Vangelis Stathopoulos, who is in Greece’s Larissa prison, is one of more than half a million people incarcerated in Europe amid the COVID-19 pandemic. And, like so many others, the prison where he is being held is an ideal breeding ground for viruses: it’s overcrowded, with cramped living arrangements, and often poor hygiene conditions.

“When I got COVID last December, around half of the prisoners in here were sick at the same time,” Stathopoulos says. “We were put into a ward with 60 people, in a space of around 110 square meters (1,200 square feet). It was a roll of the dice whether you were going to be severely or just mildly ill.”

Korydallos prison in Greece

During the pandemic, we have become accustomed to meticulously updated COVID-19 dashboards and kept a close public eye on settings vulnerable to outbreaks, such as care homes. Yet little data has been made public about the spread of the coronavirus in carceral facilities.

Together with 11 newsrooms in the European Data Journalism Network, DW has collected data from 32 countries that show how many cases and deaths were reported in prisons, how vaccinations progressed, and what measures were taken to curb the spread of the virus.

“Many prisons are overcrowded, with no possibility for physical distancing,” says Filipa Alves da Costa, a public health consultant for the World Health Organization’s Health in Prisons Program. “So, when the virus gets carried in, it gets transmitted much more easily.”

Incarcerated people vulnerable

Da Costa says the risk in prisons is similar to that faced by people living in congregate residential facilities such as care homes and shelters.

Many incarcerated people have multiple factors that put them at increased risk of severe COVID-19, including conditions such as HIV and histories of smoking or other drug use. Marginalization, poverty and poor access to health care often take their tolls on such populations even before incarceration, and prison conditions frequently have an exacerbating effect, the WHO has found. “We actually consider people in their 50s as elderly already in prisons, even though in the community they wouldn’t be,” da Costa says.

COVID outbreaks in prisons affect everyone

Outbreaks in prisons affect not only the people who are confined or working there, but also the surrounding communities. “It’s not a totally closed environment,” da Costa says. “People come in and out every day. Not only staff, but also service providers, lawyers, and prisoners themselves. So, if you’re not protecting prisons, you’re not protecting the community.”

In the US, where the coronavirus quickly swept through prisons in 2020, multiple case studies show how outbreaks in prisons spread to surrounding communities. A nationwide comparison found that COVID-19 cases grew more quickly in counties with more incarcerated people, and linked mass incarceration to more than half a million additional COVID-19 cases inside and outside prisons.

The most recent Europe-wide data collection, by the University of Lausanne, reported case numbers in prisons through September 2020. More than a year has passed since, with multiple waves, new variants and a global vaccination campaign.

First responses shut down all activity

A study by researchers in Barcelona shows that most countries locked down prisons hard and fast at the start of the pandemic.

Visits were immediately stopped or severely limited in virtually all countries. In many prisons, sports, recreational activities and work were also suspended and prison leave schemes were put on hold.

“Even our letters were quarantined,” recalls Csaba Vass, who is in prison in Hungary. Countries such as Germany, Belgium and Hungary quarantined new arrivals and prisoners who showed symptoms.

Prison infection rates follow the general population

Data collected for this investigation now show that, at first glance, these measures seem to have helped avoid the worst: Prisons have, overall, not become runaway COVID hot spots. According to the data available, infection rates in prisons in many countries seem to roughly parallel those of the population in general. 

Where infection rates were high in the general population, they also tended to be high in prisons. This is true, for example, in countries such as Slovenia, Estonia and Belgium, where more than one in 10 people have tested positive already.

In countries such as Croatia and Greece, prisoners are infected at a much higher rate than in the general population. But, in many countries, reported cases in prisons remained below the level of the general population, according to the latest available data — even in Hungary and France, countries with notoriously overcrowded prisons.

Even in countries with lower infection rates, individual prisons can still be the sites of serious outbreaks. Just recently, more than 50 people tested positive at Béziers prison in France, which currently confines 638 people to a space built for 389. 

Cases and deaths may be underreported

Official numbers may not always tell the whole story. Most prison administrations don’t collect data systematically, says Adriano Martufi, who researches prison conditions in Europe at Leiden University. “My feeling is that there is certainly a problem of underreporting,” Martufi says.

