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The Deadly Health Services of Naphcare in Alabama

It is often said that you can tell a lot about a society by checking the condition of its prisons. Based on the way prisoners in Alabama are treated (or, more accurately stated, not treated), citizens of that state have a lot to be worried about. With only a few months left to go on his sentence for marijuana possession, 43-year-old prisoner Timothy Oliff caught a cold that he just couldn't shake. Oliff's complaints went ignored by prison health care workers at the Elmore Correctional Facility until several days later when he became so ill that fellow prisoners had to carry him to the gate for emergency help.

Three days later Oliff died at the Montgomery Baptist South Hospital. Although neither prison officials nor hospital brass would comment on his death, Oliff's sister, Diane Aman, said doctors at the hospital told her he had died of pneumonia and had the worst stomach infection they'd ever seen. Aman also said they told her that prison health care workers had been too late in getting Oliff to the hospital for the emergency care he needed.

Also refusing to comment on his death are officials of NaphCare, Inc., the for-profit company that, until recently, had been contracted by Alabama to provide health care services for prisoners at its 13 correctional facilities. But while Naphcare's contract was going to be cancelled, its problems stemming from numerous lawsuits filed over the substandard and, at times, non-existent medical care they provided to their prisoner-clients, have not.

Oliff's case is just the tip of the iceberg as far as Naphcare and the Alabama Department of Corrections (DOC) are concerned. Not only does Alabama spend less on health care per prisoner-patient than any other state, the prisoner death rate in Alabama far outnumbers that of most other states.

High Prisoner Death Rate

A simple review of previously unpublished DOC statistics, obtained only after repeated requests by the media, reveal a death toll in Alabama prisons that is stunning when compared to rates in other states. The documents also revealed that the death rate has been especially high in the two years since Naphcare started delivering health to care to prisoners in 2001.

For example, in 2002 Alabama had 88 prisoner deaths out of a prison population of 24,000 excluding those in county jail awaiting a prison bed . In comparison, North Carolina had only 61 prisoner deaths out of a prison population of 32,000. Not surprisingly, North Carolina spends significantly more for health care per prisoner than Alabama, and does not use a for-profit company to do it.

According to the latest study from the U.S. Department of Justice, state prisoners across the country have been dying at an annual rate of 23 per 10,000. In each of the last four years, the Alabama death rate has exceeded the national average, and has risen above 35 deaths per 10,000 in three of them. Although these numbers exclude deaths by execution and include the occasional death by accident, suicide or homicide, the overwhelming majority result from illness.

DOC's own statistics show that the year before Naphcare took over prison health care, Alabama had 61 prisoner deaths. That number jumped to 87 deaths from March 1, 2001 through February 28, 2002, Naphcare's first year of the just-terminated contract.

In Naphcare's second year, which was completed February 28, 2003, that number rose again to 95 deaths. In that same year, as Alabama's prison population grew, so did the prisoner death rate, to 39 deaths per 10,000 prisoners, or nearly twice the national average. No other state had a death rate that high during 2000, the last year the Justice Department compiled state-by-state numbers.

Due to improved drug regimens, the HIV prisoner death rate has seen a sharp drop throughout the country in recent years. Not so in Alabama, one of two states that segregate HIV-positive prisoners. According to DOC statistics, Alabama had 12 HIV prisoner deaths in 2002, out of a HIV population of 280.

That same year though, Florida, with an HIV-positive prisoner population of 2,845, had 43 deaths, according to Yolinda Murphy, spokeswoman for the Florida Department of Corrections. Put another way, Florida has 10 times the number of HIV-positive prisoners than Alabama, but only three and a half times the number of deaths. Those numbers translate into a 4.3% HIV death rate in Alabama compared to Florida's 1.6%. And a report issued by Chicago-based medical consultants Moore and Associates showed an HIV death rate at Alabama's Limestone Correctional Facility of 0.23 deaths per thousand _ more than twice the national AIDS prison death rate.

Deplorable Conditions Lead to

Avoidable Deaths

In their report released in February 2003, Moore and Associates described the health care, system at Limestone as "dangerous and extremely poor quality." Conditions at Tutwiler Prison for Women have been described by lawyers and judges alike as brutally violent and dangerously overcrowded. The 1,500 prisoners at the St. Clair Correctional Facility have no access to a primary care physician, and are served by an under-qualified nursing staff, and a dentist who is available only two days a week.

