Public Health and Crime

Hayden P Smith. 21st Century Criminology: A Reference Handbook. Editor: J Mitchell Miller. 2009. Sage Publication.

During the decade of the 1980s, changes occurred in the field of public health that significantly impacted the field of criminology. At this time, public health professionals were evaluating a range of interventions and interventions that crossed the traditional boundaries of public health; for example, they worked on issues involving homelessness, teenage pregnancy, and violence prevention. The field of public health had even gained optimism in response to the HIV/AIDS pandemic. Starting with educational campaigns in the 1980s that addressed sexual behaviors and drug abuse and furthered by the development of antiviral medications in the 1990s, the HIV/AIDS pandemic was transformed from a death sentence into a manageable, chronic condition. Clearly public health and criminology were working side by side, if not together.

While some issues were gaining interest in both fields, three of the five leading causes of premature death—suicide, homicide, and injury—had received far less attention from public health researchers than criminologists (Rosenberg & Fenley, 1991). All three causes were strongly correlated with violence. In response, thenSurgeon General C. Everett Koop (1986) expanded the mission of public health and dedicated new resources toward the prevention and treatment of violence. By doing so, violence was now conceptualized as a public safety and community health issue, rather than principally a law enforcement matter. By 1991, the National Center for Injury Prevention and Control was housed within the Centers for Disease Control and Prevention, and the American Medical Association had initiated practices designed to address family violence. Collaborative partnerships between criminal justice and public health increased, with the hope of pooling resources and creating synergy. In short, the field of criminal justice had experienced a paradigm shift and had incorporated the perspective of public health into everyday operations.

The inclusion of a new perspective was facilitated by the need for criminal justice to reach beyond its borders. The “nothing works” ideology had reached its peak following Martinson’s (1974) assessment of 231 rehabilitation programs, which found no significant changes in offender recidivism. Also, the Law Enforcement Assistance Administration had been dissolved and its models of operation criticized as ineffectual and obsolete. Thirty years later, former Law Enforcement Assistance Administration officials now involved in the Office of Justice Programs reflected that policies should always be “based on the knowledge that criminal justice agencies alone cannot solve crime problems” (U.S. Department of Justice, 1996, p. 1).

To address threats to public safety, practitioners and academicians who had previously embraced the traditional criminal justice models accommodated epidemiological models into the study of crime and deviancy. Today, the paradigm shift experienced by criminal justice is evident. Criminologists routinely conduct surveillance of geographical conditions to identify risk factors associated with criminality and devise population-based interventions that prove to be evidence based. Practitioners now respond to “contagious” adverse events, and criminal justice syllabi include mental illness, drug abuse, and correctional health, among other public health topics. The purpose of this chapter is to link the fields of public health and criminology by showing their similar interests, methods, and goals.

The shift of the criminal justice system toward a public health perspective requires further explication. First, the notion of criminal justice as a public health issue is presented within the ecological context of mandatory sentencing, rapid incarceration, and the provision of services to an increasingly sicker and older U.S. population. Key stakeholders and administrators are cognizant that criminal justice institutions are responsible for providing interventions that directly impact neighboring communities. This includes addressing the chronic health needs of recidivists and tracking their migration among the criminal justice, public health, and community systems. Also included is the adoption of central epidemiological tenets that include surveillance, screening and testing, therapy, medication, and education.

Second, this chapter introduces readers to several classic public health experiments that have documented the social determinants of health (Marmot & Wilkinson, 1999). Specifically, the Alameda Study, the Whitehall Studies, and the Black Report highlight the relationship between the lived environment and trajectories of health.

Third, the concept of health is discussed using the accepted World Health Organization definition of “physical, mental and social well-being and not merely the absence of disease or infirmity” (World Health Organization, 1946). This broad definition includes a range of diseases, conditions, and behaviors that threaten public safety. This section is divided into the tripartite scheme of physical health, mental health, and social health, and their relevancy to the criminal justice system is explained. The Chicago Safe Start project is presented as an example of a synergistic partnership between criminal justice and public health designed to address community violence. Last, the paradigm shift within criminal justice is discussed and future directions are summarized.

The Need for Collaboration

No single actor, public or private, has the allencompassing knowledge, overview, information or resources to solve complex and diversified problems.

