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Journal of Offender Rehabilitation
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Does Offender Gambling on the Inside Continue on the Outside? Insights from
Correctional Professionals on Gambling and Re-Entry
D. J. Williams a; Gordon J. Walker b
a
California State University - Los Angeles, Los Angeles, California, USA b University of Alberta, Edmonton,
Alberta, Canada
Online Publication Date: 01 July 2009

To cite this Article Williams, D. J. and Walker, Gordon J.(2009)'Does Offender Gambling on the Inside Continue on the Outside?

Insights from Correctional Professionals on Gambling and Re-Entry',Journal of Offender Rehabilitation,48:5,402 — 415
To link to this Article: DOI: 10.1080/10509670902979561
URL: http://dx.doi.org/10.1080/10509670902979561

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Journal of Offender Rehabilitation, 48:402–415, 2009
Copyright # Taylor & Francis Group, LLC
ISSN: 1050-9674 print=1540-8558 online
DOI: 10.1080/10509670902979561

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Does Offender Gambling on the Inside
Continue on the Outside? Insights from
Correctional Professionals on Gambling
and Re-Entry
D J WILLIAMS
California State University – Los Angeles, Los Angeles, California, USA

GORDON J. WALKER
University of Alberta, Edmonton, Alberta, Canada

This study brings to light a neglected topic of particular
importance—offender gambling issues within the context of
re-entry into the community. Fifteen correctional professionals
from Nevada (high gambling availability) and Utah (no legalized
gambling) participated in semi-structured interviews to provide
insights into how gambling may impact the offender re-entry
process in their respective locations. While gambling in prisons
and jails may be common, offender gambling issues upon re-entry
reportedly are associated with substance abuse and the commission of crime. Participants in both Utah and Nevada reported a
lack of resources for dealing with offender gambling issues.
Implications for offender re-entry are discussed.
KEYWORDS correctional process, offender gambling, offender
re-entry, offender rehabilitation, prison gambling

INTRODUCTION
Opportunities for legalized gambling across North America have increased
dramatically over the past two decades. As a result, there has been a critical
The authors would like to thank the Alberta Gaming Research Institute (Canada) for funding this project. The authors also extend thanks to the Nevada Department of Public Safety
and the Utah Department of Corrections for their participation and support.
Address correspondence to D J Williams, California State University – Los Angeles, 720
San Jose Ave., #105, Burbank, CA 91501, USA. E-mail: drdjwilliams@gmail.com
402

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403

need to explore gambling and its issues among a variety of populations
within society. A rapidly-growing population that recently has received attention from gambling researchers is offenders—those who have spent time
incarcerated.
Researchers have measured disordered gambling among offenders
using established instruments such as the South Oaks Gambling Scale (SOGS,
Lesieur & Blume, 1987, 1993), clinical criteria from the Diagnostic and
Statistical Manual of Mental Disorders (American Psychiatric Association,
1994), and the Canadian Problem Gambling Index (CPGI, Ferris & Wynne,
2001). A thorough review of the literature across several countries found that
offenders have high rates of problem gambling (33% overall), higher than
any other known population (Williams, Royston, & Hagen, 2005).
Compulsive gamblers sometimes commit crimes, which result in their
entry into the criminal justice system (i.e., Blaszczynski & McConaghy,
1992; Rosenthal & Lorenz, 1992; Sakurai & Smith, 2003; Yeoman & Griffiths,
1996). Although pathological gambling may lead to criminal behavior, not all
crimes committed by pathological gamblers are gambling-related (Lahn &
Grabosky, 2003; Meyer & Fabian, 1996; Meyer & Stadler, 2002). It seems that
in some cases, pathological gambling contributes to the commission of
crime, while in other cases crime precedes the development of pathological
gambling.
In considering offenders’ behaviors, it is important to recognize contextual and process issues. Visher and Travis (2003) pointed out that although
much research with offenders has focused on factors related to criminal activity, the process of offender transition has been ignored. Similarly, research on
offender gambling has been directed at preprison experience with only a few
studies examining in-prison gambling. In their review of the literature on
offender gambling Williams and colleagues (2005) found only six studies that
focused on gambling within prisons with a prevalence range of 26% to 100%.
Besides these studies, additional reports also suggest gambling during
incarceration is not uncommon, and that it may be a way of passing the time
(Jarvis, 1988; Martinez, 1983; Williams, 2005; Williams & Hinton, 2006).
Virtually no research yet has considered offender gambling postprison.
Gambling upon re-entry is likely to be different from gambling at prior
correctional stages. Offender gambling prior to incarceration occurs, of
course, without monitoring by the correctional system, and gambling during
incarceration may include somewhat unique motivations (such as to pass the
time). Because offenders have such high rates of in-prison gambling and
preprison problem gambling, it is important for researchers and professionals
to begin exploring postprison gambling. For example, it is possible that some
offenders with problem gambling issues prior to their incarceration may
return to compulsive gambling during re-entry. Or, perhaps some offenders
who gamble regularly while in prison may continue their frequent gambling
upon release. It is also possible that some offenders who gamble regularly at

