Status of the Pandemic Heading into Summer
by Michael D. Cohen, M.D.
Though the coronavirus pandemic continues to rage in the United States and around the world, numerous areas of the country have staged re-openings. They were premature and poorly conceived, so it’s no surprise that half the states have increasing numbers of cases.
Several states subsequently had their largest single-day case reports, and hospitalizations also are rising. We are still in the first wave of this pandemic. A second wave is anticipated this winter. It is estimated that fewer than 5% of the U.S. population has been infected so far, so the population is largely still susceptible. Widespread disease can occur if uncontrolled community transmission is allowed to occur.
At press time, cases, hospitalizations and deaths continued to decline in New York, New Jersey and other states in the Northeast. It is believed that this is the result of slow and carefully calibrated re-opening of commerce. But numbers may be stabilizing at a plateau of 30 to 50 deaths a day in New York state.
Largest Clusters are
in Prisons and Jails
The New York Times publishes lists ofclusters of cases throughout the U.S. The largest cluster included over 2,000 cases at the Marion Correctional Institution in Ohio. The top five clusters were all prisons and jails, each with over 1,000 cases. Among the top 10, eight were prisons or jails, all with over 1,000 cases. The other two were meat-processing factories. Among the top twenty, 15 were prisons or jails, four were meat processing factories, and one was the Navy aircraft carrier Theodore Roosevelt.
Although the largest clusters are in prisons and jails, the largest number of deaths from COVID-19 are among nursing home residents. Roughly 50,000 nursing home deaths have been reported in the United States, out of 120,000 total deaths, 40% of the total as of June 17 when I am writing this.
Deaths Among Prisoners,
Guards and Civilian Staff
The Times reported on June 16 thatcases in jails and prisons are increasing rapidly. The total number of cases doubled to more than 68,000 in the past month. Deaths among incarcerated people also are rising. Close to 600 prisoners and prison employees have died from the virus.
However, thus far the epidemic in prisons has not been the deadly disaster that was anticipated. In one Ohio prison that tested all prisoners once, more than 80% of those who were infected had no symptoms. It was thought that prisoners would be at higher risk for more severe COVID-19 disease. Hard lives, more older prisoners than ever before, long-term organ damage from alcohol, smoking, HIV and hepatitis C, high prevalence of stress and high blood pressure all put prisoners at higher risk. We mourn all deaths, but wonder why, fortunately, prisoners are largely recovering, not getting more severe disease and dying.
No one knows for sure (yet). What factors may have made the prison population more resilient? Here are a few guesses. Jail and prison populations are largely young men and women under 40. Most younger people recover and often have no symptoms. What about increased physical fitness? Many prisoners value physical ability, muscle mass and stamina. What about diet? Could deservedly loathed prison diets be less toxic than the usual fast food diets enjoyed by more and more of the free public?
What about obesity? Is the prison population fed less than the general public? What about smoking tobacco? Most prison systems prohibit smoking or limit it to the outdoor yard. Healthier lungs may have resulted in fewer severe cases of COVID-19. What about the tuberculosis vaccine BCG suspected of helping reduce the severity of the pandemic in some countries? Many immigrants to the U.S. come from areas of the world that routinely immunize BCG in infancy, such as Caribbean and Eastern European states. Many prisoners are immigrants from these countries.
Mitigation in Correctional Facilities
Several recent articles have discussed what needs to be done to control COVID-19 in prisons and jails.
The federal Centers for Disease Control and Prevention (CDC) published a report in its Morbidity and Mortality Weekly Reports on surveillance of correctional facilities in Louisiana. It found that many facilities had inadequate space to quarantine close contacts and had to resort tocohorting groups of exposed people in dormitories. Another finding: It is impossible to practice social distancing in dormitories. Of course these are not new ideas and were predicted in advance. It is useful, however, that such observations have been confirmed in print.
The CDC made the following recommendations to mitigate spread of the virus in facilities: suspend transfers and visitation; provide ready access to hand hygiene, including running water for prisoners and staff; symptom screening and 14-day quarantine at intake; symptom screening of staff at each shift; dedicated space for isolation of cases and quarantine of close contacts; symptom screening and coordination with public health in the home community before release; personal protective equipment (PPE) for staff and prisoners with duties that may expose them to infected prisoners; and assignment of staff to specific housing units.
They also reported on reasons prisoners did not report illness or symptoms or seek care. People did not report their illness because they did not want to be medically isolated. Also, required payment for medical visits was a factor in decisions not to report illness, symptoms or seek care.
An opinion article in the New England Journal of Medicine by Dr. Anne Spaulding at Emory University in Atlanta and several colleagues discussed how to preparefor COVID-19 in a correctional setting. The goals are to delay entry as long as possible; control transmission if it is already in a facility; and prepare to manage a large number of sick people.
