We Call Mass Incarceration an Epidemic. Let’s Treat it like a Disease.

Posted on by BUJPH

illustration of pill bottles with chains linking them

by Joseph Kahn

Illustration by William Sellmayer

 

Epidemic: “An increase, often sudden, in the number of cases of a disease above what is normally expected in that population of that area.”1

 

Introduction:

The term “epidemic” evokes imagery of field hospitals, masks, and ventilators. It inspires urgency. Epidemics force the government to action, making it issue executive orders, pass legislation, and develop response plans. Funds are expeditiously funneled into vaccines, therapeutics, and medical research. Survival is a powerful motivator for even the most deadlocked of government institutions. However, to the roughly two million individuals directly afflicted by the “epidemic” of mass incarceration and the millions more with an increased risk of entry into the criminal legal system, this urgency is absent.2 The United States has an incarceration rate that is five times greater than any other country: roughly 716 people per 100,000 people.3 Compared to other countries, the United States has an incarceration rate drastically above what would be expected, placing America firmly in the middle of an epidemic. To combat mass incarceration, we must treat it like the disease it is and utilize social epidemiology to achieve a more focused and effective intervention for this epidemic.4 Social epidemiology focuses on mapping social networks to study patterns of disease and can be applied to the case of mass incarceration.1 Using social epidemiology to inform public health interventions, in conjunction with addressing the most impactful structural sources of mass incarceration, presents the best method of controlling America’s carceral epidemic.

 

Past Failures:

Creating new interventions utilizing social epidemiology requires looking at how America has mishandled crime interventions in the past. The standard practices of the American criminal legal system have long hinged on punitive measures and the threat of incarceration as sufficient deterrents to the incidence and transmission of crime. One such example of failure and thus the necessity to implement more epidemiologic interventions is the case of ‘broken-windows policing.’ Broken-windows policing, formulated by criminologists George Kelling and James Wilson, operates under the assumption that targeting minor crimes such as vandalism or jaywalking improves the appearance of communities and decreases crime.5 In theory, this recognized the role socioeconomic conditions play in perpetuating crime. In practice, it took physical indicators of poor socioeconomic status, such as “panhandling” or “street-level prostitution,” as reasons to increase the police presence through stop-and-frisk policies.5 Though it correctly recognizes which communities possess the determinants of the disease of incarceration, the intervention did not seek to eliminate the root cause. Instead, it penalized the symptoms: minor crimes of necessity. This exemplifies the absence of a public health approach that targets the core reasons for crime and incarceration. The intervention of expanded policing and stop-and-frisk policies increased the racial disparity in the criminal legal system, as a vast majority of arrests made were of racial minorities.6 Furthermore, all the consequences of interactions with the criminal legal system, such as diminished job opportunities and voter disenfranchisement, were given greater traction.7 Punitive measures furthered the epidemic of incarceration and showed the need for an alternative public health approach. Such an alternative approach requires using epidemiological methods to target non-punitive and upstream interventions.

 

Epidemiological Framework:

For an effective social epidemiology intervention, establishing a case definition and a comparison to mass incarceration is necessary. A public health disease framework considers a mixed epidemic to include a common source exposure followed by community transmission. Mass incarceration can be characterized as a mixed epidemic. Consider the 1988 outbreak of shigellosis, a bacterial infection that targets the gastrointestinal system, at a Michigan music festival: over a period of five days, 3,175 people fell ill.8 The outbreak was eventually traced to a specific dish that was served to festival-goers.8 In the days following the festival, “Several state health departments detected subsequent generations of Shigella cases propagated by person-to-person transmission from festival attendees.”8 Contact with a source in a mixed epidemic has an impact beyond just the individual: it creates the conditions for others in a community to have similar exposures.

In the case of mass incarceration, the source exposure of this mixed epidemic stems from the legal framework of the US. Sentencing laws, prosecutorial discretion, policing, and many more structural phenomena constitute the source (the dish from the music festival), as exposure to the criminal legal system is the principal mode of entry into the carceral system. Eliminating the exposure would entail legislating structural change to overhaul existing sentencing guidelines, prosecutorial conduct, and police actions. Though eliminating every source for exposure to the criminal legal system is beyond the scope of this piece, considering the most impactful mitigation measures presents an opportunity to considerably weaken the source. If exposure to the source cannot be eliminated, then lowering the ‘virulence’ is prudent. One such change that could lower the ‘virulence’ would be abolishing mandatory minimums. Between 1980 and 2010, half of the 222 percent increase in the American prison population was due to increased mandatory minimums, which are required minimum sentences for a specific crime.9 While alarming, such a large proportion of incarceration being due to a singular cause simplifies the focus of intervention. Mandatory minimums are created by Congress and state legislatures, meaning they are ultimately subject to the will of the people.10 Like any progressive change, grassroots organizing to draw attention to the injustices of sentencing guidelines must be paired with publicity and political power. Established social movements that focus on issues relating to the criminal legal system, such as Black Lives Matter, should increasingly elevate reforming mandatory minimums to a focal point of their mission. This would increase public awareness of the need for this intervention and limit exposure to one source of mass incarceration.

