Beautiful Plants For Your Interior
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 exercise by himself. According to court documents, he now faces severe depression, paranoid auditory 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 prohibition 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 treatment, 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 Pennsylvania 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, solitary 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 decarceration, which was recommended by health and safety experts as the best way to keep incarcerated people safe and to stop jails and prisons from amplifying the pandemic and spreading deadly disease throughout surrounding communities.7-9 This policy has not only failed to prevent carceral Covid-19 outbreaks — it has also generated a shadow epidemic of psychological and physiological injury that will reverberate for decades to come.
The Afterlives of Abuse behind Bars
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 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 government 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 overburdened 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 punishment, and harm more harm. What, then, will be the long-term consequences of the conclusion by leaders in one of the world’s wealthiest countries that the best they could do to protect its residents during a pandemic was to subject approximately 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 immigrant detention facilities during the pandemic — a large proportion of whom, even if spared solitary confinement, have been subjected to abusive 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 worsening of carceral conditions,12 one study estimated that each year of incarceration shortened a person’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 Moreover, recent studies have underlined that, owing to spillover effects within biosocial networks, high incarceration rates drive substantial increases in mortality for entire counties.10,11
The scale of this harm is difficult to overestimate. 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 numbers, how much of the $4.3 trillion in annual 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 deterrence in policing and incarceration,22 policymakers 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 closest 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 veterans, who have considerably higher rates of substance use disorders, severe psychiatric illness, suicide, homelessness, unemployment, and social and economic instability than the general population. The VA system, though imperfect, provides 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 bodies, 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 punishment,29 the federal government could progressively 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 “criminal justice” and a police-centric concept of public safety that focuses on crime rates alone while disregarding other statistically far more important 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 include 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 community health and justice workers with an initial target of 2 million workers, or 6 workers per 1000 residents, could be the backbone of a national project of repair.
A public jobs program of this size — roughly equivalent to the number of people now incarcerated or half the number employed by the policing, 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 substantially 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 communities is their bottom-up design. Built on a framework of mutual aid in which the giving and receiving 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 economic resources required to care for themselves.33,34 In hiring workers, then, a national program of community health and justice workers 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 release, 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 provide 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 largely attributable to high rates of poverty, homelessness, 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 dimensions of practical and ethical community — such as shared purpose and mutual trust rooted in meaningful social ties supported by caring public institutions — in neighborhoods suffering from intensive poverty, policing, and incarceration. Moreover, they would do so through concrete mechanisms: provision and receipt of properly compensated, publicly funded supportive 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 communities and thereby infusing financial resources to restore what has been stripped from them by decades of criminalization, redlining, and regressive economic policies, such a program could address a major barrier to successful reentry 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 reparation.40 Such investment would make clear that reparations not only serve racial justice but also yield multiplying returns for all U.S. residents: 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, generational 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
Abolitional Care
Institutional and government leaders may dismiss this proposal as unrealistically ambitious, but U.S. communities that have been disproportionately affected by mass incarceration cannot wait for the incrementalism typically favored by privileged actors who fear transformative changes — 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 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 approximately a decade earlier, made similar observations: “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 incarceration 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 scientists — particularly Black feminist scholars such as Angela Y. Davis, Dorothy Roberts, and Ruth Wilson Gilmore — have rejected reformism and embraced the framework of abolition as developed in earlier movements for abolishing slavery.44-49 The logic motivating abolitional politics is that some forms of human organization, such as slavery and the contemporary U.S. policing and carceral systems, are premised on intrinsically violent, racist foundations such that to invest in reforming them without an overarching agenda for abolishing them is to abet the ongoing violation of human dignity and basic rights. Abolition, however, requires not only the dismantling 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 obsolescence.
Public health and prison abolition are interwoven projects.49 Both are contingent on supportive public systems, and both are processes rather than events. And as with public health, advancing abolition will require effective political organizing. The U.S. medical profession, which has long treated the harms inflicted by mass incarceration, could play a key role. I believe that as caregivers and stewards of public health, we have an ethical responsibility to invest our collective economic and political influence to support a movement for abolitional care to address the root causes of violence, inequality, and disease. To do so effectively, we can organize with economically abandoned rural communities, racialized urban communities, labor unions, teachers, prison and jail workers, public defenders and prosecutors, fellow health care workers, and millions of formerly and currently incarcerated people to force lawmakers to reject incrementalism and take bold steps to end punishment policy that falsely equates retribution with justice.
True justice is not a stable state, nor is it reducible to law. Rather, it inheres in a practice of unending repair and reconstruction. Justice lies always beyond us, asking that we find courage enough to turn and face together the haunting wreckage of our ongoing history so that we can tend to the injuries we have caused. If we can bear the truth of that history and take collective responsibility for remedying the harm it continues to inflict on bodies, minds, and communities, we may someday learn to live freely together rather than remain perpetually captive to our violent past.
Disclosure forms provided by the author are available at NEJM.org.
This article is dedicated to the memory of Albert Woodfox (1947–2022), who, after wrongful conviction and subjection to 43 years in solitary confinement, devoted his freedom to the work of freeing others.
Author Affiliations
From the Department of Anthropology, Harvard University, Cambridge, MA; and the Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, and the Department of Psychiatry and Behavioral Sciences, Chicago Center for Psychoanalysis — both in Chicago.
Supplementary Material
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