From Pushkin Industries. This is Deep Background, the show where we explore the stories behind the stories in the news. I'm Noah Feldman. We're all in the process of doing our best to social distance to stop the spread of coronavirus. And for most of us, and probably it should be for all of us, that basically means self imposed isolation of a certain degree. But there are many people in the United States whose isolation is involuntary, and that is people who are incarcerated in jails, in prisons, or in immigration detention centers run by ICE. Prisoners have already tested positive for coronavirus in New York, in Georgia and other states as well. That's going to continue, and officials are scrambling to figure out how to stop the spread inside of institutions, prisons, in jails. To discuss this situation, I spoke to doctor Homer Vendors. Until recently he was the chief medical officer of the New York City Correctional Health Services. Now he's president of an organization called Community Oriented Correctional Health Services, which is a nonprofit that builds partnerships between jails and community healthcare providers. He has a new book called Life and death in Rikers Island, which is precisely about the health risks of incarceration. And he was involved in two thousand and nine in New York City's efforts to deal with the H one N one virus when it was spreading inside of Riker's Island. In short, doctor Vners is really the perfect person to speak to about this problem. We spoke on Monday morning, Homer. As of this morning, New York City Corrections, where you used to be the director of health for the entire system, is reporting thirty eight cases of corona among either inmates or prison staff. For jail staff, How worried should we be about that number? I think that that number should cause alarm. That should make us think about not just what's happening to people who are detained in the New York City jails and the people who work there, but every single one of the five thousand jails and prisons and ice detention centers across the country. I think this is a very small foreshadowing of things to come and implications for the survival. The welfare of the people who are in these places, who work in these places, is really in peril. And this is just the first of what I fear will be many many more headlines and reports like this around the country, many of the places, by the way, that have far fewer health resources, far less access from the press from outside eyes. So I think this is the beginning of what we've been worrying about is going to be a significant feature of this outbreak. A lot of us have a visual image of what it's actually like inside a jail or a prison only from television, and in fact, mostly from fictional television. Would you explain a little bit to us about how conditions, for example, in a big city jail like Rikers, are especially conducive to the transmission of infectious disease. Yeah. I think that there are some features of jails that we might generally understand that really contribute to the transmission of communicable diseases. So the fact that there are lots of people in very small spaces, and those people are jammed into housing areas that whether they're a dorm or comprised of cells, it's still lots of people in a small space, sharing congregate bathrooms and sinks. People to go from one part of the jail to the other have to go through hallways and go through these things called sally ports or control hubs, where they're all jammed in and you have a gate that closes behind you before a gate can open in front of you. There's intake areas where people come in, especially in county jails that have such a high churn. You know, half the people are gone by day ten or fifteen, so they're constantly filling up with newly arrested and detained people. Those folks are coming in through these intake pens that are very teeming with people, just scores of people in small spaces, nowhere to sit, laying on the floor, and that's all the physical plant. Then if you add in the fact that most of these places are filthy, they have incredibly bad sanitation. You have garbage, food trays, other types of trash built up all over the place. They really promote the spread of communicable diseases during normal times and during outbreak response. The way that they're built and designed and run promotes the spread of disease. One reaction that I had when first thinking about incarcerated population is that the lockdown, which is sometimes the word that we use colloquially to describe what's happening to everybody else. I mean, I know that Governor Quoma, New York wants to call it a pause. In California, they call it a stay in place where, or another sub called a shelter in place. But lockdown is still the vernacular phrase that comes from prison. I mean, that's a prison metaphor, and that might create the impression in somebody's mind. I think it did it. At my first uneducated thought before I started reading what you were writing about this that actually prisons might be manageable because you actually do have the capacity to control the movement of prisoners. But on closer examination of what you've been saying, that seems completely misguided. And I wonder if you would just say a word about that, because I think I might not be the only person who has that instinct. Yeah, I think that you know, prisons and jails are built for punishment and security control of people of humans. I think that we all have this desire to stop the movement of this virus through our society, and there's a lot of really important measures that we're all engaged in to try and do that. The problem in prisons and jails and in correctional spaces is that lockdown generally means putting people into locked cells. Often sometimes dorms, but often we use it. It's used of cells, locking people into cells and then keeping them there and then only bringing them out for certain circumstances. And the idea is that the problem will stay in the cell and so in this circumstance, and what I would say is inappropriate use of lockdowns as the primary response to coronavirus. The notion would be that if you lock everybody into cells, then the virus either won't get in or if it's in the cell, it won't get out and it won't move around the facility. That is erroneous for a number of reasons. First of all, people who are locked down are being punished. Whatever you say is the reason for it. When you go get locked into a cell, when you're going into solitary, it causes a lot of stress. People don't like it. It is associated with suicide and self harm, and so people don't want to go into those cells. Then to institute a lockdown that means that you'll, all