The COVID-19 pandemic has put a spotlight on many broken systems in this country, including U.S. jails and prisons, which have for decades imprisoned more people than in any other nation, the majority of whom are people of color. Many residents of prisons and jails are elderly, in poor health, or both, making them extremely vulnerable to serious illness and death from the coronavirus.
Incarcerated people are five times more likely than the general public to get infected with the virus, and at least 1,200 residents and 70 staff members of jails and prisons across the country have died from complications of COVID-19. Yet, most correctional facilities are still struggling to work out the basic steps of how to stop the virus from spreading.
The COVID-19 crisis inside jails and prisons has laid bare the public health emergency created by mass incarceration in this country. The dehumanizing, unhealthy environments of prisons and jails have profound adverse effects on the health and well-being of residents and staff alike. The harms continue when people are released. Even before the pandemic, people were 12 times more likely to die during the first two weeks after release from prison than people of similar age and gender in the community.
UC San Francisco experts say the health care system has an important role to play in helping to attenuate these harms, by improving the correctional health care system, as well as the connections to primary care once prisoners are released. The unhealthy conditions inside jails and prisons, especially chronic overcrowding must also be addressed, they say.
Amend at UCSF and the Transitions Clinic Network (TCN) are two nationally influential programs that are targeting the health problems inside prisons, and those faced by newly released prisoners. The work of both was featured in a new report on decarceration by the National Academy of Sciences (NAS). A recent decision by California’s First District Court of Appeal ordering San Quentin State Prison to reduce its population by one-half because of COVID-19 also drew heavily on recommendations from Amend. Since the pandemic began, about 2,000 prisoners at San Quentin have been infected with the coronavirus, and at least 28 have died.
“Obviously, prisons should not operate at, or even close to, 100 percent capacity during a pandemic, but actually they shouldn’t ever be overcrowded,” said Brie Williams, MD, MS, professor of medicine and founder and director of Amend at UCSF, which aims to improve the health of both prison residents and staff by transforming correctional culture to focus on humanity, dignity and rehabilitation.
“We continue to call for large-scale, well-planned decarceration to rectify the unhealthy reliance that the U.S. criminal justice system has placed on incarceration, as well as legislative policy fixes to decrease the use of prison,” Williams said. “It is past time for a national reckoning with mass incarceration in America, which prioritizes prolonged punishment and suffering over rehabilitation or health. Now, during the pandemic, we must speed up that national reckoning and urgently depopulate our prisons and jails to improve public health.”
We continue to call for large-scale, well-planned decarceration to rectify the unhealthy reliance that the U.S. criminal justice system has placed on incarceration, as well as legislative policy fixes to decrease the use of prison.
Since last spring, when it became clear the virus was spreading in California and other states, experts at Amend have tried to stop it from harming those living and working inside jails and prisons across the country. At the same time, Shira Shavit, MD, a professor of family and community medicine at UCSF who directs TCN – a national program that is building an innovative health care model for individuals returning to the community from incarceration – raced to adapt TCN’s programs to a health system that had “gone virtual” overnight, shifting many services online even as people were being released from jails and prisons without cellphones or access to the internet.
Prisons Are a COVID-19 ‘Breeding Ground’
On a routine visit to a California prison in early March, just as reports of COVID-19 cases in the U.S. were becoming more common, Williams saw at once how easily the virus would spread in unsanitary and poorly ventilated facilities packed with bunkbeds placed just inches apart. The aging residents she spoke with, some in wheelchairs, were already in poor health, with chronic conditions that would make them, as well as many of the prison staff, especially vulnerable to severe illness and death if they became infected.
“The experience of being at a prison just as the pandemic was gaining hold in the U.S. shook me to the core and has haunted me ever since,” she said. “It would be clear to any health care professionals who visited that correctional facilities are the perfect breeding grounds for explosive COVID-19 outbreaks.”
Her group at Amend immediately got to work. They developed guidelines and staff and resident trainings on mask wearing, sanitation and physical distancing, and how to “cohort,” or keep incarcerated people in separate groups, in order to reduce the risk of spread of the virus in the facility. They partnered with community advocacy organizations to reach incarcerated people and their families, made informational videos that have been shown throughout the nation to staff and residents, and formed partnerships with the California Department of Corrections and other state and national policy leaders.