The Larissa prison in Greece, for example, had reported only 200 cases officially through July 2021. Stathopoulos says he has counted far more. “Just between December 2020 and now, I believe we’ve had more than 500 cases,” he says.

Underreporting might not necessarily be deliberate — it could also be the result of organizational challenges. “Health services in prisons are understaffed, underequipped,” Martufi says. “I’m not even sure whether they have the technical capability to collect and handle such data.”

Low case numbers come at an exorbitant price

Even if infection numbers are taken at face value, the restrictions imposed to curb the spread of the coronavirus often have side effects of their own. “The tragedy that we feared did not happen, but only with enormous sacrifices for the prison population: no more activities; an end to teaching; an end to what little work exists in prison, and so on,” Dominique Simonnot, who heads France’s independent public body for overseeing conditions at places where people are deprived of liberty. “In social terms the price is exorbitant.”

For the past 18 months, many prisons have established lockdown measures that put inmates in especially harsh conditions.

One prison in Malta kept new arrivals in a cell with just a floor mattress and an open floor toilet 23 hours a day for two weeks, in conditions that the European Committee for the Prevention of Torture had already condemned in 2013. 

Quarantine confinements pose serious health risks

The UN’s Nelson Mandela Rules, or Standard Minimum Rules for the Treatment of Prisoners, state that solitary confinement should only be used as a last resort, for as short a time as possible, and never for more than 15 days. But, during the pandemic, isolating prisoners has become a standard measure in many countries.

In Ireland, where incarcerated people 70 and older or with chronic illnesses were automatically placed in solitary confinement between April and June 2020, detainees in such isolation reported feeling depressed and even suicidal.

In some facilities in Germany, pretrial detainees were isolated for 14 days after each court hearing. 

In France, two-week isolation was mandatory after any leave of absence, family visit or outpatient medical treatment, says Dominique Simonnot, the country’s chief prisons inspector. “As a result, some are refusing these trips, with all the risks that this implies for their health.” 

And even people who weren’t under quarantine were often restricted to their cells for large parts of the day and left with very little to do to pass the time.

‘Lifeline’ for prisoners cut as visits stopped

Prohibitions on visitors were also especially difficult for many incarcerated people.

“Visits are an immensely important lifeline for prisoners,” says Catherine Heard, director of the World Prison Research Programme. “It’s hard to overstate just how much of a difference it makes to them, being able to stay in touch with families and loved ones.”

Prisoners have a right to family life, according to the European Court of Human Rights.

In October 2020, people incarcerated at the Rec prison in Albania launched a hunger strike to protest the suspension of visits when the pandemic was declared. They had only been able to contact families by phone since that March.

In Hungary, Vass says, “We had two and a half hours of physical contact twice a month before the pandemic — the lack of that caused very serious mental problems.” The prison eventually set up video-calling options to at least permit virtual visits. “That made it easier,” he says. 

Most countries introduced measures for virtual visits, although low connection speeds and usage restrictions still pose problems. “There’s been a huge leap forward in many prisons across Europe to develop videoconferencing systems,” Martufi says. “That was absolutely unthinkable in many member states before the pandemic. So that was a positive development.” 

Martufi says one possible risk of this is that prisons could attempt to use video calls as a replacement for in-person visits in the long term. “We have indication that some prison administrations said: ‘Well, now you have Skype, you can live with that — there’s no real need for you to be allowed to meet your family or your lawyers anymore,’” Martufi says.

“We don’t know yet how systemic this change is, but the risk is that this might stay with us even after the pandemic is gone.”

Apart from video calls, Catherine Heard does not see much effort being made to mitigate the effects of restrictions. “I cannot off the top of my head think of anything really meaningful that was done,” she says.

“There was a huge missed opportunity, for example, to provide reading material, recorded information or access to online courses. There were a lot of things that could have been done, should have been done, but weren’t done.”

The Netherlands was one of the countries that managed to restart prison activities relatively quickly through measures such as rotational schemes or smaller, fixed groups, Heard says. But most countries didn’t implement such measures.

Structural problems exacerbate situation

As in so many other areas of society, the situation has been exacerbated by structural problems that existed long before the pandemic.

