Monkeypox has arrived behind bars, and the coming weeks will dramatically reframe how we think about this outbreak. This virus has already caused tens of thousands of cases across dozens of countries, occurring mostly among men who have sex with other men.

The current epidemiology of the outbreak in the U.S. necessitates resources to educate, vaccinate and treat men who have sex with men, especially Black and other minority men who are often pushed aside during public health crises. But we must act now to address how American mass incarceration will accelerate this health emergency, because many of the grim realities of our system of incarceration will cause a rapid spread of this virus, just as occurred with COVID-19.

In fact, the first reported case of monkeypox, in the Cook County, Ill., Jail, is a setting where the ability of jail infections to propel community transmission around the jail was well-established by researchers.

One crucial feature of monkeypox is that transmission isn’t limited to the mucosal surfaces and body fluids of sexual contact. Physical contact of skin (and potentially respiratory droplet exposure) during these close contacts can also cause transmission. This difference means that we need to anticipate transmission in other settings where these types of close contact occur, including schools, health care facilities and homeless shelters.

But unlike other settings, the nation’s 7,000 jails, prisons and detention centers are sites of common close physical contact that also remain purposefully removed from our community health systems and oversight. In a similar manner, skin infections with the bacterium Staphylococcus aureus have plagued incarcerated people for decades, often with inadequate testing and treatment.

The Centers for Disease Control and Prevention (CDC) should quickly act to provide recommendations to carceral systems to reduce close contact and increase detection and treatment of monkeypox. This requires being more explicit than they were with COVID about the extremely crowded and filthy conditions in facility intake and court pens, where people spend hours to days shoulder to shoulder, laying on the floor or sitting on benches as they wait to be processed into facilities or court appearances.

This close contact is often skin-to-skin and is more than enough to propel the spread of monkeypox. As with COVID, many of the initial cases of monkeypox will come from staff and their movement around every corner of facilities. This, combined with their daily physical contact with detained people, will likely be a feature of how monkeypox spreads.

Accordingly, the CDC should provide training materials for correctional administrators on the precautions staff should take. In addition, the CDC can be specific about the need to eliminate barriers to care, including co-pays. Monkeypox is associated with skin lesions, but people can also have vague viral symptoms while contagious, and my experience in dozens of COVID-19 inspections is that these co-pays represent a potent disincentive to reporting symptoms, as do punitive isolation practices.

The CDC should also be clear that facilities with half or more of their correctional staff positions unfilled, a common problem since COVID, should reduce the number of people who are incarcerated, otherwise the only management tools available will involve more lockdowns, more crowding and increased transmission.

State and local health departments can start their engagement by visiting these facilities and speaking with the people held there. I was initially encouraged by the efforts of the CDC and local health departments to go into facilities at the outset of COVID, but then dismayed when I saw that many visits involved no discussions with incarcerated people and amounted to manicured tours by facility administrators.

These visits should include health department monkeypox experts as well as those who are specifically charged with promoting health equity. The voices and clout of health agencies and professionals remain largely absent from the issue of mass incarceration. Our efforts to blunt the spread of monkeypox in jails and prisons must engage health resources and systems to address this systemic problem.

Dr. Homer Venters is the former chief medical officer of the New York City jail system and author of “Life and Death in Rikers Island.”


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