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Old 02-27-2005, 10:25 PM
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Default Health Care in Jails...Expose by The New York Times

February 28, 2005

In City's Jails, Missed Signals Open Way to Season of Suicides

By PAUL von ZIELBAUER

The warnings were right there in her medical file: a childhood of sexual abuse, a diagnosis of manic depression, a suicide attempt at age 13 - all noted when Carina Montes arrived at Rikers Island in September 2002.

But none of them, state investigators said, were ever seen by the mental health specialist caring for her. He could never track down the file, which by December included another troubling fact: Ms. Montes had been placed on suicide watch by a jail social worker. Not that the suicide watch was terribly reliable; it depended in part on inmates paid 39 cents an hour to check on their suicidal peers.

In her five months at Rikers, investigators later discovered, Ms. Montes never saw a psychiatrist.

It did not, however, take a psychiatrist to pick up on the alarms she sounded near the end, when another inmate saw her tearing bedsheets and threatening to kill herself. But the guard who was called had no idea she was on suicide watch, did not notice the sheets and never reported the incident. Six hours later Ms. Montes was dead, hanging from a sheet tied to a ventilation grate.

She was 29. Her offense: shoplifting 30 lipsticks.

The death of Carina Montes was one in a spate of suicides in New York City jails in 2003 - six in just six months, more than in any similar stretch since 1985. None of these people had been convicted of the charges that put them in jail. But in Ms. Montes's death and four of the five others, government investigators reached a stinging judgment about one or both of the authorities responsible for their safety: Prison Health Services, the nation's largest for-profit provider of inmate medical care, and the city correction system.

In their reports, investigators faulted a system in which patients' charts were missing, alerts about despondent inmates were lost or unheeded, and neither medical personnel nor correction officers were properly trained in preventing suicide, the leading cause of deaths in American jails.

Prison Health came to Rikers in 2001 after signing a three-year, $254 million contract and promising to deliver the health care that, compared with jails around the country, had helped make New York something of a model. And it spoke confidently about tackling the jails' biggest problem: how to handle their vast and volatile population of the mentally ill.

The rash of suicides, and nine more during Prison Health's tenure, is one measure of the company's uneven and at times troubling record in meeting that challenge. But there are others.

Ten psychiatrists with foreign medical degrees were allowed to practice without state certification for more than a year after they were supposed to have been fired for failing to pass the necessary test. When it finally dismissed them on the city's orders in 2003, Prison Health was left with about one-third of its full-time psychiatrist positions empty, according to city health department figures.

The company has employed five doctors with criminal convictions, including one who had been jailed for selling human blood for phony tests to be billed to Medicaid. In all, at least 14 doctors who have worked for Prison Health have state or federal disciplinary records, among them a psychiatrist forbidden to practice in New Jersey after state officials blamed him for a patient's fatal drug overdose.

The city's Board of Correction, an oversight agency that sets minimum standards for jails, has complained that the company shuffles doctors from jail to jail - regardless of where they are needed - to avoid city fines and create the illusion that each building is properly staffed.

Many of the 30 current or former Prison Health employees interviewed for this article described an effort that, whatever its good intentions, frequently fails to adequately treat the mental illnesses that inmates take into jail and that follow them back out.

Dr. Douglas Cooper, a psychiatrist who helped supervise mental health treatment at the nine Rikers jails until, he says, he quit in frustration in 2003, summed up the care as triage, buffeted by a sense of nonstop crisis. "The staff does the best they can," he said, "and what's left they sweep under the rug."

Prison Health Services, a Nashville-area corporation that bills itself as the gold standard of jail health care, says it has done a solid job at Rikers and a 10th jail, in Lower Manhattan, caring for more than 100,000 inmates a year as part of its largest contract among scores across the nation.

The company says it has worked hard to find qualified mental health specialists, held increases in medical expenses below the national average, and saved the city hundreds of thousands of dollars.

There is little dispute that New York City has long insisted on more generous jail care than most other places; the suicide rate, even under Prison Health, is about half the national average for jails.

Then again, the rate was lower before Prison Health arrived. And in the four years since, the rate of suicides at Rikers has been higher than in the Los Angeles jail system, the largest and one of the most violent in the nation.

Suicides - "hang-ups" in the cold vernacular of the cellblock - have always been a jailhouse reality. Because inmates can be resourceful when they set out to kill themselves, few people believe that hang-ups can be prevented entirely.

Yet they can be a critical barometer of how well medical and correction workers are performing an essential task: protecting the vulnerable people in their care. In 2003, something broke in the city's jail system, and inmates slipped through a bewildering series of cracks.

The first, Jose Cruz, a 48-year-old with H.I.V. and hepatitis, hanged himself with a torn bedsheet in January. Even though he had been put on suicide watch, correction officers placed him at the end of a cellblock where they could not see him from their post, said the State Commission of Correction, a panel appointed by the governor to investigate every death in jail. The medical staff, the commission noted, had inadequate training in preventing suicides.

Thirteen days later, Joseph Hughes, a severely disturbed 24-year-old charged with murder, was found hanged four hours after a jail psychiatrist wrote that he was no danger to himself. The commission criticized the Prison Health staff, saying that Mr. Hughes's history of hallucinations and suicidal gestures required closer observation.

Ten days after that, guards cut down Ms. Montes - whose increasing desperation had gone unnoticed because her medical file was missing, a failing the state commission had already criticized in three other deaths during Prison Health's time at Rikers.

After two more suicides, an inmate found James Davis, 43, in his cell in June with a bootlace tied around his neck. A doctor, two nurses and two guards spent 15 minutes vainly administering C.P.R., unaware that oxygen tanks and cardiac medication were nearby, the commission said.

No one thought to unknot the bootlace.

Sixteen days later in a jail-clinic waiting room, a 19-year-old who had just returned from a psychiatric evaluation unit managed to hang himself from a metal stud in the ceiling, according to the city's Board of Correction. Another inmate rescued him while he was still semiconscious.

The city's health department, which now oversees Prison Health's work at Rikers, did not contest many of the commission's findings, though it defended the work of the psychiatrist who evaluated Mr. Hughes as "not inappropriate." Company executives did not respond to the commission's reports, saying that they had never read them because city officials did not give them copies.Promising Vigilance

The catalog of missteps and missed signals could not have come as a complete shock to city officials. Prison Health, after all, had attracted criticism around the country for faulty care. And by the time of the suicides, the state commission was busy investigating - and blaming - Prison Health for inmate deaths in county jails upstate.

The city, though, has insisted that it has the tools to strictly monitor the company's performance. The state commission, too, concedes that city health officials are more vigilant than any county sheriff.

In fact, soon after the city hired Prison Health in 2001 to salvage jail medical services after three tumultuous years under the direction of St. Barnabas Hospital, New York City officials battled the company over its failure to meet many of the city's most basic clinical standards, and threatened to cancel the contract. Now, after a series of changes the city ordered - including suicide prevention and oversight measures prompted by the 2003 deaths - the health department says care has improved. On Jan. 1, it granted the company a $300 million contract for another three years.

"They were the most qualified bidder and they were the most cost effective," said Dr. Thomas R. Frieden, the health commissioner, who described Prison Health as willing to make improvements when asked. "I don't think they're angels."

Others are more skeptical. The city comptroller's office, prompted by Prison Health's record and questions raised by The New York Times, asked the health department to delay signing the new contract until the department addressed concerns, including the Board of Correction's complaints of staff shortages at Rikers. Dr. Frieden replied that he saw no reason to wait.

But the new contract, according to two state officials, appears to violate a state law intended to keep business interests from influencing medical care. For example, it fails to ensure that doctors are the ultimate overseers of all medical treatment, policy and records. And the contract makes the doctors who are actually doing the work at Rikers subcontractors to Prison Health, the reverse of what the law requires.

The health department and the company say the contract is legal.

For those who work in the jails, though, the larger issue is the quality of the care. Figures provided by the city and St. Barnabas show that the clinical staff at Rikers has shrunk by 20 percent since the hospital was in charge, despite only a modest decline in the jail population. And several doctors and other employees said that mental health care is worse than before.

Forever unable to find enough psychiatrists, the company plugs the gap by hiring part-timers, as well as psychiatrists from temporary agencies, some of whom may never have treated inmates. More than one-third of the mental health staff is part time.

