Prisoners of broken systems

When Emily Wang, MD, professor of medicine (general medicine), was in medical school in the early 2000s, she started working in prisons and jails in the United States and abroad. Her time at a prison in Botswana surprised her and profoundly changed her worldview.

The Botswana prison was in the center of town and looked no different from any home. While prisons in the United States are sealed off by layers of bars and gates, Wang walked through only one gate at the Botswana prison and found herself in the courtyard. There she saw prisoners moving around and laughing, and even one cutting hair. An American prison is a much grimmer place. “It’s meant for punishment,” she said. “You can feel it in your bones.”

The more Wang learned about prisons abroad, the more something became clear: “I saw that the criminal legal system is unique in the United States, and not in good ways” she told me.

Wang, an internist, is now the director at the Yale School of Medicine’s SEICHE Center for Health and Justice, which is focused on health equity research. The center’s name (pronounced saysh) comes from a Swiss scientist’s term for a standing wave oscillating in an enclosed body of water; it reflects the center’s goal of bringing massive structural change to unjust closed systems. At the SEICHE Center, researchers work on issues like improving the prison system; studying the effects of COVID-19 on marginalized groups; and crafting public health policy. Wang is inspired to do this work because she knows different systems exist in other countries. In Finland, for instance, there is no death penalty, and the longest prison sentence is 14 years. “We have people serving double, triple life,” she said.

Her experiences with prisons inspired her to co-found the Transitions Clinic Network program, which hires formerly incarcerated people as community health workers. The program has reduced emergency department visits and future contacts with the criminal justice system.

“Those findings don’t surprise me,” she said. “What has surprised me is how little research there is on something of such profound importance.”

That’s because prison reform isn’t just about justice; it’s also about health. The prison system in the United States is a public health disaster. Health systems within prisons are often understaffed and underfunded. Prisons were COVID-19 infection hotspots in 2020. Although taxpayer dollars pay for prisoners’ health care, the actual care provided is opaque to outside observers. “While health care is delivered behind bars, we have no way of knowing the quality or cost,” Wang said.

Yale School of Medicine has also looked at gun violence. There are plenty of government and police-led interventions to decrease gun violence, but few community-led ones. Yale decided to have a go at it. The team at Yale started by partnering with 20 community members from New Haven. The researchers learned that over 90% of the members had been exposed to gun violence; a significant minority had been present when someone was killed.

The team then used police data to do a social network analysis of gun violence in New Haven. Here’s where the Yale approach took a distinctive turn: lots of research teams trying to decrease gun violence focus on bad actors and dangerous neighborhoods. But the Yale team did the opposite: it focused on people who look like they should have been victimized but never were, and on areas that looked like they should have high levels of gun violence but didn’t. The team then tried to figure out what was so special about these areas.

“You’re looking at what works,” Wang said. That focus helped them figure out the relationship between factors like home ownership, green space, and closely connected communities to local crime levels. “The tighter your bonds are to your neighbors, and the more you’re acting in your collective benefits, the less your exposure to violence will be,” she added.

While many of these programs have been focused on New Haven, health equity research at Yale extends beyond Connecticut. Inequality has made it hard for marginalized communities to take preventive COVID-19 measures, and how existing health inequities have been worsened by the pandemic. On both the large and small scale, health isn’t just about individuals; it’s also about the societies in which they live. The COVID-19 crisis has laid those inequities bare.