These are but a few examples of the current state of affairs in Alabama's prisons. Conditions that have led not only to unnecessary deaths, illnesses and assaults, but also to a number of lawsuits (described later) designed to remedy the near-barbaric conditions.

Perhaps the situation at the Tutwiler Prison for Women best typifies the inhumane and, as one federal judge has already held, unconstitutional conditions Alabama prisoners are forced to endure.

Tutwiler, built in 1934, had a listed capacity of 364 prisoners. Today, over 1,000 women are crammed in there. "The only reasons more beds have not been added to the dorm facilities," U.S. District Judge Myron wrote in a 68-page order in December 2002, "is that, simply put, not one more bed will fit." In that order, Thompson ruled that the State of Alabama was violating the constitutional rights of Tutwiler prisoners by housing them in unsafe conditions, and gave the state until December 30, 2002 to present a plan for rectifying the situation.

Thompson was referring to the fact that so many women are packed into so small a space, prisoners literally touch while sleeping in their bunks at night. Mold grows unchecked on the dormitory walls; the pipes, sinks and shower drains are laden with sludge; showers and toilets often do not work; and medically and mentally ill prisoners are not separated from the rest of the population.

Due to the overcrowding there is a lack of job opportunities, and prisoners spend most of their day sitting idly in the unbearably hot and poorly vented living quarters. Weapons such as razors, mop handles and shanks are rampant in the prison, where the guards are often too frightened to enter the dorm areas.

Documents also describe Tutwiler as an extremely dangerous place, where a record 91 assaults were reported in 2002. And while the prison population there has increased five-fold since it opened, the number of guards has essentially remained the same. The result is an institution where guards often ignore assaults, refusing to intervene for fear of their own safety. When guards do choose to take action and stop or prevent violence, it is often too late because they have to wait for back up. With a prisoner-to-guard ratio of 240 to 1 at times, and guards being forced to work 12 and 16 hour shifts, back-up is often slow in coming [PLN, Sept. `03].

The dangerous powder keg conditions at Tutwiler, and the unsafe and inhumane living conditions, combined with the ineptitude of health care provider Naphcare, make for a lethal one-two punch, and deadly consequences for the women prisoners there.

Men confined at the St. Clair prison fair a little better than the women, but not in receiving any sort of meaningful medical care there. Problems at St. Clair include a severe shortage of trained medical staff, little access to dental care, and decisions on medical treatments based on cost rather then the needs of the patients.

Prescriptions go unfilled. Prisoners who are unable to eat because of no teeth suffer extreme weight loss which is ignored by staff. Many conditions simply go untreated unless and until the prisoner is rushed to the hospital for emergency care. Requests for hearing aids, optical exams and treatments, pain medications, wheelchairs and walkers are denied to those who need them. And required surgeries and other preventive medical treatments are simply not provided. At least not until it is too late to avoid permanent damage. It is alleged that Naphcare makes a calculated decision that it is more cost-effective to delay or deny treatment than provide it.

At the Birmingham Work Center for women, a 55-year-old woman with heart problems by the name of Claudia Muller died in an extremely hot cell in July 2002, despite screaming for help for days. Prison staff and Naphcare knew she had heart problems, as well as a serious mental illness, yet she still was not provided needed medications nor monitored by staff at the overcrowded facility.

Overall, Naphcare's treatment of chronic conditions like asthma, diabetes, seizure disorders, kidney disease, HIV, Hepatitis C, and hypertension fell far below the standard of care that is well-established in the medical community for the treatment of such illnesses. The result is that prisoners are put at unnecessary and substantial risk of serious medical problems such as seizures, strokes, heart attacks, and worst of all, death.

"It is shameful that the Alabama Department of Corrections has allowed the medical care and consequently the health of . . . prisoners to deteriorate as severely as it has," said Tamara Serwer of the Southern Center for Human Rights. "It's disheartening that lawsuits must be filed in order to get the state to fulfill its constitutionally required responsibilities."

