Objective. We examined the impact of arrest and incarceration on primary care patients in the Bronx, New York.
Methods. Patients at three clinics were asked eight questions concerning current and past involvement in criminal proceedings, arrest, and incarceration.
Results. One hundred eighteen patients were surveyed. Eleven (9%) patients were currently involved in criminal proceedings. Twenty-one (18%) currently had a family member in jail or prison. Twenty-nine (25%) reported ever being arrested; 65 (55%) reported that they or a family member had been arrested. Twenty-one (18%) had been incarcerated; 60 (51%) reported they or a family member had spent time in jail or prison. For most variables, rates were higher for men and the adults accompanying children at pediatric visits. Clinicians reported positive experiences discussing incarceration.
Conclusions. Involvement with the criminal justice system was common among our patients. Discussion of incarceration did not appear to have a negative impact on the clinical relationship. Comments:
The United States incarcerates far more people than any other country in the world. Last year, the Pew Charitable Trusts estimated that 1 out of every 100 American adults was behind bars. The impact of this policy falls primarily on men, on minorities and on the working class. The term mass incarceration was coined to describe how police targeting of specific neighborhoods (urban, minority, working class) creates communities where a large percentage of the men are in prison or jail. Taken as a whole the Bronx has high rates of arrests and incarceration, although even within the Bronx some neighborhoods are affected more than others. This is well illustrated in a series of maps produced by the Justice Mapping Center.
In our clinical work we have come to appreciate how incarceration affects not just the person imprisoned, but also their family. Ailing grandmothers end up caring for children when Dad goes to jail and Mom has to find a job. Children grow up in a single family home while their spends years in jail. Young boys who are having difficulty in school start playing hooky, get involved with petty crimes, end up incarcerated, and are then socialized by the prison gangs into more severe criminal activity. And just as families are affected by incarceration, so too are their communities.
In this study we tried to assess how common arrest and incarceration were in our patient population. Over the course of a few weeks in the fall of 2008, our clinicians asked patients a few simple questions about incarceration in the course of their clinic sessions. The data was collected in such a way as to protect the anonymity of the respondents. In all we collected data from 118 patients at three clinics. We found that 11 patients (9%) were involved in some type of criminal proceedings at the time of the visit. Twenty-nine (25%) reported that they had been arrested at some time in their life and twenty-one (18%) told us they had spent time in prison. Twelve percent of the families had someone return from jail within the past year. What was particularly concerning to us was that involvement in incarceration and arrest was more common among the adults bringing their children in for care than it was among the adults presenting for themselves.
The card study also brought to light issues that had previously been hidden. One of our residents remarked:
The card study of incarceration brought on an interesting discussion with a patient of mine whose son was imprisoned for many years. She’s a patient I’ve seen several times in clinic but with whom I had never thought to broach this topic.
This data reinforces our sense that mass incarceration has a major negative impact on the families and communities we serve. It suggested to us that knowing about an incarceration or arrest history may help doctors better care for their patients. This also seems to be an area in which doctors can advocate for system-level changes – such as reform of punitive drugs laws, expansion of drug treatment programs, improvements in the school system – that can prevent people from landing in jail.
The University of Massachusetts’ Commonwealth Medicine division and Nova Southeastern University’s College of Osteopathic Medicine will be sponsoring their 3rd Annual Academic and Health Policy Conference on Correctional Health from December 3rd and 4th, 2009 in Fort Lauderdale, Florida. This conference focuses on collaborations between academic medical centers and correctional institutions. This link will take you to a listing of the presentations at last conference.
Correctional health is an area of increasing concern to clinicians as more an more Americans find themselves arrested and behind bars. In fact, so many Americans are arrested that some have spoken of a “plague of prisons.” This impacts not only on the people who are incarcerated but also on their families and communities. Interested readers should consult our prior posting on marijuana arrests in the US (Record Marijuana Arrests Feed the Prison Industrial Complex ) and the Pew Charitable Trusts report: One in 100: Behind Bars in America 2008.
