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This is the fifth story in a series by 乌鸦传媒 examining the impact of COVID-19 on vulnerable populations. Past stories reported on the homeless, immigrants in detention, the undocumented, and nursing home residents.

Coronavirus outbreaks in prisons and jails across the country have the potential to cripple any gains made by local communities in curbing the pandemic.

"They're not some isolated spot where you can just stick people," said Steffi Woolhandler, MD, MPH, a primary care physician, co-founder of Physicians for a National Health Program and co-author of a recent editorial on this topic.

There is quite a lot of cycling in and out of these facilities, both by staff and inmates. About 600,000 people are released from prison each year, she noted.

"And if you have an incubator for COVID spreading unchecked within prisons and jails, it will get back to the community."

Eight of the 10 largest COVID-19 clusters in the country are in correctional facilities, reported, including the Cook County Jail in Chicago.

One mechanism for controlling the spread of the virus, which has the support of many public health experts and prison reform advocates including Woolhandler, is to depopulate the prisons and jails by "decarcerating" large numbers of detainees -- a seemingly straightforward solution that is not without controversy.

'It's a Cesspool in There'

Every day, Kheenan Alexander gargles hot water from the Cook County Jail "day room" in his throat and sniffs it up his nose trying to kill any virus that might be nesting there.

He mixes the water and a little soap, or toothpaste when the soap won't lather, into a solution that he feels is "sudsy enough" and wipes down everything around him.

"Maybe it's in my head, but it makes me feel a little bit secure," he told 乌鸦传媒 from a jail telephone.

Alexander was arrested for vehicular hijacking, possession of a stolen motor vehicle, and aggravated unlawful use of a weapon last year. He might have taken a plea deal and been released from the Cook County Jail in early April, but because of the coronavirus pandemic, Alexander is now "in limbo" according to his lawyer, Cierra Norris, JD.

Earlier this week, the Cook County sheriff's office said the number of inmates with positive test results , with about half currently positive and the rest recovered. Six had died, as had one corrections officer.

Just before Alexander's hearing was to take place, "the coronavirus hit and they stopped doing pleas," Norris told 乌鸦传媒.

He had already taken a plea deal for two charges in a separate court, and had he taken a plea deal for the third, "I believe he would have been very close to getting out," Norris said.

Instead he remains in the Cook County Jail with little possibility of release or even transfer, as it's rumored that no other facility is willing to take inmates from the facility.

Alexander, when he's outside his cell, spends much of this time on the phone, trying to avoid the other inmates. But the phone is only 2 feet away from the next phone and the next inmate. "There's no way for us not to get it. It's just a waiting game."

He's scared and frustrated, but mostly, he feels forgotten.

Everywhere else in America when people had to be quarantined, a building was cleared out and sanitized, before people "resume with business."

"Why aren't we in the position to do that? Why aren't we looked at as something worth saving?"

LaSonya Alexander, Kheenan's mother, has been protesting her son's incarceration outside the Cook County Jail every other day for weeks, she said during a press call with , an international activist organization led by ministers, and the National Medical Association (NMA).

In an ," the coalition and the NMA called for employing "every effort to depopulate jails and prisons of nonviolent detainees and persons convicted of nonviolent offences" to reduce crowding and make quarantining possible.

LaSonya Alexander often broadcasts a live feed to her Facebook page and shares phone conversations she's had with other inmates inside the jail.

The "guards are coming in coughing and sick," Alexander said. Inmates also tell her they haven't been given antibacterial soap -- only thin bars of hotel soap that doesn't suds up -- and they're only given one bottle of bleach to clean an entire deck.

"It's a cesspool in there," she said.

Another protester is a woman named Cassandra Greer-Lee. Alexander said she shows up nearly every day. Her husband Nickolas Lee, 42, was an inmate at Cook County until he caught coronavirus in late March.

She phoned the jail "over 132 times" to try to get help for her husband, , but he died from complications of the virus on April 12.

