Public Health and Safety:

The Social Determinants of

Health and Criminal Behavior

Gregg D. Caruso
SUNY Corning
USA

Cite as:

Gregg D. Caruso. 2017. Public Health and Safety: The Social Determinants of Health and Criminal
Behavior. UK: ResearchersLinks Books.

Gregg Caruso
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 Public Health and Safety: addressing issues of social justice—including
The Social Determinants of Health and Criminal the social determinants of health (SDH) and the
Behavior social determinants of criminal behavior (SDCB)—
and I recommend eight general policy proposals
Gregg D. Caruso consistent with my model.

There are a number of important links and I. The Social Determinants of Health and Criminal
similarities between public health and safety. Behavior
In this extended essay I will defend and expand
my public health-quarantine model (see Caruso The social determinants of health are the
2016, forthcoming-a, b; Pereboom and Caruso conditions in which people are born, grow,
2017), which is a non-retributive alternative work, live, and age, and the wider set of forces
for addressing criminal behavior that draws on and systems shaping the conditions of daily life
the public health framework and prioritizes (World Health Organization 2017). These forces
prevention and social justice. In developing my and systems include economic policies and
account, I will explore the relationship between systems, development agendas, social norms,
public health and safety, focusing on how social social policies, and political systems. A core
inequalities and systemic injustices affect health function of public health institutions is to identify
outcomes and crime rates, how poverty affects and take action on the social determinants of
brain development, how offenders often have pre- health to address health inequities. One of the
existing medical conditions (especially mental things I want to argue in this paper is that, just as
health issues), how involvement in the criminal it is important to identify and take action on the
justice system itself can lead to or worsen health social determinants of health (SDH) if we want to
and cognitive problems, how treatment and improve health outcomes, it is equally important
rehabilitation methods can best be employed to identify and address the social determinants of
to reduce recidivism and reintegrate offenders criminal behavior (SDCB) if we want to reduce
back into society, and how a public health crime and improve public safety. Since the social
approach could be successfully applied within determinants of health and criminal behavior are
the criminal justice system. My approach will broadly similar, or so I will argue, I contend that
draw on research from the health sciences, social we should adopt a broad public health approach
sciences, public policy, law, psychiatry, medical focused on prevention and social justice for
ethics, neuroscience, and philosophy, and I will identifying and taking action on these shared
deliver a set of ethically defensible and practically social determinants.
workable proposals for implementing the public
health-quarantine model. 1.1 Poverty and Socioeconomic Status

I begin in §1 by discussing recent empirical One of the most important determinants of

findings in psychology, neuroscience, and the health and criminal behavior is poverty and
social sciences that provide us with an increased socioeconomic status. In 2015, 43.1 million
understanding of the social and neurological people in the United States (13.5% of the
determinants of health and criminal behavior. population) lived below the official poverty
I then turn in §2 to my public health-quarantine line (United States Census Bureau 2016), and
model and argue that it provides the most justified, worldwide 9.6% of the world’s population lived
humane, and effective approach for addressing on $1.90 or less a day (The World Bank 2015).
criminal behavior. I conclude in §3 by proposing This is significant because we know that poverty
a capability approach to social justice grounded or low socioeconomic status can have profound
in six key features of human well-being. I argue negative effects on health. Numerous studies have
that we cannot successfully address concerns over shown that individuals with lower socioeconomic
public health and safety without simultaneously status (or SES) have higher rates of mortality and
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morbidity, including obesity, cardiovascular risk factor for subsequent criminal and substance
disease, and mental illness (see, e.g., Adler et al. misuse behaviors (Carlen 1988; Wright et al.
1994; Anderson and Armstead 1995; Chen et al. 1999; William and McShane 1998; Galloway and
2002; Chen 2004; Berkman and Epstein 2008; Akil Shardhamar 2010; Sareen et al. 2011; Fergusson,
and Ahmad 2011; Franks et al. 2011).1 One study Swain-Campbell, and Horwood 2004; Webster
found that low SES had almost the same impact on and Kingston 2014). A Norwegian total population
health than smoking or a sedentary lifestyle, and study found that children of parents in the lowest
was associated with a reduced life expectancy of income decile were twice as likely to be convicted
2.1 years (Stringhini et al. 2016). Interestingly, the of a violent or drug crime compared with their
relationship between SES and health holds true peers in the fifth decile (Sariaslan et al. 2014:
whether it is measured as the prevalence rate of 286; Galloway and Shardhamar 2010). Similarly,
illness, the severity of illness, or the likelihood of a number of longitudinal USA studies have linked
mortality, and it is true for most types of diseases, low-income levels with substance use disorders
as well as for many risk factors for disease (Chen (Sareen et al. 2011; McMillan et al. 2010).
2004: 112; Berkman and Epstein 2008). It also Additional studies have found that childhood
holds true across the life span, from childhood to socioeconomic disadvantage is associated with
older adulthood. And perhaps most intriguing, the increases in rates of both self-reported crime and
relationship between SES and health exists as a officially recorded convictions (Fergusson, Swain-
gradient—i.e., it is not just that poor people have Campbell, and Horwood 2004) and that poverty
poorer health than rich people. Rather, “each step increases the likelihood that a person will commit
increase in SES is accompanied by incremental crime, be apprehended, and be the victim of crime
benefits in health” (Chen 2004: 112). (Sampson and Laub 2003; Lewontin 2000). The
relationship between poverty and violence also
In addition to low SES, higher levels of income appears to hold across different sorts of violent
inequality have also been shown to have a crimes, including murder, assault, and domestic
negative effect on health, including higher rates violence (Kelly 2000; Martinez 1996; Parker 1989;
of mortality and morbidity (see Kawachi et al. Pridemore 2011).
1997; Kennedy et al. 1996; Pickett et al. 2005;
Diez-Roux 2000; Pickett and Wilkinson 2010; This does not mean, of course, that poverty alone
Johnson et al. 2015). In a survey of data from 12 is responsible for these anti-social behaviors since,
developed countries, Pickett and Wilkinson (2010) as we’ll see below, there are other important social
discovered that countries with higher income- determinants of drug misuse and violent behavior.
inequality had three times as many individuals We also know that poverty and low SES can
with mental illness than those with lower income- cause depression in adolescents, and studies have
inequality. And Kahn et al. (2000) found that those found that an increase in depressive symptoms
living in states with higher income inequality had is associated with a significant elevated risk of
higher rates of depressive symptoms and poorer subsequent violence (Yu et al. 2017). Behavioral
self-rated health in mothers at the bottom 20% of genetic investigations also indicate that the
household income. likelihood for both violent offending and substance
misuse are influenced by shared genetic and family
Unfortunately, these negative effects of environmental factors (Frisell et al. 2011; Kendler
socioeconomic status are not limited to poor et al. 2012). The few studies, however, that have
health. A number of studies have also found that controlled for these genetic factors have found
poverty and low SES during childhood is a distal that there still remains an inverse association
between parental income during childhood and
1
Socioeconomic status (or SES) is a multidimensional development of behavioral problems (D’Onofrio
construct. It typically combines a number of objective factors
such as an individual or parent’s education, occupation, and
et al. 2009; Hao and Matsueda 2006; Blau 1999;
income, as well as subjective perceptions of social status and Jaffee et al. 2012; cf. Sariaslan et al. 2014). It would
social class (Brito and Noble 2014: 1; McLoyd 1998). seem, then, that poverty or low SES remains a risk
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fact for substance misuse and criminal behavior.2 Disparities in the quantity and quality of linguistic
stimulation in the home, for instance, have been
Determining exactly why this is the case is no associated with developmental differences in
doubt difficult to do, but we are beginning to language-supporting cortical regions in the left
understand some of the causal mechanisms hemisphere (Kuhl et al. 2003; Conboy and Kuhl
at play. We know, for instance that: “Human 2007; Kuhl 2007; as cited by Brito and Noble 2014:
development does not occur within a vacuum. The 2). We also know that the experience of stress has
environmental contexts and social connections important negative effects on the hippocampus
a person experiences throughout his or her (Buss et al. 2007; McEwen and Gianaros 2010;
lifetime significantly impact the development Tottenham and Sheridan 2010), the amygdala
of both cognitive and social skills” (Brito and (McEwen and Gianaros 2010; Tottenham and
Noble 2014: 1). Numerous studies have shown Sheridan 2010), and areas of the prefrontal cortex
that socioeconomic disparities profoundly affect (Liston et al. 2009; McEwen and Gianaros 2010)—
physical health, mental wellbeing, and cognitive structures which are linked together anatomically
development (Anderson and Armstead 1995; and functionally (Brito and Noble 2014: 2). Several
Brooks-Gunn and Duncan 1997; McLoyd 1998; recent studies, in fact, have directly studied the
Evans 2006; Brito and Noble 2014; Nobel et al. connection between socioeconomic parameters
2015a). Studies indicate, for instance, that SES (e.g., family income and parental education) and
accounts for approximately 20% of the variance cognitive and neurological development (see,
in childhood IQ (Gottfried et al. 2003) and it has e.g., Hackman and Farah 2009; Hackman et al.
been estimated that by age five, chronic poverty is 2010; Piccolo et al. 2016; Noble 2015b; Lawson
associated with 6 to 13-point IQ reduction (Brooks- et al. 2013; Mackey et al. 2015). They found that
Gunn and Duncan 1997; Smith et al. 1997; as lower SES is related to smaller overall cortical
cited by Brito and Noble 2014). Evidence suggests surface and thinner prefrontal cortex (Nobel et
multiple possible, and non-mutually exclusive, al. 2015b; Lawson et al. 2013), that both family
explanations for these findings (Brito and Nobel income and parental education moderate non-
2014: 2). Socioeconomically disadvantaged linear age-related variations in cortical thickness
children, for instance, tend to experience less (Piccolo et al. 2016), and that female adolescents
linguistic, social, and cognitive stimulation in neighborhoods with high-inequality and low
from their caregivers and home environments household income displayed a significant age-
than children from higher SES homes (Brito and related decrease in cortical thickness compared to
Nobel 2014: 2; Hart and Risley 1995; Bradley et their peers (Parker et al. 2017).
al. 2001; Bradley and Corwyn 2002; Rowe and
Goldin-Meadow 2009). Additionally, individuals We can conclude that while we may not yet fully
from lower SES homes report more stressful understand all the causal mechanisms by which
events during their lifetime, and the biological socioeconomic factors affect health and safety,
response to stressors has been hypothesized as poverty and socioeconomic status are important
one of the underlying mechanisms for health and social determinants of both. Poverty and low
cognitive disparities in relation to SES (Brito andSES can increase levels of stress, expose agents
Nobel 2014: 2; Adler et al. 1994; Anderson and to more negative life events, limit educational
Armstead 1995; Cohen et al. 1999; Hackman and opportunities, and profoundly affect the social,
Farah 2009; Nobel et al. 2012a; Wilkson 1999). cognitive, and neurological development of
agents. To reduce crime and increase health we
These experiential differences are also “likely to need to adopt policies that directly address these
have specific downstream effects on particular socioeconomic factors.
brain structures” (Brito and Noble 2014: 2).
