A Proposal to Treat the Public Health Ills of Mass Incarceration

In this exclusive video, Eric Reinhart, MD, PhD, a political anthropologist, psychoanalyst, and medical resident at Northwestern University in Chicago, discusses his recent paper in the New England Journal of Medicine that proposed a framework of interweaving public health and prison abolition in order to improve the health outcomes of prisoners, their families, and their broader community.

The following is a transcript of his remarks:

Historically, health policy and criminal/legal policy, or public safety policy, have been regarded as separate domains, in the U.S. at least. That has allowed criminology — a sub-discipline of sociology that has always been more or less in bed with police departments, because that is their data source, that’s how they do their research, et cetera — it has allowed criminology to really dominate public safety spaces. What we’ve had as a result is a way of measuring safety in the U.S. that is oriented around crime rates.

Now, if you look around your communities or the poorest communities in the U.S., places where I’ve spent over a decade doing ethnographic work in Chicago, for example, the greatest threats to people’s lives, the greatest threats to their everyday liberties are not actually violent crime. Violent crime is really important; it’s quite substantial and I’ve done a lot of work around this.

But the much more important factors, just statistically speaking, are homelessness, addiction and overdose without access to addiction treatment, poor labor conditions, environmental degradation and exposure to toxins that’s causing long-term harm. These are the real determinants of safety, the social determinants of safety.

If we’re going to build effective safety in the U.S., we need to begin to think about the interrelationship between safety systems and health systems.

One of the major drivers of poor public health, and of extraordinarily high rates of chronic disease and infectious disease in the U.S. relative to our very wealthy status as a nation, is our system of mass incarceration. Studies have shown repeatedly that exposure to incarceration, even for short periods of time, takes a significant toll on people’s long-term health and life expectancy, as well as their economic prospects, their employment prospects and their social experiences in the world — their capacity to connect with other people, social isolation, et cetera.

These two things haven’t been connected, mass incarceration and the healthcare system in the U.S., very often, at least not explicitly within public policy conversations. I think this is a major oversight.

There are over 77 million people in the U.S. with criminal records, with tens of millions of people who have been incarcerated in the last 2 decades alone. If, as one study suggests, each year of incarceration shaves 2 years off of life expectancy and increases rates of chronic disease — and not just for those 77 million people with criminal records, but also studies have shown there are spillover effects — it has negative health consequences for their families, and not just their families, but their blocks and their entire counties. You see increased mortality rates with higher incarceration rates.

If that’s all happening, and we have out of control healthcare spending in the U.S., where right now it’s $4.3 trillion per year, or nearly twice as much per capita as the next closest nation in the world. And our health outcomes at the same time, despite all that spending, are extraordinarily poor and not nearly as good as that next nation. We need to think about what’s driving that.

Mass incarceration and police contact is a major driver of poor health outcomes in the U.S. This, I think, is an important side of the problem we have to address. I also think it offers a solution.

A basic public health principle is that you have to build from the bottom up. So, if the people who are disproportionately suffering poor health outcomes in the U.S. are people who have been exposed to incarceration, are criminalized communities, then that’s where we need to focus our resources.

The resources we need to focus are not just healthcare and basic social services, but employment. My big shtick is: we need to have a health systems transformation in the U.S. Right now we have a top-heavy system with reactive healthcare. We need to build a system that really invests in the base. And the base has to be, in my view, community health and justice workers.

This is the proposal I put forth in the New England Journal of Medicine, an idea where we’d have a new federal department for community safety and repair. It would be built around a national community health and justice worker core, where you would initially hire 2 million people — with preferential employment for people who have been incarcerated and their families who suffer from difficulty finding employment and from poverty, disproportionately — and the membership in this worker core is itself one of the interventions.

It’s not just the care they would then provide to their communities, but the investment directly in them. Giving them dignified work and living wages, that alone will interrupt cycles of rearrest, of incarceration, and of poor health outcomes.

This is what I would really like to see in the U.S. Let’s take our greatest site of pain, our national shame, and turn it into a vehicle for transformation. [Let’s] empower people who have been exposed to this to really lead a different kind of health system in the U.S.