Inside the Prison Where California’s Coronavirus Outbreak Exploded

Donald O’Brien was excited when he got the news that his transfer had been cleared — as excited as any incarcerated person can be about staying in prison, he might clarify. Late last year he learned that he’d be moving from a maximum security facility near the U.S.-Mexico border to the California Institution for Men, a primarily minimum security prison about 40 miles east of Los Angeles. He hoped it would be his last stop before freedom.

O’Brien, 56, had just been denied parole, and he hoped the transfer to less secure housing would look good when he goes before the board again. But more than that, he just needed to pass the time. Having spent all but a couple years of his adult life imprisoned, he knew that a change of scenery would make a difference. And while Chino looks nothing like coastal Santa Monica, where he grew up, something in the air made it feel more like home.

O’Brien and I began writing letters to each other five years ago and have kept in touch ever since. I didn’t contact him as a journalist; we were both just looking for pen pals. At that time, O’Brien was 12 years into a sentence he’d received under California’s controversial “three strikes” law, following a burglary conviction. Had he been sentenced for that offense alone, he’d have been on his way home by then. But because it was his third felony, California law dictated that he spend at least 25 years behind bars, and possibly the rest of his life. So even then, he was looking to pass the time.

Last year, California’s piecemeal criminal justice reform measures started to give nonviolent offenders like O’Brien a much earlier shot at parole. I wrote him a letter of support for his hearing. While we were both disappointed by the denial, the move to CIM felt like a good omen.

“This place is like a park,” he wrote to me after arriving in March, “a lot of trees and over 30 cats running around.” For the first time in decades, O’Brien could see the outside world in motion when he gazed through the prison fence, watching traffic roll by on Chino’s Central Avenue. He marveled at makes and models that didn’t even exist the last time he’d seen cars on the road. What had happened, he wondered, to all the Camaros?

There was only one downside to CIM: sleeping in a large open hall with over 100 other men. “Really no privacy at all,” he wrote to me. “That is the only downfall.”

The sense of wonder and freedom was soon eclipsed by dread. Two days before O’Brien dated his letter to me, two CIM staff members had tested positive for Covid-19. There were few precautionary measures being taken inside the facility at the time, and nobody bothered to tell the inmates that the novel coronavirus had already breached the prison’s walls, according to O’Brien. But, as an avid reader of the news, he already knew what was coming. “It won’t be long before we are quarantined,” he wrote to me.

By the time O’Brien’s dorm was put under a quarantine in late April, CIM was undergoing a full-blown outbreak. One incarcerated person had died, and more than two-thirds of the 87 people held there who had received tests so far had tested positive. Now, according to a New York Times database, more than 1,200 cases have been connected to the facility, which had a population of about 3,500 at the beginning of the outbreak. Nineteen people incarcerated there have died. That death toll is higher than that of any other California facility besides San Quentin State Prison — and San Quentin’s outbreak was imported from CIM.

CIM was patient zero for the pandemic in California’s prisons. The facility was at 120 percent of its official capacity when its outbreak began, and about 200 particularly vulnerable inmates were transferred to other institutions in late May. But because they were only tested weeks before the transfer, they brought the virus with them. As a result, San Quentin went from being virtually virus-free to having more than a third of its population test positive. Twenty-five people incarcerated there have since died.

“I think they’re trying to ride this out. Whoever doesn’t make it doesn’t make it.”

CIM’s response to its own ballooning Covid-19 count has primarily entailed limiting inmate movement, ending outside visitation, placing infected dorms under quarantine, and isolating some of the sickest people, as well as those who test positive. But these measures have failed to contain the virus. This failure is due largely to the institution’s fundamental design: Most of the facility’s inmates live in large, open dormitories that typically hold 140-200 people in bunk beds separated by only a few feet. Just a handful of centralized sinks, showers, and toilets are shared between them. By the prison’s own accounting, CIM was overcrowded for much of the pandemic. It wasn’t until June, after the ill-fated transfers to San Quentin, that the facility’s official capacity dipped below 100 percent. Even now, consistently maintaining 6 feet between the dorms’ occupied bunks is impossible.