Community spread, the second component of a mixed epidemic, can be attributed to the vectors by which incarceration affects its communities and creates a positive feedback loop of negative interactions with the criminal legal system. In the shigellosis outbreak, this would be the reproduction and transmission of the bacteria that causes the disease. This framing allows for the utilization of concrete epidemiological processes to resolve these outbreaks of mass incarceration. Epidemiological tools that already exist present new ways to prevent the conditions for crime to arise in communities and concurrently mitigate exposure to the criminal legal system. 

 

Social Epidemiology in Practice:

Social epidemiologists can assess socioeconomic status through welfare dependency and employment, mental illness, past convictions, and drug use. These variables describe the increased risk of incarceration for those facing a shortage of psychiatric and economic resources.11,12 This epidemiologic process would start with a coordinated and continuous data collection effort, involving outreach to community leaders and government officials. This would build upon existing institutional connections between universities, health agencies, and local governments. The data collection process will require public records requests under the Access to Public Records Act (APRA). Social epidemiologists and their teams could search arrest records and employment databases, and then link those names with a database of individuals’ requested addresses to provide a tool to geographically connect past and present suspected criminal activities and socioeconomic status. Furthermore, the Drug Abuse Warning Network (DAWN), which monitors the “demographic and geographic distribution” of drug-related emergency department visits, should share their data with social epidemiologists to add another important variable to the collected metrics.13 This dataset could be converted to a GIS (Geographic Information System) map, a software which overlays data inputs with their geographic location. This would provide a hub for public health workers to localize interventions and could be regularly updated and distributed to organizations that work at the community level. Mapping the social networks of those with the most risk factors resorting to crime can help organizations target implementations of further social safety nets, such as vocational opportunities, mental health care, food stamps, Head Start, and safe injection sites. Crucial community efforts such as transition clinics will use this information to better focus their resources, diminishing the incidence of recidivism. Food stamp programs would know which areas need a secure source of food and could target promotion for the program with precision. Safe injection sites could be set up in areas with the most drug-related emergency department visits according to DAWN, lowering the incidence of non-violent drug arrests and drug-related violence. Any social determinant of mass incarceration can be addressed; in practice, this social epidemiology tool functions similarly to the P.C.R. testing for COVID-19. Through regular data collection and updating, this geographic tool can provide the information to facilitate the most efficient public health response in the highest-risk areas. Unlike the American policy of the past, this new method would seek to address the factors that make incarceration propagate, not the propagation of crime, an important distinction.

 

Limitations:

This proposal is not without its drawbacks. Nina Wallerstein, director of the Center for Participatory Health at the University of New Mexico, notes that social epidemiology and community-engaged interventions, as would be necessary to target determinants of incarceration, remain “separated in practice.”14 Informing interventions and informing the creation of those interventions are two distinct entities. Testing for a disease and confirming its prevalence means nothing without a well-funded and evidence-based approach to control it. In the 1988 shigellosis outbreak described earlier, health departments contacted physicians, informing them of the epidemic, the best treatment practices, and the timeline of transmission.15 Concertgoers were informed and aware of the disease occurring, and thus could seek treatment. Information was used effectively. Effective use of the information provided by the social epidemiologists would require more sophistication than the shigellosis outbreak, but in framing mass incarceration as a disease those physicians can be viewed as the community leaders and public health officials, and the medical treatment they provided can be viewed as the interventions that target social determinants of mass incarceration. However, there must be a larger emphasis on connectivity between public-facing institutions and the academics and epidemiologists providing the information.

The most valid counterargument to using social epidemiology to combat mass incarceration as described in this piece would be concerns about epidemiological tools being used to increase individuals’ interactions with the criminal legal system. If a tool is an accurate predictor and mapper of who is most at risk of entering the criminal legal system, then those who do not view incarceration as a treatable disease will want to use it to incarcerate rather than intervene. It could serve as a justification to reinstitute broken-windows policing and stop-and-frisk policies if misused and misinterpreted. If this tool stays in the hands of epidemiologists at universities and health departments, whose primary focus is health and not incarceration, then misuse is not an issue that presents much risk. Additionally, there are concerns about the extent to which certain data can be collected and what information the data may provide. For example, drug-induced Emergency Department visits may not be the most accurate variable to represent overall drug usage or the incidence of potential drug-related crime, but data on drug use may not be publicly available or as well collected as the DAWN data. Furthermore, there are additional variables that could further pinpoint areas of high risk for incarceration, such as incidence of mental health issues and adverse events, that may be protected, and rightly so, under HIPAA. However, the strength of the variables that can be accounted for is sufficient in painting a picture of where interventions should be targeted to curb the spread.