— The Copenhagen Center (Schested, 2003, p. 89)

Criminal justice issues resonate beyond the domains of the police, court, and corrections and threaten the integrity of our society. In fact, disorganized communities experience the cumulative effects of socioeconomic disparities whereby layers of risk factors are nested within larger ecological systems of additional risk factors (M. Lynch & Cicchetti, 1998). Within a nested model, citizens are more or less likely to encounter individual-level risk factors (e.g., poor prenatal care), group-level risk factors (e.g., gang membership), and institutional/social level risk factors (e.g., political and racial oppression). Prolonged exposure to risk factors reduces what sociologist Max Weber (1922/1968) termed life chances, or the opportunities provided to improve one’s quality of life. In addition to the relative deprivation that fuels this phenomenon, there is a loss of cohesiveness in the social relations within these communities (Sampson, 2003). This builds a cyclical pattern in which collective efficacy cannot be realized and the community maintains the “bad part of town” label. Such a despairing portrayal can only reinforce the need for community empowerment through integrating diverse scientific disciplines, agencies, and programs.

Public health has been an appropriate perspective adopted by criminology because crime is “a mirror of the quality of the social environment” (Kawachi, Kennedy, & Wilkinson, 1999, p. 719). Crime and poor health are endemic in low socioeconomic communities and are thought to originate from the same ecological sources. This suggests that criminologists provide an important role in public health by participating in collaborative endeavors and by recognizing crime as a harbinger of community health. To supporters like Moore (1995), the public health and criminal justice systems can maximize outcomes by assuming a complementary rather than substituting role. Here, key stakeholders utilize the specialized training of their respective disciplines but also work with partners outside of the discipline to promote synergy and address gaps in service delivery. Differences between the criminal justice and public health systems are typically found in the following five dimensions: (1) how each views the problem, (2) what particular components of the problem warrant more attention, (3) the analytic framework selected that is based on assumptions rooted in professional experience, (4) the available resources, and (5) divergences of ethical values (Moore, 1995). However these challenges are typically minimized by the collaboration between public health and criminology. An important reconceptualization of crime and delinquency is the role of the criminal justice system as an intervention point that can promote health.

Criminal Justice as an Intervention

The United States incarcerates more of its citizens than any other country, and most of these incarcerated citizens will return to mainstream society. In fact, there are currently 500,000 inmates per year who are released from prison alone, a three-fold increase from the 170,000 inmates released in 1980 (Travis & Waul, 2004). Never before has the U.S. criminal justice system been responsible for the personal safety and health care needs of such a large portion of society. To present further challenges, many incarcerated persons are marginal members of society who have had minimal exposure to traditional health care resources. Further subsets of recidivist criminals have typically experienced serious trauma, drug/alcohol abuse, and mental illness over the life course and enter the criminal justice system with deteriorating health conditions. In response, the criminal justice system now functions as an intervention point whereby chronic conditions are evaluated and treated, with the distal goal of promoting compliance with medical directives following release.

This paradigm shift is predicated on the notion that criminal justice institutions are inextricably linked to the broader society. Lessons from the past teach that a dysfunctional correctional system acts as an incubator for communicable disease and violence that permeate neighborhoods. These adverse health outcomes are particularly salient for the children of individuals under correctional supervision, a population that currently numbers in excess of 3.2 million (Travis & Waul, 2004). The policies of mass incarceration have also reduced structural resources (i.e., housing and employment), emotional support, and hope for the future in low socioeconomic and minority communities.

Efficacious policies have been demonstrated through the adoption of the public health perspective. A public health approach includes the epidemiological tenets of surveillance, screening and testing, therapy, medication, and education. Therapy and education are promoted through a range of programs that are ideally linked to meet the needs of the individual. In addition to addressing individual-level behaviors, the field of public health seeks to understand the social determinants of health that occur at the ecological level (Marmot & Wilkinson, 1999). The antecedents of poor community health include economic inequality, fear of crime, education attrition, unsafe schools and housing, demographic vulnerabilities, environmental pollution, and racial/social oppression. These causal factors require the collaboration of several agencies to establish populationlevel interventions.

Another component of the public health perspective is the move from fragmented “silo” databases toward the construction of an integrated data warehouse. Here, data are collected from various agencies and standardized for researchers and policymakers. The integration of data systems enables the identification of at-risk populations. For example, Crandall and colleagues (Crandall, Nathens, & Rivera, 2004) found that 44% of women who were murdered by a spouse had gone to the emergency room within the previous 2 years. This represents a missed opportunity to screen and report intimate partner violence from within the safe confines of a medical setting. These victims fell between the gaps of the criminal justice and public health systems and highlight the need for suggested collaborations. With this in mind, this chapter now introduces readers to several classic public health studies and highlights their significance to the field of criminal justice.

