Urgent Memo
COVID-19 Outbreak: San Quentin Prison

June 13, 2020
San Quentin California State Prison is experiencing a rapidly evolving COVID-19 outbreak
with profoundly inadequate resources to keep it from developing into a full-blown local
epidemic and health care crisis in the prison and surrounding communities. The
combination of San Quentin’s antiquated facilities and severe overcrowding places the
prison at high risk of significant COVID19-related morbidity and mortality unless the
population is quickly reduced by 50% or more, in addition to adoption of the prevention
measures outlined below. The urgent resources San Quentin requires range from human
capital to environmental risk reduction and rapid testing. Failure to meet these urgent
needs will have dire implications for the health of incarcerated people at San Quentin,
correctional staff and the healthcare capacity of Bay Area hospitals.
 
Background
San Quentin arrives at this tenuous moment with several significant assets including a strong Chief
Medical Executive (Dr. Alison Pachynski) and a Chief Physician and Surgeon (Dr. Shanon Garrigan)
who have spent the past 3.5 months doing everything in their power to prepare for an unavoidable
COVID-19 outbreak. However, these two physicians, even with the enormous assistance they have
received from many other healthcare staff including a strong public health nurse, a notably excellent
partnership with custody leadership (Acting Warden Ronald Broomfield and the recently arrived Chief
Executive Clarence Cryer), and additional staffing from the Regional level, is simply not enough to
meet the needs of San Quentin given its size and complexity. As a result, there are multiple
vulnerabilities that we witnessed at San Quentin which must be urgently addressed to protect the
health and safety of thousands of staff, residents and surrounding community members.
Although this memo outlines the urgent needs of San Quentin Prison, it is our belief that most – if not
all – of these recommendations are important for all California Prisons that are certain to experience
an outbreak if they have not already.
Urgent needs and immediate actions required:
1. Develop a COVID-Outbreak Emergency Response Team: At present, the over-reliance on local
existing medical and correctional leadership to develop an outbreak response plan means that
these leaders are tasked with making multiple acute decisions on a daily basis without enough
people on the ground to operationalize a centralized game plan or long term strategy. This

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responsibility - overwhelming on its own - is then magnified with the additional responsibility of
providing implementation oversight of the ad-hoc plan. Instead, local leadership should have the
support needed to step back and see the whole picture with a team of staff who can implement
and recommend adjustments to the overarching central COVID-19 control strategy as needed on
the local level. There simply do not appear to be sufficient on the ground staff who are not
working from home. This daily management of the acute phase of the outbreak has the
secondary effect of making the lead physicians also less available to coordinate the care and
treatment of patients who become acutely ill in the facility and also increases the vulnerability of
San Quentin to small errors with potentially dire consequences. Minimum positions required for
such a team are included below. Dr. Pachynski and Dr. Garrigan appear to be personally
responsible for all of the tasks described below with insufficient tools to support their success.
While there may be some central guidance and support offered, additional human capital is
urgently needed to achieve the CCHCS’s pandemic response goals.
Minimum Recommended Leadership Team Positions:
• Environment of Care Leader. This position would be responsible for evaluating and

optimizing the physical plant of the prison for ventilation, sanitation, path of patient flow (for
example developing policies and procedures for how infected patients are transferred
through the institution) and planning for how to reconfigure and reimagine needed space for
quarantine, general population or medical isolation units depending on how the number of
affected patients increases or decreases over time. This position would also work with plant
operations to ensure that all air vents are cleaned and well functioning and would organize
the creation of a field hospital(s) or quarantine tents as needed.
• Healthcare – Custody Coordination Leader. This position would focus on partnering with

Custody (and working closely with the Staff Healthcare Liaison Leader, described below) to
review current housing on a daily basis, and to determine the appropriate way to cohort and
house residents including developing quarantine areas (in partnership with the Environment
of Care Leader). This position would also be responsible for ensuring that appropriate
testing is done prior to any transfer of residents to other state facilities or to the community.
• COVID-19 Testing Leader. This position would be responsible for coordinating with the

testing center (at this moment QUEST Diagnostics) including reaching out through public
and private sources and coordinating with the state and local departments of public health
to improve testing turnaround time, running the list with medical staff (and the
Epidemiologist, described below) on a daily basis to determine who has – and who needs –
testing, and coordinating contact tracing in response to testing results and reporting of
symptoms throughout the facility.

