As the world’s greatest minds focus their energies and resources on combating COVID-19, there is a growing population of underrecognized victims—the infected men and women incarcerated in frequently overcrowded prisons and local jails.

Among the more than 115,000 individuals currently held in California prisons, outbreaks of COVID-19 infection have continued to escalate in some facilities. With an average prison cell measuring just 6 by 8 feet, and often shared by more than one adult, social distancing and careful hygiene practices—the very prevention strategies used to curb the spread of the disease in communities worldwide—are difficult to implement and maintain.

A team at Stanford Medicine has established a project to help inform COVID-19-related public health policy to protect and improve the health of incarcerated people as part of the SC-COSMO collaboration. In California, this project is working directly with the California Department of Corrections and Rehabilitation (CDCR).

“Incarcerated people are a particularly vulnerable group: they reside in close proximity, making disease control measures that are being used in the general population difficult or impossible,” said Jeremy Goldhaber-Fiebert, PhD, an associate professor of medicine at Stanford Health Policy (SHP), who co-leads the project with Jason Andrews, MD, associate professor of medicine (infectious diseases) at Stanford Medicine, along with SHP’s David Studdert, LLB, ScD, professor of medicine and law.

Inmates also have high rates of comorbid illnesses and other characteristics that increase their risk of substantial morbidity and death from COVID-19.

“Consequently, the pandemic threatens to have a devastating impact,” Goldhaber-Fiebert said.

According to The Marshall Project, by June 16, nearly 44,000 people in U.S. prisons had tested positive for COVID-19 — an 8% increase from the week before. As of June 16, 522 inmates had died from SARS-CoV-2.

The California Department of Corrections and Rehabilitation reported on June 16 that there are 2,169 active cases of COVID-19 in its prisons and among those recently released — and 17 deaths.

Through a $1 million gift from the Horowitz Family Foundation, Stanford Medicine established a COVID-19 Emergency Response Fund to support research and prevention strategies to slow and eventually stop the spread of COVID-19 infection in California prisons and jails.

During the civil unrest over the death of George Floyd, which has brought out hundreds of thousands of people across the world to protests and vigils, more than 4,000 people in the U.S. alone were arrested over the weekend of May 29.

“The need for COVID research in prisons is more important than ever,” said Felicia Horowitz, founder of the Horowitz Family Foundation. Even a brief, 24- to 48-hour stay in a crowded jail could substantially increase a person’s chances of contracting COVID-19 and unknowingly bring it back to their communities.

“The work we are doing with Stanford to bring more testing to prisons is vital to curbing the spread of this disease among an already vulnerable population,” she said.

African Americans die of COVID-19 at twice the rate of whites generally. They are also greatly overrepresented in incarcerated populations, making effective COVID-19 health policies in prisons particularly important.

The project team from Stanford has begun working with medical teams inside the prisons and jails in Santa Clara and San Mateo counties to map out the best strategies to help prevent the transmission of COVID-19 among inmates. This effort will include COVID-19 testing of all men and women at the time of incarceration, in addition to screening a portion of those already incarcerated, with periodic retesting to assess new infections. The study team is also conducting mathematical modeling of the rates and patterns of transmission in correctional facilities to inform policies for containment.

“We have seen large outbreaks of COVID-19 in jails and prisons across the country, with staggering rates of infection as the virus spreads unabated through facilities. The goal of our research is to evaluate a model for screening and monitoring COVID-19 in correctional facilities that could be scalable,” said Andrews, who has studied the high rates of tuberculosis (TB) in prisons in Brazil for the past seven years.

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“The epidemic of tuberculosis in prisons in many ways foreshadowed what we could expect with COVID-19 in jails and prisons. In nearly every country in the world, rates of TB in prisons are orders of magnitude higher than that of the general population,” Andrews said. “The reasons for this—crowding, medical comorbidities, inadequate health-care infrastructure, and highly socio-demographically vulnerable populations—also explain why we have seen so much COVID-19 in correctional facilities.”

Goldhaber-Fiebert said the research has potentially broader national implications, not only for prisons but also for other congregant populations like nursing homes and dormitories.

“Our work is linked directly to conversations with California prisons’ leadership and can support the design of health measures and policy responses,” he said. “We hope to draw important lessons from our analyses of incarcerated populations in California’s prisons and jails which may help to inform the responses of other local, state, and federal correctional facilities nationally.”

Felicia Horowitz is the founder of the Horowitz Family Foundation.

In addition to Goldhaber-Fiebert, Andrews, and Studdert, the Stanford team includes Lisa Goldman Rosas, PhD, assistant professor of health research and policy (epidemiology) and of medicine (primary care and population health) and Joshua Salomon, another professor of medicine at Stanford Health Policy. The research staff on the project are SHP Research Analyst Lea Prince; Tess Ryckman, who is working on her PhD in healthy policy; Liz Chin, a PhD candidate in biomedical informatics; Stanford Law School student Ally Daniels; and Yiran Liu, a PhD candidate in cancer biology at the School of Medicine.

“This is an opportunity to shine a bright light on people who are just unseen,” Horowitz said. “Every death represents a heartache. It doesn’t matter if it’s someone who lives in your home or someone you love who is incarcerated. If we can save one life with this program, it will have been worth every cent.”

Shaka Senghor, a former inmate who spent 19 years in prison, is advising the project. Senghor is a best-selling author and an advisor on prison reform.

“Shaka’s intimate knowledge of the prison system will help Stanford navigate the administrative and cultural complexities as we fight to make prison safer for everyone,” Horowitz said. “I know that with testing, and with the experts at Stanford combined with Shaka Senghor, we can make a difference.”

If you would like to help reduce and prevent the spread of COVID-19 among California's incarcerated populations, click the button below, and in the field “Special Instructions/Other Designation,” write COVID-19 Incarcerated Assistance Fund.