CQ

Researcher
Published by CQ Press, a division of Congressional Quarterly Inc.

www.cqresearcher.com

Prison Health Care
Are prisons dumping grounds for the mentally ill?

A

high percentage of the more than 2 million inmates in U.S. jails and prisons suffer from mental
illness, addiction or infectious and chronic diseases
like HIV/AIDS and diabetes. About a quarter

suffer from major depression and a fifth from psychosis. Many had
little or no health care before being incarcerated. Providing treatment and preventive care for prisoners who eventually return to
society can help stem the spread of infectious disease in communities and keep those with mental illness and addiction from landing back in jail, say public-health officials. While prisoners are,
ironically, the only Americans who have a constitutionally guaranteed right to health care, most prison health systems are under-

Bobby Sutherland is among 300 inmates at an
Alabama prison for the aged and infirm. He is
serving 297 years on rape and pornography
charges and expects to die behind bars.

funded and understaffed, making the care they provide spotty at

I

best. Meanwhile, strict sentencing guidelines and three-strikes-and-

N

you’re-out laws have created a burgeoning — and aging — pris-

S

oner population, which is driving skyrocketing health-care costs

I

even higher.

D
E

CQ Researcher • Jan. 5, 2007 • www.cqresearcher.com
Volume 17, Number 1 • Pages 1-24

THIS REPORT
THE ISSUES............................3
BACKGROUND ....................10
CHRONOLOGY ....................11
AT ISSUE ............................17
CURRENT SITUATION ............18
OUTLOOK ..........................19

RECIPIENT OF SOCIETY OF PROFESSIONAL JOURNALISTS AWARD FOR
EXCELLENCE ◆ AMERICAN BAR ASSOCIATION SILVER GAVEL AWARD

BIBLIOGRAPHY ....................22
THE NEXT STEP ..................23

PRISON HEALTH CARE
THE ISSUES

3

• Do prisons provide decent health care?
• Should inmates get the
same care as other citizens?
• Should correctional facilities require HIV tests?

BACKGROUND

10

Population Explosion
Prisons are growing faster
than the U.S. population.

13

Legal Aid
A landmark case established
prisoners’ right to health
care.

15
15

Health Problems
Prisoners are sicker than
the general population.
Multiple Systems
Inmates receive disjointed
health care.

CQ Researcher
5
6

19

8
9

Many Jail Inmates Have
Medical Problems
Nearly 34 percent had physical impairments.

10

Drug Use Is Widespread
Nearly half of all prisoners
have abused drugs.

11

Chronology
Key events since 1955.

12

Prisons Have Replaced
Psychiatric Hospitals
Half of U.S. inmates have a
mental-health problem.

14

Prison Politics
Inmates’ health gets little attention and few resources.

17

Aging Behind Bars
Costs may skyrocket as
baby-boom prisoners age.

Health Costs Rose
States’ spending on prisoner
health care almost doubled.

Cover: AP Photo/Dave Martin

2

CQ Researcher

HIV-Positive Inmate
Population Declines
Less than 2 percent of inmates have HIV.
At Issue
Are drug courts a good
alternative to imprisonment
for substance abusers?

FOR FURTHER RESEARCH

21

SIDEBARS AND GRAPHICS 22

4

Jan. 5, 2007
Volume 17, Number 1

MANAGING EDITOR: Thomas J. Colin
ASSISTANT MANAGING EDITOR: Kathy Koch
ASSOCIATE EDITOR: Kenneth Jost
STAFF WRITERS: Marcia Clemmitt, Peter Katel
CONTRIBUTING WRITERS: Rachel S. Cox,

Sarah Glazer, Alan Greenblatt,
Barbara Mantel, Patrick Marshall,
Tom Price, Jennifer Weeks
DESIGN/PRODUCTION EDITOR: Olu B. Davis
ASSISTANT EDITOR: Melissa J. Hipolit

A Division of
Congressional Quarterly Inc.

SENIOR VICE PRESIDENT/PUBLISHER:

John A. Jenkins
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Ann Davies

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CHAIRMAN: Paul C. Tash
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Prisoners and Research
A federal panel suggests
looser rules on research.

OUTLOOK

19

Keeping Substance
Abusers Out of Jail
Only a limited number of
therapeutic options exist.
U.S. Prison Population
Topped 2 Million
The nation’s inmate population was 2.3 million in 2005.

CURRENT SITUATION

18

Inmate Mental Problems
Are Widespread
More than half of inmates
were mentally ill in 2005.

For More Information
Organizations to contact.
Bibliography
Selected sources used.

23

The Next Step
Additional articles.

23

Citing CQ Researcher
Sample bibliography formats.

PRESIDENT/EDITOR IN CHIEF: Robert W. Merry
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Prison Health Care
BY MARCIA CLEMMITT

THE ISSUES

drugs when they broke the
law. 5
Prisoners also are sicker, in
ail officials knew Bridgeneral, than the population
gett Fogell was pregnant
as a whole. More than a third
when she began serving
of jail inmates had medical
a prison sentence in
problems in 2002, including
Delaware for traffic violations
13 percent with arthritis, 11
and driving under the influpercent with hypertension and
ence. When she began having
10 percent with asthma. 6
severe cramps and vaginal disThe health problems are
charge, contract health-care
compounded by the stratoworkers checked on Fogell and
spheric HIV/AIDS rate among
deemed her healthy. 1
prisoners — more than triple
When Fogell’s water
the rate in the overall popbroke, a nurse told her that
ulation. 7 And other common
she’d simply urinated in her
inmate diseases — such as
clothes. After nine hours in
Hepatitis C — are expensive
the prison infirmary, Fogell
and not always able to be
was finally taken to a hostreated.
pital. She gave birth the next
“That creates a quandary
day, but her baby, Anna Lee,
for systems on a tight budlived only a few hours.
get,” says William J. Winslade,
As a prisoner, “you’re helpa professor of the philosophy
less,” said Fogell. She had
of medicine at the University
called for help when Anna
of Texas Medical Branch at
Lee’s breathing became shalGalveston.
low and her heartbeat slowed,
Caring for the nation’s 2.3
Diabetic inmate Ricky Douglas died in a Nashville jail
but it never came. “It’s not
million
state, federal and jail
after failing to receive his medication. Poor prison
like you can get in your car
prisoners
costs the cash-strapped
health care has prompted the courts to
and leave, looking for comfederal, state and local govorder reforms in several states.
petent medical care.” 2
ernments about $7 billion a year
St. Louis-based Correctional Med- diction, in part because non-prison — and the price tag is expected to rise
ical Services Inc. (CMS) — one of the treatment facilities are unavailable or as prisoners age and develop age-relatcountry’s two largest prison health unaffordable. More than half of all ed diseases. 8
contractors — lost its Delaware con- prison and jail inmates in 2005 had
Aside from serious budget shortfalls,
tract in 2002, shortly after Fogell’s baby mental-health problems, according to two of the biggest obstacles to delivthe U.S. Department of Justice — a ering quality health care to inmates are
died, but regained it in 2005.
Health-care horror stories like Fogell’s problem some experts attribute to the the huge size of the nation’s prison
are common throughout the nation’s jails decision beginning in the 1950s to re- population and the high percentage of
and prisons. For example, in November place mental hospitals with community- mentally ill inmates, which makes it
2006, a federal judge ordered Michigan based facilities, which remain under- difficult to hire enough trained staff. 9
to implement massive reforms in its prison staffed and underfunded. 4
“Many mentally ill people are in prison
Moreover, because of a serious short- who should not be there,” says Jeffrey
mental health-care programs after the
deaths of several mentally ill prisoners, age of drug-treatment programs, a dis- L. Metzner, a psychiatrist and clinical
including a 21-year-old man who died proportionate percentage of the nation’s professor at the University of Colorado
after being strapped naked to a concrete inmates are addicts. In a 2004 survey, 56 School of Medicine. Unless the country
percent of state and half of all federal develops a good community mentaltable for four days. 3
America’s prisons have become a prisoners said they had used illegal drugs health system, “this will continue.”
dumping ground for the mentally ill in the month before they committed their
The problem extends to mentally
and those with drug and alcohol ad- offenses, and up to a third were using ill children and teens, who often are
AP Photo/Nashville Police Department via The Tennessean

J

Available online: www.cqresearcher.com

Jan. 5, 2007

3

PRISON HEALTH CARE
“parked” in juvenile corrections facilities — even when they haven’t committed any offense, said Carol
Carothers, executive director of the
Maine chapter of the National Alliance
for the Mentally Ill. Such “parking”
typically happens when mental-health
care is unavailable locally or exasperated parents can’t cope with their
child’s behavior.
And incarceration can aggravate
mental illness, as Maine officials found
out in the case of a suicidal 13-yearold. During one of several stays in juvenile detention, Carothers said, “he
was held in isolation for 152 of his
first 240 days,” which led him to mutilate himself, “spiraling deeper and
deeper into his illness.” The state settled a lawsuit on the child’s behalf in
2004, said Carothers. 10
Two-thirds of prisoners are merely
serving life sentences “on the installment
plan,” says V. Morgan Moss, co-founder
of the Center for Therapeutic Justice,
which promotes inmate-run therapeutic
communities in correctional institutions.
“Inmates have substance-abuse problems,
mental illness and few job skills” but get
no help either inside or outside of the
institutions, Moss says.
“With a 67-percent failure rate, people just go right back in,” he laments.
“We need to do something different. Instead, we just continue to build more
jails and more prisons. It’s a joke.”
But resources and training to help ill
prisoners are sparse, says M. Douglas
Anglin, associate director of the Integrated Substance Abuse Programs at the
University of California, Los Angeles
(UCLA). For example, “you have correctional officers with no training in this
area dealing with people with both
mental illness and substance abuse.”
There has been some improvement, however, in drug treatment, says
Anglin. In the early 1990s, only about
5 percent of inmates received substance-abuse treatment, he says, compared to about 15 percent today. But
“that’s still a drop in the bucket.”

