"Do no harm" or "Do no
prisoners are dying from inadequate medical care
By Peter Wagner
written November 2003
August, the Columbus Dispatch and WBNS-TV published a multi-part
exposé of the inadequate medical care in Ohio's prisons. The
series exposed wrongful deaths, inadequate care and questionable
doctors. Almost 2,600 Ohio prisoners are known to be infected
with Hepatitis C and health officials estimate the true figure
to be closer to 9,000. As of July, the number of prisoners
receiving treatment for Hepatitis C was 16. In September, the
Prison Reform Advocacy Center in Cincinnati filed a class action
lawsuit challenging these conditions.
The attention from the series brought shock from the Department
of Corrections and Rehabilitations, but the problems appear to
be the result of neglect engineered at the budgetary level.
This year Ohio will spend $122.6 million on prison health care.
That's not counting the $1.15 million in judgments and
settlements over the last 3 years. This year, 25 of the prisons
had their health care budgets cut an average of 11%. While
medical care costs have risen 19% nationally since 2000, Ohio's
spending on prison health care has risen just 9%.
2002, the DRC's health care director Kay Northrup asked medical
providers to change their message to prisoners when denying
care. Instead of explaining that a treatment refusal was based
on budgetary reasons, doctors were to give out only clinical
explanations. A year earlier, she ordered prison podiatrists to
stop ordering special footwear for prisoners with unable to walk
in the stiff-prison issued "shoes". Admitting that the cheap
shoes caused many foot problems, she restricted the doctors to
ordering replacements only for diabetics who developed foot
ulcers. The remainder of the injured were left, in the words of
the Columbus Dispatch "hobbled".
Restricting care, $3 at a time.
Ohio charges a $3 co-payment on medical visits to discourage
them. The DRC director implies the fee cuts down on frivolous
visits without impacting good health care, but administrators at
Pickaway and Belmont Correctional Institutions disagreed when
they suspended the fees after an outbreak of staph infections.
The co-payment has raised $1.7million since 1998 intended to
fund expensive equipment purchases, but $1million of the money
Three dollars for a medical visit may not seem like a lot of
money to people on the outside, but Ohio prisoners make only
$18-24 a month. The Columbus Dispatch estimated that the $3
copayment would be the "equivalent of $594 to the average Ohio
household earning $47,521 a year."
One of the doctors highlighted in the Columbus Dispatch was Dr.
Adil Yamour, whom the London Correctional Institution's health
care administrator requested be replaced because he "orders
ibuprofen for everything, regardless of the diagnosis." The
situation gets more frightening when you factor in his defense:
he was asked to see 70 to 93 prisoners in an eight hour shift.
Yamour was also criticized for telling prisoners he could not
order certain procedures or medications because of lack of
funding, which he claims was true. In any event, this doctor who
the Department of Corrections and Rehabilitation thought should
be replaced was let go, and then started treating patients at
Pickaway Correctional Institution via contractor Clinicare.
This may not be an extreme case. Dr. Shura Hedge was fired in
2001 after he was caught spending only 10 minutes to give full
mental health evaluations, and he was giving the same assessment
scores to 30 of 31 prisoners, "some of whom where psychotic." He
was hired by the privately-operated state prison across the
street. The Columbus Dispatch identified two other medical
workers who were fired or non-renewed and then resurfaced at
other prisons. Although the state has veto rights over the
personnel decisions of its private prison operators, Hedge is
still working at his new prison.
apples in rotten prison barrel
These bad apples are a structural product of Ohio's policy of
relying on outside contractors on lump-sum contracts. While the
contractors do comply with requests to remove problematic
doctors, no company has ever lost a contract for poor
performance. The results are as unfortunate as they are
unsurprising because the prisoner-patients are powerless and the
DRC fails to require quality.
Likewise, the state has failed to do background checks in a
timely way for its doctors. Dr. Ayman Kader worked in two Ohio
prisons for more than a year while under a 35-count felony
indictment for drug trafficking and writing bogus prescriptions
Complicity for the poor care runs to the top. "We do have to
tolerate a different standard sometimes because it's hard to get
people to come and work in the prisons to provide medical care,"
says the DRC's spokeswoman Andrea Dean. (See sidebar,
International law and prisoner health for more on this
The contractor who hired Kader and called him "one of our most
valued, cooperative physicians" echoed a similar sentiment to
Dean: "People do not go to medical school dreaming of some day
working in a maximum security prison." The medical providers can
be glib that "you get what you pay for" because they make a
profit by providing doctors -- inferior or otherwise -- to the
prison. The Department's tolerance of the problems is harder to
understand, unless adequate care is of no concern.
Working in a prison is not a prestigious job, but the pay scale
reinforces rather than addresses the problem. While the
comparative pay received by Ohio's contractors was not
available, other data collected by Human Rights Watch suggests
that poor performance of prison doctors is by design, not
accident. In Maine, a psychiatrist would make $20,000 less
working in a prison than in the community. Virginia pays its
prison psychiatrists $3,251 less per year than it pays school
Ohio reduced prison medical costs by first replacing its own
doctors with contractors paid on a per-hour basis and then with
a series of fixed-rate contracts. Each year's winning bid
becomes the maximum amount the Department will pay in the next
year. Under the hourly contractor system, Ohio paid $312,000 in
wages at the typical prison in 2001. The current figure is
$175,000, or 56% less.
to medical neglect
Unlike other victims of poor medical care, prisoners don't have
the ability to get a second opinion. Instead, prisoners are
required to file administrative grievances. Attorney Alphonse
Gerhardstein summarized the procedure: "The medical grievance
goes to a bureaucrat, the bureaucrat then sends it to the
medical staff, who then say, 'We're giving fine care. What's the
inmate griping about?' Then they send the grievance back and
The state's own consultant recognizes the medical grievance
system is broken, suggesting in 2001 that the grievances get
independent medical review. No action was taken. And perhaps the
State likes the lack of oversight. The legislature's
Correctional Institution Inspection Committee, which is supposed
to oversee the prison systems, has gone without funding for
staff for two years and this year is getting funding at only
half of its previous amount.
What needs to be done is obvious. As Dr. Ronald Shansky, the
former medical director of Illinois prisons told the Columbus
Dispatch, that Ohio "'needs an independent, outside team of
correctional medical experts' to review prison medicine.... 'If
the concerns are serious, the state should want to know. Is it
getting a bang for its buck or is it creating liability?'"
The Department has created a commission to study the issue and
recommend changes. The report, due at the end of the year should
provide a clue as to whether Ohio policymakers want to provide
adequate health care for its incarcerated citizens or adequate
salaries for Department lawyers to defend lawsuits.
The Commission has hired the former head of the New Mexico DOC
to assist, but the commission is all Department employees
including Kay Northrup, the Deputy Director of the Office of
Correctional Health Care and author of the memo instructing
doctors to not tell prisoners the truth: that financial
restrictions are determining their treatment.
Worse, perhaps, is the message sent to the Commission by the
Department's Director, Reginald Wilkinson. He acknowledges that
reforms may cost money, but he's "not throwing in the towel on
money at this point" in the hopes that the Commission finds new
ways to further cut the medical budget.
Sources: Columbus Dispatch,
Human Rights Watch, Ill Equipped: U.S. Prisons and Mental
Illness. The Andrea Dean quote can be seen online in the August
25, 2003 Cincinnati