Anthony Ehlers and another of Broadway’s friends in a cell next door heard him say he was having trouble breathing and called out to a guard, according to an affidavit written by Ehlers. Roughly 15 minutes later, a nurse arrived, but she didn’t want to climb the stairs to Broadway’s cell. “It’s too hot. I’m not going up there,” she said, per the affidavit. “Tell him to come down here.” 

By the time she ambled up the stairs several minutes later, Broadway was unconscious. His history of severe asthma was well-documented, and prison medical staff had prescribed him medications for the condition. Yet the nurse instead twice administered the overdose reversal drug Narcan as she yelled at Broadway to open his eyes, according to medical records and an affidavit from someone in the cell next door. Two guards in the cell took turns giving him chest compressions while she looked on.

The guards reached for the stretcher—but it didn’t have straps or handles. A man one cell over offered up his bedsheet and eventually helped two guards carry his friend’s limp body downstairs. By the time an ambulance arrived at the prison to take Broadway to the hospital, he wasn’t breathing and had no pulse. An autopsy later revealed he died of bronchial asthma, with heat stress listed among “significant contributing conditions.”

The medical care Broadway received at the end of his life is commonplace for the nearly 30,000 people incarcerated by the Illinois Department of Corrections (IDOC). Wexford Health Sources, the company the state has paid for prison health care services for decades, has long faced accusations of neglect and abuse, including enforcing a “one good eye” policy and providing such poor treatment to older people with dementia that court monitors compared it to elder abuse. 

“Mike was far from the first, and unfortunately, he won’t be the last,” Ehlers wrote in a message to Bolts. “He died as a result of being less than in the eyes of the people who oversee us. … The staff in these prisons DO NOT see us as human beings.”

Terah Tolner, an attorney representing Broadway’s family, said his experience is “just one example of many of IDOC and Wexford’s pattern of delay and unpreparedness and inadequate medical treatment.” Illinois has been bound by a federal consent decree to improve the quality of treatment it provides incarcerated people since 2019, after a lawsuit alleging poor medical care triggered intervention by the courts. 

Nonetheless, earlier this year, IDOC inked a 5-year, $4 billion contract with Wexford, raising fresh questions about the state’s commitment to improving quality of care for incarcerated people.

Sarah Grady, a civil rights lawyer who has represented a number of incarcerated people in lawsuits against IDOC and Wexford, is disappointed in state leaders like Governor JB Pritzker and Latoya Hughes, the governor’s pick to lead IDOC as interim director since March 2023 for awarding Wexford a new contract despite its tumultuous history. 

“It was a really incredible opportunity for the governor and the state to really think about a model that does not embrace this privatization,” she told Bolts. 

Pritzker, who has heralded progressive legal reform efforts like eliminating cash bail, did not respond to a request for comment. Naomi Puzzello, an IDOC spokesperson, declined to comment on Broadway’s death, citing an ongoing investigation. “The Department has not foreclosed any reasonable ways to provide healthcare services to the patients in its custody,” Puzello said in an emailed statement. “At present, the Department remains committed to continuing to provide medical services [to] the individuals in custody through its emergency contract with Wexford.”

Wexford also did not respond to multiple requests for comment.

State prison officials are constitutionally bound to provide a very basic level of care to the people they incarcerate. While there’s no express guarantee of health care in the U.S. Constitution, the Supreme Court ruled that prison staff cannot knowingly ignore incarcerated people’s severe illnesses. Writing in a 1976 opinion, Justice Thurgood Marshall established the standard when he held that “deliberate indifference to serious medical needs of prisoners” violates the Eighth Amendment’s prohibition on cruel and unusual punishment.

For much of the nation’s history, this care was provided directly by state prison or health authorities. But around the 1980s, as the number of people behind bars skyrocketed, privatization took root as state lawmakers began to outsource these and other functions. Today, roughly two dozen states use for-profit health care contractors.

The industry is now dominated by a handful of corporations, including Corizon Health, Wellpath, and Wexford. All three have long histories of lawsuits and problems with staffing and quality of care. Corizon paid Arizona officials $3 million in penalties over six years for chronic understaffing. In May, Massachusetts officials declined to renew their contract with Wellpath following complaints that the company routinely denied care and used restraints and solitary confinement on people experiencing mental health crises.

Wexford has a long and complicated history with Illinois dating back to the 1990s, when state officials first began privatizing prison medical care. In 2005, the company had secured a $547 million contract to provide health care services to most state prisons. The following year, Illinois prison officials opened an investigation into a deputy warden who was accused of also working as a paid lobbyist for Wexford in New Mexico. Then in 2008, a former IDOC director was sentenced to two years in prison for accepting $50,000 in bribes from lobbyists, including a Wexford lobbyist. (The company itself was not accused of wrongdoing in the case.) 

By 2010, the prison watchdog group John Howard Association of Illinois was warning of serious deficiencies in the psychiatric care that Wexford provided inside the state’s main women’s prison. Around the same time, from his cell at Stateville prison, Don Lippert filed a typewritten complaint in federal court alleging that he was routinely denied treatment for his diabetes, causing him headaches and nerve damage.

Despite the mounting problems under Wexford, in 2011 the state nonetheless awarded the company a 10-year, $1.3 billion contract to provide virtually all medical care to people incarcerated in Illinois prisons. 

That same year, Lippert teamed with civil rights lawyers to argue that “widespread and persistent mistreatment” of incarcerated people extended far beyond indifference among specific staff members and was “a consequence of overarching policies and procedures put in place and executed by both IDOC and Wexford.” Others eventually joined the lawsuit, and in 2017 U.S. District Judge Jorge Alonso granted class-action certification. A court-appointed medical expert, in a report accompanying Alonso’s opinion, concluded that the state “has been unable to meet minimal constitutional standards with regards to the adequacy of its health-care program for the population it serves.”

In January 2019, the parties settled the case. A five-year consent decree, included as part of the settlement, required IDOC and Wexford to overhaul their medical and dental services by increasing staffing, improving record-keeping, and implementing policies that better protect incarcerated people. An independent monitor was tasked with overseeing the reforms and regularly updating the court.

But as the lawsuit played out in court, medical care for incarcerated people remained dismal. In 2018, a medical expert told the court that of 33 deaths behind bars studied, 12 were preventable. Another seven, the report noted, might’ve been preventable, while five others could not be determined because the deaths weren’t adequately documented.