4

CQ Researcher

Prison Health Costs
Nearly Doubled
States’ per-capita spending on
health care for prisoners almost
doubled between 1986 and
2001, according to the latest
available data. Experts estimate
that the figures have probably
doubled again since 2001,
based on the general rate of
increase in health costs.
State Health Expenditures
Per Prisoner
(for selected expenditures)
$200
150
$141
100
50
0

$154

$109
$78

1986

1991

1996

2001

Source: “State Prison Expenditures,
2001,” Bureau of Justice Statistics
Special Report, 2004

As bad as prison health care usually is, it’s often better than what inmates
were getting in their communities. A
large proportion of prisoners have no
access to health care before being incarcerated, usually because they are
uninsured and cannot afford health care.
“The average male in the New York
prison system has 12 or 13 bad teeth,
and the average woman two or three
more,” says Lester Wright, chief medical officer of the New York State Department of Correctional Services. “Most
have never seen a dentist.”
Yet, ironically, once people are incarcerated, they acquire the constitutional right to receive free health care
— unlike other U.S. citizens. The
Supreme Court in 1976 ruled that “de-

liberate indifference” to an inmate’s
medical needs is “cruel and unusual
punishment” prohibited by the Eighth
Amendment. 11
Some Americans object to lawbreakers being entitled to free health
care while more than 40 million Americans do not have health insurance. 12
Resentment over inmate health care
erupted into a nationwide debate in
2002, after a California inmate received
a $1 million heart transplant.
“The average Joe, who’s getting
squeezed by his chintzy HMO, has palpitations when he opens the paper to
see that he just bought a Stanford [University] heart transplant for a con,” wrote
Los Angeles Times columnist Steve Lopez.
The incident raised several ethical
questions, Lopez noted, including, “What
moral imperative says we should care
more about the health of 160,000 inmates than of uninsured people, onequarter of whom are children?” 13
The case also sparked a nationwide
debate over who should get scarce organs. At the time, 500 Californians and
more than 4,000 people nationwide
were waiting for heart transplants. “You
have to wonder if a law-abiding, taxpaying citizen drew one last breath
while Jailhouse Joe was getting a second wind,” Lopez wrote. 14
California officials said the 1976
Supreme Court decision compelled them
to provide quality care for the prisoner. Indeed, lawsuits have been a driving force behind improvements in correctional health care. As recently as
2005, a federal judge in California placed
jurisdiction over prison health care in
the hands of a court-appointed administrator. 15
The lack of adequate prison health
care ultimately can lead officials to ignore even glaring matters of public
health, says Dori Lewis, senior supervising attorney at the New York Citybased Legal Aid Society’s Prisoners’
Rights Project. “The Department of Corrections is likely to say, ‘What do we
care about TB [tuberculosis] testing?’ ”

But as inmates cycle in and out of
the community, they put correctional
health care center stage in the fight
against infectious disease and untreated
chronic illnesses like diabetes. “The
prisoner today is my neighbor tomorrow,” says Timothy P. Flanigan, director of the division of infectious diseases at Brown Medical School in
Providence, R.I.
Despite some court victories and
the efforts of dedicated health-care
workers, “prison health care is, by and
large, abysmal in this country,” says
David C. Fathi, senior staff counsel at
the American Civil Liberties Union’s
(ACLU) National Prison Project. “When
you cast somebody outside the human
family, you don’t care what happens
to them.”
As growing numbers of aging and
mentally ill prisoners swell jail and
prison populations, here are some of
the questions being asked:
Do correctional institutions provide decent health care?
Inmate populations suffer from
high rates of mental illness, substance
abuse and below-average physical
health. Critics say prisoner care remains substandard because too few
health professionals will work in prisons, and negative public attitudes toward prisoners keep public resources
lean. Some corrections officials say,
however, that institutions in recent
years have beefed up mental-health
staffs, launched health screenings and
hired better-trained staff — albeit
largely as a result of court orders.
“There are still some people who
think nobody in prison gets any decent care, but that isn’t true,” says chief
medical officer Wright, in New York
state. While the quality of correctional
health care varies widely, Wright acknowledges, at least some systems are
making progress. For example, more
than 90 percent of prison doctors in
New York now are either board certified or eligible for certification — “a

Inmate Mental Problems Are Widespread
More than half of all state prison and jail inmates had a mentalhealth problem in 2005. More than half of all jail inmates met the
criteria for mania and 30 percent had major depression.
Percentage of Inmates With Mental Illness, 2005
80%
70
60
50

64%
60%

56%
49%

45%

50
40%

40
30

24%

20

54%
43%

40
30%

30
21%

24%

23%

20

14%

10
0

60%

15%

10
Any mental
health problem

State Inmates

Recent
history

Federal Inmates

Symptoms

Jail Inmates

0

Mania

Major
depression

State Inmates

Psychotic
disorder

Jail Inmates

Source: U.S. Department of Justice, Bureau of Justice Statistics, September 2006

big difference from 15 years ago, when
many were unlicensed,” he says.
And prisons are getting a better handle on some infectious diseases, such
as tuberculosis, which once ran rampant, says Wright. In New York, for example, the TB rate in prisons has
dropped from 220 new infections for
every 100,000 prisoners in 1991 to
around 10 per 100,000 in the last several years — a rate comparable to New
York City’s general population, he says.
Lawsuits have helped improve mental-health services in Ohio, according
to Gary E. Beven, a psychiatrist at the
maximum-security prison in Lucasville.
In the mid-1990s, Beven was the only
psychiatrist at the facility, working part
time, with one psychiatric nurse. “There
was a psychology staff, but they were
beleaguered and overburdened . . . no
group [mental health] programs, no individual counseling,” he said. 16
In 1993, following a riot at the prison,
a federal lawsuit alleged that Ohio prisons didn’t provide adequate mental-health
care. A court-imposed monitoring sys-

Available online: www.cqresearcher.com

tem triggered big changes, said Beven.
Today “we have the staffing, we have
the support from central office,” as well
as the training and the budget to provide “care that really is effective.” 17
“There were six psychiatrists for the
entire Ohio penal system when the
[Dunn v. Voinovich] lawsuit was filed,”
Fred Cohen, professor emeritus at the
State University of New York at Albany
and the prisons’ court-appointed monitor, told “Frontline.” By the time the
case had ended, however, there were
more than 40 psychiatrists. 18
Other health-care experts point out
that even the most basic prison health
care is better than the low quality —
or total lack — of mental and physical
health care available in the low-income
communities many prisoners came from.
“It’s sad to say, but if a jail has a decent mental-health system, people are
getting better treatment than they do in
the community,” says Metzner, at the
University of Colorado. “Correctional
people almost always want to do the
right thing” by mentally ill prisoners, he

Jan. 5, 2007

5

PRISON HEALTH CARE

Keeping Substance Abusers Out of Jail

B

y the time Altamese McIntosh faced Judge Jeri Cohen
in Miami’s drug court, she had been cycling in and
out of the justice system for years, and five of her eight
children had been born drug-dependent.
That was in 1999. Today, McIntosh, 44, has been clean for
seven years. “I realized that [the judge] was . . . no-nonsense.
You either did what she said or she would terminate your
parental rights. She wanted me to live in society drug-free so
that I could be a good parent.” 1
That’s the kind of story substance-abuse experts — and a
growing number of lawmakers and corrections officials —
would like to hear more. Although American corrections officials have generally resisted drug therapy, the high cost of recidivism among abusers is forcing a re-evaluation.
About 85 percent of all incarcerated people have had substance-abuse problems at some point, says M. Douglas Anglin,
associate director of the Integrated Substance Abuse Program
(ISAP) at the University of California, Los Angeles (UCLA). And,
with two-thirds of all inmates re-entering the criminal-justice
system a few years after release, say many experts, it’s time
for new strategies.
“For the past 10 years or so, the consensus has generally
been that prison-based treatment with after-care is effective,”
says Michael Prendergast, director of ISAP’s criminal justice research group.
But ISAP researcher Betsy Hall says that little phrase “aftercare” is awfully important, because to be effective, substanceabuse programs must stretch over time. Unfortunately, few peo-

says, “but unless they’re in a very rich
or liberal state, they have a hard time
making the case” to legislators and the
public.
Lawsuits have triggered important
improvements in prison health care as
well, Metzner says. For example, he
says, “up-front health-care screening is
now pretty standard. Most systems these
days are pretty good at determining
health-care needs,” although “not all
are good at meeting them.”
Some institutions “are making significant progress” on HIV/AIDS, says Flanigan, at Brown Medical School. For example, in a longstanding collaboration
with the local health department, the
jail in Hampden County, Mass., delivers timely primary care and HIV education to detainees. “That model should

6

CQ Researcher

ple persist, either because after-care isn’t available or because
they drop out.
Moreover, despite general agreement that the right treatment
can work, only a limited number of therapeutic options exist
— either in correctional facilities or in communities. Nationwide, Anglin estimates, about 15 percent of prisoners (including those in local jails and juvenile facilities) who need assistance get it while incarcerated. Although that’s up from a decade
or so ago, it’s still “a drop in the bucket,” he says.
Corrections officials often balk at having their budgets siphoned off to therapeutic programs they don’t control, Anglin
says. And in the name of accountability, states may dump programs before they can be tweaked into shape, he says. Generally, it “takes about five years of cyclical improvements” to
get a program working properly, he says.
Even interventions that prove effective in the community
suffer from a “dilution of effect” when launched inside an institution, in part because the staff do not have an affinity for
the work or don’t believe they are worthwhile, Anglin says.
Strong staff commitment is crucial, agrees ISAP research assistant Jerry Cartier. “People in the program are being asked
for commitment strong enough to change their lives,” he says,
but if the staff appears uncommitted, it can drain inmates’ own
will to change.
Some wardens “pay lip service” to substance-abuse therapy,
but the real test of support is in the behavior of prison staff with
direct contact with inmates, says ISAP Principal Investigator
William Burdon. “I’ve seen people go back to the housing unit

be applied for other diseases, like severe hypertension and diabetes,” he says.
But critics say the overall healthcare picture is bleak. With a few exceptions, correctional health systems
are “like the HMO from hell,” says
Fathi, at the National Prison Project.
Mental-health care is often “poorly
understood, not paid for or treated,”
says Daniel P. Mears, an associate professor of criminology at Florida State
University.
Many correctional staff are unfamiliar with the mental illnesses that
afflict inmates, and “even those who
are aware of the issues are massively
hamstrung,” says Mears. Low resources and tension between correctional imperatives and health imperatives leave most facilities without the

ability to provide needed care, he says.
“The difference between theory and
practice is just monumental,” says
Mears. “Prisoners weren’t getting care
20 years ago, and when you quadruple the size of the systems that gets
worse.”
For example, all detainees are supposed to be screened for mental-health
problems when they enter institutions,
says Mears, but there is “extreme variation” across the country.
State and local bureaucracies don’t
effectively cooperate, he says. When
jail health staff diagnose an offender
with a disorder like serious depression,
“it would be good to be able to call
up a local mental-health agency and
say, ‘Please send somebody over,’ since
most jails can’t afford an in-house

in the pouring rain” after a substance-abuse treatment “and have
the guards not open the door for them,” he says. “Some guards
call treatment ‘hug-a-thug’ programs.”
Moreover, even though a very high percentage of prisoners have both mental illness and substance abuse, mental-health
programs “are not well integrated with substance-abuse programs, and they should be,” says Hall.
But even if institutions develop better substance-abuse efforts inside the walls, the need for longer-term after-care —
plus the hope of keeping some substance abusers and potential abusers out of jail altogether — means more and better
community-based programs are needed. In California prisons,
for example, most studies show that those who just get prison
treatment without after-care “don’t do any better than those
who get nothing,” says ISAP Principal Investigator David
Farabee. “That’s led to a reluctant consensus that we ought to
be spending more on the re-entry phase” — after inmates are
released, he says.
In addition, more and more experts believe that diverting
substance abusers from prison altogether is more effective, says
Anglin. The country now has more than 1,200 drug courts that
require drug offenders to get — and persist in — treatment
rather than go to jail. Both Arizona and California overwhelmingly
passed ballot initiatives directing that substance abusers who
commit minor offenses be diverted from incarceration.
Diversion programs are more effective than throwing abusers
in jail, says Anglin. Such programs give people time to change,
“acknowledging that there are inevitable slips” as people try to

counselor.” But local mental-health officials don’t want to spend their money
on patients who are the jails’ responsibility, or they believe — rightly or
wrongly — that they don’t have the
legal right to assist, he says.
Most university medical centers try
to combat health disparities — such as
the poor health of African-American
men — by offering health care to lowincome residents in their communities,
says Flanigan. But colleges and universities ignore corrections health, he
says: “Correctional health care has been
removed from the mainstream of medicine, and particularly academia.”
In fact, says T. Howard Stone, an
associate professor of bioethics at the
University of Texas Health Center at
Tyler, there are no longer any acade-

kick habits, says Anglin. ISAP research also shows that diverting
substance abusers from incarceration saves money, beyond what
is saved in pure incarceration costs, Anglin says. “I’m an advocate
of things that give people doors out of their lifestyle,” he says.
Treatment programs both within institutions and in community-based programs are getting a boost from a new idea
about substance abuse: that people can be successfully pressured into treatment. “The old idea is that people had to be
ready to accept change,” says John Roman, a senior research
associate at the liberal-leaning Urban Institute. But, “the evidence is pretty overwhelming that you can intervene with people with substance abuse,” he says. “The criminal-justice system can push them to stay in treatment.”
When substance abusers are diverted to drug courts, for example, “there’s magic in those judicial robes,” says Bruce J.
Winick, a professor of law and psychiatry at the University of
Miami and an originator of the “therapeutic courts” concept.
Having someone as august as a judge personally involved with
them, for the first time, “helps propel people through the inevitable difficulties” of overcoming addiction, he says.
Nevertheless, if people are to kick substance abuse for good,
many more services must be available, in jails and prisons and
in the community, experts say. But “accessible, evidence-based
substance-abuse treatment is just plain hard to find,” says Anglin.
1 Arles Carballo, “A Juvenile Court Judge Is Helping Drug-Addicted Women
Get a New Lease on Life Through an Innovative Approach to Administering
the Law,” The Miami Herald, www.herald.com, Sept. 3, 2006.

mic programs to train health workers
to deal with prison populations.
Low salaries, remote locations and
lack of prestige make hiring staff
difficult. “Recruiters try to keep
salaries competitive with local government pay, but even for states and
cities that try to keep up, it’s very
hard,” says Edward Harrison, president of the Chicago-based National
Commission on Correctional Health
Care.
And correctional facilities constantly “deal with financial cutbacks,” says
Alvin Cohn, a Rockville, Md.-based
consultant on conditions in correctional
facilities. “Many were built long ago.
They’re outmoded and in disrepair.”
An ailing boiler or roof “takes precedence over hiring a psychiatrist.”

