The story of the opioid epidemic that has captured the attention of the U.S. public over the past few years has been told in a particular way, which in turn has impacted the way resources and policies have mobilized around that crisis. This mostly white, mostly rural, mostly middle-America, mostly opioid-driven emergency of overdose deaths has increased the demand for an evidence base for effective substance abuse programs. It has also spurred a push for law and policy changes that permit syringe-exchange programs and create "alternative to incarceration" strategies that police departments can employ to reduce arrests.
But for many people, this current moment's attention to the opioid epidemic in white rural America can, so to speak, be a bitter pill to swallow. That's particularly true for black and Latinx advocates and providers who've been long committed to ending the drug war and addressing all forms of addiction outside of the criminal justice system. They've been working on these issues, and they see the criminal justice system and mass incarceration as a barrier not only to providing health care, but also to improving the public's health and wellness.
The Legal Action Center in New York City is trying to address these issues with a new national campaign, No Health = No Justice. The campaign's goal is to connect the work happening across states that aim to reduce participation of people in criminal justice systems, increase access to quality and affordable health care, and deal with the manifestations of racism in systems that impact health and wellbeing. The Legal Action Center held a day-long conference at Columbia University in New York City on April 3 to present their plan and the ideas that will shape this campaign.
"We have a lot of work to do to dismantle three decades of unjust public policy and begin to repair the enormous damage that it's brought," said Tracie Gardner, vice president of policy advocacy with Legal Action Center. "While there are many initiatives that are now underway to reform our criminal justice system, we cannot hope to reverse course without a cross-sector approach that recognizes the systemic racism, mass incarceration, and inadequate community health care systems."
We are seeing in places around the country that some of the overdose deaths among whites are decreasing, but they are increasing among blacks -- sometimes from opioids, but also from stimulants like cocaine and methamphetamine. During the conference, Mary T. Bassett, M.D., M.P.H., former New York City commissioner of the Department of Health and Mental Hygiene and now the director of the François-Xavier Bagnoud Center for Health and Human Rights at Harvard University, spoke about the fact that in both New York City and in Massachusetts, overdose deaths of blacks have begun to outpace those of whites. Bassett mentioned that she's seen the opioid epidemic from both sides, from her time working in Harlem Hospital in the early 1980s and witnessing the current crisis.
"We find ourselves here because of structural racism," she said. "At the root of the punitive response is the idea that substance abuse disorder represents a moral failure, a particular deficiency of people of African descent. That is what led people to think, quite implausibly, that white people would not become addicted to these prescription pain killers."
As Bassett and other panelists went on to discuss, while doctors were encouraged to prescribe opioids, many physicians also refused those new drugs to black patients, whom they viewed as either not vulnerable to experiencing the same kind of pain as white patients or as more likely to be lying about pain in order to get access to drugs to get high.
The first panel (which included Bassett) went on to tackle some difficult questions about where the national focus has shifted in the approaches to dealing with substance use since the current opioid epidemic began to be acknowledged. In the wake of increased efforts to provide alternatives to incarceration for drug users, this panel raised questions about whether many of the strategies deployed take us further away from policing and surveillance, or whether they further imbed the policing apparatus into public health and social services.
"They've co-opted our language, they've co-opted our strategies, and we have to be careful about using the term 'public health' as synonymous with equitable," said Keith Brown, M.P.H., director of health and harm reduction with the Katal Center for Health, Equity and Justice. Brown went on to describe the ways in which we as a society have "turfed" many services to aid people in need of help (overdose, mental health, etc.) to police departments or to very strict abstinence-based substance-use treatment programs, which increasingly claim to be using a harm-reduction approach.
"If we start with the premise that law enforcement needs to be at the table, we've already lost the argument," said Kassandra Frederique, M.S., New York State director of the Drug Policy Alliance.
The second panel focused on efforts created by and for people who have been in prison to support people who are being released back to their communities. This support mechanism is a strategy for decreasing the impacts of the trauma of prison, as well as the ongoing stigma and trauma that occur upon being released. All of the panelists discussed their efforts to reach different yet overlapping communities of formerly imprisoned people: women, people living with HIV, and former gang members.
Lamont Bryant, a community health worker who provides linkage-to-care support at Transitions Clinic in Brooklyn, N.Y., told the story of working with a client living with HIV to connect to health care once he'd been released from prison, and all of the barriers he had to accessing care. His barriers had less to do with having HIV, and more to do with the stigma and discrimination he faced when going to doctor visits for medical care because he was formerly incarcerated and in recovery from substance addiction Bryant recounted a story in which his client was denied medical care because he smelled of alcohol upon arrival.
"What does that have to do with his medical needs, if it's not going to interfere with what you're going to prescribe him?" he said.
There are a number of research studies that show that the days and weeks immediately after release from prison are when people are the most vulnerable to acquiring HIV and hepatitis C. For people living with HIV, studies have documented barriers to being linked to care upon release, despite the body of evidence demonstrating the value of health care continuity for people who are living with HIV. A 2007 study concluded that "former prison inmates were at high risk for death after release from prison, particularly during the first 2 weeks."
The conference expanded its view of the scope of the problems before addressing solutions. Mindy Thompson Fullilove, M.D. and Samuel K. Roberts, Ph.D., expertly cited the climate crisis we're facing as the lynchpin for all of the concurring crises in the economy, health care, housing, and criminal justice.
The final panel focused on the work being done by several advocates to build power among people who are most impacted by the criminal justice system. These advocates hope to change laws, policies, and programs, as well as create new visions for what health and health care can look like in the future. And while there was some discussion of the political realities that have created a false sense of distance between communities -- which has led to many white communities believing drug addiction, HIV, and premature death only exist in black and Latinx urban areas -- the final panel began to demonstrate that while racism persists, building solidarity across race, class, gender, and urban/rural divides will be critical in making systemic change.
"We have to transform ourselves and the world -- otherwise, there will be none," said Jawanza James Williams, lead organizer of VOCAL-New York.