The conference will take place at the Hilton Fort Lauderdale Airport Hotel. A special conference rate of $109/night will be available to conference participants; mention the 3rd Annual Academic and Health Policy Conference on Correctional Health to secure this rate.
Daphne Eviatar of the The Washington Independent reported last week on a new piece of legislation designed in response to growing awareness about the poor and even dangerous conditions experienced by detainees held by the Immigration and Customs Enforcement (ICE) Agency (see original article here).
New York Senator Kirsten Gillebrand, along with Senators Kennedy (D-MA) and Menendez (D-NJ) introduced the “Protect Citizens from Unlawful Detention Act” and the “Prevent Detainee Deaths and Abuse Act”, which would increase government accountability towards suspected undocumented immigrants and protect those already detained. The article cites the recent work of Amnesty International USA, the InterAmerican Commission on Human Rights, the National Immigration Law Center and others in documenting the abuses experienced by detainees.
Media attention on the subject has grown. Recently, the NY Times reported on the death of a detainee at a detention center in a Monmouth County detention facility. Ahmad Tanveer, a Pakistani New Yorker died after exhibiting symptoms consistent with a myocardial infarction (or heart attack). His death would have gone unreported were it not for a scrawled note of another detainee sent to a group who regularly correspond with these individuals. It is still unknown as to why Mr. Tanveer was detained in the first place.
In late July, the Times also reported on a series of three-day hunger-strikes being conducted by immigrant detainees in an ICE facility in Louisana. These men are protesting poor conditions: ”’There are rats, mosquitoes, flies, and spiders inside the cell and inside the dorm. The ventilation is terrible,” [one detainee] said. ‘We have tried to complain about all of these problems, and we haven’t gotten anywhere. They tell us, ‘It’s a jail. This is how it is.””
Immigrant detention affects the communities we serve. I met an elderly women in clinic recently whose symptoms of sleeplessness and anxiety were exacerbated by the recent detention of her oldest son, in his 40s, the father of her five grandchildren. He had been raised in the U.S. since the age of 10 and had been placed in detention after violating parole in relation to an arrest for Marijuana-related drug charges. He was described by his mother as the family’s main support person, both financially and emotionally. Further complicating his detention is a severe acquired hearing deficiency requiring hearing aids for which he had been recently fitted, but had not yet received.
The Social Medicine portal has reported on this subject before (Homer Venters (RPSM IM 2007) On Immigration Detainee Health Care, July 2008; Persistent Concerns over the Health of Immigrant Detainees, April 2009). It is encouraging that the problems outlined in those two articles is being brought to light and addressed by politicians at the national level. Physicians will have to play a role in enforcing new standards of healthcare in ICE facilities.
In the meantime, call your Senators and ask them to support this valuable piece of legislation.
The Riker’s Island Penitentiary sits in New York City’s East River between Queens and the Bronx, just to west of La Guardia Airport. Riker’s is quite literally an island, connected to the Borough of Queens by a single bridge. It is one of the world’s largest correctional facilities with an average daily census of about 13,000 prisoners. Administratively, the facility houses ten jails that sit on the island and the Vernon C. Bain Center, an 800 person facility located on a barge just off of Hunts Point in the Bronx.
Vernon C. Bain Prison Barge
Dr. Shalev divides the history of health care at Rikers into three periods. From the opening of the prison in 1932 until 1973 medical services were provided by various New York City agencies. During this period numerous reports documented the poor quality of care provided to inmates. It seems clear that the Department of Correction’s concern for security trumped attempts to provide medical care to inmates. As noted in a 1958 report: “The Department of Correction is not now in background, equipment, or personnel capable of giving modern medical care—whether preventative or therapeutic—to the prisoner.”
