Health care in jails and prisons is terrible. The pandemic made it even worse.

Clayton McCray, 27, stands by the Allegheny County jail in Pittsburgh, Pennsylvania, on June 5. McCray’s lower leg was amputated in 2020 after a wound on his heel became infected while he was incarcerated at the jail, he says. | Stephanie Strasburg for Vox

America’s 1.7 million incarcerated people have a constitutional right to medical treatment. During the pandemic, many of them say they didn’t get it in time.

This story is part of The Aftermath, a Vox series about the collateral health effects of the Covid-19 pandemic in communities around the US. This series is supported in part by the NIHCM Foundation.

When 25-year-old Clayton McCray was sent to jail in September 2019, he had no idea the detention would end up costing him his leg. But that’s what happened, in large part because the pandemic exacerbated his poor medical treatment behind bars.

A shooting injury eight years earlier had damaged his spine, initially leaving him paralyzed from the waist down. After surgery and years of physical therapy, he could once again jump, swim, and play basketball. “I fought hard to get to where I was,” he told Vox.

But he still had a condition known as “drop foot,” or foot dragging. He needed orthotic insoles, regular treatment to remove dead tissue, and daily wound cleanings; without them, he was vulnerable to developing open wounds, and even bone infections.

Clayton McCray worked hard to recover after a shooting injury left him paralyzed from the waist down, enduring surgery and years of physical therapy to be able to move again.

When the pandemic hit, McCray was still in Pittsburgh’s Allegheny County jail awaiting a hearing for alleged drug possession. Suddenly, his already-spotty medical care became even sparser. By June 2020, he needed a wheelchair. Sometimes he couldn’t hop or crawl the short distance from his bunk to the toilet and urinated on himself. Meanwhile, the smell from his untreated wound filled the cell.

Jail staff did not allow a specialist from the local hospital to examine McCray’s infected foot in person, he has claimed. “They blamed Covid,” McCray said.

By September, the infection had progressed so far that his right leg had to be amputated below the knee.

Health care in US jails and prisons was generally abysmal before the pandemic, and it appears to have fallen further, even for those who were not among the astronomical number of people sickened or killed by Covid-19 while incarcerated.

Basic requests for medical treatment often went unanswered as facilities stopped outside and specialist appointments and attempted to navigate severe staffing shortages, according to our reporting. Even as the initial crisis of the pandemic’s arrival has waned, many behind bars are still suffering the effects of denied or postponed care.

These failures have potentially affected a massive number of people. McCray was one of 8.7 million who entered a US jail in 2020, more than half a million of whom were incarcerated at any given time (and more than 80 percent were, like McCray, simply awaiting their day in court). Another 1.2 million were in state and federal prisons.

Put another way, more than 1 in every 150 adults in the US was behind bars on any given day, by far the highest rate of any country in the world.

The alleged medical neglect also adds to stark racial health disparities in the US. People of color, particularly Black people, are much more likely to be arrested and have been up to seven times more likely to be incarcerated than their white counterparts. As of 2018, approximately one in every 44 Black men in the US was locked up.

The Allegheny County jail rises on the banks of the Monongahela River in Pittsburgh, Pennsylvania, on June 5. Clayton McCray is suing the jail’s medical officials, alleging that jail health care staff failed to provide standard medical care.

Data about medical care in carceral facilities is nearly impossible to come by. But two dozen people incarcerated in more than 15 facilities across 10 states during the pandemic have told Vox about frequent cancellations of appointments, months-long delays, denials of specialty treatment, lack of post-surgery follow-ups, and going months without daily medications. Over the course of three months of reporting, their stories have been backed up by documents, lawyers, and loved ones. As a result of this lack of care, some lost limbs, others lost their mobility, and all we spoke with lost their pre-pandemic level of health.

When people are put behind bars, whether they are awaiting trial like McCray was or are serving a sentence, the loss of liberty itself is supposed to be the point, not going without basic health care. But this happens daily in jails and prisons nationwide. And the pandemic has made it far worse.

Care, postponed

Medical care behind bars is complex, with on-site nurses and physicians charged with addressing a vast range of issues, from checkups to substance use treatment to end-of-life care, often in overwhelming circumstances. Some jails and state prisons contract with private corporations to provide medical care, while others, in part, administer their own or rely on public or nonprofit providers. A few, such as New York City’s jail system, partner with the local health system.

Oversight is extremely rare, and people in custody generally cannot change doctors or even seek a second opinion.

