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SICK ON THE INSIDE: Correctional HMOs and the coming prison plague

To describe David's scrotum as swollen and red would be a failure
of language. It was about the size of a rugby ball, so raw and
irritated, shiny and crimson, that it almost seemed to be covered
with blood. David hung his head. "They give me aspirin," he said.
From the August, 2003 issue of Harper's Magazine. Since I OCR'ed it,
there's probably a gratuitous glitch here or there:

SICK ON THE INSIDE: Correctional HMOs and the coming prison plague
By Wil S. Hylton

When David Hannah walked into a small office on the second floor
of the Moberly Correctional Facility in Moberly, Missouri, last
fall, carrying his belly like a hundred-pound sack of sand, the
staff knew him well enough not to worry about what he might break
or steal or soil in their private offices, which were normally not
accessible to inmates, so I was able to close the door behind him,
and we sat together and talked about what was happening to his
body. He was a pale, fifty-seven-year-old white male, serving a
sentence of life plus three years for rape, and his gray hair was
matted to his head. His face was as worn and gaunt as a much older
man's.

Hannah was angry. "Look at it," he said, glaring at his gut. "Do
you want to see it?"

I didn't want to see it, but I nodded anyway. I had come precisely
to see it, to witness Hannah's disfigurement, the fruit of a long
series of medical miscalculations. It had begun in the 1980s with
two kinds of hepatitis, B and C, a condition that prison doctors
had largely ignored for a decade, then treated with a series of
botched, questionable procedures that caused David's cells to cease
performing osmosis properly, so that over time his natural body
fluids began to collect, trapped inside his gut with no way to
evacuate, his midsection swelling to accommodate those fluids,
expanding to such a size and weight that the mere act of walking
around had given David, by December 2000, a pair of hernias, neither
of which the prison doctors had bothered to treat. David stood
now to show me the belly and the hernias, the condition his body
had arrived at through an utter tack of attention. He pulled his
flannel shirt to the side of his waist and lifted his gray T-shirt,
and, in spite of myself, I winced. His belly was enormous, taut
and pasty, seemingly glued to his gaunt frame. At the front of it,
a hot-pink hernia, about the size of a grapefruit, seemed barely
attached where the belly button should have been, giving David's
midsection the overall contour of a giant breast and nipple. Bracing
myself, I asked him where the other hernia had emerged. He studied
me, obviously not fond of baring his physique. After a moment, he
shrugged and unbuttoned his pants.

To describe David's scrotum as swollen and red would be a failure
of language. It was about the size of a rugby ball, so raw and
irritated, shiny and crimson, that it almost seemed to be covered
with blood. David hung his head. "They give me aspirin," he said.

Later, when I heard that David had died of indeterminate causes
and that his body had been cremated, I realized that I had probably
been the last person outside of the prison staff to see David alive,
to see what his body had become from all those years of mistreatment,
and I wondered: Can such a secret be kept?

It occurs to me now that prisons are designed for keeping secrets,
for holding inside not just men but also their lives and the details
of those lives. In prison, social isolation is a matter of policy,
and inmates are neither expected nor encouraged to have more than
a modicum of contact with the outside world. This is not necessarily,
or at least not ostensibly, vindictive. In many cases, isolation
is the prison's approach to rehabilitation. As Alexis de Tocqueville
observed nearly two centuries ago, "Thrown into solitude [the
convict] reflects. Placed atone, in view of his crime, he learns
to hate it; and if his soul be not yet surfeited with crime, and
thus have lost all taste for anything better, it is in solitude,
where remorse will come to assail him."

Still, the social isolation of prisoners creates a host of difficulties,
not least of which is that of monitoring their treatment, of ensuring
that they are assailed only by their own remorse and not by anything
else -- by, say, other prisoners, or by those who keep the watch.
Opacity, after all, runs both ways, and if the prison walls keep
convicts in, they work just as effectively to keep observers out.

This problem is only made worse inside the prison infirmary. By
its very nature, medicine is a private matter, and a prisoner's
medical records are protected by the same confidentiality laws that
protect free citizens. This means that a prisoner's medical chart
is both locked inside a physical fortress and shielded by a battery
of privacy restrictions, all of which leaves the field of prison
medicine cloistered and nearly impossible to survey. Compounding
this is the fact that prison medicine, and, indeed, the principles
of medicine itself, are fundamentally at odds with all other facets
of prison life. Even the term "prison medicine" borders on oxymoron:
Whereas prison is designed to alienate and punish, medicine exists
to nurture and soothe. So where is the boundary between care and
punishment? At what point do they meet?

Until the 1970s, which is to say for the first two centuries of
American life, these were not questions that anyone felt compelled
to ask, let alone answer. As a matter of law, prison medicine had
always been considered a privilege, not a right, and the final
authority on treatment was not a doctor or even a court but the
local warden. Prisoners whose medical needs were not being met,
whose broken noses and diabetes were left untreated, who were
stabbed and not sewn, feverish and not medicated, prisoners who
had cancer but no treatment, who had prescriptions that wardens
refused to fill, whose mental health teetered at the edge of
self-destruction -- those prisoners had no recourse, nor reason to
expect it. In the early 1970s, a survey of jails by the American
Medical Association found that fewer than 30 percent had medical
facilities and only about one in five had a formal arrangement with
any medical provider.