1.2. Abuse and Domestic Violence
2
Studies also reveal that societies with greater inequality have
higher rates of violent crime (see, e.g., Vives-cases et al. 2015; In addition to poverty and socioeconomic
Enamorado and Rodrigiez-Castelan 2015; Ouimet 2010).
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status, there are also a number of other social adolescents, retrospective reports of witnessing
determinants of health and criminal behavior that violence and victimization were the strongest
a public health approach would need to address. predictor of current use of violence, such as
These include education, housing, healthcare, involvement in fights and carrying weapons
childhood abuse, and domestic violence. Take (Durant et al. 1994; Weaver, Borkowski, and
exposure to violence, for example. While it Whitman 2008: 96).3 And Flannery et al. (1998)
transcends age and SES and affects all levels of found that violent behavior among adolescents
income, education, and occupation, it overlaps who were exposed to high levels of home violence
with these other social determinants of health and were three times higher for girls and two times
crime since youth from lower SES backgrounds higher for boys when compared with adolescents
tend to have increased exposure and likelihood from low-violence homes (see also Stouthamer-
of suffering from detrimental future outcomes. Loeber et al. 2002). Additional studies have found
We know that safe, stable, nurturing relationships that exposure to violence at school is associated
and environments are essential to prevent child with concurrent violent behavior as well as
maltreatment and to assure that children reach their psychological trauma (Flannery, Wester, and
full potential (American Psychological Association Singer 2004), that observing violence and family
Fact Sheet 2017; Centers for Disease Control and conflict is correlated with increased depressive
Prevention 2014). And child maltreatment takes symptoms during high school (Eisman et al. 2015;
a large economic toll on our society through Lambert et al. 2010), that adolescents exposed
child welfare costs, physical and mental health to community violence have lower high school
costs, special education costs, and legal system grade point averages and decreased enjoyment
costs (Fang et al. 2012; APA 2017). Research and interest in school (Borofsky et al. 2013; Strom
shows that adverse childhood experiences are et al. 2013), and that neighborhood violence has
associated with risky health behaviors, crime, a negative impact on children’s math and reading
chronic health conditions, low life potential, scores on standardized tests (Milam, Furr-Holden,
and early death (Centers for Disease Control and and Leaf 2010) (see also American Psychological
Prevention 2016)—all of which have a profound Association Fact Sheet 2017).
negative impact on the health and opportunity of
individuals. Domestic violence is another social determinant
of health and safety and has been shown to
Exposure to violence during adolescence, for have long-term negative effects on employment,
instance, has been shown to correlate with mental health, and incarceration rates, especially
reduced educational attainment, decreased for women. Studies have found that women in
odds of getting married, reduced income and abusive relationships frequently lose their jobs,
net worth in adulthood, and increased instances experience high job turnover, and are fired or
of delinquency and violent behavior (Covey, forced to quit more frequently (Crowne et al.
Menhard, and Franzese 2013; Weaver, Borkowski, 2011; Adams et al. 2013). And the negative effects
and Whitman 2008; Stouthamer-Loeber et al. of abuse on the ability to remain employed is not
2002). A study conducted by Weaver, Borkowski, just short-term, it also inhibits women’s ability to
and Whitman (2008) found that witnessing maintain a job for some time after the abuse ends
violence and victimization prior to age ten (Adams et al. 2013). Domestic violence has also
predicted delinquency and violent behaviors been identified as the primary cause of family
even after controlling for prenatal maternal homelessness in seventeen percent of cities across
and early childhood externalizing problems. the United States (United States Conference of
Violence victimization, in fact, has been found Mayors 2015). Other studies have found that 85-
to be the single best predictor of juvenile violent 90% of women in prison have a history of being
behaviors for both boys and girls in a nationally 3It should be noted that the carrying of weapons is often done
representative sample of adolescents (Blum, out of fear of victimization rather than violent or malicious
Ireland, and Blum 2003). Among urban black intent (Jenkins and Bell 1994).
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victims of violence prior to their incarceration, with a parent in state or federal prison grew 80
including domestic violence, sexual violence, percent. Today, an estimated 2.7 million children
and child abuse (ACLU 2011). One reasons for in the U.S. have a parent in prison or jail—that is
this is that women are often coerced into criminal 1 in every 28 children (3.6% of all children) (Pew
activity by their abusers or forced to fight back to Charitable Trust 2010).
defend their lives or their children’s lives (Gilfus
2002). 1.3 Housing, Mental Illness, and Healthcare

A study of women incarcerated in New York’s Rikers Housing, mental illness, and access to healthcare
Island found that most of the domestic violence are also social determinants of health and criminal
survivors interviewed reported engaging in illegal behavior and quite often overlap for vulnerable
activity in response to experience of abuse, the populations. For example, about a fifth of the 1.7
threat of violence, or coercion by a male partner million homeless people in the United States suffer
(Richie 1996). Another study found that, of 525 from untreated schizophrenia or manic-depressive
abused women at a mental health center who had illness. And not surprisingly, mental illness often
committed at least one crime, nearly half had been prolongs homelessness. Approximately 26%
coerced into committing crimes by their batterers of homeless adults staying in shelters live with
as “part of a structural sequence of actions in a serious mental illness and an estimated 66% live
climate of terror and diminished, violated sense with severe mental illness and/or substance use
of self” (Loring and Beaudoin 2000). Women, disorders. Mental illness and homelessness also
however, are more likely to be incarcerated for drug puts people at an increased risk of being the victim
and property crimes compared to men, and less of a crime as well as being arrested for a crime,
likely to be incarcerated for violent crime (Carson particularly disorderly conduct and property theft.
2016). Furthermore, women of color and low- In 2005, more than half of all people incarcerated
income women are disproportionately affected by in prisons and jails had a mental illness: 56% of
mandatory arrest policies for domestic violence. state prisoners, 45% of federal prisoners, and 64%
A New York City study found, for example, that of jail inmates (James and Glaze 2006). Of those
of women who had been arrested with their who had a mental illness, about three-quarters
abusers (dual arrest cases) or arrested as a result also had a co-occurring substance use disorder
of a complaint lodged by their abusers (retaliatory (James and Glaze 2006). Researchers have also
arrest cases), 66% were African American or found that of more than 20,000 adults entering
Latina, 43% were living below the poverty line, five local jails, 14.5% of the men and 31% of the
and 19% were receiving public assistance at the women had serious mental illnesses, which taken
time (Haviland et al. 2001). together, comprises 16.9% of those studied—rates
in excess of three to six times those found in the
Sadly the incarceration of women has additional general population (Steadman et al. 2009). And
negative consequences. Studies indicate that 70% the numbers are even worse for juvenile offenders.
of women in prison are mothers (Bloom 2004) Approximately 60-70% of youth in juvenile
and many of them are the primary caretakers justice detention, correctional, or community-
of their children at home (Richie 2000). In fact, based facilities have a diagnosable mental illness
1.3 million children are affected by female and over 27% have a serious mental illness that
imprisonment, including the children left at home impairs his or her ability to function (Skowyra and
when the mother is imprisoned and the babies Cocozza 2006).
born and raised in prison (Poehlman 2003). The
impact of this on children and families is profound Studies have also found that homelessness
and hard to fully calculate. The statistics are even significantly increases the risk of incarceration
more disturbing when one looks at the number of (Greenberg and Rosenheck 2008). One national
children who have either parent in prison or jail. survey of jail inmates found that prison inmates
Between 1991 and 2007, the number of children who had been homeless (that is, those who
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reported an episode of homelessness anytime in 2002; McWilliams 2009; National Immigration
the year before incarceration) made up 15.3% of Law Center 2014). Uninsured adults are more
the U.S. jail population, or 7.5 to 11.3 times the than 25% more likely to die prematurely than
standardized estimate of 1.36% to 2.03% percent adults with health insurance (Bailey 2012). The
in the general U.S. adult population (Greenberg Institute of Medicine (2009) estimates that lack
and Rosenheck 2008). For those with mental of health insurance led to the death of 18,000
illnesses, the rates of homelessness are even adults in the year 2000, making it the sixth most
higher—about 20% (Greenberg and Rosenheck frequent cause that year of death among people
2008). And in comparison with other inmates, aged 18 or 64. Those without access to healthcare
those who were homeless were more likely to be typically avoid seeking medical care unless
currently incarcerated for a property crime, but they are faced with an emergency, or they delay
they were also more likely to have past criminal care until their symptoms become intolerable
justice system involvement for both nonviolent (National Immigration Law Center 2014; Davis
and violent offenses, to have mental health and 2003). As a result, “the uninsured are less likely to
substance abuse problems, to be less educated, receive a diagnosis in the early stages of a disease
and to be unemployed (Greenberg and Rosenheck and are more likely to suffer complications
2008). Others studies have estimated that 25- from aggravated medical conditions” (National
50% of people experiencing homelessness Immigration Law Center 2014). They are more
also have a history of incarceration (Doherty likely to receive, say, an initial diagnosis of cancer
2015). Additional studies have found that the at a later stage of the disease and die within
relationship between homelessness and prison less time after diagnosis (Davis 2003). And with
runs in the other directions as well—i.e., upon acute or sudden conditions, such as injuries, the
release from prison those who were previously uninsured tend to experience poorer medical
homeless often return to homelessness while many outcomes, are less likely to fully recover, and more
others experience homelessness for the first time. likely to die as a result of the injury (McWilliams
There are a number of reasons for this including 2009). The uninsured (and underinsured) are also
decreased employability, stigmatization, and more likely to be crushed by the healthcare costs
exclusion from public housing in some states due associated with these treatments, forcing many to
to a felony conviction. These findings suggest that go bankrupt. According to Health Affairs, nearly
homelessness and incarceration increase the 2 million Americans filed for medical bankruptcy
risk of each other, and these factors seem to be in 2001 due to unexpected health problems
mediated by mental illness, substance abuse, (Himmelstein et al. 2005).
education, and low SES. Adopting a public
health approach to health and safety would Studies have also found that people in the
require tackling the problem of homelessness criminal justice system experience chronic health
and working to more effectively transition conditions, infectious diseases, substance use
offenders back into society. disorders, and mental illnesses at much higher rates
than the general population (see, e.g., National
Access to healthcare is another social determinant Commission on Correctional Health Care 2002;
of health and criminal behavior. For many Cloud 2014; Rich et al. 2014). And since more than
vulnerable populations, including the homeless, 95% of prisoners eventually return to the general
poor, and mentally ill, not having access to population, bringing their health conditions with
affordable and consistent healthcare means them, and 80% are without health insurance
forgoing treatment for mental illness, substance upon reentry into the community (Rich et al.
use, chronic health conditions, acute care, and 2014), treatment initiated during incarceration
injuries. Those without health insurance have less frequently stops when an individual returns to
access to recommend care, receive poorer quality society—including even HIV care, which often
of care, and experience worse health outcomes receives priority treatment in the incarcerated
than insured adults do (Institute of Medicine setting (Montague et al. 2012; Rich et al. 2011).
