Jonathan Heller

Jonathan Heller
Co-Director
jch[at]humanimpact.org

Since co-founding Human Impact Partners in 2006, Jonathan Heller has worked on over a dozen health impact assessments, conducted many HIA trainings, and has mentored others on how to conduct HIAs. Prior to moving into public health, he worked for nine years in the biotech industry. Jonathan received his bachelor’s degree from Harvard University and his doctorate from University of California, Berkeley, and he served in the Peace Corps in Papua New Guinea. Jonathan currently serves as the Chair of the Provisional Steering Committee for the newly formed Society of Practitioners of Health Impact Assessment (SOPHIA) and as Chair of the Board of the Center for Community Change.

A Framework Connecting Criminal Justice and Public Health

HIP has been doing a lot of research about how criminal justice policies and practices affect health. As our work to understand these impacts has evolved, we are more and more convinced that it is a public health imperative to use the power of public health to re-envision and change our justice system and virtually all its component parts.

As conveners of the National Criminal Justice and Public Health Alliance, we’ve also been thinking a lot about how the determinants of health are more or less the same as the determinants of justice system involvement. Others are also thinking about criminal justice as a public health issue by: changing behaviors related to violence; addressing the traumas that victims face and how those perpetuate crime; reducing Adverse Childhood Experiences; ensuring those leaving prison sign up for Obamacare; and working to reinvest savings from criminal justice reform back into our hardest hit communities.

All these approaches are necessary to addressing the health and social needs of those who are justice involved. It’s useful to also think about how these individual and community level interventions tie together into a criminal justice and public health framework. This diagram represents a way of thinking about these relationships and how change in any one domain might affect change in another domain.

 

First, let me give examples of what is included in each element of the diagram:

  • Community Conditions – Social, Economic, and Environmental Determinants of Health includes employment, housing, and education; exposure to environmental contaminants like lead as well as access to healthy food; and poverty, racism and other forms of oppression, and empowerment.
  • Physical and Mental Health Outcomes includes chronic disease (e.g., cardiovascular disease, diabetes); infectious disease (e.g., AIDS, hepatitis); developmental issues; stress, anxiety, depression, and trauma; and preterm birth, infant mortality, and premature mortality.
  • Behaviors include substance abuse, theft, and violence as well as eating a healthy diet and getting exercise.
  • Criminal Justice System Involvement / Criminal Justice Policies includes involvement in system as well as policies that govern all aspects of the criminal justice system including school discipline and the school-to-prison pipeline; policing; pre-trial, prosecution, defense, adjudication, and sentencing; incarceration; and release and re-entry.

Here are some examples (though not a comprehensive list) of how elements of the framework shown in the diagram simultaneously interact with each other to generate poor health and justice system involvement.

Examples: How factors that shape health affect justice involvement, behaviors, and health outcomes

Determinants of health can affect criminal justice involvement, behaviors, and physical and mental health outcomes through:

  • Homelessness and poverty are criminalized, leading to justice system involvement
  • Both structural and institutional racism lead to over-policing of black communities and disproportionate punishment of people of color throughout the justice system.
  • Lead exposure in childhood leads to developmental delays, behavioral issues, and crime.
  • Unemployment can lead to a host of behavioral issues: drug use, involvement in the underground economy, theft, and various forms of violence.
  • Conditions that lead to Adverse Childhood Experiences, such as exposure to violence in the community, homelessness, or incarceration of a parent, can lead to behavioral issues in school and beyond, substance abuse, as well as mental health disorders.

 

Examples: How justice involvement affects factors that shape health and health outcomes

Criminal justice involvement and policies can affect determinants of
health, behaviors, and physical and mental health outcomes through:

  • People re-entering society face collateral consequences of justice system involvement, such as difficulty finding employment and housing.
  • Experiences while incarcerated, including traumas from physical, sexual, and mental abuse, and from isolation, can lead to drug use and further violence.
  • The presence or absence of rehabilitative programs while incarcerated influence recidivism upon release.
  • Restorative justice practices as an alternative to incarceration influences

 

Examples: How health outcomes affect justice involvement and factors that shape health 

Physical and mental health outcomes can affect criminal justice involvement and determinants of health through:

  • Physical or mental health issues can lead to unemployment and housing instability.
  • Mental health crises can lead to arrest.
  • Debt from health care expenses can lead to inability to pay bills, poverty, and arrest.

