CHAPTER 6
INMATE HEALTH

Through the mid-1990s, a number of studies, limited in scope, found a higher prevalence of certain infectious diseases, chronic diseases, and mental illness among prison and jail inmates. Further, each year the nation's prisons and jails release more than 11.5 million inmates. The potential that ex-offenders may be contributing to the spread of infectious disease in the community became of increasing concern. In addition, as these ex-offenders' diseases get worse, society may have to pay substantially more to treat them than if these conditions had been treated at an earlier stage—or prevented altogether—while these individuals were still incarcerated.

—Edward A. Harrison, CCHP, President, National Commission on Correctional Health Care

DEATH RATES OF PRISONERS

Data on the health status of inmates in prisons and jails are not routinely collected by the Bureau of Justice Statistics (BJS). There are some exceptions. Surveys of prisoners conducted at intervals include questions about health. Since 1990 BJS has also collected data on the prevalence of Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome (HIV/AIDS) and has reported its findings on an annual basis. Estimates of prisoners' health conditions were developed by the National Commission on Correctional Health Care (NCCHC) and published in a report to Congress (The Health Status of Soon-to-Be-Released Inmates, Chicago, IL, 2002). These estimates, however, were not based on actual examinations of prison or jail inmates but were, instead, projections developed using studies of the general population with the results allocated to the prison population based on the economic, gender, and racial/ethnic composition of prisoners and inmates of jails.

An indirect measure of the health status of inmates is provided by mortality data that BJS makes available as part of its HIV/AIDS reporting. Table 6.1 shows deaths and death rates by cause of death in state prisons for the years 1995 and 2002. In 2002 the death rate from natural causes, excluding AIDS, was 190 per 100,000 inmates. When deaths from AIDS are added, the rate was 207. In federal prisons (see Table 6.2), the 2002 death rate from natural causes, excluding AIDS, was 179 per 100,000 inmates. When deaths from AIDS are added, the rate was 190.

In the 1995–2002 period, the overall death rate (all causes combined) generally dropped in prisons as in the general population. The state prison overall death rate declined from 311 per 100,000 inmates in 1995 to 246 in 2002. Within the state prison population, the most dramatic change was the sharply dropping death rate from AIDS. Deaths per 100,000 declined from one hundred in 1995 to seventeen in 2002, with the rates dropping every year.

MEDICAL CONDITIONS, SURVEYED
AND MEASURED

The Census of State and Federal Adult Correctional Facilities (2000) included survey questions on inmate health and is the most recent survey of the health status of state and federal prisoners, but the Bureau of Justice Statistics has not yet published the results. Data from the 1997 survey provide a self-assessment of prisoners' state of health. To that the BJS has added data from official prison records for 2000. These data are shown for federal prisoners in Table 6.3 together with benchmark measures on the health status of the general public for selected conditions.

Federal prison records in 2000 showed that 4.4% of inmates suffered from asthma; 0.9% of inmates in the 1997 survey reported asthma as a medical problem; data for 1998 for the general public showed that 8.9% of the public suffered from asthma. Fewer prisoners report ailments than prison records show that they have, and, with the exception of HIV/AIDS, prisoners experience lower incidents of ailments than the general public. The data shown here are, of

course, for different years and are therefore only indicative of patterns. Asthma illustrates well the differences between the prison population—predominantly young adults—and the general public. The prevalence of asthma is much higher in the general public, which includes children and seniors; children are absent from prison, and seniors are underrepresented. Diabetes, heart disease, and high blood pressure (hypertension) are conditions that manifest later in life, hence the lower levels of such diseases in the prison population. The one sexually transmitted disease charted (HIV/AIDS) is substantially higher in prison than in the general public: 1% of federal inmates had been diagnosed with the condition compared with 0.18% of the general public as determined by the Centers for Disease Control and Prevention (CDC).

The prisoners, assessing themselves, significantly underestimated their actual medical problems compared with measurements taken in prison infirmaries and hospitals. The exception was mental health problems. The most common form of diabetes, late-onset Type II, takes a long time to result in symptoms and requires blood-sugar testing for early detection. Only prisoners who experienced acute heart episodes were likely to know they had problems. Similarly, high blood pressure does not have symptoms.

