The n e w e ng l a n d j o u r na l of m e dic i n e

Medicine a nd So cie t y

Debra Malina, Ph.D., Editor

Reconstructive Justice — Public Health Policy

to End Mass Incarceration
Eric Reinhart, M.D.

In 1994, at 26 years of age, Dennis Wayne Hope
was placed in solitary confinement in a Texas
prison after he had escaped and remained free
for 2 months. Until he was recently hospitalized,
he had been confined to a dark cell not much
bigger than a king-size mattress for the past 27
years. In that time, he had been permitted one
personal phone call — in 2013, after his mother
died — and had seen virtually no one other than
the guards who strip-searched him whenever he
was taken, handcuffed, to another room to exer-
cise by himself. According to court documents,
he now faces severe depression, paranoid audi-
tory and visual hallucinations, and suicidality.
He has written to his lawyers that he fears he
may be losing his mind.1
After an appeals court ruled against Hope’s
petition to impose limits on solitary confinement
as a violation of the Eighth Amendment prohibi-
tion on cruel and unusual punishment, the U.S.
Supreme Court may soon decide whether the
quarter-century he has spent subjected to what
the United Nations defines as torture merits
their attention.2,3 If the justices hear his case, it
will require remarkable callousness to refuse to
acknowledge the cruelty involved in Hope’s treat-
ment, but the Court will be hard pressed to
characterize prolonged subjection to solitary
confinement as “unusual” in America.
During ordinary times in the United States,
approximately 80,000 people are held in solitary
confinement, and more than 10% of them have
spent 3 years or more under these conditions.4
Solitary confinement has for decades been so
routinized that a recent study, for example,
showed that 11% of all Black men in Pennsylva-
nia born between 1986 and 1989 had been held
in solitary confinement by 32 years of age.5
Nearly all of them endured these conditions for
a period of more than 15 days — the threshold
beyond which well-established international
standards characterize solitary confinement as a
violation of human rights.3
During the Covid-19 pandemic, jail and prison
administrators have dramatically increased the
number of people held in solitary, which had
risen to approximately 300,000 by the summer
of 2020.6 As Covid-19 outbreaks continue, soli-
tary is still being widely used as a “protective”
measure. Over the first 2 years of the pandemic,
expanded use of solitary was the default infection-
control strategy to which officials turned in order
to avoid complying with calls for mass decar-
ceration, which was recommended by health and
safety experts as the best way to keep incarcer-
ated people safe and to stop jails and prisons
from amplifying the pandemic and spreading
deadly disease throughout surrounding commu-
nities.7-9 This policy has not only failed to pre-
vent carceral Covid-19 outbreaks — it has also
generated a shadow epidemic of psychological
and physiological injury that will reverberate for
decades to come.
The Af terlive s of A b use
behind B ar s
For people subjected to torture, the harm doesn’t
end when the torture technically ends. It haunts
them — in both body and mind — for entire
lifetimes. It also haunts their children, parents,
partners, families, communities, and countries.
It affects their ability to maintain relationships,
sleep, make sense of their environments, trust
others, hold jobs, make meaning and pleasure in
life, and often simply to perform the basic tasks
of bodily self-care.
When society inflicts severe injury on its

