“I feel like I’m in a prison” is a sentiment that has been echoed as stay at home orders around the country have gained traction, with almost every state in the United States having restrictions in place. People are encouraged to minimize leaving their home to “flatten the curve” of the rampaging coronavirus disease 2019 (COVID-19) pandemic. It has been two months since COVID-19 was declared a pandemic. People are itching to return to “normal,” to break out of their so-called home confinement; however, what is it like to be a person in an actual prison, right now, stuck in a crowded confinement that extends before and after this pandemic?
At the end of 2016, nearly 2.2 million people were incarcerated in the United States, which has the highest incarcerated population in the world. America’s incarcerated population is disproportionately black, as data from 2017 illustrated that Black Americans represented 12% of the country, but 33% of the incarcerated population. Correctional facilities are functioning with more prisoners than the official capacity of the prison system is meant to sustain.
Approximately one out of every four people incarcerated are charged with nonviolent drug offenses. Some people are incarcerated without actually having been convicted of a crime. When it comes to the incarcerated population’s health, one study found that 800,000 people who were incarcerated reported having a chronic medical condition, but they have limited accessibility to health care providers. In fact, one physician from a Connecticut correctional institution disclosed that he was the only physician to care for 1,500 inmates.
The Eighth Amendment of the Constitution states, “Excessive bail shall not be required, nor excessive fines imposed, nor cruel and unusual punishments inflicted [emphasis added].” In the 1976 court case Estelle v Gamble, the Supreme Court ruled that people who are incarcerated have a right to health care and that denying health care access or deliberate indifference to an inmate’s health falls under cruel and unusual punishment. Where then are we left as a pandemic floods through prison gates putting all of those inside at risk? Additionally, when the tidal wave of this pandemic recedes, what will we as future physicians carry forward to serve those who experience incarceration?
The environment of correctional facilities — to confine bodies all within the same, limited space — is unsurprisingly a perfect incubator to facilitate contagious disease spread. This potential is compounded by other factors such as bans on alcohol-based hand sanitizers, the transient movement of adults (approximately 7.3 million each year) in and out of local jails referred to as a “jail churn” and the staff of these facilities coming and going each day directly linking their local community to the residents of a correctional facility. The consequences of this environment have played out with the spread of other infections such as influenza and tuberculosis. Even with anticipation of this potential, it did not lessen the loss when, on March 28, the first inmate in a federal prison died of COVID-19 complications; his name was Patrick Jones, a 49-year-old man in Louisiana serving time for a nonviolent drug offense.
The Centers for Disease Control and Prevention (CDC) have published guidelines with recommendations for correctional facilities to mitigate the effects of COVID-19. These guidelines include loosening restrictions on alcohol-based sanitizers, providing no-cost and adequate supply of soap for handwashing and providing adequate communication to those who are incarcerated about COVID-19 risks, signs and symptoms.
In conjunction with these guidelines within correctional facilities, additional advocacy efforts are calling for active release of prisoners who are at higher risk for COVID-19 complications and who pose little threat to public safety. Advocates state that this will aid in alleviating overcrowding within correctional facilities and protect people that are at higher risk of becoming infected. Attorney General William Barr has released federal guidelines to help direct this process of decarceration. As this process of decarceration continues, some argue that health care professionals should be at the forefront of this advocacy work, citing the field’s ability to provide expert opinion, oversee release efforts and assess prioritization of prisoner release based on a comprehensive health screening. With that being said, what is the role of medical students and medical education in our responsibility to the incarcerated population?
In general, as future physicians, we are not educated on the incarcerated population. We learn about rare diseases that affect only one individual in a million, yet people who are incarcerated represent 1% of the population and correctional facility health care is mystified. How often in our medical education do we learn about anything other than the health risks associated with incarceration and understand how we as health professionals can support those who are incarcerated with transitioning into life after incarceration?
In writing this piece, we acknowledged our own gaps that had to be filled to understand just how the incarcerated population is so especially vulnerable during the COVID-19 crisis. Small studies have shown what is intuitive to most: experiences working with and learning from the incarcerated population enhances the care future physicians can provide to those who have experienced or are currently experiencing incarceration. Giftos et al state that “while Estelle v Gamble established the legal right to health care for incarcerated patients in 1976, this right has not guaranteed access to clinicians with the knowledge, attitudes and skills necessary to care for a vulnerable population in a complicated environment.” Perhaps our ignorance as physicians in training is not cruel and unusual punishment, but our complacency is at the cost of comprehensive health care that can and should be given to the millions of people who experience incarceration.
The outbreak of COVID-19 has magnified the fact that those experiencing incarceration are intimately tied to our society and community. It is our job as future physicians to choose to pay attention and make concerted efforts to not turn a blind eye toward people who are incarcerated as is frequently done by society. People who are incarcerated are entirely at the mercy of their institution as to how they are protected and medically treated. Someday we will be the physicians given the opportunity to deliver compassion and care to those individuals. Some of us will see these patients in the inpatient hospital setting for an urgent surgical procedure during their incarceration, or in a maternity ward when a person who is incarcerated is in labor, or in a primary care clinic for an annual physical months after they have been released from incarceration.
Now more than ever, we must recognize that society is intertwined no matter the geographic, political or physical boundaries. The boundary between those who are incarcerated and those on the outside is porous. If we want to be better prepared for the next pandemic and be better prepared to treat and serve our future patients, we must realize that COVID-19 is exacerbating pre-existing issues in correctional health care. It is up to us to take advantage of this opportunity to cultivate a culture that underscores the importance of correctional health care in medicine.