Jail is deadly...even if you don’t go there.
New evidence shows more incarceration in county jails predicts higher mortality—and not just for incarcerated people. Here’s why, and what we should do about it.
This week, a new study (which I co-authored with a team of epidemiologists at Columbia University) was released in Lancet Public Health. We found that jail incarceration has, quite literally, deadly consequences.
We collected thirty years worth of incarceration and cause-specific mortality data. The sample included people under the age of 75 from counties around the country that had at least two years’ worth of complete cause of death statistics. We built statistical models to look at how deaths to causes like suicide, infectious diseases, heart attacks, and cancers among people under 75 changed as a result of jail incarceration.
In short, we found that jail kills—particularly by infectious diseases, lung disease, overdose, and suicide. Every increase in jail incarceration of 1 per 1000 people in a county predicted a countywide mortality increase of 6.5% to infectious diseases, 5.9% to chronic lung disease, 2.6% to substance use, 2.5% to suicide, and smaller but significant increases in mortality to heart disease, accidental death, cancer, diabetes, and stroke.
Prison v. Jail
Most of us often refer to any system of incarceration as “jail”, but there’s actually an important distinction between jail and prison. Jails are short-term confinement facilities. They are usually operated by local law enforcement at the city or county level, and hold people before their trial. Prisons are long-term confinement facilities, usually operated by states or the federal government, where people serve out their sentences. As we’ll discuss, a large proportion of people who wind up in jails aren’t there because they were deemed dangerous or a flight risk—but because they are poor. Three out of five people sitting in jail have not been convicted of a crime and jail stays are far shorter—less than a month.
Though there are usually fewer than a million people in jails at any given time, the number of people who are processed through jails across the country is quite high—10.7 million people are jailed every year. That is nearly 20 times as many people as get admitted to prisons every year.
How jail kills.
There are plenty of reasons why jails are deadly. COVID-19 gave us a glimpse.
At one point early in the pandemic, the Cook County Jail (Chicago), was the single biggest COVID-19 hotspot in the entire country. Within the first two months of the pandemic, jails were linked to 1,324 cases and 32 deaths. The mechanism is obvious. In jails, people are forced into tight, cramped quarters. Jail staff move in and out of the facilities daily—and incarcerated people themselves are released back to their homes within weeks of being incarcerated.
But it doesn’t take a pandemic for jail to kill. Jail incarceration occurs before sentencing. Our cash bail system, which unjustly incarcerated people for their poverty, puts countless people unjustly behind bars.Take the tragic example of Kalief Browder. At 16 he was accused of stealing a backpack and his bail was set at $3,000—an amount his family couldn’t afford to pay. Kalief languished in jail for three years before prosecutors dropped all charges against him. That time destroyed is life—Kalief died by suicide in his parents’s home two years after he was released.
Jail has a compounding impact on poverty—forcing employed people out of their jobs or monopolizing the paychecks of loved ones for exorbitant bail. It also pulls key members of households responsible for the care and feeding of children, seniors, and partners out of those households, destabilizing the lives and livelihoods of entire households at a time.
How we stop jailing people and save lives.
More than 700,000 people occupy jails everyday—and nearly 11 million will be jailed and released every year. Pre-pandemic statistics showed us that despite dropping crime rates between 2010-2017, jail incarceration stayed stable. That’s in part because the average jail stay increased from 21 to 26 days. The pandemic, especially in the first few months, drove a major effort to depopulate jails - leading to a 24% drop in jail populations. But jail populations increased again over the summer.
It shouldn’t be this way. There are three things we need to do right now to vastly reduce the number of people in jail—and the consequences it has for society.
First, we need to stop arresting and booking people on absurdly minor charges. Last year, a 15 year-old girl named Grace was arrested and sent to jail for 78 days in the middle of the pandemic for not doing her online schoolwork after a local judge ruled that it was a violation of her probation. The judge, Mary Ellen Brennan, called her “a threat to (the) community.” In 2011, Kyle DeWitt was fishing in a local river and caught a bass. Unbeknownst to him, the fish was out of season. Kyle was fined $155 dollars and told he’d receive a notice in the mail. It never came. When he called to ask about the fine, Kyle was told there was a warrant issued for his arrest and when he drove to the local jail to clear up the issue, he was jailed for three days until he could come up with $215 to cover additional fees and fines. Clearly, you shouldn’t go to jail for not doing your homework, or catching a fish out of season. Yet our system is far too permissive about what people can be arrested and booked for—and that, itself, needs to change which means we need to change our laws and enforcement policies themselves.