 

 

 

How can this framework be used?
This framework provides public health and criminal justice reform advocates a common basis for talking about work to create a more just criminal justice system that creates the conditions necessary for people to succeed and therefore healthy and safe communities. Those seeking change in any element of the framework should recognize that their efforts are linked to other elements and therefore a) consider the relationship and consequences of their work on those other elements and b) build relationships with others working on other parts of the framework to think about how all efforts can reinforce one another. The less our work is isolated, the better the outcomes we will realize.

For example, many proposed criminal justice reforms can be analyzed using this framework. Our Health Impact Assessments ask how these reforms – in policing, sentencing, access to education in prison, for example – influence physical and mental health outcomes directly, and through changes in the other two elements – behaviors and determinants of health.

As we continue work with the National Criminal Justice and Public Health Alliance, we’ll make sure we represent the different aspects of the framework in our discussions and continue to strengthen relationships between the groups doing this work. We have already collaborated to create a vision for a criminal justice system that operates from public health principles. Should this vision be realized, it would improve upon virtually all elements of the framework and lead to improved health and justice system outcomes.

We hope the framework is useful to others doing work at the intersection of criminal justice and public health. We’d love to hear your thoughts!

Strategic Questions to Ask To Explicitly Address Racism and Power in Your Public Health Practice

A few months ago, I wrote about the need for public health practitioners who want to advance equity to explicitly address race and power in their work. I received positive feedback, but also found that people are interested in how to actually do this. I recently created some materials for a training and it went well.

So, here goes an attempt to share it with a broader audience…

Let’s say you and your team – a team that hopefully includes people with a variety of skill sets and perspectives, including people from communities facing inequities – are working on a project on a particular social determinant of health in a particular location. As an example, let’s use policing, and mass incarceration more generally (i.e., the determinant), in Cincinnati and Akron, Ohio (i.e., the location). (Disclaimer, these examples stem from a recent HIA HIP released).

Questions about Underlying Issues

As you begin thinking about your project, here are a set of strategic questions that you can discuss with the team that get at the underlying issues of racism and power that are at play for virtually all social determinants of health:

1. What is your long-term equity goal, as it relates to the issue in that place?
2. What is the historical and current racial context for the issue, at the structural, institutional, and interpersonal levels?
3. What is the historical and current context with regard to other forms of oppression (class, gender, age, sexual orientation, disability, etc.) for the issue at the structural, institutional, and interpersonal levels?
4. Have race and/or other forms of oppression been used as political tools in decision making around the issue? If so, how?
5. Do you have the votes or other measures of buy-in to advance your equity goal? Explain.
6. Do you have a network of organizations and individuals strong enough to advance your equity goal? Explain.
7. What is the current societal narrative as it relates to your equity goal? Does it work in your favor or against you?

Example: Here are some quick and oversimplified answers for policing in Ohio:

1. Long-term equity goal? Eliminate the use of policing and incarceration as a form of control of black communities. Invest in necessary jobs, housing, education, etc. instead.
2. What is the racial context for the issue? FDR’s compromise with southern Democrats, who were segregationist (interpersonal racism), led to housing policies at HUD that have allowed whites to build wealth and simultaneously led to white flight and disinvestment from inner cities (institutional racism). Many communities of color, like those in Cincinnati and Akron, now suffer from lack of opportunity – in jobs, housing, education, etc. – and high crime rates (systemic racism). This has led to excess policing and incarceration. Listen to this NPR piece, for example, for more details.
3. What other context and forms of oppression are important to consider? The following populations have also been over-policed in communities of color and other communities: youth, men, LGBTQ, those with mental illness, and low-income whites.
4. How have race and other forms of oppression been used as political tools? Think of who the language of “tough on crime”, “war on drugs”, “super-predators” was really about (dog-whistling). Think about how heroin addiction – which is thought to be used more by whites – is treated as a health issue, in comparison to crack addiction – which is thought to be used more by blacks – which is criminalized.
5. Do we have enough votes or buy-in to advance our equity goal? No! Most people – including people of color – consider policing to be the best solution to addressing public safety needs in inner-city communities of color.
6. Do we have a network of organizations strong enough to advance our equity goal? No! This issue is just beginning to bring people together and a movement is starting. But still, policing and incarceration are seen as separate issues from jobs, housing, and education. We are still too siloed in our work.
7. What is the current narrative? It includes “Be afraid of black people”, “us vs them”, “individuals are at fault – they choose to commit crimes and are bad people”, “punishment deters crime”, and “we are protecting the innocent”. We see these themes everywhere – in the news, on TV, and in the movies. There is a lot more that could be said about this, but the way crime and policing are now thought of, we will have a difficult time achieving significant reforms.

