COVID-19 Restrictions In Jails And Prisons: Perspectives From Carceral Leaders.

COVID-19 has been an unprecedented challenge in carceral facilities. As COVID-19 outbreaks spread in the US in early 2020, many jails, prisons, juvenile detention centers, and other carceral facilities undertook infection control measures such as increased quarantine and reduced outside visitation. However, the implementation of these decisions varied widely across facilities and jurisdictions. We explored how carceral decision makers grappled with ethically fraught public health challenges during the pandemic. We conducted semistructured interviews during May-October 2021 with thirty-two medical and security leaders from a diverse array of US jails and prisons. Although some facilities had existing detailed outbreak plans, most plans were inadequate for a rapidly evolving pandemic such as COVID-19. Frequently, this caused facilities to enact improvised containment plans. Quarantine and isolation were rapidly adopted across facilities in response to COVID-19, but in an inconsistent manner. Decision makers generally approached quarantine and isolation protocols as a logistical challenge, rather than an ethical one. Although they recognized the hardships imposed on incarcerated people, they generally saw the measures as justified. Comprehensive outbreak control guidelines for pandemic diseases in carceral facilities are urgently needed to ensure that future responses are more equitable and effective.

"It was like you were being literally punished for getting sick": formerly incarcerated people's perspectives on liberty restrictions during COVID-19.

BACKGROUND: COVID-19 has greatly impacted the health of incarcerated individuals in the US. The goal of this study was to examine perspectives of recently incarcerated individuals on greater restrictions on liberty to mitigate COVID-19 transmission. METHODS: We conducted semi-structured phone interviews from August through October 2021 with 21 people who had been incarcerated in Bureau of Prisons (BOP) facilities during the pandemic. Transcripts were coded and analyzed, using a thematic analysis approach. RESULTS: Many facilities implemented universal "lockdowns," with time out of the cell often limited to one hour per day, with participants reporting not being able to meet all essential needs such as showers and calling loved ones. Several study participants reported that repurposed spaces and tents created for quarantine and isolation provided "unlivable conditions." Participants reported receiving no medical attention while in isolation, and staff using spaces designated for disciplinary purposes (e.g., solitary housing units) for public health isolation purposes. This resulted in the conflation of isolation and discipline, which discouraged symptom reporting. Some participants felt guilty over potentially causing another lockdown by not reporting their symptoms. Programming was frequently stopped or curtailed and communication with the outside was limited. Some participants relayed that staff threatened to punish noncompliance with masking and testing. Liberty restrictions were purportedly rationalized by staff with the idea that incarcerated people should not expect freedoms, while those incarcerated blamed staff for bringing COVID-19 into the facility. CONCLUSIONS: Our results highlighted how actions by staff and administrators decreased the legitimacy of the facilities' COVID-19 response and were sometimes counterproductive. Legitimacy is key in building trust and obtaining cooperation with otherwise unpleasant but necessary restrictive measures. To prepare for future outbreaks facilities must consider the impact of liberty-restricting decisions on residents and build legitimacy for these decisions by communicating justifications to the extent possible.

An exploratory study of COVID-19-related changes in abortion service availability and use in Washington, DC, Maryland, and Virginia.

OBJECTIVES: This exploratory study aimed to assess COVID-19-related changes in abortion service availability and use in Washington, DC, Maryland, and Virginia. DESIGN: Data came from a convenience sample of eight abortion clinics in this region. We implemented a cross-sectional survey and collected retrospective aggregate monthly abortion data overall and by facility type, abortion type, and patient characteristics for March 2019-August 2020. We evaluated changes in the distribution of the total number of patients for March-August in 2019 compared to March-August 2020. We also conducted segmented regression analyses and produced scatter plots of monthly abortion patients overall and by facility type, abortion type, and patient characteristics, with separate fitted regression lines from the segmented regression models for the pre- and during-COVID-19 periods. RESULTS: Five clinics reported a reduced number of appointments early in the pandemic while four reported increased call volume. There were declines in the monthly abortion trend at hospital-based clinics at the outset of the pandemic. Monthly number of medication abortions increased from March 2020 through August 2020 compared to pre-COVID-19 trends while instrumentation abortions 11 up to 19 weeks decreased. The share of abortions to Black individuals increased during the early phase of the pandemic, as did the monthly trend in abortions among this group. We also saw changes in payment type, with declines in patients paying out-of-pocket. CONCLUSIONS: Results revealed differences in abortion services, numbers, and types during the early stages of the COVID-19 pandemic in Washington, DC, Maryland, and Virginia.

