What are you destined to be, and how can we ensure your success?

What are you destined to be, and how can we ensure your healthy success?

Criminal justice system encounters are uniquely tied to health.

No one aspires to have criminal justice system (CJS) encounters. If there is such a thing as destiny unmet, a criminal identity would be it. Ensuring that we stay on track with our destinies, even if our future intentionally changes alongside shifted aspirations, requires assertive confrontation. Healthcare should be assertive and pull up a chair at the active duty and veteran involved CJS table.

The individual aspirations of active duty and veteran persons, like civilians, illuminates self-determined destiny. It is not enough to offer recruiting counsel or military administration manuals to accompany one’s career. Criminal activity, risks and prevention, victim impact, recidivism and poor quality of life outcomes should be viewed as a health charge. Healthcare should partner as we accept our responsibility in ensuring the healthy success of those in the armed forces. Healthcare should lead the question and ask service persons what they are destined to be, and then follow-up with an accompanied, evidence-based presence to CJS work.

Learning is a lifelong endeavor

There is much we don't know about the CJS with military members and veterans, yet we can build from learning every day. While the CJS system may be less of an issue for service persons than civilians, it is still an issue. It is an issue we need to address.

*Analyze the available demographic data of Armed Services personnel with appreciation to what is available and commitment to the gaps. We know some service person demographics. A large share of the U.S. enlisted service persons are 17-24 years of age and a large share of officers are 25-34 years old. There are significantly more men than women in the military, and ethnic diversity differs by unit (1). Commentaries on other countries are available, including NATO deployment demographics (2) and country-specific analyses of service person volume, such as with Russia (3). Worldwide, there is no demographic collection, nor defined terminology for income class or ethnicity.

*Note the acceptable age ranges of military personnel, with specific focus on entry, recruitment and youth. Acceptable age ranges for military entrance difference between unit and country. The majority of recruits are young, and recruitment entry ages differ drastically (4). Entrance into the military is required for some countries and a volunteer recruitment for others.

*Note the lack of public transparency on recruitment requirements, including background and the individual’s criminality. There is no international information on this. There is no international behavioral assessment, standardized, that assesses risks of interpersonal violence, nor risk changes along life experiences.

*Recognize the demographics of military crimes, as well as investigations, that are available. It is difficult to locate a comprehensive public account of US military crimes, yet basic statistics exist for type of crime and military unit (5). There are no public demographics of perpetrators, convicts or victims. It is unclear what demographic data is analyzed, particularly the social background, recruitment medical record or prior convictions of the perpetrator or convicted criminal. There is no public measure of the CJS process, including court times, average sentences, etc, and there is no discussion on these individuals' health upon CJS entry. It is unclear if demographic or crime definitions differ in any way for military police or military courts, and these definitions likely differ across borders. Notably, there is no public metric that monitors prior convictions or records internationally.

*Recognize the available demographics of veteran-related crimes. Again, the amount and type of crimes, amount and type of reports, location, and demographics of those involved are not clear. There is no comprehensive public database on criminal justice involvement of US veterans and no public analysis of CJS encounters. Importantly, spotlight focus from UK expertise has provided measured reporting on UK veterans in prison. The literature estimates that the average length of US and UK service is somewhere between 6-7 years(6,7) and the average length of service for an incarcerated US veteran is 4 years (7). Compared to the overall US population to veteran ratio, there are less veterans than civilians in prison. There is some evidence of average CJS entry long after leave(7). Noted delay or stall of CJS entry correlated to active duty work has been discussed. There are no background statistics on veterans in prison, although some work has identified that patterns of lower socioeconomics and lower education match civilian CJS data. There is no clarity to veteran health upon entry into CJS. Additionally, potential differences in the CJS process, including investigation time, measure of average sentence compared to civilian, and measure of legal aid/representation are not available. Notably, there is no basic measure to identify veteran involvement with prior programs, interventions, etc. Internationally, the unknowns of veterans in prison remains an identified issue. We do not know how many veterans are involved in CJS for violence-related issues, nor if there was any prevention or intervention efforts in the individual’s life.

*Respect the health issues, concerns and impact related to young adults. Military administrations recruit individuals at a young age and young adults’ health needs are unique. In the US, mental health diagnoses are disproportionately represented in the CJS system. Mental health issues present more frequently in adolescence and young adulthood (8) with some literature indicating that 75% of all DSM-IV cases will start by age 24 (9). While a quarter of psychosis experiences occurring after age 40, first onset of psychosis usually occurs between age 15-25 (10, 11). One meta-analysis found that separation anxiety disorder, specific phobia, and social phobia had a mean onset of 15 years of age, while agoraphobia, obsessive-compulsive disorder, posttraumatic stress disorder, panic disorder, and generalized anxiety disorder began between 21.1 and 34.9 years (12). In one study of U.S National Guard soldiers, not generalizable to the entire military, the median age onset of anxiety disorders was 15 years of age and mood disorders was at 21 years of age. 64% of participants in this study reported that their disorders were identified before enlistment. Overall, the lifetime prevalence of DSM-IV diagnoses in this small study group was 61% (13). Mental health is not the only health issue that young adults face. Risk-taking, such illicit drug use, tobacco use, unprotected sex and other unhealthy behaviors are other common concerns (14, 15). Chronic issues such as hearing loss, obesity, and asthma persist. Injury and violence are main issues for young adults, and motor vehicle accidents are a common injury (14,15). While there are surely military task forces and medical teams dedicated to consideration of young adult trajectories, public integration is unclear.

