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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

Prisoner plagues
Thousands of untreated seriously ill prisoners are being released into communities across the US according to National Institute for Justice report

Against the backdrop of the bombing of Baghdad and the president's emergency request for nearly $75 billion in new money to conduct his war in Iraq, the last thing on most people's minds is spending money on health care for prisoners. Yet, if the government continues to disregard the explosive situation developing in prisons and within communities where released prisoners reside, there will be a health care crisis of epidemic proportions.

Tens of thousands of prisoners suffering from undiagnosed or untreated communicable disease, chronic disease and mental illness are being released into communities around the nation. And thousands more are scheduled for release in the next few years. The human costs to the health of our neighbors, and the financial well being of states, counties and cities across the country is already threatened. That's the conclusion of a report completed nearly two years ago, but inexplicably held since then by the National Institute of Justice.

Former prisoners with Hepatitis C, tuberculosis, AIDS and a battery of mental health problems are a ticking time-bomb for their families and friends as well as other members of the communities in which they live.

The report, "The Health Status of Soon-To-Be-Released Inmates: A Report to Congress," was produced by the privately-run National Commission on Correctional Health Care and sponsored by the National Institute of Justice (NIJ), "the Research, Development, and Evaluation Agency of the Department of Justice." It was finally released to the public, through the initiative of its author, Dr. Robert Greifinger, at a January 2003 conference of prison medical officers in San Antonio, Texas, a meeting sponsored by the Centers for Disease Control and Prevention.

Dr. Greifinger's study points out that "each year the Nation's prisons and [county and city] jails release more than 11.5 million inmates... [many of whom] may be contributing to the spread of infectious disease in their communit[ies]." Because prisons generally provide less than adequate health care services to its inmates, "society may have to pay substantially more to treat them than if these conditions had been treated at an earlier stage -- or prevented altogether -- while these individuals were still incarcerated."

Why aren't prisoners given adequate health care services in prison? As the report observes, there are a number of "political, logistical, and financial barriers" to doing so, most of which can be overcome. "I think this is the largest untapped public health opportunity in the country," Dr. Greifinger said in a telephone interview. "If we are going to put public health dollars anywhere, this would be the biggest bang for the buck, the best opportunity to save lives and money by focusing on prevention, early detection, and treatment according to nationally accepted guidelines, than any other health problem we are not yet dealing with." Although the returns would take a few years to be realized, he added, "the potential financial savings would be great."

When asked if there is the political will to deal with this problem, Dr. Greifinger said that unfortunately "public policy makers have little insight into the rewards from this investment. The fact that these are prisoners allows people's prejudices to surface; they think that any services to inmates are perquisites, but they aren't." In addition, the reality that millions of Americans outside of prison lack adequate health care services makes improving prisoners' health care a hard sell politically; most politicians will avoid championing this issue like, well, the plague.

In 2000, about nine million people were released from jail and prison, according to Allen J. Beck, of the Bureau of Justice Statistics, the statistical arm of the Justice Department. "This is a public health problem that has been growing and growing, but we are reluctant to do anything about it because these are bad guys," said Dr. Greifinger, a former chief medical officer for the New York State Department of Correctional Services.

An American Civil Liberties Union (ACLU) press release declared that "nearly 330,000 imprisoned individuals tested positive for Hepatitis C in 1997 and approximately 1.4 million Hepatitis C-infected individuals left prison or jail in 1996. And," the press release continues, "Hepatitis C is not the only threat from sub-standard prison health care; ex-inmates comprised 35 percent of the U.S. population infected with tuberculosis in 1996 and accounted for 17 percent of the AIDS infected population."

The federal government funds the Federal Bureau of Prisons, which represents only a fraction of the prisons in the country. Each state operates its own correctional system and each county operates its own jail. Therefore, says Edward Harrison, President of the National Commission on Correctional Health Care (NCCHC), there is really no one place where you can find a comprehensive picture of how much money is being spent on prisons nationally, let alone on healthcare for prisoners. This task is compounded by the fact that different jurisdictions often have different items in their healthcare budgeting.

In 1999, the NCCHC surveyed the 50 state correctional systems, the District of Columbia prison system, and the Federal Bureau of Prisons (BOP) "to determine how much each was spending on health services for prisoners." "Correctional Health Care: Guidelines for the Management of an Adequate Delivery System," published in 2001, covered results garnered from 41 jurisdictions and the BOP, and used numbers that varied between FY 1997 to FY 1999. The report found that total DOC expenditures for this period "ranged from a low of $18.5 million in North Dakota to a high of nearly $3.8 billion in California, with a mean DOC expenditure totaling nearly $595 million... .[T]he median expenditure... was $339 million."

