Effect Measure

Swine flu prisoner’s dilemma

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.


  1. #1 Lina Inverse
    October 16, 2009

    Heh, this time, I, an arch-conservative, agree 100% with you. I’d go even further and point out that herd immunity argues for vaccinating all prisoners to protect the subset of them who are especially vulnerable.

    One side question based on the quote: isn’t there current evidence that the HIV infected on anti-viral medication are no more high-risk than the normal population? Although this might not hold for the general prisoner demographic….

  2. #2 Paula
    October 16, 2009

    Of course, one could argue that a better solution may be to release those prisoners who are not violent, particularly recidivist, or much of a social danger. . . But then the question remains, do the remainder go to (or near) the head of the line? Another issue–what of persons forced into homelessness, especially those living in crowded shelters? And old persons whose families/social supports have left them no placement but nursing homes? And persons in . . . well, any forced institution? And does this last include kids–required, after all, to attend school? By the sheriff’s logic, with which I don’t disagree, these persons forced into crowded conditions should also get priority placement. But not only crowded conditions may form a risk factor forced by society; what of those forced through globalization to live in slums without running water or heat? And those economically forced into isolation(Canada’s priorities for vaccine include, in fact, persons in isolated regions).

  3. #3 g336
    October 17, 2009

    Yes, absolutely.

    The desire by some people to use prison as a form of revenge, is atavistic and barbaric. Seen rationally, keeping dangerous people under lock & key protects society from them; and deprivation of freedom is quite sufficient penalty in a culture that values liberty more than life itself. The penalty does not need to be compounded by gratuitous cruelty in any form.

    That said, nonviolent offenders need to be on home confinement with electronic monitoring, rather than locked up in cages. Save the cages for the truly dangerous. And give them priority for vaccines nonetheless.

  4. #4 MoM
    October 17, 2009

    Just a small point. You say:

    Massachusetts state health officials to vaccinate state prisoners…. [and then later, describing the prisoners] some awaiting trial and not yet convicted of any crime…. totally dependent on the Department of Correction for their survival.

    The salient word here is state. Prisoners in state penitentiaries have been tried and convicted. Until they are, they are held in local or county jails, like the one run by Middlesex County Sheriff James DiPaola. If the order was actually to vaccinate state prisoners, Sheriff DiPaola’s prisoners probably don’t qualify.

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