These data are for the federal prison population, which is a small part (11%) of the total prison population. With the exception of data on HIV/AIDS, the absence of data for the larger state prison population (data such as those shown in Table 6.3) illustrates indirectly some of the problems with health care in prisons. However, there have been several selective studies done of health care in prisons nationwide or in particular state prisons. In 2004 the BJS released statistics about the screening for and treating of hepatitis C in state prisons. Hepatitis C is a virus that can cause lifelong infection, cirrhosis (scarring) of the liver, cancer, liver failure, and death. It is spread most often through infected blood transferred by shared needles when using illegal drugs. Allen J. Beck and Laura M. Maruschak of the BJS reported in Hepatitis Testing and Treatment in State Prisons (April 2004) that 1,209 of the 1,584 state public and private prisons had

tested inmates for hepatitis C between July 1, 1999, and June 30, 2000. (See Table 6.4.) Of the 1,584 total state facilities, 69.5% of them tested only those prisoners who were targeted as being at high risk from the disease; 4.8% tested all prisoners in some way. Table 6.5 shows that regardless of approach, those state prisons where testing was done for hepatitis C found that an average of 31% of prisoners had the disease.

A more wide-ranging study of prison health was conducted by the Department of Pediatrics, University of Texas Health Science Center at San Antonio. The Disease Profile of Texas Prison Inmates (April 2002) examined 170,215 inmates who were in the Texas prison system any time between August 1997 and July 1998. Based on the initial medical examination each prisoner received upon entering the system, and any subsequent visits for medical treatment, the study showed that 29.6% of the prisoners had an infectious disease, 14% displayed a disease of the circulatory system, and 10.8% had a mental illness. The most common infectious disease was tuberculosis. (See Table 6.6.)

In 2002 the National Commission on Correctional Health Care, a nonprofit organization, identified some of the problems involved in measuring prisoners' health and delivering services. The following four items are quoted from the NCCHC's Report to Congress, taken from page xiv. The issues highlight barriers to effective prevention, screening, and treatment:

• Lack of leadership , such as failure to recognize the need for improved health care services, reluctance to consider that improving public health is a correctional responsibility, and unwillingness of public health agencies to advocate for improving correctional health care or to collaborate to promote improvement.
• Logistical barriers , such as short periods of incarceration, security-conscious administration procedures for distributing medications, and difficulty coordinating discharge planning.
• Limited resources that require difficult budgeting decisions to meet the high cost of many health care services and some medications, and that make it difficult to provide adequate space for medical services.
• Correctional policies , such as failure to specify minimum levels of required care in contracts with private health care vendors, delays caused by the need to escort inmates to medical treatment, poor communication between public health agencies and prisons and jails, and lack of adequate clinical guidelines.

HIV/AIDS

An HIV-positive person is infected with the Human Immunodeficiency Virus. HIV interferes with and eventually destroys the body's immune system. Once the late stage of the disease is reached, the person has Acquired Immune Deficiency Syndrome. AIDS is incurable and leads to death. HIV/AIDS is transmitted in sexual contact, through breast-feeding of babies by an infected mother, and by blood. A common pathway is the use of unclean needles when injecting drugs. HIV can be treated but not cured. A very small percentage of those infected turn out to be so-called "nonprogressors," indicating that their bodies are able to overcome the virus; they do not "progress" and acquire AIDS.

According to Maruschak in HIV in Prisons and Jails, 2002 (Bureau of Justice Statistics, December 2004), the number of HIV-positive inmates hit its highest level in 1999 (25,801). Since then, the numbers have been declining. In 2002, 23,864 prisoners were HIV-positive.

(See Table 6.7.) Nearly half of the HIV-positive prisoners were found in three states: New York (5,000), Florida (2,848), and Texas (2,528). Female prisoners had a higher HIV-positive rate (3%) than did male prisoners (1.9%).

Table 6.7 further shows that the prevalence of HIV infection was 1.9% among state and federal prisoners in 2002—2% among state prison inmates and 1.1% among federal prisoners. Among state prisoners, the percentage of those with HIV has dropped from a high of 2.3% in 1999. Among federal prisoners, the rate has varied from 0.9% to 1.1%. (See Table 6.8.) Confirmed AIDS cases were nearly 3.5 times higher in the prison population in 2002 than in the general public, 0.48% of prisoners and 0.14% of the general public. The differences between these two populations are narrowing. While the HIV rate among the general public has been slowly rising, from a low of 0.8% in 1995, the rate for prisoners has been dropping since 1999. (See Table 6.9.)