a sudden, are going to ask your correctional staff to put their hands on a lot of people, to have a lot more physical contact with people. Sometimes us as a force that get them into these cells, and then every time they come out of those cells for a shower, if they come out to go to the medical unit, if they come out for any other reason, you're often then in this position of having to have two escort officers handcuff them, escort them physically. All of that is just really escalating the amount of physical contact between humans in these facilities. The other real core problem with this is that when people get sick, and we know they're getting sick, when they're locked in a cell, you don't see that. Correctional officers coming by every fifteen minutes or thirty minutes to peek through a dimly illuminated vision panel or window in a cell door is not the way that you keep an eye on people that you're worried about getting sick or dying. So the lockdown as a public health response is not appropriate as the primary measure, and in many ways it can actually increase the flow of the virus into and out of a facility. Obviously, the most immediate ethical worry that I think we all need to have with respect to incarcerated people is that it shouldn't be the case that if someone is being locked up. They're being essentially put in a situation like being put on a cruise ship, but involuntarily and with much worse conditions, which is likely to significantly increase their chance of getting sick and dying. But I assume there's also a concern for the general public associated with enabling a coronavirus to spread rapidly within jails and prisons, partly because corrections officers are coming and going and so it will spread into the general population. Partly because of resource allocation issues, because if you get a big outbreak, a lot of resources are inevitably going to be called on, even if they were not distributed in a fair way. What do you see as the main concern for the general public here? I mean putting aside the very pressing ethical concern that we shouldn't be arresting people from minor offenses and then putting them into place where they have a better chance of catching a disease and dying. Yeah, I think the simplest way I could put it is that correctional settings, prisons, jails, and ice decession centers are going to drive this piademic curve straight up. So we hear about trying to flatten that curve about trying to relieve the strain and stress on our health system by social distancing and taking all these other measures and really extreme important measures that are being implemented today. What happens behind bars is going to drive that epidemic curve in exactly the opposite direction of what we're working towards, and so they will quickly become reservoirs. And they probably are already, but certainly as we make gains in the rest of the community, these places will become critical reservoirs for infection. They're going to continue to cycle infection out of these places in and out as staff go in and out, and to some extent the people who are held there. But you know, there's many more people coming and going every day who are staff members than there are arriving as newly arrived people in a prisoner jail. So these places, as reservoirs of infection, as congregate settings where the spread of the infection cannot really be controlled, stand to dramatically escalate the epidemic curve that we're working so hard to bring down. Homer, you mentioned crucially that prisons and jails are probably already at least in New York City becoming reservoirs of coronavirus. That leads us to the really pressing question of what we should be doing and how we should be doing it with respect to releasing people. And I want to start with just asking a question of you when you wear your epidemiologist hat. And that is given that we know now that there are presumably lots of cases, including asymptomatic cases, in jails and prisons, if we open those doors, is that going to be adding a new vector of rapid spread to the general population. And if so, is that nevertheless the right thing to do in terms of the overall cost benefit of fighting the disease. Well, I think where we're at now is that when coronavirus arrives in a community, it's part of the community is the jail or prison or is attention center, and it's going to arrive there. So places where we likely have a significant number of people who are asymptomatic, who are kind of brewing early infections. It's no different inside the jail than outside the jail. Now, in the coming weeks, we will have spread inside those facilities that you may be more accelerated than outside. But one of My primary concerns is that unlike the community, where we're going to have some family or ability some other we have capacity to see who's getting sick and who needs hospital level care. We're going to miss that behind bars. When H one N one hit, everybody who was symptomatic was tested in the New York City jails, and so sometimes the press and people on the outside would erroneously think that this was a riker's outbreak of H one N one. But we everybody who was symptomatic was in a housing area, and these weren't cells, they were dorms, but they were in housing areas where they couldn't move in and out. But also we would give them a test and then if they were symptoms attic, they'd go to the same place that the coronavirus patients are going today, the West Facility of Communicable Disease Unit. But people thought, because I think it was like two and a half percent of the people coming into the who it came into the jails during that time tested positive, they thought, boy, this is a riker's problem. It wasn't. It's a community problem. We just happened to be very aggressive about testing because we did not want to miss a single case. I think that the way to characterize what's happening behind bars is if it's in the community, it's part of the community's the jail or prison, and so I don't believe that, at least today, there's an epidemiologic reason to say releasing people is going to contribute to the infection. And I think that right now we've turned a corner in this country, which is our primary focus is on preventing death, and to do that, we have to get people out of these places. We'll be back in just a moment. There are voices, including yours, increasingly calling for release of certainly people who are jailed awaiting trial, and even of inmates who've already been convicted or guilty to crimes. Do you have a view about how that should be done, how should that be triage. I think that we'll need different strategies for county jails, for state and federal prisons, and for