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

Abstract
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 than 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 toward 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 noncarceral 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

Problem Statement
Prevalence and inequitable distribution of incarceration: The United States 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 prisons.[2] An additional 631,000 people were incarcerated in jails, almost 75% of whom were still awaiting trial.[3] Furthermore, 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 United States accounts for less than 5% of the world’s total population, people incarcerated in U.S. prisons and jails represent 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 U.S. 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]

Health harms of incarceration on individuals: It is well documented that incarcerated people have a higher prevalence of acute and chronic health conditions than the general U.S. population.[14] This includes higher rates of infectious diseases,[15] mental health diagnoses and substance use disorders,[16] traumatic brain injuries,[17] hypertension, heart-related problems, diabetes, asthma, and stroke, along with 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 United States 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] regular use of solitary confinement, and abandonment during natural disasters are known harms linked to incarceration. For example, solitary confinement, a form of torture used as an extraneous tool for punishment, is 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 the 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 the 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, although few have been as dire or made as hyper-visible as the fundamental incompatibility of the carceral system with public health imperatives for the COVID-19 pandemic.[27] When the first COVID-19 case was detected in the United States in January 2020, with cases 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. Furthermore, the daily entering and exiting of staff—often with insufficient 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 exacerbates an already dire situation by deterring symptom reporting or seeking of medical attention. Other common physical space conditions, 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 age[30] 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 10 times as likely to be unhoused as the general public[32] 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 record[34] coupled with barriers to criminal record expungement.[35] In addition, given state laws restricting voting rights for incarcerated and formerly incarcerated people, an estimated 6.1 million Americans were barred from voting in 2016,[36] excluding them from participation in political decisions that affect their health and that of their families and communities. 
 
Health harms of incarceration on families and communities: In addition to direct health consequences experienced by incarcerated people, the harms of the carceral system extend to families and communities of incarcerated people through mechanisms such as family separation and disruption of community cohesion.[37] For example, parental/caregiver incarceration is associated with food insecurity during childhood and a 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 such as added economic pressures (e.g., household income loss and paying for fees and fines) and housing precarity, which have been linked to adverse health outcomes.[40] Furthermore, emerging public health research points to “spillover” effects on 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 nondetained community members, including low birthweight, preterm delivery, and posttraumatic stress disorder.[44,45] 

Historical makings of the present crisis: Critical to identifying appropriately targeted solutions is acknowledging that rates of incarceration in the United States 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 engaged 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, to be sentenced to incarceration, and, when sentenced in federal courts, 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 (although, notably, not criminal law) recategorized 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 United States date back to slavery and that racist constructions 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 that 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 United States 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 correction”).[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 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, which range from the Department of Homeland Security to the U.S. Bureau of Prisons, state departments of correction, county and municipal departments,[1] and private (for-profit) corporations (e.g., the GEO Group).[54] For instance, about 42,000 people are currently in immigration detention, and more than 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 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 pursuing public health priorities such as policies and public investments designed to bolster existing safety net programs (e.g., Medicaid, public housing, pre-K–12 education) have had lower average prison incarceration rates[56] and better health outcomes.[57] Similarly, locales providing 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 does not achieve safety or accountability but perpetuates violence, health inequity, and social inequity, most public health recommendations to date have proposed reforms as opposed to the aforementioned primary prevention strategies. That is, they have advocated for additional funding to improve health conditions during incarceration rather than directing those funds toward 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 toward the abolition of carceral systems, and building in their stead just and equitable structures that advance the public’s health. Indeed, the harmful consequences of incarceration for 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 — Investing 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 the risk of adverse health outcomes. These preventive solutions include providing equitable access to fundamental resources that communities need to thrive, including stable and supportive housing,[59] affordable high-quality education starting in early childhood, well-paying employment, culturally responsive youth programs, and affordable and accessible health care (including access to mental health first responders and within-community mental health services).[8,60] These solutions 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 BIPOC and other communities. Investing in community-based health care, housing, and food is a more effective and just way to meet physical and mental health needs than relying on the carceral system. For example, devoting public health efforts to establishing a single-payer payment system 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 that communities maintain truly affordable housing and access to healthful foods, especially in areas known as food deserts, is an essential way 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 — Heeding recommendations from survivors of harm, including survivors of violence. Rather than assuming that 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 showed that an overwhelming majority of people who had 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), which often facilitates harm.[63] To account for harm, IPV survivors discuss 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 below).[65,66] 

