Prison health and COVID-19

We hear from Prof. Lauren Brinkley-Rubinstein and Alexandria Macmadu on how COVID-19 has affected the prison system in the USA, and Prof. Marie Claire Van Hout talks about the health problems faced by prisoners in sub-Saharan Africa.

Read all of our content at https://www.thelancet.com/?dgcid=buzzsprout_tlv_podcast_generic_lancet

Check out all the podcasts from The Lancet Group:
https://www.thelancet.com/multimedia/podcasts?dgcid=buzzsprout_tlv_podcast_generic_lancet

Continue this conversation on social!
Follow us today at...
https://thelancet.bsky.social/
https://instagram.com/thelancetgroup
https://facebook.com/thelancetmedicaljournal
https://linkedIn.com/company/the-lancet
https://youtube.com/thelancettv

Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Gavin: Hello. Welcome to the Lancer Voice. It's October 2021. I'm Gavin Cleaver, and I'm here with my co host, Jessamy Baganal. Jess and me this week, we're talking about prisons on the new episode, and we've got a couple of great interviewees and we're talking about prisons in the U. S. and in Sub Saharan Africa and the situation in low income countries a little bit more generally.

But prison health is such an interesting area, isn't it? It's it's almost a bit like a kind of bellwether for the countries that they're in. And, these are, as we often talk about, some of the most vulnerable people. And the COVID 19 pandemic, of course, tends to affect the most vulnerable people the most.

Jessamy: Yeah, we've wanted to do this topic for ages, haven't we, Gavin? And back in February, we had, we wrote this leader as a group on prison health. And actually, that argued for the fact that they're not enclosed. It's not an enclosed system. This is a group of people that cycle in and out of prisons in which there's normally extremely poor health, and back out to the community and bring that poor health.

out there. And to look at them as islands or isolated areas where you can have these pockets of poor health and it's not going to influence the community's health is lunacy. But I think, more importantly, it is something that gets neglected. And we ended that leader by, talking about Nelson Mandela's quotes about how you judge a country is not, how they treat this sort of people in the highest positions, but how they treat the people in the lowest positions.

And I think that's right. It's such a. Such a fascinating area when you think about the history of prisons and where they've come from and you know I remember reading about Michael Foucault before that leap We wrote that leader and his sort of you know how he shows the history of moving from bodily punishment To this more sort of detainment punishment of surveillance and Jeremy Bentham also writes about it with the same view that it's a change in the way that society deals with its citizens.

It's not about physical punishment. It's about detaining them and surveilling them and putting them in a place where you don't necessarily have to rehabilitate them. You're punishing them and that sends signals to other citizens in society. And I think the same issues can be said about health.

Gavin: Yes, it's almost forfeiting the right to health, really, isn't it? Countries might make the point that these people have committed a crime prisoners, and that's They have forfeited some of their rights, but I'm not sure that right should be to health. 

Jessamy: That's something that comes up in this interview that we're about to hear, which is such a brilliant interview.

But there, I think one of the interviewees makes this exact point that the U. S. system is not about rehabilitation. It is about punishment. And therefore, it's, the public health issues around these places, the high rates of infection, HIV, and, other non communicable diseases, don't get any attention or focus because that's not the narrative that is played.

It's punitive. And it's punishment on all levels. 

Gavin: Yes, it reminds me of when I used to work in in Dallas for the Dallas Observer for the newspaper there. And we used to write an awful lot about prisoners in Texas simply because the system was so shockingly inhumane towards them. And of course, as we'll hear in this interview, the U.

S. has its own kind of Prison situation where I think the stats are something like, the US has 3 percent of the world's population But about 25 percent of the world's prisoners, it's so 

Jessamy: 11 million people cycling in and out of this system a year When you think globally the total number of people in prison is 10.

74 million But because of this jail and prison system and people going in for a couple of hours and In and out. It's just bonkers. Anyway, I'm sorry to interrupt you. 

Gavin: No at all. It's wildly out of proportion, isn't it, to other countries prison populations. 

Jessamy: And it's uncomfortable. I think we don't like to talk about it.

