In the U.S. criminal justice system in 2014, an estimated 2.2 million people were incarcerated or under correctional supervision on any given day, and another 4.7 million were under community supervision, such as probation or parole (Kaeble et al., 2015). Among all U.S. adults, 1 in 31 is involved with the criminal justice system, many of them having had recurring encounters. Nearly 3 in 4 prisoners are rearrested within 5 years of release, and more than one-half of jail inmates have been previously incarcerated (Durose et al., 2014).
Although people who are involved with the criminal justice system have gradually gained recognition as being vulnerable to poor health outcomes, including high rates of infectious diseases, behavioral health conditions, and substance abuse comorbidities, the public health implications span far beyond the physical well-being of each individual. Each time a person is removed from his or her home, it affects the family unit and the community in which he or she lives—almost always in a negative way. Disproportionate rates of justice system involvement can exacerbate existing community-wide health disparities, particularly among racial and ethnic minority populations.
The ability to measure the effects of criminal justice involvement and incarceration on health and health disparities has been a challenge, due largely to limited and inconsistent measures on criminal justice involvement and any data on incarceration in health data collections. The presence of a myriad of confounding factors, such as socioeconomic status and childhood disadvantage, also makes it hard to isolate and identify a causal relationship between criminal justice involvement and health. The Bureau of Justice
Statistics collects periodic health data on the people who are incarcerated at any given time, but few national-level surveys have captured criminal justice system involvement for people previously involved in the system or those under community supervision—nor have they collected systematic data on the effects that go beyond the incarcerated individuals themselves.
This proceedings summarizes the presentations and discussions at the Workshop on Improving Collection of Indicators of Criminal Justice System Involvement in Population Health Data Programs, which was held in Washington, D.C., in March 2016. The workshop was organized as part of an effort to assist the Office of the Assistant Secretary for Planning and Evaluation (ASPE) and the Office of the Minority Health (OMH) in the U.S. Department of Health and Human Services in identifying measures of criminal justice involvement that will further their understanding of the socioeconomic determinants of health. The workshop was structured to bring together a range of experts—on incarcerated populations, on indicators of criminal justice involvement, on methods for social measurement, and on the consequences of criminal justice experience on health and life-course events—to facilitate discussion of measures and mechanisms most promising for expanding OMH’s data collections in this field.
The charge to the Committee on National Statistics (CNSTAT) of the National Academies of Sciences, Engineering, and Medicine was to organize a workshop to investigate the feasibility of collecting criminal justice experience data with national household-based health surveys (see Box 1-1 for the full charge). To address the charge, CNSTAT formed the Steering Committee on Improving Collection of Indicators of Criminal Justice Involvement in Population Health Data Programs. The main goals of the workshop were to discuss options for collecting data and producing estimates on health indicators of individuals who are or were involved with the criminal justice system, including consideration of the available measures and possible data collection mechanisms.
The workshop was organized in three parts: setting the stage, understanding what should be measured, and identifying best approaches to measurement: see the full agenda in Appendix A.1 The organization of this proceedings generally follows the workshop agenda.
This proceedings has been prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop. The steering committee’s role was limited to planning and convening the workshop. The views
1 The workshop presentations are available at: http://sites.nationalacademies.org/DBASSE/CNSTAT/DBASSE_170301 [July 2016].
contained in the proceedings are those of individual workshop participants and do not necessarily represent the views of all workshop participants, the steering committee, or the National Academies of Sciences, Engineering, and Medicine.
To open the workshop, Nadine Gracia (Office of Minority Health) described her agency’s goals in exploring how to best measure the effects of incarceration on health. She began with a bit of history. OMH was founded
in 1986—in response to a landmark report on the health status of racial and ethnic minority populations—to formulate programs and policies to end the documented health disparities. As OMH celebrates its 30th anniversary, it is an excellent opportunity to reaffirm the commitment to understanding the causes and consequences of disparities in minority health.