Things began to change in 1971, when an uprising at the Attica
penitentiary in New York forced the subject of prison conditions
into the national conversation. Amid a flurry of laws enacted in
response to Attica, state and federal legislators began crafting
measures to guarantee basic health care to prisoners. Although the
laws have changed over the past thirty years, little else has. If
anything, prison health care is in further decline now than ever.
Most departments of correction have chosen not to invest in medical
infrastructure but rather to farm out the business to subcontractors,
and these days a single, private corporation controls the health
care of all prisoners in ten states and manages a portion of inmate
health care in another seventeen, having underbid competitors
everywhere it exists. Correctional Medical Services is not merely
the nation's largest provider of prison medicine; it is also the
nation's cheapest provider, a perfect convergence of big business
and low budgets. But unlike the traditional HMO, whose risk of a
malpractice suit is real, and is felt, and is reflected to at least
some degree in the quality of medical care, companies such as CMS
have little or no reason to protect themselves. Most juries are
reluctant to decide in favor of a convict, and those juries that
do favor the convict are often reluctant to award money. Cost-benefit
analysis takes on special, human overtones behind bars.

Perhaps even more significantly, private companies such as CMS feel
no responsibility, and have no legal obligation, to account to the
public for what goes on inside their facilities. So, while CMS
receives about $550 million of taxpayer money each year, the company
chooses not to provide any accounting of how that money is spent
or even how much of it is spent -- and how much unspent, to be pocketed
as profit. And although lawsuits over the years have revealed
discredited health-care professionals working in CMS facilities,
the company refuses to reveal the names of its doctors and nurses
for verification or to provide any account of how many have been
disciplined or had their licenses revoked in other states. With
CMS responsible for so many patients nationwide, it is fair to say
that the practice of medicine in prison has reached an unprecedented
level of inscrutability -- indeed, secrecy -- and if this fact seems
abstract or unlikely to affect regular folks in the general population,
well, just wait until the hepatitis epidemic comes flooding out of
the gates.

For those of you who have never been personally acquainted with
the hepatitis virus, allow me to describe it briefly. In the spring
of 1995, I downed the wrong glass of frozen margarita somewhere in
the Chihuahua desert and unleashed the disease on my insides.
Unaware, I took a bus back to Juárez a few days later, walked across
the border, drove home to Albuquerque, and, when the travel itch
returned a few weeks later, set out for Glacier National Park,
where I intended to spend thirty days in the backcountry,
mountaineering. By the time I arrived in Montana, however, the
virus had begun to set in, and I found myself overwhelmed by fatigue.
Deciding to get some rest before starting out, I found an empty
cabin near the boundary of the park, crawled down to the basement,
settled into a bed, and, with one fast glance at my backpack by
the door, passed out. When I woke up several days later, I was
tying on my back in a medical facility 120 miles away with an IV
in my arm and a sign on the door that said, "Warning: Take Enteric
Precautions Before Entering." Asking around, I learned that I had
been delivered to the medical center by a friend who worked in the
park. My liver-enzyme levels, upon check-in, had been gauged at
more than a hundred times the normal level. The first time I looked
in the mirror, I saw that my jaundiced skin was roughly the same
color and texture as a dried tangerine. I spent several days lying
in place, flitting in and out of consciousness, playing host to an
array of curious physician's assistants, nurses, and certified
nursing assistants, some of whom ran tests on my urine and blood
white the rest mostly stood around marveling at how odd I looked.
That was the beginning. For the next six months, I was forced to
live at my parents' house, where my daily priorities became eating
healthy food, sleeping at least half of each day, and wishing that
my perpetual headache would relent. This was the face of hepatitis
A, the least virulent strain of the virus.

The difference between the type of hepatitis I contracted and, say,
hepatitis C, which is the most severe strain, is mostly a matter
of intensity. My hepatitis eventually went away; hepatitis C, in
most cases, does not. It keeps on attacking your liver for the rest
of your natural life. That means people with acute hepatitis C can
essentially forget about all the wonderful things that livers do,
such as fighting infections, filtering toxins, and storing energy.
To make matters worse, people with hepatitis C are contagious for
the rest of their lives. Even twenty years after their initial
infection, even if the virus is in remission and they feel pretty
good, they still constitute a walking weapon and had better be
careful where they bleed. It is worth noting, then, that somewhere
between 20 and 40 percent of American prisoners are, at this very
moment, infected with hepatitis C, and therefore quite contagious.
It is also worth noting that most of them will eventually be released
back into the general population, where the infection rate is, for
now, only about 2 percent. The Association of State and Territorial
Health C)officials noted in a 2000 report that "an estimated 1.4
million HCV-infected persons pass through the correctional system
each year." And although the virus is most pervasive in prison
because of the high incidence of injected drugs there, it can be
transmitted just as easily on the outside through sex, blood
transfusion, or even a nasty fistfight.

With a scourge like this roiling on the inside, threatening to boil
over to the outside, you might expect prisons to adopt some kind
of screening policy for inmates and to institute a treatment
offensive for the afflicted. Unfortunately, no such national program
exists. Although the cost of a hepatitis test is only a couple
hundred dollars, very few facilities volunteer to provide them,
and there has been no federal legislation to require the measure.
"It's a missed opportunity," says Dr. Cindy Weinbaum of the Centers
for Disease Control and Prevention. "The number of prisoners with
hepatitis C is incredibly high. It's unbelievable."

The fact that most prison doctors have not seized this opportunity
doesn't reflect any inherent challenge to their doing so. On the
contrary, a couple of states have developed simple and effective
hepatitis programs that test all prisoners upon intake, making the
disease relatively easy to track and monitor. One of those states
is Texas, and there, not surprisingly, prison health care is managed
not by a private company like CMS but by two universities, the
University of Texas and Texas Tech University. Dr. David Smith,
who is the chancellor of Texas Tech and who led the battle to make
hepatitis screening mandatory in Texas, assured me that the hepatitis
program he created is not very special at all, or anyway that it
shouldn't be. "It's just the smart thing to do," he said. "We have
almost 30 percent of our prison population in Texas infected with
hepatitis. That's not so different from the numbers you see in the
Dark Ages with the plague."

