In May of 2016, not long after his release from a psychiatric hospital, Colby Crawford, a 23-year old black man, was booked into the Orleans Justice Center (OJC) — a new $150-million-dollar jail opened a year earlier to replace the crumbling and now shuttered Orleans Parish Prison complex, and touted as a symbol of a more progressive approach to incarceration in New Orleans.

Ten months later, he was dead.

Colby Crawford was diagnosed with schizophrenia, bipolar disorder, and substance use disorder. A lawsuit argues that his death at Orleans Parish jail was in part due to a profound lack of treatment for his mental illness. Visual: Courtesy of the Crawford family.

Prior to Crawford’s incarceration, he had been diagnosed with schizophrenia, bipolar disorder, and substance use disorder. A psychiatrist at OJC noted that he was prone to “seeing spirits and ghosts, insomnia, anxiety, paranoia, and bad dreams,” and prescribed an antipsychotic and anticonvulsant. A month after Crawford’s arrest on allegations that he hit his mother and sister, he was transferred about an hour outside of New Orleans to a state prison called the Elayn Hunt Correctional Center — the one place he received adequate mental health care while incarcerated, according to a wrongful death suit filed by his mother.

But two months later, Crawford was transferred back to OJC and placed in “disciplinary segregation” for 20 days. Upon release back into the general population, he deteriorated. He stopped taking his medications consistently and started hearing voices and seeing spirits. He couldn’t sleep and got in fights. Jail records cited in the complaint show that medical staff was aware of Crawford’s declining condition. He requested to be moved to a psychiatric tier. He never was.

Then, on February 22, 2017, someone brought cocaine to Crawford’s housing unit. Video surveillance showed Crawford and other prisoners taking it throughout the day. While deputies were assigned to the video surveillance, no one informed the security staff. The deputies tasked with monitoring the tier also failed to intervene. Around 7:45 p.m. that same day, Crawford overdosed.

His mother’s lawsuit, which names Orleans Parish Sheriff Marlin Gusman, the Orleans Parish Sheriff’s Office (OPSO), and the jail’s health care provider as defendants, argues that “the failures culminating in Colby Crawford’s death — specifically, a failure to provide adequate mental health care, a failure to accommodate his known disability (mental illness), a failure to supervise or monitor his tier, and a failure to prevent contraband from entering the institution — are all long-term problems at OPSO generally and in the OJC in particular.” (Neither Wellpath — the health care provider at the Orleans Justice Center — nor the Orleans Parish Sheriff’s Office responded to multiple interview requests from Undark.)

Crawford’s case shows what can happen to prisoners with mental illness who rattle around in a broken system — and there are many. According to the National Alliance on Mental Illness, every year in the United States 2 million people with serious mental illness are booked into jails. And while black prisoners are less likely to suffer from severe mental illness compared to the broader prison population, according to the Bureau of Justice Statistics, a 2016 survey of 22,000 people entering jails suggested that basic screenings simply don’t catch mental health issues for black and Latino prisoners.

A review of the scientific literature underscores the challenges these prisoners face: a lack of qualified mental health professionals on staff to adequately screen, treat, and provide appropriate access to medication; victimization at the hands of other prisoners; difficulty following the strict rules (and thus a higher likelihood of being punished and put in solitary confinement); and ultimately longer stays in jail. The research reinforces what many in the mental health care community have been saying for decades. “There is no way to provide good mental health care in a jail,” said John Snook, executive director of the nonprofit Treatment Advocacy Center. “Even the best-funded jail, with the most effective mental health services in the country, is still a failure.”

“Even the best-funded jail, with the most effective mental health services in the country, is still a failure.”