Important Public Health Studies

The following seminal public health studies reveal the impact that ecological variables have on community health and have significant implications for criminal justice. Ecological variables include such environmental factors as where one works or how much money one makes. These studies focus on the hierarchical nature of social conditions that constitute fundamental causes of poor health and posit that higher socioeconomic groups are more favorably situated to know about health risks and to possess the resources that allow them to engage in protective behaviors to avoid those risks (Link & Phelan, 1995). The findings of the Alameda Study and Whitehall Studies are synthesized in the influential Black Report.

Alameda Study

In 1962, academics at the University of California at Berkeley allocated funds to initiate a large ecological study of community health. The Alameda Study, which had a longitudinal, cohort design, examined the causative agents of morbidity and mortality within selected residents during the years 1965, 1974, 1983, 1994, and 1995. Researchers found that, over time, living in an impoverished area was associated with a 50% increased risk in death for all sources of mortality, even after controlling for individuallevel variables (Haan, Kaplan, & Camacho, 1987). In fact, the location of where one lived was far more important than personal lifestyle choices such as diet, smoking, and exercise. This research has since been replicated, with successive research documenting a positive, linear relationship between socioeconomic status and premature mortality (J. W. Lynch et al., 2004).

Whitehall Studies

The Whitehall Studies, Whitehall I and Whitehall II, were pioneered by Sir Michael Marmot and examined a particular work group: civil servants working in one area of London. Whitehall I and Whitehall II observed a large number of workers over time in order to quantify the presence of a social gradient of poor health. Civil servants were selected because this work group had nonsignificant differences in race and ethnicity, work environment, and medical benefits. However, the English civil servants could be categorized as belonging to one of five distinct work grades, which enabled researchers to collect data on social class while holding the aforementioned variables constant.

The Whitehall I study was conducted in 1967 and included 19,019 male civil servants. Whitehall I found that individuals with high employment grades were much less likely to die prematurely than men in the lowest ranks—in fact, after a 10-year period the low-ranked workers had three times the mortality rate of high-ranking workers (EbiKryston, 1989). Low-grade workers also faced increased risk for coronary heart disease, cancer, accidents, homicides, and suicides when compared with high-grade workers (Marmot, 1986). In 1985, the Whitehall II study examined a new cohort of 10,314 civil servants and included female civil servants. Whitehall II reaffirmed the presence of a social gradient of health, with lower occupational rankings correlated with an increased risk of premature mortality while controlling for individual-level risk factors. Analyses of Whitehall I and Whitehall II reveal that low occupation ranking was associated with low control of work, which promotes feelings of helplessness and stress. Social gradients of health have since been confirmed in almost the entire developed world with virtually every studied disease and condition (Marmot & Wilkinson, 1999).

The Black Report

In 1977, The Black Report (Black, Davidson, Townsend, & Whitehead, 1993) was commissioned by English medical sociologists to report on the rising health disparities that continued in light of a socialized medical system. The working group identified four models that explain health inequalities: (1) artifact, (2) selection, (3) behaviorist, and (4) materialist/structural (MacIntyre, 1997). The artifact model suggests that the relationship between ecology and community health is primarily a product of measurement error, whereas the selection model assumes that biologically determined natural abilities lead to the allocation of social position and health. The behaviorist model argued that habits, customs, and practices of low-socioeconomic individuals produced poor health, with foremost importance placed on instances of maternal mismanagement (e.g., smoking while pregnant, inadequate prenatal care) that produce infant mortality or unhealthy offspring. The behaviorist model placed emphasis on the disease pathways of personal ignorance and irresponsible lifestyles. The materialist/structural viewpoint argues that ecological factors influence health, “independent of inherited constitution” (Szreter, 1984, p. 528). Of particular significance was the finding of The Black Report that the materialist/structuralism model possessed the greatest explanatory power in terms of health disparity. This means that, despite the contribution of genetic, behavioral, and cultural factors, the governing explanation for health inequality was material deprivation and economic stratification. No other model could justify why mortality rates in higher social classes had steadily declined while those at lower levels had stagnated or even increased.

The Black Report Committee concluded that “the availability of health care did not overcome social and economic differences,” which “were central to the explanation for the existence of health disparities” (Bundrys, 2003, p. 171). The Black Report recommended the inclusion of a comprehensive anti-poverty strategy, educational development, and equity in the distribution of resources. It is important to note that materialist/structuralism theorists would support structural changes that eliminate inequality rather than just providing interventions that ameliorate the effects. The Alameda and Whitehall Studies, coupled with The Black Report, provide valuable direction; the next section examines the contemporary state of affairs for public health and crime.