*Respect the health issues, concerns and impact related to military service. Military service does have beneficial impacts through general physical fitness and attention to self care. However, military service also negatively impacts health, and both active-duty and veteran personnel are at risk for musculoskeletal conditions, general medical conditions, injuries, brain trauma, hearing loss, environemntal exposure impacts, mental health issues, substance abuse, suicide and other issues (16,17,18,19). This is noted in the U.S. and likely similar across international borders.

*Respect the health issues, concerns and impact related to contact with the CJS. Prison health itself is in early development, with prison health delivery extremely suboptimal everywhere. There are poorer outcomes associated with prisons and there are poorer outcomes associated with involvement of CSJ. Exacerbation of chronic conditions, unmet medical needs, substance abuse, violence, injury, sexual assault, infectious disease and mental health conditions are correlated to imprisonment. There is no one system for prison healthcare operations. Poor continuity of care, a lack of quality improvement to healthcare and no ongoing epidemiology create system-wide disparities(21, 21, 22). Additionally, there is no healthcare accreditation, and there is no research portfolio, to speak to the entirety of the population. Correlation between prison health and suboptimal corrections is unknown, correlation to time in corrections is unknown and there is no information based on CSJ involvement. Policy work remains ongoing and piecemeal (23).

*Note the unknowns around military prisons, as well as non-war related military crimes, overseas. What policies are incomparable and what data is withheld or unobtainable on serviceperson crimes in other countries? How are on-base and off-base complexities in crimes accounted for (24)? Does military prison work overseas affect the service person’s ethical behavior and decision-making? If the answer is no or unknown, where is the data and legal framework comparison to support that response? There is no national or international accounting for any of this, and no attention to the service person’s health and CJS.

Interceptions: Early intervention, Re-routing international comparisons

*Organize current and future intervention work around military and veteran personnel and the criminal justice system.

*Create national and international task forces, if not already in motion, around young adult healthcare. Work with primary care on guidelines for well checks, work with medicine on screening tools and implement comparative work with civilian liaisons. Incorporate military schools. Standardize metrics and insist upon quality and organization to research.

*Compile prison program comparisons by focus and goal: prevention of CJS contact, prevention of CJS entry, support with CJS experience, re-routing to other health programs, mental health courts and support for individuals upon CJS exit. Recidivism work should also be included. Cross compare what is and is not offered in military systems, and tier the evidence for guidance. (25, 26,27). This should be done with international structure. Terminology, measures and tools should be utilized consistently. Attention to mental health and young adults, as well as mental health and departure from service time, should be included.

*Compare international programming, data and points. When there is consensus over programming methodology and tools, act. When there is agreement to remain dissimilar in military prison intervention programming, due to health resource infrastructure, court difference or policing differences, document the details (27). Detail the differences and seek the common grounds anyway. Be specific about credentials of personnel involved in programs.

*Be specific with goals of military healthcare, prison prevention and prison treatment. Create clinician proficiencies around CJS prevention and treatment in military healthcare, using current platforms (28) as springboards.

*Compare funding strategies and all points of health contact, as well as all potential points.

*Identify the task forces involved with sexual assault in the military (29). Compare epidemiological methods, programs and any prevention strategies to civilian, criminal justice, behavioral and greater public health work. Advance this for international military attention.

*Identify opportunities for epidemiology around overseas prisons. Cross-compare laws and behavioral health points. Incorporate contractors, screening tools, incidents and investigations, not just formal reprimands, into data. Identify programs or interventions to improve, and hold lax oversight accountable. Require international military, and international governance, cooperation. Just because a crime is not labeled as such, particularly with imbalances of power on overseas bases and host country laws, does not mean the criminal justice should go unexamined. This is particularly true when we prioritize health.

Training grounds can focus our beginnings.

*Create a comprehensive international strategy for young adult health, with the task forces and experts already involved. Include psychosis work (30), mental health work (31, 32), injury prevention, recruit injury prevention (33, 34, 35), attention to adverse childhood experiences (36) and general injury prevention (37).

*Make room for young adult and recruitment CJS prevention work. Commit to sustained, integrated young adult CJS prevention and interception.

