The coughing and complaints of sickness began as a procession of busloads of prisoners made its way late last month from a Southern California prison to San Quentin, California’s oldest and most widely known prison, perched on a bluff overlooking San Francisco Bay, not far from the Golden Gate Bridge.
The inmates were being moved to San Quentin as part of a plan to halt the spread of the coronavirus by reducing the number of inmates at the California Institution for Men in Chino, where nine inmates had died and nearly 700 had been infected.
At the time, there were no inmates known to have had the virus at San Quentin.
Within days, some of the 121 prisoners from the buses introduced the virus at San Quentin, public health officials say. More than 1,000 of the 3,700 prisoners have since been infected at San Quentin, the foreboding structure surrounded by barbed wire fences and dotted with guard towers that was once famously home to inmates including Charles Manson; Sirhan Sirhan, who assassinated Robert F. Kennedy; and George Jackson, an inmate who wrote “Soledad Brother,” a series of letters from prison.
The transfer of inmates — an effort intended to slow the virus, which instead apparently created a new outbreak — has been denounced by health officials and a state lawmaker as a public health failure. How San Quentin went from being a prison that had held off the virus for months to a place inundated with sick inmates represents a cautionary tale for the nation’s prison system amid the pandemic.
“What happened — what’s happening — it can really happen anywhere, particularly in an overcrowded prison, which unfortunately is the norm,” said Dr. David Sears, a physician and professor of medicine at the University of California, San Francisco, who toured San Quentin on June 13 and warned state officials about the emerging crisis. “San Quentin’s not the first prison to have a large outbreak, and unfortunately it won’t be the last.”
Days into the outbreak, the prison has grown increasingly chaotic, inmates and others say. Some among San Quentin’s death row inmates, in a secluded part of the prison, are infected, according to advocates for inmates. A number of older prisoners have hung handwritten signs outside their cells that read “Immune Compromised” so that guards will wear masks around them. Other inmates refuse to leave their cells out of fear of catching the virus, according to an inmate, and in recent days, guards have been heard screaming over their radios, “Man down!” after sickened inmates were unable to stand up.
The conversation has been dominated by talk of death.
“I don’t want to see them die,” Rahsaan Thomas, a 49-year-old inmate said of some of the older prisoners in a telephone interview. “I don’t know if I’m tough enough to survive Covid.”
The California Department of Corrections and Rehabilitation said in a statement that it was very concerned about the surge in infections in San Quentin, adding that prison workers had increased testing among inmates and had limited the number of transfers between prisons.
“Public safety is our top priority, as is the health of our community,” said Dana Simas, a spokeswoman for the agency. Workers had begun to build “air-conditioned tent structures” at the San Quentin prison, she said, as officials work to determine the best use of spaces for housing and medical triage.
Broadly, Ms. Simas said that California officials were confident that they could halt the spread of the virus given that the prison system had longstanding plans for managing other outbreaks of influenza, norovirus, measles and mumps.
A hearing is scheduled on Wednesday in the State Senate, where lawmakers say they have become alarmed about the outbreak and what they describe as a haphazard response by prison officials.
Across the United States, the number of prison and jail inmates known to be infected has doubled during the past month to more than 80,000, according to a New York Times database. Prison deaths tied to the coronavirus have also risen significantly, by nearly 30 percent since mid-May. Nine of the 10 largest known clusters of the virus in the United States are inside correctional institutions, The Times’s data shows.
In California prisons, the number of cases has risen by nearly 200 percent and deaths by 144 percent during the past month.
Public health officials in California and elsewhere have been bracing for months for what they say was inevitable — the spreading of the coronavirus in correctional facilities, which possess unique vulnerabilities.
Most jails and prisons were designed to focus on security. Ventilation is often poor and access to health care is inconsistent. Prison health care in California has historically been so substandard that health services are administered by a federal receiver.
California prisons have required everyone to wear masks, but social distancing policies and mask-wearing rules among prison guards are nearly impossible to enforce. Longstanding prohibitions on cleaning supplies that contain bleach or alcohol have made it difficult for crowded facilities like San Quentin to meet even basic sanitary standards given that hundreds of inmates share a limited number of toilets, telephones and shower stalls.
Since the pandemic, California has agreed to release as many as 3,500 inmates up to six months early and is considering more early releases, but the prison system remains at 124 percent of capacity, according to state records.
Public health experts said deficiencies were made worse at San Quentin. The prison is dominated by row after row of barred cells. Paint peels from walls, state work orders show, and puddles form after rain showers because the ceilings leak.
The prison opened in 1852, and is at 117 percent of its capacity, according to state data. As many as half of all inmates suffer from health conditions that make them especially vulnerable to the virus.
“There’s no way to address a public health problem when you need to isolate people but your system is bursting at the seams,” said Adamu Chan, a San Quentin inmate.
Dr. Brie Williams, a physician and professor of medicine at the University of California, San Francisco, and director of the university’s Criminal Justice & Health Program, said absent a coronavirus vaccine, prisons were outmatched, despite their plans for managing other sorts of outbreaks.
“The difference with this infection is that with all of those other conditions we were able to essentially, eventually throw money at them in the way of fancy medications,” she said.
Dr. Matt Willis, the top public health official in Marin County, where San Quentin is, said state prison officials had told him they were capable of handling the virus on their own.
The county’s health department was told by state prison leaders “very clearly that this is not part of our jurisdiction,” Dr. Willis said. The corrections system, he said, has a “lot of control over every aspect of their processes” and has not been transparent about their handling of the virus.
“It may work in certain settings,” he added, “but when you have a complex disaster that’s moving quickly, I think we’re finding that the process is just not matching our needs.”
San Quentin’s crisis began with a handful of decisions that were made as officials were trying to quell the outbreak in Chino, interviews with inmates, correctional officers, elected officials and health experts show.
On May 30, the inmates from Chino boarded buses for San Quentin after being told they were being transferred to reduce overcrowding, which would protect vulnerable inmates at the prison they were leaving, the California Institution for Men.
Each of the 121 inmates who boarded the buses had been tested at various points over the previous several months, but few — if any — had been tested during the previous three weeks, prison officials have acknowledged.
Arriving at San Quentin, prisoners’ temperatures were taken and they were placed in a holding area, but no Covid-19 tests were given.
For days, the men used the same showers and ate in the same dining hall as other San Quentin inmates.
It took only days, data from the prison system shows, for the virus to make its way through the prison, where hundreds of inmates sleep in bunk beds within a few inches of one another in a crowded dormitory that was once a gymnasium. In other parts of the prison, men are paired inside 4-by-9 foot cells.
Over the past week, the prison has conducted mass testing. So far, more than half the inmates tested have seen positive results, state data shows.
The virus has spread so rapidly and there is so little unoccupied space left at the sprawling prison that some infected inmates have been placed in small isolation cells where, in normal times, death row inmates are sent for punishment.
Marion Wickerd got a call last week from her husband Tommy Wickerd, 53, an inmate in San Quentin.
“He said, ‘People are dropping right and left in front of me, but I’m OK,” Ms. Wickerd said.
A few hours later, though, he called back. He had tested positive. She said she had not spoken to him in several days.
“All I know is that my husband is not dead because no one has called to tell me that,” she said. “Worried? You bet. Scared? You bet.”
Reporting was contributed by Brendon Derr, Danya Issawi, Ann Hinga Klein, Savannah Redl and Maura Turcotte.
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