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New Jersey Legionnaires’ Disease Outbreak Kept Quiet in State Prisons

After one person died and another spent a month in a coma, state officials found Legionella bacteria in the water at two New Jersey prisons.

by Akela Lacy, The Intercept

After Jamil Robinson drank the water from the infirmary at East Jersey State Prison, he became so violently ill that prison officials quietly sent him to the hospital. On February 9, Robinson was placed in a medically induced coma, which he stayed in for more than 30 days. When he woke up on March 12, nurses told him he had contracted Legionnaires’ disease, a rare form of pneumonia.

Unlike many pneumonias, Legionnaires’ isn’t spread from person to person but rather through water contaminated with a bacterium called Legionella—meaning that if Robinson had contracted it, anyone else sharing his water source was likely at risk. If left untreated, the infection can be fatal; according to the Centers for Disease Control and Prevention, one in ten people who contract Legionnaires’ will die. But Robinson said that by the time of his return, people incarcerated at EJSP had heard nothing about Legionnaires’ disease or Legionella contamination from prison officials.

“Everybody was surprised,” Robinson told The Intercept. He’s a well-known figure at EJSP, where he is president of a public speaking forum, and other people at the facility had been asking what had happened to him. When he told them, they were shocked.

Staff never announced that anyone had contracted Legionnaires’ disease, according to Robinson and one other person incarcerated at EJSP, who requested to speak anonymously for fear of retaliation. And they didn’t tell people to stop drinking the water until two weeks ago, Robinson said. According to both Robinson and the other person, prison officials did not provide free bottled water to anyone except corrections staff.

On April 16, Rutgers Health, which regularly sends public health notices to New Jersey prisons, distributed a flyer about how Legionella grows and how the disease spreads to post in all housing units and on must-read boards.

“It’s like Rutgers is taking the responsibility of explaining to us the health situation,” said the second person incarcerated at EJSP.

Robinson, who was not aware of the memo, heard about it from a prison liaison officer. “I’m like, they’re just getting around to saying this?” he said. “I almost died. Are you serious?”

The facility started posting additional information about Legionella on its internal online service kiosk [in mid-April], according to the second person.

[On April, 22, 2021], New Jersey Department of Corrections Director of Communications Liz Velez told The Intercept that people incarcerated and working at the facilities were notified about water remediation “via various communication platforms including onsite television screens, board postings, JPay kiosk messaging and through word of mouth from Tier Representatives.” She added that the NJDOC is providing access to bottled and potable water.

Both Robinson and the second person at EJSP allege that prison staff boiled tap water before giving it to the incarcerated population but then added ice from the same source. The bottled water went only to corrections staff, they both said.

Meanwhile, according to Robinson, the second person at EJSP, and two organizers who work closely with the prison’s population, residents in three wings at the facility started returning their food trays last week in what some described as a hunger strike to protest prison conditions. Their grievances include a lack of hot food, hot running water, and bottled drinking water, as well as frustration with ongoing visitation restrictions due to the COVID-19 pandemic, according to all four sources. Velez denied that any strike is currently ongoing.

Robinson and the other person at EJSP added that the prison has shut down drinking sources without explanation in the past.

“The water situation, it’s been an ongoing thing for years,” the second person said. “There’s always a problem with the water, and they’re always giving free water to the officers.”

About 14 miles away, at Northern State Prison, or NSP, officials found Legionella in the water in early April, reported. One person at the facility had recently died from what the president of the state’s largest corrections union told were causes not necessarily related to the bacteria.

News of the death traveled through the prison grapevine, eventually reaching both Robinson and Ibrahim Sulaimani, an organizer who was formerly incarcerated at EJSP until being paroled in 2018. Sulaimani, now the executive director of Transformative Justice Initiative in Camden, New Jersey, heard about the case from the cousin of Jason Guzman, who is deceased according to NJDOC records, with his last day in custody listed as February 26. Guzman’s cousin is currently incarcerated at EJSP.

Citing conversations with the cousin, Sulaimani and Robinson believe that Guzman died at NSP of Legionnaires’ disease. (Every incarcerated person and advocate who spoke to The Intercept for this story alleged that someone at NSP had died of Legionnaires’.) When reports of Legionella contamination at NSP emerged in early April, local media highlighted the concurrence with a death at the facility, though the precise cause remained unclear. Guzman’s family could not be reached for comment.

While Guzman’s record indicates a death in late February, the NJDOC told The Intercept there was a case of Legionnaires’ at NSP in early March. “The last reported cases of Legionnaires was a singular individual in early Feb at EJSP and an isolated case in NSP in early March,” Velez said.

Between the two facilities lies Union County, where last month New Jersey’s Department of Health started investigating a cluster of Legionnaires’cases now believed to be related to cooling towers. Fourteen cases, including one death, were reported in the county in February—the same month that Guzman is alleged to have died at NSP in neighboring Essex County. As of March, the health department had identified 18 cases, 17 ofwhich resulted in hospitalization.

The outbreak “is not related to a death at Northern State Prison,” Department of Health communications director Donna Leusner told The Intercept, noting that the prison is outside Union County. (Although both NSP and EJSP are outside county lines, they sit just beyond the borders.)

The NJDOC says there are no active cases of Legionnaires’ at their facilities, but it acknowledges that Legionella was found in water samples from one facility at NSP and three areas at EJSP.