After going through this exercise, your team will most likely have a better and a common understanding of the barriers you face in achieving your equity goal. That understanding should inform the approach you take.

Questions to Overcome Barriers Identified

If your project includes conducting research, like a Health Impact Assessment, a next step is to think about how you can use your research process to overcome these barriers. For example, your team could discuss the following questions.

How can you use your research process to:

1. Bring attention to the current and historical context regarding racial and other forms of oppression around your issue?
2. Unite people across the boundaries of race and other forms of oppression?
3. Diffuse the ability of opponents to use race or other forms of oppression as a political tool to block your ability to move your equity goal?
4. Build your ability to advance both your short-term and long-term equity goals by:
a. Winning enough votes or other measures of buy-in?
b. Building relationships and infrastructure to change what is on the political agenda?
c. Changing the dominant narrative related to your issue?

Example: Again, here are some quick and oversimplified answers for policing in Ohio:

1. How can we bring attention to the current and historical context of oppression? We can: discuss these with our steering committee; reflect them in our recommendations (e.g., recommend that communities come together to talk about this history); and have a section in our report that discusses this history.
2. How can we unite people across boundaries? We can discuss how both black communities and the police are negatively impacted by current forms of policing. And we can use the steering committee to start bringing people together and build trust.
3. How can we diffuse the ability of opponents to use oppression as a political tool? We can discuss approaches to overcoming dog-whistling during our research process. We can make recommendations about further and broader discussions about the use of race as a political tool as it relates to policing. We can also share information about how unconscious bias plays out today in terms of policing.
4. a. How can we build our ability to win enough votes or gain buy-in? We can use the HIA process to engage communities most impacted and help our partners build their leadership and sense of agency.
b. How can we build our relationships and infrastructure? By developing and engaging a diverse steering committee.
c. How can we use the research process to change the dominant narrative? This is hard! We can start to change the “us vs them” mentality by discussing that we are all impacted. We can humanize everyone. We can talk about wanting to have policies that improve everyone’s health and that address underlying social causes.

As you can see, these are difficult questions and advancing equity by addressing race and power is not easy. But this work is necessary and it is worth struggling – together – to figure out how to do it.

Tools You Can Use

In case it is useful, we’ve pulled these questions together as a worksheet to use with your team. And for HIA practitioners, after you go through these questions, you may want to use the Equity Metrics for HIA Practice as a planning tool for your project.

Let us know if you use these tools and, if so, what feedback you have for us! Thanks!

If we want to advance equity in public health practice, we must address race and power

This week’s blog post was originally posted on The Pump Handle on January 7, 2016.

Most public health practitioners, and those who work on health impact assessment specifically, want to improve the health of vulnerable populations. Most efforts to do so are well-intentioned, yet they often don’t lead to significant change. What do we need to do differently? Below is an analysis we at Human Impact Partners put forward. Read more…

Speak up! Health is created through collective efforts

This week’s blog was originally posted by The Pump Handle on September 21, 2015. In this post, HIP Co-Director, Jonathan Heller, reflects on how  collective efforts are necessary to improve our health and well-being. 

The dominant narrative in the United States is that, as individuals, we hold the key to our own success. We are told to pull ourselves up by our bootstraps and that if we just try hard enough, we’ll succeed. Read more…

Our Children’s Upward Mobility and Health

There is a growing awareness, both within and outside of the public health community, that where you live – down to your ZIP code – determines how healthy you are and how long you live. A study released this week looks at the reasons why this is the case, especially for children.

