Covid-19 in US jails and prisons: implications for the next public health crisis

Katherine LeMasters, assistant professor1,
Lauren Brinkley-Rubinstein, associate professor2

¹Division of General Internal Medicine, University of Colorado Anschutz School of Medicine, Aurora, CO, USA
²Department of Population Health Sciences, Duke University, Durham, NC, USA

Correspondence to: L Brinkley-Rubinstein lauren.br{at}duke.edu

Katherine LeMasters and Lauren Brinkley-Rubinstein raise concerns about the lack of sustained change in prison health transparency after covid-19 and implications for future public health crises

People in the jails and prisons across the United States are often housed in abysmal and unlawful conditions that have dire consequences for health.1 From poorly designed built environments (eg, lack of air conditioning, overcrowded dorms) to stressful and unpredictable living quarters, to a lack of quality and timely healthcare, time spent in incarceration worsens peoples’ health.2 3 In fact, the American Public Health Association considers the current state of incarceration in the US to be a public health crisis.4 Rates of incarceration are high. Although the US contains less than 5% of the global population, it accounts for 20% of the global incarcerated population.5 Furthermore, incarceration disproportionately affects Black, Native American, and Latino people, contributing to racial health inequities.6

Despite the problems of mass incarceration, it is not monitored like other public health crises in the US.7 For instance, there is no real time or comprehensive health data reporting from the country’s 53 disaggregated prison systems (50 state prison systems, the Federal Bureau of Prisons, Puerto Rico, and the national Immigrations and Customs Enforcement). These data are critical for understanding prison population dynamics (eg, when and how many people are dying in custody), quantifying health inequities (eg, rates of infectious disease spread in prisons versus the general population), and documenting how incarceration is affecting chronic health conditions. Only with these real time, comprehensive data can we work toward improving the health and wellbeing of individuals and communities affected by mass incarceration. In this article, part of a BMJ series examining US covid-19 lessons (http://bmj.com/collections/uscovid- series), we examine how despite the problems of mass incarceration, it is not monitored like other public health crises in the US.

This opacity seemed to begin to change in 2020. While covid-19 ravaged carceral systems across the country, the Covid Prison Project, led by our team, found that, in the wake of increased public attention, most state and federal systems created data dashboards on their department of corrections’ websites to provide some information on the scope of illness in their facilities (eg, daily covid-19 incidence, covid-19 deaths, and vaccine administration).8 These data dashboards allowed our team and others to monitor epidemiologic data on covid-19 spread and deaths in facilities from spring 2020 onwards, which was critical in addressing the pandemic in these often overlooked congregate settings. These data were also able to, for example, inform resource allocation, vaccine prioritization, and decarceration strategies. But these dashboards began disappearing in summer 2021. The waning attention to covid-19 has undoubtedly created a perception that tracking and monitoring is no longer necessary. But what does this return to opacity mean for the next inevitable public health crisis in US jails and prisons?

Covid-19 in American prisons and jails

Throughout the course of the pandemic, carceral facilities experienced some of the largest single site cluster outbreaks of covid-19 in the US. The documented case rate of covid-19 was five times that of the general population in the US, and the death rate was three times as high.9 10 By 6 June 2020, the covid-19 case rate was 3251/100 000 prisoners compared with 587/100 000 in the general US population.10 Additionally, based on the age specific death rates for the general population, the number of expected deaths from covid-19 for people in prison was 921 up to 5 June 2021, but 2664 deaths were reported, corresponding to a standardized mortality ratio of 2.89.9

Furthermore, the high case rates and outbreaks in carceral facilities among both staff and incarcerated people often translated to correspondingly high rates in proximate communities.11 A study in North Carolina state prisons in 2020 found that once counties reached substantial covid-19 spread (50 new cases/100 000 population detected in the past seven days), the prison case rate increased by 119 cases/100 000.12 These findings highlight that prisons and communities are deeply connected and that we must consider the health of those inside prisons and jails to be part of any public health initiative focused on community wellbeing.13

Carceral systems around the world faced high levels of covid-19 outbreaks and deaths.14 15 Incarcerated people worldwide were given low priority for vaccination, with only 43% of countries with vaccination plans prioritizing incarcerated people.16 In the US, labor policies did not consider incarcerated workers to be essential workers for vaccination (eg, those serving as firefighters).17 Additionally, over 60% of prison systems worldwide experienced overcrowding, and while some released substantial numbers of people early in the pandemic, many systems have begun returning to pre-pandemic levels (eg, England and Wales).18

