Excerpted From: Nicolas Streltzov, Ella van Deventer, Rahul Vanjani and Elizabeth Tobin-Tyler, A New Kind of Academic MLP: Addressing Clients' Criminal Legal Needs to Promote Health Justice and Reduce Mass Incarceration, 51 Journal of Law, Medicine & Ethics 847 (Winter 2023) (28 Footnotes) (Full Document Requested)

Streltzov etalThe United States incarcerates more individuals per capita than any other country in the world. Currently, there are nearly 2 million people in the U.S. living in a variety of correctional facilities, including state and federal prisons, local jails, juvenile facilities, immigrant detention centers, Indian country jails, and state psychiatric hospitals. Further, the carceral ecosystem in the U.S. extends beyond these residential facilities-- nearly 4 million people live under community supervision (probation or parole). During the COVID-19 pandemic, the U.S experienced a drop in jail and prison populations that provided some hope that the U.S. approach to punishment would begin to more closely resemble that of other countries. However, data have since made clear that these reductions were unintended results of court slowdowns as opposed to deliberate policy actions to decarcerate. As a result, the jail and prison populations are once again approaching pre-pandemic levels.

Incarceration has a profound impact on individual and population health, which drives significant racial and socioeconomic health inequities, especially for low-income Black Americans. Low-income people with chronic disease, who have experienced homelessness, and who struggle with substance use disorders and/or mental health problems face a high likelihood of carceral system involvement. As described above in the case of Ms. C, even the threat of incarceration can have overwhelming consequences for an individual with a fragile health trajectory. Healthcare providers who care for clients with carceral system involvement often experience significant frustration as they witness the effects of that system on their clients' health. Similar frustrations are often felt by public defenders who may struggle with how best to present their clients' medical history in court to demonstrate the health implications of punitive court dispositions, including incarceration.

This essay explores a new type of medical-legal partnership (MLP) that targets the health and justice concerns of people enmeshed in the U.S criminal justice system: a partnership between clinicians who care for people with criminal system involvement and public defenders. This offers an opportunity to not only improve client health outcomes but also to facilitate less punitive court dispositions. First, we highlight how partnering clinicians and public defenders draws on the typical civil legal MLP model and how it diverges by explicitly focusing on criminal defense. Next, we describe the goals and framework of the partnership between the Lifespan Transitions Clinic and the Rhode Island Public Defender's Office in Providence, Rhode Island. Finally, we discuss how an MLP focused on criminal law serves as an excellent interprofessional education and training opportunity for future legal and health care practitioners interested in mass incarceration and health justice.

Health and Incarceration

Socioeconomic status plays a central role in mass incarceration. The carceral population is disproportionately poor compared to the overall U.S. population. In addition, the criminal legal system is marked by stark racial disparities. For instance, Black Americans make up 38% of the incarcerated population despite representing only 12% of U.S. residents. Race is a central factor for two reasons: 1) people of color experience greater rates of poverty than white people, and 2) structural racism is deeply embedded in the U.S. policing and judicial systems. The criminal legal system compounds poverty by setting bail, imposing supervision fines, rendering court debt, and decimating future job opportunities, which are just a few of the many collateral consequences of being incarcerated in this country.

Carceral exposure also has a significant negative impact on the health and well-being of formerly incarcerated individuals and their surrounding communities, with both direct and indirect effects. Incarceration and community supervision directly influence health by interrupting treatment, forcing numerous transitions of care, causing stress which impacts cardiovascular and other chronic conditions, and removing autonomy and a sense of control over life, among other factors. The indirect effects relate to the social and structural determinants of health--incarceration and community supervision limit access to employment, business and occupational licensing, public benefits, housing vouchers, shelter access, and voting rights, to name a few. There is robust evidence demonstrating that lack of access to these social resources correlates with poor health. Indeed, issues of economic, racial, and health justice converge at the intersection of incarceration and health.

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Given the profound impact of the U.S. criminal justice system on health, particularly for low-income people of color and other marginalized populations, expanding the MLP approach to address clients' criminal legal needs is an important step in MLP evolution. The LTC-RIPD MLP demonstrates some of the benefits of such a partnership for clients. As an academic MLP it offers the potential for training future medical and legal practitioners about the role of mass incarceration in health and opportunities for interprofessional collaboration and advocacy. Until the U.S. begins to sufficiently address its penchant for punitive approaches to a wide range of deeply entrenched social and health problems, this type of interprofessional training and practice is a promising approach to reducing the harms of mass incarceration for individuals, families, and communities.

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