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and health in a society. The un-derlying question of social epide-miology is What are the effectsthat social factors have on individ-ual and population health? This isthe same question Durkheim posed in his 1864 treatise.2

Many early criminologists wereactually pioneering epidemiolo-gists who used community studieswith cohort groups. For example,Robert Park, Ernest Burgess,Clifford Shaw, Henry McKay,and others of the Chicago Schoolof Sociology were actually doing epidemiological community stud-ies that used cohort groups andmethodologies such as spotsmaps.3 Others such as Robert Merton applied variations of Durkheims ideas to AmericansocietyMertons versionof anomiewas unique to American society.

EVOLUTION OF CRIMINOLOGY

Around the turn of the 20thcentury, criminologists beganleaving generalists disciplinessuch as philosophy, psychology,and sociology and creating new,separate disciplines. This move-ment strengthened midway intothe century, when criminologistsand practitioners in the eld of criminal justice began an aggres-sive move toward separating themselves from their root disciplines, primarily sociology.3 A sig-nicant motivator, though not theonly one, came in the 1960s whenthe US government provided Law Enforcement Assistance Adminis-tration funds to establish academic programs in American universitieswith a criminal justice and crimino-logical focus. This structural

intervention was meant to lead thesocial and behavioral sciences to-ward better understanding of socialdeviance. During this era, morethan 600 new academic depart-ments were formed in just10 yearsas part of the1968 Omnibus CrimeControl and Safe Streets Act. 3

Initially the leaders of these new programs were very defensive in protecting their turf, or their evolving areas of expertise. Theyturned inward and rarely consid-ered integrating with disciplinessuch as public health, in part be-cause of the immaturity of their new eld as a distinct discipline.However, there were some, suchas Donald Cressey, who advocatedthe inclusion of epidemiology incriminological theory and re-search, as reected in his 1960article titled Epidemiology andIndividual Conduct: A Case From

Criminology.4

Nearly 50 years later, criminal justice and criminology haveachieved equal, if not superior,footing to that of their root disciplines. Sufcient maturity has been reached across these disciplinary domains to such extent that public health is no longer seenas a threat, but rather as an ally. It is out of this evolving awarenessthat we propose directly incorpo-rating the science, theories,methods, and practices of epide-miology into our explanatory and predictive models of criminal behavior and events.

A NEW FRAMEWORK FORCRIMINOLOGY ANDPUBLIC HEALTH

In expanding our embrace of the new term epidemiological

criminology , we do not arbitrarily juxtapose the component terms.Epidemiology and criminologyare each theoretical disciplinesupon which elds of practical application are based. Criminologyrefers to the systematic study of the nature, extent, cause, andcontrol of law-breaking behaviorwhereas criminal justice refers tothe crime control practices, phi-losophies, and policies used by police, courts and corrections.3(p4)

The relation of epidemiology to public health parallels the relationof criminology to criminal justice.Epidemiology is the study of factorsaffecting the health and illness of populations; it provides the foun-dation and logic for interventionsmade in the interestof public healthand preventive medicine. As such,it is fundamental to public healthresearch.5

The intersections betweencriminal justice and public healththeories, methods, and approachescan help to explain the dynamic relations between these 2 elds of study. The criminal justice systemdenes criminal behavior; systemsof public health dene epidemio-logical disease processes. In what areas do crime and disease con-verge? These are questions that have yet to be answered, but whose answers will form the new perspective in which to advancethe framework of epidemiologicalcriminology.

GROWING INTEGRATIONOF CRIMINOLOGY ANDEPIDEMIOLOGY

As the worlds geopolitical, so-cial, criminal justice, and healthsystems continue to change,

criminologists and epidemiologistsmust be ever more aware of how their interdisciplinary scientic models are changing, evolving,and integrating. Diverse entitiesnow acknowledge the connections between crime and health variables. For example, the US Centersfor Disease Control and Preven-tion (CDC) data sets now includecrime statistics such as those fromthe Behavioral Risk Factor Sur-veillance System. The CDC beganthat study in 1994, stating,