Defining Public Health

The World Health Organization’s (1946) broad definition of health, given earlier in this chapter, extends beyond individual risk factors and biological markers to include an assessment of ecological variables that lead to poor community health. The intersection of the criminal justice and public health domains can be explicated through the tripartite scheme of physical health, mental health, and social health.

Physical Health

Citizens who regularly interact with the criminal justice system disproportionately share the burden of infectious disease and poor health. Recent evidence identified the presence of an extensive criminal history as a strong predictor of physical illness (Mateyoke-Scrivner, Webster, Hiller, Staton, & Leukefeld, 2003). Furthermore, citizens positioned in the lower socioeconomic strata are more likely to enter the criminal justice process with limited health service utilization and with significant prior exposure to risk factors. As a result, an estimated 44% of state inmates and 39% of federal inmates at any given time have a medical problem other than a cold or virus (Maruschak, 2008). Paradoxically, many inmates discover that the medical services available in prison or jail are superior to the health resources available in the community. This is evident in research that found 80% of all state inmates received medical screening when admitted to prison, with 91% of state inmates seeking further professional care for health problems (Maruschak & Beck, 2001). Addressing physical health through the criminal justice system raises a host of complex issues; therefore, this discussion is limited to two key areas: (1) infectious disease and (2) specialized health needs.

Infectious Disease

Criminal populations account for a disproportionately large share of the total population of infectious diseases, in particular HIV/AIDS, sexually transmitted diseases (STDs), hepatitis, and tuberculosis. Infectious disease rates are even higher among incarcerated populations, with state and federal inmates approximately 2.7 times more likely than the mainstream population to have confirmed AIDS status (Maruschak, 2006). Almost all of these inmates will return to the community, and many will continue to engage in high-risk activities. This represents a public health emergency when one considers that prison and jails annually release 25% of all HIV/AIDS cases, 30% of all hepatitis C cases, and 30% of all tuberculosis cases (Hammett, Harmon, & Rhodes, 2002). Despite limitations in resources and the presence of rigid security requirements, the correctional system functions as a crucial intervention point for the identification and treatment of infectious disease.

Sentinel health events highlight that inefficient correctional systems can act as disease incubators that threaten public safety. Sentinel events are preventable and/or treatable diseases that act as a measure of unnecessary disease, disability, and death at the community level. For example, during the early 1990s a combination of prison overcrowding, poor ventilation, inmate predispositions, and minimal health care resources led to an outbreak of drug-resistant tuberculosis in New York City (Schmalleger & Smykla, 2008). Approximately 80% of the confirmed cases were traced back to inmates released from New York jails and prisons. Such lessons reinforce the notion that correctional institutions are not isolated components of society, and infectious diseases left undiagnosed and untreated can generate dangerous contagion effects that resonate to the broader community.

The antecedents of infectious disease within corrections are well known and typically include unsafe sexual behavior, intravenous drug use, and tattooing, yet currently less than 1% of all U.S. correctional facilities provide condoms to inmates, and none distribute clean needles (May & Williams, 2002). These limitations are counterbalanced by the passing of the Prison Rape Elimination Act of 2003 by the U.S. Congress, which aims to reduce rates of sexual violence within prisons and jails. The Prison Rape Elimination Act follows an epidemiological method of surveillance, collection of confidential data, sexual health education, and the development of a risk-assessment model for the early identification of prison rapists. These efforts are supported by innovative collaborations at the state level that rely on both the criminal justice and public health systems to address infectious disease.

Specialized Health Needs

The shift experienced by the criminal justice system has been facilitated by the specific health needs of vulnerable populations. In this section, the discussion of health needs is limited to three groups: (1) children/youth, (2) women, and (3) the elderly.

Children/Youth. Recent evidence from clinical neuroscience demonstrates that the human brain experiences significant development throughout childhood and adolescence. Using a brain imaging technique known as magnetic resonance imaging, neurologists have found that components of the human brain, the frontal and temporal lobes, are less developed in an adolescent brain when compared with an adult brain. As a result, youth in general are less likely than other age groups to govern impulse control. Criminologists have long known early delinquency to be highly correlated with other risk-taking behaviors, such as underage drinking and binge drinking, drug abuse, unsafe sex, and a propensity for violence. (Violence includes physical fighting, gang membership, bullying, and the use of weapons.)

