An armed California Department of Corrections and Rehabilitation officer escorts a condemned inmate at San Quentin State Prison's death row.
An armed California Department of Corrections and Rehabilitation officer escorts a condemned inmate at San Quentin State Prison's death row. (Photo by Justin Sullivan/Getty Images. Illustration by Hunter French/VICE News)

'Man Down!': Inside the Deadly COVID-19 Outbreak at San Quentin

How a massive outbreak at California's San Quentin State Prison spread to death row, killing a dozen condemned prisoners.

The frantic cries rang out across the cellblock: “Man down! Man down! Man down!”

At California’s San Quentin State Prison, that’s the call prisoners use to alert staff about a life-or-death emergency. In June and July, with the coronavirus tearing through the prison, it became a grimly familiar chorus. Each incident would trigger alarm bells and corrections officers rushing in to remove critically ill men from their cells.


Nowhere was the outbreak worse than San Quentin’s death row, home to more than 700 condemned men, more than any prison in the United States. Most of San Quentin’s death row is packed into one crumbling old building, where the cells are stacked on top of each other and have bars and wire mesh for doors. With social distancing impossible, the prisoners were stuck breathing each other’s infected air.

The “man down” call for death row prisoner Johnny Avila came in early July. He was 62 and had been on death row since 1995, but it wasn’t yet supposed to be his time. California’s governor indefinitely halted all executions in 2019, citing wrongful convictions, racial disparities, and billions spent on legal costs. Avila maintained his innocence and was fighting his case on appeal. He still had a shot at a new trial or a reduced sentence.

Avila’s family was worried about him. He had a chronic lung condition that put him at high risk for COVID-19, and on the phone he was coughing and wheezing to the point where he could barely speak. His last call home, in early July, left his younger brother Ralph shaken.

“He said guys were running around sick,” Ralph Avila recalled. “I asked what was going on and he said, ‘Nothing. They’re not doing anything. Nothing’s being done. They’re just sitting around waiting for us to get sick. They’re going to let us die in here.’ Those were his last words to me.”


Johnny eventually collapsed on the floor of his cell. Another death row prisoner housed nearby said he was “coughing and couldn’t breathe right.” He was taken to a hospital in San Francisco, where he died on July 26.

Avila was one of 12 death row prisoners who have died from COVID-19 or complications related to the disease, nearly as many people as California has executed in the last 44 years. The broader outbreak at San Quentin has infected over two-thirds of all prisoners — 2,237 men total — and left 26 dead. Nearly 300 employees have also tested positive. The lone staff fatality was Sgt. Gilbert Polanco, a corrections officer nearing retirement after 34 years at San Quentin.

San Quentin’s death row COVID-19 outbreak began after prison officials transferred in sick inmates from a known hotspot. The virus spread like wildfire, fueled by overcrowding, dungeon-like architecture, and policies that discouraged people from being isolated if they became sick. VICE News spoke to four prisoners and two staffers on San Quentin’s death row, as well as the families of Avila and Polanco about what happened. Nearly all agreed: The tragedy at San Quentin was preventable.

“Somebody dropped the ball in that prison,” Ralph Avila said. “They have to be responsible. Somebody has to be accountable for this.”

The virus comes to San Quentin

For three months, San Quentin was spared the worst of the pandemic. A lockdown and screenings that began in March kept the virus outside the gates through late May, when just six staff members and zero prisoners had tested positive for COVID-19. Then came the buses.

With an outbreak raging at another California prison, in Chino, state prison officials sought to relieve overcrowding by shipping out nearly 200 prisoners with a high risk of COVID-19 complications. Of those, 121 were destined for San Quentin.


A spokesperson for the California Department of Corrections and Rehabilitation (CDCR) told VICE News the Chino prisoners were “tested and medically evaluated before and after the transfers.” But according to four whistle-blowing San Quentin doctors who took their grievances public with a Sept. 4 op-ed in the Los Angeles Times, “many of the people transferred had not been tested for several weeks before departure.” Subsequent testing revealed that at least 25 Chino prisoners carried the virus into San Quentin. Within weeks, hundreds were infected.

“Around the first of June, people started dropping out,” said death row prisoner Steven Brown. “Once those buses full of prisoners from Chino hit, it was over. People are still sick. People are still getting sick from it.”