“Some of the most severe and prolonged restrictions were seen in the countries with the worst prison overcrowding,” Heard says. A lack of space makes distancing measures impossible to implement, and alternative measures are hindered by staff shortages. “If there aren’t staff to move people around the prison,” she says, “there is no option but to keep them locked up in their cells for most of the day and night.”

Researchers, NGOs and incarcerated people alike repeatedly mention overcrowding as key to the problem. One in three European countries operate their prisons above official capacity. 

In many individual prisons, the situation is much worse than the country average suggests. “I am in a cell that is intended for five people — now there are eight of us. It is impossible to maintain distance,” a person on hunger strike told a Croatian news outlet at the start of the pandemic in March 2020. “We are unable to see our wives and children, and, God forbid, maybe some of us never see them again. We practically feel like death row inmates, waiting for the coronavirus to break into prison.”

French chief prisons inspector Dominique Simonnot: “Imagine three people crammed 10 hours a day into a 9-square-meter cell, which is only 4.5 square meters with the bunk bed, the table and the toilet area.”

During the first wave, many countries throughout Europe released people in unprecedented numbers in order to ease the pressure on prisons. “It’s what the experts have been telling them to do for years, but it was too politically scary,” Heard says. “I think COVID gave many countries an excuse to quietly reduce their prisoner numbers.”

Heard calculated that the incarcerated population may have been reduced by as much as half a million people globally between March 2020 and June 2021. Countries such as Slovenia, Belgium, France and Italy, all of which had been operating over capacity to begin with, reduced their incarcerated populations by up to 25%, bringing them down to at or below official capacity.

“One lesson countries will have learned is that they’ve reduced their incarceration numbers without the sky falling in,” Heard says. With the pandemic offering a public health reason for reducing prison populations, she says it is vital that countries now sustain the trend.

Prison populations are rising again

But many countries seem to be reversing the progress made since spring 2020. After the initial drop, incarcerated populations are now rising again in about half of the European countries studied — in some cases even surpassing their original levels. 

French and Slovenian prisons, for example, are now back to being overcrowded at the national level, with individual prisons worse off still.

Vaccinations delayed

With these structural problems exacerbating an already complicated situation, a “return to normal” in prisons hinges on the same thing it does for the rest of society: vaccination.

“When it was announced that there would be a vaccine, people became much calmer,” Vass says. “To the best of my knowledge, almost all inmates here took it. I received my first dose in May, the second in June, and, like many, I took the third in September.”

But not everyone has gotten their jab yet. One big reason for the delay is the fact that, even with the high risk to inmates, staff and the general population, most European countries did not include incarcerated people as a priority group in their vaccination plans. Many didn’t mention them at all. 

In Germany, for example, people in communal living arrangements such as elderly care homes were prioritized explicitly, but prisoners were still vaccinated in parallel with the rest of the population.

“There has been consistent indication from independent supranational organizations that prisoners should be prioritized,” Martufi says. “It’s a good example of the absolute discrepancy between the policy indications on the one hand and the reality on the ground.”

Many attribute this to a lack of political will. In some cases, Martufi says, politics even actively hindered early access to vaccination. “In Belgium, prisoners’ being prioritized became a political discussion,” he says, “and, as a result, prisoners just stayed out of the vaccination campaign until the very end.” In Italy on the other end, he says, the decision to give incarcerated people priority access to vaccinations was an administrative decision, made without much public discussion.

This has meant that the start of vaccinations in prisons was significantly delayed, with some countries not distributing a single shot in prisons before June, while others reported starting as early as the end of March.

Facing the second pandemic winter

With vaccination rates in European prisons finally reaching the level of the general population in many countries and with infections low during the summer, incarcerated people caught a breath of fresh air as visits and activities resumed under hygiene requirements.

But, with winter and the next wave arriving in most European countries, the pandemic isn’t over for anyone — and certainly not for people in prisons. “We will not get our old life, our benefits, back soon,” Csaba Vass in Hungary says. In Italy, weekly data show active cases among staff and inmates rising. And Croatia’s Justice Ministry recently confirmed that more than 20% of incarcerated people have by now been infected with the coronavirus — that is roughly 1.5 times the rate of the population in general.

