Deficient medical care at the unit level has Texas prisons incubating a new, more virulent strain of HIV. Dr. William Obrien is one of the most noted doctors on staff with the University of Texas Medical Branch. (UTMB) Over a year ago he discovered that "patients in the Texas prison system infected with (HIV) frequently have a drug-resistant form of the virus." He links this occurrence with the "inconsistent administration of medication" at the unit level. Such inconsistent treatment produces "diminished responses to drug therapy." Obrien has determined that the source of the problem is what Texas prisoners call "the pill window."

On Texas prison units, drugs are administered in basically two ways. The preferred and most effective method is a cardboard package of pop-out pills called KOP, an abbreviation for "keep on person." The obvious advantage to KOP packs is the consistency with which medication can be taken, a consistency that is vital for the effective treatment of AIDS.

However, as with most bureaucracies, the preferred method is not necessarily the most common. A 1998 audit showed that since UTMB took over health care at the Texas Department of Criminal Justice (TDCJ) in 1993, KOP medication was reduced from 61% to 44%. However, over that same 5 year period, the number of prescriptions dispensed -has increased -by 44%. The -original goal was to increase control over drug distribution. The result has been an increasing loss of control over an already lethal disease.

Prison units now have long and unwieldy pill-window lines, that often close before all prisoners receive their medications. Sick prisoners complain about long lines, standing for prolonged periods, receiving the wrong medication, and, in some cases, no medication at all. And while prisoners are notorious for complaining about anything and everything, investigations of these allegations prove that prisoners are telling the truth.

The effect of these inconsistencies is most pronounced with TDCJ's 2,500 HIV-infected prisoners. Their inability to receive reliable treatment from the pill-window is directly linked to the drug-resistant strain of HIV detected by Dr. Obrien. In September 2000, both Obrien and UTMB warned that the "prevalence of HIV drug resistance in prisons also may have important implications for the community at large ... Most of these incarcerated patients will be released at some point and will return to the community."

Studies have shown that on average the 134,000 residents of Texas prisons are sicker than their free-world counterparts. One in seven is mentally ill and the average prisoner has the health problems of a person ten years older. Since UTMB is responsible for distributing drugs in 80% of Texas prisons, and responsible for the KOP restrictions that cause the back-logs, the problems should be simple to fix right? Wrong! UTMB has another agenda.

Secret Experiments

It was recently discovered that the UTMB has been conducting secret experiments on prisoners unbeknownst to TDCJ. Prisoners joined the covertly advertised experiments to escape the inept medical care of prison units.

Evidence provided to a federal judge in 1999 indicated "significant, even deadly, inadequacies in the level of care provided" to sick prisoners at the unit level. However, the hospital in Galveston, also run by UTMB, is described as "exemplary." Sick prisoners have always known the truth. That's why they do everything they can to get to Galvestonincluding volunteering for medical experiments.

Televisions in the hospital hallways would advertise free treatment and medication to prisoners who would volunteer for studies. It wouldn't take long for word to circulate. Prisoner Donald Manning said, "If I could get the (HIV) treatment here [on the unit] that they are giving me in Galveston, without the hassle, then, no, I wouldn't be on the study."

A July 2000 inspection of UTMB by federal officials showed that medical research involving Texas prisoners was not up to standard. Prisoners were kept in the dark about potential risks, benefits of testing were vastly overstated to induce participation, and over 50% of UTMB research projects did not meet the standard of the Office of Human Research Protection. In nine of the tests, there was question about whether prisoners should have been involved at all.

It is estimated that UTMB conducts about 1,600 medical trials annually. In September 2001 UTMB was ordered to halt prisoner enrollment in 195 of its federally funded projects. About 300 studies, which included almost 100 prisoners, were also suspended. "All research has been scaled back since the issues that arose last year," said Dr. Ben G. Raimer, a UTMB vice president.

In 2001 UTMB conducted about 200 tests in which prisoners were eligible to participate. A random sample of 25 experiments showed that 99 of the participants were prisoners. Experiments conducted by UTMB and other universities are funded partially by the federal government and partially by drug companies. Yet the Office of Human Research Protection, the watchdog for federally funded research, made only 18 on-site inspections between 1990 and 1996. Most disconcerting, however, is that no exact number is available of people participating in medical experiments.

In 1999 the Department of Agriculture made 1,816 unannounced visits to animal research facilities. Their research reported that experiments were conducted on 70,541 dogs, 288,222 rabbits, and 201,593 hamsters in 1998. But no one at any level knows how many human beings either have been or are currently involved in experimental testing.

