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Incarceration, the War on Drugs, and Public HealthLisa D. Moore, DrPH, and Amy Elkavich, BA

WITHOUT A PERSONAL

connection, scientists, researchers,and those who set public policyi-arely know the slories of thosewho are convicted ol' felonycrimes and sentenced to prison:how they came to he convicted,whom they left behind, and whatthey went home to once released.But the con.sequences of their im-prisonment—social, economic po-litical, and personal—are evi-denced daily in every major dty,suburban tovvTi, and nii-ai hamlet.

We aim to reirame the gn)wlhof the prison industrial complexand the war on drugs ft'oni thepei spective of those incarceratedfor nonviolent, drug-relatedcrimes. By framing Uie issue thisway, we hope to add an often ig-nored or poorly understood factorto analyses of health dispaiities.We also hope to highlight an areaof public health that has escapedadequate recognition and beginthe dialogue necessary to meetthe challenges facing people ofcolor in ajid out of prison while at

the same time supporting publichealth policy changes to meetthese challenges.

WAR ON DRUGS

The stories of convicted ieloiisand Iheir families, friends, andcommunities arc shaped by theoverreaching aim of the prisonindustrial complex, "ITie justicesystem that was designated to"protect and serve" took on thechallenge of the war on drugs in1968 when the Nixon adminis-tration decided to redouble ef-forts against the sale, distrihudon,and consumption of illicit dnigsin the United States. Hiis wai- ondrugs," which all subsequentpresidents have embraced, hascreated a hehemoth of courts,jails, and prison.s that have donelittle to decrease the use of drugswhile doing much to create con-fusion and hardship in families ofcolor and uriian communities.'^

Since 1972, the number ofpeople incarcerated has iiia-eased

5-fold without a comparable de-crease in crime or drug use.' ' Infact, Ulf ciecreased costs of opiatesand stimulants and tlio incl 'asedpotency of cannabis mi^t leadone to an opposing conclusion, 'Given the politics ol tlie war imdrugs, skyrocketing incarcerationrates an' decmi-d a sign f)f suc-cess, not failure, ficgardless of anyaneilysis ol' the success or failureof the war on drugs, ils impact onlives and coinmunities Ls muchless controversial. The criminaljustice system accepts rt spoasihil-ity for making (iiii- neighborhŒxisand cities safe for all. Should it beresponsible for tlie tvsulting col-lateral damage lo families andcommunities?''

A broad moral panic ahoutcrime fueled hy media headlinesand political expediency createdthe neeti to escalate the war <indrugs7 The outcome has in-cTeased incarceration producedhy tougher laws and prosecution,less judicial discretion, and greaterpolicing. Because these laws are

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not enforced equally, most oftenI ho [i<)f)i- and [wople of color whoMV fliiaiiaaliy or socially unablelo remove themselves from envi-ronnu'nLs that are labeled "drugaix-as" are porsecuted. ITioy inad-vertently place themselves di-TiTtJy in tlif midst of our nation'swar oil diiigs.

riic war becomes a never-iMidinjî hfitllc that distorts the faceof roinmunities by irmoving cru-i iaI members: parents, spouses,fnends. iiiitl employees.' " In thefyes of many politicians, policecommissioners, community lead-ers, and aflluent dbzeas, the waron drugs may ap{)ear to be a suc-cessftil one—incarceration ratesiin' (»II tlic rise and piisons arebuilt almost as quickly and thetJireat of drugs is, in theory, beingrrmoved iVf»m neighborho(K.is,sfhodi playgn)Uiidii, aiid public-

parks. It would be convenient toconsider tliis thf! end of the prob-l(>m, to wasli our bands (jf drugsand felons and move on to some-thing else, something more de-serving of attention from both tlie(riniinal justice system and publicpolity.

