- Email: [email protected]
Cruel and unusual
World Report
Cruel and unusual Health care in Californian prisons was so bad that a federal judge appointed a receiver to administer the system. The move highlighted a neglected area of medicine. Norra MacReady reports. In 2004, a California prisoner reported to the infirmary with a 2-week history of fever and chills. His condition worsened over the next several weeks. Eventually, he was diagnosed with endocarditis, but never received the appropriate antibiotics. He finally reported to the prison’s emergency room with cyanosis, severe hypotension, and a high fever. Despite the objections of a nurse, who wanted to send the prisoner to the emergency department at the local hospital, the physician on duty recommended returning the man to his housing unit. The patient died soon after from cardiac arrest. Citing this case and dozens like it, on June 30, 2005, Judge Thelton Henderson established a receivership to oversee the delivery of health care to prisoners in the California state prison system, which has 170 000 inmates— the largest in the USA. The court described the prison medical system as “broken beyond repair”, and added that “the threat of future injury and death is virtually guaranteed in the absence of drastic action”. Henderson estimated that at least 64 preventable deaths had occurred in 1 year, and characterised the system as “at times outright depravity”.
PA Photos
The printed journal includes an image merely for illustration The California Medical Facility—a state prison for men in Vacaville, CA
708
By appointing a receiver, the judge took control of prison health care away from the state of California and placed it in the hands of an administrator who answered directly to the court. More than 3 years later, as the state grapples with a budget shortfall of about US$28 billion, it still must divert billions of dollars to bring the prison medical system up to speed. The USA has two basic types of correctional facilities. Jails are usually county-run institutions that hold
“...the care that prisoners receive varies widely, depending on each state’s policies and resources.” people awaiting ajudication of their cases. Because people rarely stay longer than a few days, any treatment jails provide usually consists of urgent or emergency care. Prisons are run by the state. They house people who have been convicted of a crime and are serving terms that could last for years, sometimes for the rest of their lives. As such, a prison must be able to handle not only whatever acute problems afflict the residents, but also the chronic diseases associated with ageing. Substandard prison health care is deemed a violation of the Eighth Amendment to the Constitution that prohibits cruel and unusual punishment, making prisoners the only group of Americans who are guaranteed medical care. In reality, the care that prisoners receive varies widely, depending on each state’s policies and resources. Some states, like California, run their own prison health facilities, so the doctors and nurses who work there are state employees. Others, like New York, contract with outside companies to provide prison care. Either way, this
means that the care prisoners actually receive reflects each state’s politics, budget, leadership, and the will of the voters. Overall, health systems in US prisons have undergone “a dramatic improvement in accessibility, quality, and timeliness” over the past few decades, says Ronald M Shansky, an internist and specialist in correctional health care, who has testified in many court cases involving prison medical systems. California missed this trend in part because the state “never had the strong leadership necessary to design and implement a good health-care system”. One glaring problem was that “any doctor with a license could be hired to give primary care. You might have pathologists or anesthesiologists seeing patients with diabetes”. Understaffing was another serious drawback: some prisons had only two or three doctors to care for 5000 inmates. And prisoners are an inherently unhealthy population. Most have led hard, impoverished lives, with the drug abuse, alcoholism, violence, and neglect that goes along with such an existence. “We see the same things as any community physician, but more of it”, says Michelle StaplesHorne, medical director of the Georgia Department of Juvenile Justice, and president of the Society of Correctional Physicians. Prisoners may arrive with any of a long list of ailments, including HIV/AIDS, hepatitis B or C, sexually transmitted diseases, asthma, tuberculosis, cancer, or severe and untreated hypertension or diabetes, which, along with intravenous drug use, can lead to end-stage renal disease. Head trauma is also common, often sustained in street fights or from falls due to heart attacks or drug or alcohol intoxication. “It comes with the lifestyle”, says Staples-Horne. www.thelancet.com Vol 373 February 28, 2009
World Report
www.thelancet.com Vol 373 February 28, 2009
