Justice, Health, and Democracy

Driving Transitions from Criminal Justice to Public Health Models for Solving Social Problems 

The Justice, Health, and Democracy project (JHD) at Harvard’s Edmond J. Safra Center for Ethics seeks to help make sustainable and durable the efforts of academics, practitioners, and policy-makers to move the needle in criminal justice and drug policy reform to center human health and well-being instead of punishment as the guiding paradigm. 

In order to achieve this: 

  • We conduct research on alternatives to current models of addressing issues like substance use disorder via a criminal justice paradigm, focusing in particular on arrest diversion programs that direct substance users to health programs.  
  • We support innovation in general education and professional education curricula in the direction of preparing practitioners to work with an individual and public health and wellbeing paradigm for responding to social problems.  

  • We seek to weave together the research community and practitioner community in cross-ideological collaborations to share learnings and drive reform in the criminal justice space, via Washington D.C. based briefings for Capitol Hill staffers and staffers affiliated with the National Governor’s Association. 

JHD is a team of academics across Harvard who are leaders in their fields of law, health, criminal justice, and public policy who have been independently researching subsets of our problem; an evaluation team from the Crime and Justice Institute of Community Resources for Justice in Boston, MA; practitioners in partner organizations such as the Police Assisted Addiction Recovery Initiative; research partners at other universities; and policy-maker partners at the Leadership Conference for Civil Rights and American Enterprise Institute. The project launch has been generously supported by the Ford Foundation. 

Research 

Our core research study examines pre-arrest and non-arrest diversion programs that redirect low-level drug users into treatment instead of jail as a means to advance criminal justice reform. Our goal is to move the needle in criminal justice and drug policy reform to center human health and well-being instead of punishment as the guiding paradigm. 

We work with local discretionary authorities to combine theoretical and practical expertise in support of efforts to develop, implement, and spread to scale diversion strategies to redirect non-violent drug offenders into social services for addiction recovery. We are building on emergent interest among policy makers, prepared by the success of drug courts and now inspired by the opioid crisis, in a shift from a criminal justice to a public health paradigm for addressing control of illegal substances.  

Permanently shifting drug control strategies from a criminal justice to a public health paradigm will require defining: (1) the treatment practices and non-arrest strategies that work; (2) the statutory frameworks that will enable the transition to a public health paradigm; (3) the spectrum of feasible governance structures at municipal and state levels; (4) the training necessary for police, justice, and prosecutors to exercise discretion at key points in interactions with drug offenders; and (5) the expertise (legal, medical, policy, public health, and governance) that is necessary to sustain a new public-health based paradigm over time. 

We can achieve all five of these goals by examining the living examples of criminal justice diversion in our partner jurisdictions, distinguishing best practices, and then replicating and driving them to scale. Working together, we will review the state-level laws that must be overhauled to clear the way for dissemination and scaling of this change; we will propose strategies for reversing the force of stigma; we will develop evaluation protocols to permit identification of successful programs; and we will integrate legal, medical, public health, sociological, policy, fiscal, and governance knowledge in support of program success. 

For the past two years, we have worked with the Police Assisted Addiction and Recovery Initiative (PAARI) of Boston, MA, to evaluate their non-arrest diversion model. We conducted a portrait of PAARI’s member sites using secondary data and have begun a series of in-depth interviews with key local stakeholders in three representative PAARI partner locations to better understand how police-facilitated access to drug treatment programs were implemented across the selected sites. Interviewees include law enforcement leaders, sworn or civilian personnel responsible for running the programs, and key community leaders. The interview questions comprise three overarching concepts: (1) community context and background, (2) implementation of the programs, and (3) attitudes and perceptions about the program and addiction.  

In connection with this analysis, Dr. Vaughan Rees, a professor at the T.H. Chan School of Public Health, has begun a complementary evaluation of Plymouth, MA, from the public health and harm reduction perspective. He is also conducting in-depth interviews with stakeholders in Plymouth, notably including substance users, to evaluate their relationship with the PAARI program and the town’s new substance use treatment approach. Dr. Rees is using a mixed-methods approach combining custom-designed surveys and key informant interviews with PAARI-partner police staff, key community stakeholders in substance use prevention and treatment services, and local substance users, with the goal of generating an evidence-based toolkit to support future implementation efforts by police departments new to the PAARI network.   

We are ready to move this research beyond the PAARI model and explore other places where these interventions are happening, with the long-term goal of raising this to a nation-wide scale. Expanding this work to a national scale will involve an intensive project of education and dissemination, as well as a public opinion campaign about the core concepts structuring the change. 

The central components that drive this project are: 

  1. Research Team: A Harvard-based research network uniting researchers in law, public policy, public health, and medicine that is building an interface between criminal justice and public health conceptualizations and approaches to drug control and treatment. This network identifies the legal and health frameworks at a state-level that may require revision in order to support such a transition, clarifies where such transitions can be effected at the level of discretionary authority, and clarifies where the use of such discretionary authority also needs support through legislative change.  

  2. Diversion Professionals: A network of professionals conducting experiments in pre-arrest or non-arrest “diversion,” a strategy to direct those entangled in the drug economy from the criminal justice system to social services. Building a formal network of experimenting practitioners, and supporting their work financially, will make it possible to test and establish proof of concept for the idea that the transition from the criminal justice system to social services might be both a more just and more cost-effective strategy for approaching narcotics control. The research network will work with the professional network to evaluate experiments, develop an evidentiary foundation for best practices, and identify and execute research initiatives that would facilitate and strengthen this sort of experimentation. We are also exploring a collaboration with the Ash Center for Democratic Governance and Innovation to run an “Innovation” competition for this professional field. 

