Feeling a lump in her breast, Sherrie Chapman, an inmate at the California Institution for Women, in Frontera, first raised an alarm to her assigned doctor in 1991, explaining her family history of breast cancer. The doctor belittled her complaints. Persisting, Chapman managed to score a mammogram two years later. The recommended follow-up took place in 1995, after another two and a half years. Outside doctors ordered an immediate radical right-breast mastectomy and the removal of four lymph nodes.
Shackled in a hospital holding room, Chapman curled up on a bench. "I tried to focus, not cry, not feel bad, not hurt--so many emotions running at one time, and nobody there to make you feel better at all," she says.
More troubles ensued. Postsurgery, guards signed her out against medical advice and confiscated her pain medication. Correctional officers ignored chemotherapy appointments. "There was a lack of care, concern, compassion, sympathy, anything," says Chapman. The cancer spread, and in 1997 Chapman had a left-breast mastectomy. Now 44, she says she can feel lumps on her neck.
"Whether [out of] willful disregard or [because] they just blew it off, her doctors did not follow rather standard practice," explains Yuri Parisky, director of breast imaging services at Norris Comprehensive Cancer Center of the University of Southern California. Chapman achieved one rare victory: She won a settlement from the state.
"It's hard not to feel outrage," says Ellen Barry, founder of Legal Services for Prisoners with Children, in San Francisco, which represented Chapman. "People would see this in another country and think it's a human rights violation. This is our own backyard."
Although the silent and insidious killers of women--breast, ovarian and cervical cancer--are finally commanding pink-ribbon attention and activism in the outside world, inside prisons, women might as well be living in the dark ages. Healthcare for prisoners, male as well as female, is decidedly subpar, but women face exceptional hardships in a system based on a military design, with young and healthy men as the treatment model.
The number of women in prison has risen rapidly because of mandatory drug-related sentencing, doubling the female population in ten years, to 162,000 in 2000. Yet women are easily forgotten in corrections, where they are only 8.4 percent of 1.93 million prisoners. Few women get the death penalty; many get damaging, even deadly, medical treatment. In the area of reproductive and breast cancers, prisons fail in prevention, screening, diagnosis, treatment, continuity of care, alleviation of pain, rehabilitation, recovery--and concern.
Across the continent from Chapman, in the Danbury Federal Correctional Institution in Connecticut, Susan Rosenberg faced the opposite dilemma in March 2000. A mammogram showed changes in breast calcifications. Rosenberg, a prisoner for sixteen years until she was released in January 2001, underwent a biopsy in chains, shackles and with four armed guards in the operating room. Afterward, the prison doctor verbally reported the results. "For a week, I thought I had breast cancer and was almost ready to have a mastectomy," said Rosenberg. A health advocate in prison and a political activist, Rosenberg demanded the pathology report, contacted lawyers and got a Congressional Representative to intervene. She discovered that she had "lobular carcinoma in situ"--a condition that requires close monitoring but not breast excision. After a second opinion (something rarely granted to a prisoner), the mastectomy was rejected. "I almost went and had a breast cut off unnecessarily," says Rosenberg. But most prisoners, she says, cannot round up the same resources.
"All other issues pale before the issue of physical and psychological health of women in prison. If women are dying, what does it matter what other programs there are?" says Leslie Acoca, a former researcher with the National Council on Crime and Delinquency and president of In Our Daughters' Hands, in San Francisco. It is, says Acoca, "a tsunami."
Fears about breast and reproductive cancers run high in prisons, as in society, but the diseases receive dreadfully little institutional attention. Egregious violations of women's medical care in general were documented by Amnesty International in a 1999 report, "Not Part of My Sentence," and Amnesty issued an alert in 2001 questioning the unexplained death of nine women in the California system.
Cervical cancer took the life of Gina Muniz, who was 29 and the mother of a 9-year-old. Muniz was diagnosed and treated for stage 2B cancer in pretrial custody in Los Angeles, according to her mother, Grace Ortega. Upon sentencing in June 2000, Muniz was sent to the Central California Women's Facility in Chowchilla. Chowchilla has a chilling reputation. A national consultant, speaking on condition of anonymity, described it as horrifying.