Evidence-based strategy 3 — Investing 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 nonpunitive, nonretributive 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] Although 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 among individuals involved in the process (including those who were harmed and those who did harm), a greater likelihood of adhering to restorative agreements, and decreased rates of recidivism relative to those who did not participate in a restorative justice process.[68] Another meta-analysis of restorative justice programs with young people less than 18 years of age showed a general trend of decreased reengagement 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 in comparison with those who did not participate in a program.[69] These outcomes suggest better mental well-being for all individuals involved when a restorative justice process is used as an alternative to the carceral system. Indeed, one study showed that symptoms of posttraumatic 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 restorative justice approaches provide a more effective and less harmful means of accountability than continuing to invest in punitive paradigms. Further research is needed to evaluate programs explicitly identified as transformative justice. 

Evidence-based strategy 4 — Decarcerating with no conditions of electronic monitoring or use of risk assessments and ending continued punishment after release: An abolitionist public health approach advocates for disrupting exposure to structural determinants, such as 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 community-based treatment for people with mental health issues and substance use disorders; (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. Furthermore, release from prisons, jails, or detention centers without deploying racially biased risk assessments or 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 well-being. Criminal records, for example, are significant barriers to securing employment and housing, and in some states they restrict government assistance through Temporary Assistance for Needy Families and the Supplemental Nutrition Assistance Program.[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 (e.g., those that employ formerly incarcerated people) and evidence-based reentry approaches (e.g., transitional care coordination).[74]

Evidence-based strategy 5 — Investing in community-based mental health care: 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 community-based mental health care systems includes investing in community-based, nonpolice responses to mental health crises such as 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 health care services have been shown to reduce involvement in the legal system. For example, one study in California revealed that over the span of one year, jail bookings for people enrolled in ACT were 36% lower than bookings for 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 revealed that formerly incarcerated people who received supported housing services were 40% less likely to be rearrested and 61% less likely to be re-incarcerated.[83]

Moreover, current carceral solutions to mental health problems lack evidence of effectiveness and have documented harms,[84,85] which is especially critical given that people with serious mental illnesses are 16 times more likely to be killed by law enforcement than those without such illnesses.[85] Touted strategies such as crisis intervention training 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 be addressed only 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 employ “crime rates” as a proxy for criminalized activities show that reductions correlated with incarceration are limited to property crime. One study estimated that reductions in property crime were, at most, 6% to 12% in the 1990s and are less than 1% in this century.[87] Studies have also shown that higher rates of incarceration are not associated with lower rates of violent crime and that those released from prison after murder convictions are 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 American Civil Liberties Union showed that in 29 locations that decarcerated people during COVID-19, reductions in jail populations were unrelated to changes 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 with 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. 

In addition, this argument does not consider the outsized magnitude of health and safety harms associated directly and indirectly with 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) and health consequences for incarcerated individuals, 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 in which 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 they 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 that 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 is an appropriate consequence for certain actions and necessary to prevent convicted people from repeating these actions.[86] In other words, this argument suggests that addressing and preventing suffering and violence require 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 such as 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 including the Bay Area Transformative Justice Collective and 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 has identified key critiques of current carceral practices and an interest in noncarceral solutions. These critiques include the following:

• 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 wherein survivors cannot or do not want to sever ties.[63,64]
• 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]
• Limitations in achieving lasting safety and fears of exacerbating harms, for example through retaliation (by loved ones of the person incarcerated or upon release) for survivor roles in precipitating incarceration, particularly given that 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, such as incarceration, exacerbate harm.[61]
• Risk of harm to survivors perpetuated by the legal system, with many survivors experiencing the legal system as retraumatizing through instances of hostility, victim blaming, lack of empathy, and discrimination (particularly among survivors from marginalized communities such as 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 service involvement), and risk of deportation, among others.[61,63,64]
• How carceral approaches shape nonreporting among survivors, with research suggesting that as many as half of violent victimizations in the United States go unreported (and this number is 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; and that the legal system is racially inequitable. Most often, underreporting is attributed to a preference for alternative approaches to 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 is 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.

