In the United States, the rate of COVID-19 infections in prisoners is three times higher than that of the general population. The former Attorney General admits, “we weren’t prepared”. How do we begin to address the factors that lead to the disproportionate infection rate of American prisoners?
Marion Correctional Institution in Marion, Ohio, is a minimum-to-medium security prison built to accommodate 1,500 inmates. In 2020, when the COVID-19 pandemic struck, it was housing 2,600.
In April, at the outset of the deadliest pandemic since 1918, it rapidly rose to be one of the nation’s largest COVID-19 hotspots. By April 20th, 78% of those inmates, along with 156 guards, tested positive for COVID-19. Guards were allowed only three days of leave after symptoms subsided, returning while still in the contagious stages of the virus. The illness ripped through the densely packed facility like wildfire. Medical services here were difficult to access financially, with low wages often failing to cover copays and fees. Overcrowding allowed for rapid transmission, with no chance of social isolation. A disproportionate incidence of preexisting medical conditions, and generally lower access to healthcare left this population at a uniquely higher risk. And Marion Correctional Institution was just one of thousands of jails, prisons, detention facilities, and correctional facilities in the United States suffering from many of the same issues.
This institution, along with over eight hundred institutions like it, would experience massive outbreaks of the deadly virus. 40 of the 50 largest outbreaks in the country have occurred in jails or prisons. This pandemic has served to amplify the glaring systemic problems which have existed for decades in United States prisons.
The United States incarcerates more of its citizens than any other country in the world, with 2.3 million inmates–and this number is steadily increasing. Since 1978, there has been a fivefold increase in the number of American inmates. To really put the disproportionate nature of American incarcerations in perspective, here is another way to think about it: one in five inmates incarcerated in the entire world are incarcerated in the United States. What are the factors that lead to such a disproportionately high prison population? There is no one factor entirely responsible, but the American Academy of Family Physicians puts two main contributing factors forward.
Firstly, the failure of effective mental healthcare. A push to ‘deinstitutionalize’ mental healthcare has been underway for decades, with a push towards drug-mediated, outpatient care. Though well-meaning, the shockwave of deinstitutionalization left many people suffering from mental illnesses without adequate support. Though legislature was swift to move patients out of institutional care, no concurrent legislation was passed to financially support their outpatient treatment. Lack of finances forced people to come off expensive psychiatric drugs. Inpatient facilities quickly became much more expensive for multi-day stays. Social support and housing were withdrawn from the severely mentally ill people who were at one time cared for in public institutions. Many left psychiatric hospitals with the clothes on their back and little more to reintegrate them into a society with stigma against the mentally ill and very little support for them.
The incidence of severe mental illness in the homeless population is huge, with 25% experiencing a ‘severe’ mental illness and 45% experiencing any mental illness at all, according to a 2015 study. Members of this vulnerable population are predisposed to substance use, petty theft, or otherwise disruptive behavior leading to their arrest. In this way, many patients who were being cared for in housed facilities were transferred to the hands of the prison system. In 44 states, a jail or prison houses more people with mental illnesses than the few remaining psychiatric hospitals in those states.
Secondly, the “War on Drugs” instituted in the early 1980’s has resulted in harsher sentences for drug and paraphernalia possession. The number of people incarcerated for drug possession today is three times higher than what it was in 1980, with a clear disparity in racial distribution. Despite making up only 12.5% of substance users, black Americans make up 30% of all drug-related arrests. In state prisons, 60% of those serving time for drug offenses are people of color, despite representing only 27% of the United States population. The vast increase in arrests over drug possession, alongside with longer sentences for drug offenses, contributes greatly to prison overcrowding. Yet, the leading cause of death in inmates who have been released from prison is overdose from the drugs they were incarcerated for abusing. This tripling of incarcerations for minor drug offenses is a major contributing factor to why prisons like Marion Correctional Institute are frequently operating at up to 150% of their actual capacity.
