Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.
AMA Chief Experience Officer Todd Unger speaks with AMA Director Health Equity Policy & Advocacy Mia Keeys, CMO of the Center for Alternative Sentencing and Employment Services (CASES) Elizabeth Ford, MD, and former CMO of NYC Jail system and clinical associate professor at NYU Homer Venters, MD, on updates regarding COVID-19 including COVID-19's tremendous impact within the incarceration system and the biggest challenges physicians face when providing care in that setting.
Learn more at the AMA COVID-19 resource center.
Unger: Hello, this is the American Medical Association's COVID-19 update. Today, we're discussing COVID-19 tremendous impact within the incarceration system. I'm joined today by Mia Keeys, the AMA's health equity policy director in Washington, DC, Dr. Homer Venters, former chief medical officer of the New York City jail system and clinical associate professor, NYU College for Global Public Health in New York, Dr. Elizabeth Ford, chief medical officer, Center for Alternative Sentencing and Employment Services or CASES in New York. I'm Todd Unger, AMA's chief experience officer in Chicago.
COVID-19 has hit our incarceration system especially hard. Ms. Keeys, What are the biggest challenges physicians face when providing care in an institutional setting such as jails?
Keeys: Yes. Well, our physicians have been facing serious concerns prior to COVID and unfortunately COVID has just completely exacerbated the challenges that they were facing before, which include not necessarily having enough access to materials to properly care for inmates who are patients and not necessarily having the ability to really provide, in a way, maybe dignity for their patients the way that they are deserving of, irrespective of their status as those who are in prison. And so kudos to our frontline physicians and our health care professionals who are working hard out there. The pandemic exacerbates these existing inequities and speaks to the flaws in the system that make giving care quite difficult. And overall, jails and prisons are just—they're overrun. They're crowded. And they lend themselves, unfortunately, to spread of disease in a way that had there been policies and practices in force before that really quelled spread of disease, we wouldn't be seeing a lot of that.
The other thing we have to keep in mind is that a lot of our physicians are dealing with persons who were vulnerable to comorbidities and other chronic conditions prior to being incarcerated. And so these increased comorbidities, the lack of access to care prior to incarceration, this makes all of the inmates susceptible to complications related to COVID-19. And that includes not just physical disease, but also mental illness and those who are suffering from substance abuse disorders and such like that. So these are the things we need to keep in mind when we're talking about policies and practices that help and support our physicians who are in the frontline in incarcerated sessions.
Unger: Dr. Venters, Dr. Ford?
Dr. Ford: Hi, it's Elizabeth. Thank you very much again, for the invitation. I absolutely agree with what Mia described. I also just wanted to add from the physician perspective, working in jails and prisons is extraordinarily isolating, and you can feel much like the lowest priority when it comes to national and professional organization advocacy. And so in addition to all of the challenges that are faced in these kinds of settings, there's also a feeling that you are not as important and that you're cut off from the community, even though jails are public health outposts, where many people who are in the community health care system will cycle in and out of. And so that adds, I think, an additional burden on physicians in these settings, particularly at a time like this, with the pandemic.
Dr. Venters: Hello everybody. And thank you for the invitation. And I think I don't have a lot to add except to say that these health systems, correctional health systems, have always lacked oversight, support and resources that we assume exist for health care services. So the state departments of health, the CDC, the Joint Commission, CMS, all of these evidence-based organizations are essentially AWOL when it comes to oversight and promotion of health quality and transparency behind bars. So when something like COVID-19 happens, we find that correctional health staff and patients are assumed to be reacting in an evidence-based way. But in fact, it's impossible because the same institutions that promote health care quality and transparency for us in the community don't do that behind bars. And so we can't think that we can copy and paste a set of infection control guidelines from a hospital and slap them into a jail where nobody really has cared about infection control before
Unger: To follow up on that, why have jails become such hotspots for virus transmission?
Dr. Venters: I can give a quick answer. I'm involved in about 30 or so investigations around the country of COVID-19 response. And so that's county jails, state and federal prisons and ICE detention. And I think most of us understand the congregate nature of detention settings. People are crammed together in close spaces. The physical design promotes the spread of disease, but also the operations, the way they're run. There is a high tolerance for squalor, for filth, for having vermin, rodents, for food trays stacked up for days and days, a lack of access to handwashing. These are the realities for people who are incarcerated, almost universally. And so both the physical design, but also the operations and the lack of transparency mean that when COVID does arrive, it spreads like wildfire through these places.
Keeys: And I just want to add, Dr. Venters, to what you're saying about squalor and just the associations of institutional facilities. The tenor is not necessarily to really coddle or to really wrap our arms around those who are in prison. And so a lot of the times, the conditions of prisons can be associated with feeling like prisoners are responsible for what it is that they're experiencing. And that's not necessarily the case, because to your point about oversight and policies that are abided by within these structures, it's not supposed to be a personal responsibility of the prisoner to necessarily say, "This is the standard of care that I deserve compared to the standard of care that I may be receiving."
And unfortunately, a lot of prisoners—what we do know in the US is that those who are imprisoned are disproportionately African American men who are coming into spaces where the bias is set up such that they are not viewed as persons of society who are supposed to receive health and health care as a right, given what it is that they may have done, or at least been arrested for and adjudicated for. Those are often situations that are considered the choices that they made. Therefore, this is where they exist in. And that's unfortunate. And those are absolutely the policies that we need to change if we're talking about really infusing a health care and equity lens into our justice systems.