ice detention centers. Some of these places, like ice detention, there's not really nobody is even making a public safety argument for why people should be detained, and so you could categorically just administratively, it seems to let people out county jails have one set of pathways, which involved looking at people in the nature of their charges and figuring out how they can get people out certainly before there so they can just show up to trial. And that's and that's different than you know, when I've talked to state prison administrators in the last couple of weeks, that's a very tough off road. There are people who are on the pathway to prison release, and so those pathways can be accelerated. There are in most states prison furlough processes that can be enacted, But the state prisons I'm terribly worried about because you have just huge numbers of people. I was talking with somebody from a state prison system yesterday where the overall capacity of the state prison is at one hundred and seventy five percent of what they should have, and so incredibly densely populated places where there's really very little prospect of getting people out. And so as I think about what we need to do to react besides release, part of it is it will contemplate strategies that are different for these different types of settings. That seems very sensible, but I just you know, there is a substantial risk I think that none of that could happen fast enough. I mean, so, for example, I know some DA's offices around the city, including Brooklyn, have called for applications from lawyers for people who are detained to say, hey, explain to us why we should go to the court and move to have your or agree to your emotion to have your client release under these conditions and circumstances. I think that's a great response. I worry that it can't work at scale. It's not just that courts are moving more slowly because of their own concerns about Corona's that even under the best of circumstances, that's a very individuated way of doing it. And of course it seems sensible. Let's make sure, let's weigh, let's make a judgment about each person. That's what courts are good at. But it's not a crisis response approach. Do you think there's a plausible argument to say, for example, that all non violent offenders being held in rikers, or all non violent offenders over the age of fifty, or you know, something of that sort just ought to be straight up released. And the reason I ask this is not just about getting things right in New York city or in the jail slash prison that you know very well. It's also that this is going to become a paradigm set a presumably for other places in the country, if in most likely when we see the same scenario repeated elsewhere. Yeah, I think that's an important point that deliberative and piecemeal approaches are not always the ones we want to turn to in really die our emergencies. I reminded of a colleague who once told me that after Katrina in New Orleans, what they got was a plan that was developed by an Internet And I can say this as an Internet, but what they needed was a plan developed by an emergency medicine doc. And I don't mean that just for the medical part, and so I think that's right. I think one of the things I'm calling for in terms of what we should do besides release with keeping releases, the number one objective is every state must appoint or identify a correctional health coordinator who can manage this process, and the CDC needs to also, and so does HHS. We need state level and federal level people who have been identified to coordinate what's happening with the health aspects of corrections and to tend spaces around the country because we have five thousand of these places. If you sit as a commissioner of health or the person who's running your state's COVID emergency response, you look across this array of places you probably don't even know much about. You have county jails in all your counties, mostly, you have state prisons, and then you have ice detension centers, some of which are run by for profit companies. And so we need just like we're taking seriously what's happening in long term care facilities, assisted living, in nursing home settings, we need to identify one person in every state that's going to take on this task because we don't even have data today. Nobody could tell you how many patients inside county jails, state and federal prisons, and ice detention centers have symptoms today, how many are needing a test. And one of the critical concerns I have is we do not have pathways to hospital level care for most of these patients. Most of these patients who get sick, the traditional method of getting them into a hospital is to send them with two armed correctional officers to go to a local hospital. It's a process that for people who have seen it, like everybody who works in emergency rooms and people who work in corrections know this. It takes a ton of resources because you're sending two officers who are going to stay with this person twenty four to seven. They take up a ton of space in an emergency room. Emergency rooms that are incredibly over stretch right now in terms of their staffing and their space. And so if we get five or ten or fifteen people from one facility going to the hospital, there just won't be CEOs correctional officers to go with them. They're going to have fewer staff because they'll be sick. We won't have a magical new resource for them to go to to get this care. And my experience in investigating deaths all over the country is that these patients are patients who are behind bars today, are the ones that go to the back of the line when it comes to access to hospital level care. And so part of the priority has to be we create explicit passways for access to hospital level care when we had toify patients that need it in the real world. I don't think you'll see that happening. I mean, I think it's maybe ten or fifteen patients. You could conceive of a system saying, well, we're going to send two correctional officers, but at some point, either they're going to have to stop doing that and shoulder the risk of escape, or alternatively, simply not send people who are incarcerated to hospitals. And if that happens, what will happen within the jails and the prisons. Well, if those are the only two options, then yes, people will die preventable death because people will be held in correctional facilities where staff will to try and take care of them for too long. They'll get well passed their level of clinical competence and equipment and infection control capacity. Some of the data indicate thirty or forty percent of the people who need kind of a middle level of inpatient