HEALTH CARE
IN NEW YORK STATE PRISONS

A REPORT OF FINDINGS AND RECOMMENDATIONS
BY THE PRISON VISITING COMMITTEE
OF THE CORRECTIONAL ASSOCIATION OF NEW YORK

February 2000

The Correctional Association of New York

“Because the dangers of abuse inherent in the penitentiary are always present, the work
of the Correctional Association—an organization of knowledgeable experts unaffected
by political forces—is so important.”
—Judge Morris E. Lasker
(Former U.S. District Court Judge for the
Southern District of NewYork)
Founded in 1844, The Correctional Association of New York is a nonprofit policy
analysis, research and advocacy organization that focuses on criminal justice issues. It is the
only independent organization in New York State with legislative authority to inspect
conditions in state prisons and report its findings to policy makers and the public. Because
prisons are hidden from public view and prisoners themselves are among society’s least
powerful citizens, continual scrutiny of conditions is critical.
The Correctional Association’s Prison Visiting Committee monitors prison conditions,
conducts research, identifies problems and works with New York State Department of
Correctional Services officials to formulate workable solutions. Most recently, the Prison
Visiting Committee successfully advocated for the construction of an expanded visiting room
for inmates at Greene Correctional Facility; a statewide policy ensuring that inmate-patients
are informed of medical test results, normal and abnormal; and special training for Fishkill
correction officers who oversee inmates on psychotropic medication.
Research findings and recommendations for policy change are distributed to
legislators, the public and the media to better serve the needs of inmates, correction staff and
society at large.
Copyright © 1999, The Correctional Association of New York
All Rights Reserved
The Correctional Association of New York
135 East 15th Street
New York, NY 10003
(212) 254-5700/Phone
(212) 473-2807/Fax
E-mail to: jwynn@corrassoc.org

2

CONTENTS
EXECUTIVE SUMMARY: Key Findings and Recommendations

5

ACKNOWLEDGMENTS

12

INTRODUCTION
Background of the Study
Research Methods
How the State System Works
Portrait of the Inmate-Patient
Cost of Inmate Health Care

13
16
17
20
22
24

RECENT ACHIEVEMENTS
Decline in AIDS-Related Deaths
Construction of Regional Medical Units and Renovation of Clinics
Management of Tuberculosis
Development of Policy for Communicating Medical Test Results

26
27
27
28
29

SYSTEMIC PROBLEMS
External Oversight
Quality Assurance
Access to Specialty Care
Sick Call
Rates of Pay and Staffing
Qualifications and Leadership of Doctors
Clinical Management of HIV/AIDS
HIV Education and Prevention
Care of the Chronically Ill
Patient Confidentiality
Language and Cultural Barriers

30
30
32
34
37
38
41
43
45
46
47
49

MODEL PRACTICES
Grievance Reduction Strategy at Sullivan Correctional Facility
Medical Services at Coxsackie Regional Medical Unit
Management of HIV/AIDS at Wende Correctional Facility
Responsive Leadership at Beacon Correctional Facility
Seizure Training for Correction Officers at Albion Correctional Facility
Medical Services at Bedford Hills Correctional Facility

51
51
52
54
55
56
56

3

MEDICAL SERVICES IN WOMEN'S PRISONS
Special Needs of Female Patients
Areas of Improvement
Persistent Problems

58
58
61
61

FUTURE CONCERNS
Hepatitis C
An Aging Population

65
65
67

RECOMMENDATIONS
69
1. Increase External Oversight
69
2. Strengthen Quality Assurance Mechanisms
70
3. Increase Salaries of Medical Staff
71
4. Raise Qualifications of Physicians
71
5. Stop Subsidizing Inmate Health Care with Family Benefit Fund Monies 72
6. Broaden and Expedite Recruitment
73
7. Augment Training of Medical Staff
74
8. Expand HIV/AIDS Testing, Tracking, Education and Prevention
74
9. Expedite Computerization of Medical Records System
75
10. Improve Care of the Chronically Ill
76
11. Respect Physician-Patient Confidentiality
77
12. Increase Language Translation Services
78
13. Supplement Social Services for Female Inmates
78
14. Address Long-Term Health Needs in Discharge Planning
79
15. Take More Proactive Steps to Manage Hepatitis C
80
16. Provide Alternatives to Incarceration for Elderly Prisoners
80

REFERENCES

82

4

EXECUTIVE SUMMARY

In 1997, the Correctional Association initiated an in-depth study of the
quality of health care in New York State prisons. Over 18 months, members of the
Prison Visiting Committee made 25 site visits to 22 prisons representing all levels
of security and including both men’s and women’s facilities. Interviews were
conducted with over 1,300 inmates, approximately 100 prison medical personnel,
several former New York State prison physicians, as well as lawyers and experts in
correctional health care. Findings from the research revealed a mixed picture:
Significant improvements have been made in recent years, in some cases
producing dramatic results; however, systemic problems continue to compromise
the delivery of prisoner health care.
Recent Achievements
Given the size of the inmate population—over 71,000 prisoners in 70
correctional facilities throughout the state—and the significant number of inmates
who suffer from serious illnesses, the Department of Correctional Services
(DOCS) deserves recognition for the following:
•

The number of annual AIDS-related deaths plummeted 85% in three
years, from 258 deaths in 1995 to 39 in 1998.

•

The HIV/AIDS portion of the health care budget increased 66%—from
$38 million in 1995 to $63 million in 1999. During the same period, the
Department’s overall operating budget rose only 15%.

•

An expanded (voluntary) HIV testing program enabled 25,000 inmates to
receive anonymous HIV tests and counseling in 1998.

•

Aggressive testing and treatment of tuberculosis—for which DOCS
received national recognition—yielded a 66% decline in the number of
inmates with active TB infection, from 82 in 1994 to 28 in 1998.

•

Four of five planned Regional Medical Units (similar to hospitals or
nursing homes in the community) have been opened for inmates with
terminal illnesses or serious, chronic medical conditions. The units replace
more expensive hospital beds in the community and provide a range of
outpatient specialty clinics for inmates from nearby prisons.

•

Proactive superintendents and medical staff in some state prisons have
developed model health care procedures. These efforts are described in
the report for possible replication in other NYS prisons.

Systemic Problems
In New York, the challenge of providing health care to an inmate
population as large as a mid-sized city is made more difficult by systemic
problems that will require budgetary change, union negotiation and legislative
oversight to overcome. These problems include:
•

Little external oversight. Unlike hospitals and clinics in the community,
prison hospitals are not overseen and regulated by the New York State
Department of Health. Essentially, prison health care workers are
accountable only to prison authorities.

•

Lack of a uniform, statewide quality assurance program. Inmate health
care varies greatly among state prisons because no meaningful, coordinated
quality control program exists.

•

Non-competitive salaries. Medical personnel in prison are compensated
far below their community counterparts. This disparity has a snowball
effect: It creates problems with recruitment and leads to attrition, which
together result in long-term, hard-to-fill vacancies. Too often, the
Department relies on physicians whose qualifications are questionable and
for whom DOCS may be the employer of last resort.

•

Under-qualified doctors. Neither DOCS nor the Department of Civil
Service (the agency that sets the rates of pay and hiring standards for state
employees) requires prison physicians to be Board-certified, or even

6

Board-eligible. In addition, the majority of prison doctors interviewed in
the study lacked experience as general practitioners, training in primary
care and the leadership skills necessary to manage a busy prison clinic.
•

Unevenness in the care of inmates with HIV/AIDS. The New York State
prison system has the highest percentage of HIV+ inmates than any other
state prison system in the country. Yet, site visits to 22 prisons revealed
uneven care, medical staff who lacked basic knowledge of HIV/AIDS, and
inmates who reported they had “no idea how to get an AIDS test.” At only
two facilities did there appear to be any adherence tracking of inmates
taking complicated "drug cocktails." Non-adherence to prescribed
treatment regimens, which require frequent adjustment and continual
monitoring, can easily cause drug-resistant strains of HIV to emerge.

•

Use of Phone Company Commissions to Subsidize Health Care. Since
1995, DOCS has used over $50 million in commissions, or "kickbacks," it
receives from phone companies awarded lucrative prison phone contracts
to subsidize inmate health care. The problem is that these subsidies to
inmate health care are paid for by the recipients of prisoner phone calls,
typically friends and family members who live in New York's poorest
neighborhoods, who are charged over $1.00 per minute for collect calls
from prisoners.

•

Inadequate services for Spanish-speaking inmates. There are over 7,000
Spanish-dominant inmates in the New York State prison system.
Researchers received many reports of Spanish-speaking inmates who were
given medical information they did not understand, drug prescriptions they
could not read and substandard health care due to the lack of Spanishspeaking medical staff.

•

Insufficient discharge planning. Each year, the Department releases
approximately 30,000 inmates into the community. With the exception of
HIV+ inmates, who receive a month’s supply of medication prior to
release, the majority of inmates leave prison with little money and no
access to health care in the community. For elderly inmates and those with

7

chronic conditions such as mental illness, heart disease or hepatitis, the 45day wait for Medicaid poses serious problems to their well being and to the
public health and safety of the community.
Recommendations
The improvements the Department has made in recent years indicate that
change is possible. The following recommendations can serve as a blueprint for
rectifying remaining deficiencies in the inmate health care system.
•

Increase external oversight and accountability. Far too many taxpayer
dollars are spent on health care within prison walls ($175 million in FY
1998-1999) for there not to be external review and higher standards of
accountability. The Correctional Association urges the Governor and State
Legislature to appoint and fund an oversight committee charged with
assuring quality health care in state prisons. Such a committee might
include correctional health care experts and practitioners, individuals with
public policy, public health and fiscal management experience, the
Commissioner and chief medical officer of DOCS, and senior Department
of Health officials. The committee would monitor the quality of medical
services in state prisons and have the authority to direct facility-level and
system-wide change. It would report its findings and recommendations
annually to state officials and the public.

•

Strengthen quality assurance mechanisms. A detailed quality assurance
protocol, similar to those used in hospitals in the community, should be
developed and articulated by the Department’s chief medical officer,
carried out by facility health services directors and evaluated regularly by
regional medical directors.

•

Increase salaries of medical staff. The quality of health care in prison will
remain as is unless the Governor and State Legislature increase the salaries
of medical staff to make them commensurate with community rates of pay.

8

The rates of compensation among regional medical directors, facility health
services directors and prison physicians must also be stratified so that there
are incentives to advance and retention of valuable physicians improves.
Because of noncompetitive salaries, the Department’s efforts to recruit
qualified health care providers are limited.
•

Raise qualifications of physicians. The Department of Civil Service and
DOCS should require higher qualifications for facility health services
directors and for prison physicians generally. A minimum standard of
Board eligibility (which requires completion of an approved residency
training) and a preference for Board certification in internal medicine or
primary care should be endorsed.

•

Augment training of medical staff. DOCS, the Department of Health, the
State University of New York and teaching hospitals throughout the state
should administer and require training for prison health care providers in
the clinical management of HIV/AIDS, hepatitis C, and addressing the
psychosocial needs of inmate-patients.

•

Expand HIV/AIDS testing, tracking, education and prevention. Every
inmate should be encouraged to take an HIV test throughout the period of
confinement. Inmates who are diagnosed HIV+ should be strongly
encouraged to begin life-prolonging treatment and counseled on dosage
information and side effects. It is also essential that an HIV-experienced
physician direct treatment for HIV/AIDS, since complicated anti-retroviral
regimens must be tailored to individual patients and knowledge in the field
is advancing rapidly. In addition, the use of peer educators should be
expanded throughout the system. Finally, the Department should follow
other correctional systems in preventing contagion by making condoms
available.

•

Increase language translation services. Written and oral instructions
should be provided with all new prescriptions and made readily available in
Spanish when needed. At least one member of the medical staff, and more
in facilities with high percentages of Spanish-dominant inmates, should be

9

fluent in Spanish. The Department should also make more use of AT&T’s
telephone interpretation service, which provides translation in 17 languages
and is currently used by reception staff at Downstate Correctional Facility.
•

Address inmates’ long-term health needs in discharge planning. The
appropriate federal, state and city agencies should work together to ensure
that at-risk inmates—particularly the elderly and those suffering from
chronic illnesses—have access to health care in the community upon
release and until Medicaid coverage is available.

•

Take more proactive steps to manage hepatitis C. Recent prevalence
studies indicate that 40% of state prisoners nationwide may be infected
with hepatitis C, a long-term disease that is easy to transmit and difficult to
treat. DOCS should work with the Department of Health and the Center for
Disease Control to expand testing, explore treatment options and provide
preventive information to inmates and correction staff throughout the
system.

•

Expand social services for female inmates. Given the higher rates of HIV
infection, substance abuse, sexual abuse and clinical depression among
female prisoners, DOCS and the Office of Mental Health should expand
social services in women’s prisons. In addition, a family reunion program
should be opened at Albion Correctional Facility (the state’s largest and
most remote prison for women) so that female inmates can better cope with
separation from their children and strengthen important family ties prior to
release.

•

Stop subsidizing health care with Family Benefit Fund monies. The
Department’s practice of charging exorbitant fees to the recipients of
inmate phone calls in order to subsidize health care should be ended.
Because inmates have no way of obtaining medical services on their own,
the cost of inmate health care is clearly a state responsibility. The
Department should solicit bids for new telephone contracts that offer no
"kickbacks" to the state and more affordable rates.

10

•

Expedite computerization of medical records system. While some states
are experimenting with such innovations as inmate “smart cards” that store
a patient’s entire medical history and future appointments on a memory
chip, many New York prison clinics still operate with manual appointment
logs. State budget officials should allocate the funding necessary to
complete the computerization of the Department’s medical records system.

•

Improve care of the chronically ill. Inmates suffering from chronic
illnesses such as HIV/AIDS, heart disease, diabetes and asthma are
insufficiently monitored by prison health care providers. Important followup appointments are often missed because no single doctor examines and
treats the same patient regularly. The Department should formalize and
expand its pilot practice of assigning inmate-patients with chronic
conditions to a single primary care physician. These physicians oversee and
coordinate complicated medical services, and monitor adherence and
response to medication during the inmate's stay the facility.

