In this article series, I explore the question: How does racism make us sick? As introduced in my last piece on the medical repercussions of historical segregation, the pervasiveness of structural racism drives health inequality and poorer health outcomes for people of color. For the second installment, I focus on the routes and mechanisms by which people of color are disproportionately funneled into correctional facilities, and expose the diminishment of health and health care that is a direct consequence of incarceration. Examination of the criminal justice system serves to draw further connections between racism and sickness, and the ways in which people of color are continually exposed to greater concentrations of health hazards and risks.
Despite rates of drug use similar to white counterparts, black men are 11.8 times as likely to be arrested for drug offenses compared to whites. African Americans constitute 14 percent of regular drug users, and yet represent 37 percent of people arrested for drug offenses, 55 percent of drug convictions, and 74 percent of people sent to prison for drug possession. One in 15 black men is currently behind bars. Today, there are more people in jail for drug offenses then there were prisoners for all crimes in 1980. People of color comprise more than 60 percent of those incarcerated, yet represent only a third of the country’s population. While the issues leading to the disproportionate incarceration of people of color are many, I wish to focus on a single contributor which is the most important cause of America’s dramatic increase in incarceration — the structural racism readily apparent in our country’s approach to drug offense convictions.
In the late 20th century, the U.S. domestic policy campaign known as the War on Drugs declared drug abuse as “public enemy number one” and sought to crack down on the use and distribution of drugs. In 1986, Congress passed the Anti-Drug Abuse Act. Considered to be discriminatory, the law disproportionately targeted poor minority communities by calling for a minimum mandatory sentencing that employed a 100 to 1 disparity between crack and powder cocaine possession. This meant that five grams of crack cocaine and five hundred grams of powder cocaine carried the same sentence of five years in federal prison. Though crack and powdered cocaine are nearly chemically identical, poor minority communities have greater use of and access to crack than the powdered cocaine that is more popular among wealthy white populations. Due to mandatory minimum sentencing laws implemented by the War on Drugs, arrests for drug offenses rose by 126 percent (compared to a 28 percent increase in arrests for all crimes), accounting for 27 percent of the total growth of black prisoners.
The United States has a long history of drug policies that target and oppress specific racial groups. Though direct intent to maintain white supremacy is difficult to prove, the outcomes are indisputable. For example, drug offense arrests have played a large role in U.S. immigration policy, serving as the rationale to increase the number of immigrant deportations. In 1909, smoking opium was labeled as a federal offense through the Anti-Opium Act. While the law allowed exceptions for drinking and injecting opiates, which were popular among whites, the law served to reinforce anti-Chinese racism and disenfranchise Asian immigrants alongside xenophobic agendas and the Chinese Exclusion Act of 1882. Similarly, in the early 1920s, southwest towns prohibited marijuana for fear that it “gave Mexicans superhuman strength to commit acts of violence.”
The War on Drugs continues to funnel hundreds of thousands of individuals into correctional facilities at rates unprecedented in global history. Although rates of drug use and dealing are similar across races, the enforcement of Drug War legislation unfairly targets people of color. Black and Hispanic people are far more likely to be searched, prosecuted and convicted for committing the same acts as their white counterparts, and are thus channeled into incarceration at incredibly disproportionate rates. Importantly, the War on Drugs and its implementation prioritize the elimination of drug abuse over community safety: its practice revolves around punishment, scrutiny and incarceration as a method of social control. Its conception and perpetuation are steeped in historical agendas that center upon racism and xenophobia as key motivators. Though it targets drugs as a public enemy, the War on Drugs’ most significant result seems to be the incarceration of over half a million Americans of color every year. Drug offense convictions account for more than 60 percent of federal prison expansion, and only 7.9 percent of current federal prisoners have been convicted of violent crime. The War on Drugs has not shown success regarding public health or security, and allocates trillions of dollars to prosecuting non-violent drug users at a time when 40 percent of murders and 60 percent of rapes go unsolved. Locking up thousands of non-violent community members in poorly-resourced prisons does not make our society any safer, healthier, better. The repercussions of the War on Drugs do not parallel the declared agenda for community protection.
