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Life Sentences: Women, Prison and the Invisible Health Crisis

Women's Health Activist Newsletter
November/December 2003
by Leah Thayer

Prostitution isn’t normally a capital offense, but it was for Lisa Watson. Watson, the pseudonym of an actual prisoner in the Central California Women's Facility, had just begun a four-year sentence for prostitution when she started experiencing debilitating headaches that left her unable to stand or function.1 A CT scan performed at the prison revealed a tumor and Watson feared the worst, as her father had died of brain cancer at age 51, and her own HIV-positive status made her susceptible to opportunistic forms of cancer. She urgently needed to see a neurosurgeon — the only person capable of determining the tumor's cause, malignancy and treatment plan.
It took a full six months before Watson saw the specialist, and only then with advocacy assistance from Justice Now, a non-profit organization providing legal services for women prisoners.2 Although the tumor turned out to be benign, it had grown so much during the six-month delay that it became entangled with Watson's brain stem, threatening her life. An emergency craniotomy was performed to remove as much of the tumor as possible. As described by Justice Now cofounder Cynthia Chandler in an article on women in prison: "Less than a week after her surgery, she was returned from an outside hospital to the prison, where I met with her the next day. During our visit. Lisa did not talk about the pain she was in, her anger at the delayed treatment she received, or the legal case she had begun on her own behalf against the state for negligent care. Instead, she told me of her fear that she would not be able to keep the incision on her head clean and her dressings changed. She told me how, since she had AIDS, she would die if it became infected, and she would never get to see her daughter again. Lisa died two weeks later, after an abscess developed in her wound."3
The nation's prison system is rife with stories like that of Watson. Locked up for crimes related to poverty and addiction, denied access to basic hygiene or control over their bodies, isolated from families and friends, and routinely subjected to medical neglect, mistreatment and abuse, women prisoners are at the center of an epidemic of preventable illness, unnecessary suffering and premature death. There are no official numbers on how many women die in prison each year; although state corrections departments are "supposed to release their morbidity and mortality statistics, we've never been able to get those statistics," said Chandler in a phone conversation "There's an incredible lack of accountability. But even if they did release the report, I would be very skeptical." Her organization has found that if a patient has a chronic illness and dies, that illness is listed as cause of death, no questions asked.
Which brings us back to Lisa Watson. Because she was HIV-positive, the California Department of Corrections classified her death as expected and HIV-related. In fact, she died from an infection that developed because life behind bars made it impossible for her to keep her wound clean.
The Punitive Response
These are heady times for the nation's prisons, especially those that house women. From 1977 to 2001, the population of women in federal and state prisons grew by 592 percent, compared to 338 percent for that of male prisoners. During 2OO2 alone, the ranks of women in these prisons grew 4.9 percent (double the rate for men) to 97,491, with tens of thousands more in local jails.4
Although the numbers might suggest that women have become more violent, the opposite is true. The Bureau of Justice Statistics (BJS) admits that "the rate at which women commit murder has been declining since 1980."5 Instead, women's surging incarceration rates correspond to what Chandler calls a shift from welfare to crime control the war on drugs, zero-tolerance policies and other politically popular means of addressing "social problems and human suffering with a punitive response ... [that] arguably renders some of the most vulnerable people in our society the most vulnerable to imprisonment."6
At the same time, the widening gap between rich and poor has driven more women into poverty, exacerbating any sense of powerlessness they may already have. Chandler, a Harvard-trained lawyer who has represented hundreds of women prisoners in California, noted that "the more stigmatized an individual is, the less likely she is able to exercise any techniques to take care of her health and wellness." And the more likely she is to engage in "survival behavior," such as sex for money and self-medicating with drugs, and "to be targeted by law enforcement for surveillance." Women of color are affected disproportionately. The Sentencing Project, citing BJS statistics, notes that 43 percent of women prisoners are African American and 12 percent are Latinas, and that these women are significantly more likely to be incarcerated for a drug offense than white women.7 An African-American woman is more than seven times as likely as a white woman to spend time behind bars.8
Chandler added that the rising political sway of the pro-life movement has capitalized on women's vulnerability as well. Women have been "sentenced to life for allegedly causing miscarriage or stillbirth. I just heard a case of a woman being sentenced for child neglect for drinking while pregnant." A chilling consequence of such prosecutions is that many pregnant women with drug or alcohol addictions opt to forego any treatment — even prenatal care.