Few places typify the problem more than the New Orleans correctional system, and in many ways Crawford was the system’s typical prisoner: More than 90 percent of prisoners at OJC are black men, and more than a third are between 21 and 30 years old. Crawford was the 50th prisoner to die in custody since Hurricane Katrina in 2005. The sheriff’s office has been under a consent decree since 2013 for failing to operate the jail up to constitutional standards, and court-appointed monitors now issue compliance reports on the jail’s progress to a federal judge every six months. Mentally ill prisoners are especially at risk. Testifying in court following OJC’s opening, the mental health monitor gave a blunt assessment: “They house acutely ill inmates,” he said, “but they don’t treat them.”

He called care at the jail “abysmal.”

Now, three years after Crawford’s death, his case remains particularly relevant for dozens of other mentally ill prisoners in Louisiana. Since 2014, the Orleans Parish Sheriff’s Office has held a contract with the Louisiana Department of Public Safety and Corrections to house their most acutely mentally ill prisoners in Elayn Hunt. But in 2019, it was revealed that state corrections officials were declining to renew the contract, and the prisoners housed at Elayn Hunt will once again be the responsibility of the Orleans Parish Sheriff’s Office.

How to accommodate these mentally ill prisoners returning to New Orleans is already a significant logistical challenge for city officials and has renewed a long-standing debate between the sheriff’s office, the city, and activists over the construction of a new jail facility, known as Phase III. The sheriff’s office says that in order to properly care for the new prisoners, they will need the new Phase III facility. Jail reform activists see the expansion as a doubling down on using incarceration to address broader social challenges, and are pressuring the mayor and the City Council to block construction. They want to retrofit the current jail building, which, they argue, would provide sufficient care for prisoners with acute mental illness — who, they point out, should not be in jail in the first place — without adding jail beds.

In October, the City Planning Commission voted on a proposal to renovate what was supposed to be a temporary facility for the mentally ill prisoners while the new facility is being built, and would have increased the bed-cap from 1,438 to 1,731. After dozens of people testified in opposition, the Commission recommended denying the proposal. But the City Council, which will likely vote on the proposal in the coming weeks, will have the ultimate say.

Meanwhile, the prisoners from Elayn Hunt are scheduled to be moved in April 2020.

The defunct detention tower, once part of the now-shuttered Orleans Parish Prison complex, still casts its shadow over the Mid-City neighborhood.

In the 1950s in the U.S., there were more than twice as many people in public mental hospitals than in prisons. Following World War II, concerns over the asylums’ conditions, the efficacy of their treatment, and patients’ rights, led to a reform movement that closed many psychiatric hospitals and instigated a public campaign for more humane treatment.

In 1953, the advocacy organization Mental Health America collected iron chains and shackles from asylums across the country, melted them down, and used the metal to cast a large bell. They christened it the Mental Health Bell, and the inscription read: “Cast from shackles which bound them, this bell shall ring out hope for the mentally ill and victory over mental illness.” In 1958, First Lady Mamie Eisenhower rang it from the White House South Portico.

“Deinstitutionalization was a perfect storm of a few major forces,” said Anne E. Parsons, author of the 2018 book “From Asylum to Prison: Deinstitutionalization and the Rise of Mass Incarceration After 1945.” According to Parsons, the push for legislative and policy changes stemmed from increased awareness of asylums in American popular culture, the introduction of psychotropic drugs, a greater reliance on psychotherapy, and activism.

“There was a concept in disability rights activism — which was established in the courts and in the law — that people have the right to the least restrictive environment, but also the right to receive care in community settings,” said Parsons. In the following decades, the population of people in mental institutions declined dramatically.

But in many cases, the community-based outpatient treatment that was meant to replace the shuttered asylums never materialized. Instead, cities and states invested heavily in law enforcement and incarceration. In some instances, asylums were retrofitted and converted into prisons and jails. The war on drugs spread throughout the country — particularly in communities of color — sentencing became more punitive, and prisons and jails began to house more and more mentally ill prisoners. “Deinstitutionalization,” Parsons said, “was totally entwined with the rise of mass incarceration and imprisonment. You can’t pull them apart.” By 2016, the prison population was more than 10 times that of mental hospitals.

