How Community Health Workers Can End Mass Incarceration

The abysmal state of United States public health and safety—both of which rank last among wealthy nations—are fundamentally intertwined, and neither can be separated from the destructive consequences of mass incarceration.

In the five decades since President Lyndon Johnson gave up on the short-lived “war on poverty” and turned instead to a more electorally convenient “war on crime,” policymakers have responded to poverty, addiction, disability, mental illness, and homelessness primarily with police and prisons rather than with supportive care. As a result, the U.S. incarceration rate is now about seven times the average rate in peer countries. More than 77 million U.S. residents have criminal records. Nearly half of all Americans have an immediate family member who has been incarcerated—an experience that studies show shaves years off life expectancy and increases rates of both chronic and infectious disease for the people locked up, their family members, and their broader communities. The scale of harm that mass incarceration inflicts on public health and the cost it imposes on the floundering U.S. healthcare infrastructure is massive.

And for all this, safety in our communities is no better than in peer nations. In fact, it’s considerably worse. The U.S. suffers far higher rates of violent crime, fatal overdose, and mortality. Meanwhile, studies show that healthcare, housing, addiction treatment, mental health support, and guaranteed basic income are all more effective for building community safety than more policing and prisons. Such data underline that public health and public safety are not, as has been conventionally imagined, separate policy domains. We cannot build one while undermining the other. And to achieve either, we need to embrace a public health approach to safety.

Against this backdrop of mass incarceration’s nationally self-destructive consequences, calls to end it have become a staple of bipartisan U.S. political rhetoric. But while most Americans agree that mass incarceration should be ended, no concrete policy strategy by which to replace punishment with preventative and reparative care has yet risen to public prominence. In the leading medical journal, The New England Journal of Medicine, I recently outlined a framework for advancing this goal together with a plan to rebuild the nation’s failing safety and health infrastructure.

I proposed the creation of a new federal Department of Community Safety and Repair to build a national community health and justice worker corps to end mass incarceration, build integrated public health and safety systems, and shrink reliance on notoriously reactive and ineffective U.S. policing and for-profit healthcare industries. As the basis of a new infrastructure for public safety and renewed public health workforce, I argued for an initial target of two million community health and justice workers—about half the number of public jobs provided by policing, prosecution, and prisons. I also argue that we should preferentially employ formerly incarcerated people in these positions in order to make use of dignified, gainful public jobs as a key means of enabling safe reintegration after incarceration and repairing social fabric in criminalized communities.

It’s an ambitious, expensive proposal—and necessarily so. After spending trillions of dollars over decades to build a network of cages, to undo it will now require that the U.S. government make similarly large investments in a national decarceration program enabled by systems for community care. This means upfront investments and also finding ways to—over the coming years—reappropriate much of the $278 billion now spent annually on punishment and $4.3 trillion spent on largely reactive healthcare to instead fund supportive services with which to prevent both violence and disease.

Community health worker programs have been shown to be highly effective at improving mental and physical health while also substantially reducing healthcare costs. For example, a program in Philadelphia returned $2.47 in Medicaid savings for every dollar invested and reduced hospitalization days by 65%. In addition to their value for public health, what makes community health worker programs especially well-suited for building community safety and enabling safe decarceration is their bottom-up design that allows not just for effective provision of care but also for the inclusion of historically excluded communities in the work of caregiving. This participatory care model, based on the framework of accompaniment, rejects condescending salvific fantasies of caring for those who our society has most harmed; it is instead about caring with one another and restoring to communities the resources needed to care for themselves.

This caregiving infrastructure, integrated with proven violence-interruption strategies pioneered by groups like Cure Violence and Advance Peace together with other public-health-focused safety interventions, could play a key role in disrupting current cycles of crime and rearrest due simply to poverty, homelessness, and healthcare exclusion. It also offers a structure for rebuilding trust in one’s neighbors and government. And, importantly, it does this by providing living wages as part of meaningful, dignified public jobs that are essential to mitigate the persistent economic harms incarceration inflicts.

Health and safety policies succeed when the whole population is enabled to join in the work of care and when each community is empowered to set and realize its own priorities for itself. The most effective care and safety systems are participatory, inclusive, and community-controlled. With this in mind, to deliver maximum benefit to the entire population, public health approaches to safety must prioritize intensive social care, prevention, and employment opportunities for the most excluded individuals and groups. And as we apply this “prioritarian” logic, we must also simultaneously engage every segment of a population, including the most well-protected groups, to generate universal support for bottom-up investments in our cities and towns.

Alongside elderly and disabled individuals, among those who would benefit most from such systems for community-based care is the relatively small proportion of currently incarcerated people who, whether due to serious mental illness or other reasons, require supportive supervised living environments in order to live safely in communities rather than behind bars. With workers who live on the same block who could spend hours with them each day, staff supportive living environments, help incorporate them into community fabric, and ensure that they get to appointments and are provided any supportive services they need, for example, the need for more restrictive forms of supervised living would be substantially reduced and the use of systems of preventive care to replace police and prisons could, over time, become a realistic possibility.