The study, by Raj Chetty and Nathaniel Hendren from Harvard, found that when a child from a low-income family moves from a low-income community to a higher-income community, they have a better chance of escaping poverty in their lifetime. The younger the child is when she or he moves, the more likely they are to achieve upward mobility.

According to The New York Times, “All else equal, low-income boys who grow up in [very low-income] areas earn about 35 percent less on average than otherwise similar low-income children who grow up in the best areas for mobility. For girls, the gap is closer to 25 percent.”

The higher-income communities that these children are moving to tend to have “less segregation by income and race, lower levels of income inequality, better schools, lower rates of violent crime, and a larger share of two-parent households.” Lower-income cities, many of which are highly segregated, tend to have the opposite social and economic conditions and can drag children down. These and similar factors are at the root of the protests that have roiled Baltimore over the last two weeks.

The research, based on the income outcomes of more than five million children who moved, shows that the place one lives actually causes these impacts. As Emily Badger puts in the Washington Post, “It’s not simply that successful families chose to live in Fairfax and unsuccessful ones pick Baltimore. Baltimore itself appears to be acting on poor children, constraining their opportunity, molding them over time into the kind of adults who will likely remain deeply poor.”

The researchers also found that the age at which children moved predicted their likelihood of becoming single parents and of going to college.

Such moves also have health impacts. Kids that move to higher-income neighborhoods have better access to resources that support health, like good schools and parks. We know that an adequate income is critical for both physical and mental. Higher income correlates with lifespan, self-rated health, chronic disease rates, and stress.

So, what do we do with this information? The answer can’t be that all low-income families should move to higher-income communities. That is not realistic or feasible, and we should not put this burden on the backs of these families. Instead, this should prompt more investment in low-income communities so that they become high-opportunity areas, with all the benefits and supports that go along with that status. We must work to reduce segregation and income inequality and improve schools in these communities. We should be investing in low-income communities to rebuild their local economies and provide access to jobs and wealth-building opportunities.

Such initiatives will not only address the crises in cities like Baltimore, but are the best things we can do to do improve health and reduce inequities.

Good Jobs For All Would Boost Health, Reduce Inequities

Last week several national organizations launched the Putting Families First: Good Jobs For All campaign to bring the issues of jobs, poverty, and inequality to the center of the national debate. “Today, our country is more aware than ever before that our entire economic system is out of balance. We have reached a time in history where the need, the opportunity, and the energy are all here to create an economy that works for our families—now we need the will and the dedication of the American public to make it happen,” wrote Deepak Bhargava, Executive Director of the Center for Community Change.

The campaign will mobilize people around the country – especially poor people and people of color – to advocate for a national agenda focused on:

  1. Guaranteeing good wages and benefits, including a $15 minimum wage, access to paid sick days and paid family leave, and protections from wage theft;
  2. Valuing families by making high quality, affordable early education and child care available to all working parents and their children;
  3. Building a clean energy economy through large-scale investment to substantially reduce our reliance on carbon-based energy and to repair and rebuild our infrastructure;
  4. Unlocking opportunity in the poorest communities by channeling federal investments to communities with high unemployment and low wages to help rebuild their local economies and provide access to jobs and wealth-building opportunities; and
  5. Taxing concentrated wealth, including eliminating differences in taxation of capital gains and income, strengthening the estate tax, increasing taxes on the highest incomes, ending the ability of corporations to defer US tax payments on offshore income, and taxing corporations for wage inequality.

This is a bold and ambitious agenda that would create over five million new jobs a year by directing government to take an active role in guiding our economy through investing and shaping new and emerging sectors. These investments would be targeted to help those who need it most, closing racial and gender inequities, and be paid for by changes in our tax system that reward those who create wealth in this country – hard working people.

While those leading the campaign – the Center for Community Change (whose board I am chair of), the Center for Popular Democracy, Jobs with Justice, The Leadership Conference for Civil and Human Rights, and the Working Families Organization – are thinking about this as a jobs campaign, it is also a campaign to improve health and reduce health inequities. Several speakers at the launch event, including Senator Sherrod Brown of Ohio and SCOPE Executive Director Gloria Walton, noted the impacts of income on health and lifespan, but health is still an underutilized frame when talking about social and economic policy.

The Putting Families First campaign aligns with HIP’s new Economic Security Program, which will bring public health data, framing, and voices to social movements advancing a range of economic security policy campaigns.