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 The n e w e ng l a n d j o u r na l
members, the burden of caring for people whom
society has disabled falls on others. And even if
we reject our ethical responsibility to provide
care, we are not free from the harm our govern-
ment has caused in our names. It boomerangs
back as chronic disease that overwhelms our
already-inadequate health care system and as
high crime rates, widespread distrust, and over-
burdened welfare systems that continually fail
the people they are meant to help.10-12
History has shown repeatedly that violence
produces more violence, punishment more pun-
ishment, and harm more harm. What, then, will
be the long-term consequences of the conclusion
by leaders in one of the world’s wealthiest coun-
tries that the best they could do to protect its
residents during a pandemic was to subject ap-
proximately 300,000 of them to torture? What of
the future of the 10 million-plus people who
have been held in U.S. jails, prisons, and immi-
grant detention facilities during the pandemic
— a large proportion of whom, even if spared
solitary confinement, have been subjected to abu-
sive conditions for an extended period of time?13
Even without exposure to solitary confinement
that compounds harm,14,15 incarceration under
standard conditions in U.S. jails and prisons
shaves years off life expectancy. Already before
the Covid-19 pandemic led to an acute worsen-
ing of carceral conditions,12 one study estimated
that each year of incarceration shortened a per-
son’s future life by 2 years16; another estimated
a loss of nearly 5 years of life expectancy by age
45.17 The harm also extends to family members
of incarcerated people, whose life expectancy is
2.6 years shorter than that of peers who have not
been separated from siblings, children, fathers,
or mothers who have been incarcerated.18 More-
over, recent studies have underlined that, owing
to spillover effects within biosocial networks,
high incarceration rates drive substantial in-
creases in mortality for entire counties.10,11
The scale of this harm is difficult to overesti-
mate. With more than 2 million people behind
bars and roughly 5 million more currently on
probation or parole, the U.S. incarceration rate
is nearly seven times the average rate in peer
countries.19 More than 70 million U.S. residents
have criminal records, and nearly half of all
Americans have an immediate family member
who has been incarcerated.20,21 Given these num-
bers, how much of the $4.3 trillion in annual
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of m e dic i n e
U.S. health care spending is dedicated to trying
to undo the effects of state-sponsored violence
to which so many patients have been exposed?
How much safer might we all be if, rather than
perpetuating failed models of criminal deter-
rence in policing and incarceration,22 policymak-
ers invested in violence prevention by means of
reparative care for historically dispossessed
communities? What are the financial and human
costs of continued reliance on “tough-on-crime”
politics despite abundant evidence that mass
incarceration directly undermines, rather than
improves, collective safety?23,24
Toward a Government of Repair
As a physician, psychoanalyst, and ethnographer,
I work with both war veterans and people who
have been incarcerated. From my vantage, the
long shadow cast by America’s wars is the clos-
est parallel to the scale of harm perpetrated by
mass incarceration.
To mitigate the long-term health effects of
the wars from Vietnam to Iraq and Afghanistan,
the Department of Veterans Affairs (VA) spends
more than $300 billion per year to care for vet-
erans, who have considerably higher rates of sub-
stance use disorders, severe psychiatric illness,
suicide, homelessness, unemployment, and social
and economic instability than the general popu-
lation. The VA system, though imperfect, pro-
vides a model for a possible response to the
fallout of America’s longest-running war — the
nationally self-destructive “war on crime.”24,25
The ramifications of abuse behind bars are,
like the traumas of war, deeply etched into bod-
ies, minds, and relationships. Undoing the harms
caused by incarceration — especially in Black,
Latinx, and Indigenous communities in which
poverty has long been met with systematic
criminalization rather than support25-28 — will
require large-scale public investments like those
that fund the VA system. To this end, rather than
continue to allocate approximately $278 billion
annually for yet more policing and punish-
ment,29 the federal government could progres-
sively reallocate and supplement these resources
to fund a new U.S. Department of Community
Safety and Repair. Its mandate should be to stop
and undo the harm done in the name of “crimi-
nal justice” and a police-centric concept of pub-
lic safety that focuses on crime rates alone while
nejm.org February 9, 2023
 Medicine and Society
disregarding other statistically far more impor-
tant determinants of safety — such as stable
housing, financial security, addiction treatment
and overdose prevention systems, labor rights,
environmental regulation, and continuous health
care access.23,24
To be successful, this new department would
need sustained resources to build infrastructure
for community-based care that could replace
reliance on police and prisons. In coordination
with an expansion of existing public programs
that provide housing, basic income, and health
care, this caregiving infrastructure should in-
clude hands-on assistance that many people,
especially formerly incarcerated persons, need in
order to establish themselves as valued members
of communities. Accordingly, guided by an ethic
of community — not as an abstraction but as a
practical reality rooted in meeting one another’s
material needs30 — that has been increasingly
eroded from American life, a corps of commu-
nity health and justice workers with an initial
target of 2 million workers, or 6 workers per
1000 residents, could be the backbone of a na-
tional project of repair.
A public jobs program of this size — roughly
equivalent to the number of people now incar-
cerated or half the number employed by the po-
licing, jail, prosecution, and prison industries31 —
may at first appear unrealistic. When compared
with the 2.6 physicians and 16 nurses per 1000
people in the United States, however, 2 million
community health and justice workers charged
with a much broader range of tasks than strictly
medical care seems like a modest starting point.
In a country with high rates of homelessness,
poverty, chronic disease and disability, addiction,
elder neglect, and limited access to health care
and mental health services, the level of unmet
need for community-based support is extremely
high. We need a caregiving workforce adequate
to this need.
Community health worker systems that are
built on the model of what Paul Farmer called
