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Looking from Within The Use of Ethnographic Tools To Improve Prevention of Disease And Delivery of Health‘Care in U.‘S. Prisons Introduction Over the last thirty years, the exponential growth of the U.S. prison population has risen from 200,000 to over 2 million and counting.‘ This phenomenon in the United States is unprecedented, and the reasons are multifaceted and overlapping. They include, but certainly are not limited to, economic, political, cultural, social, and racial, to name only a few. Much quality work has been produced on this growth and some of its consequences, thereby the term “Prison Industrial Complex”, and its place as a permanent fixture on the American landscape is secure. It has affected every conceivable aspect of life in our society. A keen sense of the factors leading to and from incarceration allows for a greater understanding of the problems related to prisons, particularly in relation to health and disease. This paper intends to elucidate ethnographic methods and their application in solving advanced problems in today’s U.S. prison health care. The utilization of ethnography has moved beyond anthropology to become indispensable in the social sciences and, within the last few decades, other scientific fields, as well. Ethnography has been employed with the work of ethnobotanists, such as Marjorie Whiting in the nineteen fifties who, in her scientific pursuits, found it necessary to live with families on Guam, “cooking with the women and recording their recipes.” More recently, in his investigation of neurodegenerative diseases, Paul Cox has found ‘ it inherent in the very work itself, traveling “on skis with reindeer herders in Lapland” traversing “China to collect samples of ‘Lucky Soup’” (reported in the April 11, 2005 issue of The New _Y_c_>_r_lggr_: The Annals of Medicine column by Jonathan Weiner, “The Tangle: An ethnobotanist tries to solve the mystery of neurological disease on Guam”). The author believes public health can use ethnographic methods, as well, with respect to the effective delivery of health care and the prevention of disease. Noted ethnocriminologist, Dr. Stephen Richards and his associates have inspired and given direction to this study. The landmark work by these innovative social scientists, described briefly later, has created this distinct branch within criminology, aptly named “convict criminology.” They, too, have demonstrated that in pursuit of a complete understanding of complex problems and their essential causes, they must be immersed in a system yet maintain scientific objectivity. 2 Following this fundamental principle of ethnography, this paper incorporates the requisite scientific component of the biopsychosocial model as it relates not only to the Inmate Patient but also to various other factors, such as health care staff, security officers, prison administration, the particular prison environment, and so forth. Only through this type of examination is our investigation complete; then we can begin to create effective modalities to deliver care and prevent disease within the prison dynamic. Prison Healthcare Today The health issues within prisons are serious and complex. All U.S. prison systems experience a greater incidence of infectious diseases such as HIV, Hepatitis B and C, and tuberculosis as compared to the “Free Society”.2 Consistently studies have demonstrated that prisoners experience poor nutrition, a lack of appropriate mental health services, unsafe living conditions, rape, and violence.3 For the incarcerated person, this is a way of life experienced daily. Add the psychological stressors and the societal influences, and, then, within this framework, we begin to search for the essential, not apparent, obstacles that keep us from preventing disease and delivering quality health care. Without understanding these factors, we cannot begin to address the complex problems before us. These are not mere words on paper; they are the harsh realities surrounding prisons that cause disease and worsen disease processes already in place. Unfortunately, the actual quality of care delivered in a prison setting is extremely low within both state and federal systems.4 Recent surveys have elucidated the fact that many Health Care Providers (HCPS) lacked sufficient training and education to hold their positions, were found to be unlicensed and/or held no certification mandated for practice, and most tend to go without sufficient supervision when applicable.5 This would not be tolerated in “Free Society” and would be prosecuted to the fullest extent of the law as criminal. Compound the low quality of care with the incredible growth within the prison populations and the inability to understand the essential dynamic that plays out in this setting, and we see the prison health care crisis unfolding with its ramifications filtering back into the free communities. As we discuss convicted criminals and find that many of these men and women suffer and die every year from easily preventable conditions, must we ask ourselves, should we care? “Man’s inhumanity to man” is as old as Time, and admonitions to forgive or care for the less fortunate, almost as old. Still, this quandary need not enter into this discussion, except possibly to remind those delivering health care to prisoners why they entered the sacred field in the first place: to heal. In the context of this discourse, one needs only to acknowledge this: an Incarcerated Patient (IP) has a constitutional right to health care. The Eighth Amendment to the United States Constitution protects the IP against cruel and unusual punishment, which judges have ruled includes needless pain, suffering, and death from denial of appropriate medical care.6 This fact is clear, or so it would seem. Men and women, irrespective of being incarcerated, have this inalienable right to health care, though indirectly. So, how can these burgeoning problems not just exist, but grow at such an alarming rate? A comparison is necessary. Access to medical care by indigent and incarcerated i populations, to some extent, is a Very similar