COVID Behind Bars (with Prof. Aaron Littman)

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During the beginning of the Pandemic, prisons were a hothouse for COVID infections. In some states, deaths from Covid more than doubled. Andy talks with Aaron Littman, director of the COVID Behind Bars Data Project, about what makes U.S. prisons “incubators of disease” and what it was like for incarcerated people as the virus ran rampant behind prison walls. They discuss why incarcerated people, who already lack access to adequate health care and live in unsanitary conditions, deserve not just better care but our empathy.

Keep up with Andy on Twitter and Post @ASlavitt.

Follow Aaron Littman on Twitter @aaronlittman.

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Andy Slavitt, Aaron Littman

Andy Slavitt  00:18

This is IN THE BUBBLE with Andy Slavitt. How are you? Thank you for tuning in a new title caught our attention recently, one that was probably easy to miss, that in the first year of the pandemic, there was a 50% increase in deaths in prison across the US. And in some cases, the numbers are even quite a bit higher than that there are six or seven states that had 100% increase in deaths. No, that’s the kind of thing that’s easy to miss or to say, yeah, you know, we knew a lot of bad stuff was happening then. Or even to say, you know, with a part of your brain, well, you know, these are prisoners, after all, although I don’t think people really think that way. I think it is easy to be more dismissive of people in the criminal justice system. But, you know, it’s worth focusing on for a few reasons. You know, a lot of times we ask ourselves, well, did we learned something during the hardest parts of COVID? That were a wakeup call? And to answer that question, you know, I’ve asked Aaron Littman to come on the show today, he is the faculty director of the law schools prisoners’ rights clinic. And it is worth noting that this increase, it far exceeds the increase that exists in almost any other part of society. You know, like nursing homes, and other congregate settings. And you know, people are in the situation, not by choice. Now, you could say, well, what do you mean the end? Of course, they’re there by choice, or they chose to commit a crime after all. We did that was a lot of people in prison, committed crimes or have done something bad, of course, but you know, what, when they got their sentence, their sentence didn’t say, and you will die in prison. That’s just not how our country and her system of justice is supposed to work. So we’re supposed to keep people safe. They’re under our care. This is really no more complex than that these are people under our care. And the question is, did we let them down? How did we let them down. But also, I wanted to use this to get a window into what life is like what living conditions are like, in prison, physical health, mental health, and how we address that. And that, to me, is the kind of thing that we will take this opportunity to stop and look in the mirror and understand when will we, and that’s kind of the purpose of this episode, is to bring in somebody who we can have that conversation. This is a topic I don’t really know a lot about. I don’t know, I’ve never been to prison. I’ve never lived in prison. I don’t know what that’s like in the day to day basis. And I don’t think you get a fair depiction from just, you know, seeing movies and reading articles. So that’s exactly why we try to bring in an expert, someone who has been through the prison system, has worked with a lot of prisoners has seen what it’s like, and has been collecting the data. That’s what Aaron does. So I’m excited about this conversation, because everything I learned, it’s something new to me and everything I learned, I will be sharing with you at the same time, which is kind of exciting. Here we are. Let’s bring in Aaron.

Andy Slavitt  03:39

Aaron, welcome to the bubble.

Aaron Littman  03:41

Great to be here. Thanks so much for having me.

Andy Slavitt  03:43

I want to talk about the reports that have just recently surfaced, that prison deaths increased in the first year of the pandemic by 50%. And in some states, I will be on that. And I want to use this to give people a lens into life and living conditions and prisons in general. What is health care, like in prison? And what are living conditions like for people with illnesses in prison?