Available online: www.cqresearcher.com

To save money, some states and localities use private health-care companies, but critics say oversight is often
lax. Tennessee-based Prison Health
Services (PHS), for example, often
skimps on staff training, said a former
PHS nurse. “When they hire someone,
they don’t even orient them but put
them right on the floor,” she says. “That
is really scary for someone who’s never
been in a prison before.” 19
Should prisoners get the same
quality of care as law-abiding
citizens?
When a California court ruled in
2002 that a prison inmate could receive a publicly funded heart transplant, many people questioned whether
prisoners should receive cutting-edge

Jan. 5, 2007

7

PRISON HEALTH CARE
U.S. Inmate Population Topped 2 Million
The number of federal, state and local prisoners topped 2.3 million
in 2005 for the first time. The number of federal prisoners nearly
doubled in the decade from 1995 to 2005 while the state inmate
population grew by more than 25 percent.
Number of U.S. Inmates, 1995-2005
1,500,000
In State Custody

1,200,000
900,000

In Local Jails

600,000
300,000
0

In Federal Custody

1995

2000

2001

2002

2003

2004

2005

Source: U.S. Department of Justice, Bureau of Justice Statistics, May 2006

care at taxpayers’ expense — especially when many of those taxpayers
cannot afford health insurance. Prison
health officials say the government is
obligated to provide health care for
prisoners because incarceration prevents
them from obtaining care on their own.
Moreover, they say, it is shortsighted
to allow the mental and physical health
of prisoners to deteriorate.
But giving prisoners access to
scarce resources like organ transplants
is unwarranted, wrote David L. Perry,
now a professor of ethics at the U.S.
Army War College in Carlisle, Pa. “Imagine watching a loved one die for lack
of a heart, then reading in the paper
the story about our fortunate felon,”
wrote Perry, who formerly directed the
ethics program at California’s Santa
Clara University. 20
The 31-year-old prisoner who received the heart had been convicted
of robbery, Perry pointed out, a crime
that “implies at least the threat of injury or death to its victims. . . . In my
view, those who deliberately threaten
the lives of innocent persons thereby

8

CQ Researcher

forfeit whatever moral claim they otherwise might have had to an organ
transplant.” 21
The Supreme Court’s 1976 ruling, in
Estelle v. Gamble, that all prisoners must
be given adequate health care does not
require governments to give prisoners
sophisticated treatments like heart transplants, argued George Mason University Law School student Carrie S. Frank
in a 2005 law journal paper. To be unconstitutional, denial of medical treatment to prisoners “must be so egregious that it offends the evolving
standards of decency and is repugnant
to the conscience of mankind,” said
Frank. 22
Because of the high cost and the
scarcity of organs, transplants are only
provided to “a select few” patients,
she pointed out. So denying a transplant to a prisoner does not qualify
as the kind of “deliberate indifference”
the Supreme Court banned, she wrote.
“There is no reason why criminals living inside prison walls should be given
a financial advantage over law-abiding citizens.” 23

The outrage triggered by the prisoner’s heart transplant highlighted the
irony that in the U.S. health system
prisoners are the only citizens guaranteed a constitutional right to health
care, while many law-abiding Americans can’t afford health care. “Medical
care is better in jail than on the street,”
lamented a corrections medical director surveyed by Stone of Texas in a
nationwide study. 24
Some bioethicists analyze the transplant situation differently. “At first
glance, one thinks, ‘Why should they
get transplants?’ ” says Winslade, at the
University of Texas Medical Branch at
Galveston. “But what if a guy’s going
to prison for three years, and he’s the
most medically suitable for an available heart? He hasn’t been condemned
to death, and yet depriving him of the
heart could have that effect.
“I don’t think people on death row
should get a heart transplanted,” he
continues. “But it would be discriminatory not to give a medically eligible short-termer a transplant. If it’s a
lifetime prisoner, though, I can see
how the cost and burden of the immunosuppressive drugs raises issues.”
Transplant recipients must receive costly drugs for the rest of their lives to
prevent organ rejection.
“In a society in which we haven’t
decided that health care is a human
right, I can see how prison health
care becomes a more difficult decision,” says Felicia G. Cohn, director
of medical ethics at the University of
California’s Irvine School of Medicine
and a daughter of criminologist Alvin
Cohn.
Americans have decided to punish
millions of people, not just violent
criminals, by locking them away and
making it impossible for them to get
care for themselves, she says. The inability of prisoners, including the many
non-violent prisoners, to procure care
for themselves is what makes providing health care for incarcerated people a government responsibility, she

says. ‘There are alternative ways of
punishment that wouldn’t require us
to provide health care.”
Despite what many think, prisoners have not been granted a right to
health-care frills, the University of Colorado’s Metzner says: The Supreme
Court has said only that prisoners have
a right to care for “serious medical
needs, including mental illness.”
Since the Estelle v. Gamble decision,
lower courts and correctional systems
have struggled to define “serious medical needs,” but the definition remains
fuzzy, many analysts say.
For example, while some prisoners
do receive organ transplants, especially kidneys, in most cases “where prisoners have tried to sue for things like
transplants, they’ve lost,” says Brietta R.
Clark, a professor at Loyola Law School
in Los Angeles. “Cost is playing a role”
in the medical decisions, “and courts
have said that it’s reasonable to look
at the cost of alternatives. They aren’t
getting the best and the most expensive care.”
To put inmates on a par with other
Americans, some jurisdictions require
them to make co-payments in order
to receive care.
However, “no studies show that it
saves money,” says New York City internist Robert L. Cohen, who directed
a health-care program for city jail inmates and has been a court-appointed monitor of correctional health-care
settlement agreements in Connecticut,
New York, Ohio and Michigan.
Kidney transplants usually are costeffective, compared to the alternative
— dialysis — with a transplant recouping its additional cost in three
years, Cohen says.
The case for providing incarcerated people with decent health care is
hard to make to the public, in part
because most are “minorities that are
despised,” says Lewis, at the Prisoners’ Rights Project.
“Most people don’t think it through,”
says Lewis. “Most everyone knows

Many Jail Inmates Have Medical Problems
Nearly 40 percent of jail inmates had a current medical problem in
2002 (graph at top, left), and 22 percent reported a learning
impairment (bottom graph). Arthritis was the most common
medical problem reported (top right).
Most Common Medical
Problems Reported, 2002

U.S. Jail Inmates, 2002
(by percentage of all inmates)
40%
35
30
25
20
15
10
5
0

36.9%

36.6%

13.4%
Current
medical
problem

40%
35
30
25
20
15
10
5
0

Any
Injury
impairsince
ment admission

13%

11%

Arthritis

10%

6%

Hyper- Asthma Heart
tension
problems

Type of Impairment Reported
35%
30
25
20
15
10
5
0

33.9%
21.7%
11.3%
3.7%
Physical

Learning

Speech

8.3%

6.4%
1.7%
Hearing

Vision

Mobility

Mental

Source: U.S. Department of Justice, Bureau of Justice Statistics, November 2006

somebody who has done drugs at sometime in their lives,” and it’s drug users
who currently swell the incarcerated
population, she says. “Prisons are the
dumping grounds for poor people.”
Some 80 percent of the women in state
prisons were convicted of non-violent
offenses, and they are not “the horrible people who should languish and
die,” Lewis notes.
“If you don’t want to provide care
for humanitarian reasons, do it to ensure that your neighbors” don’t suffer
from untreated infectious disease or
mental illness, says Brown Medical
School’s Flanigan.
“Society benefits” if incarcerated people get treatment “and suffers if they

Available online: www.cqresearcher.com

don’t,” says Florida State’s Mears. Untreated mental and physical diseases end
up costing everyone more years down
the line, he says. “So why wouldn’t society demand that they get these things?”
Should correctional facilities require HIV tests?
The deadly HIV/AIDS infection can
be spread within correctional facilities
through sex and shared needles used
for illicit drug use or tattooing. And
infected prisoners can spread the disease in communities after their release.
Thus, some analysts say, prisoners
should be required to undergo HIV
testing, either at entry or before release. Critics of mandated testing, how-

Jan. 5, 2007

9

PRISON HEALTH CARE
ever, argue that HIV education and optional testing can stop the spread of
AIDS just as effectively without violating inmates’ privacy or human rights.
“There’s no question in my mind”
that prisoners should be screened for
HIV, says the University of Texas’
Winslade. “Sex occurs in prison, and
we should do everything we can to
prevent the spread of HIV,” he says.
“Testing everybody in the free world
would be silly, but prisoners are a
much higher-risk population with drug
users and high-risk sex.”
“Public-health issues far outweigh
the privacy issues” of individual inmates when it comes to HIV/AIDS,
said Louisiana Democratic state Rep.
Austin Badon Jr. in September, while
introducing legislation to require testing for HIV and hepatitis for everyone who passes through the state
prison system. 25
Some states already require prerelease screening to keep HIV/AIDS
from spreading in the community. But
Barry Zack, an assistant clinical professor at the University of California,
San Francisco, and executive director
of Centerforce, a nonprofit agency serving California prisoners and their families, says that’s too late. Released inmates who are HIV-positive are likely
to find themselves without any access
to health-care services, he says, adding,
“Yet, you just had an opportunity to
treat them and wasted it.”
One of the first things a released
inmate does is return to a wife or girlfriend and have sex, often unprotected, said Badon. “It’s a no-brainer to
do what we can.” 26
Optional testing, on the other hand,
leaves “a substantial proportion of infected inmates . . . undetected,” according to researchers at the University
of North Carolina at Chapel Hill. 27
Studies in Maryland and Wisconsin
found that infection rates among inmates
overall were twice as high as infection
rates among inmates who volunteered
to be tested. For instance, two-thirds of

10

CQ Researcher

Inmate Drug Abuse
Is Widespread
More than half of all state
prisoners were drug dependent
in 2004, and 49 percent of
federal inmates received drug
treatment or participated in a
therapy program.
Percentage of Prisoners
Who Abused Drugs,
Got Treatment
(in 2004)
60%

53%

50

45%

49%

Compulsory universal HIV testing
is “based on the paranoid position that
prisoners are responsible for spreading HIV to a chaste public,” wrote
Prison Legal News contributing writer
Gary Hunter. 31
Correctional institutions should facilitate HIV prevention, not mandate intrusive testing, says internist and correctional-health monitor Cohen. Prison
systems “should give out condoms, and
prisoners should be offered testing when
they want to be tested.”

