Physicians need to advocate for proper care of prisoners.
Over the past few weeks, our emergency department has been seeing the same type of patient: the prisoner transferred to us after a few days of worsening shortness of breath, cough and fever. We see these patients fighting hard for every breath, traversing the same dark yet familiar path: prison, ED, ICU; prison, ED, ICU, one after another, multiple times a day.
As an undergraduate student, I shadowed health care providers at a state prison and witnessed the burden of chronically ill and elderly individuals in an environment not designed for health care. The percentage of adults aged 55 and older in U.S. state and federal prisons increased from 3% to 10% between 1993 and 2013 , and continues to increase. As this aging population grows, so, too, do their medical needs. In the state of Ohio where I work, medical care for adult prisoners amounted to over $218 million  in 2019.
As a resident, I am now on the other side of the prison walls. I work in the emergency department to care for the sickest prisoners in the state. We care for the diabetic patient with bilateral BKA on dialysis transferred from prison for a fever of 102 degrees, the prisoner with a history of colorectal cancer with new metastases to the small bowel, the inmate who syncopized in the mess hall and arrived with a heart rate of 38.
It is not their pathologies that make these patients unique, but the environment from which they come: in an institution of detention and control, healthcare at best plays a secondary role.
Now, instead of the typical patient presentations, we are seeing respiratory distress again and again: one patient dropping to 60% oxygen saturation on a non-rebreather mask at 15L; another on 6L nasal cannula breathing at 35 breaths per minute. One inmate gasping between breaths, pleading not to be intubated because his son had just died after requiring intubation for the same disease.
Our ICUs and our overflow ICUs have become prison COVID-19 units: each patient intubated, sedated, paralyzed… and shackled.
Then correctional officers started testing positive, some hospitalized on ICU floors with the inmates they once guarded. COVID-19 and concern for COVID-19 have incapacitated so much of the state’s correctional work force that Ohio has had to call upon the National Guard to fill in.
Now family members of correctional officers have started testing positive. Soon, their communities will test positive. The places they go grocery shopping, where they get coffee, where they fill up gas—these can all become points of contagion. How do we protect people through these seemingly harmless activities of daily life?
Ohio had been waiting for its “surge” –when the needs of infected patients would overload our existing system and require us to expand hospital resources. Little did we know that our surge event could come in the form of the all but forgotten inhabitants of the correctional facilities at the margins of our communities.
Many of these inmates are individuals who are chronically ill or debilitated and no longer pose a threat to society, but are ineligible for medical judicial release due to our current state policy. Ohio houses two prison facilities specifically designated as skilled nursing facilities for these chronically ill and/or dying prisoners. Unsurprisingly, these facilities have among the highest COVID-19 case fatality rates in the state.
We were forewarned multiple times, as early as February. What we are seeing now was preventable.
As I write this, there are over 9,000 people in U.S. prisons who have tested positive for SARS-CoV-2, the virus responsible for COVID-19, and around 130 documented COVID-19 deaths. The rate of infection in prison populations is reported to be more than twice that in the general population.
Infection rates for correctional staff are growing as well. This increasing rate of infection is also reflected in the post-prison community–those in halfway houses and homeless shelters.
Data is sparse for infection rates in immigration detention centers, but what is known is similarly concerning. US Immigration and Customs Enforcement (ICE) both public and private continue the dangerous practice of interstate and international transport of detained individuals, sequentially exposing new detained peoples and new communities to COVID-19.
The first detained individual has recently died of COVID-19.  Robbery, missing parole, selling drugs, and seeking asylum should not be death sentences. But when vulnerable populations with poor health at baseline are placed in closed, cramped, unsanitary spaces–some lacking in even soap and water–they are left to this fate.
Detention centers, jails, state and federal prisons are quickly becoming infection hotspots. Some states like New Jersey, Wisconsin, Oklahoma and Washington have started releasing imprisoned and detained individuals, though the numbers remain small compared to the population at risk. We have far to go and little time.
The American Civil Liberties Union published a report in March stating that as many as 100,000 more lives may be sacrificed if jails do not dramatically reduce their populations.  The model shows we could save as many as 59,000 lives just by not arresting people for minor violations.
In the past few weeks, elected prosecutors released a statement regarding the rights of those in custody, including a roadmap of actions that can be taken on multiple levels to decrease the spread of COVID-19 among these vulnerable populations.  The ACLU sued multiple states for the release of individuals at risk from ICE detention centers. The WHO published a guidebook for infection control in prisons, detention centers, and similar environments.
The U.S. Attorney General called for the release of vulnerable inmates to home confinement. However, safe decarceration of individuals in custody is not as simple as a government official signing a release order and the prisons, jails, detention centers opening up their doors. There are people who have no place to go, or don’t want to go home for fear of infecting their families.
There are others who do not speak English, have no family, no means of transportation, no access to food or medicines while they are in confinement upon reentry. There must be infrastructure in place to support these individuals when they are released.
Correctional facilities and detention centers are not closed communities, no matter how much we are led to believe otherwise. These “isolated” facilities are firmly enmeshed in the communities in which they reside.
With the flow of inmates and detainees, correctional or immigration officers, social workers, health care workers, lawyers and others in and out of these institutions, our places of incarceration are ripe for the spread of infection. But we do not need to wait to treat the infections when they come — we can actively work to mitigate the spread of these infections. We can speak out to make visible these spaces that are hidden from public sight.
We can be advocates for our communities. Additionally, we can call and write letters to our elected officials to advocate for the safe decarceration of those in correctional and immigrant detention custody, or work with community partners to ensure that they are thoughtfully reintegrated into society after two weeks of safe quarantine. We can organize and support the lawyers representing these vulnerable populations as they try to save their clients from untimely illness and death. It’s important that we can hold our jails, prisons, and detention centers accountable to significantly improve infection control in their facilities, and rally around those who work in these institutions to ensure they have adequate personal protective equipment.
Ignoring the outbreaks of COVID-19 in these vulnerable populations would be not only inhumane, but also irresponsible. These will be the outbreaks that push our hospitals deeper into surge status, and at some point, we will have to choose whether the ventilator goes to a single dad with COPD, heart disease, and severe COVID-19 or a previously healthy retiree with a stroke and pneumonia. We don’t have time to lose. If we can take measures to further protect those who live and work in these institutions, we might be able to save both.