treatment but not yet I see you treatment. About thirty or forty percent of them will need a higher level of care. Well, if you're trying to manage the middle level inpatient folks in your jail or prison or detention center, than when they need that higher level of care because they deteriorate, you're not rolling them down the hall to the ICU. You're going through a two hour transfer process, so they're going to die. There is another option. We did this after Sandy to set up secure treatment units as part of what's going to be the surge in capacity at hospital. So hospitals that are currently building sometimes tense, sometimes new opening up wings that have been mothballed, setting up new space to handle this incoming flux of COVID patients. In that the states that are planning this with their hospital partners, they need to explicitly detail and plan for care for incarcerated patients. And so sometimes what you can do is you can as we did after Sandy, We've set up a new unit. We had patients go to a couple of dedicated places but when Bell was evacuated. But one of the things you need is the capacity to set up are units. So you're not relying on two correctional officers for every patient. But you can figure out how to get a better ratio of correctional officers to patients in a unit that's somewhat secured, that meets the custodial requirements of the securing authorities. And it may be that in some states and some regions you actually have multiple correctional administrations, like different sheriffs or sheriffs and state prisons cooperating to figure out how can they staff up and design these units quickly with the hospitals that are surging their capacity. Because these units and this response has to involve hospital level care by hospital staff, it's not going to work if you're keeping patients out in these correctional settings. They're just not going to survive. What's the sort of best case scenario you can picture. We've spent a lot of time in this pandemic situation talking about worst case scenarios, and you've made it pretty clear that the worst case scenario is significant number of people dying unnecessarily and prisons and jails really contributing to the rapid rise of the curve. But what's the best case scenario that you can realistically foresee if good recommendations are followed well. I think that one of the things that could happen relatively quickly is that as states in the CDC identify correctional health coordinators, they are going to get a quick snapshot of where the outbreak is impacting incarcerated patients first. And this won't be uniform, just as you know, it really reflects what's happening in the community, and so for the next few weeks we're going to have hotspots where the problems are evolving. We may in a month or two have a much more prevalent problem that is more generalized, but for the next month or so, we're going to have places Rikers being the first that's being reported. It's critical for us to appoint these correctional health coordinators right now because they need to be the ones that are in the room with the governor's staff, with people running the overall response, to understand and report to others where patients are going to need to be going, and how we can build these new units in a way that meets the statewide needs. So if you look at the footprint of incarceration in every state, one of the things that's really terrifying is in a lot of rural counties we have large overfilled county jails, we have a fair number of prisons, and we have a lot of ice dissension centers, all in places where we've lost hospital capacity in the last ten or fifteen years. That requires a coordination at a state level to understand day to day who are the patients that need higher level care and where can they go? And I think that that kind of it's not just epidemiology. A lot of this is also supply chain. How can we get people connected to the things they need. That's happening in every pretty much every other aspect of society right now. So these are not principles or tasks that are foreign to the rest of the nation. It's just that these patients and their welfare haven't traditionally been incorporated, but they must be incorporated now this week to this response if we want to save their lives and also help really bring down that curve. Homer, I want to thank you not only for the important work you're doing in this crisis, but for the work that you do all the time to try to improve conditions for public health inside of prisons and to build partnerships between jails and community healthcare providers. That's important even when we're not under conditions of the pandemic, and what you're doing now is also obviously great pressing significance. Thank you very much for your time. Thank you very much, have a good day. Speaking to home reveners makes it extremely clear that the problem of coronavirus that we're struggling with across the country now is especially acute and worrisome when it comes to people who are incarcerated. It's not only an ethical issue, it's also a public health issue of the most pressing type. He's calling for the appointment of coordinators in every state to deal with the problem. That seems like a no brainer and should certainly be adopted. It's my instinct, however, that we may need to go further than that, and I hope that governors across the country and prosecutor's offices as well, will look seriously at engaging in more systematic analysis of who could safely be released, both in order to protect them and to protect the general public against the risk of many, many acute cases of coronavirus arising among people who are locked up. Almost every university that I know of has sent home students from its dorms, and prisons in the end bear such a close resemblance to dormitory living that the probability of spread seems very, very great within them. That's a radical measure, but this is an emergency, and an emergency radical measures at least need to be considered seriously and evaluated in determining whether we should adopt them or not. Deep Background is brought to you by Pushkin Industries. Our producer is Lydia Gene Caught with research help from Zooeywyn. Mastering is by Jason Gambrel and Martin Gonzalez. Our showrunner is Sophie mckibbon. Our theme music is composed by Luis gera special thanks to the Pushkin Brass, Malcolm Gladwell, Jacob Weisberg, and Mia Lobel. I'm Noah Feldman. I also write a regular column for Bloomberg Opinion, which you can find at Bloomberg dot com slash Feldman. To discover Bloomberg's original slate of podcasts, go to Bloomberg dot com slash Podcasts. You can follow me on Twitter at Noah R. Feldman. This is Deep Background.