Second, we need to eliminate the cash bail system. If you’ve never paid bail, this is how it works: a judge sets an amount of cash to ensure you show up to trial, if you can’t pay you’re held in jail until trial (sometimes for months), if you can pay you’re released. This systematically discriminates by wealth—locking up only the poor, while the wealthy galavant until their court dates. In fact, cash bail does nothing to protect communities from dangerous people who could pose a flight risk (cough, Kyle Rittenhouse, cough). Some states and territories, like Washington DC, New Jersey, and most recently Illinois, have done away with the cash bail system. Indeed, in the two decades since Washington DC abolished it, they found no increase in crime or people skipping trial.
Third, we need to end the escalating system of court-imposed fees and fines. The GOP-motivated efforts to reduce funding for public services has left the court system reliant on increasingly costly fees and fines—expenses for hearings, filing paperwork, and processing fees. The system traps people in the cycle of poverty and jail. A simple, unimportant court date often turns into hundreds of dollars in fees and inability to pay often leads to jail time, which forces people out of jobs and the earnings they would have needed to pay fines in the first place. This system doesn’t even work. A ground-breaking study of court-imposed fees and fines by the Brennan Center for Justice found that this system forces those who can’t pay into jail and further into the poverty that left them unable to pay. They also found that this detrimental system fails to raise revenue for the courts in the first place. Why? Collecting on court-imposed fees and fines is costly. One New Mexico county spent $1.17 to collect every dollar of revenue. Worse, the cost of jailing those who can’t pay can cost as much as 115% of the amount collected.
Black Lives Matter.
De-jailing the criminal legal system would keep millions of people in their households, their jobs, and their communities. And that would save lives—particularly Black lives.
Black people are 3.6 times as likely to be jailed than white people. And that’s because the mechanisms we discussed operate more profoundly in our structurally racist society. Not only does structural racism leave Black people poorer and less likely to be able to make bail, but evidence shows that they are subject to twice the bail on average. The community-wide consequences are more profound as well. Segregation is a fact of American life, which means that majority Black households and Black communities are far more likely to suffer the insecurity that jail imposes.
Americans watched the agonizing murder of George Floyd under the knee of Derek Chauvin—a personification of the criminal legal system that has taken Black lives and livelihoods with impunity since the founding of this country. Those eight minutes and 46 seconds catalyzed a movement that saw upwards of 10% of Americans take to the streets in support of Black lives. As activists and organizers translate this moment into action, right-sizing bloated policing budgets, let’s also take into account the ripple effects that other pieces of the system, like jail, have on people who are never caught up in it. It kills them, too.
Congratulations to Dr. El-Sayed and his co-authors on their impressive and important study on the causes of mortality from incarceration. Collecting 30 years worth of incarceration and cause-specific mortality data is comprehensive. I would like to make some brief comments on this report but I must do so in the context of full disclosure.
I practiced medicine for 30 years, 25 of those in the Emergency Center at St. Joseph Mercy Hospital. In 1992, I founded SecureCare a correctional medicine service with the mission of providing quality medical care to inmates in jails, prisons and juvenile detention centers. We served the Washtenaw County Jail and several other detention facilities in Michigan and Ohio.
I completely agree with the issues identified in this study and I support all of the corrective measures recommended by Dr. El-Sayed to reduce the numbers of un-necessary deaths. It is undeniable that lacking and inadequate medical care is a contributor to increased deaths in the incarcerated population. However, the deaths are multifactorial and many of those that are causative are outside the scope of medical intervention; the doctor has no cure or therapy for poverty, racism, cultural factors or even for suicide, alcoholism and drug overdose.
The solution needs to be comprehensive and long lasting. I believe the time is right to achieve those corrective measures. Eli Savit, the recently elected Washtenaw County Prosecutor, ran on a platform endorsing the same remedies as Dr. El-Sayed. He acknowledged that people are regularly imprisoned because of poverty, mental health issues or addiction. He pledged to consider all relevant factors when making a decision about charging and sentencing. He wants to end cash bail and to treat all defendants with equal justice.
I feel much like I did in the mid 60s when the social issues were civil rights, the Vietnam War and women's liberation. Change is in the air and those with courage and vision will lead us.