Higher Prevalence in Women

In 2002 women prisoners were more likely to be HIV-positive than male prisoners—2.9% of female inmates in state prisons, or 2,164 women, were found to be HIV-positive compared to 1.9% of male prisoners, or 20,273 men. (Table 6.10.) Between 1998 and 2002, the rate of infection for both male and female prisoners declined. For men, it fell from 2.2%, while for women, it fell from 3.8%. The New York prison system had the largest number of female HIV-positive inmates (410). Florida had 340, followed by Texas, with 267. Among federal prisoners in 2002, 1.2% of females (116 inmates) were HIV-positive. (See Table 6.11.)

Race and Ethnicity

While there are no recent figures for the race and ethnicity of those inmates who are HIV-positive in prison, the BJS has published data on the race and ethnicity of HIV-positive prisoners in the nation's jails. Table 6.12, from HIV in Prisons and Jails, 2002, shows that in 2002, 2.9% of Hispanic jail inmates, 0.8% of white inmates, and 1.2% of African-American inmates were HIV-positive. African-American females (3%) had the highest rate of infection, while white males (0.6%) had the lowest. The forty-five-and-older age group had the highest rate of HIV infection (2.7%), with the twenty-four-or-younger age group having the least (0.2%).

MENTAL ILLNESS IN PRISON

Beginning in the 1970s, there was a movement to de-institutionalize the mentally ill and reintegrate them into society. This widespread trend resulted in the closing of many large-scale mental hospitals and treatment centers. With fewer options open to them, the mentally ill more often came into contact with law enforcement authorities. Morris L. Thigpen, Director of the National Institute of Corrections, wrote in Effective Prison Mental Health Services: Guidelines to Expand and Improve Treatment (Washington, DC: National Institute of Corrections, May 2004): "Since the early 1990s, an increasing number of adults with mental illness have become involved with the criminal justice system. State and federal prisons, in particular, have undergone a dramatic transformation, housing a growing number of inmates with serious mental disorders. Complicating this situation is the high proportion of mentally ill inmates who have co-occurring substance use disorders."

According to the National Institute of Mental Health (NIMH), about 22.1% of the American public suffer from a diagnosable mental disorder. The U.S. prison population, at least as measured by looking at its largest component, the state prison population, experiences a prevalence of mental illness very much in line with that of the general population. Beck and Maruschak reported in Mental Health Treatment in State Prisons, 2000 (Bureau of Justice Statistics, July 2001) that the prevalence of mental illness, broadly defined, was between 22% and 24% in the prison population.

Effective Prison Mental Health Services reported in 2004 that, of state public and private prisons, 95% provided some sort of mental health services to their inmates, with 84% providing professional therapy or counseling. Most (78%) screened newly arrived inmates for mental problems.

Prisoner Characteristics

The most recent comprehensive survey of the prison population's mental health was issued in 1999 (Mental Health and Treatment of Inmates and Probationers, BJS, July 1999). It was based on the 1997 Survey of Inmates in State and Federal Correctional Facilities, the 1996 Survey of Inmates in Local Jails, and the 1995 Survey of Adults on Probation. Although the data are now aging, they bring into focus the differences between prison inmates with mental problems and those who do not have them.

A higher percentage of women were identified as mentally ill than men in 1998: 23.6% in state prisons and 12.5% in federal prisons. This contrasts with men, of whom 15.8% (state) and 7% (federal) were mentally ill. Some 22.6% of whites in state prisons and 11.8% in federal facilities were mentally ill. Among African-American prisoners, the prevalence was lower, 13.5% (state) and 5.6% (federal). Hispanics had the lowest rates: 11% in state and 4.1% in federal facilities. (See Table 6.13.)

Guidelines for Treating the Mentally Ill in Prison

The National Commission on Correctional Health Care (http://www.ncchc.org/) has issued guidelines that prisons should follow to provide adequate mental health treatment to inmates:

• Inmates must be screened for mental health problems by a qualified health professional within two hours of admission.
• Inmates must be informed within twenty-four hours of arrival of the types of mental health services available and how to access them.
• Inmates must have a health appraisal within seven days of arrival that includes taking a history of any prior mental health problems, hospitalizations, psychotropic medications, suicide attempts, and alcohol and other drug abuse.

• Inmates must receive a mental health evaluation within fourteen days of arrival that includes a complete mental health history and current mental status and screening for mental retardation and other developmental disabilities.
• Treatment plans must be created for inmates who are identified as having serious mental health needs and who are developmentally disabled.
• Inmates should be seen by a qualified professional within forty-eight hours of a request for nonemergency mental health services (seventy-two hours on a weekend).
• Prison procedures must address psychiatric emergencies and suicide attempts.
• Mental health treatment should occur in private (except for high security risks) and with respect for the offender's dignity and feelings.