“accompaniment” have been shown to be highly
effective at improving health while also substan-
tially reducing health care costs.32-36 What makes
accompaniment-based programs well suited not
just for improving public health but also for
stopping cycles of violence and incarceration,
building shared safety, and repairing communi-
ties is their bottom-up design. Built on a frame-
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work of mutual aid in which the giving and re-
ceiving of care overlap, these community care
systems succeed by prioritizing local knowledge
and the employment of marginalized groups in
caring for their own neighbors. Rather than
paternalistically assuming a mission to care for
people whom our society has harmed, this
model embraces caring alongside one another and
restoring to dispossessed communities the eco-
nomic resources required to care for them-
selves.33,34 In hiring workers, then, a national
program of community health and justice work-
ers should give priority opportunities to people
who have been incarcerated themselves. Building
on recent prison education initiatives, this effort
could include training programs inside prisons
that guarantee participants employment on re-
lease, thereby providing a pipeline out of prisons
that supports safe decarceration, early release,
and successful reentry into broader society.
Public investments in care systems that pro-
vide such dignity-affirming, community-building
work opportunities could, by several means,
bring us closer to ending mass incarceration.
First, they could disrupt cycles of rearrest large-
ly attributable to high rates of poverty, home-
lessness, mental illness, addiction, and disability
compounded by lack of access to health care and
social support.37 Second, they could offer a
structure for rebuilding the intangible dimen-
sions of practical and ethical community —
such as shared purpose and mutual trust rooted
in meaningful social ties supported by caring
public institutions — in neighborhoods suffer-
ing from intensive poverty, policing, and incar-
ceration. Moreover, they would do so through
concrete mechanisms: provision and receipt of
properly compensated, publicly funded support-
ive care that is key for mitigating the persistent
health and economic harms that incarceration
inflicts on individual persons and families.38,39
By employing people in marginalized commu-
nities and thereby infusing financial resources to
restore what has been stripped from them by
decades of criminalization, redlining, and re-
gressive economic policies, such a program
could address a major barrier to successful re-
entry into society after release from jail or prison:
finding meaningful employment with wages that
enable people to thrive.39 Investing in a system
of community repair to end mass incarceration
could thus provide a key vehicle for economic
nejm.org February 9, 2023 561
 The n e w e ng l a n d j o u r na l
reparation.40 Such investment would make clear
that reparations not only serve racial justice but
also yield multiplying returns for all U.S. resi-
dents: dramatic improvements in public health
and collective safety in a country with a dearth
of both.41
Rebuilding U.S. public health and safety
around a national corps of community health
and justice workers would be an expensive, gen-
erational undertaking. Over time, however, funds
invested to do so could yield considerable public
savings through reduced need for spending on
health care, policing, prisons, and social services
that are organized around costly crisis response
rather than prevention.36,37
A b olitional C are
Institutional and government leaders may dis-
miss this proposal as unrealistically ambitious,
but U.S. communities that have been dispropor-
tionately affected by mass incarceration cannot
wait for the incrementalism typically favored by
privileged actors who fear transformative chang-
es — and, in a democracy, it’s the people who
determine the limits of political possibility. For
decades, influential U.S. medical, public health,
and health policy professionals have gone along
with incrementalism by emphasizing piecemeal
reforms and issuing recommendations for best
practices within jails and prisons. Although these
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of m e dic i n e
efforts have been well-intentioned, they have not
brought us closer to ending mass incarceration
nor stopped routinized abuse behind bars. As
Mark Findlay wrote in 1983, when U.S. mass
incarceration was in its infancy, “As long as
prison reformers attempt to work within the
existing correctional system to reform it, reform
will be dissipated as the reformers inevitably are
conditioned to accept the retention of the basic
correctional structure in exchange for minor
revisions.”42 Michel Foucault, writing approxi-
mately a decade earlier, made similar observa-
tions: “The movement for reforming the prisons,
for controlling their functioning is not a recent
phenomenon. It does not even seem to have
originated in a recognition of failure. Prison
‘reform’ is virtually contemporary with the prison
itself: it constitutes, as it were, its programme.”43
The rise and persistence of mass incarcera-
tion has borne out these warnings regarding the
hazards of trying to achieve meaningful change
while remaining within fundamentally punitive,
violent paradigms. In response, many social sci-
entists — particularly Black feminist scholars
such as Angela Y. Davis, Dorothy Roberts, and
Ruth Wilson Gilmore — have rejected reform-
ism and embraced the framework of abolition as
developed in earlier movements for abolishing
slavery.44-49 The logic motivating abolitional poli-
tics is that some forms of human organization,
such as slavery and the contemporary U.S. polic-
ing and carceral systems, are premised on intrin-
sically violent, racist foundations such that to
invest in reforming them without an overarching
agenda for abolishing them is to abet the ongo-
ing violation of human dignity and basic rights.
Abolition, however, requires not only the dis-
mantling of oppressive systems but also the
construction of infrastructures for economic,
medical, and social repair — that is, initiatives
like the community care systems outlined above
that can be used to put abolitional care into a
public practice to usher prisons into obsoles-
cence.
Public health and prison abolition are inter-
woven projects.49 Both are contingent on sup-
portive public systems, and both are processes
rather than events. And as with public health,
advancing abolition will require effective politi-
cal organizing. The U.S. medical profession,
which has long treated the harms inflicted by
mass incarceration, could play a key role. I be-
nejm.org February 9, 2023
 Medicine and Society

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Copyright © 2023 Massachusetts Medical Society.
February 9, 2023