Even now, bound by a consent decree, heinous treatment continues to plague Illinois prisoners. The independent monitor wrote in a 2020 report that one nurse continued to pass out medication despite being asked by a guard to check on a person who was drooling and unresponsive. In 2023, the monitor flagged the case of an 80-year-old man with dementia who drank bleach from a soda bottle that had been left in his room. 

Wexford’s 2011 contract with Illinois expired in 2021. After decades of business with the state, millions of dollars in settlements, and a trail of horror stories, incarcerated people and advocates on the outside hoped perhaps a change was finally in order.

But the company continued to provide care in Illinois prisons while IDOC solicited bids for a new provider. It received just two: from Wexford and VitalCore Health Strategies. Prison officials scored the two proposals based on the providers’ capability and experience, technical ability and methodology, resources, references, commitment to diversity, and pricing, according to Puzello, the IDOC spokesperson. Once approved by an independent state purchasing officer, the IDOC commissioner, appointed by the governor, can officially enter into the contract.

In January, IDOC announced it was again choosing Wexford—this time to the tune of more than $4 billion over five years, with an option to renew for another five. Contract talks with Wexford remain ongoing. In June, IDOC extended an emergency contract with the health care provider through the end of the year while they finalize the terms of a new agreement.

In May, four months after IDOC announced that it was again choosing Wexford, Judge Alonso agreed to extend the consent decree and court monitoring of health care in Illinois prisons for another five years. In making his decision, Alonso noted that half of the staff positions Wexford is contracted to provide remained unfilled, medical staff continued to administer incorrect medications, and IDOC still had not developed a comprehensive set of health care policies nearly four years after a July 2020 deadline.

Alan Mills, executive director of Uptown People’s Law Center, is a perennial prison litigator and one of the lawyers fighting IDOC and Wexford in the Lippert case. He questioned the factors that IDOC considered in choosing Wexford over VitalCore, which bid lower for the contract. “Clearly, the quality of medical care being provided is not ranked high enough,” he said.

Mills told Bolts that for-profit companies like Wexford have “a built-in economic incentive to provide only the minimum level of care that gets your contract renewed.” Since contractors are paid a flat rate, rather than by the services provided, “every time they actually provide care, it comes off of their profits.”

A 2020 Reuters investigation found that, of 500 state jails surveyed between 2016 and 2018 across the U.S., those that contracted with one of the five largest private providers had higher death rates than those run by government agencies.

The issue is bigger than any one company, said Grady, the civil rights lawyer. Improving medical treatment for incarcerated people in Illinois requires a culture shift, where profit motives no longer drive decisions about care.

She called for greater oversight from state lawmakers, and she urged Prtizker and Hughes to think transformatively about a system that prioritizes quality of care over profit. (Pritzker’s office did not respond to a request for comment.)

“If you spend just a little bit of time looking at this system,” Grady continued, “there can be no doubt that it is not good for the state–including the taxpayers–and it’s certainly not good for the vulnerable people who are forced to suffer because Wexford is more interested in making a profit than caring for patients.”

The post In Illinois, a Private Prison Company’s Long Trail of Deaths and High-Dollar Contracts appeared first on Bolts.

Alongside the new bans on abortion, laws have popped up to encourage people to snitch on their neighbors and empower prosecutors to file criminal charges. So-called personhood laws are exposing more people to heightened punishment, plus endangering access to other procedures like IVF. The Republican Party has proposed scaling that up further by codifying ‘personhood’ at the federal level.

But pregnancy was policed long before the Dobbs decision came down. Even under Roe, many women faced arrest and prosecution due to allegations over how they handled their pregnancy.

Grace Howard meticulously lays out this history in her new book The Pregnancy Police: Conceiving Crime, Arresting Personhood. An associate professor of justice studies at San José State University, Howard has studied over 1,000 pregnancy-related arrests since 1973, a period that saw the rapid growth of the war on drugs. Her book reconstructs how legal statutes and surveillance tools were used to punish not just abortions, but also stillbirths and miscarriages.

As part of our “Ask Bolts” series, we invited you to ask Howard any question you had about the policing of pregnancy. And once again, you delivered with many thoughtful questions, touching on everything from landmark court cases to new technology. We narrowed your submissions to just nine reader questions to share with Howard, also throwing in a tenth from our own staff.

Howard replies to your questions below, sharing what gravely worries her about the realities of policing and surveillance today, but also finding advocacy to be hopeful about. We’ve organized your questions under four themes—explore at your leisure:

Decades of policing

The realities of criminalization today

Standards of care

What lies ahead?

Read on to learn more about the most consequential legal cases, new tools of surveillance, and a lot more.

Decades of policing

Dobbs galvanized more attention on reproductive rights, but you began your research on the policing of pregnancy long before that decision. What was happening in the decades that your book covers—what has criminalization looked like, besides restrictions on abortion? And what made you start paying such close attention to it? — Bolts staff

In the decades before Dobbs, there was a lot of action in the courts and in state legislatures carving out fetal personhood beyond the scope of abortion. Fertilized eggs, embryos, and fetuses were defined as legal persons in tort law. Pointing to the reality of homicidal violence against pregnant people, pregnancies were defined as crime victims, independent of the people gestating them. 

After Roe, criminalization began in earnest in the 1980s, as the “War on Drugs” drove punitive approaches to social issues, and the anti-abortion movement became a more organized political force. Panic over crack cocaine led to a focus on impoverished Black women who tested positive for the drug while pregnant. 

Most pregnancy criminalization cases involve a positive drug test, but other arrest cases involve self-harm, car accidents, self-managed abortion or miscarriage, failing to protect a fetus from third party violence, and even failure to take good care of themselves. 

Though I had been very passionate about sexual and reproductive health issues, I actually didn’t realize that the criminalization of pregnancy was happening until grad school. We read Dorothy Roberts’ Killing the Black Body and I was forever changed. I was outraged—that it was happening, that so many people either didn’t know or didn’t care. And, there were some great law review articles on it, but not a lot of data. So, I decided I wanted to do something about that. 

What are some landmark legal cases related to the criminalization of pregnancy that concerned citizens should be aware of, and what were their implications? — Chrissy T.

This issue has only come before the Supreme Court once, in Ferguson v. City of Charleston, a 2001 case. This case began as a lawsuit against the Medical University of South Carolina, which had adopted a policy of drug testing certain pregnant patients and reporting positive tests to law enforcement. By the time the case got to SCOTUS, it wasn’t about whether we could punish pregnant folks for crimes against their pregnancies, it was about illegal searches and seizures: Can you drug test a patient for the purposes of law enforcement activity alone, without reasonable suspicion or a warrant? The court said no, you can’t. 

