Incarceration is a Public Health Crisis, During COVID-19 and Beyond

December 08, 2020

Perspectives in Primary Care (formally the Primary Care Review) features perspectives from practitioners and students representing organizations, practices, and institutions across the country and around the world. All opinions expressed in this article are owned by the author(s).

The COVID-19 pandemic has made American inequality painfully clear. As case counts continue to rise across the country, some of the largest COVID-19 clusters in the US are in jails, prisons, and detention centers.

As of November 2020, 38 different institutions have reported greater than 1,000 cases. One study estimates that rates of COVID-19 in US prisons are 5.5 times higher than case rates in the general population. In these carceral institutions, the daily entering and exiting of staff—often with no mandatory testing, poor PPE adherence, and movement throughout the facility—serves as a chronic stressor for currently incarcerated people. Once the virus enters these facilities, many of which are already over capacity, there is not space to physically distance. Moreover, given their older age and disproportionately high burden of underlying conditions, incarcerated people are at greater risk of developing severe COVID-19 infections that require hospitalization or end in early death.

In response, imprisoned people are demanding decarceration and improved conditions: a new report shows that incarcerated people in the US collectively organized at least 106 COVID-19 related rebellions from March 17th to June 15th.

Consequences of outbreaks in carceral facilities

COVID-19 also spills over into the communities surrounding carceral facilities, especially jails. High rates of jail incarceration combined with frequent churn of individuals and staff—many of whom commute long distances—put surrounding communities at risk. Cook County Jail in Chicago, for example, was reported to be the “largest-known node” of COVID-19 spread in the United States, and the cycle of people through this facility was associated with 15.7% of all documented COVID cases in Illinois as of April 2020.

What’s more, as incubators of COVID-19 transmission, carceral facilities can quickly overwhelm local healthcare resources, taxing already critically stretched systems. The only way to protect both incarcerated people and their surrounding communities is to stop the flow of people into jails by halting arrests that lead to increased jail populations.

Roots of the current crisis

Like the dangerous working conditions of essential workers and the precarity of employer-based health insurance coverage, the factors that contribute to the COVID-19 crisis in US carceral facilities are structural and pre-date the pandemic. Incarceration is associated with chronic disease, including HIV, mental health diagnoses, hypertension, heart-related problems, diabetes, asthma, stroke, and overall lower life expectancy—both due to the experience of incarceration itself, as well as pre-incarceration exposure to structural determinants of health, such as poverty, houselessness, and racism.

Overcrowding in jails, prisons, and detention centers leads to the rapid spread of infectious disease, COVID-19 or otherwise. Conditions like inadequate healthcare, lack of nutritious food, extreme temperatures, and exposure to toxic water and mold also create poor health outcomes. The health and social harms of the carceral system extend to families and communities of incarcerated people through mechanisms like family separation, disruption of community cohesion, and economic strain. The disproportionate rates of incarceration across race, socioeconomic position, among LGBTQ+ people, and other marginalized groups also mean that the harms of the carceral system create and perpetuate health inequities.

Leading scholars of mass incarceration point to many policies that explain how the US came to incarcerate large swaths of the American public for at least some moment in their lives. Policies and practices of policing that disproportionately target people of color, such as “broken windows” policing or stop-and-frisk, have served to entrench systemic racism, creating the conditions for disproportionate incarceration of Black and Brown people.

An overarching factor across many policy decisions is that the carceral system became the default way to address a broad range of social problems and public health issues (e.g., poverty, houselessness, drug use). Police, for example, are often tasked with responding to acute mental health emergencies and substance use, even though these problems would arguably be better addressed by mental/behavioral health professionals or community-based treatment centers. Arrest begins a process of criminalization that has lifelong consequences. In this view, incarceration can be thought of as the floor that millions of people hit after falling through the gaps in the social safety net.

Investment in the structural determinants of health

Investment in carceral “solutions” has always been, and continues to be, avoidable. In fact, state governments that pursued policies and public investments designed to bolster the social safety net (e.g., SNAP programs, Medicaid, primary and secondary education, unemployment insurance) had lower average prison incarceration rates and better health outcomes. Similarly, providing community-based support to people navigating substance use disorders, rather than responding with criminalization and punishment, is a recommended evidence-based policy to decrease stigma and increase uptake of treatment.

Moving forward, a primary prevention approach should reallocate funding from the construction of new jails and prisons to the structural determinants of health, including affordable, quality, and accessible housing, healthcare, employment, education, and transportation.

In the context of the COVID-19 pandemic, urgent action to release currently incarcerated people is the only way to prevent additional clusters and related deaths. The individual stories of those who have died from COVID-19 while incarcerated are heartbreaking:

  • James Allen Smith, a 73-year-old retired teacher, was only supposed to be inside a Texas prison for a few months, sentenced to a drug and alcohol rehabilitation program. Mr. Smith died in prison from medical complications of COVID-19, leaving behind a grieving family.
  • Gerald Barragan, 62 years old, was serving five years and also died in prison from COVID-19.
  • Alfredo De La Vega died of COVID-19 twelve days before his 20-year sentence was to be completed. 

The excessive amounts of time these men were serving are as upsetting as the fact that they died from an infection that could have been prevented had public health measures been quickly instituted within jails and prisons.

A recent report published by researchers at the University of Texas at Austin found that at least 231 people have died from COVID-19 in the states’ correctional facilities as of early October. While decarceration is necessary for all those who are incarcerated, regardless of conviction, it is striking that 80% of those who died in the county jails in Texas were incarcerated pre-trial and had not been convicted of a crime.

Call to action

The American Public Health Association recently issued a policy statement recommending a move towards abolition by beginning with the immediate release of incarcerated people, especially urgent during the pandemic. An abolitionist approach to treating carceral systems as a public health issue means taking an approach of primary prevention by investing in structural determinants of health, including affordable, quality, and accessible housing, healthcare, employment, education, and transportation, instead of carceral institutions.

Public health and medical professionals have a role in advocating for the immediate release of people incarcerated in jails, prisons, and detention centers, regardless of conviction, especially in light of pressing concerns related to COVID-19 transmission, but also given the longstanding health harms of incarceration.

There is an enormous need to support existing community-based interventions to address the medical and social needs of people who have been harmed by the criminal legal system, including those transitioning from incarceration, particularly during the pandemic. It is equally important to prevent incarceration by preventing arrests and criminalization overall, including those that occur in hospital or healthcare settings.


About the authors

Jackie Jahn, PhD, MPH, is a Postdoctoral Researcher at the City University of New York. Her social epidemiologic research seeks to understand and address the role of carceral systems (jails, prisons, policing, and related institutions) in producing population health inequities. 


Christine MitchellChristine Mitchell, ScD, is a Senior Research Associate with the Health Instead of Punishment program at Human Impact Partners (HIP), where her research focuses on the health harms of policing, incarceration, surveillance, and immigration enforcement. 


Cheryl Conner photoCheryl Conner, MD, MPH, is an Academic Hospitalist at the VA and an Assistant Professor of Clinical Medicine at the University of Illinois at Chicago. Her research interests include racism in medicine, structural violence like policing and incarceration, and the opioid epidemic.


**Feature photo by Wendy Alvarez on Unsplash


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