Recent newspaper articles have reported on the potential role of jails and prisons as “amplifiers” of the coronavirus pandemic (Ransom and Feuer 2020; Flagg and Neff 2020). For example, data from New York City jails show that 36 out of 1,000 inmates tested positive for the virus versus 4 out of 1,000 people in the city at large (The Legal Aid Society 2020).  Additional information indicates that 23 states across the United States have reported cases in correctional facilities (Coppola and Pettersson 2020).

The gravity of this challenge in the rest of the world is evidenced by the fact that more than 10.3 million people are held in penal institutions at any given time and more than 30 million people pass through prisons each year (Walmsley 2015; Subramanian, Henrichson, and Kang-Brown, 2015).  In addition, there is a large workforce, both within institutions and in community supervision.  With thousands of people flowing in and out of jails and prisons every week, this is a great risk not only for the detained population that could be hard hit by the coronavirus pandemic, but also for correctional workers, families of released inmates, and surrounding communities (The Marshall Project 2020). 

Facilitating Factors in Jails and Prisons 

Jails are transient, local level facilities, for the newly arrested, those awaiting trial or sentencing, those who have not yet been convicted of a crime, and people serving shorter sentences.  Prisons are run by states or central governments and are for those convicted of crimes and serving longer sentences. The people who are incarcerated are among the most vulnerable in society, often from low income and marginalized backgrounds (e.g., racial minorities, undocumented migrants).  The vulnerability of prisoners is further exacerbated by restricted movement, rampant overcrowding, poor hygiene, sanitation, and ventilation, and limited medical care in the facilities (Akiyama, Spaulding, and Rich 2020).  

Besides the sheer number of incarcerated people, often a “veil of oblivion” surrounds the dire conditions of jails and prisons, which make them potential host spots for the spread of COVID-19 because of the ease with which it transmits in congregate settings. 

Another factor that may facilitate the rapid spread of COVID-19 in jails and prisons is the large share of those incarcerated who are older adults affected by underlying chronic health conditions, including both infectious diseases such as HIV, hepatitis C, and tuberculosis, and noncommunicable diseases such as chronic lung disease, moderate to severe asthma, serious heart conditions, diabetes, chronic kidney disease, and liver disease, all of which make them at higher risk of developing severe COVID-19 disease and having poor outcomes of infection (CDC (1) 2020). 

Health risk factors that make respiratory diseases like COVID-19 more dangerous are far more common in the incarcerated population than in the general population, such as the high prevalence of cigarette smoking.  As documented, cigarette smoking may help explain the negative progression and adverse outcomes of COVID-19 in China among men, who are far more likely to smoke than women  (Marquez 2020; Vardavas and Nikitara 2020).  In other countries such as Italy and South Korea, with sizable outbreaks of COVID-19,  smoking rates in countries remain high at approximately 19-27 percent of the population (Simons, Perski,Brown 2020).

An additional factor that further compounds the poor health and social conditions in the penal system is evidenced by country data that shows that as many as half the people in jails and prisons have a mental disorder, which could be aggravated by the fear of becoming severely ill or dying if infected with COVID-19 because of their age or health conditions, and by other stressors such as frustration, boredom, inadequate supplies, and inadequate information (Brooks, Webster, Smith, et al. 2020; Marquez, 2018).  For example, as described in Alisa Roth's gripping book Insane (2018), although the overall number of people behind bars in the United States has decreased in recent years, the proportion of prisoners with mental illness has continued to go up. Data in the book indicate that in Michigan about 50 percent of people in county jails have a mental illness, and nearly 25 percent in state prisons do. This situation tends to be more pronounced among women prisoners: one study by the US Bureau of Justice Statistics found that 75 percent of women incarcerated in jails and prisons had a mental illness, as compared to just over 60 percent of men.  De facto, as observed by Roth, jails and prisons, not only in the United States but across the world, have become “warehouses for the mentally ill”, who tend to be among the most disadvantaged members of society, fare worse than others, and who are susceptible to medical neglect and abuse, since ultimately the mission of jails and prisons is punishment, not medical care. 

