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After Prison, Healthy Lives Built On Access To Care And Community

2019; Project HOPE; Volume: 38; Issue: 10 Linguagem: Inglês

10.1377/hlthaff.2019.01163

2694-233X

Rob Waters,

Healthcare Policy and Management

Leading To HealthViolence Health AffairsVol. 38, No. 10: Violence & Health Leading To HealthAfter Prison, Healthy Lives Built On Access To Care And CommunityRob Waters Affiliations This article is part of a series on transforming health systems published with support from The Robert Wood Johnson Foundation. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt, and build upon this work, for commercial use, provided the original work is properly cited. See https://creativecommons.org/licenses/by/4.0/. Rob Waters ([email protected]) is an independent journalist in Oakland, California, who writes about health and science and contributes frequently to Kaiser Health News and STAT, among other publications.PUBLISHED:October 2019Open Accesshttps://doi.org/10.1377/hlthaff.2019.01163AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits AbstractA North Carolina program helps recently released inmates connect to health care, social services, and support.TOPICSAccess to careClinicsPharmaceuticalsPrescription drugsAddictionCommunity health workersWithdrawalUninsuredMedicaidViolenceAfter prison: Community health worker Tommy Green drives about 100 miles a week visiting clients scattered around Orange County, North Carolina, and helping them cope with life after prison. He has the use of three offices but does much of his work in his car.Photograph by Rob WatersJustin Jones got hooked on prescription painkillers after he flipped his truck as a teenager, put his head through the windshield, and fractured his wrist and sternum. When doctors would no longer write prescriptions for him, he began buying—and selling—drugs on the streets of Durham and Hillsborough, North Carolina. His first arrests came before he turned twenty.At first, he used prescription pills like the Oxycodone he knew, but when they were too scarce or expensive, he turned to heroin. At his peak, Jones says matter-of-factly, he was consuming about $2,000 worth of heroin a day and selling it to feed his addiction. He’s lost count of how many times he’s been in and out of prison but guesses that it’s more than fifteen.Jones, who is now thirty-two, tells me all this in the spacious living room of his parents’ home on the wooded outskirts of Hillsborough. A buck’s head adorns the living room wall; an American flag flaps from the tidy front porch. A cursive tattoo of the family’s name decorates Jones’s left forearm.Each time he was released, Jones says, the same thing happened: He’d try to stop but would be using again within two weeks. “I would try to do better, but I didn’t have a stable system, I didn’t have insurance,” he says. Without insurance, his access to doctors or treatment programs was greatly limited. (North Carolina is one of fourteen states that have opted not to expand eligibility for Medicaid to low-income adults who aren’t disabled.)He almost resumed the pattern after his last release, in December 2018. “I started hanging around the same people and doing the wrong things,” he recalls. “Then I said, ‘Well, I need to stop this.’” His probation officer put him in touch with another former inmate, a community health worker named Tommy Green, who brought me to the Joneses’ home in July 2019 and introduced me to his client.Green has been out of prison since 2015, and he started working last year for the Formerly Incarcerated Transition (FIT) Program, which helps people coming out of prison get access to health and social services. Green called Jones a few times, “but I blew him off, thinking I didn’t need the program,” Jones recalls. “But then I saw I was going downhill, and I was like, ‘Damn, I need to do something.’”He had another motivation, too: survival. Jones says that in the six months since he was released, ten friends, most of them recently released inmates, have overdosed and died. He’s had several near misses over the years himself, overdosing but somehow surviving. He decided he didn’t want to tempt fate any more.In Search Of A ‘Normal Life’Overdoses are common among recently released inmates because while inside, inmates with opioid use disorder either go through withdrawal or take smuggled drugs—usually Suboxone, a prescription opioid substitute. As a result, when inmates are released, Jones says, “your tolerance is so low, you can’t take as much, but you may think you can. You get out, and bam, next thing you know you’re dead. Me, I used to do a gram. But getting out of prison, there’s no way I can do half of that.”Getting help: Justin Jones (right) has been addicted to opioids and has shuttled in and out of prison at least fifteen times. Now, with the help of community health worker Tommy Green and the Formerly Incarcerated Transition Program, he’s getting medication that keeps him off heroin and protects him from a fatal overdose, like the ones that have killed ten