Their recommendations included: population reduction through release of elderly and infirm prisoners and all those least likely to commit new crimes; suspend arresting and sentencing for low-level crimes and misdemeanors; isolate infected and suspect-infected people from general population; hospitalize those who are seriously ill; prepare for staff shortages that are likely to occur with widespread disease. They point out that reducing the burden of disease in prisons and jails will reduce the burden on stressed hospitals in the local community. Also, it is important to prevent prisons and jails from becoming reservoirs of disease from which the local community is repeatedly re-infected.
Releasing Prisoners to Control Spread and Protect the Vulnerable
Efforts have been undertaken to obtain release of prisoners, to protect the vulnerable from the disease and enable facilities to support physical distancing of a reduced population.
Lawsuits to free vulnerable prisoners, new state laws and advocacy for release of prisoners have been attempted in many states. Some releases and changes in arrest and bail practices have reduced populations in local jails. However, efforts to obtain release of convicted felons in state prisons have largely failed to achieve that goal.
One of the problems is the absence of any legal mechanism by which convicted prisoners can be released other than parole practices and executive clemency. Governors do not want to accept the political risks associated with clemency, especially in large numbers.
One strategy proposed in an Emergency Release bill in the New York legislature was to give the commissioner of the Department of Corrections and Community Supervision (DOCCS) “discretion” to release vulnerable people directly to parole in emergency circumstances such as a pandemic. Release was to be subject to a public safety review. Only people who had a home to be released to would be considered, so as not to further overburden homeless shelters in the home communities. Creating a legal mechanism for release of convicted felons directly to parole during the pandemic might have been a model for the nation.
This bill was being actively considered for passage in both the state Assembly and Senate in a package of COVID-specific reforms. While not explicitly requiring releases, it did provide a legal mechanism for release to parole where there was none readily available otherwise. It was widely believed that the DOCCS commissioner would have used his new discretion to release at least some of the prisoners at greatest risk for severe COVID-19 disease.
But it was not to be. Prisoner advocates, mistakenly believing that their broader proposals to limit segregation (HALT) and release older prisoners (Elder Parole; and Fair and Timely Release) could possibly pass this session, actively opposed the bill. Their bills are good, but they were not moving forward this session. The advocates found the Emergency Release bill to be too weak, unlikely to lead to much change in practice and very likely to push their bills off the agenda.
Seeing controversy, the legislative leadership killed the bill. However, since no state prisoners were being released due to COVID-19 other than accelerating parole by a few weeks or months, anything would have been better than nothing. Collaboration with legislators to achieve something on prisoner releases this session would have been a better approach and would not have permanently alienated former legislative allies.
Some Progress on Treatment
Recently announced research studies appear to have shown some positive results in treatment.
Remdesivir: This antiviral medicine was developed to treat Ebola, which is caused by another type of coronavirus. The study showed that patients treated with remdesivir had shorter time on an artificial breathing machine (ventilator) and shorter overall time in hospital. However, there was no effect on the number of people who died. This medicine is potentially useful because less time on a ventilator means the machines turn over more rapidly and can be used for more patients. There were insufficient numbers of ventilators to treat all the patients who needed them during the height of the pandemic in Italy.
Dexamethasone: This is a corticosteroid medicine that reduces inflammation. It is not an anabolic steroid that builds up muscles. It is an old drug that is already widely used, is readily available, and inexpensive. The study examined the effect of the drug on people treated with oxygen and people who required mechanical breathing with a ventilator. This is the first medicine that has been shown to reduce the number of people who died. Among people on a ventilator, 30% fewer people died. Among people treated with oxygen, 20% fewer died.
It is emerging that there are persistent consequences of more severe COVID-19 disease. People who have been hospitalized, treated in intensive care, sedated, and supported by artificial breathing machines often have persistent organ damage or disability. Physical therapy, occupational therapy, respiratory therapy, speech therapy, dialysis and special kidney failure diets, and counseling for depression are all needed to support people as they recover from COVID-19. These ongoing health care needs are just starting to be recognized. Among thousands of those who have recovered, there is still a long road ahead. The health-care system has not yet expanded rehabilitation services to meet these needs.
The virus has spread widely, butefforts to diagnose, trace contact, and quarantine those who have been exposed have prevented initiation of uncontrolled community transmission in many areas. It is not too late to stop the virus from entering a facility. It is not too late to initiate measures to mitigate virus spread if it is introduced.
About the author: Michael Cohen was the medical director for the New York state juvenile justice system for 20 years and previously provided medical care for incarcerated adults at the New York City Rikers Island jail and at Greene CF in Coxsackie, New York. For 10 years, he participated in a support group for people with diabetes at Great Meadow CF in Comstock, New York. With the group, he co-authored the Prisoner Diabetes Handbook published by Southern Poverty Law Center and distributed by Prison Legal News. Heal the sick. Raise the fallen. Free the prisoners.