Good Intentions and Bitter Disappointments: The Uncompassionate Side of Bail Reform

As a young physician trying to pay back my medical school loans, I worked at Rikers Island, the Manhattan house of detention, and “the barge,” the floating prison that was parked in the East River during the peak of the crack epidemic and AIDS crisis. During my time there, I got an insider’s look at the prison population in New York City and became well acquainted with its medical profile.

Here is what I saw: A significant portion of crimes in the city are committed by substance abusers and people with mental illness. There’s no denying it.

The problem started decades ago, when Gov. Hugh Carey began closing the in-patient psychiatric and mental health hospitals. Back in 1955, way before Carey, the total adult in-patient census, excluding forensic cases, numbered 93,314. Today, it’s just a little more than 2,200. This shift to an outpatient-oriented approach is often referred to as “deinstitutionalization.” In my opinion, it’s been a total failure.

The governor’s intentions were good — at the in-patient facilities, compassion was lacking and finances were a disaster. But no one seems to have ever thought logically and realistically about next steps — what to do with the thousands of patients who were suddenly out on the street, on their own, with no support system or supervision.

The hope was that patients would regularly attend their outpatient visits and take their psychiatric medications. It turns out that hope was monumentally naïve. These people need compassionate, supervised inpatient substance abuse detox and psychiatric treatment. Outpatient treatment doesn’t work in this patient population. Period.

Which brings us, sadly, to New York’s newly enacted bail-reform law. Back when I worked in the city’s prison system, way before our bail reform fiasco, a person who was arrested was screened for a complete medical history, which included a physical, bloodwork and cultures for sexually transmitted diseases.

Countless cases of syphilis, gonorrhea, chlamydia, herpes, AIDS, cancer, tuberculosis, depression, schizophrenia, anxiety, high blood pressure and heart disease were discovered during these screenings. Arrestees received their antibiotics, antivirals, heart medications, antidepressants, anxiety medicine and whatever other basic medical needs that were warranted.

This was compassionate care. It also protected public health and safety by reducing the spread of untreated sexual and other communicable diseases. And, frankly, it kept a lot of very potentially dangerous people off the street — at least for a while.

Under the current bail reform law however, people who are newly arrested — a significant percentage of them with the aforementioned mental health and substance abuse issues — are quickly released back onto the street within hours, in revolving door fashion, without a medical screening, a follow-up appointment for any services or even a shower. And the judges have zero discretion to hold them, even if they’re obviously dangerous to themselves and the public.

Let’s be clear: Bail reform in its current incarnation is not compassionate. Far from it. It’s misguided and ill-conceived. And it puts the public’s health and safety, as well as the health and safety of the person who is arrested, at risk. And we wonder why they return to the street to push straphangers off subway platforms, stab people, rob people, urinate and defecate on the street, spreading disease.

So what’s the solution? How can we provide compassionate care while keeping the public safe from harm? They don’t have to be mutually exclusive.

Let’s start on Rikers Island. How about if we convert one of the buildings on the island into a mental health hospital and clinic to treat the various disorders that lead so many people to commit crimes. Before being released from Rikers, they’d need to pass through the health center to be evaluated and get starter medicines, see a social worker and be given appointments to outpatient clinics.

Perhaps it could be modeled after the Bellevue Hospital prison ward. The ward, a model medical facility, provides outstanding care to inmates who require in-patient hospitalizations. Its current medical chairperson is a national thought leader on prison medicine whose book chapter is often cited.

At least it’s a start.

A word about gun violence: In New York City, 95% of the guns used in crimes are illegal guns. Most come up from down South via the I-95 corridor, often called the “Iron Pipeline.” There’s no accurate count of illegal guns in the city, but estimates range from the tens of thousands to, well, lots more.

Many well-meaning people are crying out for stricter gun laws. But stricter laws won’t solve the gun problem in New York City. The city already has extraordinarily rigorous gun permitting requirements, and it’s had virtually zero effect on gun crime. The fact is, guns, knives or clubs are only tools. But in the hands of the wrong people, they become deadly weapons. If we don’t address mental health and substance abuse, there will be no light at the end of the tunnel. In fact, it won’t be a tunnel, just the barrel of a gun.

Stop and frisk worked at reducing gun crime but was deemed too aggressive. I suggest using new handheld scanning technology and institute stop and scan procedures to help take illegal guns off the street.

There are probably many other commonsense solutions to reducing gun crime — solutions that would work effectively without infringing on citizens’ rights. But it’ll take smarts and determination to come up with them.

Let’s pray that our elected leaders have the courage to implement them.