Lessons for the future

Experts say countries need to reduce their prison populations drastically in order to better prepare for such situations in the future. “We cannot face another health crisis with these numbers of people incarcerated throughout Europe,” Martufi says. “That needs to go down.” 

But observers also see reason for optimism. “COVID should have been a wake-up call to invest in better prison conditions and to reduce the use of incarceration,” Catherine Heard says. 

For that wake-up call to be heard, public interest and political will are crucial. “It’s time to rethink our perception of prisoners as second-class citizens,” Martufi says. “We cannot allow anyone to be left behind. It will be worse for everyone.”

The project is a collaboration within the European Data Journalism Network

Project lead: Deutsche Welle

Collaborators: Alternatives Economiques, Civio, El Confidencial, EUrologus, Il Sole24Ore, iMEdD, MIIR, OBC Transeuropa, Openpolis, Pod črto, VoxEurop

This piece was edited by DW’s Milan Gagnon, Gianna-Carina Grün and Peter Hille.

Of the 43 countries analysed for this investigation, 12 do not allow single women to access in vitro fertilisation. Even more countries, 16, also prevent single women from getting assisted insemination. The list of countries that prevent single women from getting a donated egg is even longer.

The situation is worse for female couples: 24 countries ban their access to ART outright. For the LGTBIQ+ community, having children via ART is not an easy path in Europe. “The places where it’s most difficult for LGTBIQ+ people to get a job or to be out or to get married or to undergo legal gender recognition are also the places where it’s most difficult to have access to assisted reproductive technologies,” says Cianan Russell, from ILGA Europe, a federation of European lesbian, gay, bisexual, trans and intersex rights groups. They say Hungary and Poland are the countries where the situation is the worst, but the problem is widespread in Europe. Even where people can obtain reproductive assistance legally on paper, reality sometimes brings “discrimination, harassment or even violence” to the process, Russell says. Those who are suffering the most problems are trans and intersex people, they add.

People facing these forms of discrimination grapple with difficult alternatives. In the case of the LGTBIQ+ collective, says Russell, there are three. The first is misrepresenting one’s identity, such as female couples who lie by saying that just one of them is seeking treatment as a single woman, if that is allowed, or non-binary people or trans men who say they are women. The second alternative is crossing borders to seek access in another country. The third is conceiving with friends or trusted people even if they are not attracted to them.

Although this is not common, it is a path that many people who want to have children may take if the barriers seem otherwise insurmountable. In the case of single women, Izaskun Gamen, spokesperson for the association Single Mothers By Choice (MSPE), says that, during her years-long process to try to have children, some people suggested that she get pregnant by a stranger after a one-night stand and not tell the father. That seems unthinkable to her, she says: “How do you explain that to your child later? How do you explain that he or she was born of a deception?”

Older and older mothers

The only legal barrier for heterosexual couples, in most cases, is age. The women seeking ART are getting older. In the last decade, the average age of mothers at the birth of their first child , whether natural or assisted, has increased in most of Europe. In Spain and Ireland the average age was over 32 years old in 2019.

That’s average, which means that many women access ART later, when, because of their age, conceiving naturally becomes more difficult. Most countries put the legal ceiling for assisted reproduction around 50 years. This is the maximum age in Greece, for example, but in response to COVID-19 pandemic-related treatment delays the government extended the age to 52 years until June 30, 2023.

Juana Crespo, director of an eponymous fertility clinic in Spain specialised in difficult cases, says the main problem for her patients is old age: “We get old and, when our reproductive system becomes old, the whole orchestra is old.” She calls this a “new disease”: “The history of delayed motherhood is unwritten.”

Although women’s ages are a common source of reproductive difficulties, Carlos Calhaz-Jorge, a fertility doctor and researcher at the Universidade de Lisboa in Portugal and president of the European Society of Human Reproduction and Embryology (ESHRE), says that half of the problems of couples who seek ART are from the male partner.

Yet age is not a factor of legal exclusion for men and, in general, there are no limits in European countries. Only three of the 43 countries have maximums: France, 59 years; Finland, 60 years; and Switzerland, 56 years, although in these last two cases they are recommendations, not legal prohibitions. In fact, in Switzerland the recommendation is that the father can be alive until the child turns 18, a more sociological than medical recommendation.

