Conundrums1 Behind Bars

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The list of improvements (above) in correctional health care is not to say that our correctional health care systems are uniformly excellent. Too often, correctional health care is compromised by strained resources, isolation, and pressures to conform to the punitive aspects of command-control environments. Too often, correctional health professionals begin to stereotype their patients and thereby distrust them. This stereotyping results in cynicism that is destructive to therapeutic relationships. And too often, there are inadequate linkages to community health care providers and public health authorities.

1 In this section of the chapter, I use the term conundrum instead of challenge, obstacle, barrier, or hurdle. To me, these are puzzles that can be solved with rational analysis. Once the puzzles are solved, there is no detritus to bar the way.

Isolation of Correctional Health Professional from Mainstream Medicine

We have a triple system of medical care in the United States: care for the affluent in private offices and group practices; care for the poor in community health centers and hospital clinics; and care for prisoners behind bars. But at least 95% of these prisoners will return to their communities (Hughes & Wilson, 2003). The first conundrum for public policy makers to solve is how to coalesce these diverse medical care systems for better communication of medical information, access to specialty care and hospitals, and linkages for continuity of care on release.

Nexus of Correctional Medical Care with Public Health

A second conundrum is how to address the nexus of personal medical care and public health. We have learned lessons at the interface of public health and criminal justice. In the 1980s we learned about HIV and the disproportionate percentage of infected people who were behind bars. In the 1990s we learned about the prevalence and incidence of tuberculosis and the high risk of transmission in correctional facilities. And in the first decade of the twenty-first century, we are learning about viral hepatitis C and community-acquired methicillin-resistant Staphylococcus aureus (MRSA).

Every inmate who leaves a correctional facility with untreated sexually transmitted disease, viral hepatitis, HIV, or tuberculosis might be a source of transmission in the community. These are diseases typically addressed by public health authorities, agencies that because of their categorical funding may not have the resources to join efforts with correctional agencies. Every inmate who is treated for communicable disease behind bars reduces the risk to the public health. The community also benefits from treatment of chronic disease and mental illness behind bars, through the savings from early intervention (Freudenberg et al., 2005).

Episodic versus Primary Models of Care

A third conundrum is the archaic model of medical care in most prison and jail systems. Most facilities use what they call a "sick call" system. This episodic care is appropriate for acute illness, but it has no place in the care and treatment of patients with chronic disease and mental illness. There are nationally accepted guidelines, each with an evidence basis, for a wide variety of chronic conditions. If patients are treated according to these guidelines, including treatment plans for prisoners with special needs, there will be reduced morbidity and mortality. The reduction in morbidity is a substantial cost-saving for the communities to which inmates return because of their dependence on public resources for access to care in the community.

Integration of Care for Patients with Coexisting Illness

The fourth conundrum is the artificial walls between treatment for drug abuse and mental illness behind bars. For a variety of reasons, correctional systems typically provide medical care and drug treatment through parallel, but unrelated programs. And there is not enough drug treatment behind bars to help reduce recidivism. These are barriers to recovery for patients with coexisting illness.

Transfer of Medical Information

The fifth conundrum is the challenge of transfer of medical information between community and correctional providers. It is a cumbersome process. As a consequence, it happens infrequently. This interferes with continuity and coordination of care, putting incoming and outgoing prisoners at risk of harm.

Quality Management Systems

The sixth conundrum is the development of meaningful self-critical analysis, a process called quality management or quality improvement in community health care facilities. Very few correctional agencies have incorporated valid and reliable performance measurement into their medical care programs. As a consequence, they are unable to measure their problems and then reduce barriers to improved outcomes of care. Performance measurement with quantitative and qualitative analysis of data is an opportune way to improve care and reduce risk of harm and costly litigation. This has been amply demonstrated in the community. There is no reason why the same approach cannot be used behind bars.

