Why Problems in Prisons Concentrate in Medical Units

Since I moved to California last year, California’s Prison Realignment policy has been getting deserved attention. It’s no secret that prisons are the site of an acute concentration of medical and social service problems. But where did that concentration come from?

In my first post I thought I’d take a moment to enumerate some of the features of prisons and of prisoner populations that make that concentration so intractable, especially here in California:

  1. Prisons are rural and isolated, and this impedes the swift delivery of medical services.
  2. Prisoners are frequently transferred from other prisons, which complicates record-keeping – an essential feature of medical care.
  3. The architectural features of prisons themselves often either exacerbate or precipitate medical problems.
  4. Prisoners are drawn from groups where problems typically concentrate before they arrive in prison.
  5. Some prisoners refuse urgent medical care.
  6. Medical personnel don’t make much money. One would be mistaken in thinking that the high wages that prison officers enjoy carries over to medical personnel in prisons. Consequently, medical units are understaffed and, at times, the staff itself is incompetent.

Many people wonder why a sweeping policy to re-structure prisons based on overcrowding is so centrally preoccupied with the delivery of medical service specifically. The two seem related, but by no means synonymous. The answer is that the problems found in prison medical units are typically amplified by prison overcrowding, and that the medical units are the first to show indicia of deterioration.

The way problems become magnified by overcrowding in medical units is different to the way that problems are magnified in the regular prison wings. One might be able to double stack a bed in a prison cell, but the same can’t be done with a clinic bed. Medical attention requires much more prison officer manpower per inmate than is necessary for prisoners held in other parts of the facility; even simple tasks like transporting inmates from the medical unit to other facilities is vastly more difficult when the medical unit is overcrowded. The result, as was so poignantly highlighted in the Brown v. Plata decision, is an increased reliance on Secure Housing Units in instances for which the SHU was not envisioned.

Hence, the problems that accompany prison overcrowding obey a multiplicative rather than a linear function. Looking through the list, one could easily find a recipe for bleakness. Sure, it is bleak. But many of them are also eminently soluble (Number 2 in particular). There’s nothing inevitable and intractable about the way these problems are concentrated. It’s often a good idea to remind oneself that it wasn’t always like this. We got here as a result of a series of very conscious decisions. It’s generally understood that getting out of the problem of mass incarceration is going to be much more difficult than getting into it, but it’s entirely possible. We’ve just got to work for it. Hard.

13 thoughts on “Why Problems in Prisons Concentrate in Medical Units”

  1. Great opening post Johann. Speaking as one of the prison inspectors whose work was included in some of the lawsuits about California prisons, let me add an important point: The law gives prisoners a stronger right to health care than to almost anything else. Indeed, in prison, on paper at least, you have more legal expectation to quality health care than you do on the outside. That fact gives advocates a huge lever to use in trying to reform the system.

  2. “Prisoners are frequently transferred from other prisons, which complicates record-keeping.”
    In any culture that has discovered writing, let alone the computer, the problem is as you say easily soluble. Armies have had proper medical records for a century. The fact that it hasn’t been solved in US prisons today is revealing. Why not simply clone the Veterans Administration medical records system?

  3. BTW, welcome to the club. Friday afternoons are for snoozing. The staff (commenters) are a good lot, though some are unreliable at taking their meds.

  4. You called California voters “conscious.” Good one! Now, if we could just reform the electorate…

  5. I think it’s some of the same people who say that “WE don’t have access to good, low-cost or free medical care, so why should those worthless punks in prison (or on welfare/Medicaid) have what we hard-working honest people don’t?” who also scream that any sort of universal health care is awful socialism not to be tolerated – except, of course, for Medicare if you’re in that age group. It seems as if, by now, food and clean water and basic health care ought to be minimum standards for all in any “civilized” society, but obviously I’m wrong.

  6. Welcome, Johann. I read this blog so I can get smarter about things I don’t know much about. Clearly your posts will make a significant contribution. Thanks.

  7. As to salaries, I will say that when the prison psychiatric docs got a court-ordered raise, it sure as heck pushed up the salaries of every other comparable provider — to the point where rural counties up north lost every one of the psychiatrists they had previously employed and haven’t been able to recruit since.

    Different regions have different pay scales, but I’m very surprised to hear that medical personnel don’t make good money.

  8. Willkommen Johann. And kudos to you for knowing so much about policy in a place so far from your native Germany (or should I say Duetschland)?
    And speaking of realingment, is it actually a good thing? Based on your list, I’d have to say yes, just due to #1, and then also the idea that if prisoners are closer to their families (rather than isolated prison-towns), there will be people on the outside that can see them and actually lobby (however ineffectively) on their behalf and on prison care in general.

    1. Danke schön, agorabum. It isn’t yet clear whether Realignment is doing what it was supposed to, but I know that there’s a large-scale research project housed in the Stanford Criminal Justice Center that promises to find out.

      Preliminary readings on the progress of Realignment indicates that it’s going well in parts, not so well in others. Anything less equivocal than that is unavailable though, unfortunately.

  9. Wouldn’t it be safe to say that part of the problem of medical care in prisons is that mandatory minimums (and things like 3-strikes) has resulted in increased numbers of elderly prisoners with the additional medical problems of age?

    1. Absolutely true. California is witnessing an explosion not just in mass incarceration generally, but also geriatric incarceration more specifically. That has had tremendous follow-on impact for medical care.

      1. It seems that (eliding the ethical issues for a moment) prisons would be a great place to look at the longterm costs and savings of various kinds of healthcare intervention. Your population isn’t lost to followup so much as in the open world, a compliance issues may actually help your statistics if noncompliance can be tracked. (And I think that it’s not entirely impossible to set up structures that ameliorate a lot of the ethical problems.)

  10. I just think that our justice system needs to be looked at & some of these laws need to be changed. Some of these men are being incarcerated for 20,30 years for crimes that didn’t involve horrific behavior for example someone who was charged with assault with deadly weapon which did not harm a person whatsoever got 6 yrs for the crime but 20yrs for enhancements. This does not make sense, these kind of years should be given to murderers, kidnappers, psychopaths. I believe if they wouldn’t give so many years in enhancements to some of these people we wouldn’t have our prisons so crowded.

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