We don't like to think about it. People who aren't in prisons or people who don't have family members. who have been in prisons because it is uncomfortable. Because I think fundamentally, we all know that it's an unfair and unjust system that doesn't help anybody and in fact worsens inequity, worsens the social determinants of health.

And does nothing to improve them. We talked at the beginning about this development of physical punishment to detainment and that was considered to be enlightened. And many people may still think that's as enlightened as we're going to get. But actually I think from the interviews that we're hearing today, you can see that there remains an element of physical punishment because people's health in prisons is so neglected.

Gavin: Yeah, absolutely. I think those are really interesting points to make. 

Jessamy: Anyway, I'm excited to listen to this interview. So let's listen to it. 

Gavin: Yes, and for this, we're going to hand you over to Dr. Liam Messon, who's Senior Editor at the journal eBiomedicine, published by the Lancet. And he's a member of our Lancet voice editorial team.

He's speaking with Professor Lauren Brinkley Rubinstein, who's Associate Professor at the Department of Social Medicine at the University of North Carolina at Chapel Hill. And Alexandria McMaddie, candidate at the Department of Epidemiology. At the Brown University School of Public Health. 

Liam: Thanks Gavin.

And as you said, I'm here with Lauren and Alexandria to talk about COVID 19 in prisons in the U. S. Lauren, we are now well into the second year of the COVID 19 pandemic. Could you begin by just providing an overview of the situation for those incarcerated in the U. S.? For instance, how do COVID cases compare to those in and out of prison?

Lauren: People who are incarcerated have a much higher risk of getting COVID 19, of dying from COVID 19. The risk of contracting COVID 19 is about three times higher for the incarcerated population than the general population. And the risk of death is also exponentially higher. We see that same risk for staff.

So for people who work in prison or jail settings as of September 9th, 2021, we've seen about a little over 420, 000 cases of COVID 19 among people who are incarcerated in prisons, particularly. And we've seen around 2, 500 deaths. I think it's really important to contextualize mass incarceration in the United States.

It's very different than it is in other places. In this country, we have jails and prisons, which are pretty distinct and different places. Jails are places where people tend to serve short sentences be awaiting trial. So there's this idea of churn. So people spend a couple of hours in jail over and over, whereas in prison people tend to serve longer sentences.

So there are risks that are pretty unique to both of those settings. But in the U. S. 11 million people every year cycle through our jail system, and there are in our prison system about 1. 2 million people in state prison systems and about 225, 000 people in federal. Prisons and jails. So massive numbers of people turning through our system, disproportionate numbers and extreme risk.

And if we look at the largest single site cluster outbreaks at any time in the pandemic, we always see prisons and jails right up there among Grouped with other congregate living facilities. And massive risk, massive numbers of cases and deaths and very little mitigation or attention paid to this population 

Liam: and these health disparities you mentioned, are they limited to COVID or is this?

It's a much more long term problem. 

Lauren: No, they're not just limited to COVID. So people that do this work, people who are incarcerated, people who have been disproportionately affected by incarceration, have long known that there is such great disparity in the populations that are touched by incarceration. I think there are other public health crises we could point to.

We could HIV epidemic if we look at the numbers of people who are incarcerated, who have HIV. If we look at anyone who's cycling through the system, it's about one in seven people have HIV who are in our system currently, and the rate of HIV is three times higher than the general population. And that's just one example.

People who are incarcerated tend to, on average, have at least one chronic condition. And lots of health disparities in this population, and that's really primarily because of structural disparities in access to health care in this country, in particular in America. And also all of these other structural determinants of health, like lack of access to housing, to transportation, to employment, high rates of poverty.

All of these things disproportionately impact people. Who are also targeted by the system of mass incarceration in this country. And so it makes sense that you would see these health disparities as well. And so code is just one further example of a public health crisis in this setting among people who are incarcerated that has really not been the attention of public health actors and has been devastating to the population of incarcerated people.

Liam: You did mention your answer to the last question, the phrase in this country. So is this a US specific problem? Is there something like that makes the US particularly at risk to these health outcomes? 