When I visited a handful of CMS facilities last fall, I found a
very different attitude. Under CMS care, 214,000 inmates are expected
to petition for any hepatitis tests they want, and even if those
petitions are granted, and the tests given, and the results positive,
the chances of getting any kind of treatment are only slightly
better than of getting a presidential pardon. This became most
obvious to me when I heard the story of Larry Frazee.

I met Larry at the Western Missouri Correctional Center in Cameron,
about four hours west of St. Louis. He was a gaunt little man with
a circular face surrounded by brownish-gray hair, and his thin
mustache seemed to weigh on his lips when he spoke. He walked with
a silent shuffle, and from the black bruises under his eyes you
could see that he hadn't slept well in months, if not years. When
I began reading through his medical record, it was easy to see why.
Larry had first been diagnosed with hepatitis in the early 1990s,
when a prison plasma center rejected him as a donor. The diagnosis
had been confirmed by a prison infirmary in June 1994, but even
so, between then and the end of 1997, he had managed to wrangle
only a half dozen doctor's visits. It wasn't until January 2000,
a full five and a half years after his diagnosis, that CMS doctors
began formally monitoring his condition, Even then, treatment was
not forthcoming. As Larry discovered, CMS doctors required him to
meet a long checklist of conditions, known as a "protocol pathway,"
before he could receive any treatment for his disease. Some of
those items required off-site consultations. One of the things he
needed, if he wanted treatment, was a liver biopsy. But when Larry
went to the prison infirmary to ask for one, he learned that he
had to have a psychological evaluation first, then enroll in a
drug-abuse awareness class and sign a slew of forms releasing CMS
from liability for anything that might happen during the biopsy.
So Larry did those things one by one, and he signed the papers,
and he went to see the biopsy specialist, who promptly sent him
back to his cell because he didn't know his virus genotype. Larry
couldn't find anything in the protocol pathway that required him
to know his genotype, but to be a good sport he put in a request
at the infirmary for a genotype test. A few weeks later, he got
the test, but the laboratory somehow screwed up his results, so he
had to file for a second test and wait for a second appointment
and a second set of results before, in February of last year, he
finally returned to see the biopsy specialist, who sent him away
again, this time saying that Larry shouldn't bother getting treatment
anyway, because it can be somewhat dangerous. Larry argued that it
was his decision to make, and that he wanted the treatment, or at
least the biopsy that he was entitled to, and maybe afterward, when
he had the biopsy results and could take an informed took at them,
he would be willing to discuss the risks of treatment, but the
doctor just shook his head. The decision was final, he said. No
biopsy. He sent Larry back to his cell, where Larry has been ever
since, without a biopsy, without any treatment, feeling sick and
tired and a bit like he failed himself.

But what Larry didn't realize, and what he's only now beginning to
grasp, is that he never had much of a chance in the first place.
As a matter of formal company policy, CMS discourages treatment
for hepatitis, and the protocol pathway is just a way of making it
harder for prisoners to demand it. Although a CMS spokesman insisted
that CMS doctors are private contractors and that "it is the
individual physician's responsibility to make sure care is given
to patients," an internal memo from CMS regional medical director
Gary Campbell to his fellow directors in February 1999 reveals just
how much authority the doctors really have at CMS. "I am not
encouraging anyone to undergo therapy," the medical director wrote.
"However, if you have someone that is insistent, then this pathway
is to be followed." Campbell added, "Unless I have given you specific
approval to do Hep C testing, do not do so unless the patient has
obvious moderate to severe liver disease or has exposure as described
by the exposure policy of the DOC. Remember, all Hep C testing has
to be approved by me."

And so, for the 214,000 prisoners whose health is supervised by
CMS, the hepatitis epidemic continues to grow, untested and untreated,
virtually unencumbered by the forces of modern medicine, while
people like Larry Frazee remain right where the company wants them:
stalled along the protocol pathway. Whether or not this is legal
remains to be decided. In January of this year, the University of
Michigan law program filed suit against CMS for failure to address
the hepatitis problem in that state. If their case is successful,
similar lawsuits may follow in other states. Until then, however,
the policy stands: No testing, no treatment.

"CMS is an HMO with a captive audience," says David Santacroce,
the professor who is spearheading the Michigan lawsuit. "The fewer
patients they treat, the more money they make."

"This is deliberate indifference," adds Michael Steinberg, legal
director of the Michigan ACLU. "There is a standard for testing
and treatment of hep C that the Centers for Disease Control came
out with, and CMS simply is not heeding it. It's not just hepatitis,
either. You talk about the tip of the iceberg! There is a systemic
problem of not providing good health care to prisoners. Hepatitis
is the tip of it, but there's a long list of issues below the
surface that we haven't even begun to address."

Some of those issues have been addressed in other courtrooms,
however, in other states, by other groups, and taken as a whole,
the litany of malpractice crimes committed by CMS doctors begins
to read like a horror novel. Take the inmate in Alabama who died
of dehydration and starvation in a CMS infirmary after receiving
care that one medical director described as "nonexistent" and "a
gross departure from medical community standards." Or the inmate
in the same state who died when CMS staffers injected him with the
wrong medicine, Or the CMS doctor in New Mexico who testified that
he was required by the company to prevent off-site referrals. Or
the district judge in Idaho who found that an inmate's care in the
state prison "more closely resemble[s] physical torture than
incarceration." Or the inmate in Nevada who died because a CMS
doctor canceled her prescription for insulin. Or the federal judge
in Michigan who described CMS follow-up care as "bureaucratic
purgatory." Or a U.S. Justice Department inquiry in Virginia, which
found that CMS medical records "failed to meet any known professional
standard." Or the district court monitor in Georgia who found that
CMS ran a "medical gulag" in the state prisons, giving one prisoner
ibuprofen for his lung cancer and making another wait ten months
to see a doctor for a broken arm.

