BY: FRED ROTTNEK, MD, MAHCM
As I child, I was drawn to the rituals of Lent and the Easter season. It started with ashes on our foreheads, and Fridays meant Stations of the Cross. There was something about the physicality of doing the Stations — facing directions we normally didn't face in church; rhythmic kneeling, standing, listening and responding; and hearing heartbreaking stories of every type of cruelty. Holy Week opened with palms and pageantry, then foot washing, processions to kiss the cross, stripping of the altar, lights lowered and then brightened. And then Easter morning exploded with joyful hymns, alleluias, and the sights and smells of Easter lilies.
During holy season this year, I was often isolated with my cats in my home study due to our county state-at-home order. So I am surrounded by my icons and statues of my favorite patron saints, as well as crosses and crucifixes from around the world. I spent Easter Sunday writing one of four legal declarations I have done about COVID-19 and the risk of outbreak in jails and prisons. As a physician with experience in caring for those in detention, I wanted to draw attention to the very real infection concerns inmates face in their close quarters. For the St. Louis region, I worked with ArchCity Defenders; for Miami-Dade County in Florida, I partnered with the Advancement Project; in Tulsa County, Oklahoma, I wrote with Still She Rises, and in Prince George County in Maryland, I advocated with Civil Rights Corps. One of these declarations was sheer advocacy. The others were in support of plaintiffs who all have medical conditions that place them at high-risk status.
I wrote about the inability to physically distance, as well as the inadequacy of testing, protective personal equipment (PPE), cleaning supplies, and workforce to even approximate the Centers for Disease Control and Prevention recommendations to mitigate the spread of COVID-19 in correctional facilities. I combed through affidavits of people held pretrial who reported the disconnect among proposed containment plans and the realities of lockdown. These statements given under oath included reports of soap and cleaning supplies that were inadequate or absent. Some people in detention were isolated days to weeks at a time. Inmates were not given masks or were given masks with no instruction regarding how and when to use them. Inmates were forced to use one shared toilet during the day without instructions on physical distancing, regular temperature checks or updates about COVID-19 and their personal risks.
Jails have all the characteristics to accelerate the spread of COVID-19 in any community. Poor and less healthy populations are overrepresented in jails. Black and brown men and women also are overrepresented in jails and prisons, and we know these same individuals have a much increased susceptibility to infection and death with COVID-19. Infection containment and quarantine are appropriate, but they don't constitute medical treatment. The energy put into these preventive efforts pulls resources for chronic care and sick call, the process that allows inmates to get seen for medical care.
Moreover, correctional officers, medical staff and vendors who provide food, medications and other needed supplies cycle through institutions daily — often with inadequate screening, PPE and other safeguards. They risk their own infection, bringing COVID-19 into the facility as well as bringing it back to their families and their communities. Absenteeism will increase — further stressing already stressed and typically understaffed facilities. Pretrial detainees will have to be released if they make bail, if their cases don't progress to trial, or if they are found innocent. Together with staff and vendors, they serve as vectors to infect and reinfect populations — all while we have national shortages for testing, tracing and PPE.
As information about COVID-19 explodes, we are learning how much we don't know about this virus. One particularly frightening finding was published by Reuters on April 25. In an aggressive testing program in four state prisons — Arkansas, North Carolina, Ohio and Virginia — 96% of inmates who tested positive for the virus had no symptoms. And of the 4,693 inmates tested, 70% were positive. Although the 70% is startling, even more concerning is the fact that 96% of these inmates were completely unaware that they were infected and were shedding the virus to fellow inmates, medical and correctional staff and visitors to the facilities.
Some jails are taking steps to release inmates in order to free up space to more closely approximate the CDC's social distancing recommendations. As of April 22, 2020, over 1,400 people have been released from Rikers Island in New York City. By that date, there had already been at least 10 deaths and 1,200 positive tests among inmates and staff. The Prison Policy Initiative, a criminal justice think tank, reports that the Los Angeles County Jail has reduced the jail population by over 5,000 people (about a 30% decrease) "over the past several weeks." Many other county jails have dropped their populations by 30%-50%.
However, even with these releases, most facilities cannot engage in social distancing and resources remain scarce. Riots have broken out in Washington and Louisiana tied to fears of the virus and of catching it. Many inmates and families are finding venues to tell stories of their worry and of inadequate opportunities to communicate with both loved ones and administrators.
Officials face difficult decisions. And no one in these decision-making roles could have predicted this pandemic. In considering release of inmates, public and community safety must be balanced with the personal safety of inmates. No one wants to release an inmate who reoffends upon release. But no one should have a criminal justice sentence turn into a death sentence due to neglect or scarcity of basic resources.
So, what can we do with a system so hopelessly complex and frequently unjust?
Most of us know of a local jail or prison ministry. (I have worked with Criminal Justice Ministry in St. Louis for a decade.). The ministries may be independent or parish-based, but they tend to be fueled by volunteers with lived experience — either they have been incarcerated or a friend or family member has. Such lived experience ignites passion for this work and connection for people who are usually out-of-sight and out-of-mind. For those who are justice ministers, echoes of metal clanging against metal, concrete floors, stale air and sally ports are regular surroundings.
Talk to them. Ask them what they need. Use your lived experience, your professional connections and your voice to elevate the response to those who are still incarcerated during this pandemic. Support your local officials to make the right decisions. Offer the resources they need to educate and enforce guidelines for all those who live and work behind bars. Encourage release of pretrial individuals who are held because they can't raise the cash bail assigned. There are alternatives. Remind everyone there are always alternatives — and those can be considered and put into use in ways that reflect both compassion and safety.
As we move forward in Ordinary Time, in this very extraordinary time, I'm on call to testify in hearings in Miami, Tulsa and Prince George County. And I'm at work with my colleagues at Saint Louis University School of Law to determine how we can use lessons learned in our current crisis as a foundation for more justice: for effective and compassionate criminal justice and health policy.
Jesus' sentencing and death is not the end of the story. We cannot allow COVID-19 to be the end of the story for people and communities we have set up to fail in broken and biased systems. Lent is a time of repentance and reflection, and Holy Week is a story of disruption. COVID-19 is accelerating the disruption. Let us harness this spirit to disrupt these systems that have created the antithesis of health and flourishing.
FRED ROTTNEK is professor and director of community medicine, and the program director of the addiction medicine fellowship, Department of Family and Community Medicine, Saint Louis University School of Medicine. He is the medical director of the physician assistant program in the university's Doisy College of Health Sciences and teaches in the Center for Health Law Studies, St. Louis.
Copyright © 2020 by the Catholic Health Association of the United States
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