Attempts to remedy this situation made little progress until the early 1970′s when a series of prison revolts including those at the upstate Attica prison and the Manhattan House of Detention (commonly known as “the Tombs”) led to reforms. This resulted in the second period of medical care at Rikers. From 1973 to 1996 Montefiore Medical Center provided health care under an affiliation agreement with the City. Health care on the island improved and the service was “the first correctional medical program in the country to be accredited by the Joint Commission on Accreditation of Healthcare Organizations” (JCAHO). However this period also coincided with the HIV epidemic and in its wake a resurgence of tuberculosis; prisoners were particularly affected by these twin epidemics. Costs for medical care increased substantially and in 1996 the Giuliani Administration decided to turn health care at the island over to a private contactor. The initial agreement with St. Barnabus Hospital was generally recognized as a failure. Costs did not decrease and there were ongoing concerns about the quality of care. Currently, care on the island is provided by the private, for-profit Prison Health Service, Incorporated. Concerns over costs and quality of care remain. Dr. Shalev characterizes this final period from 1996 to the present as one of “managed care” and the overarching theme of her paper is that health services at Riker’s have moved from public hands (the city) into private hands (for-profit corporations).
Dr. Shalev’s careful historical research, butressed by interviews with Montefiore staff, tell the story of a particular and certainly unique experience in incarceration. But the unique story of Riker’s illustrates the larger themes of how corrections have come to be seen as one more commodity on which profit can be made. And this gives powerful players a vested interests in keeping jails full. The result is a system described by some as a prison-industrial complex, by others as a penal state.
Here is the abstract of Dr. Shalev’s paper:
Over the past 25 years, incarceration rates in the United Stateshave more than tripled. Providing health care services for thisgrowing number of inmates poses immense medical and public healthchallenges. Focusing on the administrative and financial shiftsin health care delivery, I examined the history of medical servicesin one of the nation’s largest correctional facilities, RikersIsland in New York City. Over time, medical services at Rikershave become increasingly privatized. This trend toward privatizationis mirrored nationwide and coincides with the rising prevalenceof incarceration.
In April of 2009, the Obama Administration complied with a Freedom of Information request by the American Civil Liberties Union and released four secret memos outlining the Bush Administration’s justification for various “interrogation techniques” that amounted to torture. These memos are available at the ACLU website. They are essential reading for Americans who want to understand what has been done in the name of our country.
The report is of particular interest to health care personnel because it details the alleged roles of medical personnel in the torture of the 14 detainees. Rather than summarizing the contents of the ICRC report, we excerpt below the entire text of Section 3 entitled: Health Provision and the Role of Medical Staff.
During the course of their detention, detainees described three principal roles for health personnel whom they encountered. Firstly, there was a direct role in monitoring the ongoing ill-treatment which, in some instances, involved the health personnel directly participating while certain methods were used. Secondly, there was a role in performing a medical check just prior to, and just after, each transfer. Finally, there was the provision of healthcare, to treat both the direct consequences of ill-treatment detailed in previous sections, and to treat any natural ailments that arose during the prolonged periods of detention.
Throughout the course of the initial phase of the detention, the ICRC received allegations that health personnel were directly involved in monitoring the health effects of ill-treatment. In some cases it was alleged that, based on their assessments, health personnel gave instructions to interrogators to continue, to adjust, or to stop particular methods. As with other personnel within the detention facilities, the health personnel did not identify themselves, but the detainees presumed from their presence and function that they were either physicians or psychologists.
For certain methods, notably suffocation by water, the health personnel were allegedly directly participating in the infliction of the ill-treatment. In one case, it was alleged that health personnel actively monitored a detainee’s oxygen saturation using what, from the description of the detainee of a device placed over the finger, appeared to be a pulse oxymeter. For example, Mr Khaled Shaik Mohammed alleged that on several occasions the suffocation method was stopped on the intervention of a health person who was present in the room each time this procedure was used.