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California's San Quentin State Prison was opened in the mid-1800s. (Photo: Nate Anderson / VICE News)

The CDCR said it took “extraordinary measures” to mitigate the San Quentin outbreak, setting up a 220-bed field hospital and eventually handing out N95 masks to all inmates and staff. But public health experts who toured the prison in mid-June warned that even more drastic measures were necessary to save lives, citing “poor ventilation, extraordinarily close living quarters, and inadequate sanitation,” among other concerns. When local nonprofits offered to perform free testing on prisoners and staff, San Quentin turned them down, a decision CDCR said was justified because the agency was “already in the process of securing vendors with the capability of meeting the robust testing needs for the institution.”


The Chino prisoners were initially placed in a building adjacent to East Block, San Quentin’s main death row unit. The move had been hastily organized against the advice of public health experts, who called for stringent quarantine procedures. Instead, according to the San Quentin doctors, “the new arrivals were placed in cells that had bars rather than solid doors on the fourth and fifth floors of a poorly ventilated housing unit.”

Speaking by phone from death row, prisoner Ronnie Dement said there was only one way for the virus to move between buildings: “Staff — they brought it to us,” he said. “We can't go nowhere.”

The outbreak on death row was compounded, Dement and others said, because initially anyone who showed symptoms or tested positive was sent to the Adjustment Center, a dark and decrepit old cellblock typically used to punish prisoners with solitary confinement. According to the state prison spokesperson, San Quentin follows Centers for Disease Control and Prevention protocols for isolation and quarantine, with placement in isolation determined by medical staff.

But prisoners said the prospect of being sent to the Adjustment Center led some to keep quiet about their symptoms or refuse testing.

“If you weren’t going to the hospital, you were going to the hole,” Dement said. “People didn't want to say nothing. They were getting ill and fighting the virus in their cells without even saying anything because the administration was locking them up.”


Dement was friends with Johnny Avila. The men had known each other growing up in Fresno and arrived on death row within months of each other, though their cases were not related. They were housed in neighboring cells for years. Dement was acquainted with nearly all of the men from death row felled by COVID-19, but he’s still coming to grips with Avila’s death.

“The only thing I could do was hope that he was coming back, and he never came back,” Dement said. “Everybody has their faults, but he was a good-hearted person. And in my belief, he should never even have been here in the first place.”

The path to death row

Johnny Avila’s case, like most on death row, was grisly.

His cousin, according to trial testimony, was a leader of the feared Parkside Bulldogs gang in Fresno, who ordered Johnny and a younger man to kill two young women who’d been raped at a gang party. The bodies were found next to a vineyard irrigation canal on the outskirts of town, each with two bullets to the head. Avila maintained his innocence, but testimony by cooperating witnesses who were at the party sealed his conviction.

Jose Flores, the former Fresno County homicide detective who investigated the case, told VICE News he has “zero doubt” that Avila committed the murders. Flores, now chief of campus police for Fresno’s State Center Community College District, also had no qualms about Avila getting sentenced to death.


“I believe in the death penalty,” Flores said. “I believe it’s justice for victims, especially when they die a horrific death at the hands of evil people. In this case, it was justified. We have a criminal justice system, we have a legislature, we as a society have agreed we put people to death.”

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An attendee at the funeral of Johnny Avila in Fresno, August 21, 2020. (Photo: Sam Rosenthal / VICE News)

After declining steadily over the years, national support for capital punishment has regained popularity in the Trump era. A 2018 Pew Research Center survey found that 54% of Americans favor the death penalty for people convicted of murder, up from 49% in 2016. President Trump himself is a staunch proponent, even ordering the Justice Department to resume executions of federal death row prisoners amid the pandemic.

California had the chance to abolish the death penalty in 2016, but a majority of voters instead backed a ballot measure to speed up the appeals process so executions would happen faster. Due to legal challenges, the last lethal injection at San Quentin was in 2006 and the state has carried out 13 executions total since the Supreme Court reinstated the death penalty in 1976. Before COVID-19, the leading cause of death on California’s death row was natural causes.

When Gov. Gavin Newsom, a Democrat, put his indefinite halt on executions last year, he noted that five wrongful convictions of condemned prisoners had been identified in the last four decades, and others were likely still undiscovered. “I cannot sign off on executing hundreds and hundreds of human beings, knowing among them are people who are innocent,” Newsom said.


Avila’s attorney, public defender Harry Simon, said even if Avila was guilty, he had an intellectual disability that should have disqualified him from getting the death penalty, along with other appellate claims. But Simon also said the case against his client was thin.