“Deinstitutionalization was totally entwined with the rise of mass incarceration and imprisonment. You can’t pull them apart.”

For most of the country, the shift from mental institutions to prisons, sometimes called transinstitutionalization, took several decades. In New Orleans following Hurricane Katrina, a version happened near-instantaneously. Prior to the storm, Reverend Avery C. Alexander Charity Hospital was the largest mental health care provider in the city, with 128 beds and a crisis intervention unit. The storm flooded the hospital’s basement, but an impressive cleanup and restoration effort by a diverse group — including the crew of the Navy battleship Iwo Jima, the Coast Guard, the National Guard, a group of German engineers, and a non-governmental organization made up of airline workers — brought the facility back up to what many felt was good working condition.

But both Louisiana State University, which operated the hospital, and state officials argued the building was still unsafe and refused to reopen it. Critics suggest this was a political calculation to secure funding from the Federal Emergency Management Agency (FEMA) for a new facility that would focus less on indigent care. A 2011 article in The Nation called the decision a “symbol of the many disappointments and betrayals experienced by the residents of New Orleans after Katrina.”

Whatever the reality, with Charity shuttered, the largest inpatient psychiatric care center in the city became Orleans Parish Prison.

Prior to Hurricane Katrina, the name “Orleans Parish Prison” was used to refer to a complex of 12 jail buildings located in New Orleans’ Mid-City neighborhood. On any given day, the jail could house some 6,500 prisoners — many of them state prisoners. When the storm hit, many of the buildings flooded with thousands of prisoners left inside. In the years since, these buildings — including the House of Detention formerly designated to house mentally ill prisoners — either closed or have been demolished to make way for the OJC (which locals still sometimes refer to as the Orleans Parish Prison).

In 2008, a class-action lawsuit was filed on behalf of Charity’s former patients to force the reopening of the hospital. The suit appeared to have the support of the newly overburdened law-enforcement community. In a sworn affidavit, Gusman wrote: “As Sheriff of Orleans Parish, I have been confronted with the incredible burden of dealing with mental health issues in the criminal and prison systems. While the prison in New Orleans has a facility for mentally ill prisoners and can treat prisoners who are suffering from mental health issues, before the storm police officers could take people whom they suspected were exhibiting criminal behavior as a result of mental problems to Charity Hospital. Since the closure of Charity’s Crisis Intervention Unit, police officers have limited options as to where they can take people with mental health problems outside of jail.”

While care has improved for the mentally ill since the years immediately following Katrina, there are still gaps. The University Medical Center (UMC), a trauma center and teaching hospital built with $475 million from FEMA, eventually opened in 2015, but just 86 of the 446 beds are designated for behavioral health patients. Meanwhile, behavioral health admissions at UMC increased by 45 percent between 2015 and 2017. As a consequence, people with severe mental health needs can only be treated for brief stints — sometimes no more than 24 hours. “The lack of beds and investment in mental health care has made the criteria for admission stricter, leaving out more and more people who might need help,” the hospital’s former behavioral health director told The Times-Picayune last year. “People who are gravely disabled and can barely function in society are often discharged.”

Prisoners with mental illness often cycle from brief and inadequate treatment while incarcerated, to being discharged, to re-offending and re-entering the system. Janet Hays, president of Healing Minds NOLA, which advocates for more robust mental health initiatives, called it “treat, street, repeat.”

“We call it treat, street, repeat,” said Janet Hays, president of Healing Minds NOLA, which advocates for more robust mental health initiatives in New Orleans. Hays has pushed to turn the old Charity Hospital into a complex that would combine long-term restoration treatment, transitional housing, a mental health research facility, and workspace for organizations dealing with systemic issues related to mental health. The complex, Hays envisioned, would “form a matrix that acts as an incubator dedicated to progressive and enlightened approaches to mental health care.”

But the proposal never gained much traction. Instead, developers are moving forward to turn old Charity Hospital into a mixed-use complex for housing, offices, and retail.

