Illustration by Kenzo Hamazaki
“That was an old joke you hear in some communities: I’m going to go to jail to get my tooth fixed,” said Lorenzo Jones. Jones is Co-Executive Director of the Katal Center for Equity, Health, and Justice, a New York- and Connecticut-based nonprofit that advocates for public health solutions to end mass incarceration and the drug war.
Over thirty years of community organizing for racial justice, Jones has witnessed firsthand the devastation that mass incarceration has wrought on the well-being of Black and other communities of color in the United States, particularly when it comes to mental health.
His grim joke about dental work reveals a disturbing truth: in the United States, prisons are some of the biggest healthcare providers. This is particularly true for mental healthcare, where three jails in New York, Los Angeles, and Chicago are the three biggest organizations that provide inpatient psychiatric care.
October 10th Is World Mental Health Day
October 10th is the World Health Organization’s annual World Mental Health Day. This year, the theme is “Let’s Invest,” a call for governments around the world to put serious financial resources into national mental health infrastructure. Around the world, countries spend an average of only 2% of their annual health budgets on mental health, even though investment in mental health is proven to be one of the most cost-effective ways to increase physical and economic well-being.
The announcement comes on the heels of a new WHO program, which aims to expand mental health coverage to 100 million more people in each of 12 countries, including Bangladesh, Paraguay, and Zimbabwe.
The United States is not on that list. Yet, despite U.S. citizens spending more than any other comparable national economy on health care, the nation has the highest suicide rates and lowest life expectancy compared to its peers. This is, in part, because the steep cost of private healthcare makes care, including mental health care, beyond the reach of most Americans.
This is also because, as Jones has seen firsthand, much of the United States’ mental health spending is concentrated within prisons and jails, rather than in the hands of community members and organizations. “We exist in a society that has a culture of punishment instead of a culture of care,” said Amber Akemi Piatt, Director of the Health Instead of Punishment Program at Human Impact Partners, a public health nonprofit.
Jones sums the problem up bluntly: “We are all in a relationship with an abusive country.”
In a year where the U.S. streets have been filled with calls to defund the police and invest, instead, in public services like education, housing, and public health, the WHO’s call for countries to invest in mental health infrastructure is particularly timely. It urges us to examine why American healthcare investment came to be so concentrated within the carceral system — and how community organizers and public health professionals are fighting to reallocate funds.
The Drug War and Mass Incarceration
“Our healthcare system has become, under the drug war, a gateway to the criminal justice system,” said Jones. Over the course of his organizing career, Jones has watched this shift — and its harmful fallout — happen first-hand.
The uneasy marriage between mass incarceration and mental healthcare extends back to the systems of slavery and colonialism upon which the U.S. economy was first founded. Culturally, white supremacist myths maligned Black people as irrational or inherently violent, in order to justify their enslavement. Economically and politically, early slave patrols, specifically founded to hunt and return escaped Black people to their enslavers, were one of the foundations of the American policing system. Meanwhile, racist theories like eugenics presented a supposedly “scientific” justification for medical and psychiatric abuse of people of color.
These factors combined with stigma against people with mental illness to create a system that equated punishment with mental health care. “In our capitalism, racist, white supremacist, patriarchal society there’s a very narrow definition of who is normal,” said Piatt. “Anyone who is outside of that very narrow box is marginalized, disposed of, caged.”
Since the 1970s, the United States has experienced a 500% rise in the number of incarcerated people — a problem most affecting poor, Black and other communities of color. Much of this can be attributed to the Drug War, a series of draconian, and often racist, laws, starting with the Nixon administration, that sought to punish, rather than treat, people who used or sold marijuana, cocaine, crack, and other illegal drugs.
At the same time, the shutdown of inpatient mental hospitals — a welcome move considering the historically abusive conditions of many of these facilities — left many people without adequate community-based mental health care, causing an estimated 4-5% rise in the population of incarcerated Americans.
“The drug war took the money that would be paying for health care, that would be providing in-patient services, and used that money for prison beds,” said Jones. “So now we’ve got people going to prison to get mental health services.” Today, about 20% of people incarcerated in the United States have a serious mental illness, including depression, schizophrenia, and PTSD.
From Criminalization to Public Health
Piatt did not begin as a public health professional. She began her career directly providing services to young people experiencing PTSD and early-onset psychosis. Day after day, she met with young people of color who had been subjected to violence in the home, at school, and in their communities.
One day, after she left a meeting with a traumatized young client with psychosis, Piatt reached a crossroads: “That trauma will never go away. That’s with them forever,” she thought. “Why couldn’t we have prevented that?”
