COVID-19 Pandemic Threatening Prison Population

Abstract

The prison population is one of the high-risk groups for coronavirus disease 2019 (COVID-19) pandemic. Apart from being in disadvantageous settings of “social distancing,” people in prisons are frequently elderly and with multiple comorbidities as a reflection of discriminatory punitive policies worldwide. Although the universal human rights principles ensure that prisoners, like everyone else, live their lives in a healthy environment and access qualified healthcare when they are sick, without being discriminated, the prison conditions make it difficult to comply with these principles. In this review, the basic principles and recommendations on this subject have been reviewed in the context of the COVID-19 outbreak. In addition, the situation in Turkey’s prisons was reviewed immediately before the transition to a “controlled social life.”

INTRODUCTION

Prison population is one of the groups posing a risk for the coronavirus disease 2019 (COVID-19) pandemic because most prisoners suffer from chronic diseases caused by adverse health conditions. Relatively high incidences of diseases, such as hypertension, asthma, cancer, tuberculosis, hepatitis C, and human immunodeficiency virus (HIV), in convicts and detainees puts them at a disadvantage for COVID-19. Furthermore, the fact that 11% of the prison population is 55 years or older because of harsh punishment policies, increases the risk of being infected with COVID-19 [1]. Since 1993, the incarceration rate of the population aged over 55 years has increased by 400% [2].

In addition to the risk of advanced age, the density of prison population is another important factor in COVID-19 infection risk. For example, it is known that the prison capacity is over 100% in 18 states of the United States of America (USA) and that the official capacity has been exceeded in 59% of the countries as of the end of 2014 [3]. More than 10 million people are imprisoned worldwide thus far [4].

Risk Factors

Healthcare services provided to the prison population are almost always inadequate and unqualified. High-risk behaviors are common among the prisoners and convicts. In addition, prisoners have public health concerns, and there is a lack of empathy toward the convicts [4].

The universal basic principles of health ensure that the prisoners can access health services available in the country without discrimination on the grounds of their legal status. However, it is known that almost all diseases, especially tuberculosis, HIV, hepatitis C, pneumococcal infections, and infectious dermatosis, are seen more frequently in prisoners [3, 4]. Inequalities in the social determinants of health, such as racial minority or mental illness, lead to further intensification of diseases in the prison population [4]. The incidence of tuberculosis infection is 3.4 times higher in prisons than the national average in China [5]. Historically, British prisons had more deaths than the general population during the typhus epidemic in the 16th century [3].

Influenza epidemics in prisons are also risk factors for COVID-19. One of the first documented influenza epidemics in prisons is the 1918 influenza pandemic in San Quentin prison of California, USA [6]. However, it was seen that prisons were not included in the planning effort during the 2009 H1N1 influenza pandemic despite these facts [4]. No vaccines were provided to prisoners although there was a vaccine to prevent the epidemic at that time, and it was known that non-pharmaceutical interventions were very effective in all epidemics, especially in the 1918 influenza pandemic [4].

In recent times, the Diamond Princess cruise ship is a good example of a closed structure for the COVID-19 outbreak [2]. As it is known, a small number of patients on the ship caused a rapid spread of the disease in an indoor environment. The data indicated that a few kitchen workers responsible for feeding the passengers quarantined on the Diamond Princess cruise were responsible for the epidemic in the ship [2]. Considering that the infrastructure is hardly as good as that of the Diamond Princess cruise in most prisons, it should be accepted that even a few people can trigger large epidemics in prisons. The administrative staff in prisons, especially the execution officers, are in free contact with the non-prison environment after their tasks in the prison are completed, and they return to the prison as required by their duties, further increasing the risk [2].

According to the studies, it is known that people sentenced to longer prison terms as a result of the punitive justice system implemented worldwide are those who are detained without conviction [1]. Most of these people are those whose guilt has not been proved. Furthermore, the monetary bail system implemented, especially in the USA, leads to discrimination against people with low incomes and the black Latin male population [1]. This leaves people in the lower economic and social strata and hierarchy at a higher risk of contracting COVID-19, regardless of the crime allegedly committed. An urgent reform is necessary to prevent this discrimination.

Precautions

The basis for justice reform to be implemented should be the prioritization of release by all prisons, especially those with a high spatial density. However, given that Iran, which released 70,000 people from prisons, could not prevent the spread of COVID-19 outbreak in prisons, the release process must be implemented immediately at the beginning of the outbreak [6] because it is important to prevent the outbreak before any person in any prison gets infected by COVID-19.