And yet this hasn’t stopped the practice: The case only ever applied to public medical facilities, and healthcare providers can essentially lie about why a drug test is offered. 

Today, drug testing and reporting of pregnant patients and newborns is common and widespread, though most of the time the reports result in family court cases, not criminal ones. 

Another notable case is ex parte Ankrom (2013), which is when the Alabama Supreme Court said that a 2006 law passed by Alabama to punish the chemical endangerment of a child could also be applied to pregnancy. Despite the law saying nothing about pregnancy, the court basically defined fertilized eggs as “children” and uteruses as contaminated “environments.” Though pregnancy-related arrests started years before Ankrom, the decision emboldened prosecutors and opened the door to further legal developments. 

For example, the Alabama Supreme Court case earlier this year that defined embryos created by IVF as extrauterine children, endangering the procedure in the state, cited Ankrom multiple times as precedent.

What does your research show about the way women of color and low income women have been treated on this front during the period you studied, versus white women and higher income women? — Morgan M., from California

The criminalization of pregnancy is inherently racist. Across the U.S., the drugs that women of color are more likely to use have been treated with more scrutiny and have been uniquely stigmatized than those used by white women, despite comparable rates of substance abuse. 

Alabama has been a somewhat different story, in that the racial composition of the arrest pool is much more comparable to state demographics—although this does not mean that it has a racially egalitarian criminal justice system. Alabama’s criminalization period started in 2006, when the big drug panic was related to home-cooked methamphetamine. This focus on meth, and the drug’s association with impoverished white people, led to a wave of them being targeted. 

In my book, I explore rhetorical connections between the panic over so-called “meth babies,” to the early U.S. eugenics movement’s focus on impoverished white people—a white supremacist attempt to shore up the strength of the “white race” by eliminating the whites on the fringes. While information on income was not available in all of my cases, I was able to see if a defendant qualified for a public defender. Perhaps unsurprisingly, the vast majority of the people who were arrested in my study were impoverished enough to qualify for public defense. 

The realities of criminalization today

When I was pregnant in MA in 2021, I was told that because I had a medical marijuana card prior to being pregnant, I could be drug tested at any point in my pregnancy, even though I reported not using it while pregnant. When I read up on the legality of that, I found out that women testing positive for marijuana during delivery accounted for the largest share of referrals to the Department of Children and Family Services. I would love to know more about how marijuana can be legal in a state but criminalized for pregnant people. — Mae, from Massachusetts

Unfortunately, there are a lot of areas of law where pregnancy knocks a person down a peg, legally. You can lose some of your most fundamental rights, including the right to reject medical treatment, the right to privacy, the right to liberty. And people who are reported to Child Protective Services for using drugs during pregnancy usually lose their children at least temporarily—an inherently traumatizing experience. This has included people who use legally prescribed medications, including marijuana.

A case on this question just came out of Oklahoma. The state’s Court of Criminal Appeals ruled that you cannot be prosecuted for using medical marijuana while pregnant; local prosecutors were trying to charge multiple women with criminal neglect. This does not, however, prevent CPS from getting involved—this would be left up to the discretion of the relevant agency.

I’m in Virginia, the last state in the South with access to abortion, and law enforcement here has advocated for a wide expansion of Automated License Plate Reader (ALPR) technology across the commonwealth. Attorneys general across the country have articulated their desire to access this sort of data to track movements of pregnant people to see if they access abortion care across state lines. What are some of the dangers of expansive surveillance networks, like Flock’s ALPR networks, and how does that apply to access to care? — Shawn W., from Virginia

Some of the key differences between today and the last time abortion was criminalized are that our criminal justice apparatus has expanded considerably, as have our surveillance networks.

All forms of electronic surveillance, from ALPR to credit card transactions can potentially be used as evidence in a pregnancy case. Law enforcement can get clearance to examine your text messages, your search history, your credit card statement, and even GPS data to track your location. I worry that this will frighten people away from using the internet to find safe ways of self-managing pregnancies, to arrange travel out of state, or even to find support in understanding what options and resources are available. This leaves people who need abortions isolated.

That being said, we haven’t found a single case where a person was “caught” because of their digital footprint. Everyone who has been arrested, to date, was found because a person told on them: a neighbor, a boyfriend, a nurse. We need to be cautious about who we talk to.

Is performing an abortion the only situation in which these laws apply criminal liability to men? — Alan M., from Washington

So far, yes, the only situation where cisgender men have faced prosecution is for performing abortions. But some states have also been exploring the criminalization of abortion “helpers.” A new Louisiana law goes into effect on October 1 that will classify abortion pills as “controlled dangerous substances.” Any non-pregnant person found to be in possession of these substances without a prescription has committed a crime–even if that person has secured the medication for their own future use in the event of an unplanned pregnancy.

Meanwhile, in family court, there have been a few cases where men have been targeted; not for using drugs themselves, but for failing to prevent their wives from using drugs. This is reminiscent of the law of coverture, a “olde time” legal doctrine from English common law, that basically treated women like legal dependents of whichever man they were attached to—a father or brother or husband. Men were held responsible for “making” their wives behave.

Standards of care

How do these laws affect women with ectopic pregnancies? My friend had an ectopic pregnancy after her daughter was born; the doctors recommended she have tubal ligation to ensure no additional similar pregnancies. — Kirsten, from Maryland

In case readers don’t know, an ectopic pregnancy is a pregnancy where the fertilized egg has implanted somewhere other than the uterus, most often in the fallopian tube. These pregnancies are never viable, and they are extremely dangerous, as the growing embryo can cause tissues to tear and organs to rupture. These must be treated by ending the pregnancy with surgery or with a medication called methotrexate. 

Ectopic pregnancies have been in the news since the Dobbs case, because these medical emergencies bump up against vague laws banning abortions. Healthcare providers are put into a position where they have to wonder: Will offering this life-saving care result in the loss of my medical license, or even my incarceration? For example, in Texas, healthcare providers face 99 years in prison if a prosecutor decides they have violated the abortion ban. In practice this means that emergency medical care can be dangerously delayed while lawyers try to decide whether or not your doctor is allowed to help you. 

This is what happened to Kelsie Norris-De La Cruz, a 25-year old woman in Texas who was ordered to go home and wait after she was diagnosed with an ectopic pregnancy, as there was a chance the pregnancy was still “alive.” She was unable to receive care until her fallopian tube began to rupture. 

