Clayton McCray, 27, stands by the Allegheny County jail in Pittsburgh, Pennsylvania, on June 5. McCray’s lower leg was amputated in 2020 after a wound on his heel became infected while he was incarcerated at the jail, he says. Stephanie Strasburg for Vox America’s 1.7 million incarcerated people have a constitutional right to medical treatment. During the pandemic, many of them say they didn’t get it in time. By Jun 28, 2022, 7:00am EDT Photographs by Stephanie Strasburg This story is part of The Aftermath, a Vox series about the collateral health effects of the Covid-19 pandemic in communities around the US. This series is supported in part by the NIHCM Foundation. When 25-year-old Clayton McCray was sent to jail in September 2019, he had no idea the detention would end up costing him his leg. But that’s what happened, in large part because the pandemic exacerbated his poor medical treatment behind bars. A shooting injury eight years earlier had damaged his spine, initially leaving him paralyzed from the waist down. After surgery and years of physical therapy, he could once again jump, swim, and play basketball. “I fought hard to get to where I was,” he told Vox. But he still had a condition known as “drop foot,” or foot dragging. He needed orthotic insoles, regular treatment to remove dead tissue, and daily wound cleanings; without them, he was vulnerable to developing open wounds, and even bone infections. Clayton McCray worked hard to recover after a shooting injury left him paralyzed from the waist down, enduring surgery and years of physical therapy to be able to move again. When the pandemic hit, McCray was still in Pittsburgh’s Allegheny County jail awaiting a hearing for alleged drug possession. Suddenly, his already-spotty medical care became even sparser. By June 2020, he needed a wheelchair. Sometimes he couldn’t hop or crawl the short distance from his bunk to the toilet and urinated on himself. Meanwhile, the smell from his untreated wound filled the cell. Jail staff did not allow a specialist from the local hospital to examine McCray’s infected foot in person, he has claimed. “They blamed Covid,” McCray said. By September, the infection had progressed so far that his right leg had to be amputated below the knee. Health care in US jails and prisons was generally abysmal before the pandemic, and it appears to have fallen further, even for those who were not among the astronomical number of people sickened or killed by Covid-19 while incarcerated. Basic requests for medical treatment often went unanswered as facilities stopped outside and specialist appointments and attempted to navigate severe staffing shortages, according to our reporting. Even as the initial crisis of the pandemic’s arrival has waned, many behind bars are still suffering the effects of denied or postponed care. These failures have potentially affected a massive number of people. McCray was one of 8.7 million who entered a US jail in 2020, more than half a million of whom were incarcerated at any given time (and more than 80 percent were, like McCray, simply awaiting their day in court). Another 1.2 million were in state and federal prisons. Put another way, more than 1 in every 150 adults in the US was behind bars on any given day, by far the highest rate of any country in the world. The alleged medical neglect also adds to stark racial health disparities in the US. People of color, particularly Black people, are much more likely to be arrested and have been up to seven times more likely to be incarcerated than their white counterparts. As of 2018, approximately one in every 44 Black men in the US was locked up. The Allegheny County jail rises on the banks of the Monongahela River in Pittsburgh, Pennsylvania, on June 5. Clayton McCray is suing the jail’s medical officials, alleging that jail health care staff failed to provide standard medical care. Data about medical care in carceral facilities is nearly impossible to come by. But two dozen people incarcerated in more than 15 facilities across 10 states during the pandemic have told Vox about frequent cancellations of appointments, months-long delays, denials of specialty treatment, lack of post-surgery follow-ups, and going months without daily medications. Over the course of three months of reporting, their stories have been backed up by documents, lawyers, and loved ones. As a result of this lack of care, some lost limbs, others lost their mobility, and all we spoke with lost their pre-pandemic level of health. When people are put behind bars, whether they are awaiting trial like McCray was or are serving a sentence, the loss of liberty itself is supposed to be the point, not going without basic health care. But this happens daily in jails and prisons nationwide. And the pandemic has made it far worse. Care, postponed Medical care behind bars is complex, with on-site nurses and physicians charged with addressing a vast range of issues, from checkups to substance use treatment to end-of-life care, often in overwhelming circumstances. Some jails and state prisons contract with private corporations to provide medical care, while others, in part, administer their own or rely on public or nonprofit providers. A few, such as New York City’s jail system, partner with the local health system. Oversight is extremely rare, and people in custody generally cannot change doctors or even seek a second opinion. And this is a particularly vulnerable population. Incarcerated people are more likely to have serious chronic health conditions than their outside counterparts; one study suggested they tend to have health needs similar to people 10 or 15 years older. Believe it or not, incarcerated people are the only US residents with a constitutional right to health care. In 1976, the US Supreme Court ruled that “deliberate indifference to serious medical needs of prisoners” violated the Eighth Amendment prohibition against cruel and unusual punishment. “Health care is constitutionally mandated, but it doesn’t mean it’s any good,” said Lauren Brinkley-Rubinstein, a health equity scholar at the University of North Carolina School of Medicine and co-founder of the Covid Prison Project. Arizona’s prison system has been sued for reportedly providing inadequate care. And a 2001 class-action lawsuit asserted that the California prison system’s medical and mental health care was horrific enough to be unconstitutional. The pandemic erected even more barriers between incarcerated people and medical access. Our reporting found that jail and prison officials frequently denied outside appointments and prohibited outside providers from entering, while in-house doctors and nurses prioritized Covid-19 over other concerns. Medical workers were in critically short supply as people called in sick — or quit and were not replaced. A dire shortage of correctional officers also impeded care. Officers are needed to escort people to appointments and call in medical emergencies. Homer Venters, a court-appointed federal monitor overseeing health care behind bars, told Vox this spring that he routinely visits correctional facilities now where half of the correctional officer positions are still unfilled. California prison officials have admitted that the pandemic has caused a significant backlog of essential visits, with more than 10,000 overdue specialty appointments, approximately 6,000 overdue primary care appointments, and near