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PLN Associate Editor Alex Friedmann quoted in FL article re jail health care

Ocala Star-Banner, Jan. 1, 2007.
PLN Associate Editor Alex Friedmann quoted in FL article re jail health care - Ocala Star-Banner 2007

Article published Dec 16, 2007
Health care quality at Marion County Jail raises complaints, questions


OCALA - Thoughts of suicide began to form in James Johnson's mind. He felt nauseous. He couldn't sleep. He was confused.

"Please give me my Paxil," he begged the jail's corrections officers.

Johnson, 50, had been booked into the Marion County Jail in March on a charge of driving with a suspended driver's license. It wasn't his first time. This time, though, he was charged as a habitual offender and held without bail. He admits he was at fault.

What he didn't understand then - or now - is why the jail's medical staff refused to give him the legally prescribed medications he had taken for years for his clinical depression, including the anti-depressant Paxil, an anti-psychotic called Seroquel and the sedative Trazodone.

"The psych nurse came to me and said, 'You're not going to get this medication,'" Johnson said in a recent interview. "I said I'd get violently ill."

And so he did.

He began throwing up.

He grew increasingly agitated.

Nurses wrote in his medical records, day after day, that he was asking for his medication; that Johnson was "doubled over in anguish evidenced by facial expressions"; that he was making suicidal statements.

His father, James Johnson Sr, called the jail to share his fears that his son was "very suicidal."

He was taken in and out of a suicide prevention cell.

At one point, he sat on the floor and began to pray with his cellmates.

The Lord is my shepherd, I shall not want

He maketh me to lie down in green pastures, he leadeth me beside the still waters.

Johnson's son, Jordan, said an off-duty corrections officer called and pleaded with him to do something.

"She was in tears and she said I need to get my dad out and get him a lawyer. She said they were torturing him," Jordan recalled.

As Johnson's pleas for help went unanswered, he became more desperate.

By the seventh day, he was wailing and flinging himself headlong into the concrete walls hoping to either lose consciousness or alert the guards to the depth of his agony.

"He started going crazy in front of my eyes," said Kyle Morrill, one of his cellmates. "I woke up in the middle of the night and he was running from one side of the cell and banging his head on the other side."

Johnson's frightened cellmates begged officers to do something - anything - to relieve his suffering.

But nothing changed.
So when officers opened Johnson's cell on the 10th day after his arrest, he bolted up a nearby stairway and leapt off the balcony, crashing onto the hard floor 14 feet below and shattering his right leg.

That jump earned him a trip to the hospital, where a psychiatrist put him back on an anti-depressant and painkillers and sent him back to jail.

Johnson eventually was released after 90 days on the same combination of medication he was on before he was incarcerated: an anti-depressant, an anti-psychotic and a sedative.

His son said Johnson looked like a zombie the day he walked out of the jail.

And Johnson says for the first time he's dealing with a new manifestation of his illness - paranoia.


Johnson's harrowing story isn't unique to the Marion County Jail, or for that matter, to many jails across the country.

Correctional health care is complex, costly and politicized. And many times it is outsourced to large private companies. Critics say the profit motive that drives these companies leads them to cut corners on inmate care to save money and keep their investors happy.

Prison Health Services, Inc., a Brentwood, Tennessee-based private company, has been providing medical care at the Marion County Jail for the past two years.

As one of the largest providers of correctional health care in the nation, PHS is a frequent target of complaints about the quality of the care it provides.

Just last week the company was sued by a Volusia County family accusing PHS of failing to provide suitable medical care to a man who was mentally retarded and physically ill. A few months after his release from jail there, he died in a nursing home.

Since PHS has been at the Marion County Jail, many inmates and their families say injuries often go untreated, serious medical conditions go undiagnosed and inmates are routinely denied necessary medications, even with a legal prescription.

During a seven-month inquiry, the Star-Banner spoke to nearly a dozen inmates, reviewed hundreds of pages of medical records and invited medical experts not affiliated with the jail to review the policies and procedures of PHS.

The newspaper found:
* PHS is often reluctant to prescribe medication to mentally ill inmates. Some, like Johnson, arrive with legally prescribed medications, but are taken off of them. PHS officials say that's a part of "evaluation and observation during a period of abstinence from illicit drugs and alcohol." Some medical and legal critics call the practice irresponsible or even unethical, and say it's more about saving money on prescription medications than about performing a sound medical evaluation.

PHS says the allegations aren't true, and that like all health care providers, including public and private hospital systems, it works to improve efficiencies and manage costs to be good stewards of taxpayer dollars.

* Twenty-five inmates have died while in the jail's custody in the past five years, including six who took their own lives.

By comparison, Orange, Palm Beach and Pinellas counties, all of which have populations at least three times that of Marion County, have similar jail death figures. During the period from 2000 through 2005, the Orange County Jail reported 21 deaths, Palm Beach reported 25 deaths, and Pinellas reported 28 deaths, while Marion had 20 deaths in that same period, according the federal Bureau of Justice Statistics.

Meanwhile, Miami-Dade County reported 89 deaths, and Broward reported 49 deaths.