•

Provide alternatives to incarceration for elderly prisoners. The cost of
health care for geriatric inmates is triple that of younger inmates. In
addition, the propensity for criminal behavior wanes significantly with age.
New York lawmakers should follow other states in offering geriatric parole
and electronic detention for elderly inmates who no longer pose a threat to
society.

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ACKNOWLEDGMENTS
This report is the result of prison visits, interviews and research conducted
by the Prison Visiting Committee of the Correctional Association of New York.
Numerous people contributed to the effort. Jennifer R. Wynn, director of the
Prison Visiting Project, served as principal author of the report. Robert Gangi,
executive director of the Correctional Association, and Ralph S. Brown, Jr.,
chairman of the Prison Visiting Committee, guided the project from inception to
completion. Gail Goodman, former director of the Prison Visiting Project, played a
key role in developing and initiating the research. Mishi Faruqee, director of the
Women in Prison Project, wrote the section on health care for female prisoners.
The following members of the Prison Visiting Committee volunteered
many hours of their time conducting research in prisons, writing reports of
observations and helping to shape the report that follows: Heather Barr, Safiya
Bandele, Michael Cuenca, M.D., Betty and Rudy Cypser, William J. Dean, Nancy
Duggan, Ph.D., Lourdes Falco, Carol Ferry, Barrett B. Frelinghuysen, Gail
Goodman, Clay Hiles, Marcia Hurst, William Marino, M.D., Cara Marshall, M.D.,
Anthony Ortiz, Elizabeth Osborne, Barbara Lee Perlmutter, M.D., John S.
Prescott, Jr., Marjorie Schlitt, James Silbert, Barbara Stanton, Colin Starger and
Ethel Virga. The Committee is grateful to Drs. Nereida Ferran, Peter Meacher and
Esther Schumann, whose knowledge of correctional health care and compassion
for inmate-patients informed and inspired our work.
Glenn S. Goord, Commissioner of the New York State Department of
Correctional Services, and Lester Wright, M.D., Associate Commissioner and
Chief Medical Officer, cooperated fully with the gathering of information for this
report. Members of the Department’s Counsel’s Office, in particular Donald
Matusik, former Assistant Counsel, are acknowledged for their efficiency and
graciousness in arranging prison visits. The Visiting Committee also extends its
appreciation to the many superintendents, medical personnel and correction staff
who were consistently courteous and accommodating during prison inspections.
The work of the Prison Visiting Project is made possible through the
generous support of the Irene Diamond Fund, the Pforzheimer Foundation and the
Prospect Hill Foundation.

12

INTRODUCTION

“Felons are sentenced to prison as punishment, not for punishment. Once they are
incarcerated, we are obligated to provide them with medical care that is the
equivalent of that found in the community.”
—Governor George E. Pataki,
in DOCS Today, October 1998 edition
Inherent in the nature of confinement is that prisoners cannot obtain
medical services on their own. Along with food and shelter, health care is a
component of prison life that inmates must rely on correction officials to provide.
Prisoners’ loss of liberty is essentially a loss of choice: Inmates cannot choose the
physicians who treat them or the types of medical services they receive. All
inmates can be denied medical treatment that prison officials deem unnecessary,
and some inmates can be medicated against their will if prison authorities consider
it necessary.∗ It is only ethical, then, that the state ensures access to health care,
and that inadequate treatment is never a condition of punishment.
The delivery of health care in correctional settings is fraught with
challenges. Correctional health care workers must contend not only with the
grimness of the prison environment, but the inconveniences of practicing medicine
in locked institutions governed by strict security procedures. In addition, prisons
are rarely located near major cities, and inmate-patients generally have far greater
physical and psychological needs than non-confined patients. Fundamentally, the
difficulty of providing health care in prison can be traced to the profound
differences in the purposes, training and clients of the medical and correction
professions. For example, doctors are called upon to treat and to heal a largely lawabiding population. Correction officials are called upon to maintain and confine
∗

Washington v. Harper, 494 U.S. 210, 227 (1990). The Supreme Court held that: "Given the
requirements of the prison environment, the Due Process Clause permits a State to treat a prison
inmate who has serious mental illness with anti-psychotic drugs against his will, if the inmate is
dangerous to himself or to others and the treatment is in the inmate's medical interest."

13

convicted felons. Good medical practice encourages informed choice and taking
responsibility for one’s health. Correctional practice—the very nature of
incarceration—restricts free will and choice. Training in the medical community is
based on academic study and clinical treatment. Training in the correction
profession is based on security practices and paramilitary protocol. A physician’s
highest obligation is to the patient. A correction officer’s highest obligation is to
society.
To many people, prisoners represent a hidden population. Locked away in
distant correctional facilities, prisoners are easily and often forgotten. Yet the
average length of stay for New York prisoners is 27 months, and the Department
of Correctional Services (DOCS) releases nearly 30,000 inmates annually. When
prisoners return to society, the health care they received while confined will affect
the public health of the community at large. For example, every inmate who enters
prison HIV+, or who becomes HIV+ during incarceration and remains
undiagnosed, returns to the community posing a threat to public health. For as
many years as the disease goes unnoticed, it also goes untreated. If life-prolonging
HIV medications are not administered in prison, then local communities must pay
for the ex-offender’s more advanced and costly medical needs upon release. On
the other hand, if an inmate is tested, counseled and treated while in prison, and
arrangements are made before he leaves to see a doctor in the community and
continue his medical treatments, significant personal and public health costs are
avoided.
Incarceration presents an opportunity for correctional health care workers
to test, treat and educate a population that suffers disproportionately from a host of
medical problems. Countless studies show that the majority of inmates come from
medically underserved communities plagued by high rates of disease and low rates
of immunization. Compared to their counterparts in the community, they have less
access to health care, are more likely to be victims of violence and abuse, and

14

engage more frequently in high-risk behaviors. In the New York State prison
system, for example:
•

Approximately 7,500 inmates (over 10% of the prison population) are HIV+;

•

25% of prisoners entering the system are infected with tuberculosis;

•

Nearly 70% of male inmates, and over 80% of female inmates, are selfreported substance abusers; and

•

15% of all state inmates have been diagnosed by the New York State Office of
Mental Health as “significantly, seriously or persistently” mentally ill.
In addition to the moral and public health reasons for providing prisoners

with adequate medical services, there is also a legal requirement. The U.S.
Supreme Court ruled in 1976 that prisoners have a constitutional right to health
care that people on the outside do not have. The landmark case, Estelle v. Gamble,
established that deliberate indifference to inmates’ serious medical needs
constitutes cruel and unusual punishment, and therefore is a violation of the Eighth
Amendment. In Estelle, the Supreme Court noted:
The government [has an] obligation to provide medical care for
those whom it is punishing by incarceration. An inmate must
rely on prison authorities to treat his medical needs. It is but just
that the public be required to care for the prisoner, who cannot,
by reason of the deprivation of his liberty, care for himself.
As a result of Estelle and subsequent rulings, health care in American
prisons and jails improved dramatically. Court intervention—or the fear of court
intervention—provided a catalyst for improving correctional health care across the
country. Indeed, it was court intervention in the late 1970s that prompted health
care reforms in New York’s Bedford Hills and Green Haven correctional facilities,
the former of which is recognized in this report for its model practices. However,
there is yet to be a single federal court decision applicable to all prisoners in all
states that outlines the specific medical services that must be provided. Another
problem is that in 1991 the Supreme Court restricted Estelle's rulings in Wilson v.
15

Seiter, essentially making it more difficult for inmates to successfully challenge
inadequate medical services. In order to demonstrate “deliberate indifference,”
inmate-plaintiffs must show that correction officials intended to cause the alleged
inadequate health care. This narrowed standard is much more difficult to meet.
Ultimately, the tremendous responsibility of providing adequate prisoner
health care rests with individual state governors and legislators. Only they can
ensure that necessary budget appropriations are made and sufficient oversight
exists. This effort demands wisdom and compassion from all New Yorkers, and
the recognition that public health is threatened when we forfeit our constitutional
and humanitarian imperatives to care for the sickest and least powerful among us.
Background of the Study
In the approximately 1,000 letters and phone calls the Correctional
Association receives each year from prisoners, their family members and lawyers,
inadequate health care is the single most common complaint. During prison
inspections, inmates typically identify medical services as the area most in need of
reform. Anecdotal evidence reported to the Correctional Association is consistent
with findings and observations from other organizations that have examined health
care in New York State prisons over the past decade.
An audit of DOCS’ health care system conducted by the Department of
Health in 1993 revealed weaknesses in quality assurance, the testing and treatment
of inmates with HIV/AIDS and access to specialty care. In 1990, the Legal Aid
Society filed a class action suit (currently in the later stages of discovery) against
DOCS for the substandard treatment of inmates with chronic illnesses, particularly
those with HIV/AIDS. Reports critical of the Department’s health services were
issued by The New York State AIDS Advisory Council’s Subcommittee on
Criminal Justice in 1989 and again in 1998. Members of the New York State
Assembly introduced a bill in July 1999 calling for Department of Health oversight

16

of health care in state prisons. Most recently, the Office of the State Comptroller
initiated an audit of the Department’s health care system, the findings of which
will be published in early 2000. According to a Comptroller’s Office
representative, “Health care in state prisons has been identified as a high-risk
area.” In other words, this office of state government determined that prison health
care likely involves some waste of taxpayer dollars.
To better understand the concerns of inmate-patients and the quality of care
they receive, the Prison Visiting Project launched an in-depth study of health care
in New York State prisons in 1997.
Research Methods
Members of the Prison Visiting Committee conducted a total of 25 site
visits to 22 state correctional facilities, three of which included Regional Medical
Units (RMUs)—secure hospital-like settings for chronically ill inmates. The
sample of prisons was designed to represent all levels of security, a range in
population size and both male and female institutions. Specific prisons were
identified to support or reject anecdotal evidence alleging inadequate health care.
Correctional facilities visited by the Committee are listed on the following page.

17

Correctional Facility

Security Level

Population

Albion*

Medium

1268

Arthur Kill

Medium

978

Attica

Maximum

Bayview*

Medium

175

Beacon*

Minimum

228

Bedford Hills*

Maximum

792

Coxsackie

Maximum

1067

Coxsackie RMU

Maximum

60

Downstate

Maximum

1384

Eastern

Medium

1199

Elmira

Maximum

1813

Fishkill

Medium

2103

Great Meadow

Maximum

1668

Greene

Medium

1610

Green Haven

Maximum

2159

Marcy

Medium

1469

Orleans

Medium

1300

Southport

Maximum

919

Sullivan

Maximum

810

Walsh RMU

Maximum

112

Wende

Maximum

831

Wende RMU

Maximum

80

* denotes a women’s facility

18

2181

On each visit, researchers included one to three doctors (sometimes
including a former DOCS physician), two paid staff members and up to eight
volunteer citizens with backgrounds in criminal justice, law, psychology, mental
health and public health. The group conducted field research during full-day, onsite visits. Researchers used two questionnaires—one for inmates and one for
medical staff—that were designed by physicians to probe health care policies,
procedures, problems and progress. In addition, the Committee conducted semistructured group interviews at each prison with:
•

all levels of the medical staff;

•

the Inmate Liaison Committee, a leadership group representing the
concerns of prisoners;

•

a small group of self- or facility-selected correction staff; and

•

the superintendent and senior administrators.
Committee members also spoke informally with prisoners over lunch in the

mess hall and during unmonitored conversations in cellblocks, dormitories and
infirmaries. In total, formal and informal interviews were conducted with over
1,300 inmates and approximately 100 prison health care providers.
At each prison, medical staff (sometimes accompanied by officials from
the Department’s Health Services Division) provided tours of the clinic, infirmary,
examination rooms, medical records office and dental area. At prisons with Special
Housing Units (SHUs)—disciplinary cells where prisoners are locked in 23 hours
a day—the Department permitted two Committee members to spend an hour in the
unit, interviewing inmates behind cell bars or metal doors.
Researchers took detailed notes during site visits and submitted reports of
findings to the project director. Additional information was gathered through
interviews with physicians and lawyers specializing in correctional health care,

19

former prison doctors, members of the New York State AIDS Advisory Council’s
Subcommittee on Criminal Justice, the Department’s chief medical officer and
several regional medical directors, as well as recently released ex-offenders. The
Department supplied data when requested and available. A review of the literature
on line and in print was conducted.
With guidance from Committee physicians, the project director analyzed
the data, which were mainly qualitative in nature and collected over an 18-month
period, for system-wide patterns and trends and for similarities and dissimilarities
among individual prisons. Throughout this report, the names of prisons where
substandard practices were observed have been omitted. The Committee reported
this information in writing to the commissioner, chief medical officer and
superintendent after each visit. (Attribution to sources is also omitted throughout
the report to protect privacy and to prevent the possibility of reprisals.) Through an
analysis of the data, a mixed picture of recent and substantial improvements, as
well as systemic problems in need of immediate and sustained attention, emerged.
How the State System Works
New York State—the third largest prison system in the country—has a vast
and complicated health care system that serves over 71,000 inmates in 70
correctional facilities across the state. In 1998, medical staff saw over one million
inmate-patients and provided nearly two million “medication call-outs.” Three
large state agencies (the Department of Health, the Office of Mental Health, and
the Office of Alcohol and Substance Abuse Services) each play a role in prisoner
health care; however, primary and routine health care is provided mainly by
DOCS’ medical staff, which is comprised of approximately 1,500 employees.
Acute care and specialty care are provided by outside contractors to DOCS, such
as Albany Medical Center, under coordinated specialty care contracts. HIV/AIDS
services are provided by personnel employed by DOCS, by the Department of

