Advancing Public Health Interventions to Address the Harms of the Carceral System

This version of the statement was formally adopted by the American Public Health Association (APHA) at their annual conference in Denver, CO on October 26, 2021 with majority support from Governing Council members (86% to 14%).

Access the Official Statement on the APHA website by clicking here.

ENDORSEMENTS

Organizations within APHA Endorsing:

LGBTQ Health Caucus; International Health Section; Occupational Health Section; Mental Health Section; Medical Care Section; Latino Caucus; Alcohol, Tobacco, and Other Drugs Section; Oral Health Section; Black Caucus of Health Workers; Justice and Incarcerated Health

Organizations Outside of APHA Endorsing:

Aging People in Prison Human Rights Campaign, California Coalition for Women Prisoners, Drug Policy Alliance, Do No Harm Coalition, FreeThemAllWA, Psychologists for Social Responsibility, Communities United for Restorative Youth Justice (CURYJ), Jewish Voice for Peace Bay Area, Movement for Family Power, Justice Teams Network, Anti Police-Terror Project, Deeper Than Water, Human Impact Partners, Public Health Awakened - Los Angeles Chapter, Public Health Awakened - Michigan Chapter, A New Path  (Parents for Addiction Treatment & Healing), South Asian Public Health Association, Public Health Justice Collective, Collaborative for Health Justice-UIC School of Public Health, Health and Medicine Policy Research Group, Radical Public Health at UIC School of Public Health, Coalition on Homelessness San Francisco, Gray Panthers of San Francisco, White Coats for Black Lives UCSF, The Praxis Project, Collaborative for Health Equity Cook County

SUMMARY

Keywords: incarceration, decarceration, racism, health inequities, state violence, social determinants of health

In 2019, an estimated 1,430,800 people were incarcerated in state and federal prisons, with structurally marginalized groups disproportionately affected. Incarcerated people have a higher prevalence of acute and chronic health conditions compared to the general U.S. population, and the harms of the carceral system also extend to families and communities of incarcerated people. The conditions that created this crisis are longstanding, including local and federal policies deploying the legal system to address public health concerns and the targeting of marginalized people, both of which have shaped the unprecedented levels of incarceration in the United States. Now, as ever, intervention necessitates prioritizing health by centering public health strategies. Therefore, APHA recommends moving towards the abolition of carceral systems and building in their stead just and equitable structures that advance the public’s health by: (1) urgently reducing the incarcerated population; (2) divesting from carceral systems and investing in the societal determinants of health (e.g., housing, employment); (3) committing to non-carceral measures for accountability, safety, and well-being; (4) restoring voting rights to formerly and currently incarcerated people; and (5) funding research to evaluate policy determinants of exposure to the carceral system and proposed alternatives.

RELATIONSHIP TO EXISTING APHA POLICY STATEMENTS

The following APHA policy statements are relevant to the current statement:

• APHA Policy Statement 7106: “Jails and Prisons -- Public Health Response to a National Disgrace”

• APHA Policy Statement 7315: “Health Care in Jails and Prisons”

• APHA Policy Statement 7921: “Support for a National Strategy to Help Improve Health Care in Prisons, Jails, and Youth Detention Centers”

• APHA Policy Statement 9123: “Social Practice of Mass Imprisonment”

• APHA Policy Statement 9929: “Diversion from Jail for Nonviolent Arrestees with Serious Mental Illness”

• APHA Policy Statement 200029: “The Need for Mental Health and Substance Abuse Services for the Incarcerated Mentally Ill”

• APHA Policy Statement 20048: “Correctional Health Care Standards and Accreditation”

• APHA Policy Statement 201310: “Solitary Confinement as a Public Health Issue”

• APHA Policy Statement 201811: “Addressing Law Enforcement Violence as a Public Health Issue”

• APHA Policy Statement LB20-05: “Advancing Public Health Interventions to Address the Harms of the Carceral System”

RATIONALE FOR CONSIDERATION

This statement is presented for consideration as permanent American Public Health Association (APHA) policy. It builds on a previous version adopted as a latebreaker during the 2020 APHA Annual Meeting. That latebreaker policy centered the rapidly evolving COVID-19 pandemic and its disproportionate harms to people incarcerated in US jails, prisons, and detention centers. Recognizing that the structural conditions shaping the disproportionate burden of COVID-19 harms in carceral settings have long predisposed incarcerated people, their families, and their communities to numerous adverse health outcomes, this new policy statement renews efforts to understand carceral systems themselves as a public health crisis. Building on the work of public health researchers and practitioners, survivors of harm, economic and racial justice advocates and organizers, and others, this statement also renews calls to invest in creating healthy communities, ending the expansion of carceral facilities, and prioritizing equitable and health-affirming alternatives to the carceral system. Finally, it adds recommendations for research objectives dedicated to documenting the structural determinants of carceral system exposure and evaluating the effectiveness of non-carceral alternatives to understand strategies to reduce the harms of the carceral systems at all levels. Now, as ever, guidance from this body is key to ensuring that interventions aimed at addressing the harms of the carceral system prioritize health by centering prevention-focused public health strategies.

PROBLEM STATEMENT

**Note: Bolded in-text language has been explicitly defined in the Glossary**

Prevalence and Inequitable Distributions of Incarceration. The US incarcerates more people than any other country in the world.1 In 2019 alone, an estimated 1,430,000 people were incarcerated in state and federal prison.2 An additional 631,000 people were incarcerated in jails, almost 75% of whom were still awaiting trial.3 Further, the U.S. government incarcerated 510,854 people in Immigration and Customs Enforcement (ICE) detention facilities, an increase of 29% over 2018.4 Taken together, while the US comprises less than 5% of the world’s total population, people incarcerated in US prisons and jails account for 20% of the world’s incarcerated population.1    

 Owing to experiences of inequitable, intersecting, and cyclical exposure to policing and criminalization,5 structurally marginalized people are overrepresented among those incarcerated in US prisons, jails, and detention centers. This includes people who identify as Black, Indigenous, or People of Color (BIPOC);6 people who are undocumented;7 those without stable housing;8 people with disabilities;9 people who are lesbian, gay, bisexual, transgender, and/or queer (LGBTQ+);10 people with mental illness;11 people who use substances;12 sex workers; and people who are economically disenfranchised.13

The Health Harms of Incarceration on Individuals. It is well-documented that incarcerated people have a higher prevalence of acute and chronic health conditions compared to the general U.S. population.14 This includes higher prevalence of infectious diseases,15 mental health diagnoses and substance use disorders,16 traumatic brain injuries,17 hypertension, heart-related problems, diabetes, asthma, stroke, and overall lower life expectancy.18

 The higher prevalence of these acute and chronic conditions among incarcerated people has been partially attributed to pre-incarceration exposure to adverse structural determinants, such as poverty and unstable housing.14 That is, adverse structural determinants not only create health-harming conditions (e.g., harmful weather exposure), but also increase the likelihood of legal system targeting (e.g., legislation that criminalizes sleeping in public).