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This has, as one would predict, profound negative achievement is associated with lower levels
health consequences. Numerous studies have of criminal behavior, reoffending, and better
found that risk of emergency care, hospitalization, outcomes into adulthood (see, e.g., Katsiyannis et
and death is exceptionally high after release from al. 2008). And a 2013 RAND Corporation study
jail or prison (Rich et al. 2014; Binswanger et showed that participation in prison education,
al. 2007; Spaulding et al. 2011; Binswanger et including academic and vocational programming,
al. 2013; Frank et al. 2013; Wang, Wang, and was associated with an over 40% reduction in
Krumholz 2013). If we want to improve public recidivism—while also saving $4 to $5 for each
health and safety, we should heed the advice dollar spent (Davis et al. 2013).
of Rich et al. (2014) and view incarceration as
a public health issue and draw those who are Environmental health and nutrition are also
incarcerated into the healthcare system. This is important determinants of public health and
“critical for the nation” and “is especially relevantsafety. As Georges Benjamin, the Executive
for poor communities, communities of color, Director of the American Public Health
and other socially marginalized groups that are Association (APHA), writes: “Many communities
both disproportionately imprisoned and often lack access to nutritious, affordable food; are
disenfranchised from medical care” (2014: 463). denied safe places to walk and exercise; or live
near polluting factories.” And as a result, the
1.4 Education, Environment, and Nutrition “health risks for these families are greater” (APHA
2017). The World Health Organization (WHO)
We also know that education, environmental defines environment, as it relates to health, as
health, and poor nutrition are important social “all the physical, chemical, and biological factors
determinants and have a profound negative external to a person, and all the related behaviors”
affect on public health and safety. Beginning with (WHO 2006). And environmental health consists
education, studies indicate that only about half of preventing or controlling disease, injury, and
of incarcerated adults have a high school degree disability related to the interaction between
or its equivalent (Harlow 2003) and youth in people and their environment. As APHA puts it:
the juvenile system are significantly more likely
than other youth to have academic skills well Environmental health is the branch of public
below their grade level, possess a learning or health that: focuses on the relationships
developmental disability, and drop out of school between people and their environment;
(Katsiyannis et al. 2008). According to the Urban promotes human health and well-being;
Institute, employment rates and earning histories and fosters healthy and safe communities.
of people in prison and jail are often low before Environmental health is a key part of any
incarceration as a result of limited education, low comprehensive public health system.
job skill levels, and the prevalence of physical and The field works to advance policies and
mental health problems—and incarceration only programs to reduce chemical and other
exacerbates these challenges (Holzer, Raphael, environmental exposures in air, water, soil
and Stoll 2003). A three-state recidivism study and food to protect people and provide
conducted from 2001 to 2006 found that less than communities with healthier environments.
half of people released from prison had secured (2017)
a job upon their return to the community (Visher,
Debus, and Yahner 2008). Almost all experts A comprehensive public health approach should
agree that education is important for preventing therefore incorporate a focus on, and concern
the occurrence of crime before it occurs and for, air quality, surface and ground water quality,
can help lower recidivism rates, especially if toxic substances and hazardous wastes, climate
educational opportunities (including job training) change, exposure to lead in homes and schools,
are extended into prison. In fact, numerous studies epidemiology, and other environmental factors,
show that enrollment in school and academic since we know that these can (and do) have
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profound effects on public health and safety. are primarily borne by populations in developing
counties and by children.
Given limited space, I can only briefly mention
a few of these determinants of health here—for Exposure to lead is another major determinant
a more comprehensive understanding of these of health. It can be caused (as we know from the
issues see World Health Organization (2002, tragic events in Detroit) by contamination from
2006a). Let me begin with air quality. We know lead pipes, or by inhalation of lead particles,
that poor air quality is linked to premature death, ingestion of lead-contaminated dust or paint
cancer, and long-terms damage to respiratory and chips, or eating food from lead-glazed containers.
cardiovascular systems (WHO 2005, 2006a, 2013, Lead is a cumulative toxicant that affects multiple
2016a). And while we have made some progress body systems and is particularly harmful to young
reducing harmful air emissions, the EPA estimates children. When it enters the body it is distributed
that in 2008 approximately 127 million people to the brain, liver, kidney, and bones—and no
lived in U.S. counties that exceeded national air known level of lead exposure is considered safe.
quality standards (U.S. Environmental Protection According to the World Health Organization,
Agency 2010). The World Health Organization young children are particularly vulnerable to the
(WHO) further estimates that in 2014, 92% of toxic effects of lead and can suffer profound and
the world population was living in places where permanent adverse health effects, particularly
WHO air quality guidelines levels were not met affecting the development of the brain and nervous
(WHO 2016a). These are troubling statistics since system (WHO 2010, 2016b). Lead also causes
outdoor air pollution was estimated to cause 3 long-term harm in adults, including increased
million premature deaths worldwide in 2012 risk of high blood pleasure and kidney damage.
(WHO 2016a). And exposure to pregnant women to high levels
can cause miscarriage, stillbirth, premature birth,
Surface and ground water quality is another major and low birth weight, as well as malformations
determinant of environmental health. Worldwide, (WHO 2010, 2016b). Children who survive lead
water-related disease remains one of the major poisoning may be left with mental retardation and
health concerns. Diarrhoeal diseases, which are behavioral disorders. As the WHO describes, “lead
largely derived from poor water and sanitation, affects children’s brain development resulting in
accounted for 1.8 million deaths in 2002 and reduced intelligence quotient (IQ), behavioral
contributed around 62 million Disability Adjusted changes such as reduced attention span and
Life Years per annum (WHO 2004a). According increased antisocial behavior, and reduced
to the World Health Organization, “this places educational attainment” (WHO 2016b; see also
diarrhoeal diseases as the sixth highest cause of 2010). In fact, numerous studies have found that
mortality and third in the list of morbidity and it the brain damage caused by exposure to lead and
is estimated that 3.7 per cent of the global disease the neurobehavioral changes associated with it
burden is derived from poor water, sanitation and are irreversible and untreatable (Needleman et
hygiene (Pruss-Ustun et al. 2004)” (WHO 2006b: al. 1990; Bellinger, Stiles, and Needleman 1992;
3). It was estimated that in 2002, roughly one-sixth Burns et al. 1999; Rogan et al. 2001; Wright et al.
of humanity (1.1 billion people) lacked access 2008).
to any form of improved water supply within 1
kilometer of their home, and approximately 40 per Given the focus of this paper, a few additional
cent of humanity (2.6 billion people) lack access facts are worth mentioning. First, exposure to lead
to some form of improved excreta disposal (WHO is often a byproduct of other social injustices and
and UNICEF 2004). This is clearly a public health is completely preventable. As the WHO describes:
crisis and needs to be given urgent attention. To
properly address it, though, a number of other Although lead can affect children from
social inequities will need to be addressed as every socioeconomic stratum, socially and
well, since these negative health consequences economically deprived children in low-
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 income countries carry the greatest burden homicide rates. Aizer and Currie (2017), on the
of disease due to lead. Poor people are other hand, used data linking preschool blood
more likely to be exposed to lead and to lead levels with data on school detention and
be at risk of exposure to multiple sources. suspension for 120,000 children born between
They are more likely to dwell on marginal 1990-2004 in Rhode Island. They found that a
land (near landfills and polluted sites), to one-unit increase in lead increased the probability
live in substandard housing with ageing of suspension from school by 6.4-9.3% and the
and deteriorating lead-based paint, and potential of detention by 27-74%, though the
to live near industry sites where waste is latter applied only to boys. Billings and Schnepel
burned… (2010: 35). (2015) took a different approach and studied the
effect of CDC-recommended interventions for
The WHO report goes on to say: kids with elevated blood lead levels. Since kids
are required to test positive for lead twice to get
Communities that lack political influence, services, they hypothesized that the random noise
communities that are disenfranchised, and in the test could be used to study the effects of
ethnic minority groups have repeatedly treatment—that is, they presumed that a lot of kids
been shown to be at greater risk of who test over the threshold once but not a second
exposure to lead than other populations. time do so for reasons other than their actual lead
Such communities typically lack the exposure. Using data on kids born between 1990
power to force companies, such as lead and 1997 in Charlotte, N.C., and comparing blood
recyclers or smelters, to stop polluting lead level tests with school records and adult
their environment. (WHO 2010: 35; see arrests, they found that kids who received the
also American Pediatrics Committee on intervention exhibited substantially less antisocial
Environmental Health 2003). behavior, including suspensions, absences, school
crimes, and violent crime arrests. While much
I will address the issue of social justice in the final more work in this area needs to be done, these
section of this paper, but it may already be clear findings suggest that lead exposure is potentially
to some readers that a comprehensive approach a public health and safety issue (see also Drum
to public health and safety will require our 2016).
institutions—especially our health and criminal
justice institutions—to become de facto social Climate change is another determinant and is
justice institutions. likely to have profound negative effects on public
health and safety. The Intergovernmental Panel on
The second thing I want to note is that since Climate Change (IPCC) projects, for example, that
lead exposure at young ages leaves children climate change will impact sea level, patterns of
with problems like learning disabilities, ADHD, infectious diseases, air quality, and the severity
and impulse control, it has also been proposed of natural disasters such as floods, droughts, and
that it can lead to increases in criminal behavior storms (IPCC 2014a, b, c; see also Patz et al. 2005;
(Feigenbaum and Muller 2016; Aizer and Currie Kinney 2008). And while many are beginning to
2017; Billings and Schnepel 2015). Three different understand that we need to combat climate change
research teams have recently studied the effects for the sake of society and its environmental
of lead exposure on juvenile delinquency and health (although, perhaps, not enough), very
crime rates, and each found some support for few realize that climate change is also a “threat
the claim. Feigenbaum and Muller (2016) used multiplier” and will likely increase the incidents
homicide rates between 1921 and 1936 and of war, conflict, and violence (NATO Science and
compared them to cities with municipal water Technology Committee 2017; Weaver et al. 2017;
systems that used either lead or iron service pipes. U.S. Defense Department 2015). A new NATO
They found support for the hypothesis that lead special report concludes that climate change is the
service pipes considerably increased city-level ultimate “threat multiplier”—meaning that it can
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exacerbate political instability in the world’s most Health Organization (WHO) and the Food and
unstable regions. By intensifying extreme weather Agriculture Organization (FAO) (2003) found, for
events like droughts, climate change stresses food example, that many of the deaths and disabilities
and water supplies. In poor, arid countries already caused by the major nutrition-related chronic
facing food and water shortages, this increased diseases are due to risk factors that could easily be
stress can lead to disputes and violent conflict over prevented. The report goes on to make a number
scarce resources. Rising sea levels can also cause of recommendations to help prevent death and
refugee crises as large numbers of people are disability from major nutrient-related chronic
forced to relocate, and this too can cause conflict diseases. Unfortunately, many poor, disadvantaged,
as resources get stretched and cultures clash. and marginalized people find it difficult (or even
impossible) to follow these guidelines due to larger
The U.S. Department of Defense (DoD) has systemic social inequities. This is why concern
also concluded that climate change is a threat for public health and safety cannot be separated
multiplier and that “climate change is an from issues of social justice—i.e., we will need
urgent and growing threat to national security, to address these larger social issues if we want
contributing to increased natural disasters, to promote public health and safety. With regard
refugee flows, and conflicts over basic resources to diet and nutrition, these include addressing
such as food and water” (DoD Report 2015: 3). household food security (e.g., access to affordable
Former Defense Secretary Chuck Hagel said, for and appropriate food), national and regional food
example: “Rising global temperatures, changing security (e.g., the ability to provide adequate
precipitation patterns, climbing sea levels and nutrition within a country without relying heavily
more extreme weather events will intensify the on imported products), and cold-chain reliability
challenges of global instability, hunger, poverty, (the safety of transporting products that deteriorate
and conflict.” He went on to say that, “They will microbiologically in the heat).
