Maryland Tries to Address Chronic Health Issues in Prisons
Baltimore Sun - Online

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If Phillip Tharrington hadn't been caught attempting to rob a Rockville store in 2005, he might never have gotten treatment for an HIV infection he had ignored for years.

The 47-year-old said he was persuaded to get care after being sent to the Maryland Correctional Institution in Hagerstown, where officials have been striving to identify and treat the disproportionate number of prisoners who arrive with chronic conditions such as HIV and hepatitis-C infections and diabetes.

State data suggest there are now more healthy prisoners like Tharrington among the 26,000 incarcerated in Maryland facilities ? and that's good public policy, officials say. More diseases are being controlled and fewer costly hospital trips are needed, making the system more efficient. And when offenders return to their communities, they're healthier and less likely to infect others.

"We knew we needed to have a better model," said Dr. Sharon Baucom, medical director of the state Department of Public Safety and Correctional Services. "Now we're running an HMO behind bars. And we're seeing better outcomes."

Even so, not everyone agrees that enough prisoners are getting sufficient care, despite a constitutional mandate. More troubling for cities such as Baltimore, the public health benefit may be fleeting, experts say. Few prisoners are linked to continuing health care when they are freed, and they again become sick.

Those inside and outside the long-troubled state system agreed that changes were needed for the 22,000 prisoners and about 4,000 more awaiting trials each year. A lawsuit by the American Civil Liberties Union in the 1970s sparked intervention by the U.S. Justice Department at the state-controlled Baltimore jail facilities and brought extra scrutiny to overall management. A 2002 report highlighted 107 issues, including 45 related to health, which officials say are finally near resolution.

Serious changes began in 2005 when state officials dumped the much-criticized health care contractor. The contract was split into five parts, and funding was increased by about 60 percent to more than $150 million a year to keep pace with growing health care and drug costs.

Two years later, Maryland followed other states in focusing on early care of chronic conditions, much like federal health care reform aims to do. State corrections officials now point to decreases in the total days inmates spend in the hospital to just above accepted national rates for a prison population. The total number of trips to the emergency room is better than the national standard.

More inmates have their diabetes under control, and the number voluntarily tested for HIV in fiscal year 2010 was more than double the number in fiscal year 2007. The number with undetectable amounts of active virus in their blood ? who, like Tharrington, are less likely to transmit HIV to others ? has been rising. Baucom said corrections staff members are aggressively looking for those who need care and explaining why they need to stay on their medications ? Tharrington said he was given "an education in the immune system." Top doctors at University of Maryland Medical Center and Johns Hopkins Hospital also have been enlisted to treat patients via weekly teleconferences.

Baucom also acknowledges challenges. For example, HIV testing is voluntary in Maryland and some inmates refuse. A hepatitis-C treatment protocol is offered in state prisons but is so lengthy it's not accessible to those incarcerated for less than two years.

Recent arrestees also are frequently belligerent, high or drunk and can't identify their conditions or medications, Baucom said. About 75,000 people a year go through the Baltimore jail and central booking facilities, which are controlled by the state. County jails remain under the control of local governments.

A medical assessment is required within 24 hours of being booked and follow-up is required within seven days. But that didn't happen for Gerald Washington, according to Crystal Edwards, an attorney for Washington's mother, who filed a multimillion-dollar wrongful death lawsuit in December, alleging Washington was denied asthma medication.

"I understand he asked for his inhaler repeatedly and nothing was done," said Edwards.

State officials declined to comment on the case but said exams are now tracked electronically, and the contractor can be penalized for failures. That has improved record-keeping, but not always medication distribution, said Elizabeth Alexander, former director of the ACLU National Prison Project, which filed the original lawsuit in Baltimore.

She said the American Civil Liberties Union receives far more complaints about jails than prisons, where workers have more time to address medical problems. But both immediate and long-term care are important for the public as well as the inmates, as only one in 11 prisoners is serving a life sentence, Alexander said: "The state has taken away a person's ability to get medical care on his or her own. And it's certainly in the public's interest to provide care in jails and prisons."

She and others at the ACLU note that correctional heath care has improved generally across the country with the advent of national standards. There still are major lapses, however, such as in California, where the U.S. Supreme Court recently ordered the release of 40,000 inmates to ease overcrowding that contributed to inadequate health care.

A legislative audit released last year suggests there have been improvements in Maryland, but shortcomings still exist. About 9,320 chronically ill inmates in 2009 were logged into a database that is supposed to ensure quarterly medical visits, but the audit said that probably doesn't represent the true total. Specifically, a sampling of 70 inmates found 15 of them uncounted. Auditors said the situation hadn't improved much since the previous evaluation in 2007.