And this is a particularly vulnerable population. Incarcerated people are more likely to have serious chronic health conditions than their outside counterparts; one study suggested they tend to have health needs similar to people 10 or 15 years older.

Believe it or not, incarcerated people are the only US residents with a constitutional right to health care. In 1976, the US Supreme Court ruled that “deliberate indifference to serious medical needs of prisoners” violated the Eighth Amendment prohibition against cruel and unusual punishment.

“Health care is constitutionally mandated, but it doesn’t mean it’s any good,” said Lauren Brinkley-Rubinstein, a health equity scholar at the University of North Carolina School of Medicine and co-founder of the Covid Prison Project. Arizona’s prison system has been sued for reportedly providing inadequate care. And a 2001 class-action lawsuit asserted that the California prison system’s medical and mental health care was horrific enough to be unconstitutional.

The pandemic erected even more barriers between incarcerated people and medical access. Our reporting found that jail and prison officials frequently denied outside appointments and prohibited outside providers from entering, while in-house doctors and nurses prioritized Covid-19 over other concerns. Medical workers were in critically short supply as people called in sick — or quit and were not replaced.

A dire shortage of correctional officers also impeded care. Officers are needed to escort people to appointments and call in medical emergencies. Homer Venters, a court-appointed federal monitor overseeing health care behind bars, told Vox this spring that he routinely visits correctional facilities now where half of the correctional officer positions are still unfilled.

California prison officials have admitted that the pandemic has caused a significant backlog of essential visits, with more than 10,000 overdue specialty appointments, approximately 6,000 overdue primary care appointments, and nearly 1,000 overdue ultrasound exams for end-stage and advanced liver disease, as of mid-2022. In New York City’s Rikers Island jail complex, detainees have missed nearly 40,000 appointments between January and April of this year alone.

The availability of this type of data is exceedingly rare. The Allegheny County jail where McCray was held, for instance, was not able to provide Vox with its current backlog of appointments. And inside, many people are fearful of retaliation if they speak out, which makes these critical shortcomings even harder to track. But Vox spoke with 23 individuals incarcerated during the Covid-19 pandemic, and each reported negative health consequences from pandemic-related lapses. Here are three of their stories.

McCray’s story

In 2018, Clayton McCray had been back on his feet for years after his shooting injury, going out to dinner with family and friends and playing pickup basketball games. Around the end of that year, he entered Pennsylvania’s state prison system for a charge of drug possession. Within several months, the prison provided him with regular wound treatment and allowed his orthotic shoe, brace, cane, and insoles. When he was released 10 months later, he still had the full mobility that he had worked so hard to regain.

Clayton McCray comes downstairs carrying his ankle and foot brace at his Pittsburgh, Pennsylvania, home on June 5. McCray says Allegheny County Jail staff confiscated his necessary insoles and brace while he was in jail awaiting trial for a minor drug charge, causing his foot to drag and a wound to form that became infected. Ultimately, his lower leg was amputated.

In September 2019, McCray was arrested again on a minor drug possession charge. However, because he was on probation, he was ineligible for bail and was locked up at the Allegheny County jail in Pittsburgh while waiting for his hearing.

Through December, medical staff, overseen by county and local health systems, provided the daily wound treatment he needed. But then, McCray said, those visits began to drop off. Charles E. Timbers Jr. worked as a nurse practitioner at the jail and remembers McCray. (Timbers was fired from the jail in 2020 for allegedly violating its social media policy.) “He had a hole in his foot where you could see the calcaneus [bone of the heel],” Timbers recalled. “He should have been on daily wound care,” he said of McCray, confirming that wound treatment became more sporadic.

Then the pandemic hit. Medical attention became even scarcer. McCray sometimes went for several days without wound cleanings. And other crucial treatments, such as regular debridement to remove dead tissue from his foot, stopped altogether. Meanwhile, the pandemic closed Pennsylvania’s courts, and several of his court dates were postponed, extending — through no fault of his own — his time in jail.

McCray often had to hop on his good foot or crawl on the dirty floor to get around his cell. He frequently fell. The pain and smell from his foot made it almost impossible to eat. It also kept him awake, and the only way he could snatch brief moments of sleep was to pull a blanket over his head to block the stench.

Later that spring, jail doctors diagnosed him with osteomyelitis — a bone infection — but McCray says they didn’t tell him about the serious condition until weeks later. And the course of medication they gave him was too brief to effectively treat it.

McCray filed numerous grievances (formal complaints) to the jail about the alleged neglect and requested to be placed in the jail’s medical unit, which had round-the-clock health care staff. But these requests were denied.