Naphcare's Short and

Shameful History

Nearly all of the lawsuits Serwer is referring to have named Naphcare as a principal defendant. Naphcare was started in 1989 by James McLane, a Birmingham pharmacist and its sole owner, as a provider of pharmacy services at a small Georgia jail. Over the next 10 years or so, Naphcare provided only nephrology (kidney) services to a small number of prisons.

Alabama was Naphcare's first contract to provide comprehensive healthcare services to an entire prison system, although Naphcare did have contracts with several Alabama county jails. Naphcare's web page touts their success as the States of North Carolina and Washington have recently renewed contracts to provide only nephrology services in state facilities. Naphcare further notes that a federal prison in Massachusetts also contracts for their nephrology services.

"At Naphcare, we have based our business on recognizing and meeting the needs of our clients, cutting the red tape without cutting the corners," claims Naphcare's web site,

Prior to Naphcare, prison health services in Alabama were provided by Correctional Medical Services of St. Louis, at $26 million per year. However, because of rising costs and a rapidly growing prison population, CMS demanded substantially more money from $38 million to $46 million to continue to provide sufficient health care services. The state then sought bids for the lowest possible contract that would purportedly satisfy the constitutionally-mandated requirement of adequate prisoner health care. After two rounds of bidding a process which CMS claims was done in violation of state law Naphcare won the contract with a bid of $30 million. A spokesman for then-Alabama Gov. Don Siegleman announced that the new contract had saved Alabamans millions.

Critics immediately questioned how Naphcare could possibly provide adequate health care for 25,000 prisoners for $30 million and still make a profit. Naphcare had never before provided comprehensive care to a state prison system.

"The average state spends $2,500 to $3,000 per inmate [per year), and Alabama's spending a little over $1,000," said Ron Shansky, co-founder of the Society of Correctional Physicians.

"It's off the charts."

Even before Alabama and Naphcare signed their contract in early 2001, there were many substantiated complaints regarding the level and quality of health care provided by Naphcare in the county jails. Jefferson County officials complained publicly about Naphcare's performance at its jails in Bessemer and Birmingham. In addition, amid a flood of complaints from prisoners, family members and jails officials, Jefferson, Morgan and Madison counties all cancelled their contracts with Naphcare last year. All found new jail health care providers.

Naphcare now faces a barrage of complaints and lawsuits alleging malpractice and deficient health care services during its two year tenure as Alabama's sole medical care provider. An audit report of a study conducted at eight Alabama prisons between May and August 2002, and released February 2003, revealed "serious deficiencies" in the health care services provided to prisoners by Naphcare.

The audit report "is totally consistent with what the prisoners have been telling us, that they have to wait for weeks for dental services, for things such as abscesses which are so painful that some of the women are pulling their own teeth," said Serwer, who is representing prisoners in one of the pending federal lawsuits.

Amid the numerous lawsuits and $6.9 million in cost overruns caused by off-site medical visits, Alabama Prison Commissioner Donal Cambell on May 2, 2003 finally decided to cancel Naphcare's $30 million-a-year contract. In a letter sent by Cambell to Naphcare, Campbell announced that the termination was set to take effect "90 days from your receipt of this notice." He later rescinded, and Naphcare remains the medical provider for Alabama prisons.

Naphcare claimed that the audit report contained "inaccurate and misleading information," insisting that they provide high-quality medical services to prisoners, but to date have provided no details or evidence to counter either the audit report or the many complaints lodged against it.

Naphcare's contract was set to run through 2003, with an option to extend. DOC spokesman Brian Corbett, however, said the contract was initially cancelled not for reasons relating to Naphcare's deficient performance, but "more for reasons of the deficiency in the contract itself." Corbett said the contract provided DOC with no leverage to demand changes from Naphcare in areas such as staffing, policy and costs overruns. "This does not relate to the quality of care as provided by Naphcare per se," claimed Corbett.

But whether that is true, or whether DOC as a co-defendant in all of the pending lawsuits is trying to play both sides of the fence by getting rid of the problem while claiming there is no problem, is unclear. What is clear though is that Alabama does not spend enough on prisoner health care and that for-profit health care companies cannot survive the prison atmosphere, i.e.., providing adequate health care services while always keeping an eye on the bottom line.