lockdown periods and the deference to security personnel, who have the ultimate authority. “It’s necessary, but many people find it uncomfortable”, Paris says. There is little privacy; guards may be present during examinations of prisoners considered an especially high security risk, and inmates often arrive in shackles. Obtaining specialty care in the community can be a particular problem because “what doctor wants someone in handcuffs coming to his office?” says Hill. Some prison health systems now have their own specialty units. States that contract with outside companies to provide health care to prisoners face their own special set of challenges. “The key is to have a standard of care that everyone follows, no matter where the paycheck comes from”, StaplesHorne explains. The state and the contractor “must agree on standards, policies and procedures, clinical protocols, accountability, and quality assurance.” Prison administrators
“...community physicians are usually unprepared for the special challenges of treating prisoners.” must convey their expectations of contractors very precisely, says Hill. For example, “if they don’t say what kinds of tests they expect for sexually transmitted diseases among incoming inmates, the company’s bid won’t include urinary screens for syphilis, gonorrhoea, or chlamydia. States often do not specify that vendors must do special needs assessments for people with disabilities, test for diabetes, hypertension, and hepatitis C, and provide wound care”. The result: serious problems may be overlooked and undertreated. Nevertheless, some inmates do not receive decent medical care until they enter prison. The young men who constitute most of the prison population often do not have regular employment or health-care benefits on the outside, Staples-Horne explains.
The printed journal includes an image merely for illustration PA Photos
According to one estimate, nearly 80% of inmates with chronic illnesses have never received routine medical care. What is more, this population is growing and ageing, thanks largely to “zero-tolerance” and “three-strikes” policies that require harsh sentences for relatively minor offences such as drug dealing. J Clark Kelso, the receiver in California, estimates that the state’s prisons are operating at 190% to 200% capacity, and points out that there are 650 people on death row, thanks largely to an “utterly dysfunctional death row review process”. In his opinion, if the state wants to impose such tough sentences, it must be prepared to deal with the consequences. “If the state wants to reduce its prison population by 30% to 40% by releasing older people with chronic illnesses and the seriously mentally ill, I don’t have a problem with that.” However, if they remain incarcerated for life, “there are costs that come with it. There are economic and budget consequences to the choices that California has made, and they are coming home to roost”. Kelso has asked the state for $6–7 billion to build seven facilities that will house about 10 000 patients, but, he points out, most of the money will be spent on assisted-living type facilities for older or chronically ill prisoners. It is probably not a coincidence that Terry Hill, the current chief medical officer of California Prison Healthcare Services, is a geriatrician. Another reason why the care in prisons may fall short is that community physicians are usually unprepared for the special challenges of treating prisoners. “It’s very shocking for most professionals to enter the secure perimeter”, explains Joseph Paris, former medical director of the Georgia Department of Corrections. Among other things, anyone entering a correctional facility must undergo a security check similar to those done at most airports, and “safety and security are not convenient propositions”. Physicians and nurses also may chafe at many realities of prison life, including
Substandard prison health care violates the US Constitution’s Eighth Amendment
“In general, if you look at poor people and underserved populations, they may get better care in prison. In fact, sometimes they commit offences to get into prison just to get health care. It’s a sad situation, but it’s often true.” Meanwhile, back in California, things are getting better. Inmate mortality has dropped since the receivership went into effect, Kelso points out, and from anecdotal reports “we know that health care is better now”. In at least one prison, San Quentin, “the inmates are better behaved, clinicians are working in a more professional environment, and the inmates and their families are telling us they see an improvement”. His office has awarded a contract to an outside vendor to provide pharmacy services, and has paid tens of millions of dollars in overdue invoices to medical providers in local communities. In an effort to attract and keep better employees, Kelso has increased salary ranges for new hires and instituted raises for nurses, pharmacists, and other clinicians. Still, hard decisions await legislators in California as they juggle the costs of the receivership with the state’s huge deficit. One thing is clear, says Kelso: “You cannot continue to subject inmates to an unconstitutional level of care.”
