When officials confirmed a case of Legionnaires’ disease at San Quentin State Prison midday on Thursday, Aug. 27, the warden ordered an institution wide lock-down, during which inmates were confined overnight in their cells without running water or access to flushing toilets.
Around 1,400 inmates in North and West Blocks went without drinking water or use of portable toilets until the following morning, at least 14 hours after the initial lock-down. With their toilets unable to flush due to the lack of running water, inmates reported being forced to stay in their cells with the stench of human excrement throughout the night.
North and West Block each house about 700 inmates, who are paired in 6-by-9 foot cells originally designed for one person.
Jamal Lewis, vice chairman of the Men’s Advisory Council, called the first night of the lockdown “the worst night in my 24 years of incarceration.”
Normal prison operations ground to a halt and did not resume until 12 days after the first case was confirmed, as prison officials sought to bring the water shortage, the lack of food and this disease making the national news… that’s when this whole thing got real to me,” spiratory disease under control.
Inmate Harry “ATL” Smith said he witnessed people getting sick in H-Unit, which are dorms that houses about 500 inmates in five buildings. “The lockdown, the water shortage, the lack of food and this disease making the national news… that’s when this whole thing got real to me,” he said. “I immediately had to kick into survival mode to make ends meet.”
All told, approximately 100 inmates who presented symptoms were tested and treated. In addition, at least four members of the prison staff reportedly became ill. At least seven inmates were hospitalized.
The Legionnaires’ outbreak was one of the biggest public health emergencies the California Department of Corrections and Rehabilitation has ever handled, according to Lt. S. Robinson, San Quentin Public Information Officer.
“There have been other emergencies in California prisons such as, norovirus, chicken pox, valley fever and other communicable diseases,” Robinson said. “As with the other outbreaks, there has been a collaborative effort between the California Receiver’s office, CDCR and state and local public health departments to address the issues relevant to the San Quentin situation.”
According to prison officials, the source of the disease was the cooling towers atop the new health care facility building, which was built in 2010 for $136 million.
Legionnaires’ is a bacterial form of pneumonia that poses a significant threat to the elderly and those with weak immune systems, and can be deadly if left untreated. The Legionella bacteria is transmitted through water mist, such as through showers and air-conditioning systems.
Flatbed trucks began hauling two black heavy-duty plastic containers holding 2,000 gallons of water each into the prison by 11:25 p.m. Aug. 27.
Many West Block inmates, however, said they were kept locked in their cells and did not receive water that night.
During the night and the following morning, inmates began screaming and banging in their cells, calling for drinking water and use of portable toilets.
Beginning the morning of Aug. 28, prison officials and inmates filled large containers with water from the 2,000 gallon containers and then transported them to inmates so they could fi ll their own bottles.
The only inmates who received bottled water initially were men on Death Row, the Adjustment Center, Administrative Segregation and some mainline inmates designated as medically necessary, critical workers, such as kitchen workers and support services.
“Associate Warden Kelly Mitchell came into North Block early on the day following the lock-down and addressed the inmates’ lack of access to toilet facilities and water,” said Men’s Advisory Council Chairman (MAC), Sam Johnson.
“She came back to double-check that her orders were being carried out by staff, in which they were not being carried out in full,” Johnson said. “So she again issued corrective orders to get us adequate access to toilet facilities and water. She listens to inmates and follows through with what she says.”
H-Unit inmate Tony Garcia said he went many hours without drinking water. Even after the administration announced the availability of potable water around 11 p.m. that night, “that water was gone in a matter of moments because so many people were thirsty from not drinking water,” Garcia said.
The outbreak also severely compromised inmates’ access to showers and hot meals.
According to lock-down procedures, inmates are entitled to a shower every 72 hours, but some West Block inmates reported going without a shower for fi ve days, despite the presence of portable showers onsite by Sept. 1.
As a precaution against the disease, fi ltered showerheads were installed in North and West Block. Installing filtered shower heads reduced the total number of showers in North and West Block from 46 to 20 for approximately 1,400 inmates. The reduction in shower access further exacerbated a previous restriction, enacted because of the state’s drought that limited inmates to three showers per week. By Sept. 16 all 46 shower heads were re-installed.
The prison’s kitchen staff was prohibited from using water for cooking. North Block inmate J. “Huggie” Davis said the kitchen staff worked alongside inmates to prepare thousands of bagged lunches for the San Quentin population. For the six days following the first confirmed case, all inmates were served PopTarts for breakfast and peanutbutter-and-jelly sandwiches for lunch and dinner.