BACKGROUND

40%
40

Population Explosion

30
20
10
0
State inmates

Federal inmates

Were drug dependent
Participated in treatment programs

Source: U.S. Department of Justice,
Bureau of Justice Statistics, Oct. 2006

the HIV-infected inmates in Maryland —
and 31 percent in Wisconsin — declined
testing. 28
The American Medical Association
recommended mandatory HIV testing
of prison inmates as early as 1987. The
federal Bureau of Prisons advocates
mandatory testing only of prisoners with
clear risk factors, such as a history of
injection-drug use. Many AIDS advocacy and human-rights groups oppose
mandatory testing. 29
Compulsory HIV testing of prisoners is “unethical and ineffective, and
should be prohibited,” according to
the World Health Organization. Likewise, AIDS Action calls mandatory
testing “unethical, ineffective and an
invasion of privacy.” 30

T

wo very large trends underlie the
nation’s prison health-care problems. One is the steady increase in
the prison population, resulting in oftenovercrowded facilities and the incarceration of high numbers of mentally
ill and addicted inmates. 32
The national inmate population is
now more than six times the approximately 330,000 people incarcerated in 1972 — far outpacing overall
population growth, which has not even
doubled. 33
At the same time, U.S. health care
overall faces unprecedented challenges. Care has grown astronomically more expensive, hitherto undreamed of diseases like HIV/AIDS
and antibiotic-resistant tuberculosis
have developed, the incidence of
chronic ills like diabetes has increased
as the population has aged, and
health care for mentally ill and lowerincome people has continued to decline in quality and availability. 34
All those trends are reflected, and
magnified, in corrections, says Harrison of the National Commission on
Continued on p. 12

Chronology
1950s-1970s
More mentally ill people drift
into jails and prisons as psychiatric hospitals are closed.

1955
Introduction of the first effective
antipsychotic drug, Thorazine, begins the deinstitutionalization of
the mentally ill.
1969
California becomes the first state to
make it more difficult to involuntarily hospitalize the mentally ill.
1976
The Supreme Court’s Estelle v.
Gamble ruling declares it unconstitutional for prisons to show “deliberate indifference” to a prisoner’s
serious medical needs.
1977
At the first World Congress of
Prison Medicine, corrections health
officers pledge to keep inmates’
medical information confidential,
abstain from authorizing any physical punishment and give medical
judgments priority over other concerns, like security.
•

1980s-2000s

Continued dismantling of residential mental-health facilities
and get-tough policies on crime
increase U.S. prison and jail
populations. Infectious disease
increases behind bars.
1980
Just over 500,000 Americans are
incarcerated.
1981
First AIDS case is reported.

1987
American Correctional Health Services Association opposes mandatory AIDS testing for prisoners.
1989
Supreme Court’s Mistretta v. the
United States ruling upholds federal
sentencing guidelines, barring
judges from considering prisoners’
amenability to treatment and rehabilitation during sentencing. . . .
Dade County (Miami) experiments
with a drug court to divert substance abusers from prison.
1994
Supreme Court’s Farmer v. Brennan ruling defines its “deliberate
indifference” standard for health
care that violates prisoners’ constitutional rights: Simple negligence isn’t
bad enough but prisons can violate
the Constitution even if they don’t
knowingly do a prisoner harm.
1995
Federal government begins funding demonstration drug courts to
steer substance abusers toward
treatment rather than prison. . . .
Nearly 1.6 million Americans are
incarcerated. . . . In Ohio, a
court-appointed monitor oversees
a complete overhaul of mentalhealth care in state prisons.
1997
Broward County (Fort Lauderdale)
opens the nation’s first mental-health
court to direct mentally ill offenders
into treatment instead of prison.
1999
New York City jail inmates challenge
the practice of releasing mentally ill
detainees without helping them to
continue treatment.
2001
Federal Bureau of Prisons says it
will pay for some organ transplants.

Available online: www.cqresearcher.com

2002
California court allows a convicted
felon to get a heart transplant at
Stanford Medical Center. . . . Erie
County (Buffalo), N.Y., models the
nation’s first gambling-addiction court
after drug courts.
2003
Federal Centers for Disease Control
and Prevention recommends
screening all at-risk prisoners for
hepatitis C.
2004
Alabama settles lawsuit stemming
from the death of 42 state prisoners
from AIDS between 1999 and 2004
with an agreement to provide HIVand AIDS-specific care and better
nutrition to infected inmates.
2005
Federal judge places California’s
entire $1.1-billion-a-year prison
health system under a court-appointed receiver, deeming the care
it delivers “deplorable.” . . . More
than 2.3 million Americans are incarcerated. . . . Texas prisoners
are required to get HIV testing
before release. . . . Colorado
prison audit finds that health contractor ignores inmates’ cancers
and prescribes medication without
patient exams.
2006
Landmark Department of Justice
report finds that more than half of
jail and prison inmates have mental illness, a much higher rate
than previously believed. . . . California bans shackling of women
inmates during labor and delivery.
. . . Delaware lawmakers reject
$30 million bill requiring special
care for pregnant inmates, infectious-disease screening and health
training for guards.

Jan. 5, 2007

11

PRISON HEALTH CARE

Prisons Replace Hospitals for the Mentally Ill

W

hen Catharine Harrold was arrested last summer,
police wouldn’t allow her to bring her best friends
— two stuffed bunnies — to jail with her. “What
I’ve been worried about is that they would send me to the
hospital before Little and Big get here, she said.” 1
Harrold has had seizures, mood disorders and dementia —
and has been arrested 24 times, mostly on drug and driving
charges — since suffering severe head injuries in a car crash
in the early 1990s.
Nearly six months later, Harrold is still being held in a Florida
jail, even though state law requires that mentally ill inmates be
moved to psychiatric facilities within 15 days of their arrest.
She is only one of about 250 mentally ill prisoners in Florida
who have been held for more than two weeks. In 2006, the
average wait for a transfer was three months; some inmates
waited more than five months. 2
Now, some angry Florida judges are threatening to jail state
officials themselves over the delays. “This type of arrogant activity cannot be tolerated in an orderly society,” Circuit Judge
Crocket Farnell wrote in an October ruling. 3
Treatment of mentally ill inmates is not just an issue in Florida. An angry federal judge ordered Michigan officials in November to make sure state prisons are adequately staffed with
psychologists and psychiatrists and that mental-health staff make
daily rounds. 4
“Here is the basic message,” an angry U.S. District Judge
Richard A. Enslen told state corrections officials, suggesting they

Continued from p. 10

Correctional Health Care. “It’s not that
prisons or jails are a breeding ground
for disease,” he says. “They’re a catch
basin for poor people in the community with poor health histories.”
While prisoners are in poorer health
than average Americans, prisoners’
health status reflects conditions in the
low-income communities from which
many inmates come, he says.
“The only solution to the medical
problem in California prisons [now
under federal control] is to build fewer
prisons,” says health-monitor Cohen.
That’s because “they can’t find the
doctors to run them,” he says.
To cut back on incarceration, more
mental-health and substance-abuse
treatment and prevention would have
to be available inside current correc-

12

CQ Researcher

say prayers for mentally ill inmates who have died in custody.
“You are valuable providers of life-saving services and medicines.
You are not coat racks who collect government paychecks while
your work is taken to the sexton for burial.” 5
A recent U.S. Department of Justice study found that in 2005
more than half of all prison and jail inmates in the United
States had a mental-health problem. Various analyses have traced
some of the overall rise in the numbers of incarcerated mentally ill Americans to the closing of mental hospitals beginning
in the 1950s.
For example, a 1972 California study found that the local
jail population in Santa Clara County rose 300 percent in the
four years after a local psychiatric hospital closed. And a 1992
survey by the advocacy group Public Citizen found that 29 percent of jails were holding people who had no charges against
them but were waiting for mental-health services. 6
“Jails and prisons have been viewed as the easiest place to
park the severely mentally ill,” says Morgan Moss, co-founder
of the Center for Therapeutic Justice, which promotes development of therapeutic, inmate-run communities inside correctional institutions. “Jailing people helps us avoid the problems
society needs to deal with. Instead, we just stick you there.
And if we build 500 new prison beds, we never have to bite
the bullet.”
Jails and prisons are the worst possible places for the mentally ill, who often unwittingly break institution rules and end
up in isolation. “The mentally ill in isolation . . . simply fall

tional institutions and in the community, many analysts say.
“Prior to the 1980s, rehab was a
strong component in correctional health
thinking,” says Anglin, at the University of California’s Integrated Substance Abuse Programs. “Then you
had a huge philosophical shift. Rehab
had shown only marginal results, and
the thinking became, ‘Let’s throw a
sentence at people,’ ” he says. 35
“Various epidemics of drugs” over
the years — from LSD and heroin to
cocaine, crack cocaine and methamphetamines — combined with increased emphasis on penalizing drug
use, “effectively criminalized whole
generations of black people and now,
increasingly, Hispanics,” Anglin says.
Add this to “three-strikes-and-you’reout” laws and a trend toward longer

prison sentences, “and you get a huge
proportion of people who are growing old” behind bars, Anglin says.
In 2003, more than 20 percent of
sentenced inmates were imprisoned
for drug offenses. Offense rates varied by race, however, with 24 percent
of black inmates and 23 percent of
Hispanics serving time for drug offenses, compared to 14 percent of white
inmates. 36
The deinstitutionalization of mentally ill people, which began in the
1950s with the development of antipsychotic medication and accelerated through the 1980s, also has swollen
prison populations. 37 Between 1955
and 1994, the proportion of the population living in public psychiatric
hospitals dropped by more than 90
percent. 38

apart,” said Fred Cohen, professor emeritus at the State University of New York at Albany and a court-appointed monitor
for mental health in Ohio prisons. “They have no support, they
have no sensory stimulus, their hallucinations get worse.” 7
Some courts have required state and local corrections departments to improve care for mentally ill inmates. In Ohio,
for example, prisons were ordered in 1995 to beef up their
mental-health capacity. “There just wasn’t enough staff,” said
Debbie Nixon-Hughes, chief of the Bureau of Mental Health
Services in Ohio. “We had approximately 12 doctors, and now
we have 67.” 8
Keeping as many mentally ill people as possible out of correctional institutions is a key goal, some experts say. “Jails simply cannot deal with these people,” says Bruce J. Winick, professor of law and psychiatry at the University of Miami. Winick
originated the concept of therapeutic courts, which offer a small
but growing option, similar to drug courts, he says. Instead of
jailing the mentally ill, judges refer them to treatment and exert
continuing pressure to help them stay on their medications and
out of trouble. More than 100 mental-health courts now operate
nationwide, including a handful that handle felony offenders as
well as people charged with misdemeanors. 9
Creating more humane and socially oriented environments
within correctional facilities also can provide options for mentally ill offenders, Moss says. He’s helped set up special, inmatedirected living units in correctional facilities, where like-minded
detainees agree to help each other improve their lives. “We set

Many have ended up in jails and
prisons, says Harrison. “When people
get picked up for a crime, there’s often
an underlying mental illness that led
to it. Correctional facilities have in a
sense become the dumping ground
for the mentally ill.”
“Many are being punished for behavior that could be prevented,” says
Loyola Law School’s Clark.
But “no one likes to spend money
on preventive care,” says Florida
State’s Mears. “It’s hard to sell politically” when the monetary and social
payoffs occur years down the line.