However, the experience of incarceration itself is also associated with adverse health outcomes.  Violence –– whether self-directed, interpersonal, or perpetrated by agents of the state –– is also a significant documented harm of incarceration. While men are more likely to experience interpersonal violence from another incarcerated person,19 women are more likely to be assaulted by staff.20 Strikingly, transgender people are targeted at nearly 10-times the rate of other incarcerated people. In 2012, approximately 40% of trans people incarcerated in the U.S. reported sexual assault or abuse by staff or another incarcerated person.21 In addition to widespread violence and sexual assault inside carceral settings, other extreme human rights violations such as mass forced sterilizations;22 the regular use of solitary confinement; and abandonment during natural disasters are known harms linked to incarceration. For example, solitary confinement, a form of torture, is used as an extraneous tool for punishment - disproportionately imposed on incarcerated people with mental illness and associated with deleterious effects including increased risk of death in the year following release from prison.23,24 As another example, during Hurricane Katrina, people incarcerated at the Orleans Parish Prison were left chest-deep in water, without power, water, food, or proper ventilation, while during Hurricane Sandy, New York City had no evacuation plan for Rikers Island jail, despite it being situated within an evacuation zone.25 Alarming as these data are, what is known regarding the prevalence of abuse in carceral settings is likely an underestimation given risks associated with reporting (e.g., retaliation, dismissal of reports, lack of institutional accountability). 

 Conditions within carceral settings also contribute to increased risk of infectious disease exposure and result in worse outcomes.26 This has consistently been observed across a multitude of infectious disease outbreaks in carceral settings, though few have been as dire or made as hyper visible the fundamental incompatibility of the carceral system with public health imperatives as the Coronavirus Disease 2019 (COVID-19) pandemic.27 When the first COVID-19 case was detected in the U.S. in January 2020 - thereafter spreading quickly and relentlessly across the country and globe - few U.S. residents were more affected than people incarcerated in jails, prisons, and detention centers. As early as May 2020, case rates of COVID-19 in U.S. prisons were at least 5.5 times higher than in the general population.27 As with other infectious respiratory diseases, COVID-19 spreads especially rapidly and uncontrollably in congregate settings. Further, the daily entering and exiting of staff –– often without sufficient testing, poor personal protective equipment adherence, and facility-wide access –– increases chronic stress and exposure risk for currently incarcerated people.28 Once respiratory viruses enter these facilities, many of which are densely populated, there is insufficient space to physically distance. Facilities are also not equipped to safely quarantine or medically isolate exposed individuals. Rising reliance on solitary confinement or other restrictive housing for symptomatic individuals during the COVID-19 pandemic, sites typically used for punishment and linked to psychological distress and trauma,28,29 likely uniquely exacerbate an already dire situation by deterring symptom reporting or the seeking of medical attention. Other common conditions of the physical space, such as an aging infrastructure, poor ventilation, and shared living and hygiene facilities contribute to the efficiency with which respiratory viruses spread. These transmission-promoting conditions combine with the regular transfer of individuals into and between facilities to further amplify spread. Taken together, this uniquely susceptible environment places incarcerated individuals at increased risk of not only contracting COVID-19, its variants, or other infectious respiratory diseases, but –– given their increasingly older age30 and disproportionately high burden of underlying conditions –– developing severe infections that require hospitalization or end in early death.31

 The adverse effects of incarceration on individuals do not end after release. Formerly incarcerated people are ten times as likely to be unhoused than the general public32 and face restricted access to health-promoting supports including education, employment, and public housing.33 This is in part attributable to structural stigma around having a criminal record34 coupled with barriers to criminal record expungement.35  Additionally, given state laws restricting voting rights for incarcerated and formerly incarcerated people, in 2016 an estimated 6.1 million Americans were barred from voting,36 thus excluding them from participation in political decisions that affect their health and that of their families and communities.

 The Health Harms of Incarceration on Families and Communities. In addition to direct health consequences experienced by incarcerated people, the harms of the carceral system also extend to families and communities of incarcerated people through mechanisms like family separation and disruption of community cohesion.37 For example, parental/caregiver incarceration is associated with food insecurity during childhood and greater risk of living with mental health issues in childhood and adolescence.38 These detrimental consequences also extend to adult partners and relatives, inducing relationship strain and onset of depression and anxiety.39 Some of the carceral system’s harms are indirectly mediated through pathways like added economic pressures (e.g., household income loss, and paying for fees and fines, bail, visitation and communication, and incarcerated people’s food and clothing) and housing precarity, which have been linked to adverse health outcomes.40 Further, emerging public health research points to “spillover” effects to non-incarcerated community members in heavily incarcerated communities, including county-level mortality,41 as well as individual-level preterm birth,42 depression, and anxiety.43 Immigration detention and deportation have also been linked to a range of adverse health outcomes among non-detained community members, including low birthweight, preterm delivery, and post-traumatic stress disorder among others.44,45

The Historical Makings of the Present Crisis.  Critical to identifying appropriately targeted solutions is acknowledging that rates of incarceration in the U.S. and their associated harms extend from punitive policies implemented at federal, state, and local levels. It is through these policies that certain activities and identities are socially constructed as criminal and that legal ramifications are broadened. For example, while some policies have served to increase prison admissions (e.g., deploying the legal system to criminalize mental health needs),1,46 others have extended the average length of incarceration sentences (e.g., the Federal 1994 Violent Crime Control and Law Enforcement Act as well as State “three strikes” and truth-in-sentencing laws).47