(Editor’s note: A new investigation published this week by the Associated Press identified the cases of 100 pregnant women who were denied emergency service in different states.)

How have healthcare providers become part of this apparatus of criminalization? Are there certain things they have to report if they notice them? — Anonymous | Why doesn’t federal HIPPA protect women from states accessing their medical records? — @cyndtrueme, on X   

Healthcare providers are the primary gatekeepers for this whole thing: Of the over 1,000 pregnancy-related arrest cases that I studied, 75 percent originated by a healthcare provider making a report. 

There are two federal laws to consider: HIPAA and CAPTA. HIPAA is basically a record-sharing law that places some limits on when medical information can be shared. In general, without your permission, information can only be shared when a person thinks a patient is a direct threat to themselves or others. Healthcare providers have made reports based on their belief that a fertilized egg, embryo, or fetus is a child facing imminent harm.

CAPTA (the Child Abuse Prevention and Treatment Act) provides federal funding for the “prevention, assessment, investigation, and treatment” of child abuse. Many healthcare providers assume (or are advised) that CAPTA specifically requires that states define substance use during pregnancy as child abuse, and mandate reports to authorities, but this is incorrect. CAPTA does not require prosecution, drug testing, or filing abuse reports of babies exposed to drugs in utero. 

What lies ahead?

The GOP’s official policy platform adopted at the RNC wants more states to establish ‘fetal personhood’ laws. Can you explain what the impact of this would be? — Anonymous

The GOP platform endorses the idea that the U.S. Constitution defines fertilized eggs, embryos, and fetuses as full legal persons. (Editor’s note: Courts have not recognized this conservative interpretation of the Fourteenth Amendment, but there are signs that several justices are open to it.) I can’t overstate how impactful this would be. Anybody with the capacity for pregnancy, or who even looks like they have the capacity for pregnancy, would be suspect at all times, and lose the right to medical privacy. They would be banned from doing anything considered (rightly or wrongly) unsafe for a pregnancy, from a seemingly endless list of foods and beverages that are off limits, to forms of medical care including abortion. They would lose the right to medical privacy, and we would nullify advance directives (legal documents where a person states their decisions about life-sustaining care should they become incapacitated) during pregnancy. They could be fired from jobs deemed unsafe. Pregnant people who are abused by their partners could be charged for failing to protect their “unborn child.” 

You can’t have fetal personhood and full legal recognition of people with the capacity for pregnancy at the same time: You are a womb before you are a person.

The bulk of the legal action establishing fetal personhood comes from states. One horrifying reality is that homicide is a leading cause of death for pregnant women, usually at the hands of their intimate partners. Instead of focusing on the factors that make pregnant people more vulnerable to homicidal violence, 38 states have responded by defining fertilized eggs, embryos, or fetuses as potential crime victims. The legislation is sometimes inspired by specific cases that get a lot of press coverage and cause public outrage—most often involving a white victim. For those of us who care about intimate partner violence, this might seem like a great solution to a terrible problem. I argue, however, that these laws are trojan horses, establishing fetal personhood in the criminal code under the auspices of protection. In turn, these very laws have been used as precedent to establish fetal personhood elsewhere in state law, and have been used to punish pregnant women deemed to have endangered or harmed their own pregnancies. 

Are there grassroots groups that you see are doing a good job fighting against this? — I’m worried, from Ohio

It is easy to feel overwhelmed when I think about the work that needs to be done. Thankfully, none of us have to do this work alone, and there are many groups and organizations fighting back. There are two legal advocacy organizations worth looking into: Pregnancy Justice provides legal defense, guidance, resources, and education for cases involving pregnancy criminalization and CPS reporting. If/When/How also does amazing work on legal defense in abortion cases, and they operate both a legal help hotline and a Repro Legal Defense Fund to help cover bail and legal fees. 

There are also some local and state-specific groups working on this, including Healthy and Free Tennessee, Sister Reach, and Sister Song, which focuses on the South. One of the most powerful things you can do right now is to get involved with your local abortion fund or practical support network. Not only do they help fund abortions and make arrangements for people who need support, but they also support folks who want to continue their pregnancies, give birth, and parent their children. They are the grassroots backbone of the reproductive justice movement.

The post How Pregnancy is Policed: Your Questions Answered appeared first on Bolts.

Jenny had been locked up for several years by the time Ujevich arrived at West Virginia’s all-women Lakin Correctional Center and Jail. There, Ujevich says, Jenny had complained of a persistent pain in one of her breasts, but struggled to get staff to take that problem seriously. In fact, Ujevich says, the staff hardly paid her any mind until Jenny’s condition sharply and visibly worsened. Only after that point did Jenny learn she had breast cancer. 

Ujevich still fumes over how long it took Jenny to obtain that diagnosis, and over what came next: “She couldn’t get her chemo on time,” Ujevich told Bolts.

Jenny was released in late 2016. She spent Christmas with her family, then died in January.

Ujevich is now free and heading a nonprofit project called West Virginia Family of Convicted People, where she advocates for changes to the state’s prison system, including improvements in health care. She’s nervous that a new state law, passed during a special session last month by West Virginia’s GOP-run legislature and signed by its Republican governor, could lead to more cases like Jenny’s.

Senate Bill 1009 bans the use of state funds for any health care for incarcerated people that isn’t deemed “medically necessary.” The policy leaves it to state Corrections and Rehabilitation Commissioner Billy Marshall—a career law enforcement agent who has said incarcerated people are lying when they allege inhumane treatment by the state—to define “medically necessary” and makes clear that this definition can supersede guidance from health professionals. “A provider of health care prescribing, ordering, recommending, or approving a health care service or product does not, by itself, make that health care service or product medically necessary,” the law reads.

West Virginia already routinely fails to provide basic, essential care in its jails and prisons, several formerly incarcerated people told Bolts. Kenneth Matthews, who was locked up for more than eight years and has been free since 2020, says he lived this firsthand, as a diabetic person with high blood pressure. 

In prison, he said “I didn’t get insulin, and they didn’t give me medication for my high blood pressure either. They said maybe if I lost some weight and worked out more, my blood pressure and diabetes would correct itself.”

And Zoey Hott, a trans woman who was incarcerated for about 18 months and released August 1, said people needing gender-affirming care feel this struggle acutely. She told Bolts she was promptly taken off hormone therapy when she arrived at jail and then denied this treatment as she was transferred to several different jails. The interruption, she said, caused physical discomfort and profound mental health issues. 