situation to their access to the courts: a proforma exercise giving the appearance of delivering a service, but of such a low quality that the true benefit is inconsequential or the effect is deleterious. Yes, lawsuits for malpractice, violation of civil rights, and wrongful death are filed, pro Se, by prisoners or on their behalf by others (e.g. A.C.L.U., families, etc.). Litigation and settlements are costly, but have they caused any changes in the policies that have led to the current health care crisis? It would appear not. So, if ethical considerations and constitutional rights figure only slightly into the overall equation, then, what does? We know the answer is fiscal. The same short—terrn fiscal concerns allowing unqualified staff to be hired, enforce an unwritten policy to deny treatment and grosslylimit formularies, and restrict referrals to medical experts in the community, are the same short-term concerns which exhaust the already strained budgets for prison health care. Front Door/Back Door When a simple chest cold becomes a severe lower respiratory infection and, still untreated, fulminates into endocarditis leaving the IP with aortic stenosis, it becomes clear that simple effective treatment initiated by the qualified HCP is cost effective. When an easily treatable malignant dermatologic lesion, like squamous cell carcinoma, is misdiagnosed as an infectious process and treated with an OTC antibiotic ointment rather than with a simple elliptical excision with dermatopathology, we find the slow growing cancer invades the lymphatic system. Such a patient then requires chemotherapy and/or radiation; usually the prognosis is very poor. Beyond the moral conundrum that a man serving a f1ve—year prisonterm for forgery has had his sentence, in effect, commuted to a miserable death sentence or to a life of diminished quality for the remainder of his days, now the prison must support the advanced therapies required for his treatment, possibly Hospice care, and lengthy litigation with a costly settlement. One sees quickly that we must treat hypertension on the front side, or the sequelae of end organ damage with its requisite treatment on the backside. Where an untreated or inadequately treated prisoner finds himself further removed from the possibility of returning to society as a healthy, productive, tax—paying citizen, thus he or she remains a continued societal burden. Moreover, the cycle of needless human suffering continues. His options are few. If we refuse to hire qualified HCPS to adequately treat (read PAY) at the Front Door, then we are destined to incur greater costs always at the Back Door (e.g. costs for advanced treatments, litigation, anger within prison population for unjust treatment which have varying effects, etc.). Ethnography This is not a new concept, just a new application. These methods rightly have been the foundation of anthropology since its inception. Recently, “convict criminology” as described by Dr. Stephen Richards and his associates7, has focused on this tool within sociology’s sub- specialty of criminology. The term describes “excon” academics and other experts in the field with intimate working knowledge of prison life. It is through this lens that we see the problems of prison life more clearly. Many of these social scientists, having recently acknowledged their ’ criminal pasts publicly, have been able to present their experiences as an effective research tool. Certainly, the esteemed work of ex—convict criminologist, Dr. John Irwin, Emeritus Professor, San Francisco State University and those that followed him demonstrates the importance that _ ethnography may have in quality, unbiased research. What about the practice of medicine? Competent HCPs treat diseases, like insulin dependent diabetes mellitus (IDDM), everyday. But, for a moment, take a practitioner who not only diagnoses and treats this disorder but also suffers from it as well. Any way you cut it, you have a different creature altogether. This clinician understands fully what it is like to dread a thousand finger sticks and injections to the abdomen, knows all too well the precarious balancing act of insulin and meals and illness and psychological stress and aging, has had to make the difficult decision to switch from several injections a day to an insulin pump, suffers the sequelae of the disease, and fears the loss of consciousness due to hypoglycemia while driving a busy interstate highway or walking downstairs alone at home. This trained and educated clinician has special insights into IDDM and can manage those patients in a unique way. It is this insight that we are seeking. In prison health care systems, there are many obstructions to this insight that are not readily discernible to the outsider. The Biological Component . The full understanding of disease processes and their treatment must be firmly held by the HCP. This demands education and training. Unequivocally, staff should be licensed and certified. Continuing education and training specifically in the field of prison health care must be mandated for all members of the health care staff, including some measure of health education for security and ancillary staff as well. If these minimums are not met, quality, ethnographic research tools will be of little use. These minimums are not being met.8 That being said, those who enter prison are rarely the privileged, educated, formerly insured, but, overwhelmingly, are the poor, under-educated, and marginalized who have usually had very limited access to health care. They go behind the high, razor—wired fences with addictions, untreated chronic disease, cultural biases, ethical differences, psychological trauma, and much more, which are all extremely important in the epidemiology of disease within prisons. These factors, when demonstrated, help researchers grasp the actual causes of disease, the difficulty of finding effective prevention and treatment modalities, and discovering previously unseen means of transmission. It is through the following two components that the problem of understanding the IP becomes clear. The Psychological Component It is