As we’ve said before, no single factor is more important for healthy living than an adequate income, and none is more harmful to health than persistent poverty. Economic security is necessary for people to thrive, successfully manage stress, and prevent disease. Overwork, poor quality food, housing insecurity, and other consequences of low wages and unemployment contribute to physical and mental health problems including high blood pressure, diabetes, heart disease, and depression.

Economic security requires guaranteeing that work is available, safe, and pays a decent wage. Ensuring that families have a decent standard of living is one of the most powerful tools we have to protect and promote health.

If Black Lives Matter, We Can’t Stay on the Sidelines

Let’s not sit on the sidelines.

With those words Dr. Mary Bassett, health commissioner of New York City, in a Perspective for The New England Journal of Medicine clearly and boldly declares that health professionals are accountable for fighting interpersonal and institutional racism, because of the undeniable truth that racism contributes to poor health outcomes.

In “#BlackLivesMatter: A Challenge to the Medical and Public Health Communities,” Dr. Bassett acknowledges that “tackling racism is daunting” and for many in the health community “often viewed as divisive and requiring action outside our purview.” She calls out the “dearth of critical thinking and writing on racism and health in mainstream medical journals,” pointing out that over the last decade only 14 articles in NEJM even contained the word racism. And she lists three ways we can – and should – make a difference:

  • Research: “By studying ways in which racial inequality, alone and in combination with other forms of social inequality (such as those based on class, gender, or sexual preference), harms health, researchers can spur discussions about responsibility and accountability. Who is responsible for poor health outcomes, and how can we change those outcomes?”
  • Internal reform: “Our target ‘high-risk’ communities, often communities of color, have assets and knowledge; by heeding their beliefs and perspectives and hiring staff from within those communities, we can be more confident that we are promoting the right policies.”
  • Advocacy: “Some [health professionals] may choose to participate in peaceful demonstrations; some may write editorials or lead ‘teach-ins’; others may engage their representatives to demand change in law, policy, and practice.”

Right on! These actions align completely with HIP’s new strategic direction – research, advocacy, and capacity building to bring the power of public health science to campaigns and movements for a just society. They also align with the work members of our Public Health and Equity Cohort are doing to advance racial and other forms of equity in their health agencies and communities, with an inside-outside strategy for change. And they reflect the way we do our work at HIP and what we advocate that other health professionals should do in their work.

Dr. Bassett is right. Addressing structural racism is hard. But we can’t sit this struggle out. Let’s remember why we’re in this: to improve health and reduce health inequities. We can’t back off when that means we must confront racism.

Health – and Health Professionals – Must be Front and Center in Policy Debates

This blog post was first published by the Detroit Wayne County Health Authority on Feb 9, 2015. 

Too many babies are dying in Detroit – just as in my town, Oakland, California. Too many people are dying earlier than they should be. Heart disease rates are soaring. None of these facts are in dispute. But when we ask why or what can we do, we get some different answers.

Some say we need to improve the health care system. But while health care is important, it does not address the reasons people are getting sick. Most of us go to the doctor’s office when we are already sick.

Others attribute it to personal behaviors, saying that if people ate better and exercised more, their health would be better. That’s true, but if we examine why people don’t have healthy behaviors, we quickly find that healthy options are limited – particularly for those living in low-income communities. Healthy food is scarce. Parks aren’t safe. Streets aren’t walk-able. Good jobs are scarce, so stable housing in neighborhoods with high performing schools remains only a dream.

At the root of all of these, however, is a tragic reality: The most important reason health outcomes in Detroit are so bad is that we have created public policies that mean parents can’t get good jobs, our kids go to inadequate schools, and many members of our communities are isolated from opportunity. We have created policies that mean kids don’t have the healthy food, stable housing, and good education they need to thrive. They live under constant stress because these policies have resulted in difficult family conditions and community violence. The way they live each day is simply not conducive to good health.

The good news is that change is possible. There are many things those of us working in health can do. We can use our individual and collective voices to advocate for policies that get at these core issues – policies that promote full employment and higher wages, integrated communities with affordable housing, and a strong educational system. And we can use the resources our organizations have to address these underlying determinants of health.And we should do all this recognizing that the communities suffering from poor health outcomes bring their own expertise that should be respected.