of his friends this year.Photograph by Rob WatersA 2018 study in the American Journal of Public Health backs him up.1 It examined North Carolina death reports and found that in the period 2000–15, 1,329 former inmates died of opioid overdoses. The most dangerous time was in the first two weeks after release, when former inmates were forty times more likely than members of the general population to suffer a fatal overdose; over the course of a year, they were eleven times more likely to do so.Green was unfazed when Jones blew him off. He’s a patient man who knows what it’s like to come out of prison and struggle to find housing, health care, and employment. As Green often tells his clients, “I served eleven years, eight months, six days, and six hours” in state prison for an armed robbery. It was his first and only conviction, for a crime he committed at the age of twenty-one.He makes no excuses for his actions then. He grew up in a middle-class family with two working parents, but he was drawn to trouble early. “I was always playing on the edge,” he says. He fell in with a group of people “I shouldn’t have been dealing with,” he says, “and I chose to be a criminal.” After he was convicted in 2003 and found himself in prison, he resolved to transform himself.“I made up my mind that if I lived through this experience, I would never jeopardize my life, my freedom, my family again,” he says. “And I also made a vow to help anybody I can [avoid] making these same mistakes.”In prison Green avoided conflicts with other inmates, partly because he’s big and powerfully built—“a man of size,” as he puts it, whom nobody wanted to mess with—and he read voraciously. When he checked his library card seven years into his term, he found he’d read over a thousand books.When he finally got out, Green moved back into his old room in his father’s house, and three months later he landed a job as a parking lot attendant. He earned two promotions there before learning last year that the FIT Program was hiring a community health worker to work with newly released inmates. He jumped at the opportunity and had just the right background and skills.Today his prison experience is an asset that gives him street cred, empathy, and instant entrée with his clients. It’s also a prerequisite for his job. “This is like the only profession where being a criminal is a plus,” he says. “But you have to be a reformed criminal, of course.”When Jones was ready, he met with Green and, a few days later, with Evan Ashkin, a professor of family medicine at the University of North Carolina (UNC) at Chapel Hill who serves as the primary care doctor for FIT patients in Orange County. Ashkin founded the FIT Program and works as its statewide medical director. He is certified by the Drug Enforcement Administration to prescribe Suboxone and began doing so for Jones, as he does for seven other FIT patients.Jones says that his daily dose of Suboxone “keeps me from withdrawal and makes me able to live a normal life.” The drug, which combines buprenorphine and naloxone, occupies the brain’s opioid receptors, keeping users from getting high from other opiates. “If I go out right now and get some heroin or a pain pill, it’s not going to affect me,” Jones says. He knows this to be true because he’s tried, and “it didn’t do nothing. A big waste of money.”Tackling Systemic BarriersFor Ashkin, starting the FIT Program grew out of a sense of social commitment that was nurtured by his residency at the University of California San Francisco (UCSF) in the 1990s, during the height of the AIDS epidemic. He moved to North Carolina in 1998 and ran a section of the family residency program at UNC Chapel Hill that worked to provide care to the underserved.“I started to understand that if they had a history of incarceration, that led to further barriers and really, really poor access to health care services,” Ashkin says. Because North Carolina didn’t expand Medicaid, when people were incarcerated, “it was the first time they had a constitutional right to health care. And they were getting diagnosed with high blood pressure, diabetes, and chronic kidney disease.”When they get out, most recently released inmates have other priorities than health care, like getting housing and reporting to their probation officers. Since health care isn’t high on the list, and they can’t afford it anyway, many simply don’t get care—even when they have serious health, mental health, or substance use problems. Even clinics that aim to serve low-income people often require copayments of $20 or $25 for clinical visits and $4 to $10 for medications, Ashkin says.The lack of coordination shocked Ashkin, who laughs at his own naïveté. “I was certain you couldn’t be released from prison with all those medical problems and not have a follow-up appointment,” he says. “That was incorrect.”Ashkin learned that prison health care is so separated from the health care system outside that there was no easy way to bridge the two.He learned that prison health care is so separated from the health care system outside that there was no easy way to bridge the two. Another former UCSF resident had come to the same conclusion. Shira Shavit, now a clinical professor of family and community medicine at the university’s medical school, did part of her residency at nearby Alameda County Jail in the early 2000s and later recruited physicians to work at San Quentin Prison. She succeeded—but the young doctors she enlisted soon became demoralized.