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    Prison should not be a COVID-19 death sentence

    Two doctors who have visited such hot spots as San Quentin State Prison explain why incarceration makes COVID-19 dangerous. They also share what we can do to protect prisoners and surrounding communities.

    An emergency care facility was erected to treat prisoners infected with the novel coronavirus at San Quentin State Prison in San Quentin, California, as seen in July.
    An emergency care facility was erected to treat prisoners with COVID-19 at San Quentin State Prison in San Quentin, California, as seen in July. Over 1,400 prisoners and staff there have contracted COVID-19, one of the largest outbreaks in the nation.
    Credit: Justin Sullivan/Getty Images

    COVID-19 is raging in numerous jails and prisons across the United States, fueled by a toxic mix of factors that include overcrowding, limited testing, and lack of sufficient sanitation.

    So far, more than 160,000 people have been infected in prisons or jails, and 1,000 prisoners and staff members have died. According to a recent study, the rate of COVID-19 among prisoners has been 5.5 times higher than in the U.S. population.

    At San Quentin State Prison, cases are finally down, but nearly 2 out of 3 prisoners were infected with COVID-19 earlier this summer. Twenty-six died.

    In June, early in the San Quentin outbreak, a team of health experts toured the facility, noting poor ventilation with windows welded shut, prisoners sleeping just feet apart, and other concerns. Their report laid out detailed recommendations to help prevent further spread.

    AAMCNews recently spoke with Stefano Bertozzi, MD, PhD, a member of the team and professor of public health at the University of California, Berkeley, and Brie Williams, MD, a professor of medicine at the University of California, San Francisco (UCSF) and director of a health-focused prison culture change program at UCSF called Amend.

    They shared their experiences and their plea for essential changes to protect prisoners and staff — as well as surrounding communities since, as they say, “the walls of a prison are not capable of containing viruses.”

    Describe the conditions at San Quentin that fueled the COVID-19 outbreak there.

    Stefano Bertozzi, MD, PhD
    Stefano Bertozzi, MD, PhD
    Courtesy: Stefano Bertozzi, MD, PhD

    Stefano Bertozzi, MD, PhD: The vast majority of the cells at San Quentin were built in the 1800s. They are essentially long corridors of cells with bars stacked one on top of each other five levels high, looking out onto the same atrium. So, it’s really one large space with 750 people breathing and re-breathing the same air. It certainly doesn't have any sort of modern ventilation that would negate that.

    They had transferred in prisoners from other prisons who were symptomatic by the time they arrived at San Quentin. When we visited the cellblock where the new prisoners were housed, the prisoners were upset and yelling, and you aerosolize the virus a lot more when you’re yelling.

    [For these and other reasons], we saw that this was a tinderbox waiting for a catastrophically rapid spread of infection.

    Brie Williams, MD
    Brie Williams, MD
    Courtesy: Brie Williams, MD

    Brie Williams, MD: The health care professionals at San Quentin are outstanding and really dedicated to health equity. The fact that they were unable to stem this extraordinary explosion of COVID-19 in their facility speaks volumes about how incredibly dangerous this pandemic is in prisons.

    How common and dangerous are such outbreaks in prisons in this country?  

    SB: I just looked at the list of the top COVID-19 clusters in the U.S., and of the top 100, only 11 were not a jail or prison.

    Thousands of people go in and out of prisons every day. In the California state prison system, we’re up to more than 2,700 infected staff members — nine of whom have died. Each of those staff members was going home to their families and their communities. The walls of a prison are not capable of containing viruses — either keeping them out or keeping them in.

    Are prisons inherently risky in terms of COVID-19 or can risks be addressed?

    BW: Group living where many people share airspace in a facility with poor ventilation is risky. There are ways to change that risk, but the U.S., by and large, has not done a great job of taking advantage of those opportunities.

    Number one: You need to have fewer people in one living space. Many nations have significantly depopulated prisons in response to COVID-19. That’s because they thought of public safety — which presumably is the mission of prisons — as synonymous with public health, so that means protecting prisoners and staff and the communities to which they return. There are a lot of different strategies that you can take to depopulating prisons, including home confinement with an ankle bracelet.