• Staff Healthcare Liaison Leader.This position would work with correctional leadership to

cohort staff, develop plans that eradicate staff working at more than one housing facility
throughout the day, train and enforce PPE rules, support contact tracing and administrative
leave needs among exposed and infected staff, and investigate alternatives to potential
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sources of staff-to-staff infections such as shared vanpools. This position would also track
daily staff movements in order to assist with contact tracing when needed.
• Epidemiologist Analyst Leader. This position would be responsible for maintenance of a

line listing of all active cases and for all data analysis and reporting. This position would also
be responsible for a “patient tracking process” of the facility including daily review of the
COVID Monitoring Registry to provide a close scrutiny of who has tested positive or is in
quarantine – where they are currently housed (and were recently housed), and the same for
those who have tested negative. In addition, this position would assist the Environment of
Care leader and the Healthcare – Custody Coordination Leader to manage patient
movement to quickly clear people when they have tested negative and return them to the
General Population in order to free up much-needed quarantine cells. This position would
also manage testing data (e.g., some inmates in the reception area have been tested 3-4
times and test results are coming in at different times).

2. Address Unsafe Overcrowding. Although there are currently 3547 total inmates, approximately
~1400 have at least one COVID risk factor (as do many, unknown, staff members). This means
they are at heightened risk of requiring ICU treatment and/or mortality if infected. We detail the
units of most immediate concern below. Given the unique architecture and age of San Quentin
(built in the late 1800s and early 1900s), there is exceedingly poor ventilation, extraordinary close
quarters esacerbated by overcrowding, and inadequate sanitation, we recommend that the
prison population at San Quentin be reduced to 50% of current capacity (even further
reduction would be more beneficial) via decarceration; this will allow every cell in North and
West blocks to be single-room occupancy and would allow leadership at San Quentin to
prioritize which units to depopulate further including the high-risk reception center and
gymnasium environments. It is important to note that we spoke to a number of incarcerated
people who were over the age of 60 and had a matter of weeks left on their sentences. It is
inconceivable that they are still housed in this dangerous environment. It is a frightening public
health reality that in a matter of days there may be no cells to isolate a potentially infectious
COVID-19 patient; the only way to manage the situation is to significantly reduce the prison
population (and it is too risky to move inmates to other facilities).
Housing units of most concern at San Quentin at present time:
• North Block and West Block are each open-grill, 5-tier buildings with a capacity of 800

persons each. Ventilation is poor - windows have been welded shut and the fan system does
not appear to have been turned on for years; heat on the far side of the building can be
stifling. Over 50% of the residents housed in these units have at least 1 COVID risk factor,
and an alarming ~300 inmates have 4 or more COVID risk factors. An outbreak in North and
West blocks could easily flood – and overwhelm – San Quentin as well as Bay Area hospitals.
(For example, see San Francisco hospital capacity:
https://data.sfgov.org/stories/s/Hospital-Capacity/qtdt-yqr2/)

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• Reception center which currently houses ~500 persons. In the reception Center’s “Badger

Unit” where people from CIM were transferred, the fear and outrage are palpable – people
are yelling throughout the housing unit due to discontent about the COVID-19 situation
including intake of inmates from CIM and loss of privileges (thereby increasing the risk of
COVID-19 spread throughout the tiers via respiratory droplets). It is hard to imagine that
violent incidents will not erupt at some point soon further threatening the safety and health
of residents and staff alike.

• The Gymnasium, which has been converted to a dorm. There is little to no ventilation in the

housing unit creating high-risk for a catastrophic super spreader event. At a minimum, the
gymnasium beds should be spread out more to ensure additional distance between
residents and the second set of doors in the gymnasium dorm must be opened to ensure air
turnover which may necessitate a second officer station for security reasons. This unit should
be prioritized for closure if sufficient population reduction can be achieved.