“It took me five months to even be evaluated,” Hott added. “They don’t really look at it as something of significant importance for anybody. I feel like they view it as an elective procedure.”

Stories like these abound, JoAnna Vance, an organizer with the West Virginia Economic Justice Project, told Bolts. “Health care in jails and prisons is not good. ‘Mental health services’ is just throwing people in solitary. We just had another death in one of our jails this morning. I know people who’ve been having seizures in jail and the correctional officers ignore them or tell the other inmates to deal with it. Lord, there’s so much.” 

West Virginia contracts with a private company, Wexford Health, for medical care in its jails, prisons, and juvenile detention centers. All over the country, from Arizona to Illinois to West Virginia, incarcerated people and their advocates have complained for years of medical dangers resulting from government partnerships with Wexford. Most recently, a lawsuit filed in July accused the company of denying thousands of incarcerated West Virginans medication for opioid use disorder. 

In the treatment of addiction and so much else, health care in U.S. carceral facilities is typically abysmal—even as the people locked in those facilities are, on average, much more medically vulnerable than the population at large. The situation grows even more dangerous where care is outsourced to private companies, like Wexford, a broad Reuters analysis found.

But even against this national backdrop, West Virginia stands out: it led the nation in prison deaths per capita in 2020, and, that same year, the Reuters analysis found that its jails had the highest death rate between 2009 and 2019, among dozens of regions around the country that the news agency surveyed.

And so it is alarming to those critical of this deadly system that the state has passed a new law that could soon curtail what little public funding the state currently allocates for health care in jails and prisons. Advocates worry now about what SB 1009 will mean for incarcerated people seeking gender-affirming care, contraception, disability accommodations, or anything else the state might try to argue is not “necessary.”

“I think this has the potential to be extremely abused. I really do,” Ujevich said. In West Virginia jails and prisons, she added, “They just do not give a shit about your medical care. Not one shit.”

It’s hard to know how, exactly, SB 1009 will change the status quo. The enrolled bill is less than 500 words long and leaves many blanks to be filled. Notably, it does not specify any forms of health care that are being provided today that might be eliminated under this policy and leaves broad authority to the state Division of Corrections and Rehabilitation to set new rules moving forward. 

And while the law does require the division head to consult with a “medical professional” before deciding whether a given instance of medical care is indeed “necessary,” it neither defines “medical professional” nor compels the division to accept professionals’ advice.

Delegate David Kelly, the Republican chair of West Virginia’s House Jails and Prisons Committee, told Bolts the point of the bill is to make carceral health care rules uniform across the state system—that is, he said, whether or not someone receives a certain type of medical care while locked up should not depend on their facility. But he was unable to say whether there is a lack of uniformity in the system today, and could not identify any particular procedures or benefits the state funds today that he believes should not be covered in the future.

With few specifics written into the law and such broad powers granted to prison officials, a dozen different lawyers, lawmakers, advocates, and formerly incarcerated people interviewed for this story told Bolts the best they can hope for is that the policy change won’t much affect West Virginia’s standard of care in jails and prisons. But, “worst-case scenario, it will prevent even more medical care for incarcerated people,” said state Delegate Mike Pushkin, a Democrat who voted against SB 1009.

Pushkin and several others said they believe this law could open West Virginia to lawsuits. Recent successful litigation accused Corrections officials of inadequate medical and mental health care, and a new suit filed this month in federal court alleges 10,000 people in the state’s custody live in inhumane conditions.

“The United States constitution sets the minimum floor as to what the state has to provide to people who are incarcerated, and there’s no statute that the West Virginia legislature could pass that would somehow remove that obligation,” said Lydia Milnes, deputy director at Mountain State Justice, which has sued the state over health care for incarcerated people. If SB 1009 leads West Virginia officials to deny even more basic health care in jails and prisons, Milnes said, “There can and will be more litigation.”

SB 1009 could also be a cost-saving measure for a state jail and prison system dealing with critical staffing issues—Commissioner Marshall said over 1,000 positions are vacant in West Virginia jails and prisons, twice as many as before the COVID-19 pandemic—that advocates say contribute to the state’s deadly carceral conditions. But the special legislative session last month resulted in much more discussion of pay raises for jail and prison staff than of ways to ensure safety and wellbeing for incarcerated people.

“I think they’ve barely chiseled away at the edges,” said Pushkin, one of just 11 Democrats in the 100-member state House. “You need safe places for people who are incarcerated. And we don’t have that here in West Virginia.”

Republican Governor Jim Justice called the special session, which began on the same afternoon he announced it. SB 1009 was one of the 44 bills that Justice included on his call, directing the legislature to take it up.

He requested for the session to begin at 4 p.m. on a Sunday, and some state lawmakers told Bolts they didn’t get a peek at the legislation being proposed until about 3:30 p.m. The process left many people directly concerned with or affected by the slew of legislation no time to assess it, much less to testify on it. 

“The lack of transparency during the special session was completely appalling, and it’s not the way democracy is supposed to work,” Pushkin said.

Kelly, the Republican delegate, pushed back, telling Bolts that SB 1009 had been brainstormed for “several months.” If so, that’s news to many people who work closely on and are directly affected by the issue of health care in jails and prisons in West Virginia.

This policy change concerning “medically necessary” care received only one public hearing before it became law, in a 35-minute discussion of the House Judiciary Committee. The Republicans backing the bill made little effort to identify the need for this change, and Brad Douglas, the executive officer of the Division of Corrections and Rehabilitation, offered little information when he testified under oath. 

In a private meeting the day the special session began, the Republican legislative leadership said this reform was needed “because of nose jobs and knee replacements” for incarcerated people, Democratic state Delegate Evan Hansen told Bolts. “They did not present any backup data or evidence.”

Among the few substantive public remarks any elected West Virginia Republican has made on this policy, state Delegate Brandon Steele voiced support during the committee hearing for state funds being used on voluntary sterilization of incarcerated people.

“If one of these individuals wanted to get a vasectomy or hysterectomy or something like that, I think that it’s good public policy to allow them to do that,” Steele said, in a remark that went unchallenged at the hearing. (Steele isn’t the first to advocate along these lines: GOP state Senator Randy Smith recently suggested West Virginia should shorten jail and prison sentences for anyone who agrees to be sterilized, so that those people “don’t bring any more drug babies into the system.”)

At one point in the hearing, Democratic Delegate Joey Garcia, who sits on the Judiciary Committee, pressed Douglas to identify any procedure or medical benefit that the state is funding today, but may not fund under SB 1009.