Gracia highlighted the health disparities across racial and ethnic minorities and within the majority population and explained how better data and research can help understand points of intervention to reduce such disparities. She acknowledged that significant strides have been made in addressing these disparities, but she also noted that recent events in the criminal justice system have heightened the nation’s awareness of the continuing issues. There has also been a heightened sense of urgency, not just in DHHS but across all federal agencies, to better use the available data and to innovate in data collection because of the potential to improve how agencies deal with many issues.
As strides have been made in reducing the health disparities of racial and minority populations, they have highlighted the importance of understanding the socioeconomic determinants of health—criminal justice involvement and incarceration experience being two major factors. Drawing on her experience conducting pediatric work in a juvenile detention center, Gracia explained that physical and mental health needs of people who reenter society after incarceration are significant, and data can play a role in assessing such needs. She noted that the Department of Justice designated the week of April 24, 2016, as National Reentry Week to emphasize the importance of effective reentry strategies for these people, as well as the need to ensure they are given a meaningful second chance in the community.
Gracia noted another event that led to this workshop, a 2012 study and forum on measuring incarceration in household surveys, a collaboration of ASPE, the U.S. Department of Commerce, the U.S. Department of Justice, and the National Center for Marriage and Family Research. This work was in response to the rise in mass incarceration in the United States and the growing number of individuals and families affected directly or indirectly by an incarceration experience. Though the forum and resultant pilot survey, the Survey of Criminal Justice Experience, provided valuable insight, they also showed that critical gaps still remain in terms of understanding the effects of criminal justice involvement on individuals, families, and communities.
Many of those gaps are the result of the disparate measures of history of criminal justice involvement that are collected in the national population health surveys. Thus, although the need for collecting data on criminal justice involvement as part of health data collections has been established, there is no agreement on the scope of the measures to be included. Filling such data gaps is crucial so that programs and policies can be developed
to address the many physical health, behavioral health, and social service needs of the populations involved in the criminal justice system, particularly as policy makers consider the reintegration of releasees into their communities and society in general. Given this background, OMH asked the National Academies of Science, Engineering, and Medicine, through their Committee on National Statistics, to organize a workshop to explore the feasibility of collecting enhanced information on criminal justice populations via national household-based health surveys.
Glenn E. Martin (JustLeadershipUSA) described his own experience as a convicted offender in the New York State Department of Corrections. He stressed that 65 million Americans have a criminal record, and he quoted Michelle Alexander (from her book, The New Jim Crow) saying that more black men are currently behind bars or under the watch of the criminal justice system than were enslaved in 1850.
Martin believes that jails and prisons2 have become repositories for people who cannot access health care services in the community—a situation that has essentially criminalized poverty, mental health problems, and substance abuse and addiction. Investments in community behavioral health services have declined in the last four decades, and there are currently three times as many people in jails and prisons with mental health issues than in actual mental health treatment facilities. However, even for those without serious health needs, the collateral consequences of imprisonment equate to a lifetime of punishment—the effects of which are felt long after a sentence has been served. Martin used himself as an example of such a long-term effect: in 2015 he was almost prevented from attending an event at the White House to which he had been invited by President Obama because of a 21-year-old conviction (for which he served 6 years in prison).
Martin said the primary goal of the organization he now heads, JustLeadership USA, is to invest in the leadership of people with experiences similar to his and involve them in the discussions about reforming policies and practices. He said the organization believes that people who are closest to the problem are closest to the solution, and the voices of people who have been through the journey are equally important to the dialogue,
2 In this proceedings, jails and prisons are usually discussed separately because of major differences in nature and length of confinement in them. According to the Bureau of Justice Statistics: “Jails are locally-operated, short term facilities that hold inmates awaiting trial or sentencing or both, and inmates sentenced to a term of less than 1 year, typically misdemeanants. Prisons are long-term facilities run by the state or the federal government and typically hold felons and inmates with sentences of more than 1 year. Definitions may vary by state” (see http://www.bjs.gov/index.cfm?ty=qa&iid=322 [July 2016]).
particularly because of the experiential knowledge they have. Martin said that he believes the United States is in a time of reform, in which the moment has come to reimagine the criminal justice system as well as how it handles the public health of its population.
