By Wil S. Hylton

When David Hannah walked into a small office on the second floor of the
Moberly Correctional Facility in Moberly, Missouri, last fall, carrying
his belly like a hundred-pound sack of sand, the staff knew him well
enough not to worry about what he might break or steal or soil in their
private offices, which were normally not accessible to inmates, so I was
able to close the door behind him and we sat together and talked about
what was happening to his body. He was a pale, fifty-seven-year-old white
male, serving a sentence of life plus three years for rape, and his gray
hair was matted to his head. His face was as worn and gaunt as a much
older man's.

Hannah was angry. "Look at it," he said, glaring at his gut. "Do you
want to see it?"

I didn't want to see it, but I nodded anyway. I had come precisely to
see it, to witness Hannah's disfigurement, the fruit of a long series of
medical miscalculations. It had begun in the 1980s with two kinds of
hepatitis, B and C, a condition that prison doctors had largely ignored
for a decade, then treated with a series of botched, questionable
procedures that caused David's cells to cease performing osmosis properly,
so that over time his natural body fluids began to collect, trapped inside
his gut with no way to evacuate, his midsection swelling to accommodate
those fluids, expanding to such a size and weight that the mere act of
walking around had given David, by December 2000, a pair of hernias,
neither of which the prison doctors had bothered to treat. David stood now
to show me the belly and the hernias, the condition his body had arrived
at through an utter lack of attention. He pulled his flannel shirt to the
side of his waist and lifted his gray T-shirt, and, in spite of myself, I
winced. His belly was enormous, taut and pasty, seemingly glued to his
gaunt frame. At the front of it, a hot-pink hernia, about the size of a
grapefruit, seemed barely attached where the belly button should have
been, giving David's midsection the overall contour of a giant breast and
nipple. Bracing myself, I asked him where the other hernia had emerged. He
studied me, obviously not fond of baring his physique. After a moment, he
shrugged and unbuttoned his pants.

To describe David's scrotum as swollen and red would be a failure of
language. It was about the size of a rugby ball, so raw and irritated,
shiny and crimson, that it almost seemed to be covered with blood. David
hung his head. "They give me aspirin," he said.

Later, when I heard that David had died of indeterminate causes and
that his body had been cremated, I realized that I had probably been the
last person outside of the prison staff to see David alive, to see what
his body had become from all those years of mistreatment, and I wondered:
Can such a secret be kept?

It occurs to me now that prisons are designed for keeping secrets,
for holding inside not just men but also their lives and the details of
those lives. In prison, social isolation is a matter of policy, and
inmates are neither expected nor encouraged to have more than a modicum of
contact with the outside world. This is not necessarily, or at least not
ostensibly, vindictive. In many cases, isolation is the prison's approach
to rehabilitation. As Alexis de Tocqueville observed nearly two centuries
ago, "Thrown into solitude [the convict] reflects. Placed alone, in view
of his crime, he learns to hate it; and if his soul be not yet surfeited
with crime, and thus have lost all taste for anything better, it is in
solitude, where remorse will come to assail him."

Still, the social isolation of prisoners creates a host of
difficulties, not least of which is that of monitoring their treatment, of
ensuring that they are assailed only by their own remorse and not by
anything else--by, say, other prisoners, or by those who keep the watch.
Opacity, after all, runs both ways, and if the prison walls keep convicts
in, they work just as effectively to keep observers out.

This problem is only made worse inside the prison infirmary. By its
very nature, medicine is a private matter, and a prisoner's medical
records are protected by the same confidentiality laws that protect free
citizens. This means that a prisoner's medical chart is both locked inside
a physical fortress and shielded by a battery of privacy restrictions, all
of which leaves the field of prison medicine cloistered and nearly
impossible to survey. Compounding this is the fact that prison medicine,
and, indeed, the principles of medicine itself, are fundamentally at odds
with all other facets of prison life. Even the term "prison medicine"
borders on oxymoron: Whereas prison is designed to alienate and punish,
medicine exists to nurture and soothe. So were is the boundary between
care and punishment? At what point do they meet?

IF THE SECRECY OF PRISON
MEDICINE SEEMS ABSTRACT, WAIT
UNTIL THE HEPATITIS EPIDEMIC
COMES FLOODING OUT

Until the 1970s, which is to say for the first two centuries of
American life, these were not questions that anyone felt compelled to ask,
let alone answer. As a matter of law, prison medicine had always been
considered a privilege, not a right, and the final authority on treatment
was not a doctor or even a court but the local warden. Prisoners whose
medical needs were not being met, whose broken noses and diabetes were
left untreated, who were stabbed and not sewn, feverish and not medicated,
prisoners who had cancer but no treatment, who had prescriptions that
wardens refused to fill, whose mental health teetered at the edge of self-
destruction--those prisoners had no recourse, nor reason to expect it.
In the early 1970s, a survey of jails by the American Medical Association
found that fewer than 30 percent had medical facilities and only about one
in five had a formal arrangement with any medical provider.

