A recent study revealed that out of the top three reasons why OBGYN physicians are sued for malpractice, two of them are related to inaction: 1) delays in intervention when there are signs of fetal distress and 2) the improper management of pregnancy including failing to test for fetal abnormalities when indicated, failure to address complications of pregnancy, and the failure to address abnormal findings. As a family medicine physician, I have been warned countless of times that one of the most common lawsuits relates to not identifying cases of skin cancer. In each of the instances, an inaction that results in a patient not receiving standard care is considered malpractice.
Given that not providing standard of care is malpractice, Mumia has been a victim of malpractice at the hands of the prison health system in two major areas:
- Even though Hepatitis C treatment is not always required, the failure to provide it for Mr. Abu-Jamal would be medical negligence. By even the most conservative standards, he meets criteria for treatment.
- Failing to treat his elevated blood sugars until he was unconscious is clear malpractice and gross negligence.
Unfortunately, Mr. Abu-Jamal’s case is not an isolated incident. Across the country inmates are not only being denied necessary Hepatitis C treatment, but they are also being denied other basic healthcare needs.
The discussion of Hepatitis C treatment seems complicated at first glance. In the past, in addition to being costly, treatments for Hepatitis C also took months, typically had very uncomfortable side effects, and had a poor success rate. Additionally the sense of urgency to treat can be ambiguous. On one hand it is one of the highest causes of cirrhosis, or liver failure, in the United States. On the other hand, it can take decades to cause this damage. Because of these nuances, treatment was not previously universally recommended by physicians or sought after by patients.
However, the landscape has change dramatically in the past few years. There are now new medications that have far fewer side effects, much shorter treatment times, and over 90% cure rates. In fact, this was so revolutionary that these new medications were recently added to the World Health Organization’s essential medicines list. Medications on this list are considered “the minimum medicine needs for a basic health-care system.” Unfortunately, like many new medications, they are incredibly expensive. One of the most popular medications is call Harvoni. For the full, 12-week course of treatment, it costs nearly $100,000. Whether medications should be allowed to be so expensive is a debate for another day, but the bottom-line is that treating Hepatitis C has moved from an issue of patient preference to cost. While increasing healthcare costs is an unfortunate truth for all Americans except the very rich, it is exceedingly pronounced in the prison system.
However, all this is a distracting and irrelevant context in the case of Abu-Jamal. The decision to treat or not to treat is debatable for patients with early Hepatitis C who do not have signs of significant liver disease or signs that Hepatitis C is affecting other areas of their body. In contrast, everybody agrees that when Hepatitis C is that severe, treatment is absolutely indicated. In Abu-Jamal’s case, there is evidence of both liver damage and damage to parts of his body outside the liver in the form of the debilitating skin condition that he has developed.
Additionally, regardless of the decision to treat, everyone who has positive testing for hepatitis workup deserves a full investigation of the severity of his or her infection. In Abu-Jamal’s case, it was first discovered that he had been exposed to hepatitis C in 2012. The standard of care after that is to test for a continued active infection and then evaluate damage to the liver. None of that was done until his March 2015 hospitalization for unrelated issues, when an ultrasound suggested damage to his liver.
Cirrhosis, or liver failure, is a debilitating medical condition that leads to frequent hospitalization, kidney failure, delirium, and bleeding. It causes a slow and painful death. If Abu-Jamal does not receive Hepatitis C treatment, he will ultimately die a death more miserable than his original death sentence. By medical malpractice standards, there is no difference between sentencing someone to death and withholding a life-saving treatment.
Tragically, Abu-Jamal’s case is not an isolated one as chronic Hepatitis C is very common among patients who are in jail or prison. In 2013 there were 6.9 million people were under correctional supervision. The CDC estimates that anywhere between 13% and 25% of people in correctional facilities have Hepatitis C, many of them unaware of their infection. In comparison, in the entire US population there are estimated 2.7 million cases, which is 0.84%. That’s fifteen to thirty times higher.
Chronic Hepatitis C is not only rampant in prison and jail populations, but it is also vastly undertreated. In 2013 there was a class-action lawsuit filed against Pennsylvania’s Department of Corrections (the prison system that Abu-Jamal is held in) to challenge the Hepatitis C treatment protocol that was in place. Under that, and the current protocol, multiple plaintiffs with advanced liver disease have been denied treatment. In May of 2015 another class-action lawsuit was filed, again for denying Hepatitis C treatment to prisoners. This time it was against the Minnesota Department of Corrections (DOC). Shortly after that case was filed, another class-action lawsuit was filed against the Massachusetts DOC for denying Hepatitis C treatment.
