CHINO, Calif. — On a morning in mid-May, Anna "C.J." Rugg, a 38-year-old transgender man who had tested positive for the coronavirus at the California Institution for Women, set his room in the medical isolation unit on fire.

"I made my room an inferno," he told The Washington Post by JPay, the inmate emailing system, and "laid down on the floor and waited for the smoke to get me."

Rugg had serious health issues and had struggled with acceptance since coming out in prison as transgender, but it was the extra stress of covid-19 measures that pushed him over the edge. “This lockdown is too much,” he wrote to Arlene Veronesi, a close friend and former cellmate. “I lost it. Don’t hate me.”

Even before the coronavirus pandemic, incarcerated individuals in California’s 35 state prisons faced poor mental health care. The situation is especially dire for the rapidly increasing number of female prisoners, who make up 4 percent of the state’s incarcerated population but 11 percent of suicides, according to 2016 figures. Seven women committed suicide between 2013 and 2016 at the California Institution for Women, a 1,398-bed prison currently housing close to 1,500 women; in 2018, a woman experiencing a psychotic episode waited hours for care, ripping out and swallowing her own eye before receiving treatment.

Multiple state audits of the prison have found slow response rates in mental health incidents to be a major factor in suicides. A class-action lawsuit filed in 1990, on behalf of all of California’s incarcerated individuals receiving mental health services, is ongoing.

The pandemic has exacerbated the lack of mental health care at CIW. Inmates have refused tests, temperature checks and other measures meant to contain the virus’s spread to avoid being put in isolation, and four women have attempted suicide while in quarantine or isolation for the coronavirus. “Rather than treat[ing] their mental health,” the entire correctional health-care system’s priority has been shifted by the pandemic to “basically just trying to keep people alive,” said Michael Bien, lead counsel in the class-action lawsuit.

When CIW’s first positive coronavirus test came back on April 6, correctional officials quarantined women to their own cells if they might have been exposed. Prison officials put whole housing units into lockdown and moved positive patients into separate medical isolation units.

But a number of inmates say that CIW staff never told them what was happening.

On the same day as the first positive test at CIW, the California Department of Corrections and Rehabilitation (CDCR) issued guidance requiring all staff members to wear face masks. It was “our first time seeing any staff in a mask,” Rianne Theriaultodom, an incarcerated woman who was in the medical isolation unit with Rugg, told The Post via JPay. This left the women “confused and terrified” about the disease’s progression in their facility.

After 36 hours, during which women screamed and banged on their doors demanding answers, they were officially informed that they were in quarantine because of the virus. “Everyone in my unit seemed to have lost all control over their emotions,” Theriaultodom said. Even more shocking than the women’s deterioration was “that no one from mental health came by our doors to see how we were holding up.”

It was worse, however, in the medical isolation unit. According to April Harris, an incarcerated woman who spent a month in medical isolation, women were refusing to take coronavirus tests to avoid being sent there. “People aren’t scared of covid-19, they are scared of the treatment of isolation,” she wrote to The Post in a Jpay email.

In early April, shortly after the first women were moved into medical isolation, a woman attempted suicide.

Before the pandemic, women at CIW were allowed out of their cells for 23 hours a day. They worked and participated in professional training or personal development programs. That ended in mid-March, along with family visits.

Women say they now often spend 23 hours locked in their cells, with little information on how long the latest lockdown measures will last or when they’ll be able to exercise outside, call their families or even be allowed to shower.

Amend, an organization affiliated with the University of California San Francisco’s School of Medicine that advocates for a more health-oriented approach in prisons, has warned that “keeping people socially isolated in a closed cell . . . causes immense, and often irreparable, psychological harm.”

Additionally, mental illness is associated with higher risks for infectious diseases such as covid-19, given the prevalence of underlying conditions associated with both. As of July 14, according to court documents filed by Bien and other class-action lawyers, patients from the correctional mental health delivery system made up over a third of California’s prisoners hospitalized for covid-19, and 44 percent of the 34 deaths. Prisoners with mental illnesses make up a third of the incarcerated population.

Ignoring mental health makes containing the virus more difficult, said Brie Williams, Amend’s director and a professor of medicine at the University of California San Francisco, as it is common for incarcerated individuals to hide their symptoms to avoid isolation.

