- Email: [email protected]
Jails, justice, and public health
Perspectives
Book Jails, justice, and public health Each year more than 11 million people are locked up in US jails that incarcerate those who are awaiting trial, serving sentences of less than a year, or have violated parole conditions. As criminal justice and social policies in the USA have led to the incarceration of ever more people, jails have become the entry point into the correctional system. From a health perspective, jails collect people with HIV/AIDS and other infectious diseases, drug problems, mental illness, and victims and perpetrators of violence, and so prisons are both a lens through which to view urban epidemics and a site for public health interventions. Most people stay in jail for a few days, weeks, or months—only about a quarter of US jail inmates go on to the state or federal prison system reserved for those with sentences of more than a year. As a result, most go home, back to the people, places, and living circumstances that helped get them in trouble. In many cities, more than half of those released from jail are reincarcerated in less than a year. Since the poor have higher incarceration rates than the better off, this recycling of people between jails, streets, and communities hits disadvantaged communities hardest. Some evidence suggests that the high rates of population mobility associated with mass incarceration contribute to individual, family, and community disruption and thus help to maintain or exacerbate the health inequities that burden poor neighbourhoods. In Dreams from the Monster Factory: A Tale of Prison, Redemption, and One Woman’s Fight to Restore Justice to All, Sunny Schwartz tells the story of one jail system and one programme designed to change the miserable outcomes that most US jails achieve. After spending more than a decade www.thelancet.com Vol 374 July 4, 2009
running programmes in the San Francisco jail system, in 1997 Schwartz founded and directed a new programme, Resolve to Stop the Violence Program. This programme created a special housing unit in the San Francisco jail for violent male offenders and sought to construct an environment that encouraged men to reconsider their violence and change their responses to challenge or humiliation. “I wanted our community to be safer”, writes
“From a health perspective, jails collect people with HIV/AIDS and other infectious diseases, drug problems, mental illness, and victims and perpetrators of violence, and so prisons are both a lens through which to view urban epidemics and a site for public health interventions.” Schwartz, “I wanted to banish fear and violence, and the only way to do that, it seemed to me, was to work with the people causing the fear and violence, to try to get them to do something different.” The Resolve to Stop the Violence Program took over a single housing unit in the jail and selected men who had histories of violence or were charged with violent crimes. Schwartz and her colleagues created a new social environment, in which men discussed their past, considered the effect of their actions on their victims, and supported each other’s paths to change. After release, the Resolve to Stop the Violence Program continued to provide modest levels of support and crisis intervention. As Schwartz notes, not rocket science and nothing that had not been tried before. In 1999, two psychiatrists from Harvard University evaluated this programme and found that
participation in Resolve to Stop the Violence Program led to significant reductions in re-arrest for violent crimes and shorter times in custody, compared with a comparable group of non-participating men. Men who took part in the Resolve to Stop the Violence Program for longer periods benefited more than those who spent only a shorter time with the programme. In the past decade, several other jail systems in the USA have adopted similar programmes. As someone who has developed and evaluated health and re-entry programmes at the Rikers Island Detention Center, New York City’s jail, for more than 15 years, I found that many of Schwartz’s observations ring true. For the most part, jails are organised for custody and control, not rehabilitation. Many inmates have good intentions and want to make changes in their lives and many correctional officers, even the tough guys, want to help their charges stay out of jail. But these good intentions are often overwhelmed by the harsh realities of life in jail and after release. In this sense, most jails are factories for failure. In my experience, however, the “monster” label that Schwartz pastes on the child molesters, rapists, gang bangers, and murderers applies to only a minority of people passing through jails. For every monster, there are five or ten ordinary guys who happened to smoke or sell marijuana or other drugs in the wrong place, jump the subway turnstile without paying, get in a fight, or violate the terms of their parole. By associating with other felons, using drugs or committing other less serious infractions that would not lead to jail were they not under legal supervision, parole violators now fill an increasing portion of jail cells in the USA. Among women in prison