Analysis of U.S. drug enforcement further demonstrates how racism makes us sick by illuminating how similar issues are treated differently depending on the community in question. The War on Drugs helps frame substance use in communities of color as a criminal, rather than public health concern. This framing, however, is not universal. During the conception of the War on Drugs, white females addicted to morphine were often sympathized with, framed as victims of a torturous addiction, and steered towards medical rehabilitation for recovery. Even today, increasing rates of opioid and prescription drug abuse seen in white populations are more likely to initiate conversations about over-prescription of pharmaceuticals by physicians. These instances of substance use are thereby understood as problems of public health rather than criminal correction. Meanwhile, matters of substance use in communities of color are continually entrapped under the jurisdiction of scrutiny, punishment and accusation instead of the concern allotted for their white counterparts.
In 1989, Lori Griffin underwent prenatal care, labor and delivery in handcuffs and shackles. She was a ‘patient’ of the Interagency Policy on Cocaine Abuse in Pregnancy in South Carolina, which allowed nonconsensual drug tests of pregnant women. Positive tests were reported to the police, and these women were arrested and convicted of child neglect or drug distribution to minors. Of over 40 women arrested and treated in this manner, only one patient was not black.
Issues of reproductive health intersect with the War on Drugs — and thereby join politics of race and gender — through legislation that characterizes drug use during pregnancy as aggravated assault, a crime that can warrant up to 15 years in jail. Despite research that shows similar levels of prenatal drug use between black and white women, black women are ten times as likely to be reported to child welfare agencies and undergo criminal prosecution for prenatal drug use. Black women are the fastest growing prison population, and are more than seven times as likely as white women to spend time behind bars. Imbalances in enforcement definitively showcase the racial inequalities in criminal justice.
When considering the issue of criminal prosecution for prenatal drug use, it is crucial to note that only 50 percent of pregnant women in prison receive prenatal care while incarcerated. Only 22 percent of women admitted to U.S. jails received gynecological examinations upon admission. Additionally, studies estimate that only 10 percent of female drug-abusing prisoners are offered drug treatment. When high rates of substance use disorders and sexually transmitted diseases are coupled with the consideration that more than 20 percent of prisoners are sexually assaulted while serving their sentences, it becomes starkly obvious that being imprisoned carries higher risk to women and their babies. Of course, the medical ramifications of prenatal drug use are well documented and pose a threat to newborn infants. Our societal solutions, however, need to think more critically about what is more successful for the rehabilitation, health and safety of both mother and child. Adverse Childhood Experiences (ACE), which include incarceration, substance abuse, separation and domestic violence, are strongly correlated with increased risk of heart and liver disease, COPD, depression and suicide in affected children. Why, then, are mothers who suffer from substance use disorders being shackled, incarcerated and forced into arenas of higher drug use, sexual assault, violence and infectious disease instead of being provided with drug treatment? What parts of fetal health are being emphasized when gestation is continued under poor conditions and children’s caretakers and providers are locked away?
Does drug dependency require a medical response or a punitive response? Why is the answer to this question variable, and who benefits from that variability? In order to understand the alarmingly disparate health repercussions for people of color in our country, we must understand how structural racism is perpetuated through all American institutions.
In California, a prisoner dies every seven days due to inadequate medical care. Entrance into prison significantly increases exposure to infectious disease and other health hazards. Fifteen percent of HIV positive individuals, and 40 percent of people infected with hepatitis C have spent time in correctional facilities. HIV and hepatitis C infection rates among incarcerated populations are up to ten times the national average; tuberculosis rates are up to seventeen times higher. While these statistics do not necessarily indicate direct causation, it is clear that correctional facilities provide fertile ground for disease exposure and transmission due to overcrowding and increased contact. Common and congested environments, coupled with delayed medical care, decreased access to condoms, clean needles and hygienic resources such as soap and water drastically increases rates of disease transmission and exposure. Prisons are areas of concentrated health hazards. It seems that getting people out of jail is one of the best public health interventions we have. The disproportionate entry of people of color into correctional facilities resulting from structural racism thereby represents an access point for health disparities to take root and affect communities of color at correspondingly disparate rates.
While the high concentration of health risks and infectious disease within incarceration facilities is important, a second health issue resulting from the disproportionate and mass incarceration of people of color becomes apparent after sentences are served and inmates are released. Every year, over ten million prisoners — increasingly poor, uninsured, people of color — are released back into their communities. Many of these individuals struggle with disparate burdens of substance abuse, mental illness, and infectious and chronic disease that have only been made worse by correctional facilities. They have been exposed to disease at rates much higher than the national non-incarcerated average, yet are returned home to their communities, families, partners, children and friends unequipped with adequate health resources. Thus structural racism, as it relates to criminal justice, is doubly deadly when it comes to health. It first disproportionately directs people of color who are already at risk of poorer health outcomes into jails, then exposes them to disease only to return them to their neighborhoods without adequate means to address their illnesses.