likely lead to food and water shortages, pandemic
disease, disputes over refugees and resources, and It should also be noted that like many of the other
destruction by natural disasters in regions across social determinants discussed thus far, there is
the globe” (DoD News 2014). The U.N. Secretary- good reason to think that poor nutrition and diet
General Antonio Guterres has also made similar can also negatively impact public safety, not just
statements (U.N. Press Release 2017). And in 2016, health. For instance, several studies now suggest
a coalition of twenty-five military and national that nutrient-poor diets can contribute to violent
security experts, including former advisers to criminal acts and psychopathology (see, e.g.,
Ronald Reagan and George W. Bush, warned that Gesch, et al. 2002; Zaalberg et al. 2010; Deans
climate change poses a “significant risk to U.S. 2011; Hibbeln 2001). In one study conducted
national security and international security” and by Bernard Gesch and colleagues (2002), 231
requires immediate attention from the U.S. federal adult male prisoners received a daily vitamin,
government (Center for Climate and Security mineral, and essential fatty acid supplementation
2016). It would seem, then, that climate change or a placebo. After 142 days, Gesch et al. found
is not only an environmental issue, it is a major that the disciplinary incidents per 1000 person-
public safety concern. days dropped from 16 to 10.4 in the active group,
which is a 35% reduction, whereas the placebo
One last social determinant worth mentioning group only dropped 6.7%—and for especially
here is diet and nutrition. We know that access violent incidents, the active group dropped by
to food, diet, and good nutrition are a critical 37%. Zaalberg and colleagues (2010) were able to
pathway in influencing chronic conditions replicate these findings—the only difference was
such as hypertension, diabetes, cardiovascular that in their study the supplements used included
disease, obesity, cancer, osteoporosis, and dental increased doses of omega 3 fatty acids compared
disease (Viswanath and Bond 2007; WHO to Gesch. These results, especially with regard to
2002, 2003). A joint report put out by the World omega-3s, are interesting since there is growing
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evidence that low levels of omega-3 alongside that nutritional supplementation of omega-3,
other micronutrient deficits may be linked to multivitamins, and minerals over 3 months,
antisocial and aggressive behavior (Gesch, et al. combined with cognitive behavior therapy,
2002; Corrigan et al. 1994; Schoenthaler 1983a, reduced childhood aggression in 11 to 12-year-
1983b; Schoenthaler and Bier 2000). olds.

Two randomized clinical trials, for instance, have These findings not only highlight the importance
found that anger scores were reduced among of diet and nutrition with regard to public health
substance abusers and participants with borderline and safety, they also suggest that supplements,
personality disorder when administered omega-3’s including omega-3’s, can potentially be used
(Buydens-Branchey, Branchey, and Hibbeln 2008; (along with more traditional therapies) to help
Zanarini and Frankenburg 2003). And a study by reduce aggression, violence, and crime.
Gow and colleagues (2013) conducted in children
and adolescents with ADHD and symptoms of 1.5 The Neuroscience of Psychopathy
conduct-disorder found that low blood levels of
omega-3 were negatively associated with high Let me conclude this section with a brief discussion
scores on callous and unemotional (CU) traits. of psychopathy since it is, perhaps, the best-known
This is particularly interesting since callous and personality disorder associated violent antisocial
unemotional traits are a sizeable risk factor for the behavior. Psychopathy is a “personality construct
later development of psychopathy and antisocial characterized by deficits in interpersonal relations
behaviors. These and other findings lead Adrian and affect processes (e.g., fearlessness, callousness,
Raine to suggest that omega-3s might be a place failure to form close emotional bonds, dishonesty,
to intervene given everything we know about the deficits in passive avoidance learning, and
neuroanatomy of violent criminals (Raine et al. deficient empathic responses) as well as antisocial
2016)—since it has been shown that omega-3 and impulsive behavior” (Leutgeb et al. 2015: 195;
supplementation increases the function of the Hare and Neumann 2008). Psychopathy is strongly
dorsolateral prefrontal cortex, a region Raine found associated with violence and criminal recidivism
to have higher rates of damage or dysfunction in (Hare 1991, 2003; Kiehl and Hoffman 2011)—
criminal offender (Raine 2014; Raine et al. 2000). and the conning, manipulative, interpersonal style
of psychopaths typically has a broad, destructive
In one study, Raine and colleagues (2014) impact on the individuals’ life, work, and
conducted a longitudinal study of children in the relationships (Anderson and Kiehl 2014: 103).
small island of Mauritius, and found that omega-3 The Psychopathy Checklist-Revised is widely used
may have long-term neurodevelopmental effects as the measure to identify psychopathic traits
that ultimately reduce antisocial and aggressive and it comprises two factors reflecting emotional
behavior in children. The study tracked the and interpersonal detachment (Factor 1) as well
development of children who had participated as antisocial behavior and parasitic lifestyle
in an enrichment program as three-years-olds, (Factor 2) (Hare 2003). Given its connection with
as well as the development of children who did violence and criminal behavior, psychopathy is
not participate. The enrichment program had clearly relevant to our discussion of public health
additional cognitive stimulation, physical exercise, and safety.
and nutritional enrichment—including an extra
two and a half portions of fish a week. They found Measures of psychopathy have proven to be
that at 11 years old, participants in the enrichment valuable for risk assessment in violent criminals.
program showed a marked improvement in brain As Anderson and Kiehl summarizes the findings:
function as measured by EEG, as compared to
those who did not participate. And at age 23, they While only about 1% of the adult general
showed a 34% reduction in criminal behavior. population would be classified as such
In a more recent study, Raine et al. (2016) found by Hare’s Psychopathy Checklist-Revised,
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 psychopaths make up around 20% of Leutgeb et al. (2015), for example, compared
the prison population in North America structural imaging data from 40 male high-risk
(Hare 2003). Above and beyond criminal violent offenders and 37 non-delinquent healthy
activity, psychopaths are particularly prone
controls via voxel-based morphometry. They
to violence, demonstrating increased then correlated psychopathic traits and risk for
aggressive behavior and committing a violence recidivism with grey matter volume of
greater number of violent attacks than regions of interest previously shown relevant for
non-psychopaths (Salekin et al. 1996)… criminal behavior. They found that (a) relative
Psychopathy is also a strong predictor of
to controls, criminals showed less gray matter
how likely one is to re-offend after release
volume in the prefrontal cortex and more gray
from prison (Hart et al. 1988; Porter et
matter volume in cerebellar regions and basal
al. 2001), and it is a particularly strong
ganglia structures; (b) within criminals, there was
predictor of violent recidivism (Cornell et
a negative correlation between prefrontal gray
al. 1996; Harris et al. 1991; Port et al. 2009).
matter volume and psychopathy; (c) there was
Within one year of release psychopaths are
a positive correlation between cerebellar gray
about three times more likely to recidivate
matter volume and psychopathy as well as risk of
than non-psychopaths, and four times more
recidivism for violence; (d) gray matter volumes
likely to violently recidivate (Hemphill
of the basal ganglia and supplementary motor
et al. 1998). Indeed, after 10 years, 77%
area were positively correlated with anti-sociality,
of psychopaths had committed a violent and (e) that gray matter volume of the amygdala
offense compared to 40% of the sample was negatively correlated with dynamic risk for
in a large follow-up assessment (Harrisviolence recidivism (Leutgeb et al. 2015). They
et al 1991). Non-psychopathic offenders’
concluded that in violent offenders, deviations
violent recidivism rates appear to plateau
in gray matter volume of the prefrontal cortex as
at about 40%; however after 20 years, it
well as areas involved in the motor component
was reported that 90% of psychopaths had
of impulse control (cerebellum, basal ganglia,
committed another violent crime (Rice and
supplementary motor area) are differentially related
Harris 1997). Furthermore, these trendsto psychopathic traits and the risk of violence
remain consistent outside North American,
recidivism. Other neuroimaging investigations
generalizing across a variety of cultures
have found reductions in orbitofrontal gray matter
(Hare et al. 2000). (Anderson and Kiehlin psychopaths (e.g., Boccardi et al 2011; Tiihonen
2014: 107-8) et al 2008; de Oliveira-Souza 2008) as well as
volume reduction in the most anterior frontopolar
Since the core features of psychopathy appear to be regions of the prefrontal cortex (Tiihonen et al.
developmental in nature, with relatively persistent 2008; de Oliveira-Souza2 008).
traits becoming apparent before the age of 10,
the better we understand how “neurocognitive The amygdala also features prominently in
peculiarities can hijack the development of our theories of psychopathy due to its role in forming
moral sensibility” (Anderson and Kiehl 2014: stimulus-reinforcement association, conditioned
103) the more successful we will be in developing fear responses, and the initiation of affective states
new strategies for managing the specific deficits (David 1997; Davis and Whalen 2001; Anderson
responsible for this altered developmental and Kiehl 2014: 111). And recent neuroimaging
trajectory. data has strongly implicated the involvement of
the amygdala in psychopathy-related deficits
Over the last few decades, neuroscientists have (Anderson and Kiehl 2014: 111). In one large-scale
begun to study the neuronal basis of psychopathy investigation involving nearly 300 incarcerated
(see e.g., Raine et al. 2000; Glenn et al. 2010; subjects, Ermer and colleagues (2011) found
Glenn, Yang, and Raine 2012; Viving, McCory, that psychopathy was associated with decreased
and Seara-Cardoso 2014; Leutgeb et al. 2015). regional gray matter in several paralimbic and
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limbic areas, including the amygdala. Yang et
al. (2010) also found that volume reductions in Given these new insights into the neurological
both the prefrontal cortex and the amygdala were correlates of psychopathy, neuroscientific methods
more pronounced in psychopaths with criminal may have the potential to improve existing tools for
convictions compared to both controls and prediction of violence recidivism (Leutgeb et al.