One video, made with the Marshall Project for people living in correctional settings, was disseminated by the Worldwide Prison Health Research and Engagement Network, and on “inmate TV” in prisons throughout California, Colorado, North Dakota, Oregon and Wyoming, as well as in jails in San Francisco and Los Angeles County. Another, aimed at bringing knowledge about COVID-19 to correctional officers and staff, became required viewing in several states. A third video, produced with Jenny Lutz at the Center for Children’s Law and Policy and funded by the Annie E. Casey Foundation, was tailored to the needs of youth in detention facilities.
The experience of being at a prison just as the pandemic was gaining hold in the U.S. shook me to the core and has haunted me ever since.
When prisons began putting people into punitive solitary confinement in a mistaken attempt to isolate exposed or ill prisoners, David Cloud, JD, PhD, director of research at Amend, developed guidelines with David Sears, MD, associate professor of medicine at UCSF and director of health care quality at Amend, and Dallas Augustine, MA, a research associate at Amend, that have been used internationally to explain how to create ethical medical isolation and quarantine measures for the benefit of sick and exposed residents, rather than punitive solitary confinement.
They also worked to connect the state with testing opportunities, and called for prison healthcare systems to actively seek out new partnerships with local health departments to curb the spread of the virus.
“We need centralized prison outbreak teams in each jurisdiction to be deployed to any prison in the region, so when an outbreak occurs, the beleaguered prison health care leaders are not left alone to treat their patients and simultaneously engage in systemwide emergency response and planning,” Williams said. “They need help from epidemiology, infectious disease and public health experts outside of the prison who can help with emergency response planning around staff and resident cohorting, testing and optimization of living environments to minimize viral transmission.”
Amend has also focused on the health of correctional officers and staff, urging prison leaders to ensure their staff have paid sick days and access to free testing and hotel rooms for isolation if they are exposed. Sears published Amend’s recommendations in Annals of Internal Medicine. And Amend’s program director, Cyrus Ahalt, MPP, and program manager, Kevin Reeder, MPA, led a series of virtual “COVID conversations” between U.S. and Norwegian correctional officers to encourage humane responses to COVID-19.
From Prison to Hospitals
Faced with a sudden onslaught of COVID-19 patients from jails and prisons, many health care professionals in community hospitals and clinics throughout the nation have reacted with confusion over who has control over the care offered to incarcerated patients who are hospitalized with serious, life-limiting illness, and what rights their families have to visit with them, even if by phone or video chat.
To address this issue, Leah Rorvig, MD, MS, assistant professor of family and community medicine, and director of health education at Amend, developed a guide with Re:store Justice – a research and advocacy organization for prison reform founded inside San Quentin State Prison – in both video and written form, that has been used by providers around the country. She has also worked with federal public defenders to inform health care providers about the rights of hospitalized patients.
“Most community health care professionals and community hospitals are unused to taking care of so many patients from prisons,” Williams said. “Every state should be developing local guidance around the rights and ethical care of seriously ill patients transferred from prisons to community hospitals to ensure that health care professionals understand that patients are not so-called wards of the state. They retain the right to direct the nature of their care and to appoint people to make medical decisions on their behalf if they are no longer able to make their own medical decisions.”
When federal judges began granting compassionate release to residents who were likely to suffer serious complications or die if they got infected, Rorvig organized UCSF physicians to review medical records and write declarations of support in partnership with Families Against Mandatory Minimums and the Compassionate Release Clearinghouse.
And Rebecca Sudore, MD, a professor of medicine in the Division of Geriatrics at UCSF, helped correctional health care professionals create advance care planning guidelines adapted from her Prepare for Your Care program.
Working with the Justice Collaborative Institute, Williams co-authored a white paper with Leann Bertsch, the director of the North Dakota Department of Corrections, calling on governors to engage in health-focused decarceration due to COVID-19.
On Oct. 20, 2020, the NAS Committee on Law and Justice released Decarcerating Correctional Facilities During COVID-19, which provides guidelines for early release to protect prisoners from the coronavirus and draws heavily on Amend’s and TCN’s work. The committee is co-chaired by Yale School of Medicine’s Emily Wang, MD, a former UCSF resident who co-founded TCN with Shavit, and includes Margot Kushel, MD, professor of medicine at UCSF.