20

Health’s AIDS Institute (AI), or by outside organizations under contract to DOCS
or AI.
All inmates receive a medical evaluation at a reception/classification center
when they enter the system, and another assessment when they arrive at their
assigned prison. At Downstate Correctional Facility, for example, the main
reception/classification center for maximum-security inmates from New York
City, inmates undergo a number of medical tests, including full blood work, chest
x-rays, tuberculosis screening, a dental exam, a liver function test, urinalysis and
hepatitis B screening. HIV tests are not conducted at reception but at the assigned
correctional facility on a voluntary basis. Classification personnel consider
inmates’ medical needs when determining their prison assignment.
Inmates are treated for routine health problems in prison clinics and
infirmaries. Medications are supplied mostly through a formulary (a catalog of
state-approved medications) and, in about 20% of prisons, through outside
contractors. In 1997, the Department introduced telemedicine—interactive
teleconferencing connecting physicians in the prison with community medical
centers. Currently, 27 facilities have telemedicine, which is used on a limited basis
to enhance emergency triage, broaden specialty services and minimize the costs
and security risks of inmate transportation to off-site providers. A pilot program in
teleradiology is under way, whereby x-rays can be read immediately at distant sites
to provide rapid feedback.
The Department’s chief medical officer oversees all aspects of health care
in New York State prisons. Reporting to the chief medical officer are five regional
medical directors and five regional health services administrators, who oversee
care in their designated areas. At each prison, a facility health services director
serves as the prison’s highest medical authority. Facility health services directors
report directly to the superintendent and indirectly to the regional medical director.
They supervise all aspects of inmate health care and medical staff, and are

21

involved in budget decisions, clinic mortality and morbidity reviews, and
scheduling medical coverage.
Portrait of the Inmate-Patient
According to Department figures released in January 1998, approximately
95% of state inmates are male. Fifty percent are black; 33% are Hispanic; 16% are
white. The average age is 33 years. Approximately 68% are from New York City;
13% are foreign-born. The Department classified 10% of state inmates as
“Spanish-dominant,” meaning that Spanish is their primary and preferred
language.
Nearly 65% were classified as never married; 60% have one or more living
children. The median minimum sentence is 48 months, but the average length of
stay is 27 months. A little over half of the inmate population (52.4%) is serving
time for violent offenses. The majority of inmates (69%) served previous jail or
prison terms.
Almost 60% of state inmates do not have a high school diploma or
equivalent degree. Of this 60%, nearly 25% read below the fifth grade level, and
33% read at less than the eighth grade level, the eligibility level required for the
high school equivalency exam. According to the Department’s 1998 report, The
Hub System: Profile of Inmates, “56.7% of the inmates without a high school
diploma needed educational services simply to help them read at the level
necessary to earn a G.E.D.”
As noted previously, inmates suffer disproportionately from a host of
medical conditions. Approximately 9% of the state’s male inmates and 18% of
female inmates are HIV+. Almost 25% of inmates entering the system are infected
with tuberculosis. Fifteen percent have been diagnosed as “significantly, seriously

22

or persistently” mentally ill. Nearly 70% of male inmates and over 80% of female
inmates are self-reported substance abusers.
These data and Visiting Committee interviews with over a thousand
prisoners reveal this composite portrait of the inmate-patient:
He is a male of color in his early 30’s, born and raised in poverty,
unmarried, with children, and lacking a high school diploma. His educational
deficiencies have likely resulted in low-paying or menial jobs. His history of
substance abuse, parental neglect and high-risk behavior has compromised his
physical and mental health as well as his ability to find and keep a job. Chances
are strong that he supported his drug dependence by entering the neighborhood
drug trade, which further exposed him to a life of violence and instability and
prompted his decline into homelessness, joblessness and addiction.
He enters prison in poor health and withdrawing from drugs. Once the
reality of his situation becomes clear, he will likely grow angry at “the system,”
frustrated by the rigidity of prison life and the remoteness of the facility that
confines him, and depressed by the prospects of his life upon release.
In the daily grind of prison life, the clinic may appear as a bright spot, a
place where he will be cared for by nurses rather than confronted by “guards.” Is it
any wonder, then, that he might “play sick call” (inmate jargon for faking illness)
because he is lonely and seeking attention? (More than likely, however, he is
suffering from any of a host of ailments: asthma, diabetes, depression, high blood
pressure, rotting teeth, migraine headaches, hepatitis, cancer or HIV.) Is it any
wonder that his social and coping skills are not as developed as those of his
counterpart from a stable home and community? Is it any wonder that the
abruptness of an overworked nurse—likely untrained in the psychosocial needs of
inmates—is particularly distressing to him?

23

Cost of Inmate Health Care
As in the community, the cost of health care in prison has risen
dramatically over the past decade. According to the National Institute of Justice:
The costs of prison health care have risen faster than other
correctional costs. Upward pressure on spending comes from
several sources: growing numbers of inmates; rising costs of
health care in the larger society upon which offenders rely for
services; the threat of litigation and federal court demands to
improve services; aging inmate populations; and the higher
prevalence of HIV/AIDS, tuberculosis, hepatitis and other
infectious diseases among prison populations.
New York’s mushrooming inmate population, the soaring costs of health
care in the community, and the twin challenges of tuberculosis and HIV/AIDS
have caused the prison health care budget to more than triple in the past 12 years.
In fiscal year 1986-1987, the health care budget was $50 million. By fiscal year
1998-1999, it had risen to $175 million. In keeping with the rate of medical care
increases in the community during the same time period, annual per-prisoner
health care costs nearly doubled from $1,250 in 1986-1987 to $2,465 in 19981999. (The total cost of maintaining a New York State prisoner for one year is
$32,000.)
Notably, the HIV/AIDS portion of the budget has risen by two-thirds in the
past four years alone,∗ from $38 million in fiscal year 1994-1995 to $63 million in
fiscal year 1998-1999. (During the same period, the Department’s overall
operating budget increased by only 15%.) The cost of treating one HIV+ inmate in
1998 was $1,000 a month.
The Department’s increases in health care spending are laudable. However,
it is troubling that DOCS prides itself on the fact that “$41 million of the $200
million in inmate AIDS spending since 1995-1996 has come from the Family

24

Benefit Fund,” as was written in the state-issued magazine, DOCS Today (October,
1998). Actually, a closer look at Department expenditures indicates that the
Department has used over $51 million from the Family Benefit Fund since 19951996 to subsidize inmate health care.
The Family Benefit Fund was created to help the families of inmates
maintain important ties with loved ones behind bars, not to pay for health care—
clearly a state responsibility. It should be noted that DOCS supplements the
Family Benefit Fund, but it does so with monies from commissions (“kickbacks”)
it receives from phone companies for awarding them with lucrative prison phone
contracts. In its current contract with MCI, DOCS receives a 60% commission.
State officials project a telephone commission income of $21.5 million in this
fiscal year alone.
The problem is that it is essentially prisoners’ family members and friends
who pay, not the inmates. Only collect calls are allowed from prison. Recipients of
prisoners’ collect calls are saddled with surcharges and per-minute costs, which
amount to over a dollar per minute for long distance calls. Therefore, it is the
friends and family members of inmates, the majority of whom live in New York
City’s poorest neighborhoods, who are subsidizing inmate health care. A New York
Times editorial (“When Johnny Calls Home, From Prison,” 12/6/99) described the
state’s practice as “cruelly exploitative,” and stressed that “it is wrong to penalize
and profit from the families of inmates.”
The Correctional Association agrees with the Times and other
organizations, such as the AIDS Institute’s Subcommittee on Criminal Justice, that
the practice of using Family Benefit Fund monies for health care is unjust and may
also be illegal. Neither inmates nor their families have any choice in the medical
services they receive or influence over funding decisions. More pertinent is that
funding for inmate health care is clearly a state responsibility.
∗

Coincident with the development of anti-retroviral therapy.
25

RECENT ACHIEVEMENTS

The Department has made a number of system-wide improvements over
recent years, yielding meaningful and in some cases dramatic results. The number
of AIDS-related deaths, for example, has plummeted 85%, and the Department’s
strategies for controlling tuberculosis have gained national recognition. In
addition, DOCS has constructed state-of-the-art Regional Medical Units, which
provide comfortable settings for terminally and chronically ill patients while
reducing statewide costs, and has renovated a number of prison clinics throughout
the state.
Decline in AIDS-Related Deaths
Between 1995 and 1998, the number of annual AIDS-related deaths
dropped from 258 to 39. This 85% reduction was largely due to the state’s
commitment to offering the newest HIV medications (anti-retroviral therapy) to
control HIV infection before more serious symptoms emerge. Health services
officials report that collaboration between DOCS and Department of Health’s
AIDS Institute also contributed to the decrease in AIDS deaths. In 1989, the AIDS
Institute and DOCS initiated a joint project in which DOCS funded positions in the
Institute to form regional teams to provide HIV counseling and testing for inmates
and educational programs for inmates and correction staff. This effort was closely
coordinated by the central offices of both agencies. In 1990, DOCS and DOH
established the Criminal Justice Initiative (CJI), which provides training for inmate
peer educators, anonymous counseling and testing, support services for HIV+
inmates, and transitional planning for parolees.
Currently, approximately 1,400 state inmates have been diagnosed with
AIDS. According to Department officials, approximately 2,800 inmates who are

26

infected with HIV and/or AIDS receive anti-retroviral therapy. Officials report that
they “will spend more money than ever [in 1999] for voluntary inmate HIV
testing, a process that gets inmates into treatment earlier, prolongs their lives and
reduces treatment costs for taxpayers.”
In addition, the Department recently developed courses for registered
nurses to help them identify symptoms associated with HIV infection. With
knowledge of these “triggers,” nurses can recognize opportunistic infections that
might otherwise be discounted as colds or flu.
Construction of Regional Medical Units and Renovation of Clinics
Inmate health care has also improved through the consolidation of medical
services into Regional Medical Units and through major renovations of prison
clinics throughout the state. Regional Medical Units (RMUs) are secure facilities
that provide a range of medical services for inmates who are too ill to be treated in
regular prison infirmaries but who do not require acute care. The units not only
replace more expensive hospital beds in the community for inmates requiring longterm care, but provide specialty clinics for inmates from nearby prisons. RMUs
provide step-down care for inmates returning from a hospital stay, rehabilitation
care, chronic disease care, long-term care and hospice care. Outpatient clinics in
such specialty areas as ophthalmology, infectious disease, endocrinology,
orthopedics, dermatology, gastroenterology, podiatry and urology are offered.
Specialty care is provided by physicians from medical centers such as Albany
Medical Center, SUNY Health and Science Center in Syracuse, and Strong
Memorial Hospital in Rochester.
Four of five planned RMUs have been opened at a total capital cost of $130
million: a 112-bed unit at Walsh, in the central part of the state, in 1993; a 60-bed
unit at Coxsackie, in the eastern part of the state, in 1996; and an 80-bed unit at

27

Wende, in the western region, in 1998. An RMU at Bedford Hills in southern New
York opened in late 1999; a unit at Fishkill is scheduled to open in 2000.
Committee researchers visited three RMUs and were favorably impressed
by the state-of-the-art equipment, the use of telemedicine, the professionalism of
the staff, and the spaciousness and cleanliness of the units. The majority of the
inmate-patients interviewed expressed satisfaction with the care they received.
In addition, DOCS has renovated the majority of prison clinics throughout
the state. Many correctional facilities were built prior to the era of modern
medicine and were unable to accommodate a significantly larger and sicker
population. In fact, the leading recommendation in the Department of Health’s
1993 audit was for DOCS to “modernize the physical plants…so as to provide an
environment conducive to modern medical care.” Auditors noted that such steps
“should be implemented expeditiously,” and it appears that they have been. On the
majority of site visits, Committee physicians noted that physical plants were
consistent with modern infection controls and often compared them favorably to
clinics in the community.
Management of Tuberculosis
Relatively recently, DOCS faced a tuberculosis crisis, as cases of active
infection doubled from 55 per 1,000 inmates in 1989 to 111 per 1,000 just two
years later. Since then, aggressive testing and treatment have dramatically reduced
the number of active cases of tuberculosis. In fact, the number of active cases
declined 66% over four years, from 82 cases in 1994 to 28 cases in 1998. No staff
developed active TB in 1998 and only 10% converted to positive skin tests, for a
conversion rate of .03%. For inmates, the conversion rate to positive was 1.15%.
Both rates are lower than the rate among most community health care workers.

28

The Department’s success in controlling tuberculosis earned it national
recognition. In 1998, a report by the National Institute of Justice stated:
Since 1988, the New York State Department of Health
Bureau of Tuberculosis Control and DOCS have had extensive
and, according to DOH staff, ‘exemplary’ collaborations in
screening, treatment, case management, surveillance, outbreak
investigation, discharge planning education, training of staff and
inmates and technical assistance to staff. Tuberculosis cases
have declined steadily since reaching a peak in 1993. No
tuberculosis outbreaks have occurred in DOCS facilities since
1993.
Currently, the Department mandates annual screening for inmates and
employees and requires inmates taking TB medications to do so under direct
observation. Employees suspected of having TB are prohibited from working.
Inmates suspected of having TB are moved to special negative pressure rooms in
prison infirmaries, where transmission is mitigated and chest x-rays, sputum tests
and treatment are administered. The results of these efforts show that system-wide
strategies and collaboration with DOH can have a measurable impact.
Development of Policy for Communicating Medical Tests Results
A source of frustration inmates reported to the Committee was difficulty in
obtaining results of medical tests. The Correctional Association reported this
concern to the Department’s chief medical officer, and in 1999 a policy was issued
that requires medical staff to notify inmates on a routine basis of results of medical
tests and x-rays. Inmates are now told of positive (abnormal) findings by a licensed
member of medical staff during sick call. Negative (normal) results are reported to
inmates on a written medical slip, signed and dated by a licensed member of the
medical staff.

29

SYSTEMIC PROBLEMS

As previously noted, the Department has improved many aspects of inmate
health care over the past decade—by no means an easy task. With a vast and
complex system, a sicker than average patient population, difficulty recruiting
qualified personnel, and thorny bureaucratic issues to resolve, the Department
deserves praise for the results achieved. However, systemic problems persist and
will be difficult to remedy under current budget and personnel constraints. While
some of the problems observed during site visits in 1997 have since been solved,
others remain and are detailed in the following section. Most appear to stem from a
lack of external oversight and accountability and a lack of internal quality control.
A fundamental problem plaguing the system is non-competitive salaries: DOCS
medical personnel are compensated far below their community counterparts. This
disparity has a snowball effect: It creates problems with recruitment and leads to
attrition, which together result in long-term, hard-to-fill vacancies, and reliance on
health care workers whose qualifications are questionable and for whom DOCS is
sometimes the employer of last resort.
External Oversight
Because inmates cannot choose their health care providers or influence the
medical decisions made in their behalf, the state has a strong ethical obligation to
provide adequate health care and to establish strict standards of review. However,
the delivery of health care in New York State prisons operates virtually free of
external controls. Unlike hospitals and clinics in the community, those on prison
grounds are not overseen and regulated by the Department of Health. Essentially,
prison medical personnel are accountable only to prison authorities.

