safe and healthy

The US has too many prisoners and not enough community health workers. Here's an idea to solve both problems

Could employing formerly incarcerated people as community health workers improve community health and end mass incarceration?
The US has too many prisoners and not enough community health workers. Here's an idea to solve both problems
Photo: John Moore (Getty Images)
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The US is the prison capital of the rich world: With 2 million incarcerated people, and 5 million on probation and parole every year, its detention rate is almost seven times the average of comparable nations.

Nearly 80 million Americans (or 23% of the population) have criminal records, and about half of all Americans have a close family member who has been incarcerated. This shapes society long after people have been released: For former convicts, regular tasks in life, from accessing to health care to finding reliable employment, are a struggle.

As a consequence, people released from prison often end up in similar or worse circumstances than they were before incarceration, feeding recidivism. But what if there was a way to provide formerly detained people with reliable paths back into society after they have done their time, and at the same time improve the health of the communities they are released into?

Eric Reinhart, a physician and anthropologist at Northwestern University in Chicago, has a proposal that is equally as ambitious as it is straightforward: A corps of 2 million community health and justice workers, or 6 per every 1,000 residents, recruited among formerly incarcerated individuals.

The benefits of community health workers

Community health workers are key figures in many healthcare systems around the world. They aren’t highly specialized medical professionals, but rather community members who have training to support their peers as they deal with health issues. These workers can provide essential services ranging from reminding neighbors of screenings and follow-ups, to ensuring they take their medications correctly, to assisting them in navigating health care needs. A senior citizen who lives alone needs help finding a covid vaccine, or daily check-ins to avoid moving to a nursing home? A patient with hypertension needs blood pressure checked? Community health workers are there for it. They belong to the communities they serve, know their members, understand their lifestyle and have their trust, allowing these workers to deliver effective, necessary care.

This idea requires a profound change in how we think about community intervention in America, says Reinhart, who published a paper about his proposal in the February issue of the New England Journal of Medicine.

“[We need to invest] directly in people to care for one another, not from outside communities, not with a kind of humanitarian social work model where I’m gonna go in and help some other community,” he says. “[It’s a] basic model of building health from the bottom up, by taking advantage of the lived experience of people who know what it is to confront the obstacles to health and safety in the communities they live with every day.”

In the US, community health workers aren’t quite as common as in other parts of the world—though not because there isn’t a need for them, or because their input wouldn’t be helpful. Local programs and studies have shown tangible benefits from the employment of community health workers, including higher perceived quality of care for patients and overall lower number of hospital days for the community.

A follow up study led by Shreya Kangovi, the founder of Pennsylvania University’s center for community health workers, quantified the savings: Every dollar invested by Medicaid in community health yielded $2.47.

“A lot of the diseases that we need to care for in the 21st century [...] are diseases that people often don’t know that they have, and that are best taken care of in the community—things like blood pressure, diabetes, certain infectious diseases that you can screen people for,” says Salmaan Keshavjee, a professor of global health and social medicine at Harvard. “You need mechanisms for delivering care in the communities where they live and work,” he says.

The involvement of formerly incarcerated people

The presence of community health workers could be particularly important in disadvantaged communities, where residents might not be able to get care because of lack of insurance, or a scarcity of local resources and infrastructures. These are often the same low-income communities disproportionately affected by chronic conditions such as hypertension or diabetes, and they are home to many of the people who end up in the prison system.

In turn, when these people are released, they face huge struggles getting access to health care, decent-paying jobs, housing, and all the social support, often ending up in poor health conditions and at risk of recidivism. “We’ve created this system where the punishment is constant and unending for those who are being punished,” says Keshavjee.

But if someone getting out of jail had the option to accept a community health worker job, and one that paid fairly, that person would have solid ground to build back a life, all the while providing a service in the home community.

“This is, in my mind, a reparative project; we have to repair the harm that has been done to these communities,” says Reinhart.

“Mass incarceration, having been formerly incarcerated, having been in a family where one has been incarcerated, dramatically changes one’s social status, and changes in social status always create changes in the status of one’s health,” says Robert Fullilove a professor of clinical sociomedical sciences at Columbia University. “So there is no question that getting people who have experienced that first hand to become engaged in efforts to try and improve the quality of health of their community is certainly an idea whose time has come.”

