Appendix B.

Representative quotes.

Resource	Quote no.	Quote
Hospitalization	1	Respondent: “We had a handful of deaths. Those were tough to deal with. [It was] unclear as to who needed to be hospitalized and who didn’t. So that was difficult. Some people that were sent out and came back ended up going back to the hospital and dying or some died in our facilities.”—PID 111 (Medical Director)
Hospitalization	2	Respondent: “A lot of my time was spent negotiating with [community hospital] about accepting patients. Instead of treating patients, I was negotiating whether they could accept. So you’re kind of using me as a clinical administrator, rather than a clinician. It’s a subtle distinction. But, if I’ve got an hour, and I could see three patients during that time—that’s a better use of my time than me calling up another facility and saying, ‘I’ve got these six patients.’”—PID 109 (Doctor)
Masks	3	Respondent: “It was a really hard time getting everyone masks, getting people to wear masks. The COs (correctional officers) said that they were going to strike unless they got N95s, but we couldn’t get them N95s. So, there was there was the cloth, the surgical, the KN95, and the N95. And so, writing—I wrote a lot of memorandums that if you’re interacting with someone who has COVID, we want you to wear an N95. Otherwise, you know, a KN95 in the jail is okay, and permitted. It felt squabbling. It was so much time squabbling with unions.”—PID 101 (Doctor)
Masks	4	Respondent: “I think it really helped to be able to wear whatever mask you wanted. You know because, first of all, they (N95s) weren’t here and we were just doing the best we could to get what we could initially. But I think that made a big difference [with compliance] to allow that.”—PID 102 (Deputy Warden)
Physical space	5	Respondent: “In isolating inmates, you know, you can’t put certain inmates with other inmates. It was literally an ongoing, okay, can we move this high-custody inmate who’s only on day two of his quarantine in with this other inmate. How do you manage this?”—PID 117 (Warden)
Physical space	6	Respondent: “I know patients of mine died because, I don’t want to say because they were decarcerated, but they were rapidly pushed out without opioid use disorder treatment, not through the jail’s fault necessarily, but basically Fridays in March or April, they would come around and they would release tons of people. And then we couldn’t get their medication, their healthcare activated. And so, they would go out without the buprenorphine or the methadone that they needed. And then they would overdose and die.”—PID 101 (Doctor)
Vaccination	7	Respondent: “Phase 1 in [state] was clearly healthcare workers. So, when that happened for the jails, they were allowed to do health care workers. In some of the jails, if a CO was working in a health area, he could be considered a healthcare worker. For the employees that were not already vaccinated as a healthcare worker, this is where the first line thing comes in. There are some corrections officers that are also police officers, or fire marshals, etc. So, if you didn’t qualify in that first one, then they rolled out at the same time to the COs and the people who are incarcerated. That was the goal.”—PID 101 (Doctor)
Vaccination	8	Respondent: “I think the biggest thing to come out of [the pandemic] should be that if your incarcerated population is there and they end up having outbreaks, it’s not because of them. It’s because either you’re not testing them or it’s coming from the sheriffs and the guards because they’re the ones that go back and forth. Then, if you don’t end up dealing with that and testing them and masking them, the general public will be impacted because those infections are going to go back into the community. If you don’t treat the congregate population, whether they’re in a group home, juvenile jail, or jail, the whole community is going to suffer.”—PID 116 (Medical Director)
Vaccination	9	Respondent: “We decided early on that we weren’t going to vaccinate anybody outside of what the general public’s level was. So, when it first came out and, you know, you had to be a certain age with a pre-existing to get the vaccine. We had maybe five elderly inmates with a preexisting condition. So, those were the only five we offered it to. Mainly because, you know, we don’t need the community screaming at us for giving advantages to people who are incarcerated because they wouldn’t view it as fair.”—PID 107 (Chief Deputy)
COVID testing	10	Respondent: “The other determination that we made early on was we were going to test everybody in the vehicle sally [a double-gated area through which incoming and exiting vehicles travel through] prior to coming in. So that wasn’t just challenging for us. It’s also challenging for all law enforcement bringing people in because now we were holding them out in the vehicle sally until a nurse could get out there and rapid test the individual. So it slowed down their booking time, which means that they weren’t getting back out on the street. We had to navigate our way through that and say, no—we really need to do this.”—PID 105 (Public Health Nurse)
Staffing	11	Interviewer: “Are there any specific examples you can provide of how the security staff resistant to your recommendations and guidelines impacted your COVID response in a negative way in the beginning?” Respondent: “So, things like custody overrides, housing people in a gym. We set up tents and housed people in it. These were all directives coming from medical to custody, which were huge workloads but also, from their viewpoint, absolutely crazy. I had people living in libraries and all sorts of places around the facility in nontraditional housing units that they then had to place their officers to man those units and create more stations and overtime. Simultaneously, we were mapping their staff out.”—PID 127 (Medical Director)
Staffing	12	Respondent: “Anything that was felt to be routine was taken off the schedule. So the schedules were now just seeing the COVID-positives with COVID quarantine and the more urgent cases. All the routine stuff really got lagged behind for several months. And that certainly caused a problem. Dental care was also stopped. Optometry was stopped. So that was difficult. And, also, you know, unless it was really an urgent situation, it was very difficult to get any consultant to see the patients at this time. That caused many backlogs to develop in people getting seen both at the clinic level and, certainly, at the and at the consultant level. So that was a big challenge. And, now, we’re seeing a lot of people going out for consultants and we’re kind of catching up from what that was at that time.”—PID 111 (Medical Director)