COVID-19 vaccination hesitancy and uptake: Perspectives from people released from the Federal Bureau of Prisons.

People in United States (US) prisons and jails have been disproportionately impacted by the COVID-19 pandemic. This is due to challenges containing outbreaks in facilities and the high rates of health conditions that increase the risk of adverse outcomes. Vaccination is one strategy to disrupt COVID-19 transmission, but there are many factors impeding vaccination while in custody. We aimed to examine the perspectives of former residents in the Federal Bureau of Prisons (BOP) regarding COVID-19 vaccine hesitancy and acceptance. Between September-October 2021, we conducted semi-structured interviews with 21 recently released individuals who were incarcerated before and during COVID-19 and coded transcripts thematically. We assessed perceptions of the vaccine rollout and factors shaping vaccination uptake in custody and after release. The vaccine was available to seven participants in custody, of whom three were vaccinated. Interviewees had mixed attitudes about how vaccines were distributed, particularly with priority given to staff. Most were reluctant to get vaccinated in custody for varying reasons including observing staff declining to be vaccinated, lack of counseling to address specific questions about safety, and general lack of trust in the carceral system. By contrast, twelve got vaccinated post-release because of greater trust in community health care and stated they would not have done so while incarcerated. For residents in the BOP, COVID-19 vaccination was not simply a binary decision, instead they weighed the costs and benefits with most deciding against getting vaccinated. Institutions of incarceration must address these concerns to increase vaccine uptake as the pandemic continues.

A Human Rights Framework for Advancing the Standard of Medical Care for Incarcerated People in the United States in the Time of COVID-19.

The COVID-19 pandemic has underscored the lack of resources and oversight that hinders medical care for incarcerated people in the United States. The US Supreme Court has held that "deliberate indifference" to "serious medical needs" violates the Constitution. But this legal standard does not assure the consistent provision of health care services. This leads the United States to fall behind European nations that define universal standards of care grounded in principles of human rights and the ideal of equivalence that incarcerated and non-incarcerated people are entitled to the same health care. In this paper, we review a diverse legal and policy literature and undertake a conceptual analysis of policy issues related to the standard of care in correctional health; we then describe a framework for moving incrementally closer toward a universal standard. The expansion of Medicaid funding and benefits to corrections facilities, alongside a system of comprehensive and enforceable external oversight, would meaningfully raise the standard of care. Although these changes on their own will not resolve all of the thorny health problems posed by mass incarceration, they present a tangible opportunity to move closer to the human rights ideal.

COVID-19 impacts on abortion care-seeking experiences in the Washington, DC, Maryland, and Virginia regions of the United States.

CONTEXT: Many people wanted to avoid or delay childbearing during the COVID-19 pandemic. This study sought to examine the extent COVID-19 influenced abortion care-seeking in a region that did not enact policy restricting abortion due to the pandemic, has high service availability, and few abortion-restrictive policies. METHODOLOGY: We conducted telephone surveys with adults (n=72) requesting abortion appointments between September 2020 and March 2021 at five clinics in Washington, DC, Maryland, and Virginia. We used χ2 tests to compare sociodemographic, reproductive history, service delivery characteristics, and pandemic-related life changes by whether COVID-19 influenced abortion care-seeking. RESULTS: Most respondents (93%) had an abortion at the time of the survey, 4% were awaiting their scheduled appointment, and 3% did not have an appointment scheduled. Nearly 40% of people reported COVID-19 influenced their decision to have an abortion. These individuals were significantly more likely to report "not financially prepared" (44% vs. 16%) as a reason for termination compared to people reporting no influence of COVID-19. They were also more likely to have lost or changed their health insurance due to pandemic-related employment changes (15% vs. 2%), report substantial money difficulties due to COVID-19 (59% vs. 33%), and report that paying for their abortion was "very difficult" (25% vs. 2%). CONCLUSION: COVID-19 influenced many people to have an abortion, particularly those financially disadvantaged by the pandemic. Expansion of Medicaid abortion coverage in Washington, DC and Virginia could reduce financial barriers to care and help people to better meet their reproductive needs amid future crises.

COVID-19's Effect on Pregnancy Care for Incarcerated People.

