The role of epidemiologists in addressing the public health consequences of the United States criminal legal system

Exposure to the US criminal legal system-whether through contact with law enforcement, incarceration in a jail or prison, or community supervision-is associated with a range of adverse health outcomes. There is mounting evidence that mass incarceration drives health inequities, particularly for Black, Indigenous, and People of Color. However, relative to its outsized impacts on health and health inequities, the criminal legal system has received limited attention in epidemiology. In this commentary, we use a public health prevention framework to highlight opportunities for epidemiologic research aiming to (1) reduce the number of people entering the criminal legal system (primary prevention), (2) improve conditions of confinement (secondary), and (3) reduce recidivism and re-involvement in the system (tertiary). We describe common biases (confounding, selection, measurement, and missingness) encountered in research at each prevention level and identify ways in which epidemiologists can help to address these challenges. Our goal is to emphasize the unique strengths that epidemiologists can bring to investigating and intervening on the wide-ranging health consequences of a societal system that disproportionately impacts its most marginalized members.