Issue: October 2020
Source: Hagan LM, et al. MMWR Morb Mortal Wkly Rep. 2020;doi: 10.15585/mmwr.mm6933a3.

“Responses to the COVID-19 pandemic;” by the Prison Policy Initiative. Accessed Aug. 6, 2020.

Saloner B, et al. JAMA. 2020;doi:10.1001/jama.2020.12528.
Disclosures: Anderson, Gibson and Keller report no relevant financial disclosures.
October 19, 2020
14 min read

Hard time and health care: Challenges in caring for the prison population

Issue: October 2020
Source: Hagan LM, et al. MMWR Morb Mortal Wkly Rep. 2020;doi: 10.15585/mmwr.mm6933a3.

“Responses to the COVID-19 pandemic;” by the Prison Policy Initiative. Accessed Aug. 6, 2020.

Saloner B, et al. JAMA. 2020;doi:10.1001/jama.2020.12528.
Disclosures: Anderson, Gibson and Keller report no relevant financial disclosures.
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The environment is uninviting and uncaring. It’s loud, it’s cold and it’s dangerous. And it’s even worse for the inmates.

According to the Bureau of Justice Statistics, there were nearly 2.2 million adults locked in prisons and jails across the United States as of 2016. If this group were its own U.S. state, it would rank 36th in population, just ahead of New Mexico.

Source: Adobe Stock.
Scott T. Anderson, MD, PhD, FACR, CCHP-P, noted that U.S. prisons are not built with inmates’ medical care in mind. “They are constructed to prevent escapes, not to comply with the Americans with Disabilities Act.”

Source: Adobe Stock.

Among this population, approximately 15% have some form of arthritis or rheumatism, according to a revised 2016 Bureau of Justice Statistics report. In terms of prevalence, these conditions collectively rank only behind high blood pressure and hypertension among the incarcerated.

“The U.S. Senate Committee on Aging found that arthritis is one of the top chronic health condition among elderly Americans,” Scott T. Anderson, MD, PhD, FACR, CCHP-P, clinical professor at the University of California Davis School of Medicine’s division of rheumatology, allergy and clinical immunology, told Healio Rheumatology. “There is nothing about being incarcerated that protects against arthritis, so everything that individuals in the community would get, people in prison get.”

“It’s also important to note that there is an informal rule of 10 years, which states that individuals who are incarcerated for prolonged periods of time tend to be physiologically 10 years older than their chronological age,” Anderson continued. “So, you have this population that may be largely consisting of people in their 40s, but they look like they are in their mid-50s. They have all the problems people in middle-age have in the community.”

“There is nothing about being incarcerated that protects against arthritis,” noted Scott T. Anderson, MD, PhD, FACR, CCHP-P. “Everything that individuals in the community would get, people in prison get.”
“There is nothing about being incarcerated that protects against arthritis,” noted Scott T. Anderson, MD, PhD, FACR, CCHP-P. “Everything that individuals in the community would get, people in prison get.”

Source: Scott T. Anderson, MD, PhD, FACR, CCHP-P.

Despite the clear need for rheumatic treatment among U.S. prisoners, care among this population is uneven at best. According to Anderson, who has 22 years of experience evaluating and treating state inmates and corrections officers in California, barriers to care range from lack of continuity, to safety concerns, to the very nature of prison infrastructure and bureaucracy.

“The problem in terms of access to care is that the culture of corrections is very bureaucratic and hierarchical,” he said. “As such, all doctors are viewed as being physicians and surgeons. It doesn’t matter if you are a retired pediatrician, or a neurologist doing primary care medicine, you are all put in the same basket as physicians and surgeons. So, the idea of having a subspecialty clinic itself is somewhat alien to the concept of being in a correctional setting.”

A Tale of Two Systems

From 1998 to 2013, Anderson served as a physician and surgeon within the California Department of Corrections and Rehabilitation, where the medical care system has been in receivership since 2006, when a federal court ruled that the state failed to provide a constitutional level of medical care to its prisoners.

It was in this environment that Anderson, in 1998, created the California Department of Corrections’ first rheumatology clinic.

Since leaving corrections in 2013, he has maintained his certified correctional health professional-physician (CCHP-P) status by formerly serving as a prison surveyor for the National Correction Commission on Health Care (NCCHC), an independent nonprofit dedicated to improving correctional health care across the United States. In addition, he continues to see correctional patients and staff in the hallways of UC Davis, and evaluates correctional workers for health conditions sustained on the job, as a Qualified Medical Evaluator for the State of California.

“Physicians in corrections have resources, but whether they are adequate would depend on your point of view,” Anderson said. “The problem doctors have is that in rheumatology you have to make a diagnosis and then you have to initiate a treatment. To initiate a treatment, you must order off of a formulary, and most of the medications we would use, such as biologic agents, are nonformulary. The reflex position in a large bureaucracy is to say no to most requests.”