The CDC Behavioral Surveil-lance Branch (BSB) is pleased toannounce a data set [that] willallow users to compare health behaviors and outcomes. [These]variables include health care de-livery information, health andvital statistics indicators, envi-ronmental measures, crime statistics , business indicators, and poverty/income gures [italicsadded].6

This integrationist trend is alsoreected in policy initiatives suchas the National Institutes of HealthRoadmap Initiative, which focuseson new pathways to interdisciplin-ary discovery and encompassesnot only the biomedical sciences but also their relation to the epi-demiological, behavioral, and so-cial sciences.7 As early as 1991, the US Surgeon General labeled vio-lence a public health issue.8 In2000, the Federal Bureau of In-vestigation published a white paper titled A Medical Model for Com-munity Policing in which the com-munity, referred to as a healthycommunity was recognized asanalogous to a patient.9 This modelwas an effort to help cure sickcrime-ridden communities by using community policing. In May 2002,the worlds largest funder of bio-medical and behavioral research,

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the US National Institutes of Health, began to espouse interdisciplinaryresearch methods, approaches,and teams.7 These and other seemingly unrelated events contin-ued the momentum toward recog-nizing and fullling the need tomore directly link epidemiologyand criminology.

In short, the need for integra-tion has not gone unnoticed. Epi-demiological theories, principles, practices, methods, and models,increasingly, are directly and publicly acknowledged as relatedtoand important toepistemo-logical and etiological approachesto criminology as a discipline andscience. Space precludes an ex-tensive review of the literature of this new awareness, but the fol-lowing short examples may indi-cate its outlines.

Injection Drug Users andHIV/AIDS

Burris et al.10 noted the public health harm caused by the criminal justice system, primarily throughineffective laws, misguided policy,and poor application at the streetlevel. They make a forceful argu-ment in several related areas. For instance, criminal laws and en-forcement practices can also inu-ence IDU [injection drug user] risk by deterring public health agentsfrom delivering preventive serv-ices.10(p133) After considering con-temporary Russian and (we argue)American prisons and jails, theynoted, imprisonment itself isan important risk factor for disease.10(p132)

In fact, the criminal justice sys-tem itself may make health issuesworse for many marginalized populations, both incarcerated

and nonincarcerated. Burris et al.stated that

drug users interactions with thecriminal justice system may plausibly be the cause of much of theirvulnerability to blood-bornediseases; the criminal justice sys-tem should also be recognized asan important target of public health research and action.10(p134)

They summarized their argu-ment as follows:

From the laws on the books and police practices on the streets tothe operation of the courtsand the conditions of prisons and jails, the criminal justice systemcontributes much to the everydaylives of IDUs living at or beyondthe margins of legality. We con-tend that greater attention to andwork with law enforcement should be a public health priority [italics added].10(p126)

The pandemic of HIV/AIDS incorrectional systems worldwide provides another example of an

area in which criminal justice and public health intersect. HIV andAIDS have been examined by in-terdisciplinary teams combining public health, medicine, and crimi-nology for more than 20 years.1114

For example, Lanier and Gatescritically analyzed the AIDS RiskReduction Model, a popular public health theory based on the HealthBelief Model, from a criminologicalframework.15 They found that ra-tionally based theories such as theAIDS Risk Reduction Model do not always explain deviance or health-seeking behaviors.

Other texts have connected public health to criminal justice.Two books, Prisons and AIDS 16

and The Impact of HIV/AIDS on Criminology and Criminal Justice,17

have linked public health withcriminal justice, although theoreticaland methodological integration and

discussion of the 2 disciplines havenever been attempted. Historicaltexts have discussed the link be-tween the mental and physical sideof health and of criminology (seeFoucaults Madness and Civiliza- tion,18 The Birth of the Clinic,19 andDiscipline and Punishment ,20 sum-maries of which are available inthe works of Timmermans andGabe21 ). Other authors have dis-cussed the nature of ideology,natural rights, and denitions of crime.22

Need for DiscussionThroughout these divergent

bodies of literature, there has beencontinued direct, if not tacit, ex-amination of thecorechallenges of both criminal justice and public healthspecically, the examina-tion of those correlates to crimeand to health disparities that tend

to mirror one another (i.e., pov-erty, minority status, lack of edu-cation, family history, neighbor- hood characteristics, geography,other psychosocial indicators).These correlatesincluding themethods in which they werestudied, strategies to prevent their transmission, the mechanism bywhich they harm people, and theindividual and public health con-sequencesare often taken for granted by scholars, students, and practitioners who presume tounderstand their relationships(R. Langworthy, PhD, Department of Criminal Justice, University of Central Florida, oral communica-tion, April 2008).

