By Jeff Stryker - 03/26/01 

Critics of the quality of health care services in California prisons filed suit last week in San Francisco Superior Court. They claim that California Department of Corrections (CDC) officials have failed to obtain required licenses to operate 33 inpatient clinics within the state's vast prison system, which houses more than 160,000 inmates. The suit was filed by a nonprofit firm, the Prison Law Office of San Quentin, whose representatives maintain that the lawsuit was necessary because of a rising tide of complaints about poor medical treatment systemwide. 

The lawsuit does not address quality of care issues directly by alleging, for example, any malpractice. The prisoner advocacy group decided to litigate over the issue of licenses because licensing standards cover a variety of measures related to quality of care, such as staffing levels, nursing care, medication procedures, and the layout of physical facilities. A similar suit against the California Youth Authority (CYA) prompted a San Francisco judge to direct the CYA to obtain licenses for all of its 11 health care facilities within two years. 

According to the most recent lawsuit, only five health care facilities for adult prisons are licensed by the Department of Health Services, as required by a state law enacted in 1996. Representatives of the California Department of Corrections maintain that only 16 of the 33 units deliver the type of health care services requiring state licenses. CDC spokespersons expressed surprise at the timing of the lawsuit, maintaining that the department is on track to secure licenses for the remaining facilities within 18 months. 

A String of Controversies and "Bipartisan Disgust" 

California spends approximately $4 billion each year to operate its prison system; it takes 43,000 employees to run it. California spends more on corrections than it does on higher education. In the past 20 years the state has built 21 new prisons and one new college. 

Prison health care in California has come under increasing criticism as the prison population has skyrocketed. Last October, California legislators heard testimony from women, confined in the Valley State Prison for Women in Chowchilla, who complained of medical mistreatment and neglect. Although the testimony involved harrowing anecdotes rather than systematic data, the prisoners' laments were enough, in the words of San Francisco's Bay Area Reporter, "to evoke bipartisan disgust." 

"What I heard today curdled my stomach," commented Senator Cathie Wright (R-Simi Valley). "It seems as though most cats and dogs are treated better," chimed in Assemblyman Carl Washington (D-Paramount), after hearing complaints of women testing positive for diseases and never being told. Inmates also complained of waiting years to be retested after the prison system discovered that BCL Clinical Labs of Santa Fe Springs in Southern California had faked hundreds of inmate HIV, hepatitis, and cancer test results, while working under contract to the Department of Corrections. 

Just a few weeks after the Chowchilla hearings, a Sacramento federal jury awarded a Livermore woman $1.5 million, the largest malpractice award in CDC history. The woman's son, Mark Holton (aged 20) died from an adverse reaction to a prescribed psychotropic drug while incarcerated at the California Medical Facility in Vacaville. 

At the end of last year, the prison system launched an investigation of seven inmate deaths in a single month at the Central California Women's Facility. Amnesty International had called for an investigation into the deaths, noting that "local prison groups who have visited the prisons have blamed the slow and shoddy medical care for at least some of the deaths." Deaths by themselves might not be remarkable; the facility includes a nursing home and hospice and at least four of the women were apparently suffering from a terminal illness. But critics allege that the women were not given adequate treatment once their diagnoses came to light. Investigations are underway into how prison staff responded to the women's complaints. 

CDC officials had pointed to the establishment of a hospice at Chowchilla as a positive step. Some activists disagree, maintaining that the availability of hospice care removes any impetus for granting compassionate release of terminally ill prisoners who are no longer dangerous to society. 

Double Agents 

Complaints about the string of deaths in Chowchilla highlight a controversial California practice: the use of guards as "medical technical assistants (MTAs)." Amnesty International charges "that the use of guards as medical personnel conflicts with their custodial role. Inmates have reported, for example, that the prison's medical technical assistants—guards who serve as the first line of prison health care—disregarded the complaints of one inmate, Pamela Coffey, less than an hour before her death." (Ms. Coffey, 46, died last December 2. Her fellow inmates charge that MTAs failed to respond quickly enough to her cries for help.) 

The marriage of health care and corrections will probably always be a rocky one. The goals of health care and corrections, if not entirely antithetical, are often at odds. The values health care workers seek to uphold—confidentiality, patient autonomy, and equitable access to care—are not necessarily shared by prison guards and administrators, for whom security and punishment are paramount concerns. Outside of prisons, medical ethicists have sounded alarms when doctors act as "double agents," owing an allegiance both to their employers and to individual patients, as in the case of doctors employed by corporations or schools who have employees and students as patients. 

The problem of double agency is nowhere more acute than in the prison setting. Prison systems in no other large states combine health care and guard functions so explicitly. Senator Sheila Kuehl (D-Santa Monica) has promised to introduce legislation to end the CDC's use of MTAs. 