Objections to Change Underline Its Necessity

Attempts to reorient U.S. safety systems around care rather than punishment will meet considerable opposition from police and correctional officers’ unions, and also from many lawmakers who have built their careers through destructive “tough on crime” politics. A key reason for this revolves around the primal fear that has long been stoked by manipulative rhetorical uses of the small minority of individuals currently confined in jails and prisons who pose a high risk of harm to themselves or others if released to unsupervised settings. Using exceptional cases to defend the status quo, opponents of change have repeatedly insisted for decades that without mass incarceration, we would see out-of-control violence. These arguments are often presented in bad faith. But the fact remains that––as in all human societies—there are some individuals who do in fact pose threats to the safety of others. This concern must be honestly addressed.

Of individuals held on either charges or convictions for violent crimes, the overwhelming majority do not commit further violent offenses following release and are not at substantially higher risk of committing violent crime than the average person in the general population. For example, among the nearly 5,000 individuals released from Michigan prisons between 2007-2010 who had been convicted of homicide or sex offenses, more than 99% were not reincarcerated for any similar violent offense over the three years after release (despite grossly inadequate reentry systems to support successful transition back into communities). In the case of those held in jails pretrial, the numbers are similar. In recent data from New York City, for example, over 99% of people released with a pending felony violent case were not rearrested for any alleged felony within one year.

Many more such analyses demonstrate that those convicted of violent crimes can and should be included in evidence-backed, safe decarceration plans. Still, notwithstanding the very low rate of repeat violent crimes, I can testify from my own work as a psychiatrist, psychoanalyst, and anthropologist of prisons and policing that it is undeniably true that a small number of individuals require ongoing custodial care in controlled settings in order to protect both their own safety and that of others. Supportive housing arrangements with proper medical, social, and psychiatric services—not warehouses of abandonment like existing prisons nor America’s historically abusive asylums—must be provided to care for these individuals and to support their families and communities.

Encouragingly, both basic reasoning and my own ethnographic and clinical experience suggest that the degree to which such custodial care is needed to prevent violence is proportional to the degree of violence that society inflicts on its members. If we can implement reparative policies to mitigate the systemic violence inflicted by current U.S. systems of inequality and punishment, the need for custodial care to manage the long-term consequences of severe social and psychic injury will progressively decrease over time.

But just as not every currently incarcerated person should be released to unsupervised living arrangements, it is also a fact that the U.S. confines approximately one million people whose continued incarceration serves no plausible public interest. This includes approximately 500,000 people held in jails pre-trial (i.e., they have not been convicted of a crime), 150,000 serving short sentences in jails for misdemeanors, and 450,000 people imprisoned for drug offenses entailing no violence against others. Additionally, mandatory sentencing laws have kept hundreds of thousands more locked up for years—often decades—longer than defensible under any possible logic of safety. The result is a large number of elderly, sick, and disabled people in prisons.

If the objection to decarceration is the claim that it will erode safety, then those opposing decarceration should be held to basic standards of logical consistency: if there is no safety justification for someone’s continued incarceration and data even show that it worsens safety in the long-term, then that person should be freed. While debates will continue with respect to even broader decarceration and the ethical vision of a world without prisons, there should be universal support in any rational society for the release of all individuals for whom incarceration clearly does not serve the public good.

To build a national health and justice workers corps to enable the end of mass incarceration and a new integrated health and safety infrastructure will require significant investments. But the return on this investment would be incalculable. By restoring to historically dispossessed communities the public resources required to collectively care for themselves, a national corps of community health and justice workers would improve public health and safety for everyone, regardless of race or class. It would also further the ability of criminalized Black, Latinx, and Indigenous communities to craft full, satisfying lives on their own terms—that is, to enjoy what has long been denied to them: a right to self-determination.

Turning Ideals into Policy

A national decarceration program need not start from scratch, and, realistically, it will likely have to begin at a city, county, or state level, and then be scaled up. Already-funded but unfilled jobs in police departments, such as in Chicago where there are over 1,000 police vacancies that the Chicago Police Department has for years been unable to fill, could be reallocated to local health departments to hire community health and justice workers with equivalent compensation packages to take over the mental-health crisis response and basic community support roles that police officers are currently inappropriately asked to play. And we should look to already-existing federal and state funding programs already for community health worker initiatives and make use of the growing interest in such programs that has arisen due to the undeniable inadequacy of U.S. public health systems.

Motivated by the bottom-up ethos of community programs rather than rigid top-down administration, an effective national program should consist of interlocking local, state, and national initiatives. Given the predictable opposition to change that would be mounted by some state governors and others whose careers have relied on the politics of fear stoked by crime paranoia, a program to end mass incarceration will also need to be underpinned by federally administered mandates and incentives. These could be assembled by utilizing a combination of civil rights laws, executive orders, mass clemency, Department of Justice oversight and funding power, Department of Health and Human Services’ ability to leverage Medicare and Medicaid funding eligibility requirements, and new congressional legislation, such as the recommendations outlined in The BREATHE Act.

Large-scale decarceration is the only sustainable and ethical solution to the protracted catastrophe to which we all remain captive. Rather than blame everyone and everything but the system itself, our public servants—from President Biden and Attorney General Merrick Garland to governors, mayors, district attorneys, prosecutors, sheriffs, judges, and parole boards who possess already-existing tools with which to release hundreds of thousands of unnecessarily incarcerated people—need to stop feigning helplessness and find the courage to do the right thing.

Together, we can—and must—forge a politics of care to build public systems adequate to end mass incarceration and redefine justice as a matter of reconstruction rather than retribution.

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