Keep Criminals Healthy—Or Else

One of the most infamous records the U.S. holds is that of the world’s incarcerator. As of 2006, 2.2 million Americans were incarcerated, more than even China—which has over four times the population of the U.S.

California is the most cell-happy state in the union, with its prison population in midyear 2006 at over 175,000, or 11.3 percent of the total prisoners in the country.  The Golden State’s 175,000 inmates are held in 33 prisons—meaning there’s roughly 5,307 inmates per prison.

Put differently, every prison health care system has 5,307 potential patients, day in and day out. That’s quite a caseload, and it’s made much worse by the fact that prisoners are in much poorer health than the general population. Indeed, the California prison system is in the throes of a health care crisis—one that highlights why we should all care about the quality of medical services for inmates.

As you might guess, prison is an unhealthy place. Prisoners are more than eight times as likely to be infected by HIV, four times as likely to have active tuberculosis, and more than nine times as likely to have hepatitis C. According to the National Commission on Correctional Health Care, about 3 percent of the U.S. population spends time in prison or jail—but between 12 and 35 percent of the total number of people in the nation with some communicable diseases (like AIDS and Hepatitis B) pass through a correctional facility.

Commission data shows similar trends occur for mental illnesses (see the table below). Prison inmates have rates of schizophrenia and other psychotic disorders that are three to five times greater than the general population. Their incidence of bipolar disorder is up to three times greater than people outside prisons. And prisoner rates of drug and alcohol abuse are also higher.

The Commission’s report is a little dated (from 2002), but there’s no indication that the problem has gotten any better. Thus for all intents and purposes, California has 33 facilities dealing with large populations of individuals far more likely to need serious and regular medical care. The problem is, of course, these facilities aren’t hospitals—they’re prisons. They’re meant to quarantine and punish, not to treat. And in California especially, they traditionally have done little good for patients.

Just how bad is the California prison health care system? Unconstitutionally bad—and that’s not just me talking. In 2001, a class action law suit against the state was brought to a U.S. District Court judge who found that the system’s quality of medical care was so abysmal that it violated the U.S. Constitution’s Eighth Amendment, which forbids cruel and unusual punishment.

The state settled the suit in 2002, agreeing to institute reforms—except it never made any real headway. In 2005 the judge got fed up and established a federal receivership. The receivership is an arrangement that literally strips all state officials, from the Governor to the Department of Corrections, of their authority to manage medical care operations in the prison system. The state government is no longer responsible for prison health care; the reins were handed over to Robert Sillen, a long time health care expert, who began his tenure in September 2006.

He has his work cut out for him.  On the receivership program’s home page you can read Sillen’s memos, which point out some of the more startling problems. In 2006, the California prison system saw 426 deaths—15 percent of which were preventable or possibly preventable. Among the remaining unpreventable deaths (315) “more than half reflected lapses in care that may have contributed to earlier death or more suffering among terminal patients.”

Part of the problem has been poor staffing. Before the receivership, prison health care workers were grossly underpaid and there was a high level of turnover and vacancies. Correctional officers doubled as nurses, blurring the line between enforcement and care. In 2005, at least 40 health care staff—about half of which were physicians—were found to have spent weeks, months, and even years at home with full pay because of insufficient oversight.

Sillen has taken various measures to bring in honest, medically accredited staff and offer them better compensation. He’s also had to push for an increased equipment budget, because for years California prisons have lacked things as basic as gauze, whiteboards, and training texts. 

Before Sillen the prison pharmacy system was a mess, wasting California taxpayers anywhere from $46 to $80 million. Sillen has brought a company called Maxor on board to vet the pharmacy framework and restructure it. Maxor started its work with a thorough overview of the system as it stands, and the findings were ugly. There were little to no drug tracking systems in place—in other words, there was no way of knowing what drugs or how many of them were being given to prisoners, circulated around, etc. In 2005, there were variations of  more than 30 percent between the amount of drugs prisons purchased and what was dispensed to patients. The biggest gap—where more than 95 percent of the amount purchased was never dispensed to prisoners—was for narcotic controlled substances with a very high potential for abuse, Roxicodone and Oxycotin. You can imagine where most of it went. Oversight was non-existent.

