key: cord-0804499-itl79ln6
authors: Nelson, Bryn; Kaminsky, David B.
title: A COVID‐19 crisis in US jails and prisons
date: 2020-08-03
journal: Cancer Cytopathol
DOI: 10.1002/cncy.22335
sha: fa85c2bcaa1cdd14378b0f517ec4d7e7cc32953e
doc_id: 804499
cord_uid: itl79ln6

nan

T o fight the ongoing coronavirus disease 2019 pandemic, public health officials have implemented a range of social distancing measures aimed at reducing the risk of person-to-person transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, physical separation can be nearly impossible in confined spaces such as jails, prisons, and detention centers throughout the United States.

Indeed, experts believe that overcrowding, together with a lack of testing, inadequate infection control measures, and shortages of basic supplies for both staff and inmates, has fueled massive outbreaks in US correctional facilities. The revelations have spurred uncomfortable questions about how the facilities perpetuate and exacerbate racial disparities and how inadequate testing can blind public health officials to emerging hotspots. More broadly, experts are asking why correctional facilities were overlooked in pandemic planning and are examining the role that the nation's criminal justice system plays in infection control.

Marcella Alsan, MD, MPH, PhD, a professor of public policy at Harvard Kennedy School in Cambridge, Massachusetts, says that highly susceptible inmates are often interlinked with vulnerable and disadvantaged communities. Up to half of all US inmates have chronic conditions; several of those conditions, including hypertension, heart disease, and diabetes, are specific risk factors for worse COVID-19 outcomes. African Americans not only make up a disproportionate share of the incarcerated population but also have been disproportionately affected by In the absence of a vaccine or cure, the easily transmitted respiratory virus "exposes all of the weak points in our health system, and in the way we treat other people, especially those who are the most vulnerable and disadvantaged," Dr. Alsan says. "So hopefully this will awaken sensibilities across all of us that what happens within the criminal justice system doesn't just stay within the criminal justice system. It percolates throughout."

By June 30, 2020, the Covid-19 Behind Bars Data Project at the University of California Los Angeles School of Law had counted approximately 53,400 cases and 620 deaths among correctional facility residents. The project and other reporting efforts found that multiple outbreaks had swept through local, state, and federal facilities. Among them, researchers tallied nearly 550 cases in Chicago's Cook County Jail; nearly 2100 cases in Ohio's Marion Correctional Institution (which was built to house 1500 inmates); and nearly 900 cases in the Federal Correctional Institution in Lompoc, California. In addition, the reporting tallied approximately 12,600 cases and 50 deaths among jail and prison staff.

According to a separate tally by The New York Times, outbreaks in correctional facilities accounted for 16 of the nation's top 20 COVID-19 clusters by the end of June.

In March, Dr. Alsan and Crystal S. Yang, PhD, JD, AM, a law professor at Harvard Law School in Cambridge, Massachusetts, launched a project with the National Commission on Correctional Health Care to survey jails, prisons, and juvenile detention facilities across the United States. Over a 2-month period, the collaborators received responses about COVID-19 case counts, testing, and screening procedures and about ongoing challenges from hundreds of sites in all but a handful of states.

So far, the data have revealed at least 2 startling findings. Toward the end of the weekly surveys, the researchers began asking facilities about the race and ethnicity of COVID-19-positive

Alarmed over massive outbreaks and racial disparities, experts are urging better planning, more decarceration, and increased testing and infection control measures inmates. "The incidence rate of cases and suspected cases for African Americans was, from week to week, anywhere from 2 to 4 times higher than for white inmates," Dr. Yang says.

One concerning possibility, Dr. Alsan says, is that African American inmates are being treated differently within individual correctional facilities. Alternatively, the disparity may refl ect the larger structural inequalities contributing to similar disparities in outside communities. "Basically, the correctional facilities are a mirror of the injustices that we see in the health system writ large," she says. A third possibility is that the disparities are instead tied to the types of correctional facilities that tend to house more African American individuals and that the gaps may refl ect how such facilities prioritize testing or use social distancing and other control measures.