Mortin for Cancer: Systemic Abuses
However you dissect the incarceration boom, the sum of its parts is a steady influx of women entering prison with serious medical and emotional disorders (see bottom of article, “The Prison Health Index”). Yet many people, even those who consider themselves progressive - feel that women prisoners are lucky to have any health care at all, given that millions in the "free world" have none. Chandler acknowledged this paradox, noting that prison has become one of the few places where poor people can get health care. But she pointed out that "prisoners don't take health care away from anyone." More importantly, the medical attention they receive in prison "is almost more the appearance of health care." Behind the flimsy facade are these realities:
• Inadequate, indifferent or incompetent medical attention. California has just one skilled nursing facility (with approximately 50 beds) tor more than 11,000 women prisoners. Nationwide, pain management is inadequate or nonex istent — prison officials tend to believe that prisoners just want the drugs to feed their addictions. Wrote Chandler: "One of my clients with metastasized breast cancer was refused pain management stronger than Motrin until the cancer had spread to her bones and had fully eaten away both of her hips." Prisons sometimes medicate and or operate on prisoners without informing them of their diagnosis or asking their consent. Women prisoners undergo surgery, give birth and even die while chained to their hospital bed. Prisoner advocates also question the quality of prison physicians. Civil Service rules do not require prison doctors to be board-certified tor specialties, according to an article in the Poughkeepsie Journal. "It's almost equivalent to a lawyer not passing the bar," said an official with the Correctional Association of New York.9
• Additional risk factors inside prisons. Even if they enter prison relatively healthy, "[incarceration itself can increase the risk of infection, sexual assault, and improper medical care or contribute to posttraumatic stress disorder," according to an article in the American Journal of Public Health.10 Tattooing -- common in prisons -- spreads the hepatitis C virus, but prisons have no sterile tattooing tools. Result: prisoners reuse ink wells with the live virus in the ink. Likewise, intravenous drugs are readily available, but safety paraphernalia such as bleach and syringes are either nonexistent or prohibitively expensive. Guards routinely pressure inmates into sex, using their power to convince the women that the relationships are consensual when the women know that saying no can lead to their loss of basic services or rights.
• Denial of basic nutrition and hygiene. Once their immune system is compromised, prisoners must fight an uphill battle to maintain their health. An estimated 5 percent of hepatitis C-infected inmates receive drug treatment.11 Even without drugs, most people with the virus find that eating lots of fresh fruits and vegetables keeps the virus in check. But food in women's prisons is notoriously unhealthy - not one has a salad bar, though several men's institutions do. "A salad bar sounds trivial, but it could really make a difference for someone with hepatitis,” said Chandler. Even basic hygiene products are restricted. California prisoners' monthly ration of soap is a travel size bar that they must use to clean their bodies as well as their cells.
• A system modeled on men. Prisons are an economy of scale, and since male prisoners far outnumber women they also tend to set the standard of care. Chandler noted that a review of prison medical records showed that women inmates with hepatitis B were being given "the dosage that would normally be prescribed to a 200- pound man." Gynecological care "is treated as a specialty service" and is thus "the first to go if there's a financial problem." Another example, from Chandler's article: "The California Department of Corrections terminated women prisoners access to special medical diets such as low-sodium, high-protein, or low-sugar diets for women with heart disease, liver disease, or diabetes respectively — unless women are housed in a skilled nursing facility." This policy change did not affect male prisoners. Staples of women prisoners' diets include the likes of pancakes, bologna, American cheese, chips, corn dogs, potatoes and Jell-o. California also spends half as much money on women prisoners' food as on men's $1.25 a day vs. $2.45.
• Prison profitability "at any human cost." Chandler calls the current push to turn prisons into profitable enterprises one of the most significant factors (along with the shift from welfare to crime control) impacting prisoner health. The trend puts nearly all prisoners to work (refusing to work can prolong a sentence) while allowing the companies that employ them to pay pennies an hour.12 It also results in prison commissaries selling basic items like soap, toothpaste and relatively healthy alternatives to prison food at grossly inflated prices. "Within this economy of human chattel," wrote Chandler, "there is no space for the sick or permanently disabled." She cited a former client who broke a foot, then, by overcompensating for the foot, developed an ulcer on the other foot. "Since she is a diabetic, the ulcer would not heal. She could not walk or stand, and the ulcerated foot was gravely infected. Yet the prison refused to recognize her medically compromised status. She continued to be assigned a job requiring that she stand during an entire shift." A year later, her wound "has escalated to the point at which a bone now protrudes from her foot," and amputation may be necessary.13
Amid these conditions, incarcerated women are physically and emotionally isolated from their families and communities. Most prisons constructed during the building boom of the 1980s and '90s are in remote rural areas far from public transportation. Even prisoner advocates, lawyers and the media are thwarted by restricted visitation policies, restricted litigation rights and severely capped attorney fees. Without outside assistance, women prisoners have few means of filing grievances against the prison system. Phone usage is monitored as well as prohibitively expensive (prison phones generate as much as $1 billion in profits each year for prisons and the phone companies they use).14 And although "most prisons have set up complaint procedures, they're inherently flawed when they ask the prison to police themselves," observed Chandler.
Hope From the Underground
It's difficult to imagine a happy outcome tor many women prisoners, but a few budding trends suggest that some former inmates perhaps even a growing percentage of them will reenter the free world with a stronger sense of their empowerment and individual rights. A significant force behind this hope is peer-education programs in which health professionals train prisoners to take care of their own health, and the prisoners go on to train others. (It would be difficult to understate the need tor this kind of education. A letter from an inmate at the Federal Medical Center at Carswell, Texas, where some 1,400 women inmates are treated, said the center has exactly one book on hepatitis, one book on lung and breast cancer and one book on HIV/AIDS.16)
Momentum is also building tor rape crisis training -- teaching prisoners how to set up their own rape-crisis centers. Not surprisingly, prison officials don't always support these programs, noted Chandler, so her organization sometimes "funnels information underground" to circumvent authorities. "It takes a lot of perseverance to get in, but the prisoners are extremely grateful."
