Preventing Childhood Vision Loss Through Exploitative Prison Labor: A Call for Action

In July 2020, together with a corneal surgeon, I (J. T. O.) performed complex eye surgery for a two-month-old baby born with a congenital malformation of the front of the eye requiring corneal transplantation and cataract removal. Postoperative care required obtaining a pair of glasses as soon as possible to prevent irreversible vision loss from amblyopia. Conversations with the optical dispensary revealed a several month delay in glasses production with an unexpected cause: COVID-19 outbreaks in the California prison system.

The California Prison Industry Authority (CALPIA), a semiautonomous prison labor agency under the California Department of Corrections and Rehabilitation, runs two optical laboratories operated by people incarcerated at Valley State Prison and California State Prison, Solano,¹ and these laboratories supply ophthalmic lenses to eligible Medicaid recipients, such as this young patient. Three months before this child’s surgery, CALPIA had paused the vast majority of its operations, including those at its optical laboratories, because of the COVID-19 outbreak.² This situation did not just illuminate a surprising connection between public health care and prisons. It caused the authors—two physicians and one lawyer in California—to rethink public health care stakeholders’ participation in a system that supports exploitative prison labor.

With more than 1.5 million people incarcerated in state and federal prisons and approximately half of the incarcerated population assigned to work programs, the United States is home to a sprawling prison labor economy.^3–5 Prison labor, which refers to the work performed by incarcerated individuals, was explicitly licensed by the Thirteenth Amendment, which states that slavery and involuntary servitude may serve as “punishment for crime whereof the party shall have been duly convicted.”

This practice became common in postbellum Southern states and allowed private companies and slave labor camp owners to “rent” predominantly Black imprisoned people to perform uncompensated work. Despite this practice falling out of favor, the underlying philosophy behind state-controlled prison labor remains essentially unchanged in 2022: the government, without violating the Constitution, may order incarcerated people to perform uncompensated or minimally compensated labor. Incarcerated people may be required to perform tasks to keep the prison running, work for private companies that contract with prisons, or work for public entities such as CALPIA, California’s prison labor agency, that create products (e.g., eyeglasses) to supply both public and private entities.

An example of prison labor’s entrenchment in US commerce is its use in public health care. Documents we obtained through a public records request revealed that our state’s public health agency, the California Department of Health Care Services (DHCS), agreed to pay CALPIA up to $37.9 million for the 2021/22 fiscal year for optical services alone. A CALPIA representative confirmed that DHCS, through its Medicaid contracts, makes up 74% of CALPIA’s optical service revenue. In other words, California’s Medicaid program is far and away the largest funder of the optical division of the state’s prison labor system.

So, despite the virtuous principles underlying public health care, DHCS relies on unambiguously exploitative labor. CALPIA wages in prison-based optical shops range between $0.35 and $1.00 per hour,⁶ up to 55% of which can be deducted by law for restitution and administrative costs, resulting in an effective pay rate as low as $0.16 per hour.⁷ Courts have routinely rejected legal challenges to these meager wages by concluding that, because the Thirteen Amendment permits the involuntary servitude of incarcerated people, the federal minimum wage law does not apply to prison labor.⁸

The result is a strange supply chain that is not always transparent or top of mind: medical devices produced by poorly paid imprisoned people are provided to the poorest members of free society, such as the infant who needed sight-saving glasses. We (two medical providers and a lawyer for incarcerated people) have observed firsthand how interconnected the two groups’ vulnerabilities are. The medical care of poor, publicly insured patients depends in part on the low wage labor performed by incarcerated workers. The low wages of incarcerated workers depend in part on a complacent buyer—the public health department—and, arguably, complacent medical providers who prescribe devices purchased by state Medicaid entities.

Put simply, a system designed to protect children who otherwise would not have access to care supports exploitative conditions affecting another vulnerable population. Money allocated for public health ultimately funds an institution known to disproportionately punish marginalized people.⁹ This use of prison labor to manufacture glasses is not unique to California and has been described in Pennsylvania and New York, but more research is needed to determine whether this labor relies on publicly funded resources.^10,11

Some argue that prison labor benefits incarcerated people. For instance, an incarcerated worker could learn marketable skills through their assigned job and may derive meaning from contributing to society by making medical devices that will help someone’s sight. In our state, for example, the incarcerated people working for CALPIA’s prison-based optical laboratories can and should be credited with producing the device that prevents childhood vision loss. Participation as a prison laborer can also be viewed favorably with regard to decisions about parole. But these “benefits” must not distract from the exploitative context in which they arise. In our state, prison work is not only extremely undercompensated but also mandatory—governing law states that incarcerated people are “obligated to work”¹² and subjects them to discipline if they do not.¹³ How meaningful is a benefit that one is forced to accept?

Ultimately, this situation illuminates a complex system that ties physicians and their patients to the prison industrial complex. Increasing awareness of this relationship could result in a greater understanding of the far-reaching effects of prison labor and greater scrutiny of the role of physicians in acknowledging and addressing the systems we support through our clinical care. The two-month-old patient was not the first and will not be the last to rely on an exploitative system to provide a medically necessary and sight-preserving treatment prescribed by her physician.

Others have called for public health officials, researchers, and physicians to address the sprawling reach of the prison industrial complex.¹⁴ Medical providers could use their position of authority to advocate better pay and conditions for incarcerated workers who produce the very devices that providers prescribe. Alternatively, medical providers could organize around resisting a systematic reliance on prison labor–sourced medical devices. In other words, “First, do no harm” may extend beyond the patient–doctor relationship and include a broader obligation to think critically about how one’s medical practice is indifferent to, or even causes, harm to others besides the patient. As care providers, we are not free from the social complexities that underlie the US history of incarceration or prison labor.