When I found out that health systems across the country contract with prisons for hospital laundry and other services, the same systems that train medical students like myself, someone dear to me was in prison. Each time I walk into a patient’s room and see fresh linens, when I wear fresh scrubs, I am still flooded with my friend’s calls and letters. Imagery of being surrounded by only concrete. Without access to healthy food or quality care. No connection to the Earth. I recalled how much his time in prison was changing him. Was breaking him. When I see those linens, I remember how many tears I shed after our phone calls.

Introduction

Unpaid labor, slave labor, is older than the United States itself. Nearly 250 years after the first enslaved African was sold on this continent, the U.S. abolished slavery, with a caveat: slavery could not exist except as punishment for a crime. Presumptively, driven by the threat of a decimated economy, prison labor served as a cheap surrogate that allowed for continued exploitation. A surrogate that prevails to this day and weaves health systems in its web of contracts, labor, and illness.

Today, in all federal and most state prisons, people who are able to work are legally required to. Those in prisons are not considered employees, are not required to receive minimum wage, and cannot receive workers compensation if injured on the job. The United States incarcerates the largest percent of its population in the world and furthers the racism of its predecessors, chattel slavery and colonization, by disproportionately criminalizing — then working — people of color.

In my home state of Oregon, hospitals contract with prisons to launder linens, scrubs, and gowns, with average wages between 5 and 47 cents per hour — still a slightly higher wage than states like Texas, where workers are not paid at all. On the backs of these workers lies the billion-dollar industry that is prison enterprises.

Working conditions

Expecting justice from an unjust design, built on devalued and exploited labor, is senseless. And the deep-running injustice of our system is particularly apparent in the state of health and the health care in our prisons.

Incarcerated people are more likely to have chronic health problems including diabetes, hypertension, TB, and HIV, as well as substance use and mental health disorders. Yet, within prisons there is little access to nutritious food, and health care quality varies with significant barriers to access. One barrier being the sheer cost of care, as most prisons require a copay for provider visits. An impossible hurdle, when hard-earned cents may rather be spent on other needs like a box of tampons, which can cost two weeks’ worth of wages alone. This dim picture is compounded by few rights to healthy working conditions. In 2017, incarcerated members of Operation PUSH in Florida organized a strike to end “slave labor” and directly called out “environmental conditions [they] face, like extreme temperatures, mold, contaminated water, and being placed next to toxic sites such as landfills …” These same sentiments echoed across 17 states in the National Prisoners Strike of 2018.

COVID-19, incarcerated

It is clear that the health of some in our community relies upon the harm of others. Each patient visit to a provider wearing prison-laundered scrubs, becomes rooted in the coerced labor and illness that it seeds and exacerbates. In other words, the healing we hold space for with our patients is intricately enmeshed in the illness-provoking labor of those incarcerated. We are complicit in a complex web of contracts that is in direct opposition to the oath we all take.

This tension becomes achingly visible as COVID-19 ravages through our health systems and our prisons. With 86 percent of reporting correctional jurisdictions with confirmed cases, we see an aging prison population with chronic health conditions washing the laundry of infected patients; we see them then struggle to quarantine in prison cells, their bunkmates always less than six feet away. Those with inconsistent access to health care are the same who make face masks and hand sanitizers for doctors and nurses. Amidst growing fear of their own fate in this pandemic, they dig mass graves while, we can imagine, praying theirs won’t be the bodies to fill them. The pandemic has shown just how much health care systems rely on prison labor, and reinforces how little those in prison receive in health care in return.

While health care workers are lauded as heroes with funds raised to ensure our protection, what acknowledgment and care is demonstrated for those whose labor lays the foundation for our own? What protection is there for them, for their essential work? As providers, we continue to exploit an injurious system for our own benefit, both economically to avoid higher labor costs, and medically, through putting those of perceived lower social value to work on these tasks. Heartbreaking signs in the window of a Chicago jail put it starkly, “Help, No Supply” and “Don’t Let Us Die.” This is not justice. This is a human rights crisis.

Calling for change

As a society, we seem reluctant to remember that people incarcerated are exactly that: people. We construct concrete walls and iron cages around them, but they are not separate from us. They are our neighbors, parents, children, siblings, friends. People who are deeply loved. And who deserve to be radically transformed by what we call “justice,” not further harmed by it. We in the field of medicine commit ourselves to improving health, to doing no harm, and to remembering our responsibility to all human beings, not just those in front of us. COVID-19 has only served to further widen our own cracks in that commitment.

We must find ways to mend these cracks. To turn to restorative justice, to divestment, to decarceration to save lives, and transform these legacies of oppression. Bit by bit weaving a world where health isn’t traded for harm, where care is offered over cages, and where justice and health systems are allied in authentically healing us all.

Alexandria Dyer is a medical student.

Image credit: Shutterstock.com