Suicide in Prison

Broadly defined, mental illness is a leading cause of suicide in prison. According to Juvenile Suicide in Confinement: A National Survey (Washington, DC: National Center on Institutions and Alternatives, February 2004), there were 110 juvenile suicides in confinement between 1995 and 1999. These deaths occurred in training schools, detention centers, and residential treatment centers, among other correctional facilities. The study found that "a history of mental illness was found in 65.8% of the victims, with the vast majority (65.3%) suffering from depression at the time of their deaths."

Suicide among adult inmates in prison is also an unfortunately common occurrence. Prison Suicide: An Overview and Guide to Prevention (Washington, DC: National Institute of Corrections, June 1995) contains a report on a ten-year survey of prison suicides conducted by the National Center on Institutions and Alternatives (NCIA) from 1984 through 1993. This survey found that prisoners committed suicide at a much higher rate than does the general population. During the ten-year period, prison suicides occurred at a rate of twenty-one per 100,000 inmates per year, while suicides in jails occurred at the rate of 107 per 100,000 inmates. The rate of suicide in the general population during this period was 12.2 per 100,000. The study did find that prison suicide rates

declined from 1985 through 1993. In 1995 state prisons reported 160 inmate suicides; the number in 2002 was 166. In federal prisons, the number for 2001 was eighteen suicides; in 2002 it was seventeen.

Methods of preventing suicide in prison have been advanced by several organizations. The American Correctional Association (ACA) has developed suicide prevention standards that are now used in many prisons across the country:

• A written policy and procedures to ensure that all special management inmates are directly observed at least every thirty minutes.
• More frequent observation for inmates who are violent or have a mental illness than for inmates who are not violent and do not have mental illness.
• Continual observation for actively suicidal inmates.
• A written suicide prevention and intervention program approved by a qualified medical or mental health professional.
• Training for all correctional staff in the suicide prevention and intervention program.
• Intake screening, identification, and supervision of inmates who may be prone to suicide.

INJURIES IN PRISON

Data on injuries suffered by prisoners, whether in accidents or in fights, also date back to the 1997 survey of state and federal prisons. BJS has not published any new data since Medical Problems of Inmates, 1997, a report by Laura M. Maruschak and Allen J. Beck that was published in January 2001. The 1997 BJS data includes statistics on injuries and is based on prisoner reporting. In the report, Maruschak and Beck present statistics on prison inmates who reported injuries by time served in months. Both accidental injuries and injuries sustained in fights are reported.

Medical Problems of Inmates, 1997 indicates that 13.2% of state prisoners and 17% of federal prisoners, both with less than twelve months of time served, had suffered injuries. Of these, 2.9% of state and 0.8% of federal prisoners reported being injured in fights, while 10.2% of state and 15.6% of federal prisoners were injured in accidents in this group. Prisoners who had served twelve to twenty-three months had higher

incidence of injury: 19.8% of state prisoners and 22% of federal inmates reported an injury since admission. The longer prisoners serve, the higher the percentage of those injured. The survey format used by the BJS researchers produces what amounts to a cumulative measure of injury over time. (See Table 6.14.)

RAPE IN PRISONS

In September 2003 President George W. Bush signed into law the Prison Rape Elimination Act. This act mandates that the Bureau of Justice Statistics begin a comprehensive program to monitor the prevalence of rape in prisons and develop a set of guidelines to reduce such crimes. While the problem is acknowledged to be a major one, few studies have been conducted on the subject of rape in prison, and those have been typically small in scale and limited in scope. Victims of same-sex rape are often reluctant to discuss the event with authorities. Inmates attacked by guards often fear retribution if they speak of the matter. The Prison Rape Elimination Act was instituted to get accurate numbers from which effective measures can be determined. Under the act's provisions, those prisons with both the highest and lowest rates of sexual assault will be studied to determine what measures have been the least and most effective in preventing such crimes.

According to Data Collections for the Prison Rape Elimination Act of 2003 (Bureau of Justice Statistics, June 2004), the primary objectives of the bureau's data collection are to determine:

• The number of reported incidents of inmate-on-inmate sexual violence and staff-on-inmate sexual misconduct, by gender
• How prison systems and facilities record these incidents (e.g., in disciplinary, grievance, investigative, or medical files)
• What information is recorded (e.g., allegations, confirmed incidents, only incidents involving serious bodily harm, or threats)
• Where the incidents occur (e.g., in the victim's cell/room, in a common area, or outside of the facility)
• What additional data are available (for purposes of administrative collections in future years)

REDUCING THE COST AND IMPROVING THE
AVAILABILITY OF TREATMENT

Telecommunications links make it possible for physicians and other health care specialists to evaluate and treat patients who are hundreds or thousands of miles away. This technology, called telemedicine, offers the prospect of providing prisoners with cost-effective health care. For example, telemedicine makes it possible for

physicians to examine prisoners without the inconvenience of traveling to prison facilities, often located in remote or isolated areas. Likewise, the cost and security concerns of transporting prisoners to physicians are also eliminated.