Besides sorting out the competing demands of health care and corrections in the prison setting, there are any number of factors that pose challenges to delivering quality care within prisons. Confidentiality can be difficult to maintain within a prison setting; it can be impossible if certain inmates are sequestered for a particular condition, such as when HIV-positive inmates are segregated in some prison systems. Getting to see a doctor first requires following sick call rules and obtaining a guard's approval. Even with permission, securing access to needed services can still be a struggle; it is alleged that typical waiting times in California can be six weeks or more to see a doctor and eight months or more to receive dental treatment. 

Just as on the outside, prison health care officials are struggling with fixed budgets as costs rise, especially for pharmaceuticals. In many parts of the California prison system, inmates must pay a $5 co-payment before seeing a doctor. This small fee can be a considerable hurdle when a typical hourly wage for prison labor is 17 cents. Senator Kuehl has suggested doing away with the co-payment. 

Corrections Trends and the Impact on Health Care Needs 

The burden of delivering correctional health care is growing greater, largely due to policies the United States has chosen in embracing incarceration. The past two decades has seen a boom in prison building. The United States incarcerates a greater proportion of its populace than Russia; it is second in this regard only to Rwanda. More than 1.7 million people were either in prison or jail in 1998. In the United States, 690 per 100,000 residents are incarcerated; in Canada the rate is 115 per 100,000; and in Germany and Italy, approximately 85. 

Criminal justice and correctional policies have an impact on health care needs beyond just the sheer numbers of prisoners in need of services. Today, more of an emphasis is placed on punishment and repression than on rehabilitation as correctional goals. Judges are given less discretion in tailoring sentences to individual defendants. The prison population is aging, a result of trends in mandatory and life-long sentences, such as "three strikes" policies. Geriatric prisoners cost three times as much to take care of as their younger counterparts. 

Criminal justice policies also have an impact on the particulars of health care needs in prisons. Many inmates are current or former substance abusers, in need of drug treatment. A large part of the California prison population, as much as 41 percent by some estimates, is infected with hepatitis C, in part because of needle-sharing habits of inmates. Tuberculosis (especially its multi-drug-resistant strains) is of particular concern in prisons. California inmates, who enter the system at a rate of 60,000 per year, are routinely screened for TB. 

Differentiating between the Criminal and the Mentally Ill 

Other trends of concern are the defunding of many mental health services and the closing of many inpatient mental health facilities, resulting in more mentally ill people being caught up in the criminal justice system. Mandatory sentencing laws give judges less discretion in taking mental illness into account in sentencing decisions. The Bureau of Justice Statistics estimates that more than a quarter million mentally ill people are housed in U.S. jails and prisons; this translates into approximately 85,000 mentally ill prisoners in California. 

The influx of mentally ill people into the criminal justice system has a profound impact on life within bars. As prison activist B. Cayenne Bird editorialized in the Los Angeles Times last year, "Cells were built for one person, yet the inmates are jammed together because of overcrowding. To get a taste of living in a cell, go into your 8-by-10 foot bathroom for a month. Take a mentally ill person with you.... It puts great stress on inmates when their 'cellies' are mentally ill, so great that they must sleep with one eye open and be afraid for their lives at all times." 

Another trend bearing on the treatment of mentally ill offenders is the increasing reliance upon so-called "supermax" or "security housing unit (SHU)" facilities. These are isolation cells, typically six-by-eight feet, in which prisoners are held for 23 hours a day. These units are often operated by remote control; prisoners have human interactions only when guards deliver meals. Prisoners in control units are typically allowed three one-hour solitary exercise periods per week in small cement yards. 

As recently as 15 years ago it was rare for a prisoner to spend more than a month in isolation. Today, according to the National Campaign to Stop Control Unit Prisons, about 20,000 prisoners are confined in 57 supermax units in 42 states, including California. Studies of the use of supermax facilities indicate that they are used more than necessary to control the most dangerous of prisoners, the original argument for their existence. Control unit prisoners do not participate in educational, vocational, or religious programs. Reading and writing is one possible pastime, but many prisoners are functionally illiterate, a factor that heightens the sensory deprivation and imposed idleness. Isolation can literally drive prisoners crazy. Prisoners who exhibit extreme emotional disturbances as a result of solitary confinement may receive temporary treatment in mental hospitals, but are returned as soon as they are stabilized, often with medication. 

Looking Ahead 

Gauging the quality and accessibility of health care within prisons and other correctional facilities is exceedingly difficult. Many dedicated providers work in prison settings. Yet anecdotes of callous and indifferent care persist, with lawsuits opening windows on the darkest corners of prison health care. 

Many corrections officials and observers maintain that prison health care delivery in California has improved markedly, in part because of a previous class action lawsuit (Shumate v. Wilson), which helped set standards for medical care. But some of the provisions provided by Shumate have expired, worrying prison advocates. 

While it may take continuing litigation to ensure that prison officials live up to their obligations in providing health care for prisoners, other avenues for improving prison health care exist. One promising venture involves creating alliances between prisons and medical centers or teaching hospitals. Models for such alliances exist, such as the agreement between the Los Angeles County Sheriff's Department and the County-USC Medical Center to provide medical and surgical care in Los Angeles county jails. 

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