Aaron Littman  04:09

Yeah, so I think what the pandemic has done is really given us a vantage point into these obscure places, but they’ve been public health catastrophes for a really long time. So these are places where people who are disproportionately suffering from a variety of conditions from heart disease to mental illness are housed in really, really, really close quarters and have very limited access to care. So, you know, it varies between systems that varies between states, but one’s Access to care is often contingent on several factors. One is just going to be actually physically getting to see the doctor so being, you know, having enough security staff that you can be moved, brought to a doctor’s appointment. Once you get there you have access to whatever medical staff the prison has provided. But often there are not enough. Not enough doctors and nurses. And so you may have a very long way to see somebody. The ability to manage complex conditions in prison is really limited. You know, folks have limited access to specialty care, their ability to get medication on time, can often be compromised. And so health outcomes are really, really bad, pretty much across the board. And conditions more broadly make, particularly infectious disease spread really rampant.

Andy Slavitt  05:42

So is this neglect? Is it lack of prioritization? Is it that there are no caring and feeling people? What’s the root of why prison, health care is so bad.

Aaron Littman  05:56

So it’s a combination of some of those things, but at basis that we incarcerate a huge number of people. And we are not willing to invest the resources required to care for them appropriately. There are some other factors that I think play a particular role in certain states. So often, we build prisons in really rural areas. And we do that because it’s cheaper to build them there. Because there’s a labor force that wants to work in the prison there, that makes it even harder to get qualified medical providers out there and get access to, you know, hospital care when that’s required.

Andy Slavitt  06:38

So it’s not all poorly intentioned, some of it is just difficult.

Aaron Littman  06:42

I mean, some of it’s difficult. And also, it’s a societal refusal to see incarcerated people as human beings who are who are worthy of care and health and safety, like, like the rest of us. And you know, to be frank, I think that is, often because they’re poor people, and particularly disproportionately people of color, who, you know, in other aspects of our public policy, we treat pretty poorly.

Andy Slavitt  07:10

You know, what is the reason we put people in prison is one of the sort of age old questions. So we put a lot of people in prison in this country, and you could probably give us some of the statistics on how that compares to other parts of the world. But what we intend to have happen to people, are we hoping to rehabilitate them, or are we just trying to protect society from them? Are we, in fact, lost the plot, and just literally putting people away? Because it makes certain people feel like we’re getting some retribution? What’s the goal? Because I think the notion that people have done something wrong, maybe they shouldn’t have done, whether a violent or not violent, and they have a sense meted out to them by a judge. That sense doesn’t include putting their life at risk, does it?

Aaron Littman  08:00

Right, so it certainly doesn’t, right, it includes losing their liberty for a period of time. And all of the other hardships that being incarcerated brings lack of access to their family, you know, the stigma of serving time in prison. But, you know, our Constitution requires that officials who run these places keep the folks inside safe. And when you have no ability as an incarcerated person, to call up a doctor to go to a hospital to, to seek care on your own, that needs to be provided. So, you know, to your question about why we do this, I think that lost the plot is probably closest to it. Although there are, you know, there are real worthwhile debates to be had about whether we should incarcerate people and to what degree. But no matter what you think, it’s pretty fair to assume that most people want our prisons to promote public safety and public health that feels like, you know, if our practices of incarceration are making people less safe and making people less, well, something’s really wrong. And one of the things that the COVID pandemic really illustrated was that these facilities were, were really dangerous for the people inside them. But they were also really dangerous for the communities around them. Right. So prisons became incubators of disease, and they then spread, you know, spread infection into surrounding communities. These were these were facilities where, you know, in some instances early in the pandemic, 90% of people were infected. And those infections didn’t stay within the prison walls. And so if you were concerned about, you know, ICU beds or ventilators in your local community, you ought to be concerned about what was happening in that prison nearby.

Andy Slavitt  09:57

Okay, we’re gonna do a quick break after that. Let’s go Get into the numbers. Because I catch you can’t believe how bad things are in some places. Let’s jump into the data. So what we know is that there was a 50% increase in deaths during the first year of the pandemic, that in a handful of states, it was not 50%, but 100%. And if I’m reading this right, and you’ve got to correct me if I’ve got this wrong, because I almost don’t believe it’s has to be wrong, that in West Virginia 1% of prison population died. What percent of prison population died? Is that? Is that what the data is telling us?