Improving baseline health conditions through community health workers would address health and crime crises by preventing the conditions that cause them. And, as a consequence of the program, the detained population, and related police force demand, would decline significantly.

Every year, there are about 11 million admissions into US jails, though that accounts only for about 5 million people, meaning that most are repeat admissions. These aren’t people who have been sentenced to prison, but people who are typically being detained awaiting trial. A program that meaningfully employed people once they left the prison and jail system, preventing recidivism, would have a significant, rapid impact in reducing the jail population.

The effort could even be more radical. According to the Brennan Center for Justice, around 40% of the people in jails and prisons would not pose a threat if they were released. Freeing them would significantly reduce the prison and jail population, with all the associated savings, and involving them in the community health and justice corps would help them stay out of detention.

The challenges of such a program

Naturally, a program of this scale presents several challenges. The first is financial: The investment necessary to start such a program is very large, in the order of billions of dollars just for salaries, without accounting for the necessary training and administrative costs.

But if the spending is high, the savings down the line would be even higher. There are the direct savings in decreased need for hospital-based care and lower incidence of chronic disease complications, as well as the reduction in the cost of detention management. And, there is the long-term benefit of a healthier, safer population. “Rather than spending $4.3 trillion on health care—almost twice as much per capita as the next closest nation—we could invest that money in things that enable people to flourish rather than to survive after they have a disease,” says Reinhart.

There could be, too, a challenge when it comes to training such a large workforce. A program must strike a balance between equipping individuals with the skills they need to deliver health care in their communities, without burdening them with education requirements that can be a barrier to access the role. “You can overly professionalize it, and if you do that, then the risk becomes that the very people who want to go into it can’t afford to do the training. We’d have to think of a way where the training portion of it could even start into prison,” says Keshavjee.

Fullilove, who oversees a program to provide training to community health workers, has direct experience precisely in training for such a program, and believes it reasonable. For 15 years, he taught incarcerated people as part of the Bard Prison Initiative, a program by New York’s Bard College to provide college education during detention, and five of his students ended up getting master’s degrees in public health at Columbia University. “I have direct evidence of how providing public health education as part of time behind bars produces individuals who are very capable doing graduate work in public health,” he says.

“It’s not just a matter of showing up with a group of healthcare workers, which I think is half the battle for sure, but it’s also having the linkage to care so that if I find someone in the community that’s sick they can get care,” says Keshavjee. Community health workers need to have access to health infrastructure where they can refer the patients they are following, which is often a challenge particularly in the areas where their work is more essential.

“So there’s multiple pieces that have to be into place for this to work; but it’s all doable, it’s all achievable—100%, but it requires some work,” he adds.

A matter of political will

Ultimately, the biggest challenge to a program of this ambition isn’t financial or logistical. It’s political.

“I think it’s something that has unbelievable medical, economic, social, and public health logic, but it is also something that involves making a commitment to something that the American public really seems quite reluctant to commit to,” says Fullilove. Even with the financial and social benefits generated by a community health and justice workers corps, he says, American culture is too sold on the necessity of providing harsh punishment to incarcerated people, and would hardly be willing to invest in them.

But what further complicates the issue is the structure of governance of the prison system and related programs. The political will and reforms would not just have to gain federal support, but often be embraced on a state level, too.

The resistance to investing in incarcerated and formerly incarcerated individuals could take many shapes. For instance, an argument that Keshavjee could easily see arising is whether people with criminal records could be a danger for the communities they serve as health workers. This is, he says, largely based on a prejudice, with little logical grounds. “More people are dying from lack of healthcare than anything else, so the fear that some pot smoker giving you your insulin or helping you walk around the block is somehow going to lead to your early demise, versus the fact that you don’t actually have care, it doesn’t make any sense,” he says.

These challenges should not dissuade policy makers from pursuing the proposal, even if it means cutting it in two, says Keshavjee. “Even if we pursue the two separately, thinking about how to get jobs for people who’ll come out of prison and setting up a public health corps, each of these on their own are meritorious activities. And then if you could tie them together, that would be even better,” he says.