Legal Aid

A

ctually, it’s a step forward in
human rights for anyone to

up a community inside the jail built on pro-social values like
honesty and respect,” says Moss. “Behind the walls, inmates
mostly run things anyway.”
Once a community is running, “the jail itself often will put
mentally ill prisoners in there and have the other inmates look
after them,” reducing suicides and the isolation that often worsens the condition of mentally ill prisoners, says Moss.
Cohen cautioned that while jail and prison environments
can be made more helpful for the mentally ill, the real support work is needed in the community. “The prison is simply
not a place of first choice in which to provide mental-health
care,” he said. “We should be devoting ourselves to . . . keeping people out.”
1 Quoted in Sarah Lundy, “ ‘Humanity’ ” Put to Test as Mentally Ill Languish
in Jails,” Orlando Sentinel, Dec. 12, 2006, p. A1.
2 Ibid.
3 Quoted in Abby Goodnough, “Officials Clash Over Mentally Ill in Florida
Jails,” The New York Times, Nov. 15, 2006, p. A1.
4 David Ashenfelter, “Fix Prison Health Care Now, Judge Says,” Detroit Free
Press, Nov. 14, 2006, p. 1.
5 Quoted in ibid.
6 E. Fuller Torrey, Out of the Shadows: Confronting America’s Mental Illness
Crisis (1997), quoted in “Deinstitutionalization: A Psychiatric Titanic,” “The
New Asylums,” PBS “Frontline.”
7 Quoted in “The New Asylums,” ibid.
8 Ibid.
9 For background on drug courts, see Mary H. Cooper, “Drug-Policy Debates,”
CQ Researcher, July 28, 2000, pp. 593-624.

worry at all about prisoners getting
health care. Throughout history,
prison conditions have been atrocious,
with inmates facing health-threatening
conditions such as rotten food, no heat
and cells flooded with raw sewage.
As late as the 1970s, prisoner lawsuits
complained about “health-care” incidents in which unsupervised prisoners were allowed to perform “medical” procedures like tooth pulling and
suturing on their fellow inmates. 39
In the landmark 1976 case that established prisoners’ constitutional right
to health care — Estelle v. Gamble —
a falling bale of hay injured inmate
J. W. Gamble while he worked on a
prison farm in Texas. Gamble — who
claimed that prison staff failed to adequately diagnose and treat his injury
— lost his case. In its ruling, however,

Available online: www.cqresearcher.com

the U.S. Supreme Court did establish
the fundamental principle that corrections facilities must not show “deliberate indifference to serious medical
needs” of inmates. 40
“The Supreme Court made it very
clear that people on the outside and
people locked up are in very different positions with regard to their entitlements,” says the ACLU’s Fathi.
“When the state disables you from acting on your own behalf,” as it does
with prisoners, then there’s a presumption that the state must provide
you with health care.
In fact, all major initiatives to improve correctional health care have
come from the courts, not from legislators or the public. “This is a population that nobody wants to interact
with, that nobody feels a connection

Jan. 5, 2007

13

PRISON HEALTH CARE
HIV-Positive Inmate Population Declines
The number of HIV-positive prison inmates dropped to less than 2
percent of the nation’s overall prison population in 2001 and
dropped again in 2004.
HIV-Positive Prison Inmates
Year

Number

1998
1999
2000
2001
2002
2003
2004

25,680
25,807
25,333
24,147
23,866
23,663
23,046

Percentage of
State and
Federal Inmates
2.2%
2.1
2.0
1.9
1.9
1.9
1.8

Source: U.S. Department of Justice, Bureau of Justice Statistics, November 2006

with,” says Centerforce Executive Director Zack. “That’s why the court has
to make these decisions.”
Since 1976, the courts have struggled to define “deliberate indifference” and “serious” medical need.
The broadest outlines are clear, says
Fathi. Mental-health care and physicalhealth care both are covered, but substance-abuse and addiction treatment
are not — except for treating withdrawal. “Once you’re done withdrawing and just want help to get off
opioids, no one’s required to give you
that,” he says.
Lower-court decisions have clarified
that it is not enough to prove that a
correctional system was “negligent”
with regard to a prisoner’s care, says
Fathi. One must prove “deliberate indifference” on the part of corrections
officials who knew but ignored the
fact that a prisoner was at serious risk
due to a medical condition. “They’re
not entitled to care for a hang nail;
they are entitled to care for a heart
attack,” Fathi says. Questions arise when
a prisoner has a condition somewhere
between those two extremes, he ex-

14

CQ Researcher

plains, “with something like a hernia
being a prime example of a gray area.”
The major role of lawsuits has
been to ensure that prisoners get access to at least some health care, says
Lewis of the Legal Aid Society. “One
of the first goals of lawsuits has been
to ensure sufficient staff,” and most
litigation has played out over many
years, she says.
“Litigating quality of care is one
of the hardest parts,” says Lewis.
“You can say you have to have a
person who’s a board-certified internist [on staff]. But this doesn’t mean
he’s competent or cares or hasn’t had
his license suspended in three other
states.” Using legal means to improve
care quality is “where we have a bad
time.”
Many cases are too narrow to offer
much guidance, says the University of
Texas’ Stone. Most “are limited to a
specific fact pattern — like certain levels of HIV care,” he says. A ruling in
such a case does nothing to help set
care standards for other diseases like
cancer or diabetes, or even for future
HIV cases, as medical research and

standards of care keep advancing, he
says. So, despite the fact that lawsuits
have been by far the strongest instrument for improving correctional
health care, “litigation has only limited usefulness when it comes to setting real standards and broader goals
for health care,” Stone says.
In cases involving access to care,
“the two most common themes are
lack of resources and security interfering with medical treatment,” says
Fathi. When a federal judge ordered
the court takeover of California’s prisons last year, for example, a key issue
cited was that health-staff salaries were
too low, says Fathi.
“If lawsuits are done right, they can
demonstrate problems [occurring] on
a massive scale,” says Loyola’s Clark.
“You have to be able to amass enough
evidence and show that the problems
aren’t rare.”
In addition, lawsuit allegations are
not necessarily valid, said Martha
Harbin, a spokeswoman for Prison
Health Services (PHS), which provides
contract correctional health care. “Inmates are one of the most litigious
groups in society, and a vast majority of the suits filed against PHS are
dismissed as baseless,” she said. 41
Meanwhile, correctional health professionals and researchers also work
from within to improve correctional
health care. Two main organizations
— the National Commission on Correctional Health Care and the American Correctional Association — certify facilities and workers and offer
training on care improvement.
For example, the commission accredits about 500 facilities, including
prisons, jails and juvenile facilities, says
Harrison. Its most important role is
training and educating correctional health
staff, through consultations, conferences
and care guidelines, he says. The group
issues care guidelines for many conditions, customizing diabetes-care guidelines created by the American Diabetes
Association, for instance, by “adding a

description of the barriers to meeting
those guidelines in correctional institutions and how they might be handled.”

The percentage of HIV-positive prisoners varies by prior involvement with
illegal drugs. Of prisoners who had never
used drugs, 1.3 percent are HIV-positive compared to 2.8 percent who have
used a needle to inject drugs and 5.1
percent of those who say they have
shared a needle. 46
elivering health care in correcChronic diseases like diabetes and
tional institutions is difficult behypertension also are more prevalent
cause funding is low, and prison buin prisons, especially in their most sereaucracies focus primarily on providing
rious forms.
security and punish“If you’re 50 years old
ment — not health
[and in prison], your concare. And, inmates
dition probably makes you
show a higher incigeriatric,” says Metzner.
dence of all types of
“The biggest problem
illness, making prisis that they didn’t have
ons the “crucibles”
care before we got them,”
for all the nation’s
says Wright. “They come
health-care probin with undiagnosed hylems, says Florida
pertension and pulmonary
State University’s
disease,” often coupled
Mears.
with a history of unhealthy
In 2005, around
substance abuse, “and we
23 percent of state
see advanced cases of
prisoners and 30 perdiseases like diabetes that
Female inmates take part in a substance-abuse program at a prison in
cent of jail inmates
we don’t see in the comMitchellville, Iowa. About 15 percent of the nation’s inmates participate
reported symptoms
munity.”
in such programs, but many experts say more programs are needed
of major depression,
The high proportion
in both correctional facilities and local communities.
while 15 percent of
of racial minorities among
state prisoners and 24 percent of jail probation or incarceration, compared inmates increases the rate of some
inmates had symptoms of psychotic to 32 percent of other prisoners. 44
serious chronic diseases. For example,
disorders. 42
That makes it important to try ad- the prevalence of diabetes in AfricanBeyond the overall rate of mental dressing prisoners’ substance-abuse is- Americans is 70 percent higher than
illness, “at any given time, from 5 to sues while they’re inside, says Wright of in the white population, and the dia15 percent of inmates will need some the New York state system. “If 80 or 90 betes rate in Hispanics is nearly twice
kind of crisis intervention,” says the percent had these issues in the past, that in whites. 47
University of Colorado’s Metzner.
why not take advantage” of the fact that,
The growing number of incarceratSome studies show that improving while incarcerated, “they have time” to ed women adds another burden to
community mental-health treatment can work on a substance-abuse program? correctional health care, says Wright.
keep people out of jail and save money. “Once they’re on the outside, they’ll have “About 5 to 6 percent come in pregFor example, an Arkansas program the same problems as everybody else, nant,” he says.
decreased patients’ mean number of going to work, trying to make ends
annual jail days to between 46 and meet. We have committed to giving it
83 from well over 100. An Illinois pro- to everybody who needs it, at least begram decreased both jail days and fore they get out,” he says.
hospital days for a group of 30 paPrisoners and jail inmates also have
tients, saving $157,000 in jail costs and high rates of infectious diseases, ineyond the poor health of entercluding AIDS.
$917,000 in hospital costs. 43
ing inmates, many aspects of inIn 2003, nearly 1-in-13 prisoner deaths stitutionalized life make providing
Helping prisoners get off addictive
drugs isn’t part of prisoners’ constitu- was from AIDS-related causes. 45
health care difficult. There’s a constant

Population Health

AP Photo/Steve Pope

D

tional guarantee of health care, but with
substance abuse being the reason many
people end up behind bars in the first
place, it’s an inescapable feature of the
correctional health landscape.
Twenty-one percent of state prisoners and 55 percent of federal inmates were being held for drug-law
violations in 2004. Among state inmates who had been dependent on
or had abused drugs, 53 percent had
at least three prior sentences to either

Multiple Systems

B

Available online: www.cqresearcher.com

Jan. 5, 2007

15

PRISON HEALTH CARE
and probably unavoidable culture clash
between security concerns and health
concerns.
For example, “In many jails and
prisons mentally ill people, because
of their illness, don’t follow rules,” says
Metzner. “So they get put into lockdown, which makes their illness worse,
and where they again don’t follow
rules,” ending up in more and more
stringent segregation, which can greatly worsen their illness. “That’s a tragedy.’
Pre-incarceration health-care regimens get disrupted because “offend-

In addition, as people move through
different parts of the corrections system — juvenile-detention centers, jails,
prisons, probation and parole — the
health care they receive, if any, is completely disjointed.
“One of the biggest problems is
the criminal-justice system is not a
system,” says Moss, of the Center for
Therapeutic Justice. “Nobody talks to
anybody else. Judges rarely ever talk
to anybody. Most have never been
inside a jail to look at what goes on
in there. You’ll find almost no one

“In many jails and prisons mentally ill people,
because of their illness, don’t follow rules. So they
get put into lockdown, which makes their illness
worse, and they again don’t follow rules.”
— Jeffrey L. Metzner, M.D.,
University of Colorado
School of Medicine

ers can’t bring their own medication
into a facility,” says correctional-care
consultant Cohn. “Often, they don’t
know what they were taking. It was
‘a blue pill and a green pill.’ ”
And “offenders know how to manipulate,” says Cohn. “They want to
get out of their cells, and a significant
number come to the infirmary when
there’s nothing wrong.”
“Many problems are fundamentally structural,” says the ACLU’s Fathi.
For example, often a serious medical
problem requires a time-and-resourceconsuming trip outside the prison to
see a specialist, and “sometimes the
security staff will keep this from happening.”