Hie consequeuces of "cleanstreets" are antithetical to what ittakes to build healthy communi-ties; tlie residual elTeets of system-atic removal and efficient impris-onment of dnig users creates amuch lai:ger challenge. The reper-cussions of removing people fromtheir lamilie.s and communitiesand then depositing them backlater, without any assistance orsubstantial rehabilitation, aregi-ave.'' Men and women whohave served extensive prison sen-tences fof nonviolent drug of-íénses are not only left with littleor no social support but alsoclearly maiiwl by the criminaljiistitx- system as potentiallyIlireatening irpt^at otlenders.they are not only taken away

from their loved ones but alsoplaced ill an impossible situation.one in which they are unable toprovide for their families or retainemotional ties with tlieir lovedones. On release, most, as con-victed felons, find it difïîcult toprocure gainful, legitimate em-ployment, .Xs with many wai-s. thecollateral damage of the war ondrugs LS made invisible but is noless destructive.**

WHO'S USING AND WHO'SDOING TIME

There are discrepancies sur-rounding rates of drug useamong the general public andtlie population serving prisontime for nonviolent, drug-relatedoffenses. In addition, social andhealth policy issues are createdby these differences left un-detected or unaddressed bythose who have created them:the criminal justice system andthe current political agenda. Pub-lic health as a discipline is now ina prime position to call attentionto these di.screpancies. designprograms to assist both tlie iticar-ceiBteii individuals and theirfamilies, and create the social en-vironment necessary to changethe political climate and socialpolicy surrounding who's usingand who's doing dme.

Drug use in suburban areasgoes unchecked and underre-ported. while people of color areprofiled in urban areas as poten-tial drug users and dealers. Al-though there is a serious drugproblem in urban, minority com-munities, the prableni also existsin every other community. Profil-ing is innre difficult to conductin suburban aix-as: tlieiefore,cities are most often the loca-tions in wbich minorities arean^ested for nonviolent drug-related offenses.

Who's Using

Although tlie current rates of il-lidt drug use are rouglily the samebetween Blacks and Whites (7.4%and ZS' ii. resix-cdvely) and lowerfor Latioas (fi.4"/ü), the number ofWhite drug users is vastly greatertiian that of drug ust*rs of color be-cause White people are a largershare ofthe population."' In 1998,Whites composed 72'%] of all illidtdrug users compared with the15"/() share contributed by Blacks.Whites were neai'ly 5 times morelikely than are Blacks to use mari-juana and were 3 times morelikely tha:i Blacks to have everused crack.'

The communities reportingdrug use are not the only onestypically considered to be higli

Public health as a discipline is now in aprime position to call attention to these

discrepancies, design programs to assist both theincarcerated individuals and their famiiies, and

create the social environment necessary tochange the political climate and social policy

surrounding who's using and who's doing time.

drug traffic areas: drug use isprevalent in suburban, middle-class areas aroimd the country aswell as in rural settings aiul incities. However, suburban policepresence is largely concernedwith the residents' desirc to keepthe "bad element" out rather thanturn attention to its ovm citizens.From a public health perspective,this is probably a goixi thing, be-cause the middle class and afflu-ent are more likely to use drugtreatment, counseling, and simplematuration as solutions to prob-lematic dmg iLse.'""

Who's Doing TimePersons of color compose 60*'/b

ofthe incarcerated population."

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In 1996, Blacks constituted62.6% or drug offenders in .stateprisons. Nationv/ide. the rate oi'persons admitted to prison ondrug charges lor Black men is 13times that for Wliite men, and in10 states, the rates ai« 26 to 57times those for White men," Peo-ple of color are not more likely todo drugs; Black men do not havean abnormal predilection for in-toxication. They are. however,more likely to be aiTested andprosecuted for their use.

The prison system Is designedto remove a criminal ft-om sode^,but it leaves an inadequate sys-tem to cope with what is left be-liind. A vital member ol' botli afamily and community is gone,weakening emnlional family andcommunity ties. Prisons arc typi-cally located far away from thecities in which most inmates live."For a family, tlie cost of trans-portation and accommodations,not to mention time to visit theirincarcei-ated relative, will typicallydiscourage frequent visits, Qiil-dren lose vital contact with par-ents and other caregivers."'"' In-caix:eration also bleeds tliebroader community of men andwomen who woulfi otherwi-iecontribute to the workforce andto community life.

From a broader political per-spective, this has led to system-atic disenfranchisement of thepoor and of people of color, par-ticularly in the South. Personswho are incarcerated lose theirright to vote, in some states forthe rest of theii- lives.""'' Becausethe US Census and other popula-tion surveys base residence onwhere one cun'ently lives, as op-posed to where one customarilylives, population counts in ruralcommunities tliat bouse prisonsare artificially bloated, whereasurban populations shrink propor-lionately.' Tlais has negative

implications for cities in regardsto the allocation of resources andpolitical ^districting. Taken as awhole, the latter 3 points ulti-mately result in the erosion ofrepresentative democracynationwide.