Yet, perhaps because juries so rarely award money to convicts,
there is essentially no incentive for lawyers to bring these crimes
together into a comprehensive, class-action lawsuit. Without the
lure of a large settlement, most trial attorneys are unwilling to
fork out millions of dollars in research and lost wages to fund
such a massive endeavor. As a result, the central figure in the
movement against CMS is not a major national law firm or even a
renegade lawyer, but an aging, confrontational activist named Karen
Russo.

I met with Karen, who runs a prisoner-advocacy group called the
Wrongful Death Institute, one evening last winter at her home in
the suburbs of Kansas City, and she invited me inside to sit at
the small wooden table in her dining room, where we ate meat loaf
and potatoes while her three dogs scurried around and her teenage
kids and their friends traipsed up and down the stairs. Karen was
undaunted by the chaos around her. When she had finished eating,
she smoothed her dark brown hair behind her ears, sat back in her
chair, and, as if she were in an office or behind a podium, she
cleared her throat, blinked her heavily painted eyes, and launched
into a tirade against CMS, her voice ringing through the house
fervently, sometimes furiously.

"They don't want anyone to know what's going on in these facilities,"
she said. "Getting medical records and company documents is like
going up against Fort Knox. We have to resort to all sorts of
methods. We have a network of prisoners across the country who have
ways of getting paperwork out to us, a couple of pages at a time.
We have nuns who go in and bring documents out with them. We have
nurses, doctors, whistleblowers. It's a war for information, and
CMS knows it. They're just waiting to take me out. They hate me.
Every Monday at noon I do a radio show on a local station, and it's
like a fireside chat. The CMS headquarters is just over in St.
Louis, so they have people listening. Everybody wants to know,
'Who's she going to get today?' And it could be anyone. I could go
after a nurse, I could go after a doctor, I could go after the
corrections staff. And I've gone after all of them. I'm putting
together a file on every one of them. I call out their names on
the air. 'Nurse so and so, I want you to know that I'm onto you.'
And the prisoners are listening, too. This thing is growing like
wildfire. A couple of years ago I was getting maybe two or three
letters a week; now it's anywhere from twenty to thirty letters a
day, from all over the country. Of course, some of those are from
CMS decoys. That's what they're doing now -- they get offenders to
write me letters that say, 'I'm not sick, but I heard about what
you're doing and I was just wondering how you got started,' and so
on. You know, just dripping with it. They want to know what I've
got. But I'm not naive: I can see right through that; I can smell
it. They're scared, and they should be. We've got them. I know
what they're doing."

Karen's invective seemed over the top, but she was the genuine
article: a nearly obsessive crusader who had long ago discarded
any semblance of a normal life in favor of late-night phone calls
with sick inmates and interminable afternoons poring over their
medical records. The dust on her antique piano had become so thick
and sticky that it made my eyes itch after only a few bars, and
the ceiling in her bathroom was crumbling to the floor. Yet Karen's
memory was immaculate; she had converted herself into a database
of detail, packed with accounts of prisoners met, their medical
histories, life stories, and extraneous personal minutiae. To
reinforce this glut of information, the back rooms of her house
were stuffed with thousands of papers, most of which she could
locate and produce within a few frenzied moments. When pressed,
she could also furnish names and numbers for a whole range of
sources, including guards and activists and prisoners'family members
(though she was more reluctant to reveal others, such as the nuns
and nurses she claims to consult). In her utter submersion into
the topic, Karen had even developed a personal bond with one of
the prisoners, a man named Raymond Young, who was locked up nearby
on drug charges and whose persistent back problems and hernias kept
him in a wheelchair, but who gave off an almost eerie radiance on
the day I met him, with a great, black, bald head that shone like
an eclipsed sun and a grin full of golden teeth inscribed with the
numbers 3, 3, and 1/3. ("Thirty-three and a third," he said in a
gravelly whisper. "I'm a traveler. A lone traveler.")

On the night I visited Karen, however, she took me to meet a
different friend, Leland Hunley, who had only recently been released
from the prison where Raymond is housed. When I saw Leland's
apartment, it was hard for me to imagine that he was any more
comfortable than he had been on the inside. His building, an
indistinct brick high-rise, was in the kind of neighborhood that
most middle-class people choose not to know about. There were crack
dealers selling openly and loudly on the corner and drunks fighting
in the street. The Plexiglas front doors were smeared with random
grub and old graffiti, and the spun-polymer carpeting of the lobby
seemed almost melted across the floor. Up the clattering elevator
a few floors, down the narrow, echoing hallway, Leland's door opened
into a single shabby room where he sat in a wheelchair watching a
fuzzy television set that was on top of a little table above a
small collection of right-footed shoes. Leland's left leg was
missing.

"Come on in," he mumbled to us, pointing toward a couple of chairs
and wheeling himself around beside them. I sat down, and we made
small talk for a minute, then Leland cut to the story. "Basically,
what happened was, I was living on the bay," he said. "That's the
common area. It wasn't meant to be a living quarters, but the rooms
were all full, so they had to put about thirty or forty cots in
the bay, and I lived on one of them. I was there for about a year.
The whole time, they never turned out the lights. But anyway, I
was getting up for breakfast one morning and I reached over and
put my sock on, and I felt a sting. So I pulled the sock back off
and a spider run out of it. Well, I stomped it. I knew it was a
brown recluse, pretty good size, so I scooped it up on a piece of
paper to bring to the infirmary."