16

CQ Researcher

who’ll tell you that this system is
working.”
Since jails are the first stage in the
criminal-justice process, typically 80 to
90 percent of their inmates “are pretrial,” explains Cohn. Many small-town
jails are small and have no on-site
health staff.
There are 3,360 jails nationwide, and
well under 10 percent “have any significant program of any kind” to assist
inmates, such as education, therapy or
substance-abuse treatment, says Moss.
“The smaller the jail, the less likely . . . you’re going to have any kind
of medical and mental-health care,”
said court-appointed prison monitor
Cohen.

“Yet, if prisons have become the
hospitals, the jails are the emergency
rooms,” Cohen said. 48
Nevertheless, jails must cope with
serious health issues. Many detainees
are in acute phases of mental illness
and have committed relatively minor
offenses like urinating on someone’s
lawn or leaving a restaurant without
paying. In addition, “people in jails
are withdrawing [from drug addiction],
they get taken off their meds and
they’re dealing with the situational stress
of just being arrested,” says Fathi.
So-called supermax prisons or
units keep presumably the most
violent and dangerous inmates
isolated and deprived of sensory stimulation. But supermax imprisonment carries special dangers for mentally ill people, who
often end up there because their
illness leads them to inadvertently
break prison rules.
In one such unit in Indiana,
“at least half the inmates were
mentally ill,” says Fathi. “They
do therapy by locking the prisoner and therapist into adjacent
cells.” The prisoner bends down
and talks through the floorlevel slit through which food
trays are passed, “The therapist
sits on a milk crate on the other
side. . . . It’s been well established
that mentally ill people break down”
in such conditions, he says. The
ACLU has worked with several states
to keep mentally ill prisoners out of
supermax, Fathi says.
“We’ve got to stop spending money
to build [supermax] prisons,” says Stone
at the University of Texas. Building
the prisons, then staffing and maintaining them over the facilities’ lifetime drains money from other priorities, like health care, he says.
In recent years, juvenile facilities
frequently have housed mentally ill
children as they wait for mental-health
services to become available.
Continued on p. 18

At Issue:
Are drug courts a good alternative to imprisonment for
substance abusers?
Yes

d

JOHN ROMAN

STEVEN K. ERICKSON, J.D., LL.M., PH.D.

SENIOR RESEARCH ASSOCIATE
JUSTICE POLICY CENTER
THE URBAN INSTITUTE

MENTAL ILLNESS RESEARCH, EDUCATION
AND CLINICAL CENTER FELLOW
YALE UNIVERSITY

WRITTEN FOR CQ RESEARCHER, DECEMBER 2006

WRITTEN FOR CQ RESEARCHER, DECEMBER 2006

rug-fueled crime is hard to conquer, but drug courts
are a strategy that has been shown to work. For the
past 15 years, judges have used a new approach to
penalizing drug-involved offenders: requiring treatment under
criminal-justice supervision, incarcerating those who fail and letting
those who succeed return to the community for a new chance.
The operating principle is that chronic criminal behavior — such
as street crime, prostitution and domestic violence — results from
drug dependence that can be addressed therapeutically, thus
preventing future offending.
According to the best available research, drug courts not
only work but also represent a solid investment. In a review
of published drug-court evaluations, University of Maryland
researchers found that future offending dropped an average of
20 percent. Reviewing 27 drug-court studies, the Washington
State Institute of Public Policy found drug courts yield at least
$2.83 in benefits for every dollar spent.
Despite complaints that drug courts are “soft on crime,” analysis
shows no reduction in jail time. Instead, jail beds are simply used
more effectively, as those who continue to use drugs stay behind
bars and those who do not are released. More important, addicts
who succeed in drug treatment will commit fewer crimes, on average, while addicts sent to prison without treatment are likely to resume criminal activity after release. The effect of this approach on
crime rates could be substantial because drug-involved offenders
commit voluminous crimes.
Drug courts have evolved from a small, grassroots movement to business as usual in some — but not nearly enough
— jurisdictions. The Urban Institute estimates that each year
fewer than 5 percent of drug-dependent arrestees receive
drug-court services. If drug courts reduce crime but serve only
a small percentage of offenders, the effect on crime will be
negligible and a great opportunity wasted.
The bottom line? We recommend a dramatic expansion in
the number of drug courts, and, even more important, in the
number of drug-involved offenders being served by drug courts.
Experiences in New York City provide important insight. In the
last decade, crime has declined there and — reversing the
trend elsewhere in the United States — so has the number of
people incarcerated. Not coincidentally, during this time more
than 9,000 offenders — including almost 7,000 felony offenders
— have been treated in a drug court in New York.
If policymakers expand access to drug courts, the level of
crime in the United States can be expected to fall measurably.

i

mplementing alternative punishments to drug offenders is
a noble attempt to stem the tide of recidivism that
plagues our criminal-justice system. So, too, is the wish to
provide leveraged, integrated treatment in the hope that our fellow citizens will quit abusing drugs. But in the zeal to do both
the drug-court movement has become more of a dogmatic belief in therapeutic courts than an effective intervention program
supported by science. Numerous taxpayer-funded studies about
the effectiveness of drug courts leave much to be desired and
do not answer many questions about the proper role of our
court system.
While proponents frequently claim a large body of studies
demonstrates the effectiveness of drug courts, a careful review
of those studies reveals many troubling aspects. Most prominently, many fail to use “intent-to-treat” analysis. Simply put,
defendants who leave the program before completion are routinely excluded from drug-court analysis. Thus, claims about
the courts’ effectiveness are highly questionable.
It is hardly beyond imagination that many drug-court defendants will leave the program for a number of reasons — chief
among these is to use more drugs — and thus choose to suffer
the traditional punishment of incarceration. Excluding these
participants not only confounds the analysis of effectiveness
but also is dishonest, since intent-to-treat analysis is the gold
standard in outcomes research and mandatory in most published studies that appear in science journals.
The claims of effectiveness are plagued by other shortcomings as well. In addiction research, sustained sobriety is the
benchmark of treatment success. Yet, few drug-court studies follow participants for any length of time, and none follow participants beyond the term of drug-court monitoring. Since research
has consistently shown that internal motivation is largely responsible for sobriety success, the elephant-in-the-room question is
whether drug-court defendants maintain their sobriety beyond
their participation in the drug courts themselves.
More crucial, though, is the question of whether transforming
courts into mental-health providers is wise and proper. Therapeutic courts, like drug courts, fundamentally alter the criminaljustice system in a manner that is at odds with our Constitution
and traditions. Defense attorneys are relegated to passive-treatment
advocates, judges are presumed behavioral experts and the judicial
process becomes less about justice than about engineering social
change. The good intentions of the therapeutic courts are not
enough to overcome these troubling aspects.

yes no

No

Available online: www.cqresearcher.com

Jan. 5, 2007

17

PRISON HEALTH CARE

CURRENT
SITUATION

calling me up and saying, “ ‘What do
“On any given night, nearly 2,000 you recommend for this guy when he
children and youth — some as young gets out?’ ” says Moss. “Parole people
as 7 — languish in juvenile-detention talk to jail people? It could happen, but
facilities across the country because hell could also freeze over.”
So-called discharge planning isn’t easy,
they cannot access needed mentalhealth services,” Tammy Seltzer, senior says Flanigan, at Brown Medical School.
staff attorney at the Washington-based To ensure that discharged inmates conBazelon Center for Mental Health Law, tinue to get care for serious diseases,
“people need a personal contact, not
told a Senate panel. 49
orrectional health remains low on
According to a 2003 study, nearly just the name of a clinic,” and an inithe political agenda, although a
15,000 young people — around 8 per- tial appointment, he says. That’s avail- few initiatives may be bubbling up in
cent of those in juvenile detention able to few inmates, however, because state legislatures and Congress. Howduring a six-month period — were both institutional discharge planning and ever, lawsuits seeking better care are
detained while they awaited mental- community services are scarce.
ongoing, and some corrections health
health services, said
systems are being overSeltzer. “Many had
hauled under court suno criminal charges
pervision.
pending, while othFor example, in 2005
ers were arrested for
a federal judge placed
minor offenses,
California’s entire $1.2-bilsuch as truancy or
lion-a-year health system
trespassing, generalunder a court-appointed
ly traced to their
receiver empowered to
mental-health proborder new medical facillems.”
ities built, charging it to
The study authors
the state treasury, and
believe their survey
waive any law, regulaprobably understattion, contract provision,
ed the extent of the
or labor agreement in
problem,
said
order to bring care up to
Seltzer. Juveniles
snuff. 50
with mental disorAlso in 2005, Ohio
ders also stay in desettled a prisoner classtention 36 percent
action suit, agreeing to
longer than other dehire 321 new medical
Prison inmates in Mississippi talk with AIDS counselor Jackie Walker, of
tainees and have
the American Civil Liberties Union. Civil liberties advocates argue
personnel, add $7 bilthat HIV education and optional testing can stop AIDS just as
four times the rate
lion to the annual
effectively as mandatory testing without violating
of suicide or other
health-care budget and
inmates’ privacy or human rights.
self-harm, Seltzer
overhaul prison medical
said.
facilities. 51 In July 2006
Increasingly, corrections officials want a Missouri court ordered all of that
In addition, thousands of people
in the criminal-justice system are on to provide those opportunities, says Col- state’s prisons to transport women
probation or parole every day, or are orado’s Metzner. “A decade ago, you prisoners to abortion facilities at their
nearing their release date and a pe- could talk to wardens about mental health, request. 52
riod that criminologists call commu- and they would say we’re a prison not
Also in 2006, an expert panel at
nity “re-entry.” But few prisoners have a hospital,” he says. “They don’t say that the Institute of Medicine recommendaccess to adequate health care in the now. Sheriffs and wardens are in favor ed changes to 30-year-old federal guidecommunities they return to, and even of adequate discharge planning.” One lines on research involving prisoners.
fewer get help finding and obtaining big reason, says Metzner: “When menAs late as the 1960s and ’70s, “some
tally ill prisoners get it, they come back very bad things” were done to priswhat services there are.
“I can’t remember a parole officer slower — or not at all.”
oners recruited for research studies,
Continued from p. 16

Prisoners and Research

AP Photo/Rogelio Solis

C

18

CQ Researcher

mainly because prisoners are powerless, says Harrison, of the National Commission on Correctional Health Care.
In a Pennsylvania prison, for example, a dermatologist reportedly gloated over the “acres of skin” the prison
would provide for experimentation with
cosmetics, Harrison says.
Such cases have spurred federal rules
strictly limiting most research involving
prisoners. But prisoners themselves
eventually questioned those restrictions, says Harrison. Early in the AIDS
crisis, many treatments were available
only to people participating in research, and “prisoners were coming to
us, saying that it’s unfair we can’t be
in trials,” he says.
Under the new guidelines, prisoners
can be subjects in a much broader range
of studies. Instead of strictly excluding
prisoners from some kinds of research,
the new rules stipulate that risks and
benefits of each proposed study must
be weighed, just as they are when the
subjects are non-prisoners.
That change “is a major step forward,” says the University of Texas’
Stone. However, he says the new rules
won’t accomplish what ought to have
been their most important goal: stimulating research to improve prisoners’
health, decrease recidivism and find
ways to keep the mentally ill, substance
abusers, sex offenders and others out
of prison in the first place. “The panel
missed a big opportunity by not naming research priorities” related to criminal justice, he says.