“So, you don’t have any examples?” Garcia asked.

“I do not,” responded Douglas.

Only when asked directly about West Virginia’s extreme rate of jail and prison deaths did Douglas even acknowledge them. “It would be accurate to say we’ve had inmates die in jails, yes,” he said. When asked if that is a “problem,” Douglas said only, “It’s never good if any inmate passes away.” 

SB 1009 passed the legislature the following day. It passed the Senate unanimously, including with support from Democratic members. The House passed it on a margin of 86 to 9, with eight Democrats and one Republican opposing. 

“The guy was playing dumb,” Hansen said of Douglas. “But that happens with a lot of bills in the legislature in West Virginia, now that the Republicans have a supermajority. They work things out in their caucus ahead of time, and it’s very rare for someone from the majority party to slow things down by asking questions.”

For the previously incarcerated people who spoke to Bolts, SB 1009 has reaffirmed their feeling of abandonment by the state and renewed their outrage with what they perceive to be indifference by state officials to the lives and livelihoods of those locked up in West Virginia. 

“It’s horrible, to say the least,” Matthews said. “I think they’re putting a lot of men and women’s lives at risk over the sake of potentially saving some money. Somebody’s life shouldn’t have a dollar amount attached to it.”

Soon after he was released, Matthews was hospitalized with diabetic ketoacidosis, a life-threatening condition. “My endocrinologist told me I should have been on medication for a long time,” he said. “I asked, ‘What’s a long time?’ and he said at least the last five or 10 years. I said, ‘That’s interesting, because I was incarcerated for most of that time.’”

Matthews said that his own experience underscored for him that whether a particular procedure or treatment is considered elective or necessary can depend on the whims of whomever gets to make the call.

“It would have been very easy for them to get me on medication to control this early, but I guess they didn’t feel that it was ‘medically necessary,’” he said. “A lot of guys’ life expectancy is shortened because of this. I could’ve died in my sleep because they didn’t take my issues seriously.”

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Maurice Monk, who died inside Alameda County’s notorious Santa Rita Jail last year on November 15, was there because he had threatened a bus driver who told him to put his mask on—and because his family could not afford the $2,500 necessary for his bail. He was 45 years old, the father of two teenage children, and the brother of two sisters, Tiffany and Elvira. He suffered from schizophrenia and bipolar disorder, and nine days before his death—because he was in jail—he had missed a shot of antipsychotic medication he’d been receiving regularly for years. 

Elvira was a fierce advocate for Maurice, managing his medication and doctors appointments. When he was sent to Santa Rita, she tried over and over to get his prescription information to the jail, terrified of him missing a dose. There were a series of bureaucratic hoops to jump through: obtaining permission to send the information directly rather than wait for Kaiser to do it; a series of emails that went nowhere. Elvira kept calling. Finally, the jail gave her a fax number. Elvira felt relieved, but shortly thereafter, she heard a knock at the door. When she opened it, sheriff’s deputies were standing there. 

“They told me that my brother was deceased,” Elvira recalled. The deputies had nothing else for her: no paperwork, no proof of his death, nothing about how or why her brother had died. “They just said, ‘Maurice Monk passed away.’” Maurice had died the day before—he had been dead while his sister was scrambling to get him his prescription. “The day that he died, they could have came and told me that day,” Elvira told Bolts. 

Cases like Maurice’s are not an anomaly at Santa Rita Jail. Gregory Ahern’s 15-year tenure as the sheriff-coroner of Alameda County—a populous East Bay county that is home to Oakland and Berkeley—has seen a string of deaths at the lockup, leaving grieving families struggling to accept the loss of their loved ones behind bars. Fifty-eight people have died in custody there since 2014, making Santa Rita the deadliest jail in Northern California. Repeated allegations of neglect for incarcerated people with mental health needs led to a federal class action lawsuit, Babu v. Ahern, that recently ended in a massive settlement requiring officials to overhaul mental health care and suicide prevention at jail. Under the settlement, the Santa Rita Jail will now be under court oversight for at least the next six years. 

Ahern is now seeking a fifth term, and somehow this is the first cycle he has faced challengers: he initially ran unopposed in 2006 and became sheriff by default. Mental health care and solitary confinement at Santa Rita have emerged as key issues of the race given years of deaths and legal challenges tied to lax treatment at the jail. Both of Ahern’s opponents as well as many organizers in the community blame the sheriff, who has presided over the lockup for years, for the deaths and dangerous conditions that have occurred on his watch. 

Yesenia Sanchez, one of the candidates running against Ahern, became the division commander in charge of Santa Rita Jail just after the pandemic started. She is now in the tricky position of both criticizing the status quo and defending her own record at a time when local activists say conditions have not improved at the lockup. 

The other candidate in the race is San Francisco Police Department veteran JoAnn Walker, who has focused on preventing jail deaths, reducing solitary confinement, and improving mental health care for incarcerated people as core campaign issues.

The three candidates will share one ballot in a nonpartisan June 7 primary, and if no one receives more than 50 percent of the vote, the top two contenders will face off in November. 

Whoever wins will be responsible for implementing the consent decree, which has been heralded as a liberal victory by the San Francisco law firm that litigated it, but bitterly opposed by much of Oakland’s activist community, as well as a number of people currently incarcerated at Santa Rita. Critics of the settlement say it only gives more money and power to the sheriff’s department. The problems with Santa Rita, they say, run too deep to be fixed by more funding, more staff, or a new sheriff—they can only be adequately addressed by removing the jail from the equation entirely. “The county should be focusing its energy into looking at preventative resources and alternatives to incarceration, so that folks don’t end up in jail to begin with,” said Jose Bernal, the organizing director at the Ella Baker Center for Human Rights. 

A recent investigation of Santa Rita by the U.S. Department of Justice concluded that poor treatment of incarcerated people with mental illness there violated the Constitution and the Americans with Disabilities Act. “Clinicians often provide seriously mentally ill prisoners nothing more than handouts that list coping skills or describe deep breathing techniques that may help reduce stress,” the investigation observes. In 2021, a state audit found that there was inadequate information sharing between mental health providers and Santa Rita jail staff regarding the mental health status and needs of incarcerated people, and that jail staff neglected to screen everyone coming into the jail for mental health issues.

Moreover, in-custody deaths at Santa Rita have cost Alameda County millions of dollars in the form of payouts for the families of the deceased, including the largest wrongful death payout in a civil rights case in California history.