From Pushkin Industries. This is Deep Background, the show where we explore the stories behind the stories in the news. I'm Noah Feldman. We're all in the process of doing our best to social distance to stop the spread of coronavirus. And for most of us, and probably it should be for all of us, that basically means self imposed isolation of a certain degree. But there are many people in the United States whose isolation is involuntary, and that is people who are incarcerated in jails, in prisons, or in immigration detention centers run by ICE. Prisoners have already tested positive for coronavirus in New York, in Georgia and other states as well. That's going to continue, and officials are scrambling to figure out how to stop the spread inside of institutions, prisons, in jails. To discuss this situation, I spoke to doctor Homer Vendors. Until recently he was the chief medical officer of the New York City Correctional Health Services. Now he's president of an organization called Community Oriented Correctional Health Services, which is a nonprofit that builds partnerships between jails and community healthcare providers. He has a new book called Life and death in Rikers Island, which is precisely about the health risks of incarceration. And he was involved in two thousand and nine in New York City's efforts to deal with the H one N one virus when it was spreading inside of Riker's Island. In short, doctor Vners is really the perfect person to speak to about this problem. We spoke on Monday morning, Homer. As of this morning, New York City Corrections, where you used to be the director of health for the entire system, is reporting thirty eight cases of corona among either inmates or prison staff. For jail staff, How worried should we be about that number? I think that that number should cause alarm. That should make us think about not just what's happening to people who are detained in the New York City jails and the people who work there, but every single one of the five thousand jails and prisons and ice detention centers across the country. I think this is a very small foreshadowing of things to come and implications for the survival. The welfare of the people who are in these places, who work in these places, is really in peril. And this is just the first of what I fear will be many many more headlines and reports like this around the country, many of the places, by the way, that have far fewer health resources, far less access from the press from outside eyes. So I think this is the beginning of what we've been worrying about is going to be a significant feature of this outbreak. A lot of us have a visual image of what it's actually like inside a jail or a prison only from television, and in fact, mostly from fictional television. Would you explain a little bit to us about how conditions, for example, in a big city jail like Rikers, are especially conducive to the transmission of infectious disease. Yeah. I think that there are some features of jails that we might generally understand that really contribute to the transmission of communicable diseases. So the fact that there are lots of people in very small spaces, and those people are jammed into housing areas that whether they're a dorm or comprised of cells, it's still lots of people in a small space, sharing congregate bathrooms and sinks. People to go from one part of the jail to the other have to go through hallways and go through these things called sally ports or control hubs, where they're all jammed in and you have a gate that closes behind you before a gate can open in front of you. There's intake areas where people come in, especially in county jails that have such a high churn. You know, half the people are gone by day ten or fifteen, so they're constantly filling up with newly arrested and detained people. Those folks are coming in through these intake pens that are very teeming with people, just scores of people in small spaces, nowhere to sit, laying on the floor, and that's all the physical plant. Then if you add in the fact that most of these places are filthy, they have incredibly bad sanitation. You have garbage, food trays, other types of trash built up all over the place. They really promote the spread of communicable diseases during normal times and during outbreak response. The way that they're built and designed and run promotes the spread of disease. One reaction that I had when first thinking about incarcerated population is that the lockdown, which is sometimes the word that we use colloquially to describe what's happening to everybody else. I mean, I know that Governor Quoma, New York wants to call it a pause. In California, they call it a stay in place where, or another sub called a shelter in place. But lockdown is still the vernacular phrase that comes from prison. I mean, that's a prison metaphor, and that might create the impression in somebody's mind. I think it did it. At my first uneducated thought before I started reading what you were writing about this that actually prisons might be manageable because you actually do have the capacity to control the movement of prisoners. But on closer examination of what you've been saying, that seems completely misguided. And I wonder if you would just say a word about that, because I think I might not be the only person who has that instinct. Yeah, I think that you know, prisons and jails are built for punishment and security control of people of humans. I think that we all have this desire to stop the movement of this virus through our society, and there's a lot of really important measures that we're all engaged in to try and do that. The problem in prisons and jails and in correctional spaces is that lockdown generally means putting people into locked cells. Often sometimes dorms, but often we use it. It's used of cells, locking people into cells and then keeping them there and then only bringing them out for certain circumstances. And the idea is that the problem will stay in the cell and so in this circumstance, and what I would say is inappropriate use of lockdowns as the primary response to coronavirus. The notion would be that if you lock everybody into cells, then the virus either won't get in or if it's in the cell, it won't get out and it won't move around the facility. That is erroneous for a number of reasons. First of all, people who are locked down are being punished. Whatever you say is the reason for it. When you go get locked into a cell, when you're going into solitary, it causes a lot of stress. People don't like it. It is associated with suicide and self harm, and so people don't want to go into those cells. Then to institute a lockdown that means that you'll, all