Norra MacReady 709
Cruel and unusual Health care in Californian prisons was so bad that a federal judge appointed a receiver to administer the system. The move highlighted a neglected area of medicine. Norra MacReady reports. In 2004, a California prisoner reported to the infirmary with a 2-week history of fever and chills. His condition worsened over the next several weeks. Eventually, he was diagnosed with endocarditis, but never received the appropriate antibiotics. He finally reported to the prison’s emergency room with cyanosis, severe hypotension, and a high fever. Despite the objections of a nurse, who wanted to send the prisoner to the emergency department at the local hospital, the physician on duty recommended returning the man to his housing unit. The patient died soon after from cardiac arrest. Citing this case and dozens like it, on June 30, 2005, Judge Thelton Henderson established a receivership to oversee the delivery of health care to prisoners in the California state prison system, which has 170 000 inmates— the largest in the USA. The court described the prison medical system as “broken beyond repair”, and added that “the threat of future injury and death is virtually guaranteed in the absence of drastic action”. Henderson estimated that at least 64 preventable deaths had occurred in 1 year, and characterised the system as “at times outright depravity”.
PA Photos
The printed journal includes an image merely for illustration The California Medical Facility—a state prison for men in Vacaville, CA
708
By appointing a receiver, the judge took control of prison health care away from the state of California and placed it in the hands of an administrator who answered directly to the court. More than 3 years later, as the state grapples with a budget shortfall of about US$28 billion, it still must divert billions of dollars to bring the prison medical system up to speed. The USA has two basic types of correctional facilities. Jails are usually county-run institutions that hold
“...the care that prisoners receive varies widely, depending on each state’s policies and resources.” people awaiting ajudication of their cases. Because people rarely stay longer than a few days, any treatment jails provide usually consists of urgent or emergency care. Prisons are run by the state. They house people who have been convicted of a crime and are serving terms that could last for years, sometimes for the rest of their lives. As such, a prison must be able to handle not only whatever acute problems afflict the residents, but also the chronic diseases associated with ageing. Substandard prison health care is deemed a violation of the Eighth Amendment to the Constitution that prohibits cruel and unusual punishment, making prisoners the only group of Americans who are guaranteed medical care. In reality, the care that prisoners receive varies widely, depending on each state’s policies and resources. Some states, like California, run their own prison health facilities, so the doctors and nurses who work there are state employees. Others, like New York, contract with outside companies to provide prison care. Either way, this
means that the care prisoners actually receive reflects each state’s politics, budget, leadership, and the will of the voters. Overall, health systems in US prisons have undergone “a dramatic improvement in accessibility, quality, and timeliness” over the past few decades, says Ronald M Shansky, an internist and specialist in correctional health care, who has testified in many court cases involving prison medical systems. California missed this trend in part because the state “never had the strong leadership necessary to design and implement a good health-care system”. One glaring problem was that “any doctor with a license could be hired to give primary care. You might have pathologists or anesthesiologists seeing patients with diabetes”. Understaffing was another serious drawback: some prisons had only two or three doctors to care for 5000 inmates. And prisoners are an inherently unhealthy population. Most have led hard, impoverished lives, with the drug abuse, alcoholism, violence, and neglect that goes along with such an existence. “We see the same things as any community physician, but more of it”, says Michelle StaplesHorne, medical director of the Georgia Department of Juvenile Justice, and president of the Society of Correctional Physicians. Prisoners may arrive with any of a long list of ailments, including HIV/AIDS, hepatitis B or C, sexually transmitted diseases, asthma, tuberculosis, cancer, or severe and untreated hypertension or diabetes, which, along with intravenous drug use, can lead to end-stage renal disease. Head trauma is also common, often sustained in street fights or from falls due to heart attacks or drug or alcohol intoxication. “It comes with the lifestyle”, says Staples-Horne. www.thelancet.com Vol 373 February 28, 2009
World Report
www.thelancet.com Vol 373 February 28, 2009