“There was no physical evidence tying Mr. Avila to the crime,” Simon said. “The people who testified against him had real strong incentives to testify in a way the prosecution liked.”

Avila’s brother Ralph and other family members insist Johnny was innocent, saying the man they knew was not capable of such violence. They remember him as a gentle jokester who loved dancing, playing pool, and backyard cookouts. Ralph always figured he’d be exonerated. His brother had been sentenced to death, but Ralph was not prepared to lose him.

“That's the part that hurts the most,” Ralph said. “It probably could have been avoided. They could've avoided death in that prison. They could have protected them guys a little bit more.”

‘Dead man walking!’

Ralph Avila knew exactly what conditions were like for his brother at San Quentin because he’d experienced it himself. Avila, now 57, did just over a year in the prison starting in 1986, mostly housed in East Block, during a period when death row was relegated to just the top floor.

San Quentin is California’s oldest prison, dating back to the mid-1800s, and Ralph described feeling like he was in the decrepit old lockup from The Shawshank Redemption, with paint chipping away on the walls revealing names carved by prisoners through the years. His 4-by-10- foot cell was so small he could spread his arms and touch both walls.


With death row on the floors above him, Ralph constantly heard the calls of “Dead man walking!” that corrections officers would shout to each other when a condemned man was removed from his cell. Years later, after Ralph was free and living a happy life with his family in Fresno, he was haunted by the thought of his brother being called a “dead man walking.”

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Death row prisoner Johnny Avila in an undated photo from his family.

Today death row is segregated from the general population at San Quentin. Regular prisoners are told to avert their gaze if they come in contact with someone from death row being moved. While uniformly violent offenders, many death row prisoners are senior citizens. The average age is 56, a major reason why the population was especially vulnerable to COVID-19.

Michael Bien, a San Francisco attorney whose firm is litigating several health issues on behalf of California prisoners, told VICE News that security precautions on death row have made on-site care more difficult during the pandemic, sometimes to the point of absurdity.

“Something ironic is that death row prisoners can’t be treated at the field hospital because they’re deemed too dangerous,” Bien said. “You know where they're treated instead? In the community. They take them to an outside hospital.”

Bien said about a third of the death row inmates at San Quentin have been diagnosed with some type of mental illness, and the rate of serious cases is higher than the rest of the prison population. That too has presented unique challenges to the prison medical staff. COVID-19 testing is voluntary for prisoners — one source said mandatory testing would have required forcible “cell extractions,” which was decided to be too risky and inhumane — and some on death row have declined. Fear of solitary confinement is one factor, Bien said, but years of harsh confinement has also made death row prisoners deeply suspicious of prison staff.


One death row prisoner said it felt like a biblical plague had come through the cellblock because staff were marking doors with strips of red tape as a way to keep track of who had tested positive. All four who agreed to interviews were outraged by the decision to transfer sick prisoners from Chino, with some wondering if it was done intentionally.

“Somebody had to have known that at least one or two of those guys were positive,” said James Anderson, a death row prisoner since 1979. “That's the general thought around here, that at least somebody in the administration had to have known.”

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Members of Johnny Avila's family grieve over his remains during a funeral mass in Fresno. (Photo: Nate Anderson / VICE News)

Even the whistle-blowing doctors from San Quentin disputed that notion, saying the move from Chino was intended to take vulnerable men at that prison out of harm’s way. The CDCR spokesperson said the move was “part of measures to deal with COVID-19 and protect vulnerable populations at prisons with known infections.”

San Quentin’s workers have not been spared the fallout from the Chino transfer, with more than 75 still sick with COVID-19 and unable to work. “Everybody is pretty upset about that,” one death row corrections officer not authorized to speak to the media told VICE News. “There's no need for that to happen. I don’t know or understand why that move was even made.”

Just like the prisoner alarmed by the red tape, the officer compared the outbreak to a biblical plague. “Everyone is going to get it at one point,” he said. “There’s no hiding from it.” He has since returned to work, but he’s not the same. Neither is death row.


“It’s probably affected a lot of people’s mental health,” he said. “It’s not something normal. It affects people in different ways. You’re coming to work and seeing people die left and right.”

