By Diana Ho
I. Introduction
During the COVID-19 pandemic, the majority of the largest single-site outbreaks in the U.S. were located in jails and prisons, and incarcerated people were deprioritized in the distribution of COVID-19 vaccinations. Furthermore, the prevalence of sexually transmitted infections (STIs) such as Chlamydia trachomatis and Neisseria gonorrhea in incarcerated populations is 3 to 5 times more than the general population and other STIs such as syphilis, trichomonas, herpes, and HPV are more prevalent in jail and prison inmates. At the same time, about 40 percent of incarcerated people in state and federal prisons are disabled, which presents a problem in which disabled people are more susceptible to infections while incarcerated.
In “A People’s Guide to Abolition and Disability Justice,” author and organizer Katie Tastrom argues that while any space with a congregation of people inherently creates a risk for infections, the tightly-enclosed nature of prisons and jails and deprioritization of infection management for incarcerated people may suggest evidence for a concept called “carceral epidemiology.” Tastrom states that carceral epidemiology is understanding public health in the way in which the state (i.e., the government and its formal and informal uses of control) uses communicable diseases as part of the informal punishments of incarceration.
This article will present current data on the status of disease and infection management in the U.S. federal and state prisons and its impact on the 40 percent of the incarcerated population who are also disabled. Following the introduction, the article will inform the reader on the history and management of communicable diseases in prisons, the impact of these diseases on disabled incarcerated people, and the current proposed steps to address these issues.
II. History and management of communicable diseases in carceral settings
Overall, the management of COVID-19 infections in U.S. federal and state prisons were a failure but its impact may be more appropriately viewed through Tastrom’s view of “carceral epidemiology” in which the mismanagement is not necessarily a one-off mistake or coincidence but an informal practice of carceral punishment. Historically, U.S. federal and state prisons have been the epicenter for communicable diseases and infections due to its dense population, enclosed spaces, deprioritization in vaccinations, failures to adhere to guidelines on infection management, and poor hygienic and sanitation practices.
For example, two correctional facilities in Maine witnessed influenza outbreaks which resulted in one intensive-care unit (ICU) admission, one death, and a total of 46 infected inmates and staff members in 2011. During the outbreaks, the correctional facilities faced a number of obstacles: (1) insufficient staff to handle the surge in medical care, (2) inaccessible medical records to establish vaccination status and underlying medical conditions, (3) inaccessibility to sufficient quantities of vaccine and antiviral drugs; and (4) a lack of skilled personnel who were trained to administer a large volume of vaccine and antiviral drugs in a timely, appropriate manner.
Furthermore, the flu season from 2017 to 2018 was particularly impactful in correctional facilities, partly due to the strain, but also correctional facilities failed to adhere to the standards of care for flu prevention and management set by the Centers for Disease Control and Prevention (CDC). In January 2018, at the Coffee Creek correctional facility in Oregon, only 18 percent of its prison’s population were vaccinated for the flu. Despite the fact that the Oregon Department of Corrections (ODOC) had purchased about 500 vaccines for its over 1,600 population, only 300 of the vaccines were actually administered. Some incarcerated individuals complained that the ODOC failed to notify them of the availability of the flu vaccines, and the Coffee Creek correctional facility was not the only prison in Oregon that fell short of the recommended vaccinations; in fact, other prisons and jails in Texas, Iowa, and Kentucky also witnessed low vaccination rates.
Other communicable diseases such as STIs and tuberculosis (TB) have also been problematic in carceral settings. Specifically, about 1 in 7 people who are infected with HIV pass through the correctional system each year and despite the fact that TB has declined steadily between 1993 and 2013, incarcerated people continue to witness TB at a higher incidence than the general population.
It is important to note that the management of communicable diseases in carceral settings, or infection prevention and control (IPC), is contemporary. IPC was not formally introduced to healthcare in carceral settings until 1991 when the National Institute of Corrections published the inaugural prison healthcare guidelines by Jaye Anno. In 1994, the CDC hired the first position focused on carceral health—an assistant position for corrections and substance use—but this position was dissolved by 2003. The CDC failed to create another position specifically for healthcare in carceral settings until 2022 during the COVID-19 pandemic despite the fact that the CDC created positions for HIV, hepatitis, STD, and tuberculosis prevention in its other centers for the general population. Evidently, IPC in carceral settings is not a high priority—if a priority at all.