These behaviors present as a constellation of risk and ultimately lead to comorbidity, or a state in which the individual suffers from multiple chronic diseases or conditions. The Youth Risk Behavior Surveillance System (YRBSS) created by the Centers for Disease Control is a longitudinal data source used to monitor priority healthrisk behaviors in youth. Results from the 2007 YRBSS found that 72% of all deaths among persons aged 10 to 24 years result from four causes: (1) motor vehicle crashes (30%), (2) other unintentional injuries (15%), (3) homicide (15%), and (4) suicide (12%; Centers for Disease Control and Prevention, 2008). Alcohol and drug abuse are strongly associated with this early mortality and represent an early intervention point that the fields of criminal justice and public health have yet to adequately address. The YRBSS also revealed substantial youth morbidity due to teenage pregnancy, STDs, and HIV/AIDS. In addition to these risky behaviors, the majority of youthful offenders who enter the criminal justice system are less likely to have access to preventive medical care, educational programs, and supportive family units. Moreover, adolescence is a period of significant changes, with youth moving from strict attachment to parental figures toward the attainment of social status in accordance with peer standards. These at-risk youth are susceptible to victimization, homelessness, and drug abuse that further deteriorate health status.

Women. The sevenfold increase in female incarceration rates between 1980 and 2000 means that there are now over 950,000 women in the United States under some form of criminal justice supervision (Chesney-Lind & Pasko, 2004). The majority of these incarcerated women (55% in state facilities and 63% in federal facilities) report having a child under the age of 18, which equates to 1,498,800 children who are directly impacted by incarceration (Mumola, 2000). The effect of the mass incarceration of women has been disproportionately experienced by communities of color and in low socioeconomic areas.

Women who interact with the criminal justice system have discrete needs that differ from male populations. First, typical female offenders are more likely than their male counterparts to be convicted of a crime involving alcohol, drugs, or property, and they are more likely to have histories of sexual victimization. Typical juvenile female offenders are between 14 and 16 years of age, of a racial or ethnic minority, and likely to have significant academic problems (Boyd, 2008). These deficiencies are further compounded by a history of negative interactions with social institutions, such as the family, school, and work, that promote noncompliance with health directives.

Second, higher rates of HIV/AIDs and STDs are reported in women who interact with the criminal justice system on a regular basis. The sequelae of HIV/AIDS include victimization due to intimate partner violence and/or a history of sex work. As such, at-risk women may draw the attention of law enforcement systems that can intervene to address public health issues. Within incarcerated populations female inmates are more likely than their male counterparts to request medical services; however, gynecological examinations are frequently conducted by nonspecialized providers, and preventive services, such as Pap smears and breast examinations, are not routinely provided in many institutions. This represents an underutilized intervention that could be altered to improve the sexual health of female offenders, most of whom are returning to families and children.

The third relevant need of female inmates relates to maternity and jail/prison visitation. Approximately 3% to 4% of female inmates enter the criminal justice system pregnant, and many will give birth while under correctional supervision (Maruschak, 2006). A lack of prenatal care places many of these women at increased risk for a complicated and/or high-risk pregnancy, which in turn increases the cost of health care for the institution and, eventually, the broader society. In general, women experience more guilt, anxiety, and worry about their children when compared with men. Jail visitation policies that balance the needs of incarcerated mothers with the need for institutional security will greatly benefit the emotional health of these women.

Fourth, women who interact with the criminal justice system are at increased risk of intimate partner violence. Feminist scholars posit that patriarchal societies relegate women and girls to subordinate social positions in order to maximize the power and status of men. As such, the often cyclical pattern of partner violence continues over the life course and requires gender-based programming to restore self-efficacy and address issues of drug dependency and learned helplessness. Interestingly, the classic Minneapolis Domestic Violence Experiment conducted by criminologists Lawrence Sherman and Richard Berk (1984) addressed the health needs of women by using a medical model. This research viewed law enforcement as an intervention and randomized the treatment effect in order to identify an evidence-based policy outcome that supported mandatory arrest protocols in cases of domestic violence.

The Elderly. The term baby boomer signifies the rapid increase of birth rates following the second world war. In the year 2000, this boomer generation constituted between 22% to 32% of state populations, with the 50-to-54 age group exhibiting a 55% growth rate between 1990 and 2000 (Meyer, 2001). In addition, the national life expectancy of the elderly increased in part because of medical developments but also because the notion of “age” was reconceptualized and a greater proportion of elderly people have benefited from active and healthy lifestyles. These demographic changes have impacted the country’s social structure and the criminal justice system.