30

By contrast, hospitals in the community must meet a number of external
standards. Nearly all hospitals are accredited by the Joint Commission on
Accreditation of Health Care Organizations (JCAHO), and patients and physicians
have come to expect that hospitals will maintain their JCAHO accreditation as
evidence of quality care. Moreover, if a patient in the community receives
substandard care, he or she can file a complaint with various oversight agencies,
including the Department of Health. In addition, and perhaps even more important,
community health care providers are driven by external market pressure to
maintain certain standards. The federal government, for example, reimburses
Medicare and Medicaid expenses only to those hospitals with JCAHO
accreditation, so it is rare to find a community hospital that lacks this stamp of
approval. Finally, non-incarcerated patients have some choice in their primary care
provider and can “take their business elsewhere” if they are not satisfied. On the
other hand, incarcerated patients must accept the health care that the state provides
or prove in court through protracted legal battles that prison officials denied them
adequate services.
It is important to note that no law in New York State requires that DOCS
seek or achieve accreditation for inmate medical services. As stated in the 1998
publication, Clinical Practice in Correctional Medicine: “There is no obligation
for correctional facilities to seek accreditation of any kind. Many systems have
nonetheless voluntarily sought American Correctional Association (ACA)
accreditation, and a smaller number have sought National Commission on
Correctional Health Care (NCCHC) or JCAHO accreditation.”
In fact, all of New York State’s 71 correctional facilities have achieved
ACA accreditation, and DOCS is the only correction department in the country to
have earned that status. ACA-accreditation, however, does not guarantee a
consistently high level of care, as was evidenced during prison visits. Committee
physicians identified practices in several prison clinics that violated ACA
standards, such as correction staff involvement in accessing sick call as well as

31

insufficient and/or inaccurate instructions given with prescription drugs. When the
ACA evaluates a facility, its assessment covers the entire spectrum of prison
operations. By contrast, the NCCHC and JCAHO focus exclusively on a facility’s
medical services. Perhaps the best distinction between NCCHC and ACA
standards was made by an employee of the ACA itself: “Our standards are merely
minimal requirements—certainly not measures of excellence.”
Quality Assurance
Quality assurance is a critical component of health care delivery. It is
practiced in a number of ways and evaluated on many different levels. While
external oversight and regular audits by outside agencies are a part of quality
assurance, more important are internal controls and self-assessments including
weekly staff meetings, utilization and morbidity reviews and patient chart
analyses. As a correctional health care expert at Montefiore Medical Center in
New York City explained, “Quality assurance is a process of always looking at
ways to improve the system. Most hospitals have a quality assurance or
Continuous Quality Improvement (CQI) committee that meets weekly, that
collects data regularly and makes decisions based on that data.” In fact, JCAHO
and NCCHC require, as a condition of accreditation, that correctional facilities
have a CQI program in place.
On the majority of prison visits, medical staff’s knowledge of CQI as a
concept, or of actual procedures for assuring quality care in the prison clinic, was
vague. Most described quality assurance as a discrete event that occurred when the
regional medical director visited the prison rather than an ongoing program. When
asked if these visits were random or anticipated, a nurse at one prison aptly replied,
“There are no surprises in prison. Clearances need to be arranged. We always
know when they’re coming.”

32

Health service officials also pointed to regional medical directors as the
guarantors of quality. However, it was clear to that regional medical directors do
not have the necessary staff or resources to spearhead, coordinate and oversee
quality assurance in their prison districts. “Regional medical directors do problem
solving,” said a Legal Aid attorney familiar with prison health care in New York,
“not oversight.” It should be emphasized, however, that the regional medical
directors whom the Committee met seemed knowledgeable about the medical
practices and problems in their designated facilities. They appeared to be
professional and energetic individuals, who are compensated, as discussed later,
far below their level of responsibility.
Quality assurance requires adherence to articulated internal controls and
hands-on leadership from the facility health services director. In both respects,
DOCS’ facilities are generally lacking. For example, a State Comptroller’s Office
audit of medical expenditures at Arthur Kill Correctional Facility released in June
1999 found that the Department had misspent almost $300,000 because of poor
internal controls and lack of oversight. The report states:
Department and Facility managers are responsible for
developing and maintaining a system of internal control to
ensure that medical service expenditures are necessary and
appropriate. We found that while Department and Facility
managers had developed systems to control medical and related
payroll expenditures, they did not properly monitor these
systems to ensure they operated as intended. Consequently, the
Facility incurred and paid unnecessary medical costs totaling
nearly $300,000…
The Comptroller’s office added, “We identified numerous internal control
weaknesses that contributed to these operational deficiencies. We recommend that
internal controls be strengthened and the overpayments be recovered, where
possible.”

33

Illogical employee reporting structures compound the problem of quality
assurance. Health services directors at individual prisons, for example, report to
and are evaluated by the superintendent, meaning that security specialists judge the
decisions and performance of medical doctors. As a superintendent at a maximumsecurity prison stated, “I have no medical training. How can I adequately evaluate
doctors?”
Quality assurance is also compromised by the fact that too many facility
health services directors work part-time and spend substantial amounts of paid
work hours off site on an “on-call” basis. They are therefore not present enough to
monitor staff performance, review and improve procedures, ensure quality or carry
out their leadership functions. The court-appointed medical auditor of a DOCS
facility, where a consent decree governs medical services, criticized the
Department for inadequate medical leadership at the prison. Describing the many
responsibilities of health services directors, the auditor wrote in a 1998 evaluation
report: “The medical director has responsibility for recruiting physicians and
physician assistants. The medical director is responsible for the quality assurance
program, and is responsible for the scheduling of physicians for clinics,
segregation rounds and vacation coverage.”
Access to Specialty Care
“If it’s not an emergency, you’re not seeing a specialist.”
—Comment from an inmate on a prison visit
Specialty care in the state prison system is provided by outside specialists.
Using a “specialty care coordinated system,” the Department contracts the
coordination of specialty health services and acute care to managed care
companies in the community. The state’s 71 prisons are grouped into four regions;
a separate contractor arranges specialty care in each region. Currently, the
Department uses Corrections Physicians Service (CPS), Correctional Medical

34

Services (CMS) and Wexford in three regions, and its own medical staff to
coordinate specialty care in the western region. This region, which includes two
large maximum-security prisons (Attica and Wende) as well as an RMU, was
previously serviced by CPS. In the fall of 1998, DOCS terminated its contract with
CPS.
While the use of specialty care contractors has some benefits, such as
improving access to specialists in remote areas and controlling costs, it adds
another level of gate keeping that often creates lengthy delays. For example, an
inmate in need of specialty care must first be screened by a nurse in order to see a
physician, which can take up to three weeks. The physician then examines the
patient and determines whether a consultation for specialty care is merited. If it is,
the facility health services director must then approve the consultation and
designate the level of urgency: “emergent” (24 to 48 hours); “urgent” (5 to 7 days);
“soon” (14 days) or “routine” (30 days.) The facility health services director then
submits the consultation request to the specialty care contractor, which can reject
it. If this happens, the prison physician is in a difficult position, having to tell the
inmate that the medical procedure he approved (thereby implying it was necessary)
was deemed unnecessary by the specialty care contractor. Unlike patients in the
community, inmates have no recourse if a procedure is denied.
The reverse can also occur. A procedure recommended by a specialist can
be denied by a prison’s health services director. Ultimately, it is the facility health
services director who makes the final determination as to whether a procedure
recommended by a specialist will be followed, which in itself is problematic.
Inmates frequently reported that prison doctors ignore the instructions or
treatments prescribed by outside specialists. Although beyond the scope of this
research, it can be said that any form of managed care presents the possibility that
efforts to control costs will conflict with the delivery of care.

35

Another problem with managed care is the lengthy delays that arise when a
series of off-site diagnostic procedures (such as CAT scans or MRIs) are needed to
identify or rule out a medical condition. In the community, a physician will
typically schedule a series of diagnostic procedures over a period of one to two
weeks. In prison, given the complicated consultation process described above, the
time from the initial consultation to needed surgery, for example, can easily stretch
out over four to six months, during which time a sick individual will likely grow
sicker and a serious medical condition can become life-threatening.
Moreover, there is rarely collaboration between inmates’ prison doctors
and specialists who see them in the community. The medical records maintained
by specialty care contractors do not include the primary care administered in the
prison. There is no effective system for prison physicians to ensure that follow-up
appointments on the outside are made or kept, or for community-based specialists
to know whether prison medical staff is following their instructions. The following
letter from an inmate illustrates the problems that arise when health care is
disjointed.
I caught a case of food poisoning and was sent to the emergency
room in an outside hospital, where the doctor who examined me
prescribed two different medications. I was returned to the facility,
and the prison doctor, who had not examined me, changed that
prescription to an antibiotic called Cipro. I took it but got worse and
worse and was finally sent to the emergency room at Albany Medical
Center. (The prison doctor had mistakenly diagnosed me as having a
bladder infection.) I was sent back to the prison and continued on the
Cipro. I got worse and was eventually taken to the prison hospital in a
wheelchair. I was then placed in an observation room, where the
medical staff and correction staff informed me that there was nothing
wrong with me to cause me so much pain. “What drugs are you
withdrawing from?” they asked. Near death, and being in so much
pain that I wanted to die, they finally agreed to send my urine and
blood out to be tested.
Several hours later they told me I didn’t need the Cipro after all
and that I didn’t have a bladder infection. They gave me pain
medication, and I got better quickly after being taken off the Cipro. I
asked the nurses and doctors why, as trained medical personnel, they

36

didn’t do the logical thing and ask what medication I was on that
could have caused adverse reactions, instead of assuming I was
“kicking.” They said the symptoms I had weren’t typical to adverse
reactions to that drug. Well, I got the product information and checked
it out, and every symptom that I experienced was listed in the
literature.
In general, I’ll tell you what any prisoner knows and will tell you:
Get sick in prison and you’re in trouble.
Sick Call
“I had a very bad pain in my chest and signed up for emergency sick call. I was
informed the nurse would come by later. I'm not a doctor but I do know when
something is wrong with me. The pain was so great that the other prisoners and I
had to start fires in our cells to have the nurse come up. Do we have to act like
savages in order to be listened to?”
—Letter from an inmate in solitary confinement
Problems associated with sick call fall into three categories: impeded
access to physicians, superficial screening, and hostile attitudes of nurses. At many
prisons, inmates reported that they must sign up for sick call three times before
they are seen by a doctor. According to a 1998 publication by the American
Correctional Association, Health Care Management Issues in Corrections:
For inmates of jails, prisons or juvenile detention facilities,
access to the health care system and to needed care essentially
must be unimpeded. This means that the inmate, without risk of
interference by anyone and without fear of reprisal, must be able
to alert health care staff of a health need, to receive a timely
professional evaluation of that need and to receive treatment in
the manner prescribed by a competent provider.
Inmates at nearly every prison reported impeded health care access due to
gatekeeping by nurses. Time and again prisoners complained bitterly about both
the time it takes to be evaluated by a doctor and generally brusque and
occasionally hostile nursing staff. A deputy superintendent explained that nurses
receive the most negative feedback because “they are the ones who have to say

37

‘no.’” There is certainly truth to this comment, but in most instances inmates were
quick to distinguish between callous and humane treatment, and often provided the
names of nurses or other medical staff who treated them respectfully. Inmates were
careful to make sure that researchers were given an accurate picture of the people
who treated them well and those who treated them badly.
Some nurses were said to dismiss inmate concerns as a matter of routine,
allowing minor illnesses to progress into serious ailments. Even though nurses are
required to provide screening and triage, inmates reported that they often do not
take vital signs, or physically examine patients. At three facilities, inmates said
that nurses did not look at inmates’ medical records during sick-call visits. An
Inmate Liaison Committee member at a women’s prison described having a large
and painful cyst on her groin. The physician assistant apparently refused to
examine the inmate or look at the cyst. “I don’t need to see it,” she allegedly said,
and gave the inmate Tylenol. Prisoners at many facilities said medical personnel
refused to touch them.
Nurses are not licensed to write prescriptions, but taking vital signs and
checking patients’ records are essential functions of sick call duty. The Committee
received too many reports of nurses not performing these basic tasks for these
complaints to be dismissed as isolated incidents. At one prison, inmates reported
that nurses who believe inmates are malingering punish them with “medical
keeplock,” meaning they issue the inmate a misbehavior report and lock him in his
cell for the day. “The whole system is designed to discourage usage,” one inmate
said, echoing the sentiments of many others. “I won’t go to sick call unless I’m
dying.”

38

Rates of Pay and Staffing
There are many drawbacks to working in a prison clinic, from the grim
environment to the inconvenience of administering care in a locked institution
governed by strict security procedures. In addition, prisons are rarely located
anywhere near major cities. Inmate-patients, in general, are sicker, needier and
more difficult to work with than non-confined patients. Compounding these
problems is that state-employed medical personnel earn considerably less than
their community counterparts.
For example, according to the Bureau of Labor Statistics, the average
annual income of a physician in the community is $110,000, while that of a New
York State prison physician is $92,000. Nurse administrators (head nurses) in
community hospitals earn, on average, $53,000 annually, while nurses in New
York State prisons earn $39,000. According to Department officials, the salaries of
prison pharmacists are also dramatically lower than those in the community, which
has resulted in severe recruitment and retention problems.
An articulate and energetic nurse administrator at a medium-security prison
explained that the salary differential has made it increasingly difficult to attract
quality nurses. “Even at the maximum levels of state pay, nursing income in
corrections still falls way short of community rates.” At her facility, a part-time
nurse position had been vacant for two years. “We haven’t been able to fill it so we
decided to stop recruiting and just try to make do with what we have,” she said.
“But this is definitely a problem, because our population has nearly doubled while
our medical staff has stayed the same.” With overtime pay more available for
nurses in the community, she said, they can make far more money, and the state
provides no incentive to work with inmates. When asked why she stays, she cited
her many years in the system and the reward of a pension if she stays. The facility
health services director and a deputy superintendent present during the interview
agreed wholeheartedly with the nurse administrator’s assessment.

