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Can incarceration be thought of as disease?

This review by me in the BMJ

It’s fashionable to treat social problems as if they were diseases. Stephen Ginn reflects on a book that considers an epidemiological solution to the huge and rapidly rising prison population in the United States

Among its many marvels, some things about the United States of America are stubbornly unfathomable. The persistent, widespread opposition to socialised medicine is one of them. And despite a murder rate impressive for all the wrong reasons, US gun laws remain unreformed.

Add to this America’s prisons. This is not an area in which the United Kingdom basks in glory, but the American dedication to incarcerating its citizens remains without rival. “If this population had their own city, it would be the second largest in the country,” dryly remarks author Ernest Drucker.

The numbers tell the story: of a population of 310 million, 7.3 million people are under the control of the US criminal justice system. Of these, 2.3 million are imprisoned, 800 000 are on parole, and 4.2 million are on probation. The US has 5% of the world’s people but 25% of its prisoners. This section of the US population grew fivefold between 1970 and 2009.

Drucker, an epidemiologist, sees this increase as a plague and amenable to examination using the tools of his trade. Although imprisonment is not usually considered a disease, this framing isn’t meant to be metaphorical. The American fondness for imprisoning its citizens meets all the key criteria for an epidemic: its growth rate is rapid, its scale large, and it shows self sustaining properties.

During London’s 1854 outbreak of cholera, John Snow’s insight famously led to the removal of the handle of the Broad Street water pump. Soho’s residents could no longer drink its contaminated water. What is the pump filling America’s prisons, and is it possible for the handle to be removed? Drucker shows how in one state­­—New York—the rate of incarceration clearly surged from the 1970s. This coincides with the introduction of the state’s so called Rockefeller drug laws: punitive legislation introduced in response to a rise in heroin use in the 1960s. These laws made it possible for those caught in possession of even small amounts of illegal drugs to receive the same sentences as imposed for violent crime. Similar legislation would be enacted throughout the country.

Most of New York City’s prison population comes from just six neighbourhoods. This echoes the distribution of deaths on the Titanic, which reveal the rigid social structure of the Edwardian era. On the Titanic, those in the highest social class were more than twice as likely to survive as those in the lowest social class. In New York some areas are plunged into near anarchy by the so called war on drugs being waged on their streets, while others are almost untouched.

Incarceration also causes disability, just like disease, and is passed on to future generations, just like disease. The children of families where a member is incarcerated have a lower life expectancy and are six to seven times more likely to go to prison themselves.

The notion of applying an analysis to social problems that is more conventionally used to understand disease has gained recent cultural currency. The Interrupters, a 2011 feature length documentary, focused on CeaseFire, a Chicago antiviolence programme that deploys street workers as mediators between factions during incipient street conflict. It was founded by Gary Slutkin, another US epidemiologist, who considers violence to be primarily a public health issue. Slutkin has publicly encouraged David Cameron to adopt CeaseFire’s approach in London.

Something must be done about prisons, but is this the way ahead? Labelling people as victims of a plague has never been a good way to rehabilitate them back into society. No matter how neatly it may fit a disease model, bringing epidemiological theory to bear on the problem of prisons reframes that problem as something dispassionate and treatable, when in fact it is intensely political. Drug laws may be America’s prison pump but behind those laws lies the willingness of lawmakers and politicians to treat marginalised groups and their problems within a punitive criminal justice framework. If drug laws are reformed then opprobrium for other misdemeanours may take their place. Some US schools now use police to enforce school discipline, for example, and increasing numbers of children are being convicted via this route.

This criticism is unacknowledged by Drucker, but to his credit, the public health response he offers to high levels of incarceration is more radical than might be expected. It’s no surprise that he writes that, as primary prevention, drug laws like the Rockefeller laws have to go. Secondary prevention involves prison reform. But as tertiary prevention, and to address the “great task of healing to be done on both sides of crime and punishment,” he proposes a programme of restorative justice in a shape of a formal peace process, not unlike South Africa’s Truth and Reconciliation Commission.

In a time when public inquiries are not in short supply, it’s easy to be cynical about such a suggestion, as it is about Drucker’s approach in general. But this book is accessible and persuasive. Prisons on both sides of the Atlantic represent an immense waste of human potential and financial resources. The questions of what to do about them need to be asked more often. This analysis has much relevance beyond US borders; British incarceration rates are lower, but the UK has one of the highest rates of imprisonment in Europe. Successive recent governments have presided over a steadily increasing UK prison population that has doubled in 20 years.


(June 2018 review – Ceasefire is now known as ‘Cure Violence’ it seems)

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  1. The McCarthy Witch-hunts against communism and the fear of “Reds under the Bed” must have left a whole generation afraid of anything left wing or socialist. So “socalised medicine” is “communist medicine”. Perhaps that is why this generation who were born during that period are so afraid of “socialist” Europe – many Americans really do think that the UK is “socialist” and that Europe is “socialist”. I wonder if that is why they are encouraging the world to ditch the public sector because it might encourage “communism” and “reds under the bed”?

    From the book “Get a life” by David Burke and Jean Lotus of The White Dot Campaign. Bloomsbury 1998. Chapter 9:

    Brandon Centerwall, an epidemiologist, did a study on homicide rates for two industrialised countries where TV arrived late, controlling for urbanisation and how easy it was to obtain arms. He found that after a ten year lag, while the first television generation came of age, murder rates went up. He published the findings in the 1993 issue of The Public Interest. He wrote: “If, hypothetically, television technology had never been developed ..[in the United States]… violent crime would be half what it is.”

    South Africa did not have television until 1973. Centerwall compared white homicide rates for the US, Canada and South Africa and he found that from 1945 to 1974, the white homicide rate in the US increased 93%. In Canada the homicide rate increased 93%. In South Africa where television was banned until 1973, the white homicide rate declined by 7%. Centerwall also tracked murder rates across the US: as different regions got television, after a 10-15 year gap, violent crime doubled and the same thing appeared to happen in Canda. He found that in England and Wales, the homicide rate doubled about 15 years after television became widespread. In South Africa, 8 years after television was introduced, the white homicide rates became equivalent to the rest of the Western world. Centerwall thinks that the fifteen year period is the time it takes for the first television generation to “come of age”.

    At a press conference of the American Medical Association in Chicago in July 1996, Centerwall presented these findings, calling TV-related violence an epidemic but it was not reported in the media at the time, although the US senate has since taken some interest.

    Leonard Eron of the University of Illinois asked prisoners about how much television they watched as kids and found that the amount of television watched at age eight was proportional to the seriousness of crimes committed by age 30.

  2. As you rightly point out, the problem is intensely political. No American politician wants to be seen as ‘soft on crime.’ Moreover, the problem was exacerbated by the different treatment of crack cocaine vs. powder cocaine. If memory serves, sentencing guidelines for crack cocaine possession and distribution were an order of magnitude greater than those for powder. Of course, crack is far cheaper than powder cocaine, which means these far more stringent sentencing guidelines disproportionately affect poorer Americans, usually racial minorities.

  3. Hello,

    This is not the most relevant discussion, but I am trying to raise a discussion about mental health services post-Winterbourne View case as it shocked me to the core. I’ve written two posts about this in my blog:

    Agree that prisons are an outdated institutions and globally everybody should think of ways to make them redundant. It’s a long journey though.