Doctors rely on medical charts that have often been out of date or simply unavailable because of a shortage of clerks, according to the Board of Correction. Psychiatric evaluations and medications have been delayed for days or weeks, while inmates sometimes turn violent or suicidal, say the board and Prison Health employees.

Of course, the demands on Prison Health and the correction system are tremendous. The mentally ill have flooded New York's jails ever since the city cracked down a decade ago on lesser crimes like vagrancy. As many as one in four of the 14,000 prisoners in city jails on an average day have psychological ills, which need close supervision and expensive medicines. Often they fake symptoms or attempt suicide as a way of getting special treatment. In those ways, a mentally ill inmate jailed on a minor charge usually requires closer attention than a career criminal.

"If you asked every jail administrator in the country what kind of criminal they want in their jails, everyone would say murderers," said Michael P. Jacobson, who was city correction commissioner from 1995 to 1997. " 'Give me a nice murderer.' "

Just what society owes these troubled inmates is open to debate. But the guilt or innocence of most of them have not been settled. Many are in jail on minor charges or because they are unable to make bail. And though most leave within a week, many remain for months, and jail is the only place where they are likely to get any treatment or medication. The city, in fact, is required to create treatment plans for the most seriously disturbed upon their release.

Since The Times began last year to request information on the suicides, examining jail records and details of the Prison Health contract, city and company officials have made changes to prevent more deaths. The rate of suicides has slowed; in the 20 months since the spate of six suicides, there have been four.

Still, there are lapses. One of those four, David Pennington, 27, killed himself in July. Over three days in which he became increasingly irrational, correction officers went to the mental health staff for help three times, and a doctor even sent him to a psychiatrist, yet Mr. Pennington was never examined, state records say.

In a letter, a health department official disputed that finding and defended the care Mr. Pennington received. The official said the inmate was seen by a psychiatrist the day he died and was not clearly suicidal. The psychiatrist was fired three months later, Prison Health said, for reasons unrelated to the death.

In the end, though, Prison Health is just the latest partner of a bureaucracy with its own blemished history: the correction system, which was unable to deal decisively with suicides for decades, as recommendations from state and local authorities were ignored, and fitful attempts at change failed.

A Moment of Opportunity

The company's arrival at Rikers in January 2001 was a milestone for New York. The contract, negotiated with the administration of Mayor Rudolph W. Giuliani, was a linchpin in the city's effort to privatize government programs, and made New York's jail system the largest in the nation to entrust its health care to a commercial enterprise.

The deal was driven in great part by a determination to save money, and dovetailed with efforts to get the city out of the business of everything from job training to welfare enforcement. For years the city had used public hospitals to provide care in its jails, only to face skyrocketing costs and plenty of embarrassments. Prison Health, with its already shaky reputation, marked a calculated gamble.

The contract, though, was an even bigger deal for Prison Health. It raised the company's $382 million yearly revenue by 21 percent, and pushed Prison Health to the forefront of a booming correctional health care industry. It also made the company responsible for treating more mentally ill people than anyone else in the nation except the Los Angeles County Jail.

Yet Prison Health had not told its new employer the whole nature of its operations, records and officials in the city comptroller's office suggest. In 1999, the company bought EMSA Correctional Care, which had been working for the city's Department of Juvenile Justice for three years. Prison Health, according to documents and interviews with city officials, subsequently became responsible for providing care to the 5,000 youngsters in the juvenile system every year.

That care, during 2000, would come under fire by a half-dozen Family Court judges in the city, who found that children were often receiving inadequate treatment.

But when negotiating the Rikers contract later that year, Prison Health filed papers with the city saying the company had "no N.Y.C. presence." The comptroller's office, which was not obligated to review the Rikers contract at the time, now says that Prison Health's filings were incomplete and misleading.

The company rejects that claim, and says the papers were accurate and honest, and had properly listed EMSA as an affiliate doing the work at juvenile justice. City health officials say they have no problems with Prison Health's representations.

Prison Health not only won the Rikers contract, but also benefited from an added bonus: an easy act to follow. St. Barnabas Hospital in the Bronx had just been fired after a striking number of jail deaths - 34 in its final year, including 2 suicides - prompted a criminal investigation. Though no charges resulted, the Board of Correction, an eight-member watchdog panel, complained about the cost-cutting it saw as a root cause.

But under Prison Health, the rates of inmate deaths and suicides have risen slightly. In a foreshadowing of the spurt of suicides to come, six inmates killed themselves from May 2001 to January 2002.

In a string of memos to city health officials, the Board of Correction told of missing medical records, delayed psychiatric medications and minimal, inexperienced staffs. Correction officers, it said, sometimes had to pitch in, referring inmates for mental evaluations.

It was not supposed to be that way. Stung by the St. Barnabas experience, city health officials had set up elaborate ways of measuring Prison Health's performance, including a beefed-up quarterly report card with 35 standards. But during its first year, the company met those standards only 39 percent of the time. Its overseer at the time, the city's Health and Hospitals Corporation, threatened in July 2001 to scuttle the contract, and fined the company $568,000.

Company executives say that the transition from St. Barnabas was rocky, but that their performance has improved, and they have managed some significant achievements: speeding distribution of medicine, creating a program to monitor inmates with hypertension and installing a computer system for appointment scheduling.

Yet the company has not made good on several requirements in its contract. For example, it frequently sends inmates to hospitals without performing tests or providing information on their medical history and treatment, according to reports by the State Commission of Correction. And Prison Health never came up with the rigorous suicide-prevention plan it promised the city in 2000.

"I had no training as to what we do when a patient becomes depressed and becomes suicidal," said Michele Garden, a psychologist who was treating Mr. Cruz, the first to kill himself in 2003. She quit later that year.

The correction system had its own problems, having failed to tackle the issue of suicides despite a series of detailed studies that began in the late 1960's.

The city hired a suicide-prevention coordinator in 1980, but gave him only a paltry budget. John Rakis, who got the job, recalls having doubts about the assignment while interviewing his first patient in the only spot available in the Bronx House of Detention: the barbershop.

"He was hallucinating, and at some point got up and started screaming and threw over the barber chair," said Mr. Rakis, who now advises the state and city on jail health care. "I went upstairs and thought, 'I don't think this is going to work.' "

He was right. When he quit in 1984, the Correction Department eliminated the job. A rash of suicides followed in 1985 - 11 for the year, with 3 in one week.

In the early 1980's, the city created a Prison Death Review Board, including members from the mayor's office and the Health and Hospitals Corporation, to investigate and prevent deaths. But fearing that the board's inquiries could fuel lawsuits, Health and Hospitals representatives began refusing to discuss the deaths, said Board of Correction officials. The review board has not met since 1997.

When Prison Health arrived in 2001, the entire machinery for monitoring suicidal inmates remained lethally porous. The system depended, as it still does, on "suicide prevention aides," inmates paid pennies an hour to make checks every 10 minutes. In an investigation last year, the state commission found that one of these aides was responsible for watching troubled or newly admitted inmates in 34 separate cells.

Guards were supposed to help, too, looking in on suicidal inmates every 15 minutes. But that often became a half-hour, said the correction commissioner, Martin F. Horn.

"You could pick and choose which rules you wanted to follow," said Mr. Horn, who arrived in January 2003.

Inmates continued to kill themselves, and in its reports on the deaths, the state commission insisted repeatedly that those on suicide watch be observed at all times. In late 1999, it sent all jails and prisons a directive to make that the rule. City correction officials ignored it.

Not until four years later, after the spate of six suicides, did the city follow the directive. Two weeks after the sixth suicide, in July 2003, the health department replaced the Health and Hospitals Corporation as Prison Health's direct overseer, and took action to tighten suicide watches.

The Correction Department ordered a flurry of other changes to ensure closer monitoring, and hired Lindsay M. Hayes, a nationally known expert on jail suicides, to recommend improvements. But it gave The Times only an edited version of his report, stripped of his analysis and recommendations, and would not allow Mr. Hayes to discuss his findings publicly. The health department also refused to disclose its own investigations of the 2003 suicides.

Yet Mr. Horn, who became correction commissioner the month the six suicides began, said they were a jarring sign that something was dangerously wrong.

"I found it personally distressing," he said. "I was shellshocked."'

A Scramble for Help

On any given day, a psychiatrist walking the halls at Rikers could be a doctor from a temp agency who had never practiced there before. He could be a doctor who had never treated prisoners at all.