Command-Control versus Collaboration

The seventh conundrum is the apparent contradiction of the command-control organizational model, so essential for safety, and the collaborative-autonomy model used in health care. For example, there are challenges to provide meaningful diagnosis and treatment for inmates who are confined in isolation for breaking facility rules, typically with disruptive behavior. Many inmates are disruptive because of mental illness. Segregation for 23 hours per day is not likely to be an effective treatment for mental illness. To the contrary, isolation is contraindicated for serious mental illness, yet correctional agencies often rely on deprivation as a way to reduce disruptive behavior. This is but one of the ongoing challenges between the command-control model of correctional facility operations and a public health model of care.

Command-control is critical to safety behind bars. It requires rigorous adherence to rules and does not easily tolerate uncertainty. Even in their most scientific modes, medicine and public health are filled with uncertainty, more uncertainty than is often tolerated in command-control environments. Physicians and other health professionals are used to managing with much more uncertainty than is often tolerated by custody staff. This creates a natural tension, even when the leadership of correctional facilities works hard both to keep a facility safe and to provide good medical care through autonomous health professionals.

Reentry—Seven Tasks

The eighth conundrum is reentry. Until recently, the responsibility of correctional agencies stopped at the gate. Recent public attention to reentry offers correctional and public health professionals the finest opportunity to make a difference, for the prisoners themselves and for the communities to which they return. But it requires a revised scope of responsibility for correctional agencies. A revised scope often means a revised budget. With increasing attention to reentry among public policy makers and correctional system leaders, social conditions are favorable for personal health care and public health practitioners to make a real difference here. This is a time and place where their advantage to our communities can shine. It is a place where correctional and public health practitioners can honor their moral duty to provide continuity of care for their patients (AMA, 2001).

Among many other risks, recently released inmates are at higher risk of death after release than people in the community, matched for age, sex, and race (Binswanger, 2007). The reentry process contributes to excess mortality relative to incarceration itself, which might have a small protective effect, especially among blacks (Mumola, 2007). In the Binswanger study, conducted in the State of Washington, the relative risk of death within 2 weeks of release was 12.7 times expected and the overall risk of death in the several years following release was 3.5 times expected, and higher among women. In the studied cohort, the most frequent causes of death were overdose, cardiovascular disease, homicide, suicide, cancer, motor vehicle accidents, and liver disease. Surely, some of this risk could be reduced by thoughtful reentry planning.

From a medical perspective, a successful reentry program has seven tasks (Mellow, 2006):

1. Define the target population. Of course this would include patients with incompletely treated communicable disease such as tuberculosis, HIV, skin infections, and sexually transmitted diseases. And it would include patients with acute medical conditions, such as alcohol withdrawal, organ failure (e.g., heart, kidney, or liver failure), fevers, trauma and those who are recovering from surgery, and patients with suicidal behavior and uncom-pensated psychosis. There are other questions that correctional programs should answer to help define the target population:

• Will the program target patients at risk of serious illness, such as those with abnormal Pap smears, pregnancy, and abnormal laboratory tests?

• Will the program target patients with well-compensated chronic mental illness (on medication), such as major depression, schizophrenia, bipolar disorder, posttraumatic stress syndrome, or any mental illness being treated with medication?

• How about patients with severe chronic diseases, such as uncompen-sated cirrhosis, moderate or severe asthma, poorly controlled diabetes, and symptomatic coronary artery disease? Or all patients with chronic diseases, including hypertension, asthma, diabetes, stroke, arthritis, viral hepatitis and partially treated latent or active tuberculosis?

• For a larger target, could facilities target patients with nonemergent dental or gum disease, or a history of drug and/or alcohol abuse?

• How much medication will be supplied at release? Will the facility provide written prescriptions and an address of a pharmacy that might fill the prescriptions for impoverished patients, in addition to the medications dispensed?

• What are the limitations on distributing certain medications at the time of release, for example, antipsychotic medication, narcotics, benzodi-azepines, medication for tuberculosis?

2. Develop formal linkages with commonly accessed community providers including public health departments, community health centers, and public or private hospitals.

3. Determine an individual patient's risk and eligibility for reentry services as early as the intake process.

4. Summarize essential information for the patient and the subsequent provider of care.

5. Provide medication or a combination of medication and written prescriptions.

6. Enable access to care on release with community providers, including an appointment and information for access to community-based organizations.

7. Designate staff with a clearly defined discharge planning function.

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