However, todate,noonein either the scientic or practitioner com-munities has explicitly linked the2 disciplines etiologically, epistemo-logically, or phenomenologically.

This central unifying ideal has not been operationally dened in a comprehensive manner to allow se-rious contemplation, comparison,analysis, and integration from di-verse theoretical perspectives, asgood science demands. Contempo-rary practice is to discuss crimecausation andhealthbehaviors onlyfrom a particular ideological per-spective, usually that of the particu-lar domain, i.e., crime in criminal justice or health in public health.Consequently, we have already be-gun explicitly linking the 2disciplines in our research and practice.3,23,24

COMMONALITIESBETWEEN CRIMINOLOGYAND EPIDEMIOLOGY

Students of medical epidemiol-ogy, the biomedical sciences, en-

vironmental justice, medicine, public health, nursing, and manyother environmental and healthscience elds have long examinedcriminal behavior within their own discipline-specic theories.Public health and criminal justice have shared similar theories,approaches, and lexicons of termsin their quest to describe anddene various preventionapproaches. As an example, public health prevention theories discuss primary, secondary, and tertiaryinterventions. Primary preventionis used to avoid a health care problem before it occurs, such asimmunization or health educationfor protective behavior. Secondary prevention measures are thosethat treat asymptomatic personswho have already developed riskfactors but in whom the conditionis not yet apparent.25 Tertiary

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prevention involves dealing with a disease that has now entered the host person (or environment) bytrying to minimize any negativeeffects while continuing tostrengthen the higher-order func-tions to ght off any related com- plications.

These concepts are not new tothe criminal justice eld with re-spect to crime prevention; analo-gous to these public health pre-vention theories are crime prevention theories. Primary andsecondary prevention in criminol-ogy are sometimes referred to asroot causes or opportunity re-duction theories of crime and prevention, respectively. Theoriesabout the root causes of crime canrange from illiteracy to cranial le-sions that have been known tolead to deviant and criminal behavior.3 Some of the root causes of

crime could be prevented by pri-marily targeting the vectors of thedisease, such as street maintenance, broken windows, and abandonedor dilapidated buildings, all of which have led to disordered com-munities.26,27 These measureswould be analogous to a public health practice of immunization.

On the other end of the crime prevention spectrum is opportu-nity reduction, which, for example,may refer to more locks and lightsin homes and neighborhoods toreduce the risk of crime. In thecontext of public health, the use of protective barriers (e.g., the use of condoms or washing of the hands)can be employed to help prevent cross-contamination. For example,targeting at-risk youths or of-fenders directly may be another form of secondary prevention to help avoid a superspread of a

disease; from a criminologicalframework, such targeting could be an attempt to prevent a dra-matic increase in gang member-ship. However, after a crime (or vector) has been committed (or entered the host), tertiary preven-tion measures, such as incarcera-tion (or, in the context of public health, quarantine in a diseaseoutbreak) or, for victims (or pa-tients), programs that provide in-struction on how to avoid becom-ing revictimized (or reinfected),can be put into action to prevent future occurrences or reduce therecidivism rate.

DIFFERENCES BETWEENCRIMINOLOGY ANDEPIDEMIOLOGY

The Association of AmericanColleges has identied the need

for new combinations of disciplin-ary knowledge and researchmethods to solve new and com- plex problems.28(p1) To fulll thisneed, criminology could have a subdiscipline of epidemiology, or,conversely, epidemiology could have a subdiscipline of criminology,to help explain disease patterns andtheir linkage to the human condi-tion. These subdisciplines shouldcarry out the analyses of the bio-medical, behavioral, structural, andenvironmental factors that can ad-vance our understanding of crimi-nal behavior.