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D J Williams and G. J. Walker

some point prior to re-entry discontinue such behavior upon release. We do
not know if postprison gambling is (or might be) a significant correctional
problem, or how offender gambling may influence the re-entry process.
In light of the above background the purpose of this study is to gain
insights into how gambling may influence the re-entry process for offenders.
The focus here is primarily on the latter stages of the correctional process,
specifically from incarceration through re-entry, rather than preprison.
Although there are many important questions and potential issues regarding
offender gambling upon re-entry, this project is intended to be a starting
point for future research on this novel topic. The primary research question
for this project is: Is gambling during incarceration and upon re-entry perceived by correctional professionals working in the field to be a significant
correctional issue—and why or why not? The responses generated may then
be used to guide future research.

METHODS
Participants and Locations
Fifteen correctional professionals currently working with offenders in the
re-entry process agreed to participate in one-time semi-structured interviews
lasting approximately 45 minutes each. Semi-structured interviews are especially useful in gaining a detailed perspective about a particular topic (Smith,
1995). Using this format, it was possible to ask a few general questions about
offender gambling at preprison, during incarceration, and upon re-entry
without the interviewer leading them toward particular answers. More details
could then be obtained by probing further, asking clarifying questions, and
obtaining explanations and examples.
Participants were selected based on Patton’s (1990) concept of
maximum variation sampling. However, a few potential participants declined
to participate due to time constraints. Participants had a wide range of
experience working directly with offenders, and included administrators,
supervisors, and parole officers. Years of experience ranged from 4 to
30 years (mean ¼ 15.5).
Legalized gambling availability is likely to be significant to re-entry, thus
participants were selected from urban centers in Utah (Salt Lake City-Ogden)
and Nevada (Las Vegas). Utah and Nevada border each other, yet Utah is one
of very few locations where there is no legalized gambling. On the other
hand, opportunities for gambling in Nevada are plentiful. Specifically, 10
participants worked for the Nevada Division of Probation and Parole and 5
worked for the Utah Department of Corrections. Nine participants were male
and six were female. Ages ranged from 30 to 60 years (mean ¼ 44.5). Interviews were conducted in order to obtain insights regarding gambling issues
from incarceration to re-entry.

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Interview Procedure
All interviews were conducted by the first author on site at corrections
locations. Participants were given a brief explanation about the purpose of
the study, and it was explained that the project takes a broad view of
gambling that may include many possible forms, both legal and illegal. They
were told that gambling may include, but is not limited to: betting,
sports-betting, card games or games of chance (to win money, services, or
items of value), and various casino activities. Although multiple examples
were offered, a strict definition of gambling was not provided.
Participants were asked basic demographic questions regarding professional background and experience, current job title and function, and information on their specific correctional institutions and programs. They
were then asked about the prevalence of offender gambling within their
prisons=jails and any associated issues—essentially, how common gambling
is, what it looks like and any significant effects. Finally, participants were
asked about whether or not gambling is a problem when offenders re-enter
the community following incarceration—again, how common is it, what it
looks like and any significant effects. Following these broad questions, they
were asked to provide explanations and examples when relevant, and to discuss how any reported gambling issues are addressed. Participants’
responses yielded detailed information regarding their beliefs and experiences surrounding gambling issues within correctional settings.

