As part of a growing understanding of the social determinants of health in recent years, there has been increased acknowledgement of incarceration as a social determinant of health. Yet many people believe the impact is almost entirely at an individual level, addressed by providing healthcare in prisons and jails.

That was what the Minnesota Department of Health (MDH) found when it was asked by the Minnesota Legislature to report on how incarceration affects the health of those who are incarcerated, their families, and their communities. But MDH knew the story was much bigger and more complicated. So the department teamed up with ReThink Health to see what a “systems thinking” approach would reveal.

More than 30 individuals attended two workshops in the Winter of 2016. They represented diverse perspectives on the criminal justice system, including public safety, economic development, education, health, human services, and the community. Participants were led through a discussion of the question: What are the issues, opportunities, and obstacles that impact incarcerated individuals and their families as they attempt to lead truly healthy lives? The goal was for participants to work together to develop a shared, high-level understanding of the systemic impacts of incarceration on health. Based on group discussions and mapping workshops, they created a report identifying reinforcing loops involved when “an event such as incarceration can set off domino effects that increasingly ensnare individuals, families, and communities and lead to poor individual and community health.”

The workshops were just a first step in any action Minnesota might take related to its incarcerated population, composed of nearly 10,000 adult prisoners. Together, the workshops resulted in a system map that explores the complexity of how health is created. But perhaps even more importantly, the workshops brought together a broad set of stakeholders and asked them to step outside their own frames of reference. The process of developing the map gave rise to a deep and rich discussion about the elements that are missing from the map in its current form, a discussion that was passionate and at times agitated. Participants wondered: If the map represents the system as designed, isn’t it a construct of prevailing social values, like the choice of incarceration over treatment for illness or substance abuse?

Throughout the course of this work it became clear that incarceration has a profound impact on the health of Minnesotans and on health inequities. The resulting system map will help the Minnesota Department of Health interpret the data and discussion in its report to the Minnesota Legislature. Any future work expanding the conversation and the boundaries of the map can serve to further explore what it would take to redirect that system to improve health.

ReThink Health’s report on its work with MDH offers additional information.