Prisoner's Dilemma: Ethical questions and mental health concerns about the COVID-19 vaccination and people living in detention.

Like with all crises, the need to protect the most vulnerable, disadvantaged and marginalized in society becomes increasingly acute (Liebrenz, Bhugra, Buadze, & Schleifer, 2020). As the multiple COVID-19 vaccines are rolled out globally, there has been growing concern about the nature of their distribution on a supranational, national, community, group and individual level (Emanuel et al., 2020; WHO, 2020; Persad, Peek, & Emanuel, 2020). Organizations and health experts alike have called for an equitable approach to address humanitarian concerns (Foppiano Palacios & Travassos, 2020; Mukumbang, 2020), to transcend international socioeconomic boundaries (Garfinkel, Sansonetti & Pulverer, 2020; WHO, 2020) and to meet the needs of high risk individuals, such as those living in detention (American Medical Association 2020; Siva 2020).

The latter concern is especially relevant as the pandemic has reportedly taken hold and ripped through prison systems throughout the globe (Li & Liu, 2020; Montoya-Barthelemy, Lee, Cundiff, & Smith, 2020; Steinböck, 2020; Циганенко & Великодна, 2020). Overcrowding has turned prisons into “incubators” (UNODC, 2020), rendering it extremely difficult to stop the spread of COVID-19 and other communicable diseases (Beaudry et al., 2020; Puglisi, Malloy, Harvey, Brandeau, & Wang, 2020). This pattern has been reported internationally in both the developing and developed world (Gannon, 2020; Harsono, 2020; Rapisarda & Byrne, 2020).

The role of inmates during the COVID-19 crisis has become “politically charged”, with different approaches and opinions being put forward internationally; at the onset of the crisis, during earlier vaccinations trials, and more recently when planning and implementing a vaccination strategy (Mannix, 2020; Stanley-Becker, 2021). For example, in May 2020, Vladimir Zhirinovsky of the Liberal Democratic Party of Russia suggested the coronavirus vaccine “[should be] be tested by people who are motivated to do so” (Mamontow, 2020). In the politician's opinion, prisoners who agree to try the vaccine should have their time in prison halved. According to Zhrinovsky, thousands of inmates would respond to such a proposal. From a different perspective, the inclusion of detainees in vaccination trials was also being called for by U.S. scientists. They argued that “correctional settings present the opportunity to determine vaccine efficacy when trials are ethically conducted and perhaps to the benefit of the health of people who live and work there” (Wang, Zenilman, & Brinkley-Rubinstein, 2020).

In the view of the authors, such proposals (although some may be well-intentioned) are problematic, as it has been widely observed that a disproportionate number of people living in detention (PLD) suffer not only with somatic but also mental illnesses (Fazel, Hayes, Bartellas, Clerici, & Trestman, 2016; Fazel & Seewald, 2012; Maccio et al., 2015; Stürup-Toft, O'Moore, & Plugge, 2018), thereby putting into question some prisoners' ability to freely consent in times of unprecedented crisis. Falconer recently emphasized the high rate of mental illness in prisons by comparing the prevalence of serious mental illness in the general U.S. population (about 4%) to the number of PLD who reported symptoms of severe mental disorder (39.8–60.5%), such as schizophrenia, affective disorders, substance use disorders, and also neurotic and stress-related disorders (Falconer, 2019).

Within this context, the distinct and complex features of healthcare provision in the correctional system must always be taken into account, especially when developing and implementing vaccination strategies for COVID-19. Depending on the jurisdiction and societal considerations, this could result in the exclusion of vaccinations of offenders or, on the contrary, in the compulsory vaccination of inmates with sanctions for refusal. The latter may become increasingly prevalent in the following months as vaccines come to be more widely available as production is accelerated.

All these issues create the following complex concerns that must be considered in the upcoming immunization efforts within correctional systems, which have large numbers of mentally ill detainees:

It is likely that there will be a nationalist upsurge in attitudes to get the vaccine first and clear commitments are needed to ensure that PLD are included in the vulnerable groups and offered vaccinations accordingly. Policy makers must understand that a public health risk reduction for the general population can only occur if the prison population is included in immunization programs at an early stage, which will entail a multiagency approach. Here, the first considerations are beginning to emerge. For example the US National Academy of Medicine (NAM) recommends vaccinating people in prisons, jails, detention, and similar facilities in phase 2 of their 4 phased approach to vaccine allocation, at the same time as teachers and critical workers in high-risk settings who are in industries essential to functioning of society but before young adults and children (National Academies of Sciences & Medicine, 2020). Whether this plan is implemented and followed through remains to be seen.

