The COVID-19 outbreak is essentially a reaping of what we’ve sown with mass incarceration, from a public health perspective. In other words, while it’s important that there is so much attention on the issue right now, we should have been paying attention all along.

Myriad public health crises have been developing in prisons for a very long time. In the late 1980s and early 1990s, for example, there was a very serious outbreak of tuberculosis in New York City, which could be traced back to New York’s prison and jail system. In more recent years, we have seen outbreaks of diseases like tuberculosis, MRSA, and HIV in prisons around the country.

It’s also not new for prisoners themselves to call attention to the issue of infectious disease. For example, prisoners in Texas used their own radio stations to bring attention to the serious problem of MRSA. And then, of course, lo and behold, MRSA started showing up in Texas prisons and spreading to the nation’s hospitals, too.

We’ve known about the negative relationship between public health and prisons for some time. Prisons don’t just pose a health risk to those locked inside of them, but also to the general public. This is because most people do, in fact, come home from prison, and they often bring with them highly infectious diseases — whether we’re talking about HIV or tuberculosis or COVID-19.

Rural counties are going to feel this health crisis particularly acutely.

As rural and formerly industrial areas become poorer, many counties are increasingly locking people up for misdemeanor offenses, and also holding defendants forever and a day before they’re tried for more serious offenses. It really is a perfect storm. Those who find themselves arrested and sitting in jail are usually the nation’s most marginalized citizens, and thus they are also the group most compromised in terms of preexisting conditions and general poor health. We know that many of the people in rural jails, if they become sick, are going to need to be placed on a ventilator.

The stark reality is that many rural hospitals have, at best, one ventilator and twenty or thirty beds. For health systems in rural counties, this can create a real crisis. But this could create major problems in big cities, as well. Even Chicago’s Cook County Jail, for example, which has a full medical staff, can’t possibly deal with the spread of infection to its detainees and staff. Neither can Rikers Island in New York City.

In some facilities, prisoners aren’t even getting treatment — for example at Wende Correctional Facility in New York. But what’s even worse is that in Delaware, Nevada, and Hawaii officials are refusing to waive medical co-pays for prisoners seeking treatment for possible COVID-19 symptoms. It’s shocking.

If an incarcerated person in Nevada has any income whatsoever (from working on a prison farm or something like that), their wage is about thirteen cents an hour. Expecting a prisoner to pay a co-pay is the equivalent of expecting someone on the outside to pay between $200 and $500 for a medical visit.

Incarcerated people not only know that this is deeply unjust, but they are also acutely aware of just how dangerous this disease really is for them in particular. They are scared. Also they are utterly alone in this. Due to social-distancing measures taking place on the outside, prisoners’ visitation has (in most cases) been fully shut down. That’s why we are beginning to see protests in prisons in places like Washington and Oregon. (And, by the way, worldwide — in places like Iran and Italy.)

For people on the inside, this is daily business. The entire prison system runs on repression. So, when people try to speak up on their own behalf, the response is brutal. Lockdowns, beatings, the withdrawal of food, putting people in strip cells, shoving people off into solitary confinement — this is how prisons are run.

The COVID-19 crisis is an unusual moment when the public, via the media, is allowed actually to see what the inside of prison looks like and how it operates. It is ugly and inhumane, but not surprising to anyone who has been kept in those facilities or whose loved ones have spent time in them.

Everyone on the outside is terrified of COVID-19. Imagine how terrifying it would be to not only worry about getting sick, but also know that there was no medical care available. That’s terrifying! I think the American public is finally feeling the same terror that folks on the inside experience every time they hear of a new bug or feel themselves falling ill.

Again, we now see some of the repression that happens when incarcerated people stand together to demand health care, but such repression is actually a regular and everyday occurrence. Well before COVID-19 hit, the lack of medical care and level of repression that rained down on people for asking that it be addressed was a reality for people locked up from Alabama to South Carolina to the women’s prison in Ann Arbor, Michigan. This situation was already appalling, and thank goodness people can now get a glimpse of just how awful it is.

Despite high levels of repression, when people on the inside stand together, and especially when they have the support of folks on the outside and the attention of the media, they can indeed cause prison management to bend. The activism around COVID-19 in prisons today reminds me of other moments in American history when protest in institutions of confinement has actually been quite successful.

Activists and reformers today are calling attention to COVID-19 from outside the walls of prisons and jails, but what’s important is that this is happening at the same time that people on the inside are refusing to come out of their cells, or refusing to labor, or refusing to participate in other prison routines until their health and safety concerns are addressed.