The most common obstacle: lack of financial resources

Once the legal obstacles are overcome, the economic ones rear their heads. According to Calhaz-Jorge, “the problem for most of the population is the lack of public funding. Even in countries where heterosexual couples are allowed to have ART it depends a lot on the public financial support.” Another discrimination, to add to the previous ones, is the economic one: not all countries cover these techniques (six do not cover it at all), and those who do sometimes only pay part of it, or the waiting lists are years-long, in a matter in which every delay works against you.

For example, in Switzerland and Poland, only insemination is funded, not in vitro fertilisation, which is much more expensive. In Greece, the public healthcare system only covers very specific cases, such as people living in faraway islands.

In fact, there are gaping differences between European countries. There are even differences between regions of the same country, such as in the United Kingdom, Italy and Spain. In Spain, for example, single women can access artificial insemination in Navarra, but not in vitro fertilisation, even if they have medical problems that prevent them from becoming pregnant through insemination. Spain’s other regions do permit that. Germany, meanwhile, does not cover in vitro fertilisation for lesbians and single women.

Age limits, already an important legal barrier for those seeking private ART access, are lower for people seeking ART through national health services. Once again, in the case of heterosexual couples, very few countries put a ceiling on the age of men. Portugal sets it at 60 years and Austria, 49. For women there are limits: from 38 in Latvia to 46 in Italy or 48 in Malta, to the most common figure in Europe, 40.

In other countries, publicly funded assisted reproduction has additional barriers, such as not exceeding a certain weight (in Serbia, Romania and some Spanish regions) or not having previous children, as in Denmark, Malta, Portugal, Romania, Spain, Sweden and Turkey.

Another of the most common limits is to cover only a maximum number of attempts. Few countries are clear on insemination, or do not establish limits, although if they do, it is usually six or three cycles. Countries are clearer about in vitro fertilisation: almost all limit the number of funded attempts. Belgium, Slovenia and Italy fund six attempts. 15 other countries fund three attempts. Romania, Moldova, and Kazakhstan fund only one. There, either you get pregnant the first time, or if you want to keep trying you have to pay for it out of pocket.

Irene Cuevas, director of the embryology laboratory of the public General Hospital of Valencia (Spain), says that after a certain number of attempts the probability of success drops a lot. “We have very limited resources and we have to try to optimise them in some way. It is a very logical number,” she argues.

Then there are the copays, which mean that access is not free in practice. The most common are those for medicines, and they are significant. Each round of hormonal treatment for in vitro fertilisation in Spain, for example, can cost more than a thousand euros.

There are also the long waiting lists. Cuevas calls them, “the fundamental problem.” Long waits are also common, for example, in Hungary. At one point Hungary did not permit sperm donors that were not Hungarian. Even after they removed that obstacle, things did not improve, Sandor says. Last summer, Hungary nationalised all fertility clinics. “Everyone knows that this means that they’re going to be five- to 10-years-long waiting lists for those who don’t have any money,” Sándor says.

Calhaz-Jorge says this is not only a problem of rights: “I’d like to have more support in my country, Portugal, because there are too-long waiting lists and as in the rest of Europe. Our fertility is declining. More support could help slow the decline. We have an intention of providing reproductive assistance to up to 5% of all babies born in Portugal. This is realistic but for that we need more money.”

Spain is the country in Europe, together with Greece, in which more children are born thanks to assisted reproduction procedures, reaching 7.9% of the total number of children born in 2017 (last year with comparable data, but in 2019 this number grown to 9,5%). In Italy, the UK, and Portugal, the rate is around 3%.

Faced with all these difficulties, is a common European regulation possible that guarantees equal access for all? Russell, the LGBTIQ+ spokesperson, says that would be difficult. European countries, not the EU, have jurisdiction over this matter, so the only alternative when it comes to defending LGTBIQ+ rights are the courts.

Calhaz-Jorge, chairman of the ESHRE, says: “I’m convinced that it is not possible to have similar rules. If in one country it is not legal to treat single women, which kind of regulation will they have if going abroad? The political views and the cultural sensitivities are very different.” Indeed.