Other detainees who were shackled in a stress standing position for prolonged periods in their cells were monitored by health personnel who in some instances recommended stopping the method of ill-treatment, or recommended its continuation, but with adjustments. For example, Mr Bin Attash (the detainee has had a right-sided below knee amputation) alleged that while being held in a form of stress standing position with his arms shackled above his head, and his feet touching the floor, had his lower leg measured on a daily basis with a tape measure by a person he assumed to be a doctor for signs of swelling; the health person finally ordered that he be allowed to sit on the floor, albeit with his arms still shackled above his head. Mr Hambali alleged that, after a period of the same form of prolonged stress standing, a health person intervened to prevent further use of the method, but told him that “I look after your body only because we need you for information”.
As well as the monitoring of specific methods of ill-treatment, other health personnel were alleged to have directly participated in the interrogation process. One detainee, who did not wish his name to be transmitted to the authorities, alleged that a health person threatened that medical care would be conditional upon cooperation with the interrogators.
The second alleged role of the health personnel was to perform a medical check prior to and after each transfer from one detention location to another. The purpose and results of this medical examination appear not to have been divulged to the detainees.
The third alleged role was to provide medical care to detainees, either for injuries resulting directly from the various forms of ill-treatment employed, or treatment for common ailments that arose throughout the course of the detention.
With regard to this third role, when such medical treatment was necessary it appears from the descriptions given that the care was appropriate and satisfactory. In two specific cases, detainees indicated that exceptional lengths were taken to provide very high standards of medical intervention.
Medical ethics are based on a number of principles’ which include the principle of beneficence (a medical practitioner should act in the best interest of the patient—salus aegroti suprema lex), non-malefiance (first do no harm—primum non nocere) and dignity (the patient and the person treating the patient have the right to dignity). These principles guide any relationship between a medical doctor and a person whom he or she is relating to as a medical doctor.
There are accepted roles for health professionals working in recognised, official, places of detention such as police stations and prisons wherein the health professionals have the health care and best interests of the detainee as their primary consideration.’ To this end, when a person enters an official detention facility or system, a medical assessment of their medical status is required in order to meet their current and ongoing health needs. In the case of a normal, lawful interrogation, a physician may be asked to provide a medical opinion, within the usual bounds of medical confidentiality, as to whether existing mental or physical health problems would preclude the individual from being questioned. Secondly, a physician may rightly be requested to provide medical treatment to a person suffering a medical emergency during questioning. This accepted role of the physician, or any other health professional, clearly does not extend to ruling on the permissibility, or not, of any form of physical or psychological ill-treatment. The physician, and any other health professionals, are expressly prohibited from using their scientific knowledge and skills to facilitate such practices in any way. On the contrary, the role of the physician and any other health professional involved in the care of detainees is explicitly to protect them from such ill-treatment and there can be no exceptional circumstances invoked to excuse this obligation.”
With the exceptions detailed in the above paragraph, any interrogation process that requires a health professional to either pronounce on the subject’s fitness to withstand such a procedure, or which requires a health professional to monitor the actual procedure, must have inherent health risks. As such, the interrogation process is contrary to international law and the participation of health personnel in such a process is contrary to international standards of medical ethics. In the case of the alleged participation of health personnel in the detention and interrogation of the fourteen detainees, their primary purpose appears to have been to serve the interrogation process, and not the patient. In so doing the health personnel have condoned, and participated in ill-treatment.
Commentary on the ICRC Report
Medical participation in torture has been discussed in several articles in the medical literature over the past several years. Stephen Mile’s 2004 Lancet article entitled “Abu Ghraib: its legacy for military medicine” pointed to multiple ill effects of medical participation in torture. These included damage to the reputation of the US Army and its medical corps as well as “[t]he eroded status of international law has increased the risk to individuals who become detainees of war since Abu Ghraib because it has decreased the credibility of international appeals on their behalf.“ Calls arose the same year for an investigation of doctors who had been involved in torture.
As of today no health care personnel have been prosecuted or lost their license to practice for these breaches not only of basic ethical principles, but also of international law. Of course, the problem does not reside in a “few bad apples” who did wrong, but rather in the larger system that was designed to torture and abuse. Medical personnel were one part of that machine.