In addition, widespread screening is required for the prison population through improvements in prison hygiene and tests. Complete entrance screening and personal protection measures are vital. However, testing capacity and personal protective equipment are limited in most prisons [7]. Because of these shortcomings, it is crucial that the emergency and elective planning systems be transparent, including the transfer protocols for patients who are sick or those who require special care [6]. Restrictions and barriers to access the healthcare services for prisoners and convicts should be revised within this framework. Similarly, plans should be made by foreseeing that there are no real hospitals within the walls of any prison, the number of people involved in healthcare is proportionally low in all prisons, and the quality of the services provided is always quite low [7]. In addition, although it may be necessary to isolate the patients in prisons to control the spread of infection, this isolation should be designed so as not to cause serious mental health problems [6].

Safe and adequate food supply for the prison population is also critical. Access to healthy and nutritious food is a challenge in prisons in many countries. For example, in the Democratic Republic of Congo, where occupancy capacity of prisons is 432%, prisoners and convicts receive only one meal a day [7]. According to the United Nations peacekeeping mission in the country, at least 60 people died of hunger in Kinshasa’s central prison within the first 2 months of 2020 [7].

It is equally important to ensure access to housing, food, and healthcare services to the released prisoners to protect them from the risk of the pandemic outside the prison [1]. Appropriate support should be provided for the elderly after being released from the prison because it may not be possible for these people to have social support networks in society after all their life has been spent in the prison.

The recommendations of the World Health Organization (WHO) for people who will remain in prison during the COVID-19 pandemic are as follows [8]:

1. Screening and risk assessment for all individuals entering the prison.

2. Similar measures for the persons released from the prison.

3. Environmental cleaning and disinfection in prisons at least once a day.

4. Encouraging individual hygiene and hand washing and supplying the materials necessary to take these measures for the entire prison population, including personnel.

5. Education on implementing respiratory hygiene.

6. Addressing the problem of the prison crowd.

7. Preparing an action plan, determining the people responsible for implementing the plan and preparing a workflow for possible and definite cases.

8. Developing plans for information about emergencies.

The guidelines published by WHO recommend that patients with COVID-19 should not be admitted to prison [9]. The guidelines emphasize the concept of human rights and labeling and underline that quarantine decisions for prisons should be made by physicians objectively and should not be used as a punishment tool [9].

Finally, it is obvious that all of the measures to be taken should be considered in terms of humanitarian law and defined as a part of public health practices. Furthermore, it should be known that it is a crime not to do anything for the prison population in a pandemic setting [1].

Measures Taken by Turkey and Problems Experienced

According to the data published by the Civil Society Association in the Penal System, there are 282,703 people in prisons, although the total capacity of the 355 prisons in Turkey is 220,230 people. In total, 199,681 (71%) of these prisoners are convicted; of these 200 are lesbian, gay, bisexual, or transgender.

There are 3,019 children under the age of 18 years in prisons. A total of 743 children are in prison with their mothers [10].

Turkey’s targets that are being implemented in prisons because of the COVID-19 pandemic are [11]:

• For the administrative staff

• Supplying and using general purpose detergent and disinfectant solutions.

• Proper cleaning of the prison environment.

• Frequent cleaning and disinfection of waste bins.

• Decontamination and disinfection of transfer vehicles.

• Having informative material in the common areas of prisons.

• Attention to food to prevent transmission and strengthen immunity.

• Suspension of all collective activities, except emergency ones.

• Suspension of education and training activities.

• Suspension of all working activities within the prison.

• Having a physician to minimize hospital transfers.

• For the prisoners

• Educating prisoners on general hygiene and transmission routes.

• Supplying personal protection equipment and other needs.

• A total of 14-day isolation of new prisoners and convicts.

• Triage for symptoms, travel, and fever in prison entrance areas.

• Ensuring that all the visitors use surgical masks.

• Having disinfectants and face masks in the visitor settings.

• For the personnel

• Educating the personnel on transmission routes and basic disease information.

• Distribution of medical masks to probation officers and information on using these masks.

• For patients with COVID-19 infection

• Supervision of suspected patients with COVID-19 in hospitals.

• Medical isolation of individuals with complaints compatible with COVID-19.

According to the prison follow-up bulletins published by the Community and Legal Research Foundation, the relatives of the prisoners and convicts are concerned about life and safety of the prisoners because data about the spread of COVID-19 in Turkey’s prisons are not shared with the public by authorities in a transparent manner [12]. According to the information compiled by this foundation, the problems experienced in Turkey’s prisons related to COVID-19 include performing headcount collectively, lack of medical aid, providing only one pair of gloves and one mask per prisoner, not informing the family about the disease and burial of a prisoner who died because of COVID-19, not admitting patients to the quarantine ward despite positive polymerase chain reaction (PCR) test, not transferring patients to hospitals, presenting hygiene products for sale at excessive prices, crowding of wards, disrupting treatment of patients with other comorbidities like cancer, inaccessibility to hot water, and restriction of phone call rights [12–14]. It is also stated that the practice of working for 15 days and then staying quarantined in the dormitories for 15 days to not increase the execution officers’ risk of disease is not applied to the healthcare workers in prisons [13].