Martin recounted his childhood and early involvement with the criminal justice system. He was born and grew up mostly in the Bedford-Stuyvesant neighborhood of Brooklyn, New York, the biracial child of immigrant parents from Grenada, and he stood out as different. He witnessed violent crimes in his neighborhood, including being robbed at gun point at the age of 14, and said that he believes that incidents and conditions such as these perpetuate victimization and trauma, which can ultimately lead to more violence. Martin said: “I didn’t learn how to pull a gun on someone until someone pulled a gun on me. And that’s not to minimize the responsibility of people who engage in criminal behavior, but that is to have a real conversation that moves us away from where we are now about solely focusing on individual responsibility.”
Martin’s first encounter with the criminal justice system occurred at the age of 16, when he was arrested for shoplifting and charged and treated as an adult offender. (New York is one of two states that automatically charges 16-year-olds as adults.) At the Rikers Island correctional facility, he encountered antiquated, egregiously overcrowded facilities with poor climate control in extreme temperatures, bad plumbing, leaky roofs, limited resources (inmates sharing razor blades, etc.), and lack of safe recreational space (and therefore little to no recreational time). Even at that young age, he realized that the right to health care in jails and prisons was not a guarantee of quality care or even of suitable living conditions. He talked about how in the 1990s New York City opened Rikers Island up to competitive bidding for privatized health care services and how hospitals purposely underbid to obtain the contract, only to provide subpar health care to its 22,000 or so residents—8,000 more than the facility was designed to hold.
Martin recounted his more harrowing personal experiences in the correctional system. He was arrested six times before he ultimately served his 6-year sentence, and several of those arrests also placed him in Rikers, albeit for much shorter stays. Martin witnessed riots and was involved in several fights while he was incarcerated. During his first 48-hour stay, he was stabbed four times with a pen that was fashioned into a knife by another inmate who wanted Martin’s leather jacket. The correction officers looked on and laughed, and one warned Martin that if he reported the incident he would not go to court the next day as planned and would be further penalized for trying to go to sick call. As a result, the untreated wound in his neck ended up becoming infected. During another arrest Martin broke his ankle after being pushed down a flight of stairs and physically assaulted by his arresting officer: then he was threatened that, if he wanted the offi-
cer to report the injury, the officer would add an assault charge to his file. Martin said that the dissuasion from visiting sick call was commonplace, in part because of the attitudes and threats of the correction officers, but also because the inmates knew the facility would opt for the solution that was most financially beneficial to the franchise and not the patient, such as pulling a tooth with a cavity instead of drilling and fixing it.
Martin also commented on how surprised he was to see so many young, elderly, and physically disabled inmates in prison and how many people resided in mental health units. He told the group a very moving story about an inmate named Arthur, with whom he was bunked during a transitional stay between facilities. Arthur had a mental health condition, and while he was in prison also started using heroin, which Martin said was an incredibly common occurrence; he said he saw more drugs in prison than he ever did growing up in Bed-Stuy. Martin talked about Arthur’s unyielding optimism, despite his circumstances, and said that he was a prime example of the type of person who was perhaps ill-served by the justice system. Martin cautioned the workshop participants that one should not move people from being criminalized to being pathologized.
Martin concluded his personal story by describing the obstacles he faced after serving his 6-year sentence, which was 15 years ago. He owed more than $100,000 in debt, fines, court and legal fees, and child support, and in his quest to obtain employment he was turned down almost 50 times in his first month because of his record. Martin was eventually hired as a front desk clerk at a public interest law firm, a job that piqued his interest in learning about and hearing from the people who are directly involved in the criminal justice system. He then went on to work for a long-standing reentry organization that serves thousands of formerly incarcerated people each year.
Martin highlighted the irony that men and women often wind up in the criminal justice system because of poor community health care and resources, only to receive poor health care in that system and then return to the same ill-resourced communities. On average, 600,000 people are released from correctional supervision and return to the community each year, and the effects of this reentry are wide-reaching. It is important to note that the dispersion of this reentry is not evenly spread. In New York, for example, seven communities accounted for 50 percent of the prison population for about four decades, so the impact on those communities was particularly compounded. He closed by urging the participants to push the rhetoric toward providing true opportunities, knowledge, and proper consideration for criminal justice involved populations.
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