By the time Rugg set his mattress on fire, he had made four formal requests to be seen by mental health staff, starting from the first day of lockdown on April 6, as well as spoken requests during twice-daily temperature checks. He says one mental health worker came to see him, but only to tell him to put in his paperwork. “I can’t sleep and my doctor won’t come,” he wrote to Veronesi in one letter, and in another: “I feel overwhelmed by everything.”

In the medical isolation unit in mid-May, Rugg refused food, medicine and the temperature checks required for everyone who tested positive for the coronavirus for three days, without any of the staff taking action. “I tried to cut my wrists . . . but the blade kept breaking,” he said. That’s when he resorted to fire.

“Those [who] express they are in distress or seek assistance are seen within 24 hours by a mental health professional to determine if the patient requires a higher level of care,” Dana Simas, a CDCR spokesperson, said in an emailed statement.

Bien, the lawyer, said that “the whole mental health-care delivery system depends on the ability to identify people who medically need it and refer them to a higher level of care.” Other women confirmed the difficulty of accessing care.

Corene de la Cruz, an incarcerated woman who has not contracted the coronavirus, said that she made multiple requests for counseling but that neither mental health staff nor “chaplains were available on the premises to speak to.”

Once, after quarantine had already been lifted, a male mental health worker she had never seen or spoken to before offered her a counseling session in the day room, in front of other inmates. According to CDCR policy, counseling is supposed to be private.

Since mid-May — shortly after Rugg’s suicide attempt — mental health staff members have walked through the women’s general housing units once or twice a week passing out connect-the-dots puzzles and Hello Kitty images to color, de la Cruz said. Sometimes there are handouts on how to cope with anxiety, she added, but she said she did not find any of this helpful.

Neither did April Harris, who spent a month in isolation with covid-19, just across the hall from Rugg. She was the first to see the fire.

Harris screamed for help. “I thought she was going to die, and I was going to watch her burn,” she wrote in a journal entry she shared with The Post.

Her actions might have saved Rugg’s life. After his suicide attempt, Rugg was moved to an inpatient psychiatric facility, where he says he is receiving care and awaiting transfer to a state psychiatric hospital. However, he’s not sure when he’ll be moved, as transfers to outside facilities have been paused because of the virus.

After witnessing the suicide attempt and being temporarily evacuated from the burning building, several residents requested counseling. A week passed before any mental health staff visited the unit. When they arrived, it was not to offer counseling but to slide sheets of yoga poses, crossword puzzles and coloring pages under their doors.

Recently filed court documents state that the correctional department is working to replace the loss of programming during the covid-19 restrictions with “therapeutic treatment packets” and “workbooks.”

“It was an emergency for a while, but now it’s 100 days out,” Bien said of the pandemic’s effect on mental health care. “The question is: What’s the plan? This is going to last at least a year, maybe two. . . . How are you going to improve mental health care?”

On July 15, Bien and class-action lawyers presented a comprehensive solution to the court, requesting that “the State reduce the mental health population commensurate with the reduction of the overall prison population.” As a measure to contain the spread of covid-19, the state has already released 3,500 incarcerated individuals, and Gov. Gavin Newsom (D) announced this month that California would release up to 8,000 more, with a partial focus on eight state prisons with outbreaks, including CIW. By July 24, 280 incarcerated women at CIW had tested positive for the coronavirus, and one had died, while 7,481 incarcerated individuals in all of California’s prisons had tested positive, and 42 had died. Mental health patients, however, were not specifically included in either cohort for release.

The only solution in providing better mental health care, Bien told The Post a few days ahead of the filing, is to “reduce the patient population.”

If you or someone you know needs help, call the National Suicide Prevention Lifeline at 800-273-TALK (8255). Crisis Text Line also provides free, 24/7 confidential support via text message to people in crisis when they text to 741741.

This story is a partnership between The Washington Post and The Fuller Project, a global nonprofit newsroom reporting on issues that impact women.

Correction: An earlier version of this story misreported that CDCR spokesperson Dana Simas didn’t respond to a question about coloring pages being distributed at the prison. The story has also been updated to clarify Simas’s response about the care available to inmates in distress.