Education 

One of JHD’s priorities has been to cross professional silos and bring together stakeholders to maximize the effectiveness of this kind of intervention through the university curriculum. We have identified an urgent need for curriculum reform in professional schools, particularly law and medicine. Will we not be able to achieve long-term, effective criminal justice reform unless we transform how future lawyers, doctors, and policy makers are trained. Lawyers and health professionals can implement and stabilize new paradigms only if their basic professional training prepares them to do so. How law schools teach criminal law evolves but evolves slowly over the course of time, and it may be time to consider whether more proactive re-engagement with the legal curriculum is necessary to connect with changing legal and health environments. Similarly, U.S. medical and public health education has historically given minimal training in substance use disorders and addiction to medical students, even in the face of the opioid crisis of the past few years. Indeed, this has only recently begun to change with recent decisions from professional associations to prioritize this domain of education. A goal of this project is to learn about the various curricular efforts emerging in this area and to explore whether curricular innovation in these domains could be effectively pursued at Harvard. 

We have already made progress in this area in two ways: (1) a dynamic group of faculty and students from Harvard college and the professional schools comprises the JHD core team; (2) one of our faculty team members, Allan Brandt, taught a graduate-level course on stigma and the history of the opioid crisis that he developed directly out of JHD’s work. You can find the student papers and related work that came out of this exciting course at this website, which is rich with resources. We are also in conversation with Harvard Kennedy School’s Bloomberg Harvard City Leadership Initiative to explore ways that JHD might contribute to their executive education program for city mayors. 

Impact 

In January 2019, in a rare moment of bipartisanship, Congress passed the First Step Act, an important piece of legislation moving criminal justice reform forward. This Act has many valuable features, but it did push aside another important proposed piece of legislation, “The Sentencing Reform and Corrections Act of 2017,” co-sponsored by Senators Grassley and Durbin. Among other features of this act, Senators Grassley and Durbin proposed establishing a national criminal justice commission. The purpose of the commission would have been to “undertake a comprehensive review of the criminal justice system; to make recommendations for Federal criminal justice reform to the President and Congress; and to disseminate findings and supplemental guidance to the federal government, as well as to state, local, and tribal governments.”  

In the absence of such a Commission, the Edmond J. Safra Center for Ethics has undertaken to build a cross-ideological partnership of academics and policy-practitioners to drive conversations of this kind forward. In particular, we have formed a partnership with the Leadership Conference for Civil Rights and the American Enterprise Institute to co-sponsor briefings for Capitol Hill and National Governor’s Association staffers on key themes in the criminal justice reform space. We are also bringing in academic partners at other institutions, including Bruce Western and the Square One Project at Columbia University. The need for such a series of briefings was identified through a series of meetings in June 2018 with Senate Office staffers for the Judiciary Committee.  

Just as the academic world has approached the relevant questions in a siloed way, so too has the world of practitioners. There is a need to help the different streams of the criminal justice reform movement converge and coalesce. The siloed areas are: sentencing reform; prison reform; re-entry; bail/probation; substance use disorder reform; drug policy reform; and diversion programs.  Also, there is a need to build a strategy that aligns state-level and federal work. Most people are currently choosing one or the other. 

Conclusion 

Our country currently spends $80 billion a year on incarceration, and African Americans are incarcerated at six times the rate of Whites. Although Blacks and Latinos are only one-quarter of the US population, they were 58% of the total incarcerated population in 2008. The disproportionate incarceration rate can be directly traced to the aggressive criminalization of drug use during the War on Drugs and related violence. At the same time, we are in a national crisis of opioid drug use. There has been a 300% increase in opioid prescriptions for pain treatment since 1999, and opioid use has led directly to our crisis of heroin abuse. Alarmingly, HIV and Hepatitis C infection rates have increased substantially in the past two years, and Hepatitis C is now considered an epidemic in populations of people who inject drugs and in incarcerated populations. 

Questions of both justice and efficacy are at stake in how we steer this transition. Researchers have suggested this kind of shift to a public health paradigm in the past; the difference now is that there are significant initiatives at the grassroots law enforcement and prosecution level, as well as growing political interest in facilitating such change. Criminal justice diversions for low-level drug offenders are a promising new paradigm for drug control that will reform the criminal justice system and address the national crisis of opioid abuse. Pre-arrest and pre-booking diversion programs empower police officers, attorneys, and judges to help redirect drug offenders to recovery services offered by their non-profit service provider partners. Diversion programs stem the flow of drug offenders from cycling in and out of jail, which reduces recidivism, increases public safety, and drastically cuts costs to the community. 

Ultimately, a dramatic shift in our national drug policy will have an immediate benefit to our most vulnerable populations: men and women of color in urban communities, homeless populations, veterans, and those with diagnosed and undiagnosed serious mental illnesses who self-medicate with drugs. By stemming the tide of the exploding prison populations and redirecting the funds from incarceration to mental health and addiction services, we will ensure that millions of people gain access to necessary resources for immediate and long-term care. The burden of responsibility for addiction care will be removed from police, attorneys, judges, and hospital Emergency Rooms that are currently the first access point to care for many people and redirected toward those best equipped to assist these vulnerable populations. The impact of this type of change and on this scale will affect not only current but also future generations through the promotion of stability within families and communities that have been hardest hit by the current failing system.