Studies routinely demonstrate that elderly populations fear crime more than other groups despite the fact that they have a lower risk of being victimized. In San Francisco, a survey of elderly people residing in a crime-ridden area found that fear of crime was the most important health problem in their lives, supporting an association between low self-perceptions of public safety and reduced physical activity (Robert, 1999). Stated differently, fear of crime directly impacts the health of the elderly as they are forced to restrict daily activities, and fear of crime indirectly harms the community by reducing the level of collective efficacy its citizens can muster.

The health needs of an increasingly graying population have also impacted correctional facilities, where it is estimated that 83% of elderly prisoners have a long-standing disability and an average of three chronic illnesses (Fazel, Hope, O’Donnell, Piper, & Jacoby, 2001; McCarthy, 1983). Elderly health concerns can be separated into topics of morbidity and mortality. Elderly inmates experience morbidity due to incontinence; arthritis; and the potential need for corrective aids and prosthetic devices, including eyeglasses, dentures, hearing aids, ambulatory equipment, and special shoes. Early mortality, or early death, is usually the result of advanced medical conditions such as dementia and kidney, liver, or prostate disease. The resources needed to provide specialized health services to the elderly can overwhelm correctional facilities. Small jails have experienced difficulties in meeting the expense of constructing disability-friendly facilities, which is a component of the Americans with Disabilities Act. One cost-saving measure involves compassionate release of the sick. Elderly inmates who are terminally ill are provided palliative care services and can apply for a compassionate release; however, this is granted on the basis of poor physical health rather than consideration of age.

Mental Health

Mental health is defined as “a state of successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity” (Satcher, 1999, p. 4). Conversely, mental illness is associated with interpersonal dysfunction and increased risk of homelessness and drug/alcohol abuse. Mental illness can also lead to abnormal social behaviors that draw the attention of law enforcement. Even though the appropriateness of criminalizing and incarcerating mentally ill persons remains a controversial ethical debate, the criminal justice system remains the primary form of mental health care for a sizeable portion of society. The criminal justice system is now responsible for the provision of mental health services through the identification of evidence-based interventions. To be considered successful, these interventions must improve the mental health of individuals while also justifying distal goals such as lowering recidivism, maintaining fiscal responsibility, and reinforcing public safety.

In 1939, Penrose wrote that “criminality, insanity and mental deficiency are, all three, relative terms, for the difference between normal and abnormal implied in each of them is a matter of degree” (p. 2). Penrose identified a population whose aberrant behavior was labeled either criminal or mentally ill in relation to the parameters of social standards. The presence of a marginalized group that migrates between the mental health and criminal justice systems is still evident. The most noteworthy example of this migration centers on the deinstitutionalization of state mental institution patients that began in 1955. Deinstitutionalization involved the reassignment of patients out of state mental institutions and into community mental health centers. Deinstitutionalization was stimulated by advancements in psychotropic medication (e.g., Thorazine) that enabled better control of patients’ symptoms. Despite having earnest goals, the proponents of deinstitutionalization inadvertently shifted the burden of care of the mentally ill to the criminal justice system.

Studies estimate that the prevalence rate of psychiatric morbidity is now 10 times greater in prison samples when compared with the community (Brugha et al., 2005). Incarcerated populations are also estimated to contain between two and five times the rate of individuals with severe and persistent mental illnesses, such as schizophrenia/psychosis, major depression, bipolar disorder, and posttraumatic stress disorder, when compared with mainstream society (Lamberti & Weisman, 2004). The association between mental illness and substance abuse compounds problems. One study found that the preponderance of offenders were under the influence of substances at the time of arrest and estimated that 90% of inmates with severe mental illness experienced a substance use disorder during the life course (Abram & Teplin, 1991). Current practices of mental health by the criminal justice system include treatment in the form of psychotropic medications and/or therapeutic interventions.

Changes in practices are also evident in the accommodation of the mentally ill by the criminal justice system. The war on drugs carried harsh and punitive sentencing that resulted in the mass incarceration of mentally ill and/or substance-addicted people. As a result, the criminal justice system devotes significant institutional resources to an increasingly sick population. A case in point is the Los Angeles County Jail, where a daily population of 3,300 severely mentally ill inmates constitutes the largest de facto mental institution in the United States (The Sentencing Project, 2002). Furthermore, the state of California now treats more mentally ill people in prison and jails than all hospitals and residential treatment centers combined (12.5% vs. 10%, respectively; Beck & Maruschak, 2001). The adoption of a public health perspective has allowed for the inclusion of programs that can direct suitable mentally ill individuals into more appropriate avenues of care. These initiatives include jail diversion programs and drug courts that redirect suitable mentally ill offenders away from the criminal justice system.