Aaron Littman  11:01

I’ll have to go back and look at the figure for West Virginia to make sure that that’s right. But we saw really staggering rates in in lots of states. And, in particular, it’s important to note that the, the prison populations dropped over the course of this period. So the rate was actually higher, that increasing rate was actually higher than 50%. It was it was in the 60s. Because the denominator, the number of people in these prison facilities actually declined over the course of the pandemic, largely because jail stopped sending as many people to prison.

Andy Slavitt  11:41

So we get that congregate settings like nursing homes, were particularly dangerous places. But this death rate exceeds the death rate increase in nursing homes. So can you help us understand what happened? And I love a macro answer. But what I really love is a is actually kind of a preview paint a picture of what it was like, during that first year of COVID. In a prison for a prisoner,

Aaron Littman  12:07

It was a pretty scary time, because you understood that this virus was running rampant, and you didn’t have the same tools to protect yourself that the rest of us did, you didn’t necessarily have access to masks. And if you did you at the whim of guards as to whether you got to get one, you didn’t have any ability to social distance, right. So in a dorm with, you know, 120 bunk beds, just wasn’t meaningful, we saw instances where prison and jail officials would file things in court with diagram showing how they intended to keep people six feet away from each other. And in part, it involved having one person on top bunk sleep with their head in one direction and the person on the bottom bunk sleep with their head in the other direction. And it was just sort of absurd, right? The idea that you could safely house this many people, when we were all staying at home was absurd. And, you know, these are prisons that were many of them overcrowded to begin with, crowded beyond the capacity that was deemed safe, even pre pandemic, and even much more. So when the virus was spreading.

Andy Slavitt  13:18

Was there any access to testing with? And if so, did any prisoners try to create COVID wards and non-COVID words, things like that?

Aaron Littman  13:29

Yeah. So there was certainly access to testing, but it was very variable. So, you know, when tests were scarce, initially, there was not adequate testing. As testing became more available, some states are doing a very good job. So California, for example, had a very robust testing regimen. Some states, Alabama, for example, continued to have test positivity rates that were really high. And that was a pretty clear indication that they just weren’t testing very many people. We know that, you know, states tried to do something to protect people, right? There were quarantine policies. Movement was limited within facilities. Sometimes those quarantine policies were not very well thought out. So an entire unit would be quarantined together after one person tested positive, and then the whole unit would get infected. But you know, there were more thoughtful approach is the CDC issued guidance that some states followed. But really the challenge was that in these facilities, it wasn’t possible to keep people separate. And to the extent that they did, it was an incredibly restrictive environment where we’re basically people were just stuck in their cells all day.

Andy Slavitt  14:48

So the nature of being imprisoned itself, in an overcrowded prison, makes it really, really hard to prevent an infectious disease in the best of circumstances. Sounds like that’s what […]

Aaron Littman  15:00

Right. And these are places without adequate sanitation, where, you know, I often have heard folks complain about ventilation in prisons, you know, decades old H fax systems that don’t really work properly. And, and so all of the space and infrastructure required to mitigate the spread was unavailable,

Andy Slavitt  15:22

dying in prison. It’s one of the saddest things I can think of, I think about someone who is trying to turn their life around, I think about families, spouses children of, of someone who’s in prison, who they love dearly, I think about people who are working to get released from prison, who are have years of their life to look forward to. And I think about their life ending behind bars, and I really can’t think of many sad her things. And yet 1000s of people die in prison every year. And I’m curious what the typical, put even putting COVID aside, the causes of that are, what portion of those do we think are really preventable and shouldn’t happen? What portion are people who are really sick and terminally ill, and then they would have died under no matter where they were?

