Protesters in Philadelphia demand decarceration during the COVID-19 pandemic. Photo by Joe Piette, shared under Creative Commons https://creativecommons.org/licenses/by-nc-sa/2.0/
by Yosef Robele
Editor’s note: With this thoroughly researched academic article, Prison Health News has the rare privilege of offering scientific data—in addition to our continuing testimonies from people in prison—about how the COVID-19 pandemic has impacted incarcerated people. We agree with the author, Yosef Robele, that decarceration is the winning strategy we all must fight for.
Yosef is a 2nd year masters student in the Environmental Health Science & Policy Track at George Washington University School of Public Health. He was born and raised in Denver, Colorado. He went to undergrad at the University of Pennsylvania, where he majored in Environmental Science and minored in Physics. He hopes to have a career tackling environmental justice issues from a scientifically informed background.
The COVID-19 pandemic has done much to reveal structural inequalities in American society. Throughout the pandemic, the Prison Industrial Complex has been shown to be wholly inadequate in protecting incarcerated persons, prison staff and the surrounding communities. As both the incarcerated persons and the staffs have higher rates of chronic disease than the general population (Wildeman & Wang, 2017), this places them at higher risk of an adverse outcome from contracting COVID-19. While the prison population has actually decreased by about 10% for various reasons during the pandemic, (Franco-Paredes et al., 2021) prison reform advocates have called for more radical slashes. This paper will advocate not only for these radical slashes but also for other forms of support for formerly incarcerated people. Over summer 2020 alone, over 500,000 cases of COVID-19 can be attributed to the carceral state (Hooks & Sawyer, 2020). In order to prevent further cases and deaths, it’s imperative that incarcerated people are not only released but released with enough health care and housing to support themselves during the pandemic.
Mass incarceration and public health before COVID-19
The United States is home to the world’s largest prison population. The War on Drugs started by Richard Nixon and popularized by Ronald Reagan led to an explosion in the prison population. This population continued to increase until the early 2010s and has decreased modestly since. Despite this, the U.S. still holds the world’s largest incarcerated population, with about 2.3 million people (Sawyer & Wagner, 2020). This system that not only involves incarcerated people but also their communities and half a million employees is responsible for a wide range of health issues that have only been exacerbated by the COVID-19 pandemic.
The issues that affect the incarcerated population are reflective of a diverse (Sawyer, 2020), aging (Porter et al., 2016) and vulnerable population. The prison population has over-represented Black, Latinx and low-income populations (Sawyer, 2020). As a result of this, members of the incarcerated populations share the risk factors and health disparities that come with being members of these groups (Schnittker et al., 2011). The health of the population can be characterized by high rates of mental illness and chronic and infectious diseases relative to the general population (Wildeman & Wang, 2017). With this, it’s important to consider not only the immediate issue of protecting against the COVID-19 virus but also ensuring the other conditions are treated as well.
Interestingly, this population is one of the only groups in the U.S. with a constitutional right to health care. Under the 1976 Supreme Court Estelle V. Gamble decision, the “Court found that the deliberate failure to provide adequate medical treatment to prisoners constituted cruel and unusual treatment” (Applebaum PS. 2011 as cited in Dumont et al., 2012). Due to this, as much as 40% of the incarcerated people with a chronic condition are first diagnosed while incarcerated (Wang et al., 2012 as cited in Wildeman & Wang, 2017). This interaction is commonly the only interaction both formerly incarcerated and currently incarcerated populations have with the health system. This is often due to incarcerated populations lacking access to health insurance prior to being incarcerated. It’s important to note, however, that this is a reflection of the lack of care available to impoverished communities and not the quality of care offered by the system (Schnittker et al., 2011). The quality of the care itself is highly variable and often substandard, and data collection on the quality of care is scant (Dumont et al., 2012).
