The Lancet, 04 February 2012

Arriving at Washington DC's Reagan National airport last year, I, like other visitors, was greeted with large signs featuring the Statue of Liberty and the words: “Welcome to America, home to 5% of the world's people and 25% of the world's prisoners.” The posters were produced by the National Association for the Advancement of Colored People (NAACP) to help publicise their “Misplaced Priority: Over Incarcerate, Under Educate” campaign.

The message is (or should be) deeply disturbing. Shouldn't the USA be ashamed at having the world's largest prison system and highest incarceration rate (754 per 100 000 people)? The richest country in the world has so many of its citizens in prison that it can't afford to house them with even basic minimum medical care (more than half of all prisoners have mental health or drug problems). Prison overcrowding itself has become so terrible in California, that in May, 2011, the US Supreme Court affirmed a lower court order that California release some 46 000 prisoners because of the inhuman conditions under which they were being held. In the Court's words, “A prison that deprives prisoners of basic sustenance, including adequate medical care, is incompatible with the concept of human dignity and has no place in a civilised society.”

The world is overly familiar with the US “war on terror” prisons like Abu Ghraib and its off-shore Guantanamo prison. Less well known or cared about is the vast complex of more mundane prisons, much of whose population is collateral damage from the equally misnamed “war on drugs”. The personal and societal damage from treating drug use as a criminal problem is the focus of Ernest Drucker's A Plague of Prisons: The Epidemiology of Mass Incarceration in America. Drucker is a physician-epidemiologist with a specialty in family and social medicine. Following John Snow's example, Drucker mapped the very beginning of the AIDS epidemic in the South Bronx and discovered that the maps he produced “charting poverty, poor education, crime, and deaths due to drug overdose [were] almost identical to the AIDS maps”. His own Bronx drug treatment programme helped him learn about networks of drug users who shared needles and syringes. Needle-sharing turned out to be the “AIDS pump” in the Bronx (as it soon turned out to be elsewhere).

Drucker's attempt to prevent AIDS transmission by treating drug addicts, however, had little public support, primarily because the public associated injection drug use with violent crime. In his words, “The default response to drug use quickly became (and still is) arrest and jail, not the effective treatment for heroin injectors”. Instead of reducing the spread of AIDS, criminalising drug use spread the AIDS epidemic into New York's prison system. Drucker quotes epidemiologist Rodrick Wallace as calling the ensuing pattern “a synergy of plagues—drugs, AIDS, prisons, TB—creating a new and very lethal ecology that has now become a global pattern”. Drucker's insight is to apply epidemiological analysis to a related outbreak, the “plague of prisons”. The number “infected” is staggering: 7·3 million under the control of the US justice system, 2·3 million in prison, 800 000 on parole, and 4·2 million on probation. More than 10 million Americans are arrested each year, 600 000 imprisoned annually, and 700 000 released. 67% of those released will be reimprisoned within 3 years. Millions of children have also been directly exposed to parental incarceration, as have other family members.

Recently, The New York Times published an op/ed by Nicholas Peart, a young black college student from Harlem, who had been stopped and frisked, often aggressively, by New York police at least five times for no other reason than that he was black (in 2010 the NYPD stopped more than 600 000 people, 84% of whom were black or Hispanic). Peart seems right to conclude that targeting minorities as likely criminals has not made anyone in the minority communities feel safer, but rather has only amplified distrust and alienation. Those arrested in the USA are overwhelmingly poor and minority, mostly black and Hispanic. The system is (like the military-industrial complex and the “homeland security complex”) self-perpetuating. The impoverished communities targeted by law enforcement (like the Bronx) become even more damaged, as the children of prisoners have fewer support systems themselves, and become much more likely to be imprisoned.

Can a public health/prevention approach help halt mass incarceration, or at least reduce its harmful effects? Here's what Drucker suggests. First, as to primary prevention (reducing the number of new cases), he suggests identifying the most preventable cases first, and concentrating on them. That turns out to be fairly straightforward. These cases are the 30% of those in prison for non-violent drug offences, mostly young African American men who, once imprisoned, tend to cycle in and out of the system for years. This would require the reform of many of our drug laws and the treatment of drug use and addiction as a public health rather than a criminal justice problem. We also must change our policing strategy to include prevention of imprisonment by having alternatives to prison, including drug treatment, education, and job training. Second, Drucker argues, we should set a goal of reducing the number of people currently imprisoned to its pre-1970 level (before the “war on drugs”). Secondary prevention requires community support for those released from prison to help prevent recidivism, such as drug treatment, mental health treatment, housing, and employment. Tertiary prevention involves minimising the stigma and economic disadvantages imposed on those with a prison record.

Drucker ends his book with an eloquent plea for America to move away from “the current failed model of retributive justice” by devising a plan for “restorative justice as part of its recovery from the damage of more than three decades of mass incarceration”. Yes. Even, yes, of course. But allusions Drucker makes to slavery, the Civil War, South Africa's Truth and Reconciliation Commission, and post-genocide Rwanda, won't get us there. Nor does the accusation that mass incarceration “is one of our own society's greatest crimes against the humanity of millions of our countrymen”. Crimes against humanity are a special category of horrors—and incarceration after trial, even on a mass scale, has not historically met this threshold. Slavery, murder, torture, genocide, and apartheid do—as does indefinite imprisonment in Guantanamo, perpetual isolation in a Supermax prison, and, as the US Supreme Court has found, imprisonment in grossly overcrowded prisons where lack of decent medical care can produce “torture or a lingering death”.

Nonetheless, a human rights analysis can enrich a public health analysis. Public apathy to poverty, racism, and drug use help account for our plague of incarceration. One of the major weapons of human rights campaigners is shame, and Drucker's epidemiological exposition, like the NAACP campaign, could help to shame the US public into demanding remedial action.

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