Lauren: Yeah, it's a great question. Carceral settings in particular are settings of risk regardless of the country, right?

So if we have lots of people crowded in dormitory style congregate settings. There is going to be increased risk. But I think the U S is particularly risky for a number of reasons. So one, it's not just the setting itself. It's the fact that prisons are at about 104 percent capacity at any given time.

So that means that. Prisons are always on average overcrowded. And so it's not just congregate settings with lots of people. It's congregate settings with lots and lots of people. I think the other reason why the U S is particularly risky is because our system of mass incarceration is decidedly punitive, right?

Like we have decided that this is not a rehabilitative program. We don't want to better folks. We want to. Punish them. And so because of that, there tends to be a lack of public health programming, a lack of access to adequate healthcare in these settings, which makes the U S really distinct. And I guess the other thing I'll point out is our mass incarceration in America is a system that is born out of longstanding racist traditions, right?

So the system as we know it is an evolution of slavery to Jim Crow to. The current paradigm of mass incarceration. So we disproportionately target people of color in this country and incarcerate them at rates so much higher than any other country in the world. And so I think these are the things that make the United States unique.

And really is one important reason why the incarcerated population in this country was particularly impacted. 

Liam: Given this situation. What would you advocate to improve prison health, either for COVID or more long term? 

Alexandria: So in my view, there are really three strategies that are the key to curbing COVID 19 in prisons and jails, as well as immigration detention centers.

So those are mass testing, prioritized vaccination and decarceration. So the first two are really specific to the COVID pandemic. And the third can help us to narrow some of these vast health disparities that we've been seeing. And the long term, so I'll talk a bit about each of these. So first is mass testing of all people who are incarcerated and all staff members.

So mass testing of all incarcerated people at intake. At release and prior to any transfers is really key to reduce transmission. It's important because correctional facilities often rely on symptom based testing strategies. And these fail to identify people who are asymptomatic and people who are pre symptomatic.

This approach also dramatically underestimates the burden of COVID 19 in prisons and jails. That's one component. Mass testing of all staff members is also key. According to recent estimates, staff in prisons and jails are among the highest risk occupations for COVID 19 transmission, second only to healthcare workers.

But testing rates among staff are low. In a recent study of correctional facilities in Arkansas, less than a quarter of staff members consented to being tested. And unpaid leave was a key driver. So mandatory and routine testing of staff members and paid medical leave to those who test positive are really urgently needed to bolster staff testing.

The second of these three strategies is prioritize vaccination of all people who are incarcerated and all staff members. So I think this strategy is particularly important for those countries that haven't yet scaled up vaccine access to the full general population. So prioritizing people who are incarcerated and staff members in vaccine distribution plans is really important because their risks are astronomical.

So prisoners are three times more likely to contract COVID than the general population and case rates among staff are similarly high. And unfortunately, these groups are frequently overlooked when state and local governments start to devise their vaccine distribution plans. So in the U. S., only about 15 states included incarcerated folks and staff in phase one of their plans.

And in addition to being prioritized, whenever it's possible, vaccinations should also be mandatory for staff. So the third and last of these three strategies is decarceration. Decarceration, which is an umbrella term for strategies that reduce the number of people who are incarcerated, is really key to curb transmission.

Recent research from Dr. Brinkley Rubinstein's team found that in Texas, operating facilities at least 15 percent below their capacity COVID 19 infections and death. This is important because while several states enacted decarceration measures in initial months of the pandemic, incarceration rates in many areas of the country now meet.

or exceed pre pandemic levels. So how do we do that? Decarceration requires both reducing the number of admissions and releasing more people. For example, people who are at a greater risk of severe disease, like older adults, people with chronic conditions, and people who are immunocompromised should be prioritized for release.

In my view, The misfortune of being incarcerated during a pandemic should never be a death sentence. And more broadly, by curbing our over reliance on the criminal legal system, we can start to dismantle many of the norms that preserve and exacerbate systemic inequality. Decarceration can help us to narrow these huge racial disparities in health, alleviate the dual burdens of overcrowding and underfunding and mitigate our largest COVID 19 outbreaks.