Things began to change in 1971, when an uprising at the Attica
penitentiary in New York forced the subject of prison conditions into the
national conversation. Amid a flurry of laws enacted in response to
Attica, state and federal legislators began crafting measures to guarantee
basic health care to prisoners. Although the laws have changed over the
past thirty years, little else has. If anything, prison health care is in
further decline now than ever. Most departments of correction have chosen
not to invest in medical infrastructure but rather to farm out the
business to subcontractors, and these days a single, private corporation
controls the health care of all prisoners in ten states and manages a
portion of inmate health care in another seventeen, having underbid
competitors everywhere it exists. Correctional Medical Services is not
merely the nation's largest provider of prison medicine; it is also the
nation's cheapest provider, a perfect convergence of big business and low
budgets. But unlike the traditional HMO, whose risk of a malpractice suit
is real, and is felt, and is reflected to at least some degree in the
quality of medical care, companies such as CMS have little or no reason to
protect themselves. Most juries are reluctant to decide in favor of a
convict, and those juries that do favor the convict are often reluctant to
award money. Cost-benefit analysis takes on special, human overtones
behind bars.

Perhaps even more significantly, private companies such as CMS feel
no responsibility, and have no legal obligation, to account to the public
for what goes on inside their facilities. So, while CMS receives about
$550 million of taxpayer money each year, the company chooses not to
provide any accounting of how that money is spent or even how much of it
is spent-----and how much unspent, to be pocketed as profit. And although
lawsuits over the years have revealed discredited health-care
professionals working in CMS facilities, the company refuses to reveal the
names of its doctors and nurses for verification or to provide any account
of how many have been disciplined or had their licenses revoked in other
states. With CMS responsible for so many patients nationwide, it is fair
to say that the practice of medicine in prison has reached an
unprecedented level of inscrutability--indeed, secrecy--and if this
fact seems abstract or unlikely to affect regular folks in the general
population, well, just wait until the hepatitis epidemic comes flooding
out of the gates.

For those of you who have never been personally acquainted with the
hepatitis virus, allow me to describe it briefly. In the spring of 1995, I
downed the wrong glass of frozen margarita somewhere in the Chihuahua
desert and unleashed the disease on my insides. Unaware, I took a bus back
to Juarez a few days later, walked across the border, drove home to
Albuquerque, and, when the travel itch returned a few weeks later, set out
for Glacier National Park, where I intended to spend thirty days in the
backcountry, mountaineering. By the time I arrived in Montana, however,
the virus had begun to set in, and I found myself overwhelmed by fatigue.
Deciding to get some rest before starting out, I found an empty cabin near
the boundary of the park, crawled down to the basement, settled into a
bed, and, with one last glance at my backpack by the door, passed out.

When I woke up several days later, I was lying on my back in a medical
facility 120 miles away with an IV in my arm and a sign on the door that
said, "Warning Take Enteric Precautions Before Entering." Asking around, I
learned that I had been delivered to the medical center by a friend who
worked in the park. My liver-enzyme levels, upon check-in, had been gauged
at more than a hundred times the normal level. The first time I looked in
the mirror, I saw that my jaundiced skin was roughly the same color and
texture as a dried tangerine. I spent several days lying in place,
flitting in and out of consciousness, playing host to an array of curious
physician's assistants, nurses, and certified nursing assistants, some of
whom ran tests on my urine and blood while the rest mostly stood around
marveling at how odd I looked. That was the beginning. For the next six
months, I was forced to live at my parents' house, where my daily
priorities became eating healthy food, sleeping at least half of each day,
and wishing that my perpetual headache would relent. This was the face of
hepatitis A, the least virulent strain of the virus.

The difference between the type of hepatitis I contracted and, say,
hepatitis C, which is the most severe strain, is mostly a matter of
intensity. My hepatitis eventually went away; hepatitis C, in most cases,
does not. It keeps on attacking your liver for the rest of your natural
life. That means people with acute hepatitis C can essentially forget
about all the wonderful things that livers do, such as fighting
infections, filtering toxins, and storing energy. To make matters worse,
people with hepatitis C are contagious for the rest of their lives. Even
twenty years after their initial infection, even if the virus is in
remission and they feel pretty good, they still constitute a walking
weapon and had better be careful where they bleed. It is worth noting,
then, that somewhere between 20 and 40 percent of American prisoners are,
at this very moment, infected with hepatitis C, and therefore quite
contagious. It is also worth noting that most of them will eventually be
released back into the general population, where the infection rate is,
for now, only about 2 percent. The Association of State and Territorial
Health Officials noted in a 2000 report that "an estimated 1.4 million HCV-
infected persons pass through the correctional system each year." And
although the virus is most pervasive in prison because of the high
incidence of injected drugs there, it can be transmitted just as easily on
the outside through sex, blood, transfusion, or even a nasty fistfight.

With a scourge like this roiling on the inside, threatening to boil
over to the outside, you might expect prisons to adopt some kind of
screening policy for inmates and to institute a treatment offensive for
the afflicted. Unfortunately, no such national program exists. Although
the cost of a hepatitis test is only a couple hundred dollars, very few
facilities volunteer to provide them, and there has been no federal
legislation to require the measure. "It's a missed opportunity," says Dr.
Cindy Weinbaum of the Centers for Disease Control and Prevention. "The
number of prisoners with hepatitis C is incredibly high. It's
unbelievable."