At Chowchilla, Ortega visited weekly, watching her daughter wither away--unable to eat, unable to walk, hurting. "That was the ugliest thing to see. It's so much pain in my life. They broke my heart. No one lifted a finger," Ortega says. When Muniz complained of severe stomach cramps, prison officers prescribed Metamucil. In late August, the prison rushed Muniz to an outside hospital, where intensive-care doctors found a large tumor in her bladder and her kidneys failing. She never recovered. A spokesperson for the California prisons declined to comment, and Ortega is still seeking explanations.
Effectively protected from public scrutiny, the barbed-wire medical system is uncoordinated, underfunded and has almost zero accountability. Doctors are ill trained and overburdened, and even competent ones can be trumped by correctional personnel. "It's like Alice going down into a rabbit hole," says Bonnie Kerness, a lawyer who directs the American Friends Service Committee's Prison Watch project in New Jersey.
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.
Gruesome stories roll out across the country:
§ In New Jersey, Margaret De Luca, 52, was sentenced to prison in April 2000 after having received a diagnosis of stage 3A breast cancer and a left-breast mastectomy. She endured eleven-to-fifteen-hour trips, sometimes without food, for radiation and chemotherapy. "Whenever I returned to this facility or needed medication for my pain, nausea, whatever--even though it was prescribed by the medical oncologist--I have to battle this staff to get it," she wrote in a letter. Her cancer has spread to vital bone areas, De Luca says. Lawyer Bonnie Kerness has sent thirty letters complaining about De Luca's treatment to Correctional Medical Services, the private corporation that has an annual $89 million contract for New Jersey's correctional healthcare. The company has contracts with more than 300 prisons and jails in thirty-one states.
§ In Chicago, Rochelle Bowles, former director of the transitional program Grace House, tried to sort out the medical records of a 52-year-old resident diagnosed with breast cancer shortly before her incarceration in fall 2000. Zero treatment or care had been provided in her six-month incarceration, and her condition worsened. "It boggles the mind," says Bowles.
§ After a review of more than 1,200 medical complaints of California women prisoners, professor Nancy Stoller of the University of California, Santa Cruz, reported scores of calamities. They included a woman with cancerous cells in her reproductive system who was denied a hysterectomy because of cost; a prisoner who underwent removal of a breast lump but had not received results; a doctor who broke a speculum inside a woman during a biopsy and used unsterilized pliers to remove it.
Recourse for the women is, unfortunately, limited. Copies of records are difficult to secure. Prisoners must file a formal grievance to appeal a medical decision, since healthcare is intertwined with strictly correctional functions.
To navigate the bureaucracy, lawyers are as necessary as doctors, but they too are handicapped. Prisoner advocates feel that judges let prisons off the hook, prematurely releasing them from complying with hard-won improvements in women's healthcare after legal settlements were obtained in Washington in 1995 and in California in 1997. Attorney Patricia Arthur in Washington says issues of inadequate care and chaotic staffing remain, and an appeal is pending.
In any case, under rulings of the US Supreme Court, no remedies are available unless prisoners can meet the monumental standard of showing that there was "deliberate indifference to serious medical needs." As the health concerns for women intensified with the prisoner influx of the 1990s, the federal government further closed courtroom doors through stiff hurdles to lawsuits via the Prison Litigation Reform Act of 1996, inscribing onerous pre-filing requirements, placing time limits on remedies and jacking up costs.
Advocates want to see women prisoners treated by the standards of acceptable medical care in the outside community. The mainstream National Commission on Correctional Health Care agrees, and even adopted the guidelines of the American Cancer Society and American College of Obstetricians and Gynecologists for breast and reproductive cancer testing and treatment.
Prisons, however, seem unwilling or unable to meet those standards. "If there is no means of redress, what would motivate them to want to treat you?" Fink asks. Deprived of adequate legal or medical recourse, and with hardly a nod from the flourishing and powerful women's health or breast cancer organizations, incarcerated women with health problems seem to have bleak prospects. "Part of me wants to see the silver lining, and it's hard these days," says Ellen Barry.
Cloistered inside the walls, Sherrie Chapman presses hard to send a message: "There are women with serious medical conditions, and they are scared to approach medical, scared of the repercussions. They'll tell you they have lumps in their breasts, in their thighs, all kinds of things. I've seen so many women die. It's really sad, you know?"