One of the most interesting projects that I was involved with relating to health care was improving health care in county jails in Pennsylvania. Funded by one of the federal programs that REALLY worked (the Law Enforcement Assistance Administration under President Carter), this program was sponsored by the American Medical Association. The project team there developed standards for county jails that would be applied to those county that WISHED to be certified. In other words, it was not a mandatory program.
At the time, there had been a spate of lawsuits under the Eighth Amendment. Here is what that amendment says:
Excessive bail shall not be required, nor excessive fines imposed, nor cruel and unusual punishments inflicted.
County jails had been sued for cruel and unusual punishment for denying or providing inadequate health care to inmates. So, to protect themselves, some county jails were anxious to demonstrate their compliance with voluntary standards.
Whether denial of health care, or inadequate health care, constitutes "cruel and unusual punishment"--I will let you decide. Suffice it to say, the U.S. has a distinctly vindictive bent where incarceration is concerned. The current statistics tell part of the story. A recent article in the Boston Review provides these numbers: the U.S. has 5 % of the world's population, yet has 25 % of the world's inmates. Read the following passage from that article.
"Our incarceration rate (714 per 100,000 residents) is almost 40 percent greater than those of our nearest competitors (the Bahamas, Belarus, and Russia). Other industrial democracies, even those with significant crime problems of their own, are much less punitive: our incarceration rate is 6.2 times that of Canada, 7.8 times that of France, and 12.3 times that of Japan."
But I digress. Back to visiting county jails.
As I began to go around to visit Pennsylvania's county jails, I noticed something unusual about the appearance of these old county jails. See if you notice anything--here are three such jails.
What do you notice about them? They look alike, you say? Well, I made the same observation. In fact, I said--on one visit--these jails look like they were all designed by the same architect. BINGO! I was right--some architect developed this quasi-castle look, and went around to counties in the late 1800s building jails. Many of these jails are no longer occupied as jails, but that's what I was visiting when this program was running.
To test the standards, we had to interview many people in a county jail--from the warden, through the intake personnel, to the correctional officers (COs), to the doctor and nurses in the jail, to the inmates. We would pick a random sample of inmates and ask them things like: when you came into jail, did you get something in writing telling you how to get health care? how do you get health care? have you ever had a health care request denied. Etc.
We were trained NOT to make any promise to an inmate--no taking messages out, or doing any favors. I also decided I would never ask an inmate why he (usually he, but sometimes she) was in "there." I encountered one young inmate who scoffed when I asked if he got something in writing--nah, he sneered, I can't read. And he said it with pride. Oh, my.
I broke my rule on not asking why an inmate was in only once. Usually inmates were younger men, but this one black man was in his mid 50s. And he quoted poetry and was very urbane. I was curious and asked. Well, he said, I was "Chesterized." What? Turns out, there was a murder in a known bad section of a Pennsylvania county, and the police grabbed the first black man they found. Was he guilty? I don't know, although I am sure he was not innocent.
I made several special trips during this project. One was for the U.S. Marshall Service--when I was asked to go to a county jail that housed federal prisoners in transit. The county in question had a horrible jail where inmate health records were kept on 3 by 5 cards, where meds from inmates long gone were piled up in the warden's safe, and where psychiatric cases were put naked into cells with nothing but a bare foam rubber mattress. Needless to say, that county jail was roundly castigated in my report.
I also visited several other state prisons, including Graterford the year before they had massive riots.
Finally, when I had left working for our state medical society, and had gone to work for the state health department, I had one more occasion to examine prison health. An inmate had died in a state prison, and the superintendent didn't know what kind of investigation to conduct. So he asked the Secretary of Health for help. Since I had done jail health surveys in my prior job, the Secretary asked me to investigate.
What I found was that the inmate had gone on a hunger strike. And he had stopped drinking. Rather than order a psychiatric evaluation, or order the inmate be intubated, the doctor prescribed showers. Showers? Yes. The doctor reasoned that if the inmate had to shower several times a day, he would have to drink water. It turns out the reason the inmate died was due to dehydration. In my report, I indicated the doctor had exercised poor judgement--I don't know about you, but I never DRINK the water I am showering in! I couldn't imagine that an inmate bent on refusing food and water would suddenly start drinking in the shower.
A book-ended career, indeed. The volumes in between--well, sometimes it's fun to take one off the shelf and browse a little.