Dreams from the Monster Factory: A Tale of Prison, Redemption, and One Woman’s Fight to Restore Justice to All Sunny Schwartz with David Boodell. Simon and Shuster, 2009. Pp 224. US$24·00. ISBN 1-416-56981-2. To watch Sonny Schwartz talk about this book see http://books.simonandschuster. com/Dreams-from-theMonster-Factory/SunnySchwartz/9781416569817
17
Perspectives
in the USA, the majority are there as a result of using or selling drugs or committing other crimes to get drugs. To be sure, many people in jail and prison did terrible things—and had terrible things done to them from childhood on. Most of these damaged people would benefit from the type of programme Schwartz and her colleagues established in County Jail 7 in San Francisco. And as Schwartz observes, there was no magic to what she and her co-workers did: “RSVP can be re-created in every jail and prison in the country.” More programmes like this one are needed not only to prevent violence, but also to treat drug abuse and mental illness and reduce
recidivism among people discharged from jails and prisons. By themselves, however, they are not sufficient to create a correctional system that is effective, humane, or affordable, as Schwartz herself acknowledges. As long as the US continues to use jails to solve its public safety, mental health, substance abuse, and unemployment problems, it will be hard pressed to improve outcomes or reduce costs. We simply lock up too many people for too many reasons to realistically use the correctional system effectively to reduce problems better addressed by other systems. In recent months, as the economic crisis drains public coffers, many US
states have discharged prisoners early or rescinded mandatory sentencing laws. Whether this surge in early discharges and shorter sentences will lead to lower rates of incarceration or simply put those newly released at risk of reincarceration when their drug use or mental health problems worsen or the economy improves remains to be seen. In the final analysis, it’s hard to decide whether Schwartz’s monster label applies to the people behind bars or to the designers of the system that put them there.
Nicholas Freudenberg [email protected]
In brief Book Healthy spaces
Healing Spaces: The Science of Place and Well-Being Esther Sternberg. Harvard University Press, 2009. Pp 325. US$27·95 (£20·95). ISBN 0-674-03336-1. To watch Esther Sternberg talk about this book see http://www. youtube.com/watch?v=HkLoHtv wLIA&feature=channel_page
18
I am sitting down outside, in a city. It’s pleasantly sunny and I can feel the warmth of the sun on my skin. I can hear a faint skirl of bagpipes and children laughing in the park as they hurl themselves down a steep bank. The smell of freshly cut grass is in the air. It feels good (even the bagpipe bit) and I’m relaxed. Before I’d read Healing Spaces by Esther Sternberg though, I wouldn’t have been thinking about how the features of this environment that my senses are detecting could affect my capacity to heal. After this fascinating, engaging, and challenging read I’ll think about the health consequences of where I am in a different way. In Healing Spaces: The Science of Place and Well-Being, Sternberg examines the science of, and evidence for, the influence of environment on our immune system. She sets out how our senses perceive the world (and I mean “how”, as in which chemicals, cells, organs, and neural pathways do the work). She then describes how neurologists and others have pieced together the
ways in which the brain’s reactions to sensory information, and to our feelings for and reactions to place, can enhance or suppress our bodies’ capacity to heal. Perhaps in the 21st century we all like to imagine that the places we inhabit and the environments we are exposed to are fairly benign. Yet, as Sternberg shows, the evidence for significant immune response to what we see, hear, smell, touch, and experience is strong. Sternberg believes that her subject matters because we all need to heal, all the time. If particular environments promote or inhibit healing, we could and should use this knowledge in urban planning and in architecture. Making this evidence directly relevant for a clinical audience, Sternberg suggests that “Patients in the hospital are constantly exposed to stressors that impair health, slow healing and weaken the immune system. Understanding and reducing stress in the hospital environment is to twenty-first century medical care what understanding germ theory and reducing infection were to nineteenth-century care.”
Some will be sceptical of such environment–human health interactions and their significance for health. Such scepticism is well met by Sternberg, with honest appraisal of the evidence she presents. Despite a slight American bias in this book, Sternberg explains the strengths and weaknesses of the evidence with rigour and clarity. There is, of course, a certain misery that comes from reading a book like this. Somehow it’s worse experiencing an annoying noise (and no, I’m still not talking about the bagpipes), that slight unease at losing your way in a hospital, or the melancholy of another cloudy day when you know that there’s a brain–immune response occurring as a consequence. But you can at least console yourself and combat the stress by deploying your new-found knowledge; find a healing space of your own. Go somewhere that feels, smells, and sounds welcoming. Enjoy the benefits and enjoy knowing how they occur.
