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."

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