Leland shook his head at the memory and ran a bony hand over his
short white hair. "But see, you can't just walk into the infirmary.
You've got to fill out a whole deal called a Medical Service Request,
and then they'll call you whenever they get to you. By the time I
got up there, it was a couple hours later. The bite was swelled up
to the size of a quarter. I showed it to the nurse, and she put a
salve on it and sent me back. I mean, you could just took at it
and see that it was going to get infected. It was swollen, throbbing,
hurting like crazy. So a couple days later, I put in to go back,
and she soaked my foot in a solution. It got to where she was doing
that every three or four days. I would put up an MSR and she'd soak
it and wrap it up again. I could tell it wasn't getting better,
but I wasn't allowed to look at it or anything. I could get a
conduct violation if I took the bandage off. Every time she unwrapped
it, though, it looked worse. It was a big black welt on top of my
foot, with a red hole in the middle. After a while, you could see
my bone through the hole. It kept opening up more. At one point
they had a doctor to lance it and drain out the pus. It looked like
it might get better after that, but it didn't. It just swelled up
more. Eventually, my whole foot got black. It was just a big black
scab. That's when they started giving me antibiotics, but it was
already too late. I couldn't even walk. Finally, the nurse took
off the bandage one time and just run out of the room. She was
really upset. I don't know what she told the doctor, but it wasn't
a matter of a day before they was taking me to the hospital. The
doctor said, 'I'm gonna have to take it off.' There was nothing I
could say at that point. He told me, 'If you refuse, it'll kill
you.' So I said, 'Okay, take it off."'

At fifty-eight, Leland couldn't have weighed more than 120 pounds,
with knobby shoulders and elbows and a thin wisp of a neck. He
rubbed his knees while he spoke, hunched over in his wheelchair,
weak and almost emaciated. Toward the end of the interview, Karen,
who had been struggling to remain silent, broke in to ask if he
was okay. "You look like you're losing weight," she said.

He shrugged. "Well," he said. "You know, I can't get to the store
by myself."

To someone on the outside, what happened to Leland's leg might
sound, at the most fundamental, instinctive level, like a blatant
case of malpractice. The notion of losing a leg to a spider bite
has no place in the modem sensibility, and the suggestion that a
person wait several weeks to receive antibiotics for an infection
is almost unthinkable (though Leland's medical records confirm it).
But like so many other things in prison, the term "malpractice" is
inscrutable. On the outside, if a doctor does not conform to certain
standards of care, then he is guilty of negligence, plain and
simple, and finding a trial attorney to sue him is no challenge.
By contrast, in prison, mere negligence is not necessarily enough
for a lawsuit. Most prison malpractice cases are filed under the
Eighth Amendment, which guarantees protection from cruel and unusual
punishment. Unfortunately, in order to convict a prison doctor
under these terms, the inmate must prove not only that the doctor
provided substandard care but also that he did so intentionally.
This rather elusive criterion is called "deliberate indifference,"
and under its protective banner a prison doctor is free to be as
negligent and irresponsible and incompetent as he wants, just as
long as he is not intentionally causing patients to suffer. Needless
to say, this makes the practice of prison medicine significantly
harder to regulate, and the care of patients harder to ensure. What
could be more difficult to prove -- or more secret -- than a man's unstated
intentions?

While I was visiting Karen and Leland in Kansas City, I placed a
call to CMS headquarters in St. Louis, hoping to interview someone
there. I did not have high expectations. I had already called
several times from my home in New Mexico (another CMS state) trying
to arrange interviews with hospital administrators and doctors and
nurses, but I had mostly been ignored. On those occasions when my
calls were returned, the CMS spokesperson had, in an exasperated
tone, made it clear that virtually every member of his medical
staff was far too busy to spend time with reporters, and that
furthermore this would remain the case indefinitely, no matter how
flexible my schedule was, no matter when I offered to visit. The
timing, he explained, was simply awful, and it was not likely to
get any better, ever.

Still, I held out some hope. Calling from within the state, I
figured, would seem more real and immediate to them; and besides,
I was no longer planning to ask for interviews with medical staff,
or even company higher-ups, but to settle for a sit-down with the
spokesperson, which seemed like a modest request, to say the least.
I had even begun looking forward to that interview, wondering how
the spokesperson might respond to the accusations I was hearing.
I could imagine that some of his points might be reasonable.
Certainly, prison medicine must be difficult to administer, and I
assumed that the spokesperson would be eager to point out just how
difficult, and to illuminate the challenges of working with convicts,
of sorting through faked illnesses and phony requests for medicine,
ornery personalities and violent outbursts.

But when Ken Fields, the spokesperson, called me back, and I
mentioned my desire to visit, he didn't sound nearly as eager as
I had hoped.

"What do you want to talk about?" he asked. "How were your interviews
with inmates?"

I explained that most of them were angry at CMS, which was why I
wanted to get his point of view. "I think we're going to have to
handle this on the phone," he said. I suggested that it would be
preferable to meet in person, since I had met the inmates in person
and didn't want them to have an advantage, but he replied, "We've
had bad experiences with the media." I assured him that I knew
this, yet I felt that, as a member of the company's communications
team, he needed to communicate the company's message, but he
insisted, "I can't do it this week. I'm too busy." I offered to
return the following week, but he repeated that he preferred to
speak on the phone. So I repeated my preference to meet in person,
and he repeated that he was too busy. Then I repeated my offer to
return, and he repeated his preference to speak on the phone. So
it went, until finally, perhaps just to stop the routine, he barked,
"Welt, I don't want you to come back here. Why don't you just stop
by tomorrow?" I agreed and we hung up, but a couple of hours later,
I found a message on my voice mail from Fields, saying that he had
decided not to meet with me in person.

"It's a situation where we have been misquoted at times in the
past," he said, "and we're gonna respond to your questions in
writing. So I wanted to give you notice of that. Thanks, bye."

But even in response to written questions, Fields was hardly
forthcoming: of the fourteen questions posed, he offered only eight
complete answers. For example, he was willing to provide rudimentary
statistics about the company, such as the total number of patients
under CMS care, but would not describe any company protocols or
reveal how much money the company actually spends on patients,
except to insist that, of the more than half a billion dollars that
CMS receives in taxpayer money each year, a "very, very significant
portion goes to patient care." Although he was quick to claim that
all CMS doctors and nurses are licensed in the states where they
work, he dodged the question of how many have been suspended or
had their licenses revoked in the past or in other states, insisting
that the company is "not obligated" to reveal those statistics.
Nor would he answer the question of whether or not the company has
any plans to begin screening for hepatitis, claiming that CMS leaves
those decisions to state legislatures and individual doctors, a
claim contradicted not only by the company's detail-heavy and
restrictive hepatitis pathway but also by the internal communications
of its regional medical director.