These punitive policies and practices disproportionately harm historically and structurally marginalized communities. For example, stop-and-frisk, which was codified into law via a 1968 Supreme Court ruling, permits law enforcement officers to stop and pat down any individual they perceive has or may engage in a criminalized activity. One study in New York City examining the use of stop-and-frisk showed that this practice disproportionately targeted Black people, with an overwhelming majority of stops resulting in no charge.48 These racial inequities extend beyond policing. Data show that given the same charge, Black and Latinx people are more likely than white people to be detained pretrial, sentenced to incarceration, and when sentenced in federal courts, more likely to receive longer sentences.1 Similarly, the vast majority of immigrants who are deported are Black and Latinx men.49 As with U.S. jails and prisons, these patterns of detention and deportation reflect policies designed to target structurally marginalized people. For example, in 1996, when immigration law (though, notably, not criminal law) re-categorized a range of criminalized activities as “aggravated felonies,” the numbers of mandatory detentions began to rise.50 While touted as universally applied, these “tough-on-crime” policies are rooted in efforts to exert social control over structurally marginalized people. Legal scholar Dorothy Roberts argues that racialized notions of criminality and social control in the U.S. date back to slavery and that the racist construction of Black communities as criminal are used to justify contemporary racially discriminatory law enforcement policies and practices. These and other inequitable practices construct “crime rates” along axes of structural marginalization, with cyclical consequences for targeted policing. These ideologies also underlie race-based ideas of who is “deserving” of rehabilitation which have been shaping legal policy since at least the early 1900s.51

 Types of Incarceration. Lastly, it is critical to identify the different ways incarceration operates across institutions and domains. The majority of incarcerated people in the U.S. are confined in state or federal prisons and local jails (about 2.3 million people).1 However, as noted above, the modern era has seen a rapid expansion of the carceral system, encompassing additional institutions (e.g., detention centers, hospitals, schools, homes)1 and deploying novel or non-institutionalized methods (e.g., digitally monitored E-carceration, probation, parole, “community-based corrections”).52 For example, in addition to facilities constructed explicitly to incarcerate over 44,000 young people (i.e., “youth jails”),1 incarceration also manifests in their school spaces through the use of seclusion as a form of discipline (i.e., isolated confinement).53 Similarly varied are the governing bodies that coordinate this carceral system. These range from the Department of Homeland Security, to the U.S. Bureau of Prisons, to state departments of correction, to county and municipal departments,1 as well as private (for-profit) corporations (e.g., GEO Group).54 For example, about 42,000 people are currently in immigration detention and over 73% of immigrant detention facilities are privately owned and operated.3 Recognizing the multiple modes by which people are incarcerated, understanding their shared and unique consequences, and identifying the profiting and governing bodies overseeing these institutions are key to designing appropriate solutions to stem incarceration and its health consequences.

EVIDENCE-BASED STRATEGIES TO ADDRESS THE PROBLEM

A Public Health Approach

Deploying the carceral system largely remains the default policy approach to societal concerns.51,55 Yet, this investment in a punitive paradigm was, and continues to be, ineffective and avoidable. In fact, state governments that have pursued public health priorities - such as policies and public investments designed to bolster existing safety net programs such as SNAP and Medicaid, public housing, and pre-k through 12 education -  have had lower average prison incarceration rates56 and better health outcomes.57 Similarly, locales that provided community-based support to people navigating substance use disorder, rather than responding with criminalization and punishment (also significantly more costly, by comparison), have minimized stigma and increased uptake of treatment.58

Despite sufficient evidence that incarceration neither achieves safety nor accountability but does  perpetuate violence, health inequity, and social inequity, most public health recommendations to-date propose reforms as opposed to the aforementioned primary prevention strategies. That is, they advocate for additional funding to improve health conditions during incarceration rather than directing those funds towards preventing incarceration altogether. While efforts to improve health conditions both during and after incarceration are important, they do not address the root causes of incarceration, prevent the associated negative health consequences, or provide accountability and healing for harm consistent with survivors’ justice goals.

Incarceration is an insufficient intervention to resolve social problems, and jails, prisons, and detention centers should not be the point of access for necessary resources aimed at improving any number of social, emotional, or economic conditions. Public health researchers and practitioners can play a key role in shifting away from these punitive paradigms, moving towards the abolition of carceral systems, and building in their stead just and equitable structures that advance the public’s health. Indeed, as a field concerned with population health, the harmful consequences of incarceration on currently and formerly incarcerated individuals, their families, their communities, survivors of harm, and the general public, demand an effective and preventive public health response.

Evidence-Based Strategy #1: Invest in communities. An abolitionist public health approach advocates for primary prevention by disrupting the ideologies and structural determinants that shape incarceration prevalence, target marginalized populations, and increase risk for adverse health outcomes. These preventive solutions include providing equitable access to fundamental resources that communities need to thrive, including: stable and supportive housing,59 access to affordable high quality education starting in early childhood, well-paying employment, culturally responsive youth programs, and  affordable and accessible health care, including mental health first responders and within-community mental health service access among others.8,60 These can be achieved through efforts to implement anti-discrimination labor laws, decriminalize housing instability, eliminate redlining, and fund reparations of generational wealth that has been actively denied to Black, Indigenous, and communities of color, to name a few. Investing in community-based healthcare, housing, and food is a more effective and just way to meet physical and mental health needs than relying on the carceral system. Devoting public health efforts to establishing a single-payer payment system, for example, that provides health care access to everyone -- including mental health and substance use support -- would dramatically reduce inequities and prevent further harms to economically disenfranchised communities. Similarly, ensuring communities maintain truly affordable housing and access to healthful foods, especially in areas known as food deserts, are essential ways in which public health can promote health equity rather than continuing to support punitive measures that fail to recognize root causes and perpetuate inequities.