“They started feeling, ‘What am I doing?’” Shavit recalls. “‘I’m caring for these patients, they’re getting healthy, and then they’re released and don’t have any access to services. Then they come back [to prison] on a parole violation and they’re sicker than when they left.’”Several studies have found that inmates coming out of prison are significantly more likely to die—and not only from drug overdoses. A 2007 study in the New England Journal of Medicine tracked 30,327 people who were released from prison in Washington State in the period 1999–2003 and compared them to other Washington residents matched by age, sex, and race.2 During the first two weeks after release, the former inmates were more than 12 times as likely to die of any cause and 129 times more likely to die of an overdose. Over two to three years the former inmates were 3.5 times more likely to die than the other residents. A total of 443 former inmates died, nearly a quarter of them from an overdose. Heart disease, homicide, suicide, cancer, and auto accidents were the other leading causes of death.Shavit and her colleagues saw the need to build better linkages between prisons and the community. In 2006 they started a pilot program in a community health center run by the San Francisco Department of Public Health. They called it the Transitions Clinic, and its aim was to connect former inmates with chronic health conditions to health, social, and support services within two weeks of their release.Shavit and colleagues began the process by conducting focus groups to get input from people who’d been incarcerated. One piece of advice stood out: They would need to overcome the natural distrust of the health care system felt by people who had long been outside of it and often felt ignored or disparaged by its practitioners.The best way to do that, they were told, was to hire people who had been incarcerated themselves and put them at the center of the program. Community health workers like Green now fill that role, connecting and building relationships with potential patients and serving as supporters, advocates, and mentors.The focus groups had another suggestion, too: People with a history of incarceration didn’t want to be segregated from other patients and served in a separate program. Instead, they wanted to feel like part of the community and to “sit in the waiting room with kids and families and the rest of the community,” Shavit says.Since its start thirteen years ago in San Francisco, the Transitions Clinic has grown: Now the Transitions Clinic Network, it contains thirty-four affiliated clinics in twelve states and Puerto Rico that follow the same model, including the FIT Program in North Carolina. Ashkin started FIT with support from the North Carolina Division of Public Health. The first site, in Durham, opened in 2016. A grant from the Duke Endowment and a contract with the North Carolina Department of Public Safety, which administers the state’s fifty-five prisons, enabled the program to expand to Orange County, where Green works, and to the counties that include Charlotte and Raleigh, the state’s largest cities. Ashkin hopes to start a program in Greensboro this year and to provide greater access to mental health services in all FIT sites.Maintaining and growing the program is challenging because of the state’s decision not to expand Medicaid. The grants and contracts Ashkin has obtained help pay the salaries of community health workers like Green and cover the copays that patients would otherwise have to shell out at safety-net community clinics. The clinics lose money for every uninsured client Ashkin brings them.“They’re hoping to get more insured patients to offset the cost of treating the uninsured, and I keep bringing them more uninsured patients,” he says. “If we don’t expand Medicaid, it will become harder and harder [to raise] private funds for this.”Today the FIT Program serves about 85 inmates, Ashkin says, a number he hopes to increase to 350 by year’s end. But that’s a small fraction of the roughly 25,000 North Carolina inmates who come out of prison each year.The failure to provide health and social supports to so many former inmates fuels recidivism and violence, says Dorel Clayton, another former inmate who was hired last year as FIT’s Durham County community health worker. Before that, he worked as a supervisor for Bull City United. As described in a Health Affairs Blog post published concurrently with this article, Bull City United works to interrupt violence and retaliation in Durham’s high-crime neighborhoods.3 At FIT, Clayton continues to collaborate with the staff of Bull City United