Jail Diversion Programs

The traditional models of law enforcement provided minimal guidance regarding how to respond to mentally ill people. As a result, police officers used rigid techniques that promoted the warehousing of the mentally ill within correctional facilities. Inadequate training on the etiology and manifestation of specific mental disorders were also associated with police officer injuries. In response, jail diversion programs were created as an interface between the criminal justice and mental health systems. According to Steadman (2002), mentally ill misdemeanants should be diverted into community mental health facilities that provide services in an appropriate and fiscally responsible manner. Not eligible for diversion are mentally ill offenders who commit violent and serious crimes, because these felonies constitute a threat to public safety.

Diversion programs can be separated into prebooking or postbooking depending on the time point of the criminal justice system intervention. The Crisis Intervention Team (CIT) within the Memphis (Tennessee) Police Department is the most publicized form of prebooking jail diversion in the United States. The CIT program was devised to offer law enforcement personnel specialized training and resources in order to divert suitable mentally ill offenders into community health facilities. This diversion occurs in lieu of the alternatives: release or arrest of the offender. This program provides 40 hours of training in psychiatric and substance use disorders, including use of crisis de-escalation techniques. Prebooking programs require the commitment of police officers, and discretionary decisions are conducted at the street level. Postbooking programs, on the other hand, target the intervention within the court or correctional milieu. During these processes a mental health professional identifies misdemeanant offenders who are eligible for transfer to a facility for the provision of psychiatric services. Jail diversion programs are ideally coupled with the defragmentation of social services, which can allow for streamlined reintegration back into the community. The Memphis CIT program is still in need of a public health/criminal justice program evaluation in order to test its efficacy, yet it is included here as an example of innovation and synergy.

Drug Courts

In recent years, the field of criminal justice has become reluctant to employ strictly punitive responses to drug and alcohol addiction and has moved toward an acceptance of treatment-oriented responses. Drug courts are based on the recognition of comorbidity between mental illness and drug/alcohol addiction. They afford the offender the opportunity to meet treatment, screening, and technical mandates in order to have charges dropped. Failure to meet these requirements can lead to criminal sanctions, including incarceration and restitution. There are currently 2,000 drug courts in the United States, and research supports a 10% to 20% reduction in recidivism among participants (Draine, Wilson, & Pogorzelski, 2007).

The adoption of the public health perspective by courts can enable mentally ill/drug-addicted offenders the opportunity to reframe their interaction with the criminal justice system. Few would argue that punitive criminal justice policies in the area of drug abuse have maintained community health or reduced recidivism. Instead, these punitive responses have overwhelmed the criminal justice system and alienated communities (Bobo & Thompson, 2006). Conversely, efficacious drug courts link vulnerable populations with much-needed community services. The offender faces the decision of whether to address health deficits through these services or risk incarceration. Beyond these issues that bring the fields of public health and criminal justice together is the social health of citizens.

Social Health

Crime represents a serious threat to neighborhood stability that can affect the residents’ health directly through violent acts, substance abuse, and financial loss. Crime directly impacts neighborhoods when residents decrease outdoor activity to avoid exposure to unsafe conditions (Ross, 1993). Fear of crime is also associated with prolonged stimulation of the fight-or-flight response, which in turn is linked to reduced resistance to infection and cancer as well as the exacerbation of chronic health conditions (Fremont & Bird, 2000). Crime influences health indirectly because the presence of recognizable cues sends a message that social cohesion is weak. Even low-level property crimes such as littering, vandalism, and graffiti are signs of a disorganized community, the implication being that social cohesion has been replaced by individualism and alienation. An organizing framework that distinguishes social health in a neighborhood includes the following: (a) physical features of the environment shared by all residents in a locality; (b) availability of health environments at home, work, and play; (c) services provided, publicly or privately, to support people in their daily lives; (d) sociocultural features of a neighborhood; and (e) the reputation of an area (MacIntyre, Ellaway, & Cummins, 2002). This chapter now presents these components with reference to an existing public health and criminal justice collaboration: the Chicago Smart Start project.