Burying the dead

Johnny Avila was laid to rest August 21 in Fresno, at a graveside service attended by dozens of friends and family members. His ashes were entombed inside a small mahogany box hand-built by his brother Ralph. One of Johnny’s dying requests was to be buried in a wooden coffin, and so Ralph, a former carpenter, designed a shoebox-sized casket to hold the urn, lining it with silk and affixing a gold crucifix to the lid.

“It was a hard thing to do,” Ralph said. “But I felt joy when I was making it. I felt good. ’Cause I was doing it for him. I was honoring his request.”

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A small coffin built by Ralph Avila for his brother Johnny's ashes. (Photo: Nate Anderson / VICE News)

One week later, on August 28, the family of Sgt. Gilbert “Bobby” Polanco spread his ashes beneath the Golden Gate Bridge, just a short boat ride away from the prison where he’d worked for more than three decades. Dozens of San Quentin staffers gathered on shore to show support as a flotilla of police boats escorted the Polanco family out to sea for the ceremony.

To those who knew him, the 55-year-old Polanco was “Mr. San Quentin,” a fixture at the prison who was dedicated to his family and community service outside of work. Polanco worked in a unit next to death row, but he was known as a mentor to staffers throughout the prison. Polanco’s son Vincent was on a deployment with the U.S. Army in South Korea when he heard the news about the outbreak. Vincent could tell the situation was intense when he spoke to his family.


“I was scared,” Polanco said. “Just getting the call and hearing my dad talk about what's going on, how they're transporting people to the hospitals and all this stuff… He was very confident on certain things, but from my mom I would get more of the honest truth, and it was just like unsure what's going on and how things are running.”

Polanco, his friends and family said, was terrified of bringing the virus home from the prison to his wife and daughter. Despite his best precautions, they still got infected. While they recovered at home, he was hospitalized and died August 9. Vincent said his father’s death was “a hundred percent” preventable, blaming “higher-ups and their decisions” for sparking the outbreak and not providing proper protective equipment in the early stages.

Across the state, nine California prison workers have died from COVID-19 and over 3,000 have been infected. A union for prison workers filed a grievance against the state in July, alleging that dangerous working conditions caused a “failure to quarantine or isolate inmates with suspected exposure” and “inadequate supplies” of masks and other protective gear.

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Corrections officers watch boats heading toward the Golden Gate Bridge to spread the remains of San Quentin Sgt. Gilbert Polanco. (Photo: Nate Anderson / VICE News)

A spokesperson for the CDCR said the agency took “unprecedented measures” to bring the outbreak at San Quentin under control, noting that the infection count is down to just 11 active cases among prisoners. Staff at the prison, the spokesperson said, are being tested every 14 days and undergoing screenings upon arrival at work. While most of the 289 sick employees have recovered, 76 are still unable to return to work.

Accountability for the COVID-19 disaster at San Quentin has been hard to come by. When CDCR chief Ralph Diaz announced his retirement on August 28, the governor’s office said he had “truly met the moment” during the pandemic. No others have resigned or been fired.

Advocates for prisoners want to see further steps to reduce severe overcrowding, not just at San Quentin but across California. The state has reduced the prison population by over 19,000 during the pandemic by stepping up releases and freezing intake from county jails. But most prisons — including San Quentin — remain over capacity.

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Attendees at a memorial for San Quentin Sgt. Gilbert Polanco in San Jose. Photo by Sam Rosenthal / VICE News.

Given the nature of their crimes, death row inmates will never be among those considered for early release. But advocates say the only way to make San Quentin safe is to spread inmates out, and creating that space requires releasing more non-violent offenders and others with a low risk of recidivism. Despite the sense of urgency, state courts have been slow to act. Statewide, at least 13 prisoners dead from COVID-19 were eligible for parole in 2020 or 2021. Of the 60 total prisoners dead, 87% were deemed “low risk” by the state’s own evaluation tool.

The family of one San Quentin prisoner felled by COVID-19 is pursuing a wrongful death lawsuit against the state in early September, claiming he was kept at the prison despite being eligible for early release after serving time for a minor drug crime.

Johnny Avila’s friend Ronnie Dement and the other prisoners on East Block know they aren’t going anywhere, except maybe an outside hospital if they fall ill. The governor may have paused executions, but the coronavirus turned the whole prison into a death chamber.

“I don't think any of these people should have or had to die,” Dement said. “If they would've done what they were supposed to do in the first place and not brought that stuff to us, or treated us the way they were supposed to treat us, a lot of these people would still be alive.”

Ani Ucar contributed reporting.