“successful” psychopaths. And in their overview 2015: 194; see also Meixner 2014). But unlike the
of the neuroscientific literature on psychopathy, social determinants of health and criminal behavior
Anderson and Kiehl describe a number of other discussed earlier, I want to flag a few potential
findings related to the amygdala and prefrontal ethical concerns about the use of neuroscience
cortex: in predicting future violent behavior. The use of
neuroscience in criminal law has recently become
Kiehl and colleagues (2001) were the first a topic of much debate and has even given birth to
to report amygdala dysfunction in criminal a new area of study called neurolaw (see, e.g., Shen
psychopaths using fMRI, demonstrating 2010; Jones 2013; Jones et al. 2013a, b; Meixner
reduced activity there when comparing 2014). John Meixner identifies three major areas
emotional and non-emotional words. of interest regarding the application and use of
Amygdala deficits in psychopathy have neuroscience within the law: (1) neuroscience-
also been demonstrated during aversive based credibility assessments, which seeks to
conditioning (Birbaumer et al. 2005; detect lies or knowledge associated with a crime;
Rilling et al. 2007; Veit et al. 2002), when (2) application of neuroscience to aid in assessment
viewing pictures depicting moral violations of brain capacity for culpability, especially
(Harenski et al. 2010), viewing pictures of among adolescents; and (3) neuroscience-based
facial affect (Gordon et al. 2004), when prediction of future recidivism (Meixner 2014). I
viewing pictures depicting moral violations am only concerned here with the last of these—
(Harenski et al. 2010), and when viewing the potential use of neuroscience to predict violent
fearful faces (Dolan and Fullam 2009). and criminal behavior before it occurs. While
Many of these reports are the same as a public health approach to criminal behavior
those indicating lower prefrontal activity should welcome any and all improvements in
in psychopaths, and this likely speaks to our current risk assessment instruments, including
the extensive connections between the those provided by neuroscience, I fear that
amygdala and prefrontal cortex. Building these measures can potentially be used to justify
on the pattern noted above, youth with preemptive incapacitation for those who are
callous/unemotional traits and conduct deemed a risk to society. There is also the very real
disorder also show lower amygdala activity potential for stigmatization—identifying children
when engaged in passive avoidance who exhibit early psychopathic traits, for example,
learning (Finger et al. 2011) and viewing may be helpful in providing early interventions,
fearful faces (Jones et al. 2009). This but it can also stigmatize them by labeling them
result suggests that disruption in affective as potential future criminals.
processing evident in adults is a deficit
which begins early in life, having persistent While these issues are important and demand
effects into adulthood. (2014: 112). more attention than I can give them here, I would
like to make a few broad suggestions. First, I have
Additional studies have found reduced gray matter elsewhere argued that preemptive incapacitation
volumes in psychopaths’ cingulate cortex and should be prohibited in all but the most extreme
other paralimbic structures (Boccardi et al. 2011), circumstances (Caruso forthcoming-c; see also
tissue reduction in the temporal pole (Muller et al Pereboom and Caruso 2017). Given that we are
2008) and insula (de Oliveira-Souza et al. 2008), unable to assess with certainty the likelihood of
and tissue reduction in the posterior cingulate future violent behavior, and given the potential for
(Ermer et al. 2011). false positives, I maintain that significant weight
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should be given to protecting individual liberty.
Just as we adopt the presumption of innocence in Anderson and Kiehl go on to outline a number
the criminal justice system, we should likewise of these alternative strategies, including targeted
adopt the presumption of harmlessness since the treatments tailored for specific groups of
social and neurological determinants of crime offenders (see also Andrews et al. 1990). They
outlined above are like individual dials on a acknowledge that therapeutic interventions and
vast combination lock—even if four out of five rehabilitation strategies with adult psychopaths
numbers (say) are in place, the lock will not open have traditionally proven ineffective and even
until the last number (e.g., the last environmental occasionally counterproductive, but they also
or neurological trigger) is put in place. Since we note that “successful interventions might be
are in a poor epistemic position to judge when more likely at an earlier stage when the focused
(if ever) all the numbers/conditions will trigger a reinforcement of socially adaptive behaviors
violent episode, and since this will likely remain is likely to have a more robust impact on the
true for some time, I propose that we put a bright developing personality and behavioral habits
line in the sand in favor of protecting individual of the fledgling psychopath” (2014: 115). The
liberty and against preemptive incapacitation, Mendota Juvenile Treatment Center (MJTC) in
especially with regard to risk assessed by brain Madison, Wisconsin, for example, has designed
scans or other demographic risk factors. and implemented an ambitious treatment program
that employs intensive one-on-one therapeutic
Second, since the potential for stigmatization in attention, several hours a day, for a minimum of six
youth who exhibit callous-unemotional traits moths (Caldewll and Van Rybroek 2001). Studies
(an early indicator of psychopathy) is a serious indicate that this intensive treatment protocol may
one, I recommend that we favor interventions cut violent recidivism rates in half, compared
that (a) maximize the autonomy of agents, (b) to juveniles receiving standard group therapy
acknowledge the potential for change, and (c) focus sessions (Caldewll and Van Rybroek 2001, 2005).
on current antisocial behavior rather than future
risk of offending. In fact, studies have found that It is also worth noting that recent research has
not all children that exhibit callous-unemotional found that psychopaths—especially those with
traits grow up to be adult psychopaths, which antisocial personality disorder and psychopathy—
is important. This challenges us to find the right do not learn well with punishment (Gregor et al.
interventions—and there are some promising 2015). A recent study by Gregor et al. (2015) found
treatment approaches out there for young people. that people with antisocial personality disorder
As Anderson and Kiehl point out: and psychopathy appear to have reinforcement-
learning systems that don’t operate in the
[The] patterns of delinquency [in “normal” way. In particular, the behavior of men
psychopaths] are persistent from a young with antisocial personality disorder “seems to be
age, and are a conspicuous cause for driven more by potential rewards than potential
concern that the developmental nature punishments (reward dominance)” (2015: 153).
of psychopaths may place even the very This suggests that punitive approaches to criminal
young on a trajectory for incorrigible behavior, like those currently favored in the United
antisocial deviance. Evidence suggests, States, are not likely to be effective in altering the
however, that such a bleak outlook may antisocial behavior of psychopaths. When it comes
only apply when traditional intervention to adult criminal psychopaths, “the best strategy
strategies are implemented…In fact, might be to focus on minimizing the harm they
alternative strategies which incorporate cause others by reinforcing specific behavioral
knowledge of psychopaths’ impaired forms patters and self-control” and the most effective
of social reasoning have proven to be more means of doing this “might be to promote such
effective, particularly, when applied to behavior with measured rewards” (Anderson and
younger offenders. (2014: 113) Kiehl 2014: 114).
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 Pereboom 2001, 2014). Once we abandon these
II. The Public Health-Quarantine Model antiquated notions, we can, as Bruce Waller
notes, “look more clearly at the causes and more
Everything we know about the social determinants deeply into the systems that shape individuals
of health and criminal behavior indicates that and their behavior” (Waller 2011: 287), and this
we need to adopt a public health approach that will allow us to adopt more humane and effective
focuses on addressing poverty and socioeconomic approaches to education, criminal justice, and
issues, education, abuse, domestic violence, social policy. While my free will skepticism is
unemployment, housing, healthcare, mental not a necessary condition for adopting a public
health, environmental health, and nutrition. This health approach to criminal behavior, I maintain
conclusion is in line with the recommendations that (a) it is the most justified position given our
of the World Health Organization Commission on best philosophical and scientific theories about
Social Determinants of Health, the Vera Institute the world (see, e.g., Caruso 2012, 2013, 2015,
of Justice (Cloud 2014), the Acheson Report in 2017; Pereboom 2001, 2014; Levy 2011; Waller
Britain (1998), and the National Criminal Justice 2011), (b) it provides distinct advantages over the
and Public Health Alliance (Heller 2016) (see retributive justification for criminal punishment;
also Lee 2005; Irwin et al. 2006). I contend that and (c) it best captures the intuition that the lottery
if we really want to improve public health and of life is not always fair (we do not all have equal
safety it is imperative that we use the power of starting points in life) and that luck profoundly
the public health framework to re-envision and affects our life outcomes—an intuition that should
change our criminal justice system and all its be reinforced by our discussion of the social
component parts (see also Heller 2016). I concur determinants of health and criminal behavior.
with Jonathan Heller that we need to start thinking
about criminal justice as a public health issue Free will skepticism maintains that what we do
by: “changing behaviors related to violence; and the way we are is ultimately the result of
addressing the traumas that victims face and factors beyond our control, and because of this
how those perpetuate crime; reducing adverse agents are never morally responsible in the basic
childhood experiences; ensuring those leaving desert sense—the sense that would make us truly
prison [have access to healthcare]; and working to deserving of praise and blame, punishment and
reinvest savings from criminal justice reform back reward, in a non-consequentialist, backward-
into our hardest hit communities” (2006). looking sense (see Pereboom 2001, 2014; Caruso
2012, 2017; Caruso and Morris 2017). A number
My own public health-quarantine model goes of contemporary philosophers have argued for
further, however, by also recommending that we and defended free will skepticism, but I will
reject the notions of free will and basic desert not rehearse these arguments here (see, e.g.,
moral responsibility, and with them individual Pereboom 2001, 2014; Strawson 1986, 1994;
blame and retributive punishment (Caruso 2016, Levy 2011; Waller 2011; Caruso 2012). The
forthcoming-a, b, c; Pereboom and Caruso 2017). important thing for this discussion is that free will
My reasons for rejecting the concept of free will skepticism is inconsistent with one of the leading
are hard incompatibilist and have been spelled justifications for punishment in the criminal justice
out at length elsewhere (Caruso 2012; Pereboom system—retributivism. The retributive justification
and Caruso 2017; see also Pereboom 2001, of punishment maintains that the punishment of
2014). I have also argued that life without free a wrongdoer is justified for the reason that she
will and basic desert moral responsibility is not deserves something bad to happen to her just
only possible but also preferable. Belief in free because she has knowingly done wrong—this
will can stifle personal development, encourage could include pain, deprivation, or even death. As
punitive excess in criminal justice, and perpetuate the retributivist Mitchell Berman puts it, “A person
social and economic inequalities (Caruso 2017, who unjustifiably and inexcusably causes or risks
forthcoming-d; see also Waller 2011, 2014; harm to others or to significant social interests
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deserves to suffer for that choice, and he deserves in the basic desert sense (perhaps because no one
to suffer in proportion to the extent to which his is ever in this way morally responsible) it could
regard or concern for others falls short of what is be as legitimate to preventatively detain him as to
properly demanded of him” (2008: 269). For the quarantine the non-responsible carrier of a serious
retributivist, it is the basic desert attached to the communicable disease.
criminal’s immoral action alone that provides
the justification for punishment. The desert the The first thing to note about the theory is that
retributivist invokes is basic in the sense that although one might justify quarantine (in the
justifications for punishment that appeal to it are case of disease) and incapacitation (in the case
not reducible to consequentialist considerations of dangerous criminals) on purely utilitarian or
nor to goods such as the safety of society or the consequentialist grounds, Pereboom and I want
moral improvement of the criminal. to resist this strategy (see Pereboom and Caruso
2017). Instead, on our view incapacitation of the
Free will skepticism undermines this justification dangerous is justified on the ground of the right to
for punishment because it does away with the idea harm in self defense and defense of others. That
of basic desert (see Pereboom 2001, 2014; Caruso we have this right has broad appeal, much broader
2012, 2016). If agents do not deserve blame than utilitarianism or consequentialism has. In
just because they have knowingly done wrong, addition, this makes the view more resilient to a
neither do they deserve punishment just because number of objections (see Pereboom and Caruso
they have knowingly done wrong. The challenge 2017; Caruso, forthcoming-c; Pereboom 2016).
facing free will skepticism, then, is to explain how
they can adequately deal with criminal behavior Second, the quarantine model places several
without the justification provided by retributivism constraints on the treatment of criminals (see
and basic desert moral responsibility. I contend Pereboom 2001, 2014; Pereboom and Caruso
that this challenge can be met and that the public 2017). First, as less dangerous diseases justify
health-quarantine model is the best and most only preventative measures less restrictive than
comprehensive approach to criminal behavior— quarantine, so less dangerous criminal tendencies
one that is ethically defensible, practically justify only more moderate restraints. In fact, for
workable, and more humane than retributivism certain minor crimes perhaps only some degree
(see Caruso 2016, forthcoming-a, b, c). of monitoring could be defended. Secondly,
the incapacitation account that results from this
The public health-quarantine model is based analogy demands a degree of concern for the
on an analogy with quarantine and draws on a rehabilitation and wellbeing of the criminal that
comparison between treatment of dangerous would alter much of current practice. Just as
criminals and treatment of carriers of dangerous fairness recommends that we seek to cure the
diseases. It takes as its starting point Derk diseased we quarantine, so fairness would counsel
Pereboom’s famous account (2001, 2013, 2014). that we attempt to rehabilitate the criminals we
In its simplest form, it can be stated as follows: detain. If a criminal cannot be rehabilitated, and
(1) Free will skepticism maintains that criminals our safety requires his indefinite confinement, this
are not morally responsible for their actions in account provides no justification for making his
the basic desert sense; (2) plainly, many carriers life more miserable than would be required to
of dangerous diseases are not responsible in guard against the danger he poses.
this or in any other sense for having contracted
these diseases; (3) yet, we generally agree that Third, this account provides a more resilient
it is sometimes permissible to quarantine them, proposal for justifying criminal sanctions than
and the justification for doing so is the right to other non-retributive options. One advantage it
self-protection and the prevention of harm to has over consequentialist deterrence theories, for
others; (4) for similar reasons, even if a dangerous example, is that it has more restrictions placed on
criminal is not morally responsible for his crimes it with regard to using people merely as a means.