Some have drawn the parallel between current medical studies involving prisoners and the experiments conducted in Nazi concentration camps. Speaking of their atrocious experiments at the Nuremberg trials, Nazi doctors offered the defense that their experiments were no different from those practiced in American prisons. There was some truth to their statements.

In 1906, American prisoners were given a defective cholera vaccine which caused 13 deaths. From 1919-1922 over 500 prisoners were forced to receive testicular transplants using animal genitals. These revelations combined with Nazi atrocities culminated in the Nuremburg Code which regulates the conditions that govern human experimentation.

The Nuremburg Code should have eliminated virtually all experimentation on prisoners; it didn't. Post-war experimentation continued. A 1950's article from the Atlantic Monthly quoted one doctor as saying "criminals in our penitentiaries are fine experimental materialand much cheaper than chimpanzees." Yet even this revelation has not taught doctors a lesson about monkeying with prisoners.

A federal study revealed that one of the most inviting features of prison subjects was their potential for rapid enrollment. According to a report by the Food and Drug Administration, "sponsors will often explicitly state when contracting with a research site that the site will be dropped if they do not enroll adequately." The upshot is that the Galveston facility has a vested interest in making sure its services are superior to prison unit health care. "There's a long history of this kind of thing," said Dr. David Egilman of Brown University. Egilman, a professor in the community health department observes that, "prisoners who join trials get better care. Better care is coercive." [See Acres of Skin advertized on p. 34 for more on this topic.]

Secret Files

A nest of potentially lethal problems is cached inside a bureaucratic web of secrecy. Initially, UTMB officials appeared cooperative, agreeing to release minutes of a university board meeting requested by the Austin American Statesman newspaper. Then, citing cost constraints, they refused to release this information. The universities also had an advocate in the then state Attorney General, John Cornyn, who ruled that prisoner grievances, doctor's reports on prisoner's deaths, facility inspection reports, and correspondence between health-care administrators are all classified. "There are confidential areas of state law, and these records just happen to fall within those areas," said a Cornyn aide.

Administrators had a good reason for not wanting their records made public. In 1996, conditions at the Stiles prison unit near Beaumont Texas became so bad that health care workers were compelled to report violations to prison officials. They described conditions so poor that prisoners were literally dying.

What system administrators found was shocking. The charts of 24 dead prisoners revealed that at least 16 received "improper" medical treatment. One prisoner died shortly after he had been found covered in his own excrement. Another prisoner died of starvation while housed in the unit infirmary.

The audit of the deaths on Stiles was never intended for public view. If not for the anonymous letter sent to the Texas Board of Criminal Justice it would still be secret.

TDCJ has a $279 million annual contract with UTMB and Texas Tech University to provide medical services for prisoners. A nine-member committee oversees the conditions of the contract, including health care. The committee should have received copies of the audit. However, at meetings held in December 1996 and March 1997 they never publicly acknowledged the damaging report. Of the more than 1,000 prisoners who have died since 1993, the year UTMB took over, the Stiles report is the only one that has managed to find its way into the public eye.

A 1997 inspection of the dialysis office on the Estelle unit near Huntsville yielded 99 pages worth of deficiencies. The facility was closed by the Department of Health. But it wasn't until 1995 that inspections by the Health Department even began. Alerted by an outbreak of hepatitis B that eventually infected nine people, Rep. Garnet Coleman, D-Houston, sponsored a bill that required Health Department inspections. But in true Texas tradition, the findings of these inspections are secret.

The American Statesman did manage to get a portion of the "reinspection" of the dialysis clinic that was conducted in 1998. The second inspection was equally frightening. It revealed that prisoners had to wipe blood off the chairs before they could receive treatment and that staff was inadequately trained in dialysis procedure. When they learned that the damaging information was in the hands of reporters, the medical department and the Attorney General cried foul. They demanded the report be returned but the Statesman refused.

An attitude of secrecy is also reflected in the Texas Legislature. During the 2002 session, Senator Jane Nelson, R-Flower Mound, proposed a bill that would have prohibited all participants of drug research experiments from having access to their own medical records. She withdrew that provision when the extreme nature of her proposal was exposed in the Austin American Statesman .

Legislature

The trepidations of the prison health-care system can be traced directly back to the Texas legislature. In 1993, the state House of Representatives removed the bidding process from prison health care. By law, TDCJ is required to go through the Correctional Managed Health Care Committee to obtain health care services for prisoners. The committee, created by the legislature, decides who gets the contracts. UTMB and Texas Tech University control almost 50% of the committee seats. Since the universities essentially hire themselves, there is no real way to tell if UTMB prices are competitive.

