The Shame of Prison Health
A report is sitting at the Justice Department, unpublished. It has been there for two years. Titled The Health Status of Soon-to-be-Released Inmates, it was compiled by experts who sat on three panels: one on communicable diseases, one on chronic diseases and a third on mental illness. Their findings are, to say the least, somewhat startling. Estimating that 11.5 million Americans cycle in and out of jail or prison each year (the great majority of them short-term jail inmates), the report suggests that more than 18 percent of hepatitis C virus (HCV) carriers in the country pass through the jail or prison system annually, as do 8 percent of those with HIV and one-third of those with active tuberculosis (TB). Six percent of incoming inmates, according to the report, show evidence of recent syphilis infection, 6 percent have chlamydia and up to 4 percent have gonorrhea. Experts believe that for these diseases, the infection rates (the number of cases per 100,000) among prisoners are upward of ten times those found in the American population as a whole.
"It's clearly a public health issue," says Ted Hammett of the Boston-based research group Abt Associates. "These people find themselves in prisons and jails; therefore there's a tremendous opportunity for intervention."
Intervening would be a smart economic move, too. In tandem with the medical report, economists affiliated with the Centers for Disease Control were commissioned to write three background papers positing economic models for treatment and screening protocols inside prisons. Although their data also remain unpublished, one of the authors, CDC health economist Dr. Beena Varghese, reports that their models predict that for such a disease as HIV, offering screening to an additional 10,000 inmates will likely detect fifty new cases; counseling those who test positive will, their model estimates, prevent the disease from being passed on to four more people than would be the case absent such a program. Since the additional screening and counseling (minus the fixed costs already incurred for starting up a blood-testing program) runs to approximately $125,000, while the cost of treating four more cases of HIV/AIDS over the patients' lifetime is estimated to be $800,000, Varghese's team believes such screening to be extremely cost-effective.
The economists also predicted that universal screening of inmates for STDs and treatment for those who test positive would curb transmission of diseases like syphilis when inmates return to the community and thus save the public health system tens of millions of dollars per year. "You get a bigger bang for the buck," says one doctor involved in compiling the report. "If there's only one in a thousand, it's not very cost-effective" to screen all inmates. "But if you have a prevalence rate of more than one in twenty and you're able to cure the disease, you have tremendous costs saved."
In response to these dramatic statistics, The Health Status of Soon-to-be-Released Inmates, according to those with access to its contents, recommends a massively expanded data collection system that would allow public health authorities to track and treat infectious diseases among this population group (that is, of cons and ex-cons) and their friends and lovers out in the community. It also endorses a policy of universal hepatitis B (HBV) immunization for incoming inmates--as a way to limit the amount of liver disease in an at-risk group already deeply vulnerable to the often-untreatable HCV. And it urges a far greater degree of coordination between correctional health systems and public health authorities, so as to provide continuous medical treatment and adherence to treatment regimens, for patients both inside jail or prison and those recently released.
In interviews, recently released inmates describe a patchwork health system with gaping holes. At the Fortune Society in New York, ex-inmates with HIV gather in peer education groups, where their stories reveal widely varying degrees of access to medical care. Rochelle, for example, left New York State's Bedford Hills Correctional Facility in 1995 with an AIDS Drug Assistance Program (ADAP) card that gave her immediate access to the medications she needed for her HIV infection, and with contacts at a residential therapeutic community where she went to wean herself off drugs. Hector, by contrast, left his prison in 2000 with no ADAP card and only one month's supply of HIV medication. Carol, a resident of Bedford-Stuyvesant with a string of convictions behind her, took no medication for her HIV while in prison, and only began taking these lifesaving drugs when she was sent to Phoenix House upon her release. None of those in the room also infected with HCV had received treatment for it while behind bars.
When such nonprofits as the Fortune Society are not available to help ex-inmates navigate the medical bureaucracy, many never manage to access the public health system--because they do not know how to fill in application forms for Medicaid, because they lack the necessary identification to apply, because they have no permanent address. And even those who do successfully complete the process generally have to wait several months before their benefits kick in. "Public assistance is expedited for HIV sufferers to get these services. For people with other serious illnesses it's very difficult," explains Deborah Santana, risk-reduction services coordinator of the Osborne Association program in the Bronx.
