Breaking Bonds
Why Health Providers Should Consider Prison Abolition
by Sydney H. Russell Leed
Recently, a man named Anthony Dickerson violated his probation and received a punishment far worse than prison. Mr. Dickerson’s 2-year-old son needs a kidney transplant, and Mr. Dickerson is a perfect match. Yet because of the probation violation, he is being held in a county jail, unable to donate a kidney to his son. The local hospital says he has to wait months before they decide if he can donate.
How should health providers look at this situation? How can we advocate for patients affected (either directly or indirectly) by the criminal justice system? And at what point should we begin to consider broad-scale structural changes to the problems that plague us?
Searching for an Evidence-Based Treatment
As medical students, we are trained to identify evidence-based treatments for the problems our patients face, while considering the unique situation of each patient. Instability in housing, personal finances, or family life may lead to poor compliance. Genetic variations may change a patient’s responsiveness to medication. We are honored with the challenge of balancing individual needs with decades of biomedical research and centuries of adaptations in health care. So why don’t we take the same approach to public policy?
Incarceration is not an evidence-based treatment for delinquency, nor is it cost-effective. More than 75% of released prisoners are rearrested within five years (Durose et al., 2014), and the annual cost per inmate is over $33,000 (Mai & Subramanian, 2017). With over two million people in prison, why should taxpayers pay tens of billions of dollars every year for an intervention with such poor outcomes? In fact, research from the Vera Institute of Justice shows a “tipping point”, a prison population at which further incarceration actually increases the crime rate (Stemen, 2017). They attribute this to the disintegration of community and familial bonds caused by incarceration.
Yet we continue to imprison people at ever-increasing rates. We live in a punitive culture, where both sentencing and release seem arbitrary, where prison living conditions breed violence and disease, where prisoners are expected to suffer in recompense. For example, consider the case of Gladys Scott, a Black woman living in Mississippi who was sentenced to life in prison for stealing $11. She was released 16 years later when she offered to donate a kidney to her sister, at which point the parole board decided she was “no longer a threat to society” (Burkle, 2011). The punishment was unjust, and the release was arbitrary, rooted in unscientific ideas about repaying a ‘debt to society.’
That same punitive mindset tells patients that they deserve their heart disease or diabetes because of their lifestyle. However, in both medicine and criminal justice, punishment is not a treatment, and we need to look for treatments that work.
Prisons as a Public Health Issue
While many prison abolitionists are fundamentally opposed to the idea of caging human beings, there are other arguments that may be more approachable for those new to the idea. Particularly relevant to clinicians is the myriad of public health concerns related to incarceration. These include mental health, physical wellness, and infectious disease, as well as occupational hazards faced by working prisoners.
People with mental illness are sixteen times more likely to be victims of police brutality (Fuller, 2015) and are overrepresented within the prison system. In one study, half of evaluated prisoners had a mental illness (Al-Rousan et al., 2017). Unsurprisingly, spending time in prison may exacerbate mental health issues. This is especially a concern with solitary confinement, which the UN considers psychological torture. Prisoners who were held in solitary confinement are four times more likely than other prisoners to have PTSD (Hagan et al., 2017).
There is also the issue of disease, particularly infectious diseases that spread easily through prisons. People with HIV or chronic hepatitis B or C are disproportionately likely to have been incarcerated in the past (Weinbaum et al., 2005). In other countries, tuberculosis is rampant in prisons. In one Colombian prison, nearly 30% of people who were negative for tuberculosis when they entered prison became infected within just 2 years, with a quarter of those people developing active infections (Arroyave, 2017). This is a public health concern not just within the prison, but for all of those who interact with prison employees, prison volunteers, and the formerly incarcerated. In the US, this amounts to millions of people.
These issues are compounded by the stress and physical difficulty of working for low wages in poor conditions.
Prison Labor
We have often heard rebukes of the private prison system, which requires increased incarceration rates in order to remain profitable and puts prisoners to work for low wages. But it is time to recognize that public prisons are also used for prison labor, often saving state governments millions of dollars a year while inmates toil in unsafe conditions.
Take, for example, the California Department of Corrections and Rehabilitation. CDCR employs inmates to fight the state’s frequent wildfires for $1 per hour. Inmates volunteer for these positions, even though the work is dangerous and sometimes fatal, because a mere $1 per hour is still higher than other prison jobs. The position also gives the prisoners the respect and dignity which they are denied through their imprisonment. A recent New York Times article on the subject quotes David Fathi from the ACLU, “If these people are safe to be out and about and carrying axes and chain saws, maybe they didn’t need to be in prison in the first place.” This calls into question not just the practice of prison labor, but the prisons themselves. Why should we imprison those who are not a danger to society?
Some of the inmate firefighters compare the working conditions to slavery. This may not be a dramatization. The 13th Amendment prohibits slavery, with one loophole: “except as a punishment for crime.” The legal loophole of slavery, the disproportionate incarceration of Black people at five times the rate of whites, and the extensive reliance on prison labor by governments and for-profit corporations, all paint a picture of a modern America not too distant from its antebellum predecessor.
How, as health providers, can we pledge to “do no harm” while passively accepting the existence of slavery in our country?
Let’s recognize that prison labor, and prisons themselves, are a massive public health problem, affecting the wellbeing of millions of Americans. Once we acknowledge the problem, we can direct our efforts to building alternatives.
Alternatives to Incarceration
There are opportunities to redirect at-risk individuals away from incarceration at every step of the criminal justice system. Health providers are best suited to intervene in the primary prevention stage, preventing crime from happening in the first place. We must also support programs which prevent unnecessary police involvement, as well as programs that prevent prison sentences for those who have been arrested. Physicians know the importance of preventive care, and we should extend extend this approach into the sphere of public policy.
In order to prevent crime from occurring, we can encourage our patients to utilize community resources such as confidential drug rehabilitation programs. We can talk to our patients about intimate partner violence and emotional well-being. We can get trained as mental health first responders, so that we can respond to 911 calls instead of police when appropriate. Beyond these actions, we must also recognize that a crucial step of crime prevention is altering laws that don’t actually make our society safer or healthier. This includes advocating for changes to unjust drug laws and gang injunctions.
For alternatives to sentencing, we can support the work of organizations such as the Vera Institute of Justice, Centers for Community Alternatives, and Critical Resistance. The San Francisco Community Health Initiative has produced a framework for identifying and implementing community-based alternatives to a prison-based criminal justice system. These groups recognize the need for safe housing, bail reform, and reliable access to health care, including mental health and addiction treatment.
Finally, if as you read this, you remain shocked by the idea of a world without prisons, I urge you to step back and reconsider ‘abolition’ as a set of small goals diverse in their aim and approach. Each of us can take a small role in creating a just society as we see fit. Perhaps you are opposed to the legalization of marijuana, but are disgusted by the brutalization by police of the mentally ill. You can sign up for a mental health first aid training, and start making an impact without committing to the eventual goal of prison abolition.
There is room for all health providers in this growing movement, and we have the power to advocate for, and work alongside, marginalized people most affected by these policies.
