Prisons and jails are coronavirus epicenters – but they were once designed to prevent disease outbreaks

Calls for help at Chicago’s Cook County jail, where hundreds of inmates and staff have COVID-19, April 9, 2020.
Kamil Krzaczynski/AFP via Getty Images

Jails and prisons around the United States are considering freeing some of their inmates for fear that correctional facilities will become epicenters in the coronavirus pandemic.

COVID-19 has infected hundreds of prisoners and staff in city jails, state prisons and federal prisons.

New York, California and Ohio were among the first to release incarcerated people. Other states have followed, saying it is the only way to protect prisoners, correctional workers, their families and the broader community.

Jails and prisons often lack basic hygiene products, have minimal health care services and are overcrowded. Social distancing is nearly impossible except in solitary confinement, but that poses its own dangers to mental and physical health.

As a prison scholar, I recognize a sad irony in this public health problem: The United States’ very first prisons were actually designed to avoid the spread of infectious disease.

Early American jails

The first U.S. prisons emerged in reaction to the overcrowded, violent, disease-infested jails of the colonial era.

Prisons as we understand them today – places of long-term confinement as a punishment for crime – are relatively new developments. In the U.S. they came about in the 1780s and 1790s, after the American Revolution.

Previously, American colonies under British control relied on execution and corporal punishments.

Jails in America and England during that period were not themselves places of punishment. They were just holding tanks. Debtors were jailed until they paid their debts. Vagrants were jailed until they found work. Accused criminals were jailed while awaiting trial, and convicted criminals were jailed while awaiting punishment or until they paid their court fines.

The British penal reformer John Howard visiting a prison.
Wikipedia, CC BY-NC

Consequently, early American jails were not designed for long detentions, even if people sometimes stayed for months or longer.

The physical structure of these unregulated local facilities – often run by sheriffs or private citizens who charged room and board fees – varied. Jail could be a spare room in a roadside inn, a stone building with barred windows or a subterranean dungeon.

Fear of disease

Disease, violence and exploitation were rampant in these squalid American colonial and British jails.

John Howard, a British aristocrat whose ideas influenced American penal reformers, became concerned about living conditions in these “abode[s] of wickedness, disease, and misery” when he became a sheriff. In a 1777 book, Howard recounts smelling vinegar, a common disinfectant of the era, to protect against the revolting smell of the jails he visited.

Howard warned readers that jails spread disease not only among inmates but also beyond, into society. He recalled the so-called Black Assize of 1577, in which prisoners awaiting trial were brought from jail to an Oxford courthouse and “within forty hours” more than 300 people who had been at court were dead from “gaol fever” – what we now call typhus.

He also wrote of infected prisoners who, once released, brought diseases from jail into their communities, killing scores.

Disease also shaped Howard’s understanding of how criminality spread.

He described how young “innocents” – the children of people jailed for debt or those awaiting trial for a petty offense – were seduced by dashing bandits’ stories of crime and adventure. Thus “infected,” they went on to become criminals themselves.

America’s first prisons

Howard’s ideas, particularly the realization that jails posed a threat to the public, were brought to the U.S. by Philadelphia reformers like Benjamin Rush, a physician and signer of the Declaration of Independence.

Following the recommendations in Howard’s book, American penal reformers pushed for new jails designed to ward off disease, crime and immorality of all kinds.

Howard envisioned new facilities that would be well ventilated and cleaned daily. Clothing and bedding should be changed weekly. There would even be an infirmary staffed by “an experienced surgeon” who would update authorities on the state of prisoner health.

Howard’s plan for a ‘County Gaol’
The Royal Collection Trust

American reformers followed Howard’s advice that “women-felons” should be kept “quite separate from the men: and young criminals from old and hardened offenders.” Debtors, too, should be kept “totally separate” from the “felons.”

Prisoners should be separated from one another, ideally in cells. Crowding should be avoided. All this would prevent the spread of disease and enable the prisoners’ repentance – and thus their rehabilitation.

Using Howard’s book as their guide, Rush and his colleagues transformed Philadelphia’s aging and overcrowded Walnut Street Jail into one of the country’s first state prisons by 1794. The Walnut Street Prison model was soon adopted nationwide.

