A pattern of failures across the nation points to systemic pathology. "Every single state will tell you women's healthcare is the top problem in women's prisons," says Lucy Armendariz, a former ombudsman for women prisoners in California, now working as counsel to the state's legislature. The federal government refuses Medicaid payments for prisoners, placing the entire burden on states. "And it's pretty much political suicide when you say, 'Let's give more money for prisoners,'" explains Armendariz.

A web of social, medical, legal and political circumstances conspire against the medical care of women inmates. "Women have gynecological issues that men don't have," said Nawal Ammar, an associate professor at Kent State University who researched women in Ohio prisons. "Women have issues of abuse that are different. Women have self-image problems. Women are more depressed. These are all issues that impact on healthcare in prison." Yet Ammar found Ohio institutions operating with an emergency-ward mentality, where systemic diseases can be pushed aside.

From the point of entry, women present more health problems. A 1997 Bureau of Justice study discovered that 30 percent of women in federal facilities reported a medical problem, compared with 23 percent of men. Poverty, substance abuse and lack of access to community healthcare all take a toll. "Pervasive and severe" histories of prior sexual and physical abuse affect 94 percent of incarcerated women, according to Angela Browne, a senior research scientist at the Harvard Injury Control Research Center of the Harvard School of Public Health. This factor alone complicates medical care. The National Commission on Correctional Health Care warned that sexual assault histories require special sensitivity in gynecological examinations and Pap smears.

Danger signals for cancer appeared to be pervasive in a unique comprehensive health survey of 115 women held in Connecticut's York Correctional Institution. "You can see they are at risk for cancer," says public health researcher A. Siobhan Thompson, who found that the women self-reported cancer at a rate six times the rate men did and had unusually high numbers of parental deaths from cancer.

Despite community attention to early detection and effective treatment as a strategy to prevent breast cancer deaths, screening programs are virtually nonexistent in women's prisons. In 1998 Roma Williams, then an associate professor at the University of Alabama School of Nursing, conducted one of the few correctional research projects specifically on breast cancer, in an unnamed Southern prison. Although she found women at high risk because of family histories, she learned that inmates were not provided with a clinical breast examination upon entry, information or basic education on self-examination. Seventy percent of the women who should have had mammograms under standard medical protocol had not been tested.

The federal Bureau of Prisons generally conducts yearly mammograms for women over 40, according to Susan Rosenberg, but that does not guarantee competent analysis. Liz Fink, a Brooklyn prison lawyer, says that misdiagnosis is rampant. "Medical care in the BOP is a scandal, a can of worms as big as a house," says Fink. One of her clients, Silvia Baraldini, was deemed fine after a mammogram in 1999. But when Baraldini, an Italian national, was transferred to a prison in Italy shortly afterward, doctors reviewed the same tests and detected cancer. Baraldini underwent a lumpectomy, removal of lymph nodes and chemotherapy. In contrast to US policy, prisoners with breast cancer in Italy are discharged, and Baraldini was sent home to recover in May 2001, although under restrictions demanded by the United States.

The medical complaints of women inmates are regularly ignored, according to Patricia Arthur, project director of the Columbia Legal Services Institutions Project in Washington State, which sued to secure acceptable healthcare for women in prison. "The presumption is 'you're not telling the truth.' Women are discounted, misperceived to be drug seeking or trying to get attention," says Arthur.

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