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For instance, as it is illegitimate to treat carriersnecessary to achieve a sufficient level of health
of a disease more harmfully than is necessary to is considered a grave injustice. An important task
neutralize the danger they pose, treating those of public health ethics, then, is to identify which
with violent criminal tendencies more harshly than inequalities in health are the most egregious and
is required to protect society will be illegitimate thus which should be given the highest priority
as well. In fact, in all our writings on the subject,in public health policy and practice. The public
Pereboom and I have always maintained the health approach to criminal behavior likewise
principle of least infringement, which holds that maintains that a core moral function of the criminal
the least restrictive measures should be taken to justice system is to identify and remedy social
protect public health and safety (Caruso 2016; and economic inequalities responsible for crime.
Pereboom and Caruso 2017). This ensures that Just as public health is negatively affected by
criminal sanctions will be proportionate to the poverty, racism, and systematic inequality, so too
danger posed by an individual, and any sanctions is public safety. This broader approach to criminal
that exceed this upper bound will be unjustified. justice therefore places issues of social justice at
the forefront. It sees racism, sexism, poverty, and
In addition to these restrictions on harsh and systemic disadvantage as serious threats to public
unnecessary treatment, the model also advocates safety and it prioritizes the reduction of such
for a broader approach to criminal behavior that inequalities.
moves beyond the narrow focus on sanctions.
On the model I have developed, the quarantine III. Social Justice and Public Policy
analogy is placed within the broad justificatory
framework of public health ethics (Caruso 2016). While there are different ways of understanding
Public health ethics not only justifies quarantining social justice and different philosophical accounts
carriers of infectious diseases on the grounds of what a theory of justice aims to achieve, I favor
that it is necessary to protect public health, it a capability approach according to which the
also requires that we take active steps to prevent development of capabilities—what each individual
such outbreaks from occurring in the first place. is able to do or be—is essential to human well-
Quarantine is only needed when the public health being (e.g., Sen 1985, 1999; Nussbaum 2011;
system fails in its primary function. Since no Power and Faden 2006). For capability theorists,
system is perfect, quarantine will likely be needed human well-being is the proper end of a theory of
for the foreseeable future, but it should not be the justice. And on the particular capability approach
primary means of dealing with public health. The I favor, social justice is grounded in six key features
analogous claim holds for incapacitation. Taking of human well-being: health, reasoning, self-
a public health approach to criminal behavior determination, attachment, personal security, and
would allow us to justify the incapacitation of respect (see Caruso, forthcoming-c; Powers and
dangerous criminals when needed, but it would Faden 2006).4 Following Powers and Faden (2006),
also make prevention a primary function of the I maintain that each of these six dimensions is an
criminal justice system. If we care about public essential feature of well-being such that “a life
health and safety, the focus should always be substantially lacking in any one is a life seriously
on preventing crime from occurring in the first deficient in what it is reasonable for anyone to
place by addressing the systemic causes of crime. want, whatever else they want” (Powers and Faden
Put simply, prevention is always preferable to 2006: 8). The job of justice is therefore to achieve
incapacitation. a sufficiency of these six essential dimensions
of human well-being, since each is a separate
Furthermore, public health ethics sees social indicator of a decent life.
justice as a foundational cornerstone to public
health and safety (Caruso 2016). In public health 4
Note that this is a pared down list from the ones offered by
ethics, a failure on the part of public health Martha Nussbaum and other capability theorists (see Nussbaum
institutions to ensure the social conditions 2011).
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The key idea of capability approaches is that women are not allowed to ride a bike, then
social arrangements should aim to expand it will become difficult or even impossible
people’s capabilities—their freedom to promote to travel by means of a bike. As this example
or achieve functionings that are important to them. makes clear, different factors will influence
Functionings are defined as the valuable activities the number of times the individual travels.
and states that make up human well-being, such (Tabandeh, Gardoni, and Murphy describe
as having a healthy body, being safe, or having a 2017)
job. While they are related to goods and income,
they are instead described in terms of what a Thinking in terms of capabilities raises a wider
person is able to do or be as a result. For example, range of issues than simply looking at the amount
when a person’s need for food (a commodity) is of resources or commodities people have, because
met, they enjoy the functioning of being well- people have different needs. In the example
nourished. Examples of functionings include given above, just providing bicycles to people
being mobile, being healthy, being adequately will not be enough to increase the functioning
nourished, and being educated. The genuine of being mobile if you are disabled or prohibited
opportunity to achieve a particular functioning is from riding because of sexist social norms. A
called a capability. Capabilities are “the alternative capabilities approach to social justice therefore
combination of functionings that are feasible for requires that we consider and address a larger set
[a person] to achieve”—they are “the substantive of social issues.
freedom” a person has “to lead the kind of life he
or she has reason to value” (Sen 1999: 87). Bringing everything together, my public health-
quarantine model characterizes the moral
As Tabandeh, Gardoni, and Murphy describe foundation of public health as social justice, not
(2017): just the advancement of good health outcomes.
That is, while promoting social goods (like health)
Genuine opportunities and actual is one area of concern, public health ethics
achievements are influenced by what as I conceive it is embedded within a broader
individuals have and what they can do with commitment to secure a sufficient level of health
what they have. What they can do with and safety for all and to narrow unjust inequalities
what they have is a function of the structure (see Powers and Faden 2006). More specifically, I
of social, legal, economic, and political see the capability approach to social justice as the
institutions and of the characteristics of the proper moral foundation of public health ethics.
built-environment (i.e., infrastructure). For This means that the broader commitment of
example, consider the functioning of being public health should be the achievement of those
mobile. The number of times an individual capabilities needed to secure a sufficient level of
travels per week can be an indicator of human well-being—including, but not limited to,
mobility achievement. When explaining a health, reasoning, self-determination, attachment,
given individual’s achievement or lack of personal security, and respect. By placing social
achievement, a capability approach takes justice at the foundation of the public health
into consideration the conditions that must approach, the realms of criminal justice and
be in place for an individual to be mobile. social justice are brought closer together. I see
For instance, the possession of certain this as a virtue of the theory since it is hard to see
resources, like a bike, may influence how we can adequately deal with criminal justice
mobility. However, possessing a bike may without simultaneously addressing issues of social
not be sufficient to guarantee mobility. If justice. Retributivists tend to disagree since they
the individual has physical disabilities, approach criminal justice as an issue of individual
then the bike will be of no help to travel. responsibility and desert, not as an issue of
Similarly, if there are no paved roads or collective responsibility. I believe it is a mistake to
if societal culture imposes a norm that hold that the criteria of individual accountability
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can be settled apart from considerations of social being cannot be met. The capability approach and
justice and the social determinants of criminal the public health approach work well together
behavior. Making social justice foundational, here since both maintain that we need to take
as my public health-quarantine model does, into consideration the conditions that must be in
places on us a collective responsibility—which is place for an individual to be capable of achieving
forward-looking and perfectly consistent with free a sufficient level of health and safety. Adequate
will skepticism—to redress unjust inequalities and housing and freedom from abuse are often
to advance collective aims and priorities such as essential for this. Hence, our health, safety, and
public health and safety. The capability approach justice institutions should work together to reduce
and the public health approach therefore fit nicely the instances of abuse and domestic violence
together. Both maintain that poor health and safety and address the social inequities responsible for
are often the byproducts of social inequities, and poverty and homelessness.
both attempt to identify and address these social
inequities in order to achieve a sufficient level of (2) Increase funding for mental health services
health and safety. with a focus on the early and active treatment of
mental illness. Mental illness can severally impact
To conclude, I would like to offer the following an individual’s life-potential and negatively affect
eight general policy proposals. I maintain his/her health and well-being. It can also impact
that each is consistent with my public health- public safety. As we saw earlier, more than half
quarantine model as well as everything we know of all people incarcerated in prisons and jails in
about the social and neurological determinants of 2005 had a mental illness: 56% of state prisoners,
health and criminal behavior. My intent is for each 45% of federal prisoners, and 64% of jail inmates
to serve as a general guiding principle by which (James and Glaze 2006)—and of those who had a
more specific policy proposals can be generated. mental illness, about three-quarters also had a co-
While wide reaching and ambitious, I maintain occurring substance use disorder (James and Glaze
that any approach to public health and safety that 2006). Consider depression as just one example.
hopes to be effective should adopt practices and A recent longitudinal study by Yu et al. (2017)
policies consistent with these eight proposals. examined the association between depression and
subsequent violence from three representational
(1) Invest in programs and policies aimed at samples in the Netherlands, United Kingdom,
reducing poverty, homelessness, abuse, and and Finland. They found a consistent pattern of
domestic violence. As we saw in §1, poverty, increased relative risk for violence in adolescents
low socioeconomic status, homelessness, abuse, with depressive symptoms. In the Finnish sample,
and domestic violence, are important social for example, the odds of violence in individuals
determinants of health (SDH) and criminal behavior with a diagnosis of depression were increased
(SDCB). They also severely diminish human well- two-fold, compared to those without depression.
being by limiting an individual’s ability to secure We also know that higher rates of depression have
a sufficient level of health, personal security, been reported among adolescents in juvenile
meaningful attachment, and self-determination. detention and correctional facilities (e.g., 11% in
Under the capability approach, poverty is a boys and 29% in girls). These findings highlight
capability deprivation rather than a mere lack of the need for active and early treatment of mental
money. It severally limits what each individual is illness, especially in adolescents and young
able to do or be, and in some cases makes certain people.
essential functions impossible. For example,
decent and stable housing is essential for human (3) Secure universal access to affordable and
survival and dignity, a principle affirmed both by consistent healthcare for all. Access to affordable
U.S. policy and international human rights law. and consistent healthcare is essential for human
Without access to housing or the ability to secure well-being. It is also key from the perspective
housing, this essential function for human well- of public health and safety. As we saw earlier,
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for many vulnerable populations, including the in the community” (2014: 464).