because he sees the links between health, substance abuse, and community violence.People who lack access to the care and medications they need to treat their addiction or mental illness are more likely to self-medicate, Clayton says, by “getting the drug from street pharmacies, and that ties into a whole bunch of stuff.”Another factor is trauma. “Someone who is dealing with bipolar disorder or posttraumatic stress disorder—it might be a result of having seen gun violence and people killed right in front of them,” Clayton says. “So their mind-set is to continue to hurt one another. We try to educate, but the lack of resources, the inability to get health care and insurance definitely contributes to violence.”The Case For ExpansionTransitions Clinic Network cofounders Shavit, the network’s executive director, and Emily Wang, its evaluation director, have worked to build the case for expansion by conducting regular evaluations that document the program’s effectiveness.An early evaluation found that recently released inmates who got care from the Transitions Clinic in San Francisco made fewer emergency department visits than those who were offered care in a standard primary care clinic, resulting in an estimated savings of $912 per patient.4A more recent study, published this year in BMJ, looked at outcomes at the Transitions Clinic in New Haven, Connecticut.5 The authors found that in the twelve months after they were released from prison, patients who were getting cared for by the program were neither more nor less likely to be rearrested than another group of former inmates who were not part of the program. The big difference: When they were rearrested, Transitions Clinic patients spent 45 percent fewer days locked up in jail or prison. Wang and her colleagues wrote that the ninety-four people in the control group would have spent 2,300 fewer days incarcerated if they’d been clients of the Transitions Clinic. The authors also found that the clinic’s patients were less likely to be hospitalized for preventable conditions and spent 60 percent less time in the hospital when they were admitted. While the authors couldn’t say precisely why clinic patients spent less time imprisoned, they speculated that being part of the clinic helped patients get into drug treatment more quickly or gave them access to advocates who helped them bail out sooner.Green helps his clients in these ways and more. He once convinced a magistrate to drop charges against one of his clients and often talks to parole officers on his clients’ behalf. He works out of three offices scattered around the county to be accessible to his clients, but he spends most of his time in his mobile office: the county-owned Honda Civic he uses to go to clients’ homes or ferry them to court dates or doctor’s appointments.Green manages a caseload of almost thirty-five former inmates and gives priority to those he calls his high-touch patients, people he considers vulnerable and wants to connect with at least once a week. He drives with a Bluetooth earpiece in one ear and makes me slightly nervous as he engages in animated phone conversations while making frequent U-turns. He logs about a hundred miles in a week, he says, while visiting up to fifteen clients.I’m pleased when he actually pulls over to call one client, Pete Jacobs, before driving to his mobile home on a country road in Hillsborough. Jacobs is a big man who’s being treated for high blood pressure and heart problems, as well as a leg hematoma he suffered in an auto accident. Before the accident, he did roadwork and landscaping. Now, he says, he’s unemployed and broke.Jacobs spent five years in prison on drug charges, and while he was there, he was diagnosed with heart failure. When he got out, he went a few weeks without medication until his probation officer told him about the FIT Program and gave him Green’s phone number.Green checks in with Jacobs about how he’s doing as he drives Jacobs to an appointment at a county social services office and then to a local food pantry. Jacobs is hungry and has no money for food. Under North Carolina law, he’s ineligible for benefits from the Supplemental Nutrition Assistance Program (formerly known as food stamps) because of his drug conviction. At the food pantry, run by a local United Way affiliate, he gets a few bags of groceries. Green helps him load the food in the car and then drives Jacobs back home.Without the FIT Program, Jacobs says, he doesn’t know how he’d get the food, health care, or medications he needs.Without the FIT Program, Jacobs says, he doesn’t know how he’d get the food, health care, or medications he needs: “I don’t get Medicaid. I don’t get food stamps. I don’t get no check every month.”Still, he says, he’s doing a lot better. He’s taking fewer medications and no longer needs diuretics. “My health is doing good,” he says. “I take my medicine every day. I got Dr. Ashkin. I got Tommy. And I made it through my probation.”Green’s next call is to Jeffrey Fradsham, who at that moment is at a construction site applying for a job. Green