The impact of tbe criminal jus-tice system is evident in the Blackand Latino communities in majordties who often sufTer from un-derserved state and governmentassistajice for education, health,and employment Services thatmight prevent dnig use are un-derixinded. and the budget for thewar on drugs increases. Moretlian $ 11 billion was spent on thewai" against dnigs in ^003. Thatbudget has steadily increased,with mom tban $12 billion infunding for 2006.'^ State andlocal governments are ^nd inganother $30 billion on the oflbn-sive against dmgs.' " There aremore than 2 million men andwomen sei-ving sentences inUnited States piisons. nearly threequarters lor nonviolent of-fenses."'"' The unequal enforce-ment of the war on drugs servesto fuel our spiraling incarcerationi-att s and the removal of men,women, and cliildren from ourcommunities.

HEALTH ON THE INSIDE

Prisons are not healthy places.Ironically, although medical care Lsneither mandated nor consideredto be a right for tlie general popu-lation, it Is mandated for prison in-mates. In spite of this, prison med-ical care is substandard in manystates. The Calift)nna prisonhealth system's enti ance into fed-eral receivership is an extreme ex-ample of the (Tisis,"' í'iTson in-matfs suffei- from high rates ofmental illness, HIV. tuberculosisand other infectious diseases, andof eoui"se, v i ^ ^ ^ *

Although prisons are mandatetlto ti"eat infectious diseases andother conditions, they art! in noway required to support amtro-versial prngi-ams such as cnntiomdistribution luul needle exchangesfor HIV and hepatitis C preven-tion. Pnsuiis oiien house inmatesfram communities dispmpoilion-ately affected by health inequitiesand, in turn, return .sick fwople tothose same communities.

Tliere are no guarantees thatincarcerated persons will behealtliier on Ilieir return home. In-cairt^riition Incixíases tlic risk ofexposure to HIV and other pn'ventable conditions: families andsexual pailiii?rs n'linited witli tlieii-loved ones in tum find themselvesat an increasi ti ri.sk of infedion.l artnei-s and cbiktn^n of incairei--ated persons and the wider com-munities of color bear iJie bunlenof morbidity and mortality." '

LIFE AFTER PRISON?

The challenges tliat lead a person to prison—drug addition, al-coholism, untreated mental ill-nesses, lack of employmentopportunities—are not abated byincaireration: they are oitetîworsened, f'onner inmates mayhave lost family and sodal ties.'Iliey are certainly less employ-able thaji before. becaiLse manyemployers do not hire convidedfelons. Zero tolerance laws pro-hibit people with drug-relatedfelonies from using goveninientassistance such as public housingand federal linancial aid to at-tend college. However, violentfelons are not excluded fromthese programs.^'' The trendaway from rehabiliUUion in thepast 20 years means that fewerpeople are able to get college dvgrees or transferable job skillswhile in prison.' ' Three quartei>iof state piTson inmates lack a

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high school diploma, and less-

educated inmates an? more likely

iJiaii their educated peers to be

recidivists/" Policymakers dis-

cii.ts the need for increasing the

iL'chnological skills ofthe coun-

try's workforce by olTering edu-

calii)n for meaningtul employ-

ment, yet we have a massive and

growing population of formerly

incarcerated persons that may

never he able to paiticipate in

ihe legitimate job market aside

fmm unskilled, minimum-wage

labor.

The popular war on drugs

Limislates to a war on people of

color in terms of their overall

healtJi and well-b(!Íng, It is unlikely

that an ex-felon will navigate with

success the hurdles constnicled by

liic cnniiiiiil justice system during

impiisonmetit and then tackle ad-

ilitional barriers s(3t up by both the

liovcniniciit and society onee R"-

Icased. These consequences are

(he byproduct of a double stan-

(Ianl Uiat gives Lix'atini'iit to die

nch and prison to the poor. They

air aLso a n'sult of the ¡lotitics of

ti'iu-. wliich comiM-'Ls politicians to

fund prisons over schools and pun-

ishment over health.

