Via Crof’s blog (invaluable, as always) I learned of the decision of Massachusetts state health officials to vaccinate state prisoners before the rest of the population:

Prison officials warn that inmates could quickly spread the flu if not inoculated — particularly those in high-risk groups such as AIDS patients.

Middlesex Sheriff James DiPaola told the Boston Herald that prisons were the perfect flu “breeding ground.”

DiPaola dealt with riots in a Cambridge jail when rumors of swine flu spread there. (AP)

State legislators are already complaining that there are other, more vulnerable groups that deserve to be at the head of the line. That’s probably true, but like a lot of things about flu, this one raises some knotty questions which we can choose to ignore but which we shouldn’t. Let me raise a couple of them.

The Sheriff defends this priority use on practical grounds. In the first phases of this outbreak, at a time when nobody knew how bad this variant of influenza was, there was a riot at the Middlesex Country Jail when an inmate who was diagnosed with swine flu was medically isolated. Ten more cases among inmates followed on short order. This was a jail designed to hold 160 prisoners but which, at the time of the outbreak, was holding 403. It was grossly overcrowded and indeed a perfect incubator for flu. Many of the inmates were incarcerated for non-violent crimes like drug possession and would soon be released into the community in any event, so the idea of breeding illness that is loosed on everyone else is a public health consideration. After this experience, which resulted in considerable damage to the facility, it’s no wonder the Sheriff was concerned, just on pragmatic and management grounds.

It’s unlikely these issues hold much sway for the public or for legislators always looking for a torch to carry to satisfy the public. And the claim that there are probably more vulnerable groups is likely true. Certainly there are more deserving groups. While people wind up in prison for all sorts of reasons, many of them related to behaviors that in another day and age we can hope will be seen as essentially normal and not criminal (e.g., marijuana use), the public has little sympathy for prison inmates, in general, and lumps them all together.

Public sympathy or lack thereof aside, these are people we have forcibly deprived of their freedom, some awaiting trial and not yet convicted of any crime. They are wards of the State in the most literal sense, totally dependent on the Department of Correction for their survival. Epidemiologically they are near the center of the viral bulls eye for swine flu. Because they are not able to care for themselves or seek care on their own (in particular, seek vaccination), the state has an extra legal duty of care. That extra duty is a legal one if their incarceration deprives them of protection or treatment for a serious medical condition. It isn’t clear whether this would rise to a sufficient level of seriousness if reviewed by a Court, but we know that people similar to the prison population are dying of the disease. But beyond the purely legal issue is the ethical one: what is the right thing to do?

Frequent readers here will see a familiar public health theme emerging. Much or most of what we do is a balancing act. We often make decisions without knowing if we are doing the right thing but decisions have to be made. In this instance, it seems to us there are other groups that should and could come ahead of the average prisoner (groups such as pregnant women, people with underlying medical conditions predisposing them to complications), but even here many prisoners will fall into these categories and should be vaccinated along with them.

But even if prison inmates as a class aren’t at the head of the line, they should come towards the head of the line. We locked ‘em up. Now we own them.