Epidemiological models,methods, and theories that havetaken into account disease pat-terns and distribution, causal link-ages, methods of transmission,identication of hosts and vectors,and the like are useful because human population modeling

should not be limited to traditionalinterpretations of diseases from a biomedical framework. Suchmodels have been used in thestudy of aberrant behavior, as inthe case of drug abuse and traf-cking, suicide, gang membership,intimate partner violence, sexualassault, bullying, and other behavioral and societal abnormali-ties.29 However, the study of aber-rant behaviors incorporates manytraditional methodologies and the-ories that apply current statisticaltechniques and constructs in fram-ing and interpreting the analysis.

In effect, by conceptualizing, for example, the study of violence as a disease, we can develop innova-tive models that advance our thinking about biomedical, behavioral, or structural interven-tions.29,30 Incorporating epidemio-logical perspectives and their

various scientic frameworks intoour analysis can lead to new inqui-ries andmethods, perhapsincluding the use of key informants, focusgroups, and other qualitativeapproaches to contextualize and help us understand our models.From a quantitative perspective,developing an epidemiologicaland biostatistical approach tocriminology further strengthensand broadens (i.e., legitimizes) our population health modeling.

Conceptually, incorporating ep-idemiological methods andmodels can at times mean nothing more than understanding the lex-icon of terms used across bothdisciplines. However, different disciplines may at times be study-ing the same issue through differ-ent lenses. Thus, the challenge becomes introducing the interdis-ciplinary student, practitioner, or

scientist to a commonality inapproaches, methods, or tech-niques while clarifying distinctlydifferent terminology.

COMING FULL CIRCLE

History shows that theories ebband ow according to the zeitgeist,experiencing cycles of change anddominance in policies, practices,and social mores. Some theories have long dominated the disciplinary landscapes of both crimi-nology and epidemiology, eventu-ally taking a back seat to other new and emerging theories (e.g., fromrehabilitation to punishment).Theories guiding the war on pov-erty and the war on crime in the1960s differ from the theoriesguiding the war on drugs in the1980s andthe present-daywar onterrorism. (It is disturbing to us

that the war metaphor is the persistent rhetorical choice).

The opportunity now exists todraw a signicant number of the-ories into a coherent frameworkthat accommodates examining criminal and health behaviors in a consistent manner grounded inthe same paradigms regardless of discipline. Now that criminology has reached maturity as an aca-demic discipline, it can come fullcircle back to the academic public health roots rst articulated byDurkheim.

The 21st century is embracing a new era of enlightenment that leads toward an interdisciplinaryscience of epidemiological crimi-nology. Indeed, public health hasitself taken steps toward address-ing criminal justice and criminol-ogy issues. Consider the CDCsefforts to thwart violence and

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homicide; there is also an abun-dant literature documenting theadverse health effects perpetuated by the criminal justice system.3035

In 2008, the American Public Health Association hosted Epide-miological Criminology: A 21st Century Interdisciplinary Paradigmat the Crossroad,24 a panel of leading public health and criminal justice researchers invited to foster scientic debate. Likewise, criminal justice programs are embracing ep-idemiological criminologya seriesof courses on EpidemiologicalCriminology is currently being taught to students in the College of Health and Public Affairs at the University of Central Florida, inOrlando.

Despite these rst steps, muchremains to be accomplished. Weenvision the eld of epidemiolog-ical criminology as addressing a

wide range of issuesessentially,anything that affects the healthand well-being of a society. Weadvocate a closer relationship be-tween criminology and epidemi-ology, resulting in the emergence,from either domain, of promising theories that will inform the other domain. We anticipate that meth-odological breakthroughs in onediscipline will more quickly be-come available to the other, im- proving the quality of informationused in decision-making and lead-ing to healthier and safer commu-nities. Finally, strengthening thetheoretical integration of crimi-nology and epidemiology will fur-ther the integration of public health and criminal justice practice by giving practitioners in bothdomains a common language andgranting practitioners in each do-main a heightened awareness of

the disciplinary demands of theother.

At the highest policy levels,war metaphors must be replacedwith health metaphors. Policy-makers should rely more heavilyon social science methodologies-such as crime mapping and medi-cal geographyfor legislativedecision-making. The theory andresearch domains should more explicitly dene methodological and programmatic linkages.