In 1999 the legislature voted not to allow TDCJ to monitor health care in its own prisons. Currently, the universities are responsible for monitoring themselves. While the universities hold four of nine seats on the regulating committee, it is a slight improvement over a year ago when they held four out of six seats. UTMB provides 80% of the health-care in Texas prisons. Texas Tech University provides the rest.

Allen Hightower, former state representative and one of the original designers of the current system, is head of the committee. He explains that in order to meet the demands of the federal courts, control had to be taken out of the hands of TDCJ, which is why the universities have complete control. "As long as medical stayed under (TDCJ), people who were delivering health care were answering to corrections officers or the board," said Hightower. "The court felt that medical people ought to be making medical decisions on their own."

In 1998, however, a state auditor complained that the current system blurred "the lines of responsibility" and lacked "a comprehensive monitoring system." University doctors still basically review themselves. The contract reads that the universities themselves "shall be used to the greatest extent feasible for clinical oversight of quality-of-care issues." The auditor pointed out the absurdity of allowing the universities to both hire and monitor themselves as well. But when TDCJ proposed using its own doctors to perform quality care review, the legislature and the committee refused to give them permission.

"There is no other system that works that way," said B. Jaye Anno, a former Texas prison official and author of a book on prison health care. "The state always retains the authority to monitor the care that is given ... Texas is unique in this respect: The client, TDCJ, does not have the authority to monitor the services of its outside consultants (the universities)."

Watching the Watchers

As head of the committee one would think that Hightower would be abreast of TDCJ health-care issues. However, when asked, Hightower admits that he knows little about the quality of care in prisons. "Should I know more about quality of care?" he asks rhetorically. "Maybe. I don't know. I've never really sat down and thought about it. It's not something I think about. I have confidence that the universities are thinking about that."

Dr. David Smith is head of the Texas Tech University Health Sciences Center. For a time he was also head of the Managed Health Care Committee which was responsible for hiring the universities. In an interview with Donna Brorby, counsel for prisoners in the Ruiz litigation, Smith admitted that during his years as head of the committee he had spent no more than 10 hours on a prison unit and less than an hour total talking to prisoners.

By contrast, The Correctional Medical Authority which oversees health-care quality in Florida prisons is independent of both the prison system and the health-care providers. The CMA inspects all aspects of the health-care system, reviews deaths, and issues citations for violations. Most importantly, its findings are -in the public domain.

A few clicks on the internet would reveal that of the fifty-seven prisoners who died in Florida prisons during the year 2000, fifteen received inadequate or improper health-care. The authority lists the name of the units responsible for the treatment and a description of the prisoner's condition. Florida residents' can read about the prisoner who died from untreated pneumonia or about the ten month delay between a Pap smear and hysterectomy that "likely contributed" to a prisoner's death from uterine cancer. [ PLN , May 2000]

CMA supervisor, Mike Traugott, related a recent incident in which Florida prison psychologists removed many prisoners from their medication. "Inmates were decompensating (getting sicker) across the board, ending up in confinement and such," he said. The problem was corrected when the authority issued a citation.

The Florida system is far from perfect. CMA reports show that Florida has its own share of prison health-care problems. What Florida also has, however, is a form of checks and balances, an independent agency that confronts problems instead of covering them up.

Mike Vaughn teaches criminal justice at Georgia State University in Atlanta. He advocates a national system comparable to Her Majesty's Inspectorate of Prisons, designed to monitor prison health-care in England. "We could really use something like that here (in the United States), somebody who is independent from the prison hierarchy and can candidly discuss problems that are occurring. We don't have anything like that now. Now, if there are problems they just fester."

According to Hightower, "Texans, by and large, have always been really interested in getting their criminals off the street and then they just want to forget about them." Rep. Patricia Gray, D-Galveston has "no quarrel with the fact that we have to deliver health care in prisons." However she also points out that "there are a lot of people who think it should be an 18th century dungeon." There is a haunting truth to her words.

Abuse

Cruelty in Texas prisons has been documented for nearly a century. In 1909, the Texas prison system was accused by an investigative committee of practicing "atrocious and brutal treatment" against prisoners rented out to private businesses as laborers. In 1930, after a visit by Governor Dan Moody and 100 legislators, conditions in Texas prisons were deemed "not fit for a dog." The visit resulted in a new prison medical facility and marked the beginning of the educational programs for prisoners. In 1947 the Texas State Council of Methodist Women pressured the system and initiated a school for prison guards. In the 1960's prisoners themselves initiated litigation that culminated in a 1980 ruling by Federal Judge William Wayne Justice which brought Texas prisons under federal oversight, which only recently ended. As recently as 1999 Judge Justice cited evidence of "significant, even deadly, inadequacies in the level of care provided to ill inmates."