Prison Politics

P

olitically, prisoners’ health gets
little attention and few resources,
although some observers think that as
lawsuits continue and prison populations and budgets keep rising, the lack
of attention to health care will have
to change.
Health care for this sicker-thanaverage population “is a big-ticket item

at a time when legislatures are continually asking, ‘Do we cut prisons, or something else?’ ” says ACLU’s Fathi. “You
often see the prison system just not get
the money for health care, despite their
sincere pleas to the legislature.”
But it may be high costs that finally drive lawmakers to action on
prison-related health care, such as community mental-health and substanceabuse services that could keep some
people from being incarcerated.
“State legislators that have to deal
with prison health are overwhelmed
by the costs,” says Winslade, the professor of the philosophy of medicine
at the University of Texas.
Several Texas lawmakers currently
are saying, “Rather than build two more
prisons, divert that money to substanceabuse” treatment, says Stone.
While in recent years substance
abuse has received little legislative attention, research on treating it has
been piling up, says UCLA’s Anglin.
“We have a vast store of knowledge.”
Meanwhile, the public and lawmakers
are becoming somewhat “more receptive” toward the idea of treatment
rather than long incarceration, he says.
“That shift will only be enhanced with
the Democratic takeover” of Congress.
In the past few years, Congress has
discussed but not acted on bipartisan
legislative proposals to assist released
prisoners with community re-entry, to
help prevent recidivism.
In 2007, Congress also may move
legislation to improve mentally ill detainees’ access to Medicaid upon release. Without such insurance, mentally ill people can’t get needed services
and are likely to wind up right back
in jail or juvenile detention, mentalhealth advocates say.
“Keeping detainees with severe mental illness on Medicaid can benefit the
criminal-justice system as well as the
mental-health system,” said Joseph P.
Morrissey, a professor of health policy and psychiatry at the University of
North Carolina, Chapel Hill. 53

Available online: www.cqresearcher.com

OUTLOOK
Aging Behind Bars

A

s the incarcerated population ages,
health costs will rise. But it’s not
clear where the money will come from.
Over the past several decades, longer
and longer prison sentences have been
handed out, and people have been required to serve more of their sentences.
Couple that with the huge size of the
baby-boom generation and the frail health
of many prisoners over age 50, and you
have a cost nightmare.
“The geriatric problem is going to be
huge,” says Florida State University’s
Mears. “When someone’s on tubes with
five different diseases, it sucks up a lot
of money.”
One wave of the future is already
beginning, as some prisons erect units
for dementia patients, train inmates to
work as hospice volunteers and plan
for assisted-living sections. In October
2006, New York state’s corrections department “opened its first 30-bed unit
for people who’ve developed dementia,” says Deputy Commissioner Wright.
An assisted-living center is in the planning stages.
Many jurisdictions are struggling with
how to care for a coming generation
of older prisoners. The average cost
of housing an elderly inmate is estimated at $70,000 per year, three times
the cost of a younger inmate. 54
For example, California has a “compassionate early release” program for
sick inmates who are expected to die
within six months and are low risks to
the community; about a dozen people
per year are released under the program. But California, like most other
jurisdictions, is reluctant to commute
sentences or risk being accused of
“dumping” sick released prisoners on
the community. 55

Jan. 5, 2007

19

PRISON HEALTH CARE
Other options being discussed by
corrections experts include shifting aging
prisoners into hospices and other medical facilities in the community. In recent years, some analysts have recommended that large states like
California build special geriatric prisons. However, except for a few small
facilities, such as the dementia ward in
New York, corrections systems haven’t
gone that far. 56
Hospice care or the “early release
of terminally ill prisoners” also are in
corrections systems’ future, says medical ethicist Cohn at the University of
California, Irvine.
Wright, of New York’s Department
of Correctional Services, would like to
see public-health agencies set up
branches in jails and prisons to treat
inmates for chronic and infectious diseases so that prisoners will be healthier when they return home, reducing
disease in the general population. “My
[prison] patients are all insured, and I
can find them,” he points out.
But the prison-building boom of the
last three decades is siphoning off a lot
of cash that otherwise might go to health
care, says Mears. Texas, for example,
“quadrupled its system in just over a
decade, from 40,000 to 160,000” inmates.
Besides paying to erect the buildings, their staffing and upkeep “is a substantial expense — billions of dollars
you can’t spend on other needs,” Mears
says. Thus, while some prisoner advocates would like to see drug-addicted
and mentally ill prisoners diverted into

a more therapeutic system, Mears says
that’s not likely now, because states are
so invested in the current prison system. “We can’t close the beds.”
Analysts point to better preventive
health care and a rethinking of long
sentences as potential solutions, but
there’s no easy way out, they concede.
“To change things, there has to be
real leadership,” says prisoner-advocate
Zack, “and this is not a constituency
that people care about.”

Notes
1

David M. Reutter, “Privatized Medical Services
in Delaware Kill and Maim,” Prison Legal News,
December 2005, p. 1.
2 Quoted in Ibid., p. 3.
3 David Ashenfelter, “Judge Orders State
Prisons to Clean Up Act,” Detroit Free Press,
Nov. 13, 2006.
4 Doris J. James and Lauren E. Glaze, “Mental Health Problems of Prison and Jail Inmates,”
Bureau of Justice Statistics Special Report, U.S.
Department of Justice, September 2006.
5 Christopher J. Mumola and Jennifer C. Karberg, “Drug Use and Dependence, State and
Federal Prisoners, 2004,” Bureau of Justice
Statistics Special Report, October 2006.
6 Laura M. Maruschak, “Medical Problems
of Jail Inmates,” Bureau of Justice Statistics
Special Report, U.S. Department of Justice,
November 2006.
7 Laura M. Maruschak, “HIV in Prisons, 2004,”
Bureau of Justice Statistics Bulletin, U.S. Department of Justice, November 2006, p. 5.
8 Maureen Milford, “Inmates grow old,
health costs rise,” The [Wilmington, Del.]
News Journal, March 26, 2006.

About the Author
Staff writer Marcia Clemmitt is a veteran social-policy
reporter who previously served as editor in chief of Medicine and Health and staff writer for The Scientist. She has
also been a high-school math and physics teacher. She
holds a liberal arts and sciences degree from St. John’s
College, Annapolis, and a master’s degree in English from
Georgetown University. Her recent reports include “Climate Change,” “Controlling the Internet,” “Pork Barrel Politics” and “Cyber Socializing.”

20

CQ Researcher

9

That figure includes those in state and federal prisons, jails, juvenile detention centers and
other facilities, such as Bureau of Immigration
facilities and jails on Indian reservations.
10 Testimony before Senate Governmental Affairs Committee, July 7, 2004, www.nami.org.
11 The case is Estelle v. Gamble, 429 U.S. 97
(1976).
12 Keith Epstein, “Covering the Uninsured,”
CQ Researcher, June 14, 2002, pp. 521-544.
13 Steve Lopez, “The Prisoner With the MillionDollar Heart,” Los Angeles Times, Feb. 13, 2002.
14 Steve Lopez, “Doin’ Time With a New Ticker,” Los Angeles Times, Jan. 28, 2002, p. 1.
15 For background, see James Stemgold, “U.S.
Seizes State Prison Health Care,” San Francisco
Chronicle, July 1, 2005, http://sfgate.com/cgibin/article.cgi?file=/c/a/2005/07/01/MNGOCDHPP71.DTL.
16 “Frontline” interview with Gary Beven, “The
New Asylums,” October 2004, www.pbs.org.
17 Ibid. The case is Dunn v. Voinovich.
18 “Frontline” interview with Fred Cohen, ibid.
19 Quoted in John E. Dannenberg, “PHS
Redux: Sued in a Dozen States, Contract Losses, Stock Plummets, Business Continues,”
Prison Legal News, November 2006.
20 David L. Perry, “Should Violent Felons Receive Organ Transplants,” Markkula Center
for Applied Ethics, www.scu.edu.
21 Ibid.
22 Carrie S. Frank, “Must Inmates Be Provided
Free Organ Transplants? Revisiting the Deliberate Indifference Standard,” George Mason
University Civil Rights Law Journal, spring 2005.
23 Ibid.
24 T. Howard Stone and William J. Winslade,
“Report on a National Survey of Correctional Health Facilities: A Needs Assessment of
Health Issues,” Journal of Correctional Health
Care, spring 1998.
25 Quoted in Ed Anderson, “Badon Presses
for HIV Tests in Prisons,” Times Picayune
[New Orleans] and Nola.com, Sept. 15, 2006;
www.nola.com.
26 Ibid.
27 David L. Rosen, Victor J. Schoenback and
Andrew H. Kaplan, “HIV Testing in State Prisons; Balancing Human Rights and Public
Health, Infectious Diseases in Corrections Report,” April 2006, www.IDCRonline.org.
28 Ibid.
29 Ibid.
30 Quoted in Jeffrey Young, “Waters Seeks
to Sway AIDS Groups on Prisoner Testing,”
The Hill, Nov. 27, 2006, http://thehill.com.
31 Gary Hunter, “Texas Legislature Requires

HIV Testing for Prisoners,” Prison Legal News,
www.prisonlegalnews.org.
32 For background, see David Masci, “PrisonBuilding Boom,” CQ Researcher, Sept. 17,
1999, pp. 801-824.
33 Marc Mauer, “Comparative International
Rates of Incarceration: An Examination of
Causes and Trends,” The Sentencing Project,
paper presented to the U.S. Commission on
Civil Rights, June 20, 2003.
34 For background, see Marcia Clemmitt, “Rising Health Costs,” CQ Researcher, April 7, 2006,
pp. 289-312.
35 For background, see Peter Katel, “War on
Drugs,” CQ Researcher, June 2, 2006, pp.
481-504.
36 Harrison and Beck, op. cit., p. 9.
37 For background, see “The New Asylums,”
PBS “Frontline,” op. cit.
38 Ibid.
39 William J. Rold, “30 Years After Estelle v.
Gamble: A Legal Retrospective,” CorrectCare,
National Commission on Correctional Health
Care, summer 2006, www.ncchc.org.
40 Ibid.
41 Quoted in Dannenberg, op. cit.
42 James and Glaze, op. cit.
43 J. Steven Lamberti, Robert Weisman and
Dara I. Faden, “Forensic Assertive Community Treatment: Preventing Incarceration of
Adults With Severe Mental Illness,” Psychiatric Services, November 2004, p. 1285.
44 Mumola and Karberg, op. cit.
45 Maruschak, op. cit., p. 8 (“HIV in Prisons,
2006”).
46 Ibid., p. 10.
47 Lois M. Davis and Sharon Pacchiana, “Health
Profile of the State Prison Population and Returning Offenders: Public Health Challenges,”
Journal of Correctional Health Care, fall 2003,
p. 303.
48 “Frontline” interview with Fred Cohen, op. cit.
49 Testimony before Senate Committee on
Governmental Affairs, July 7, 2004, http://
hsgac.senate.gov.
50 Marvin Mento, “Federal Court Seizes California Prisons’ Medical Care; Appoints Receiver With Unprecedented Powers,” Prison
Legal News, www.prisonlegalnews.org.
51 John E. Dannenberg, “Ohio DOC Stipulates to Vastly Improved Medical Care,”
Prison Legal News, www.prisonlegalnews.
52 “ACLU Applauds Decision Allowing Women
Prisoners in Missouri to Access Abortion Care,”
American Civil Liberties Union, July 18, 2006,
www.aclu.org.
53 Joseph P. Morrissey, “Medicaid Benefits