In a 2003 chapter in the book Military Medical Ethics, Volume 1, Drs. Vic Sidel and Barry Levy argued that the concept of a physician-solider contained an irreconcilible ethical dilemma: that of divided loyalties or dual agency.
The overriding ethical principles of medical practice in our view are “concern for the welfare of the patient” and “primarily do no harm.” As we understand them, the overriding principles of military service are “concern for the effective function of the fighting force” and “obedience to the command structure.” Although there may be rare exceptions to these principles, they have been the fundamental bases of medical practice and military service over the centuries. In our view, the ethical principles of medicine make medical practice under military control fundamentally dysfunctional and unethical.
In making this critique Drs. Sidel and Levy were speaking of primarily physician-soliders who were caring for other soldiers. But the situation of the medical personnel operating at the CIA “black sites” is the ultimate expression of the problems of dual agency in military medicine.
More on the ICRC
This posting excerpts only a small portion of the ICRC report which is worth reading in full for its careful documentation of the conditions of detention in the CIA black sites. It is worth pointing out that the ICRC’s involvement in defending prisoners extends far beyond this report. The Committtee’s work can be appreciated on their website. Finally, the ICRC has provided some background in response to the publication of the report. The ICRC statement concludes with the following:
The ICRC is concerned that any information it divulged about its findings in places of detention could easily be exploited for political purposes. It deplores the fact that confidential information conveyed to the US authorities has been published by the media on a number of occasions in recent years. The ICRC has never given its consent to the publication of such information.
Rev. Joseph Danticat died in Immigration Detention. Shown here with his wife & niece Edwidge
In July of last year we wrote about the activites of RPSM alumni Dr. Homer Venters to bring attention to the medical conditions in the detention facilities of Immigration and Customs Enforcement (ICE). Two reports issued in March – one from Human Rights Watch and the other from the Florida Immigrant Advocacy Center - provide further evidence that ICE is not adequately caring for those in its custody.
A bit of context
To understand the health problems in ICE facilities it is necessary to have some sense of the massive growth in ICE’s detention operations. In March of this year Amnesty International USA produced a report on ICE entitled Jailed without Justice which notes:
More than 300,000 men, women and children are detained by US immigration authorities each year. They include asylum seekers, torture survivors, victims of human trafficking, longtime lawful permanent residents, and the parents of US citizen children. The use of detention as a tool to combat unauthorized migration falls short of international human rights law, which contains a clear presumption against detention. Everyone has the right to liberty, freedom of movement, and the right not to be arbitrarily detained.
According to the ICE website the average daily number of “detained aliens” in custody rose from 20,838 in 2002-2005 to 31,2345 in 2008 (fiscal years). By contrast the Amnesty reports notes that as recently as 1996 the immigration system had the capacity to detain only 10,000 people a day. While the absolute numbers of detainees has increased, ICE has also decreased time each detainee spends in custody. The result is a massive machine to detain and incarcerate.
It is important to remember that the vast majority of those detained are not criminals. Those who are in the US without authorization have committed a civil violation not a crime. In the language of ICE they are “deportable aliens.” As Human Rights Watch notes it is precisely their status as civil – and not criminal – detainees that deprives them of their right to a lawyer.
In fact, many of those detained are victims of crime themselves. In July of last year our journal, Social Medicine, published an interview with Victor Toro, an immigration activist in the Bronx. Victor, who had been severely tortured in Pinochet’s Chile, described his experience with ICE detention:
On 6 July of 2007, when I was traveling from California to New York in an Amtrak train, when we had just passed the city of Buffalo, in one of the stations, the Immigration service entered the train with dogs producing great alarm and upsetting the English-speaking passengers, asking for papers from everyone and acting especially rude and hateful toward the persons who had Hispanic features or looked as if they were from some other part of the world than the USA. I was among these persons, among them I was traveling and had lived nearly 25 years in this country. Without many questions I was hand-cuffed and forced with blows from the train, then handcuffed to the others and taken to the regional immigration offices, afterwards to the Cayuga jail, where I was stripped and forced to wear the orange prison jump-suits, which are the same that everyone in the world saw on the prisoners tortured and tied-up in Guantanamo and Abu Ghraib. This squeezed and cramped all the fibers and vibrations of my body, it took me immediately to sessions of torture and mistreatment that I lived through in Chile, in the torture centers and the concentration camps of Pinochet. It was horrible, I cannot even talk about it and just thinking about and seeing the photos of the prisoners in Guantanamo converted into animals by the authorities of the United States, this has no name. It is pure savageness, a total lack of humanity.
