Conversations on COVID: Flattening the curve in jails and prisons

Stemming the tide of COVID-19 cases in jails and prisons isn’t just about protecting those who are incarcerated; it’s also about saving the lives of those living outside prison walls, says Brown professor Josiah Rich.

PROVIDENCE, R.I. [Brown University] — In the midst of the COVID-19 outbreak, public health officials are stressing the importance of social distancing to prevent the spread of the virus. But for millions of people in America’s jails and prisons, social distancing is not an option. And medical experts are sounding the alarm of an additional public health disaster waiting to happen. 

Dr. Josiah Rich, a professor of medicine and epidemiology at Brown University, is co-author of an essay published on April 2 in the New England Journal of Medicine urging immediate action to mitigate mass outbreaks of COVID-19 behind bars. Among the authors’ recommendations is the immediate release of prisoners who are unlikely to commit further crimes, as well as those who are elderly or ill. Doing so will free up precious space to enable facilities to better manage the remaining population in the event of an outbreak. 

Taking no action, Rich says, will not only endanger thousands of lives among incarcerated populations, but poses a dire threat to everyone by further overtaxing health care systems. Last Friday, the Rhode Island Supreme Court cleared the way for 52 prisoners in the Ocean State, but Rich says that further action nationwide is required.

“When these people get sick, they’re going to get sick all at once,” said Rich, who is a practicing infectious diseases specialist at the Miriam Hospital in Providence. “That means there’s likely to be a large spike in people coming from corrections to the surrounding health care facilities. We can ill afford to have local health care systems overrun by a wave of people coming from the correctional setting. The consequences of that are dire.”

Rich, who is the director of the Center for Prisoner Health and Human Rights, discussed the situation and proposals to address it in an interview. 

Q: First, can you provide a sense of the scope of the problem?

We have 2.3 million people incarcerated in this country. That’s 2.3 million people in a congregate setting, and that’s a huge problem. All of the maneuvering that we’ve been doing to slow the spread of this virus — the social distancing — is very challenging to do in congregate settings. We’re going to see rapid spread in those populations, much like we saw in China and like what’s happening now at Rikers Island

And incarcerated populations are particularly vulnerable to severe infection. Older people are at particular risk from COVID-19 and our prison population is aging due to things like mandatory minimum sentencing and three-strikes laws that were enacted decades ago. There’s also a high prevalence of underlying medical conditions that could complicate infections. About half of the people in jails and prisons have at least one chronic medical condition. That’s a problem for the people in those institutions when this gets in there and spreads. 

Q: You make the point that the risks here don’t stay inside prison walls. Can you explain that?

For one thing, we have to think about the staff who work at these facilities. They’re obviously at risk as well, and they could in turn put their families at risk. But the problem goes far beyond that. The big worry is about the surrounding health care facilities.

Having been taking care of patients sick with this disease for over two weeks now, I can tell you that there are almost no correctional facilities that are going to be able to keep people alive who are very sick with this disease. They will be transferred out to surrounding health care facilities. If the incarcerated population got infected at the same rate as everybody else, they’d just be another part of the burden on the health care system. But the reality is that, because of the congregate setting,  incarcerated populations are likely to get infected all at once. And they’ll be flooding into the health care system.

Every other democracy in the world can function just fine without incarcerating nearly the proportion of people that we incarcerate in our society. And now it’s become a matter of public health.

Dr. Josiah Rich professor of medicine and epidemiology

Q: Is there any precedent for something like this?

We’ve certainly had outbreaks before in correctional settings. There was an outbreak of chickenpox at the Rhode Island Department of Corrections a few years ago. Chickenpox can be a serious disease in adults. People who hadn’t gotten vaccinated were vulnerable. It wasn’t as if it was going to take over the whole facility like COVID-19 could, but we had a cohort who had to be isolated. We had to make rapid diagnosis, do rapid testing and quickly get people vaccinated. 

To me, this was an instructive outbreak because it highlighted the rapidity with which a contagious disease can spread through a facility. And the chickenpox case was a situation where some of the population had immunity. In this situation now, there’s zero immunity. Everybody’s vulnerable, and it’s spread by people who are not easy to identify early on, so this will go even faster.

Q: Why are you recommending prisoner release as a way to deal with this problem?

The biggest impact you can have early on is to release as many people as you can, I believe. That’s especially true of people who are at risk of severe disease, but it’s worth noting that in our hospitals now, we have people in their 20s and 30s who are extremely ill. This is not just a disease of the elderly. It’s more severe in the elderly, but it’s plenty severe in young people. So the more people you can get out the better, before the virus gets into the population. 

The advantage of getting people out is not necessarily for those individuals themselves. Freeing up that space allows you to do the other things that need to happen. Those other things include segregating people into the smallest units possible and not letting units intermingle. And once people start getting ill, you need to figure out where to keep those people and figure out how to quarantine people who were exposed to them. That space could be freed up by letting some people out. And we really need to start doing that as soon as possible. 

It’s like a slide puzzle, where you have a few empty spaces and you have to move the blocks around. If you only have one empty space, it takes a while to move things around. But the more empty spaces you have, the easier it is to move things around. 

The Rhode Island Department of Corrections is doing an outstanding job of doing everything they can to prepare for this, but their efforts are ultimately going to be hamstrung by the sheer number of people that they have to deal with, something that they have almost no control over. We need the judiciary and executive branches to work together to release all that they safely can as quickly as possible to delay and minimize these predictable and avoidable catastrophes.

Q: What would you say to someone who might be unnerved by the sudden release of prisoners? 

We’re not saying let every murderer out. We’re saying look at each individual and assess whether that person poses an immediate threat to public safety. Some people certainly need to stay incarcerated. You have to be savvy about who to let out. But we absolutely need to decrease the population. The risks involved in letting some people out are far lower than the risks to public health if we keep all of these people locked up.

This is really something we need to think about even after this immediate threat is all said and done. Every other democracy in the world can function just fine without incarcerating nearly the proportion of people that we incarcerate in our society. And now it’s become a matter of public health. People who are not incarcerated are going to die because we’ve made the decision to incarcerate so many people. We’re about to pay the price for it, and we’re going to pay in human lives.