Consideration should be given to the fact that the large group of mentally distressed and especially anxious prisoners may have greater reservations about vaccination than the general population (Zwanzger, 2016). For instance, a study on hepatitis B virus (HBV) vaccination in prison found that while PLD were generally willing to be vaccinated for HBV, barriers to being vaccinated during times of incarceration included distrust of correctional and prison health staff which led some inmates to “try to avoid blood tests or injections during incarceration because of concern about what their blood was being used for, what they were being injected with, and whether they were being tested for drugs” (Buck et al., 2006).

PLD should be individually encouraged to vaccinate by the medical staff and provided with educational materials about the vaccine. Studies in forensic psychiatric settings demonstrated that such requests for action by the medical staff can significantly influence vaccination behavior (Borthwick, O'Connor, & Kennedy, 2020). Structured conversations, the use of decision aids and motivational interviewing methodology in particular is recommended, although evidence gathered among the general population remains modest so far (Borthwick et al., 2020; Brewer, Chapman, Rothman, Leask, & Kempe, 2017). In this regard, preparations need to be made now, such as the training of medical (and possibly non-medical) staff to provide education or language-independent material to help address inmates' possible reservations and fears (Dutilleul et al., 2019); such information has to be clear and targeted according to cultural norms. This is increasingly pertinent in the 2020s as disinformation proliferates (Nguyen & Catalan, 2020). In addition, it is important to remember that some incarcerated people may come from countries that do not have a robust public health system and thus may have less experience with vaccination programs (Bangura, Xiao, Qiu, Ouyang, & Chen, 2020; Lydon et al., 2017; Mipatrini, Stefanelli, Severoni, & Rezza, 2017).

Contemporaneous reports are surfacing from countries where vaccination is not compulsory that considerable numbers of health care staff are reluctant to participate in the COVID-19 vaccination campaigns (Beer, 2021; Michel, 2021; Polke-Majewski, 2021). For now, such reports primarily stem from hospitals and nursing homes but they still raise concerns about the participation rates of health staff working in correctional facilities. In addition, data from Switzerland, for example, show that in the winter of 2019–2020, on average only 30 percent of nurses in hospitals were vaccinated against influenza. Among doctors, the figure was twice as high at 60 percent (SRF, 2021). Similar data is available from many other European countries as well, where vaccine coverage remains at rates below 30% (Lorenc, Marshall, Wright, Sutcliffe, & Sowden, 2017; To, Lai, Lee, Koh, & Lee, 2016). While a COVID vaccine may or may not be more widely adopted than an annual influenza vaccination, this raises the issue of what can be done if broad-based vaccination campaigns are not supported by individual professionals who are the first point of contact for health issues in the prison system.

A further question arises as to how the prison system should manage those detainees who freely and consciously refuse vaccination. In contrast to extramural conditions, sanction mechanisms are available in prison that go far beyond the disadvantages that people in the general population may experience if they refuse vaccination. In Europe, for example, travel restrictions and digital health passports for the general population are currently being considered by some (Rodriguez Martinez, 2020; Walsh, 2020). Under prison conditions, on the other hand, severe measures such as segregation or contact and visitation restrictions could quickly be raised and implemented. A similar precedent for this can be found when prisoners face solitary confinement for minor infractions (Cloud, Drucker, Browne, & Parsons, 2015). This could potentially lead to a scenario in which punitive measures could be holistically adopted to suppress personal choice regarding vaccination.

Prison health care workers face several challenges in the coming months, of which concern about the ease and breadth of delivery of a COVID-19 vaccine to detainees (with and without mental health issues) may only be the first. From our point of view, finding a balance between public health efforts on the one hand, and individual rights on the other, especially for people living under prison conditions, may become an issue of equal importance.

Unaffected by these considerations is the call for an equitable distribution of the vaccine on a global level, which the authors of this article fully endorse. Underprivileged populations especially those in prisons are stigmatized and ignored and more so in the current climate where they may be seen as deserving of infections. Public attitudes about safety and self-protection can further contribute to ignoring vulnerable groups. This health crisis with a virus that knows no “boundaries” underlines once again that “today real borders are not between nations, but between, powerful and powerless, free and fettered, privileged and humiliated” as the then Secretary-General of the United Nations Kofi Annan famously put it (United-Nations, 2002).

Declarations of competing interest

In his role as Editor-in-Chief, Michael Liebrenz had no involvement in the peer-review of this article and has no access to information regarding its peer-review.