Internal policy has played a role too. Though inmates are forbidden from leaving quarantined dorms, CIM has elected to transfer coronavirus-positive people who have recovered from their symptoms into both quarantined and “clean” dorms. Because inmates are not typically retested after once testing positive, these frequent transfers have the potential to introduce or reintroduce the virus into new dorms. Furthermore, the non-profit Prison Law Office discovered that in one dorm elderly inmates with disabilities and severe preexisting medical conditions have been housed alongside people with active Covid-19 infections, ostensibly because there was no other accessible housing available. Incarcerated people who spoke with me and other news outlets have also faulted the facility’s failure to implement universal mask-wearing until at least the end of April, as well as its reliance on twice-daily temperature checks to identify new positive cases, in lieu of comprehensive testing.

In response to a detailed list of questions, a spokesperson for the California Department of Corrections and Rehabilitation, or CDCR, insisted that the department has been “strongly committed to responding to this public health emergency and to protecting both staff and the incarcerated population.” Among other measures, the response cited CIM’s construction of temporary housing to relieve overcrowding and increase treatment space for positive cases, its use of town hall meetings and posters to “educate” CIM’s population about Covid-19, its provision of personal sanitation supplies, and the regular screening of each housing unit by nursing staff.

But CDCR’s confidence in the thoroughness of CIM’s response does not appear to be shared by prisoners who still have to spend every day and night in a single open hall with 100 other people. When they hear announcements reminding them to engage in social distancing, while sitting on bunks 3 or 4 feet apart from each other, they can’t help but question the commitment of prison officials.

“I think they’re trying to ride this out,” O’Brien told me in July. “Whoever doesn’t make it doesn’t make it.”

As an older man with preexisting medical conditions that make him acutely vulnerable to the virus, O’Brien is typical of CIM’s population — half of the people held there at the onset of the outbreak were 50 or older, and the same portion were considered medically high-risk. It could be argued that O’Brien’s vulnerability was actually caused by his tenure in California prisons: Within one month of arriving at Pleasant Valley State Prison in November 2005, O’Brien was diagnosed with valley fever, an airborne infection caused by fungal spores found in soil. While valley fever is not unusual in the inland part of central California where Pleasant Valley is located, infection rates within the prison at this time were 400 times higher than they were in the community next door, according to a 2015 investigation by Mother Jones. O’Brien says he and others were exposed due to a major state construction project adjacent to the prison, a claim echoed by prison officials at the time. Regardless of its cause, O’Brien survived his infection and the bout of pneumonia that accompanied it, but it left him with chronic obstructive pulmonary disease and permanent scarring on his left lung.

Nearly 15 years later, O’Brien stared down another pandemic at CIM. Though the first two cases at the facility were staffers, the virus soon spread. The first positive inmate was identified on April 4, along with 11 more staff. By the end of the month, the virus had arrived in O’Brien’s dorm. One man, gasping for breath, was isolated, and the entire dorm was placed under quarantine. Guards told the inmates that “one of their visitors” had infected the dorm, according to O’Brien, even though outside visitation hadn’t been permitted in well over a month and the first positive cases at the facility were staff members.

As a result of quarantine, the dorm’s residents lost much of the relative freedom that their reduced custody status entailed. With no visitors allowed, they are reliant on exorbitantly expensive phone calls for contact with friends and family. They can no longer access their jobs, religious services, self-help groups, the dining hall, and recreation in the large yard with its basketball courts, baseball field, and track. Instead, if they want to get outside, dozens of men now share three tables, two benches, a handful of pull-up bars, and not much else in the dorm’s enclosed 1,650-square-foot yard. O’Brien walks as much as he can in the limited space, and alternates sitting between sun and shade. Given the 100-degree heat that’s come with summer, he feels lucky that his yard actually has a few trees.

The irony of being asked to engage in social distancing while being trapped in such close quarters was not lost on O’Brien or any of the nearly 100 other men who sleep in the same large hall. When meals are delivered, they have no choice but to eat them on their beds. The food now is often uncooked, or cold by the time it reaches the dorm, O’Brien said. (After first hearing this, I bought him a package of food items he can prepare himself while quarantined.)