So Piatt returned to graduate school for public health. Now, she and her organization work with Bay Area initiatives seeking to move funding and public support away from prisons and jails, and toward community-based health infrastructure. “We will fail if we try to address mental health needs in a vacuum,” said Piatt. Instead, she favors deeper investment in what she calls “life-affirming institutions,” the building blocks of a good life — housing, education, and recreation.
“Part of the system of criminalization is this massive infrastructure for taking people out of sight, out of mind, and putting people behind these walls that are designed to keep people out of community and out of connection,” said Piatt. This is a tragic irony, as social connection has been shown to be one of the greatest determinants of physical and mental wellbeing. “People cannot get well in a cell.”
For Jones, community organizing and political involvement are also part of an overall vision of public health. “That’s not just making sure people get insulin and prostate checks and mammograms,” he said. “It’s this same regimen around your political health, of your local neighborhood and communities.”
Imagining Community-Based Alternatives
For Piatt, investment in mental health comes from both above and below. It represents a governmental investment in institutions, and an interpersonal investment in each other. “If we had a culture of care it would necessitate us seeing each other’s humanity and creating more space for us to get along,” she said.
That begins with destigmatizing mental illness, challenging racism and sexism in our interpersonal relationships, and understanding that poverty is a systemic problem, not an individual failure. That also includes harm reduction, a framework that seeks to support people engaged in potentially harmful behaviors to make healthier decisions, without shame or punishment. “We meet people where they are without judgement, but we don’t leave them there,” said Jones.
Investment in mental health can mean several things: it can be pressuring the government to fund valued community initiatives, organizing autonomously within the community, or using creative solutions to promote greater connection and well-being.
All politics are local
Slogans like “defund the police” and “invest in mental health” can feel large and out of reach. But Jones has a message for people passionate about mental health: “All politics are local.”
Piatt agrees. Sometimes, she said, change comes when we think a little smaller. “We want everything at scale, immediately, when I think very localized small initiatives can actually be what’s needed,” she said.
Jones suggests paying attention to local funding processes in your area, and learning more about how governmental grants are apportioned. For him, this process of self- and community empowerment is another measure of community well-being. “Community organizing is about teaching people to self-advocate,” he said. “We prioritize that as a success over getting a victory in the capital.”
Once communities learn those skills, they can activate again over what is important to them. “What we’re trying to do is make sure people understand that process, because it’s like riding a bike.”
Enrichment, not punishment
The United States’ reliance on punishment can limit public imagination of what sustainable, care-oriented mental health systems could look like. It can be useful to turn toward other countries that have high rates of mental well-being and low rates of incarceration, such as Denmark, which has one of the happiest populations in the world — and a low rate of incarceration.
This is due, in part, to a comprehensive public health infrastructure, including free universal healthcare, generous sick leave and parental leave, and universal childcare. Denmark’s mental health infrastructure, which includes nationally funded clinics and locally funded supportive housing, also includes innovative programs using culture and physical activity to counter depression and anxiety.
“I think the Danes are quite happy,” said Mikael Odder Nielsen, project manager of the city of Aalborg’s “Culture Vitamins” program. “But we are 5 million people in Denmark and 37,000 people are sick every day with stress,” including anxiety and depression, according to the Danish government.
Culture Vitamins is one way the Aalborg government is combatting that stress. Inspired by similar programs in the U.K., it is a free, city-provided program that provides cultural immersion experiences for citizens on mental health leave for depression or anxiety.
While accessing fully funded governmental and employer-provided sick leave, program participants experience three collaborative cultural experiences a week, from choir singing to literature classes to historic excursions. There are also courses that focus on physical activity to alleviate the symptoms of depression. The program has been shown to have a significant positive impact on participants’ symptoms.
“What we’re trying to do here is to use culture to get them out of the social isolation that follows when you’re on sick leave,” said Nielsen. Trips to the orchestra — twelve participants alone in a concert hall with a full live ensemble — provide space for awe and connection. Literary study invites participants to expand their imaginations. Singing provides a space for participants to let go of their inhibitions, make mistakes, and release pent-up emotions. “Sometimes people started to cry, but in this room, that’s okay,” said Nielsen.
Until We All Are Well
The United States is still a long way away from universal, free prescription-based culture programs. But Piatt points to local initiatives, like Decarcerate Alameda County, a local Bay Area Coalition fighting to shift resources from jails to communities, as an example of the steps community members are currently taking to achieve mental healthcare for all.
As the WHO calls for a massive increase in mental health investment, and activists in the United States call to defund the police, Jones has faith that the younger generation will achieve a more equal public health and justice system. “We’ve got to survive to get to that point,” he said, “But these young people are going to do it.”