Philadelphia’s Walnut Street Jail.
Wikipedia Commons

Health care in prisons today

The U.S. long ago departed from the idea that prisons should protect both prisoners and society.

The biggest shift in prison health care occurred between the 1970s and today – the era of mass incarceration. The U.S. incarceration rate doubled between 1974 to 1985 and then doubled again by 1995. The number of people in American prisons peaked in 2010, at 1.5 million. It has declined slightly since, but the U.S. still has the world’s largest incarcerated population.

Prison building, although unprecedented in scale, has not kept pace. Many corrections facilities in the U.S. are dangerously overcrowded.

A gymnasium turned dorm at the California Institution for Men in Chino, May 24, 2011.
Ann Johansson/Corbis via Getty Images

In 1993, 40 states were under court orders to reduce overcrowding or otherwise resolve unconstitutional prison conditions. Many more lawsuits followed. Still, the prison population grew.

One consequence of overcrowding is that prison officials have a difficult time providing adequate health care.

In 2011 the U.S. Supreme Court ruled that overcrowding undermined health care in California’s prisons, causing avoidable deaths. The justices upheld a lower court’s finding that this caused an “unconscionable degree of suffering” in violation of the Eighth Amendment’s prohibition on cruel and unusual punishment.

Amid a worldwide pandemic, such conditions are treacherous. Some of the worst COVID-19 outbreaks in U.S. prisons and jails are in places – like Louisiana and Chicago – whose prison health systems have been ruled unconstitutionally inadequate.

Criminologists and advocates say many more people should be released from jails and prison, even some convicted of violent crimes if they have underlying health conditions.

Opponents of coronavirus-related releases, including state officials in Louisiana, contend that the move poses a high risk to public safety. And victims of violent crimes complain that they have not been notified when their victimizers are set to be released.

The decision to release prisoners cannot be made lightly. But arguments against it discount a reality recognized over two centuries ago: The health of prisoners and communities are inextricably linked.

Coronavirus confirms that prison walls do not, in fact, separate the welfare of those on the inside from those on the outside.

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Ashley Rubin, Assistant Professor of Sociology, University of Hawaii

This article is republished from The Conversation under a Creative Commons license.

South Africa's COVID-19 lockdown: cigarettes and outdoor exercise could ease the tension

There is no documented health benefit that warrants banning cigarette sales for 21 days.
Getty Images

What do South Africa, China, Germany, the UK and the US have in common? That each differs from the other. Ample empirical evidence shows that economic and health measures that work sometimes, in some places, don’t always work everywhere.

South Africa’s President Cyril Ramaphosa has been praised for being decisive in the face of the COVID-19 outbreak. We agree with this positive view. Ramaphosa has demonstrated a quality of leadership matched by disappointingly few leaders globally. But we fear that some of the recently implemented policies are not best for the South African context. South Africa could be charting its own course, for the benefit of the nation and continent.

As matters stand, the South African lockdown emulates and, in some respects, surpasses restrictions elsewhere. Some of the restrictions are gratuitous, impractical or harmful.

What is lockdown in South Africa?

South African lockdown restrictions are among the most extreme globally. South Africans may not leave their homes except to procure essential goods and services. This excludes the purchase of cigarettes and alcohol. It also excludes outdoor exercise.

For those living in freestanding properties in the suburbs, and enjoying an uninterrupted salary from a large company or institution, the lockdown is a little like a spiritual retreat. They can stay at home and drink coffee in their pyjamas on the deck without even a passing car to disturb them.

But most South Africans do not live like this. Even wealthy South Africans often live in complexes or estates without access to non-communal outside space. And many more live in crowded accommodation, whether in poor urban areas, formerly wealthy suburbs, central business districts, or well-spaced rural dwellings that are nonetheless occupied by many people.

It is one thing to stay in a suburban house, with a nice garden for fresh air and sunshine. It is another to spend the day in a small shack with 10 other people, especially when only “an estimated 46.3% of households had access to piped water in their dwellings in 2018”.