The audit also found the state's own review of HIV patients showed that of 82 prisoners with the virus, 27 percent were not seen on schedule.

Baucom, the state's medical director, said the audit focused on record-keeping, rather than outcomes, which show chronic care was improved. She also said records have improved since the report.

Baucom argues the new efforts make the system more efficient, though she and financial officials couldn't say exactly how many dollars have been saved. They believe money was saved on reduced trips to the emergency room and hospital stays, for example.

In general across the country, there isn't evidence that prevention and early intervention efforts save money, said Mark Barnes, a Harvard lecturer in law and public health who formerly worked for the New York State correctional system. In the United States, HIV infection was long undertreated because good medications hadn't been developed in the 1980s, and they were too expensive in the 1990s, Barnes said. And while HIV drug costs have dropped, others have not. For example, the newest hepatitis-C drug costs $48,000 annually.

"In prison health care, whatever the budget is, that's the budget," he said. "People who supervise the systems have difficult choices to make."

And there are certainly problems to choose from. Diseases spread more readily in an incarcerated population through sex, drug needles and crude tattoo implements, observers say. And those who are in the system tend to be far sicker than the general public.

For example, about 41 per 10,000 prison inmates were estimated to have AIDS in 2007, compared to 17 per 10,000 persons in the general population, according to the Justice Department. Most large prisons have an HIV infection rate of about 3 percent to 6 percent, officials estimate.

A study published in 2005 using unidentified blood samples collected from every Maryland prisoner showed the prevalence of HIV was 6.6 percent and the prevalence of hepatitis-C was almost 30 percent. Those rates are among the highest in the nation, said Liza Solomon, former director of the Maryland State AIDS Administration and now a principal associate at the research and consulting firm Abt Associates. The tests were anonymous, and many inmates didn't know they were infected.

And Solomon said traditional prevention methods can't always be used. Few corrections systems hand out condoms because they can be used to smuggle drugs, and none provides clean needles because they can be used as weapons.

Officials instead try to educate prisoners about lifestyle choices and risky behaviors, said Richard Rosenblatt, a former assistant secretary for treatment services in Maryland's public safety department. He said inmates are treated "like they are any other patient, and that may have an impact on health, but it really has an impact on the safety of the facility because they feel respected."

But Rosenblatt knows no matter the successes inside, few prisoners will continue to see a doctor once they are released. He said federal Medicaid dollars can't be spent on inmates so prison workers can't sign them up for care upon release unless it is HIV treatment, which has a separate pot of federal money. But most ex-offenders have chaotic new lives and typically don't make or keep appointments on their own.

Rosenblatt said there is little political will at the state level to fund any kind of program for ex-offenders when so many others go without health care.

"This is why the mentally ill get drugs on the street. They're self-medicating," he said. "And those with other diseases often get sicker and then they end up back in prison, and they've developed resistance so our drugs don't work as well ? or at all." And then they become a threat to the rest of the prison population and the general public.

A recent study confirmed those infected with HIV are not returning to care when they leave jail or prison. A Johns Hopkins researcher looked at the amount of active virus in subjects' blood while they were in treatment before incarceration and up to six months after, and found the average was higher after, making them more likely to infect their partners.

Finding out why ex-offenders don't get care is the next step, said Dr. Ryan Westergaard, a postdoctoral fellow in Johns Hopkins's department of medicine who also conducts HIV-related research in the Bloomberg School of Public Health.

"The improvements are almost universally lost when people walk out of the correctional facilities," he said. "That doesn't mean the prison or jail itself is bad for care. But it means you're not really having an impact on their long-term health, or the health of the community."

Westergaard said some prison systems, including those in Rhode Island and North Carolina, assign workers to escort ex-offenders to HIV clinics. In Maryland, officials do sign up HIV patients for care, but they don't routinely attend appointments.

Solomon, at Abt, said she also is studying those states and others to determine how best to successfully link ex-offenders to care. She said officials can use the results to build their own programs.

Still, funding them will likely remain tough because of prejudice against offenders, said Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania who has studied prison health care.

"It makes eminently good economic sense to provide adequate primary care and try to manage prison health to protect society," he said. "But officials are up against the moral reality that people just have a low priority for prisoners."

Tharrington said he doesn't care what people inside or outside prison think of him. With help from Christian Gordon, a Hagerstown prison nurse, he said he's come too far, coping with complications, regaining 40 pounds, restoring his health and reconnecting with his daughter and grandson.

"It's called 'the bug' in jail," Tharrington said about AIDS. "There's a lack of education, an ignorance about it. ? I'm healthy and waiting to leave now. And when I do, I know I have to go to the doctor, and not go around getting other people sick."