Data Analysis
Interviews were audio taped and transcribed verbatim, and responses to
questions were coded and subjected to a categorical-content analyzing
procedure (Lieblich, Tuval-Mashiach, & Zilber, 1998). The purpose of this
procedure is to develop basic knowledge about core themes that emerge
from participants’ responses. During the interview process and specifically
during content analysis of data, attempts also were made to identify potential
frameworks that guided participants’ understanding of issues. For example, a
few respondents used the word ‘‘triggers’’ when discussing gambling and
substance abuse, which signaled that a relapse prevention framework might
be guiding those respondents’ views. Potential meanings associated with
the data were then further considered from within such a perspective. This
process was helpful given that participant member checking to obtain
clarification only occurred during the interview itself.
We have included several quotations by participants in the Results and
Discussion section to reflect general emergent themes that summarize responses.
Although quotes are organized around emergent themes, we have chosen to
privilege participants’ voices rather than including extensive commentary about
them. Descriptions by participants may be particularly useful given that that
this project is a first at exploring offender gambling as it may impact re-entry.

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Limitations
There are several limitations to this study. Foremost, we are obtaining participants perceptions, rather than measuring actual offender gambling behavior. Offender gambling is prohibited within correctional facilities, and it is
impossible to measure accurately due to its secrecy. Offender gambling upon
transition into the community may also be hidden and is difficult to assess.
Although extensive correctional experience is represented herein, this sample is small and specific, so generalizations across locations cannot be made.
Finally, single interviews with each participant were utilized, thus extensive
follow up was not possible. However, despite these limitations, the data
obtained are valuable in helping to understand the possibilities of how
offender gambling may impact re-entry.

RESULTS AND DISCUSSION
In order to maintain discussion structure herein we have divided this section
into a brief summary of findings regarding gambling in incarcerated settings
before presenting a summary of findings concerning offender gambling postincarceration.

Gambling in Prisons and Jails
Several participants from both Utah and Nevada believed that gambling in prisons and jails is common. However, a few reported that they were not sure how
prevalent gambling is. Sports betting, betting on recreational activities, card
games, and board games were all mentioned as types of gambling. Participants
reported that offenders gamble for money (when possible), commissary items,
personal favors, extra supplies, and cigarettes. A Utah administrator who had
worked at multiple levels of the correctional system reported:
It’s [gambling] very common. It’s not openly seen at all times as, uh,
a gambling episode . . . You don’t actually see individuals rolling dice
on a dice table anymore. You don’t see people playing 21 . . . They disguise it very well as different types of, uh, games of chance . . . There
are all different types of gaming going on constantly.

A Utah parole officer who had worked for several years in and out of the
prison system agreed:
It’s very common. They bet on about anything . . . I think it’s more prevalent in the general population areas of the prison . . . In halfway houses
we find groups of gambling, what we call gambling rings that get going
and then someone gets beat up because they can’t pay a debt.

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While the parole officer believed gambling is common in both the Utah State
Prison and halfway houses, he thought that gambling problems were
reported more in the halfway houses:

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I think it’s reported more outside (of prison). Inside it’s, you know, you’re
apt to get a much more severe punishment from other offenders if you
tell on them, and it’s a stronger code (inmate code of conduct). ’Cause
in the halfway house environment you have parolees and probationers
and they’re both different animals.

A parole officer in Nevada who had worked previously inside the prison
stated, ‘‘Inside the prison it’s [gambling] a daily occurrence.’’ A Nevada correctional supervisor who had worked in various locations believes gambling in
Nevada prisons and jails is no more common than in any other state. He added,
I believe you have to look at the institutions as a small city where you
have your vice issues—gambling, book making, prostitution, drug sales,
uh, exchange store. It’s just, you know, you have to look at it as a smaller
segment of society that is divided up the same way that society is.

Participants’ perspectives regarding offender gambling in prisons generally are consistent with other reports suggesting that gambling is common,
may be part of the culture of prison, and that it occasionally results in
violence (Martinez, 1983; Williams & Hinton, 2006). It should be expected that
offender gambling would be prevalent in a relatively monotonous, predictable, highly structured environment inherent to incarceration. A recent study
found that gambling in prisons and jails may be considered leisure experience
for many offenders (Williams, 2008a). In other words, such free-time gambling may bring a sense of freedom and various positive emotional states.

