Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

Captivity and COVID-19


Severely ill incarcerated individuals will be hospitalized at disproportionately high rates during this pandemic. As always, healthcare professionals should treat them with dignity and respect. Better care of those who are imprisoned may help with our public health efforts and response.

We’ve all already been affected by the COVID-19 pandemic. Some have been infected and are still presymptomatic; others are ill or have recovered. As many as 30% of people could lose their jobs, and many are unable to pay rent or buy food and other essential items. This pandemic is laying bare many ways in which systems fail our communities. Yet, in the public eye, detainees and the incarcerated remain unseen and are being forgotten.



Incarceration facilities encourage infectious disease spread

As of April 2020, 2.3 million of the United States population is incarcerated, 30,737 of which are in the custody of Immigration and Customs Enforcement or Customs and Border Protection. Thus about 0.7% percent of the population is incarcerated in some form. This population is at higher risk of preventable COVID-19 and other infections. Jails, prisons, and other detention centers are overcrowded, even requiring their inmates to exist in standing-room-only conditions for weeks to over a month. Reports from one facility cite nearly 900 people crammed into space intended for 125. Baby bottles have gone unwashed between uses. State and federal prisons also overcrowd: the three feet between the incarcerated at these facilities is impossible to reconcile with the CDC’s own recommendations for six feet of separation, including in jails and prisons.



Such facilities are historical and are modern incubators for infectious diseases. Concentration camps and prisoner of war camps are well known examples. More recent incarcerated populations worldwide are also at risk of infections. An estimated 15% are infected with hepatitis C virus, almost 4% have HIV, almost 3% have tuberculosis. As recently as 15 years ago, 100 per 100,000 people processed through ICE detention have been diagnosed with tuberculosis.



Continued intentional negligence of detainee health

These detention facilities are not just theoretical breeding grounds for disease. Their existence is even now a health hazard. The U.S. Customs and Border Protection agency’s refusal to vaccinate detainees violates safety recommendations from the Centers for Disease Control, and has already led to deaths in their facilities. While CBP has cited difficulties in setting up such a program as an excuse, that agency has continued to refuse private citizen volunteers to come and administer influenza vaccinations for free, going so far as to facilitate arrests of physicians demanding vaccination and themselves offering their own labor to vaccinate. Other infectious diseases such as mumps, lice, chickenpox, and scabies have already spread through detention centers. Continued inaction will lead to so much preventable morbidity and mortality that one has to wonder if exposing the incarcerated to infections is a mere side effect of incarceration, or if it is being welcomed as a component of retribution.



Incarceration facilities are predictably facilitating disease spread

Predictably, prisons are now experiencing COVID-19 outbreaks. As of April 26, an increasingly infamous outbreak in the Rikers Island facility in New York City had 378 confirmed-positive cases—close to 10% of the population has been diagnosed as a confirmed positive case of SARS-CoV-2 infection, compared to the whole of New York City’s close to 2% of the population. Across the facilities for which the Bureau of Prisons is responsible for, almost 10,000 cases have been confirmed. All of these numbers are likely undercounts. 131 people have already died as of April 24  within these facilities, and more will die—transmission is ongoing, and not all existing cases have yet resolved.



Detention centers had begun to see the same and detainees raised the alarm, driven to the desperation of initiating hunger strikes. As of April 27, ICE has reported 360 cases among detainees, and 35 among the employees assigned to detention facilities. These facilities could be interpreted as much more crowded parallels to the Diamond Princess, the cruise ship off the coast of Japan in February 2020. Over the course of the almost full month it took to disembark everyone on board, the ship served as an incubator as staff transferred the virus from room to room ending in over 700 people infected out of the total 3,711 on board. Keeping prisons and detention centers populated is the same sort of mistake but in more densely populated enclosures.



Though the Federal Bureau of Prisons (BOP) states that cloth masks have been administered to prisoners, a review of the evidence thus far doesn’t support that universal requirement of worn cloth masks demonstrates significant enough benefit to justify the decision to keep people incarcerated and at greater risk of infection. Additionally, from the same document, the BOP assures that inmates are placed in isolation if symptomatic. However, recent evidence suggests that nearly half of transmission occurs prior to symptom onset. Neither mask wearing nor isolation of symptomatic cases are replacements for what needs to be done to protect the incarcerated humans we are sentencing to inhumane punishment by disease: release.



Release of the imprisoned and detained is required to guarantee public health.

The time to release detainees and other incarcerated populations was well before COVID-19 cases began to appear in prisons. Prison walls are not magically virus deterrent. Enforcement officials can serve as carriers between the incarcerated and free population, and the opposite is also true—new prisoners and detainees can seed new outbreaks in prisons. The incarcerated that become severely ill will contribute to the filling up of hospitals that are already struggling to cope with the sheer number of patients seeking critical care, ventilators, and other supplies. The legal sentence is not punishment by disease. For the sake of the incarcerated, which includes a disproportionate number of persons of color and LGBT individuals we are demanding a much larger scale release of incarcerated populations than has begun to happen both for their own health, as well as for the safety of everyone. Elected officials need to save lives by releasing incarcerated populations. Every minute wasted is another opportunity for a new transmission event and yet another life lost.



Because of the great risk those behind bars are being forced to endure, more of them may be coming under your care than before the COVID-19 pandemic. But as before the pandemic, incarceration is itself a source of trauma. We urge our fellow caretakers, now more than ever, to work at practicing trauma-informed care. It’s not an easy road. For the individual in front of you, it depends on both their experiences and the ways in which systemic issues like racism can traumatize. Safety is a key component of trauma-informed care, but that is difficult to secure for our patients right now. We can only guarantee their safety by repairing systemic traumas beyond the pandemic itself.



Supporting patients who have experienced incarceration, as noted above, requires applying principles of trauma-informed care, including the following tips:


1. Provide a welcoming and supportive environment for patient visits.


2. Be transparent about why sensitive questions are being asked, emphasizing that it is the patient’s choice whether to share information.


3. Limit documentation of incarceration or involvement in the legal system unless clearly relevant to patient’s medical care. Understand the real risks of stigmatization if incarceration is mentioned in the medical chart.