Aaron Littman  16:19

Yeah. So that’s a really important question. And one that the data we’ve collected is, is starting to allow us to answer our data collection is in part a response to a step back by the Department of Justice, in collection of data under the death and custody Reporting Act. And one of the main purposes of that Act, as Congress said, was to answer this question to figure out why people are dying and how to stop. And so we have some sense of that, but not a good enough sense yet. And this sense we do have is that, of course, some deaths are not preventable, or are, you know, folks get very old. And we have an aging prison population, we have a population that because of very, very harsh sentencing laws is increasingly getting old and dying in prison. Even with respect to those people, though, it’s important to say that there’s really good evidence that incarceration, and particularly long term incarceration takes years off people’s lives. So people would have died, but they would have died later outside. But there are a lot of deaths that are clearly preventable. So, you know, infectious disease deaths, but also, you know, unfortunately, a significant number of suicide and homicide deaths. And those are things that, at least some preliminary evidence suggests really did increase during the pandemic. In large part, because conditions became so bad. So staffing levels declined, because people didn’t want to work in prisons or got sick. And that made them even more dangerous and violent places

Andy Slavitt  18:01

are at let me do one final break. And I want to come back. And here’s some of the actual stories about what it is like in prison, and particularly solitary confinement, and the effect that has on our physical and mental health, right back. Literally do want to talk about mental health for a moment and access to mental health services? Look, even if you’re not in prison, it’s hard to find a mental health professional. And I think there’s a lot that is, hopefully being done needs to be done to work on this. But picking up where we begin the conversation, which is there is a sentence and all that goes with it. And then there is the additional suffering that I don’t think a good society needs to have, which is people suffering from emotional distress they had maybe they had mental health issues before they went to prison. certainly plenty of reasons to feel depressed or anxious, or have other severe mental illnesses while in prison. And I’m curious, and I should say that we have to come back and we have to talk about solitary confinement and some of those things, but before we’re done, but even without that, what is it like for people who are suffering mental health issues, the suicide risks are, as you mentioned, sadly, quite high and even higher when there’s a sense of neglect and hopelessness.

Aaron Littman  19:48

So our prisons and jails are, unfortunately our largest mental health institutions in this country by far and are really High percentage and depending on how you characterize, you know, whether it’s serious mental illness or all mental illness, but, you know, in in some facilities over 50% of people are on mental health caseload, right. So it’s just staggering.

Andy Slavitt  20:15

Do they have access to prescriptions? And do they have access to therapy?

Aaron Littman  20:19

So, you know, certainly prescription medication is more available than is meaningful psychotherapy, although, you know, the kinds of intensive treatment that are required for people with serious mental illness are often not available. There, there’s, you know, a real shortage of care, as you say, but a lot of that care should be allocated to the population that we’re incarcerating right, these are, these are folks many of whom, who are there in the first place because of their serious mental illness. And, and then you have a situation that really exacerbates mental illness. So inability to, you know, maintain family relationships, inability to get adequate exercise. You know, really abusive environments are aren’t are not good for people who are, who have mental illness, right, exactly the opposite of what those folks need to do well and thrive. So there are things that can be done to reduce the number of suicides particularly, but more broadly, we need to rethink how we’re responding to people with mental illness and, you know, provide care in the community so that they don’t end up in prison and then provide care, once they’re in prison in in an effort to allow them to live their lives.

Andy Slavitt  21:50

What is your perspective on what you’ve seen? And in some very specific ways, how would you paint a picture to help people understand what’s going on?