“We’re still sleeping 3 feet apart from each other, but they’re encouraging social distancing,” James Menefield, who was housed in O’Brien’s dorm until this month, told me by phone. “It doesn’t make any sense.”

Though CDCR claims that all CIM staff and inmates were provided with masks on April 7, Menefield and O’Brien don’t recall receiving theirs until weeks later. For at least the first two weeks in April, according to Menefield, inmates who donned DIY masks for their own safety were sometimes threatened with discipline by guards — despite the fact that the Centers for Disease Control and Prevention officially recommended universal mask-wearing at the beginning of the month.

Darrell Harris, a trained respiratory therapist incarcerated at CIM, had been telling other inmates to wear masks even before it became government policy. But, according to an account he gave the health news website Stat, a corrections officer confiscated his mask on April 1. (Face coverings are usually prohibited in prisons.) Harris appealed the disciplinary action, ultimately requesting that a judge order the facility to return his mask, require CIM corrections officers to wear masks and gloves, and provide cleaning supplies to inmates.

According to Stat, CIM adopted most of Harris’s requests as its best practices by the end of the month. However, while the CDCR spokesperson told me that CIM provides “ongoing distributions” of personal cleaning supplies (including “hospital-grade disinfectant”), Menefield and O’Brien said that they have received no such supplies, except for 8-ounce bottles of hand sanitizer and bars of soap.

The three masks provided to each incarcerated person at CIM are made from the pants legs of the orange jumpsuits inmates wear during transfers, according to O’Brien. The CDCR spokesperson would neither confirm nor deny this, noting only that the masks are “made of two layers of 100 percent cotton twill.”

While the prison dithered over the measures it would take to contain the virus in April, cases continued to rise sharply.

While the prison dithered over the measures it would take to contain the virus in April, cases continued to rise sharply. The first person incarcerated at CIM to die of the virus passed away on April 19. Still, prison staff did not regularly wear masks through early May, despite the new guidelines, according to inmates interviewed by Stat. Menefield corroborated this account.

“For a month and a half, staff were wearing masks in a discretionary manner,” he said, adding that only about a quarter of staff he observed at any given time during this period were following the guidance. (In response to questions about staff compliance, the CDCR spokesperson pointed to an April 15 memo “requiring the use of face coverings with notification that non-compliance would result in progressive discipline.”)

O’Brien, on the other hand, wore his mask religiously from the moment he received it. “I am not taking any chances,” he wrote to me the day after CIM’s first Covid-19 death. “I sleep wearing one.”

O’Brien estimates that 98 percent of inmates wear their masks regularly, and he says compliance among staff is now widespread as well (though he added that it sometimes takes the presence of their superiors to motivate some staff to comply.) Still, he pointed out, inmates can’t really wear their masks while they shower — which they do eight men at a time, with 2 feet between stalls. The reality of 100 men all eating meals on their beds poses additional challenges for containing the airborne virus.

In late April, 25 elderly and high-risk inmates were transferred out of O’Brien’s dorm and into individual single-bed cells in another building. The move was, in part, meant to finally enable social distancing in the dorm. But though the move got the dorm’s population to just under 100, it wasn’t nearly enough to create 6 feet of space between each occupied bunk.

“For every four bunks, there’s an empty bunk,” Menefield told me, “but in between those four bunks that are occupied, there’s only 3 feet of living space.”

The first comprehensive testing of people incarcerated at CIM was conducted on May 6, more than a month after the first positive case. Of the eight dorms clustered together on O’Brien’s yard, six came back with at least one positive. One of the two that did not was O’Brien’s.

The relief was short-lived. Within two weeks of the test, people who had been living in dorms with positive cases were being transferred into the two dorms that were considered clean — including people who had tested positive and subsequently been isolated for two weeks. Because people who tested positive once were not retested, residents of the “clean” dorms worried that the transfers could be introducing the virus into new areas of the prison.

Whether the virus was introduced through these transfers or from some other source — like staff, who were not tested by their employer until late May, and were instead asked to seek their own tests and self-report — every dorm at CIM had been infected by the end of May, and new positive cases popped up again in O’Brien’s dorm shortly after the transfers. One of these was his bunkmate. The dorm has never gone two weeks without a positive case. It’s entering its fourth month of quarantine.

