As Arkansas began rolling out covid-19 vaccines to staff members in the state's prison system last week, one group remained left off the priority list: inmates.
Advocates for placing inmates as a priority for vaccines say they are vulnerable because, like nursing home residents, they live, eat and sleep in confined areas.
The state says that it's the staff -- guards, office workers and others -- who carry the virus in.
Opponents to inmates joining priority groups argue that those who committed sometimes-heinous crimes shouldn't have access to vaccines before others. Colorado Gov. Jared Polis, for example, said in December that there was "no way" prisoners would get shots before people who had not committed crimes.
"That's obvious," Polis said.
Arkansas officials say they have not decided when those who are prison will have access. Arkansas is one of 11 states that has not included prisoners in any vaccine blueprint, according to a December report from the Prison Policy Initiative, a research group. At least 38 states have included inmates in plans.
Rhode Island, California and Massachusetts have begun or will soon start vaccinating inmate populations alongside prison staffs.
"Subsequent phases to include the possible inoculation of our offender population are still under discussion with the Department of Health," Solomon Graves, the state's secretary of the Department of Corrections, said Tuesday in Little Rock, where two prison health care workers were vaccinated to kick off the employee vaccination phase.
That rollout first includes health care workers and support staffers for the health care workers, followed by the department's security staff and parole and probation officers.
As of Friday, 268 out of a first batch of 975 doses had been given, according to the Department of Corrections, which has about 5,000 employees who are eligible for vaccinations.
Officials say the hope is that by vaccinating employees first, those who are behind bars will be protected. Graves said data indicates that most inmate cases stem from workers who carry the virus in from outside.
On Dec. 30, the Department of Corrections announced a lockdown, suspending "non-essential movement within facilities or between facilities" after a spike in cases among staff members. The lockdown will be reevaluated on Friday when it is set to expire, the department said.
"We know the cases are predominantly coming in through asymptomatic staff spread," Graves said. "It [covid-19] is not floating through space and dropping down over the fence."
"We know that," he said. "We have never said anything different."
Public health experts disagree.
They also say that in Arkansas -- which has higher incarceration rates, according to the Prison Policy Initiative -- it's even more imperative to vaccinate inmates to prevent community spread.
Since the start of the pandemic in March, the state has ranked among the worst in terms of per capita infections, with more than 11,500 prisoners and staff members getting sick, according to The Marshall Project, a nonprofit covering criminal justice.
More than 50 inmates have died, representing 29 deaths per 10,000 prisoners, which is 129% higher than the overall death rate from covid-19 in Arkansas, The Marshall Project said.
"It isn't a correct statement that vaccinating workers in prisons is enough to save lives," said Dr. Alysse Wurcel, an infectious disease doctor at Tufts Medical Center in Boston. "It will not protect the people who are incarcerated."
"Maybe a little bit, but not enough," said Wurcel, who is also a covid-19 consultant to the Massachusetts Sheriffs' Association, adding that there are still unknowns about the vaccines, such as, for example, whether those who are inoculated can still transmit covid-19.
Wurcel said she believes the public has a perception that prisons are completely walled off from the outside, when, in fact, their operations are porous, with visitors, employees, contractors and inmates constantly moving in and out.
Thus, the higher the rates of infection within prison walls, the more likely that there will be higher rates of infection in surrounding communities, she said.
A December study from the Prison Policy Initiative found that "over half a million covid-19 cases this summer were directly linked to mass incarceration."
The study called such facilities "super spreaders."
It found that "mass incarceration led to more than half a million additional covid-19 cases nationwide -- or about one in eight of all new cases -- over the summer, including cases both inside and outside correctional facilities."
Public health experts say that prisons are petri dishes for infectious diseases such as covid-19. Social distancing is nearly impossible. Sanitation products, like hand sanitizer, cannot always be distributed because they contain alcohol.
"These are facilities where infectious diseases can spread out of control," said Dr. Nick Zaller, a professor at the University of Arkansas for Medical Sciences' Fay W. Boozman College of Public Health. "It is really a significant public health crisis in correctional facilities."
That public health crisis extends outside prisons, to hospitals where inmates who are critical will require the same resources, such as ventilators, that are already scarce.
Many housed in prisons have underlying conditions or are from minority groups, making them more at-risk for severe cases, Zaller said.
"When we let this virus go rampant, the sheer numbers of people getting infected, and by extension the sheer numbers of people needing hospital-based care, that is what is overwhelming our system," Zaller said.
"Wherever we can release some of that tension and try to vaccinate some of our population we know are in high-risk categories, then obviously that will have the biggest impact on hospital capacity," he said.
And it reduces costs.
Inmates have a right to health care, and ultimately the money spent on that care, whether it be for basic checkups or for time in an ICU because of covid-19, will trickle down to taxpayers.
"Let's just talk about it from an economic perspective," Zaller said. "Ultimately we will have to pay the bill."
From an ethical perspective, public health experts and advocacy groups point out that while some who are incarcerated have committed horrific crimes, there are many who are behind bars because of addiction, mental illness, or being at the wrong place at the wrong time.
"The bottom line is people may have been sentenced for a particular crime, but they weren't sentenced to death," Zaller said. "So is it ethical to say: 'We are going to let this spread? Whatever happens will happen?'"
Across the country, groups have been calling for the compassionate release of people for nonsexual and nonviolent offenses to try to mitigate the spread of covid-19 in already crowded prisons. In Arkansas, the Department of Corrections as of Dec. 10 granted 1,350 inmates compassionate release. The total inmate population as of Friday was 13,767 in state prisons, according to the Department of Corrections.
A study released Friday from DecARcerate, a Little Rock-based advocacy group, said the Department of Corrections "grossly underestimates the prevalence of serious mental illness" in facilities, adding that national data shows at least 50% of those in state prisons have symptoms that indicate serious mental illness.
In April, the Arkansas chapter of the American Civil Liberties Union, in partnership with a coalition of civil-rights groups, filed a federal lawsuit on behalf of inmates.
That class-action suit is seeking "the release of those who can be safely released" from state prisons and "protection for those who aren't -- including ensuring adequate soap, sanitization and personal protective equipment for people incarcerated and for prison staff," the Arkansas ACLU said.
"Prisoners are typically treated as third-class citizens," Holly Dickson, Arkansas ACLU executive director, said. "We have been saying since the start of the pandemic, if you don't control the outbreaks in lockup, not only are we putting lives at risk for the people who are detained, but the entire community, the entire state."
Dr. Jennifer Dillaha, the state's chief epidemiologist, said she supports inmate vaccination, but with limited supplies of vaccines, it will take time before they are included in Arkansas' plans.
"I do agree that it is important to protect this population," Dillaha said. "I would like to see them protected sooner than later. However, at this point, I don't yet know when we will be able to provide them the vaccine to protect them."
The U.S. Centers for Disease Control and Prevention had issued loose guidance for congregate living facilities, such as prisons. The agency said officials "may choose to vaccinate persons who reside at congregate living facilities at the same time as frontline staff, because of their shared increased risk of disease."
Wurcel, the Tufts Medical Center doctor, said vaccinating those who are incarcerated is crucial for the eventual end of the pandemic.
"There is no doubt that withholding vaccines to people who are living in congregate settings is going to negatively impact the process of returning to normal life," she said. "It will negatively influence the way we get back to school, the way we get back to travel, everything."