Or he could be someone like Dr. Edward M. Berkelhammer, whose work the New Jersey Board of Medical Examiners called "a danger to the public" in 1986. It suspended his medical license for two years, fined him and ordered him to see a psychiatrist himself after a patient died in his care.

Dr. Berkelhammer was putting a 26-year-old woman through drug detoxification when his mistake in administering drugs resulted in her overdose, the board ruled. He was working with an expired license, and he continued to compound his troubles. In 1989, New York suspended him for two months for lying about his record in applications for a license. And in 1990, New Jersey revoked his license for failing to obey its orders.

In an interview, Dr. Berkelhammer said that the girl's death was a single incident long ago, and that he was "very well thought of" at Kings County Hospital in Brooklyn, where he worked for several years afterward, treating psychotic inmates. "Of all the people at Rikers, I'm the last person anyone has to worry about," he said.

Indeed, there are doctors at Rikers with checkered pasts, including criminal convictions.

Dr. Ammaji Manyam, for instance, was sentenced to a year in jail in 1990 on charges of conspiracy and attempted grand larceny, for selling blood in a scheme to charge the state for bogus tests. Her medical license was revoked in New York, New Jersey and California, but restored in New York in 1997, after she said she wanted to work in a jail clinic because she knew from experience how poor the medical services were. Dr. Manyam did not return calls seeking comment for this article.

Others have had their medical credentials called into question. New York officials revoked the license of a Prison Health psychiatrist, Joseph S. Kleinplatz, in 2003 after Illinois officials concluded that his diploma from a Mexican medical school had been forged. The company then fired him. His lawyer, Karen S. Burstein, said he was a good doctor with a real diploma; a state appellate court has ordered that his case be reconsidered.

The health department is now reviewing Prison Health's system for checking doctors' credentials.

Becky Pinney, the vice president in charge of Prison Health operations in New York City, said the company had done its best to weed out doctors with disciplinary records. Most of them, she said, had first been hired by St. Barnabas Hospital - though Prison Health rehired them, as it did most of the hospital's staff at Rikers. She said the company was thorough in investigating job candidates, running names through state and federal databanks, and rechecking credentials every two years.

Finding qualified doctors, particularly psychiatrists, is a fundamental challenge for any jail medical operation. While Prison Health says it pays competitive salaries, doctors who have left for other jobs said they made much more working fewer hours.

"You have so many people vying for psychiatrists in a city this size, it makes it even more difficult," Ms. Pinney said. The company has responded aggressively, she said, recruiting at Columbia University's medical school and mailing solicitations to every psychiatrist in the city and North Jersey.

The company, then, often takes what it can get - witness the 10 unlicensed psychiatrists who Prison Health was supposed to fire by the end of 2001 because they had failed to pass state medical tests. The city allowed the company to keep them on for another 16 months, but when the doctors failed even then to obtain certification, it had them dismissed.

Prison Health soon rehired three of the psychiatrists, at reduced salaries, as social workers and mental health specialists.

"There's a reason these people have failed to demonstrate to the board that they are qualified," said Dr. Robert L. Cohen, who was medical director at Rikers from 1982 to 1986, when Montefiore Medical Center ran health care.

But if hiring doctors is hard, keeping them is tougher, say many who have worked at Rikers. "They cannot get psychiatrists to stay there," said Roberta Posner, a psychologist who headed a mental health unit when she was fired in 2001 after 12 years at Rikers. The company would not say why it dismissed her; Ms. Posner said it was for complaining. "The staff is so stressed and so spread out that they can barely manage," she said.

There are only 10 full-time psychiatrists working with inmates at Rikers, the company said. It employs 30 part-timers, and 8 others from two temporary agencies, including one in Atlanta called Psychiatrists Only.

Some current and former workers at Rikers said the reliance on such help disrupts treatment. A deputy health commissioner, James L. Capoziello, conceded, "It's not the optimal way of doing things."

When doctors cannot be found, the company has filled in with less skilled workers, say city officials and Prison Health employees. Since 2002, the city has allowed more than one-third of the psychiatrist positions to be filled by nurse practitioners or physician assistants, who are licensed to diagnose medical problems and prescribe medications. The health department says that the company is now using only seven of those workers to substitute for psychiatrists, and that it plans to end the practice.

Cathy Potler, deputy director of the Board of Correction, said that some of those nurses and physician assistants had little or no background in psychiatry.

"The result," she told city officials in a May 2003 letter, "is that the least experienced mental health staff are assigned to the facility with patients who are in need of the highest level of care."

'Juggling Hand Grenades'

As soon as Dr. Douglas Cooper arrived at work in the summer of 2003, the phone would ring and, he said, his heart would sink. He was facing another day of too few employees, too many psychotic inmates and a corporate boss that he says was more interested in paperwork than patients.

As the assistant supervising psychiatrist for all nine Rikers jails, he would have to figure out how to handle more than 300 patients at the island's largest mental health unit, in the largest jail at Rikers, where he worked. On the line was Prison Health's Rikers office, ordering him to send one or two of his four or five psychiatrists - each of whom might already have 30 patients to see - to jails that could not meet their city-mandated staffing quotas that day.

Rikers had a lyrical name for the practice: floating. But Dr. Cooper likened it to a bumpy ride on a unicycle with three punctures and only one patch. "They move the patch around to whichever hole is leaking air the fastest," he said.

Mental health care, he said, was merely damage control, and the inmates treated first were the many who knew they could get attention by threatening violence to themselves or others. Meanwhile, the staff tried to keep tabs on the patients who were quieter but often in more peril.

"You were juggling hand grenades, and one of them was going to go off, hopefully not in your hands," said Dr. Cooper, 52, who quit that August after nine years at Rikers.

His experience goes to the heart of what many employees say is the reality of daily medicine at Rikers. In interviews, more than two dozen current and former Prison Health doctors, physician assistants, psychologists and social workers said they were spread so thin that most mental health care was minimal. Most spoke on the condition that their names not be printed, saying they feared losing their jobs.

The numbers do not lie, they say. In 2000, the last year under St. Barnabas, the jails had about 830 full-time clinical employees, according to the hospital. Today, Prison Health has a clinical staff of about 670, the health department said.

That figure, set by the city, is inadequate, Dr. Cooper said - "designed to ration health care to cut costs as close to the bone as possible, and to provide a semblance of health care when one doesn't really exist." Prison Health, or P.H.S. as it is commonly known, goes along, more concerned with pleasing the city than with serving patients, he said.

The company's approach, he said, is essentially this: "Put your best face forward, hide as many problems as you can and hang on to the contract for as long as you can."

As a case in point, he and others cited the way the company regards different kinds of paperwork. Medical records, on one hand, are often outdated or unavailable, they said. Senior clinicians said they commonly had to sign off on treatment without seeing a medical history, a practice they said could jeopardize their licenses, and inmates' health.

But at the same time, employees said, Prison Health uses doctors and other highly trained specialists to produce and double-check another set of papers: the blizzard of documents that city bureaucrats use to gauge the company's performance. The paper chase actually appears to have grown out of an effort by the city to prevent a reprise of the St. Barnabas years. In its first contract with Prison Health, the city listed the numbers of doctors, nurses, clerks and other staff required at each jail. Failure to document compliance with that list, known as the staffing matrix, for a single day, or even a shift, could result in a $5,000 fine.

But Prison Health has turned the matrix into a meaningless yardstick, several doctors and physician assistants said. Some mental health clinicians said that a number of their most experienced colleagues - the clinical supervisors helping run the medical programs in each jail - work full time reviewing reports for the city, making sure boxes are marked and evaluations signed. Even those working with inmates said they were overwhelmed.

"It became impossible to have a therapeutic conversation with a patient - it was just checking off boxes," said Dr. Daniel Selling, a clinical psychologist who quit in March after about eight months at Rikers. "The P.H.S. administration could care less what I do with a patient."

In the practice known as floating, the company has often sent a doctor or nurse with a backlog of patients at one jail to another where there are fewer inmates to treat, simply to avoid fines, the Board of Correction said. The city has repeatedly fined Prison Health for incomplete filings, but never for treatment that resulted in injury or death.

"The constant shuffling of mental health providers from one facility to the next keeps them from being able to see his/her patient caseload," Ms. Potler, the board's deputy director, complained to city officials in her May 2003 memo. The company says it has greatly reduced that problem.

