Addressing Mass Incarceration to Achieve Health Equity

In 2018, the Robert Wood Johnson Foundation added a measure of incarceration to the 35 national-level measures we are using to track the nation’s progress toward the vision of a culture of health. We made this change for two reasons.

First, there is a well-established and growing body of research on the intersection of health and incarceration. In addition, advocates of justice reform have recently argued for making jails and prisons more transparent, questioning the quality of health care within those facilities and the access incarcerated people have to needed services. Their demands have opened up a new frontier of research and programming that will likely shine an increasingly critical spotlight on the country’s problem of mass incarceration. Second, incarceration is an issue that has origins and effects across many systems, and it has a detrimental impact well beyond those individuals who are incarcerated. As a result, it requires the kind of integrated, systems-level thinking and cross-sector collaboration that is at the heart of our vision for a culture of health.

Around the same time that we decided to include incarceration in our culture of health measures, we were approached by the guest editors of this supplement of AJPH. We saw this supplement as an exciting opportunity to show how efforts to influence the US system of mass incarceration illuminate the four action areas of a culture of health: making health a shared value; fostering cross-sector collaboration; creating healthier, more equitable communities; and strengthening the integration of health services and systems. The supplement also highlights promotion of well-being as a national priority and the critical importance of a health equity focus in our work.

A key component in creating a culture of health is getting people to think differently about health—specifically, to see more clearly how health is related to a host of social issues, including incarceration. As illuminated in the set of articles in this supplement, the nation’s incarceration problem is a health problem, not simply one of crime and the justice system. We know that health practitioners do not always think their patients’ histories with the justice system are relevant to their health, but research shows that rates of communicable diseases, chronic health conditions, and psychiatric and substance use disorders are significantly higher among individuals who have been incarcerated than among those who have not been incarcerated.

A widened lens for understanding social problems also fosters a need for wider cooperation across sectors, as this collection highlights well. And because people who have been incarcerated are more likely to have histories of social marginalization—including poverty, unemployment, and a lack of educational attainment—the problem requires a holistic approach to solutions, one in which community developers, workforce development agencies, schools, employers, financial institutions, and, of course, the health care field work together. The process of formulating connections across such diverse sectors and taking the next steps toward action is at the heart of building a culture of health.

In showing the ways incarceration affects so many different areas of American life, this supplement of AJPH can broaden our understanding of how incarceration negatively influences possibilities for hope, happiness, sense of security, and agency as well as other critical components of community well-being. We believe that policy decisions are improved when collective well-being is a national priority. For example, the practices and policies that have largely driven this era of mass incarceration—among them the War on Drugs and the Anti-Drug Abuse Act of the 1980s, the three-strikes provision of the 1990s, and New York City’s “stop and frisk” strategy—may have been viewed differently at the time if well-being was an elevated priority in our country. Our goal is to ensure that in the future our leaders can better identify the practices and policies likely to cause harm and those most likely to promote health for all.

Finally, we supported this supplement because mass incarceration is the most pressing civil rights issue of today. Our central aim at the Robert Wood Johnson Foundation is the achievement of health equity, and we know we can’t reach that goal unless, as a nation, we address mass incarceration. Black and brown people make up 60% of the incarcerated population in America, largely as a result of unequal targeting of practices and policies such as those described here, especially in poorer communities. The underlying problem of racism in America also perpetuates the disparities we see in health across the board. We hope this supplement of AJPH not only illuminates our culture of health vision through the lens of one of our key outcome measures but also engages new partners and catalyzes overdue discussion—and action—on race and equity in our country.