How one Wisconsin prison failed to contain a COVID-19 outbreak

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    MADISON, Wisconsin (Wisconsin State Journal) — As COVID-19 cases slowly started to tick up at Kettle Moraine Correctional Institution in early September, inmate Shun Warren was trying his best to stay healthy.

He wore a mask, kept 6 feet away from his fellow inmates, tried not to touch his face and washed his hands as often as possible, he said.

What Warren didn’t expect was on Sept. 4 to be put in the same cell as an inmate who had just been exposed to COVID-19. The inmate’s old cellmate was sent to isolation the night before after testing positive for COVID-19, Warren said.

Four days later, Warren’s new cellmate also tested positive. Six days after that, Warren did too, he said.

“It first began with headaches, then stuffy and runny nose, and it progressively got worse,” Warren said. “My vision became sensitive to light, and my tasting and smelling was off.”

Wisconsin Department of Corrections spokesperson John Beard said it’s not the department’s “policy or practice” to allow coronavirus-exposed cellmates to interact with other prisoners. DOC isolates infected inmates and quarantines those exposed in separate areas “as space allows,” Beard said. When there isn’t enough space, all inmates are quarantined to their cells.

But despite DOC policies, three inmates — Reginald Clytus, Frank Burt and Douglas Stream, who all ended up testing positive for COVID-19 — and three Kettle Moraine staff confirmed cellmates of COVID-19-infected inmates were not separated from other inmates. The two guards and one employee asked not to be identified for fear of possible retaliation, including being fired.

“They moved all the infected to one unit but didn’t take their cellmates, so they in effect left knowingly exposed inmates on the unit with negative cases,” Stream said.

That’s just one example in a series of missteps that allowed cases to skyrocket at Kettle Moraine from just 12 active cases at the start of September to 74 by Sept. 16 to more than 440 by the end of the month. Cases continued to grow in October and totaled more than 870 infections — one of the largest outbreaks in the state prison system.

Active cases have now dropped to zero at Kettle Moraine, but inmates and staff are frustrated with how the outbreak was handled.

According to Warren, the three other inmates, two guards and one staffer: Prisoners interacted indoors when there were dozens of cases, some staff came to work with symptoms despite health screenings, other staffers continued to work after being exposed to the virus, contact tracing stopped, and inmates who transferred from another facility tested positive and likely infected others.

To mitigate spread in the state prisons, DOC gave inmates masks, required staff to wear masks, conducted nearly 80,000 COVID-19 tests for the 20,000 inmates, suspended visitation and work release, locked down prisons with outbreaks, increased cleaning, released more than 2,000 nonviolent inmates early and implemented social distancing wherever possible in crowded facilities.

“We absolutely try everything we can to keep the virus from spreading to our prison population,” Gov. Tony Evers said in a Dec. 1 press call.

But Evers said when many areas of Wisconsin have community spread, the virus gets into the prisons through DOC’s employees. He said Wisconsinites need to do their part to stop the spread outside so prisoners don’t get infected.

So far, 23 inmates have died from COVID-19 while in custody. At least one of those inmates was from Kettle Moraine.

Warren is grateful that wasn’t him. Although he’s 40 and exercises frequently, he has bronchial problems. And while he’s mostly recovered, he still has light sensitivity, foggy vision and headaches. His sense of taste is slowly returning.

“What if my system was not as strong? What if I was not as fortunate?” Warren said. “I could have really been sick and maybe died.”

Said Burt: “They played with our lives.”

Already inside
Despite its large size of about 1,100 inmates, Kettle Moraine seemed to have one of the best setups for preventing a wide-scale COVID-19 outbreak.

The medium-security prison east of Fond du Lac has 12 regular housing units, each separate buildings with about 65 inmates.

Patti Reese, a former DOC employee of 30 years who advocates for correctional officers, said Kettle Moraine’s administrators could have stopped the virus from spreading to multiple buildings. Instead, she said, they created “a catastrophe.”

The virus spread to every housing unit and infected more than three-fourths of the inmate population.

Clytus, Stream, Burt and both guards independently confirmed that the gym, library, school and inmate work areas — all settings where inmates from different housing units mix together indoors — were open through about Sept. 16, when Kettle Moraine had 74 active cases.

Beard said there was “a brief time” when the prison had a few cases, and some inmate programming continued.

“It is important to note, at this time, the outbreak was small enough that the institution could isolate all positive cases in a separate unit,” Beard said, adding that those exposed were also separated.

Inmate movement was shut down shortly, if not immediately, after positive test results came back, internal DOC emails obtained by the Wisconsin State Journal show. Most of the 70 active cases Sept. 16 were concentrated in two housing units, 1 and 11, which were put in quarantine that same day. The rest of the prison was locked down a few days later.

But the problem was inmates were likely spreading the virus to each other before testing positive.

“I think what happens is they get to a prison and find that the virus has been inside the prison for a little while and has managed to infect hundreds of people,” ACLU staff attorney Tim Muth said. “Once it’s inside, there’s very little I think they can do.”

‘Mixing pot’
Warren, for instance, said he and others from Unit 11 — where he was put in the same cell as the exposed cellmate — could “interact with everyone” from the rest of the prison until about Sept. 14. He began experiencing symptoms Sept. 6.