Furthermore it has been found that treating Hepatitis C in prisons is feasible and just as effective as in the non-incarcerated population. Additionally, although Hepatitis C treatment is expensive, it’s been found to be cost-effective in the long term. Complications of cirrhosis rack up medical costs far greater than the Hepatitis C treatment itself. It is thought that prison healthcare systems, which are already tight on funds, frequently do not see the return on this prevention, as most patients will be released. However, a study released in 2008 found that in fact, except for certain segments of the population, treatment for Hepatitis C was still cost-effective.
The final nail in the coffin is that the Department of Corrections for other states are successfully treating Hepatitis C. Dr. Mark Beiter, a physician in Washington state correctional facilities from 2009-2013 reported that “we didn’t have a lot of money… [but] anyone with stage 2 fibrosis or above would get treatment for Hepatitis C.” He also notes that the prison went out of their way to facilitate the completion of the treatment, “If [a patient] went on Hepatitis C treatment they had a hold placed on them and couldn’t be moved unless the medical team [approved it].”
In 2008 the Connecticut DOC released a study that found that under their protocol 49% of patients who wanted Hepatitis C treatment were given it. Of those that were denied treatment, 40% were due to release being sooner than the duration of the treatment and 22% were due to other medical reasons.
The mantra that DOCs like Massachusetts, Pennsylvania, and Minnesota repeat is that the financial and logistical barriers to Hepatitis C treatment in prisons are too great. However, DOCs such as Washington and Connecticut prove them wrong. It’s not that they can’t provide Hepatitis C treatment; it’s that they won’t.
Abu-Jamal tested positive for diabetes while imprisoned, and yet it was intentionally left untreated. In his medical records, blood tests taken on March 8, 2015 showed a glucose level of 419, well exceeding the diabetic level of 200.
There are two major forms of Diabetes. Type 1 Diabetes is the kind that frequently presents young in life. While it is very common for this form of diabetes to be initially diagnosed in a crisis setting (coma, severe dehydration, electrolyte disturbances), Type 2 Diabetes, the form that typically starts in adulthood and the form that Abu-Jamal has, very rarely gets to that point because it develops more slowly and is caught early before it ever reaches that level of severity.
Standard of care for a blood sugar that high is to immediately give medication to lower it, or at least monitor three times a day. One of the main medications for the treatment of diabetes is metformin. It costs $4 a month. But because he didn’t get any treatment, his sugars climbed to levels so toxic that his brain stopped functioning and he went into a diabetic coma.
Sadly, Abu-Jamal’s healthcare is not an exception. It’s an example of the poor healthcare that is rampant in prisons and jails across the country. Examples of the felonious level of healthcare are so numerous that they are impossible to list in their entirety. However a few examples illustrate the severity of the negligence.
Anthony Carvajal, a Florida inmate, needed treatment for cancer, but instead was given ibuprofen for six months. An inmate in California was denied cardiac medications after being discharged from the hospital for heart failure. Ieasha Meyers, an inmate in Iowa, was forced to give birth without medical personnel on the floor of her cell when her reports of contractions went ignored.
The situation in jails is even more deplorable. Because jails are seen as temporary holding institutions, the quality of healthcare falls short of even that of prisons. The justification for this is that the average length of stay in jails is less than 30 days so only minimal healthcare services are needed. However, because of prison over-crowding, inmates can reside there much longer. Dr. Smith (named changed out of fear of retaliation) is a physician who worked for Advanced Correctional Health Care, a private company that provided services for a network of jails. According to her experience, she saw inmates that were there for over 7 months on a regular basis.
Dr. Smith recalls struggling daily to provide basic the medical care that she knew the inmates deserved. Whether she was requesting a procedure as simple as a dental extraction, attempting to secure a needed medication, or trying to order indicated blood tests, she always came up against the same mantra, “The bottom line of what they said is that you just want to keep people alive. You don’t actually need to treat anything unless to prevent a deterioration of their health.”
The facilities and lack of access horrified her. She provided care for four different jails and opportunities for inmates to see her were extremely limited. She would provide access to patients for 1 or 2 hours once or twice a week at most at each location. Given that most patient visits last 15-20 minutes, at maximum she would see only 8 patients a day. One facility only had her come only once every two weeks. Inmates were required to request appointments, and if there wasn’t enough space, they just didn’t get to see the doctor.
Dr. Smith recalls a case where she was called in the middle of the night for a medical emergency. A woman who was 8 months pregnant was being held for failing to appear in court for a minor offense. While there she developed acute abdominal pain that Dr. Smith realized she needed hospital care to treat. She was worried it could be fatal to both the inmate and her fetus.
By the time the guards had called Dr. Smith the woman had been suffering for four hours and her pain was getting worse. When she asked why it had taken the guards so long to contact her, they responded that they thought that the inmate was just whining. Though Dr. Smith insisted that they call an ambulance immediately, as precious time had already been lost, it took them several more hours to transport the patient because they required that she first complete all the paperwork to be “released on her own recognizance.” According to Dr. Smith, this was routine. By doing this, the medical bills would be charged to the patient rather than the jail.