Sheriff Ed Dean attributes the deaths here to the graying of the jail population and the fact that many people who come to jail have life-threatening illnesses. "Any death in jail is one too many," he said. "What we need to do is do anything possible to extend life, but only the giver of life knows when their time comes."

No formal link has been shown between the deaths in Marion County and the care provided by PHS.

Herman Tucker's death, however, is one that his family blames on the lack of appropriate treatment provided by PHS. Tucker was arrested at a local mental health facility in 2002 for attacking a doctor. At the Marion County Jail, he received a cocktail of drugs to subdue him, but no treatment. Deputies shocked Tucker with a Taser, pepper-sprayed him and bound him to a chair. Thirty-six days after his arrest, they found him unresponsive on the floor of his jail cell, his esophagus filled with half-chewed food. He was pronounced dead a short while later. The cause of death was asphyxiation. His family is now suing PHS, jail staff and Sheriff Ed Dean for what it says is criminalization of mental illness.

* Many of the jail's medical staff and guards are skeptical of inmates' medical complaints, because some inmates fake symptoms for a variety of reasons. As a result, though, legitimate health complaints sometimes are overlooked or ignored. Anita Lesner, who was jailed in April 2007 for fraud charges, began showing symptoms of a debilitating neurological disease and lost her ability to walk. Jail staffers called her a faker and put her in suicide prevention when she wouldn't stop crying. Shortly after her release, she was diagnosed with Guillain-Barre syndrome, a severe nerve disorder.

* PHS has been the subject of numerous lawsuits. Private Corrections Institute, a Florida-based nonprofit devoted to highlighting the pitfalls of privatization of correctional institutions, keeps rap sheets on companies like PHS, documenting allegations and lawsuits from around the nation, ranging from Alabama to Florida to Maryland. And the attorney general waged an unsuccessful campaign to keep PHS from working in New York State.

* No state health agency oversees the medical operation of jails, mainly due to budget cuts. Although there are a variety of accreditations and standards that spell out minimum requirements for medical operations, critics say most of them are just paperwork and policy standards, not performance audits for care. The sheriff says he knew of the PHS checkered track record when he agreed to a contract with the company two years ago and said he added two extra layers of oversight: an independent contract monitor, and a medical doctor to go over PHS operations regularly.

The sheriff decided not to renew that contract earlier this year because he could only offer a 2.6 percent increase in the health care budget for next year and PHS was seeking a 6 percent increase. Dean insists the decision to part ways with PHS was a strictly financial one and that inmate care was not an issue. And both Dean and PHS insist that ailing inmates receive adequate care and dismiss allegations of poor medical treatment.

PHS officials, however, would not agree to be interviewed for this story. The company would only respond to questions submitted in writing.

Dean said in a recent interview that PHS provided community standards of care, and he had in place several layers of oversight.

"Perfect health care does not exist," Dean said. "With 16,000 inmates going through MCJ [each year], you'll have issue where someone missed a diagnosis."

Neither PHS nor the sheriff would answer questions about individual inmates' medical care.

For example, why would an inmate like James Johnson with a medically diagnosed mental illness be denied prescribed medication?

Critics say the answer is as simple as dollars and cents.

"The biggest problem is that often the profit motive gets in the way of providing medical care," said Randall Berg Jr., executive director of Florida Justice Institute in Miami. Berg's experience with PHS began more than two decades ago, when the company was one of the first private correctional medical providers to come to Florida. "My first experience dealt with [PHS's] refusal to provide medication to an indigent inmate ... since then I've sued them a number of times for failing to provide needed care," Berg said.

Johnson's attorney, David Kerce of Daytona Beach, is also suing PHS, alleging the company failed to administer psychotropic medication.

Kerce represented eight inmates in Volusia County in a class-action lawsuit, alleging they, too, were denied their psychotropic medication. A federal judge dismissed the case without prejudice, meaning it could be refiled, but Kerce doubts the families involved could afford to hire an expert or a doctor to examine their cases individually. He said he will pursue Johnson's case because Johnson suffered a physical injury.

"Pulling patients off medication is not acceptable and Hager has a history of it," Kerce said of Dr. David Hager, a psychiatrist who serves the Marion County Jail and also the Volusia County Branch Jail. "From my understanding, it's just not safe. You've got to step them down."

Johnson, for instance, was told by the jail's medical staff that he had to go through a "30-day wash" period and that's why he was taken off of his medication. PHS says the term is not accurate. And there is no documentation of it in Johnson's records.

Two independent psychiatrists, one of whom reviewed Johnson's records, said cutting patients off of their psychotropic medications is not common practice.

"Most commonly, antidepressants are discontinued in a step-wise fashion so as to avoid 'withdrawal' symptoms, such as increased anxiety, depression, etc.," wrote Dr. Louis W. Solomon, assistant clinical professor of psychiatry at the University of Florida in an e-mail. He did not review Johnson's records. He added that a psychiatric examination is used to determine whether medications should be changed. Johnson never received such an examination at the time he was booked and taken off of his medication.