Clytus called the school an indoor “mixing pot.” Inmates from different units sit in classrooms together and “congregate” in the hallways, he said.

In the housing units, all inmates share a single bathroom. Beard said staff limited the number of people who could go in at once.

Both guards said inmates from one unit hid their symptoms from staff because they didn’t want to be quarantined. One guard said inmates he works with began showing symptoms about five days after going to the gym with that unit.

Even if inmate mixing was mitigated, guards and staff were shuffling around to different units and filling in for random positions because of staffing shortages and employees out with COVID-19, all three DOC employees said.

Beard said staff “have to interact with” inmates, but precautions are taken.

“We provide PPE to staff and persons in our care, and emphasize handwashing, face coverings and other safety measures,” Beard said.

How did it get in?
Beard said DOC has not determined how COVID-19 entered Kettle Moraine. But the three staff members, Clytus, Stream and Warren said that in mid-August about 10 inmates were transferred from another prison facility and ended up testing positive shortly afterward.

DOC’s policy is for transfers to be tested, quarantined for 14 days before leaving a prison and quarantined for another 14 days when arriving at a new prison. Beard said Kettle Moraine followed this policy.

Clytus and the staffer said the transfers were “quarantined,” but not in the sense public health officials define that, which is having no contact with anyone.

Multiple staff and inmates worked in the quarantine unit, interacted with the infected inmates and then were allowed to move about the rest of the prison, Clytus and the staffer said.

“Everybody who came in contact with those transfers all tested positive,” one guard said. “From there on out, all the other mistakes and missteps that we did along the way just pretty much, it created the outbreak that we had.”

‘Run down, exhausted’
Inmates and staff both reported seeing guards come to work with symptoms, and guards continued to come into work after being exposed because of staffing shortages.

Kettle Moraine had 53 full-time vacancies in late September, according to DOC data. That’s 16% of the total staff positions unfilled.

Nearly half of Kettle Moraine’s staff have tested positive for COVID-19 over the course of the pandemic. As of Sept. 28, 30 staff were out with COVID-19, Beard said.

Staff who test positive self-quarantine at home, Beard said. If an employee hasn’t tested positive but has both a fever and respiratory symptoms, the employee must stay home until they’ve had no fever for three days and 10 days have passed since symptoms first appeared.

DOC screens employees with a temperature check and health questions before they enter a prison, Beard said.

But the staff member said some employees came into work with coughs, stuffy noses and even loss of taste. A guard said people would say, “I just have allergies,” and not report their symptoms to supervisors. During health screenings, he said people would lie because they didn’t want to lose the work.

Clytus, Warren and Burt also said they saw guards come into work with symptoms of COVID-19, mostly coughs.

The same guard said he himself came into work while questioning whether he was sick after working marathon shifts.

“I don’t know how to word this without sounding terrible, but with how much people have been working, there were days when I came in, and I felt run down, exhausted. I worked 12-hour shifts every day, or 16-hour shifts,” he said. “So you kind of weigh it out. Am I run down and exhausted from all the hours I’m working? Or am I sick?”

All three staff said they continued to work after coming in contact with someone who tested positive for COVID-19 and were not notified by prison leaders. Infected employees sent out mass emails saying they tested positive.

“I know for a fact there were people on my shift that I worked directly with, and who relieved me on other shifts who tested positive,” one guard said. “The only reason I knew was because they told me.”

When asked why contact tracing was not happening, Beard said leadership at Kettle Moraine had initially contacted each staff member about a potential exposure, but when the outbreak grew “all staff were notified to assume potential exposure.”

Hope still
Peggy West, campaign coordinator for EX-incarcerated People Organizing, said DOC should have used Kettle Moraine as a “case model” for what not to do at other prisons. But she’s heard similar stories of improper quarantines and crowded conditions from the thousands of inmates her organization is in contact with. Sixteen other state prisons have had outbreaks with hundreds of cases.

“The same thing that caused outbreaks at Kettle Moraine is still continuing system wide,” West said.

But Beard said DOC is learning and improving. Leadership and health staff in prisons provide feedback that helps other prisons, and DOC is regularly evaluating its COVID-19 response.

Although 10,400 prisoners have now been infected — more than half of all state prisoners — cases are growing at a much slower rate than in previous months, when cases in a single day were often in the hundreds. Daily new cases have not been higher than 200 since Dec. 4, and many recent days had fewer than 30.

“That decline gives us hope that the worst is behind us,” DOC Secretary Kevin Carr said in a statement.

DOC is currently engaged in discussions with the Department of Health Services regarding vaccines and timing, but “no definitive date has been set,” Beard said.

Both Reese and West said DOC needs to take more action. Reese said Evers should activate the National Guard to help staff the prisons so exposed guards don’t have to work.

West said people are dying on the government’s watch, and DOC should release more prisoners, especially those who are vulnerable.

On Oct. 18, a 56-year-old man who was incarcerated at Kettle Moraine died from COVID-19 pneumonia, with diabetes and obesity as contributing factors, the Fond du Lac County Medical Examiner said.

West said that man, and the 22 others who died, have loved ones. She worries for her nephew and husband, who are both incarcerated in Wisconsin.

“My hope is that we can stop worrying,” West said. “I can’t imagine the heartbreak that is associated with finding out that your loved one has passed away, and that they’re never coming home.”

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