Limited Resources in Jails and Prisons

What should be of concern is that in different countries across the world, penitentiary facilities often struggle with limited resources to provide basic levels of healthcare and psychological support services to inmates.  So, it is not a far-fetched idea to assume that the risk of an exponential spread of COVID-19 infection in jails and prisons is real as it will be greatly facilitated by the overcrowded and unsanitary conditions and the disease burden in these facilities. The urgency for taking early and decisive action in correctional facilities is best illustrated by COVID-19 outbreaks that have occurred in other confined settings, such as in the long-term care skilled nursing home in King County, Washington, where ineffective infection control and prevention procedures and staff members working in multiple facilities contributed to intra- and inter-facility spread in the community (McMichael, Clark, Pogosjans, et al. 2020). In addition, dozens of nursing homes across 42 states in the United States have suffered outbreaks (Coppola and Pettersson 2020).  Another warning sign of what could happen in the face of inaction in jails and prisons is the COVID-19 outbreaks on cruise ships, which are often settings for infectious disease transmission because of their closed environment and contact between travelers from many countries.  As documented, more than 800 cases of laboratory-confirmed COVID-19 cases occurred during outbreaks on three cruise ship voyages, and cases linked to several additional cruises have been reported across the United States (Moriarty, Plucinski, Marston, et al. 2020). Places of worship could also become loci of infection if religious institutions facilitate the congregation of large number of people by not closing services. 

While case detection, contact tracing, medical isolation, quarantines, and social distancing, along with basic sanitation measures such as hand washing, are critical measures  to “flatten the curve” of the COVID-19 pandemic among the civilian population, the adoption of these measures in the closed environment of jails and prisons presents significant challenges. Given the nature and characteristics of these facilities, it would be difficult or impossible for most incarcerated people to follow guidelines on social distancing, since they are living in overcrowded quarters, interact in dining halls,  and sleep in rows of beds in a common room, have two or more people in a single cell, and have to use group showers and bathrooms that serve dozens, often without running water, with broken sanitation services, and lacking soap, towels to dry hands, and other supplies for disinfecting surfaces (Flagg and Neff 2020). 

Since these dire conditions are typical of jails and prison systems across the world, it is imperative that allocation of required resources for supporting prevention, containment, and mitigation activities in these settings be included as part of country-wide emergency response strategies to prevent that these facilities become “transmission centers” for COVID-19. If widespread COVID-19 outbreaks occur in jails and prisoners, a large number of patients at once may overwhelm the often-constrained capacity of the healthcare services in the penitentiary system but also of referral hospitals in the community where the very sick and dying will be transferred.

Policy and Institutional Measures to Minimize COVID-19 Risk

Different observers and organizations have highlighted possible actions that if effectively implemented could help inhibit the spread of this highly infectious virus among those already incarcerated, prison guards, correctional staff, and administrators, and among people on probation or parole, who are in regular contact with the penal system (Prison Policy Initiative 2020; CDC (2) 2020; American Correctional Association Resources 2020; Markham 2020). Some of the proposed actions include the following:

Release people from jails and prisons following depopulation and de-incarceration policies and strategies.  As noted above, jails and prisons house large numbers of people with chronic health conditions and diseases that make them more vulnerable to COVID-19.  One way to protect these vulnerable populations is to reduce overcrowding in correctional facilities by releasing inmates charged with low-level, non-violent crimes and elderly and infirm inmates, and by focusing on preventing people with health issues who are charged with non-violent offenses from going into the prison system in the first place, for example, by allowing the posting of personal bonds. Different states in the United States such as California, Ohio, New Jersey, and Texas have undertaken the controlled release of low-level offense prisoners and have pushed for the “compassionate release” of inmates over age 50 facing nonviolent charges (Tamkin 2020; Williams, Weiser, and Rashbaum 2020). In other countries, such as Iran, 54,000 prisoners have been temporarily released to combat the COVID-19 spread (BBC 2020). The adoption of these measures would in turn help to reduce the risk of unrest and rioting by prisoners who fear being the last in line to be tested and at high risk of being infected as recently seen in several countries such as Brazil, Colombia, France, Italy and Venezuela (Turkewitz 2020; Amante 2020). The pandemic also offers the opportunity to release political prisoners on humanitarian grounds.

