GERONIMUS ET AL. RESPOND

Between 1980 and 2009, the US incarcerated population exploded from 300 000 to more than 2 million. This unprecedented increase, set in motion by the 1980s War on Drugs and exacerbated during the 1990s by Get Tough on Crime policies, resulted in more than 7 million individuals being incarcerated or placed on probation or on parole by 2004. Because of race- and place-selective stops, searches, arrests, prosecutions, and sentencing, 90% of felons convicted of drug offenses have been Black or Latino.1,2 The implications of massive, selective incarceration for public health research and practice are profound. Underwood and Treadwell call attention to the high burden of disease among imprisoned Black men and to the grossly inadequate health care options available to them, especially when reentering their communities. The implications for their families and communities are similarly dire and may include increased economic and caretaking responsibilities; disrupted social networks; enduring stigma, fear, and anxiety; and increased risk of post-traumatic stress disorder (e.g., secondary to the increased use of SWAT team drug raids in residential neighborhoods).1,3 Civil penalties for felony drug offenses, including marijuana possession without intent to distribute—which, alone, accounted for 80% of the increase in felony drug convictions over the 1990s—now encompass lifetime restrictions from welfare, food stamp, and public housing eligibility as well as the loss of voting rights,1 all with possible health implications for those convicted and their families.4 The failure to make sustained progress in reducing excess mortality among Black female residents of high-poverty urban areas5 might, in part, reflect the ripple effects of the prison boom, as women who cope with its psychosocial implications face weathering and little time or resources to attend to their own health.6,7 As we noted,5 given data limitations, the reductions we estimated in excess mortality among urban Black men between 1990 and 2000 might partly be an artifact of the explosion in the incarceration of urban Black men during this period. More broadly, given changing residential composition over the 1990s (owing not only to inequitable imprisonment, but also to gentrification, residential displacement in the wake of public housing demolition policies, and other factors that have disproportionately affected high-poverty Black urban populations),8 the health outlook for these populations may be bleaker than we reported. The fact that most of the data available to monitor the health of poor populations in the United States are cross-sectional and do not allow researchers to track the geographic movement of individuals over time makes it difficult, if not impossible, to gauge the magnitude of these effects.