Domestic violence, rape and child abuse are serious problems in South Africa. Most of these crimes are committed by people close to the victim. The lockdown measures are likely to place stress on abusers and make it hard for the abused to escape.

It is no surprise that the lockdown restrictions are already being widely violated. This is not about disobedience: it is about the difficulty of complying. If you have to leave your dwelling merely to answer a call of nature, then you are not in a meaningful lockdown. And even with army support, policing will be extraordinarily difficult. Communities would need to fall into line of their own volition, and their circumstances make it hard for them to do so.

Cigarettes as essential goods

Nicotine withdrawal causes bad temper, frustration, agitation, anxiety and mood swings. The damaging health effects of smoking are well established, but although early stages of lung-recovery are visible a full month after one stops smoking, there is no evidence suggesting that COVID-19 symptoms are alleviated by 21 days of abstinence. There is no documented COVID-19 health benefit within a 21-day window to warrant prohibiting the sale of cigarettes. But there is considerable short-term risk to the mental wellbeing of those who use tobacco as a coping mechanism.

This restriction on civil liberties causes misery for no public health benefit and may increase the risk of domestic violence as people suffer withdrawal in confined and stressful circumstances.

The prohibition of alcohol makes more sense. But behavioural factors must be considered, including the incentive to stockpile and the criminal opportunity for bootlegging. Restricting alcohol purchase prior to the lockdown might have made sense. That window has closed. At this stage the case for putting alcohol on the list of essential goods is weak. The case for including cigarettes, however, is strong.

Outdoor exercise is essential

“No jogging. No dog walking. Stay inside.” That is the message from the government. This is a public health problem of note: exercise, even a small amount of it, is essential to stay healthy, especially for the elderly, and thus many of those most at risk from COVID-19.

Exercise, including mild exercise such as going for a walk, appears to alleviate or prevent depression. It is easy to write off the value of mental wellbeing at a time when serious physical disease threatens. But this is a mistake. Mental illness has physical consequences for the sufferer and those around them, and can make life seem not worth living.

When defining “essential goods and services”, we must ask “essential for what?” There is much that is not strictly essential to our survival that nonetheless we value greatly. We may even value some of these things above survival, such as the wellbeing of our children.

The current usage of the word “essential” imposes a value judgement. It makes the avoidance of COVID-19 infection the paramount goal. It implicitly places less value on mental health, and even physical health where that is independent of COVID-19.

Is a lockdown right in South Africa?

Context matters. Whether the lockdown works depends on the context in which it is done. The lockdown is worthwhile if it prolongs life for a significant number of people. But some of the measures in South Africa have no health benefit.

South African leaders should consider the full range of responses available to them, and assess the costs and benefits within their context. Regional quarantine arguably failed in Italy, but was apparently more successful in China. South Africa was designed by the apartheid government to keep people apart.

What is to be done?

We are not advocating inaction or negligence. Reducing the rate of infection is a laudable goal. We would suggest, in particular, the addition of cigarettes to the list of basic goods, and the insertion of a right to exercise out of doors provided physical distance is maintained (along the lines of guidelines elsewhere).

More generally we suggest that, given very different conditions in relatively wealthy suburbs, inner cities, crowded low-income areas and rural areas, restrictions be considered on a provincial or local rather than a national basis. This is in line with the successful practice in China.

Benjamin T H Smart, Associate Professor, University of Johannesburg and Alex Broadbent, Director of the Institute for the Future of Knowledge and Professor of Philosophy, University of Johannesburg

This article is republished from The Conversation under a Creative Commons license.

Pandemic underscores gross inequalities in South Africa, and the need to fix them

Per-Anders Pettersson.
GettyImages

Now more than ever, South Africans are painfully aware of the inequalities that continue to play out in the country. In people’s pre-COVID-19 lives, the realities of living in a country that is among the most unequal in the world were easily overlooked. The pandemic shines a very bright light on this reality. It asks us to fundamentally address them – not just at this time of the pandemic, but as a social justice imperative.

As messaging about preventing the coronavirus ramped up, the consequences of inequalities in the provision of basic service provision in the country have become clear. These disparities between rich and poor are reflected across a range of interventions that have been put in place to manage the pandemic and its social and economic consequences. These include access to water, housing circumstances, as well as people’s very high dependence on social grants and the informal sector for income.