wants him to meet Marcus Pollard—a job placement specialist with the Reentry Council, a local agency that assists released inmates. We drive around looking for Fradsham and finally pull over to the side of the road to pick him up. He is covered in tattoos.Fradsham tells me he’s been in and out of prison since he was seventeen and learned to do tattooing there because “the only thing to do in prison is fight or tattoo yourself.” He’s nothing if not ingenious: In prison he made tattoo needles out of the springs in ballpoint pens and used the motor of an old CD-ROM player to drive the needles. Outside prison, he has worked as a professional tattoo artist, so when we get to Pollard’s office in Chapel Hill, Fradsham tells him he’d like to go back to that line of work. He says he’s been offered a seat in a local tattoo parlor but needs around $400 to buy a tattooing machine. If the offer from the parlor is real, Pollard tells him, he can probably get him the money.Fradsham has struggled with heroin addiction but says he quit cold turkey during his last stint in prison. He’s been out for ten months and struggles with posttraumatic stress disorder from the violence he experienced. He once watched a man get stabbed thirty-seven times “over nothing” with a shiv made from a light fixture. It’s difficult to be back outside, he says: “People move out of the way when I walk down the street.”Green drops Fradsham at his house, and we head to Hillsborough and the Orange County Jail, where Alison Zirkel, a social worker with the county’s Criminal Justice Resource Department, is about to meet with an inmate. She’s sitting at a card table in a small meeting room, near a bank of phones and a sign: “Inmates, pick up your phone first.”In a jail with a capacity of 120 inmates, Zirkel typically works with 20–30 at any one time who have mental health or substance abuse problems—frequently both—and little or no access to medical care outside of custody. For many, the combination of being homeless and abusing substances has led to public intoxication, assaults, and fights.A deputy leads a tall, gray-haired man into the room and slides the barred door closed, securing it with handcuffs and a chain. Zirkel asks the man if he saw the psychiatrist the previous week. He says he did and was given a prescription for Prozac, which he started taking. Since he’s likely to get out soon, Zirkel suggests that he sign up with the FIT Program.She leaves and Green comes in. “I’ve been in your shoes,” he says. “I’ve been in this very jail.” The man, who asked to be identified only by his first name, Graylin, tells Green he has diabetes, hepatitis C, and high blood pressure. He does not have a drug abuse problem, he says, though he was arrested for driving under the influence. His big needs, he says, will be housing and transportation.Graylin was released two weeks later, and Green has been helping him get services and housing. He’s also one of several FIT clients, including Jones, who will be able to get a free eight-to-twelve-week course of Harvoni, a drug made by Gilead Sciences that eradicates hepatitis C. That supply of the drug normally costs $63,000–$95,000, but Ashkin and his colleagues have made arrangements with Gilead’s Patient Assistance Program.Medication-Assisted TreatmentUntil now, medication-assisted treatment (the prescribing of opioid substitutes to people with opioid use disorder) has been banned in nearly all jails and prisons, including the Orange County Jail—which leaves inmates to rely on smuggled drugs, primarily Suboxone, if they don’t want to go into withdrawal.One exception is the state of Rhode Island, which in July 2016 began providing three opioid substitutes—methadone, buprenorphine, and naltrexone (a long-acting injectable opioid blocker)—to inmates with opioid use disorder. The state also organized a network of community clinics that could continue providing the drugs after people were released. A study published last year in JAMA Psychiatry demonstrated the success of this effort.6 The authors found that in the first six months of 2016 (before the program started), twenty-six people recently released from prison died by overdose. In the first six months of 2017 (after the program was up and running), the number of fatal overdoses fell to nine. Even more impressively, ten people died in the first thirty days after release in 2016, compared with just one in 2017.The refusal of most correctional facilities to provide opioid treatment is drawing mounting criticism, as well as court challenges.The refusal of most correctional facilities to provide opioid treatment is drawing mounting criticism, as well as court challenges. Last November, in a closely watched case, Pesce v. Coppinger, Judge Denise J. Casper of the US District Court for the District of Massachusetts issued a preliminary ruling that the sheriff of Essex County, Massachusetts, could not deny methadone to a man sentenced to serve time in the county jail. Despite a six-year history of addiction, the man was able to stop using heroin and hold onto a job after he