In addition, the group's survey results initially turned up significantly more COVID-19 cases among correctional offi cers and other staff members than inmates until inmate case counts began to spike at the end of April. The researchers, though, cannot yet say whether that means staff were introducing COVID-19 from outside communities or whether early cases among inmates were largely hidden because of a well-documented lack of testing capacity. "It's hard to distinguish between the 2, given that the testing really lagged throughout the entire country," Dr. Alsan says.

Because the staff rates seemed to mirror those of surrounding communities, however, the researchers issued an interim report to make clear that initial infection control measures based largely on banning outside visitors would be inadequate to curtail the spread.

In their survey responses, correctional staff also reported a shortage of cleaning supplies, wipes, hand sanitizer, and even disposable covers for thermometers, and this interfered with their ability to conduct temperature screening among inmates. A lack of adequate personal protective equipment (PPE) further added to staff members' fears. "The fi rst week that we asked that question, only 59% of responding facilities indicated that they had adequate access to PPE," Dr. Yang says. By June, that percentage had risen to 89%.

Tom Meagher, managing editor for digital and data journalism at the Marshall Project, a nonprofit news organization focused on the criminal justice system, says that inmates have likewise raised major concerns over shortages of masks and hygiene supplies. Because it contains ethanol, hand sanitizer is often considered contraband, although some jails and prisons have loosened their restrictions to permit some types. Initially, inmates and their families told reporters at the Marshall Project that even soap was in scarce supply, despite denials from prison offi cials.

Many prisons, Meagher says, fi rst tried to isolate symptomatic individuals but often did not test them. Subsequently, they often limited the screens to symptomatic patients and did not test other inmates in close contact.

More recent tests have begun to hint at the magnitude of the blind spots. In mid-April, Ohio became the fi rst state to conduct mass testing within its prison system. The strategy revealed an astonishing infection rate of nearly 75% within Ohio's Marion Correctional Institution alone, and the rate has risen further yet through subsequent testing. By June, however, only a handful of other states had adopted a similar mass-testing strategy.

The persistent problems have raised larger questions about why correctional facilities were caught so unprepared. After the H1N1 infl uenza pandemic of 2009, researchers chronicled an acrossthe-board failure to include jails in pandemic planning and response efforts. "We've seen a repeat of that behavior, where there has been inadequate consideration of those who are incarcerated," says Anne Spaulding, MD, MPH, associate professor of epidemiology at the Rollins School of Public Health at Emory University in Atlanta, Georgia.

In early April, she and 2 colleagues again warned in a New England Journal of Medicine perspective that "improved preparation is essential to minimizing the impact of this pandemic on incarcerated persons, correctional staff, and surrounding communities." 1 Not all jails and prisons have struggled since then, she says, noting that some have managed to keep their case rates low through aggressive infection control measures. Overall, however, public health and other agencies have failed to address how the outbreak has intersected with an "epidemic of incarceration." Although many facilities have tried to isolate sick inmates and enforce social distancing, observers note that their design works against such precautions. "It is a real challenge for many prison systems. They weren't designed to permit a whole lot of space per person," Meagher says. Before the COVID-19 pandemic, he says, some overcrowded prisons were even putting 2 inmates into solitary confi nement cells.

Jails have more fl exibility in reducing population sizes through strategies such as releasing low-level offenders and medically vulnerable inmates. To help to lower the COVID-19 risk, the Prison Policy Initiative found that in a strategy known as decarceration, US jails reduced their population sizes by 20% to 30% on average. State prison populations, on the other hand, dropped only slightly. Dr. Spaulding says that the strategy is a necessary but not suffi cient part of the solution. "I think we need decarceration plus quality infection control programs plus adequate testing and screening," she says.

Dr. Yang says that the crisis has focused new attention on the country's incarceration rates-the highest in the world-and agrees that one big lesson is the necessity of integrating high-risk settings such as prisons and jails into wider pandemic preparation plans. "The link between the communities and these correctional facilities is, as we're seeing, really strong," she says. "And so you can't discount correctional facilities when you're thinking about policies."

Flattening the curve for incarcerated populations-Covid-19 in jails and prisons

Basically, the correctional facilities are a mirror of the injustices that we see in the health system writ large