Evidence-Based Strategy #2: Heed recommendations from survivors of harm, including survivors of violence. Rather than assuming punitive measures are preferred by survivors of harm, an abolitionist public health approach uses evidence-based strategies to understand the complexity of survivors’ expressed needs in order to collectively and effectively build systems that support healing and both prevent and account for harm.61 In 2016, a nationally representative survey found that an overwhelming majority of people who have experienced interpersonal harm, including survivors of violence, preferred accountability measures facilitated outside of the carceral system such as rehabilitation, mental health treatment, voluntary drug use disorder treatment, community supervision, or community service.62 For example: to prevent or mitigate harm, research with survivors of intimate partner violence (IPV) recommends structural interventions that address systems-induced precarity (e.g, related to housing, employment, and immigration status, etc.) that often facilitate harm.63 To account for harm, IPV survivors discuss both currently relying on retributive systems (e.g., incarceration) as their only recourse, as well as how such systems fail to meet survivors’ primary justice goals, including acknowledgment of harm and rehabilitation through “support-oriented frameworks.”64 Finally, to promote healing, survivors of IPV and other forms of violence have called for approaches that (1) support processing their experience of harm (having their questions answered and experiences validated), (2) acknowledge their agency,  (3) repair the harm, and (4) prevent any further harm.61 In both understanding that survivors do not have uniform experiences of harm and reflecting on the insufficiency of punishment-centered systems to address the scope of these recommendations, interdisciplinary scholars, researchers, practitioners, and survivors increasingly propose developing evidence-based, prevention strategies and community solutions for healing and accountability guided by the expressed needs of survivors as opposed to the limitations of currently available systems (see next section, Evidence-Based Strategy #3).65,66

Evidence-Based Strategy #3: Invest in restorative and transformative justice. An abolitionist public health approach advocates for health and health equity-promoting approaches to ensuring accountability and repairing harm. Restorative justice is a non-punitive, non-retributive process to address interpersonal harm that centers survivors of harm and brings together everyone affected to decide collectively how to heal and to repair the harm. Transformative justice builds upon this process by focusing not only on the individuals involved, but also on the larger systems and structures that created the conditions for that harm to occur.67 Though restorative and transformative justice processes vary widely in implementation, making evaluation of their effectiveness challenging, research on restorative justice shows it to be a promising solution to the problem of incarceration. For example, one of the most comprehensive meta-analyses on restorative justice revealed higher levels of satisfaction from individuals involved in the process (including those who were harmed and those who did harm), greater likelihood of adhering to restorative agreements, and decreased rates of recidivism compared to those who did not participate in a restorative justice process.68 Another meta-analysis of restorative justice programs with young people under 18 found a general trend of decreased re-engagement with the legal system, a greater sense of fairness among both the young people who did harm and the people who were harmed, and greater satisfaction than those who did not participate in restorative justice programs.69 These outcomes suggest better mental well-being for all individuals involved when using a restorative justice process as an alternative to the carceral system. Indeed, one study showed that symptoms of post-traumatic stress disorder, including avoidance and intrusion, were reduced among those who had been harmed and underwent a restorative justice process.70 Preliminary evidence suggests that rather than continuing to invest in punitive paradigms, restorative justice approaches provide a more effective and less harmful means of accountability. Further research is needed to evaluate programs explicitly identified as transformative justice.

Evidence-Based Strategy #4: Decarcerate with no conditions of electronic monitoring or use of risk assessments, and end continued punishment after release.  An abolitionist public health approach advocates for disrupting exposure to structural determinants, like incarceration, known to be associated with adverse individual-, family-, and community health outcomes. Decarceration practices and policies are those that are aimed at reducing the number and rate of people imprisoned in a particular jurisdiction. Studies estimate that such decarceration practices could have prevented as many as 23,000 COVID-19 infections among incarcerated people and 76,000 infections in surrounding communities - suggesting that decarceration is a lever for improved population health.71,72  Decarceration practices include: (1) ending cash bail;73 (2) providing people living with mental health issues and substance use disorders with community-based treatment; (3) employing community-based interventions to address the medical and social needs of people who have been harmed by the legal system including those transitioning from incarceration;74 (4) decriminalizing substance use,75 housing insecurity , and other “quality of life” charges; and (5) decriminalizing sex work. Further, release from prisons, jails, or detention centers without deploying racially biased risk assessments or under conditions of electronic monitoring was found in one study to be  associated with health benefits for former detainees, including greater life satisfaction, improved mood, and  declines in suicidal ideation.76 Conversely, the experience of wearing an ankle monitor is associated with job loss, loss of housing, and adverse health outcomes, including anxiety, sleeplessness, depression, aches, burns, and swelling.77

Moreover, once people are released from carceral facilities, they face punitive policies and practices that restrict their abilities to maintain health and wellbeing. Criminal records, for example, are significant barriers to securing employment, housing and, in some states, restrict government assistance through TANF and SNAP.34,78 Criminal record expungement has been shown to increase employment, but significant legal and policy barriers prevent many from having their records expunged.35 Similarly, ending felony disenfranchisement and restrictions on voting for currently incarcerated people would allow them to participate in decision making that ultimately shapes the social determinants of health.79 Finally, parole, probation, and other technical violation policies in the absence of other new charges, often applied inconsistently, lead to high rates of reincarceration; in New York State, parole violations recently made up nearly 40% of admission charges.80,81 These strategies can be implemented through or supported by community organizations - such as those that employ formerly incarcerated people - and evidence-based re-entry approaches, including Transitional Care Coordination.74

Evidence-Based Strategy #5: Invest in community-based mental healthcare. Consistent with the public health and clinical evidence on health-promoting interventions, an abolitionist public health approach urges the use of community-based mental health systems as the primary population-level policy for providing care. Bolstering the community-based mental health care system includes investing in community-based, non-police responses to mental health crises, like assertive community treatment (ACT), which provides comprehensive, team-based, non-law enforcement support services to people living with mental health issues. Such community-based mental healthcare services have been shown to reduce involvement in the legal system. For example, one study in California found that over the span of one year, jail bookings for people enrolled in ACT were 36% lower than those not enrolled in this type of treatment, and importantly, ACT increased outpatient contacts and reduced hospital days.82 Investing in services such as supported housing, which includes both a housing subsidy and social support (i.e., case management) for people living with mental health issues, has also been shown to reduce incarceration rates. For instance, an Ohio study found that formerly incarcerated people who received supported housing services were 40% less likely to be re-arrested and 61% less likely to be re-incarcerated.83

Moreover, current carceral solutions to mental health problems lack of evidence of effectiveness and have  documented harms,84,85 which is especially critical given people with serious mental illnesses are 16 times more likely to be killed by law enforcement than those without.85 Touted strategies such as Crisis Intervention Trainings (CIT) are predicated on interactions with police rather than mental health professionals responding to crises independent of the carceral system.5

OPPOSING ARGUMENTS/EVIDENCE

Opposing Argument #1: Incarceration increases public safety. A primary opposing argument suggests that prisons and jails improve public safety by confining people convicted of criminalized activities behind bars. This argument is predicated on conceptualizing criminalized activity as a static individual attribute that can only be addressed via incapacitation.86  A similar argument is that releasing incarcerated people convicted of violent crimes is a risk to public safety.