"It was not realistic from the word go," said Gary McWilliams, vice president of sales and marketing at CMS the company that owned the Alabama contract before Naphcare. "Now the chickens are coming home to roost."

"They cut corners," said Sam Eichold, a physician who serves on a prison medical oversight committee. "That's how they make their profit." He notes that Naphcare is no better or worse than CMS.

But getting rid of Naphcare will not necessarily solve the problem, claims Rhonda Brownstein, a lawyer for the Southern Poverty Law Center. "The DOC, and ultimately the Alabama taxpayers, will have to bite the bullet and triple the amount currently spent on [prison] medical care," she said.

Until that happens, though, and Alabama decides to spend upwards of the $45-$50 million to bring health care service to the level seen in most other states, the complaints, lawsuits, and deaths will continue to grow.

Lawsuits, Lawsuits, Lawsuits

"When the state takes away a person's freedom including the freedom to go to a doctor when you are sick the law is clear that the state must provide care for serious medical needs. That is not happening in Alabama's prisons." So says Lisa Kung, an attorney from the Southern Center for Human Rights (SCHR) representing the women prisoners in the class action suit filed over conditions at the Tutwiler Prison for Women.

The 69-page second amended complaint filed in Dec. 2002 has 34 named plaintiffs, all with specific complaints of medical neglect.

The suit alleges that long delays in health care services provided by Naphcare at Tutwiler (as well as the women's Birmingham Work Release Center) are the practice, not the exception. The suit also details dangerous lapses in providing prescription medication, along with a severe shortage of qualified medical personnel.

The complaint also details how the dangerous and overcrowded conditions at Tutwiler cause extremely high levels of psychological stress and chronic sleep deprivation. Such conditions lower a prisoner's threshold for illness as well as exacerbating symptoms of chronic diseases such as seizures, hypertension, and mental illness. And there are only seven infirmary beds, some in the hallway, for the 1,500 female prisoners confined in Alabama.

Dental care is not provided for the women, sometimes for years. Many prisoners, in excruciating pain and left without dental care, have resorted to pulling their own teeth, the lawsuit says.

Finally the suit claims that many of the 91 assaults were avoidable, the result of mentally ill prisoners being forced to live amongst the general population and without adequate mental health treatment. Most of the recent assaults with razors were committed by mentally ill prisoners. Alabama's women prisoners have access to a far fewer number of psychiatrists and mental health counselors in comparison to male prisoners, according to the suit.

The suit seeks a declaration that the conditions at the women's' prisons violate the Eighth and Fourteenth Amendments to the U.S. Constitution, and injunctive relief, as well as costs and attorneys fees. See: Laube, et al. v. Haley, et al., No. CV-02-T-957-N, U.S. District Court, Middle District of Alabama, Montgomery Division.

A separate wrongful death lawsuit against DOC and Naphcare was filed by the family of Pamela Brown. Brown was a 28-year-old prisoner at Tutwiler in 2001, when she died suddenly on March 14. The suit charges that Brown was refused medical treatment for her heart condition, severe headaches, and blackouts.

An autopsy revealed that Brown had an undiagnosed condition called coronary hypoplasia, or abnormally small arteries supplying the heart. The report said that Brown had a "history of tightness of the chest during the last several months," and had collapsed in the prison yard on February 27, 2001. An echocardiogram, which would have detected the heart defect, had been scheduled, but never performed.

Another suit over conditions at the Elmore Correctional Facility was settled in December 2002. Many prisoners at Elmore are employed at a recycling plant, and sued claiming they were denied treatment when injured while handling hazardous materials.

The suit, filed in 2001 and certified as a class action, was actually settled in January 2001. In the settlement agreement, Naphcare agreed to provide blood tests, vaccines, counseling, and other treatment to prisoners stuck by dirty needles or otherwise injured while working at the recycling plant. But Ty Apler, another lawyer from SCHR representing the Elmore plaintiffs, told the court Naphcare is not living up to the January agreement.

"When you agree to it, you're stuck with it," Circuit Judge Tracy McCooey of Montgomery told DOC attorney Jane LeCroy Brannan. McCooey gave the state and Naphcare 30 days to fully comply with the settlement agreement or face fines of $100 per day. Following the hearing Brennan said McCooey's order "was very fair and we're happy to comply with it."