*Request that military and academia work partnerships (38) focus on young adult health. Create space for international effort.

*Incorporate better data, assessments, standardized tools and ongoing healthcare integration with recruitment and entry level military operations.

Never settle, there is a reason to rush

*Acknowledge what is known and unknown regarding older individuals and veterans who are at risk for CJS. Metrics indicating favor toward veterans in comparison to civilians should not deter effort to prevent further service person or veteran crimes, nor should it deter work to prevent CJS entry. Create a gameplan inclusive of veteran population voice (39).

*Consider health science and risks with middle aged and older adults. Older persons account for 25% of PE (40, 41) and the mental health science in aging remains of ongoing scientific interest.

*Consider the unknowns of military interventions on the veteran’s lifespan. Mental health research, particularly as it correlates with military occupational experience, remains subpar. Incorporate a strategic CJS plan into the veteran epidemiological framework. Do not ignore the violent offender data. Incorporate cognitive function considerations in this work. International collaboration is key.

We'll never know until we try

*Accept the limitations of criminal justice data, yet navigate for streamlined improvements for this particular subset.

*Focus on standards for data definitions, program evaluation, outcome definitions, and research quality. Tools and methodology can be consistently applied across borders. Published and unpublished data around service persons and CJS can be aggregated. Programs tailored to national criminal justice systems can still be rooted in, and establish, international guidance. Just as in validated research tools, guidance can be tailored with consistency across cultures and borders, in effort of best practice and ongoing surveillance.

*Compare international progress. Even if this is a simple 5-10 question evaluation, with metrics asks, it is necessary structure and a great starting point. Follow up should be annually at minimum, and should be consistent in reporting.

*Evaluate the legal aid component of all military, veteran and CJS work. Consider a standard metric to measure legal aid access and CJS outcome. Interventions such as alternative support referrals, rehabilitative frameworks (42) mental health courts (43) and even veteran employment after CJS experience (44, 45) can benefit from legal aid access measures.

*Tie funding to marked, measured improvement when public reports identify concerns (46).

*Be accountable to military health and criminal justice overseas. Militaries are not only accountable to military prisoners on overseas territories; they are accountable to the servicepersons (and contractors) recruited. Lack of oversight, lack of accountability and lack of international military laws on prisons should not go without attachment to the outcomes they are responsible for. Health impacts and outcomes associated with intentional overseas disorganization are likely, and unknown. Overcomplication can be intentional and a diversion to CJS health and epidemiology. Overseas CJS should be structured in a direct, no-nonsense approach to this CJS health work. In example, if a contractor is a former active duty individual, the contractor is classified as a veteran. If improvements to decades old military prison system failures (47, 48) have been made, they should be accompanied by structure to misconduct epidemiology, with a prioritization on health.

*Commit to access to healthcare with CJS collaboration and work. All too often the work is brushed aside for fear of identification of needs. We know there is and will continue to be identified health needs. We needn’t fear a shortage of resources.

*Accept responsibility. At some point along the way, our counterpart associated with the armed forces stepped toward a criminal turn. What could healthcare have prevented, how do we improve and how do we help the individuals already involved with CJS? Equally, how do we help the CJS remain better equipped to help these individuals?

There is such a thing as fulfilling destiny. We should ensure equitable healthcare strategies and partnerships so that every individual who enters the military realizes and achieves their own.

Traveling with the Refs:

1. https://www.cfr.org/backgrounder/demographics-us-military

2.https://www.nato.int/nato_static_fl2014/assets/pdf/pdf_2017_11/20171122_2016_Summary_of_NRs_to_NCGP.pdf

3. https://www.rand.org/content/dam/rand/pubs/research_reports/RR3000/RR3099/RAND_RR3099.pdf

4. https://www.cia.gov/library/publications/the-world-factbook/fields/333.html

5. https://www.bjs.gov/content/pub/pdf/p19.pdf

6.https://www.pewsocialtrends.org/2011/10/05/chapter-6-a-profile-of-the-modern-military/#:~:text=The%20average%20length%20of%20service,now%20stands%20at%206.7%20year

7. https://howardleague.org/publications/report-of-the-inquiry-into-former-armed-service-personnel-in-prison-2/

8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2174588/

9. https://pubmed.ncbi.nlm.nih.gov/15939837/

10.https://www.nimh.nih.gov/health/topics/schizophrenia/raise/evidence-based-treatments-for-first-episode-psychosis-components-of-coordinated-specialty-care.shtml#:~:text=First%20Episode%20Psychosis,-Approximately%20100%2C000%20adolescents&text=With%20a%20peak%20onset%20occurring,a%20trajectory%20of%20accumulating%20disability.

11.https://academic.oup.com/schizophreniabulletin/article/42/4/933/2414019?login=true