Floating, in turn, led to fudging, said several current and former employees. To sidestep a fine, they said, Prison Health has had employees sign in at one jail but then work at another. When there have been too few doctors to float, medical administrators have signed in - but without seeing any patients, said three senior clinicians. One added, "The practice is clearly fraudulent."

Health department officials said they were not aware of any deception by Prison Health. But they said the staffing matrix had been changed in the new contract to ensure that a core group of mental health workers at each jail cannot be floated. The fines have been eliminated, officials said, and the company will be graded more on treatment than on paperwork.

Company officials denied that any employees had been forced to sign in at jails falsely. Ms. Pinney said that she tried to avoid moving employees between jails, but that it was sometimes necessary to meet patients' needs. The complaints about short-staffing, she said, were untrue, if expected.

"We've set a very high standard of performance for our employees," she said. "Some people like that and some people don't like that."

Several doctors said that an overextended and discouraged medical staff would not pick up on suicidal behavior.

"People lose touch, because the pressure is on," one mental health supervisor said in exasperation. "And if patients are not the priority," he added, "the consequence is those six suicides."

Alone at the End

From the first days she spent at Rikers Island, charged with shoplifting 30 tubes of Revlon lipstick from a Rite-Aid in the Bronx, it was obvious that Carina Montes was carrying around something a lot weightier than stolen merchandise.

A 29-year-old former gang member with a gunshot scar on her stomach and a teardrop tattooed under her right eye, Ms. Montes was sexually abused as a child. She was 8 when she began seeing a psychiatrist for depression, medical records show. She tried to kill herself three times, at ages 13, 18 and 25, and arrived at Rikers severely depressed.

She told some of this in her intake exam, to a physician who diagnosed manic depression and prescribed antipsychotic medication, state investigators said. But little of the information would follow Ms. Montes, they said, as Prison Health passed her from one staff member to another, losing track of her records and even seeming for months to lose track of the young woman herself.

Over the five months she had left, she would never be seen by a doctor again, the State Commission of Correction found. At the end, she would have no one to help her but other inmates and a rookie jail guard.

Isolation was nothing new for Ms. Montes. Born in Puerto Rico, she dropped out after the ninth grade into a different sort of education, selling crack on the Grand Concourse, then paying for it in city jails and upstate prisons. Paroled from a drug sentence in March 2002, she had no family to turn to - just Ana Torres, a lover who took her in from a women's shelter.

That Sept. 13, the day after Ms. Montes landed at Rikers, the doctor recommended an immediate mental health examination. But nearly three months passed before Prison Health performed the exam, which took place only because a guard had noticed Ms. Montes acting strangely, records show.

The social worker who finally examined her on Dec. 7 was a "floater" who rarely worked in the women's jail. Learning of Ms. Montes's three attempts to kill herself, he placed her on suicide watch.

It took another 23 days before Ms. Montes was seen by a mental health specialist, Brett Bergman. But he did not know his patient was on suicide watch, he later told investigators, because he could not find her medical file. "Patient appears to be doing well and was stable," Mr. Bergman wrote. Although he saw her twice more in the next month, he still could not locate the file.

No other clinician had a chance to help her; on Dec. 2, after she fought with another inmate, the correction staff placed her in a protective-custody cellblock that had no regular mental health services.

On Feb. 6, her isolation proved deadly. Although she was on suicide watch, Ms. Montes had not been seen by any mental health worker for nine days, records show. No one noticed that Ms. Montes, a diabetic, had refused her insulin injections for two days.

But another inmate, Linda Vega, saw her weeping in her cell that morning, distraught over a quarrel with a new lover four cells away. "Everything I love don't love me," she lamented, according to Ms. Vega, and said she would hang herself. "I then noticed sheets torn apart between her legs," Ms. Vega told city investigators.

At 11 a.m., alerted by inmates, a newly hired guard, Kje Demas, stood outside Ms. Montes's open cell door and asked if she was all right. "I'm O.K., I'm just going through something," she said, the guard told investigators. Officer Demas said he had never been told she was on suicide watch. He did not see the bedsheets or any cause for alarm.

Shortly before 5 p.m., another guard heard inmates screaming and found Ms. Montes hanging from an air vent.

The Correction Department fired Officer Demas for failing to notify a superior. The health department said it "counseled" Mr. Bergman and his supervisor for not reviewing the medical charts they could not find, and imposed a rule that inmates on suicide watch be interviewed every two days.

There was no penalty for Prison Health.

Ms. Montes's body was shipped a few miles northeast of Rikers - to Hart Island, where the city buries its unclaimed dead.

Joseph Plambeck contributed reporting for this article.
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"I learned that familiar paths traced in the dusk of summer evenings may lead as well to prisons as to innocent, untroubled sleep." (Albert Camus, The Stranger)
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Old 03-01-2005, 12:24 AM
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Default NYTimes:A Spotty Record of Health Care at Juvenile Sites in New York

March 1, 2005

A Spotty Record of Health Care at Juvenile Sites in New York

By PAUL von ZIELBAUER

It was early February 2000, and Judge Paula J. Hepner said she could hardly believe what a doctor in the city's juvenile justice system had done to the girl standing before her in Brooklyn Family Court.

The girl, Tiffany S., was 14, with a history of suicide threats and a set of serious psychological problems well documented by doctors at a psychiatric hospital for children. They had treated her bipolar disorder with powerful medicines and, knowing that she was facing detention, had recommended that she keep receiving them when the Department of Juvenile Justice took her into custody.

But soon after Tiffany entered the system, Dr. Ralph L. Williams - an employee of Prison Health Services and the only full-time doctor for 19 juvenile centers across the city - stopped her medications. Instead, he placed her on Ritalin, a drug meant to treat attention deficit hyperactivity disorder.

It took only days for Tiffany to deteriorate. Soon, she said in an interview, she was hallucinating, fighting with other girls and spending hours staring at a wall. As an additional measure, she said, a Prison Health employee asked her to sign a pledge not to kill herself.

Judge Hepner ordered Tiffany back to the hospital, records show, and moved to hold Dr. Williams in criminal contempt. In doing so, Judge Hepner joined at least five other judges who would order more vigorous treatment by Prison Health, a company that cares for hundreds of thousands of inmates in New York State and across the country.

That May, for instance, Judge Philip C. Segal of Brooklyn Family Court held the juvenile justice commissioner - whose agency represented Prison Health in court - in contempt after the company staff neglected to give a 13-year-old boy his H.I.V. medication. Later that month, Harold J. Lynch, a judge in the Bronx, ordered a 13-year-old girl in the agency's custody returned to the Bronx Children's Psychiatric Center. The girl, court records show, had tried to kill herself after a Prison Health doctor discarded her psychiatric medications and gave her Ritalin instead.

"This is not just a single case," Judge Lynch told city lawyers. "It's many cases."

But those cases are only one distressing facet of what would be a four-year effort by Prison Health to provide care to young people in the city's network of juvenile detention centers and group homes - a job that made the company about $15 million in revenue before it was replaced in 2003. Independent investigations have criticized the quality of that care. Questions have also been raised by some city officials about whether the company was forthright with various other city agencies about its work at Juvenile Justice.

Of the roughly 500 youngsters, ages 7 through 16, who were in custody on any given day, some had committed serious crimes. Others had been turned over by parents who could not or would not care for them. Still others were there simply because there was nowhere else to go. One thing is clear about most of them: they were sick and in need of help.

Prison Health, a profit-making corporation with a troubling record in many states, appears to have poorly served many of those youngsters, according to a review of its work, based on court records and audits, as well as interviews with children, judges, Legal Aid Society lawyers and current and former Juvenile Justice employees. The results, those documents and interviews make clear, were often confusion and mistreatment throughout the company's time in the juvenile justice system, from January 1999 to April 2003.

For the 5,000 youngsters who passed through each year, the one full-time doctor Prison Health employed oversaw a staff composed mostly of part-time physician assistants, social workers and nurses. Sometimes, current and former counselors who worked at Juvenile Justice said, the medical staff mistakenly gave children medication that had not been prescribed to them. One counselor said that to avoid further errors, Polaroid photos were stapled to medical files to help nurses match names with faces.