Since CMS officials were declining the chance to meet with me, or
to set up interviews, or even to talk on the phone anymore, I
decided to contact some of their employees directly. This turned
out to be easier than I expected. Nurses tend to know one another,
and after speaking with a few nurses who didn't work for CMS, I
was able to reach a few nurses who had once worked for CMS and,
finally, nurses who still do. At the very least, I hoped they would
take the time to reassure me that the gritty standard of "deliberate
indifference" was not being met; that nurses and doctors were not
intentionally ignoring their patients. But what I heard from CMS
nurses was, in many ways, more upsetting than what I had heard from
inmates. One conversation in particular stands out.

I had reached Christy through a series of referrals by other nurses
and their friends. At first, she was anything but eager to speak
with me. Her relationship with CMS was still good, and she didn't
want that to change. Although she was no longer working in the jail
in the northern United States where she had been a CMS supervisory
nurse for half a decade (she had left to manage a hospital facility),
she was considering a return to the company and didn't want to
jeopardize her ability to do that. The money was good at CMS, she
explained, and besides, she didn't need them as enemies. But after
thinking about it and talking with her friends, Christy decided to
speak with me anyway, mostly because, as she put it, she needed to
tell somebody what she had seen and done, especially what she'd
done.

I was immediately drawn to Christy's story, even before I had heard
the details. As a supervisory nurse, she had been the highest-ranking
member of the medical staff on duty, so she had been privy to many
of the political and economic machinations behind company policy.
I was also interested to hear about jailhouse medicine in general.
People in prison, after all, have been convicted of a crime and
have forfeited some of their rights (the right to vote, the right
to own handguns, etc.), but most people in jail are still awaiting
trial, and they haven't necessarily been convicted of anything.
Not only have those awaiting trial not forfeited their rights; they
are still officially innocent. Our legal system takes great pains
to insist on this, so I was curious to know whether or not it made
any difference to CMS.

The short answer, according to Christy, was no. "The way we treated
inmates was a horror," she said. "Whenever a new inmate came in,
they would have to see me, and I would assess their medical condition.
If it looked like they were going to require any kind of serious
treatment, I would go to the lieutenant and explain what I felt
the cost of the treatment would be. I would say, 'We have this
person here, and the treatment is going to be horrendously expensive.
We need to get them out of here.' If they were a real serious
criminal, like a murderer, the liability was high, so they would
keep them under arrest and we would incur the cost of treatment.
But if the lieutenant thought the person was not a serious risk to
the community, he would proceed to get hold of judges and other
people to try to release the inmate, or make arrangements to get
the bail lowered. The lieutenants would often call judges late at
night and on holidays to tell them the situation, then we would
release the inmate and take them to the hospital, so CMS wouldn't
incur the cost of treatment. The lieutenants went along with it
because they didn't want to incur the cost of a deputy to stay with
the inmate in the hospital. So we would let them know, and they
would make a call and release the inmate, then they would take them
to the hospital. After the inmate got their medical treatment, we
would immediately rearrest them.

"We did this frequently also with pregnant inmates. If they vent
into labor, we would release them or give them a signature bond,
then rearrest them and the child was put into the custody of child
services. I did that for years. You just ignore what you're doing.
The whole atmosphere of the jail was, these criminals, these
convicts, these scumbags, they get what they deserve.

"Appointments were made for weeks or months down the road, knowing
that the inmate would not be there anymore. Or we would make
appointments for days that we knew the inmate was going to be in
court. They don't keep the trial dates in the medical file, but
you just call the booking desk up front and ask them when the trial
date is. Then you make their next appointment for that date. We
were told to tell them, there was a canned phrase, 'Don't worry,
you have an appointment. We just can't tell you when it is because
of security reasons.' So you would be consoling someone, knowing
full well that they weren't going to get to see anybody. You just
put them right back at the bottom of the list again.*

* In response to these claims, CMS wrote, "Correctional health care
staff make every effort to work with corrections agencies to
coordinate such offsite trips in ways that do not create conflicts
with scheduled court appearances."

"It was absolutely appalling, to the point that I can't even tell
you. You knew that as long as you worked there, you did not challenge
any of it. But your disgust builds as the horrible cases build.
Even though a good majority of these people ended up being guilty,
I just felt from a moral standpoint that it was wrong. They always
play up, 'Well, look what they did to this other person,' so a lot
of people say, 'Okay, justice is served.' But the way I feel is,
we've all taken an oath and we have a license, and just because
one person has died, that doesn't mean that a second person dying
or being denied care ... one doesn't justify the other. As far as
I'm concerned, if you're sick and you get into one of these places,
you might as well be signing your death certificate. Even if you
don't have a death sentence."

The more I spoke with nurses like Christy, and looked at inmate
medical files, and studied infectious-disease statistics, the
clearer it became that, no matter where you looked or to whom you
spoke, this was a medical system run amok, one that not only ignored
sick patients but was actually skirting the limits of the law and,
in the process, helping to unleash an epidemic on society. As one
nurse put it bluntly, "We have no accountability. If I deny care,
that's it. You have no recourse." Yet the clearer this reality
became, the more baffling it seemed. Wasn't anyone keeping track?
Where had the media been?