The fact that most prison doctors have not seized this opportunity
doesn't reflect any inherent challenge to their doing so. On the contrary,
a couple of states have developed simple and effective hepatitis programs
that test all prisoners upon intake, making the disease relatively easy to
track and monitor. One of those states is Texas, and there, not
surprisingly, prison health care is managed not by a private company like
CMS but by two universities, the University of Texas and Texas Tech
University. Dr. David Smith, who is the chancellor of Texas Tech and who
led the battle to make hepatitis screening mandatory in Texas, assured me
that the hepatitis program he created is not very special at all, or
anyway that it shouldn't be. "It's just the smart thing to do," he
said. "We have almost 30 percent of our prison population in Texas
infected with hepatitis. That's not so different from the numbers you see
in the Dark Ages with the plague."

When I visited a handful of CMS facilities last fall, I found a very
different attitude. Under CMS care, 214,000 inmates are expected to
petition for any hepatitis tests they want, and even if those petitions
are granted, and the tests given, and the results positive, the chances of
getting any kind of treatment are only slightly better than of getting a
presidential pardon. This became most obvious to me when I heard the story
of Larry Frazee.

I met Larry at the Western Missouri Correctional Center in Cameron,
about four hours west of St. Louis. He was a gaunt little man with a
circular face surrounded by brownish-gray hair, and his thin mustache
seemed to weigh on his lips when he spoke. He walked with a silent
shuffle, and from the black bruises under his eyes you could see that he
hadn't slept well in months, if not years. When I began reading through
his medical record, it was easy to see why. Larry had first been diagnosed
with hepatitis in the early 1990s, when a prison plasma center rejected
him as a donor. The diagnosis had been confirmed by a prison infirmary in
June 1994, but even so, between then and the end of 1997, he had managed
to wrangle only a half dozen doctor's visits. It wasn't until January
2000, a full five and a half years after his diagnosis, that CMS doctors
began formally monitoring his condition. Even then, treatment was not
forthcoming. As Larry discovered, CMS doctors required him to meet a long
checklist of conditions, known as a "protocol pathway," before he could
receive any treatment for his disease. Some of those items required off-
site consultations. One of the things he needed, if he wanted treatment,
was a liver biopsy. But when Larry went to the prison infirmary to ask for
one, he learned that he had to have a psychological evaluation first, then
enroll in a drug-abuse awareness class and sign a slew of forms releasing
CMS from liability for anything that might happen during the biopsy. So
Larry did those things one by one, and he signed the papers, and he went
to see the biopsy specialist, who promptly sent him back to his cell
because he didn't know his virus genotype. Larry couldn't find anything in
the protocol pathway that required him to know his genotype, but to be a
good sport he put in a request at the infirmary for a genotype test. A few
weeks later, he got the test, but the laboratory somehow screwed up his
results, so he had to file for a second test and wait for a second
appointment and a second set of results before, in February of last year,
he finally returned to see the biopsy specialist, who sent him away again,
this time saying that Larry shouldn't bother getting treatment anyway,
because it can be somewhat dangerous. Larry argued that it was his
decision to make, and that he wanted the treatment, or at least the biopsy
that he was entitled to, and maybe afterward, when he had the biopsy
results and could take an informed look at them, he would be willing to
discuss the risks of treatment, but the doctor just shook his head. The
decision was final, he sad. No biopsy. He sent Larry back to his cell,
where Larry has been ever since, without a biopsy, without any treatment,
feeling sick and tired and a bit like he failed himself.

But what Larry didn't realize, and what he's only now beginning to
grasp, is that he never had much of a chance in the first place. As a
matter of formal company policy, CMS discourages treatment for hepatitis,
and the protocol pathway is just a way of making it harder for prisoners
to demand it. Although a CMS spokesman insisted that CMS doctors are
private contractors and that "it is the individual physician's
responsibility to make sure care is given to patients," an internal memo
from CMS regional medical director Gary Campbell to his fellow directors
in February 1999 reveals just how much authority the doctors really have
at CMS. "I am not encouraging anyone to undergo therapy," the medical
director wrote. "However, if you have someone that is insistent, then this
pathway is to be followed." Campbell added, "Unless I have given you
specific approval to do Hep C testing, do not do so unless the patient has
obvious moderate to severe liver disease or has exposure as described by
the exposure policy of the DOC. Remember, all Hep C testing has to be
approved by me."

And so, for the 214,000 prisoners whose health is supervised by CMS,
the hepatitis epidemic continues to grow, untested and untreated,
virtually unencumbered by the forces of modern medicine, while people like
Larry Frazee remain right where the company wants them: stalled along the
protocol pathway. Whether or not this is legal remains to be decided. In
January of this year, the University of Michigan law program filed suit
against CMS for failure to address the hepatitis problem in that state. If
their case is successful, similar lawsuits may follow in other states.
Until then, however, the policy stands: No testing, no treatment.

"CMS is an HMO with a captive audience," says David Santacroce, the
professor who is spearheading the Michigan lawsuit. "The fewer patients
they treat, the more money they make."

