Preventing the Spread of COVID-19 Among US Inmates
Author: Annie Valenziano
Why are Incarcerated Populations at Risk?
The number of individuals who are incarcerated has exploded since the early 1980s due to a number of factors including changes to minimum sentencing for the over criminalization of drugs/the “war on drugs”, institutional racism, and poverty. Currently in the US, there are 2.3 million people behind bars. This is roughly 25% of all incarcerated people worldwide (Sawyer & Wagner, 2020). However, this does not fully represent the number of people who are cycling in and out of the multitude of imprisonment systems; jails, prisons (state and federal), youth facilities, immigration detainment centers, and Indian Country jails, as well as involuntary/civil commitment (mental health). It is estimated that over 600,000 enter prisons every year with another 10.6 million pass through jails systems in that same time frame (Sawyer & Wagner, 2020).
Jail
Jails are facilities that hold individuals while they await trail or sentencing, and inmates who have sentences less than 1 year; typically misdemeanors. These can be be run by city, county, state, or federal agencies.
Prison
Prisons are longer term facilities that are state or federally run who house inmates with longer sentences, generally over a year, generally charged with felonies.
Video overview of preventing the spread of COVID-19 among US inmates (4:50m)
(Slide 1) As more and more people are attempting to keep themselves safe from COVID-19, it can be easy to forget about those who are removed from society via incarceration. Currently in the united states there are 2.3million people incarcerated. Additionally, there are around 600,000 people who enter prisons every year, with another 10.3 million cycling in and out of jails. Those who are incarcerated are currently being infected by COVID-19 at 5x the rate of the general population, and frequently have more difficulties in protecting themselves.
(Slide 2) The unites states holds about 25% of the worlds incarcerated population. Mass incarceration in the united states can be attributed to many factors, namely unfair sentencing practices, racial discrimination, the over criminalization of drug crimes.
(Slide 3) There are a number of reasons that incarcerated populations are at a higher medical risk for COVID-19 infections and having presenting more severely. First is that incarcerated populations are sicker than the average population. It is estimated that over a third of inmates have AT LEAST one chronic health condition. Frequently inmates are not engaged with primary care services outside of incarceration, and those that are can have a lag in treatment initiating once incarcerated. Frequently, treatments and medications are not continued at all behind bars. Secondly, around 25% of inmates have been diagnosed with at least one mental health condition. Frequently these can be severe such as bipolar, severe depression, schizophrenia and/or unspecified psychosis. This is compounded by a high tendency for incarcerated persons to have co-occurring substance use disorders. Lastly, incarcerated peoples are disproportionately people of color or from lower socioeconomic backgrounds with high occurrences of homelessness or housing instability.
(Slide 4) Looking at the diverse and frequently vulnerable population that make up US inmates, there are a number of factors that contribute to the inability to reduce the spread of covid-19. The first is physical structure in which they reside. The largest issue within correctional facilities is just the pure number of people within a facility. It is was found that half of states reported overcrowding within correctional institutions. This overcrowding results in inmates being unable to social distance, one if the first line defenses In preventing the spread of covid-19. Frequently there are not isolation spaces available to separate people who report feeling ill. Additionally, shared bathroom and living space make it difficult to contain infections. Adding to that are continued issues of poor or improper ventilation, lack of access to fresh air, and frequent risk to food contamination, and non-enforcement of proper hand hygiene. While COVID-19 is not directly a food borne illness, frequently workers who are sick are not removed from their duties, and frequent handwashing practices are not employed as strongly as they should be.
The second layer is personal protection for inmates. Again, living in a congregate setting already presents a risk factor for the spread of COVID-19. In many facilities, inmates do not have access to proper resources to disinfect their hands. Soap might not be free or readily available and hand sanitizer is frequently considered contraband. Masks are not always available to inmates, and currently only 15 states require inmates to wear masks at all, despite the CDC’s current recommendations. Accessing medical services can be difficult for many inmates they frequently require a disproportionately large copay. While originally implemented as a deterrent to prevent unnecessary medical visits, it is now becoming a barrier to early identification of sick individuals. Lastly, staff at correctional facilities can be frequent carriers of COVID-19. There are currently around half a million employees in the prison system alone, considered essential employees, staff frequently come into direct contact with inmates, work in under resourced facilities, lack access to appropriate PPE, and have the continual strain of increasing mental health burdens and burn out.
(Slide 5) So what can be done? The largest and simplest step to prevent the spread of COVID-19 within correctional facilities is to simply have less people incarcerated. There has been a recent push for release of those who have low level non-violent crimes, those who are elderly or medically fragile, and those who are already within 1 year of release. Additionally, within facilities, we can reduce the barriers to accessing medical services by reducing or eliminating costs, ensuring that inmates and staff have access to proper PPE and hand washing supplies, supporting mental health concerns of employees and inmates, and lastly partnering with outside institution to ensure that appropriate medical guidance, policies, and research is being done within facilities. Thank you for viewing this project and taking the time to learn about barriers that are disproportionately effecting those who are most vulnerable within society.