39

The New York State AIDS Advisory Council’s Subcommittee on Criminal
Justice provided a cogent analysis of the situation in 1998:
DOCS has suffered from a lack of adequate medical staffing
for the past decade. For fiscal year 1990-91, DOCS requested a
health care staffing increase of more than 30%. In 1993, DOCS
recommended that, ‘The existing ratios of professional and
support staff should be enhanced,’ and noted the need to
increase professional salaries, citing especially ‘Glaring
examples of large competitive differences…for physician
assistants, pharmacists…physical therapists…and [nurses].’ In
fiscal year 1994-95, the requested staff increase for nurses alone
was more than 40%. These requests for major increases in
health care staff, each following a DOH audit, were not reflected
in the Governor’s budgets and failed to result in financial or
personnel changes. No effort was made to reassess or redeploy
health staff at prisons when these proposals were not
implemented.
A related problem is the lack of pay differentials among the highest levels
of medical staff. The salaries of a regional medical director or a facility health
services director are the same as those of regular staff physicians. Given the
substantial responsibilities of a facility health services director, including oversight
of the entire health care staff (medical, dental and pharmaceutical), responsibility
for all inmate health care services (clinic, infirmary, ambulatory, specialty care)
and involvement with budgets, operations and scheduling, “Why,” as a deputy
superintendent asked the Visiting Committee, “would anyone take this job?”
A former DOCS physician noted: “A regular prison physician and the
health services director make the same amount of money, so there is no incentive
to be a leader.” In fact, this physician left DOCS to work for a private correctional
health care company. “I didn’t leave because I was unhappy,” she said. “DOCS
simply could not compete with the salary I was being offered, and the facility was
closer to my home.”

40

Even more illogical is that the salary of a regional medical director is the
same as that of both a facility health services director and a staff physician.
Regional medical directors oversee facility medical directors and are responsible
for the health care of thousands of inmates in entire hubs (clusters of up to 10
prisons). Again, given the tremendous responsibility of the position and the
considerable travel time going from prison to prison, there seems to be far more
disincentives than incentives for assuming a high-level medical position in DOCS.
Qualifications and Leadership of Doctors
Inadequacies in the qualifications, leadership skills and onsite work hours
of staff physicians emerged as a common problem.
Correctional health care experts consider the most appropriate training for
inmate health care to be either in family practice or internal medicine. The
Committee rarely met a staff physician with this training. Instead, urology and
surgery were common areas of practice. Specialty areas such as these do not
properly prepare doctors for work in a busy prison clinic. They involve far less
patient interaction than a primary care specialty and offer little training in
preventive health care. Not surprisingly, when inmates described problems with
medical staff, their criticisms focused typically on physicians who were trained as
specialists rather than general practitioners.
Also problematic is that many prison doctors are not board-certified.
Neither DOCS nor the Department of Civil Service, the agency that sets standards
for state-employed medical personnel, requires or encourages them to become
board-certified. In the community at large, board certification demonstrates a level
of commitment to practicing medicine. Requirements include an approved
residency program, continuing medical education and passing re-examinations on
a regular basis. Completing an approved residency program makes a physician
board-eligible, which should be the minimum qualification for a doctor to practice

41

primary care in prison. A non-board-certified or non-board-eligible doctor would
be hard pressed to find work as a medical practitioner in the general community.
Leadership and managerial skills appeared to be greatly needed but
generally lacking. This deficit was most directly conveyed by the absence of
facility health services directors on five separate prison visits, despite advance
notice that a site visit was scheduled and the Committee had requested an
interview with the director. Explanations were that the health services director was
on vacation, worked part-time, was on call, or that the position was vacant. Several
facility health services directors told the Committee that they had their own
medical practices in the community, and that the position with DOCS attracted
them for the generous hours “on call,” which enabled them to continue their
community practices. According to an attorney familiar with the Department’s
health care system, “For many of them it’s a paycheck. They’re getting $50,000 a
year to work half-time and to supplement the income from their community
practice.”
When facility health services directors were present during Committee site
visits, they tended to rely on nurse administrators to answer researchers' questions.
Frequently, the health services director would turn to the nurse administrator when
a question was posed, unless asked directly to answer. It was often unclear as to
whether the medical director did not know the information inquired about, or
deferred to the nurse administrator for other reasons. A Department health services
official admitted, “We don’t have good courses in management, leadership or
sensitivity training for physicians who work with this population. Until recently we
didn’t even have correctional health care orientation for nurses and physicians.”
Finally, in answer to the question as to why they chose to work in the
prison clinic, several physicians said that managed care had put their health care
practice in the community out of business. The prison, it seemed, was their
employer because they had no other feasible choice.

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Clinical Management of HIV/AIDS
“By choosing mass imprisonment as the Federal and State governments’ response
to the use of drugs, we have created a de facto policy of incarcerating more
individuals with HIV infection…Clearly, we are thus concentrating the HIV
disease problem in our prisons and must take immediate action to deal with it more
effectively.”
—National Commission on AIDS, 1991
Twenty-five site visits to 22 correctional facilities revealed uneven clinical
management, a vagueness among staff physicians about critical HIV/AIDS issues,
wide variations in HIV testing, support services and education, and an absence of
prevention measures. Despite Department officials’ estimates that by the end of
1999 approximately 25,000 inmates have been tested, in many prisons the
Committee visited, inmates told researchers they had not been tested and had no
idea how to get an HIV test. Part of the problem can be traced to the absence of
Criminal Justice Initiative (CJI) contractors in many state prisons. CJI provides
HIV testing, counseling, education and transitional support. However, according to
the AIDS Institute, nearly half of state facilities have no CJI education programs,
and 14 other facilities are not served by CJI for any service whatsoever, e.g.
testing, counseling, education or transitional support.
The Department reports that approximately 1,400 inmates with AIDS have
been identified, and that approximately 2,800 inmates (with either HIV or AIDS)
are receiving anti-retroviral therapy. However, the number of inmates receiving
treatment (2,800) is less than half the number of inmates who the Department
believes are HIV+.
At the majority of prisons visited, the facility health services director could
not tell researchers how many inmates under his or her care had either sought
treatment or were receiving treatment for HIV/AIDS, citing only vague estimates.
At a large maximum-security prison, none of the medical staff interviewed knew

43

how many HIV+ prisoners had an AIDS diagnosis. One staff member told
researchers that “the figure is registered in Central Office in Albany. That is where
they have an HIV surveillance system,” and said that an HIV specialist visits the
facility regularly for onsite clinics. While infectious disease clinics are offered
throughout the system and are provided on an as-needed basis, far too few staff
physicians have HIV training or are knowledgeable about the treatment plans of
inmate-patients under their care. It should be noted that DOCS developed and
issued HIV Primary Care Practice Guidelines in July 1995 (revised in December
1996, July 1997 and February 1998), which were often referred to during visits.
Guidelines, however, are not quality assessment tools that can be used to monitor
actual practices.
Furthermore, there appeared to be few procedures to ensure that sufficient
information is given to inmates receiving HAART medication (drug cocktails), or
to ensure that adherence to treatment is monitored. Both of these are essential
components of HIV/AIDS management, which requires continuous scrutiny,
frequent adjustment and ongoing patient education. An HIV service provider who
works in New York State prisons reported: “I know of at least one facility where
complicated medications are commonly dispensed with no directions other than
‘take twice a day.’ Many of these medications have very specific conditions under
which they should be taken or they won’t be effective. Conditions such as with or
without water, or how much time before or after a meal they should be taken
should always be clearly defined.”
Similarly, after a visit to a medium-security prison, a Committee physician
noted:
One HIV+ inmate I spoke with was clearly confused about
his complicated though totally appropriate HAART medication
and was taking it improperly. I was concerned that the medical
staff does not have enough time to explain such regimens to
patients. Successful HAART includes far more than a
medication prescription. Taking a complex regimen of drugs

44

that often cause unpleasant side effects without any immediately
obvious benefits requires intensive supportive counseling.

HIV Education and Prevention
Despite the high number of HIV-infected inmates, the Department does
little beyond providing limited HIV education to reduce the spread of HIV in
prison, and therefore into the community when inmates are released. State officials
commonly cite education as an adequate form of prevention, but HIV education is
not available or easily accessible in all correctional facilities to all inmates. Peer
education groups were frequently described by inmates as unsuccessful and/or
unattended because of a lack of support from prison officials and because
measures to protect inmate confidentiality were not taken seriously. These
concerns create anxiety among inmates who fear stigmatization.
As a matter of policy, condoms are not provided and are therefore
considered as contraband. Yet anecdotal evidence suggests that sexual activity
occurs in prison and that condoms are necessary and desired to prevent the spread
of HIV/AIDS. According to an informal survey of 108 former New York State
prisoners conducted in 1999 by the Latino Commission on AIDS, 63% of
prisoners said they had witnessed inmates having sex while in a New York State
correctional facility. Moreover, 17% reported that they had engaged in sex while
incarcerated, and 45% reported knowledge of correction officers having sex with
prisoners. Because of the frequency of sexual activity in prison, the majority of
respondents (80%) felt that condoms should be made available. “Sex in prison is a
fact,” noted one respondent, “and protection should be provided.”
Sex upon release from prison is also a fact—as well as a threat to public
health. A study of Latino ex-offenders in California found that 51% reported
having sex in the first 12 hours after release. Inmates also indicated a preference
for sex without condoms once they leave prison.

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Given the prevalence of HIV among New York State inmates, the
reportedly high level of sexual activity in prisons, the tremendous costs of treating
HIV/AIDS and the public health threat infected inmates present once they are
released, state policymakers would be wise to permit supervised access to
condoms. Currently, three prison systems (Mississippi, Washington, D.C., and
Vermont) and three jail systems (San Francisco, Philadelphia and New York City)
make condoms available during HIV counseling sessions or when requested
privately in sick call. The practice is quietly accepted by the staff, inmates and
administration.
Care of the Chronically Ill
DOCS lacks a statewide system for monitoring the care of inmates with
chronic illnesses, whether HIV/AIDS, asthma, diabetes, liver disease or chronic
heart conditions. No standard tracking system exists for scheduling routine followup care, ordering and reporting laboratory results, monitoring appointments and
ensuring that critical medications are not only administered, but administered
properly. Committee members observed that medical personnel in some prisons
address the needs of chronically ill inmates by manually scheduling future visits in
appointment books. In other prisons, tracking was done on a computer; in some
prisons it wasn't done at all.
The following account, written by a Committee physician following a visit
to a maximum-security prison, illustrates the problems that arise when inmates
with chronic conditions are insufficiently monitored.
I spoke with an inmate in one of the cellblocks who had been
diagnosed with asthma several years prior. He was concerned
that he had a chest infection, which had not improved. He
showed me all his medication. He was on Theophylline (an
asthma management drug considered outdated for several years
now), which requires that the drug level in the patient’s blood is

46

monitored regularly to ensure it remains in the narrow
therapeutic range. The inmate said he had not had a
Theophylline level test done for at least two years. In addition,
he showed me his inhalers, one of which (the steroid inhaler)
had the wrong instructions on the label: ‘2 puffs every 4 to 6
hours as needed.’ A steroid is a baseline treatment that should be
taken on a regular and daily basis, not as needed. Furthermore,
the use of a steroid inhaler does not help in an acute situation of
asthma-induced shortness of breath as the label falsely
suggested.
When I asked the inmate if he understood when and how to
take his medication, he had no clue; he would therefore be
unable to help himself in the event of an emergency…I also
checked to see whether the inmate used his inhalers correctly.
The proper technique is critical for the delivery of the drug into
the lung, where it is meant to act. It takes a bit of patience to
teach the technique and perseverance from the patient to learn it.
The inmate was using his inhaler as a sort of breath spray, with
no awareness of the proper technique and function of the
inhaler. (I showed him the right technique and clarified the
schedule of medication, which the pharmacist or prescribing
doctor obviously had confused.) I brought his case to the
attention of the nursing administrator. He promised to look into
it and thanked me for having ‘picked that up.’
Patient Confidentiality
“Inmates have a constitutional right to privacy in their medical diagnoses and other
medical information. The ‘casual, unjustified dissemination of confidential
medical information to non-medical staff and other prisoners is unconstitutional,’
as are actions or policies by prison administrators that indirectly disclose medical
information without justification.”
—American Correctional Association, citing Casey v. Lewis (1993)
In the confined world of prison, confidentiality is difficult to maintain. In
the outside community, doctor-patient confidentiality is held in the highest esteem
and considered a cornerstone of professional health care. Despite the difficulty of
maintaining confidentiality in prison, it can be argued that inmates have a greater

47

need for privacy than those outside because they live in a closed community, in an
environment where violence, coercion and extortion can and do occur.
At many prisons the Committee visited, correction officers’ knowledge of
inmates’ medical concerns was a source of tension. Counter to standards of both
the American Correctional Association and the National Commission on
Correctional Health Care, several New York State prisons require that inmates
receive correction officer approval in order to sign up for sick call. They must
either obtain a correction officer's signature on the sick call slip or register in a sick
call appointment book held by a correction officer. At one facility, correction
officers post the names of inmates on a medical “call-out” list that can be seen by
any prisoner in the dormitory; at several facilities, inmates must first submit sickcall requests to correction officers, who then compile a list for the medical staff.
Inmates in many of the Special Housing Units reported incidents in which nurses
gave inmate medication to correction officers to deliver. At a large maximumsecurity prison, inmates reported that a correction officer frequently was present in
the doctor's examining room. This practice breaches confidentiality, as well as
DOCS’ own policy, which states: “Absent indications of possible physical
confrontation or upon request by health services staff, a discreet, out of earshot
position is appropriate.” At prisons where correction officers serve as gatekeepers
to sick call, or insist on being present in examining rooms, inmates reported
incidents where correction officers used prisoners’ medical information to ridicule
them, or denied them access to medical attention.