Response: This argument is inconsistent with the available evidence. Higher incarceration rates have not been shown to increase public safety. For example, studies that use “crime rates” as a proxy for criminalized activities find that reductions correlated with incarceration are limited to property crime. One study estimated that reductions in property crime were, at most, by 6-12% in the 1990s and less than 1% this century.87 Studies also find that higher rates of incarceration are not associated with lower rates of violent crime and that those released from prison after murder convictions were unlikely to be re-incarcerated for a similar conviction.88 Many states including California, Michigan, New Jersey, New York, and Texas have reduced their prison populations while crime rates have continued to fall.87  Recent decarceration efforts during COVID-19 and policy changes that reduce incarceration have also not corresponded to an increase in crime rates. A study by the ACLU found that in 29 locations that decarcerated people during COVID-19, the reduction in jail populations was unrelated to a change in crime trends. In fact, crime rates were lower between March and May 2020 than they were in the same time period in 2019.89 In San Francisco, where District Attorney Chesa Boudin ended the use of cash bail in 2020, the overall crime rate reduced by 23%, in comparison to the overall crime rate in 2019.90 While incarceration has not been shown to increase public safety and decarceration has not been shown to decrease public safety, any instance of interpersonal violence is a grave concern that cannot be ignored. Thus, an abolitionist public health approach requires both prevention of harm and accountability for/healing from harm when it does occur, with the experiences of survivors as a central component for effective, sustainable, and comprehensive implementation. See Evidence-Based Strategy #2 and Opposing Argument #3 for further information.

Additionally, this argument does not consider the outsized magnitude of health and safety harms associated directly and indirectly by the carceral system. As outlined in the problem statement, incarceration has far-reaching legal (e.g., longer mandatory-minimum sentencing, voting disenfranchisement, deportation, inability to access housing and other social supports, etc.) and health consequences incurred to individuals who experience incarceration, their families and communities. 

Notably, those who argue that incarceration increases public safety often focus on violent charges. First, it is important to note that many actions that a court defines as “violent” do not cause physical harm to others (e.g., in some states, marijuana possession), or they involve actions in self-defense among survivors of physical or sexual abuse. However, in cases where violence against another person does occur -- including domestic violence, child sexual assault, and homicides -- existing restorative justice programs in California and New York have demonstrated effective accountability approaches that center survivors, heal trauma, and build safer and healthier communities. These programs acknowledge that violence is not happening within a vacuum but is often the result of having experienced violence -- structural and interpersonal -- and aim to address the root causes of violence by interrupting the cycle.61 When asked, survivors of violence themselves overwhelmingly support reducing incarceration and investing in prevention, accountability, and rehabilitation outside the carceral system.62   

Opposing Argument #2: Punishment through incarceration advances justice and accountability. A second opposing argument suggests that punishment is necessary for ensuring individuals are held accountable for interpersonal harms or harms to society.91 This argument is premised on the idea that the loss of freedom over daily routines, bodily habits, pastimes, relationships, and mobility, are appropriate consequences for certain actions and necessary to prevent convicted people from repeating these actions.86 In other words, this argument suggests that to address and prevent suffering and violence requires imposing suffering and violence.

Response:  The carceral system is often presented as a tool for advancing justice and accountability, essentially conflating punishment with accountability. Yet this punitive paradigm - which operates by disrupting community cohesion, separating families, and warehousing people, with known health consequences - awaits the occurrence of interpersonal harm and punishes it, rather than preventing or repairing it. It also fails to interrogate and hold to account the ways in which the harms of structural injustice, including that perpetrated by the legal system itself, manifest interpersonal harm.  

Punishment provides neither justice nor accountability, and in many cases, the criminal legal system actually perpetuates harm rather than reducing it.. Those who are incarcerated face the violence and harms of incarceration without transforming the conditions that allowed the harm or violence they perpetuated to occur or being held accountable to those they hurt. In contrast, community-based organizations, like Project NIA,92 are working to end the reliance on carceral systems in response to violence, instead promoting the use of restorative and transformative justice practices within communities. Collectives like the Bay Area Transformative Justice Collective or the NYC Transformative Justice Hub create spaces for community members to learn about and engage in community accountability practices to address harm, conflict, and violence when it occurs and before it escalates further.

Opposing Argument #3: Alternatives to incarceration would not be fair to survivors of crime. Another opposing argument expresses concern over the impacts of pursuing alternatives to incarceration on survivors of harm for whom incarceration has often served as the only available recourse for addressing the harm they have experienced.

Response: Meaningfully centering the expressed needs of survivors cannot be overstated and is consistent with an abolitionist approach to prevention, accountability, and healing from harm.61 While recognizing that survivors do not have uniform experiences of harm, research seeking to document survivors’ justice goals identifies key critiques of current carceral practices and an interest in non-carceral solutions. These critiques include: (1) Reductions in survivor agency, for example through the exclusion of survivor voices in legal processes, requirements to engage law enforcement - over which many survivors express safety concerns - in order to access critical services to heal from harm,61 and a disregard for survivors’ preferences around healing and maintaining relationships with those who created harm in instances where survivors cannot or do not want to sever ties.63,64 (2) Justice preferences being inconsistent with carceral practices, including inadequacies of incarceration for meaningfully achieving accountability (e.g., remorse, reckoning, healing) and rehabilitation (e.g., developing new, healthful relationships).61,64  (3) Limitations on achieving lasting safety and fears of exacerbating harms, for example through retaliation (by loved ones of person incarcerated, or upon release) for role in precipitating incarceration, particularly given carceral processes do not address root causes of harm.61,64 Indeed, as many as 52% of survivors have reported that they believe retributive approaches, like incarceration, exacerbate harm.61 (4) Risk of harm to survivors perpetuated by the legal system, with many survivors experiencing the legal system as re-traumatizing through instances of hostility, victim-blaming, lack of empathy, and discrimination (particularly among survivors from marginalized communities, like LGBTQ, immigrant, low-income, and racially minoritized survivors), as well as fears of their own arrest, loss of housing, family separation (e.g., through child services involvement), and risk of deportation among others.61,63,64 (5) How carceral approaches shape non-reporting among survivors, with research suggesting that as many as half of violent victimizations in the US go unreported - this number still likely an underestimate.61 Research with survivors attributes underreporting to perceptions that the legal system cannot or will not intervene; that the legal system does not achieve survivors’ justice goals; that harms, regardless of severity, do not warrant legal system involvement; that the legal system is racially inequitable; and/or, most often, a preference for alternative approaches for intervention (e.g., reporting to non-legal system supports, resolving harms privately).61,64