“NJDOC has been working with the Department of Health to address this issue,” Velez said. The corrections department moved 19 people housed at the unit where Legionella was detected at NSP and monitored them for two weeks while they fixed water lines, she added. Water samples with Legionella at EJSP were found in areas where water was not utilized by incarcerated people or staff, so no one at that site was relocated.

When Legionnaires’ infections happen, the health department steps in and begins an investigation, which includes testing water samples to determine whether Legionella is present, said Dr. Janet Stout, president of the Special Pathogens Laboratory and research associate professor at the University of Pittsburgh Swanson School of Engineering, who is credited with discovering the link between Legionella bacteria in hospital water systems and Legionnaires’disease infection. If the bacteriais present, the health department should then take steps to disinfect the water. There are challenges to carrying out that process in a prison, Stout said, but it’s not impossible—and the risk would likely not be confined to one unit.

“It’s unusual to move people out of a unit or facility,” Stout said. “It wouldn’t be confined to that because the water system’s not confined to there.”

According to Stout, the complex nature of prison water systems and the concentration of people at a high risk for Legionnaires’—the elderly and people with chronic lung and other health conditions—make prisons prone to Legionella growth and susceptible to outbreaks of the disease. Prisons use mixing valves to temper water, she explained, meaning that warm water comes out of a single fixture at an ideal temperature for Legionella to grow.

“The way they deliver water for security reasons and safety reasons may increase the likelihood of Legionella being there,” Stout said. “Legionella is the problem you don’t think you have until you have it.”

Amos Caley, a pastor and organizer with a faith-based advocacy group called New Jersey Prison Justice Watch, claimed that officials knew for more than a month that Robinson had contracted the disease. Robinson and his wife Cheryl agreed, adding that a nurse had told Cheryl about Robinson’s diagnosis while he was still in the coma.

“The doctors and I guess the staff here kept it under wraps,” Robinson said. “It wasn’t until I got back that this word started spreading and they started covering water fountains and telling people not to drink the water. People are saying, why didn’t they give a public announcement earlier, before I came back?”

Caley suspects that Guzman’s death, too, resulted from Legionnaires’ disease. “It wasn’t until somebody died that Legionella was found in the water,” he said, referring to the nearly two-month gap between when Guzman died and when the NJDOC acknowledged their Legionella findings.

Velez directed questions about Guzman’s case to the state medical examiner, who told The Intercept they could not provide his autopsy report or cause of death at this time. Asked about Robinson’s case at EJSP, Velez said the NJDOC would not comment on an individual’s medical history out of concern for privacy.

New York is one of the only states that mandates preemptive water testing for Legionella, so it makes sense that the New Jersey corrections department didn’t detect the bacteria until after someone had died, Stout said. An industrywide standard from the American Society of Heating, Refrigerating, and Air-Conditioning Engineers recommends preemptive water testing to monitor potential Legionella growth, but such testing is voluntary in most states.

“More likely than not they didn’t know Legionella was in the water until a case occurs,” Stout said. “Which is obviously not how you want to find out about a risk.”

Caley pointed out that the handling of both cases is characteristic of how incarcerated people are treated, and this has been especially true throughout the pandemic. “We’ve seen it over the past year, just this complete and utter neglect of people’s lives.”

New Jersey was one of several states to drastically reduce the number of people in state correctional facilities amid the coronavirus pandemic, releasing more than 2,250 people on one day in November. At the same time, people incarcerated at New Jersey state prisons have reported inadequate medical attention.

According to NJDOC data, just one person in New Jersey state correctional facilities has died from COVID-19 since July 27. More than 50 people died between April and July 2020, prior to advanced phases of testing. Since late August, more than 1,600 incarcerated people in New Jersey have tested positive for the coronavirus, which could explain why other potential cases of Legionnaires’ may have gone undetected—if someone got sick, it was assumed they had COVID-19.

Robinson was expecting to be released in February pending enactment of a new law ending mandatory minimums for certain offenses. A state sentencing commission, which recommended the law as a way to remediate the state’s record disparities in the number of Black people behind bars, recommended the reduction of mandatory minimum sentences for two of the crimes Robinson was convicted of, finding that they were typically“subject to penalties associated with far more serious offenses.”

Then Robinson got sick, and when he came out of his coma, lawmakers in Trenton were bickering over the piece of legislation that would have secured his release. Though the law passed the New Jersey General Assembly last August, Gov. Phil Murphy conditionally vetoed a reintroduced version of the bill last week, citing a state Senate amendment that would have expanded the law to cover public officials and law enforcement charged with corruption or misconduct. The same day, New Jersey’s attorney general issued an order to law enforcement that ended mandatory minimum sentences for nonviolent drug offenses, which Robinson hopes will give him another shot at returning home. Murphy said the order took“strong action to stop these unfair prison sentences”and made it easier to return the bill for revision.

Earlier this month, Robinson filed a tort claim in preparation to sue the state for negligence.

He’s still getting his fine motor skills back and learning to feel steady on his feet again. Legionnaires’ can have lasting neurological effects, and Robinson thinks that spending a month lying on his back, staring at the ceiling without his glasses, didn’t help.

“I find myself staring out.” Robinson said. “Cognitively, it may seem like I’m OK. But it’s certain things that I know—it’s not right.” 


This article by Akela Lacy was originally published by The Intercept on April 29, 2021; republished with permission from The Intercept, an award-winning nonprofit news organization dedicated to holding the powerful accountable through fearless, adversarial journalism. Sign up for The Intercept’s Newsletter at

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