lockdown periods and the deference to security personnel, who have the ultimate authority. “It’s necessary, but many people find it uncomfortable”, Paris says. There is little privacy; guards may be present during examinations of prisoners considered an especially high security risk, and inmates often arrive in shackles. Obtaining specialty care in the community can be a particular problem because “what doctor wants someone in handcuffs coming to his office?” says Hill. Some prison health systems now have their own specialty units. States that contract with outside companies to provide health care to prisoners face their own special set of challenges. “The key is to have a standard of care that everyone follows, no matter where the paycheck comes from”, StaplesHorne explains. The state and the contractor “must agree on standards, policies and procedures, clinical protocols, accountability, and quality assurance.” Prison administrators
“...community physicians are usually unprepared for the special challenges of treating prisoners.” must convey their expectations of contractors very precisely, says Hill. For example, “if they don’t say what kinds of tests they expect for sexually transmitted diseases among incoming inmates, the company’s bid won’t include urinary screens for syphilis, gonorrhoea, or chlamydia. States often do not specify that vendors must do special needs assessments for people with disabilities, test for diabetes, hypertension, and hepatitis C, and provide wound care”. The result: serious problems may be overlooked and undertreated. Nevertheless, some inmates do not receive decent medical care until they enter prison. The young men who constitute most of the prison population often do not have regular employment or health-care benefits on the outside, Staples-Horne explains.
The printed journal includes an image merely for illustration PA Photos
According to one estimate, nearly 80% of inmates with chronic illnesses have never received routine medical care. What is more, this population is growing and ageing, thanks largely to “zero-tolerance” and “three-strikes” policies that require harsh sentences for relatively minor offences such as drug dealing. J Clark Kelso, the receiver in California, estimates that the state’s prisons are operating at 190% to 200% capacity, and points out that there are 650 people on death row, thanks largely to an “utterly dysfunctional death row review process”. In his opinion, if the state wants to impose such tough sentences, it must be prepared to deal with the consequences. “If the state wants to reduce its prison population by 30% to 40% by releasing older people with chronic illnesses and the seriously mentally ill, I don’t have a problem with that.” However, if they remain incarcerated for life, “there are costs that come with it. There are economic and budget consequences to the choices that California has made, and they are coming home to roost”. Kelso has asked the state for $6–7 billion to build seven facilities that will house about 10 000 patients, but, he points out, most of the money will be spent on assisted-living type facilities for older or chronically ill prisoners. It is probably not a coincidence that Terry Hill, the current chief medical officer of California Prison Healthcare Services, is a geriatrician. Another reason why the care in prisons may fall short is that community physicians are usually unprepared for the special challenges of treating prisoners. “It’s very shocking for most professionals to enter the secure perimeter”, explains Joseph Paris, former medical director of the Georgia Department of Corrections. Among other things, anyone entering a correctional facility must undergo a security check similar to those done at most airports, and “safety and security are not convenient propositions”. Physicians and nurses also may chafe at many realities of prison life, including
Substandard prison health care violates the US Constitution’s Eighth Amendment
“In general, if you look at poor people and underserved populations, they may get better care in prison. In fact, sometimes they commit offences to get into prison just to get health care. It’s a sad situation, but it’s often true.” Meanwhile, back in California, things are getting better. Inmate mortality has dropped since the receivership went into effect, Kelso points out, and from anecdotal reports “we know that health care is better now”. In at least one prison, San Quentin, “the inmates are better behaved, clinicians are working in a more professional environment, and the inmates and their families are telling us they see an improvement”. His office has awarded a contract to an outside vendor to provide pharmacy services, and has paid tens of millions of dollars in overdue invoices to medical providers in local communities. In an effort to attract and keep better employees, Kelso has increased salary ranges for new hires and instituted raises for nurses, pharmacists, and other clinicians. Still, hard decisions await legislators in California as they juggle the costs of the receivership with the state’s huge deficit. One thing is clear, says Kelso: “You cannot continue to subject inmates to an unconstitutional level of care.”
Norra MacReady 709