Finally, more people are challenging the prevailing argument in favor of imprisonment for even minor infractions. A growing body of research shows that prisons are not the economic forces many perceive them to be, and in fact drain local economies by putting enormous wear and tear on the infrastructure and the environment, among other factors. Similarly, individuals are questioning whether prisons actually make them safer. The reality, according to Chandler, is that aggressive imprisonment "has alienated many people of color and is contributing to the fragmentation of families in communities of color." This emerging thinking has fostered the rise of grassroots groups that want to redirect public funds from prison development to programs that make life outside prisons healthier in the first place. California's Education Not Incarceration (, consisting of politicians, teachers, students, parents and unions, noted that the state's 2003 - 04 budget called to cut $11 billion from K- 14 education while adding $40 million to prison spending — the only area of spending slated for an increase.15
Asked what steps ordinary individuals can take to improve the health care of women prisoners. Chandler suggested that "they look at this differently than they would a health issue in the outside free world," where the common approach is to ask for more money. When prisons get money, "they don't put it into health care; they put it into guards and buildings," thus decreasing the pool for services "that make communities stronger." To that end, she recommended contacting legislators and asking that they decrease prison funding and increase funding for services such as education and universal health care.
What Else Can You Do?
• Intervene if you know somebody who has been arrested. Educators, social workers, legal aid workers, medical providers and "basically anyone who works with all races" can have a profound influence by writing a quick letter to a judge, said Chandler. She suggested outlining the person's medical history and explaining why it's important that the person get health care in the community. (Sample letters are available from Justice Now:
• Build awareness of prison life within your own community. Organizations that work with prisoners and give presentations to community groups include the ACLU Prison Project (, Citizens United for Rehabilitation of Errants ( and the Prison Activist Resource Center (www.prisonaetivist. org) .
• Organize health fairs inside prisons. Besides rape-crisis training and peer-education training, as noted earlier, possibilities include teaching battered women how to improve their self-esteem and how to stop the cycle of violence.
The Prison Health Index
• Odds that a woman prisoner was using alcohol, drugs or both when she committed the offense for which she was incarcerated: one in two
• Reason one-third of women in prison committed the offense: to buy drugs
• Percentage of women prisoners who had experienced physical or sexual abuse prior to incarceration: 60
• Likelihood that a U.S. prisoner is mentally ill: one in six
• Prevalence of mental illness among inmates versus that among the general population: three to one
• Percentage of women prisoners who are mothers: 80
• Percentage of incarcerated women in the District of Columbia who are HIV positive: 41
• Percentage of incarcerated women in New York State who are HIV positive: 18.2
• Chances that a woman prisoner in California is infected with the Hepatitis C virus: between 40 and 60 percent.

Leah Thayer is editor of The Women's Health Activist.

1 Watson’s story and other parts of this article (as indicated) were excerpted from "Death and Dying in America: The Prison Industrial Complex's Impact on Women's Health," by Cynthia Chandler. Berkeley Women's Law Journal Volume 18, 2003, and clarified in two phone discussions and follow-up e-mails with Chandler.
2 As noted in an e mail from Chandler. Justice Now advocated for Watson to see a neurosurgeon for six months. "During that period, she was sent to a neurosurgeon times by the prison, but each time the prison forgot to send the ct scan with her and the specialist had to send her back untreated.... It was tragically comical. After months, she finally got the tests and ct scan review required to diagnose/treat the tumor."
3 Chandler. "Death and Dying in America."
4 Women's Prison Association & Home. Inc WPA Focus on Women & Justice. August 2003.
5 Bureau of Justice Statistics Special Report: Women Offenders December 1999, revised October 2000.
6 Chandler. "Death and Dying in America.
7 The Sentencing Project. Factsheet: Women in Prison. May 2003.
8 Nicholas Freudenberg, "Adverse Effects of US. Jail and Prison Policies on the Health and Well-Being of Women of Color," American Journal of Public Health, December 2002.
9 Mary Beth Pfeiffer, "Prison is riskiest for the sick." Poughkeepsie Journal, January 5, 2003.
10 Freudenberg, "Adverse Effects."
11 According to Michele Bonan, assistant legislative affairs director for the Gay Men's Health Crisis, quoted in "Inmates' health care is in crisis, panel told." By Mary Beth Pfeiffer, Poughkeepsie Journal, November 15, 2003.
12 In California, "prisoners collect seven to thirteen cents per hour, on average." From Chandler. "Death and Dying in America." citing California Department of Personnel Administration, Fair Labor Standards Act Manual.
13 Chandler, "Death and Dying in America.”
14 Robert Tanner. The Associated Press. March 30, 2003.
15 Education Not Incarceration Final Report, available at
16 Letter from Carolyn McGuire, July 2003.