A fourth lawsuit was filed by two out-of-state lawyers claiming that HIV positive male prisoners at the Limestone facility receive negligent medical care. The suit, which names DOC and Naphcare as co-defendants, alleges that the death rate among HIV prisoners at Limestone is twice the national rate.

Still yet another suit claims that DOC and Naphcare are providing inadequate care for diabetic prisoners. The complaint, filed April 9, 2003 in the U.S. District Court for the Middle District of Alabama, is another class action with five named plaintiffs. According to the complaint, "prisoners with diabetes are at serious risk of substantial harm and death as a result of the grossly inadequate medical care provided to them by the Alabama Department of Corrections."

Among the ailments the plaintiffs claim are the direct result of Naphcare's "deliberate indifference" to the medical needs of diabetic prisoners are: Blurred vision, amputation of toes, kidney damage, hypoglycemia, dizziness, and pain. The plaintiffs and the class are placed at further risk of blindness, amputation of feet and legs, kidney failure, nerve damage and numbness, pneumonia, strokes, heart attacks, and death, because of Naphcare's deliberate negligence, the suit claims.

Diabetic prisoner Michael Gaddis has had two toes amputated and suffers from nerve damage and severe numbness. The suit links these ailments "to the grossly inadequate" medical care provided by Naphcare.

24-year-old Alabama prisoner Edward Hamilton has been a diabetic since the age of five and is currently incarcerated at Easterling prison. He had not been seen by a doctor in five months and does not receive adequate blood sugar tests. He began losing his peripheral vision about a year ago, yet his repeated requests to see an eye doctor went unfulfilled. On April 5, 2003, Hamilton had a seizure yet guards refused to transport him to the infirmary for medical attention because it was count time.

The remainder of the plaintiffs in this case all complain of slow treatment or no treatment at all. Infrequent finger stick blood tests, a complete lack of urine testing, infirmaries that routinely run out of needed medications, and a lack of treatment for high blood sugar typify the complaints the plaintiffs say are bound to lead to permanent damage or death if not remedied.

The plaintiffs, represented by attorneys Rhonda Brownstein, Grace Graham and Danielle Lipow of the Southern Poverty Law Center, seek declatory and injunctive relief as well as statutory costs and attorneys' fees. See: Gaddis et al., v. Campbell, No. CV-03-T-390-N, U.S. District Court for the Middle District of Alabama.

The 12 named plaintiffs in a final suit also a class action (amended complaint filed May 23 of this year) are also represented by attorney of the Southern Poverty Law Center. The complaint seeks relief on behalf of seriously ill prisoners locked up at the St. Clair Correctional Facility. DOC, Naphcare and St. Clair warden Ralph Hooks are the defendants named in the suit.

Prisoners at St. Clair are "suffering from serious harm and are at great risk of further harm, including death," due to the "grossly inadequate medical care" provided there, the suit says.

Among the most serious complaints in the suit include prisoners lying in beds unable to control their bowels that sometimes go for hours without being changed or cleaned. "Because of the shortage of nursing staff, nurses depend on inmates to perform these tasks," the suit contends.

Prisoners with colostomies must wear a bag attached to their abdomen to collect their stool. The prison exchanges these bags only three time a week instead of daily. Some prisoners have gone a month without a new bag, requiring them to clean the bags out in the sink in their cells without gloves or disinfectant. Their cellmates must then use the same sink to wash, brush their teeth, and drink.

Prisoner Billy Ray Davis, 47, who has been at St. Clair since 1987, complained to prison doctors that he had difficulty breathing. Naphcare doctors told Davis his condition couldn't be diagnosed. An outside doctor later examined Davis and told him his lung had collapsed. The damage could have been corrected had prison medical staff diagnosed and treated his condition properly, the suit said.

Another prisoner who had been at St. Clair for 19 years, was diagnosed with testicular cancer in Nov. 2002. The cancer later spread to 45-year-old Darryl Mullins' lymph nodes. However, he did not receive chemotherapy at St. Clair until April 29 because "there was not a nurse [who was] certified to provide it," the suit stated. And after having a testicle removed Jan. 22, Mullins was given pain medication for only a week. Despite begging for more, he was not provided any until March 10 when one of the prisoners' lawyers wrote a letter.