Greater understanding andaccommodation are required be-tween criminal justice practi-tioners and those working in pub-lic health. Emergency medicaltechnicians and police, correc-tional staff and nurses, physiciansand lawyers, and so on, will sig-nicantly benet from greater interdisciplinary interaction byincorporating a greater under-

standing of the other eld intotheir own. Epidemiological crimi-nology provides the framework to help these disciplines to integrate.Individual researchers, theorists,students, and teachers are now tasked with developing specic linkages between the disciplines,identifying problems common to both domains, and providing solu-tions grounded in fully integratedtheory and practice. j

About the AuthorsTimothy A. Akers is with the School of Community Health and Policy, Morgan State University, Baltimore, MD. Mark M.Lanier is with the Department of Criminal Justice and Legal Studies, College of Health and Public Affairs, University of Central Florida, Orlando.

Requests for reprints should be sent to Timothy A. Akers, MS, PhD, Ofce of Research, School of Community Health and Policy, Morgan State University, 1130 E Cold Springs Lane, Portage Building,

Baltimore, MD 21239 (e-mail: [email protected]).

This article was accepted June 21, 2008.

ContributorsThe authors contributed equally to thearticle.

AcknowledgmentsThe authors are grateful to Robert Langworthy, PhD, for his insightfulcritiques.

Human Participant ProtectionNo institutional review board approvalwas required because the paper is con-ceptual in nature.

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3. Lanier MM, Henry S. Essential Crim- inology . 3rd ed. Boulder, CO: Westview;2008.

4. Cressey DR. Epidemiology and indi-vidual conduct: a case from criminology.Pacic Sociological Rev. 1960;3:4758.

5. Krieger N, Kass PH, Steineck G. Epi-demiologic theory and societal patterns of disease. Epidemiology . 1993;4:276278.

6. US Centers for Disease Control andPrevention. Behavioral Risk Factor Sur-veillance System. Available at: http://www.cdc.gov/cancer/conference/index.htm. Accessed February 28, 2008.

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Prevention. A Timeline of Violence as a Public Health Issue. Available at: http://www.cdc.gov/ncipc/dvp/timeline.htm.Accessed December 17, 2008.

9. Harpold J. A medical model for community policing. FBI Law Enforcement Bull . 2000:69:2327.

10. Burris S, Blankenship KM, DonoghoeM, et al. Addressing the risk environ-ment for injection drug users: the mys-terious case of the missing cop.Milbank Q . 2004;82:125156.

11. Akers T, Hervey W. Why classica-tion for HIV/AIDS prevention

interventions? J Assoc Nurses AIDS Care .2003;14:1720.

12. Rowan GT, Akers TA. Technologicalchange and human resources: organiza-tional differentiation in African American human service organizations. J Afr Am Men . 1996;1:275295.

13. Rowan GT, Pernell E, Akers TA.Gender role socialization in AfricanAmerican men: a conceptual framework. J Afr Am Men . 1996;1:322.

14. DiClemente R, Lanier MM, Horan P,Lodico M. Comparison of AIDS knowl-edge, attitudes, and behaviors among in-carcerated adolescents and a public school sample in San Francisco. Am J Public Health . 1991;81:628630.

15. Lanier MM, Gates S. An empiricalassessment of the AIDS risk reductionmodel (ARRM) employing ordered probit analyses. J Criminal Justice . 1996;24:537547.

16. Braithwaite RL, Hammett TM,Mayberry RM. Prisons and AIDS: A Public Health Challenge . San Francisco,CA: Jossey-Bass; 1996.

17. Lanier MM. The Impact of HIV/AIDS on Criminology and Criminal Justice .Hampshire, UK: Ashgate Publishing;2006.

18. Foucault M. Madness and Civiliza- tion . New York, NY: Pantheon; 1965.

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20. Foucault M. Discipline and Punish- ment: the Birth of the Prison . New York,NY: Random House; 1979.

21. Timmermans S, Gabe J. Introduction:connecting criminology and sociology of health and illness. Sociol Health Illness .2002;24:501516.

22. Henry S, Lanier MM. What Is Crime? Controversies Over the Nature of Crime and What to Do About It . Boulder, CO:Rowman and Littleeld; 2001.