Challenges of Reentry After Release
Since the start of the pandemic more than 21,000 people have been released early, while many more have been released from county jails. This has caused an increase in people seeking care from primary care clinics that partner with TCN, led by Shira Shavit, MD, clinical professor of family and community medicine at UCSF. TCN has 44 programs in primary care clinics in 10 states and Puerto Rico, including 22 in California.
Leaving jails and prisons can be overwhelming for people who suddenly need to find housing, food and jobs, access to which may be restricted because of their criminal records.
“These challenges have been exponentially magnified by the pandemic and the economic downturn,” Shavit said. “Early releases leave little time to create reentry plans or enroll people in Medicaid or food stamps. People in jails and prisons are also much more likely to have been exposed to COVID-19, which makes returning home that much more difficult.”
TCN seeks to engage newly released people in primary care by utilizing community health workers who have firsthand experience of what it’s like to be incarcerated, and they know how hard it is to try to return to the community after being released. They are able to build trusting relationships with their clients to help connect them to the services they need. The network’s community health workers are trained by a UCSF/community collaborative led by senior community health worker Joseph Calderon.
The program also works with primary care systems to confront systemic racism and other forms of discrimination that make it hard for formerly incarcerated people to engage with care.
Because of the poor coordination between correctional and community health systems, people returning from incarceration tend to have high rates of emergency department (ED) use and preventable hospitalizations, a disastrous combination for health systems that are already under strain from COVID-19.
A study from 2012 showed TCN reduced ED use, and another from last year showed it helped prevent people from returning to prison for technical violations and, for those who did return, shortened their length of stay. These issues are of paramount importance with hospitals under strain because of the pandemic.
Supporting Re-entry in the COVID Era
Before the pandemic, TCN’s community health workers would often visit people before their release from incarceration to establish a relationship. But now they have had to find new ways of connecting, as jails and prisons are closed to visitors.
With funding from the California Health Care Foundation, TCN created the Reentry Healthcare hotline which the incarcerated can call toll-free. Traffic on the hotline, which has proved popular not only with incarcerated people, but with probation and parole officers struggling with early releases, has doubled each month since starting this summer.
To improve care coordination from state prison to community health systems in California, the UCSF team expanded an existing on-site medical discharge planning clinic based at San Quentin State Prison to a virtual clinic serving all 35 state prisons. Now, nurses in the state prisons can for the first time directly refer patients to community primary care services for treatment for chronic conditions or for medications for opiate use disorder.
In collaboration with Medicaid managed care plans and the California Primary Care Association, Liz Kroboth, MPH, the California Program Manager at TCN, and Anna Steiner, MSW, MPH, the national program manager at TCN, engaged other primary care clinics to serve people returning from prison and trained prison nursing staff in how to better coordinate care with community health systems.
The referral platform they created has received more than 800 direct referrals from state prisons in the first months of opening its online portal. Similar efforts have been launched in Connecticut and North Carolina, which have TCN-led statewide networks of primary care clinics serving people returning from incarceration.
“It’s been amazing to see how quickly innovations can be disseminated across the network,” Shavit said. “Clinics have come together statewide to create new systems and safety nets for people coming out of state prison.”
Signs of Change
Shavit and Williams noted other signs of positive change.
For the first time, federal lawmakers are looking at ways to optimize COVID-19 testing and make the prison health system more transparent. For example, a new law signed by California Gov. Gavin Newsom will enable incarcerated wildland firefighters, who fight wildfires on behalf of the state, to be hired by fire agencies following their release. CalAIM, the next California state Medicaid waiver, will support collaborations between correctional and community health systems sustaining the groundwork laid during COVID-19.
And a California effort, called the “Returning Home Well” initiative, is matching state investment with philanthropic funds to provide housing, health care, transportation, employment, and financial support to people returning to the community during COVID-19.
“The criminal legal system does not provide enough support to help people be successful in their reentry,” Shavit said. “Health systems also play a key role in reentry. We need to take a much broader perspective on health and well-being.”
Williams said controlling the COVID-19 pandemic in the U.S. will require addressing its rapid and devastating spread in our prisons and jails.
“We can’t do that until we address the concomitant epidemic of mass incarceration in our nation,” she said. “While there is a long way to go, the first step is through academic/community/government partnerships, such as those developed by Amend and the Transitions Clinic Network.”