“It took too long to get water to us,” said North Block inmate Roosevelt “Askari” Johnson. “Two men in a one-man cell without running water is inhumane, and getting sack lunches for seven days is totally unhealthy.”
“They’re killin’ us with peanut-butter-and-jelly sandwiches,” said West Block inmate Charles Reece.
Inmates criticized the prison’s response to the outbreak, noting that there seems to be no emergency response in place. According to published prison regulations, “Each warden must have in effect at all times an Emergency Operations Plan, approved by the Emergency Planning and Management Unit, to assist in the preparations for response to and recovery from ‘All Hazards’ incidents.”
“This institution just passed the American Correctional Association (ACA) inspection, so there should have been standards set,” said MAC Chairman Johnson. “This institution should have been prepared for this type of emergency.”
ACA say its accreditation is only given after a visiting committee endorses an institution that shows compliance with its more than 500 standards, such as conditions of confinement, staff training, policy and procedure, continuity of care and health care needs.
Compliance is proven three ways: review of standard files, interviews with staff and inmates, and touring the facility.
According to the ACA, their purpose is to “promote improvement in the management of correctional agencies through an accreditation program,” and to “offer CDCR the opportunity to evaluate their operations against national standards, remedy deficiencies, and upgrade the quality of correctional programs and services.”
“We believe that we have comprehensive emergency operations in place to deal with any number of emergencies,” Lt. Robinson said. “These procedures were in place well before the ACA inspection and accreditation; and so we were already prepared whether it be an earthquake or some other natural disaster, or public health issue. Our protocols have been established with a lot of forethought and planning. And, with this particular issue, although the dynamics were consistently evolving, we stuck to the plan, collaborated with interested parties and ultimately prevented potential casualties with our response. Even Steve Fama from the Prison Law Office who toured the facility indicated that our response was appropriate.”
“This is an old prison and possibly the maintenance isn’t kept up,” said Pete Brooke, a North Block inmate. “There should be a set time where maintenance comes through and does periodic checks and cleaning. For instance, for at least six months there’s been a dead bird in the vent where the correctional officers sit, and there’s a pipe in the shower area that leaked for about a good month before it was fixed.”
In addition to concerns about the prison’s emergency preparedness and response to the outbreak, inmates said that local news coverage of the prison’s response downplayed the troubles.
“[The administration] lied to Channel 5 News (KPIX) about bottled water. Nobody on the mainline had received bottled water,” said West Block inmate Russell Bowden.
Bowden, among others, claimed that prison staff consumed the bottled water that was allegedly set aside for inmates.
North Block inmate John “Yahya” Johnson saw a KRON4 segment on Aug. 29 which reported that inmates had access to hot food. Another news segment purported that the CDCR was trucking in hot food. However, Johnson said he had not received a hot meal until Sept. 4.
“There are too many inconsistencies about information we’re being told concerning the Legionnaires’ disease,” said H-Unit inmate Gerald Marquez.
H-Unit inmate Al Garner said that, after suffering a constant cough since June, he felt particularly vulnerable to the outbreak. “When the Legionnaire’s crisis came about, I felt that I actually had the disease,” Garner said. “So after 20 days of antibiotics, three inhalers, a five-day course of prednisone, two X-rays, the full gamut of lab tests, two days spent at Marin General Hospital, I felt like I was a human experiment. Yet still, after all these procedures, my cough is yet to be diagnosed.”
“This situation has increased my stress level because I am under three months to my release, and I do not want to take this disease home with me,” Garner added.
Sam Johnson said that this incident was the first time disease caused a prolonged lock-down in the 17 years he has lived at San Quentin. The incident most similar to the Legionnaires’ outbreak, he said, was when norovirus hit the prison several years ago and the institution was quarantined.
The outbreak came less than a week after the prison hosted the nation’s largest health fair inside of a state prison. The 12th Annual TRUST/Centerforce Health Fair was conducted in conjunction with the Alameda County Health Department and the Bay Area Black Nurses Association.
This summer, 12 people in the South Bronx died and more than 115 people were hospitalized after contracting Legionnaires’ disease, according to the New York City health department. All the dead were adults with underlying medical conditions. In Illinois, four persons in a veteran’s home died of the disease.