So these three strategies, mass testing, prioritized vaccination and decarceration are the key to saving lives both inside and out. 

Liam: Finally, what would you say to those that might be just dismissive of prisoner health? 

Alexandria: So to those who might be dismissive about the health of people who are incarcerated, I would say prisons and jails are not an island.

While they have fences and bars and intimidating security to keep people inside, their populations are very dynamic. Each day, thousands of people are admitted and thousands of people are released. Each day, all the staff members in all the facilities go home to their families. There is constant movement and daily turnover in these facilities.

For this reason, disease outbreaks that occur in prison and jails rarely stay there. In spring of last year, nearly 16 percent of COVID 19 cases in the state of Illinois were linked to people churning through a single facility, the Cook County Jail. So to that person who might be dismissive about the importance of prisoner health, I would also say that this is an issue of equity.

So people who are involved in the criminal legal system are often also the most disenfranchised. So black people, for example, are hugely overrepresented. While black folks like myself are just 13 percent of the U. S. population, we're 40 percent of the incarcerated population. Prisons and jails are also filled with people who are poor, people who use drugs, and people with mental health conditions.

Truly, the overt discrimination and covert criminalization of people in these groups have widened disparities in health over the past few decades. And systemic anti black racism has both created and reinforced mass incarceration. I would say that mass incarceration is a manifestation of structural racism that perpetuates injustice, including huge disparities in health.

While the COVID 19 pandemic has placed a spotlight on these disparities, these problems aren't new. Policies that dismantle institutions that preserve and exacerbate systemic inequality and place at the forefront restorative justice and public health are urgently needed to protect human lives. By prioritizing the health and the humanity of people who are incarcerated, we can begin to unravel decades of racialized health disparities, and I think that's an ideal worth fighting for.

Gavin: Thanks so much to Liam and to his interviewees for doing that interview. It's just, it's So fascinating to hear about American prison dynamics is something that really interests me. And as well, we because America is such its own kind of fixed system when it comes to talking about prisons, American justice isn't really applicable to the rest of the world.

We also wanted to talk about COVID in low income settings. So the interview you'll hear after this. Is with Professor Marie Claire von Haut talking about situation in sub Saharan Africa. The thing that really struck me when setting up for this interview is not only how difficult it was to find someone with such a broad expertise of prisons and low income settings, but actually just how little data there is out there on the health situation in prisons in low income settings.

These are already countries that might have pretty fragile health systems. And so prisoners are then even lower on the rung to receive any kind of health care at all. And also it's probably not something really the states want you to talk about generally, the access to these prisons is restricted.

So health data. In terms of talking about prisons in low income settings is really quite scarce and difficult to put together and caheir across different countries. It was really great to find Marie Claire and talk to her about this. But yeah, a really fascinating situation, especially, given what we know about prisons in low income settings and generally the funding that goes towards prison health in those places.

Jessamy: And I'm so pleased that you did find her. I think it's brilliant to be able to platform her voice because she's obviously got a complete dedication to be able to get inside these places and to explore what's happening. That's deserves so much praise and much more attention. 

Gavin: It would be great to hear more voices from researchers on prison health in low income settings.

If anyone's listening to this podcast and is involved in that kind of research and wants to get in touch with us, we'd be we'd be extremely happy to hear from you. Because it's it's something I think we'd like to talk about more. With our advocacy for the vulnerable. People who are in prison and can't access Proper health care in low income settings.

It it doesn't often get much more vulnerable than that. 

Jessamy: And it does play into all other types of social determinants of health. And there are many lessons to be learned from looking at these extremely vulnerable people and trying to have some very deep understanding of how they've got there and the relationship that they have with other aspects of, the social determinants of health, education, family, food, jobs, employment, how those all feed into each other.

I think is a fascinating area that needs much more unpicking. 

Gavin: So I'm very pleased to be joined by Professor Marie Claire von Haut. She is Professor of International Public Health Policy and Practice at the Public Health Institute and Associate Dean for Research and Knowledge Exchange at the Faculty of Health at Liverpool John Moores University.