In the course of nearly a decade, only two newspapers had undertaken
major investigations of CMS, and both were located in Missouri,
which has become a kind of ground zero in the debate over prison
medicine, largely because CMS is headquartered there. Even more
discouraging, the reporters who wrote those stories had, in the
aftermath of their work, become just as tortured and frustrated as
everyone else who confronts the company. Not long ago, one of them
agreed to meet with me in the basement of his office, but within
the first two minutes of our conversation he insisted that I keep
his name out of my story. In the weeks after his articles appeared
in the Columbia Daily Tribune, he said, he had been under attack
by CMS lawyers and publicists, who deluged his editors with
denunciations, and he didn't want to be perceived as settling the
score. He sat nervously with me, fidgeting, smiting, and trying to
be as helpful as possible without getting further involved.

The other reporter I spoke with was less reserved, but only because
he had less to lose. He had already lost it all. In 1998, Andrew
Skolnick had been an editor at the Journal of the American Medical
Association, a recent recipient of the Harry Chapin Media Award,
and an inaugural fellow of the Rosalynn Carter Fellowship in Mental
Health Journalism, which is a $ 10,000 grant. Using these lofty
connections, he had managed to get himself and two journalists from
the St. Louis Post-Dispatch into CMS facilities, where they spoke
with several inmates and doctors before publishing articles in both
JAMA and the Post-Dispatch, revealing a national pattern of abuse
and neglect by CMS. As the organizing force behind both projects,
Andrew had helped expose several CMS doctors with checkered histories
and had revealed more than a dozen cases of egregious mistreatment,
some of which resulted in death. One story revealed a memo from
the medical director of the New Mexico corrections department
explaining that several prison doctors had q it because CMS
administrative officials were "changing physicians' orders and
adding orders without seeing the patient or consulting the physicians
directly." Another story exposed a CMS doctor in Alabama who had
been convicted of having sex with a sixteen-year-old "mentally
defective" patient in Tennessee. Another described the chief of
mental-health services for CMS in Alabama, whose license had been
revoked in both Michigan and Oklahoma after he was found guilty of
sleeping with patients, harassing female staff members, and defrauding
insurance companies. The newspaper series had won awards from both
Amnesty International and the American Medical Writers Association
in the late 1990s, but even still, looking back, Andrew said that
he wasn't always certain it had been a good idea to publish it.
After the articles appeared, he told me, CMS had sent a letter to
JAMA, accusing him of hiding his involvement with the Post-Dispatch,
which they called "fraud," and threatening to sue the journal.
Within a week, JAMA had fired Andrew and, although CMS later paid
him to settle a defamation lawsuit,* his professional life never
quite recovered. Even today, the editors of JAMA refuse to comment
on "the conditions surrounding his termination" or to defend his
award-winning exposé, which has never been refuted or retracted.

* According to CMS, "Company attorneys determined that a small
settlement of Mr. Skolnick's baseless' claim was less expensive than
the cost of ongoing litigation. "

"I had an exploding career," Andrew told me, "and it crashed. We
may have won some awards, but the horrible fact is we lost. CMS
won. After the articles appeared, they went to the state legislature
in Missouri and protected themselves. They got a law passed expunging
the records of physicians who are accused of malpractice in
correctional facilities. So now, anytime the medical board doesn't
take action on an allegation they disappear it. This means no
pattern can emerge against a doctor. That is our legacy. That's
our achievement. We actually made it worse."

But Andrew's investigation had a resonance far beyond that. It was
his work that started CMS down the path of information lockdown,
building barricades to public scrutiny, hiding numbers and statistics
and the names of employees, refusing even to sit for a formal
interview, and stifling the efforts of journalists to cover the
field at all. Andrew's series had put pressure on CMS, but that
pressure had only deepened the company's aversion to publicity.
CMS officials were happy to continue operating with public funds,
but they were no longer willing to provide any serious accounting
of them.

Like almost any wound, the weakness of an institution festers
without proper attention, and as CMS has retreated into its shell,
its facilities have only grown worse. Outside of anecdotal evidence,
however, it is difficult to assess exactly how much worse -- it is
nearly impossible, for example, to know how many doctors and nurses
it employs, or how adequate its facilities are, or even what pathways
and protocols it adheres to. Few lawsuits have managed to expose
details of the company's inner mechanisms, and aside from the
Michigan hepatitis suit there is no major legal action pending
against the company at the moment, only scattered individual
lawsuits -- the great majority of them, it is safe to say, doomed. In
Massachusetts a small network of attorneys has been threatening to
file a comprehensive class-action suit, but nothing has gained much
traction so far. And although the U.S. justice Department has
reportedly kept an open file on CMS since the mid-1990s, collecting
evidence and reviewing cases, no formal charges have been leveled
against the company, and sources say it is not a high priority in
the post-9/11 climate. Even Karen Russo has her doubts that CMS
will change. "It's not going to happen," she says. "They don't want
to be rehabilitated. They probably can't be rehabilitated. So the
only solution is to get rid of them, and they're going to fight
that in every state, at every step. They're going to use all their
money and power, and they have a lot."

But if the battle over prison health care is beginning to seem
lost, littered with the bodies of the wounded, the sick and sickened
alike, with inmates and nurses and journalists by the wayside, if
the whole field seems deathly unwell and bordering on hopeless, it
may, in the end, have more to do with the way we look at prisons
in general than with anything CMS has done. This is not to obscure
or to apologize for the company's failures and crimes. It is simply
to suggest that the secrecy afforded to prisons would be easy enough
to strip away. When we, as a culture, choose to see our prisoners
as a part of our society (which they are, of course, and an ever
growing part), when we remove the wall of secrecy that surrounds
the prison itself, when we are willing to face and bear witness to
the punishments we disburse, there will be no more need to wonder
what is being done on the inside, in our names.

homepage: homepage: http://www.harpers.org

US Prisoner Healthcare among the worst in the 1st world 29.Aug.2003 16:22

xyz

I wholly agree that the healthcare that prisoners in the US receive is among the worst in the "1st world". I do, however, have a letter to share and a few comments about inaccuracies in the initial statement.

