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Covid-19 and the Struggle for Health Behind Bars

For many, harming the health of people in prison appears to have become part of their punishment. That needs to change.

  • Homer Venters
June 14, 2021
Spencer Platt / Getty
View the entire Punitive Excess series

This essay is part of the Bren­nan Center’s series examin­ing the punit­ive excess that has come to define Amer­ica’s crim­inal legal system.

A little more than a year ago, I left my job as pres­id­ent of a nonprofit so I could respond full time to the spread of Covid-19 in jails, pris­ons, and immig­ra­tion deten­tion centers. Since then, I’ve conduc­ted about 30 inspec­tions of facil­it­ies to assess their Covid-19 responses and provide recom­mend­a­tions.

How do things look from this perspect­ive? Are we any closer to build­ing systems and cultures that promote health in these settings, instead of harm­ing the health of the incar­cer­ated to such a degree that it actu­ally becomes a part of punish­ment? When I compare Covid-19 to past health crises in carceral settings, I’m concerned that we will simply improve care deliv­ery for one disease instead of using this moment to push for trans­par­ency about all health risks and health outcomes behind bars.

The Centers for Disease Control and state health depart­ments are currently engaged in carceral settings, but their gaze will soon shift once vaccines have been delivered and rates of Covid-19 abate. We must keep their focus there, to learn and report on the truth of health care access, adequacy, and outcomes just as they do for the rest of our soci­ety.

Now, some notes from the field. As of June, most of the atten­tion regard­ing Covid-19 behind bars is focused on vaccin­a­tion efforts, with good reason. Start­ing in Janu­ary, vaccines became widely avail­able to most correc­tional staff. For detained people, access star­ted in waves in Febru­ary and March. Low accept­ance rates among correc­tional staff created a surplus of avail­able vaccine in many facil­it­ies, enabling even more detained people to become vaccin­ated. By March and April, the low vaccin­a­tion rate among correc­tional staff was a national prob­lem, and many pris­ons, jails, and deten­tion centers were strug­gling to exceed a vaccin­a­tion rate of 40 percent among staff, while achiev­ing vaccin­a­tion rates over 60 percent among detained people.

But in some insti­tu­tions, the way vaccines are offered — usually to large groups of indi­vidu­als, for example every­one in a hous­ing area or dining hall — is itself a prob­lem. This approach often leaves little room for people with ques­tions about vaccine safety or complex medical prob­lems to ask their own ques­tions about vaccin­a­tion. As a result, some of the people who need the vaccine the most, like those who have multiple seri­ous health prob­lems and those who are taking numer­ous medic­a­tions, end up not being vaccin­ated simply because they are denied the oppor­tun­ity to learn what they wish to know.

Both of these vaccin­a­tion chal­lenges — the hesit­ancy of correc­tional staff and the defi­cien­cies of the assembly line approach to vaccin­a­tion of the detained — can be addressed with engage­ment. An engage­ment approach, which entails elicit­ing the indi­vidu­al’s input and parti­cip­a­tion in his or her health care, is stand­ard for community health clin­ics, hospit­als, and other health organ­iz­a­tions. But in jails, pris­ons, and immig­ra­tion deten­tion facil­it­ies, the very notion of indi­vidu­al­ized engage­ment can be seen as a threat to the para­mil­it­ary approach of correc­tions.

For example, a common response to a patient exhib­it­ing suicidal beha­vior is to lock them in a cell, naked except for a rough “suicide smock,” with the goal of depriving them of the means to harm them­selves. This approach not only fails to address the actual mental health crisis but also adds addi­tional humi­li­ation and isol­a­tion for a person who desper­ately needs treat­ment and engage­ment.

Some penal systems are work­ing to increase Covid-19 vaccine engage­ment via one-on-one meet­ings with high-risk patients. These sessions are often added into the preex­ist­ing visits that people with chronic health prob­lems already have, so as to target high-risk patients who may have ques­tions about their health prob­lems, medic­a­tions, and Covid-19 vaccines. Some law enforce­ment agen­cies have also conduc­ted surveys of their staff to under­stand atti­tudes and reluct­ance and to provide incent­ives for vaccin­a­tion. But most Amer­ican correc­tional health services remain under the author­ity of secur­ity forces, which often have little appet­ite for public health and infec­tion control.

Much of the current focus in the battle against Covid-19 behind bars has been to identify the morbid­ity and mortal­ity of the disease among a vulner­able group of people. But this work has also iden­ti­fied the numer­ous weak­nesses in care and condi­tions before Covid-19, includ­ing fail­ing sick call and chronic care systems and lack of consist­ent access to specialty care and medic­a­tions.