The Chicago Smart Start project is budgeted for $3,350,000 over a 5 1/2-year period and is cofunded by the city of Chicago and the U.S. Department of Justice, Office of Juvenile Justice and Delinquency Prevention (Chicago Safe Start, 2008). The mission of Chicago Safe Start is to prevent and reduce the impact of exposure to violence on children ages 5 and younger. The project is a true reflection of the adoption of a public health perspective by the criminal justice system. With an emphasis on quantifiable outcomes, Chicago Safe Start categorizes social health into risk factors, protective factors, and treatment (Chicago Safe Start, 2008).

Risk factors are characteristics, variables, and/or conditions present in individuals or groups that increase the likelihood of that individual or group developing a disorder or adverse outcome (National Center for Children Exposed to Violence, 2008). Chicago Safe Start subdivides risk factors into four categories: (1) biological (e.g., prenatal exposure to drugs and/or alcohol), (2) individual (e.g., low academic achievement, including poor reading skills or a weak commitment to education), (3) family (e.g., exposure to and reinforcement of violence in the home), and (4) community (e.g., presence of gangs and drug dealing, which provide violent role models and rewards for violent behavior).

Protective factors are characteristics, variables, and/or conditions present in individuals or groups that enhance resiliency, increase resistance to risk, and fortify against the development of a disorder or adverse outcome (National Center for Children Exposed to Violence, 2008). Chicago Safe Start subdivides protective factors into three categories: (1) individual (e.g., capacity for empathy and respect for all people and their values), (2) family (e.g., positive, sustained attachments with at least one adult family member, teacher, or other adult), and (3) community (e.g., schools, families, and peer groups that teach children healthy beliefs and set clear standards).

The accumulation of protective factors can theoretically offset the accumulation of risk factors, leading to a promotion of social health; however, when communities disproportionately experience the burden of risk factors, then efficacious treatments must be developed. Public health officials define treatment as a form of intervention that is typically long term and characterized by an ongoing relationship with a particular type of service provider. The goal of treatment is to provide long-term support and remediation of symptoms (National Center for Children Exposed to Violence, 2007). The Chicago Safe Start project addresses physical health by linking Medicaid to clinical services. Services include, but are not limited to, screening, diagnosis and assessment, testing, psychotherapy, prescriptions and medication monitoring, emergency care, and health education. Mental health treatments are provided by linking separate funding sources, such as the Committee on Women’s Treatment and the Domestic Violence and Substance Abuse Initiative. Community health targets highrisk teen parents, by providing home visits, screening and assessment, and parent group services.


The paradigm shift toward public health is expected to evolve as criminologists seek interdisciplinary perspectives to reduce social problems. Both the criminal justice system and public health systems share commonality in the population they regularly serve. Criminogenic populations are more likely to have weathered lives of early trauma, adolescent delinquency, and adulthood addiction. Over the life course, these risk factors increase rates of physical, mental, and social abnormalities. By the time these individuals commit infractions serious enough to warrant the attention of the criminal justice system, they present with a constellation of chronic disease and egocentric behaviors. Certainly, ill health and high crime are disproportionately experienced by urban, poor populations in which people of color reside.

The social gradient of health demonstrates the extent to which environmental variables impact rates of mortality and morbidity. With time, the burden of disease manifests in crime, delinquency, drug and alcohol addiction, and criminogenic behavior. Furthermore, social inequalities promote abuse, victimization, and fear of crime that can restrict daily activities. The inclusion of a public health perspective enables criminology the opportunity to extend its mission beyond issues of crime and deviance in order to address public safety, public health, and social justice. This involves the adoption of epidemiology tenets of screening and testing, surveillance, data consolidation, and educational campaigns and programs. The public health perspective favors prevention strategies rather than treatment or response strategies and population-level interventions rather than individual-level interventions. Meeting these objectives will require the synergy of collaborative partnerships that involve criminal justice agencies and public health agencies.

The policies of the U.S. criminal justice system have led to the mass incarceration of groups that disproportionately experience the burden of physical, mental, and social pathologies. Paradoxically, criminologists have adopted the public health perspective in order to direct citizens into more appropriate avenues of care and away from the criminal justice system. A shift in perspective inherently carries conflicts in methodology and ethics; however, the potential efficacy offered through interdisciplinary partnerships outweighs these concerns. This chapter leaves readers a final quote that highlights the disastrous state of affairs in the California criminal justice system and the need for new perspectives to address crime and delinquency:

It has been projected that over the next five years, the state’s budget for locking up people will rise by 9 percent annually, compared with its spending on higher education, which will rise only by 5 percent. By the 2012-2013 fiscal year, $15.4 billion will be spent on incarcerating Californians, as compared with $15.3 billion spent on educating them. (Harris, 2007)