Up for re-election and under increased scrutiny, Ahern recently noted at a candidate forum that his department was using the recent audit as a guide to help reduce the number of people in isolation and overall jail deaths. Why had it taken 15 years, a DOJ investigation, multiple lawsuits, and a federal consent decree to make changes at the jail? Ahern told Bolts he has tried to make reforms in the past but lacked necessary funding from the county’s board of supervisors, which controls the purse strings for the sheriff’s department.  

“We were doing the best that we could,” Ahern said.  

In 2020, Ahern asked for and received a $318 million expansion despite the county’s budget crisis. Activists in the community are highly skeptical that lack of funding is the root of problems at the jail. “It’s a ridiculous statement for him to say that he doesn’t have enough funding when the rest of county services are continuing to suffer because of the bloated budget that the sheriff’s department has,” liz suk, the executive director of Oakland Rising Action, told Bolts. 

suk also criticized Sanchez’s more recent tenure as division commander in charge of the jail. “We have continued to see high rates of COVID infection happening at Santa Rita,” she said, observing that jail deaths have also continued to occur under Sanchez. 

Sanchez, for her part, blamed Ahern for why more hasn’t changed at Santa Rita during her tenure, saying that she had brought up ideas for reforms that seemed to go nowhere, including changes to how the jail manages in-custody deaths and a better on-site presence for Root & Rebound, a community organization that provides post-release support for incarcerated people and currently occupies a trailer in the jail’s parking lot. “You would think that being a division commander, I would have ultimate say on anything that goes on at the jail, but it’s just not the structure,” Sanchez said. “It’s definitely a paramilitary kind of organization.” 

JoAnn Walker has the benefit of being the outsider candidate—at least as much as anyone can be under California’s sheriff candidate requirements, which since 1989 have required a law enforcement background. “I have not heard either of the candidates take responsibility for what is going on at Santa Rita Jail,” Walker told Bolts. “They’ve been in power now for many, many years.” 

Walker, who has a background in telephone crisis counseling and has trained others in de-escalation and crisis support, says unequivocally that “the jail is not the place for anyone who is suffering from a mental illness to heal.” She supports the county board of supervisor’s “Care First Jails Last” resolution, which aims to decouple mental health care from incarceration.   

Walker has received endorsements from some local progressive groups, including Our Revolution. But suk and Bernal both told Bolts that their organizations are staying away from the sheriff’s race. “We’re focused on reducing the overall power and size of the sheriff’s office so that no matter who’s in that office, they don’t have the same reach and power as their predecessor,” Bernal told Bolts.

The first hurdle for a person with mental health needs arriving at Santa Rita is the intake process. Ahern claimed that he has improved how the jail conducts mental health screenings, adding more nursing staff and addressing mental health during the intake process. “In many instances, we have a very positive environment for people that have suffered a mental health crisis,” Ahern said. “In many cases,” he added, “we are providing treatment and care for those individuals that they would not be receiving otherwise.” 

Santa Rita has a ‘behavioral health unit’ where people with mental health needs are sent. There, Ahern said, incarcerated people with mental health needs are provided medication that “they may or may not have been utilizing correctly while they’re out on the street.”   

The sheriff’s characterization ignores the barriers Elvira Monk experienced trying to get her brother’s prescription transferred to Santa Rita last year. “There needs to be a better way for the family to be able to get medical records up there,” she said. Maurice Monk was one of three people who died while being held in the jail’s behavioral health unit within a single month in 2021. 

Walker criticized the current intake process, saying that newcomers to Santa Rita determined to have mental health needs shouldn’t be sent to the behavioral health unit—in fact, they shouldn’t be in jail at all. “If it is a yes for any of the mental health questions that are asked [on the intake form], then that person must be transported to a hospital so their medical needs can be assessed,” she said. When asked if she believed that the behavioral health unit could not adequately meet the needs of people with mental health issues, Walker answered with a question: “Well, does it work? And if it is working, why have we had [58] people who have died since 2014?”

Jose Bernal has personally experienced the toll that incarceration can take on a person’s mind and spirit. “Jail exasperates people’s mental health conditions,” he told me. “It is not and will never be a viable, legitimate place for mental health.” Solitary confinement, in particular, can be a uniquely damaging experience for someone with a history of mental illness—but it is paradoxically often used as a tool to manage incarcerated people experiencing mental health crises.

The Department of Justice investigation found that people with “serious mental illness” are regularly placed in isolation inside the jail, which has led to outcomes such as “prisoners swallowing objects, not eating, smearing or eating feces, banging their heads against the wall, and attempting or completing suicide.” When asked if the jail puts people diagnosed with mental health conditions in isolation, Ahern demurred, saying “based on each individual’s jail classification, we monitor where they can be housed.” He also quibbled over the language used to describe isolation conditions—the jail, Ahern says, doesn’t practice solitary confinement but rather “administrative separation.” Although people in “ad-sep” are confined to their cells for 23 hours a day, that shouldn’t be considered solitary, the sheriff argued, because “there are six pods to a housing unit, and they have access to communicate with everyone in their pod.”

Ahern also called it “inflammatory, if not insulting” to say that jail deaths have been high on his watch.  

Both Ahern and Sanchez told Bolts that they are working to reduce the number of people in solitary conditions and that the current count of people in “administrative separation” has decreased significantly; on April 8, Sanchez said the number was at 57. Walker says that number is still an indication that the jail’s current mental health care services are not working. Walker committed to working towards fully ending the practice of “administrative separation” at Santa Rita. “We have got to bring in our community-based organizations and let them take the lead on dealing with mental health issues because that is their specialty,” she said. 

Elvira Monk says that she continues to deal with problems at Santa Rita jail. She says communication from the sheriff’s department about her brother’s death has been sporadic and incomplete; in late April, more than five months after her brother died, officials sent her a death certificate that labeled his death “natural” and blamed heart disease. “They keep giving me the runaround,” Elvira said. Her experience struggling to find answers, too, is not unique: other families have detailed similarly maddening experiences trying to get more information about what happened to their loved one inside Santa Rita Jail. 

Sanchez said the office should better communicate with family members of people who die in jail as well as the public when tragedies occur. The fact that we don’t give the family of those who lose loved ones incarcerated any information at all—it’s definitely not the way to treat family” she said. “It’s not humane in my eyes.”

In-custody deaths at Santa Rita also highlights the issue that, like many counties in California, the sheriff of Alameda doubles as its coroner—which raises questions about the thoroughness and independence of inquiries into deaths in custody.  “While it’s true that the sheriff isn’t personally conducting the autopsy, the person that is is reporting directly to the sheriff,” said Bernal. “There’s a clear conflict of interest.” State law doesn’t require independent autopsies for people who die in law enforcement custody.