Spending on prisoner health care "ranged from a low of less than $1 million in North Dakota to nearly $500 million in California, with a mean total expenditure of about $70 million per state, and a median of a little more than $32 million."

NIJ holds the study

Dr. Greifinger said that after three years of work, the study -- which had been requested by Congress -- was completed in March, 2001, and turned over to the National Institute of Justice (NIJ). He was told that it would be released within a short period of time; months passed and the report wasn't released to the public. Finally, in July 2002, the report was made available electronically by the Centers for Disease Control. As of this writing (early February) Kara Gotsch, the Public Policy Coordinator for the National Prison Project, says that the complete work has not yet been delivered to Congress.

Why did it take so long for the study to be brought to the attention of the public? Some observers have speculated that the NIJ thought that the report was flawed methodologically and there wasn't the political interest in implementing its recommendations. While acknowledging that "there are certainly some weaknesses in methodology," Dr. Greifinger pointed out that "we used the best available data and the best available science and came up with projections that we were comfortable with."

Dr. Greifinger has not heard from the NIJ since he helped engineer its release at the late-January conference in San Antonio. There are currently "no copies of the report in the library," Brian (he would not divulge his last name) who works at the National Criminal Justice Reference Service, a program of the NIJ, told me.

In early February, I spoke with Ann Voight, the Public Affairs Specialist for the Office of Justice Programs, and I asked her about the report. She claimed that the report had been released and was available online at the web site of the National Commission on Correctional Health Care. "We gave a grant for the publication, but we don't have the funding to publish everything produced by our grantees," Voight said. "Our responsibility is to make sure it is available and as far as I know, we have fulfilled our responsibility." Other than the report's standard disclaimer, Voight said that as far as she knows, the NIJ did not have any problems with the report's conclusions. As for holding the report for nearly two years: "The sequence of events was not unusual; we don't have a huge publication budget. We paid for the report."

ACLU files class action lawsuit

In a related development, the ACLU filed a class action lawsuit against the state of Michigan in late January that "charg[ed] state prison officials with allowing an infectious disease to reach epidemic proportions by failing to adequately test and treat inmates with Hepatitis C, a blood-borne virus that is in many cases fatal."

According to the lawsuit, over four million Americans (1.8% of the US population), the majority of whom are asymptomatic, are infected with Hepatitis C (HCV). Some eighty-five percent of those infected "develop chronic hepatitis, and at least twenty percent of these develop irreversible cirrhosis within two decades of the onset of infection." Nearly ten thousand people in the US "die from complications due to HCV each year."

"This is a very serious problem for everyone in Michigan," said Kary Moss, Executive Director of the ACLU of Michigan. "Unless the prisons begin to follow appropriate protocols for testing and treating Hepatitis C among inmates, HCV will continue to spread well beyond the prison walls. And unless the disease is treated in the early stages, the cost of treatment will undoubtedly rise dramatically."

"The Michigan class action suit demonstrates how poor prisoner health care -- in this case involving the rampant spread of Hepatitis C -- can impact the general public as a whole," said Elizabeth Alexander, Director of the ACLU's National Prison Project. "Reforms need to be implemented, not just to ensure a baseline level of medical treatment for prisoners, but to protect us all from real health risks stemming from inadequate care in prisons."

In response to the suit, Russ Marlin, a spokesman for the Michigan Department of Corrections, told the New York Times' Fox Butterfield that "We are treating hepatitis C in accordance with federal guidelines."

According to Marlin, Michigan did not do blood tests of all incoming inmates or all those who engage in risky behavior. "Our position is that indiscriminate testing is not useful" and it would cost $200 million to test and treat all suspected cases of hepatitis C among Michigan inmates. Marlin also pointed out that the drugs used in treatment -- a combination of interferon and ribarvin given over a 6 to 12 month period -- is very toxic.

On January 27, The Coalition for Better Treatment, a coalition of more than two dozen Civil Rights organizations, medical practitioners, and corrections officials, pointed to the recently released report and called on Congress to hold hearings to investigate the health care crisis in the nation's prison system. According to the Coalition's press release, "Corrections departments are overwhelmed by the high cost of providing medical care and face serious challenges to providing treatment to patients. Untreated patients jeopardize the health and safety of prison and jail staff, institution visitors, prisoners and the communities to which they return."

The National Prison Project's Gotsch said that "We don't know the full extent of this health care crisis. Many states are not doing across the board testing, so no one knows what the real numbers are." The cost of treating hundreds of thousands of people after they've been released from prison far outweighs treating them in prison and will further cripple already overextended state budgets. "We are talking about a potential health care crisis with financial costs that will be incredible. We need to be paying for their care in prison when it's less expensive to treat them."

Bill Berkowitz is a longtime observer of the conservative movement. His WorkingForChange column Conservative Watch documents the strategies, players, institutions, victories and defeats of the American Right.



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