In June 2020, he went several days without showering because no correctional officers were available to escort him there. This lack of basic hygiene was especially harmful, he said, because of his infected open wound.

In mid-June, five days after he lost a toenail on his infected foot, McCray was finally granted a five-minute video exam with a local hospital’s director for advanced wound healing, Elisa Taffe. A jail doctor held the phone to McCray’s foot. Although she had trouble examining him through the fuzzy video, Taffe told jail doctors that McCray was at high risk of complications and of developing osteomyelitis, which McCray had already been living with.

McCray says he was in so much pain while in jail that he had to hop or crawl to retrieve his meal trays or use the toilet, and sometimes was unable to do either.

One night in June, his body reached a breaking point. His chest was tight, his body felt inflamed, and he could not even hop to the sink for water. “I was in so much pain,” McCray said. The man in the adjoining cell called for an officer, but by the time staff responded, McCray was so ill he could not get out of bed and go to the door to speak to them. “They said they’d see what they could do,” McCray said. No one else came. (That month, 53 of the jail’s 150 health personnel positions were vacant.)

Later that night, McCray recounted that he saw a mental health specialist making rounds and took drastic action, shouting a threat: “I’m harming myself!” An emergency team showed up, stripped him, gave him a suicide-proof smock, and brought him to a bare cell for suicide watch. “I was still in there crying, hurting, urinating on myself because I couldn’t make it [to the toilet],” he recalled.

By the end of that month, he was finally moved to the medical unit.

But the cumulative delays had already taken their toll. In August, McCray was briefly hospitalized for excruciating pain in his right foot and leg. Upon his return to the jail, workers there reportedly failed to provide him with more antibiotics to treat his bone infection, telling McCray they weren’t necessary because he would need an amputation.

That September, one year after entering the jail, McCray underwent an amputation of his right leg below the knee.

Two weeks later, after the multiple postponements, his court date finally arrived. He pleaded guilty to a misdemeanor drug possession charge so that he could be released and seek medical treatment outside. Had he contested the charge, he would have stayed in jail even longer while awaiting a formal trial.

McCray walks toward the Allegheny County jail. After spending more than a year in jail waiting for his court date on a minor drug possession charge, he pleaded guilty so he could be released and seek medical treatment outside. Just two weeks earlier, his lower leg had been amputated.

McCray is not alone. The Abolitionist Law Center, which is representing him, has filed three separate lawsuits against the Allegheny County jail alleging medical and mental health mistreatment between 2020 and 2022 so far. Jesse Geleynse, a spokesperson for Allegheny County, said in a statement to Vox that the county does not comment on pending litigation.

“The Covid-19 pandemic has been a challenging and unprecedented time,” Geleynse said. He added that the jail has ensured “all incarcerated individuals continued to receive routine and emergency medical care,” and that cancellations of off-site medical care have come from the provider, not the jail.

But internal emails from jail medical staff show that at least one of McCray’s outside appointments was canceled because of a lack of correctional officers, not by the hospital. And in a record from Taffe, the hospital wound specialist, she noted that any follow-up care she could provide was at the discretion of the jail.

“There will always be an excuse as to why they can’t render adequate medical care,” stated McCray’s attorney, Jaclyn Kurin. The pandemic, she added, should not justify the jail’s reported continual failure to treat McCray and others.

Brown’s story

Kim Brown was used to spending her days working for a chaplain and serving as a porter at Bedford Hills Correctional Facility, the New York state prison where she has been incarcerated for more than a quarter-century. On Wednesday evenings, she plays keyboard in a music class. She is normally healthy and prefers sleeping off ailments to seeking medication.

Kim Brown poses for a graduation photo in 2009 while at Bedford Hills, where she earned a bachelor’s degree in sociology while incarcerated.

But on the last day of 2020, she woke to pain unlike anything she had ever experienced. It seemed to double in intensity by the minute, and she quickly realized she needed medical help.

At an outside hospital, a physician diagnosed Brown with kidney stones. Surgeons inserted a stent in her ureter to let the stones pass. They told her they would remove the stent in six weeks.

About a month after the surgery, however, Brown had blood in her urine and was brought back to the hospital. They gave her antibiotics and returned her to Bedford with the stents still in.

Over the following weeks, as Covid-19 cases remained high, she says prison officials halted outside non-emergency procedures. Among them was her surgery to remove the stents.