• HVAC - in all units above and in other housing areas there is an immediate need to clean

and turn on all fan and HVAC systems immediately (North Block, Gymnasium, Dorms) in
order to maximize air exchange and ventilation as soon as possible – ideally in the next few
days. Of note, the exhaust pumps and filters appear dirty on visual inspection, and require
clearing and cleaning. Since maximizing ventilation and air exchange decreases COVID-19
transmission, doors and windows should be opened as much as possible (some have been
welded shut - and must be remediated). If opening doors makes it difficult for officers to do
their jobs then we would recommend that officer stations be rearranged or new ones set up
so as to improve air exchange. Note that the important aspect is air exchange, not only the
movement of air within the room. Fans that blow air around may help cool people, but they
don’t decrease rebreathing aerosols unless they filter the air or increase air exchange
(diluting the aerosol).

3. Immediately Improve Testing. It is inconceivable that in the Bay Area the medical leadership at
San Quentin is having to manage an outbreak in their massive antediluvian facilities with PCR
tests on a 5-6 day turn-around time. We would argue that there is no higher testing priority for
around 100 miles and resources need to be shifted immediately to respond or there will be a
massive, uncontrollable outbreak (if it is not too late already). In addition (and this certainly goes
without saying), transfers between all facilities must halt until medical staff are able to certify that
all testing and quarantine procedures can be followed. Our recommendations are as follows:
• Liaise with testing laboratory to streamline testing, including exploring observed selfcollection of samples and alternate anatomic sites of testing (e.g. saliva, nares swabs)
• Improve testing turnaround time at QUEST or go through other laboratories that will be
able to improve turnaround time (5-6 days or more is completely unacceptable). As an
example, CMC was able to respond rapidly to their outbreak with a turnaround testing time
of 24 hours at some points in the outbreak. Large-scale testing with rapid receipt of results is
essential to allow the medical team to minimize community spread. If tests are sent to
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laboratories other than QUEST, support San Quentin in adding these results to the
EMR as the current process of scanning and manual entry is overly laborious.
• The California Department of Public Health should be compelled to prioritize specimens
from San Quentin given the potential for super-spreading in that environment.
• Testing of symptomatic patients must be done with individual testing. Testing of
asymptomatic patients to identify people who are shedding virus can be done with
pools of samples. Without additional information, pools of 10 should be used. This
approach can be used for frequent retesting of people at especially high risk of spreading
the virus (staff and inmates in large housing units — i.e. almost all of San Quentin).
• San Quentin requires on-site testing - including cartridges and well-trained staff to conduct
these (currently they have inadequate staffing to conduct mass swabbing). Sample transport
just adds time. San Quentin will need high volume testing for many months, perhaps
years. They should have testing capacity on-site and available round-the-clock.
• Of note, because testing time is so slow, little to no contact tracing can happen.
Furthermore, patients cannot be appropriately housed based on test results when these
results return 6 days later as a patient may have been exposed in the interim. As a result,
entire units are put on lockdown status for the span of a quarantine. In the long term, as this
pandemic will last at least another year and likely longer, this will threaten long term
goodwill between residents and staff and have profound mental health consequences for
the population and staff alike.
4. Develop Additional Medical Isolation and Quarantine Housing. Those in Quarantine (for

those with a credible exposure to COVID-19 and are asymptomatic) are housed in Carson.
Of note, all who arrived from CIM were housed in the Reception Center’s Badger Unit 4th
and 5th Tiers. This was beyond usual practice due to volume. Those in Medical Isolation
(for those who have tested positive for COVID-19 and suspects with symptoms who are
awaiting testing) have been housed in the Adjustment Center as this is the only unit at
San Quentin that has single cells with solid doors. There are ~102 cells in the Adjustment
Center of this type and already ~80 cells are full. At the advice of the local health
department, 3 of the CIM buses were placed in this isolation unit once a person from the
bus turned positive due to the high-level serious exposure. Therefore, some of these
individuals might end up with negative tests and can then be moved out of Medical
Isolation.
However, a massive outbreak at San Quentin will significantly overwhelm the availability of these
102 Medical Isolation cells, and there will quickly be nowhere for infectious cases to be moved.
For this reason, we believe that there is an urgent need for immediate creation of a field
hospital to relieve the imminent overflow problem in the Medical Isolation unit. In addition,
people with COVID-19 are known to experience rapid physical decompensation; this is therefore
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not an ideal time for a patient to be behind a solid door in the most secure areas of the prison out
of the sight of medical or nursing staff in the case of an emergency.
Some suggestions for additional Quarantine and Medical Isolation space below:
•