 

Conclusion:

Mass incarceration is a multifaceted phenomenon, with systemic changes needed at all levels, including policy reform, decriminalization of substances, rehabilitation, and many more. However, one of the most impactful methods of decreasing the number of Americans entering the prison system is to improve their material conditions. Social epidemiology presents a tool by which we can alleviate the largest comorbidities of incarceration with surgical precision. An inception of this tool could also spawn a new area of focus in the epidemiologic community and place evidence-based and scientific approaches to curing mass incarceration at the forefront of progressive movements for prison reform and in the minds of governing officials. Additionally, tools of this nature could provide a means for further research into the social determinants of incarceration, which would inform public health and community leaders of increasingly effective ways to address mass incarceration. Rewriting America’s role in mass incarceration will not be simple, but framing it as a disease places needed social reform within a practical apparatus for stopping this epidemic.

 

References

  1. Centers for Disease Control and Prevention. Principles of Epidemiology | Lesson 1 – Section 11. Available from: https://www.cdc.gov/csels/dsepd/ss1978/lesson1/section11.html. Accessed December 12, 2022.
  2. Prison Policy Initiative. Mass Incarceration: The Whole Pie 2022. Available from: https://www.prisonpolicy.org/reports/pie2022.html. Accessed December 12, 2022.
  3. Prison Policy Initiative. States of Incarceration: The Global Context. Available from: https://www.prisonpolicy.org/global/. Accessed December 16, 2022.
  4. PubMed Central (PMC). Social Epidemiology: Definition, History, and Research Examples. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2723602/. Accessed December 12, 2022.
  5. Vedantam S. How A Theory Of Crime And Policing Was Born, And Went Terribly Wrong. NPR. November 1, 2016. Available from: https://www.npr.org/2016/11/01/500104506/broken-windows-policing-and-the-origins-of-stop-and-frisk-and-how-it-went-wrong.
  6. The Legal Aid Society: Justice in Every Borough. Broken Windows, Broken Trust: The NYPD’s Racially Discriminatory Quality-of-Life Policing. March 2022.
  7. Kamalu N, Onyeozili E. A Critical Analysis of the ‘Broken Windows’ Policing in New York City and Its Impact: Implications for the Criminal Justice System and the African American Community. Afr J Criminol Justice Stud. 2018 Apr;11. University of Maryland Eastern Shore.
  8. Lee LA, Ostroff SM, McGee HB, Johnson DR, Downes FP, Cameron DN, Bean NH, Griffin PM. An outbreak of shigellosis at an outdoor music festival. Am J Epidemiol. 1991 Mar 15;133(6):608-15. doi: 10.1093/oxfordjournals.aje.a115933. PMID: 2006648.
  9. Fair Fight Initiative. Mandatory Minimum Sentence Statistics. Available from: https://www.fairfightinitiative.org/mandatory-minimum-sentence-statistics/. Accessed December 16, 2022.
  10. Families Against Mandatory Minimums. Mandatory Minimums in a Nutshell. Accessed December 16, 2022.
  11. Prison Policy Initiative. Mental Health. Available from: https://www.prisonpolicy.org/research/mental_health/#:~:text=U.S.%20prisons%20and%20jails%20incarcerate,resulting%20in%20violence%20or%20incarceration. Accessed December 12, 2022.
  12. Prison Legal News – Dedicated to Protecting Human Rights. Brookings Institute Study Finds Direct Connection between Poverty and Crime Rates. Available from: https://www.prisonlegalnews.org/news/2018/dec/7/brookings-institute-study-finds-direct-connection-between-poverty-and-crime-rates/. Accessed December 12, 2022.
  13. SAMHSA – Substance Abuse and Mental Health Services Administration. Drug Abuse Warning Network. Available from: https://www.samhsa.gov/data/data-we-collect/dawn-drug-abuse-warning-network. Accessed December 17, 2022.
  14. Wallerstein NB, Yen IH, Syme SL. Integration of social epidemiology and community-engaged interventions to improve health equity. Am J Public Health. 2011 May;101(5):822-30. doi: 10.2105/AJPH.2008.140988. Epub 2011 Mar 18. PMID: 21421960; PMCID: PMC3076386.
  15. Griffin JL. MUSIC FESTIVAL IN MICHIGAN SPAWNS A WARNING ON DYSENTERY. Chicago Tribune. August 19, 1988. Available from: https://www.chicagotribune.com/news/ct-xpm-1988-08-19-8801240183-story.html.
Joey Kahn William Sellmayer