"Once I was released, I had absolutely no medical benefits," says 44-year-old Edmond Taylor, who served fifteen years in New York prisons for drug-sales convictions. Taylor, a tall African-American man with a cleanshaven head and a gentle, expressive, bespectacled face, suffers from acute facial psoriasis. "I was released back to New York City with very little cream and no pills left. I had no way of getting any help." When he applied for Medicaid at a center in Harlem--after standing in lines for two afternoons straight--they told him his application wouldn't even begin to be processed for forty-five days. "So," says Taylor, "I found someone who had Medicaid and I got them to go to the doctor and ask for stuff I needed. I paid them. I know it's illegal. I needed to get it because it affected me in my facial area and forehead--which made me very uncomfortable to go look for a job."
Because this stratagem was illegal, Taylor could have been sent back to prison as a parole violator. As it happens, he was lucky. Instead of winding up in prison again, Taylor was eventually hired by the Fortune Society, and his job provides him with health coverage. "The systems in place are designed to have people go back to prison," argues Santana. "Because they make it so difficult for them to access the services they need."
"We're in an Internet society," Taylor says in amazed frustration. "Information gets passed in the blink of an eye. If they can pass information to society that you're violent, a threat, why can't they pass medical information and eliminate the red tape? There shouldn't be a forty-five-day waiting period [for medical coverage] for someone coming out on parole."
Perhaps not surprisingly, in an era when investment in public services has been sacrificed to the funding of corporate tax cuts and tough-on-crime, tough-on-criminals rhetoric has replaced the language of rehabilitation, the Justice Department has been in anything but a hurry to make The Health Status of Soon-to-be-Released Inmates public. And so the report, along with the economic background papers, remains unpublished, and public health continues to bear the long-term costs of dealing with diseases suffered by, and spread by, ex-cons without adequate access to healthcare behind bars or upon release.
With the economic effects of 9/11 producing across-the-board budget contractions, access to public health facilities in cities like New York could become even more limited. Transitional spending on the healthcare of ex-inmates may well decrease, at a moment when HCV is emerging as a huge epidemic with long-term public health implications, and when several million Americans per year are being released from jail or prison. "We should be looking at what public health opportunities there are for intervention," says Jack Beck, a New York legal aid attorney. "When they're in prison, they're a captive audience. When the opportunities aren't being exploited, that's tragic."
In part this is a story about the inadequate resources devoted to public health institutions in America, especially since the early Reagan years. But it is also about entrenched bureaucracies, each trying to protect its own turf, rather than looking at health issues in a holistic way. With HCV, for example, among such at-risk groups as AIDS sufferers, the disease is thought to be easier to treat, or at least contain, at an early stage than at a later stage, when liver disease has set in. For that reason, the CDC and city health authorities recommend testing all at-risk individuals, especially intravenous drug users, and then treating them depending on symptoms, the genotype of the disease and other factors. Yet, currently, even though many prisoners are in the early stages of HCV (in California, an estimated 40 percent of inmates are HCV-positive), prison health authorities are reluctant to test or treat them, either because it costs them money they don't have in their specific budgets, or because they fear infected prisoners would then seek legal redress, as some have already begun to do, in order to receive medication. When they do test, prison officials often proceed to put up almost insurmountable obstacles in the way of treatment.
In the majority of states, any inmate within fifteen months of a parole board hearing won't be eligible to start HCV treatment, even though most people who appear before a parole board are denied parole and remain behind bars. States also deny HCV medication to inmates with a background of intravenous drug use unless they are in a drug program--even if they are on a waiting list to get into one. (The National Center on Addiction and Substance Abuse estimated that in 1996 more than 840,000 prisoners needed drug treatment, yet fewer than 150,000 were actually enrolled in these programs.)