This is quite clear as Bick (2007) presented that carceral settings face a plethora of challenges regarding infection management: clinical care settings lack hand washing stations, soap and soap dispensers are considered to be valuable commodities and may be stolen, PPE is often stored in locked containers, most jails and prisons are overcrowded, shower access is restricted, clothing and linen is strictly rationed which may be problematic for instances that may include exposure to blood, bleach is contraband, common areas are infrequently cleaned, incarcerated populations are moved between facilities without consulting clinical services, and most clinical settings have delays to see incarcerated people. Coupled with aging infrastructure and poor ventilation, there is an imminent yet largely unacknowledged need for IPC.
III. Impact of communicable diseases on incarcerated disabled people
Nearly 2 in 5, or about 40 percent of incarcerated people in federal and state prisons are disabled: about 24% have a cognitive disability, 12% have an ambulatory disability, 12% have a vision disability, and 10% have a hearing disability. About 43.9% of incarcerated people in federal and state prisons have ever had a chronic condition: cancer, hypertension, stroke-related problems, diabetes, heart disease, kidney disease, arthritis, asthma, or liver issues. In comparison, about 26.9% of the general population have been impacted by the same chronic diseases.
Chronic diseases such as hypertension and diabetes rose among incarcerated populations: the rate of diabetes in 2011 to 2012 was almost twice the rate in 2004 and the rate of hypertension was almost 1.5 times the rate in 2004 which was similarly observed in trends for asthma, arthritis, and heart diseases. About 73% of incarcerated populations reported that they had this chronic condition at admission, and 6 in 10 incarcerated people reported taking prescription medication and more than 3 in 10 people reported receiving a different type of treatment.
However, there is minimal literature on how the prevalence of communicable diseases in carceral settings impact incarcerated disabled people specifically. While it is known that, in the general population, those with chronic diseases are at higher risk for severe outcomes from infectious diseases, there is little literature on how communicable diseases impact the lives of incarcerated people with a pre-existing chronic health condition or disability. It may be assumed that, in light of the information revealed on the poor IPC and management of communicable diseases in carceral settings and that, in the general population, people with chronic diseases face more severe outcomes from infections, incarcerated people living with pre-existing chronic health conditions or disabilities are both more susceptible to infections and may face severe outcomes at a more frequent level.
IV. Further steps
During the COVID-19 outbreak, groups in carceral settings took it upon themselves to create their own provisional healthcare system as prepandemic governance structures failed to involve incarcerated individuals as a part of the decision-making process. Instead, the ‘informal role’ of incarcerated people in the decision-making process with the local leadership of carceral settings for COVID-19 testing and education allegedly witnessed improvements in unification. Within the framework of existing carcerality, other researchers suggested that carceral health should be a part of the public health framework by collaborating with the CDC and state and local health departments to establish partnerships, improve IPC training and education, implement rigorous accreditation processes, train and deploy more IPC workers, increase disease surveillance by requiring regular reports, develop evidence-based guidance, allocations of federal funding for vaccination programs, strengthen guidelines, and fund research for the implementation of IPC in carceral settings.
However, these recommendations all operate under the current carceral framework: (1) it assumes that there is nothing flawed with the punishment system of carceral systems to begin with, (2) that the fundamental, structural nature of carceral settings (i.e., overcrowded correctional facilities with poor infrastructure) is inherent to society, (3) collaboration with other apparatuses of the state will somehow grant long-term improvements, and (4) the propagation of the idea to continuously rely on the state (such as through federal funding or collaboration with federal agencies).
Under the current carceral framework, perhaps minimal changes may be made in terms of improving IPC, but incarcerated individuals will still continue to be incarcerated to begin with—and they will not be free from the underlying problem. Carceral settings are not systems or places for healthcare; carceral systems are institutions of punishment. Its existence and its neglect of the health of its populations is not by coincidence: evidence has demonstrated that prisons and jails are epicenters of communicable diseases and that federal agencies (such as the CDC) failed to act upon its consequences. Alternatively, carceral settings would benefit from the abolitionist perspective: it recognizes that the carceral system is entrenched in the prison industrial complex (PIC) in which the majority of incarcerated people also face social issues outside of carceral settings. The PIC is defined as an interwoven web of rules, policies, institutions, businesses, government interests, and policies which benefits from the carceral punishment of incarcerated people. Moving mass amounts of people (specifically those who are susceptible to being targeted by the PIC such as undocumented or non-white people) between both public and private institutions like hospitals to cages, the PIC is far more globalized than local. Private enterprises have an integral and key stake in the PIC: their presence is ubiquitous. In order to properly address the problem of disease and infection management in U.S. prisons and jails, it is most appropriate to approach it through a carceral epidemiology framework which recognizes the PIC and its capitalist interests as its underlying structure.
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