Why Prisons Should Be Prioritized in COVID-19 Spread Reduction

Laura Hawks, MD

The communal spread of coronavirus 2019 (COVID-19), combined with limited testing capabilities, makes US facilities including prisons a potential tinderbox for cases.

Riker’s Island, for example, reported its first positive case in mid-March. Within 2 weeks, cases in the New York facility had exceeded 200.

To combat these severe risks of spread, experts are public health and legislative decisions that are both proactive and aggressive in nature—from reducing jail populations to deferring nonviolent prosecutions for the greatest disease-risk convicted persons.

In a viewpoint published in JAMA Internal Medicine, Laura Hawks, MD; Seffie Woolhandler, MD, MPH; and Danny McCormick, MD, MPH, of Cambridge Health Alliance and Harvard Medical School, argued policies which reduced prison populations and streamlined public healthcare access to at-risk prisoners would limit the risk of COVID-19 spread seen in facilities like Riker’s.

As Hawks and colleagues noted in their essay, state prisons are increasingly comprised of older persons (131,500 older than 55 years in 2013), and those with chronic conditions (about half; 10% with cardiovascular conditions, 15% with asthma, and more). The rate of at-risk patients is far greater than that of the overall population.

What’s more, the prison and jail infrastructure does not harbor social distancing capability nor immediate care.

“Crowding and clinical vulnerability compound the barriers to adequate health care inherent in carceral settings,” investigators wrote. “Although the US Constitution guarantees a right to health care for people who are incarcerated, available medical care varies greatly with regard to both access and quality, and services have been challenged by the increased needs of the aging prison population.”

Similar outbreaks to that of Riker’s have been reported more recently: the Cook County jail in Chicago had approximately 350 persons and staff members test positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as of earlier this month.

Recently, US Attorney General William Barr set an order to release at-risk persons convicted of a nonviolent crime, incarcerated on a crimeless parole violation, and those with <2 years remaining on their sentence from federal prisons in order to combat the spread concerns—yet, the actual order has yet to have been fully executed. Hawks and colleagues point to criminology data suggesting such a decision would not risk public safety, as large municipalities’ prosecutors have prioritized shorter sentences already for nonviolent crimes without issue.

There is, of course, a series of issues present when a prisoner or convicted felon is released: homelessness risk is highly prevalent, and most with chronic conditions—including opioid use disorder&mdash;require immediate and recurring care. Persons are at an increased risk of death, investigators wrote, in the 2 weeks following incarceration release.

Hawks and colleague advised pharmacologic care come via an established telemedicine system for released at-risk prisoners—and that safety net programs including Medicaid and food stamps become better streamlined. They also noted states such as Connecticut have addressed homelessness issues during the pandemic by housing persons in hotels&mdash;facilities that assure lower risk of virus spread than most homeless shelters.

During the Spanish influenza pandemic of 1918, the San Quentin prison reported that half of all 1900 inmates had been infected during the first wave of the disease, increasing daily sick calls by nearly four-fold. Such an outbreak today, in an even more crowded prison population, could be doubly worse.

“Addressing the COVID-19 pandemic requires bold policy changes throughout society,” Hawks and colleagues wrote. “In the criminal justice system, aggressive and proactive measures are needed to minimize the catastrophe brewing in prisons and jails.”