Medicine Behind Bars: Quality Care Is Elusive, Despite Lawsuits : Hostile Public, Shortage of Good Doctors and Nurses Worsen Prison Problem

NEW YORK —  Medicine behind bars begins with the fundamental paradox of caring for misfits banished from a society that couldn’t care less about their well-being.

This and a heap of more specific problems add up to a constant struggle.

Doctors and nurses, in great demand in the outside world, must be recruited to work for civil service wages in steel-barred surroundings. The National Health Service Corps, a federal program that allowed doctors to pay off education loans by working in prisons, was dismantled by the Ronald Reagan Administration.

Convicts bring a hodgepodge of untreated ailments into prison. Overcrowded cellblocks sizzle with fear of AIDS, tuberculosis and other contagious diseases, and prisons are being forced to open costly geriatric wards for graying inmates with heart or lung disease and other chronic conditions.

One source of relief from many other societal ills, the state legislator, has been more likely to dole out condemnation than compassion for criminals--who cannot vote.

Inmates’ advocates say that quality medical care in prisons remains elusive despite court orders, national guidelines and more money grudgingly given.

“There’s a general contradiction in providing health services and locking people up in steel cages. Prisons deform everybody,” said Robert Cohen, former medical director at New York City’s Rikers Island Prison and an expert medical witness.

Armond Start, medical director of the Wisconsin prison system, added: “Prisons are the most anti-therapeutic places there are.”

Most Americans seem indifferent to what happens inside prisons.

“Prisoners are a pariah kind of constituency,” said Edward Koren of the American Civil Liberties Union. “We treat them like garbage. You leave it outside in the trash can and don’t want to see it again. Nobody cares--unless it comes back again.”

Minnesota inmate Henry Jackson, a 69-year-old sex offender who has diabetes and high blood pressure, said: “We’re just dogs. We’re nothing.”

Medical care for inmates is a legal obligation, however.

The Supreme Court ruled in 1976 that “deliberate indifference to serious medical problems of inmates constitutes cruel and unusual punishment.” The decision made prisoners the only U.S. citizens who are guaranteed medical care at government expense.

Having the right to care does not guarantee Mayo Clinic-style treatment, however. No federal or state authority has spelled out what constitutes adequate medical attention, so it remains a matter of court interpretation. Since 1982, only 10% of the nation’s 600 prisons have complied with guidelines offered by medical professionals.

The following court cases illustrate some of the problems in prisons since the guidelines were issued:

* Six inmates in a Pittsburgh prison died within the last two years under “appalling, shocking and dangerously inadequate” conditions, according to Cohen, who testified in May in a federal lawsuit brought by several inmates. Cohen said that one AIDS-afflicted prisoner died of pneumonia, a diabetic died from lack of insulin and the other deaths resulted from improper diagnoses and treatments of heart attacks and cancer.

* In Minnesota’s Stillwater Prison, a third of the 1,200 inmates and at least five guards contracted tuberculosis between 1982 and 1986. The first case was not diagnosed until six months after the inmate sought treatment, and corrections officials waited until two years after inmates filed suit to test for the airborne bacterium in the prison.

* A 25-year-old convict died in May, 1987, after suffering an asthma attack at Deer Island House of Corrections, a pre-Civil War lockup near Boston. According to a pending wrongful-death suit, the man was turned away from the infirmary at the 8 p.m. lockup, and the guards who dragged him to his cell ignored agony so intense that the inmate urinated as he was hauled up three flights of stairs.

* Hospitalized inmates from Rikers Island were shackled to bed frames and watched by guards until 20 months ago. Among them were AIDS patients, pregnant women and life-support patients.

“They were too ill to get out of bed, much less get out of the building,” said Dale Wilker of the Prisoners Rights Project, which sued to have the shackles unlocked.

* At New York’s Bedford Hills Correctional Facility for Women, several patients had to be hospitalized because dentist Donald Collings’ drill slipped in their mouths while he was drunk, according to a 1984 suit filed by the Prisoners Rights Project. Collings resigned and the state paid damages of $650,000.

