India Porter is scared. A tiny women who stands barely five feet tall, she is confined to the Huron Valley Correctional Facility, where, she explains, “the officers are stressed, and my peers and I are in a calm panic.” Everyone at the facility has been told that they must socially distance to stay safe. But this is “impossible,” Porter said in an email. “We live on top of each other. 2 to a cell if you are lucky but others are 4, 6, 8, 10, 12, and 16 people in one living space.”
Her fear is well founded. Not far away, in another Michigan prison, Efren Paredes, sent to prison at 15, has already seen what it means for the coronavirus to start spreading on the inside. Men there have been “exhibiting a dry cough, dizziness and vomiting” but are told to stay in their housing units. The truth is that corrections officers, those who would take a prisoner to the infirmary, are also afraid that they will get sick. At the Parnall Correctional Facility, also in Michigan, 21 percent of the staff members are infected.
Covid-19 is terrifying for those who live and work inside prisons, their families and the broader community. Governments have moved sluggishly, if at all, to release elderly and medically compromised people, or sufficient numbers of the nearly 800,000 people who are locked in crowded jails each day simply because they can’t afford to pay bail. The overcrowding that remains has contributed directly to the outbreaks at these facilities. An astonishing number of people inside of Ohio’s Marion Correctional Institution, more than 80 percent, now have covid-19, and their infections are already spreading to the outside public.
Notably, however, we might have been spared so much of this recent trauma altogether if we had simply paid closer attention to what was happening in the nation’s prisons, in its poorest neighborhoods and in the halls of Congress, in the 1990s.
Beginning in that decade, a deadly tuberculosis outbreak rocked jails, prisons and poor neighborhoods nationwide. New York City was hit particularly hard — soon reporting 15 percent of the country’s cases with only 3 percent of its population. And the extent to which this highly contagious disease soon taxed not just the nation’s prison system, but also its health-care system, should have taught us some critically important lessons.
We might well have learned then that this nation pays a terribly high price when it chooses to lock up too many people in filthy, overcrowded and unsanitary facilities while simultaneously not ensuring that everyone inside and outside of them has access to regular and affordable health care. Politicians, at least, should have learned that the walls they imagine separating those serving time from those outside are, in fact, completely porous.
They did not, and the consequences are on display today.
Tuberculosis is a disease that had been virtually eradicated after 1950 but, as the 1980s came to a close, was suddenly back, and spreading — especially in New York City. Between 1984 and 1991, the number of New Yorkers infected with TB doubled, with much higher incidences among the city’s most marginalized communities. TB afflicted about 469 per 100,000 black men ages 35 to 44, nearly 45 times the national average.
Even scarier than the reappearance of a disease that destroyed people’s lung function and spread quickly among people who coughed or were merely in proximity, this TB epidemic was characterized by mutant strains of the bacteria that proved almost impossible to eliminate with existing treatments. By 1991, public health officials were sounding the alarm, expressing their “deepening concern about a shadowy new health menace” that was, as one reporter put it, “the most alarming medical development” New Yorkers had seen “since AIDS was discovered a decade ago.”
It was in New York’s prisons that doctors began to notice just how worrisome this new TB epidemic was. In 1991, the New York Times reported not only that there had been a rise in tuberculosis cases on the inside — one that posed a “‘deadly threat’ to the prison system’s 60,000 inmates and 28,000 guards and other employees” — but also that this outbreak could spread quickly to “their families and communities.” Indeed, the prison population of the New York Department of Corrections would eventually experience “a 900% increase in active tuberculosis” cases in its facilities, and those who were infected had loved ones on the outside who visited, and friends as well as families to whom they returned after serving their time.
The reaction of physicians and public health officials to the sudden resurgence of this scourge was dismay and disgust. As Lee B. Reichman, a leading medical expert on TB, opined in 1992, “We should be ashamed.” Tuberculosis was fully preventable, but the combination of overcrowding and lack of access to health care and poor management of existing infections had created the conditions for its return. Worse, this time around it was much harder to treat. As Reichman pointed out, as “many as half these patients will die of the disease, and many will spread their resistant strains to others."