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Language and Cultural Barriers
“The typical health care professional originates from and lives in a world very
different from that of the inmates, 95% of whom are from a lower socioeconomic
class. The prevailing cultural view is that people are poor not because they have no
money, but rather because they have not made the necessary effort to become
successful…This further generalizes into ‘they really don't care about
themselves.’When a prisoner is seen with a longstanding medical problem it is all
too easy to assume that patient neglect or carelessness is to blame. These class
prejudices combine with ignorance about patients’ culture, background and
environment to create barriers to high-quality interactions and communication.”
—Gordon Schiff, M.D. and Ronald Shansky,
in Challenges of Improving Quality in the Correctional Setting
Approximately 85% of state prisoners are either black or Latino, yet
Committee researchers met few African-American or Latino heath care providers.
Obviously, inmate-patients can be served well by qualified health care providers
from any country, but when language and cultural differences inhibit
communication, as was sometimes the case, the quality of health care interactions
suffers. It was reported to the Committee that the racial and cultural differences
that exist between urban, minority patients and foreign-born physicians are
common sources of tension that prevent open communication of sensitive
information. On several prison visits, language barriers made it difficult for
Committee researchers themselves to understand the meaning of staff physicians'
comments.
In addition, 10% of New York State prisoners are classified by the
Department as “Spanish-dominant,” yet it was rare to find a member of the
medical staff in any prison who was fluent in Spanish. In addition, medical
instructions regarding dosages, important side effects and expiration dates are
provided only in English, making them useless at best, or dangerously confusing at
worst, for Spanish-speaking patients. Medical staff told Committee members that
other inmates, correction officers or non-uniformed staff with Spanish language

49

knowledge served as translators. This practice raises a host of problems. First,
translation errors are likely to occur when individuals who are not trained in the
very specific discipline of medical translation serve as interpreters. Translation
errors, in this case, can involve matters of life and death. Further, confidentiality is
breached and safety is jeopardized when inmates must rely on other inmates or
correction officers to communicate sensitive health care concerns. Members of
nearly every Inmate Liaison Committee interviewed cited a lack of Spanishspeaking staff as a great concern to the Hispanic population. As one inmate in a
maximum-security prison explained: “Imagine you only speak Spanish, and you
have to tell a doctor who barely speaks English, through a C.O. who barely speaks
Spanish, that you have hemorrhoids.”
Moreover, the exponential growth in foreign-born inmates over the past ten
years poses considerable challenges for correctional health care providers.
Between 1985 and 1995, the number of foreign-born inmates in New York more
than tripled. Department officials report that less than a third of foreign-born
inmates come from countries where English is the dominant language. In its 1998
report, The Impact of Foreign-Born Inmates on the New York State Department of
Correctional Services, DOCS notes: “If the proportion of foreign-born inmates
continues to grow, it will likely produce an increasingly serious strain on DOCS
resources in the future.” A senior DOCS health official said that the growing
number of inmates, from the Caribbean and South America in particular, poses
serious health and fiscal concerns for the prison system that confines them and for
the taxpayers who subsidize it. Inmates from these countries have lower rates of
immunization, higher rates of HIV/AIDS and suffer more from other chronic
illness compared to native-born prisoners. Thus, they will require a greater number
of medical services, from treatment to translation assistance.

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MODEL PRACTICES

The Visiting Committee observed model practices at several prisons, most
of which were the products of thoughtful and proactive senior prison
administrators working closely with dedicated medical staff. At these facilities,
Committee members observed a commitment to quality health care on the part of
both correctional and medical staff. Some of these practices are described here for
possible replication in other prisons.
Grievance Reduction Strategy at Sullivan Correctional Facility
Sullivan Correctional Facility is a maximum-security prison with
approximately 800 inmates. At the time of the Committee's visit in early 1999,
prison officials expressed concern about the high number of medical grievances.
Several months later, the facility made a number of changes, resulting in a 50%
reduction in medical complaints.
The administration established an “ILC/Administrative Sub-Committee,”
comprised of members of the Inmate Liaison Committee, senior prison
administrators and medical staff. The group meets monthly to discuss concerns and
identify ways to reduce medical grievances. “These meetings have proven to be
successful by opening paths of communication, whereby information can be
shared to alleviate misconceptions and make for a better informed committee,” the
superintendent said. The minutes of the meetings are posted throughout the dorms.
ILC members learn from medical staff why certain policies or procedures exist and
share this information with their constituents. Medical staff gains insight into the
needs and concerns of inmate-patients and determines ways to address them.

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To assess inmates’ access to sick call, Sullivan designed a triplicate sick
call form. Copies are retained by the inmate, the clinic and the administration.
“This way, we can see whether and when the inmate submitted the request for sick
call,” the deputy superintendent reported. “It is another way to determine that
access is unimpeded.”
Finally, Sullivan administrators took a proactive approach to expediting
specialty care consultations with outside service providers. They held two
meetings with facility physicians, specialist contractors and the regional medical
director to better understand why referrals are either postponed or denied.
“Currently, MD’s are being trained so that pended [medical jargon for postponed]
referrals can be answered more quickly,” reported the superintendent.
“Additionally, a review was done regarding the six points of a well-written
consultation request. The group is working on a ‘fast track’ method, whereby
certain conditions can be monitored by case managers assigned to both the facility
as well to [the specialty care contractor]. Regional meetings will be held at
quarterly intervals in order to eliminate unnecessary ‘pendeds’ and denied
consultations.”
Medical Services at Coxsackie Regional Medical Unit
The Coxsackie Regional Medical Unit (RMU) represents the Department’s
first experiment in privatized health care. Based on three separate site visits (in
1996, 1997 and 1998), feedback from inmate-patients and in-depth interviews and
phone conversations with medical staff there, the Committee concluded that the
Coxsackie RMU offers superior health care services. The facility is staffed and run
by Correctional Medical Services (CMS), a division of the publicly traded
Spectrum Health Care, the largest health care provider in U.S. prisons. In the
spring of 1998, the unit housed 60 inmate patients, a significant number of whom
were terminally ill and would die in the unit’s hospice (22% of the inmates had
cancer; another 20% had AIDS). The staff was knowledgeable and answered

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Committee questions with ease, revealing the strength of the unit’s data collection
and tracking systems. The medical director, a prison doctor for nearly two decades,
was formerly employed by DOCS and now works for CMS. Staff and inmatepatients valued his leadership and communication skills. Committee members
were favorably impressed with the hospice and moved by the staff’s humane and
caring treatment of the inmates. “We work hard to reunite terminally ill patients
with their family so that no inmate dies alone,” a nurse said. “We do what we can
to facilitate medical parole.” She added that some prisoners choose to die in the
RMU hospice, where they have formed relationships with staff and inmates, rather
than in an outside hospital. The following inmate letter was received in June 1998
after the Committee’s visit.
I am writing this letter of appreciation about the doctors and
nurses at the Coxsackie RMU and the care I receive here. I
know the only time you hear from inmates is when there are
problems. Well, I don’t have any problems with this unit. I have
been in the infirmary at Mt. McGregor and Green Haven. I have
been locked down since 1995 and in and out of hospitals since
1980. Of all the places I’ve been, this is the best by far.
I have a very bad heart disease, and it is good to know that
the doctors and nurses and yes, even the C.O.’s, are very
professional. They don’t mind going that extra mile to provide
me with the best of care. I just wanted you to know that there is
bad and good everywhere, but here the good outweighs the bad.
I know good care when I receive it, and I’m receiving it right
now. I just wanted the doctors and nurses and yes, even the
C.O.’s, to get a ‘two-thumbs-up,’ and I think they should all get
a raise.
Does high-quality health care come at an exorbitant price? In the case of
Coxsackie, it may come at a cost saving. In March 1999, the Department supplied
the Correctional Association with a comparison of the costs estimated to operate
the unit by DOCS versus an outside provider. The Department’s projected costs
were $4,706,801; those of CMS were $3,800,000. The “savings,” according to
DOCS, if these projections were accurate, would be nearly one million dollars
($906,801).

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“Another benefit of privatized health care is that it is more visible,” said a
CMS employee who requested anonymity. “Public companies have more
accountability, so there is naturally a higher level of scrutiny.” While there are
certainly pros and cons to privatized correctional health care, in the case of
Coxsackie, at this time there are clearly more pros.
Management of HIV/AIDS at Wende Correctional Facility
Wende Correctional Facility is a maximum-security prison in the western
region of the state. It houses approximately 925 inmates. It is highlighted here for
its model HIV services and its knowledgeable and energetic medical staff.
When committee members asked about HIV/AIDS treatment, the physician
assistant displayed impressive knowledge of the latest treatments and the levels of
infection among Wende inmates. Of the 32 HIV+ inmates, he reported, without
having to look at a chart or notes, 24 were taking HIV medication. He explained
how inmates are tested, the counseling and education they receive and how he
tracks medication compliance.
At Wende, inmates request testing through sick call. A nurse does post-test
counseling and, if a person is positive, he is immediately referred to a physician.
“We try to reiterate the importance of testing, treatment and compliance with
medication,” the physician assistant said. “I review their charts regularly to
determine viral load counts and check the pharmacy records to see if they are
taking their meds.” If an inmate is not compliant, the physician assistant offers
counseling, education and encouragement. “Currently, 20 of the 24 are doing
pretty well with their medication,” he noted.

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Responsive Leadership at Beacon Correctional Facility
The value of compassionate, responsive leadership in a prison setting
cannot be overemphasized. In 1998, when Susan Schultz became superintendent of
Beacon Correctional Facility, a 228-bed prison for women, one of her first
priorities was to identify the reasons behind the high number of medical
grievances. She asked the Department’s Health Services Division to conduct an
internal audit. “I wanted to determine if inmates’ complaints were justified,” she
said, “and that malingering wasn’t the problem.” According to the superintendent,
early results of the audit indicated that malingering was not, in fact, the problem.
Committee members were impressed with the superintendent’s candor and her
commitment to improving inmate health care.
Because Beacon is a minimum-security prison known as a “camp,” where
the length of stay (approximately two years) is lower than average, the Department
does not provide full-time, onsite medical coverage. Beacon inmates in need of
medical attention are transported to the clinic at Fishkill, a men’s prison half a mile
up the road. This arrangement presents problems when staff is not immediately
available for transportation and seemed to concern both inmates and staff.
Several months after the Committee’s visit, the Department agreed to
assign a physician to Beacon one day a week (for four hours) to review patient
charts and examine up to six inmate-patients. Superintendent Schultz said she was
hoping to double the physician’s time. Patients in need of specialty care are seen
by specialists, who now come to Beacon on a regular basis to conduct clinics.
Superintendent Schultz also responds well to new issues. When the
Correctional Association reported that inmates expressed concern about Lyme
disease (Beacon inmates live and work in a heavily wooded area), the
superintendent took action. The Department’s Health Services Division developed

55

two Lyme disease protocols: an educational guide for inmates who work outdoors,
and a guide for staff on the symptoms and treatments of Lyme disease.
Seizure Training for Correction Staff at Albion Correctional Facility
Correction officers are typically the first to arrive on the scene of medical
emergencies. Certification and training in certain life-saving procedures are vital.
At the state’s largest women’s prison, Albion Correctional Facility in western New
York, inmates reported that housing area correction officers either did not know
how to, or were reluctant to, respond when an inmate had a seizure, leaving her to
be tended by other inmates. Prisoners expressed a high level of anxiety about the
frequency of inmate seizures and the lack of response from medical or security
personnel. After the visit, the Correctional Association recommended that a
protocol be developed to educate correction staff on seizure response. Medical
staff at Albion has since developed a training module for correction officers on
responding to inmates with seizure disorder.
Medical Services at Bedford Hills Correctional Facility
Bedford Hills Correctional Facility, New York’s maximum-security prison
for women, is recognized in correctional health care circles as providing first-rate
medical services. It is rare for the Correctional Association to receive a complaint
about medical care from a Bedford Hills inmate.
Improvements in health care were prompted by litigation (Todaro v.
Coughlin, filed by the Legal Aid Society in 1974) resulting in a court order
governing all aspects of care, and by a superintendent who has championed reform
from the start. Among the most significant changes at Bedford Hills are enhanced
staffing levels and access to physicians. The facility health services director has
expertise in the clinical management of HIV/AIDS; staff physicians have training
in primary care. Furthermore, the ruling mandates that a prisoner has the right to

56

see a physician if requested. Regardless of the recommendation of the sick call
nurse, if a patient requests a physician appointment, one must be scheduled no
more than 14 calendar days from the request. Also, the court order requires that
nurses conducting medical screening at Bedford Hills receive training in triage
assessment and the diagnosis and treatment of infectious diseases.
Finally, Bedford Hills deserves praise for its peer education program for
HIV+ inmates. Known as “ACE” (AIDS Counseling and Education), the program
has received national recognition for its effectiveness in educating inmates about
HIV/AIDS. Breaking the Walls of Silence (Overlook Press, 1998) traces the
development and successes of the program.

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MEDICAL SERVICES IN WOMEN'S PRISONS

Special Needs of Female Patients
Participating in a nationwide trend, New York State has experienced a
tremendous rise in its female prison population. Fifteen years ago, 900 women
were confined in New York State prisons. By 1999, that number had nearly
quadrupled to over 3,500 women.
Between 1997 and 1999, the Correctional Association conducted site visits
to four women’s prisons: Albion Correctional Facility, a medium-security prison
near Rochester; Bayview Correctional Facility, a medium-security prison and work
release center in New York City; Bedford Hills, the system’s only maximumsecurity prison for women, and Beacon Correctional Facility, a minimum-security
work camp in Dutchess County. In addition to touring the medical clinics,
Committee researchers discussed health care issues with prison administrators, all
levels of the medical staff, members of the Inmate Liaison Committees and
individual prisoners during conversations in dorms, Special Housing Units and the
mess hall.
Studies show incarcerated women require more health care services than
male prisoners and tend to use health services more often. In fact, in response to
the growing number of women behind bars, the National Commission on
Correctional Health Care recommended separate standards in 1994 for addressing
the special needs of incarcerated women. The Commission cited evidence that the
traditional, male-centered model of prison health care neglected the needs of
incarcerated women.