Incarceration in America
Chronic Health Conditions
Individuals who are incarcerated are, on average, sicker than the general population (Wilper et al., 2009)
Inmates contract viral infections at higher rates than general public.
38.5% federal inmates, 42.8% of state inmates, and 38.7% of jail inmates have at least one identified chronic health condition.
Among inmates with a persistent medical problem, 13.9% of federal inmates, 20.1% of state inmates, and 68.4% of local jail inmates had received no medical examination since incarceration.
More than 1 in 5 inmates were taking a prescription medication for some reason when they entered prison or jail; of these, 7232 federal inmates (26.3%), 80 971 state inmates (28.9%), and 58 991 local jail inmates (41.8%) stopped the medication following incarceration.
Mental Health and Substance Use
Individuals who have a mental health diagnosis and/or Substance Use Disorder (SUD) are more vulnerable than the general population. Their diagnosis may impede their ability to follow instructions surrounding social distancing/personal hygiene, an inability to advocate for themselves if they need medical services, and longer incarceration times with more periods of disciplinary action, frequently worsening symptoms.
Around 25% of inmates have mental health diagnosis, but only 1/3 are taking medication while incarcerated, less receiving psychotherapy interventions (Wilper et al., 2009).
In 44 states, jail or prisons hold the largest population of adults with serious mental health diagnoses (general psychosis, severe bipolar, schizophrenia) (Treatment Advocacy Center, 2016).
Inmates with mental health diagnoses stay longer, on average, 26 days vs 51 days (Treatment Advocacy Center, 2016).
In Washington state, mentally ill inmates accounted for 41% of infractions (facility rule violations) even though they only made up 19% of the population, causing them to receive disciplinary action while incarcerated (Treatment Advocacy Center, 2016).
It is estimated that 65% of incarcerated individuals have a SUD diagnosis, and another 20% are incarcerated while under the influence (National Institute on Drug Abuse, 2020a).
Individuals who have a SUD are more likely to contract COVID-19 because of the direct impacts of substance use on the respiratory system (National Institute on Drug Abuse, 2020b).
Those with SUD have higher rates of unmanaged chronic health conditions and immunocompromisation verses the general population (National institute on Drug Abuse, 2020b).
Race and Poverty
Incarceration disproportionately affects people of color and those of lower socioeconomic status because of racial profiling, racial discrimination, criminalization of homelessness, and racist drug laws and sentencing (Wilper et al., 2009). Additionally, people of color exhibit higher rates of COVID-19, along with increased levels of severe presentation, higher likelihood of hospitalization, and increased rates of poverty (Van Beusekom, 2020).
African Americans are 5.4x more likely to test positive for COVID-19 than other races (Van Beusekom, 2020).
African Americans are 1.9x more likely to require hospitalization for COVID-19, those also impoverished were 3.8x more than their Caucasian counterparts (Van Beusekom, 2020).
Poverty alone increased the risk of requiring an ICU admission by 3.6x (Van Beusekom, 2020).
Formerly incarcerated people are 10x more likely to be homeless (Couloute, 2018).
People who are homeless have higher likelihoods of COVID-19 transmission because of shared supplies, forced congregate settings, and decreased access to health services (Lewer et al., 2020).
Incarcerated Persons Per 100,000
(Sawyer & Wagner, 2020)
Whites-450 (1x)
Latinx-831 (2x)
Hawaiian/Pacific Islander-1017 (2.5x)
Native American/Alaska Native-1291 (3x)
African American-2306 (6x)
Listen to First Hand Accounts
Podcast by In Public Safety. Interview with Dr. Jarrod Sadulski who describes some of the limitations and successes of trying to control COVID in correctional facilities.
Podcast by NPR. Uncuffed is a podcast run by people behind bars in the California prison system. This episode looks at inmate perspectives from early in the COVID outbreak (recorded March 13th, 2020). See episode posted 3/26/2020
Barriers and Limitations
Even before the COVID-19 pandemic, outbreak, disease, and infections were common within correctional facilities. The structure of the building itself presents many challenges to infection control. An additional factor is that safety and control are the primary goals of correctional facilities, not healthcare. The secondary difficulty is that the intention of incarceration is remove someone’s rights and autonomy; individuals cannot choose their living environment, where they go, who they interact with, what they eat, and what supplies they have access to. It was found in 41% of studies, that environmental factors negatively impacted health of inmates (Guo et al., 2019).