Like other facets of the prison industry, treating mentally ill prisoners is potentially lucrative for the private sector. In jails and prisons across the country, health care, including mental health care, is often the domain of for-profit companies. Wellpath, for example, which currently administers mental health care at the OJC, is one of the largest suppliers of correctional health care in the country, and has repeatedly come under fire for appearing to prioritize profits over care. Wellpath’s tenure with the Orleans Parish correctional system, which began in 2014 when it was known as Correct Care Solutions, has likewise faced chronic criticism and litigation. The company has been named in several wrongful death suits at the Orleans Justice Center in addition to that of Colby Crawford’s mother. The family of Jaquin Thomas, a 15-year-old black teen who hanged himself in the jail in 2016 after staffers allegedly ignored his need for antidepressants, also named the company in the lawsuit they settled with the Orleans Parish Sheriff’s Office last year.

More recently, however, Wellpath has enlisted psychiatrists from Tulane University to assist with mental health care in the jail, and the jail monitors and others say there have been some improvements. In their most recent report, issued in March, the monitors praised the Tulane doctors as “an invaluable asset in providing required and consistent psychiatric services for prisoners at OJC.”

It is unclear how long New Orleans will stick with Wellpath to provide care, however. The company is currently operating on a contract extension, and at a budget hearing in October, the sheriff said the city plans to open the contract up to other bids when that extension ends.

Last April, Barksdale Hortenstine, Jr., the senior attorney for mental health litigation at the Orleans Public Defenders Office, sat in a small office on the sixth floor of a gray, concrete building, blocks away from the Orleans Justice Center. The defender’s office staff is notoriously overworked and underfunded, and Hortenstine’s caseload is representative. He is involved in any case in which the defense is likely to be not guilty by reason of insanity, and if a client wins he continues to monitor their mental health evaluations and represents them in court when they want to be processed into a less restrictive setting. He is also the primary attorney on cases in which those clients are facing a life sentence. His caseload is well over 100.

Despite Hortenstine’s position, he said he doesn’t have much access to the jail’s operations and that he’s had “difficulty penetrating that wall they put up.” He’s not alone: A similar opacity plagues lawyers, researchers, activists, and reporters throughout the country, though it varies by location and prison. (The Orleans Parish Sheriff’s Office did not respond to repeated interview and tour requests from Undark.)

Hortenstine doesn’t know, for instance, exactly how many psychiatric tiers the jail has, though he thought there were two (“They have switched them around some, in the past,” he said. “At least, it appears like they have”); how often his clients were held in solitary confinement or administrative segregation (the difference between the two was “very unclear,” Hortenstine said); or the criteria the jail uses to determine who gets sent to Elayn Hunt, and who gets put on a special tier for prisoners with mental illness (“It’s sometimes very surprising to me”). The lack of transparency makes it hard to advocate for specific improvements to his clients’ treatment. “I think the jail does need to increase its functional capacity to treat the mentally ill,” he said, “but I’ve never been back there. I don’t know what it looks like, I don’t know what changes need to be done.”

Barksdale Hortenstine, Jr. is the senior attorney for mental health litigation at the Orleans Public Defenders Office. He sometimes handles as many as 100 cases at a time. “I think the jail does need to increase its functional capacity to treat the mentally ill,” he said.

One thing Hortenstine has witnessed again and again is what he calls the “yo-yo effect.” This occurs when one of his clients in jail is deemed incompetent to stand trial, sent to a state-run forensic hospital to treat the incarcerated where they are restored to competency, sent back to jail where they deteriorate and are again deemed incompetent, sent back to the forensic hospital, and on and on — the same path, perhaps, Crawford started down before his death. Ultimately, Hortenstine said, most of these yo-yoing clients are never found competent for long enough to make it to trial. And once they’re behind bars, both due to their illness and because psychotropic medications can slow cognitive processing, they can be easy targets for scams — “Like, you know, I’ll give you five pieces of gum, if you give me one of your hundred-dollar phone calls,” Hortenstine explained — or physical or sexual assault.