The prison administers twice-daily temperature checks, to isolate potential vectors of the virus, but Menefield said that his own experience calls into question their effectiveness. On the evening of June 7, his body temperature clocked in at 101 F. He says he was instructed to return to his bunk, take Tylenol, and return for another check in an hour. By then, his temperature had normalized and he was again cleared to return to his bunk.

That night, however, prison staff shook him awake and told him to report for another temperature check. This time the reading was 103 F. A doctor ordered that Menefield be given a Covid-19 test and transferred to an isolated unit. Four days later, his results came back positive. Menefield thinks the gap between his first reading and his isolation could have put many other residents in danger.

“For seven hours after presenting with a fever, I was allowed to be around other inmates,” he told me. “Every inmate in that immediate area — within 10 bunks of me — has [since] tested positive.”

O’Brien, for his part, has not broken a fever or had any unusual respiratory difficulty since the outbreak began. He did, however, experience extreme fatigue and mild body aches in late June and spent the better part of the week doing little besides sleeping. His temperature checks came back normal, so, in the fog of sickness, he wrote it off as a depressive episode. (O’Brien has a history of bipolar disorder and depression.) He recovered after about five days. Later, when I asked him if he might have had an undetected case of Covid-19, he thought for a second and said, “It could be, I don’t know.” He added that he’d never had an illness that felt the same way. Whatever the experience was, O’Brien endured it in close proximity to dozens of other inmates.

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With only three widespread Covid-19 tests administered since the facility’s first cases appeared in March — the most recent occurred on August 6 — it’s entirely unclear the extent to which asymptomatic or partially symptomatic transmission has gone unchecked at CIM. Another potential blind spot is CIM’s decision not to retest people who have tested positive in the past. Since July, even the temperature checks have largely been limited to inmates who have only ever tested negative, according to O’Brien.

A round of testing in July revealed 13 additional positive cases in his dorm, including his new bunkmate, who had arrived in June to replace the first bunkmate who left after catching the virus. O’Brien says this new bunkmate was exhibiting symptoms for weeks prior to being tested — constantly coughing and sweating profusely — but he was not isolated until his results came back positive. Once the 13 positive cases were moved out, 15 formerly positive people were moved into the dorm to replace them. Another test in early August, too, resulted in seven new positive cases being shuffled out of O’Brien’s dorm.

The result of the facility’s piecemeal and largely unexplained mitigation measures has been the festering of low-level paranoia in the dorms. O’Brien avoids the many inmates who cough and sneeze regularly, and he eyes the formerly positive cases that get moved into his dorm with suspicion. “They’re not completely healed,” he told me. “I don’t know if you’re ever completely healed.”

A California legislator called it “the worst prison health screw-up in state history.”

Suspicion of prison authorities is even more acute. More than once, O’Brien has told me that he thinks the corrections department’s goal is to expose everyone to the virus. Menefield was slightly more circumspect. “Given all of these facts, either staff were grossly incompetent in handling this crisis, or they did this intentionally,” he told me.

CIM’s internal coronavirus policies have received relatively little publicity, but CDCR’s transfer of hundreds of inmates from CIM to other facilities without timely testing in late May was widely condemned after it caused the outbreak at San Quentin. One California legislator called it “the worst prison health screw-up in state history.” As a result, CDCR’s chief medical director was demoted to an advisory role in early July.

O’Brien points to this ousting as acknowledgment that the system is not taking appropriate measures to keep him and thousands of others incarcerated at CIM safe. But it has changed little about the day-to-day operation of the facility. The paranoia caused by the ongoing outbreak has been blunted by the continuing banality of a regimented daily life spent between the crowded dormitory and the spartan yard. The summer heat makes the air in the dorm even more stifling than usual: It’s cooled only by fans, not air conditioning, and the exhaust vent on O’Brien’s side of the building is broken. So when things start to get unbearable just after noon, he puts his head under a faucet and goes out into the yard to sit in the shade of one of the trees. He’s not as hopeful as he was when he first arrived at CIM, but he can still see the cars zooming by on Central Avenue, reminding him of what it might be like to be free — and to be able to finally prioritize his own safety the way he sees fit. He’s learned in prison that nobody else will.