Overcrowding played a huge role in the rapid spread of COVID-19 in the populations of prisons. One Texas study found that the highest capacity for a prison to successfully combat the effects of COVID-19 is 85% of the maximum. However, in December, 2020, there were nine states in which prisons were still operating at over 100% of their capacity, and forty-one states operating at over 75% of their capacity. It is clear that the failure to address overcrowding issues, which have been around for decades, helped lead to a perfect environment for a respiratory virus–and any virus that spreads through air– to spread through prison populations with ease.
SARS-CoV-2, the virus that causes COVID-19, is an extremely contagious pathogen. Direct transmission is by person-to-person spread, mainly through droplets expelled by coughing, sneezing, and other respiratory output. These droplets can transmit over six feet, and can remain suspended in the air for three hours without proper ventilation and disinfection. Indirect transmission can occur from contact with contaminated surfaces, which can subsequently be introduced to the body by touching mucus membranes.
The relative transmissibility of a virus is determined by many factors. One yardstick for the measure of relative transmissibility of pathogens is the infectious dose, or ID50. The infectious dose is a number of viral particles which, upon coming into contact with a subject’s mucus membranes, would cause infection in 50% of cases. Some illnesses, like tuberculosis, have a very low ID50 of only ten viral particles, making it extremely contagious; SARS-CoV-2 is believed to have an ID50 similar to the flu, around 790 particles, but the exact number is not yet known. Due to the high aerosol nature, low ID50, and ability to remain active on surfaces and in the air, the transmission of SARS-CoV-2 globally was ruthlessly efficient. The transmissibility in prison populations, with overcrowding and poor sanitation, is understandably higher than those who have the luxury of sheltering-in-place in their own homes, away from large crowds.
Another factor influencing how inmates are disproportionately effected by this virus is the limited accessibility of healthcare while incarcerated. Considering that prisoners make around 14 to 36 cents an hour, it would seem logical that healthcare be budgeted for and provided to prisoners readily. Astonishingly, most institutions make it difficult for inmates to get access to a doctor at all, and when they do, they usually charge a copay for the service. At one Texas prison, inmates often choose to forego a yearly medical service fee of $100 simply because their meager wages make it impossible to afford without outside sources paying the deposit for them. This financial deterrence of seeking medical care leads to many conditions going untreated in the prison population. As a result, prisoners are more likely to forego treatment for COVID-19 unless it’s severe or life-threatening. Additionally, chronic health issues like diabetes, heart problems, or hypertension, all of which occur at a statistically significant higher rate in prisoners than in the general population, are less likely to be properly managed for the same reason. These conditions have been identified as risk factors for more severe and more deadly cases of COVID-19. [Scientific articles supporting this fact for diabetes, cardiovascular conditions, and hypertension.]
In April 2020, the pandemic was just beginning to truly tighten its vice on an unprepared American population. States were beginning to institute stay-at-home orders one-by-one, with scant federal organization and action. Ohio, where Marion Correctional Institution is located, instituted a stay-at-home order for citizens early in April, so people could shelter away from large crowds and reduce transmission. Prisoners do not have the luxury of isolating, and the overcrowding of prisons, alongside the limited accessibility of healthcare for the incarcerated, was a powder keg for a virus with this type of transmissibility.
As of November 2020, state and federal prisons reported a total prisoner death count of 1,412– a number that is 721 deaths higher than the expected death rate in a group of the same size in the general population. With twice the mortality and four times the overall infection rate, it’s clear that prisons are hit hard. This massive disparity of infection and mortality between general populations and prison populations is due to preventable, systemic issues that have been established for decades. The silent suffering of a massive prison population in the United States continues. Initially, when vaccine rollout began, only five states qualified prisoners for Phase 1 vaccine rollouts– after national outcry however, that number rose to twenty-five states in which prisoners are qualified to receive the first wave of vaccines. Although this is a move in the correct direction, resolving overcrowding and lack of accessible healthcare will take widespread action across several states. Fixing these systemic issues will be the only way to ensure the safety of inmates and correctional workers from future pandemics– and possible future waves of the COVID-19 virus.