Concerns about immigrant health care
Given the rapid expansion of the ICE facilities it is not surprising that health problems have arisen. Indeed the Inspector General of the Department of Homeland Security had issued a report in December of 2006 noting “instances of non-compliance at four of the five detention facilities, including timely initial and responsive medical care.” Among other concerns the Inspector noted that procedures did not exist for detainees to report abuse or human rights violations.
In November of last year the ICE issued a fact sheet on Detainee Health Care which stated that detainees received care for both acute and chronic medical conditions in accordance with community standards. Further ICE claimed that health care in its facilities was evaluated using “applicable health care standards from the American Correctional Association (ACA), the National Commission on Correctional Health Care (NCCHC), the Joint Commission, and the ICE National Detention Standards to evaluate the care provided to detainees.”
The reports by Human Rights Watch and the Florida Immigrant Advocacy Center paint a very different picture.
Detained and Dismissed
Detained and Dismissed:Women’s Struggles to Obtain Health Care in United States Immigration Detention is the title of the report by Human Rights Watch. It is based on a series of interviews & detention facility visits conducted in 2008. The interviewees included 48 women who were either in an ICE facility at the time or had been in the past. The report began by noting that the standards for medical care adopted by ICE were problematic:
Official ICE policy, which focuses on emergency care and keeping the individuals in its custody in deportable condition, effectively discourages the routine provision of some basic women’s health services. ICE’s Division of Immigration Health Services (DIHS) has chief responsibility for the medical care provided to detained immigrants, whether it provides those services directly or through a contractor at a local facility. The DIHS Medical Dental Detainee Covered Services Package, which governs access to off-site specialists, says that requests for non-emergency care will be considered if going without treatment in custody would “cause deterioration of the detainee’s health or uncontrolled suffering affecting his/her deportation status.” Although, on occasion, officials have offered generous interpretations of this policy in its defense, the message about the scope of care provided remains clear. “We are in the deportation business…. Obviously, our goal is to remove individuals ordered removed from our country,” ICE spokesperson Kelly Nantel told a reporter in June 2008. “We address their health care issues to make sure they are medically able to travel and medically able to return to their country.”
As Human Rights Watch notes, the decision by the US government to deprive someone of their liberty means the government is responsible for their care.
The report documented numerous violations of humane treatment:
We met women who were denied gynecological care or obtained it only after many requests, including a woman who entered detention shortly after receiving news of an abnormal Pap smear. She told detention authorities that her doctor instructed her to get Pap smears every six months, but after 16 months in detention and many requests, she had still not gotten a Pap smear.
We met women who complained of inadequate care during pregnancy, including one diagnosed with an ovarian cyst threatening her five-month pregnancy shortly before she was detained. Her doctor said the cyst should be monitored every two to three weeks, but during her stay in detention of more than four weeks, she was never able to see a doctor. The medical staff’s response to her last sick call request read, “be patient.”
We met women who had to beg, plead, and in some cases work within the facility just to get enough sanitary pads not to bleed through their clothes, and one woman who sat on a toilet for hours when the facility would not give her the pads she needed.
The report concluded with a series of specific recommendations.
Dying for Decent Care
Dying for Decent Care: Bad Medicine in Immigration Custody was released in February by the Florida Immigrant Advocacy Center. It begins with the story of Reverend Joseph Dantica (actually Danticat) who is one of more than 80 people who have died in immigration detention.