"This is deliberate indifference," adds Michael Steinberg, legal
director of the Michigan ACLU. "There is a standard for testing and
treatment of Hep C that the Centers for Disease Control came out with, and
CMS simply is not heeding it. It's not just hepatitis, either. You talk
about the tip of the iceberg! There is a systemic problem of not providing
good health care to prisoners. Hepatitis is the tip of it, but there's a
long list of issues below the surface that we haven't even begun to
address."

Some of those issues have been addressed in other courtrooms, however, in
other states, by other groups, and taken as a whole, the litany of
malpractice crimes committed by CMS doctors begins to read like a horror
novel. Take the inmate in Alabama who died of dehydration and starvation
in a CMS infirmary after receiving care that one medical director
described as "non-existent" and "a gross departure from medical community
standards." Or the inmate in the same state who died when CMS staffers
injected him with the wrong medicine. Or the CMS doctor in New Mexico who
testified that he was required by the company to prevent off-site
referrals. Or the district judge in Idaho who found that an inmate's care
in the state prison "more closely resemble[s] physical torture than
incarceration.? Or the inmate in Nevada who died because a CMS doctor
canceled her prescription for insulin. Or the federal judge in Michigan
who described CMS follow-up care as "bureaucratic purgatory." Or a U.S.
Justice Department inquiry in Virginia, which found that CMS medical
records "failed to meet any known professional standard." Or the district
court monitor in Georgia who found that CMS ran a "medical gulag" in the
state prisons, giving one prisoner ibuprofen for his lung cancer and
making another wait ten months to see a doctor for a broken arm.

Yet, perhaps because juries so rarely award money to convicts, there
is essentially no incentive for lawyers to bring these crimes together
into a comprehensive, class-action lawsuit. Without the lure of a large
settlement, most trial attorneys are unwilling to fork out millions of
dollars in research and lost wages to fund such a massive endeavor. As a
result, the central figure in the movement against CMS is not a major
national law firm or even a renegade lawyer, but an aging, confrontational
activist named Karen Russo.

I met with Karen, who runs a prisoner-advocacy group called The
Wrongful Death Institute, one evening last winter at her home in the
suburbs of Kansas City, and she invited me inside to sit at the small
wooden table in her dining room, where we ate meat loaf and potatoes while
her three dogs scurried around and her teenage kids and their friends
traipsed up and down the stairs. Karen was undaunted by the chaos around
her. When she had finished eating, she smoothed her dark brown hair behind
her ears, sat back in her chair, and, as if she were in an office or
behind a podium, she cleared her throat, blinked her heavily painted eyes,
and launched into a tirade against CMS, her voice ringing through the
house fervently, sometimes furiously.

"WE HAVE NUNS WHO GO IN AND
BRING DOCUMENTS OUT.
IT'S A WAR FOR INFORMATION,
AND CMS KNOWS IT"

"They don't want anyone to know what's going on in these facilities,"
she said. "Getting medical records and company documents is like going up
against Fort Knox. We have to resort to all sorts of methods. We have a
network of prisoners across the country who have ways of getting paperwork
out to us, a couple of pages at a time. We have nuns who go in and bring
documents out with them. We have nurses, doctors, whistleblowers. It's a
war for information, and CMS knows it. They're just waiting to take me
out. They hate me. Every Monday at noon I do a radio show on a local
station, and it's like a fireside chat. The CMS headquarters is just over
in St. Louis, so they have people listening. Everybody wants to
know, 'Who's she going to get today?' And it could be anyone. I could go
after a nurse, I could go after a doctor, I could go after the corrections
staff. And I've gone after all of them. I'm putting together a file on
every one of them. I call out their names on the air. 'Nurse so and so , I
want you to know that I'm onto you.' And the prisoners are listening too.
This thing is growing like wildfire. A couple of years ago I was getting
maybe two or three letters a week; now it's anywhere from twenty to thirty
letters a day, from all over the country. Of course, some of those are
from CMS decoys. That's why they're doing now-----they get offenders to
write me letters that say, 'I'm not sick, but I heard about what you're
doing and I was just wondering how you got started,' and so on. You know,
just dripping with it. They want to know what I've got. Bit I'm not naive:
I can see right through that; I can smell it. They're scared, and they
should be. We've got them. I know what they're doing.

Karen's invective seemed over the top, but she was the genuine
article: a nearly obsessive crusader who had long ago discarded any
semblance of a normal life in favor of late-night phone calls with sick
inmates and interminable afternoons poring over their medical records. The
dust on her antique piano had become so thick and sticky that it made my
eyes itch after only a few bars, and the ceiling in her bathroom was
crumbling to the floor. Yet Karen's memory was immaculate; she had
converted herself into a database of detail, packed with accounts of
prisoners met, their medical histories, life stores, and extraneous
personal minutiae. To reinforce this glut of information, the back rooms
of her house were stuffed with thousands of papers, most of which she
could locate and produce within a few frenzied moments. When pressed, she
could also furnish names and numbers for a whole range of sources,
including guards and activists and prisoners' family members (though she
was more reluctant to reveal others, such as the nuns and nurses she
claims to consult). In her utter submersion into the topic, Karen had even
developed a personal bond with one of the prisoners, a man named Raymond
Young, who was locked up nearby on drug charges and whose persistent back
problems and hernias kept him in a wheelchair, but who gave off an almost
eerie radiance on the day I met him, with a great, black, bald head that
shone like an eclipsed sun and a grin full of golden teeth inscribed with
the numbers 3, 3, and 1/3. ("Thirty-three and a third," he said in a
gravelly whisper. "I'm a traveler. A lone traveler.")