The most damning fail­ure illu­min­ated by Covid-19 is how the CDC and state depart­ments of health are essen­tially AWOL when it comes to track­ing health outcomes or provid­ing object­ive assess­ments of the qual­ity of care for people behind bars. For hospit­als, nurs­ing homes, and many other cohorts of our soci­ety, these are tasks that both state depart­ments of health and the CDC perform routinely, and with great skill — but not in carceral insti­tu­tions. The CDC created help­ful Covid-19 guidelines early in the pandemic, but it has almost no involve­ment in track­ing actual adop­tion of those recom­mend­a­tions, nor does it even aggreg­ate stat­ist­ics about deaths and illness from Covid-19 in carceral settings.

And despite clear evid­ence of the increased risk of illness and death from Covid-19 behind bars, the CDC has been all but silent on the most effect­ive tool: release. Release of high-risk patients has been essen­tial to protect the most vulner­able people from seri­ous illness and death from Covid-19, and it has also been crit­ical to allow­ing facil­ity admin­is­trat­ors the room to estab­lish medical isol­a­tion and quar­ant­ine units when the need arises.

This lack of over­sight and interest among our national and state health bodies has rein­forced the horrible real­ity that harm­ing health is part of the punish­ment of incar­cer­a­tion. People are routinely incar­cer­ated with and even because of health prob­lems for which they will never receive treat­ment; instead, they are exposed to new health risks that can cause them to suffer seri­ous illness, long term disab­il­ity, or death.

For example, people arres­ted on substance use-related charges rarely receive evid­ence-based treat­ment for that health prob­lem. In many communit­ies, the primary response to a mental health crisis is the same: incar­cer­a­tion in a local county jail. These beha­vi­oral health prob­lems lead to incar­cer­a­tion for people of color, those who are poor, and espe­cially those who are unin­sured, yet these same health prob­lems are unlikely to be treated appro­pri­ately, caus­ing many jail deaths.

I recently told European colleagues work­ing on Covid-19 about two aspects of our system that shocked them — and should shock all of us into action. The first was that the most recent data on deaths in U.S. jails dates from 2016. Just recall the contro­versy over how deaths from Covid-19 were repor­ted in New York nurs­ing homes; imagine wait­ing five years to learn of those deaths. The second shocker: Covid-19 is estim­ated to have reduced the life expect­ancy of pris­on­ers in Flor­id­a’s state system by four years. Both of these facts indict a national public health appar­atus that has turned its back on incar­cer­ated people, inev­it­ably widen­ing racial dispar­it­ies in the process.

We must make an affirm­at­ive decision to apply the same lens of health expert­ise and trans­par­ency to carceral settings as we do to other parts of soci­ety. Concretely, we can begin to address this fail­ure by setting up an office of deten­tion health in the CDC that is charged with track­ing the health of incar­cer­ated people nation­wide and the care provided them. In fact, this is one of the many interim recom­mend­a­tions recently made by the Biden-Harris Health Equity Task Force (which I am a member of) to involve the CDC in track­ing health outcomes and promot­ing health among incar­cer­ated people.

With federal support, the same monit­or­ing process could be used in state health depart­ments, and then we can join the effort to meas­ure how incar­cer­a­tion harms health, how carceral settings should provide health care, and how undo­ing mass incar­cer­a­tion can improve indi­vidual, family, and community health.

The CDC has a lot of work to do in this realm, and it can start by look­ing at the rates of “long Covid,” determ­in­ing the effic­acy of release and other Covid-19 responses during the pandemic, getting involved in suicide preven­tion (still the number one cause of death among the incar­cer­ated), and analyz­ing the health needs (and costs of care) of the enorm­ous and grow­ing portion of elderly people behind bars.

These minimal inter­ven­tions are crucial for improv­ing our response to Covid-19, as well as the next pandemic, and for inform­ing the nation of public health prob­lems that arise from mass incar­cer­a­tion. They are also small but neces­sary steps towards address­ing the real­ity that harm­ing health is not a byproduct of incar­cer­a­tion but, seem­ingly, one of its object­ives.

Dr. Homer Venters is a member of the Biden-Harris COVID-19 Health Equity Task Force and former chief medical officer of NYC Correc­tional Health Services. He is an epidemi­olo­gist and a clin­ical asso­ci­ate professor at the New York Univer­sity College of Global Public Health. Unless other­wise stated, his opin­ions are presen­ted here as his own.