Medical care of prisoners in the USA

Universal access to health care for incarcerated persons has its modern roots in the 1929 Geneva Convention and, more recently, through advocacy organisations such as Amnesty International and the International Red Cross. In the USA, prison officials are implicitly obligated by the Eighth Amendment of the Constitution to provide adequate medical care to prisoners. For physicians who interact with detained and imprisoned persons around the globe, the ethics of medical care and its non-judgmental administration are similar. However, division of health-care resources is complex and limited in even the most technologically advanced and wealthy nations. At one extreme, nationwide public debate erupted in 2002, when a twice-convicted felon became the first US prisoner to receive a heart transplant. He was constantly accompanied by armed guards, and his aftercare costs were estimated to be US$1 million during the first year after transplantation. Many argued that with tens of millions of law-abiding citizens lacking health insurance, the injustice of providing scarce and expensive resources to a felon at public expense was intolerable. Others forcefully argued that using gradations of social worth to determine medical care was ethically untenable. Nevertheless, from any perspective, the provision of health care to prisoners is hardly equal to that provided to their law-abiding counterparts. Because of security, administrative, medical-legal, and financial issues, the health care of prisoners is both qualitatively and quantitatively different from that of the general population. It is difficult to make generalisations, because most health care variability is determined in the treatment room by the individual physician–patient dyad. In the USA, unlike countries where nationalised health-care programmes exist, such as Canada, the UK, and Japan, civilian health-care delivery is largely determined by a payment mechanism, ie, privately owned or publicly regulated insurance programmes. Nevertheless, all law-enforcement systems aiming to provide medical care for prisoners face the same issues regarding patient safety, security, and efficient use of public funds. Access to a primary-care provider is one of the cornerstones of the US health-care system, with prisoners seemingly having the advantage over their civilian counterparts. Within 2 weeks of admission to a California state prison, an inmate will receive full dental and physical examinations, including testing for tuberculosis and HIV, whereas an insured person might wait 6 months to see a new doctor. Uninsured civilians commonly have no access to a regular doctor and depend on emergency departments for their health care, which in the USA are mandated by law to assess and treat all individuals regardless of ability to pay. People who have been arrested have faster access to care for minor complaints, such as skin abrasions, or for chronic complaints, such as a 20-year history of back pain, because it is common practice to have all detainees with any medical complaint or condition to be medically cleared at the local county emergency department before incarceration. Those who receive jail screenings are usually given triage priority in emergency rooms to facilitate a quick return of the arresting officer to the street, limit detention time of the suspect in the less-secure hospital environment, and to limit the time prisoners are in contact with civilian patients. Screening of trivial or chronic complaints and application of triage administrative priority to people under arrest has caused many emergency physicians to remark cynically that the fastest way to obtain medical care is to be arrested. For security reasons, access to true emergency care may be delayed in the prison system. An inmate cannot dial the emergency services phone number for an ambulance—this privilege is denied to those in custody. An inmate who is ill must first convince the prison guard of the need for treatment, activating the prison's medical-care system. Medical personnel who have had basic training then decide whether the request warrants further medical evaluation and treatment. Because most prisons are located far from civilian populations and hospitals, further delay in reaching an emergency department can be expected. In the civilian population, helicopters are frequently used for emergency transport over long distances or in congested areas. This type of rapid transport is not feasible in prisons because of rules that restrict helicopter landings on prison grounds. Furthermore, the additional bodyweight of two guards who must accompany the inmate would overload most helicopters. Arrangement for guards to leave the prison, the securing of appropriate paperwork, and identification of patients may also contribute to delays. Ambulances must negotiate a network of security gates to exit the prison grounds, causing further delays. Thus, security concerns work against rapid removal of the inmate from the prison. Once the ambulance has left the prison, there can be further delays when inmate patients are not taken to the closest appropriate emergency department. Typically, they are taken to a hospital that is under contract with the prison to care for its inmates. These hospitals are usually designed with extra security for the care of prisoners. An ambulance will divert to a closer, non-contract hospital only for life-threatening emergencies. Even then, the final decision is made by the prison guard, after clearance from a supervisor, rather than by the medic or medical control. Medical assessment, including history, physical examination, laboratory testing, and radiography in the primary and specialty clinic or office, is fairly similar in both penal and non-penal environments. Notable exceptions are prisoners with a history of violence, so-called administrative segregation prisoners, who are not afforded privacy or confidentiality because two guards are always present with them in the examination room when they are with a doctor. Because of concerns about secondary gain, prisoners who require chronic-pain medication are often assessed by a pain specialist. Such consultations are done less frequently for private patients. Doctors in both prison and private settings lament the time pressures of seeing too many patients in too short a time and of not being able to closely follow their patients. Many emergency physicians believe that prisoners are more likely to pursue litigation, and as a result these doctors may order more tests to justify their determination that the prisoner is not ill or injured. This behaviour seems driven by rare malpractice lawsuits brought by prisoners, which almost always garner media attention. Another reason for further testing may be the prejudice that inmate patients are not reliable historians and that they are driven by secondary gain, such as claiming police brutality or the desire to be given a diagnosis that will result in being housed in the more comfortable infirmary environment. The issue of secondary gain, for any reason, can poison many clinical encounters, leaving both patient and physician disappointed. The choice of drugs given in prison is generally broader than in a civilian environment. Limited drug formularies and concerns from the patient about drug costs are almost non-existent issues in the penal system. On the other hand, some dental and plastics procedures, prosthetics, and equipment are simply not available to people in prison. Even crutches can be used as weapons and require a higher level of security. Risk of diversion causes prisoners to undergo directly observed treatment for psychotropic pain, seizure medications, and for treatment of tuberculosis. Interestingly, prisoners in the USA are not uniformly treated for latent tuberculosis unless they are to be detained for several months or more, or are at high risk of developing active disease. The use of directly observed treatment in this population—likely to be more effective as a result of incarceration and an opportunity to improve public health—is not new. Most jail and prison systems in the USA pay for and maintain in-house infirmaries. However, since the 1970s, many have started contracting privately run medical groups to care for inmates. Studies have shown this system to be economical and one that seems to provide adequate, basic medical care. In California, nearly half of jails and prisons contract private groups to manage the health of their inmates. The provision of psychiatric care has some distinct features in the prison setting. For example, psychotropic medications may predispose to dehydration through inhibition of sweating. Thus, these individuals are given so-called hot cards on request, which excuses them from yard time. Despite fairly open access to psychiatrists, continuity with the same psychiatrist is far from assured. Although many inmates have complex health-care problems, others are expert malingerers who drain the energy and resources of those contracted to assess and treat them. Similar to military medicine, prison medical care is sometimes dictated by a high-ranking administrator (usually the warden), rather than medical personnel. Anecdotally, this has led to curious mandates, such as a so-called stat mammogram (because the inmate threatened the warden with a lawsuit) and the banning of tricyclic antidepressants from a drug formulary (because of a completed suicide). Unexpected prisoner deaths in the USA, as in other countries, continue to stimulate debate, self-reassessment, and reform. The discipline of prison medicine and its presence in the medical literature is expanding, which may result in improved and efficient medical care for this vulnerable and challenging group of people.

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