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 not only will 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., the ability to assert choice in treatment without fear of retaliation). Third, one of incarceration’s far-reaching consequences is that often formerly incarcerated people are actively prohibited from reentering or meaningfully participating in their communities.[33] Barriers to reentry 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, 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 nonpolice, 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 in the harms of incarceration by reforming jails and prisons through human-centered, trauma-informed planning. These designs endeavor to overcome the punitive nature of incarceration by instituting “trauma-informed” practices and policies through staff training and oversight and use of “humane” facility architectural plans, building materials, and landscaping surrounding carceral facilities.
 
Response: While these novel carceral system designs 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 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 such as recidivism; however, concerns remain regarding poorer health-related outcomes, including higher suicide rates[96] and low satisfaction with health services provided.[97] Furthermore, a 2019 National Preventive Mechanism against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment special report on solitary confinement in Norwegian prisons showed that one out of four people incarcerated in Norway were 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 eight hours of “meaningful daytime activity” outside of the cell each day. The same report revealed that, in some prisons, prison staff did not notify medical personnel when incarcerated people requested care, even in some cases of obvious mental health crises or physical injuries.[98] Even in Norwegian prisons, upheld as “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 section, community-based care, support, and accountability best promote health, well-being, and justice. 
 
Opposing argument 6 — Public health can play an oversight role to ensure that prisons and jails mitigate health risks and support the health of people incarcerated and those detained: Another reform-based approach to intervening in the health harms of incarceration suggests that 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 the 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 is common and harms health. For example, even in the presence of active outbreaks within prison facilities during the COVID-19 pandemic, prison policies and practices 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 prioritization of preventive 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 as insufficient (e.g., solitary confinement as COVID-19 isolation) and illuminated the feasibility of policies once considered unattainable as government and public health officials have strived to protect society from a once-in-a-century pandemic. Third, public health oversight in carceral facilities does not address “spillover” health effects on families, communities, and the broader environment. For example, parental, caregiver, or other household member incarceration is an adverse childhood experience associated with a higher risk of poor health in adulthood.[100] In addition, evidence suggests an association between incarceration and poorer population health outcomes such as infant mortality, life expectancy, immunodeficiency syndrome infection rates, 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 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 deployment of the carceral system).[101] Second, decarceration efforts that rely on electronic monitoring or excessive supervision continue to be harmful to health via multiple pathways, including increased risk for loss of housing, employment, and access to health care across all systems. For example, a 2011 survey conducted by the National Institute of Justice showed that among 5,034 people with 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 increased hospitalization rates.[104] These harms are additive to the direct harm to mental and physical health caused by ankle monitors. In a recent survey of immigrants forced to wear ankle monitors, 90% of respondents reported harm to their physical health (including aches, impaired circulation, and swelling) and 88% 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 showed that drug testing requirements in parole did not deter most drug use.[101] Given that more than a third of prison admissions stem from technical violations of parole and probation conditions, these methods of decarceration also end up feeding the carceral system.[105] The numbers 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, and regular visits and check-ins with parole officers. The stress of meeting all of these conditions—alongside factors such as 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 health care, housing, and food: A frequent argument against decarceration is that housing, health care, and food access is better in jails and prisons than in communities. Proponents point out that relative to uninsured community control samples, access to health care can sometimes be better in prisons[107] 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 investing 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. 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 health care while in a jail, prison, or 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] In addition, one study showed that among 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 revealed that although more than one in five 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 their medication upon incarceration.[109] Furthermore, instead of adequate food during incarceration, those incarcerated report food with inadequate portion sizes, with inadequate nutritional content, and prepared without sanitary precautions.

Action Steps
To move toward 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:/p>

1. Decriminalize activities shaped by the experience of marginalization, such as substance use and possession, housing insecurity, and sex work
2. End the practice of cash bail and pretrial incarceration
3. Meet patient rights requirements for people with mental illness and substance use disorder 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
4. Significantly and continually reduce the number of people incarcerated in jails, prisons, and detention centers through release
5. Reallocate funding from the construction of new jails, detention centers, and prisons to the societal determinants of health, including affordable, quality, and accessible housing and health care, 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 reductions in staff and/or closures of prisons, jails, and detention facilities
7. Develop, implement, and support noncarceral 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 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

Furthermore, APHA urges Congress, the Centers for Disease Control and Prevention, and the National Institutes of Health, 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

Finally, 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 levels 
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 needs (e.g., mental health rapid response) rather than deploying the carceral system 

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