Objective/background: Prisons and jails are high risk environments for COVID-19. Little is known about COVID-19's impact on pregnancy care for the tens of thousands of pregnant people who pass through these institutions each year. This study aimed to describe how COVID-19 has influenced prisons' and jails' pregnancy care services. Methods: We conducted a cross-sectional survey of a convenience sample of U.S. prisons and jails and report descriptive statistics. Results: We received 17 responses. Sites reported changes in prenatal care delivery, support programming, housing, and visitation. Most sites implemented changes in housing arrangements to quarantine individuals at-risk for COVID-19. Many sites increased their use of virtual technology to supplement for suspended in-person appointments, programming, and visitation. Conclusions: The impact of COVID-19 on pregnancy care delivery and support services for incarcerated pregnant people is variable. As the pandemic continues, research and policy should ensure that incarcerated pregnant people have access to full scope pregnancy care.

COVID-19 vaccine prioritization of incarcerated people relative to other vulnerable groups: An analysis of state plans.

BACKGROUND: Carceral facilities are epicenters of the COVID-19 pandemic, placing incarcerated people at an elevated risk of COVID-19 infection. Due to the initial limited availability of COVID-19 vaccines in the United States, all states have developed allocation plans that outline a phased distribution. This study uses document analysis to compare the relative prioritization of incarcerated people, correctional staff, and other groups at increased risk of COVID-19 infection and morbidity. METHODS AND FINDINGS: We conducted a document analysis of the vaccine dissemination plans of all 50 US states and the District of Columbia using a triple-coding method. Documents included state COVID-19 vaccination plans and supplemental materials on vaccine prioritization from state health department websites as of December 31, 2020. We found that 22% of states prioritized incarcerated people in Phase 1, 29% of states in Phase 2, and 2% in Phase 3, while 47% of states did not explicitly specify in which phase people who are incarcerated will be eligible for vaccination. Incarcerated people were consistently not prioritized in Phase 1, while other vulnerable groups who shared similar environmental risk received this early prioritization. States' plans prioritized in Phase 1: prison and jail workers (49%), law enforcement (63%), seniors (65+ years, 59%), and long-term care facility residents (100%). CONCLUSIONS: This study demonstrates that states' COVID-19 vaccine allocation plans do not prioritize incarcerated people and provide little to no guidance on vaccination protocols if they fall under other high-risk categories that receive earlier priority. Deprioritizing incarcerated people for vaccination misses a crucial opportunity for COVID-19 mitigation. It also raises ethical and equity concerns. As states move forward with their vaccine distribution, further work must be done to prioritize ethical allocation and distribution of COVID-19 vaccines to incarcerated people.

Care for Incarcerated Patients Hospitalized with COVID-19.

The COVID-19 pandemic has reshaped health care delivery for all patients but has distinctly affected the most marginalized people in society. Incarcerated patients are both more likely to be infected and more likely to die from COVID-19. There is a paucity of guidance for the care of incarcerated patients hospitalized with COVID-19. This article will discuss how patient privacy, adequate communication, and advance care planning are rights that incarcerated patients may not experience during this pandemic. We highlight the role of compassionate release and note how COVID-19 may affect this prospect. A number of pragmatic recommendations are made to attenuate the discrepancy in hospital care experienced by those admitted from prisons and jails. Physicians must be familiar with the relevant hospital policies, be prepared to adapt their practices in order to overcome barriers to care, such as continuous shackling, and advocate to change these policies when they conflict with patient care. Stigma, isolation, and concerns over staff safety are shared experiences for COVID-19 and incarcerated patients, but incarcerated patients have been experiencing this treatment long before the current pandemic. It is crucial that the internist demand the equitable care that we seek for all our patients.

Rethinking "Elective" Procedures for Women's Reproduction during Covid-19.

Common hospital and surgical center responses to the Covid-19 pandemic included curtailing "elective" procedures, which are typically determined based on implications for physical health and survival. However, in the focus solely on physical health and survival, procedures whose main benefits advance components of well-being beyond health, including self-determination, personal security, economic stability, equal respect, and creation of meaningful social relationships, have been disproportionately deprioritized. We describe how female reproduction-related procedures, including abortion, surgical sterilization, reversible contraception devices and in vitro fertilization, have been broadly categorized as "elective," a designation that fails to capture the value of these procedures or their impact on women's overall well-being. We argue that corresponding restrictions and delays of these procedures are problematically reflective of underlying structural views that marginalize women's rights and interests and therefore threaten to propagate gender injustice during the pandemic and beyond. Finally, we propose a framework for triaging reproduction-related procedures during Covid-19 that is more individualized, accounts for their significance for comprehensive well-being, and can be used to inform resumption of operations as well as subsequent restriction phases.