“The other thing is that the gatekeepers who decide whether drugs will be approved do not need to have any specialty training in rheumatology,” he added. “So, as a rheumatologist, you might order a medication, but the medication may not be available.”

Another issue is continuity of care. Even if an individual is given follow-up appointments, any appointment can be canceled for days or weeks due to lockdowns and fights among inmates.

Appointment issues are also common among smaller jail systems, albeit for different reasons.

Jeffrey E. Keller, MD, FACEP, FACCP, is the medical director of Badger Medical, which provides services to several county jails and juvenile facilities in Idaho. With 25 years of emergency medical experience, he has spent the last 8 years working exclusively in county jails.

Jeffrey E. Keller, MD, FACEP, FACCP
Jeffrey E. Keller

“Jails across the country have different systems,” Keller told Healio Rheumatology. “For my jails, as with the better-run jails, they do have access to care. That may not be true of all jails, but for my jails, yes, inmates have access to rheumatologists, and get treatment for rheumatic diseases, just like they do for any other specialty.”

However, as is common even in the outside world, the availability of rheumatic care can be sparse, especially in rural locations.

“There are problems, and one of them is getting the initial consult,” Keller said. “If I have a patient who has a rheumatologic disorder, and they come to me in my jail and I need to get them to a local rheumatologist, I call for an appointment but that appointment is not going to be for another 4 to 6 months.”

“That is just a function of there not being enough rheumatologists as a group in many parts of the country, including mine,” he added. “It’s just like if someone is not in jail, and someone calls up as a new patient, they may not be able to get in for several months. What I do as their primary care physician, in the intervening months, is I do the best I can.”

Care in an Uncaring Place

Jails and prisons, at least in the United States, are not built with the inmates’ medical care in mind.

Scott T. Anderson, MD, PhD, FACR, CCHP-P
Scott T. Anderson

“They are constructed to prevent escapes, not to comply with the Americans with Disabilities Act,” Anderson said.

As such, prescribing exercise regimens can be difficult in a correctional setting. According to Keller, individuals in county jails are housed largely in a dormitory environment, with some people able to walk laps around the living area.

“They get to go out to an exercise yard, but it is more difficult than the outside, where they can go walking out in the street,” Keller said. “There are limitations, but we do the best we can with that.”

Meanwhile, in the California state system, cell blocks tend to be as much as four stories high, connected by staircases and narrow passageways.

“Typically the authorities try to make the locations as conducive to access as can be done under the circumstances, and there may even be some specially constructed cells for people with disabilities, but the overall buildings tend to be very old,” Anderson said.

Although exercise, or “yard time,” is required by law for all inmates, how this time is defined can vary from institution to institution.

“For example, I visited Pelican Bay as part of a fact-finding mission with various administrators from the Department of Corrections, and at that time, inmates housed in the secure housing unit would go to a room that had a small hole in the ceiling,” Anderson said. “And because the small hole in the ceiling allowed you to see the sky, that was viewed as a yard and that was considered yard time. They also had some enclosed cages that were open to the light above, which were very spartan, and that constituted yard time. That was 20 years ago, so I think a lot of it may have been improved since then. But that was the experience when I visited.”

Dietary regimens are even more of a challenge.

“At their best, jails and prisons offer a heart-healthy diet, and, at their worst, they offer crap diets,” Keller said. “I’ve seen both. The crap diets are done because they are cheap. It is true that we, as doctors, will say I want a specific kind of diet, and then the patient will come back and say they aren’t getting the right diet.”

In addition, the patients themselves can sometimes be resistant to restricted diets, opting to supplement their provided meals with high-fat offerings from the canteen.

“The main issue would be for gout, and ordering a low-purine diet,” said Anderson. “That would be difficult to do in a correctional setting. Also, inmates have access to canteens, which allow them to get very high-saturated-fat foods. So, you also have the problem of obesity.”

According to Anderson, overcoming these challenges means not only being a diagnostician and a treating physician, but also an advocate.

“You also have to advocate for injured or debilitated people,” he said. “You do that by filling out such things as nonformulary forms. You complete something called a ‘chrono,’ which is a chronologically limited order for special privileges, such as a lower bunk. You advocate for housing on special units, where people who are disabled get special care.”

This can also include securing assistive devices, such as canes and wheelchairs, for patients. However, such items pose several risks of their own in prison.

Danger for Both Patient and Provider

According to an article co-authored by Anderson and published in the Journal of Personal Healthcare, three-quarters of individuals in prison who received walking canes were serving sentences for violent crimes, often involving bludgeoning someone with an object or a similar offense. Meanwhile, wheelchairs can be used to hide contraband, and their pieces can be removed and used as weapons, Anderson said.