And prisoner Jerry Baker suffered from a serious lung disease. The 63-year-old man had been at St. Clair for 14 years. The lawsuit details how Baker was not given any of his numerous medications for several months in 2003. His weight dropped dramatically from 155 to 115 pounds, but he received no medical treatment for the severe weight loss. Baker had only two teeth on the top of his mouth yet was given no replacement for his broken denture plate. The suit says that this may have contributed to his rapid weight loss due to his inability to eat.

Prison staff also refused to provide Baker with any sort of nutritional supplements, such as a nutrient drink, to help him combat his weight loss.

Baker died on May 16, 2003 after the original complaint was filed in this case. In the amended complaint, lawyers charge that the failure to prescribe him his needed lung medication and the lack of adequate nutrition led to his death. The Alabama DOC and Naphcare both refused to comment on his death.

Other allegations in the lengthy suit include charges that Naphcare and the St. Clair prison implemented a sick call system which is designed to dissuade prisoners from seeking medical services. Prisoners are charged $3.00 when they sign up for sick call and then often are not even seen by medical staff. Prisoners often have to wait so long for health care they refuse to sign up altogether. As a result, preventable illnesses and disease progress into serious medical problems. Lack of other necessary medical care such as inhalers, antibiotics, gauze treatments, low protein diets, antiviral drugs, liver treatments, pain medications, hearing aids and surgeries are also alleged in the complaint.

The suit seeks declatory and injunctive relief, and all costs and attorneys' fees. The plaintiffs are represented by attorney Morris S. Dees, Rhonda Browstein, Grace Graham and Kelly Bruner, all of the Southern Poverty Law Center in Montgomery. See: Baker et al., v. Campbell, et al., No. CV-03-C-1114-N, U.S. District Court, Northern: District of Alabama.

It should be noted that all plaintiff attorneys mentioned in this article are loyal PLN supporters and subscribers, and are dedicated to protecting the rights of prisoners. Their efforts do not go unrecognized.

Will Anything Change?

The new bidding process now underway for Alabama's medical care services contract promises to substantially increase the amount the state spends on prisoner health care. The number is expected to rise to $46-$50 million a year over the term of the next contract. However, as critics point out, this would still rank Alabama last in the nation in per-prisoner health care spending.

The disparity in money spent appears to translate into lethally inferior care in Alabama prisons, and has had obvious consequences in prisoners' access to doctors. According to information compiled by local media, Alabama employs only one doctor for every 3,000 prisoners. Compare that to a state like Georgia which employs one doctor per 1,100 prisoners.

Reports contained in the recent audits by Moore and Associates found that no mortality reviews were on file in facilities where prisoners have died in the last year, as required by law. Under Naphcare, those reviews have been late or not done at all, confirmed DOC spokesman Brian Corbett. "We used to do it in every case," a DOC lawyer said. "We do it now [only] in the worst cases."

DOC has recently had to ask the state legislature for an extra $6.9 million to cover cost overruns incurred by Naphcare. This number does not include the cost of defending the numerous lawsuits nor paying out settlements on them. Under the terms of the prior contract, the state is responsible for all cost overruns.

With the new bidding process underway for the next DOC health care contract, one might reasonably assume that a more responsible care provider would be found and that conditions for prisoners seeking medical treatment in Alabama would vastly improve. Not necessarily so, says CMS' McWilliams.

He said that Alabama needs to get the bidding process completed quickly, or risk the possibility of prisoners getting no care at all. "Normally on these statewide programs, you have a minimum of 90 days many times 120 to 150 days to transition and get a program up and running. They're putting themselves behind the eight ball."

Serwer agrees. "My experience with these kinds of situations is that this is often a very difficult period, as far as patients actually getting care."

Naphcare retains the contract for now, and, amazingly, there is a very real possibility that they can join the new round of bidding. Corbett said that Naphcare could theoretically win the contract again. However, he expects that DOC will require that any bidders have at least five years experience in providing comprehensive care to a large prison system something Naphcare doesn't have.

Sources: Associated Press, Birmingham News, Prison Talk, Mobile Register, Southern Center for Human Rights, Montgomery Advertiser

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Related legal cases

Baker v. Campbell

Laube v. Haley

Gaddis v. Campbell