In "Can Telemedicine Reduce Spending and Improve Health Care?" (National Institute of Justice Journal, April 1999), authors Douglas McDonald, Andrea Hassol, and Kenneth Carlson reported on a demonstration program to evaluate a telemedicine system in prison. The pilot project was conducted jointly at four federal prisons:

• U.S. Penitentiary, Lewisburg, PA. Maximum security. Houses an average of 1,300 male prisoners
• U.S. Penitentiary, Allenwood, PA. Maximum security. Houses an average of 1,000 male prisoners
• Federal Correction Institution, Allenwood, PA. Low and medium security. Houses an average of 1,100 male prisoners
• Federal Medical Center, Lexington, KY. Medium and minimum security. Houses an average of 1,450 mostly male prisoners with chronic illnesses

The pilot program was conducted from September 1996 to December 1997. It did not replace routine medical care provided by prison staff. As reported, the goal of the telemedicine test program was to reduce three types of care:

• Consultations with specialty physicians who would normally visit the prison
• Prisoner trips to hospitals or off-site physicians
• Transfers of prisoners to federal medical centers for intensive or long-term treatment

At each prison a dedicated telemedicine room was equipped with interactive video-conferencing equipment, specialized medical cameras, an electronic stethoscope, and a computer workstation with appropriate software. For most examinations a medical staff member from the prison (usually a physician's assistant) presented the inmate patient to an off-site specialist linked via video-conferencing and equipped with remote controls that enabled the specialist to manipulate cameras located in the patient examination room.

During the fifteen months of the demonstration project, physicians made approximately one hundred telemedicine consultations each month, for a total of 1,321 consultations. About 58% of the telemedicine "visits" were for psychiatric consultations, followed by dermatology (13.3%), orthopedics (10.7%), dietary (6.4%), and podiatry (4.7%). The remaining 6.5% of telemedicine consultations were with specialists from other disciplines, including infectious diseases, cardiology, and neurology.

Four specialties were selected for purposes of comparing conventional medical care in prisons with telemedicine consultations—psychiatry, orthopedics, dermatology, and cardiology. Specialists in these four fields were among the most frequently consulted prior to the pilot project, and that frequently increased with the implementation of telemedicine.

During the pilot program, the cost of in-prison consultations decreased from approximately $108 per conventional consultation to $71 per telemedicine consultation, a savings of $37 per consultation. However, because there was not a one-for-one substitution of regular consultations and telemedicine consultations, the total number of consultations increased with the addition of telemedicine.

Some thirty-five trips for inmates to visit specialists outside of prison were eliminated through telemedicine for a total savings of about $27,500. Some trips were unavoidable when inmates required invasive tests, surgery, or intensive trauma care. The Bureau of Prisons estimated that it saved an additional $59,134 because, in certain cases, telemedicine eliminated the need for air transfers of inmates to federal medical centers. Most of the averted air transfers were for psychiatric patients who required intensive monitoring that was made possible through telemedicine consultations.

There were other nonfinancial benefits to the implementation of telemedicine consultations. Waiting time to see specialists decreased and new services became available, including more specialized HIV/AIDS care. Also, inmate patients reported feeling that the quality of care improved with telemedicine.

As a result of the success of this pilot program, the National Institute of Justice (NIJ) began studies using telemedicine in jails. It also funds a program to inform corrections staff of the benefits of telemedicine and to help prison administrators decide if telemedicine will succeed at their facilities. Some of the points to consider are space constraints and access to nearby medical centers. In addition, the program suggests ways to develop and launch prison telemedicine systems. Designing such systems is discussed in Implementing Telemedicine in Correctional Facilities by Peter L. Nacci and others (Washington, DC: U.S. Department of Justice and U.S. Department of Defense, May 2002).

One of the new systems implemented in 2003 involves the University of Texas Medical Branch (UTMB) and the Federal Medical Center in Lexington, Kentucky. Under the telemedicine agreement, medical specialists in Galveston treat inmates in Lexington nearly 1,000 miles away. Among the specialties offered are orthopedics and urology.