While many lawyers don’t have a clear view of what goes on inside jail and prison walls, academics — depending on the facility’s location and the whims of its administrators — can get some access for research. And that limited research supports Hortenstine’s observations. Studies have found that prisoners with mental illness are more likely to be victims of abuse, both physical and sexual, while incarcerated. Research from the Colorado Department of Corrections also suggests that mentally ill prisoners are more likely to be cited for breaking the rules than other prisoners, and that those infractions are often a direct result of mental illness.

“Prisoners have been punished for self-mutilation because that behavior entailed the ‘destruction of state property’ — to wit, the prisoner’s body,” notes a 2006 article in the Harvard Civil Rights-Civil Liberties Law Review. “Prisoners who tear up bedsheets to make a rope for hanging themselves have been punished for misusing state property. Prisoners who scream and kick cell doors while hearing voices have been charged with destruction of property and creating a disturbance. And prisoners who smear feces in their cells have been punished for ‘being untidy.’”

The punitive reactions by staff point to a central contradiction of addressing mental illness in jail. As one 2016 literature review published in the Journal of Offender Rehabilitation put it: “The same dissonance that individual officers confront, the conflict between treating and managing inmates, characterizes the correctional system itself.”

The range of mental health issues for prisoners in solitary confinement or restrictive housing — which typically means removing a prisoner from the general population and keeping them locked in a cell for 22 hours a day or more — are also documented and include anxiety, depression, paranoia, and problems with impulse control. “Despair is just very widespread,” said Terry Kupers, a psychiatrist who has been studying the effects of solitary confinement since the late 1980s. When people with a pre-existing mental illness get put into solitary, their illness is exacerbated.

“Someone with schizophrenia is likely to have a psychotic episode, or if they are already having a psychotic episode it’s going to get worse, and more chronic,” Kupers added. “If they are depressed, they are going to get more depressed — and that accounts for some of the suicides. If they’re manic, they’re going to have a manic episode.”

The New Orleans Justice Center officially replaced the Orleans Parish Prison in 2015. A year later, Colby Crawford would die of an overdose of drugs while being held here.

Such outcomes are hardly unique to New Orleans. Last year, for example, Sacramento County entered into a consent decree meant to address unconstitutional jail conditions as the result of a lawsuit filed by two advocacy groups, the Prison Law Office and Disability Rights California. The original complaint alleges that one man with serious mental illness, repeatedly found incompetent to stand trial, was held in solitary confinement for nearly a decade. This led to “auditory hallucinations, worsening depression, suicidal thoughts, and a diagnosed Vitamin D deficiency related to the lack of exposure to sunlight.”

Last December, a federal judge in Illinois ordered that state’s Department of Corrections to address mental health treatment deficiencies within the prison system. “Of the roughly 1,100 Illinois prisoners in solitary confinement,” The Chicago Tribune noted in its coverage of the order, “more than 900 of them have been diagnosed with mental illnesses.”

Many jurisdictions across the country are trying to come up with their own strategies for improving treatment options for prisoners with mental illness. In 2020, for example, Miami plans to open a 200-bed mental health diversion facility that will offer a continuum of treatment, from crisis-stabilization to short-term residential treatment, along with other services such as employment training and primary care. In Los Angeles, a plan was approved by the LA Board of Supervisorsin February to replace the Men’s Central Jail with a mental health jail for prisoners that would have been staffed and run by the Department of Mental Health, with security being provided by a limited number of deputies. While some saw it as a way to improve the mental health care prisoners are currently receiving, one activist called the plan “a jail with a bow on it.” In August, after an “alternatives to incarceration” working group issued a report to the board, the plan was canceled in favor of expanding community care options.

