Addressing mass incarceration: a clarion call for public health.

The United States has the highest incarceration rate in the world with 2.2 million people in jails and prisons. The growth in the number of people behind bars over the last four decades is staggering; since the mid-1970s, it has swelled by more than 500%. The United States constitutes less than five percent of the world’s population, yet accounts for about one quarter of its prisoners, and at 756 per 100 000, the per capita incarceration rate far exceeds that of other industrialized democracies.1 People in correctional facilities are among the unhealthiest and most medically underserved in society. Compared with the general population, they have significantly higher rates of infectious and chronic diseases. People with addiction and serious mental illness are gravely overrepresented in the criminal justice system: an estimated 16% of men and 31% of women in jail have a serious psychiatric condition, compared with 5% in the general population and at least 50% experience problems related to drug or alcohol use.2 Although access to health care within jails and prisons is constitutionally mandated, the quality of health care services in these settings lags far behind the standard of care in the community. Furthermore, correctional facilities are unhealthy environments, where individuals are exposed to a range of conditions that are detrimental to physical and mental health—overcrowding, violence, poor nutrition, unsanitary conditions, and solitary confinement. As the US Supreme Court affirmed in the landmark case Plata v. Brown (2011) addressing overcrowding in Californian prisons, such conditions can result in an “unconscionable degree of suffering and death. ”3 During a visit to San Quentin State Prison in California, Sunshine, aged 7 years, makes a Father's Day card for her father Kinney who said he was serving a life sentence for murder. An annual Father's Day event, Get On The Bus, brings children in California . The cycling of people between jails, prisons, and poor communities is a likely contributor to population health disparities. Each year, roughly seven million people cycle between jail systems and the community, while about 700 000 are released from prisons.4 People returning home bring with them the negative health consequences of incarceration and a disproportionate percentage return to impoverished communities of color, further exacerbating existing health disparities and social inequalities.5 While there is much still to learn about the complex relationship between mass incarceration and population health, existing research illustrates how punitive criminal justice policies can affect the social ecology of communities in ways that are known to negatively influence mortality and morbidity. High concentrations of incarceration in a geographic area can impact the social determinants of health by criminalizing and stigmatizing the medically underserved,6 exacerbating education achievement gaps, crippling the social mobility of young men of color, disenfranchising millions from the democratic process,7 depriving children with incarcerated parents of economic and familial support, undermining the collective efficacy of urban neighborhoods, and stymieing the economic progress of historically oppressed groups.8