Richard Mitchell [email protected]
www.thelancet.com Vol 374 July 4, 2009
Book Jails, justice, and public health Each year more than 11 million people are locked up in US jails that incarcerate those who are awaiting trial, serving sentences of less than a year, or have violated parole conditions. As criminal justice and social policies in the USA have led to the incarceration of ever more people, jails have become the entry point into the correctional system. From a health perspective, jails collect people with HIV/AIDS and other infectious diseases, drug problems, mental illness, and victims and perpetrators of violence, and so prisons are both a lens through which to view urban epidemics and a site for public health interventions. Most people stay in jail for a few days, weeks, or months—only about a quarter of US jail inmates go on to the state or federal prison system reserved for those with sentences of more than a year. As a result, most go home, back to the people, places, and living circumstances that helped get them in trouble. In many cities, more than half of those released from jail are reincarcerated in less than a year. Since the poor have higher incarceration rates than the better off, this recycling of people between jails, streets, and communities hits disadvantaged communities hardest. Some evidence suggests that the high rates of population mobility associated with mass incarceration contribute to individual, family, and community disruption and thus help to maintain or exacerbate the health inequities that burden poor neighbourhoods. In Dreams from the Monster Factory: A Tale of Prison, Redemption, and One Woman’s Fight to Restore Justice to All, Sunny Schwartz tells the story of one jail system and one programme designed to change the miserable outcomes that most US jails achieve. After spending more than a decade www.thelancet.com Vol 374 July 4, 2009
running programmes in the San Francisco jail system, in 1997 Schwartz founded and directed a new programme, Resolve to Stop the Violence Program. This programme created a special housing unit in the San Francisco jail for violent male offenders and sought to construct an environment that encouraged men to reconsider their violence and change their responses to challenge or humiliation. “I wanted our community to be safer”, writes
“From a health perspective, jails collect people with HIV/AIDS and other infectious diseases, drug problems, mental illness, and victims and perpetrators of violence, and so prisons are both a lens through which to view urban epidemics and a site for public health interventions.” Schwartz, “I wanted to banish fear and violence, and the only way to do that, it seemed to me, was to work with the people causing the fear and violence, to try to get them to do something different.” The Resolve to Stop the Violence Program took over a single housing unit in the jail and selected men who had histories of violence or were charged with violent crimes. Schwartz and her colleagues created a new social environment, in which men discussed their past, considered the effect of their actions on their victims, and supported each other’s paths to change. After release, the Resolve to Stop the Violence Program continued to provide modest levels of support and crisis intervention. As Schwartz notes, not rocket science and nothing that had not been tried before. In 1999, two psychiatrists from Harvard University evaluated this programme and found that
participation in Resolve to Stop the Violence Program led to significant reductions in re-arrest for violent crimes and shorter times in custody, compared with a comparable group of non-participating men. Men who took part in the Resolve to Stop the Violence Program for longer periods benefited more than those who spent only a shorter time with the programme. In the past decade, several other jail systems in the USA have adopted similar programmes. As someone who has developed and evaluated health and re-entry programmes at the Rikers Island Detention Center, New York City’s jail, for more than 15 years, I found that many of Schwartz’s observations ring true. For the most part, jails are organised for custody and control, not rehabilitation. Many inmates have good intentions and want to make changes in their lives and many correctional officers, even the tough guys, want to help their charges stay out of jail. But these good intentions are often overwhelmed by the harsh realities of life in jail and after release. In this sense, most jails are factories for failure. In my experience, however, the “monster” label that Schwartz pastes on the child molesters, rapists, gang bangers, and murderers applies to only a minority of people passing through jails. For every monster, there are five or ten ordinary guys who happened to smoke or sell marijuana or other drugs in the wrong place, jump the subway turnstile without paying, get in a fight, or violate the terms of their parole. By associating with other felons, using drugs or committing other less serious infractions that would not lead to jail were they not under legal supervision, parole violators now fill an increasing portion of jail cells in the USA. Among women in prison