Reasons for high rates of covid-19 in carceral facilities are multifaceted. People who are incarcerated, on average, have at least two chronic conditions, which is a risk factor for developing severe covid-19.19 The environment of prisons and jails are risk factors too. At the beginning of the pandemic, prisons were on average at 103% capacity.19 Most prisons and jails lacked the medical infrastructure and the space to provide adequate care and to isolate or quarantine people who became ill, often placing them in solitary confinement—a punitive practice—instead of medical isolation.20

Some carceral systems implemented strategies to mitigate covid-19 harms. These included robust testing practices, placing people in smaller cohorts, providing masks and other personal protective equipment, and limiting unnecessary transfers. Interviews with 100 incarcerated people and staff across the US during 2021-22 suggested that a successful response was related to external and internal collaboration and communication, providing sufficient resources for mitigation, and understanding the link between the health of staff and that of incarcerated people.21 Decarceration—for example, by prioritising certain populations for early release (eg, those near their release date) or clemency from state leaders—also emerged as an important mitigation strategy. A study in Texas state prisons in 2020 found that prisons at no more than 85% capacity were less likely to experience an outbreak than their more crowded counterparts.22

Covid-19 reporting in prisons

The covid-19 pandemic provided a unique and pressing opportunity to gain insight into overcrowded and inadequate carceral conditions and the health of those living there.23 24 25 Senators such as Elizabeth Warren raised concerns about the crisis covid-19 was causing in prisons and jails and the need for data reporting,26 and national news networks covered effects such as staffing shortages and prison closures.27 28 While those who are incarcerated, staff in carceral facilities, advocates, and researchers have long known that the system detrimentally impacts health outcomes, it was perhaps the first time that the broader public and media were exposed to and began to understand the breadth and depth of the crisis of mass incarceration. It was also the first time that all 53 prison systems reported real time health data: covid-19 testing, infections, and deaths. In 2020, we created the Covid Prison Project—an interdisciplinary, public health focused project to provide real time data on the state of covid-19 in US carceral facilities, funded by the Jacob and Valeria Langeloth Foundation. The Covid Prison Project was used to track and compile these data, allowing public health researchers, policy makers, and family members of those incarcerated to see what was happening beyond prison walls.8 We have also endeavored to use the project and its data to hold these systems accountable. For example, data from the project were used in testimony advocating the need for increased covid-19 testing in Alabama prisons, documenting high prison covid-19 death rates and supporting the concern that the state’s prison transfers were contributing to covid-19 incidence.9 29

Yet, these data were not without limitations. We found that only four states (Vermont, Massachusetts, Tennessee, and Washington) reported any demographic information about covid-19 cases.30 In Vermont, the only state to report race and ethnicity information for these cases, the cumulative prevalence from March to October 2020 was 6% for Black people compared with 2.6% for white people.30 The lack of covid-19 data by race and ethnicity within prisons and jails makes it impossible to understand the racial health inequities that have been documented in general among incarcerated people in the US.31

This flow of real time data ended in May2023 for one of America’s largest prison systems. The Federal Bureau of Prisons explicitly stopped collecting data on covid-19 in May 2023 because the federal public health emergency ended.32 Similar actions were taken in other jurisdictions.8 33 The Rhode Island Department of Corrections, for example, also stopped data collection and has since required those interested in covid-19 historical data to submit public records or research requests, which are not free of charge.34 The data that are still available are less comprehensive than previously provided, with most states no longer reporting vaccination or staff data.

This makes it difficult for public health experts to prevent future outbreaks or advocate to ensure that facilities have the resources to provide treatment. We also cannot use these data to guide best practices for this pandemic or the next one. The real time reporting of covid-19 data in carceral settings provided an example of transparency that could have grown over time to provide an understanding of the scope of illness, or the damage done by? certain conditions of confinement in America’s prisons and jails. Today, we still lack basic information about the wellbeing of people behind bars and have non-existent accountability structures. For example, although the 2000 Deaths in Custody Reporting Act mandates the reporting of in-custody deaths, many states still do not meet federal protocols.35 Only 36 of 50 states make public any information on deaths in custody, with eight providing only the number of deaths and three additional states providing contradicting numbers on deaths in different reports. Thus, not even the most basic health data are reported in real time across US carceral settings.

Although covid-19, in many ways, demonstrated what is possible—the real time collection and public reporting of communicable disease—the return to the status quo underscores that without more accountability, the carceral population will continue to be more severely affected by public health emergencies than the general population. This is already evident with the climate crisis. The lack of transparent health data has prevented researchers from calling for, for example, improved policies related to temperature control, ventilation, and emergency management. While the next infectious disease pandemic may be unknown, climate change is already affecting prison and jail conditions, and real time, comprehensive data are necessary to understand the scope—and what to urgently do about it.