This leads to a unique issue among formerly incarcerated people, in that it is common for formerly incarcerated people to lose access to treatment and medications shortly after release (Dumont et al., 2012). “Eighty percent of released individuals have chronic medical, psychiatric, or substance abuse problems, yet only 15% to 25% report visiting a physician outside of the emergency department (ED) in the first year post-release” (Wang et al., 2012). This vulnerable population can lose access to medical care, which can lead to adverse health outcomes. Coupled with other issues that these populations have to face, such as homelessness and unemployment, this can lead to long stretches of time before they can receive treatment outside of an emergency room visit (Wang et al., 2012).
Lastly, it’s important to consider the health issues that plague these populations. As mentioned before, the currently and formerly incarcerated prison populations both suffer from high rates of chronic, infectious and mental health conditions (Dumont et al., 2012; Wildeman & Wang, 2017; Wang et al., 2012). Around 40% of incarcerated people suffer from at least one chronic medical condition (Wilper et al., 2009). While prevalence of obesity appears to be lower in the incarcerated population, conditions such as asthma, hypertension, diabetes, arthritis, hepatitis and cervical cancer are more prevalent than that of the general population (Binswanger et al., 2009). Infectious disease is also more common. Again, research on this is scant, but an example of this is that the incarcerated population has 2.4x the rate of HIV as the general population (Maruschak & Beavers, 2009). Lastly, mental health conditions are extremely prevalent, underdiagnosed and undertreated in these populations.
It’s also important to note both the employees under this system and the heavily policed communities have their fair share of health concerns. Again workers tend to have higher rates of chronic and behavioral conditions compared to the general population (Sears et al., 2020). Workers in this sector tend to lack adequate health care as well as benefits such as paid sick leave (Sears et al., 2020). “Neighborhoods with high levels of incarceration are associated with poor population health, including high prevalence of asthma, sexually transmitted infections, and psychiatric morbidity” (Clear, 2008; Frank et al, 2013; Khan et al, 2008; Khan et al, 2008; Thomas & Torrone, 2006; Roger et al 2012 as cited in Wildeman & Wang, 2017). With this, we’ll now examine the relationship between COVID-19 and these populations.
COVID-19 and prison depopulation
All of these issues were present before the COVID-19 pandemic hit. The pandemic has hit not only incarcerated populations significantly but has also done much damage to the neighborhoods incarcerated people typically come from. With cases skyrocketing in federal and state prisons as well as local jails, and with recent shifts in the perception of the criminal justice system among Americans after the George Floyd protests, there have been calls to decarcerate the prison population. As of January 1st 2021, case counts are at 317,986 people and deaths are at 1881 (COVID-19 Prison Project, 2021). Case counts and deaths are likely underestimated, as mass testing in 16 facilities showed a 1.5-157x increase from the numbers previously reported (Hagan, 2020). Several academics (Akiyama et al., 2020; Franco-Paredes et al., 2021; Wang et al., 2020), politicians and reformists (Ghandnoosh, 2020) have taken action to reduce the incarcerated population to lower the COVID-19 risk. As a result of this and reduced jail admissions, the incarcerated population was reduced by about 11% (Franco-Paredes et al., 2021). For the remainder of the paper, we’ll examine the expected effect as well as highlight health areas that should not be ignored if this is to be carried out on a larger scale.
COVID-19 prison outbreaks in the U.S have been large and mostly left unchecked (Hooks & Sawyer, 2020). According to The New York Times, the largest outbreaks in the country have all been in correctional facilities (Times, 2020). In addition to this, it’s important to note that these are not self-contained and that these outbreaks make their way into communities. Responses to the outbreaks have varied, with no unified national response to guide correctional facilities. Many facilities have demonstrated through the pandemic that they are inadequate in protecting their incarcerated populations or their workers (Burki, 2020). A report from the Prison Policy Initiative showed that at least half a million COVID-19 cases can be directly attributed to the carceral system (Hooks & Sawyer, 2020). Decarceration would be an important step in alleviating the overcrowding which allows COVID-19 to spread quickly through the facilities as well as protect those that are of high risk of adverse health outcomes from COVID-19. However, it is important to note that prison decarceration must be coupled with health transition and housing programs to prevent shifting the burden from the carceral state to the heavily policed, low-income and minority communities.