By early March 2021, weeks after her stents were supposed to have been taken out, Brown started experiencing incontinence. Hoping to prevent accidents, she emptied her bladder whenever she could and layered several sanitary napkins as a makeshift diaper.

“Stents do irritate the bladder,” said Denise Asafu-Adjei, an assistant professor of urology at Loyola University Chicago and practicing urologist. But, she said, when patients experience severe symptoms, such as Brown’s, a simple medication can usually fix it.

The stents were finally removed later in March. But Brown’s incontinence continued.

More than a year later, she still risks incontinence if she’s not near a bathroom. It’s a chance she takes every other week when she shops at the commissary, the prison’s sole store, for toothpaste, bottled water, or the handful of fruits and vegetables she can’t get otherwise. She must stand in line for up to an hour, with no bathroom nearby. After each commissary wait, she said, “I have to take a shower when I come back.”

Brown is now 55 years old, but the pandemic-related delay in removing her stents, she says, leaves her “feel[ing] like an old granny — and I’m not that old.” Prison staff have told her that there is nothing they can do.

Her first parole hearing is in 2033 but, Asafu-Adjei said, Brown need not wait another 11 years for standard treatment. Medical workers at the prison could prescribe her oral medications or refer her to an outside urologist for other established interventions. But so far, none of that has been done.

Brown isn’t the only incarcerated woman at Bedford who says their health has deteriorated precipitously during the ongoing pandemic. Taliyah Taylor started having painful infections in February 2020. Several different medications didn’t resolve the pain, but due to the pandemic, she had to wait eight months to see a specialist and another five months for his recommended diagnostic procedure. “I’m at a 8 regarding the pain,” she told Vox in late April 2022. “It doesn’t matter if I’m standing, sitting, or laying down.” Two other women at the prison told Vox about delays in surgeries and post-surgical care, impeding their mobility.

Rachel Connors, a spokesperson for New York’s Department of Corrections and Community Supervision, said that the department could not comment on Brown’s or Taylor’s experiences but that “all incarcerated individuals in DOCCS facilities receive the community standard of care.” She pointed out that appointments have been frequently canceled due to the pandemic for patients on the outside as well. “Specialty referral requests that were determined to be urgent or emergent were addressed by alternate means when necessary (such as via emergency department visits),” she said in a statement to Vox.

But for Brown, Taylor, and others in the prison, initial setbacks have been compounded by additional delays. While outside patients can reschedule their own missed appointments, incarcerated people must rely on prison administrators to do so, even if the system is overburdened. Furthermore, they cannot typically get second opinions if medical providers tell them that nothing can be done.

Junior’s story

Junior entered Pennsylvania’s prison system in his late 20s and in good health. (Vox is identifying Junior by a pseudonym and not disclosing his specific medical condition because of his concerns about possible retaliation.) Junior is a sociable person, willing to lend an ear to anyone in need. He loves to write — poems, essays, and one-act plays — and has been teaching himself college-level math. Before his incarceration, he had been a popular DJ.

After about a decade of being locked up, Junior was diagnosed with a serious degenerative disease, which brought constant pain, difficulty speaking, and the need for a wheelchair.

He was eventually approved for a drug treatment, but it did little to better his condition. So when a doctor recommended that he be switched to a different regimen, he and his family pushed for months until it was finally approved.

Shortly after the pandemic began, Junior was brought to an outside medical center for his first treatment and scheduled for follow-ups every six months.

He noticed a dramatic improvement on day one of his new treatment. “Immediately, my speech got faster,” he told Vox in a phone call from prison.

The pain also decreased dramatically, waking him less frequently. “Being able to go to sleep a full night means I’m not weak, sluggish, and fighting to stay awake during the day,” Junior said. “I can get something accomplished, either some writing or having the clarity to continue teaching myself calculus.” His mobility got better, and it took him less time to get dressed and accomplish other basic tasks.

But when it came time for his next appointment, prison staff told Junior that it had been rescheduled. He was offered no explanation, which is typical in many jails and prisons. Medical records later indicated that his missed therapy was “due to Covid.” (Junior and his records confirm that he had not had Covid-19.) A lawyer for the Pennsylvania Department of Corrections said that outside specialists canceled the appointments. But no new one was offered.

The pain returned, sometimes in bouts bad enough to bring tears to his eyes. Some days it prevented him from using the shower during his allotted 25 minutes out of his cell.

His condition deteriorated once again. “I might have four or five days in a row where my speech mobility [was impacted], and I could hardly use the phone,” he said. Speaking with his loved ones allowed him to feel connected to the outside world. Otherwise, he told Vox, “being in the cell all day, that cell felt closer and closer to the grave.”