Physical Space and Building Limitations
Contamination
Food contamination was found to be the most common source of infection. While some facilities contract to outside agencies for food service, many employ inmates for food preparation. There are varying levels of competency among inmates for appropriate food handling resulting in higher rates of infection disease spread throughout facilities (Guo et al., 2019).
Overcrowding
At the end of 2018, 25 states reported that their prison populations exceeded their bed count (EJI, 2020). As a result, inmates are often put into shared dorms or cells. With the overfill of people, it is nearly impossible to remove sick individuals from the general population or implement social distance guidelines.
Additionally, there can be a deterrent to even saying that you are sick. In many medium and lower security prisons, where people are housed in large dorm rooms, saying that you are sick could mean facing solitary confinement as those are the only single cells or isolation option available (EJI, 2020).
Ventilation
One difficulty to manage in correctional facilities is appropriate ventilation and access to fresh air. Proper ventilation reduces the risk of inhaled disease. Guo et al. (2019), stated that, secondary to food contamination, improper ventilation was the second largest risk for infection. With COVID-19, a respiratory illness, proper ventilation is key.
Personal Protection
Hygiene
In congregate settings personal hygiene can be difficult. In many facilities, shower and bathroom facilities are shared by a large number of individuals. Soap might not be readily available or must be purchased for individual use. Additionally, hand sanitizer in many facilities is considered contraband because of the risk of ingestion, use as a weapon, and fire hazard (Montoya-Barthelemy et al., 2020).
Masks
Widra & Herring (2020) reported that less than half of states require staff to wear masks while on duty. Furthermore, less than 1/3rd of states require inmates to wear masks (15). One of the easiest ways to reduce the spread of COVID is to wear a mask when out in public. The CDC (2020) recommends that all staff and inmates wear a mask whenever possible, and issue cloth masks to inmates for personal use.
Medical Access and Staffing Concerns
Access to Medical Care
While many larger facilities have medical staff on site, smaller sites frequently do not. Currently, the CDC (2020) recommends all inmates to be evaluated for symptoms upon arrival. If no medical staff are present it can fall to the deputies/guards to determine if someone is "sick enough" to send out, however, that would require using staffing resources to escort inmates, causing a conflict of interest (Burki, 2020).
Additionally, if access to medical staff is available, many places charge for evaluation. A copay of $2-$10 can be burdensome on inmates who heavily rely on outside assistance for money or their salary of $0.14-$0.26/hr. Currently only 7 states DO NOT have co-pays for medical visits (Sawyer, 2017).
Staff Risk
Staff present another risk to inmates as they are frequently carriers of the infection, with over half a million correctional staff in the US. Staff are required to come into physical contact with inmates on a daily basis, as part of their job duties.
Additionally, mental health stability is decreasing for these employees during the pandemic. Correctional officers are reporting depression, anxiety, PTSD and suicide rates 40-100% higher than police officers. Staff work in chronically underfunded system and are frequently not prioritized to receive PPE like medical facilities. In previous outbreaks, such as SARS, many correctional workers were reluctant to come to work for fear of exposure, which placed increased stress on staffing and facility resources (Montoya-Barthelemy et al., 2020).
As of November 23rd, 2020, 4 of the 5 largest COVID-19 outbreaks in Oregon are in correctional facilities (KGW8, 2020).
What can be done?
"For the most part, states are not even taking the simplest and least controversial steps, like refusing admissions for technical violations of probation and parole rules, and to release those that are already in confinement for those same technical violations. In 2016, 60,000 people were returned to state prison for behaviors that, for someone not on probation or parole, would not be a crime. Similarly, other obvious places to start are releasing people nearing the end of their sentence, those who are in minimum security facilities and on work-release, and those who are medically fragile or older. "--Equal Justice Initiative, 2020
Decarceration
By reducing overcrowding, inmates have an increased ability to social distance. Facilities and their corresponding criminal justice systems should be evaluating inmates for early release who are there for low-level non violent crimes, technical violations, those who are on minimum security clearance/work release, those who are medically fragile (within reason), and those within 1 year of release.
Reduce Barriers to Accessing Medical Care
By eliminating fees for medical appointments, inmates have easier and less burdensome access to appropriate health care services. If onsite medical staff are not available, training all non-medical staff on the risks/symptoms of COVID-19 and ensure policies are in place so individuals can get tested efficiently or have the ability seek outside treatment if needed without being subjected to the opinion of whether non-medical staff (deputies/guards) feel like they are "sick enough" for medical treatment.
Provide PPE/Improve Cleaning Practices
Ensuring that all inmates have access to appropriate hygiene supplies (free of charge), ensuring that masks are available for everyone within the facility (staff/inmates) and enforcing rules around wearing them in common areas. Set standards for facilities on cleaning appropriately between inmates and that common spaces/bathroom facilities have increased cleaning schedules.