Because we are all in this to improve people’s health, we must use the power and resources we have to work for that change. For example:

  • Public health professionals and organizations can contribute data and research that connect the dots between public policy and health outcomes.
  • Non-profit hospitals can include an analysis of the determinants of health in their community health needs assessments and use their charitable community benefits dollars to address the root causes of disease instead of,or at least in addition to, treating the symptoms of public policy.
  • Medical professionals can support community organizers and policy advocates fighting for policy change by using their individual and collective voices in support of those community-led efforts.
  • Public health nurses can help build social cohesion and strengthen social networks when they are out in the community providing services.
  • All of us in health professions can help build the capacity of low income people and people of color to advocate on their own behalf for policies that improve living conditions.
    And all of us can use the power of our positions to build relationships between those facing the greatest inequities and those who can change policy.
  • These are all components of a Healthy Public Policy or a Health in All Policies approach that is based on advancing health equity. Health in All Policies is the concept of incorporating health considerations into the policies and programs of sectors that are the root causes of health – education, housing, land use, transportation, jobs, and incarceration.

We know this approach works. In the early 20thcentury, child mortality rates plummeted as a result of new child labor, sanitation, worker safety, and zoning laws passed by our government and implemented in the face of opposition from those who were profiting from the lack of regulation. This all happened before penicillin was invented or immunizations were available.

So, why not get involved in policy decisions that are being debated right now? Both Governor Snyder’s proposed sales and gas tax increase and Detroit Future City will affect the health of huge numbers of people. Health must be part of the debate.

There are many excuses we can give for not doing this work, including that it makes us uncomfortable and it feels alien. But if we are serious about improving health in Detroit, these are the kinds of actions that are required of us.

Jonathan Heller is, Co-Director of Human Impact Partners, and will be the keynote speaker at the 2015 Population Health Forum on March 2.

Using an Inside-Outside Strategy to Build Power and Advance Equity

HIP recently started the Public Health and Equity Cohort, a group of twelve emerging leaders from public health agencies around the country who are coming together to build their leadership to advance equity within their departments. In developing the 15-month curriculum for the Cohort, we had to think through and articulate a strategy for how health departments could advance equity. Our strategy is based on our experience working with public health departments and with community groups to make change.

It is important to first recognize that inequity exists because groups who benefit from it hold power. Those groups often include rich, white men interested in maintaining their status or expanding and consolidating their wealth and power. They also include corporations – usually run by rich, white men – who benefit from cheap labor and lax regulation. To maintain power, they use racism, classism, and sexism to divide those who should be united in working for change.

To move toward equity, those who want to change the system need to build power. How do allies of those who are negatively impacted by inequities – specifically allies in public health – support the work of building power? Our answer is through using an inside-outside strategy.

On the inside, health agencies, both leadership and staff, must first build their understanding of equity, including racism, classism, sexism and other forms of oppression. This can be done through internal dialogues and trainings such as those that have been done at health agencies in Alameda County, Calif., and Ingham County, Mich., at the state level in Minnesota, and elsewhere. With everyone in the agency involved, it is less likely that a change in leadership would undo this understanding and emphasis.

These agencies then must build the will to act on that understanding, beginning by changing the narrative about what leads to good health – for example, from a medical model that focuses on health care to the social determinants of health – and then using the power of the agency to advance equity. As I’ve written before, this takes tremendous leadership that must be willing to take risks. The model is power with – public health working in close and inclusive partnership with those facing inequities – rather than power over, in which public health institutions try to amass their own power.

But by itself a health agency will never have enough power to advance equity. Political forces favoring the status quo will slap down an agency acting alone. This is where the outside component of the inside-outside strategy to advance health equity comes in.

A demand to address equity should come from the community – from those facing inequity exercising their democratic rights. Health agencies must build relationships and work closely with community groups that can demand change and hold the agency and others in government accountable to their needs. They can also come to the rescue in tough political situations and have the health agency’s back.

