This piece is a commentary, part of The Appeal’s collection of opinion and analysis.
The COVID-19 epidemic is quickly finding its way into every corner of the nation, and in a growing number of states — Georgia, New York, Illinois, Massachusetts, California, and Louisiana to name just a few — it has now entered our jails and prisons. This development is particularly worrisome for the friends, family members, and loved ones of incarcerated people, many of whom have chronic illnesses that put them at heightened risk of hospitalization or death in the event of an outbreak. But it should also be deeply concerning to the greater public, which is far more closely connected to our nation’s correctional institutions than is commonly understood.
Earlier this week, the Prison Policy Initiative reported that there remain over 2.3 million people incarcerated in a jail or prison in the United States. This includes over 400,000 people over the age of 50. The people we incarcerate are spread across nearly 2,000 different prisons and over 3,000 jails comprising over 5,000 institutional settings with housing conditions remarkably similar to COVID-19 “hotspots” — cruise ships, nursing homes, places of worship — with confined spaces that hold large numbers of people in close proximity, making it nearly impossible to follow the CDC’s social distancing precautions or to routinely disinfect hands or surfaces.
Gregg Gonsalves, an epidemiology professor at Yale School of Public Health, told the New Yorker, “It’s nearly impossible to provide infection control” in correctional facilities. As he described it, if one was intent on setting up “a situation that would promote rapid transmission of a respiratory virus, you would say prison: it’s close quarters, unsanitary, individuals in frequent contact.”
Because of this unsettling reality, it is only a matter of time before a COVID-19 outbreak in one of our nation’s jails or prisons has significant public health consequences in surrounding communities. Because COVID-19 is highly transmissible, including by asymptomatic carriers, the thousands of people each day who leave their homes, enter a correctional facility and interact in close proximity with colleagues and incarcerated people in these often overcrowded, chaotic environments are at considerable risk of transmitting the virus back to their families and into their communities when they return home.
What’s more, correctional facilities are simply not equipped to handle a pandemic. It is unrealistic to expect correctional healthcare staff to minimize or treat outbreaks with the limited resources at their disposal. Correctional healthcare facilities are designed to treat relatively mild types of respiratory problems for a limited number of people and rely on transfer to local community hospitals for delivery of more complex care. This means that COVID-19 outbreaks in correctional settings will almost certainly immediately compound the resource strain already faced by a growing number of community hospitals. In New York City, for example, the number of COVID-19 diagnoses on Riker’s Island Correctional Facility is increasing far more rapidly than in the city itself. Many of Riker’s most medically vulnerable patients are soon to require care in a public healthcare system already stretched thin to the point of breaking.
Similarly, most large state prisons are located in rural areas near small towns (communities that are also typically demographically older than average). A COVID-19 outbreak in one of these institutions will place a particularly heavy burden on small community hospitals, where a surge in the number of people needing immediate medical attention both inside and nearby correctional facilities will quickly overwhelm hospital and ICU bed capacity. For this reason, public health leaders must factor correctional settings into their pandemic planning, and must do so at once.
North Dakota, has embarked in recent years on a partnership with Amend at UCSF to transform its correctional culture from one of punitive, dehumanized warehousing into one that recognizes the dignity, humanity and inner strength of every individual that works and lives in our prisons and jails. Why is this more humanistic approach to corrections important now? In a time of crisis when there is heightened fear among us all, North Dakota’s prison staff continues to receive letters of appreciation from residents thanking them for keeping them well-informed and being caring and patient during a very stressful time. North Dakota’s prison residents are the department of corrections’ partners in the effort to keep our facilities safe, and are doing extra cleaning, maintaining social distancing as much as possible in a congregate housing situation, and sharing their ideas on how to maintain a calm environment. In these days of heightened panic and uncertainty, it is of vital import that we pause to recognize a simple truth about our correctional communities — they are us. Correctional health is public health — ignoring the health of those living and working inside the walls of our nation’s correctional facilities poses a grave threat to us all.
The President and every state governor are tasked right now with mitigating the risks associated with the spread of COVID-19 for the country. A bi-partisan group of fourteen senators, including Senators Richard Durbin, Elizabeth Warren, Charles Grassley, and Mike Lee, sent Attorney General William Barr and Federal Bureau of Prisons Director Michael Carvajal this week sent a letter urging them to “take necessary steps to protect” the “health and well-being of federal prison staff and inmates[.]”
Such steps will require close partnership between correctional and public health leaders (such as ours between the Department of Corrections and Amend at UCSF) to develop a sound, measured and well-informed response to limiting the harm that COVID-19 can cause in our prisons and jails and, by extension, our communities.
We can start by immediately suspending intake at all jails and prisons except in rare instances when a person poses a serious, imminent, credible threat to public safety. Continuing business as usual in our intake processes ignores the impossibility of accurately assessing whether a person being admitted has been exposed to the virus and would require countless staff to come into close contact with each admittee — while relying on an immediate 14-day quarantine upon entry to a facility is unrealistic given the numbers of people that come into and are discharged from our overcrowded correctional systems each week.
Second, we must reduce the population density inside jails and prisons by evaluating individuals for suitability for accelerated release – focusing on those at high medical risk and/or low public safety risk. This should include any person age 50 or older or within two years of a parole or release date. People over the age of 50 inside a correctional facility are most at risk from this virus but also pose little to no threat of violence upon release. In addition, due to often burdensome administrative hurdles, many incarcerated people with serious or life-limiting illnesses have already begun a compassionate release application process and have developed a housing and medical plan for release. These people should be released. And finally, release should include any person who has already been positively adjudicated in a pardon or parole process and is awaiting release pending administrative processes. North Dakota, is giving immediate priority to the release of individuals in these categories in order to free up much needed bed space for effective quarantine in our facilities and medical resources both inside its prisons and at nearby community hospitals.
The rapid spread of COVID-19 inside jails and prisons will profoundly accelerate the humanitarian disaster already taking shape in communities first and hardest hit by infection. Decisive action by governors and the President now can save lives – of incarcerated people, correctional and medical personnel, and nearby community members. Business as usual will not. North Dakota’s Department of Corrections has decided that putting public health first is the best, and only, way to effectively achieve its public safety mission during the COVID-19 pandemic. It is actively working with public health professionals to emergently decrease the population in its correctional facilities. As leaders in public and correctional health and correctional leadership, we challenge our colleagues in corrections, public health and medicine to do as we have and follow suit.
Brie Williams, MD MS is a professor of medicine in the University of California San Francisco Division of Geriatrics and is the Director of Amend at UCSF and the Criminal Justice & Health Program at UCSF.
Leann Bertsch, JD is the Director of the North Dakota Department of Corrections and Rehabilitation.