Dr. Hager, who agreed to respond to the Star-Banner's questions via e-mail, wrote: "The '30-day washout period' has become an overused and misunderstood catchphrase. It refers to the process of evaluation and observation during a period of abstinence from illicit drugs and alcohol. It is not a rigid 30 days. It may be more or less depending on each patient's situation and does not apply to every patient referred to the mental health team. The determination to apply a washout period is fully dependent upon gathering reliable information and observations, including our ability to obtain outside medical and pharmacy records."

Hager referred to the American Psychiatric Association's Practice Guidelines and Diagnostic and Statistical Manual of Mental Disorders, 4th. Edition, or DSM-IV, which requires that patients be clean of drug addiction so that the provider can make accurate diagnoses of major psychiatric syndromes such as schizophrenia, major depression or bipolar disorder. Johnson's records do not show that he was using illicit drugs.

Dr. Don Sherry, a psychiatrist who practices here, said he doesn't suddenly cut off his patients' medication. He said even if Johnson had been taking illicit drugs, he could have been kept on his psychotropic medication. "This is [Hager's] standard of practice, and it's fine, as long as he doesn't hurt people," Sherry said. "[As a doctor] you have authority, but you also have the responsibility ... this jail psychiatrist is hurting people by doing things his way."

Even critics of PHS and other private correctional services say there is no simple solution to the problem of providing adequate medical care to inmates.

Sherry has a motto: "Cheap ain't good; good ain't cheap."

"When you start putting profit motive ahead of medical care, medical care becomes bad," he said.

But with tight budgets, counties don't have many good options for jail health care.

"You've got people who haven't taken care of themselves and have to be taken care of, and you just can't let them die. And they're a burden for the taxpayer," said Ken Kopczynski of Private Corrections Institute, a Florida-based nonprofit organization that opposes the for-profit private corrections industry. "The county commission looks and sees it getting expensive, so they go to private groups, because their price is lower. But not only do they have to look at care, but also profit for shareholders. And that's no way to operate the jail."

While health care is an inmate's legal right, most people in jails and prisons are poor, lack education, have high rates of mental illness and chronic illness and are frequently substance abusers or addicts. Many are uninsured and have not seen a doctor or dentist for years.

"Rarely you find someone who has one illness. Providing service to these individuals is complex and costly, because they haven't received quality health care. And it's expensive, outside and inside the prison," said Dr. Melvin Delgado, author of the 2006 book Health and Healthcare in Prison.

In addition, prescribing medication to inmates is not a quick process, because inmates are not allowed to use the medication they bring in to the jail.

"[Jail staff] don't know what the medication is. They didn't hand it to the person, so its puts them in a Catch-22. They should have the doctor to say 'yes, they are psychotic and need XYZ,'" said Kopczynski.

Meanwhile, many people have little sympathy for those behind bars. "Inmates don't have a very large advocacy group, or lobbying group. Nobody is clamoring at the sheriff's door to provide better care to inmates," said Paul Sheehan, chief operating officer of Community-Oriented Correctional Health Services, a nonprofit group whose mission is to help correctional facilities use local resources for providing medical care.

The U.S. adult correctional population - incarcerated or on some form of community control - reached 7.2 million, increasing by 159,500 this year, the Justice Department's Bureau of Justice Statistics announced earlier this month. About 3.2 percent of the U.S. adult population, or 1 in every 31 adults, was in prison or jail or on probation or parole at the end of 2006.

Another report by the Justice Department shows the inmate population in jails increased by 306 percent, from 184,000 in 1980 to 748,000 in 2005. The spike in the number of people behind bars is largely a result of sentencing and correctional policy changes over the past 30 years involving tougher sentences for a variety of crimes, and particularly for drug-related offenses.

While privatized correctional health care might control costs in the short run, cases such as Johnson's show that in the long run, it potentially can pose a higher cost to taxpayers and the community, inmate advocates say.

Even if inmates who sue over alleged poor care lose their case, the county still must pay to defend against those lawsuits. And sick inmates who go untreated in jail can endanger public health when they're released back into the community. Taxpayers also share the burden if those inmates land in a publicly-funded hospital.

Medical care at jails is costly and complicated, "but it's necessary and required," said Alex Friedmann, associate editor of Prison Legal News, an independent monthly magazine that provides a review and analysis of prisoner rights, court rulings and news about prison issues. "Once you remove a person's freedom, you're required to provide that medical care for them.

"People in jail are people, they're neighbors, brothers, daughters. Ninety-five percent of them get out," Friedmann said. "When people think of jail, they think of rapists and murderers, but that's not representative of the jail population."

With the pending departure of PHS, Sheriff Dean is about to launch a community-collaborative nonprofit group, called Ocala Community Care, that will take over medical care at the jail.

"I concluded that the future of inmate health care needed a change," he said. "We needed to embrace the community and figure out how $5 million of taxpayers money could be better utilized for delivery of care to inmates."

His initiative is uncommon and it remains to be seen if it will help people like James Johnson.

Editor's note: Since his release, James Johnson has been living in motels, trying to hold down a job. He told the Star-Banner he didn't want his picture printed, because he was afraid he would lose his job. But he said he wanted people to hear his story.