Five areas where inequality is starkest

Living circumstances: The preventive measures have highlighted inequalities in living circumstances. Take the case of hand washing. The 1.1 to 1.4 million people who live in informal settlements in South Africa don’t have access to water in their homes or in their yards. An estimated 19% of the nearly 19 million people living in rural areas lack access to reliable supply of clean water; 33% do not have basic sanitation. This makes regular hand washing difficult. And social distancing or quarantining is near impossible when water access and ablutions are communal, and where settlements are overcrowded.

Livelihoods: For many people at the upper end of the wage spectrum, working remotely has been relatively easy, with limited impact on their ability to earn a living. Such workers are in the formal labour market. They are protected by both a legal and social contract as well as a safety net of unemployment benefits.

Small business owners will be under significant pressure in the coming weeks and months. But they will be partially cushioned by the business support measures announced by the government.

In contrast, the most vulnerable workers will struggle without support at this time. Casual workers (like many domestic workers), those who are self-employed (such as Uber drivers), and those working in the informal economy are not protected by legal contracts.

In general these workers, who make up over 20% of South Africa’s workforce, cannot access unemployment benefits. They will be under enormous pressure financially, potentially unable to feed themselves and their families.

President Cyril Ramaphosa has made it clear that the government is aware of these challenges and will move to ensure support. But it remains to be seen what that entails.

Education: Inequalities in education were also immediately evident when school were closed. While private schools and many suburban public schools were able to switch to technology-supported learning relatively easily, most public schools were not.

The directive by the Department of Basic Education was to ensure that learning continued by providing workbooks and worksheets online. But, many parents will be facing the very real struggle of supporting their families in a locked down economy. This, and other problems, including limited access to technology and data, means that many parents will struggle to supervise their children’s learning.

Equally concerning is how this will affect education outcomes in the longer term. Analysis already shows how learning backlogs in the early years, forged in an unequal education system, are compounded over time. Further backlogs under the current situation are likely to have long-term effects.

Access to the internet: Manuel Castells, a sociologist concerned with the internet age and inequality, notes in his book The Internet Galaxy:

The fundamental digital divide is not measured by the number of connections to the Internet, but by the consequences of both connection and lack of connection.

At universities and other higher education institutions, wealthier students have been able to switch to online learning quickly, while poorer students battle with high data costs.

Inequalities in access to data further entrench existing inequalities in education and livelihoods during the COVID-19 crisis.

Food security: The effects of panic buying on the food security of people with limited income has received attention. But a less well-known impact of the measures is that over 9 million children will not receive a daily, nutritious meal while schools remain closed.

The National School Nutrition Programme potentially has positive effects on reducing stunting and obesity. In the face of prolonged school closures, these children face increased food insecurity, with potential long-term consequences for their health.

There have been heartwarming responses from the public to ensure that food packs are provided to children. But it is simply not possible to reach the over 9 million children who depend on this meal.

What can be done?

The measures announced by President Ramaphosa to mitigate the problem reflect an understanding of how existing inequalities will affect especially the most vulnerable people, and a willingness to address the problem.

Social protection measures that can quickly provide a safety net are crucial at this time. But, the current social protection system provides a safety net only to those outside of the labour market – children, older people, and people with disabilities. Unemployment benefits accrue to those in formal employment who contribute to the Unemployment Insurance Fund. This leaves the vast majority of working-age adults without a safety net at this time.

While there have been relatively quick changes to existing mechanisms to provide support to small, medium and micro enterprises there are, as yet, no measures to protect informal and casual workers and ensure cash injections into vulnerable households.

The country needs to devise a social contract to better address the vulnerabilities that low-wage, casual and informal workers face daily.

The country must also move towards having low-cost, reliable internet access that can open up opportunities for learning and work for its most vulnerable citizens. Basic services – such as clean water, electricity and sanitation – must also be of a quality that not only promotes people’s right to dignity, but also help protect people from the effects of such a pandemic as COVID-19.