Rev. Joseph Dantica, an 81-year-old Baptist minister, fled Haiti after he was targeted for persecution. Gangs had burned and ransacked his home and church. Although Rev. Dantica had a valid visa to enter the United States, where he had traveled many times, he was detained at the Miami airport when he told officials he sought political asylum. At the Krome immigration detention center, he was accused of “faking” his illness and later transferred to the prison ward of Miami’s public hospital in leg restraints. Rev. Dantica died there alone five days after his arrival in October 2004. His family was allowed to see him only after his death.
FIAC provides free legal services to detainees in Florida. The organization is, therefore, exposed to the realities of life inside the ICE facilities in Florida. The report provides detailed information on the following health issues:
Deaths in Detention
Abuses in Medical Care
Unacceptable Mental Health Care
Physcially Disabled Detainees
Mismanaged Medication
Forcible drugging to depart
Language barriers
Unhealthy living conditions
Detainees treated like criminals
Denied medical records
This report closes with a set of specific recommendations. Among these are that independent, external scrutiny needs to be exercised over the work of ICE.
Commentary
Deportable aliens are not criminals and alternatives to incarcerations should be fully utilized before we deprive someone of their liberty. Once someone is incarcerated they should receive humane treatment. ICE’s report of last December seems to say that “everything’s ok.” This is perhaps the most concerning part of the story and justifies FIAC’s claim that in an oversight vacuum “ICE tolerates a culture of cruelty and indifference to human suffering.”
Each October our Residency Program in Social Medicine does something rather unusual. We take our interns off the hospital wards to participate in “Orientation Month.” For four weeks they learn about social medicine and the Bronx, the place in which they are practicing medicine. They are introduced to the philosophy, theoretical framework, and practice of Social Medicine through a curriculum of didactic and experiential learning. The month emphasizes a biopsychosocial perspective that integrates patients, their communities, and the medical system into a holistic view of health problems. At the conclusion of the month residents present a synopsis of the clinical problem they have studied and develop a proposal to address its social determinants.
This year the overall theme of the Orientation month was The Impact of Violence on Clinical Practice. We explored this through three cases: one involved a patient who had been incarcerated, the second a case of domestic violence and the third an immigrant. These cases were tightly integrated into a series of activities that included visits to prisons (Riker’s Island and Sing Sing), community organizations, community centers (e.g. the Bronx Community Pride Center), local businesses (such as botanicas) and Bronx institutions such as the Botanical Gardens and the Bronx Museum. The interns also learned practical skills such as how to perform a medical evaluation of an ayslum seeker and how to do community organizing (a workshop taught by Steve Max of the Midwest Academy).
On Tuesday, November 18th the interns presented their work as part of our regularly scheduled Social Medicine Rounds. A standing room only crowd listened as they shared what they had learned and made a a variety of project proposals. Their presentation can be downloaded as a Powerpoint. While the Powerpoint does not capture the richness of their actual presentation, it suggests the themes they explored and learned about.
Robert Greifinger, an RPSM graduate in Social Pediatrics in 1976, has been extensively involved in examining the prison system from a public health point of view. Last year, he published Public Health Behind Bars: From Prisons to Communities, the title of which suggests his social conception of the problem of prisons and health. He is currently an adjunct Professor at the John Jay College of Criminal Justice. Previously, he was the Chief Medical Officer for the New York State of Correctional Services, which was responsible for the health care of 68,000 inmates.
The health of prisoners and the impact of mass incarceration on the communities we serve is an area of very interest in the DFSM.
Here is the description of the book from the publisher’s website:
Prisoner reentry is a topic of current interest in correctional and public health
Coverage includes both health care and topics in law and public policy
Contributors are experts from such fields as public health and correctional health
Projecting correctional facility-based health care into the community arena, Public Health Behind Bars: From Prisons to Communities examines the burden of illness in the growing prison population, and analyzes the considerable impact on public health as prisoners are released. More than forty practitioners, researchers, and scholars in correctional health, mental health, law, and public policy make a timely case for correctional health care that is humane for those incarcerated and beneficial to the communities they reenter. These authors offer affirmative recommendations toward that evolutionary step.