On the night I visited Karen, however, she took me to meet a
different friend, Leland Hunley, who had only recently been released from
the prison where Raymond is housed. When I saw Leland's apartment, it was
hard for me to imagine that he was any more comfortable than he had been
on the inside. His building, an indistinct brick high-rise, was in the
kind of neighborhood that most middle-class people choose not to know
about. There were crack dealers selling openly and loudly on the corner
and drunks fighting in the street. The Plexiglas front doors were smeared
with random grub and old graffiti, and the spun-polymer carpeting of the
lobby seemed almost melted across the floor. Up the clattering elevator a
few floors, down the narrow, echoing hallway, Leland's door opened into a
single shabby room where he sat in a wheelchair watching a fuzzy
television set that was on top of a little table above a small collection
of right-footed shoes. Leland's left leg was missing.

"Come on in," he mumbled to us, pointing toward a couple of chairs
and wheeling himself around beside them. I sat down, and we made small
talk for a minute, then Leland cut tot he story. "Basically, what happened
was, I was living on the bay," he said. "That's the common area. It wasn't
meant to be a living quarters, but the rooms were all full, so they had
about thirty or forty cots in the bay, and I lived on one of them. I was
there for about a year. The whole time, they never turned out the lights.

But anyway, I was getting up for breakfast one morning and I reached over
and put my sock on, and I felt a sting. So I pulled the sock back off and
a spider run out of it. Well, I stomped it. I knew it was a brown recluse,
pretty good size, so I scooped it up on a piece of paper to bring to the
infirmary."

Leland shook his head at the memory and ran a bony hand over his
short white hair. "But see, you can't just walk into the infirmary. You've
got to fill out a whole deal called a Medical Service Request, and then
they'll call you whenever they get to you. By the time I got up there, it
was a couple hours later. The bite was swelled up to the size of a
quarter. I showed it to the nurse, and she put a salve on it and sent me
back. I mean, you could just look at it and see that it was going to get
infected. It was swollen, throbbing, hurting like crazy. So a couple days
later, I put in to go back, and she soaked my foot in a solution. It got
to where she was doing that every three or four days. I would put up an
MSR and she'd soak it and wrap it up again. I could tell it wasn't getting
better, but I wasn't allowed to look at it or anything. I could get a
conduct violation if I took the bandage off. Every time she unwrapped it,
though, it looked worse. It was a big black welt on top of my foot, with a
red hole in the middle. After a while, you could see my bone through the
hole. It kept opening up more. At one point they had a doctor to lance it
and drain out the pus It looked like it might get better after that, but
it didn't. It just swelled up more. Eventually, my whole foot got black.

It was just a big black scab. That's when they started giving me
antibiotics, but it was already too late. I couldn't even walk. Finally,
the nurse took off the bandage one time and just run out of the room. She
was really upset. I don't know what she told the doctor, but it wasn't a
matter of a day before they was taking me to the hospital. The doctor
said, "I'm gonna have to take it off." There was nothing I could say at
that point. He told me, "If you refuse, it'll kill you." So I said, "Okay,
take it off."

At fifty-eight, Leland couldn't have weighed more than 120 pounds,
with knobby shoulders and elbows and a think wisp of a neck. He rubbed his
knees while he spoke, hunched over in his wheelchair, weak and almost
emaciated. Toward the end of the interview, Karen, who had been struggling
to remain silent, broke in to ask if he was okay. "You look like you're
losing weight," she said.

He shrugged. "Well," he said. "You know, I can't get to the store by
myself."

To someone on the outside, what happened to Leland's leg might sound,
at the most fundamental, instinctive level, like a blatant case of
malpractice. The notion of losing a leg to a spider bite has no place in
the modern sensibility, and the suggestion that a person wait several
weeks to receive antibiotics for an infection is almost unthinkable
(though Leland's medical records confirm it). But like so many other
things in prison, the term "malpractice" is inscrutable. On the outside,
if a doctor does not conform to certain standards of care, then he is
guilty of negligence, plain and simple, and finding a trial attorney to
sue him is no challenge. By contrast, in prison, mere negligence is not
necessarily enough for a lawsuit. Most prison malpractice cases are filed
under the Eighth Amendment, which guarantees protection from cruel and
unusual punishment. Unfortunately, in order to convict a prison doctor
under these terms, the inmate must prove not only that the doctor provided
substandard care but also that he did so intentionally. This rather
elusive criterion is called "deliberate indifference," and under its
protective banner a prison doctor is free to be as negligent and
irresponsible and incompetent, as he wants, just as long as he is not
intentionally causing patients to suffer. Needless to say, this makes the
practice of prison medicine significantly harder to regulate, and the care
of patients harder to ensure. What could be more difficult to prove---or
more secret---than a man's unstated intentions?