Aaron Littman  22:01

I think that having a glimpse into what some of these places look and feel like is really important, I wish that more people had that and I’ll describe one particular solitary unit where I had clients in Georgia several years ago. And it was without question the worst place I have ever been on this earth. And when you walk into it, there is this den of clanging steel of people who are banging their bodies against steel doors repeatedly, because they have been left in windowless rooms for months and often years alone. And are, so are in such pain and our suffering to such an extent that they want to be heard. And this is this is their, their only means of being heard. The walls are coated in excrement and blood. There our, you know, floods of various kinds on the floor because the plumbing so folks have toilets and showers that are in their own cells. And those flood periodically and with their the contents onto the floor and not into the hallway. And if you stop at the door of one of these cells, and you talk to somebody, you will encounter several people who in the past month have swallowed batteries and razor blades in an effort to end their own life. Atul Gawande wrote a New Yorker piece years ago about solitary confinement that was called hellhole. And that’s about right. You know, not every unit of every prison looks like this, to be sure. And some of the ways that prisons brutalized people are much more mundane. But that is not an uncommon sight in in American prisons, and it’s appalling. It’s not a way that human beings should be treated.

Andy Slavitt  24:32

Yeah, I just, I just think this whole idea of someone not having any agency or any community to belong to, it feels like it goes beyond any sense of even the most Law and Order minded person sense of what justice should be. And I feel like Thankfully, there’s people like you They’re trying to shine a light here. But it’s what I also worry about is that to fix the issue, it’s going to require both rethinking and resources that are curious now, where you think that rethinking and where those resources and the public outcry necessary to commit those resources is going to come from.

Aaron Littman  25:24

I think that the outcry is happening, I think it’s being led by people whose loved ones are incarcerated, people from communities that are really profoundly affected by mass incarceration, whose families are broken up by it, who, whose, you know, economic opportunities are, are really profoundly undermined by our criminal legal system. And, you know, I think the resources question is a hard one. But it’s also important to remember that fewer resources are needed if we have fewer people in prison. And so, you know, California is after many years of building more prisons, talking about closing some. And, you know, really, meteoric rise nationwide and incarcerated population has slowed and really plateaued and started to come down in many jurisdictions. Rural jails are still growing. And, you know, I think there are causes for concern that this trend may not continue unless we make it continue. But if we have a smaller incarcerated population, and really make the argument forcefully that investing resources in dealing with this problem will serve the rest of society. I, I think it I think it’s, it’s something we can get traction on, at least in at least in some jurisdictions. That’s one of the things that the pandemic really illustrated. And, you know, treating, treating hepatitis C among incarcerated people means that when they get released, they’re not infecting other people with hepatitis C.

Andy Slavitt  27:24

I like you’re thinking about lift to start with, what do we imprison people for? And I think that’s a really important topic. It’s interesting, I just learned the other day that at Walmart, if you shoplift at Walmart, and you haven’t done it before, they don’t call the police. They asked you to sit through a crime prevention and theft prevention program, which is like a video or something, or two, and just, but they don’t call the police. And he’s like, Okay, well, that’s a small thing, like these people aren’t in a prison for shoplifting. But I think that, you know, once people get involved in the criminal justice system, at a young age, or any age, and then they are locked up in a jail, that that life begins. And it begins in many ways, just like how they think of themselves. Well, I am now this is who I am. This is what I do. And having the note sounds small, but having the compassion to say that somebody you tried to steal from me, and I’m not going to treat this as a crime. I’m not going to treat this as something that’s going to upend your life. But I’m going to treat it with some compassion, some understanding, it’s a proportion feels like it’s your point, you know, you don’t have the problem of bad in overcrowded prisons, and people suffering in prisons, if they don’t get there in the first place. I don’t know what you think about things like that. That’s obviously not a policy or a law, but it’s, it’s an action by an individual company.

Aaron Littman  28:55

Yeah, well, I think there are all sorts of ways to decrease the funneling of people into incarceration. And that sounds like a really valuable one. And you say, people aren’t ending up in prison for shoplifting, which, formally is probably true. But people certainly end up in jail for it, they lose their jobs, when they end up in jail, they end up in dire economic straits, they end up engaging in other kinds of behavior as a result. So these things really, you know, there’s, there’s a cycle to them. And, you know, we have, you know, pretrial probation systems in this country where, you know, sometimes people are ending up, you know, going into debt because they can’t pay certain supervision fees. They, you know, most people there’s a reason that that prisons are full of poor people, which is that if you have resources and access to services for Things You Need, you’re much, much less likely to engage in the kinds of behavior that end up getting you arrested. And frankly, police are much less likely to be interested in arresting you. But you know, it’s not a mystery that every push into a criminal legal space increases the chance of you ending up in one of these really terrible situations.