Chapter authors identify the most compelling health problems behind bars (including communicable disease, mental illness, addiction, and suicide), pinpoint systemic barriers to care, and explain how correctional medicine can shift from emergency or crisis care to primary care and prevention. In addition, strategies are outlined that link community health resources to correctional facilities so that prisoners can transition to the community without unnecessarily taxing public resources or falling through the cracks. Between the authors’ research findings and practical suggestions, readers will find realistic answers to these and similar questions:
Can transmission of HIV, tuberculosis, and other communicable diseases be reduced and prevented among prisoners?
How can correctional facilities treat addiction more effectively?
What can be done to improve diagnosis and treatment of psychiatric disorders?
Can correctional care benefit from quality management and performance measurement?
How can care be coordinated between correctional and community health care providers?
What are the health risks to communities if action is not taken?
Public Health Behind Bars: From Prisons to Communities is a challenge of immediate interest to readers in correctional health and medicine, public and community health, health care administration and policy, and civil rights.
Dr. Homer Venters, a 2007 RSPM Internal Medicine Graduate, is currently working as an Attending Physician at the Bellevue/NYU Program for Survivors of Torture and is a Public Health Fellow, New York University. During his residency at Montefiore, Dr. Venters worked with Bronx Defenders, a legal aid organization in the Bronx, helping to get people involved in the criminal justice system into primary care. This work resulted in the publication of an article about the tragic case of Scott Ortiz in the Harm Reduction Journal. His work as a resident was awarded the Dan Leight Social Medicine Award.
On June 4 2008, Dr. Venters testified in front of the House Judiciary Committee’s Subcommittee on Immigration, Citizenship, Refugees, Border Security, and International Law. He discussed problems with the medical care provided to Immigration and Customs Enforcement (ICE) detainees. It is clear to people working in the field that ICE detainees are not accorded the same medical care provided to other US prisoners. Dr. Venters outlined some of the reasons why. Specifically he pointed out that the ICE medical system is designed to care for acute problems; it is not set up for persons with chronic medical issues. To quote from his testimony:
“This institutional aversion to caring for detainees with chronic disease is evidenced in recent detainee deaths. One year ago, a 23 year old transgender woman, Victoria Arellano was detained by ICE. Ms. Arellano had AIDS and was taking a life saving medicine to prevent opportunistic infections that could quickly cause pneumonia and death were she to stop. These medicines are essential for people with AIDS and even a brief interruption risks sickness and death for a patient. Despite reporting her medical history and her medication when detained (and throughout her detention), Ms. Arellano was refused her medicine. Over the following weeks, Ms. Arellano developed a cough and fever, which should have prompted hospitalization and evaluation. Instead, Ms. Arellano was given an inappropriate antibiotic by the detention center medical staff, was still refused her needed medication, and returned to her cell. By the time Ms. Arellano’s cellmates staged a protest to draw attention to her deteriorating condition, she had become very ill and died soon thereafter, comatose and shackled to her bed. Faced with a common chronic disease, ICE medical staff withheld the correct medicines, gave inappropriate medicines and failed to seek more competent care for Ms. Arellano. The care that Ms. Arellano required would be routine in almost any medical clinic or hospital in the United States.”
The views and opinions expressed on this site do not necessarily reflect the views of Montefiore Medical Center, Albert Einstein College of Medicine, Yeshiva University or the Social Medicine Publishing Group.
The most recent issue of the Journal of Health Care for the Poor and Underserved includes an article we wrote on the impact of mass incarceration on the communities we serve in the Bronx:
In April of 2009, the Obama Administration complied with a Freedom of Information request by the American Civil Liberties Union and released four secret memos outlining the Bush Administration’s justification for various “interrogation techniques” that amounted to torture. These memos are 