In 2016, the U.S. Department of Justice issued a report recommending that federal prisoners with serious mental illness not be placed in restrictive housing. But in jails, which are usually run by local sheriffs, Kupers said guards will often put seriously mentally ill prisoners in a cell by themselves as a matter of convenience, not as a response to any transgression or security concern. The mentally ill prisoners then might stay in the cell to avoid trouble, creating de facto solitary confinement, and all the problems it entails.

For Colby Crawford, it’s impossible to know the specific effects of solitary confinement on his mental health. But given his subsequent deterioration, and ultimate fate, it doesn’t appear that it was therapeutic.

Even when prisoners aren’t abused or held in solitary, the environmental conditions of jails can damage mental health. In 2016, an article in the Fordham Law Review examined how environmental features that are known to harm the brain — overcrowding, noise, and toxins — may translate to correctional facilities. The authors, Arielle Baskin-Sommers, a Yale University psychologist, and Karelle Fonteneau, then with the New York City-based nonprofit Bronx Defenders, found a range of examples, which, like solitary confinement, exacerbate pre-existing mental illnesses.

“They started with a shaky foundation to begin with,” Baskin-Sommers said. “And now you just put them in the middle of an earthquake zone, essentially.”

Baskin-Sommers and Fonteneau examined what they call the “ecology” of the general population setting in a jail or prison, and identified factors that are harmful from a neurobiological standpoint. Most of the research comes from studies and experiments conducted outside jail and prison settings, likely due to lack of access. But Baskin-Sommers and Fonteneau argue that the findings they present are relevant to — and often illuminate — the effects of incarceration on mental health.

For instance, the researchers argue that some neurobiological impacts of jail and prison might be gleaned from a 2011 study published in Nature on the effects of urban living, which has “similar environmental stressors.” The Nature study found that urban environments harm parts of the brain responsible for processing stress, which it links to anxiety disorders and depression.

Baskin-Sommers and Fonteneau also suggest that studies on chronic noise exposure are applicable to incarceration. The noise in prisons and jails, they note, is unpredictable, varied, and amplified by the hard, reflective materials used to construct the facilities.

Researchers have linked chronic excess noise to all sorts of health problems, from increased stress hormones to cardiovascular disease. And noise is particularly disturbing for people in solitary confinement as well as a primary contributor to prisoners’ sleep problems. “You get the clanking of cell doors, the boots on the floor, you have other people in solitary who are screaming because they are mentally ill,” Kupers said. “You have a lot of noise going on. It’s like cacophony. It’s not meaningful.”

The problems linger even after someone is released back into the community. Following incarceration, people with mental illness are often homeless, less likely to find and maintain employment, and, some studies have suggested, more likely to end up back in jail or prison (particularly for those who also have a substance use disorder). A 2010 study in the American Journal of Community Psychology exploring the challenges of community reentry among prisoners notes that they also have trouble accessing care for their illness, in part due to inadequate discharge planning services and lack of community care options.

As with the yo-yo effect, the issues with prisoner reentry could suggest an over-reliance on the criminal justice system to provide mental health treatment and the inadequacy of the system to do so. In New Orleans, as Hortenstine watches his clients bounce from OJC to Elayn Hunt to the state forensic hospital, he said the prevailing question is how to keep them out of the criminal justice system to begin with. The answer, he added, lies in robust community treatment services and monitoring when people are released from hospitals. With better treatment options outside of jail, he said most mentally ill people wouldn’t need to be locked up at all.

“There certainly are people who are not capable of being in society at large because of the way their mind is failing them,” said Hortenstine. “But that number is not nearly as high as people want to believe it to be.”

In New Orleans, despite Wellpath’s improved reviews from the court monitors, problems persist. Of central concern is that there are no acute mental health care beds for female prisoners, either at OJC or Elayn Hunt. In a status hearing in Federal Court in 2018, the judge overseeing the consent decree said he was “very unhappy” about the lack of medical and mental health services for incarcerated women. “I mean they’re human beings,” he pointed out, “and they deserve to have decent and constitutional medical and mental health treatments.”