This held true for pharmaceutical contracts as well. There was no system to keep track of contracts or keep tabs on whether or not they were being fulfilled, meaning the prison system never really knew it was being ripped off by suppliers. Medication was dosed out by medication aids—again, without the oversight of a pharmacist—in big bulk bottles, with almost no system to distinguish or separate medications.

Prison health care was so abysmal that it resembled “One Flew Over A Cuckoo’s Nest”—complete with a slew of Nurse Ratchets. In 2004 the California Department of Corrections report found that a whopping 19 percent of its on-staff physicians had been forced to make some sort of malpractice payment or had actions taken against their licenses by the state Medical Board.

As unsettling as all of this is, my point isn’t that California stinks; just that health care in prisons is a very precarious affair. Prisons are where we throw the unwanted and the offensive—they’re usually hidden from the public eye, which means they’re incubators for shady dealings and mismanagement. That may seem okay—after all, why should we care about the environment in which the dregs of society live? But it’s not.

There’s obviously a moral issue here—the fact that prison health care became so bad in California that it was actually unconstitutional makes it clear that there is some minimum level of health care that we think every human being, criminal or not, has a right to have. What makes this worse is the fact that about 20 percent of inmates in state prisons are for drug offenses—which means people caught for possessing marijuana are getting the same shoddy care as murderers. Does that seem fair?  Do these people deserve to die from asthma—of all things—as six California prisoners did in 2006?

There are practical issues as well. Prisoners are more likely to acquire communicable disease and suffer from chronic conditions than the rest of us; the fact that the quality health care they receive is sub-standard only exacerbates these complications. And guess what? They’re getting out, and mixing with the general population.

According to the Justice Department, 95 percent of all state prisoners will be released from prison at some point, with the average age of released prisoners increasing from year to year, along with the proportion of released inmates who are drug offenders. A graying population of drug users who go for long periods of time with poor health care in an environment that incubates disease—this is really the last thing our straining health care system needs. And how many newly released inmates do you think have health insurance?

Our options are three-fold: leave things as is and let wasteful, ineffective prison health care burden public coffers and churn out public health risks that drive up the cost of health care nationwide; release fewer prisoners without improving prison health care (the “let ‘em rot” approach), which will drive up corrections costs and push our already critical mass of prisoners over the edge; or follow California’s lead and take a long, hard look at prison health care around the nation. The last option clearly makes the most sense, and has the added bonus of being the most compassionate strategy. We need to strive for accountability so that we can push for improvement.

In 2005 the New York Times did just this by taking a hard look at Prison Health Services, a for-profit firm that contracts with 28 states and provides health care for about ten percent of the 2.2 million persons incarcerated in the U.S. The Times’ series, called “Harsh Medicine,” is required reading for anyone interested in the issue (see part one here, two here, and three here). The series’ recounting of disturbing deaths and inadequate care is proof that what happened in California was no isolated instance—and importantly, not a failure somehow applicable to the backwardness of the public sector.

Indeed, there’s something far more fundamental than just bureaucratic failure at work. The fact is that in prison you can get away with murder. And that’s just unacceptable—from both a moral and practical perspective. It’s time to get serious about reforming health care in U.S. prisons.

Comments

[joe blow]

"So joe, i'm going to take issue (in part) with you comment, because I think the problem is more systemic than criminals being scary.

By your logic, doctors should never go to wartorn African villages in the throes of epidemics--where they're needed the most!--because "no one wants to work with diseased nobodies in a warzone."

Those situations are not comparable. Working with criminals every day who would like nothing more than to shank you so they can escape is a far cry from working in Africa. Almost no medical volunteers go to warzones in Africa anyways.

