated at some point in their lives. As outlined by a recent Sentencing Project report, the health harms from mass incarceration are indisputable: for incarcerated individuals, intense mental and physical health impacts both during incarceration and upon release, inadequate health care, overall elevated mortality risks, and increased rates of communicable diseases such as HIV and viral hepatitis (https://bit.ly/3upt2vd); for the partners, children, and communities of incarcerated persons, overall health impacts that partially underlie systemic health disparities (i.e., the disproportionate burden of morbidity and mortality borne by racial minorities, particularly African Americans).³ These direct health impacts of incarceration have been even more evident during the COVID-19 pandemic, with 5.5 times higher case rates for incarcerated persons than the overall US population case rate.⁴

American mass incarceration is a direct result of systemic racism, and a broader project to enforce both traditional and novel methods of discrimination and oppression through “systems of racialized social control.”^5(p18) This racial project also interacts with a broader economic project: by fueling the dehumanization of minority communities, notably African Americans, systemic racism enables the commodification of bodies. A CDOH lens allows not only an exploration of commercial aspects of mass incarceration but also of power asymmetries in the institutionalization of racism in societal structures, and of how it enables the commodification of African Americans and other minorities for the profit motive. Moreover, CDOH frameworks incorporate theories of power to guide the study of the structural factors that enable corporate influence on health. Madureira Lima and Galea,² for instance, apply Lukes’ tridimensional view of power⁶ to examine the dimensions, vehicles, practices, and outcomes of corporate power. Such frameworks are indispensable in outlining the ways in which mass incarceration power operates along both racial and commercial avenues.

One irrefutable factor underlying mass incarceration and associated health risks is the PIC. In speaking about the PIC, we are referring to the private sector that profits from mass incarceration as a whole, as well as the prisons that are directly privatized. More than just prison operations and management, the PIC includes commercial actors involved in bail programs, community surveillance, prison construction, corrections data systems, security equipment, prison food and vending machines, transportation, health services, communications, and prison labor.⁷ The PIC also includes the wide range of tactics actors employ to maintain systems of mass incarceration. A relatively recent Washington Post article outlined the many strategies that PIC actors have used to extensively shape the policy environment, including lobbying, providing direct campaign contributions, and building relationships and networks to a range of state and federal politicians, often leading to the awarding of state contracts for high-price prisons (https://wapo.st/3bWHtjM). Moreover, in recent decades, the same private actors involved in the prison sector have expanded their operations to encompass migrant detention centers. A recent New York Times article estimated that about 10% of American prisons and 73% of migrant detention centers are now privatized (https://nyti.ms/3fpLgbH). This level of privatization has created incentives to increase prison and migrant detainee populations while cutting health and safety measures for incarcerated persons. Although there have been no comparative studies, an American Academy of Family Physicians report noted anecdotal evidence from multiple court cases of increases in inmate mortality upon privatization of prison health care; significant deficiencies in care; and allegations of increased risk of serious harm, including amputation, preventable injuries, and disfigurement (https://bit.ly/3yIcPV5). Yet systematic data on the connections remain sparse.

US President Joe Biden recently signed an executive order aiming to end the use of private prisons by the Justice Department. Although an important first step, the order does not apply to private facilities used by the Department of Homeland Security to detain immigrants, nor does it include the approximately 90% of private prisons that are state run.⁷

AREAS FOR RESEARCH

Building on previous research and CDOH frameworks, we advocate for four primary areas of inquiry.

First, a CDOH framework provides guidance on a wide range of methods for the analysis of corporate activities, including Freedom of Information requests, corporate document analysis, social media research methods, and interviews with key informants from the corporate sector. Research on prisons remains limited, in large part because of the difficulty of obtaining access. Although these methods are not unique to CDOH, taken together they provide important tools for in-depth investigations of the PIC in their ability to focus on the impact of specific PIC interests and the policy environment surrounding them.

Second, although the health harms of mass incarceration have been well documented, the impacts of the PIC, both in terms of private prisons and the broader set of industries that profit from mass incarceration, have received far less attention. In order to isolate the particular harms of the PIC, it is vital to understand the extent to which these harms are a result of industry practices, as opposed to the broader carceral system. This can be achieved by examining the specific pathways, such as lobbying and political influence, through which the PIC wields its power.

Third, research must extend past the PIC’s role as an economic actor into its positioning as a stakeholder and influencer of policy. Applying a power lens to this positioning may shed light on the process through which the state has delegated one of its core functions: the monopoly over the administration of punishment to the private sector. This shift in the role of corporations has been outlined more generally, but the PIC’s influence has not been comprehensively outlined to date. Although understanding the impact of privatization within prisons is vital, equally important is its role in affecting both social policy and public opinion more broadly.

Finally, research on the PIC should have an inbuilt equity component. CDOH frameworks can complement a social determinants of health framework by illustrating the specific paths through which social inequities are borne out of corporate and commercial interests. Crime and antisocial behavior are heavily determined by social factors, including access to quality education, employment, housing, and social protection. In other words, the PIC draws its profits from those at the bottom of the socioeconomic scale, including both incarcerated individuals and their families. Moreover, US incarceration is deeply stratified by race, with African Americans five times more likely to be imprisoned than Whites. An equity-minded research agenda must explore the role of the PIC in exacerbating and perpetuating these health and social inequities.

CONCLUSION

Most of what we know about the links between the PIC and health comes from a combination of investigative journalism and legal documents. We believe it is well past time for public health researchers to turn our focus toward the issue as well. CDOH frameworks allow for shared paradigms and methodologies from researchers from a wide range of fields that have been similarly affected by different commercial interests.

We don’t believe the justice system should be conducted through the motivation of profit. But while such a profit incentive remains, it is vital that the CDOH framework illustrate the connections between this profit motive and health outcomes—among incarcerated individuals as well as affected communities more broadly. The CDOH framework allows for important critical attention to be paid to one of the root causes of mass incarceration—immoral corporate practices—and the broader political–economic structures and strategies that enable these inequities. It is time we bring this focus to an enormously health-harming industry that has so far escaped the field’s scrutiny.