LIKE SO MANY THINGS IN PRISON,
"MALPRACTICE" IS INSCRUTABLE.
NEGLIGENCE IS NOT NECESSARILY
ENOUGH FOR A LAWSUIT

While I was visiting Karen and Leland in Kansas City, I placed a call to
CMS headquarters in St. Louis, hoping to interview someone there. I did
not have high expectations. I had already called several times from my
home in New Mexico (another CMS state) trying to arrange interviews with
hospital administrators and doctors and nurses, but I had mostly been
ignored. On those occasions when my calls were returned, the CMS
spokesperson had, in an exasperated tone, made it clear that virtually
every member of his medical staff was far too busy to spend time with
reporters, and that furthermore this would remain the case indefinitely,
no matter how flexible my schedule was, no matter when I offered to visit.
The timing, he explained, was simply awful, and it was not likely to get
any better, ever.

Still, I held out some hope. Calling from within the state, I
figured, would seem more real and immediate to them; and besides I was no
longer planning to ask for interviews with medical staff, or even company
higher-ups, but to settle for a sit-down with the spokesperson, which
seemed like a modest request, to say the least. I had even begun looking
forward to that interview, wondering how the spokesperson might respond to
the accusations I was hearing. I could imagine that some of his points
might be reasonable. Certainly, prison medicine must difficult to
administer, and I assumed that the spokesperson would be eager to point
out just how difficult, and to illuminate the challenges of working with
convicts, of sorting through faked illnesses and phony requests for
medicine, ornery personalities and violent outbursts.

But when Ken Fields, the spokesperson, called me back, and I
mentioned my desire to visit, he didn't sound nearly as eager as I had
hoped. "What do you want to talk about?" he asked. "How were your
interviews with inmates?"

I explained that most of them were angry at CMS which was why I
wanted to get his point of view. "I think we're going to have to handle
this on the phone," he said. I suggested that it would be preferable to
meet in person, since I had met the inmates in person and didn't want them
to have an advantage, but he replied, "We've had bad experiences with the
media." I assured him that I knew this, yet I felt that, as a member of
the company's communications team, he needed to communicate the company's
message, but he insisted, "I can't do it this week. I'm too busy." I
offered to return the following week, but he repeated that he preferred to
speak on the phone. So I repeated my preference to meet in person, and he
repeated that he was too busy. Then I repeated my offer to return, and he
repeated his preference to speak on the phone. So it went, until finally,
perhaps just to stop the routine, he barked, "Well, I don't want you to
come back here. Why don't you just stop by tomorrow?" I agreed and we hung
up, but a couple of hours later, I found a message on my voice mail from
Fields, saying that he had decided not to meet with me in person.

"It's a situation where we have been misquoted at times in the past,"
he said, "and we're gonna respond to your questions in writing. So I
wanted to give you notice of that. Thanks, bye."

But even in response to written questions, Fields was hardly
forthcoming: of the fourteen questions posed, he offered only eight
complete answers. For example, he was willing to provide rudimentary
statistics about the company, such as the total number of patients under
CMS care, but would not describe any company protocols or reveal how much
money the company actually spends on patients, except to insist that, of
the more than half a billion dollars that CMS receives in taxpayer money
each year, a "very, very significant portion to patient care." Although he
was quick to claim that all CMS doctors and nurses are licensed in the
states where they work, he dodged the question of how many have been
suspended or had their licenses revoked in the past or in other states,
insisting that the company is "not obligated" to reveal those statistics.

Nor would he answer the question of whether or not the company has any
plans to begin screening for hepatitis, claiming that CMS leaves those
decisions to state legislatures and individual doctors, a claim
contradicted not only by the company's detail-heavy and restrictive
hepatitis pathway but also by the internal communications of its regional
medical director.

Since CMS officials were declining the chance to meet with me, or to set
up interviews, or even to talk on the phone anymore, I decided to contact
some of their employees directly. This turned out to be easier than I
expected. Nurses tend to know one another, and after speaking with a few
nurses who didn't work for CMS, I was able to reach a few nurses who had
once worked for CMS and, finally, nurses who still do. At the very least,
I hoped they would take the time to reassure me that the gritty standard
of "deliberate indifference" was not being met; that nurses and doctors
were not intentionally ignoring their patients. But what I heard from CMS
nurses was, in many ways, more upsetting than what I had heard from
inmates. One conversation in particular stands out.

I had reached Christy through a series of referrals by other nurses
and their friends. At first, she was anything but eager to speak with me.
Her relationship with CMS was still good, and she didn't want that to
change. Although she was no longer working in the jail in the northern
United States where she had been a CMS supervisory nurse for half a decade
(she had left to manage a hospital facility), she was considering a return
to the company and didn't want to jeopardize her ability to do that. The
money was good at CMS, she explained, and besides, she didn't need them as
enemies. But after thinking about it and talking with her friends, Christy
decided to speak with me anyway, mostly because, as she put it, she needed
to tell somebody what she had seen and done, especially what she'd done.