a sudden, are going to ask your correctional staff to put their hands on a lot of people, to have a lot more physical contact with people. Sometimes us as a force that get them into these cells, and then every time they come out of those cells for a shower, if they come out to go to the medical unit, if they come out for any other reason, you're often then in this position of having to have two escort officers handcuff them, escort them physically. All of that is just really escalating the amount of physical contact between humans in these facilities. The other real core problem with this is that when people get sick, and we know they're getting sick, when they're locked in a cell, you don't see that. Correctional officers coming by every fifteen minutes or thirty minutes to peek through a dimly illuminated vision panel or window in a cell door is not the way that you keep an eye on people that you're worried about getting sick or dying. So the lockdown as a public health response is not appropriate as the primary measure, and in many ways it can actually increase the flow of the virus into and out of a facility. Obviously, the most immediate ethical worry that I think we all need to have with respect to incarcerated people is that it shouldn't be the case that if someone is being locked up. They're being essentially put in a situation like being put on a cruise ship, but involuntarily and with much worse conditions, which is likely to significantly increase their chance of getting sick and dying. But I assume there's also a concern for the general public associated with enabling a coronavirus to spread rapidly within jails and prisons, partly because corrections officers are coming and going and so it will spread into the general population. Partly because of resource allocation issues, because if you get a big outbreak, a lot of resources are inevitably going to be called on, even if they were not distributed in a fair way. What do you see as the main concern for the general public here? I mean putting aside the very pressing ethical concern that we shouldn't be arresting people from minor offenses and then putting them into place where they have a better chance of catching a disease and dying. Yeah, I think the simplest way I could put it is that correctional settings, prisons, jails, and ice decession centers are going to drive this piademic curve straight up. So we hear about trying to flatten that curve about trying to relieve the strain and stress on our health system by social distancing and taking all these other measures and really extreme important measures that are being implemented today. What happens behind bars is going to drive that epidemic curve in exactly the opposite direction of what we're working towards, and so they will quickly become reservoirs. And they probably are already, but certainly as we make gains in the rest of the community, these places will become critical reservoirs for infection. They're going to continue to cycle infection out of these places in and out as staff go in and out, and to some extent the people who are held there. But you know, there's many more people coming and going every day who are staff members than there are arriving as newly arrived people in a prisoner jail. So these places, as reservoirs of infection, as congregate settings where the spread of the infection cannot really be controlled, stand to dramatically escalate the epidemic curve that we're working so hard to bring down. Homer, you mentioned crucially that prisons and jails are probably already at least in New York City becoming reservoirs of coronavirus. That leads us to the really pressing question of what we should be doing and how we should be doing it with respect to releasing people. And I want to start with just asking a question of you when you wear your epidemiologist hat. And that is given that we know now that there are presumably lots of cases, including asymptomatic cases, in jails and prisons, if we open those doors, is that going to be adding a new vector of rapid spread to the general population. And if so, is that nevertheless the right thing to do in terms of the overall cost benefit of fighting the disease. Well, I think where we're at now is that when coronavirus arrives in a community, it's part of the community is the jail or prison or is attention center, and it's going to arrive there. So places where we likely have a significant number of people who are asymptomatic, who are kind of brewing early infections. It's no different inside the jail than outside the jail. Now, in the coming weeks, we will have spread inside those facilities that you may be more accelerated than outside. But one of My primary concerns is that unlike the community, where we're going to have some family or ability some other we have capacity to see who's getting sick and who needs hospital level care. We're going to miss that behind bars. When H one N one hit, everybody who was symptomatic was tested in the New York City jails, and so sometimes the press and people on the outside would erroneously think that this was a riker's outbreak of H one N one. But we everybody who was symptomatic was in a housing area, and these weren't cells, they were dorms, but they were in housing areas where they couldn't move in and out. But also we would give them a test and then if they were symptoms attic, they'd go to the same place that the coronavirus patients are going today, the West Facility of Communicable Disease Unit. But people thought, because I think it was like two and a half percent of the people coming into the who it came into the jails during that time tested positive, they thought, boy, this is a riker's problem. It wasn't. It's a community problem. We just happened to be very aggressive about testing because we did not want to miss a single case. I think that the way to characterize what's happening behind bars is if it's in the community, it's part of the community's the jail or prison, and so I don't believe that, at least today, there's an epidemiologic reason to say releasing people is going to contribute to the infection. And I think that right now we've turned a corner in this country, which is our primary focus is on preventing death, and to do that, we have to get people out of these places. We'll be back in just a moment. There are voices, including yours, increasingly calling for release of certainly people who are jailed awaiting trial, and even of inmates who've already been convicted or guilty to crimes. Do you have a view about how that should be done, how should that be triage. I think that we'll need different strategies for county jails, for state and federal prisons, and for