The only independent audit of the company's medical care, commissioned by the Juvenile Justice Department in 2003, six months after Prison Health had already left, found that patient records had been in disarray, and that no doctor had appeared to consult them anyway. Many children with serious illnesses received no follow-up care, the audit said, and most teenagers were not tested for sexually transmitted diseases. The audit was never made public.

"The work was poor and put young people at risk," the city comptroller, William C. Thompson Jr., said in an interview. "I'd almost say deplorable."

Juvenile Justice officials have said they were "generally satisfied" with the company. The agency declined interview requests for this article for five months, until aides to Mayor Michael R. Bloomberg ordered the department's spokesman to answer questions about Prison Health's tenure. Even then, in two interviews, department officials would not discuss the company's record.

Richard D. Wright, the president and chief executive of Prison Health, defended its work and the services it offered youngsters in custody. "There were a lot of professional people dedicated to that contract," he said in an interview. "We thought that they were sufficient to deal with the workload."

Prison Health's performance at Juvenile Justice is the least known aspect of its long and lucrative work in New York. The care the company provided in upstate county jails in recent years has been assailed by state investigators. And its work at the jail complex on Rikers Island has been consistently, if not always diligently monitored by New York City, which awarded the company a new $300 million contract in January.

But the care Prison Health provided children in the juvenile system, the city comptroller now says, should have been examined by the city when the company was seeking the Rikers contract in 2000.

Prison Health took over care at Juvenile Justice in 1999 when it bought EMSA Correctional Care, a smaller competitor that had been doing the job for three years. When it was vying for the Rikers contract, though, Prison Health listed EMSA in disclosure statements as an affiliate and indicated that EMSA was still working at Juvenile Justice.

The city comptroller now says that Prison Health was in charge of providing juvenile care from the time it bought EMSA, and that EMSA existed only on paper. The comptroller says that the company misled the city, and that as a result, the city missed an opportunity to get a hard look at Prison Health's work in its own backyard before it hired the company for its adult jails.

Prison Health says that its filings properly listed EMSA as a separate concern in 2000. The city agencies in charge of awarding the Rikers contract, the Health and Hospitals Corporation and the Mayor's Office of Contract Services, say they found no problem with Prison Health's disclosures.

Over the years, as Prison Health has expanded nationally, followed by accusations of flawed care by regulators, many of its critics have wondered how it kept winning new contracts, sometimes in a county or state next to one it had left under a cloud. In New York City, anger among judges and lawyers in the juvenile justice system did not prevent the company from landing a huge jail contract across town.

Of course, caring for youngsters inside the city's three jail-like detention centers and 16 less restrictive group homes can be as dangerous and frustrating as caring for adult inmates. Few young people entering the system have received consistent health care and, as a result, lack any medical record to guide doctors. Often, there are not even family members to question.

For many of them, as a result, detention offers the only opportunity to get a physical or dental examination, or even talk to an adult willing to listen. Proper medical and mental health care, say experts and the department's own employees, is vital in helping them become productive adults.

That care has improved under the two companies hired to replace Prison Health, say city officials and lawyers working in the Family Court system. It could hardly have gotten worse, said Jennifer Baum, a Legal Aid lawyer who represented many youngsters during Prison Health's tenure.

"I saw troubled and needy children being mistreated by shabby medical care," she said.

Checkups and Warnings

By the time Prison Health Services acquired it, EMSA had been treating the city's incarcerated children since 1996. EMSA had more experience with children than Prison Health, but it had problems, too.

In Westchester County, EMSA had paid $750,000 to settle a lawsuit by the parents of a 17-year-old girl who hanged herself at the jail there in 1996, after a psychiatrist stopped her antidepressant medication. The doctor, Harvey N. Lothringer, had pleaded guilty to second-degree manslaughter three decades before, admitting that he dismembered the body of a young woman who had died during an illegal abortion he performed, and then flushed her remains down a toilet. He spent four years in prison, but in 1973, the State Board of Regents declared the doctor "rehabilitated" and restored his medical license. He began working for EMSA in 1996.

At Juvenile Justice, counselors and Legal Aid lawyers said they had found EMSA's medical staff too small to properly treat all the children who needed help. But a little less than a year after Prison Health arrived, taking responsibility for the care, that private grumbling turned public.

Prompted by complaints from Ms. Baum, a half-dozen Family Court judges filed at least 12 court orders or contempt motions in 2000 to force Juvenile Justice to fix mistakes in care. In one instance, Dr. Joseph K. Youngerman of the Bronx Children's Psychiatric Center pleaded with Judge Lynch to help the suicidal 13-year-old girl who had been taken off her medication; if he could not, the doctor wrote, the center would take her back - "to spare her (and us all) any repeat" of her breakdown.

For nearly two years, though, those concerns remained buried in court files. Then, in 2002, the city comptroller, during a routine review, uncovered several problems.

He urged Prison Health to re-examine its staffing, which provided only one full-time psychiatrist and one part-time physician for all medical services. The company, the comptroller's office found, did not provide the group counseling required in its contract. There was no system, the comptroller said, to ensure that children taking psychiatric drugs received them on days they were sent to court; unmedicated, they sometimes broke down in front of a judge.

Indeed, several employees said that they sometimes were told that drugs for some of the children were unavailable or simply unnecessary, leaving them to handle the untreated patients.

"If they get disruptive," said one longtime counselor at a group home, "the staff has to put them in a restraining position, and then you end up with a child-abuse charge."

For reasons that its spokesman declined to disclose, the Department of Juvenile Justice commissioned its own review in 2003. It was a rare move, and it came only after Prison Health had left.

This would be the only outside medical audit. Done by IPRO, a well-known nonprofit health-care auditing firm, it found serious deficiencies, showing that things had been even worse than the comptroller's office had thought.

Medical charts had been badly disorganized, the audit said, and "there was little evidence of an oversight physician" reviewing them. Young people who developed medical problems were "almost never" seen by a doctor, but typically examined instead by a nurse, the audit said.

About one in six youngsters with chronic health problems like epilepsy, sickle cell anemia and kidney disease never received follow-up treatment while in custody. Tests critical to running an institution full of troubled young people were so haphazardly administered that fewer than one-third of the eligible girls received a Pap test, and only about 1 in 5 eligible youngsters were tested for gonorrhea, chlamydia and syphilis.

But Prison Health was by now largely beyond accountability. It had left the previous April, when the Department of Juvenile Justice replaced it with two other companies: Health Star Plus, which now provides medical care, and Forensic Health Services, which handles mental health services. Department officials, who had given Prison Health mostly satisfactory evaluations during its four years, would not discuss the problems raised by the audit.

"At this point, we have new providers," said Scott Trent, a department spokesman. "It's a new contract. It's entirely irrelevant."

One Girl's Tale

Tiffany grew up in Brownsville, Brooklyn, and her early life was a painful one. She was put in her grandmother's care by city child-welfare workers when she was 3 to escape the abuse of two drug-addicted parents. But that did not last long. After her brother sexually abused her sister, Tiffany was moved yet again. When she was 13, she ran away.

On the streets, she was beaten, and she began to hear voices. She found herself telling people, "I'm not crazy!"

Tiffany ended up in the custody of the juvenile justice system after she was accused of a minor nonviolent crime in 1999; she agreed to be interviewed on the condition that the charge not be disclosed. But before she got there, she spent a month in the adolescent psychiatry unit at Kings County Hospital Center in Brooklyn.

The conclusion of doctors there was precise: Tiffany suffered from bipolar disorder and behavioral problems and required psychiatric medication and individual psychotherapy. Without them, her doctors wrote, "Tiffany is at risk for harming herself."

Once in custody, Tiffany was placed in a holding center in Manhattan on Jan. 5, 2000. She was taking Depakote to control her mood swings, and Risperidone, an antipsychotic. The next day, records show, she was examined by Dr. Williams.

Prison Health had hired the doctor several weeks earlier. But Dr. Williams had already made a mostly negative impression on some lawyers working with the youngsters in custody. In interviews, the lawyers said he replaced psychiatric medication with cheaper, less appropriate drugs.

Mr. Wright, the president of Prison Health, said Dr. Williams felt that black children were too frequently put on psychiatric medications they did not need. But Mr. Wright said that the doctor's decisions to withdraw those medications were inappropriate, and that Prison Health forced the doctor to resign in August 2001. Dr. Williams did not return messages left with his lawyer seeking comment for this article.