While, at present, incarceration is often the only available recourse for harm - and therefore often pursued as an alternative to “nothing” - survivors express concern over its capacity to achieve their justice goals and to ensure individual and community safety, healing, and well-being.61,64 Taken together, evidence suggests that identifying alternatives to incarceration to prevent, hold to account, and heal from harm is consistent with survivors’ justice goals (refer to Evidence-Based Strategy #2 and #3).

Opposing Argument #4: Prisons and jails exist for the purposes of rehabilitation. Another justification for incarceration is that rehabilitation services can be provided in prison. This idea proposes that the skills, medical care, and treatment offered through incarceration will not only prevent people from engaging in criminalized activities after incarceration but may serve as access to care points that are otherwise unavailable in the community.

Response: First, prisons and jails often fail to provide services to people incarcerated in these facilities. More than half of all incarcerated people do not receive rehabilitation services.93 Second, carceral facilities expose people to trauma and - by virtue of their punitive nature - likely cannot uphold patient rights requirements for care settings (e.g., ability to assert choice in treatment without fear of retaliation). Third, incarceration’s far-reaching consequences often actively prohibit formerly incarcerated people from re-entering or meaningfully participating in their communities.33 Barriers to re-entry include a debilitating criminal record that precludes people from basic rights such as voting and obtaining jobs, housing, and other social supports.34 There are many examples of successful substance use disorder treatment, job training, food, community-based conflict-resolution, anger management, adult education, and mental health programs that can be implemented in the community. One example occurring in Oakland and Sacramento, California is Mental Health First, a non-police, community-led response to mental health crises.94 Such programs provide examples of opportunities to invest in communities rather than in the legal system. 

Opposing Argument #5: We can improve the carceral system by building and maintaining more humane and trauma-informed jails and prisons. Citing examples in other nations, this approach seeks to intervene on the harms of incarceration by reforming jails and prisons through human-centered, trauma-informed planning. Rationale for these designs endeavor to overcome the punitive nature of incarceration by instituting "trauma informed" practices and policies through staff training and oversight, and utilizing "humane" facility architectural plans, building materials, and landscaping surrounding carceral facilities.

Response: While these novel designs of carceral systems seek to incorporate trauma-responsive approaches,95 they often rely on practices and policies associated with chronic stress and adverse health consequences (e.g. use or threat of solitary confinement, punitive-based policies enacted by prison staff).23 As one of the most recognized examples of this approach, Norway’s reformed prison system has been lauded for its success across legal system indicators like recidivism; however, concerns remain regarding poorer health-related outcomes, including higher suicide rates96 and low satisfaction with health services provided.97 Further, a 2019 National Preventive Mechanism against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment special report on solitary confinement in Norwegian prisons found that one out of four people incarcerated in Norway was confined to their cell for at least 16 hours per day, likely an underestimate, violating the European Committee for the Prevention of Torture’s recommendation for at least 8 hours of “meaningful daytime activity” outside of their cell each day. The same report found that, in some prisons, prison staff did not notify medical personnel when incarcerated people requested care, even in some cases of obvious mental health crisis or physical injury.98 Even in Norwegian prisons, upheld as a “more humane” examples of carceral systems, punitive practices persist, resulting in documented instances of human rights violations and harms to physical and mental health. Instead, as outlined in the Evidence-Based Strategies, community-based care, support, and accountability best promotes health, well-being, and justice.  

Opposing Argument #6: Public health can play an oversight role to ensure prisons and jails mitigate health risks and support the health of people incarcerated and those detained. Another reform-based approach to intervening on the health harms of incarceration suggests carceral facilities can promote health and well-being if under the purview of public health officials. These models propose that by incorporating public health frames and practices, and by meeting health needs of people confined to carceral settings, documented health harms can be overcome or minimized. At times, this has been framed as an ethical responsibility of public health

Response: First, even with medical and public health oversight, prioritization of custody protocols over health recommendations are common and harm health. For example, even in the presence of active outbreaks within prison facilities during the COVID-19 pandemic, prison policy and practice superseded halting transfers and otherwise constrained delivery of care according to health imperatives.94 Second, public health oversight is not prevention. While APHA has had established standards for health services within prisons and jails since 1976,99 a public health, equity-based approach to addressing incarceration necessitates a prioritization of preventative measures and alternatives to the health harms of incarceration altogether. Primary prevention strategies fall squarely in the purview of public health’s ethical responsibility, and stipulate preventing incarceration as a health harming exposure, not simply mitigating its effects. Prevention is a primary tenet of public health practice and to ignore this professional responsibility is neither reasonable nor sustainable in the practice of prioritizing the health and well-being of all people. COVID-19 has both underscored the status quo is insufficient (e.g. solitary confinement as COVID-19 isolation) and illuminated the feasibility of once considered unattainable policies as government and public health officials strived to protect society from a once-in-a-century pandemic. Third, public health oversight in carceral facilities does not address “spillover” health effects to families, communities, and the broader environment. For example, parental, caregiver, or other household member incarceration is an Adverse Childhood Experience (ACE) associated with higher risk of poor health in adulthood.100 Additionally, evidence suggests an association between incarceration and poorer population health outcomes like infant mortality, life expectancy, infection rates of immunodeficiency syndromes, and inequities observed with AIDS infection rates.18

Opposing Argument #7: Decarceration can be facilitated through furloughs, electronic monitoring, parole, and other surveillance tactics. Many reforms aimed at reducing incarcerated populations argue for the imposition of alternative forms of surveillance (e.g., electronic monitoring) in order to prevent criminalized behaviors.

