People in prison are fully reliant on these facilities and their staff for their health needs. Thus, the health and safety of people who have been and who are currently incarcerated during the COVID-19 pandemic demanded rapid, health-focused responses by systems that were not built to promote health and that often have a substantial shortage of healthcare providers and are notorious for poor quality care. Even as state-and national-level guidance on reducing virus transmission was being determined, prisons were having to decide and implement pandemic responses in the hopes of preventing outbreaks or, at least, limiting them. The full outcome of these efforts remains to be seen as the pandemic remains ongoing. Our work provides foundational knowledge by describing the wide breadth of policies that were reported in the first year of the pandemic. This information may be used as a base for quantitative work on policy effectiveness and as well as qualitative studies examining policy implementation.
Our results—which highlight the social, privilege, and programming restrictions that incarcerated people experienced during the pandemic—underscore the importance of examining policy effects through the lens of both possible benefits and possible harms. We would hypothesize that some policies could have had a decidedly negative effect because the very policies that will stop the spread of COVID-19 are likely to worsen other aspects of health and further limit already tenuous access to health care services and enrichment programs. For example, programming is typically offered in prisons, including but not limited to education, substance abuse and mental health treatment, and religious services. Community volunteers and contracted providers normally provide a portion of this programming (Taxman et al., 2007). Thus, limitations on facility access have the collateral consequence of limiting programming. Additionally, many facilities enacted medical isolation procedures, requiring people who are incarcerated to stay isolated within single cells or barracks. Given that most prison-based programming is provided in groups, such policies effectively suspend access to these programs indefinitely. Ironically, in some states that are moving to decarcerate, a lack of access to treatment services is the very thing that is preventing early releases because people are unable to meet the conditions required to be eligible (Widra & Sawyer, 2020).
Movement and social restriction policies (e.g., lockdowns, visitation restrictions, suspension of yard/rec time and other social activities) are also of concern because of the negative impact of isolation. Indeed, research has found that people who are subjected to full isolation while incarcerated have higher rates of death by suicide, homicide, and opioid overdose post-release (Brinkley-Rubinstein et al., 2019). Thus, the precautions that are necessary to limit outbreaks may ultimately cause increased risk of future morbidity and mortality. Efforts to reduce the likelihood of such negative outcomes are in place in some states (e.g., greater access to phone, email, and video visitation), but these substitutes are clearly not the same as in-person visitation.
It is impossible to know whether the extreme infection rates in prisons are due to the policies being overall ineffective or implemented poorly. The substantial volume of lawsuits currently facing state prison systems (e.g., Valentine v. Collier, Waddell v. Taylor) highlight the rampant problems in policy implementation that could reduce or eliminate effectiveness of even the most robust policies. While the CDC has published ongoing guidelines for U.S. correctional facilities, legal scholars have argued that courts are giving excessive deference to CDC guidance given its informal nature (Conditions of Confinement, COVID-19, and the CDC, 2021) and other researchers have argued that collaboration between state department of corrections and public health are necessary to better address COVID-19 among incarcerated people (Hamblett et al., 2022). CDC guidance falls short of recommendations by international and national agencies which called for safe decarceration (e.g., Human Rights Watch (2020); National Academies of Sciences (2020)). Nevertheless, understanding the degree to which pandemic procedures were or were not implemented in the manner dictated by policy has far-reaching health implications for those living in prisons and jails, those who work in these facilities, and the communities which surround them. A full accounting of institutional pandemic response is also vital in crafting policies designed to lessen the effects of the next pandemic and other disease outbreaks. Taken together with the steady drumbeat of new lawsuits, Occupational Safety and Health Administration violation claims, and desperate pleas from prison staff and residents, these examples strongly suggest that there exist further cases of DOC policy non-compliance which will require study.
Limitations
Our study was limited by the availability of information; we could only incorporate public-facing directives and it is possible that internal communication was used to disseminate some changes. We also monitored only public DOC sources (i.e., DOC webpages, Twitter accounts, Facebook pages, and public-facing statements) and it is possible that information released via other venues (e.g., internal staff emails) could have added to our accounting. This strategy was important for methodological rigor (i.e., standardizing the approach to sources that were included); however, for this reason, we anticipate that the results that we report are the minimum number of states that enacted each of the policies examined. Indeed, due to their direct work with state prison systems in other contexts, the authors are aware of policies that could not be counted in this study because they did not appear in public-facing documents but that were being implemented in practice at various times during the pandemic.
Even within public sources, there was great variability as to ease of access of information, and it is thus possible that despite our best efforts, documents that should have been included were missed. As above, we would assume that any errors in our accounting of policies released would lead to underestimates. Additionally, we have chosen to focus our analysis on summarizing policies that were ever in place. We do not view this as a major limitation because, once released, policies were rarely lifted during the time frame of the study. Visitation policies are a notable exception as some states did resume visitation. Finally, it is worth noting that policies were at times extremely vague (e.g., using terminology such as “no unnecessary transfers”). While we had internal protocols regarding how to handle these instances, it is possible that interpretations of terms like “unnecessary” varied widely and influenced implementation.
A potentially larger limitation to this study—and in many policy-focused research studies—is that we were unable to assess policy implementation. We had endeavored to do so when we first launched the project; however, it became clear that this would be impossible due to the vagueness that was written into many policies (e.g., requiring that masks be worn by staff and residents only in certain, ill-defined, situations; providing lengthy descriptions of when masks were and were not required). It was also notable that for many of the social policies that involved free access to communication, such as free phone calls or video visits, was the result of fee waivers by the vendors that provide those services. Thus, the degree to which residents were able to access such resources remains unclear and could have been counteracted by other policies (e.g., movement restrictions) that were in place simultaneously.