Convert nearby chapels (there are 3) into field hospitals. This field hospital can house all
people with confirmed COVID-19 (“Medical Isolation Unit”) as there are not substantial risks
to housing infected patients together and these patients would then have access to
supervising nurses who could regularly check their respiratory status and comfort
levels. The chapels are large, well-ventilated rooms conveniently located near the current
Medical Isolation Unit and with road access for ambulances and other transport. We
recognize the housing plans will become increasingly complex as people of multiple
security levels require housing in Quarantine or Medial Isolation housing. This again
reinforces the need for a dedicated team leader (the Healthcare – Custody Coordination
Leader) who oversees the work of partnering with corrections to identify medically
appropriate housing solutions.

•

Once a field hospital is created, San Quentin will need another site for Quarantine. One
option is to keep Adjustment Center housing for Quarantine. Due to the incredible fear
involved with being moved to the Adjustment Center cells not to mention possible shortand long-term mental health effects, we would strongly recommend that custody
immediately develop additional, positive incentives to improve mental health for the 14-day
quarantine period for those housed in the Adjustment Center for Quarantine, such as
access to personal tablets with movies, increased access to canteen items, personal effects
and a certain number of free phone calls, perhaps on state-owned cell phones. While these
interventions may seem beyond the normal routine of prisons in California, they are simple,
low-cost measures that would go a long way toward building good will and ensuring that
inmates who become symptomatic are willing to come forward to medical treatment with
their symptoms. Furthermore, they may dampen the growing security risk associated with
the aforementioned discontent among inmates. It is also possible that if enough highsecurity level individuals need medical isolation then they would need to use this unit for
them and would require alternate housing options for Quarantine (perhaps the Carson
housing unit which is currently being used for quarantine, although ideally the Carson
housing unit would be only used for quarantine, further necessitating population reduction
to control this epidemic at San Quentin). An mentioned above, in a matter of days/weeks,
there may be no reasonable isolation locations for infectious COVID patients.

5. Improve General Prevention efforts throughout the facility. In particular, we witnessed
suboptimal mask use by staff, and three “medical pass nurses” sitting in a work room without
masks. Moreover, custody work stations are not set up to physically distance, no additional
workstations appear to have been built yet. As a result, even with the best of efforts, officers wind
up clustered near each other around a central podium. An infection control nurse and
environmental assessment would go a long way towards identifying opportunities to partially
alleviate these problems.
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6. Staffing Cohorting is a necessity. At present work shift plans are inadequate from a public health
perspective. For example, we learned about staff who were working in the Medical Isolation Unit
(Adjustment Center) during the shift and were scheduled to work the next shift in the dorms. This
is an enormous risk for the spread of COVID-19 between housing units.
Sandra McCoy, Associate Professor of Epidemiology & Biostatistics, The University of California, Berkeley School
of Public Health
Stefano M. Bertozzi, MD, PhD, Professor of Health Policy & Management and Dean Emeritus, The University of
California, Berkeley School of Public Health
David Sears, MD, Assistant Professor of Internal Medicine, Infectious Diseases,The University of California, San
Francsico
Ada Kwan, PhD Candidate, Division of Health Policy & Management, The University of California, Berkeley School
of Public Health
Catherine Duarte, PhD Candidate, Division of Epidemiology & Biostatistics, The University of California, Berkeley
School of Public Health
Brie Williams, MD, MS, Professor of Medicine, The University of California, San Francsico and Director of Amend at
UCSF
Amend at UCSF is a health-focused correctional culture change program led by experts in medicine,
infectious diseases, public health, and correctional health and policy that is providing correctional leaders,
policymakers, and advocates the evidence-based tools they need to protect the health and dignity of those
who live and work in jails and prisons during the COVID-19 pandemic.
The University of California, Berkeley School of Public Health is working on the leading edge of research,
educating the public, and mobilizing to serve California’s most vulnerable populations during the COVID-19
pandemic.
For more information:
https://amend.us/covid

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