Professor Von Hout, thank you very much for joining me today. 

Marie Claire: Oh, you're very welcome. Thanks very much for having me on. 

Gavin: We're here to talk about prison conditions in Sub Saharan Africa, and we're looking more broadly at how prisons have fared during the COVID 19 pandemic worldwide. If we could set the scene, what are some of the difficulties that prison services normally face in low income settings, aside from the pandemic?

What are health conditions like for prisoners in these countries and what kind of aid treatment can they generally expect to receive when they're having health problems? 

Marie Claire: So it's a great first question particularly in the context of COVID 19. To give you some background prisons in low resource settings or low income settings are Generally very compromised, very congested at times, and this is often due to very high pre trial detention rates.

For example, in Africa, in some African member states, the pre trial detention rates can be up to 45 percent of the total prison population. I've visited many of these prisons in Africa. And conditions are dire, the cells are extremely congested, for example, at night, you would have up to 40, 50 people in one cell that could be designed for 8 to 10 people.

Conditions in terms of sanitation and hygiene are very poor. There are prisons for example, that don't have access to clean water. They don't have access to sufficient supplies of soap and disinfectant. The congested environmental conditions in cells, of course, are very conducive to the spread of disease, particularly airborne disease, such as TB.

There are also risks of spread of HIV due to this congestion and the risks for sexual abuse and sexual violence occurring. Of course, all of these environmental factors contribute to chronic ill health of prisoners. And when you couple that with a lack of access to adequate health care provision, in prisons, it leads to chronic ill health.

One other thing to mention is that there are also prisons that that are suffering from a lack of access to sufficient food. And this, compounds the chronic ill health and the ability of prisoners to maintain a standard of health. Again, one last comment to make, the congestion is caused by pretrial detention.

And that means you have mixing of remand detainees with sentenced prisoners. You have a high turnover of human traffic through the prison. And again, we have seen this now in COVID. And I'd like to say also that, the focus is very much on prisoners, but we are forgetting prison staff who experienced the same biohazards in the prison environment.

They work there, very often they live very close to prisons, their families live very close to the prisons and of course this creates a huge risk of transmission into and out of prison settings and it impacts on their families. 

Gavin: So moving on to talking about the pandemic, what evidence do we currently have about how COVID 19 has affected prisons in low income countries?

And I know of course your expertise is in Sub Saharan Africa. 

Marie Claire: Yeah, so first and foremost to say that, at the start the UN High Commissioner for Human Rights in March 2020 called for a range of measures to tackle COVID 19 in prisons. One of them was to instigate decongestion measures.

When I talk about Africa, there were a range of amnesties and presidential pardons and early release schemes instigated by all African member states to decongest their prisons. However, there is still an issue with the lack of transparency of exactly who was detained and the numbers of prisoners. who were detained.

States have different ways of publishing and not publishing their information. The pretrial detention continued during that time. So you have the revolving door of in and out of prisons. In terms of the growing empirical literature, what is encouraging to see is that there are, for Africa, more and more situation assessments that have been conducted in prisons.

For example, using the WHO COVID checklist for prisons to see the extent to which human rights have been upheld the level of preparedness in the COVID response and how disease mitigation measures have been instigated. And this is really encouraging. For example, I have seen some from Ethiopia.

I've been leading on several of the main South Africa, Zimbabwe and Malawi. And I think that it has maybe kick started an interest in prison health in Africa, which is very good because historically in Africa, the focus is on security and punishment. And there hasn't really been a lot of prison health research.

It's mostly being confined to HIV and TB studies. And, some small scale qualitative work on women's experiences in prison. So I think it's encouraging. I think there's more and more going to come now and more researchers are interested in prison health. 

Gavin: And of course, you mentioned HIV and TB there, which has always been a major problem in Sub Saharan Africa.

Has the pandemic had any knock on effects on incidence of HIV and TB? 