ice detention centers. Some of these places, like ice detention, there's not really nobody is even making a public safety argument for why people should be detained, and so you could categorically just administratively, it seems to let people out county jails have one set of pathways, which involved looking at people in the nature of their charges and figuring out how they can get people out certainly before there so they can just show up to trial. And that's and that's different than you know, when I've talked to state prison administrators in the last couple of weeks, that's a very tough off road. There are people who are on the pathway to prison release, and so those pathways can be accelerated. There are in most states prison furlough processes that can be enacted, But the state prisons I'm terribly worried about because you have just huge numbers of people. I was talking with somebody from a state prison system yesterday where the overall capacity of the state prison is at one hundred and seventy five percent of what they should have, and so incredibly densely populated places where there's really very little prospect of getting people out. And so as I think about what we need to do to react besides release, part of it is it will contemplate strategies that are different for these different types of settings. That seems very sensible, but I just you know, there is a substantial risk I think that none of that could happen fast enough. I mean, so, for example, I know some DA's offices around the city, including Brooklyn, have called for applications from lawyers for people who are detained to say, hey, explain to us why we should go to the court and move to have your or agree to your emotion to have your client release under these conditions and circumstances. I think that's a great response. I worry that it can't work at scale. It's not just that courts are moving more slowly because of their own concerns about Corona's that even under the best of circumstances, that's a very individuated way of doing it. And of course it seems sensible. Let's make sure, let's weigh, let's make a judgment about each person. That's what courts are good at. But it's not a crisis response approach. Do you think there's a plausible argument to say, for example, that all non violent offenders being held in rikers, or all non violent offenders over the age of fifty, or you know, something of that sort just ought to be straight up released. And the reason I ask this is not just about getting things right in New York city or in the jail slash prison that you know very well. It's also that this is going to become a paradigm set a presumably for other places in the country, if in most likely when we see the same scenario repeated elsewhere. Yeah, I think that's an important point that deliberative and piecemeal approaches are not always the ones we want to turn to in really die our emergencies. I reminded of a colleague who once told me that after Katrina in New Orleans, what they got was a plan that was developed by an Internet And I can say this as an Internet, but what they needed was a plan developed by an emergency medicine doc. And I don't mean that just for the medical part, and so I think that's right. I think one of the things I'm calling for in terms of what we should do besides release with keeping releases, the number one objective is every state must appoint or identify a correctional health coordinator who can manage this process, and the CDC needs to also, and so does HHS. We need state level and federal level people who have been identified to coordinate what's happening with the health aspects of corrections and to tend spaces around the country because we have five thousand of these places. If you sit as a commissioner of health or the person who's running your state's COVID emergency response, you look across this array of places you probably don't even know much about. You have county jails in all your counties, mostly, you have state prisons, and then you have ice detension centers, some of which are run by for profit companies. And so we need just like we're taking seriously what's happening in long term care facilities, assisted living, in nursing home settings, we need to identify one person in every state that's going to take on this task because we don't even have data today. Nobody could tell you how many patients inside county jails, state and federal prisons, and ice detention centers have symptoms today, how many are needing a test. And one of the critical concerns I have is we do not have pathways to hospital level care for most of these patients. Most of these patients who get sick, the traditional method of getting them into a hospital is to send them with two armed correctional officers to go to a local hospital. It's a process that for people who have seen it, like everybody who works in emergency rooms and people who work in corrections know this. It takes a ton of resources because you're sending two officers who are going to stay with this person twenty four to seven. They take up a ton of space in an emergency room. Emergency rooms that are incredibly over stretch right now in terms of their staffing and their space. And so if we get five or ten or fifteen people from one facility going to the hospital, there just won't be CEOs correctional officers to go with them. They're going to have fewer staff because they'll be sick. We won't have a magical new resource for them to go to to get this care. And my experience in investigating deaths all over the country is that these patients are patients who are behind bars today, are the ones that go to the back of the line when it comes to access to hospital level care. And so part of the priority has to be we create explicit passways for access to hospital level care when we had toify patients that need it in the real world. I don't think you'll see that happening. I mean, I think it's maybe ten or fifteen patients. You could conceive of a system saying, well, we're going to send two correctional officers, but at some point, either they're going to have to stop doing that and shoulder the risk of escape, or alternatively, simply not send people who are incarcerated to hospitals. And if that happens, what will happen within the jails and the prisons. Well, if those are the only two options, then yes, people will die preventable death because people will be held in correctional facilities where staff will to try and take care of them for too long. They'll get well passed their level of clinical competence and equipment and infection control capacity. Some of the data indicate thirty or forty percent of the people who need kind of a middle level of inpatient