Ahern rejects the idea of separating the coroner’s duties from the sheriff’s department. Walker said she would be open to separating the two if it’s “something that people want,” and Sanchez said she needed to look into the issue more but did support independent autopsies in cases of in-custody deaths. 

Elvira still finds herself struggling to accept her brother’s loss. For a while after Maurice passed, she says she was consumed by trying to find answers for his sudden absence. “It was like: I want to know why. I want to know why. I want to know why.” 

In death as in life, Elvira has continued to act as her brother’s champion, reaching out to other families who’ve lost loved ones at Santa Rita, working to organize a candlelight vigil, and continuing to contact the jail, demanding updates. “It was no reason why he shouldn’t have got that next medication,” she said.

Updated with information from Maurice Monk’s death certificate, which officials provided to his sister the day this story was initially published

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Last week, Massachusetts unveiled how it will determine which patients will have access to ventilators and intensive care beds in the event that these resources become scarce—and, by extension, which patients will not. If the epidemic curve does not flatten enough, the virus may overwhelm hospitals, and the number of patients who require intensive care and mechanical ventilation to survive an infection may outstrip available resources.

The state, where I have been caring for COVID-19 patients at a safety-net public hospital since the pandemic began, rolled out an algorithm intended to make rationing decisions “as objective as possible,” to quote the new state guidelines. The Department of Public Health assures us that this algorithm excludes “factors that have no bearing on the likelihood or magnitude of benefit, including but not limited to race…socioeconomic status, [or] perceived social worth.”

This statement sounds comforting. But beneath its cloak of objectivity, the state’s proposed algorithm relies on measurements shaped by the very factors that the Department of Public Health claims that it excludes. 

If it is implemented in the event of a ventilator shortage, it will consign a disproportionate number of Black, Latinx, and poor Americans to death. 

The same is true of the algorithms other states have outlined. It is already clear that the virus is not an equal-opportunity predator, and Black and Latinx Americans are disproportionately affected. How we choose to ration care may worsen that trend.

Decision-makers have long turned to algorithms to resolve thorny dilemmas in healthcare, education, and criminal justice. Besides diluting responsibility for outcomes, these tools foster the perception of impartiality based on the illusion that they are not subject to the same biases as human beings. This stems in part from their “black box” quality—the relationship between the data that goes into them, the factors shaping that data, and the resulting decisions is opaque. However, such algorithms are only as good as their inputs. If they are fed the trappings of an inherently unjust society, they will return unjust decisions, not just reflecting but also amplifying and systematizing the preexisting disparities.

At least Massachusetts has foregone the most biased type of algorithmic tool, one that explicitly bases decisions on the presence of chronic underlying illnesses.

The Charlson Comorbidity Index, a prominent example, is a key component of Colorado’s new rationing plan. It has already been used to triage ventilators in Italy’s hard-hit Piedmont region. It tallies a patient score based on pre-existing illnesses, including kidney disease, diabetes “with chronic complications,” and HIV/AIDS.

But these are uniformly diseases of disparity. They are a direct consequence of poverty and low access to health care, conditions that in the United States are marred by immense racial and ethnic disparities. Moreoever, Americans of color suffer from worse health outcomes regardless of wealth, the consequence of systematic discrimination and of a history of fraught relationships with the healthcare system.  

Black Americans are 60 percent more likely to be diagnosed with diabetes, 2.8 times as likely to have end-stage kidney disease, and 8.4 times as likely to be diagnosed with HIV than their white counterparts. Latinx Americans are also considerably more likely to be diagnosed with diabetes or chronic kidney disease. 

The likelihood of developing diabetes, for instance, reflects a lack of access to healthy foods. For individuals without insurance and primary care, disproportionately people of color, diabetes often goes undiagnosed until later stages, when treatment is more difficult. Even once they are in the healthcare system, Black and Latinx Americans are routinely offered worse care and less monitoring for their diabetes. Insulin, an essential treatment for some diabetics, has to be refrigerated—not a reliable option for many Americans. People with poor nutrition, healthcare and treatment are thus far more likely to develop the “chronic complications” of diabetes that worsen a patient’s score on the Comorbidity Index. They would fare worse if hospitals use that index to withhold ventilators from some patients. 

Massachusetts, unlike Colorado, is not using scores that directly input chronic conditions. But Massachusetts still uses another algorithm, the Sequential Organ Failure Assessment (SOFA) score, which still brings such measurements in, just more surreptitiously. 

On the surface, the SOFA score may appear more equitable.  It takes into account only the state of organ systems within the body at the moment the triage decision is being made. But even these metrics are likely to favor white patients over patients of color and wealthy patients over their poorer neighbors—it is impossible to divorce the state of one’s body in a moment of crisis from the accumulation of chronic illnesses that result from a lifetime of inequality. 

For instance, the SOFA score considers creatinine level, which measures kidney function. Creatinine is affected by the presence of underlying chronic kidney disease—one of the diseases that Black patients are significantly more likely to suffer from.

The decision to use the SOFA score is based on the notion that the only relevant variable in allocating scarce resources should be a patient’s likelihood of surviving their illness. Even if this were a fair way of making such decisions, there is no satisfactory evidence that differences in SOFA scores between patients accurately predict who is likeliest to survive in the setting of an infection (COVID-19) that remains such a considerable unknown.

In fact, some racially determined factors that feed into SOFA say nothing about a patient’s health at all. Multiple studies have found creatinine to be significantly higher in black Americans than white Americans, even when both have fully functioning kidneys.

The Massachusetts plan and other algorithms like it, then, would not adequately predict who is likely to survive. Instead, they would determine who gets to survive, generating a devastating and racially biased self-fulfilling prophecy. 

If we use these algorithms when faced with patients who have a still-substantial chance of surviving if given equal access to ventilators and ICU beds, we would be making a decision to withhold critical care resources from them for reasons that are tied to their race and class.

The virus has become a crushing reminder of the inequality of our existing healthcare system. But the current state of crisis will not last forever. At the other end of this pandemic, we will remember the irrevocable decisions we have made. We should make them with eyes wide open rather than relying unquestioningly on barely veiled proxies of inequality in deciding who should live and who should die.

Pria Anand is a writer and physician. She cares for patients at Boston University School of Medicine, where she is an assistant professor of neurology.

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