"Standing by Cassandra Greer, listening to her story, was gut-wrenching," Alexander told 乌鸦传媒, "Her husband is dead. I don't want that to be me. I don't want to sit up and have my son's name be a hashtag. I don't want that."

Too Many People in Jail?

At least 1,300 inmates have been released from the Cook County jail, roughly a quarter of the jail's population, Cook County State's Attorney Kim Foxx told .

"We've proactively single-celled the majority of the jail population and maximized social distancing to the extent it is possible in a correctional facility, including preparing and opening previously closed detention areas," the Cook County Sheriff's Office said in a press statement.

"We have 2.3 million people behind bars, and most U.S. prison and jails were not built to accommodate the number of people that we now have incarcerated," said Woolhandler.

"There's a right way to do this," said Josiah Rich, MD, MPH, who has worked in the Rhode Island prison system for over 25 years and co-authored a recent on the topic.

"I think the first step is 'decarcerate' as much as possible as soon as possible. The second is prevent the virus from coming in, to the best of your ability" using appropriate screening measures, he said. "Third is to make sure you minimize the spread once it does get in, and identify those people that are positive."

Homer Venters, MD, president of Community Oriented Correctional Health Services (COCHS) and the former chief medical officer and assistant commissioner of Correctional Health Services for New York City's Health and Hospital System, also advocates for a policy of mass decarceration.

If an inmate becomes ill and the facility is at 50% capacity, designating certain areas for isolating the sick patient and imposing a 14-day quarantine is realistic. But "if you're at 100 or 120% that's physically impossible," he said.

Other infectious diseases such as HIV, hepatitis C, and tuberculosis have shown high rates of transmission in jails and prisons, said Matthew Akiyama, MD, assistant professor at Albert Einstein College of Medicine and the lead author of the NEJM editorial.

"I think this will be no different with COVID-19," he said.

Akiyama and his co-authors called on jails and prisons to release "elderly and infirm" inmates and temporarily suspend arrests for low-level crimes and misdemeanors.

Iran released more than 70,000 prisoners in an effort to "bend the curve" of its epidemic, while "failure to calm incarcerated populations in Italy led to widespread rioting," they noted.

As communities begin to flatten their case rates, if no action is taken inside prisons and jails, they could become an "ongoing source of community transmission," Akiyama said.

It's not just conditions in jails and prisons that create risk for COVID-19 -- the inmate population's demographic and medical profile is a factor too.

African Americans are vastly overrepresented in jails and prisons, and they have been disproportionately affected by the illness. In the Chicago area, 70% of deaths have been among blacks, who represent just 30% of the overall population.

Inmates also suffer from chronic illnesses such as asthma and heart disease at higher rates than people on the outside, Woolhandler and colleagues noted in their JAMA editorial.

While predicting prevalence rates in any one jail or prison is challenging, because these rates will vary across the country, Akiyama said, "I think we can probably expect to see prevalences ... as high as 10 times or more of the community in certain jurisdictions."

Another reason to support decarceration for older inmates and those with underlying conditions is that "crime is mostly committed by younger people," Woolhandler said.

Older inmates and those with severe illness have , but high risks of severe outcomes from the virus, she said.

Because healthcare systems have limited amounts of personal protective equipment, and life-saving devices such as ventilators, the community benefits from a policy of decarceration that puts less pressure on that system, Akiyama said.

"Every case ... that is entering hospitals from the criminal justice system leads to more resources that may not be available for others in the community," he said.

Rich also suggested that detainees won't be well served by hospitals overwhelmed with COVID-19 cases. "You got one open ventilator and you got 10 patients, and the one that is dressed in stripes and is just brought in from the jail" is not going to be the one to get it, he said.

Social Distancing Not Perfect, but Possible

Keith Ivens, MD, immediate past president of the American College of Correctional Physicians, said facilities can find ways to create some distance between inmates.