Medical care remains a frequent topic of lawsuits filed by U.S. inmates, whose numbers reached a record 627,402 in January.

Courts have ordered eight states and Puerto Rico to improve the medical care in their prison systems, and are demanding corrective actions at individual prisons in 30 other states. Lawsuits are pending in five states, according to the ACLU.

Obvious Improvements

But there is unanimous agreement that prison medical care has improved since the courts got involved.

Robert Brutsche, who retired last year after 19 years as medical director of the Federal Bureau of Prisons, said the quality of care “improved by light years. The changes are like night and day.”

One indication of progress is the amount of money being dedicated to the problem. The states spent $80 million on prison health care in 1975 and $215 million in 1980, according to a survey conducted by the Associated Press. The costs this year will be about $1 billion, or about 8% of the $16 billion it costs to house inmates, according to national estimates.

Michigan spends the most, an average of $7.58 a day, for its inmates’ medical care, according to Corrections Yearbook. Hawaii spends the least, $1.14 a day. The national average is $3.57.

The tide began to turn 15 years ago, when federal Judge Frank Johnson found “barbarous” and “shocking” conditions in Alabama and for the first time placed an entire state system under federal control.

Judge’s Complaints

Johnson said that “unsupervised prisoners without formal training regularly pull teeth, screen sick-call patients, dispense as well as administer medication, give injections, take X-rays, suture and perform minor surgery.”

The conditions, which inmates’ attorney Matthew Myers called “symptomatic of a national crisis,” included these atrocities:

* A quadriplegic’s bedsores developed into open wounds and became infested with maggots. His bandages weren’t changed in the month before his death.

* An inmate who required intravenous feedings received no nourishment for three days before he died.

* An inmate who had suffered a stroke was forced to sit on a bench so he wouldn’t soil his bed. He fell so frequently that his legs became swollen and crippled, and he died a day after one leg was amputated.

Alabama improved conditions enough that federal control was lifted last December. One problem Alabama shared with other states was that unlicensed doctors were hired to practice on inmates. It was the first state to contract with a private company that supplied licensed physicians; now, all or part of medicine in the prisons of 29 states is handled by such contractors.

Doc Holiday Syndrome

“The norm 15 years ago was a broken-down doctor with an institutional license, someone who couldn’t practice on the outside because he was too old, too sick or an alcoholic,” said Dr. Jay Anno of the National Commission on Correctional Health Care.

At about the time the courts began demanding improvements, health-advocacy groups were reacting to conditions exposed through rioting at several prisons, including the 1971 uprising at Attica, N. Y.

In 1982, the National Commission on Correctional Health Care identified 71 minimum standards for medical care in prisons. About 60 prisons have met the standards.

The guidelines recommend medical screening of all incoming inmates, daily access to sick call, 24-hour nursing care in hospital wards and uniform licensing standards and regulation of doctors, nurses and other personnel.

While most state prisons now employ only reputable physicians, problems with doctors persist. Many facilities have hired graduates of foreign medical schools who understand little English.

Communication Difficult

“That doesn’t necessarily mean they’re quacks. Their English is terrible and they have a hard time communicating,” said William Rold of the Prisoners Rights Project in New York.

Prison doctors may also treat ailments for which they have no training. In the 1970s, a gynecologist did dental exams at Bedford Hills, the Prisoners Rights Project said. In another New York prison, a pathologist practiced general medicine and a pediatrician served as an internist.

Low salary is one of the biggest barriers to attracting doctors.

Hawaii, for example, pays prison doctors $35,000 a year--and a third of the nursing jobs in Hawaii prisons are unfilled.

“What doctor in his right mind would want to practice medicine for civil-service pay under harsh conditions for a group of patients that doesn’t like or trust him?” Curtis Prout, director of the internship program at Harvard Medical School, asked.

Or, as Dr. Ronald Shansky, medical director of the Illinois prison system, put it: “No one goes to medical school and says, ‘Boy, when I get out, I’m going to go to a prison and make my mark.’ ”