If current rates continue, black men will have greater than a 25 percent chance of going to prison in their lifetime. This is more than six times the average for white men. The United States now imprisons a larger percentage of its black population than South Africa did during apartheid. Research from 2007 in a study of more than 30,000 released inmates over two years shows an overall mortality rate of 3.5 times that of other state residents. In the first two weeks after release, risk of death was almost 13 times the average rate for non-incarcerated individuals. Leading causes of death include drug overdose, cardiovascular disease, homicide and suicide. There is little debate: prison is bad for your health.
The punishment of incarceration does not end after a prisoner’s sentence is served. As Michelle Alexander describes, incarceration acts as an entry point to a larger system of “racial stigmatization and permanent marginalization” that bar people not only literally within prison, but also within a web of legalized discrimination and social exclusion that force prisoners into a social undercaste. Incarceration influences economic and financial opportunity, family structure, and sociopolitical participation. One in 13 black Americans are disenfranchised due to laws that deny felons the right to vote. This is seven times the national average, and serves as a potent mechanism for limiting the ability of black communities to advocate for their needs and issues. Research by sociologist Devah Pager shockingly demonstrates that even when carefully controlling for qualifications and experience, white job interviewees with felony records were still more likely to receive job call backs compared to black peers whose job applications did not include a felony record. Think on that. In America, white felons have a greater chance of a second interview than equally qualified black citizens with no criminal record. This begs the question: where and what are the possible economic opportunities for the thousands of black citizens who do possess felony records, which are in part a result of social disparities in criminal scrutiny and the sociopolitical exertion of the War on Drugs? These high rates of incarceration erode opportunities for employment and financial mobility, producing further barriers and additional obstacles to health care access. Ultimately, the conduction of people of color into prisons has a multitude of repercussions, all of which can circle back to influence probabilities of health equity, access and attainment.
Institutions of education and incarceration also have a direct link. We cannot discuss the disproportionate incarceration of people of color without the school-to-prison pipeline. Failed education systems are primary points of entry into correctional facilities, and children of color are excessively targeted to be suspended and expelled from school. Black students are suspended or expelled three times more often than their white counterparts despite no evidence that infractions by minority students are more frequent or more serious. Consequently, more and more students of color are unable to graduate, leaving them with fewer options for social mobility and higher chances of entanglement with crime and the criminal justice system. The intersection of education and incarceration is integral to the discussion on structural racism’s entanglement with drug conviction, prison and health inequity.
Health in incarcerated populations is a complicated problem that is home to a multitude of interweaving issues including the philosophy and use of incarceration in the United States, education disparities, race, mental and public health in America and the economics of the prison industrial complex. What is clear is that entry into incarcerated facilities is influenced by race and racism in the United States. Racism disparately increases scrutiny from the criminal justice system, which funnels people of color into the prison industrial complex at inordinate rates. All together, this damages health through increased infliction of police violence, greater exposure to infectious disease and chronic stress, and eventual issues with stigma and lower positioning in social hierarchy, which continue the cycle of disenfranchisement, unemployment and inaccessibility towards sociopolitical mobility and health care resources. The prison industrial complex is a direct threat to the health of individuals, entire communities and our society as a whole.
How do we understand state violence to be a part of health disparity? Prison systems represent an important departure point from which we can begin to more heavily analyze public health as both a discipline and powerful tool. The difference in treatment of individuals as criminals or patients speaks volumes to the distinct ways citizens of this country navigate and experience America. Variances in thought and practice towards different populations pervade the United States, and are insidious, subtle and strong in impacting the ways people of color are treated, not only in the greater community, but in hospital wards as well. The problem of prison health is a potent reminder of how structural racism directly contributes to health inequity, and thereby merits the attention of health care providers. Understanding the medical repercussions to systemic racism helps not only to bolster our understanding of health and well-being in this country, but convince us why examining these issues are essential to our understanding of health disparity in a professional context. Social medicine is crucial not only to our understanding of national politics as it relates to health, but also our fundamental ability to do our job well.
Writer-in-Training and in-Training Staff Member
Warren Alpert Medical School of Brown University
The white coat is a scary, scary thing, and I'm still trying to figure out if I should have one. If you like screaming about ethnic rage, dance, or the woes of medical education, we should probably do some of those fun activities that friends do.
I have few answers, many questions. Dialogue is huge. Feel free to email with questions and comments!