If phone booths are too near each other, he directs inmates to use only every other one and applies the same policy to showers. At meals, inmates are required to stand 6 feet apart as they pick up their trays, and just like at the grocery story, markers on the floor reinforce the proper distance.

In the case where officers must house both COVID-19 positive and COVID-negative inmates in one unit, Ivens puts some positive inmates in one area and some negative in another and leaves a few empty rooms between them.

Inmates have "plenty" of access to soap and water, said Ivens, who is the medical director for a private correctional health services contractor serving 40,000-50,000 inmates in Tennessee facilities.

Hand sanitizers, however, are 60%-90% alcohol, which is flammable. Soap is more effective anyway, he suggested.

While he does not believe that a regular face mask can prevent the spread of virus, since virus particles are much smaller than the mesh in a mask, his organization has bought tens of thousands and there's a prison industry making cloth masks.

"There is a comfort that people get from masking," he acknowledged, and it does help prevent people from touching their nose and face as often.

One other physical distancing tactic for open dormitories with bunk beds is a "head to foot" sleeping arrangement, such that inmates' faces remain 6 feet apart, Ivens said.

"There's almost always a way to make things better, even though, admittedly, complete social distancing is impossible," he said.

Weighing the Risks and Benefits

On the issue of decarceration, Ivens said that as a physician, he's "neutral," but then cited the story of a man "decarcerated" from a Florida jail who was .

"I'm sure somebody determined that that offender was low risk and he killed somebody," Ivens said. "So there you go."

It's about managing risk, he said. "If you're a guy who smokes pot on the corner, all right. Maybe that guy ought to get out. But if you're going to be released ... and start killing people in the streets, I'd rather him have COVID inside the jail."

Woolhandler said it's better to rely on science. "The data support the idea that a large share of people in prisons and jails do not need to be there," she said.

For instance, people in jail because they can't make bail have already been determined by a judge to be safe in the community.

"Frankly, this is a reform we needed before COVID," she said. "We need to avoid putting people in jail who don't need to be in jail."

Woolhandler also highlighted one wrinkle in decarceration policies: thoughtful re-entry. "It's not a great idea to release someone from a very crowded prison to a very crowded homeless shelter," she said.

People leaving corrections also need support to quarantine or isolate themselves. Some states have been renting motels to keep inmates out of homeless shelters, and helping former inmates to get food stamps and enroll in Medicaid.

Giving people the services to comply with self-quarantine has to be a priority, she said, because "just releasing people to the streets is a prescription for disaster, both for them and the community."

Staff as COVID Vectors, Victims

Most states are now banning visitors to jails and prisons, although some do allow visits from lawyers. But one inevitable threat to inmates' health is the correctional staff, said Venters.

In a jail or prison with 1,000 detainees, probably hundreds of staff enter and exit multiple times a day, depending on the length of their shifts. "[T]hat is the movement of virus in and out" of the facility, he stressed.

An officer at the Washington, D.C., Department of Corrections told 乌鸦传媒 that the health of guards doesn't seem to be a priority at his facility. He asked not to be named for fear of repercussions.

"I think there's quite a few people that probably might have it, at this point," he said of his fellow officers. "So now, you're in a situation that's kind of like a crisis, because you don't really have the manpower to do what needs to be done."

The American Civil Liberties Union and the Public Defender Service for the District of Columbia sued the D.C. Department of Corrections on March 30, for "flagrant disregard of basic public health measures to limit the spread and severity of a COVID-19 outbreak."

An ACLU asserted that inmates experienced delays in medical care and were denied COVID-19 tests. The corrections department also failed to "adequately quarantine" 65 individuals exposed to a deputy U.S. marshal who tested positive for the virus, or to provide staff and inmates with adequate gloves and masks.

Ivens said his biggest fear is an infection surge among corrections officers forcing half of them to stay home.

"It would be very hard to keep the place safe," he said.

But medical staffing hasn't been an issue. He's even witnessed a "boom" in recruiting as local physicians have had to shut their practices. "I interviewed a man just last night and hired him," Ivens said.

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