Going Upstream: Prisons and the Social Determinants of Health

A couple of weeks ago, I joined with hundreds of other students and scholars at Johns Hopkins for a conference on prisons and the social determinants of health. The star of the conference was this story:

One day three men were fishing in the river when they noticed a baby floating towards them. Two of the men jumped out of their boat to save the child, and the third brought the baby and the boat to shore to care for it. As they stood around comforting it, one of the men spotted a second baby floating downstream! As he ran back towards the river, he was shocked to see his friend turn and run upstream. “What are you doing?!?” he cried. “There’s a baby in the water!” His friend shouted back over his shoulder: “I’m going to find the asshole throwing kids into the river!”

It was repeated and referenced throughout the day; it is a story about root causes and priorities, and it’s quite appropriate in a public health context where there’s always a tension between treating the symptoms or identifying the etiology. “Going upstream” means looking for the systematic and institutional causes of the illnesses and deaths public health workers encounter every day. We have to save the babies in the water, but we can’t ignore how they got there.

What we heard time and time again at this conference was a curious mix of ideas and arguments: on the one hand, many of Baltimore’s and America’s worst public health problems could be laid at the feet of the mass incarceration of its least advantaged residents. The nexus of poverty and educational failures were closely correlated with racism and prisons, and these were closely correlated with premature mortality, disease, and lost capacities. Put simply: prisons are one of the primary mediating terms for the creation of disparate health outcomes for whites and blacks.

And yet: we heard from a number of scholars who tried to give us a window onto criminality and delinquency through the neurobiology of adolescent impulsivity or the experience of substance abuse and dependency. These scholars didn’t even mention these racial disparities, and so they seemed to offer us little hope of a connection between the putative objectivity of brain and addiction science and the clear biases in arrests, prosecutions, convictions, and incarcerations. We even heard from one scholar who spent a long time touting his credentials and then accused African-American men of “compensatory narcissism.” (What was *he* compensating for?)

by Flickr user John Watson

Each panel was punctuated by a student poet from Dew More Baltimore, and these sizzling lyrics gradually seemed to impress the speakers that they could not ignore race any more. As the day went on, we heard from Elijah Cummings and Eddie Conway. We heard from a group of formerly incarcerated men who ran non-profits working on reentry and job placement. And we started to hear more talk of solutions: ways to reduce the number of people in jail, divert juveniles from the school-to-prison pipeline, and deal with substance abuse issues. David Kennedy‘s work with SafeStreets is designed to reduce the number of crime victims, and as a side effect reduce the number of people incarcerated: this is certainly laudable work worthy of all the celebration it has received, but it’s not really about abolishing prisons so much as it is about better-managing policing to increase efficacy,  reduce costs, and mitigate harms. In that sense, it’s meliorist rather than abolitionist. It goes upstream, but does it go upstream enough? Or does it tarry there in the water because there are lives to be saved right now?

What I never heard was a response to Vesla Weaver‘s challenge from the beginning of the day: African-Americans who encounter the criminal justice system are increasingly socialized with a dual logic: they are held responsible for the outcomes in their lives, while being actively disenfranchised in the decisions that will affect the conditions that produce those outcomes. The language of personal responsibility is rampant, even in public health; yet we know that demographic and institutional factors will play a major role in shaping outcomes. Disenfranchisement is the ultimate “up stream” moment; building social capital and public health seems to require re-enfranchisement.

Of course, Weaver herself didn’t tell us how to accomplish that. And so I return to Elinor Ostrom: you have to create an alignment between responsibility and the power to act. Ostrom showed that institutions can “crowd-in” responsibility: those who will experience the consequences of an action have to be the ones who control it. Civic capacities are hampered by medical and social incapacities, but at the same time civic capabilities can produce better outcomes in medicine and the economy.

Right now, we seem committed to more expert management of disenfranchised populations, and so we continue to create the mismatched logic of powerless responsibility and unaccountable power. The alternative is to let the Dew More poets take center stage and ask the scholars to wait for the intermission.

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