Records show that Dr. Williams, after one 80-minute exam, concluded that Tiffany suffered from attention deficit hyperactivity disorder, and despite three court orders discontinued her psychiatric medications in late January. Soon the hallucinations started again, she said in an interview, and her antisocial behavior came roaring back.

"I'd see stuff, shadows, people's faces," Tiffany recalled. "I'll be scared. I'll be crying. I always think people are out to get me."

She eventually threatened to kill herself, she said, setting in motion her return to Judge Hepner's courtroom, and ultimately the psychiatric hospital, where doctors put her back on her previous medication.

"When you have medicine that is working, it seems really irresponsible to alter it," Judge Hepner, in an interview, recalled saying in court. She ordered Dr. Williams to pay a $1,000 fine.

The kind of treatment Tiffany received, records and interviews show, began before Prison Health took over EMSA, but judges and lawyers said the pattern grew increasingly familiar afterward.

In July 2000, a suicidal 15-year-old girl was taken off Depakote - prescribed by doctors at Craig House, an upstate psychiatric clinic - and placed on Ritalin, according to court filings and lawyers and judges involved in her case. It would take five weeks to have her medication restored.

In March of that year, a 15-year-old boy at Bridges Juvenile Center, a secure center in the Bronx, went days without his psychiatric medications because Dr. Williams visited the center only twice a week. Prison Health's policy, according to court transcripts and interviews, was to discontinue youngsters' medications until a company doctor could complete his own evaluation.

But rather than wait for Dr. Williams to show up days later at Bridges, a Manhattan Family Court judge, alerted by the boy's lawyer, ordered the boy sent to Bellevue Hospital Center. "They can't say there's no psychiatrist on staff at the hospital," the judge, Sheldon M. Rand, said in a hearing.

The company's strategy for treatment, when it went beyond drugs, included the unusual approach of asking a youngster to write up and sign a pledge not to commit suicide. Such pledges, experts in mental health treatment say, accomplish little.

"It's an awful tool," said a former Prison Health mental health supervisor in the juvenile system. "It's designed to make the clinician go home and sleep better at night."

Tiffany said the whole exercise was stupid. "I just wrote it so they would stop following me," she said.
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"I learned that familiar paths traced in the dusk of summer evenings may lead as well to prisons as to innocent, untroubled sleep." (Albert Camus, The Stranger)
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Old 03-01-2005, 09:01 PM
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Default Harsh Medicine: New York Times Exposes How Private Health Care in Jails...

Harsh Medicine: New York Times Exposes How Private Health Care in Jails Can Be a "Death Sentence" for Prisoners


We take an in-depth look at the for-profit health care in prison and jails in this country. The New York Times published a series titled "Harsh Medicine" based on a yearlong investigation of Prison Health Services, the nation's largest for-profit provider of prisoner medical care, that exposes how inadequate care has resulted in death and suicides by prisoners.

Today, we are going to take an in-depth look at for-profit health care in prison and jails in this country. Prison Health Services or PHS is the nation's largest for-profit provider of inmate medical care - a 2 billion dollar a year industry. They have 86 contracts in 28 states and care for 237,000 inmates - which is one in every 10 people who are incarcerated.
Earlier this week, the New York Times published a series, titled "Harsh Medicine." The articles, based on a yearlong investigation of PHS, expose how the company provided medical care that was widely inadequate in some cases - and deadly in others. The articles detail a range of problems with PHS" medical services - some of which resulted in death or suicides by inmates. The list of problems include: skeletal medical staffs, under qualified doctors and nurses, doctors who were practicing without proper certification, prescription drugs being withheld from patients, and employee misconduct that went unpunished.

PHS began receiving contracts in New York State over the last decade despite a tarnished record of providing care in Florida and Pennsylvania. Since then, the State Commission of Corrections has faulted the company in 23 inmate deaths and has recommended disciplinary action of PHS doctors and nurses, 15 times in the past four years. The New York Times notes that in one report, the chairman of the commission's medical review board - Frederick C. Lamy - labeled the company, "reckless and unprincipled in its corporate pursuits, irrespective of patient care." Despite this, New York City renewed PHS' contract in January of this year.

PHS declined to make someone available for our program but they sent us a statement which reads in part - "since the story appeared, PHS has received calls from clients around the country and every one has been supportive and expressed their disagreement with the Times coverage."


Paul von Zeilbauer, reporter for the New York Times. Wrote series Harsh medicine about the severe deficiencies of Prison Health Services. PHS is a private company that provides health care to prisons and jails all over the country.
Dr. Bobby Cohen, federal court appointed doctor who monitors health care in prisons and jails in Michigan, Ohio, Connecticut and New York.
Barbara Ferguson, sister of Brian Tetrault . Inmate with Parkinson's disease who, she alleges, was denied proper medical care and died behind bars. PHS was the health care provider in the jail that Brian was locked up in.

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RUSH TRANSCRIPT
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AMY GOODMAN: Joining us in our studio is Paul von Zeilbauer, the reporter who wrote the series in The New York Times, and Dr. Bobby Cohen, who monitors prison health care for federal courts. On the phone with us from Clearwater, Florida, Barbara Ferguson, whose brother died in a jail cell because he was denied proper treatment by P.H.S. staff, she alleges. We welcome you both and all of you to Democracy Now! Paul von Zeilbauer, this is quite an astounding series. Lay out for us what you exposed.

PAUL VON ZEILBAUER: Okay. Well, over the course of about 15 months, 12 to 15 months, I began looking at the jail medical -- the medical – the system of delivering medical care in the New York City jail system where P.H.S. is the medical provider, and there was a series of suicides that occurred in the first half of 2003, and I wrote, I believe, one or two articles, one of which was about how two of these six suicides were people who were on suicide watch at the time, which, you know, brings up the obvious question of what is suicide watch and how does that happen. And from there, we began looking at who the actual provider is, Prison Health Services being the contractor, and then from there, I think it just sort of naturally took a little bit of flight. When you wonder who is doing the medical care, and you begin looking at where else they provide it. And as it turns out, you know, they have had contracts with upstate jails, and of course, they're a large company, so they have had many other contracts that we just began looking at. And finding other problems, you know, around the country. And that's how it began, and then, you know, like any good story, the details lead to other details, and you begin opening doors, and that's how everything sort of came to light over time.

JUAN GONZALEZ: And you originally got on the story because you were covering some of those deaths as part of your regular beat, or how did you get actually involved yourself in the story?

PAUL VON ZEILBAUER: Yes. Right. My job is -- in the metropolitan desk at the Times is covering prisons, jails. So Rikers Island was sort of the centerpiece of my beat, if you want to call it that. And so when these suicides occurred, like I said, in the first half -- six in the first half of 2001 which may not sound like a lot, but in the world of Rikers Island, it was a lot. In fact, I think I mention in the story, it was the largest -- the highest rate of suicide in any six-month period since I think 1985. So, it was remarkable that it occurred, and my beat was covering the jail system and, you know, it became something obviously to look at.

AMY GOODMAN: Tell us about Jose Cruz?

PAUL VON ZEILBAUER: Jose Cruz. Jose Cruz, if I remember correctly, was the first of the six people who killed themselves in this six months period, to do so in January, I believe, of 2003. And, let me see, I don't want to get any details wrong, but I believe Jose Cruz was a man who was arrested for an assault. He was HIV positive. I believe he had tuberculosis. He was in the -- how do you call -- it's called Maui in the vernacular. How do you refer to --?

DR. BOBBY COHEN: One of the infirmaries.

PAUL VON ZEILBAUER: Yeah, he was in an infirmary, because he was contagious. And he was also put on suicide watch, because he had become despondent over time. What occurred, if you just want me to give -- I can give a quick history of what happened to him. He was put in a cell in this medical lockdown unit that was at the end of the wing where guard -- where the jail officers couldn't visually see him unless they walked down and actually looked into his cell. So, while he was on suicide watch, he was effectively out of sight. And he used that opportunity, apparently, to kill himself.

AMY GOODMAN: I wanted to turn to Barbara Ferguson. If you could tell us the story of your brother. What happened to Brian Tetrault.