WHAT I HEARD FROM CMS NURSES
WAS, IN MANY WAYS, MORE
UPSETTING THAN WHAT I HAD
HEARD FROM INMATES

I was immediately drawn to Christy's story, even before I had heard
the details. As a supervisory nurse, she had been the highest-ranking
member of the medical staff on duty, so she had been privy to many of the
political and economic machinations behind company policy. I was also
interested to hear about jailhouse medicine in general. People in prison,
after all, have been convicted of a crime and have forfeited some of their
rights (the right to vote, the right to own handguns, etc.), but most
people in jail are still awaiting trial, and they haven't necessarily been
convicted of anything. Not only have those awaiting trial not forfeited
their rights; they are still officially innocent. Our legal system takes
great pains to insist on this, so I was curious to know whether or not it
made any difference to CMS.

The short answer, according to Christy, was no. "The way we treated
inmates was a horror," she said. "Whenever a new inmate came in, they
would have to see me, and I would assess their medical condition. If it
looked like they were going to require any kind of serious treatment, I
would go to the lieutenant and explain what I felt the cost of the
treatment would be. I would say, 'We have this person here, and the
treatment is going to be horrendously expensive. We need to get them out
of here.' If they were a real serious criminal, like a murderer, the
liability was high, so they would keep them under arrest and we would
incur the cost of treatment. But if the lieutenant thought the person was
not a serious risk to the community, he would proceed to get hold of
judges and other people to try to release the inmate, or make arrangements
to get the bail lowered. The lieutenants would often call judges late at
night and on holidays to tell them the situation, then we would release
the inmate, and take them to the hospital, so CMS wouldn't incur the cost
of treatment. The lieutenants went along with it because they didn't want
to incur the cost of a deputy to stay with the inmate in the hospital. So
we would let them know, and they would make a call and release the inmate,
then they would take them to the hospital. After the inmate got their
medical treatment, we would immediately re-arrest them.

"We did this frequently also with pregnant inmates. If they went into
labor, we would release them or given them a signature bond, then re-
arrest them and the child was put into the custody of child services. I
did that for years. You just ignore what you're doing. The whole
atmosphere of the jail was, these criminals, these convicts, these
scumbags, they get what they deserve."

"Appointments were made for weeks or months down the road, knowing
that the inmate would not be there anymore. Or we would make appointments
for days that we knew the inmate was going to be in court. They don't keep
the trial dates in the medical file, but you just call the booking desk up
front and ask them when the trial date is. Then you make their next
appointment for that date. We were told to tell them, there was a canned
phrase, 'Don't worry, you have an appointment. We just can't tell you when
it is because of security reasons.' So you would be consoling someone,
knowing full well that they weren't going to get to see anybody. You just
put them right back at the bottom of the list again." *

"It was absolutely appalling, to the point that I can't even tell
you. You knew that as long as you worked there, you did not challenge any
of it. But your disgust builds as the horrible cases build. Even though a
good majority of these people ended up being guilty. I just felt from a
moral standpoint that it was wrong. They always play up, 'Well, look what
they did to this other person,' so a lot of people say, 'Okay, justice is
served.' But the way I feel is, we've all taken an oath and we have a
license, and just because one person has died, that doesn't mean that a
second person dying or being denied care&one doesn't justify the other. As
far as I'm concerned, if you're sick and you get into one of these places,
you might as well be signing your death certificate. Even if you don't
have a death sentence."

The more I spoke with nurses like Christy, and looked at inmate medical
files, and studied infectious-disease statistics, the clearer it became
that, no matter where you looked or to whom you spoke, this was a medical
system run amok, one that no only ignored sick patients but was actually
skirting the limits of the law and, in the process, helping to unleash an
epidemic on society. As one nurse put it bluntly, "We have no
accountability. If I deny care, that's it. You have no recourse." Yet the
clearer this reality became, the more baffling it seemed. Wasn't anyone
keeping track? Where had them media been?

In the course of nearly a decade, only two newspapers had undertaken
major investigations of CMS, and both were located in Missouri, which has
become a kind of ground zero in the debate over prison medicine, largely
because CMS is headquartered there. Even more discouraging, the reporters
who wrote those stories had, in the aftermath of their work, become just
as tortured and frustrated as everyone else who confronts the company. Not
long ago, one of the agreed to meet with me in the basement of his office,
but within the first two minutes of our conversation he insisted that I
keep his name out of my story. In the weeks after his articles appeared in
the Columbia Daily Tribune, he said, he had been under attack by CMS
lawyers and publicists, who deluged his editors with denunciations, and he
didn't want to be perceived as settling the score. He sat nervously with
me, fidgeting, smiling, and trying to be as helpful as possible without
getting further involved.