Offender Gambling upon Transition into Community
Findings suggest that gambling issues during transition into the community
may be varied and complex. Most participants seemed to believe that
gambling can be a problem for some offenders upon re-entry. Utah correctional professionals generally acknowledged that gambling occurs within
halfway houses, but were aware of only rare cases where parolees or probationers drove out of state (often to Nevada) to gamble. An officer at a Utah
day treatment program stated, ‘‘We don’t see a lot of gambling. They [offenders] come in for classes. We don’t see a lot here.’’ However, a supervisor
noted that the Utah Department of Corrections does not look for possible
problem gambling when offenders are living on their own in the community.
Because gambling is illegal in Utah, the possibility of some offenders having
gambling problems seems to have escaped the attention of many correctional
professionals.

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D J Williams and G. J. Walker

Responses revealed that specific behaviors were paired with gambling,
which seemed to legitimize some gambling as being problematic. The links
mentioned were (a) gambling and substance abuse, and (b) gambling and
crime. Interestingly, despite significant differences in gambling availability,
correctional professionals in both Nevada and Utah reported a lack of
feasible treatment resources to address cases of problem gambling. Finally,
several re-entry difficulties for offenders with gambling histories (preincarceration) were reported.

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Gambling and Substance Abuse Connection
Correctional professionals are aware of the need to manage closely offenders
who are at risk for substance abuse relapse. Findings reflect perceptions of a
strong link between gambling and substance abuse. Several interviewees in
the Nevada correctional system reported that offenders in their state with
substance abuse histories are likely to have a ‘‘do not enter casino’’ clause
in their parole or probation agreements. A Nevada supervisor with two decades of police and corrections experience stated, ‘‘I would say that maybe,
uh, 50% [of transitioning parolees] would start gambling, but it always seems
to fall in line with alcohol use and abuse and drug use and abuse.’’ He
believes that problem gambling is ‘‘connected with alcohol and drugs’’ and
if low substance abuse risk offenders gamble, then, ‘‘they are able to control
it and stay to their twenty dollar limits or whatever on paydays.’’ A Nevada
probation officer suggested,
I think that [substance abuse and gambling] might coincide with each
other somewhat. I think that it’s possible that it [substance abuse and
gambling] might be a lot higher than what is actually documented, and
they [offenders] probably get convicted of something else.

One Nevada officer had considerable experience working with a drug
court program, and he discussed specific recent cases of re-entry where risky
gambling was linked with substance abuse. He summarized:
. . . Issues that I’ve had usually involve the use of methamphetamines. The
amphetamines keep them awake for a few days at a time, and one of the
things they do is go drink andgamble. You know, they’re awake and they
gotta do something and they’re in Las Vegas. The only thing to do is to
go to the casino . . . I think methamphetamine was the problem,and
then the gambling was just they had something they needed to
do. . .It’s hard to tell, I guess when I’m dealing with substance abusers,
it’s hard to tell which one’s first. Um, I’ve had them say they use meth,
that’s the trigger. They have something they need to do; they need to
go gamble. While they do the gambling they drink. I’ve also had it the

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opposite way where they’ve said they started gambling. As a result of
gambling, they started drinking. As a result of drinking, they next step
is using their dope. I’ve seen both sides. I’ve seen it both ways where
the gambling triggered the drug use, and I’ve seen it where the drug
use triggered the gambling.

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Comments by a Utah administrator also reflect a prioritization of
substance abuse. He stated:
What we’d like to try to say is that you [offender] have other problems.
You have a problem with alcohol or drugs. So, if it’s alcohol, that
probably led you into the gambling and you could go through the 12-step
program with alcoholics anonymous. But that does not focus on the
individual with a real gambling problem. The individual with a real
gambling problem needs specific help. And, there are very few states that
have programs specifically designed for those gamblers who have the
addiction.

Comments by several participants reflected a belief that substance abuse
contributes to problem gambling. However, some accounts also indicated
that non-problem and problem gambling can contribute to substance abuse.
A review of the literature does reveal a strong association between problem
gambling and substance use disorders (Argo & Black, 2004). Given that many
offenders have histories of substance abuse problems, it seems reasonable
that ‘‘do not enter casino’’ clauses would be common in Nevada parole
and probation agreements.

Gambling and Crime Connection
Nevada participants were aware of numerous re-entry cases when gambling
was related to criminal activity. Mostly, these were cases when problem
gambling lead people to commit crimes to support their gambling problems.
A Nevada supervisor noted:
They’re [offenders] out there committing crimes to feed the gambling. It’s
like one addiction is feeding the other. So, that’s why, where most of the
problems are . . . You know, they’re gambling, they’re committing the
other crimes to support the gambling habit . . . The gambling itself is leading to the crimes they’re committing, because they’re trying to support
the [gambling] habit.