This pandemic highlights how crucial it is to fundamentally address the inequalities that exist in South African society. If a social justice imperative does not push us to do so, perhaps the realisation of mutual connections, borne of a pandemic that knows no class or race lines, will.

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Read more:
South Africa can – and should – top up child support grants to avoid a humanitarian crisis

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Lauren Graham, Associate professor at the Centre for Social Development in Africa, University of Johannesburg, University of Johannesburg

This article is republished from The Conversation under a Creative Commons license.

South Africa needs to end the lockdown: here's a blueprint for its replacement

An elderly man at a social grant paypoint in South Africa after the COVID-19 lockdown. (Photo by MARCO LONGARI / AFP) ()
Photo by Marco Longari/AFP via Getty Images

The public debate on strategies to tackle COVID-19 often unhelpfully positions health and economic considerations in a diametric fashion – as trade-offs. In fact, economic policy has health consequences. And health policy has economic consequences. The two need to be seen as parts of a coherent whole.

In the case of South Africa, the country currently faces three interrelated problems. These are the public health threat from the COVID-19 pandemic, the economic and health effects of the lockdown, and a range of intractable economic problems not directly due to the current pandemic. These include high unemployment, low economic growth and falling per capita income.

Any potentially viable response to COVID-19 needs to address all three aspects in concert. This is particularly important as the country plans for the next stage of its response after the lockdown. Focusing only on the health challenges and not paying attention to the economic issues will result in significantly higher economic costs, and will also undermine the health imperatives.

Our view is that a protracted lockdown won’t necessarily have the effect of ridding the country of the virus, but it will result in unacceptably high health and economic consequences.

The cost

The initial lockdown was prudent and is likely to have lowered the risk of community spread of SARS-CoV-2.

But the true number of COVID-19 (the disease caused by SARS-CoV-2) cases is difficult to quantify. A limited number of tests have been done, and community-wide screening for suspected infectious cases has been delayed.

The available evidence on the COVID-19 pandemic suggests that any initial containment of the disease through a lockdown will be short-lived. Also, it’s likely to result in a rebound of cases in the absence of aggressive community-wide screening for SARS-CoV-2 infectious cases, isolation of the identified cases and quarantine of their close contacts for at least 14 days.

On top of this, South Africa may find itself permanently harmed by the simultaneous destruction of both the demand and supply sides of the economy under an extended generalised lockdown.

This will have other unintended long term health and economic consequences. For example, an extended lockdown could result in the undermining of other health services, such as the immunisation of children.

The economic effects of a lockdown, too, are severe.

Early forecasts suggest significant economic disruption from the current lockdown, which is costing the economy an estimated R13 billion per day. Preliminary projections by the South African Reserve Bank indicate that South Africa could lose 370,000 jobs in 2020. Projections by private banking analysts (based on the initial 21-day lockdown) suggest a GDP contraction of 7% during 2020, leading to a fiscal deficit of 12% of GDP (forecast at 6.8% in the 2020 budget) and a debt-to-GDP ratio in excess of 81% in 2021. This means that the country’s already limited public finances will be further constrained.

Towards a post-lockdown strategy

Globally, attention is turning from initial containment through generalised lockdowns to short- and medium-term risk-based public health and economic strategies. We present some considerations for a health and economic policy beyond the lockdown in South Africa.

In this we proceed from the following assumptions:

• The SARS-CoV-2 will not be eliminated in South Africa until either a vaccine is introduced (yet to be developed), or sufficient natural immunity in the population is achieved. It is therefore necessary to put in place and maintain a sustainable mitigation strategy for COVID-19 for the remainder of 2020, or until a vaccine is available (an optimistic timeline for this is 18-24 months).
• A generalised lockdown is not a viable long-term prevention strategy for COVID-19 due to its deleterious effects, including the resultant long-term impact on society, public health and the economy.
• Removal of the lockdown without appropriate health and economic measures will result in an excess mortality from COVID-19, resulting in further economic hardship.

South Africa’s health and economic strategy beyond the current lockdown must be designed to ensure good health care and be economically sustainable. We argue that the country needs to transition to a risk-based strategy which offers effective health protection and allows for the resumption of some economic activity.