homeless, poor, and mentally ill, not having access
to affordable and consistent healthcare means (4) Reject retributivism and purely punitive
forgoing treatment for mental illness, substance approaches to criminal justice and shift the focus
use, chronic health conditions, acute care, and to prevention, rehabilitation, and reintegration.
injuries. This in turn has profound negative effects While retributivism is one of the (if not the) main
on public health and safety. To prevent these sources of justification for punishment within the
deleterious effects we should adopt policies that U.S. criminal justice system, I contend that there
strive to make healthcare accessible and affordable are at least two good reasons for rejecting it. The
for all. We should also extend the public health first is that retributive punishment is inconsistent
framework to those in the criminal justice system with free will skepticism and the rejection of just
and do everything we can to improve the health desert—hence, if free will skepticism is correct
of offenders and link them up with programs and (as I believe it is) then retributive punishment is
services that will provide continued access to unjustified. The second maintains that independent
healthcare. As Rich et al. (2014) argue: of free will, there are good practical grounds
for rejecting retributivism since it often leads to
Incarceration can cause harm to individual ineffective, excessively punitive, and inhumane
and community health, but prisons and jails practices and policies. Several studies now show
also hold enormous potential to play an that retributivism often leads to excessively
active and beneficial role in the health care punitive forms of punishment and that such
system and, ultimately, to improve health. punitiveness is often counterproductive from the
Traditionally, incarcerated populations perspective of public safety. Of course, there are
have been incorrectly viewed as isolated many reasonable retributivists who acknowledge
and self-contained communities with only that we imprison far too many people, in far
peripheral importance to the public health too harsh conditions, but the problem is that
at large. This misconception has resulted retributivism remains committed to the core belief
in missed opportunities to positively affect that criminals deserve to be punished and suffer
the health of both the individuals and the for the harms they have caused. This retributive
imprisoned community as a whole and impulse in actual practice—despite theoretical
potentially to mitigate risk behaviors that appeals to proportionality by its proponents—
may contribute to incarceration. Both often leads to practices and policies that try to
community and correctional health care make life in prison as unpleasant as possible. It
professionals can capitalize on these was this retributive impulse, for instance, that lay
opportunities by working together to behind 2014 changes to the incentives and earned
advocate for the health of the criminal privileges (IEP) scheme in England and Wales and
justice-involved population and their which resulted in an effective blanket ban on
communities. (2014: 462) sending books to prisoners. Luckily, the high court
declared the ban unlawful, reasoning that books
Public health and safety affects all of us and are often essential to the rehabilitation of people
it should be the goal of everyone to provide in prison. It is also this retributive impulse that has
affordable and consistent healthcare to all led, at least in part, to the mass incarceration crisis
members of society. Doing so would not only help in the U.S.
improve public health and safety, it would also
help address a number of other social inequities. By now most people know the numbers. With only
As Rich et al. argue, “Given the racial disparities 5% of the world’s population, the U.S. imprisons
of incarceration, if criminal justice involvement 25% of the world’s prisoners—far more than any
were to lead to increased access to health care other nation in the world. The U.S. has more than
upon release, this could cause a decrease in the 700 prisoners for every 100,000 people, whereas
racial disparities regarding health and health care Scandinavian countries such as Sweden, Finland
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and Norway hover around 70 per 100,000. And not justice. Prevention should always be the mission of
only does the U.S. imprison at a much higher rate, our health and justice institutions and one way to
it also imprisons in notoriously harsh conditions. try to achieve this aim is to systematically address
American prisons are often cruel places, using a the social determinants of criminal behavior. The
number of harsh forms of punishment, including public health-quarantine model, however, also
extended solitary confinement. The watchdog realizes that not all crimes can be prevented and
organization Solitary Watch (2012) estimates that occasionally dangerous criminals will need to be
up to 80,000 people in the U.S. are currently incapacitated for the safety of society. The model
in some form of solitary confinement. These provides the justification needed for incapacitation
prisoners are isolated in windowless, soundproof in such cases, but even here the goal should always
cubicles for 23 to 24 hours each day, sometimes be rehabilitation and reintegration. Unfortunately,
for decades. Under such conditions, prisoners the current U.S. prison system is not well suited
experience sever suffering, often resulting in for the task of rehabilitation—e.g., within many
serious psychological problems. Supreme Court prisons offenders are typically housed in inhumane
Justice Anthony Kennedy, for instance, recently conditions, deprived of mental health services,
stated that, “solitary confinement literally drives drug treatment, and educational opportunities.
men mad.”5 We cage offenders like animals, dehumanize them
from the moment they arrive, segregate and isolate
Such excessively punitive punishment not only them, and give them minimal autonomy, then we
causes severe suffering and serious psychological release them and expect they will somehow be
problems, it does nothing to rehabilitate prisoners, model citizens. This is clearly not working.
nor does it reduce the rate of recidivism. In fact,
the U.S. has one of the highest rates of recidivism I recommend adopting policies aimed specifically
in the world, with 76.6% of prisoners being at the rehabilitation and reintegration of offenders.
rearrested within five years of release. Norway, by To focus on just one example, we need to
contrast, averages around 20%. One of the reasons address the physical design of prisons. With few
for this wide divergence in recidivism rates is that exceptions, U.S., U.K., and Australian prisons are
the Norwegian system prioritizes rehabilitation harsh, restrictive institutions, designed to enable
and reintegration (providing prisoners with maximum control over inmates’ behavior at any
educational programs, work training, etc.) time. As Lutham and Klippan write: “Their scale
while the U.S. system is focused more on giving and appearance instill mistrust and anonymity...
offenders their just deserts. Looked at empirically, The ability to personalise space, have ownership
it’s nigh impossible to defend the claim that and have personal control over one’s situation
commitment to just deserts and retributivism is intentionally absent. Mostly, these are overtly
ensures proportional and humane punishment. punitive environments, unlike any other” (2016).
In fact, the opposite seems to be the case—the These “cold” prison environments have an effect
problem of disproportionate punishment seems to on the people inside them and they are typically
grow more out of a desire for retribution and the not good. Just consider the rates of suicide and
belief that people justly deserve what they get. self-harm in U.S. prisons. According to the federal
Bureau of Justice Statistics, suicides account for
Once we reject retributivism and purely punitive more deaths in state and federal prisons than
approaches to criminal behavior, we can move drug and alcohol intoxication deaths, homicide,
away from the myopic focus on punishment and and accidents combined. And things are even
embrace instead a holistic approach to criminal worse in county jails where the suicide rate was
behavior that prioritizes prevention and social 46 per 100,000 in 2013. Incidents of self-harm
5
He made this statement before the House Appropriations in England and Wales are also at an all-time
Subcommittee on Financial Services and Federal Government, high (Ministry of Justice 2016). Furthermore,
as reported on in the Huffington Post on 3/24/2015: http:// U.S. and U.K. prisons are also breeding grounds
www.huffingtonpost.com/2015/03/24/anthony-kennedy- for violence (Bowker 1980; Irwin 1980; Johnson
solitary-confinement_n_6934550.html
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1987; Ministry of Justice 2016), which is not trees intentionally scattered across its 75-acre
surprising given that they typically confine large site, whereas U.S. prisons are usually devoid of
numbers of people in overcrowded quarters and vegetation to maximize visibility. In addition,
in conditions characterized by material and social to help inmates develop routines and to reduce
deprivation (Bowker 1980; Toch 1985; Wolfgang the monotony of confinement, designers spread
and Ferracuti 1976; Wortley 2005). Halden’s living quarters, work areas, and activity
centers across the prison grounds. This provides
In his book Situational Prison Control (2005), offenders with some degree of autonomy and
former prison psychologist Richard Wortley encourages interpersonal interactions—mirroring
articulates strategies to reduce negative behavior the kinds of conditions they will return to upon
in prison contexts, including through physical release. In fact, the Norwegian Correctional
design. He suggests (a) setting positive expectations Services has officially adopted something called
through domestic furnishings that confer trust; (b) the normality principle—a principle I strongly
reducing anonymity through small prison size; (c) endorse. The principle maintains that during the
personalizing victims through humane conditions; serving of a sentence “life inside [prisons] will
(d) enabling a positive sense of community through resemble life outside as much as possible.”6 It
ownership and personalization of the space; and further states that, “No one shall serve their sentence
(e) reducing provocation and stress by designing under stricter circumstances than necessary for
in the capacity for inmates to enact control over the security of the community. Therefore offenders
environmental conditions and personal space. shall be placed in the lowest possible security
The current model of U.S. correctional facilities is regime.” Lastly, it states that prison should be a
the antithesis of each of these strategies. Lutham restriction of liberty but nothing more, that is, “no
and Klippan correctly note, “When we create other rights have been removed by the sentencing
environments that fuel the negative behaviors court.” According to the normality principle, an
we naturally associate with criminals, we are offender should have all the same rights as other
caught in a vicious cycle: harsh community and people living in Norway and life inside should
political attitudes toward prisons and prisoners resemble life outside as much as possible. All
are perpetuated, and overtly punitive prisons Norwegian prisoners, for example, have the
continue to be built” (2016). right to study and they are all allowed to vote.
Sentences are also kept short. On average they are
Some good examples of innovating prison design no more than eight months long, and nearly 90%
exist in Scandinavian counties—including Halden of sentences are for less than a year. Additionally,
Prison in Norway, Leoben in Australia, Enner Mark the longest sentence permitted by law is 21 years,
in Denmark, and the Norwegian prison island of but that can be extended in five-year increments if
Bastoy. These prisons are purposely designed to a prisoner is not rehabilitated and is considered a
reduce crime. Lutham and Klippan explain: continued risk to society. Since most prisoners will
eventually return to society, Norwegian prisons
They do this by providing positive prepare inmates for reintegration by mimicking
opportunities for inmates and building the outside world as much as possible.
a greater sense of optimism for their
future…These spaces are designed to Adopting the goal of rehabilitation and reintegration
more closely reflect environments in the will force us to reexamine not only the physical
outside community. The design treats these design of prisons but all aspects of the carceral
people not solely as “prisoners” but also as experience. We should aim for the rehabilitation
community members—with all the social, and reintegration of offenders back into society
vocational and emotional responsibility
6
that this entails. (Lutham and Klippan 2016) For more details, see the Norwegian Correctional Service’s
full document: http://www.kriminalomsorgen.no/information-
in-english.265199.no.html
Halden Prison in Norway, for example, has
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and we should adopt practices and policies that the retributive impulse for payback and the desire
best achieve this goal. The normality principle is to give offenders their just deserts. If we wish to
just one example of a policy specifically designed adopt effective, data-driven policies aimed at
with this goal in mind, but other policies will be promoting public health and safety, as I believe
needed as well. Unfortunately, retributivism and we should, these disenfranchisement policies
purely punitive approaches to criminal behavior need to be abandoned.
remain a stumbling block in the way of progress.
