The Carceral Shadow: Criminal Justice as a Determinant of Health and Challenges for Policymakers

Policy Points The criminal justice system functions as a primary social determinant of health in the United States, generating disproportionate physical, psychological, and chronic health burdens on Black communities and other marginalized groups. Policing structural barriers-including qualified immunity, police union contracts, and municipal financing of misconduct settlements-systematically shield law enforcement from accountability and divert public resources from health-promoting investments. Evidence-based interventions-including coresponder programs, community violence interruption, diversion initiatives, and Medicaid prerelease enrollment-demonstrate measurable improvements in public safety and health equity outcomes. Policymakers must adopt a health-in-all-policies approach that reallocates resources from punitive criminal justice practices to upstream investments in housing, mental health care, youth employment, and community well-being. Transforming criminal justice into a health-promoting system requires cross-sectoral leadership, rigorous research, and training reform that centers racial equity, officer well-being, and community-driven public safety models. CONTEXT: The United States incarcerates more people per capita than any peer nation, and its criminal justice system disproportionately impacts Black, Indigenous, and other communities of color. Police violence, mass incarceration, and carceral health crises each independently generate significant health burdens, while their intersection compounds longstanding racial health disparities. The COVID-19 pandemic amplified these structural failures, exposing the lethal consequences of overcrowded facilities, inadequate health care access, and systemic racism embedded across criminal justice institutions. METHODS: This perspective piece synthesizes peer-reviewed literature, national surveillance data, and policy analyses to examine the criminal justice system as a social determinant of health. Drawing on the Public Health Critical Race Praxis framework, the authors identify mechanisms linking carceral practices to population health outcomes and evaluate both policy gains and persistent failures across policing, mass incarceration, and community health domains. FINDINGS: Police violence, disproportionately directed at Black individuals-who are 3.5 times more likely than White individuals to be killed by police when unarmed-generates illness spillovers including elevated rates of chronic disease and mental health disorders in affected communities. Carceral settings function as breeding grounds for infectious disease, with COVID-19 infection rates in some US detention facilities reaching up to 14 times higher than surrounding general populations. Policing structural barriers including qualified immunity, police union contracts, and municipal financing of misconduct settlements insulate officers from accountability and redirect billions in public funds away from health-promoting services. Evidence-based alternatives-including coresponder programs, diversion initiatives, community violence interruption, and Medicaid prerelease enrollment-demonstrate measurable reductions in crime, use of force, and health disparities. CONCLUSIONS: The criminal justice system is not a neutral arbiter of public safety but a potent and often detrimental determinant of health, particularly for Black and other marginalized communities. Dismantling the carceral shadow requires policymakers to adopt a health-in-all-policies approach that reallocates resources upstream, holds law enforcement accountable, and centers rehabilitation over punishment. A fundamental reconception of public safety as public health is both a moral imperative and an evidence-based strategy for advancing health equity and reducing the chronic disease, mental health, and mortality burdens generated by current carceral practices.