Moreover, because of official denial regarding the widespread use of drugs in prisons, policies that could contain the spread of HCV aren't implemented. Many European countries, including Germany, now provide needle-exchange programs inside their prisons, and until prison guards protested, policy-makers in Australia were heading in that direction. Some countries give inmates access to bleach so that they can at least disinfect their needles. American prisons do none of the above. As a result, although no systematic research project has yet been carried out exploring HCV transmission rates in prison, experts believe prisons are serving as incubators for the HCV epidemic, in much the same way they did for multidrug-resistant strains of TB in New York in the early 1990s and in Russia throughout the past couple of decades. Says Judy Greenspan, HIV/HCV coordinator for California Prison Works, "We estimate in California that 85 percent of prisoners who have HIV also have HCV."
Of course, when the inmates are eventually released with an untreated disease evolving from chronic to acute status, the public health system has to step in and pick up the bill. At that point, far more costly medical intervention is required, and the treatment is less likely to be successful. Says Dr. Hugh Potter of the CDC's National Center for HIV, STD and TB Prevention: "If we have substantial numbers progressing to the stage where they need [liver] transplants, we're going to see an incredible impact on the public health system."
For this reason, advocates such as New York legal aid attorney Jack Beck, some CDC experts and others in the field of public health have begun advocating a drastic overhaul of correctional healthcare, removing it from the budget of the Department of Corrections and instead making it the responsibility of the public health system. In particular, in a June 2001 paper for the Journal of Urban Health, Dr. Varghese and colleague Thomas Peterman recommended that the public health budget pick up the cost of expanded HIV screening and counseling for prisoners. Only in this way, they argue, can public health be protected from the spread of epidemics emanating outward from the prison system without the prison system itself going bankrupt because of exorbitant medical bills. In the meantime, the correctional health system and the postrelease medical care provided to ex-inmates continue to value short-term cost-cutting over long-term public health effects.
As a public health strategy, it's hard to imagine a more counterproductive situation. "The public health opportunity is that inmates are a group of people who have a highly concentrated morbidity for communicable diseases and mental illness," says Dr. Robert Greifinger, the former head of New York State's correctional medical system, and the man who helped coordinate efforts by the Department of Corrections and city/state health departments to tackle a serious TB outbreak in the early 1990s. In the absence of strong prison disease-tracking systems, Greifinger believes that "you can't measure the risk to the community--so you can't make good public policy decisions as to how aggressively to screen and treat."
When prisoners without treatment are released back into the community, they raise the risk of impoverished, medically underserved neighborhoods being struck by escalating health problems--such as that of the TB epidemic a decade ago, or today's spreading HCV epidemic.
The irony is that much of what the authors of The Health Status of Soon-to-be-Released Inmates are recommending, and much of the work that needs to be done in converting correctional healthcare into a branch of public healthcare, isn't revolutionary. In fact, needed healthcare reforms have already been introduced, piecemeal, in a handful of vicinities. For as America's incarcerated population quadrupled in size from 1980 to the present day, some enlightened sheriffs, wardens and correctional systems' medical directors realized that, paradoxically, this created an opportunity for a significant public health intervention. After all, those in jail and prison were at particularly high risk for such diseases as HIV, hepatitis and TB, and for many of these generally poor individuals, this was the first time they had ever had guaranteed access to medical services.
At the sprawling Hampden County Jail in western Massachusetts, for example, Dr. Thomas Conklin--a massive, ruddy-faced, 6'10'' ex-Louisiana State basketball player and longtime psychiatrist--heads a medical team of approximately thirty-five full-time and thirty-five part-time staff. His medical center is sparkling and new, looking more like a small suburban hospital than a jailhouse station. It contains a dental facility, an infectious diseases center, a state-of-the-art X-ray lab specially designed to focus on the identification of TB cases, a pharmacy, primary care rooms and a host of offices. And here's the rub: Through a careful accounting system, an efficient use of resources and a determined trimming of profiteering fat on purchases of drugs and other equipment, Conklin runs his top-notch system at approximately the same cost per year, per inmate as do other correctional healthcare systems throughout his state. (CDC economists are currently analyzing Hampden County's data to determine the exact scope of the program's long-term cost savings for the community.)