"After all, doctors are supposed to heal the sick and the weak--they're not supposed to limit their aid to society's "winners."

Yes and lawyers are supposed to work for justice and not money. What people are "supposed" to do and what actually motivates them are two entirely different things, and if you want actual solutions instead of platitudes to real-world problems, then you'd better understand that distinction very quickly.

Newsflash, EVERYBODY works for money. We're all part of the same ratrace. So go ahead and hope that people will work against thier financial interest, but I'm telling you thats not sound policy.

Do you want better healthcare and more access to doctors in prisons or not? If you do, then financially incentivize them to do so. Thats the ONLY policy decision that will work.

Isolated anecdotes about doctors who are playing Mother Teresa and devote their entire lives to the prison system with zero pay is not something to base policy on.

[drmatt]

Maggie,
The war on drugs is an economic machine, what would all those people do who spend thier whole lives working against the importation, sale and use of illicit drugs? Since Reagan I believe the cycle to be unstoppable. The addicts need help, they are sick, incarceration is not the answer for them, though an incredibly difficult topic, the addict who kills (or commits some other significant crime) to get his/her next fix can not be excused. I actually worked in Drug and ETOH rehab for over a year. The honest truth is, nobody who is not ready to get better, gets better, rich to poor, old to young. Anyone who is not ready is wasting the time of those who are making efforts to "help" them.

Joe Blow, I get job offers every day, I am considered one of the best of what I do, I work the jail because they need it and I like it. By the way, being that you have passed judgement on a huge population of people you have never met and don't know I believe you should change your handle to GOD.

[Niko Karvounis]

Hi all, thanks for commenting--drmatt, joe, and jail nurse, thanks for your comments. It's a tough situation--on the one hand, it's jail, right? It seems like there's an inescapable ceiling on how good a work environment/health care system/professional setting, etc. it can be.

But I don't think this is right--we make things worse than they have to be through our reliance on incarceration, as jail nurse suggests.

It's a vicious cycle: prisons are such horrendous places in part because they are overcrowded; the more dangerous they are, the fewer doctors want to work in them; the more prisons we build to hold our growing prison population, the more we out-pace the supply of qualified staff; and the worse health care in prisons becomes, the more the downward spiral continues.

So joe, i'm going to take issue (in part) with you comment, because I think the problem is more systemic than criminals being scary.
After all, doctors are supposed to heal the sick and the weak--they're not supposed to limit their aid to society's "winners."

By your logic, doctors should never go to wartorn African villages in the throes of epidemics--where they're needed the most!--because "no one wants to work with diseased nobodies in a warzone."

But hold on: I'm not actually saying you're wrong. An incentive scheme, or service program, to help improve prison health care might help institutionalize it as a professional option.

My point is just that there's something more going on here than just working with criminals. The prison health care system tends to be mismanaged in such a way that even those that want to help probably feel they can't. As drmatt says, there are unique challenges to be dealt with--and they have to be thought through systematically through research and examination, not hypotheticals like "what would it take to get you to work in prison?"

jail nurse, thank you much for the kind words. we look to take new angles on untraditional health care issues here at health beat, so do stay with us.

i also second your and maggie's comments on punishment being counter-productive for drug users.the war on drugs is part of the problem here.
We imprison users with inflexible sentences, which has the double whammy of overcrowding our prisons AND filling them with people who need treatment. Again, another vicious cycle--we lock up the people who need medical attention, meaning that we fill our prisons with people who need more than prison health care can provide. Then the people don't get better, they get released without treatment, they re-offend--and the whole cycle starts over again.

As you can probably tell, I think that this nexus of criminal justice and health care is something that doesn't get nearly enough attention--thanks to you all for chiming in.

[maggie mahar]

This is Niko's post, but let me chime in to say that I agree with jail-house nurse--this is an excellent post.

I admire both dr. matt and jailhouse nurse for being willing to try to help prisoners in an all-but-impossible situation.

