Mass incarceration: A public health epidemic

We're number one; and that's not a good thing. Compared to other countries, the US imprisons the most people in the world, and among developed nations, leads in both the number and proportion of imprisoned people. Since the 1970s, the correctional population in the US has ballooned by 700 percent.  This phenomenon is often referred to as mass incarceration.

Many factors have contributed to the vast increase in the nation's incarceration rates, namely the "war on drugs," an under resourced mental health care system, and mandatory minimum sentencing laws. Incarceration is disproportionately concentrated among low-income and often non-white communities. Increases in drug-related arrests have contributed to a growing rate of incarceration among people of color, especially African American men. Despite similar rates of illicit drug usage across racial groups (9.6% among blacks, 8.8% among whites), African Americans are 13 times more likely to be imprisoned for drug charges.Other trends indicate that jails and prisons have become an ill-equipped replacement of mental health treatment facilities. According to a recent report by the Treatment Advocacy Center, there were an estimated 356,268 people in jail and prisons with severe mental illness in 2012: ten times the number in state hospitals.

What does all of this have to do with health? A new report by the Vera Institute of Justice indicates that overall, people who are in jail or prison have worse health than the general public. They experience higher rates of chronic and infectious diseases, substance abuse and mental illness. This may be partly tied to poorer health upon entry to the correctional system related to poverty, education, and poor access to healthcare. But incarceration may expose inmates to other health risks, particularly for people with mental illness. Solitary confinement has an especially negative impact on people with mental illness, such as anxiety, self-harm and disabling long-term effects. In some cases, imprisonment may mean better access to healthcare, but this mostly reveals the poor access to care among those most at risk of incarceration: low-income communities of color.

After release from prison or jail, the host of social and economic obstacles that people face can also negatively impact health. Several states have chosen to uphold a ban that bars those with a drug related felony from receiving nutrition assistance (formerly called food stamps) or cash assistance. Although exclusions vary, many cities prohibit felon parolees from renting in public housing. Often, individuals with a prison record are ineligible for student loans, decreasing access to education. As described in a previous post, felon disenfranchisement policies prevent people who have committed a felony (including non-violent and violent crimes) from voting after release. So – a previously incarcerated person may face barriers to social programs, stable housing, education and the ballot box – all of which can impact health in direct and indirect ways. Michelle Alexander, legal scholar and author of The New Jim Crow, calls these many policies "legalized discrimination."

In the public health and medical communities, some refer to mass incarceration as an epidemic that impacts health outcomes and can be examined through a public health lens. It's a fitting label—beyond the individual, mass incarceration also impacts the health of families and communities. For one, imprisonment fractures families, and exacerbates childhood inequities that may have lasting effects. Children with incarcerated fathers, for example, are significantly more likely to experience homelessness. Dr. Ernest Drucker, author of "A Plague of Prisons: The Epidemiology of Mass Incarceration in America" has noted that mass incarceration "exhibits all the characteristics of an infectious disease—spreading most rapidly by proximity to prior cases."

What has and can be done to address mass incarceration? First – prevention. In August 2013, Attorney General Eric Holder released guidelines to reduce the use of harsh mandatory minimum sentencing for low-level, non-violent drug offenses without any connection to large-scale drug activity or gangs.  We also need to increase national emphasis on building a stronger mental health infrastructure and treatment and support for individuals dealing with substance abuse. The Affordable Care Act presents an opportunity, with state Medicaid expansions and better insurance coverage of mental health and substance abuse treatment. Yet challenges remain.

We also must recognize the negative impact of post-release bans to social programs—not only on the individual but also on their families. Policy makers should continue to modify or lift these bans.

Lastly, we need a widespread recognition that mass incarceration has far-reaching impacts on health and is indeed a public health concern. A recent New York Times editorial has called for a multilevel approach that brings together public health professionals and the criminal justice system to address the issue. Let's talk.

Erin Shigekawa, MPH, is a Health Policy Fellow at the Center for Healthcare Research and Transformation, a non-profit health policy center based at the University of Michigan in Ann Arbor. The views expressed in this article are those of the author only.

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