"This public health thing is an outgrowth of community corrections," says Conklin's boss, 62-year-old Sheriff Michael Ashe, a onetime social worker with the clipped manners and spit-polished leather shoes of a Marine (although he was never in the military) and a genuine vision for the role of corrections within the community. "Meaning simply the inmates come from the streets and neighborhoods of our county, and they're all coming back. We wanted to not just warehouse them. Law enforcement and social agencies should all work together in the interest of public safety. A lot of times, society has shortchanged itself. They throw their hands up. We haven't done that. We're continuing to fight the good fight."
Unlike virtually every other correctional center in the country, Hampden County doesn't rely on underpaid, often underqualified, overworked in-house docs. Instead, Conklin has contracted out with health clinics in the four ZIP codes in the greater Springfield area from which more than 90 percent of his inmates are drawn. Each of these clinics sends a doctor to the jail for a few hours a week, and inmates are assigned to the doctors by the ZIP codes from which they have come. Upon release, the inmates thus have a primary care physician already in place. (Conklin's early surveys of inmates indicate that prior to incarceration more than eight in ten inmates lacked continuity of medical care.) "Your doctor in jail is your doctor in the community," Conklin explains, his huge, bearlike hands gesturing in sync with his words. "If, for the first time, you see Dr. Lincoln, when you leave here he's your doctor. We have gradually shifted into what we call a public health model of care."
As a result of this program, inmates at Hampden County have an almost seamless transition from correctional to public healthcare. At Hampden County, any inmates over the age of 30, and any others who test positive for HIV or HCV, are immediately inoculated against HBV. If they are released from jail before the completion of this three-part inoculation, the community health center completes the procedure. If inmates test positive for an STD, the staff tries to get their permission to allow sexual partners in the community to be notified and then treated at the local health center. If Dr. Conklin has his way, in years to come, when inmates are released they will be given a "goodbye package" that includes condoms, educational materials, referral materials and a supply of discharge medications.
Unfortunately, Hampden County's program has not been taken up by other local governments, says Dr. Conklin, who travels the country as a member of a national commission investigating prison medical facilities. At Hampden County, all inmates, upon admission, are given a physical exam, urinalysis, liver-function studies, a complete blood count, chest X-rays and even, if needed, tests for such diseases as gout. "Many, many places where I go do nothing [like this]," Conklin declares, exasperated. "They don't want to know--because if they know, they gotta treat you." Jacksonville, Florida, is experimenting with a similar community-based approach to medical care; Atlanta's Fulton Jail has identified and treated large numbers of syphilis sufferers; Rhode Island's small prison system has pioneered continuity of care for inmates with HIV; Pennsylvania has introduced fairly widespread inmate testing for HCV; and, in the early 1990s, after the deadly outbreak of multidrug-resistant TB in its prisons, New York State developed an efficient mechanism for tracking and treating ex-inmates with active TB. But overall, correctional medical care remains a shambles across the country. With the exception of former inmates with HIV--who are supposed to leave prison with an ADAP card, giving them access to medicine and fast-track admission to the public health system, and who are frequently linked up with nonprofit advocacy groups upon release--sick ex-cons frequently drop out of the healthcare system altogether.
Clearly, programs that treat correctional healthcare as a branch of good public healthcare should be models for systems nationwide. And yet, as Massachusetts and other states face serious budget shortfalls, it is, tragically, programs like these--seemingly expensive in the short term, money-saving in the long run (not to mention humane)--that are facing huge cuts. Hampden County stands to lose upward of half its mental health dollars, and a project to expand HCV testing recently lost a $50,000 grant. Its AIDS-education program is also likely to be seriously undermined. "Our lifelines, our ties to the community, are going to be cut," Dr. Conklin says sadly.
"Public health funding, and the support network around it, are going to be severely impacted," Jack Beck asserts. "If the economic situation worsens, there'll be a rise in demand for public health services. There's a likelihood that inmate and ex-offender populations and poor communities are going to be suffering for some time to come."