Unfortunately, Advanced Correctional Health Care is no different than most of the other companies in this industry. The four largest companies in corrections healthcare are Corizon Healthcare, Correct Care Solutions, MHM Correctional Services, and Wexford Health Services. Together, the top four companies are responsible for the healthcare of nearly half of the incarcerated population in the United States. Just as in prisons, the examples and lawsuits over egregiously poor healthcare in jails are too numerous to catalog in their entirety, but a few examples demonstrate the atrocities.
In Alabama, Tanish Jefferson died from something as simple as constipation. New York City recently terminated their contract with Corizon due to at least two cases where the company’s employees contributed to the deaths of inmates. Bradley Ballard, an inmate at Rikers Island, died after being denied insulin, food, and running water for nearly a week. Correct Care Solutions has been sued for allowing Farah Saleh Farah to die from dehydration in a Virginia jail. In New York, Rashad McNulty died in Westchester County Jail after his complaints of chest pain were ignored. He was having a fatal heart attack. In North Carolina, Jen McCormack also died from a heart attack that was ignored while in jail custody. The list goes on and on.
All of these companies are for-profit organizations. The motivation of greed over human life is illustrated in not only the poor medical care, but also the poor ethics at the core of these companies.
The president of Correctional Medical Associates, a subsidiary of Corizon, was indicted for embezzlement when he was a medical student. In Alabama, Corizon employed two physicians who had previously lost their licenses for sexual misconduct with patients. Nurses in a California prison are continually so short staffed that in April they threatened to go on strike. The Department of Investigation in New York found 658 fingerprint cards, accumulated over 4 years, that had never processed as part of Corizon’s employee background checks. These self-serving, immoral practices are clearly incompatible with providing healthcare, an industry focused solely on the welfare of patients.
What’s shocking is that these companies continue to operate despite consistent malpractice. The lack of regulatory oversight of healthcare in correctional facilities is appalling. Private companies have exploited the poor regulatory standards. There has been a growing trend for correctional facilities to outsource their healthcare. Typically these contracts are negotiated on a per inmate fee. This creates a perverse incentive where the less the healthcare companies spend on each inmate’s health, the more profit they make.
The privatization of healthcare in correctional facilities has been fingered as the root cause of poor healthcare for the over 2 million inmates in US jails and prisons. It is true that greedy business practices that value money over human life is the most direct causal agent to these atrocious conditions. However, they are only exploiting a government that doesn’t care enough to require standards to begin with.
Individual whistle blowing, institution-level inquiries, and journalism have identified poor healthcare for years and yet these poor conditions persist. Interventions on an individual level do not create sustained change. What’s needed is a systems level approach.
For example, if every department of corrections in the country required accreditation within the first six months of every contract, conditions would improve. In a recent review it was found that “there is considerable evidence…that accreditation programs improve clinical outcomes.”
Money is what really influences behavior, even in the most benevolent of companies. Tying payment to health outcomes guarantees that standards will be met, a fact so obvious that mainstream healthcare systems have been moving in this direction for years. Insurance companies such as Medicare will only pay for services at facilities that meet certain standards, usually indicated by an accreditation from a recognized organization such as The Joint Commission.
Another possibility would be to create a more robust quality tracking system that is tied to payment. For example, one could create a contract that required meeting certain quality metrics. Failure to do so would result in fines or payment withheld. Metrics could range from service indicators such as the time delay between when a patient requests an appointment and is actually seen, to clinical indicators such as how frequently cholesterol is being checked. This is already becoming the standard in the mainstream healthcare system.
It’s possible that linking payment to quality will save the system so much money in litigation and preventable healthcare complications that correctional facilities will suffer no additional cost burden. But it’s also possible that our correctional healthcare budgets are simply too small and that providing humane healthcare will require more money. If that’s the case, as citizens who support a system of involuntary confinement, the responsibility rests on our shoulders.
The majority of inmates are not psychopathic serial killers, but actually people not all that different than those of us outside of bars. They just can’t afford to pay their speeding tickets on time so they’re sent to jail; they just don’t have a solid network of financially stable friends and family that can help them weather tough financial times so they steal things; they just don’t have any educational or career opportunities so they join gangs.
This is our system. We punish people who were born with the cards stacked against them. Then, on top of that, we refuse to provide them with basic healthcare, which then only makes it more difficult for them to create fulfilling, productive lives when they are released.
It’s convenient to blame profit-driven corporations for the poor state of healthcare in prisons and jails so we point our fingers and play the blame game. It’s much harder to realize that we are also culpable.