EMERGENCY CALL AS APERSONAL CONNECTION

Communities of color face an

'•scalating public health pmblem

rn'atcd by our s(X"iety's s(»Iution to

imprison those arrested for nonvi-

olent tiiug offcnstis, Oialleiiges

iliHl plague inner dties—fnim JH»V-

vtty and hopelessness to substance

use and increased morbidity and

mortality—ail' exacei^ated by high

incarceration rates; suburban com-

munities ait' not "hannwi" when

nonviolent tlrug olTenilei's aiie

given tn-aünent and second

cJiaiices. fublic bealtli practitioners

and (X)li<ymakerN bhoulil work in

rollaboration to treat this as a

public health problem, one that

desen,'es prevention and treatment

rather than piiiiLshment Piiniary

prevention includes the creation of

stitrng. viable communities in

wliich membei-s have employment

and other options besides drugs.

Substance use tiT'atment can be

more etTodive only in places

where the conditions of primary

()reveiiti()ii ai-e established,

Public health professionals

should advocate for tlie famiiies

of incaR'erated people. Family

separation is a likely cause of re-

cidivism and can contJibute to the

risk of children joining their pai'-

erits in tbe system. Everyone

should be able to access quality

health care and education inside

and out of prison. We shouJd sup-

port ex-feloas after their prison

terms in their attempts to find

meaningllil employment bousing,

and education. Disenminating

against those who have served

prison sentences does nothing but

pn>pagate the perception tlial ).)('r-

sons in poor communities are lim-

ited to illegal and bigh-risk em-

ployment and ensures their

individual lutures as unemploy-

able, unsafe, and unwanted by so-

Recent years have seen changes

in what was once a monolithic

dnve to incarcerate drug users.

States have increasingly accepted

drug courts as a more humane an-

swer lo dmg pnjblems." People

within and outside the criminal

justice commuriily are ifcognizing

the iiewl ÏOV tíducatioiiíil pR)grams

within prisons and viable reentiy

prograjiis for i-elease. Some judges

arv reasserting Lheir disca'tion

with sentencing.'''^ Jurisdictions are

even being forced to cap inmate

¡ïopulatJons aiul institute eaily i-e-

ieases.''^ It would reflect a vast im-

provement if cohei-ent treatment

and prevention policies guided

their early releases; early releases

work best when prompted by co-

herent prevention and ti-eatment

policies, not piison oveixrowdiiig.

Activists have struggled to change

punitive zero tolerance and disen-

tranchlsement laws.

Tbe circular pattern of prison

and eventual release with limited

rights has presented health risks

tliat have gone unchecketl by the

public health system, ci^ating a

public health i.ssue witli no system

to bajitik' the outcome. There is

no program in place to address

tbe consequences created by the

impiTsonmcnt and subsequent

life-altering pi-ogress of whole

populations. I h e issues cn^ated by

incarceration must be systemati-

cally addressed through public

healtli policy set forth by t)ur state

and federal governments. Calling

these issues to the attention of

our government is ttie overall re-

sponsibility of public health pro-

fessionals because these are our

communities and their stories are

our sturies. •

Abotit the AuthorLisa Moore Ls with the Dqmrtment ofHeaith I'.diwation. Sun Fmncisin Stale Uni-v-ersitt/. Äin Frimñsa). G-t. Amy FAkavichIhvs w .•\llanta. G.'\.

Requests for rvprints .should he sent lo¿¿sy Miiore, San Fmniiso) State Uniiier-sitji. 1600 Holloway Ave. HSS 3t5. SanFrancisco. CA 94J32-4I6I (e-maii

This article was aaxpted September 16.2007.

doi: ¡0.2I05/AJPH.2007.126284

AcknowledgmentsThe R'search for this articlf was par-tially suppoi-tcd by ihc NHlicmal Insti-tutes (ll 1 lefittli National Onier for Mi-nority llcaitJi and Health Disparities(P^nt P20 MD000544).

Contributors1.. Moore originated the aiüde and ledtlic wTitirig. A. lilkavich asüistcd wiüi Ihewriting and research.

Human Participant ProtectionNo human [laniniianLs were invoK'ed inthis study

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786 I Going Public 1 Peer Reviewed | Moore and Elkavich American Journal of Public Health | May 2008, Vol 98. No. 5