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.

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