was prescribed methadone in late 2016. Since the jail doesn’t allow inmates to have methadone, being sentenced there could throw him into withdrawal and disrupt his recovery. And that, Judge Casper said, would violate the Americans with Disabilities Act of 1990.Some North Carolina jails and prisons are starting to shift their stance. The Orange County Jail began making Suboxone available to a handful of inmates in August. Ashkin says that the initial priority will be people already on Suboxone from a community provider and pregnant women with opioid use disorder, to prevent them from going through withdrawal and harming the fetus or baby. Being on prescription Suboxone under the care of a doctor is considered far less risky.Charles Blackwood, the elected county sheriff, says that providing medication-assisted treatment in the jails will help inmates “transition from heroin to a drug that will allow them to control their cravings” and minimize the disruptive effect on the jail population of having inmates go through withdrawal.“We’ve got to try something new, something innovative,” Blackwood says. “When I ran for sheriff, they didn't tell me ‘Get elected, mistreat people, and ignore their needs.’ They said ‘Take care of your people. Serve the public.’ If you plant a garden of discontent, you’re going to have trouble, but if you plant a garden of good, it’s going to pay back.”Meanwhile, the North Carolina Department of Public Safety is starting a pilot program in three prisons that will give inmates with a history of opioid use disorder who are “on their way out the door” a choice of Suboxone, methadone, or naltrexone. This will give them a bridge into treatment and help them avoid death from overdose, says department spokesperson John Bull. The department will also refer patients to the FIT Program in the counties where it operates. Bull says that “it’s a paradigm shift for North Carolina” that will give inmates a better chance to overcome addiction and lead better lives.Back in Chapel Hill, Warren Levy, a fifty-four-year-old Jamaican who grew up in Brooklyn, is waiting to meet Green for the first time. Levy was released from prison a few months earlier after serving a couple of stints. He has prostate cancer, sickle cell trait, bipolar disorder, and a history of substance abuse. He tells Green he’s staying at a shelter for homeless men and working at Burger King, a job that’s bad for his fragile health. “It’s 100 degrees in there, and it’s killing me,” he says.Green tells Levy about the FIT Program and gives him the number of his personal cell phone. He also tells Levy about his own background of incarceration “because I want you to feel comfortable dealing with me and to let you know that I've navigated all the systems that you will have to navigate.”Levy is convinced. “Sign me up!” he says. Within two weeks, Ashkin had seen him for an exam.NOTES1 Ranapurwala SI , Shanahan ME , Alexandridis AA , Proescholdbell SK , Naumann RB , Edwards D et al. Opioid overdose mortality among former North Carolina inmates: 2000–2015. Am J Public Health. 2018;108(9):1207– 13. Crossref, Medline, Google Scholar 2 Binswanger IA , Stern MF , Deyo RA , Heagerty PJ , Cheadle A , Elmore JG et al. Release from prison—a high risk of death for former inmates. N Engl J Med. 2007;356(2):157– 65. Crossref, Medline, Google Scholar 3 Waters R . Interrupting violence in Durham, North Carolina. Health Affairs Blog [blog on the Internet]. 2019 Oct 7 [cited 2019 Oct 7]. Available from: https://www.healthaffairs.org/do/10.1377/hblog20190821.440449/full/ Google Scholar 4 Wang EA , Hong CS , Shavit S , Sanders R , Kessell E , Kushel MB . Engaging individuals recently released from prison into primary care: a randomized trial. Am J Public Health. 2012;102(9):e22– 9. Crossref, Medline, Google Scholar 5 Wang EA , Lin HJ , Aminawung JA , Busch SH , Gallagher C , Maurer K et al. Propensity-matched study of enhanced primary care on contact with the criminal justice system among individuals recently released from prison to New Haven. BMJ Open. 2019;9(5):e028097. Crossref, Medline, Google Scholar 6 Green TC , Clarke J , Brinkley-Rubinstein L , Marshall BDL , Alexander-Scott N , Boss R et al. Postincarceration fatal overdoses after implementing medications for addiction treatment in a statewide correctional system. JAMA Psychiatry. 2018;75(4):405– 7. Crossref, Medline, Google Scholar Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article MetricsCitations: Crossref 1 History Published online 7 October 2019 InformationThis open access article is distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license.PDF downloadCited ByIndiana’s Section 1115 Medicaid Waiver And Interagency Coordination Improve Enrollment For Justice-Involved Adults Study examines Indiana’s Medicaid waiver and enrollment for justice-involved adults.Justin Blackburn, Connor Norwood, Dan Rusyniak, Amy Lewis Gilbert, Jennifer Sullivan, and Nir Menachemi2 November 2020 | Health Affairs, Vol. 39, No. 11Related articlesThe Effects Of Violence On Health07 Oct 2019Health Affairs