Dreams from the Monster Factory: A Tale of Prison, Redemption, and One Woman’s Fight to Restore Justice to All Sunny Schwartz with David Boodell. Simon and Shuster, 2009. Pp 224. US$24·00. ISBN 1-416-56981-2. To watch Sonny Schwartz talk about this book see http://books.simonandschuster. com/Dreams-from-theMonster-Factory/SunnySchwartz/9781416569817
17
Perspectives
in the USA, the majority are there as a result of using or selling drugs or committing other crimes to get drugs. To be sure, many people in jail and prison did terrible things—and had terrible things done to them from childhood on. Most of these damaged people would benefit from the type of programme Schwartz and her colleagues established in County Jail 7 in San Francisco. And as Schwartz observes, there was no magic to what she and her co-workers did: “RSVP can be re-created in every jail and prison in the country.” More programmes like this one are needed not only to prevent violence, but also to treat drug abuse and mental illness and reduce
recidivism among people discharged from jails and prisons. By themselves, however, they are not sufficient to create a correctional system that is effective, humane, or affordable, as Schwartz herself acknowledges. As long as the US continues to use jails to solve its public safety, mental health, substance abuse, and unemployment problems, it will be hard pressed to improve outcomes or reduce costs. We simply lock up too many people for too many reasons to realistically use the correctional system effectively to reduce problems better addressed by other systems. In recent months, as the economic crisis drains public coffers, many US
states have discharged prisoners early or rescinded mandatory sentencing laws. Whether this surge in early discharges and shorter sentences will lead to lower rates of incarceration or simply put those newly released at risk of reincarceration when their drug use or mental health problems worsen or the economy improves remains to be seen. In the final analysis, it’s hard to decide whether Schwartz’s monster label applies to the people behind bars or to the designers of the system that put them there.
Nicholas Freudenberg [email protected]
In brief Book Healthy spaces
Healing Spaces: The Science of Place and Well-Being Esther Sternberg. Harvard University Press, 2009. Pp 325. US$27·95 (£20·95). ISBN 0-674-03336-1. To watch Esther Sternberg talk about this book see http://www. youtube.com/watch?v=HkLoHtv wLIA&feature=channel_page
18
I am sitting down outside, in a city. It’s pleasantly sunny and I can feel the warmth of the sun on my skin. I can hear a faint skirl of bagpipes and children laughing in the park as they hurl themselves down a steep bank. The smell of freshly cut grass is in the air. It feels good (even the bagpipe bit) and I’m relaxed. Before I’d read Healing Spaces by Esther Sternberg though, I wouldn’t have been thinking about how the features of this environment that my senses are detecting could affect my capacity to heal. After this fascinating, engaging, and challenging read I’ll think about the health consequences of where I am in a different way. In Healing Spaces: The Science of Place and Well-Being, Sternberg examines the science of, and evidence for, the influence of environment on our immune system. She sets out how our senses perceive the world (and I mean “how”, as in which chemicals, cells, organs, and neural pathways do the work). She then describes how neurologists and others have pieced together the
ways in which the brain’s reactions to sensory information, and to our feelings for and reactions to place, can enhance or suppress our bodies’ capacity to heal. Perhaps in the 21st century we all like to imagine that the places we inhabit and the environments we are exposed to are fairly benign. Yet, as Sternberg shows, the evidence for significant immune response to what we see, hear, smell, touch, and experience is strong. Sternberg believes that her subject matters because we all need to heal, all the time. If particular environments promote or inhibit healing, we could and should use this knowledge in urban planning and in architecture. Making this evidence directly relevant for a clinical audience, Sternberg suggests that “Patients in the hospital are constantly exposed to stressors that impair health, slow healing and weaken the immune system. Understanding and reducing stress in the hospital environment is to twenty-first century medical care what understanding germ theory and reducing infection were to nineteenth-century care.”
Some will be sceptical of such environment–human health interactions and their significance for health. Such scepticism is well met by Sternberg, with honest appraisal of the evidence she presents. Despite a slight American bias in this book, Sternberg explains the strengths and weaknesses of the evidence with rigour and clarity. There is, of course, a certain misery that comes from reading a book like this. Somehow it’s worse experiencing an annoying noise (and no, I’m still not talking about the bagpipes), that slight unease at losing your way in a hospital, or the melancholy of another cloudy day when you know that there’s a brain–immune response occurring as a consequence. But you can at least console yourself and combat the stress by deploying your new-found knowledge; find a healing space of your own. Go somewhere that feels, smells, and sounds welcoming. Enjoy the benefits and enjoy knowing how they occur.
Richard Mitchell [email protected]
www.thelancet.com Vol 374 July 4, 2009