An experienced Nevada parole officer observed, ‘‘They’ve stolen from their
employer or written bad checks or whatever to get money to gamble. Or,
[they’ve] missed work or lied to a family member, stolen from family
members, things like that to support their gambling habit.’’

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Although an awareness of the potential for problem gambling among
offenders seemed to be somewhat less in Utah than Nevada, there were
a few reported instances of an association between problem gambling
and crime. A Utah supervisor recalled a specific case, ‘‘For him [offender]
to end up here for gambling, that would have meant that he had stolen
something, or [committed] a forgery, as a result of the gambling.’’ Unfortunately, it is not clear whether this case refers to an apparent original
crime prior to incarceration or a violation (new crime) of parole or
probation.
One Nevada supervisor recalled an unusual parole case where a new
crime seemed to precede the development of problem gambling:
I think of one drug dealer who, that [gambling] was her way of getting rid
of cash. And, she started making so much [money] she was gambling
because she had too much cash all the time. And, and she says gambling
became very addictive to her, but then she’d sit there [gambling] all day
long because she’d sell drugs all day long.

The relationship between problem gambling and crime is complex.
However, a thorough literature review found that about half of all crime
committed by incarcerated problem and pathological gamblers was reportedly committed to support gambling behavior (Williams et al., 2005). It
would be expected that some offenders with preprison gambling problems
might struggle with gambling problems again upon re-entry, particularly in
environments where gambling is readily available. Insights from Nevada
correctional professionals in this study confirm that expectation. Although
gambling issues pertaining to re-entry in Utah are less clear, recent data
from offender self reports in Utah suggest some offenders are at high risk
for problem gambling upon re-entry despite not having gambled prior to
their incarceration (Williams, 2008b). In these relatively few cases, frequent
gambling behavior seemed to originate during incarceration.

Need for Offender Gambling Treatment Resources
Most participants mentioned that they were aware of few resources for
offenders who might have gambling problems. Gamblers Anonymous was
mentioned almost exclusively, but a couple of Nevada participants also mentioned counseling within the community for impulse control disorders. A
Nevada parole officer reported:
I don’t think there are sufficient resources here in Vegas, particularly, and
if there is, it’s not out in the open where offenders or even some staff
would be made aware of the resources that are available. So, no, I think
there’s a need for more programs and I think there’s a need to market
those programs so everyone’s aware of what’s available.

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Talking about treatment programs for gamblers, a Nevada supervisor with
over 20 years of experience stated:
I would say there are none [programs] in the prison that I know of. Informally, there may be some of the guys sitting around talking about it, but I
kinda doubt it. Out here [parole and probation] depending on whether or
not you have insurance, there’s Gamblers Anonymous. Depending on if
you have very good insurance, the hospital has a program but it’s hours
and hours a day.

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A Nevada parole officer reported:
I think that Vegas is lacking. I think that being a gambling state, when we
do have offenders that need rehabilitation as far as gambling resources
needed, it’s extremely hard to find facilities that have Gambling Anonymous. It’s more impulse-control type counseling instead of focusing
on the addiction of gambling.

A field supervisor in Nevada added:
The state’s pretty weak when it comes to social services. You know,
when they [offenders] come out [of jails=prison] we don’t have a free
place for them to go. So they gotta like, they gotta pay to go to the counseling, you know. We don’t really have anything that we can offer on
itself. It’s not a real great state as far as social [services] goes.

Utah correctional professionals interviewed were aware of few
resources. An experienced officer in Utah stated, ‘‘The only thing I know
about is Gamblers Anonymous.’’ She added that, ‘‘if they’re serious in their
programming, they’re utilizing their substance abuse or sex offender treatment to help with the gambling problem as well.’’
Although cases of offender problem gambling in Utah appeared to be
rare, Utah professionals interviewed tended to view it as a type of addiction.
However, Nevada professionals seemed to be divided, or perhaps unsure,
regarding whether problem gambling was an addiction or an impulse control
disorder. Pathological gambling is classified by the APA (1994) as an impulse
control disorder. However, compulsive gambling also has been conceptualized as an addiction, similar to substance use disorders but without the
drug, and as an obsessive-compulsive spectrum disorder (Moreyra, Ibanez,
Saiz-Ruiz, & Blanco, 2004). Thus, it is not surprising that responses reflect
differences in how problem gambling is understood.