Hightower recalls how "back in the '70s, medical care in the [Texas] prison system was almost non-existent. Inmates doctored on each other. They did operations on each other. They set broken legs on each other without painkillers. If you were in prison back then you just prayed you didn't get sick."Donna Brorby agrees. "In the old days the problem was getting people to a doctor at all," she said. "They do have a system in place. They didn't used to, and they do now. It's no mean feat."

Voices

Texas prisoners learned long ago that the squeaky wheel gets the grease. Kenneth Malone's time on Ramsey I unit in Rosharon, Texas was spent locked in battle with the medical department. He was released in March 2001 but his battle continues. Today, Malone is legally blind. He blames his disability on the poor medical care he received in prison. A diabetic, Malone says he was consistently taken off insulin so often that it eventually cost him his sight. However, it is his refusal to passively accept his condition that could cost him his freedom.

Malone has filed complaints on state and prison officials at every level. He has filed grievances and lawsuits. He has even written the United Nations Commission on Human Rights. He is asking for monetary damages but most of all he wants to damage the present system of medical abuse and neglect in Texas prisons.

Malone told reporters, "At UTMB prisons, there was no care. You can't get in to see the doctor. At Texas Tech, I got perfect medical care. I had two doctors and six nurses crawling all over me.... When Texas Tech started (in the prisons), they started from scratch, so they had a chance. UTMB took over a system that was already corrupt, busted and confused."

Prison officials say Malone wrote "excessive, frivolous grievances." They say he complained about problems where no problems existed. They accused him of threatening staff with lawsuits. Parole officials have virtually placed Malone under house arrest. They have made it difficult for him to attend college classes and have made it impossible for him to have surgery on his throat by not allowing him to spend the night in a hospital. When they tried to revoke his parole, Malone took the offensive. He took his accusers to court where he convinced the judge that he was being unfairly treated. The judge agreed and ruled that the state could not take his parole.

"I've never seen that happen," said Van Williamson, an Amarillo attorney. "It all has to do with the suit," he said. "They [parole] normally don't screw around with people like this." Malone is proof of the high cost that comes with bucking the system.

But like Malone, other prisoners also refuse to let go once they get out. Cadrell Freeman spent 11 years in TDCJ for passing bad checks. He left prison in a wheelchair as a result of his poor medical care. He had one major advantage. Freeman managed to smuggle his medical files out with him. Within a month after he was on the streets he was back on his feet. However, his condition now demands $3,000 dollars in prescriptions per month, a burden that's passed on to taxpayers in the form of Medicaid.

"How can health care in prison be improved? That's a good question," replied Freeman. "They must have some way of making these people more accountable. You need to set up some outside agency that has no interest either way. It would -make the staff think twice about the kind of care they pass out."

Lester Allen spent 10 years in TDCJ where he spent time working with sick and dying prisoners. He now works with a peer-counseling program that warns teens about the dangers of AIDS. He says that Texas sorely needs "a governing body that will look and say `This is not healthy."'

Prisons are now required to pass inspections by either the National Commission on Correctional Health Care or the American Correctional Association. Not surprisingly, Texas has chosen the latter. The NCCHC is an organization accredited by the American Medical Association. The ACA is a lobbying group composed primarily of prison employees and corporate backers. The NCCHC performs three-day inspections with a group of doctors, psychiatrists, psychologists, and nurses. The ACA performs a two-day inspection with two or three nurses. Dr. Don Bennett, executive director of the Correctional Medical Authority in Florida says, "In my opinion, NCCHC and ACA are not sufficient to measure true quality of prison health care. They are very good at ensuring that systems are operating. But if you are checking for quality, more resources would have to be provided."

Obviously, any improvement in Texas prisons will necessarily result from outside intervention. Hightower admits that state elected officials, and for the most part citizens, are not concerned with the health and welfare of prisoners. He says that many times discrepencies go undiscovered because no one bothers to ask. He said, "The only thing that changed was that the federal court got on us and made us change," he said. "Talk on the street certainly didn't get us to change."

"It's tough working in prison health care," said Professor Vaughn. "It's not easy. And the more you look, the more depressing it gets."

"TDCJ has never been open," says Steve Martin, a prison consultant and former general counsel for the Texas prison system. "Very few, if any major initiatives or changes have been incorporated by the agency of its own initiative. Up to now it's been because of external pressurethe courts, the Legislature, public reaction. It's always been that way."

Source: Austin American Statesman