Baskin-Sommers and Fonteneau suggest implementing new treatment programs based on therapeutic interventions shown to be effective in addressing mental health issues that contribute to prisoners returning to the criminal justice system after they are released. But the realities of implementation in correctional settings are a challenge, Baskin-Sommers said.

“The issue is that, day to day, in most prisons, while they might say they are implementing cognitive behavioral therapy,”— a talk therapy meant to increase a person’s awareness of negative thoughts and emotions in order to reshape them — “it does not look anything like cognitive behavioral therapy that you or I might get — or would probably be provided in a more secure mental health facility,” she said. “Many of the materials are outdated. Many of the staff are completely overwhelmed. It’s hard to implement a more effective treatment when you have to see someone every five to 10 minutes.”

“The issue is that, day to day, in most prisons, while they might say they are implementing cognitive behavioral therapy, it does not look anything like cognitive behavioral therapy that you or I might get.”

Other organizations advocate for a continuum of mental health care — much like what was promised during the move towards deinstitutionalization — after prisoners are discharged from the hospital and before they land in jail. One example is Hays’ organization, Healing Minds NOLA. Continued care is particularly necessary, Hays said, for people who lack insight into their illness — a condition called anosognosia — and are more likely to refuse medication and treatment.

In addition to an increase in psychiatric beds, Hays is a proponent of Assisted Outpatient Treatment (AOT), a civil-court-ordered outpatient treatment program that enlists a team of specialists to monitor an individual’s treatment plan and ensure their participation. An AOT law was passed in Louisiana more than a decade ago, but until recently there had been no funding, and its implementation is still limited. AOT is somewhat controversial, however, with some groups arguing that it infringes on individual rights by lowering the standards for forced treatment.

On a national level, the Treatment Advocacy Center is also campaigning for improved AOT implementation, revised civil commitment laws, and more psychiatric beds. The difficulty for advocates is knowing where to start. “The reality is you need all of it,” Snook, the center’s executive director, said. “If this was a heart care center, you’d be like, ‘Do you need to take blood pressure, or do you need to do surgery?’ Well, you need both.”

Ultimately, the difference between being treated in a jail or prison as opposed to a hospital — even a forensic hospital in which patients are involuntarily committed — comes down to the institutional purpose. “Whether people with mental illness need to be incarcerated in jail or treated in a hospital is a very important distinction with a difference, in my mind,” Hortenstine said. “You’re going to get treatment at a hospital. Even if you’re going to be there for the rest of your life, they’re still treating you as a patient. They’re caring for your illness, and they’re attempting to help you get better or ease your suffering to the extent that they can.”

Still, the Orleans Parish Sheriff’s Office remains firm in their plan to build Phase III to eventually hold the mentally ill prisoners from Elayn Hunt. (The first two phases consisted of the jail itself and a support facility.) The new jail building has become a symbol, not just of how the city should address the problem of mental illness, but of a persistent impulse by some city leaders to expand their capacity to incarcerate citizens.

“It’s always ‘We have to build something new,’” said Hortenstine. “It seems to me that the jail will never be satisfied until it’s built another facility and another facility and another facility.”

In the past decade, reform advocates have been successful in dramatically reducing the jail population, which was more than 6,000 before Katrina, through a combination of penal code reform, reduced incentives for housing prisoners, and revised bail policies, among other things. When the City Council approved the Orleans Justice Center in 2011, they capped the number of beds at 1,438. Now the actual jail population is significantly less. The addition of new beds as a way to accommodate mentally ill prisoners, as opposed to making space in the current facility, is seen by some as a backdoor effort by the sheriff’s office to expand the jail population past the agreed-upon cap.

Sade Dumas, the director of Orleans Parish Prison Reform Coalition, said she found this especially troublesome given the persistent staffing shortages in the current facility. “Adding more beds won’t help,” she said. “Buildings don’t take care of people. People take care of people.”