This nexus of outside pressure and inside activism has always been really important. There have been widespread letter campaigns to governors and to local sheriffs, and there has been a lot of pressure levied on governors to consider clemency petitions at a faster pace (and in some cases for the first time). But all this has had an impact because folks on the inside are speaking up too. We’re seeing effects even in places that don’t have a particularly liberal reputation — like Kentucky, which is now considering mass clemency petitions.

And, as advocates both inside and outside of jails and prisons succeed in winning emergency releases, people’s ideas about what else is possible start to change. If a governor can, with the sweep of a pen, release a thousand people to their homes, then why were they in jail to begin with?

Indeed, the COVID-19 crisis has not just posed immediate ethical questions and medical questions, but it has raised powerful and deeper, frankly scratching-your-head, questions about why we have a criminal justice system that looks like this in the first place.

As in all moments when there is disruption inside prisons, especially when it’s simultaneous with pressure coming from the outside, there is always the potential for swift and severe backlash. Every time we start to make gains, there are always people who are very discomfited and alarmed by that, and they will push back very severely against that. And, if the economy is also in trouble, things can get ugly quickly.

After the 1971 Attica rebellion, which itself pressured the New York State prison system to enact some critical reforms, not only was there a backlash to those reforms, but it was very much fueled by the fact that the economy really tanked in the early 1970s. People were losing jobs, and soon there were an increasingly number of folks in the streets hungry and desperate. The response was more aggressive policing along with calls for tougher laws and longer prison sentences.

Today, many thousands of people are wondering how they’re going to feed their children or pay their rent, and they have to imagine surviving indefinitely right now with zero income. I think officials are very concerned. So right at the same moment that officials are considering compassionate releases, clemency petitions, and wholesale jail releases, they are, at the same time, growing increasingly concerned about what happens if the city of Detroit or Philadelphia or Chicago goes a few more weeks without food. History shows us that if we start to see social protests in the streets, those officials will once again start clamoring to lock people up and will care little about what happens behind bars.

Prisons really are microcosms of the broader society. There is so much about what is happening today that is eerily reminiscent of our history, both the good and the bad.

In moments when it is clear that certain members of our society are suffering much more than others, there is always the possibility that they will come together to stand up and demand changes. The unequal distribution of suffering in our society was certainly evident to African Americans and Chicanos and numerous groups in the 1950s and early 1960s, just as it is today.

In the 1960s, many certainly did come together to fight for equality and equal justice under the law. But the backlash to those gains — the ground-level response to civil rights protesters, welfare rights protesters, and other people who wanted greater equity in society — was to call them criminals. Once you deem someone a criminal — and suggest you are merely trying to keep the peace and restore order — movements suffer and prisons fill.

Indeed, when the recession hit in the 1970s, backlash was no longer tethered in an obvious way to resistance to civil rights. The police, prosecutors, and politicians suggested that they were merely trying to keep the public safe, responding to a “crime wave.”

I think there is every possibility that something like that can happen again. The economy is even more fragile now in the wake of our disastrous and belated response to COVID-19 than it was in the 1970s. I worry that the repression, the backlash, could be even uglier. And if it is, I have no doubt it will be sold as “good for public safety.”

Again, this is a moment when history is very instructive.

People don’t realize that, on the eve of mass incarceration — before three-strikes laws, before mandatory minimums, before all the repressive legislation that caused the prison rate to skyrocket — we were also in sort of a moment of national criminal justice reform. People were imagining prison populations shrinking, we were moving away from institutionalization to community corrections and community mental health.

Indeed, this was an era of quite remarkably progressive legislation, with effects felt both inside and outside of prisons — Miranda rights, for example, as well as religious freedom for prisoners and rights to medical care on the inside. Reporters were exposing prison brutality — especially in southern institutions — and the public was even moving away from support of the death penalty.

Then, right after Attica, all hell broke loose, for a variety of reasons. In part this had to do with lies told to the public about what had happened there, and in other critical clashes between people and the police at places like Kent State, or Orangeburg, or Wounded Knee. But it also had a lot to do with the onset of severe recession. And then official support of prison reform evaporated. We will see what happens to recent bipartisan calls to humanize today’s prison system in the wake of COVID-19.

I don’t mean to sound alarmist, but these are unstable times. You cannot shut down the US economy for this long, with income inequality at the highest rate it has been since the Gilded Age, without expecting some social unrest. I don’t doubt that people will protest, and they will have every right to do so. But I worry about the repression.