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To provide adequate health care to female prisoners, it is important not
only to move beyond the traditional male-centered model of correctional health
care but beyond the community model as well, which has narrowly defined
women’s health needs in terms of reproductive health. In 1994 former New York
Governor Mario Cuomo directed the New York State Division for Women and the
Department of Health to study women’s health issues. According to the report
issued by this group, the Governor’s Interagency Work Group on Women’s
Health, it is essential that health care providers who treat female prisoners
understand the social illnesses that affect their physical and mental health.
Problems such as domestic violence, drug addiction and sexual assault must be
addressed in the broader treatment plans of female offenders.
Because of poverty, chronic drug use and impeded access to medical care
in the community, incarcerated women are more likely to experience serious health
problems—epilepsy, diabetes, high blood pressure, asthma, HIV/AIDS and mental
illness—than their counterparts in mainstream society. In New York, mortality
among female prisoners is double that of women in equivalent age groups in the
community.
Similarly, female prisoners are disproportionately affected by HIV/AIDS
compared to incarcerated men and to society as whole. Overall, HIV prevalence is
50% higher in incarcerated women than it is in male inmates throughout the
United States and almost 100% higher in northeastern correctional facilities.
According to DOCS’ most recent blind HIV seropositivity study, 18% of women
in New York State prisons are infected with HIV, compared to approximately 9%
of men. In addition, women prisoners are at higher risk for contracting other
sexually transmitted diseases and gynecological infections, for many of the same
reasons they are at higher risk for HIV infection: drug use, unprotected sex with
multiple high-risk partners and sexual abuse. At Albion Correctional Facility, for
example, a nurse reported that approximately 80% of inmates had been treated for
sexually transmitted diseases.

59

The frequency among women prisons of physical and sexual abuse,
considered antecedent to HIV infection, contributes to health problems among
women prisoners. In a 1998 study of Bedford Hills inmates, approximately 80%
reported histories of severe physical violence and/or and childhood sexual abuse.
For many incarcerated women, such abuse is an underlying cause of drug and
alcohol addiction. The vast majority (nearly 80%) of the women in New York
State prisons are self-reported substance abusers.
It has also been determined that female inmates have a higher prevalence of
clinical depression than male inmates, particularly because of the severe emotional
stress women experience when they are separated from their children. Fully threequarters of women in prison are mothers, and most of these women were the
primary caretakers of their children prior to incarceration. (About 10% of women
inmates are pregnant when they enter prison.) For many women, being separated
from their children produces profound depression and anxiety, which can lead to
mental and physical illness, including self-injury and/or mutilation. Not
surprisingly, recent studies reveal high rates of post-traumatic stress disorder
among female inmates. In Prison Madness: The Mental Health Crisis Behind Bars
and What We Must Do About It, author Terry Kupers, M.D. writes:
Studies show there is a high incidence of depression in women
prisoners—higher than in men. Perhaps it is merely a matter of men
acting out their emotional turmoil in aggressive acts that draw a lot
of attention, whereas women suffer their depressions silently. But we
also know that the experiences that make women prisoners a unique
group—their long history of abuse, their deep commitment to
mothering, their difficulty in maintaining self-esteem for an entire
prison term filled with harsh treatment and sexual harassment—are
also serious risk factors for depression and other forms of emotional
distress.
Finally, depression can dampen a patient’s motivation to adhere to antiretroviral therapy. “This emphasizes the need to address core issues such as

60

depression so that patients will be motivated to adhere to ART,” according to
participants at a February 1999 conference on the care of HIV+ prisoners.
Areas of Improvement
Over recent years, DOCS has made system-wide improvements in
addressing the medical needs of its growing female prisoner population. In 1998, it
revised its policy on gynecological examinations and Pap smears to include annual
instead of three-year check-ups. In addition, in 1999 the Department established a
comprehensive Primary Health Care Guideline for Female Prisoners. According to
Department officials, the Guidelines were reviewed and approved by the New
York State Chapter of the American College of Obstetrics and Gynecology. They
require all new prisoners to receive a breast and pelvic exam, Pap smear, chest xray, blood work and urinalysis (including a pregnancy test), and an EKG.
Mammograms are given to women aged 40 and above.
The Department also now requires that a female “observer” be present
when a male physician performs a gynecological examination, a standard of care
in the community. This practice not only minimizes the potential for sexual
harassment and protects male employees against allegations, but helps relieve
women’s apprehension of undergoing a gynecological exam. Female prisoners
with histories of sexual trauma are particularly fearful of gynecological
examinations conducted by a male practitioner.
Persistent Problems
The three leading concerns of female inmates were poor HIV/AIDS
management, lack of confidentiality and insufficient mental health services.
Researchers concluded that, except at Bedford Hills, HIV/AIDS services in
women’s prisons are in need of improvement. The most noticeable shortcomings
were the lack of adherence tracking for inmates taking HIV medications; delays in

61

receiving medication; too few medical staff with HIV/AIDS training; and a lack of
administrative support for peer counseling and support services for infected
inmates.
At two different women’s prisons, inmates reported that medical staff
administered the wrong medication. One inmate interviewed by a Committee
physician said she received HIV medication even though she was not HIV+. The
inmate became quite sick, and said the physician assistant admitted she had made a
mistake and told the inmate not to report it. This story seemed unbelievable until
Committee members heard of a similar incident at another women’s prison. An
HIV+ inmate in the infirmary told a Committee member that a nurse had given her
the wrong HIV medication. Despite her protests, the inmate said, she could not get
past the nurse to bring the matter to a doctor’s attention. When meeting with the
medical staff, Committee members raised the inmate’s complaint. A physician
assistant checked the inmate’s records and confirmed that she had, indeed, been
given the wrong medication. Apparently, the quality of HIV/AIDS care at this
prison had deteriorated sharply after a staff nurse specializing in infectious
diseases left the facility.
The following observations of a Committee physician following a 1997 site
visit to a women’s facility illustrate the range of issues associated with
inadequacies in the Department's delivery of HIV/AIDS services.
Instances of delays in receiving prescribed medications were
cited by the inmates. In one case, AZT (Zidovudine) was not
available for two weeks. This delay has the potential to seriously
compromise anti-HIV therapy by leading to viral resistance. On the
other hand, most of the inmates interviewed were receiving
combination anti-retroviral therapy for HIV disease.
A number of the women expressed a need and desire for an HIV
support group. While acknowledging that a counselor had organized
a six-week educational program on HIV, there was no ongoing
support for inmates who had been diagnosed with HIV/AIDS.
Indeed, the superintendent had refused to permit the periodical AIDS

62

Newsline to be distributed to the inmates, insisting it had to be
mailed to individual inmates for them to receive it. She maintained
her position even when the Visiting Committee pointed out that
inmates might be concerned with confidentiality if AIDS-related
material was being mailed to them.
In addition, inmates consistently raised concerns about the lack of medical
privacy and confidentiality, particularly related to disclosure of HIV status. At one
prison, women reported that sick call was sometimes conducted behind a curtain
rather than in a soundproof area. At this facility and another women’s prison,
medical staff said they used inmate interpreters to translate the concerns of
Spanish-speaking inmates.
In its standard on confidentiality, the National Commission on Correctional
Health Care states: “Recognizing that being labeled as HIV+ may put an inmate at
undue risk for compromised personal safety, it is particularly important that the
rules of physician/patient confidentiality regarding HIV test results and diagnoses
of AIDS be followed.” Fear of stigmatization discourages women from being
tested, from participating in support groups and from seeking life-prolonging
medication.
Insufficient counseling is among the top three complaints the Correctional
Association receives from female inmates. On every prison visit, inmates
expressed an intense need for better and more mental health services. Separated
from their children and confined in correctional facilities far from home, many
female prisoners experience profound depression. Given the prevalence of
HIV/AIDS, mental illness, addiction and victimization among female prisoners,
Committee members were not surprised by their appeals for professional support.
For example, an inmate whom the Committee interviewed said she had
been struggling with a painful and pressing situation, but was informed she would
have to wait three weeks to see a mental health worker. According to the inmate,
the counselor listened to her for a few minutes and summed up the session with a

63

brusque: “There is nothing I can do for you.” This account was similar to many
others reported to the Committee.

64

FUTURE CONCERNS

Hepatitis C
“Hepatitis C is a long-term disease. We have ineffective therapy, and there is no
vaccine. The problem is of overwhelming size.”
—Dr. Emil Miskovsky, a correctional health care expert
at the University of Texas, Medical Branch
Described by health care professionals as “the next epidemic,” hepatitis C
poses a serious threat to inmates, correctional health care workers and the public at
large. Recent prevalence studies of hepatitis C in U.S. prisons indicate that 40% of
inmates are infected with the virus. Chronic hepatitis C develops in approximately
70% of infected people; 20% of these individuals will develop cirrhosis, which
seriously damages the liver. Figures from the American Liver Foundation show
that:
•

African-Americans are twice as likely to be infected with hepatitis C as
non-Latino whites;

•

About 3.2% of African-Americans are infected with hepatitis C, compared
to 2.1% of Latinos and 1.5% of the general population;

•

75% of injection drug users acquire hepatitis C; and

•

Approximately 40% of individuals who are HIV+ are co-infected with
hepatitis C.
Hepatitis C is easy to transmit and difficult to treat. The main drug therapy

available for hepatitis C, interferon, is not only expensive (costing more than
$10,000 annually for medication alone), but has numerous side effects. According
to the Hepatitis C Practice Guidelines issued by the Department in March of 1999,
these side effects include: “chronic irritability, fatigue, myalgia, headaches, rage,
confusion and neuropsychiatric disorders.” The guidelines also state that “severe
and incapacitating depression can develop in persons without a history of
65

depression.” Equally troubling is that, according to the guidelines, “HIV infection
is a relative contraindication to interferon treatment for hepatitis C. Since response
to therapy is poor and current treatment regimens for this population are
investigational, treatment should only be considered for inmates with normal Tcell counts and low viral loads and who have been compliant in their total HIV
management process.” As noted previously, Committee researchers found that
treatment compliance among HIV-infected inmates is generally uneven and
insufficiently monitored.
According to DOCS, “The Department has recognized the growing
importance of hepatitis C within the community and in its inmates.” Recently,
DOCS asked the Department of Health to include testing for hepatitis C in its
upcoming HIV seroprevalence survey and hosted a teleconference about hepatitis
C in 1999.
In mid-1998, the Correctional Association began receiving letters from
inmates and their relatives regarding hepatitis C. Complaints concern insufficient
information about the disease, a lack of support from health care workers for
infected inmates, perceived impediments to treatment and denial of vitamins and
dietary supplements. The following letter from the mother of an inmate illustrates
these concerns:
My son needs immediate care by a clinic specialist. He has
hepatitis C that is in an advanced stage. The facility took him to
a clinic once. Nothing else was done for him. Most of the time
he is nauseated. He doesn’t eat for three days at a time. He
asked about Ensure (a dietary supplement DOCS provides for
some inmates) because he wanted to get some vitamins and
nourishment from that at least. The doctor told him he had to
order it. He has requested blood work for three weeks now to
see if his condition is worsening. He is in pain and depressed,
which is part of the disease. He has asked to see a psychologist,
all to no avail.

66

An Aging Population
“Death is not the worst possible outcome of medical care. Death is not even the
worst possible outcome of incarceration. Dying alone, in pain, without social,
familial and spiritual supports is the terrifying end that many prisoners fear.
Unfortunately, it is too often the reality they experience.”
—Nancy Neveloff Dubler and Budd Heyman,
in Clinical Practice in Correctional Medicine
Although the research did not include geriatric care in New York State
prisons, this report would not be complete without a discussion of the strain on
health care resources that elderly inmates present. In New York State prisons, men
55 and older comprise one of the fastest growing cohorts. With the reenactment of
the death penalty in 1995, which included a sentence of life without parole, many
inmates will spend their final years behind bars. Department figures show that 560
state inmates are currently facing a minimum of 50 years in prison:
•

335 are serving minimums of 50 to 74 years;

•

88 are serving minimums of 75 to 99 years;

•

91 are serving minimums of 100 years or more; and

•

46 are serving life without parole.
As the elderly become a larger percentage of inmates, correctional

administrators will confront many challenges in addressing their needs. As
discussed in the 1998 publication, The Changing Career of the Correctional
Officer:
If aging inmates are simply placed with the overall
population, they will be vulnerable to being preyed upon by
younger, healthier inmates. They are also less likely to be able
to participate physically in recreational and vocational programs
that are traditionally offered in correctional facilities. Nor, in
many cases, can they eat the same foods as other inmates,
because aging is often accompanied by more restrictive diets.
67

Meeting the housing, recreational, rehabilitative and even
dietary needs of geriatric inmates presents issues that
correctional agencies will be confronting in the years ahead.

Studies show that nearly every geriatric inmate has some long-term chronic
debilitation that requires frequent medical attention. In fact, the annual cost of
confining a prisoner age 55 and older averages $69,000 per year, about triple the
cost of confining younger inmates because of the higher rates of chronic illness
among older prisoners.
In addition, there are policy and moral implications to keeping elderly and
infirm inmates behind bars. Countless studies show that as people age, both the
tendency and the ability to commit crime decline. Housing elderly people who
pose little threat to society in nursing homes with bars defies sound prison
management when overcrowding already threatens security. In 1999, the New
York State prison system operated at 130% capacity.
Morally, too, society must examine its values when it subjects hundreds of
people to spending their final years in prison when alternative sanctions, such as
electronic monitoring, for example, exist.

68

RECOMMENDATIONS

1.

Increase External Oversight
Far too many taxpayer dollars are spent ($175 million in fiscal year 1998-

1999) on health care within prison walls for there not to be external review and
higher standards of accountability. Given the longstanding problems associated
with health care in New York State prisons and the larger public health issues at
stake when inmate health care is inadequate, more stringent external oversight is
recommended.
To this end, the Correctional Association urges the Governor and State
Legislature to appoint and fund an oversight committee charged with assuring
quality health care in state prisons. Such a committee might include correctional
health care experts and practitioners, individuals with public policy, public health
and fiscal management credentials, the commissioner and chief medical officer of
the Department of Correctional Services (DOCS), and senior officials from the
Department of Health. The committee would monitor the quality of medical
services in state prisons and have the authority to direct facility-level and systemwide change. It would disclose its findings and recommendations regularly, in the
form of a published report or conference, to the Governor, the legislative
leadership and the Senate and Assembly’s Committee on Correction and
Committee on Health. Findings should also be made available to the public.
Clearly, the challenge of providing health care to 71,000 state prisoners is
made more difficult by systemic constraints that will require budgetary changes,
union negotiation and legislative oversight to overcome. The Correctional
Association recommends that the state give serious consideration to developing
and implementing the following recommendations, and that the proposed oversight
committee guide their implementation.