23. Lanier MM, Lucken K, Akers T.Correctional opportunities: epidemiologi-cal criminology. In: Muraskin R, ed. Key Correctional Issues . 2nd ed. Upper SaddleRiver, NJ: Prentice Hall; In press.

24. Akers R, Akers T, DiClemente RJ,et al. Epidemiological criminology: a 21st century interdisciplinary paradigmat the crossroad. Panel presented at:American Public Health AssociationAnnual Meeting; October 2529, 2008;San Diego, CA.

25. US Preventative Services Task Force.Guide to Clinical Preventative Services . 2nd

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ed. Baltimore, MD: Williams & Wilkins;1996.

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Expanded Access to Naloxone: Options for Critical Response tEpidemic of Opioid Overdose Mortality

Daniel Kim, MPH, Kevin S. Irwin, MA, and Kaveh Khoshnood, PhD

The United States is in themidstof a prolongedandgrow-ing epidemic of accidental andpreventable deaths associated

with overdosesof licit andillicitopioids. For more than 3 de-cades,naloxone hasbeen usedby emergencymedicalperson-nel to pharmacologically re-verse overdoses. The peers orfamily members of overdosevictims, however, are most of-ten the actual rst respondersand are best positioned to in-tervene within an hour of theonset of overdose symptoms.

Data from recent pilot pro-grams demonstrate that laypersons are consistently suc-cessful in safely administeringnaloxone and reversing opioidoverdose. Current evidencesupports the extensive scaleupof access to naloxone. We pres-ent advantages and limitationsassociated with a range of possible policyandprogramre-sponses. ( Am J Public Health.2009;99 :402407 . do i :10 .2105/AJPH.2008.136937)

RAPID INCREASES IN DEATHS

from heroin-related overdose began in the 1990s, as averagemortality per 100000 population

in 25 US cities increased from8.7 in 1988 to 13.8 in 1997. 1

By 2004, poisoning was the secondleading cause of death from unin-tentional injury in the UnitedStates.2 Nearly all such deaths wereattributed to illicit and prescriptiondrugs,2 fueled by a dramatic rise inthe incidence of opioid-involvedoverdose, which paralleled similar increases in Denmark, Finland,Iceland, Norway, Sweden, Spain,Italy, Austria, Australia, England,and Wales.35

Fatal overdose is the leading cause of death among those whomisuse illicit drugs, exceeding mortality from AIDS, hepatitis,or homicide.6 In a 33-year longi-tudinal study in California, 581opiate-dependent participants hadexperienced an average of 18.3 years of potential life lost before age65,7 with heroin overdose

accounting for the largest propor-tionate mortality (22.3%). The years of potential life lost for thisgroup was 6 times greater than in

the general US population.Although heroin-related over-

dose deaths have continued torise, recently there has been analarming increase in mortalityfrom drug overdose associatedwith the misuse of prescriptionopioid analgesics. Data from theNational Vital Statistics Systemindicate that the recent 62.5% increase in deaths from uninten-tional poisoningfrom 12186 in1999 to 20950 in 2004was primarily attributable to increasedmisuse of prescription opioidanalgesics.2 According to mortalitydata on multiple causes of deathfrom the National Center for Health Statistics, the number of opioid analgesic poisonings listedon death certicates increased91.2% between 1999 and 2002;in the latter year, it accounted for 5528 deaths, more than those

associated with either heroin or cocaine.8

The current US epidemic of opioid-related overdoses is

spreading geographically and de-mographically. Mortality fromsuch overdoses is expanding fromurban areas to suburban and ruralregions, where overdoses areusually prescription related andgeneral awareness and treatment services are relatively lacking.9

Likewise, overdose mortality is onthe rise among non-Hispanic Whites, women, adolescents and young adults, and those with a his-tory of chronic pain and depres-sion.2,912 Methadone, oxycodone, hydrocodone, and fentanyl account for the vast majority of misused prescription opioids.10,13 Commonsources include not only illicit dealers but friends, relatives, physi-cians, and emergency depart-ments.11 For instance, in a study inrural southwestern Virginia, about half of the women who died of opioid-related overdose had


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