Not every community group can support this kind of work. Best suited are base-building (or grassroots) organizations, staffed by community organizers. A base-building group is one that:

  • Brings people who identify as part of a community together to solve problems they themselves identify. These people often become members of the organization and are referred to as its base.
  • Helps a community identify common problems or change targets, mobilize resources, and develop and implement strategies to reach their collective goals.
  • Works to develop civic agency – the capacity of citizens to work collaboratively across differences to address common challenges, solve problems, and create common ground ¬– among individuals and communities to take control over their lives and environments. Ultimately, these groups are working to strengthen democratic processes.

So, for the outside part of the strategy, health agencies must learn how to partner with and support these kinds of base-building community organizations, who typically work to address the social determinants of health (even though they may not call them that). This is not easy, but health agencies from San Francisco to Kansas City to Boston have been leading the way.

This inside-outside strategy reflects at least one way to build the power to advance equity in a lasting and sustainable manner. Members in our Public Health and Equity Cohort will be exploring what this all means for their work, and trying to understand how to grow in this way.

To learn more about how these some of these ideas have been implemented, see:

A New Public Health Approach to Criminal Justice Reform in New York City

New York City just announced a bold but smart step forward: it will allocate $130 million over the next four years to a public health approach to criminal justice. The goal, according to The New York Times, is “to break the revolving door of arrest, incarceration and release that has trapped many troubled individuals in the system for relatively minor, quality-of-life offenses.”

Recognizing that almost 40% of those in New York City’s jails are mentally ill, and that people were cycling in and out of jail repeatedly as a result of substance abuse and mental health problems, the City will implement public health programs throughout the criminal justice system, from “tripling the size of . . . pretrial diversion programs” to increasing “the amount of resources devoted to easing the transition from jail back into society.”

“I think this is what criminal justice looks like in the 21st century,” said Elizabeth Glazer, Mayor Bill DeBlasio’s criminal justice coordinator, who was co-chair of a task force that developed the new policy.

We couldn’t agree more. New York’s shift reflects findings and recommendations of two recent HIAs we conducted – one on treatment alternatives to incarceration in Wisconsin and one on Proposition 47 in California, which reduced the penalties for drug possession and petty theft crimes. Both studies found that so-called tough-on-crime strategies have not succeeded in increasing public safety but have led to recidivism rates around the country greater than 50%. People in prison or jail are six times more likely to have a mental health disorder and 20 times more likely to have a substance abuse problem. Most importantly, we found that programs to address mental health and substance abuse issues reduce recidivism and are cost-effective.

The Vera Institute of Justice recently released an expansive report – On Life Support: Public Health in the Age of Mass Incarceration – that backs up the City’s approach by describing the myriad intersections between the justice system and public health. David Cloud, author of the report, writes:

Mass incarceration is one of a series of interrelated factors that has stretched the social and economic fabric of communities, contributing to diminished educational opportunities, fractured family structures, stagnated economic mo¬bility, limited housing options, restricted access to essential social entitlements, and reduced neighborhood cohesiveness. In turn, these collateral consequences have widened the gap in health outcomes along racial and socioeconomic gra¬dients in significant ways.

These findings parallel our own. The Vera Institute also sees an opportunity in the Affordable Care Act to address these issues. The report is part of a new initiative called Justice Reform for Healthy Communities, which fundamentally recognizes that “mass incarceration is one of the major public health challenges facing the United States.”

An amazing New York Times editorial on the day before Thanksgiving, Mass Imprisonment and Public Health, also reflects this public health approach. Citing the Vera report, the editors point out the obvious: people in prison are not healthy. People in prison also often come from impoverished communities that have serious health issues and less access to health care. The Times said: “The experience of being locked up — which often involves dangerous overcrowding and inconsistent or inadequate health care — exacerbates these problems, or creates new ones.” Solitary confinement and other prison “management” practices do additional harm. As the Times noted, this also affects future generations, with 2.7 million children nationwide having a parent in prison. The editors conclude:

If this epidemic is going to be stopped . . . public health and criminal justice systems must communicate effectively with one another. . . . Public health professionals should seize a unique opportunity to help guide criminal justice reform while they have the chance.

Again, we couldn’t agree more. It’s time for public health leaders across the nation to step up and seize this moment. Human Impact Partners is happy to support those in public health that want to move in this direction. This new direction only further affirms what we are focused on: Transforming the policies and places people need to live healthy lives by increasing the consideration of health and equity in decision-making.