“All these issues related to housing, mobility, assistance devices and mobility devices are fraught with challenges in a correctional setting, because it’s not like the outside world,” he said.

However, the most pressing safety concerns, both for the patient and, at times, the physician, revolve around the issue of drugs, particularly opioids.

According to Anderson, about two-thirds of inmates have some form of substance abuse disorder, with many of them also demonstrating personality disorders, including anti-social personality disorders. Therefore, there are strong contraindications to the provision of narcotics in prison.

Despite these dangers, Anderson described a corrections environment rife with narcotics where he worked.

“The issue of drugs and narcotic prescriptions was probably the most challenging clinical conundrum I faced in the correctional system,” he said. “They were widely prescribed, and they were often sequestered, with patients hiding them and pretending to swallow them, and there was a secondary market for them. That resulted in a lot of violence, as well as anger directed at physicians. It made the entire environment really unpleasant for any fair-minded doctor who wanted to take care of people.”

In addition, the knowledge of who receives these drugs spreads fast, with stronger inmates sometimes intimidating weaker inmates, stealing their medication and then selling them.

Physicians who serve in prisons are by no means immune to this violence, particularly when they deny or cease treatment with an opioid, according to Anderson.

“It’s not uncommon for doctors and nurses to be physically accosted and attacked in prison,” he said. “That would happen when someone is prescribed a narcotic, and another doctor elects not to do so, and so that doctor is attacked. I know anecdotally of a doctor who was punched in the mouth and had a molar loosened. I had another doctor who was grabbed by his necktie and almost choked, and on a couple occasions, I myself felt that I was in a situation where I might have to defend myself to some extent.”

All of this institutional violence, plus the violence experienced by many inmates prior to their incarceration, often leads to both physical and mental trauma. And although physical trauma may complicate treatment in rheumatology, mental trauma can kill any potential therapy before the physician even has the opportunity to see the patient.

“The mental trauma is very important, because one of the things we have to do in rheumatology is foster a therapeutic alliance with our patients, and individuals who have been traumatized throughout their lives often have a level of hypervigilance that borders on suspicion, particularly directed toward health care figures,” Anderson said. “Obviously, this can also be informed by issues related to ethnicity.”

“For example, we are all familiar with the history of the Tuskegee trials, in which African-Americans were studied for syphilis without giving consent, and did not receive treatment,” he added. “I think there can often be some level of culturally-mediated apprehension toward the doctor-patient encounter.”

Potential for Fulfillment

Keller, on the other hand, described a treatment environment in his county jails not unlike what is found on the outside. He positively compared the stress of his work to that of emergency medicine, his previous focus before dedicating his professional life to corrections.

“In my experience, the main hardship that comes embedded in emergency medicine is shift work,” he said. “You are going to have to work nights, you are going to have to work swing shifts and you are going to have to rotate — days, nights and swing shifts — and that is hard, especially over the course of many years.

“However, the hardest job requirement of correctional medicine is the environment,” he added. “You have to go into a jail with steel and concrete, and you may have to go through seven secure doors. Someone has to look at you through a camera and buzz you in, and you do that seven times and then you realize you left your stethoscope in your car, and you have to go back through the seven doors, go get it and then come back through the seven doors again. It’s loud, the doors clang. Sometimes it smells funny. It’s cold, even when it’s 95 degrees outside. The facility is crap. But the actual delivery of medicine is the same as in any other clinic.”

However, he did note one major difference: In jail, there is no such thing as a patient who cannot afford care.

According to Keller, unlike health care in the outside world, jail care has a dedicated funding source. For this reason, among many of his patients, being incarcerated is the first time they can see a physician.

“I have had rheumatology patients who have had no medical insurance on the outside, and no access to a rheumatologist, or any rheumatic drugs because they can’t afford them,” Keller said. “They come to jail, and now they can. That is just the way our society is set up.”

Providing this care for patients, who may have several uncontrolled diseases, can be daunting but also fulfilling, Keller said.

“It’s fulfilling work because many of these patients couldn’t get care before,” he said. “They come in with uncontrolled diabetes and I get their diabetes under control. They come in with uncontrolled high blood pressure, and I get that under control. A lot of patients who have been there for, say, 6 months, after that time they look way better than when they first came in. They feel better, too, which is rewarding work.”

COVID-19’s Specter

COVID-19 has, like with seemingly every other aspect of daily life across the United States, complicated the issue of prison health care even further. According to a research letter published in JAMA, as of June 6 there had been 42,107 cases of COVID-19 and 510 deaths among 1,295,285 state and federal prisoners, with a case rate of 3,251 per 100,000. This case rate was 5.5 times higher than the overall U.S. population.