The Pennsylvania Department of Corrections said that it could not comment on individual situations. In an email, DOC press secretary Maria Bivens told Vox, “The PA DOC continued to offer all outside medical visits where the community specialist was available. When community providers closed their offices or canceled appointments, we had to reschedule those appointments.”

Unlike patients in the community, however, Junior could not reschedule the appointment himself. Instead, he had to wait and hope for prison officials to do it.

In mid-2021, six months after that canceled follow-up, the prison finally sent Junior out for his long-overdue treatment. Over a year after his missed appointment, however, he says he’s still shaken by the experience of feeling his body break down again. “I’m still recovering from being in a situation where I couldn’t even move hardly,” he said.

Even now, health care delays continue for many other incarcerated people. As of the beginning of June 2022, the Pennsylvania Department of Corrections has more than 560 overdue outside specialist appointments. That impacts about one in every 64 people in their system, and, as Junior’s experience illustrates, delay in specialty treatment can have dire consequences.

Potential solutions

Researchers and practitioners agree that the outlook for medical care behind bars is bleak, particularly since the pandemic began.

However, no one knows the full extent of the problem. “We have little real-time data,” Brinkley-Rubinstein and Covid Prison Project director Meghan Peterson wrote in October 2021. National prison statistics are released with up to a two-year delay, while jail data are reported separately. Neither includes information about health care.

More transparency about how jails and prisons are — or aren’t — treating medical issues could help ameliorate conditions. Brinkley-Rubinstein reminded Vox that jails and prisons, including the privately run ones, are funded by tax dollars, which should entitle the public to know how they’re operating. Even family members often don’t receive word about serious illnesses, injuries, or deaths.

Greater oversight could also improve health care. For example, in 2009, New York passed a law allowing the state’s health department to oversee HIV and hepatitis C care behind bars and to develop protocols that match community standards of care. That oversight markedly improved HIV and hepatitis care in the state’s prisons, bringing it more in line with treatment people would get on the outside. Such oversight, however, remains rare.

Reducing the number of people in the system could also help. The beginning of the pandemic saw a rapid decrease in the number of people behind bars. For example, because fewer people got sentenced in the first year of the pandemic while courts were shut down, state and federal prison populations dropped 15 percent by the end of 2020 (the latest figures available) compared with 2019.

Clayton McCray stands on the basketball court at his former grade school, where he used to play. He had “hoop dreams” growing up, he says, but feels unable to play anymore because of pain and mobility issues.

In 2021, after years of advocacy, New York passed Less Is More, which prohibits re-imprisonment for technical parole violations (such as missing an appointment or violating curfew). Implemented in March 2022, the law resulted in the release of almost 1,000 people who can now seek medical attention outside. A similar rule in Pennsylvania could have kept McCray out of jail — and possibly saved his leg.

Lawsuits can also force jails and prisons to improve health care, as California prisoners have repeatedly sought to do. But bringing them to court is difficult. In 1996, then-President Bill Clinton signed the Prison Litigation Reform Act requiring that a person first exhaust the system’s internal grievance procedure. The law also prohibits incarcerated people from suing for mental or emotional injury without physical injury.

McCray, who has certainly suffered a physical injury, is now suing the jail’s medical director and staff and Allegheny County for allegedly failing to provide medical care and for numerous violations of the Americans with Disabilities Act.

McCray sits in his Pittsburgh home on June 5. He’s still adjusting to life with a prosthesis and experiencing phantom pain where his leg once was.

McCray has been home since October 2020. He now experiences phantom pain where his leg once was, keeping him awake at night. His prosthetic irritates his leg. And if his family goes out to a restaurant or a movie, the pain prevents him from joining them. Instead, the 27-year-old spends his days at home, feeling frustrated and depressed.

For those behind bars, medical neglect is not supposed to be an additional punishment. But people’s experiences show that jails and prisons have often been doing just that. The pandemic has exacerbated that neglect with debilitating consequences.

“There are so many stories that never get told,” McCray said. “It’s bigger than me. The excuse is that people are coming in with preexisting conditions.” But, he said, “the whole job of medical is to treat people, no matter what.”

CREDITS
Editors: Katherine Harmon Courage, Susannah Locke
Visuals editor: Bita Honarvar
Copy editors: Tanya Pai, Tim Williams
Fact-checker: Matthew Giles

Matira Matibay