Response: First, alternative forms of state-supervised monitoring such as electronic monitoring (e.g., ankle monitors) are still mechanisms of surveillance and control. As a coercive, punitive strategy this is not an effective means of connecting recently incarcerated individuals to needed services, which public health professionals are in position to advance (i.e. prevention strategies without deploying the carceral system).101  Second, decarceration efforts that rely on electronic monitoring or excessive supervision continue to be harmful to health via multiple pathways, such as increased financial cost for the person made to wear them and increased risk for loss of housing, employment, and access to healthcare across all systems. For example, a 2011 survey conducted by the National Institute of Justice found that among 5,034 people who were on ankle monitors, 22% said they had been fired or asked to leave a job because of electronic monitoring.102 Job loss is correlated with worse mental health,103 worse self-reported health, more cardiovascular disease, and an increase in hospitalization rates.104  These harms are additive to the direct harm to mental and physical health caused by ankle monitors. A recent survey of immigrants forced to wear ankle monitors found that 90% of respondents reported harm to their physical health (including aches, impaired circulation, and swelling) and 88% of respondents reported harm to their mental health (including anxiety, sleeplessness, and depression) due to the electronic monitoring.77 Excessive surveillance, such as regular or random mandatory drug testing, can harm health along similar pathways and does not effectively address substance use disorders. Indeed, one study found that drug testing requirements in parole did not deter most drug use.101 With over a third of prison admissions due to technical violations of parole and probation conditions, these methods of decarceration also end up feeding the carceral system.105 The number of conditions people on parole or probation are required to meet have increased in recent years, including required employment, participation in educational programs, abstinence from drugs or alcohol, approved housing, restrictions on out-of-state travel, regular visits and check-ins with parole officers. The stress of meeting all these conditions - alongside factors like a lack of resources, unmet health needs, and racism - has a detrimental effect on the health of formerly incarcerated people.106

Opposing Argument #8: We cannot decarcerate because people do not have access to healthcare, housing, and food. A frequent argument against decarceration is that housing, healthcare, and food access is better in jails and prisons as compared with communities. Proponents point out that relative to uninsured community control samples, access to healthcare can sometimes be better in prisons107 and that group-housing infrastructure for unhoused people is currently insufficient to meet the needs of those being released from incarceration, particularly during the COVID-19 pandemic.

Response: First, such an argument makes clear the grave health consequences of economic disenfranchisement, lack of affordable housing, inadequate access to healthful foods, and lack of health insurance. Rather than invest more in incarceration, this argument underscores the need for better public health and social policy solutions for all marginalized populations – incarceration should not be the primary point of access to care. Second, this argument neglects the explicit health harms of carceral settings. Incarcerated people are exposed to infectious diseases in confined and overpopulated spaces without the ability to take proper public health precautions. Overwhelmingly, instead of healthcare, people who are incarcerated often face unhealthy conditions such as poor ventilation, extreme temperatures, black mold, poor plumbing infrastructure, and lack of nutritious food that exacerbate sickness and poor health outcomes, with or without a pandemic. They are also unlikely to receive needed healthcare while in a jail, prison, or a detention center. For example, trans individuals, who are disproportionately affected by this lack of access, experience substantial barriers to receiving medically necessary transition-related services, including denial of hormone replacement therapies and genital reconstructive surgeries.108 Additionally, incarcerated people with chronic medical issues, 13.9% of federal prisoners, 20.1% of state prisoners, and 68.4% of people incarcerated in local jails had not received a medical examination since incarceration.109 The same study found that although more than 1 in 5 people were on prescription medications prior to incarceration, almost 30% of people incarcerated in federal and state prisons and 41.8% of people incarcerated in jails stopped the medication upon incarceration.109 Furthermore, instead of adequate food during incarceration, those incarcerated report food with inadequate portion sizes, inadequate nutritional content, and prepared without sanitary precautions.

ACTIONS STEPS

To move towards the abolition of jails, prisons, and detention centers and to build in their stead just and equitable systems that advance public health and well-being, APHA urges federal, state, tribal, territorial, and local governments and agencies to take the following iterative action steps while prioritizing historically and structurally marginalized communities:

1. Decriminalize activities shaped by the experience of marginalization, like substance use and possession, housing insecurity, and sex work;

2. End the practice of cash bail and pretrial incarceration;

3. Meet patient rights requirements to be in the least restrictive environment for care, by redirecting funding and referrals from jails, prisons, and involuntary and/or court-mandated inpatient psychiatric institutions to inclusive, community-based living and support programs for people with mental illness and substance use disorder;

4. Significantly & continually reduce the number of people incarcerated in jails, prisons, and detention centers through release;

5. Re-allocate funding from the construction of new jails, detention centers, and prisons to the societal determinants of health, including affordable, quality, and accessible housing, healthcare, employment, education including in early childhood, and transportation;

6. Adopt policies to ensure employment and economic security for the individuals and local communities affected by reduction in staff and/or closures of prisons, jails and detention facilities;

7. Develop, implement, and support non-carceral measures to ensure accountability, safety, and well-being of varying degrees to meet different levels of individual and community needs for support (e.g., programs based in restorative and transformative justice);

8. Develop, implement, and support existing community-based programming interventions, to address the medical, social, and financial needs of people who have been harmed by the criminal legal system, including those transitioning from incarceration;

9. Implement policies and practices designed to remove barriers to stable employment and housing for formerly incarcerated people, including expungement of criminal records;

10. Restore voting rights for all formerly or currently incarcerated people to ensure their basic democratic right to participate in elections.

Further, APHA urges that Congress, the Centers for Disease Control and Prevention (CDC), and the National Institutes of Health (NIH), in collaboration with community organizations, survivors, and formerly incarcerated individuals, to:

1. Fund research on the effectiveness of alternatives to incarceration (e.g., transformative justice) and how to effectively change carceral policies and perceptions of criminality in society;

2. Fund research on policy determinants of exposure to the carceral system;

3. Put forth a set of recommendations that will decrease the population within carceral settings based on the principles of human rights and health justice.

