The path to establishing widespread Covid-19 testing in the United States has been slow and painful. There finally appear to be preliminary levels of success in some institutions with congregate housing where individuals cannot easily socially distance. These institutions are rapidly implementing routine testing to identify positive cases and mitigate the spread of Covid-19.
Yet routine testing in congregate housing settings is not being universally or equitably implemented. It has been deployed in universities and nursing homes, but is not being used in prisons, jails, and immigration detention centers. This unequal distribution of resources demonstrates how the needs of vulnerable populations are often disregarded and ignored.
Nursing homes were one of the first institutions to adopt the model of frequent testing, largely to protect their older populations, which have higher death rates from Covid-19 than younger populations. Many local health departments across the country adopted routine testing protocols for residents and staff of nursing homes and long-term care facilities. When these facilities faced supply chain and funding challenges for continued testing, the Department of Health and Human Services procured hundreds of millions of point-of-care testing kits from manufacturers such as Becton Dickinson, Quidel, and Abbot.
College and universities with congregate housing have followed suit. Many colleges have scaled up testing for students to allow for hybrid education models, sometimes up to three times a week at places like Amherst College and Harvard University. Harvard has been able to sustain such expanded testing measures by partnering with organizations such as the university-affiliated Broad Institute and the third-party vendor Color.
Achieving weekly mass testing to effectively isolate Covid-19 cases and protect communities is commendable. But as our governments and institutions operationalize testing to establish a new normal, it is important to be aware of how resources are being allocated, and which lives are prioritized and ultimately saved.
Other large settings for congregate housing, such as prisons, jails, and immigration detention centers, have not provided testing anywhere near the levels achieved by universities and nursing homes, even though they have experienced massive Covid-19 outbreaks and house vulnerable individuals who disproportionately live with comorbidities that increase their risk of developing Covid-19-related complications.
Most testing performed in correctional and immigration detention facilities is still reactionary — only symptomatic individuals get tested — and many of these facilities have not performed mass testing a single time, let alone routinely. In settings where even soap can be hard to come by, the lack of testing has proven to be a disaster. The infection rate in federal prisons and jails is nearly six times higher than the rate among the U.S. population, while the age-adjusted death rate is three times higher. In 16 prisons and jails where mass asymptomatic testing has been implemented, the true burden of Covid-19 infection was found to be 12 times higher than levels previously established by symptom-based testing.
Not testing those in facilities can put entire communities at risk. A University of Chicago researcher estimated that, in the spring of 2020, nearly 16% of all Covid-19 infections in Illinois may have been linked to Chicago’s sprawling Cook County Jail. Since then, however, Cook County Jail officials, with help from the U.S. Centers for Disease Control and Prevention, have ramped up testing and other measures to significantly limit the spread of Covid-19.
Unlike in nursing homes and universities, the barriers to testing inside correctional and immigration detention facilities are incredibly high. Our research team at the Harvard Asylum Clinic interviews individuals held in Immigration and Customs Enforcement detention centers across the country. We recently spoke to a detainee who had a cough for two days but was denied testing because he wasn’t “sick enough.” Last week, we spoke to another detainee who did not report her symptoms to staff because she feared being sent to “the hole” for medical isolation.
It’s a stark contrast. Asymptomatic students get tested twice a week so they can meet in large groups to build their professional networks, while a detained man with a cough is denied testing and forced to return to his dormitory where he shares a room with 50 other people.
Our priorities must change.
Correctional and immigration detention facilities often report, in line with guidance from the Centers for Disease Control and Prevention, that they do not provide mass testing because they do not have sufficient staffing and housing infrastructure to appropriately respond to the results of testing with appropriate contact tracing and isolation.
When lives are at stake, such reasoning is unacceptable. Alternatives avenues that make mass routine testing and isolation possible, such as reducing the incarcerated population, building housing infrastructure, and expanding funding for point-of-care tests in correctional and immigration detention facilities, must be pursued.
The failure to provide routine testing to these high-risk populations is driven by the lack of a national testing strategy. The Trump administration’s decision to shift the responsibility of testing to states that compete with one another for limited resources has contributed to disparities in which populations are tested.
While the National Institutes of Health recently expanded funding for Covid-19 testing among underserved populations, additional direct investment and testing mandates are essential for correctional and immigration detention facilities. Without them, the federal government is turning a blind eye to populations it is tasked to protect.
People in correctional and immigration detention facilities are people with families, passions, and aspirations, whose lives are worth protecting. We must organize, mobilize, and invest resources to protect them, just as we are doing for students and the elderly.
Parsa Erfani, Caroline Lee, and Nishant Uppal are students at Harvard Medical School, medical evaluators at the Harvard Asylum Clinic, and research associates at the Peeler Immigration Lab at Harvard Medical School.
Editor’s note: This article was updated to reflect the turnaround at Chicago’s Cook County Jail.