Allow Research in Correctional Facilities
Currently, it is difficult for outside/third parties to access correctional facilities to get a true understanding of the number of cases that are occurring, what day to day life looks like, and provide additional insight on measures that can be implemented to slow spread. By allowing researchers and/or local public health authorities to access facilities there could be improved resources and guidance made available to those working/housed inside. There should be more done to evaluate the medical facilities and practices within incarcerated populations while still protecting those people from inherent power imbalances and exploitations. (Montoya-Barthelemy et al., 2020)
References
Center for Disease Control and Prevention. (2020). Guidance for Correctional & Detention Facilities. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/community/correction-detention/guidance-correctional-detention.html
Couloute, L. (2018). Nowhere to go: Homelessness among formerly incarcerated people. Prison Policy Initiative. Retrieved from https://www.prisonpolicy.org/reports/housing.html
Equal Justice Initiative. (2020, August 21). COVID-19’s impact on people in prison. Retrieved from https://eji.org/news/covid-19s-impact-on-people-in-prison/
Guo, W., Cronk, R., Scherer, E., OOmmen, R., Brogan, J., Sarr, M., & Bartram, J., (2019). A systematic scoping review of environmental health conditions in penal institutions. International Journal of Hygiene and Environmental Health, 222(5), 790-803. https://doi.org/10.1016/j.ijheh.2019.05.001
KGW8. (2020) Here are the 76 active COVID-19 workplace outbreaks in oregon. Retrieved fromhttps://www.kgw.com/article/news/health/coronavirus/here-are-the-76-active-workplace-outbreaks-in-oregon/283-ec4cd2ba-cab7-495a-b9c0-a7f9db963979
Lewer, D., Barithwaite, I., Bullock, M., Eyre, M. T., White, P. J.. & Aldridge, R. W. (2020). COVID-19 among people experiencing homelessness in England: A modelling study. The Lancet: Respiratory Medicine, 8(12), 1181-1191. doi: https://doi.org/10.1016/S2213-2600(20)30396-9
National Institute on Drug Abuse, National Institutes of Health. (2020a). Criminal justice drug facts. Retrieved from https://www.drugabuse.gov/publications/drugfacts/criminal-justice#:~:text=The%20substantial%20prison%20population%20in,population%20has%20an%20active%20SUD
National Institute on Drug Abuse, National Institutes of Health. (2020b). COVID-19 and SUD: FAQs for clinicians. Retrieved from https://www.drugabuse.gov/nidamed-medical-health-professionals/resources-to-help-your-patients-sud-during-covid-19-pandemic/covid-19-sud-faqs-for-clinicians
Montoya-Barthelemy, A. G., Lee, C. D., Cundiff, D. R., & Smith, E. B. (2020). COVID-19 and the correctional environment: The american prison as a focal point for public health. American Journal of Preventative Medicine, 58(6), 888-891. doi: 10.1016/j.amepre.2020.04.001
Nembrini, P. G. (2005). Water, sanitation, hygiene, and habitat in prisons. International Committee of the Red Cross. Retrieved from https://www.icrc.org/en/doc/assets/files/other/icrc_002_0823.pdf
Sawyer, W. & Wagner, P. (2020, March 24). Mass incarceration: The whole pie 2020. Prison Policy Initiative. Retrieved from https://www.prisonpolicy.org/reports/pie2020.html
Sawyer, W. (2017). The steep cost of medical co-pays in prison put health at risk. Prison Policy Initiative. Retrieved from https://www.prisonpolicy.org/blog/2017/04/19/copays/#:~:text=In%20most%20states%2C%20people%20incarcerated,treatment%2C%20and%20other%20health%20services.&text=Fees%20are%20also%20meant%20to%20deter%20people%20from%20unnecessary%20doctor's%20visits.
Treatment Advocacy Center. (2016, September). Serious mental illness prevalence in jails and prisons. Retrieved from https://www.treatmentadvocacycenter.org/component/content/article/220-learn-more-about/3695-serious-mental-illness-prevalence-in-jails-and-prisons-
Van Beusekom, M. (2020, September 25). Studies spotlight COVID racial health disparities, similarities. Center for Infectious Disease Research and Policy. Retrieved from https://www.cidrap.umn.edu/news-perspective/2020/09/studies-spotlight-covid-racial-health-disparities-similarities
Widra, E. & Herring, T. (2020). Half of states fail to require mask use by correctional staff. Prison Policy Initiative. Retrieved from https://www.prisonpolicy.org/blog/2020/08/14/masks-in-prisons/
Wilper, A. P., Woolhandler, S., Boyd, J. W., Lasser, K. E., McCormick, D., Bor, D. H., & Himmelstein, D. U. (2009). The health and health care of US prisoners: results of a nationwide survey. American Journal of Public Health, 99(4), 666-672. doi: 10.2105/AJPH.2008.144279