Andy Slavitt  30:33

So I want to close by discussing a little bit about what you’ve done your work and what your project has accomplished, what we need to be doing and what we need to be prioritizing. Now, as a country, because, you know, my rallying cry during the pandemic, was, Let’s prevent the next death. If we’re sad about the number of people who died today, then the best way to honor them, is to prevent the next person from dying, needlessly for the same reason. And I think there’s a simple principle we have to apply here, which is to create any meaning from these terrible statistics that are truly astounding and terrible, we have to honor that by doing something. And I want to know what it is

Aaron Littman  31:22

one first step, which is not nearly sufficient, but as a good start, is to honor these people who’ve died by accounting for them and understanding what happened. And it is outrageous, in my view, that we don’t have a national accounting of who died, and why. And that really hamstrings our ability to at least, you know, engage in really serious policy discussions about what will what will address this problem. So, one thing that needs to happen is that both the federal government and state governments need to engage very, very seriously in collecting good data, and publishing it so people can analyze it, and in responding to it and making changes on that basis. And, you know, I think we also need to shift our conversation in media spaces and public health spaces and law enforcement spaces towards an appreciation that these are, these are places that cause profound harm, these are places that don’t just address harm to the extent that that maybe they do that in some instances, but that they cause profound harm that when, you know, when somebody dies inside a prison, when somebody gets sick inside a prison, when somebody is attacked inside a prison, that those things happen in our community in our society and need to matter to us. And when we decide whether to increase a penalty for some kind of behavior, or invest resources and policing a certain community that, that we should understand those outcomes as bad outcomes, you know, that that threats to public safety don’t just happen outside prisons, they happen inside them, too.

Andy Slavitt  33:22

If we’re serious about being a compassionate country, a country that gives people second chances, a country that cares about people, which I think, honestly, our themes that I hear across the political spectrum, those aren’t democratic themes, those aren’t Republican themes. Those are things that I think people believe, then we’re going to focus on this, and we’re going to support people like you in your work. We’re going to provide links to your work, and our notes. And I want to thank you for calling attention to this what to do all the time, and coming in the bubble.

Aaron Littman  34:02

Thanks so much, Andy. I really appreciate the opportunity to talk with you about it.

Andy Slavitt  34:19

Coming up, we have a fascinating show on Wednesday, where we ponder the question. Are we on the cusp of curing Alzheimer’s? And even more interesting, are we on the cusp of preventing Alzheimer’s in the first place? The answer is pretty interesting and exciting. We have somebody who is working on developing what could be the next breakthrough, as well as one of the leading conductors of research into Alzheimer’s who can give us a state of affairs. And I want to know when are we going to get there because this is a terrible disease that impacts so many. So tune in on Wednesday for that. Enjoy. Your next couple days we’ll talk to you then.

CREDITS  35:15

Thanks for listening to IN THE BUBBLE. We’re a production of Lemonada Media. Kathryn Barnes, Jackie Harris and Kyle Shiely produced our show, and they’re great. Our mix is by Noah Smith and James Barber, and they’re great, too. Steve Nelson is the vice president of the weekly content, and he’s okay, too. And of course, the ultimate bosses, Jessica Cordova Kramer and Stephanie Wittels Wachs, they executive produced the show, we love them dearly. Our theme was composed by Dan Molad and Oliver Hill, with additional music by Ivan Kuraev. You can find out more about our show on social media at @LemonadaMedia where you’ll also get the transcript of the show. And you can find me at @ASlavitt on Twitter. If you like what you heard today, why don’t you tell your friends to listen as well, and get them to write a review. Thanks so much, talk to you next time.

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