This approach has been advocated by researchers in both Germany and the Indian state of Kerala.

Accordingly, the following objectives should be central to any policy.

• First, mitigate the rapid spread of the virus, while allowing for natural immunity in the population to increase gradually.
• Second, strengthen health care systems to ensure optimal treatment for as many patients as possible, both those with COVID-19 and those with other serious illnesses.
• Third, protect individuals at high risk for severe COVID-19 disease; and
• Fourth, make economic activities possible with measures in place to manage the health risks associated with these activities.

Economic and health strategies

At the highest level, there are three broad intervention strategies available to South Africa (summarised in the table below), adapted from a recent article by leading Australian health academics James Trauer, Ben Marais and Emma McBryde. We believe that option three is the only practicable one for South Africa. And the details of its implementation matter.

Table 1: Typology of interventions and risks

Adapted from (Trauer et al., 2020)

A health strategy based on an extended generalised lockdown is economically unsustainable. It is also damaging to public health. Instead, we need a unified health and economic strategy that allows for some economic activity while inhibiting the uncontrolled spread of the virus. This requires a number of health and economic measures to be implemented in a coordinated manner.

First, to reduce the rate of infections, the country must have ready the capability of mass virus testing and efficient contact tracing before the end of April 2020. This must be accompanied by a comprehensive approach to social distancing. Relying solely on screening of symptomatic individuals will not effectively reduce the rate of infection because high viral loads of SARS-CoV-2 in the upper airway occur in pre-symptomatic and possibly asymptomatic people.

To be successful, the scale of testing needs to be at least equivalent to that in South Korea (17,322 tests per day in South Africa, eventually testing 1 in 150 people). At best, it must be equivalent to that carried out in Germany (36,399 tests per day in South Africa).

Test turnaround times must result in identification of infected individuals within 12 to a maximum of 24 hours. This must be followed by immediate isolation and contact tracing. Isolation of infected individuals and contact quarantine must last for at least 14 days, either at home, if suitable, or in designated isolation and quarantine facilities.

The annual cost of conducting 17,000 tests per day is approximately R5 billion. There would perhaps be an additional annual cost of R4 billion for contact tracing and quarantine. These costs compare favourably to the daily economic cost (R13 billion) of the generalised lockdown.

Secondly, economic activities must be allowed in a way that is consistent with the aim of preventing the uncontrolled spread of the virus. Within the constraints of the health strategy outlined above, a risk-based economic strategy is required that balances economic and health imperatives.

Decisions on differential opening of the economy should be made in line with the criteria proposed in a recent paper by German researchers. This includes, for example, opening sectors with low risk of infection (highly automated factories) and less vulnerable populations (child-care facilities) first. It could also include areas with lower infection rates and less potential for the spread of COVID-19. Of course, these decisions will have to be based on a careful assessment of factors such as household structure and composition in South Africa, and public transport.

To do this, the country will need excellent data on the extent and location of any community outbreaks of the virus. Such data will be generated by mass testing, and accurate information about the ability of certain sectors of the economy to reopen safely and in compliance with the health protocols.

The health and economic strategy will thus need to be implemented in a dynamic fashion, responding to the latest evidence.

This article has been amended to reflect updated estimates of the daily cost of the lockdown.

Cas Coovadia, member of the University of the Witwatersrand Council, also contributed to the discussions that led to the writing of this article

Shabir Madhi, Professor of Vaccinology and Director of the MRC Respiratory and Meningeal Pathogens Research Unit, University of the Witwatersrand; Alex van den Heever, Chair of Social Security Systems Administration and Management Studies, Adjunct Professor in the School of Governance, University of the Witwatersrand; David Francis, Deputy Director at the Southern Centre for Inequality Studies, University of the Witwatersrand; Imraan Valodia, Dean of the Faculty of Commerce, Law and Management, and Head of the Southern Centre for Inequality Studies, University of the Witwatersrand; Martin Veller, Dean of the Faculty of Health Sciences, University of the Witwatersrand, and Michael Sachs, Adjunct Professor, Economics, University of the Witwatersrand

This article is republished from The Conversation under a Creative Commons license.