69

2.

Strengthen Quality Assurance Mechanisms
Inmate health care varies greatly among state prisons and no meaningful,

coordinated quality control program exists to regulate care. To raise the quality
and uniformity of prison health care, a commitment to quality assurance must be
articulated by the chief medical officer, practiced by facility health services
directors and evaluated regularly by regional medical directors. Specifically, the
Department should:
•

Design and implement a system-wide quality control protocol to guide
practitioners in improving and evaluating the quality of inmate health care.

•

Conduct yearly medical audits at each prison. The Department should
publish and compare audit findings, including the number of medical
grievances among prisons as a way to stimulate improvements. Baseline
numbers should be established, and the Department should require action
plans for lowering grievances in those facilities with above average
grievances.

•

Include the performance of health care staff and the number of medical
grievances in the annual performance evaluations of state correctional
facilities.

•

Encourage accreditation by either the National Commission on
Correctional Health Care (NCCHC) or the Joint Commission on
Accreditation of Health Care Organizations (JCAHO). These agencies are
known for rigorous audits and higher standards of evaluating correctional
health care than the American Correctional Association.

70

3.

Increase Salaries of Medical Staff
Prison medical personnel earn considerably less than their community-

based counterparts. The quality of inmate health care will likely not improve
unless the Governor and State Legislature increase the salaries of medical staff to
make them competitive. In addition, there is little difference in the annual wages of
regional medical directors, facility health services directors and prison physicians,
and therefore little incentive for advancement. The Correctional Association
recognizes that the salaries of state health care providers are determined by the
Department of Civil Service (not DOCS) and that it will take collective bargaining
to increase them. It is recommended that state legislators work with the appropriate
union representatives, DOCS and Department of Civil Service officials to:
•

Make the salaries of prison health care providers competitive.

•

Stratify the levels of compensation among regional medical directors,
facility health services directors and prison physicians.

•

Enhance the salaries of physician assistants, nurse practitioners and
pharmacists significantly. Increased pay for these positions, in particular, is
essential.

4.

Raise Qualifications of Physicians
For many of the physicians the Committee interviewed, the prison clinic

appeared to be the employer of last resort. Lack of board certification, training in
primary care and the leadership skills necessary to manage a busy prison clinic
emerged as common problems. The Committee recommends that the Department
of Civil Service and DOCS:

71

•

Require higher qualifications for facility health services directors. A
minimum standard of Board eligibility (which requires completion of an
approved residency program) and a preference for Board certification in
internal medicine or family medicine should be considered. Leadership
ability and communication skills should also be more carefully evaluated in
hiring decisions.

•

Explore ways to terminate unqualified medical staff more expeditiously.
Having to recall a physician’s medical license in order to terminate
employment (as an official reported is sometimes the Department’s only
recourse) is a profound indication of misguided policy.

5.

Stop Subsidizing Health Care with Family Benefit Fund Monies
Since fiscal year 1995-1996, the Department has used over $50 million

from the Family Benefit Fund to subsidize inmate health care. The Family Benefit
Fund was created to help the families of inmates maintain important ties with
loved ones behind bars, not to pay for health care, which is clearly a state
responsibility. The Department currently supplements the Fund with commissions
(“kickbacks”) it receives from phone companies, to which it awards lucrative
phone contracts. Recipients of prisoner phone calls (inmates can only make
“collect” calls) are charged $1.10 per minute for long distance calls. Therefore, it
is prisoners’ friends and family members—the majority of whom live in New York
City’s poorest neighborhoods—who are subsidizing inmate health care. In addition
to not using Family Benefit Fund monies to subsidize health care, the Department
should:
•

Solicit bids for new telephone contracts that offer no kickbacks to the state
and that provide the lowest rates possible.

72

•

Consider issuing inmates pin numbers as is done in New York City jails.
This way, funds for calls can be deducted from commissary accounts and
inmates are not restricted to making collect calls only.

6.

Broaden and Expedite Recruitment
Staff shortages and long-term vacancies compromise the quality of care in

many prisons. Despite increases in the prison population in the past decade,
staffing levels have remained virtually the same in many clinics. Such critical
positions as facility health services director go unfilled for months, in some cases
years. In addition, more aggressive efforts should be made to increase minority
representation among medical personnel. Health care providers who understand
the cultural and psychosocial issues of inner-city patients are needed throughout
the system. The Department should:
•

Recognize the serious burdens that clinic vacancies place on existing staff
and develop creative, more effective ways to expand and expedite
recruitment. Better efforts should be made to re-deploy existing health care
staff to cover unfilled positions.

•

Offer a loan payback system for graduates of New York City or New York
State medical schools. Physicians accustomed to working with inner-city
patients are more likely to be familiar with the language, culture and
ailments of New York State prisoners.

•

Develop relationships with primary care residency programs in city
hospitals to attract graduates who will look favorably upon loan repayment
options.

•

Consider sponsoring or piloting a residency training program in a prison
clinic to improve recruitment.

73

7.

Augment Training of Medical Staff
Appropriate officials at DOH, the State University of New York (SUNY)

and teaching hospitals throughout the state should work with DOCS to:
•

Train facility health services directors and staff physicians in Continuous
Quality Improvement, the clinical management of HIV/AIDS and hepatitis
C, and methods for addressing the psychosocial needs of inmate-patients.

•

Provide training modules in the identification of infectious diseases and
opportunistic infections for all medical personnel who conduct sick call.
Restrict sick-call assignments to those individuals who have received this
training.

•

Offer special training for and evaluation of nurses who conduct sick call.
Nurses should be required to take vital signs and document information on
medical charts and be better skilled at distinguishing between (and coping
with) malingering inmates and those with genuine health care concerns.

•

Require facility health services directors to offer nurses support and
guidance on how to handle inmate complaints, identify depression, deescalate conflict and reduce grievances.

8.

Expand HIV/AIDS Testing, Tracking, Education and Prevention
The Department lacks a statewide quality assurance program for the

clinical management of HIV/AIDS. Twenty-five site visits revealed uneven care of
HIV+ patients, too many health care personnel untrained in the clinical
management of HIV/AIDS, and wide variations in the availability of HIV testing,
support services and education. To avoid the public and personal health care costs
associated with poor HIV/AIDS management, the Department should:

74

•

Encourage every inmate who enters the system to take an HIV test.
Prisoners should be offered testing opportunities every three to six months
thereafter since inmates are often deluged with information upon entry and
likely to postpone testing. More inmates should be receiving primary
treatment of HIV sooner rather than later.

•

Increase funding for the Criminal Justice Initiative so that the established
goal of providing the full range of HIV services in each prison can be
realized.

•

Distribute (in writing or on video) educational materials on HIV/AIDS, in
English and Spanish, to all inmates, not just those considered high-risk or
known to be infected.

•

Strongly encourage inmates who are diagnosed with HIV to begin lifeprolonging treatment. More opportunities for pre- and post-test counseling
and peer education and support groups should be offered.

•

Recognize the existence of high-risk behavior among inmates that leads to
the spread of HIV/AIDS (sexual activity, intravenous drug use and
tattooing). As other correction departments throughout the country have
safely done, the Department should help prevent transmission by making
condoms available to inmates requesting them from the clinic.

9.

Expedite Computerization of Medical Records System
While some states are experimenting with such innovations as inmate

“smart cards” that store a patient’s entire medical history and future appointments
on a memory chip, many New York prison clinics still operate with manual
appointment logs and medical records. Lack of a uniform, computerized medical

75

system results in serious and costly problems: Inmate charts and medical records
are lost during transfers to other facilities; chronically ill patients miss
appointments and critical follow-up procedures. While DOCS has begun the
complicated process of computerization, it is critical that state officials:
•

Immediately allocate the funds and resources needed to expedite the steps
DOCS has taken toward computerizing its medical system.

•

Explore ways to link the medical records systems of the New York City
and New York State corrections departments so that costly tests
administered in city jails are not repeated unnecessarily, days later, in state
facilities.

10.

Improve Care of the Chronically Ill
Inmates with chronic conditions, such as asthma, diabetes, HIV/AIDS and

heart disease, are insufficiently monitored by prison health care staff. Important
follow-up appointments to determine medication adjustment and adherence and
changes in a patient’s condition are frequently missed because no single doctor
examines and treats the same patient regularly. The Department’s pilot practice of
assigning inmate-patients to a single primary care provider in prisons is a step in
the right direction. The following steps also should be taken:
•

Designate a chronic health care services coordinator at each prison to
ensure that regular services and treatments, as well as outside specialty care
appointments, are scheduled and completed in a timely manner.

•

Assign every inmate who has a chronic condition to a regular primary care
provider who coordinates medical services, educates and counsels the
patient and monitors medication adherence and response to therapy.

76

•

Use incarceration as an opportunity for patient education and devise
innovative programs for that purpose. At Green Haven, for example, a
nurse is developing an inmate health education program that will be
broadcast on the prison television station.

•

Create and distribute in English and Spanish disease prevention brochures
and guidelines for living with chronic illnesses. Such measures encourage
inmates to take responsibility for their health, mitigate the costs of serious
and preventable illness, reinforce doctor recommendations, and save
precious medical staff time.

11.

Respect Physician-Patient Confidentiality
In the closed and idle world of prison, rumors and gossip spread quickly.

Personal information can be used by inmates and staff to embarrass and humiliate
inmates. Many prisoners complained about instances in which medical personnel
and/or correction officers disclosed confidential medical information, which was
later used against them. To address this problem, DOCS should:
•

Emphasize in staff training the community standard of physician-patient
confidentiality. Inmates’ medical information should be restricted
exclusively to health care providers, unless the security of the institution or
the well being of staff or inmates is seriously threatened.

•

Eliminate security staff involvement in sign-up procedures for sick call.
Consider installing locked boxes throughout facilities, accessible only by
medical staff, in which inmates place requests for sick call.

•

Announce call-outs for health services as general medical appointments,
not HIV-specific, mental health-specific or other dead giveaways such as
“Time for psych meds,” as inmates at one facility reported to researchers.

77

12.

Increase Language Translation Services
There are over 7,000 Spanish-dominant inmates throughout the New York

State prison system. Researchers received reports of Spanish-speaking inmates
who were given medical information they did not understand, drug prescriptions
they could

not

read

and

generally

substandard

health

care

due

to

miscommunication. The following recommendations should be implemented so
that the needs of a significant and growing population of prisoners can be met:
•

Give written—as well as oral—instructions with all new prescriptions. This
information should be readily available in Spanish if needed.

•

Require that at least one member of the medical staff, and more members
in facilities with significant percentages of Spanish-dominant inmates, be
fluent in Spanish.

•

Expand use of AT&T’s telephone interpretation service, which provides
instant translation in 17 languages. This service is currently used by intake
screening staff at Downstate Correctional Facility.

13.

Supplement Social Services for Female Inmates
Female inmates suffer more from clinical depression than male inmates,

mainly because of the profound despair they feel at being separated from their
children. In conjunction with the New York State Office of Mental Health, the
Department should:
•

Increase funding for social workers for individual and group counseling.

•

Open a family reunion program at Albion Correctional Facility (the largest
women’s prison in the state) to help female prisoners cope with separation

78

from their children, strengthen family ties and prepare family members for
the inmate’s return.
•

Contact women’s organizations in the community for volunteer speakers,
mentors and post-release services.

14.

Address Long-term Health Needs in Discharge Planning
The Department releases approximately 30,000 inmates annually. With the

exception of HIV+ inmates, who receive a month’s supply of medication at
discharge, inmates with chronic medical conditions are released without even a
prescription. Obviously, most prisoners do not have jobs with medical benefits
awaiting them in the community and must rely on Medicaid to cover their medical
expenses. However, the New York City agency that oversees public assistance and
Medicaid (The Office of Human Resources Administration) takes a minimum of
45 days to process applications, which presents serious problems for inmates who
need medication daily and/or medical treatment regularly. It is recommended that:
•

The appropriate federal, state and city agencies work together to ensure that
the medical needs of ex-offenders, particularly the elderly and those with
chronic illness, are met at least temporarily in the community.

•

Prison medical staff and correction counselors begin transitional planning
for inmates with HIV/AIDS and other chronic or life-threatening
conditions at least six months prior to release.

•

Discharge planning be conducted by trained counselors (not inmates) in
each prison, who are able to identify community resources, process
paperwork and guide inmates in how to access treatment upon release.

79

15.

Take More Proactive Steps to Manage Hepatitis C
The steps the Department has taken in addressing hepatitis C—issuing

treatment guidelines, initiating testing and hosting an educational conference—are
steps in the right direction. However, given the prevalence of the virus in prisons
throughout the country, the high cost of treatment and the complexity of treatment
regimens, New York health officials might be wise to:
•

Work with DOH and SUNY to enhance diagnosis and treatment
procedures. (The Virginia Department of Corrections, for example, is
collaborating with the University of Virginia to develop a telemedicine
program to treat infected inmates.)

•

Offer hepatitis C awareness and prevention information to all inmates,
correction staff and health care providers.

•

Since the virus is easily transmitted through sexual contact, make condoms
available to inmates through sick call.

16.

Provide Alternatives to Incarceration for Elderly Prisoners
The growing number of elderly inmates presents significant fiscal, policy

and moral dilemmas. Given that the health care costs for geriatric inmates is triple
that of younger inmates and the likelihood of re-offending by elderly prisoners is
low, many states have adopted compassionate release programs and alternatives to
incarceration such as electronic monitoring. New York lawmakers should reexamine the value of mandating that hundreds of people spend their final years in
nursing homes with bars, and do taxpayers, correction staff and elderly inmates a
service by following their enlightened colleagues from other states, such as
Virginia, Maryland and Louisiana, in identifying more humane alternatives for
elderly prisoners. The Governor and state legislature should:

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•

Endorse and enact Senate Bill 2582A and Assembly Bill 00257A, which
would provide for the geriatric parole and electronic detention of elderly
inmates who no longer pose a threat to society.

81

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