Marie Claire: So I think at the moment to my knowledge, it would be too early to say. However, I have been part of a UNAIDS UNODC consultation, a global consultation on this very issue. And there are huge concerns with regard to the threat that COVID poses to the gains that we have made in reaching HIV targets.

What we do know is that for many low resource settings. Government resources have been diverted to the COVID 19 health response. And this, of course, takes away from the general health response and even more so to prison health services, which are often last on the list to be resourced. During this consultation, the themes that came out were, there is still continued.

stigma and discrimination around HIV, AIDS and prison settings. The availability, the accessibility, and the coverage of evidence based HIV continuum of care is still unevenly distributed and coverage is low in prisons. The sustainability of these efforts are, very dependent on donors.

And, if there's low government resource allocation, there's a threat there. And also to say, we are increasingly viewing HIV as a chronic condition rather than a significant health threat. So in that way, COVID 19 threatens its place in the public health debate. And we do know through these situation assessments that are published at the moment.

That access to medication ART for HIV care, that is a challenge and that has been a challenge during COVID lockdowns in prisons. 

Gavin: Thinking about it in broader terms, without kind of vaccine justice for Sub Saharan Africa, which of course has seen incredibly low levels of vaccine provision and vaccination, what other provisions could be made to protect the health of prisoners in those settings?

Marie Claire: Yeah, so it's, it's a very topical issue at the moment. I am aware some African member states are designating prisoners as vulnerable populations and prison staff as well to be part of the priority list for vaccination which is very positive. I think aside of that because COVID 19 has amplified the gaps that are still there in, in prison infrastructure and prison system operations.

It needs to be used now to instigate government measures to improve prison infrastructure, which in Africa is very often dated and old and to, dedicate more resources in a strategic manner, not a proactive manner, but now a strategic manner. for disease control, disease mitigation and access to medical care for prisoners and also prison staff who are affected.

I know I would like to say also that it is reflective of rather weak criminal justice functioning. So it's a broader agenda that needs to be looked at. As I mentioned before, the pretrial rates are so high. that, in some African member states, individuals can be in pretrial detention for many years before their trial is heard.

There are very positive initiatives, for example, in Malawi, where there are camp courts, and these are used to, speed up the efficiency. of the justice side of things. And I think, a strategic public health and human rights approach is so important now to improve the situation for those who live and who work in prisons.

Many member states when they declared disaster measures or emergency measures it wasn't possible for Independent monitoring bodies to access prisons to, to assess and to document standards. And this needs to improve going forward that there are more regular inspections of prisons.

There needs to be, a greater focus on developing a system of alternative communication using technology so that prisoners can access their families and their legal representation. During prison lockdowns, there also needs to be more of a movement towards preventing solitary confinement as a way of medically isolating someone in quarantine.

There are reports of that occurring, and also the in, in addition to the reports of the complete lack of PPE provided to prisons in Africa and the complete inability for prisoners and prison staff to adequately protect themselves, that needs to be addressed. Because, I don't think we're at the last of pandemics and, now is the time for these prison systems to put together their strategies, their action plans.

And to make the prison environment safer for everyone. 

Gavin: We've been talking, of course, throughout, haven't we? As if, as if this data is here and it's easy to talk about and we have a kind of overview of it. But it must be actually really difficult to get health data about prisoners in these settings.

Marie Claire: Yeah, and, it goes back to my earlier answer, is that the, In some African member states, the level of health monitoring is weak, and some of the situation assessments on the COVID preparedness and response have also indicated a weak level of health monitoring. And often, in some of these situation assessments, the COVID tests were coming back two weeks too late.

And individuals were not isolated whilst waiting for test results and things like that. And when you think of how congested these prisons are, it's so conducive to the spread and transmission of disease. Yeah. So I think capacity building of prison systems and prison staff in health monitoring and the connection of prison health data to community level data and public health data is so important now.

Gavin: Thanks so much for listening to Lancet Voice. You can of course subscribe to the Lancet Voice, where you usually get your podcasts And we'd love to hear your feedback. You can reach us on podcasts at lancet. com. That's podcasts at lancet. com. Thanks so much for listening and we'll see you again next time.