Dr. Ford: If I could just add with respect to the infection risk, it's important to remember that jails also have very rapid and unexpected turnover, meaning that the admission rate is very high. People are coming in, sometimes directly from the street, and jails frequently have—they don't have the appropriate screening or resources available to appropriately care for people coming in so quickly. And then on the backend, on the entrance back into the community, very, very rarely are they resourced well enough to be able to safely transition somebody back out.
Unger: Well, given those challenges, what can we do to address those?
Dr. Ford: Well, for one—
Dr. Venters: Well, go ahead, please.
Dr. Ford: After you, Dr. Venters.
Dr. Venters: I would just say the first job is release. And this is something we've seen really great progress in some particularly county jail systems, local systems. Because first of all, we know that there are people who are incarcerated that are at much higher risk of serious illness and death if they contract COVID. We know generally who those people are. And working with local prosecutors and judges, many local jurisdictions have been effective at really reducing the number of people behind bars. That's important for their safety. It's important to decrease the likelihood that local health systems will be completely overrun, like we saw in Joliet, Illinois, one community hospital overrun by one correctional facility over a weekend.
But it's also important because as we manage outbreaks behind bars. And having done that for a lot of smaller outbreaks, it's impossible to manage the outbreak operationally if you can't move people around, if you can't say, "These people will stay in this house or housing unit because they're sick or because they've had contacts." All of that basic infection control management for an outbreak requires space. And so if you're Alabama state prisons and you're at 150% of your capacity in the prison system, it's virtually impossible. And they're not the only ones. And so I think that the release is critical for all three of those reasons.
Dr. Ford: Not just a—sorry, go ahead.
Keeys: In addition to release, also evaluating what happens on the front end in terms of evaluating certain codes that really place people into prisons to begin with. During COVID-19 we're hearing stories. And I can offer an anecdote about what's happening in Toledo, Ohio. There have been young men who have been picked up and imprisoned because they are "participating in non-essential activities," which essentially just means that they're hanging on the corner, and that they may not be doing anything but talking to friends and practicing bad physical distance and hygiene. But those are not grounds for arrest, and certainly not grounds for long-term detaining or detention of those persons. And then also just re-evaluating keeping certain persons in prisons. And while certainly none of us condone the use and sale of narcotics, but really evaluating the codes around small crimes that are nonviolent, that may or may not necessarily be drug related. But releasing people on one of those grounds is an imperative.
And then also to your point, Dr. Venters, about release, once persons who are formerly incarcerated are released, so justice-involved persons who are released, ensuring that they're set up with social benefits that put them in safe housing, that help them to restore full benefits with respect to civic engagement, with respect to foods and such like that, that are nutritious and that are affordable. These are the policies that we absolutely have to have on the front end with respect to reevaluating who's arrested in the first place and detained. And then on the release end, ensuring that persons are really put back into society in a way that promotes success as opposed to recidivism back into the system.
Dr. Ford: Yeah, I absolutely agree and was going to—my point was about the admission process also. I think there is no reason that individuals need to be incarcerated for anything other than acute danger. It should not be because they cannot pay bail, or because there's some quality of life issue that is leading them into that institution. But I would also add, in terms of solutions, I think reducing the isolation of these institutions from the community is critical, even with a simple thing like medical information exchange and record exchange. When a community provider's patient goes into one of these facilities, very rarely is there communication with the health care providers on the inside. And that that creates fractured care. And that is terrible for the patients and bad for staff morale in all sorts of situations.
And then these institutions also really struggle with consistent leadership and consistent staffing. And to me, as earlier point about these problems existing for a long time and being exacerbated in the pandemic, if there's not consistent and strong leadership across these systems and institutions, policies will not change, and they will not be durable. And then whatever next administration comes in, we'll have to start over, or we'll start something new. And that's not a way to manage medical care or systems in my opinion.
Unger: Yeah. Dr. Ford, those challenges also seem like they would take a significant toll on the actual physicians within those settings. Can you talk a little bit about how we address the mental toll that this pandemic has taken in this type of setting?
Dr. Ford: Sure. It's not psychiatry. It's the thing kind of stuff that I think everybody should be doing and trying to do for each other. But in these institutions, I think it's imperative that the leadership take accountability and responsibility for allowing their staff flexibility in perhaps ways that they haven't been accustomed to, flexibility around schedules, recognition of the importance of things like sleep and exercise, and regular breaks. These are not things that are generally encouraged in jails or prisons. And so I think that part is very important. Having rotational work so that the expectation is not that you come in 12 hours a day or double shifts for weeks on end at a time like this. And this is across all of the disciplines, correction officers, health care staff. Unfortunately, correction officers in this country have very high rates of suicide without the added stress of this pandemic. And so all of the care that we're thinking about for the patients also has to apply to the staff.
Unger: Well, I want to thank you very much for your thoughts and perspectives. Appreciate you being here, Ms. Keeys, Dr. Venters and Dr. Ford. That's it for today's COVID-19 update. We'll be back with another COVID-19 update tomorrow.
In the meantime, for additional resources on COVID-19 go to the AMA COVID-19 resource center at ama-assn.org/COVID-19. Thanks for being with us here today.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.