First my e-amil from a friend rec'd earlier this week (I've withheld identifying info for his family):

" I came to cover a conference and to see family, including my brother, who
I hadn't seen in five years. He had been in prison in [state] and had just
succeeded in getting transferred to his home state. I was going to see him
yesterday.

But he died in prison on Thursday. Fell over dead of a burst aneurysm. He
had been complaining of sudden severe headaches, had asked the prison
medical staff for a Cat-scan, and they gave him aspirin. He was a couple
of months from getting out, after spending about the last 3 1/2 years
rotting down in [state]. (He got convicted of burglary there in 1991,
served a prison sentence, got out on probation, returned to [home state],
where he continued to get in minor trouble, [state] would then drag him
back, let him rot in county jail for a few months, then kick him back out.
The last time he got in trouble here, he got a prison sentence here, then
when he finished that, [state] dragged him back again and resentenced him
to more time than his original sentence! He was doing that time when he
died. Did any of that do the state of [state] any good?) He was waiting to
see his kids, but he never got to. I went and saw them last night. It was
heartbreaking.

I'll be looking into the adequacy of his medical care here. If I find that
there was negligence or indifference, which is a pretty good bet, we will
go after those guys. The health care of prisoners is a national scandal,
or at least it should be, and if my brother died because of that, I'll do
everything I can to ensure that doesn't happen to other people.

In the meantime, we bury him on Friday. I will speak at his funeral. I
feel like I need to. He was my little brother, and he wasn't as slick as
me, and he lived an outlaw life. I will talk about how he got trapped in
the criminal justice system and how that was a tragedy, but I don't want
to seem too tragic. You know, he got to ride with the Bandidos and the
Outlaws, go on those road trips with the Harleys rumbling and the wind
blowing through his hair. And we enjoyed many a good time together.

We'll send him off with a packed bowl, a pint of Jim Beam, and a pack of
Camels. I've also got my daughter [xxx] on the hunt down in [Texas] for
some "Law Stay Away" candles. I think we'll burn those during the viewing.
And by God, we'll have the [name withheld] Memorial Kegger Friday night.

I think he sums it up well.

In regards to the hepatitis case and the evil HMO...I have several comments as an RN, who has a husband with Hep C and a sister-in-law who dies of a ruptured aneurysm earlier this year:

1. For profit HMO's should be run out of this country. There are GOOD HMO's (read "non-profits") who don't have the dollar as their mission.
2. The writer's experience with Hep A has little to do with the course or treatment of Hep B or C. Get a vaccine for Hep A & B...everyone, if you can... there is none yet available for hep C.
3. The story indicates that the patient had had Hep B & C "sionce the 80's". There is no treatment for Hep B except, in limited cases, liver transplant. As opposed to Hep A, which gets you ill within a few weeks, Hep B & C don't tell you they're there until it's too late in many cases. 20 years is too late. The patient had advanced liver failure clinically. No biopsy required. Hep C treatment wasn't going to help him.
4. The treatment for Hep C has been FDA approved for about 5 yrs or so. It's called interferon, can is sometimes combined with a medication called Ribavirin. Interferon is a naturally occuring substance, which when given "therapeutically" put all of the cells in your immune system on "marching orders". It is injected 3 times a week, and each time, the recipient feels like they have a severe flu... body aches, fever to 104F, insomnia. My husband did it and it nearly killed him. He got Hep C on-the-job (and had to prove it via the court system), so we didn't have to worry about insurance "co-pays" or cost. We did have to fight tooth and nail to have the treatment covered. At the time (5 years ago) cost was about $3K/month for the medication alone.
5. Liver biopsy releases are par for the course. Of course you sign away liability. That's what "informed consent" indicates. That's not just for prisoners. And again, the fact that he didn't get one doesn't indicate any kind of malpractice. It was already clear that his liver was in massive failure based on the fluid in his abdomen. That's the end stage of liver failure, not a sign of malpractice, per se. If you're not going to be a liver transpant candidate, there's really no reason at ALL to have your genotype done or a liver biopsy.

SJ, RN

i know someone who got messed up in jail 30.Aug.2003 11:14

me

I know someone who was taking Trizaone in prison. A know n side effect of it is a palpitizm, where the victum gets a painful and prolonged erection that lasts hours.

I know its weird, but this is a medical emergency. My friend had read the product info pamphlet on the outside and knew what was happening. He told the guards but thought it was hillarious that he wanted to see a doctor because he had an erection. He tried to get them to read the medicine's disclosure which explained that it was ESSENTIAL that he see a doctor within 4 hours, the sooner the better, if he had an unexplained erection while taking it.

He was literally screaming in pain. They left him like that for six days until finally they sent him to a nurse who glanced at the product info. Within 5 minuetes of seeing her he was on his way to the emergency room.

The doctors at the ER had no idea what to do; they had only seen cases in the past where people put up with painful unexplained erections for a very short time before seeking medical help.

Usually the cure would be a shot, in the arm, of an anticoagulant. That failed. They tried the shot directly in the effected area; no dice. finally they decided on surgery.

This was so unprecedented the doctors didn't know what to tell my friend. Even after surgery it didn't go down. It was about a week before he got out of jail when he got back from the hospital. The guards publicly embarassed him; lauging to everybody in his quad what had happened.

It was about time for him to get out, and literally for the first 2 weeks he was out of jail he had to walk around this way, with stiches from the helmet to his bunghole and an erection that was very painful even before the surgery.

After it went down he couldn't get it up for over six months. He very slowly recovered over the course of a year.

I never could convince him to sue, tho every lawyer we called said that he could of made millions. He's terrified that the guards would kill him if he ever went back in or even hunt him down on the outside.

i know this is prolly a little more gory that everyone wants to hear but it fits the topic i guess.

it was at inverness.