The complaints compiled by the Civil Society Association in Penal System according to the information obtained from 68 different prisons between April 15 and April 28, 2020, and from 72 prisons between April 29 and May 12, 2020, included “social distance” violations because of overcrowding of prisons, insufficient hygiene measures, disinfectants being sold at fees ranging from 10–45 TL, prisoners not being provided with masks or being charged, unhygienic and inadequate food, additional food not being available even by paying the price in some prisons, serious limitations in accessing healthcare rights, no access to medical treatments, limited phone calls replacing the right to visit, and prisoners who recently moved from closed prisons to open prisons being employed for long hours because of accumulated work [15, 16].

COVID-19 in Turkish Prisons

News cases on the spread of disease were reported in many prisons. Although regular and periodic public information was not made available by the Turkish Ministry of Justice, it was stated by the ministry on April 13, 2020 that COVID-19 was detected in 17 prisoners and 3 of them had died. However, the Izmir Public Prosecutor’s Office announced that a person’s COVID-19 test was positive in Buca prison a week after this statement was made. As specified in the literature, it was later announced by the Public Prosecutor’s Office that more 64 people tested positive for COVID-19 thereafter because the important principle of preventing the epidemic before being infected with COVID-19 could not be implemented. A similar situation was observed with 55 people being infected in the Konya E Type Closed Prison at the end of April [17].

Mr. Huseyin Yayman, the chairman of the Rights of Prisoners and Convicts Subcommittee of the Grand National Assembly of Turkey (GNAT), stated that they had to stop the visits to prisons because of the pandemic and that they were in contact with the Ministry of Justice. He also stated that the ministry has taken the necessary precautions [17]. Mr. Sezgin Tanrıkulu, the deputy chairman of the GNAT Parliamentary Human Rights Investigation Commission, emphasized that approximately 100,000 convicts were released from prisons with supervised liberty or allowed to go with the execution regulation adopted by the assembly and stated that, “Yes, releases were provided and transfers were made from closed to open prisons, but ultimately, the capacity of prisons is 188,000. The compressed capacity is 220,000, and there are people in prisons close to this compressed capacity. These people are living together, and there is a shortage of access to disinfectants. Unlike the past periods, we have more complaints about nutritional problems because nutrition is important in the fight against disease, and there are complaints that they are malnourished. There is information that the prisoners in Buca, who were positive, were transferred to the relevant hospitals, but there are complaints from some prisons about the difficulties in accessing the healthcare services. Necessary measures must be taken in this regard and we will follow” [17]. In the “Marmara Region Prisons COVID-19 Outbreak Report” published by the Lawyers Association for Freedom, it was reported that the COVID-19 epidemic is spreading rapidly in prisons, the environment where prisoners stay are not cleaned adequately, hygienic materials had to be purchased by prisoners because there was no adequately supplied, a mask is sold at an excessive price of 17 TL in some prisons, and prisoners and convicts have problems in accessing the healthcare services [18, 19].

Finally, 2 prisoners/convicts and then 42 more prisoners and convicts were diagnosed with COVID-19 through tests in Silivri Prison. The Bakirkoy office of Chief Public Prosecutor stated that the treatment and follow-up of 40 people who did not have any complaints would continue in prison and that of 4 people in the hospital environment, and their families were informed about the situation [20]. In contrast, although the number of cases in all prisons was 17 on April 13, 2020, it increased by 606% in 15 days and reached 120 on April 28, 2020 [21]. Furthermore, the Minister of Justice announced that 14 judges and public prosecutors, 32 judicial and 34 forensic personnel, and 79 execution officers were infected by COVID-19 as of April 13, 2020 [22]. Although the number of physicians and healthcare professionals working in the prison infirmary is not disclosed, it is known that there are people who have positive COVID-19-PCR outcomes.

What Should Be Done?

It was requested in a statement by the Turkish Medical Association published on April 6, 2020 that considering the disadvantages of prison conditions and prisoners in terms of immunity in the face of the pandemic, the number of prisoners should be reduced, prisoners and convicts should be released without any discrimination, and an equal and fair change of execution should be made including all prisoners [23]. As stated by the United Nations High Commissioner for Human Rights, to prevent COVID-19 from causing problems for prisoners and employees in prisons, all those arrested without sufficient legal basis, including those arrested for political reasons just because they express critical or dissenting views, should be released [24, 25]. In this context, it is critical to release 100,000 prisoners early in Turkey because of the COVID-19 pandemic. However, although the Amnesty International’s representative views this legal regulation by Turkey as a step for reducing overcrowding in prisons, this regulation does not cover the people who have been convicted as a result of unfair trials within the scope of extremely broad antiterrorism laws in Turkey, and this inadequacy condemns these people to the possibility of contracting a fatal disease [26].