Offender Financial and Family Support Issues
Participants reported financial and family support issues that impact re-entry.
Some of these apparently result from gambling inside of prison (mostly from

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unpaid debts), but other issues stem from offender gambling pre-or postincarceration. Regarding issues from gambling while incarcerated, a Utah
administrator reported:

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The hardest part is that it’s not always the offender committing the act of
gambling; it’s those support systems that he has on the outside. Those
are the ones that have to come up with the money to maybe pay off
his debt, or they have to deliver the dope, or it’s them that have to do
other degrading acts in order to pay off those debts.

Family members on the outside may feel pressure to help offenders with
gambling debts on the inside, which may add considerable stress to these
relationships including later when offenders are released.
Problem gambling and its adverse consequences prior to incarceration
may strain family relationships later in the re-entry process. A Nevada supervisor noted that offender problem gamblers sometimes ‘‘don’t have support
of the family.’’ He added that upon re-entry, some offenders with problem
gambling histories don’t want help for their gambling issues, and they may
‘‘live by themselves, their families have kicked them out, their wives have left
them.’’ Regardless of whether or not offenders are motivated to try to manage
their gambling upon re-entry, particular attention by correctional professionals toward strengthening family and positive support systems during
reintegration into community may be warranted.
It is to be expected that offenders with histories of problem gambling are
more likely to have significant clinical issues associated with their gambling, and
that these issues may carry over into the re-entry process. Offender gambling
during any phase of the correctional process may have an impact on offenders’
re-entry experiences. A summary by Shaffer and Kidman (2004) of the potential
adverse consequences of gambling include family dysfunction and domestic
violence, alcohol and drug problems, mental health issues and potential for
suicidal behavior, significant financial problems, and of course, crime.

CONCLUSION
Research has demonstrated that offenders have very high rates of problem
gambling prior to incarceration (Williams et al., 2005). However, research on
offender gambling within prisons and jails and upon subsequent release is
lacking. Given the many potential adverse consequence of gambling, it should
be expected that various gambling issues may continue to influence the offender re-entry process. Findings here show that according to correctional professionals interviewed in this study, gambling in various forms may be common
during incarceration, while offender problem gambling occurring in the community often is paired with substance abuse or crime. Furthermore, offenders
with gambling problems may alienate family members and drain financial

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resources specifically due to compulsive gambling. Building support during
re-entry is crucial for offenders under the best of circumstances, but it seems
problem gambling further complicates this process.
We are in need of much research that addresses multiple forms of offender gambling and how these affect re-entry. This project, drawing on ‘‘real
world’’ accounts of correctional professionals in Nevada and Utah, is a starting point for future research. Although there is a stark contrast in gambling
legality and availability in these two states, the potential for significant offender gambling issues is present in both. Perhaps a next step for qualitative
researchers might be to identify a group of offenders who have struggled
with gambling issues upon re-entry and conduct interviews or focus groups
for more insights. Projects might be designed that build from findings here,
such as learning more about potential relationships between gambling and
substance abuse or crime, or how to rebuild social and financial support systems more effectively. Surveys designed to gain statistical information about
gambling behavior during re-entry could be administered to a large sample
of offenders at the end of the correctional process. Because offender gambling remains largely unseen but brings sanctions when discovered, it is
always a challenge for researchers to obtain accurate information while
protecting participant confidentiality.
The significance of offender gambling issues easily may be overlooked
and resources for offenders with gambling problems seem to be lacking. We
suspect that perhaps gambling issues to those identified here may be present
in other states that fall between the extremes of gambling legality and availability that are represented herein by Utah and Nevada. However, the
insights provided via this investigation may be worth considering for correctional professionals in various locations. Given the widespread availability of
gambling across North America and our findings herein, we urge correctional
administrators and policy makers to look closely for gambling issues within
their jurisdictions and work to develop sound policies to address them. Similarly, we encourage parole and probation officers to monitor the potential for
gambling problems among the offenders they supervise. Gambling can be
enjoyable to many people, but it also can bring huge costs to human lives.
It is important to work together to understand and manage it as best we
can, especially among those who are most vulnerable.

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