Reduce jail and prison admissions.   This action will help slow down the rapid movement of people in and out of jails and prisons, while also facilitating the reduction of the incarcerated population.  Rather than arresting and locking up more people in jail and prisons for misdemeanors and nonviolent felony offenses, and in some countries, for nonviolent immigration or drug charges, public officials have started to order the police to issue citations and to strike plea deals to resolve cases quickly (Gillispie 2020).  There are other innovative approaches that could be used during the pandemic.  For example, as reported in an article in The Financial Times, approaches being implemented with good results in the United States, such as the “judge-led therapy programs”, offer non-violent offenders with mental and substance use disorders the opportunity to avoid jail, by agreeing to intensive mentoring and support (Waldmeir 2018).  Among the vast majority of offenders who opt for this alternative approach, where they are connected with housing and other services, it has been reported that recidivism is low, patients get the support they need, and the judicial system saves a significant amount of funds that could be directed to improve the health and sanitary conditions in jails and prisons.

Reduce or suspend visitation by community members, limit visits by legal representatives, and reduce facility transfers for incarcerated persons.   As observed in a recent article, physical contact between staff and the incarcerated is often unavoidable: while officers fingerprint, handcuff and supervise prisoners, as well as escort them to court and drive them to medical appointments, many other people also flow in and out of jails, like family members who visit; volunteers who counsel or teach or preach; contractors who stock vending machines; and lawyers who meet their clients (Flagg and Neff 2020).   The adoption of social distancing actions to limit visits, services, and vendors, and by moving to online and phone communication, is a required disease prevention measure to reduce the risk of asymptomatic cases spreading COVID-19 in jails and prisons.

Improve capacity for infection prevention and control, and well as care and treatment, in the penitentiary health system.  This would require that the penitentiary facilities have in place health promotion and disease prevention measures, the capacity to monitor the onset of infectious diseases, test individuals who present COVID-19 symptoms (e.g., fevers, coughs, and symptoms of respiratory illness) and have a known exposure to the virus, record and report to national health department positive COVID-19 cases, and conduct epidemiological investigations to identify individuals who may have had close contact with infected individuals (CDC (2) 2020).  Prison health services need to also medically isolate suspected and confirmed cases from the prison general population, follow up the progression of the infection by taking the temperatures of inmates who are elderly, are considered at risk for the virus, or are in medical isolation, and treat or refer to specialized facilities patients with severe COVID-19 disease and other co-occurring chronic health conditions in accordance with national standards.  Additional measures include medical screenings for all staff entering a prison, including temperature checks with no-touch thermometers and denial of entry to a prison to anyone with a temperature of 100 degrees or more, has symptoms of respiratory illness, or who has been exposed in the past 14 days to anyone who is suspected or diagnosed with COVID-19. A 14-day quarantine period, in addition to previously noted medical screening, could be instituted for all incoming prisoners to prevent the introduction of COVID-19 into the prison system.  The use of washable masks should also be promoted in all sites where there have been reported COVID-19 cases, as well as ensuring the availability of personal protective equipment, face shields and masks, and protective gowns for prison health workers and other staff in direct contact with infected inmates, as well as establishing designated rooms to separate infected people from other inmates. A comprehensive response that connects correctional facilities and the community is of great importance for managing transition in the care of people to and from the community given the “revolving door” nature of jails and prisons.

Eliminate medical co-pays.  In countries where universal financial protection in health is lacking or limited such as in the United States, incarcerated people are expected to make copayments for physician visits, medications, and testing.  As observed among the civilian population, the imposition of medical copayments becomes a barrier that discourages demand and utilization of needed medical services, which in turn will only help increase the tally of infected cases within the facility’s inmate population and security and administrative personnel.

Way Forward

The impact of the adoption of the measures described above would have dual benefits:  on one hand, it would help prevent the spread of COVID-19 among inmates and penitentiary system workers, and hence among their families and surrounding communities, that could undermine efforts to flatten the curve in countries. It would also help contain a resurgence of the virus during the suppression phase of the pandemic.   And, on the other hand, it would help advance prison reform by depopulating jails and prisons in combination with the provision of health care, rehabilitation, education and skills development, and social support programs as an alternative to incarceration.  A glimmer of hope? Yes, but one that is possible if political commitment and public and private efforts push forward these policy choices as part of a multisectoral strategy for human capital development, and as a moral imperative in society to offer vulnerable people a second chance for rebuilding their lives. 

Picture 1: Inside the Prison Industrial Complex, Guess Contributor.  https://www.patheos.com/blogs/rhetoricraceandreligion/2015/09/inside-the-prison-industrial-complex.html

Picture 2: “Detainees in Manila City Jail, where most are still awaiting trial, and may stay for months or even years before that happens.” By Hannah Reyes Morales for The New York Times https://www.nytimes.com/2019/01/07/world/asia/philippines-manila-jail-overcrowding.html