The other reporter I spoke with was less reserved, but only because
he had less to lose. He had already lost it all. In 1998, Andrew Skolnick
had been an editor at the Journal of the American Medical Association, a
recent recipient of the Harry Chapin Media Award, and an inaugural fellow
of the Rosalynn Carter Fellowship in the Mental Health Journalism, which
is a $10,000 grant. Using these lofty connections, he had managed to get
himself and two journalists from the St. Louis Post-Dispatch into CMS
facilities, where they spoke with several inmates and doctors before
publishing articles in both JAMA and the Post-Dispatch, revealing a
national pattern of abuse and neglect by CMS. As the organizing force
behind both projects, Andrew had helped expose several CMS doctors with
checkered histories and had revealed more than a dozen cases of egregious
mistreatment, some of which resulted in death. One story revealed a memo
from the medical director of the New Mexico corrections department
explaining that several prison doctors had quit because CMS administrative
officials were "changing physicians' orders and adding orders without
seeing the patient or consulting the physicians directly." Another story
exposed a CMS doctor in Alabama who had been convicted of having sex with
a sixteen-year-old "mentally defective" patient in Tennessee. Another
described the chief of mental-health services for CMS in Alabama, whose
license had been revoked in both Michigan and Oklahoma after he was found
guilty of sleeping with patients, harassing female staff members, and
defrauding insurance companies. The newspaper series had won awards from
both Amnesty International and the American Medical Writers Association in
the late 1990s, but even still, looking back, Andrew said that he wasn't
always certain it had been a good idea to publish it. After the articles
appeared, he told me, CMS had sent a letter to JAMA, accusing him of
hiding his involvement with the Post-Dispatch, which they called "fraud,"
and threatening to sue the journal. Within a week, JAMA had fired Andrew
and, although CMS later paid him to settle a defamation lawsuit,** his
professional life never quite recovered Even today, the editors of JAMA
refuse to comment on "the conditions surrounding his termination" or to
defend his award-winning expose, which has never been refuted or
retracted.

"I had an exploding career," Andrew told me, "and it crashed. We may
have won some awards, but the horrible fact is we lost. CMS won. After the
articles appeared, they went to the state legislature in Missouri and
protected themselves. They got a law passed expunging the records of
physicians who are accused of malpractice in correctional facilities. So
now, anytime the medical board doesn't take action on an allegation they
disappear it. This means no pattern can emerge against a doctor. That is
our legacy. That's our achievement. We actually made it worse."

But Andrew's investigation had a resonance far beyond that. It was
his work that started CMS down the path of information lockdown, building
barricades to public scrutiny, hiding numbers and statistics and the names
of employees, refusing even to sit for a formal interview, and stifling
the efforts of journalists to cover the field at all. Andrew's series had
put pressure on CMS, but that pressure had only deepened the company's
aversion to publicity. CMS officials were happy to continue operating with
public funds, but they were no longer willing to provide any serious
accounting of them.

Like almost any wound, the weakness of an institution festers without
proper attention, and as CMS has retreated into its shell, its facilities
have only grown worse. Outside of anecdotal evidence, however, it is
difficult to assess exactly how much worse----it is nearly impossible, for
example, to know how many doctors and nurses it employs, or how adequate
its facilities are, or even what pathways and protocols it adheres to. Few
lawsuits have managed to expose details of the company's inner mechanisms,
and aside from the Michigan hepatitis suit there is no major legal action
pending against the company at the moment, only scattered individual
lawsuits----the great majority of them, it is safe to say, doomed. In
Massachusetts a small network of attorneys has been threatening to file a
comprehensive class-action suit, but nothing has gained much traction so
far. And although the U.S. Justice Department has reportedly kept an open
file on CMS since the mid-1990s, collecting evidence and reviewing cases,
no formal charges have been leveled against the company, and sources say
it is not a high priority in the post-9/11 climate. Even Karen Russo has
her doubts that CMS will change. "It's not going to happen," she
says. "They don't want to be rehabilitated. They probably can't be
rehabilitated. So the only solution is to get rid of them, and they're
going to fight that in every state, at every step. They're going to use
all their money and power, and they have a lot."

But if the battle over prison health care is beginning to seem lost,
littered with the bodies of the wounded, the sick and sickened alike, with
inmates and nurses and journalists by the wayside, if the whole field
seems deathly unwell and bordering on hopeless, it may, in the end, have
more to do with the way we look at prisons in general than with anything
CMS has done. This is not to obscure or to apologize for the company's
failures and crimes. It is simply to suggest that the secrecy afforded to
prisons would be easy enough to strip away. When we, as a culture, choose
to see our prisoners as a part of our society (which they are, of course,
and an ever growing part), when we remove the wall of secrecy that
surrounds the prison itself when we are willing to face and bear witness
to the punishments we disburse, there will be no more need to wonder what
is being done on the inside, in our names.


* In response to these claims, CMS wrote, Correctional health care staff
make every effort to work with corrections agencies to coordinate such
offsite trips in ways that do not create conflicts with scheduled court
appearances."


** According to CMS, "Company attorneys determined that a small settlement
of Mr. Skolnick's baseless claim was less expensive than the cost of
ongoing litigation."


Wil S. Hylton is a writer at large for GQ magazine.

This article is copyrighted © by Wil S. Hylton 2003. All Rights Reserved.
This article may not be copied, transmitted, forwarded, reposted, or
republished, in whole or in part, electronically or in any other format,
without express written permission of the author. Permission was obtained
from the author to use this article.

Subscribe today

Already a subscriber? Login