Prison overcrowding is not a new issue; as the U.S.’s prison population has grown, overcrowding has become a feature of the incarceration system. In 2011, the Supreme Court found that California’s overcrowding constituted cruel and unusual punishment, as its facilities were at 200% capacity (Appelbaum, 2011). This overcrowding has already been linked to an increased risk of infectious disease among incarcerated populations, as described earlier (Wildeman & Wang, 2017). During the COVID-19 pandemic, it has led to a difficulty in implementing social distancing measures in these facilities (Wallace, 2020). Overcrowding also poses an occupational risk. Correctional officers often must be in close proximity to inmates. Even if correctional officers attempt to practice social distancing, their cumulative interactions throughout the day can result in having close contact with a case (Pringle et al., 2020). The most straightforward way to reduce risk for both staff and those incarcerated is to decarcerate the system so that overcrowding is no longer an issue. (Akiyama et al., 2020; Burki, 2020; Franco-Paredes et al., 2020; Sears et al., 2020; Wang et al., 2020).
Simply releasing the incarcerated population is not enough, however; it’s important to ensure that formerly incarcerated people are supported after release. As mentioned earlier, continuity of health care is an issue for those formerly incarcerated. Formerly incarcerated people, especially in their first year of release, are unlikely to have regular contact with the health care system outside of the emergency room (Wildeman & Wang, 2017). They are also more likely to have interruptions in medications for chronic conditions as a result of the discontinuity (Dumont et al., 2012). Incarcerated people also are much more likely to use the emergency room during their first year of release, but Wang has shown that transition care can reduce emergency room usage among formerly incarcerated people. Thus, “discharge from corrections should include a 90-day supply of medications, appointments with primary care physicians, an internet-enabled phone (because engagement in primary care now requires telemedicine access), and a place to safely quarantine in the community” (Wang et al., 2020). Hospitals and emergency rooms are already struggling to keep up with demand due to COVID-19, thus it’s imperative that formerly incarcerated people are given the care that will prevent them from having to utilize emergency care.
Lastly, it’s important that housing is attainable for formerly incarcerated populations. Formerly incarcerated people are frequently discriminated out of housing. This causes high rates of homelessness among formerly incarcerated populations. This homelessness is a risk to communities, as incarcerated people must rely on their networks which often themselves are at high risk of COVID-19. Consider the case of Tom, an African American, who, despite having a full-time job at a recycling plant, can’t secure housing due to his record. Tom thus splits his time between his father’s home and the mother of his daughter’s home, putting both households at additional risk of COVID-19 (Rosenberg et al., 2020). Tom’s situation is not unique, and it’s important to ensure that those released have adequate and stable access to housing so that they can both quarantine properly and mitigate any unnecessary risks to the people in their networks.
Both current and formerly incarcerated people in the U.S. have been subjected to health disparities that have only been exacerbated by the COVID-19 pandemic. The harm done to all participants in the carceral system has been inexcusable, but there is an opportunity to both mitigate the damage and reform the system to become humane and equitable. The first step in this process is to decarcerate the system to protect those involved in it from COVID-19. The next step is to support those formerly incarcerated people as they transition back into the community. The final step is to make these actions the norm and not just a temporary measure to prevent COVID-19 transmission. It is to reimagine and move beyond the punitive model of mass incarceration. COVID-19 has shown that mass incarceration is not just inhumane but also a risky proposition for the general population as well. This moment will be seen as a tragedy in American history, with facilities proving to be inadequate to protect incarcerated people, but it can also be seen as a moment for progress if we take the steps that are required of the moment.
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Special thanks to Dr. David Michaels for allowing me to work in his research group and to Dr. Ans Irfan for his guidance.