Lastly, APHA calls on state and local health departments to:

1. Provide accurate, timely, and publicly available data on incarcerated, detained, and released populations at the state and facility-level;

2. Advocate for, collaborate and educate around, and support both the decarceration and defunding of all carceral facilities and systems in the ongoing mission to advance the public's health, regardless of jurisdiction; and invest in programs and interventions that better address human need (e.g. mental health rapid response) rather than deploying the carceral system.
   

GLOSSARY & FURTHER READINGS

• 1994 Violent Crime Control and Law Enforcement Act: The Violent Crime Control and Law Enforcement Act of 1994, signed by President Bill Clinton, is the largest-ever crime bill in U.S. history, providing for 100,000 new police officers and allocating $9.7 billion for prisons.1 Scholars note that the successful passage of the bill was predicated on “fear of Black crime in the wake of racially motivated riots in Los Angeles, Chicago, and New York. Each of these events heightened fear of Black people and incited politicians in the federal government to declare a need to ‘restore order in society’”110

• Abolition: According to the work of abolitionist scholar Ruth Wilson Gilmore, “Abolition is about presence, not absence. It is about building life-affirming institutions.” Abolition is a process of changing the social and economic conditions that lead to harm and of ensuring that people have what they need to thrive and be well, thereby eliminating the need for jails, prisons, detention centers, and policing. For additional reading on abolition, please see: Are Prisons Obsolete? by Angela Davis.

• Carceral System: An extensive interconnecting network of both public and private institutions and structures designed for imprisonment, policing, and surveillance based in policies and practices relying on punishment, social control, and criminalization. The carceral system includes prisons and jails; immigrant as well as juvenile detention centers; the courts, probation and parole programs; law enforcement including immigration enforcement agencies; and other types of incarceration (e.g. e-carceration; confinement in schools, hospitals, and homes).

• Community-Based Corrections: programs and transitional homes where people are mandated to live in order to be released from incarceration early (e.g., https://www.cdcr.ca.gov/rehabilitation/mcrp/)

• Decarcerate: To reduce the number or rate of people incarcerated at the federal, state, and municipal levels or in any particular jurisdiction, including mental health treatment facilities. A range of practices and policies may fall under the practice of decarceration, all with the result of removing people from carceral institutions (i.e. the opposite of incarceration).

• Detention Centers:  Detention centers in this document refers to any place where people who are awaiting a determination of their immigration status or potential deportation are incarcerated. Immigrants in detention can be undocumented or documented immigrants, including people whose immigration status is not current, is expired or is under review.  Many of the immigrants detained in Immigration and Custom Enforcement’s (ICE) nominally civil system are held in county and local jails that contract with ICE to detain immigrants. The rest are held in dedicated immigration detention facilities run by ICE or contracted to private prison corporations, including family detention centers that hold mothers and children. ICE’s detention system is built and operated on a correctional model, in direct conflict with the civil nature of immigration detention.

• E-carceration: E-carceration is an alternative system of incarceration that deprives people of liberty through tracking, surveillance, and control outside of prisons by technological means.  Electronic monitoring technologies that are used to monitor individuals in pre-trial, probation, parole, or immigrant deportation proceedings, include ankle bracelets, GPS monitors, or phone apps that track the person’s location at all times.  Due to the restrictions placed on those being monitored, the physical jail becomes an electronic jail in our homes and communities, severely limiting where someone can go within certain boundaries and punitively tracking a person’s behavior.  Typically the state, usually via the criminal legal system, enforces E-Carceration. But corporations may also be contracted by the state and often charge fees for repressive regimes of parole and probation which frequently include monitors.

  For additional reading on e-carceration, please see: Chaz Arnett’s excellent analysis, “From Decarceration to E-carceration.”52

• Jails vs. prisons: Jails are typically short-term facilities that predominantly incarcerate people who are either pretrial or who are convicted of misdemeanors and serving relatively short sentences, generally less than one year. Unless they are private jails run by corporations, jails are run and operated by local governments and county sheriff’s departments. More recently, jails have also been used as immigration detention sites. Prisons, on the other hand, are typically run by state or federal government and are meant for people who have been convicted of more serious offenses and who have received longer sentences. As of 2019, there are 3,163 local jails, 1,719 state prisons, and 109 federal prisons operating in the U.S.

• Public safety: While legal scholars define “public safety” primarily as the “protection of the general public,” a public health understanding of public safety must also focus on what allows people to be healthy and free: investment in the health-promoting social determinants of health, including food, clean water and air, housing, a basic income, education, jobs, health care, health insurance, and the freedom from racism and discrimination. For more, read Barry Friedman’s “What is Public Safety?” (2021).111

• Reform vs. abolition: In contrast to abolition, which seeks to invest in the health and safety of communities using non-carceral means, reformist approaches seek to make changes to the current carcel system requiring further investments, including that of financial and human resources while perpetuating systems that rely on punishment, isolation, and incarceration. For specific examples, please see Critical Resistance’s chart “Reformist reforms vs. abolitionist steps in policing” at https://tinyurl.com/reformvsabolitionCR.

• Stop-and-Frisk: Stop-and-frisk, which allows law enforcement officers to stop a person if they assume the person is involved in criminalized activities, and to frisk a person if they presume the person may be armed, was codified into law in 1968 via a U.S. Supreme Court ruling.

• Three strikes laws: The first three strikes law was enacted in California in 1994, but similar laws are now prevalent in states across the U.S. The laws impose a longer prison sentence, usually a mandatory life sentence, to individuals who were previously convicted of certain felonies. Three strikes laws and truth-in-sentencing laws, below, have been widely criticized for increasing prison sentence lengths and therefore contributing to the large number of people who are incarcerated.1

• Transitional Care Coordination:  an evidence-based intervention model based on social work and public health tenets facilitates collaboration among correctional facilities, public health agencies, and community-based organizations to improve health outcomes.

• Truth-in-sentencing laws: These laws require individuals to be incarcerated for the entire duration of their sentence, instead of becoming eligible for early release or parole on the basis of “good behavior”, usually participation in educational or work programs.

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