Future crisis preparation

Covid-19 showed that the prison and jail infrastructure is not adequately prepared to protect health in the next public health crisis, the climate crisis. As noted above, prisons and jails are overcrowded,36 have poor ventilation,37 and have inadequate labor policies for incarcerated workers.17 Furthermore, few academic publications, administrative data, or policy documents are available to help predict and ameliorate the effect of factors such as extreme temperatures in carceral settings or an increase in climate disasters that may affect the health of prisoners and the prison environment.38

In the few emerging studies examining the effect of climate change on carceral settings and the inadequate infrastructure with which to respond, the results are dire. Extreme heat is associated with an increase in suicide watch incidents in Louisiana prisons,39 increased all-cause mortality in Texas prisons,40 and increases in incidents of extreme violence in Mississippi prisons.41 A review of departments of correction documents and state emergency management plans found that few prison systems had emergency plans for climate disasters and tended to focus on the protection of buildings and use of incarcerated people as labor during crises rather than the safety and wellbeing of people who were incarcerated.42 More specifically, 33 departments of correction (66%) did not have emergency management plans on their website. While each prison and jail system is unique, universal emergency management plans to safeguard the health of those incarcerated are necessary.

Climate change and covid-19 are different public health emergencies, but their effect on carceral populations is similar. We suspect that people who are incarcerated will be disparately affected, prison populations will experience long term health effects, and the preparedness and responses to climate change are under-resourced. What is needed now is a commitment to and collection of data in prisons to both understand the scope of the problem and help support policies and practices that promote health within carceral systems. Doing so will ensure a better path than that in the covid-19 pandemic and previous health crises such as the HIV pandemic in the 1980s and 1990s, when carceral systems were slow to respond, punitive practices were unnecessarily used for disease management, and a lack of legislative oversight resulted in little information being available to policy makers and the general public.43

Moving forward, the US needs real time data on conditions of confinement (population size, architecture of buildings, and ventilation systems) for all systems, reported to state and federal authorities and publicly available for transparency. This is needed to assess the scope of the problem and how to act. As of May 2023, some systems maintained regularly updated dashboards on some of these pieces of information (eg, California, North Carolina), but most did not. Legislation at the local, state, and federal level can mandate data standards and reporting. Congress introduced the Covid-19 in Corrections Data Transparency Act in 2020, which, although not successful, could serve as an outline for future bills that have more expansive data transparency goals. Furthermore, the Federal Prison Oversight Act, introduced in 2022, requires inspections of prisons and establishment of an ombudsman in the justice department given the current lack of accountability.44 Ideally, an independent agency would manage the reporting of deaths in custody and make in-custody deaths a “notifiable condition.”35 Then, if jurisdictions fail to adhere, they would be penalized with cuts to grant funding and this funding could be redirected to public health programs working toward preventing incarceration.

Regardless of this legislation, public health experts must be included in decision making around criminal legal systems. For example, state departments of health rarely collaborate with departments of corrections; only nine states had robust working relationships (eg, data sharing or public health guidance for carceral settings) during the covid-19 pandemic.45 Such collaborations are critical for all states.

Lastly, while improving conditions of confinement is important to increase the wellbeing of people who are incarcerated, the most effective intervention to eradicate health inequities in this population is to decrease exposure to the setting itself. Decarceration and community investment in alternatives to punishment are essential to mitigating the impact of all future public health threats.

Key messages

Reporting of covid-19 data during the pandemic made public the breadth and depth of the crisis of mass incarceration in US prison systems
Most systems have now stopped providing health data and there is still little collaboration with health departments
Lack of transparency for health data in carceral systems prevents public health from looking forward to the next crisis
The climate crisis is already disproportionately affecting carceral systems and demands urgent action by public health authorities and policy makers

Footnotes

Contributors and sources: Katherine LeMasters is a social epidemiologist and assistant professor at the University of Colorado Anschutz School of Medicine. Lauren Brinkley-Rubinstein is an associate professor at the Duke University School of Medicine. She founded the COVID Prison Project and Third City Project. Both authors work at the intersection of the criminal legal system and health equity.
Competing interests: We have read and understood BMJ policy on declaration of interests and have the following interests to declare: Lauren Brinkley-Rubinstein founded the COVID Prison Project and Katherine LeMasters worked as a graduate research assistant on the COVID Prison Project.
Provenance and peer review: Commissioned; externally peer reviewed.
This article is part of a series commissioned by The BMJ (https://bmj.com/collections/us-covid-series). The guest editors were Ana Diez Roux and Gavin Yamey and the lead editor for The BMJ was Jocalyn Clark.