FOR MORE INFORMATION
American Civil Liberties Union National Prison Project, 915 15th St., N.W., 7th
Floor, Washington, DC 20005; (202) 393-4930; www.aclu.org/prison/gen/14759
res20010131.html. Founded in 1972; litigates to secure prisoners’ constitutional rights,
including adequate health care.
American Correctional Association, 206 N. Washington St., Suite 200, Alexandria,
VA 22314; (703) 224-0000; www.aca.org. Sets standards for corrections health care
and advocates for corrections professionals.
American Correctional Health Services Association, 250 Gatsby Place, Alpharetta,
GA 30022-6161; (877) 918-1842; www.achsa.org/index.cfm. Trains corrections staff and
informs other health-care workers and the public about corrections health issues.
Bureau of Justice Statistics, U.S. Department of Justice, 810 Seventh St., N.W.,
Washington, DC 20531; (202) 307-0765; www.ojp.usdoj.gov/bjs/welcome.html. Federal agency that compiles and publishes statistics on U.S. correctional systems.
Human Rights Watch, 350 Fifth Ave., 34th Floor, New York, NY 10118-3299; (212)
290-4700; www.hrw.org/prisons. Nonprofit advocacy group that monitors treatment
of prisoners in the United States and internationally, including prison health care.
Integrated Substance Abuse Programs, University of California, Los Angeles,
11075 Santa Monica Blvd., Suite 200, Los Angeles, CA 90025; www.uclaisap.org/
index.html. Conducts research and training on substance abuse and substanceabuse treatment, including in corrections facilities.
Legal Aid Society of New York Prisoners’ Rights Project, 199 Water St., New
York, NY 10038; (212) 577-3300; www.legal-aid.org/supportDocumentIndex.htm?
docID=19&catid=45. Lawyers’ group that litigates and advocates for better conditions in New York correctional facilities.
National Commission on Correctional Health Care, 1145 W. Diversey Pkwy.,
Chicago, IL 60614; (773) 880-1460; www.ncchc.org. Sets standards for correctional
health care and trains correctional staff.
The New Asylums, Frontline, PBS, http://149.48.228.121/wgbh/pages/frontline/
shows/asylums. Web site of PBS documentary; contains interviews with corrections
mental-health experts and data on mentally ill prisoners.
The Real Cost of Prisons Project, The Sentencing Project, 514 10th St., N.W.,
Suite 1000, Washington, DC 20004; (202) 628-0871; www.realcostofprisons.org/blog.
Activist group that educates and provides news about prison issues, especially
through its news weblog.
Understanding Prison Health Care, http://movementbuilding.org/prisonhealth/
barriers.html. Education and advocacy Web site that archives audio and video
interviews with physicians, activists and correctional health experts.
and Recidivism of Mentally Ill People Released From Jail,” National Institute of Justice, Dec. 8, 2004, www.ncjrs.gov/pdffiles1/nij/grants/214169.pdf.
54 Jonathan Turley, testimony on “California’s
Aging Prisoner: Demographics, Costs, and
Recommendations,” before California Senate
Subcommittee on Aging and Long-Term Care,

Available online: www.cqresearcher.com

February 2003, www.sen.ca.gov/ftp/SEN/COMMITTEE/SUB/HHS_AGE/_home/AGING_PRISONERS_TRANSCRIPT.DOC.
55 Sandra Kobrin, “Dying on Our Dime —
California’s Prisons Are Teeming With Older
Inmates Who Run Up Staggering Medical
Costs,” Los Angeles Times, June 26, 2005.
56 Turley, op. cit.

Jan. 5, 2007

21

Bibliography
Selected Sources
A for-profit company makes questionable health decisions
for mentally ill children in New York City juvenile facilities.

Books
Anderson, Lloyd C., Voices From a Southern Prison, University of Georgia Press, 2000.
A professor of law at the University of Akron who led a legal
team representing inmates at the Kentucky State Reformatory
recounts the prisoners’ decades-long fight for better conditions.
Hornblum, Allen, Acres of Skin, Routledge, 1999.
An instructor in urban studies at Temple University recounts
the history of medical experiments carried out on prisoners
at Philadelphia’s Holmesburg Prison.
Jacobson, Michael, Downsizing Prisons: How to Reduce
Crime and End Mass Incarceration, New York University
Press, 2005.
A former chief of the New York City Department of Corrections — who argues that mass incarceration fails to reduce
crime and has created a permanent criminal underclass —
suggests political strategies to develop an alternative system.
Kupers, Terry, Prison Madness: The Mental Health Crisis
Behind Bars and What We Must Do About It, Jossey-Bass,
1999.
A psychiatrist and professor at the Wright Institute in Berkeley,
Calif., describes the lives of mentally ill inmates in overcrowded
prisons.
Latessa, Edward J., and Alexander M. Holsinger, eds.,
Correctional Contexts: Contemporary and Classical Readings, Roxbury Publishing Co., August 2005 (3rd edition).
Criminal-justice professors at the universities of Cincinnati
and Missouri assemble readings on the history of corrections, including sections on treatment programs, prison conditions and community re-entry.
Petersilia, Joan, When Prisoners Come Home: Parole
and Prisoner Reentry, Oxford University Press, 2003.
A professor of criminology at the University of California,
Irvine, describes the plight of the more than half a million
prisoners released each year after receiving little treatment
or training while incarcerated.

Articles
Lundy, Sarah, “ ‘Humanity’ Put to Test as Mentally Ill Languish in Jails,” Orlando Sentinel, Dec. 12, 2006, p. A1.
A mentally ill woman spends weeks in jail because beds
in local mental hospitals are filled.
Von Zeilbauer, Paul, “A Spotty Record of Health Care for
Children in City Detention,” The New York Times, March 1,
2005, p. A1.

22

CQ Researcher

Reports and Studies
“Adult Drug Courts: Evidence Indicates Recidivism Reductions and Mixed Results for Other Outcomes,” Government
Accountability Office, February 2005.
Congress’ nonpartisan research and analysis agency found
that drug courts that divert adults from prison into substanceabuse treatment prevent many from committing subsequent
offenses.
“Confronting Confinement,” Commission on Safety and
Abuse in America’s Prisons, June 2006.
A national expert panel reports on dangerous cultures inside
prisons, including poor health and bad health care, and argues
that prison health deficiencies harm communities as well.
“The Health Status of Soon-to-be-Released Inmates: A Report to Congress,” National Commission on Correctional
Health Care, 2002.
The main accrediting and training organization for correctional health care details the prevalence of infectious, chronic
and mental disease among inmates.
“Mental Health in the House of Corrections: A Study of
Mental Health Care in New York State Prisons,” Correctional Association of New York, June 2004, www.correctionalassociation.org.
An independent advocacy group found that New York state
prisons have too little space and provide too little treatment
for their many mentally ill inmates, whose numbers increased
by 71 percent between 1991 and 2004.
“The Public Health Dimensions of Prisoner Reentry:
Addressing the Health Needs and Risks of Returning
Prisoners and Their Families,” Urban Institute Justice
Policy Center, December 2002.
Criminal-justice and health-care analysts summarize the presentations and discussions from a national symposium on
health concerns related to prisoner re-entry.
Mears, Daniel P., Laura Winterfeld, John Hunsaker, Gretchen
E. Moore and Ruth M. White, “Drug Treatment in the
Criminal Justice System: The Current State of Knowledge,”
Urban Institute Justice Policy Center, January 2003.
Analysts affiliated with a liberal-leaning think tank describe
the recent history of substance-abuse treatment in prisons,
including a decline in treatment-program enrollment through
the late-1990s, after which participation began to increase.

The Next Step:
Additional Articles from Current Periodicals
Drug Courts
Brulliard, Karin, “Uncertain Future For County’s Drug
Court,” The Washington Post, June 19, 2005, p. T1.
Commonwealth’s Attorney James E. Plowman (R) has been
vocal about his lack of support for Loudoun County’s pilot
drug program in Virginia.
Hahn, Valerie Schremp, “Drug Court Marks Success,” St.
Louis Post-Dispatch, June 5, 2006, p. B1.
A young, former cocaine addict charged with marijuana
possession successfully graduated from a drug court in Lincoln
County, Mo.
Tilghman, Andrew, “Alternate Offender Program Growing,”
The Houston Chronicle, March 27, 2005, p. B1.
The drug court in Harris County, Texas, is getting a boost
from President Bush’s faith-based initiatives, which include
money to expand drug courts by giving addicts the option
of treatment with church-based groups.

Elderly Prisoners
Ove, Torsten, “Growing Old in Prison,” Pittsburgh PostGazette, March 6, 2005, p. A1.
Because a growing number of baby-boomer prisoners are
getting older, policymakers are debating whether to continue
keeping so many older prisoners incarcerated.
Sterngold, James, “California Bracing For A Flood of
Elderly Inmates,” The San Francisco Chronicle, Dec.
25, 2005, p. A21.
California’s legislative analyst’s office projects that by 2022
there will be at least 30,200 inmates 55 and older, compared
with 7,580 now.
Wright, Gary L., “As Inmates Age, Cost of Health Care
Climbs,” Charlotte Observer, April 17, 2005, p. A1.
The cost of providing health care to prison inmates in North
Carolina has nearly doubled in less than 10 years because of
a growing elderly population and rising medical costs.
Yamaguchi, Mari, “Japan’s Prisons Adapting to Rapidly
Graying Populations,” The Houston Chronicle, Feb. 12,
2006, p. A28.
Japan’s 67 prisons are being forced to adapt to a new
trend of an aging population — with the number of inmates
60 years old or older tripling in the past decade.

Infectious Diseases and Prisons
Fox, Maggie, “Prisoner Medical Research Lacks Oversight,
Group Says,” The Houston Chronicle, Aug. 6, 2006, p. A15.
The U.S. prison population needs more protection from

Available online: www.cqresearcher.com

potential medical-research abuses, according to a panel of
experts from the Institute of Medicine.
von Zielbauer, Paul, “A Company’s Troubled Answer for
Prisoners With H.I.V.,” The New York Times, Aug. 1,
2005, p. A1.
Prison Health Services, the nation’s largest commercial
provider of prison health care, has a turbulent record in
many of the 33 states where it has provided jail medicine.

Mentally Ill Prisoners
Lopez, Steve, “Mentally Ill in the Jail? It’s a Crime,” Los
Angeles Times, Dec. 11, 2005, p. B1.
Lopez says jails have become dumping grounds for the
mentally ill because there is often nowhere else to put them.
Puente, Mark, “Care of Mentally Ill Prisoners Costly For
Jails,” Plain Dealer (Cleveland), Jan. 20, 2006, p. B1.
Jails across Northeast Ohio say mentally ill inmates who
used to be sent to psychiatric institutions are filling up prison
cells needed for more traditional criminals.
Scott, Rebekah, “Three-Year-Old Program For Mentally
Challenged Prisoners To Be Reviewed,” Pittsburgh PostGazette, June 2, 2005, p. EZ-7.
Two mental-health caseworkers at Pennsylvania’s Westmoreland
County Prison have helped about 60 prisoners connect to
services and get out of jail sooner.
Wachtler, Sol, “A Cell of One’s Own,” The New York Times,
Sept. 24, 2006, p. 15.
A former judge with bipolar disorder writes about why he supports alternative confinement for disruptive mentally ill prisoners.

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