BARBARA FERGUSON: Yeah, Brian Tetrault. Good morning. My brother in November of 2001 made the mistake of going to his ex-wife's house and taking some things he thought belonged to him. She pressed charges and had him arrested. My family and I, who live in Florida, had no knowledge of this at the time. Ten days later, I got a phone call at my house from his ex-wife that my brother died. My brother was very, very sick, very ill. He had undergone some surgeries and things to improve his life, quality of life, but he was an obvious ill person. We were very confused. We had no idea, you know, what had happened. And it wasn't really until Paul had come to meet with us in last July that I was able to put together the whole story. We didn't -- we were lied to by his ex-wife about how he had gotten into jail. We found out exactly how that happened. But we didn't understand why he would have died there, and so when we started to pursue some of the information that we wanted, my parents did through the Freedom of Information Act, we got more confused. Just didn't make sense. Excuse me. As, you know, it got harder and harder to get more information, and also being in Florida, it made it harder for us to try to figure it out. And at one point, my parents tried to be the party to act on my brother's behalf to, you know, allege a suit against the jail, because we knew that something had happened, and in that pursuit, my nephew was named the person who would do that, and he is in the suit with them currently.

AMY GOODMAN: When we come back from our break, we'll find out more about the circumstances of when he was put into jail. Our guest, Barbara Ferguson, who lost her brother in the New York City jail system -- the New York State jail system. Dr. Bobby Cohen, who is the federal court appointed doctor who monitors health care in the prisons, and Paul Von Zeilbauer, who is the reporter for The New York Times that did this series for The New York Times called "Harsh Treatment."

[break]

AMY GOODMAN: We're talking about “Harsh Medicine.” It’s a series of exposés in The New York Times this week by Paul von Zeilbauer about the Prison Health Service, which is P.H.S., a for-profit prison health care industry in this country. And we're looking at some of the cases he exposed this week. We're also joined by Bobby Cohen, who is the federal monitor for prisons, as well as Barbara Ferguson, who has been telling us the story of her brother, Brian Tetrault, who died in his jail cell. I'm Amy Goodman here with Juan Gonzalez.

JUAN GONZALEZ: Paul, let's continue with the Brian Tetrault case. Again, how did you get on this particular case? He was a former nuclear scientist who had struggled with Parkinson's disease and was in jail on a minor charge.

PAUL VON ZEILBAUER: How I got onto that --

JUAN GONZALEZ: And also, then, what you discovered about his case.

PAUL VON ZEILBAUER: As I mentioned to you, after I began looking at the – after the company's record became an issue and became relevant, I went to the State Commission of Correction. It's a small agency in New York State. Its members are appointed by the Governor, and its mission is to enforce standards in the New York City jails – sorry, in the jails and prisons in New York State. It actually -- this Commission began as or got its current mandate after the Attica riots, I believe, in 1971, to prevent that very thing from happening again and to make sure there were humane levels of care and so forth in the jails and prisons. So, what the Commission does is investigate every jail death that occurs, whether it's in a, you know, Broome County jail or whether it’s in Attica or another state prison. So, they publish these reports. The reports are public. I filed a Freedom of Information Act request for every report that the Commission had done that mentioned or included or referred to Prison Health Services, because like I said, the company had become a focus of my reporting. So, Mr. Tetrault's case became -- was one of those reports. In fact, it's interesting, you know, there were many reports that I received. Some were more interesting than others. And Mr. Tetrault's case was interesting because he had died in 2001, but the Commission Of Correction only became aware of his death in 2003, by mistake, really. One of their employees read a newspaper article upstate that explained one of his family members had filed a lawsuit over the death, which was news to the Commission. And so they began looking into it and found, you know, this case.

AMY GOODMAN: So in that particular case, the correctional authorities had not reported the death to the Commission?

PAUL VON ZEILBAUER: Yeah. It was the Schenectady County Jail where Brian Tetrault was incarcerated. And the law in New York says that every time you have a death of an inmate, every time an inmate dies or is injured, you have to – excuse me --

AMY GOODMAN: Turn off your watch?

PAUL VON ZEILBAUER: Yeah, turn off your watch and then report it to -- no, you have to report it to the State Commission, so that there is no excuse for not having a public inquiry. But in this case, Brian Tetrault was released – was supposedly released from jail, even though he was in the hospital bed by the time he died. He was released by the sheriff's office ten minutes before, supposedly ten minutes before he expired.

AMY GOODMAN: I want to just read those first two paragraphs of your piece, "Private Health Care in Jails Can Be a Death Sentence.” “Brian Tetrault was 44 when he was led into a dim county jail cell upstate New York in 2001, charged with taking some skis and other items from his ex-wife's home. A former nuclear scientist, who’d struggled with Parkinson’s, he began to die almost immediately, and state investigators would later discover why. The jail's Medical Director had cut off all but a few of the 32 pills he needed each day to quell his tremors. Over the next ten days, Mr. Tetrault slid into a stupor, soaked in his own sweat and urine, but he never saw a jail doctor again, and the nurses dismissed him as a faker. After his heart finally stopped, investigators said corrections officers at the Schenectady jail doctored records to make it appear he had been released before he died.” Dr. Bobby Cohen, how did this happen?

DR. BOBBY COHEN: Well, I think that the problem in medical care in prisons is that for a variety of reasons -- and this is a general issue, not specifically on what Paul wrote -- is that medical care operates within prisons and tends to see its role as supporting its client, which is the system, which is the jail, which is the city, which is the state, rather than the patient. Now, that's not always the case. There are dedicated people, and you know, Paul's article talked about people who had really tried to do a good job. But the nature of incarceration creates a very, very difficult situation in which to provide medical care. It's possible, but difficult. And it is deforming to medical staff just as it's deforming to prisoners and to correctional officers to be in these institutions, but it's hard to understand how nurses could ignore a situation that was just described right now, or how doctors could ignore a situation that -- like that, which was described. That is incredibly disturbing, and it happens. It's not the usual, but it happens. It happens often enough. I think that the task is to -- in terms of providing medical care in prisons -- is to instill and inspire medical staff to understand that their job is difficult, and it can only be done in opposition, actually, to the prison. You cannot provide medical care in a prison, if you go along with the prison rules. You have to complain when patients are not seen. You have to complain when transportation doesn't bring the patient to the specialist. You have to complain when medications are not delivered. Now, I think it is particularly hard for for-profit companies to do that, because they need to have their contract renewed by the facility or the state or the county, and they want to be on good terms with them and not make their job of corrections more difficult.

JUAN GONZALEZ: Well, but Paul, I'd like to ask you, I remember years ago, I covered quite a bit of what was going on in the city jails at The Daily News, and I would often get calls from doctors or medical staff who worked on Rikers Island. At that time it was Montefiore Medical Center which had the contract. It was a non-profit voluntary hospital in New York to handle the situation and to deal -- provide medical treatment to Rikers. But there would be doctors and nurses who were definitely concerned about what was going on and the kind of treatment that they were being forced to deliver. What has been, from what you can tell, the impact of this move toward more for-profit operations moving into these jails?

PAUL VON ZEILBAUER: Well, in the -- I can speak in the context of what I have learned through my reporting, and what I understand is that privatization of -- if you want to call it private, I mean, it's a public company, Prison Health Services, so “private” is a bit of a misnomer, but it seems as if the difference between a for-profit company providing jail or prison health care and a teaching hospital or a public hospital doing it is that the staffs -- the staffs, the clinical staff seems to be smaller. I mean, that just seems -- not just in New York City that it occurred, but it’s what I found everywhere.

AMY GOODMAN: You used the term “skeletal.”

PAUL VON ZEILBAUER: Yes, the doctors used that term. In fact, I think it was the first article of the three here quoted a doctor who had just resigned in Alabama. She was one of, I think, two doctors in the prison, the state prison in Alabama for about 2,200 inmates who had complained about absolute skeletal staff. This is – I mean, the reason we used it not because it was an aberration or a nice word it use to play gotcha, but it really reflected what I had heard from medical clinicians and medical people who worked for this company in many places.

AMY GOODMAN: A second story in your piece. You say, “Two months later, after Mr. Tetrault died, Victoria William Smith, mother of a teenage boy was booked into another upstate jail in Duchess County, charged with smuggling drugs to her husband in prison. She, too, had only ten days to live after she began complaining of chest pains. She phoned friends in desperation. The medical director would not prescribe anything more potent than Ben Gay or the arthritis medicine she had brought with her, investigators said. A nurse scorned her pleas to be hospitalized as a ploy to get drugs. When at last an ambulance was called, Ms. Smith was on the floor of her cell shaking from a heart attack that would kill her within an hour. She was 35.” Now, Dr. Bobby Cohen, you're the Federal Court appointed doctor who monitors health care in prisons and jails in Michigan, Ohio, Connecticut, New York. Where does P.H.S. fit into this? Prison Health Services. How does it compare to non-profits that run the system. We're sorry they couldn't be us with, but is this a serious crisis in this country, and should they have their contracts pulled?