It is imperative that we reject these and consider (6) Prioritize and properly fund education,
anew the aims and ends of criminal justice. especially in low-income areas, and support
educational programs in prison. Research has
(5) End all policies that disenfranchise ex-offenders, shown that education is an important SDH and
making it more difficult for them to reintegrate SDCB. Not only can it have a profound impact
back into society. In 2016, an estimated 6.1 on an individual’s life-potential, receiving an
million people were prohibited from voting due to adequate education is an important (and perhaps
laws restricting voting rights for those convicted of essential) functioning for human well-being. Yet
felony-level crimes (Uggen, Larson, and Shannon despite its obvious importance, there still remains
2016). The African American community has enormous educational inequity within the United
been disproportionately impacted by these felony States. We need to adopt programs and policies
disenfranchisement policies, with a recent report aimed at leveling the playing field. In particular,
from the Sentencing Project estimating that 1 in we need to make it a public health priority to
every 13 black Americans has lost their voting provide low-income communities with adequate
rights (Chung 2016). Voter disenfranchisement, educational opportunities. We also need to
however, is not the only barrier ex-prisoners face. support and fund educational programs in prison.
Under the Personal Responsibility and Work We know that correctional education improves
Opportunity Reconciliation Act (PRWORA), 13 inmates’ chances of not returning to prison. A
states fully prohibit anyone with a drug-related major 2013 study by the RAND Corporation
conviction from receiving public assistance under found, for example, that inmates who participate
the Temporary Assistance to Needy Families (TANF) in correctional education programs have 43%
program—and 23 other states maintain a partial lower odds of recidivating than those who do not
ban. Additionally, people with a felony criminal (Davis et al. 2013). This translates to a reduction
record are restricted from jury service in 47 states in the risk of recidivating of 13 percentage points.
(Love 2016), and the American Bar Association has These programs also improve the chances of
documented 27,254 state occupational licensing offenders obtaining employment after release.
restrictions nationwide for people with a criminal The odds of obtaining employment post-release
record (Love, Roberts, and Klingele 2013). Public among inmates who participated in correctional
housing is also restricted for many ex-offenders. education was 13% higher than the odds for those
In fact, under current housing policies, everyone who did not (Davis et al. 2013). Furthermore,
convicted of a felony is automatically ineligible providing correctional education is cost-effective
for a minimum of five years—condemning people when it comes to reducing recidivism—saving $4
with criminal records to homelessness or transient to $5 for each dollar spent.
living at precisely the moment when reintegration
is most important. Policies like these make it more (7) Adopt policies that protect the environmental
difficult for ex-offenders to reintegrate back into health of our communities by combating climate
society and end up increasing the chances of change, protecting air and water, and reducing/
recidivism. They are counterproductive from the eliminating harmful toxins. As we saw in §1.4,
perspective of public health and safety. Rather public health and safety can be negatively affected
than making us safer, these policies are a hangover by environmental factors such as poor air and water
from an antiquated and largely discredited quality, exposure to lead and toxins, and climate
approach to criminal justice—one grounded in change. Exposure to lead, for instance, can cause
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long-term harm in adults, including increased (2010: 644)
risk of high blood pressure, kidney failure, and,
in pregnant women, miscarriage, stillbirth, Bullard provides numerous examples of
premature birth, and minor malformations (WHO environmental discrimination and argues that
2016b). Young children are particularly vulnerable unequal environmental protection undermines
to the toxic effects of lead and “can suffer three basic types of equity: procedural, geographic,
profound and permanent adverse health effects, and social (2010; see also Bullard 1983, 1987,
particularly affecting the development of the brain 1990). Some examples of environmental
and nervous system” (WHO 2016b). Furthermore, discrimination include: how the U.S. government
lead exposure is also a potential threat to public cleans up toxic waste sites and punishes polluters
safety since studies have found that it can lead to (e.g., white communities see faster action, better
increases in criminal behavior (Feigenbaum and results, and stiffer penalties than communities
Muller 2016; Aizer and Currie 2017; Billings and where black, Hispanic and other minorities
Schnepel 2015). This is just one example since live [see, e.g., Lavelle and Coyle 1992]); the
there are many other toxins and environmental geographical placement of landfills, incinerators,
factors that affect health and safety. Climate sewage treatment plants, lead smelters, refineries,
change, for example, is a threat to public health and other noxious facilities, which are more
and safety since it is likely to cause more variable often put in poor and minority communities (see,
weather, heat waves, heavy precipitation events, e.g., Costner and Thornton 1990); and the role
flooding, droughts, more intense storms, sea level of sociological factors, such as race, ethnicity,
rise, and air pollution (IPCC 2014a, b, c)—each of class, culture, lifestyle, and political power, in
which has the potential to negatively affect public environmental decision-making (Bullard 1983,
health as well as be a threat multiplier, increasing 1987, 1990, 2010).
conflict and military involvement around the
world. To correct for these inequities and to end unequal
environmental protection, Bullard proposes the
If we wish to adopt a broad, holistic approach following five principles of environmental justice
to public health and safety—one grounding in (abstracted from 2010: 647-55):
social justice and aimed at promoting health
and preventing criminal behavior—we need to (a) The Right to Protection: Every individual has
adopt practices and policies that address these a right to be protected from environmental
environmental threats. Robert Bullard (2010), degradation. Protecting this right will require
for example, proposes a number of helpful enacting a federal “fair environmental act.”
solutions in his discussion of overcoming racism The act could be modeled after the various
in environmental decision-making. He begins by federal civil rights acts that have promoted
noting that: nondiscrimination—with the ultimate
goal of achieving ‘zero tolerance’—in
Despite the recent attempts by federal such areas as housing, education, and
agencies to reduce environmental and employment. The act ought to address
health threats in the United, States, both the intended and unintended effects
inequities persist. If a community is poor of public policies and industrial practices
or inhabited largely by people of color, on ethnic minorities and other vulnerable
there is a good chance that it receives groups.
less protection than a community that is
affluent or white. This situation is a result of (b) Prevention of Harm: Preventing, the
the country’s environmental policies, most elimination of the threat before harm
of which distribute the costs in a regressive occurs, should be the preferred strategy
pattern while providing disproportionate of government. For example, to solve the
benefits for the educated and wealthy. lead problem, the primary focus should
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 be shifted from treating children who have example of what a more specific set of proposals
been poisoned to eliminating the threat by might look like. Of course, one or more of Bullard’s
removing lead from houses, replacing lead principles might be debated and additional
pipes, etc. proposals will still need to be added—e.g., ones
that directly address climate change, global
(c) Shift the Burden of Proof: Under the environmental justice, and the allocation of
current system, individuals who challenge scarce resources. But whatever more specific set
polluters must prove that they have of proposals we adopt, if they are to be consistent
been harmed, discriminated against, or with the general public health framework I have
disproportionately affected. Few poor or outlined, they will need to identify and address
minority communities have the resources social inequities in environmental health and
to hire the lawyers, expert witnesses, and aim to promote human well-being by seeking to
doctors needed to sustain such a challenge. achieve a sufficient level of health and personal
Thus, the burden of proof must be shifted security for all members of society.
to the polluters who do harm, discriminate,
or do not give equal protection to (8) Research more effective interventions and
minorities and other overburdened classes. rehabilitation strategies for psychopathy. The
Environmental justice would require the success of the Mendota Juvenile Treatment Center
entities that are applying for operating (MJTC) program indicates that certain interventions
permits for landfills, incinerators, smelters, and treatment protocols can in fact work in cutting
refineries, and chemical plants, for violent recidivism rates in juveniles who exhibit
example, to prove that their operations callous-unemotional traits (Caldewll and Van
are not harmful to human health, will not Rybroek 2001, 2005). While genetic factors and
disproportionately affect minorities or the neurobiological deficits are widely believed to be
poor, and are nondiscriminatory. involved in the development of psychopathy, early
identification of the personality traits associated
(d) Obviate Proof of Intent: Laws must with psychopathy, as well improvement in the
allow disparate impact and statistical social conditions identified above, can help
weight—as opposed to “intent”—to infer mitigate the development of psychopathy.
discrimination because proving intentional Furthermore, as we come to better understand
and purposeful discrimination in a court of psychopathy and its neurological correlates,
law is next to impossible. we can potentially develop better “intervention
strategies that are informed by an understanding
(e) Redress Inequity: Disproportionate impact of the neuropsychological obstacles to healthy
must be redressed by targeting action and development” (Anderson and Kiehl 2014: 116).
resources. Resources should be spent The MJTC program is one intervention strategy that
where environmental and health problems needs to be studied further—and, as Anderson and
are greatest, as determined by some ranking Kiehl point out, “it will be necessary to carry out
scheme—but one not limited to risk rigorous investigations of changes in functional
assessment. Such targeting should channel circuitry over the course of reasonably successful
resources to the hot spots, communities intervention efforts” (2014: 116).
that are burdened with more than their fair
share of environmental problems. The use of neurofeedback in correctional settings
has also been suggested as “an innovative
Each of these proposals would, I believe, be an approach that may ultimately lessen criminal
improvement over existing practices since they behavior, prevent violence, and lower recidivism”
go a long way in correcting for the procedural, (Gkotsi and Benaroyo 2012: 3; see also Evans
geographic, and social inequities that currently 2006; Quirk 1995; Smith and Sams 2005). As
exist. I present them here, however, only as an Gkotsi and Benaroyo describe:
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 further investigate whether neurofeedback can
Neurofeedback or neurotherapy is a produce similar results with psychopathy.
relatively new, noninvasive method which
is based on the possibility of training and Conclusion
adjusting the speed of brainwaves, which
normally occur at various frequencies In this essay I have attempted to do five main
(Hammond, 2011). An overabundance, things: (a) argue that the social determinants of
or deficiency in one of these frequencies, health (SDH) are broadly similar to the social
often correlates with conditions such as determinants of criminal behavior (SDCB); (b)
depression, and emotional disturbances identify poverty, socioeconomic status, abuse,
and learning disabilities, such as Attention violence, housing, mental health, access to
Deficit Hyperactivity Disorder (ADHD) healthcare, education, environmental health, and
(Greteman, 2009)…Therapists attach nutrition as key social determinants; (c) argue that
electrodes to the patients’ head and a we should adopt a broad public health approach,
device records electrical impulses in focused on prevention and social justice, for
the brain. These impulses are sorted into identifying and taking action on these shared
different types of brain waves. Using a social determinants; (d) introduce and sketch my
program similar to a computer game, own non-retributive alternative for addressing
patients learn to control the video display criminal behavior, the public health-quarantine
by achieving the mental state that produces model; and (e) recommend eight broad public
increases in the desired brain wave activity. policy proposals for moving forward. If what I
Neurofeedback has gained recognition have argued is correct, we cannot successfully
for its potential benefits for children with address concerns over public health and safety
ADHD, alcoholics and drug addicts. It without simultaneously addressing issues of social
can also enhance athlete and musician justice—including the social determinants of
performance as well as improve elderly health and criminal behavior. Criminal justice and
people’s cognitive function (Greteman, social justice are intimately connected and as a
2009). (2012: 3) result retributive and purely punitive approaches
to criminal behavior end up missing the mark,
Douglas Quirk, a Canadian researcher, tested the since they see the problem as generally a matter
effects of a neurofeedback treatment program on of personal responsibility and desert. The best
77 dangerous offenders in an Ontario correctional and most comprehensive way to address criminal
institute who suffered from deep-brain Epileptic behavior is to adopt the public health-quarantine
activity. The results demonstrated reduction in model and the eight proposals outlined above.
the subjects’ criminal recidivism and suggested
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