treatment but not yet I see you treatment. About thirty or forty percent of them will need a higher level of care. Well, if you're trying to manage the middle level inpatient folks in your jail or prison or detention center, than when they need that higher level of care because they deteriorate, you're not rolling them down the hall to the ICU. You're going through a two hour transfer process, so they're going to die. There is another option. We did this after Sandy to set up secure treatment units as part of what's going to be the surge in capacity at hospital. So hospitals that are currently building sometimes tense, sometimes new opening up wings that have been mothballed, setting up new space to handle this incoming flux of COVID patients. In that the states that are planning this with their hospital partners, they need to explicitly detail and plan for care for incarcerated patients. And so sometimes what you can do is you can as we did after Sandy, We've set up a new unit. We had patients go to a couple of dedicated places but when Bell was evacuated. But one of the things you need is the capacity to set up are units. So you're not relying on two correctional officers for every patient. But you can figure out how to get a better ratio of correctional officers to patients in a unit that's somewhat secured, that meets the custodial requirements of the securing authorities. And it may be that in some states and some regions you actually have multiple correctional administrations, like different sheriffs or sheriffs and state prisons cooperating to figure out how can they staff up and design these units quickly with the hospitals that are surging their capacity. Because these units and this response has to involve hospital level care by hospital staff, it's not going to work if you're keeping patients out in these correctional settings. They're just not going to survive. What's the sort of best case scenario you can picture. We've spent a lot of time in this pandemic situation talking about worst case scenarios, and you've made it pretty clear that the worst case scenario is significant number of people dying unnecessarily and prisons and jails really contributing to the rapid rise of the curve. But what's the best case scenario that you can realistically foresee if good recommendations are followed well. I think that one of the things that could happen relatively quickly is that as states in the CDC identify correctional health coordinators, they are going to get a quick snapshot of where the outbreak is impacting incarcerated patients first. And this won't be uniform, just as you know, it really reflects what's happening in the community, and so for the next few weeks we're going to have hotspots where the problems are evolving. We may in a month or two have a much more prevalent problem that is more generalized, but for the next month or so, we're going to have places Rikers being the first that's being reported. It's critical for us to appoint these correctional health coordinators right now because they need to be the ones that are in the room with the governor's staff, with people running the overall response, to understand and report to others where patients are going to need to be going, and how we can build these new units in a way that meets the statewide needs. So if you look at the footprint of incarceration in every state, one of the things that's really terrifying is in a lot of rural counties we have large overfilled county jails, we have a fair number of prisons, and we have a lot of ice dissension centers, all in places where we've lost hospital capacity in the last ten or fifteen years. That requires a coordination at a state level to understand day to day who are the patients that need higher level care and where can they go? And I think that that kind of it's not just epidemiology. A lot of this is also supply chain. How can we get people connected to the things they need. That's happening in every pretty much every other aspect of society right now. So these are not principles or tasks that are foreign to the rest of the nation. It's just that these patients and their welfare haven't traditionally been incorporated, but they must be incorporated now this week to this response if we want to save their lives and also help really bring down that curve. Homer, I want to thank you not only for the important work you're doing in this crisis, but for the work that you do all the time to try to improve conditions for public health inside of prisons and to build partnerships between jails and community healthcare providers. That's important even when we're not under conditions of the pandemic, and what you're doing now is also obviously great pressing significance. Thank you very much for your time. Thank you very much, have a good day. Speaking to home reveners makes it extremely clear that the problem of coronavirus that we're struggling with across the country now is especially acute and worrisome when it comes to people who are incarcerated. It's not only an ethical issue, it's also a public health issue of the most pressing type. He's calling for the appointment of coordinators in every state to deal with the problem. That seems like a no brainer and should certainly be adopted. It's my instinct, however, that we may need to go further than that, and I hope that governors across the country and prosecutor's offices as well, will look seriously at engaging in more systematic analysis of who could safely be released, both in order to protect them and to protect the general public against the risk of many, many acute cases of coronavirus arising among people who are locked up. Almost every university that I know of has sent home students from its dorms, and prisons in the end bear such a close resemblance to dormitory living that the probability of spread seems very, very great within them. That's a radical measure, but this is an emergency, and an emergency radical measures at least need to be considered seriously and evaluated in determining whether we should adopt them or not. Deep Background is brought to you by Pushkin Industries. Our producer is Lydia Gene Caught with research help from Zooeywyn. Mastering is by Jason Gambrel and Martin Gonzalez. Our showrunner is Sophie mckibbon. Our theme music is composed by Luis gera special thanks to the Pushkin Brass, Malcolm Gladwell, Jacob Weisberg, and Mia Lobel. I'm Noah Feldman. I also write a regular column for Bloomberg Opinion, which you can find at Bloomberg dot com slash Feldman. To discover Bloomberg's original slate of podcasts, go to Bloomberg dot com slash Podcasts. You can follow me on Twitter at Noah R. Feldman. This is Deep Background.