Meanwhile, a CDC report published in August, describing mass testing in 16 U.S. prisons and jails from April to May, found rates of COVID-19 prevalence ranging from 0% to 86.8%. This represents a median 12.1-fold increase over the number of cases found through earlier symptom-based testing alone, according to the CDC.

Officials have been making efforts to limit infections in jails. In California, approximately 8,000 people — mostly consisting of individuals who are already scheduled to be released soon and those who are medically vulnerable — could be released by the end of August. In Philadelphia, the local jail population dropped by 17% in the month of April, following special court hearings to release hundreds of people held for low-level charges, cash bail and nonviolent offenses.

“It makes a lot of sense, when moving any patient from one environment of care to another, you need to have an understanding of what their health care is, so there is continuity of care during any transition,” Brent Gibson, MD, MPH, chief health officer for the NCCHC, told Healio Rheumatology. “I will add that many of the nation’s correctional facilities provide high-quality care. I think it is fair to say, in the communities, high-quality care is not always available. That’s in any community. That’s just the way things are.”

Brent Gibson, MD, MPH
Brent Gibson

According to Gibson, the basics of COVID-19 prevention in the correctional setting remain the same as in any other — personal protective equipment, or PPE, for patients and providers, as well as occupation limits in waiting rooms. However, as his organization accredits only a small number of the hundreds of prisons, and thousands of jails, across the United States, it is difficult to gauge just how widespread these precautions are.

“There are probably 3,000 jails in the country and hundreds of prisons, and we accredit a small proportion of those, so, I think it’s fair to say that if we don’t accredit a place, we don’t know what’s going on,” Gibson said. “Our standards are about what our expectations are, and that includes good emergency preparation, defensive control, et cetera.”

However, based on his own experiences, Gibson said the facilities he has worked with are “absolutely” taking the appropriate precautions.

“It would be impossible to comment on every facility, but in the places we work with, the folks we know are absolutely taking the same precautions,” he said. “However, I would say that emergency preparedness, including the emergence of a pandemic, is very much a part of any correctional health care environment, so I think people were pretty quick to respond to this threat, as they would for any other.”

In addition, Gibson stressed the importance of following the national guidelines released by the CDC, as well as health surveillance in tracking the coronavirus within institutions.

“For correctional workers, it’s like any other profession — they need to understand the risks of the job and be sure that the health surveillance is in place to protect them,” he said. “That is somewhat outside the purview of the NCCHC, but it’s something you always want to keep in mind — the health of the correctional workforce, whether it is a doctor, a nurse or a corrections officer, or someone else.”

Still, even with the best preventative measures in place, curbing the spread of COVID-19 in prisons and jails remains a daunting task.

“The real issue is congregate living environments,” Anderson said. “I don’t see how you can possibly prevent the spread of COVID-19 in a congregate living situation. The prison population in California maxed out at 165,000 inmates. Now, I believe it is down to 130,000, but it is still 25% over capacity. COVID demonstrates the problems you get in a densely populated, congregate living environment. And I think that is something that is very difficult to solve.”

A Way Forward

Anderson has more than a few ideas regarding how to improve the general health care of people incarcerated in state prison.

First, every effort must be made to instill a sense of professionalism and high standards among individuals working in the correctional system.

“That means promoting people with clean records,” he said.

Another option, he said, would be to administer care through university medical centers rather than the prisons.

“This would require correctional medicine to emerge more as a respected medical specialty,” Anderson observed. “It would also require ample fellowship training, and offering board certification, in correctional medicine through the American Board of Internal Medicine and similar organizations. If one, for example, had a correctional medicine fellowship at UC Davis, that facility would be within a couple hundred miles of probably 30 different correctional facilities, if you include county jails, state and federal facilities.”

A third, albeit unlikely, possibility would be to emulate the public health service that manages U.S. federal prisons.

“They have their own medical school, Uniformed Services University of Health Sciences, they are affiliated with the CDC and the NIH, and they have full access to the resources of the federal government,” Anderson said. “Given the political realities, however, I don’t think this would happen any time soon.”

Still, Anderson argued that health care inside prisons must improve, one way or another. And more likely than not, that will mean decreasing the prison population across the country, he said.

“It becomes a constitutional issue — the 8th Amendment outlaws cruel and unusual punishment,” Anderson said. “At some point, as a society, we have to address how many people we can really afford to incarcerate. I think if individuals are overcrowded, if we are having epidemics of infectious disease, if health care cannot be provided adequately, then the prison population has to be diminished. I consider myself a law and order advocate, but to imagine being incarcerated and receiving care through the correctional system is an unpleasant thing to contemplate.”