Thankfully, by 1994, and only after concerted measures were taken to mitigate it, the TB outbreak had begun to slow. But it had left its mark. As one study put it a full decade later, “Given the presence of a large reservoir of latently infected individuals in the city and an ongoing tuberculosis pandemic, New York City continues to face significant challenges from this persistent pathogen.”
Disturbingly, the conditions that had made this TB epidemic possible were insufficiently autopsied. The hard truth was that the very problems that had made the nation’s poorest and most marginalized populations a petri dish in which the TB bacteria could flourish anew — prison overcrowding and a lack of decent health care for the poor — were utterly man-made.
TB became the scourge that it was in the early 1990s in no small part because of the significant welfare cuts that had taken place in the 1980s, as well as that decade’s newly funded and aggressively waged war on drugs. And at least some understood this connection at the time. As one observer noted wryly in 1992, “The return of TB is not a fluke or a mystery but the predictable outcome of a glaring social failure. … America has essentially cultivated the contagion.” And even years later, one doctor looked back on this terrible outbreak and opined as well that tuberculosis was “a political as much as a medical problem.”
But those were voices in the wilderness.
Directly on the heels of the scariest public health crisis the nation’s urban centers had seen in decades, and most ironically, in the name of “public safety” and “personal responsibility,” Democrats and Republicans joined to pass two pieces of legislation that would make the nation even more vulnerable to the spread of dangerous diseases. These acts would, less than three decades later, ensure that the nation’s poorest residents would pay the highest price once covid-19 arrived.
In 1994, and with much fanfare, Congress enacted the Violent Crime Control and Law Enforcement Act. The public health repercussions of this $30 billion expenditure, the largest commitment to policing and prisons in American history, were profound. In short, it made the nation’s prison overcrowding crisis much worse.
The law, and subsequent add-ons to it, fueled an explosion in the federal prison population, going from 94,162 people inside in 1994 to 219,298 people by 2013. Even worse, the law incentivized enforcing draconian new mandatory sentencing laws at the state level, leading to an explosion of prison and jail building at the state and local levels — where most of the nation’s incarcerated are housed. Soon state prisons were more overcrowded than they had ever been in their history.
Two years later, the newly Republican-controlled Congress passed the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA), which gutted what remained of the American welfare system after the cuts of the Reagan era — a safety net that countless people had depended on for their health care. The PRWORA turned out to be the icing on the poisonous cake that had been the 1994 crime bill. What President Bill Clinton claimed was the “end [of] welfare as we know it” not only took needed income away from already marginalized communities, but it also, as studies have made clear, made it harder for the poor to attend to their basic health-care needs. As one study observed in 2006, welfare reform had had a particularly adverse effect on “the health insurance coverage of economically vulnerable women and children, and that this impact was several times larger” than most acknowledged at the time.
Taken together, these two major pieces of legislation, both passed just as the TB epidemic began to subside, made the nation’s most marginalized residents even more susceptible to illness and death should any deadly new airborne disease begin to circulate. Because of key pieces of legislation in this period, such as the 1994 crime bill, today 2.3 million people sit in unsanitary and overcrowded prisons with little access to good health care, while 12 million more cycle through the country’s equally dangerous jails each year. And because of the PRWORA’s ravaging of the safety net for the nation’s poorest residents both in and outside of prison — making it harder not just to see a doctor, but also to have housing and to stay home from work if they are ill — we have left countless people dangerously exposed to disease for reasons that were utterly preventable.
Indeed, in their zeal to “get tough on crime” or to “crack down” on welfare dependency, U.S. politicians had completely missed the cold, hard reality that the TB epidemic of the early 1990s revealed. Once unleashed, epidemics can afflict any of us, regardless of whether we live behind prison walls or in gated communities and whether we can pay for our health care. And for those who are on the inside, and all who live without such care, those epidemics are much more likely to be fatal.
Covid-19 has merely reaped what they have sewn.