As jail-house nurse puts it the work "is challenging, at times frustrating, and only very occasionally rewarding."

We need a completely different approach to our penal system. For one, I believe that the "war against drugs" does as much --or more-- damage than the drugs themselves.

If the two of you could be working with drug addicts in a separate (non-prison) setting-I supsect you could help many more of them. Not all. But more.

And there is no reason why prisons shouldn't be able to get the same discounts on drugs, etc. that the VA gets.

Finally Joe Blow-- the fact that Dr. Matt and jailhouse nurse are willing to work in prisons demonstrates that some people will do discouraging work like this for its own sake--because sometimes, it is "rewarding"--without a financial incentive.

Large financial incentives might, in fact, attract the wrong people. (It could attract health care workers so driven by financial incentives that they would begin selling drugs to inmates on the side.)

But I do agree that doctors and nurses who are willing to work in prisons richly deserve to be rewarded. My guess is that what they need is better working conditions-- conditions that would allow them to do what they are trying to do.

For example: adequate supplies and more like-minded health care staff-- enough staff to separate prisoners into groups: the mentally ill; those who need drug re-hab; those who are physically ill. . .

I'd also like to know what each of you think about he war against drugs--and how we might better fight it.

[joe blow]

If i was a doc, there's no way in hell i'd work in a jail/prison unless you paid me at least double what i would make on the outside.

Is it any surprise that only the docs who cant get jobs elsewhere would work in prisons?

WTF do you expect? Jail/prisons pay about half what a doc would make on th outside. Nobody wants to work with violent scumbag criminals all day long.

Until you start paying doctors at least double what they make on the outside, you arent going to get anybody to work there other than the losers that couldnt get a job anywhere else.

[California Jail Nurse]

This is the best synopsis article I have seen on the issue of the prison (and jail) health care systems problem we face nationally and in California. A large part of the problem is that jails and prisons are out of sight, out of mind. The more awareness the better. I would add that serious review and changes are required in sentencing laws, parole, and providing viable reentry services for people returning to the community. Why does the US incarcerate at the rates we do? Why are we criminalizing the mentally ill? And the racism is blatant. It has been proven that incarceration does not repair social problems, addiction, or mental illness. We know that putting kids in Juvenile Hall does not improve the quality of their lives, or inspire them to do the best they can in the long run, quite the opposite. How do we break the chain of warehousing people? Lets make jails and prisons what they should be, a place to keep the sociopaths and true criminals separate from society.

Thank you for this article and thank you drmatt for your wisdom and experience. The work for medical staff in corrections is challenging, at times frustrating, and only very occasionally rewarding. It is true that the successes are not often acknowledged, inmate patients can be extremely ungrateful, entitled, demanding and want prescribed drugs for the black market to support addiction. You speak the truth!

[drmatt]

Among my other undertakings I am the attending physician at the local county jail. To make a distinction for reader, jail is a mix of pretrial (presumably innocent but couldn't post bail) and offender who are sentenced to less than 18 mos. making for a very transient population.
In my three year tenure we have had one death, a young man who was huffing cleaning supplies and found dead. The challenges are unique, all insurance is lost (including medicare and medicaide) the cost of care is shifted completely to the county. The population is litiginous and file many law suits (I am much more likely to be sued here than practicing anywhere else, despite similar care on my part). There are rewards for complaints, a chest pain complaint gets you a night in the hospital with nurses, and better food, but it also absorbs the pay of a correctional officer who has to go with you, and transport costs. Additionally there is no negotiated price for health care as in insurance so we pay full price for everything. Why should cost be so important? Because when tax payers and politicians are making budgets, no one likes to spend budget money on prisoners.
Furthermore, many medications either support addictive habits or can be traded for other commodities in jail, making the number of complaints to recieve such way out of proportion to actual pathology.
Finally, inmates often mistreat staff leading to greater turnover.
I think I could go on and on, it is a unique population with many barriers to proper care, even with well intended medical staff.