DR. BOBBY COHEN: I have not had a chance to review all of the data that Paul looked at, although I have no reason to believe that he did not carefully review it and that it reflects the reality. Certainly, New York City should have thought very carefully about renewing it at that time, and there should have been a process which allowed this information to get out. I think that in general, the trend towards for-profit health care in the United States is a serious problem, that just as in other health care in the United States, when you put profit into the situation, you get that profit significantly by denying care. And when a company like P.H.S. or other for-profit companies go into a system, the first thing they establish is a utilization review system, which all of your viewers are familiar with from their own encounters with medical care. Utilization review is a really a process of denying access to specialty care. That's in a contract where there’s a fixed amount of money, and whatever they don't spend, they keep. That’s a very easy way and effective way to make money. That was not the case on Rikers Island right now, because the previous contractor had had a risk contract where they made millions and millions of dollars, tens of millions of dollars by denying care on Rikers Island. Actually, they were kicked out because of the serious morbidity and mortality, many, many deaths that occurred during the St. Barnibace reign. I think that there is no room for for-profit health care in prisons, because of the kinds of situation that Paul has described. The process, when a company goes in, and then it gets its contract renewed after two or three years, it essentially has to underbid itself because there are other for-profits who are willing to come in and take the care, so it doesn't ask for increases in fees. When I monitored the Philadelphia jails a number of years ago when P.H.S. was running it, I encouraged them to ask for additional funds when they were renewing the contract, because they had new problems. They had to take care of HIV infection. They had to fix what was not being done. And they were extremely reluctant to do that, because they knew that they would lose their contract. And so this -- the process of competition among for-profits drives the amount of funds available to prisoners down. And that's a serious problem.

JUAN GONZALEZ: Doesn't ultimately the problem reside in the fact that, because we are dealing with an inmate population or prisoner population that the local governments, the state governments basically don't care, and want to spend as little money as possible in maintaining the health of these inmates, and there is no constituency -- organized constituency to insist on better health care?

DR. BOBBY COHEN: I think that's absolutely right, and it actually is the law in this country. I mean, there are two legal issues. One, in the United States, prisoners are actually entitled to health care which is not deliberately indifferent to their serious needs. The Supreme Court ruled that in 1976, and that's why all of the lawsuits have been filed, and actually, P.H.S. exists because of these lawsuits, because they said, “We can fix it,” when the courts told the states or the cities that you are providing unconstitutional care. But there's another legal issue here, which is that the cities and states cannot say it's P.H.S.'s fault. They are responsible. And they have to monitor it. As Paul points out in the article, previously, New York City's Board of Correction, which developed standards for care of medical and mental health in the jails, had a death review board, which reviewed every death, and that process has not been continuing of late. More of that is needed. More involvement of -- you know, I really think the more non--- the more people who come into prisons and see what's going on, the more people looking the better, because these are deforming, terrible institutions that need as much fresh air as possible.

AMY GOODMAN: Tell us about the Philadelphia case that you're quoted in the article, Dr. Robert Cohen, about women who were pregnant in the Philadelphia jails. Again, this Prison Health Services provides service in this case. “In Philadelphia in 1999, federal court monitors report warned the company's failure to segregate prisoners who were suffering from T.B. posed a public health emergency. Pregnant inmates, it said, were not routinely tested or counseled for HIV, endangering their babies. In fact, the women were encouraged to refuse pelvic exams.”

DR. BOBBY COHEN: I believe that I was the state monitor at that time. There's another doctor, Robert Greifinger, who was the federal monitor at that time. My experience in Philadelphia, in terms of care for women in prison, was that there was a process in which women were encouraged to refuse pap tests and pelvic examinations. I would look at the charts and they would say, “refuse, refuse, refuse, refuse, refuse.” And then I would ask people, and they told me why, that there were -- when supposedly these exams had taken place and they were tested for chlamydia or gonorrhea, common illnesses among women who were in prison, the rates were unbelievably low to zero when we know that the rates of these are very, very high in this population. Additionally, while I was there, while I was reviewing it, two women delivered in their cells who were pregnant. That's -- there's -- of course, these things happen, but it's usually a story in The Daily News, when someone delivers in a cab. This does not have to happen in a setting with medical care present.

JUAN GONZALEZ: Paul, I'd like to ask you, who runs P.H.S.? Who are the – I mean, there are obviously individuals behind these companies. Is it part of a larger corporation, and how did it develop?

PAUL VON ZEILBAUER: Yeah, well, Prison Health Services was founded in 1978, not coincidentally, I believe, two years after the Supreme Court ruling that Dr. Cohen mentioned that required adequate medical care to be provided to all inmates. So, you know, there was an opportunity there, because governments weren’t interested in it, and in providing it necessarily. I mean, they had to, but they weren't eager to. Companies like Prison Health evolved, and currently the company -- make sure I get this right, Prison Health Services is a -- there's a holding company that basically owns Prison Health Services. The holding company is called America Service Group. Its stock ticker is A.S.G.R. It's based in Tennessee. Under the America Service Group umbrella, there is Prison Health Services, and there is a pharmacy operation called Secure Pharmacy Plus, which, you know, is a complementary business because the pharmacy provides the medicines to the jails and prisons where P.H.S., Prison Health Services has contracts. So, it -- you know, the -- it's a public corporation. You can go on the S.E.C. website or anywhere else – or your Ameritrade account, for that matter, and look up the company's performance and who owns it. It's a regular public company.

AMY GOODMAN: Just ending with Barbara Ferguson. What are you calling for right now in the death of your brother?

BARBARA FERGUSON: At this point, my family, meaning myself and my parents, we are not doing any legal action. My nephew is doing that. He, I believe, and Paul, you can verify this, because you probably have more information. They are trying to settle a suit, I believe, with Prison Health Services. But what we really, really want is that, to go along with Paul, to help these people be aware.

PAUL VON ZEILBAUER: This, I mean, as Dr. Cohen mentioned, it's just -- you know when you go into jails and prisons, it's by almost necessity, but certainly, there is not a lot of sunlight shed on these institutions.

AMY GOODMAN: Well, thank you for doing some of that with your series, “Harsh Medicine.” I want to thank you, Paul von Zeilbauer for joining us, reporter for The New York Times, wrote the series in the paper.

PAUL VON ZEILBAUER: Sure.

AMY GOODMAN: Dr. Robert Cohen, federal court-appointed doctor, who monitors health care in prisons and jails, and Barbara Ferguson, sister of Brian Tetrault, who is the prisoner with Parkinson’s who, denied proper medical care, died behind bars.




http://www.democracynow.org/article..../03/04/1437213
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Old 03-05-2005, 12:47 AM
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There were actually three articles:
I posted the first in the World Prison & Related News forum on the 26th under its original title
Private Health Care in Jails Can Be a Death Sentence

The other two are in

New York News and Events

A Spotty Record of Health Care at Juvenile Sites in New York

and

In City's Jails, Missed Signals Open Way to Season of Suicides


All three are worth reading...but horrible and disgusting.
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Old 03-05-2005, 10:02 AM
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the first in the World Prison & Related News forum on the 26th under its original title
Private Health Care in Jails Can Be a Death Sentence
http://www.prisontalk.com/forums/sho...Death+Sentence
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Last edited by Manzanita; 03-05-2005 at 10:12 AM..
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Old 04-05-2005, 06:55 PM
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Default Examining Prison Health Care on The Leonard Lopate Show

Examining Prison Health Care The Leonard Lopate Show March 21

In a three-part series for the New York Times, reporter Paul von Zielbauer reveals the disturbing state of health care in New York prisons—from cases of neglect and poor treatment as health care is privatized, to cases of mistreatment in juvenile detention centers.

You can listen to the program by going to

http://www.wnyc.org/shows/lopate/episodes/03212005
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Last edited by titantoo; 04-05-2005 at 06:58 PM..
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