“Buildings don’t take care of people,” said Sade Dumas, the director of Orleans Parish Prison Reform Coalition. “People take care of people.” Here she holds a sign protesting the city’s use of a temporary detention center.

As of October 18, the mayor’s office is grudgingly proceeding with the sheriff’s proposal, including the expensive renovation of a temporary facility to hold the incoming prisoners from Elayn Hunt, until Phase III is built. The initial renovation has an estimated price tag of $4.5 to $5 million. The new facility will cost nearly $65 million. And they are working on a tight timeline. The prisoners are scheduled to arrive at the temporary facility in April 2020, just weeks after the targeted construction completion date of March 13.

What will happen to those prisoners if the City Council ultimately rejects the sheriff’s plan, or if there are delays, is unclear. And given the lack of preparation to care for mentally ill patients when the Orleans Justice Center opened, there is cause for concern.

“I don’t know what they think is going to happen, or how it’s going to play out,” Hortenstine said. “And like so often is the case, we don’t know until they start to do things what they’re actually going to do. Because they’ll say one thing and then do another.”

In her civil suit, Colby Crawford’s mother sought to hold the sheriff’s office, Wellpath, and a handful of their respective employees accountable for her son’s death. But the criminal justice apparatus in New Orleans had other ideas. A 1987 change to Louisiana’s statute on murder allows drug dealers to be charged if someone overdoses on drugs they have provided, and in May of 2017 the Orleans Parish Sheriff’s Office booked Darrell Fuller on a count of second-degree murder for Crawford’s death. The warrant accused Fuller of giving Crawford the cocaine, but didn’t explain how he got it into the jail in the first place, or why the guards failed to intervene.

In June, Fuller pleaded guilty to a lesser charge of manslaughter and was sentenced to five years in prison.

Like Crawford himself, Fuller was a black man, still in his 20s at the time he was charged. As the head of the Orleans Public Defenders Office, Derwyn Bunton, pointed out in a forum on race and justice hosted by The Atlantic in March, people of color bear the brunt of the parish’s reliance on incarceration as the solution to social problems.

“If the problem is substance abuse, and the symptom is crime, I don’t go to jail to get drug treatment; I go to a hospital,” Bunton said. “If the problem is education, and the symptom is crime, I don’t go to jail to learn; I go to a school. Keep us in school, keep us in hospitals, like regular folk. And I say us, because this is largely aimed at the poorest and most vulnerable in our community, folks of color. Folks of color ought not be learning that jail is the place to get your diploma, ought not be learning that you get mental health treatment, substance abuse treatment, in a jail.”

To Emily Washington, a lawyer with the MacArthur Justice Center, which filed the lawsuit against the sheriff’s office that led to the 2013 federal consent decree, Fuller’s prosecution appeared to be a way to shift the focus from the officials’ failure to keep prisoners safe. “The problem is that the sheriff’s office has not acknowledged its own role in this tragedy,” she told The New Orleans Advocate. “OPSO seeks to blame others, but there has to be a self-critical analysis. Mr. Crawford’s death was preventable.”

But if Fuller’s prosecution diverted attention from the sheriff’s office, perhaps it also diverted attention from the public’s broader failure to develop meaningful structures of care to address mental illness outside of the criminal justice system.

“The issue is, when are we as a city going to say, ‘In New Orleans we provide meaningful health care to our citizens,’” said Hortenstine. “We must have an understanding that mental [illness] is a sickness that requires treatment; that people are in need of care, not incarceration. A fundamental understanding, that when you try and treat mental health through the justice system, the results are neither healthy nor just.”

UPDATE: An earlier version of this article included a final statement from Barksdale Hortenstine, Jr., the senior attorney for mental health litigation at the Orleans Public Defenders Office, in which he was quoted as saying that “mental health is a sickness.” His intent was to say “mental illness is a sickness.” The article has been updated.

Nick Chrastil is a freelance reporter based in New Orleans. His work has appeared in Slate, ThinkProgress, Roads & Kingdoms, and other outlets.