    Another option used in prisons in Europe is single-cell living. Cells have a window and a door instead of bars. When there's an outbreak, you can just close the door to help prevent spread.

    What else can be done to prevent major outbreaks in prisons?

    SB: There can easily be 4,000 people in a prison. Within that large prison, you want to create the equivalent of many smaller prisons where people don’t cross over boundaries — so if you have an infection in a unit, it stays in that unit. Also, in a setting with the potential for explosive spread, frequent testing is needed — and testing is only useful if you get the results back quickly.

    Another issue is that there needs to be a certain level of cooperation and trust between staff and inmates. As a guard, I can't ask you to put on your mask as an inmate if I'm not doing the same thing to protect you.

    BW: Because the cultures can vary greatly, when you've seen one prison, you've seen one prison. So, while we can have some overarching guidelines, it’s extraordinarily important to engage people who live and work in these facilities to share homegrown solutions.

    For example, one issue is quarantining people who likely have been exposed to COVID-19.

    The problem is that people sometimes are quarantined in cells that have been used for punitive isolation, known in common parlance as solitary confinement cells, which means a lot of prisoners understandably don’t want to admit exposure. So, we need to know what incentives need to be offered and what fears need to be allayed in order for people to feel comfortable reporting exposure and contacts.

    People worry about the risk of crimes increasing because of decarceration. Do you have thoughts on this concern?

    SB: There's a very strong inverse correlation between risk to society and risk to the individual from severe disease. So, people who either are very elderly or have serious coexisting medical conditions are unlikely to be a danger to society. Unfortunately, the easiest thing is to release prisoners who have a short time left on a sentence. But we should be looking instead at the question of whether a person is a danger to society and using a more holistic view of who should be released.

    Steps that may protect prisoners physically, like lockdowns, may harm mental health. What can be done about that?

    BW: The emotional toll of lockdowns, where people are confined to their cells all day, every day, with little to no access to yard time is profound. Many times, these cells are the size of a parking space and they house two people who eat, sleep, and toilet together in this small space. The stress of being ill or fear of becoming ill in such an environment can be overwhelming.

    It’s important to understand whether communication about the situation would be helpful: what is happening in terms of COVID-19 measures and why, how, and when it will end. Such medical care is really Doctoring 101.

    SB: Because of COVID-19, visitation may be suspended and prisoners may not have nearly as much telephone access. At least in California, that hasn't been replaced with access to tablets and Zoom as a way to stay in touch with people outside. It’s tragic for parents who are in prison who can’t communicate with their children. It’s also tragic because community contact is an important part of prisoners’ mental health and their motivation for transforming their lives.

    Is there a particular role for academic medicine in protecting incarcerated populations from COVID-19?

    SB: Medical schools and teaching hospitals care about health disparities. Well, we're often not addressing an extreme end of those health disparities, and that is people who are incarcerated.

    During the acute phase of an outbreak in a prison, academic medical centers can lend staff to help. If a plane crashes, a teaching hospital responds. A teaching hospital should think of a major outbreak in a prison in the same way.

    Many of our academic medical centers have testing capacity that can be used in prisons. UCSF, for example, stepped up in a big way to help San Quentin overcome that crunch when they were having far too long response times from the commercial labs.

    Also, faculty can provide consulting advice to the prison system. We got our HVAC specialist to help with ventilation issues. We got epidemiologists to help with thinking about social distancing issues.

    What else is key to consider when thinking about prisons during COVID-19?

    SB: We talked earlier about the threat to the community. But we need to remember that the fact that somebody is being punished for a crime doesn't limit all of their human rights — and one of those rights is to not be put in a position where you're much more likely to die of preventable infection.

    And if you're a worker, you shouldn't be put in a position where you're much more likely to become infected and potentially die because you are not working in a safe environment.

    Both the inmates and the staff in our prisons don't deserve to die of COVID because of unsafe housing or work conditions. That's a responsibility we have as a society.