this aspect of understanding prison health issues that helps us to first move beyond mere pathophysiology. It is the psychological influences that greatly determine how disease is contracted, how it is transmitted, and why it progresses the way that it does within a prison setting. Several examples follow: The IP may fear retribution in voicing concerns about his HIV or hepatitis status. He may not be able to answer health questions honestly about sexual activity, tattooing, or - intravenous drug abuse due to disciplinary reports and time in segregation, which he fears may be tied to affirmative responses — open admission to violations of institutional policies. The IP decides to not seek a follow-up appointment for a dull headache he has experienced for more than six months, even though he is now experiencing visual disturbances, with weakness and tingling occasionally in the upper extremities. At previous visits, he remembers that the HCP seemed very patronizing and suggested he buy some aspirin at the prison canteen. He cannot afford coffee or tobacco, and the aspirin he has borrowed from a friend has had no effect. Only after a grand mal seizure is the brain tumor diagnosed. It is determined to be inoperable, at this point. Many of the incarcerated simply do not seek treatment because they perceive that as weakness and believe others will perceive them as weak or vulnerable as well. Juxtaposed to this, some seek treatment for other than health concerns. Many seek extra benefits, such as wheelchairs and canes that let a prisoner use a shorter line or keep a single cell. Others seek more subtle emotional benefits from contact with health care staff. Still, many seek prescriptions that may be sold on the yard or split with another who refuses to go through the process of being examined and treated by staff. Many seek continual medical attention to remain classified at a relatively safe facility as opposed to one of the more violent prisons that holds non-medical residents. Added to psychological factors that influence the IP are those held by the HCPS as they deliver health care to convicted felons; most of these perceptions are formed in society and reinforced during their years of practice in prison. It is at this point that we appreciate the next component in the biopsychosocial dynamic. The Sociological Component The way that the HCP perceives prisoners is often based on various societal cues. There are political reasons from which ideological platforms are built and elections are won. Many of these have been called “The War on Crime,” which also has been referred to as “The War on the Poor.” There are economic reasons, as well, that are rigorously studied in the context of “The Prison Industrial Complex.” Many have come to believe, quite readily, the characterizations of prisoners as “animals” or “monsters,” not sons and daughters, fathers and mothers. Monsters and animals are words used to dehumanize convicted felons and to sensationalize events. Just as crime sells votes, it also sells commercial time, newspapers, movie tickets, and popular books. These societal views comfortably negate much of the reality that led to the incarceration of such a large number of our citizenry and relegate the treatment of prisoners to that of chattel. The same beliefs reinforce written and unwritten policies that restrict health care, education, and rehabilitative efforts in prisons. In the practice of prison medicine, nursing, and allied health, their pervasive influence can be observed within each interaction between IP and HCP well beyond security constraints required to protect staff. In juxtaposition to societal influence on the HCP and prison staff, societal influences on the IP and his perceptions remain a contributing factor to health and disease. Cultural influences prior to incarceration may support alcohol, tobacco, and other drug usage, may diminish the importance of a healthy diet, or may altogether neglect to emphasize dental care, hygiene, or proper exercise. Some cultures within our society View HCPS and the medicine or surgery they prescribe as completely unnecessary. Understanding these perceptions may help us augment many unhealthy behaviors that were formed prior to incarceration. ' The society within prison and its related culture are greatly influenced by security, which means, to some extent, control of the population. As touched on briefly, it promotes a circumspect, even suspicious, way of life for prisoners. So, even when the IP is sent briefly to an outside facility under contract for medical care, he is quickly returned to the prison and faced with inadequate follow-up care, at best. Often, scheduled revisions of rotational flaps or grafting never occur. Temporary colostomies placed after a gunshot wound are never reversed, even though the IP has return of bowel function. The “security” concerns outweigh the need for treatment every time, though it is still difficult to ascertain exactly why a man experiencing a myocardial infarction must be handcuffed to a gurney prior to the administration of available oxygen. Security remains the rule of thumb that most of us remember while growing up: “Because told you so.” It has also kept many from life-saving treatment. It remains carte blanche within prison fences. Inaccurate beliefs about infectious diseases and their transmission have led to a greater incidence of disease in prison than in “Free Society.” Habits as varied as hand washing to the use of condoms have contributed to this problem. Many avoid diagnosis about HIV, not just for fear of time in segregation, but for fear that it will limit relationships “on the yard” or that the infection will be discovered by wife, girlfriend, or loverout in the community. Even in prison, AIDS carries a heavy social stigma. Also affecting infectious disease as well as other disease processes are the crowded living conditions, incidence of violence and rape, sharing of needles, and many other factors found in prison life, each and every day. Disease followed these IPs in and, invariably, will follow them out again to their family and friends, to their communities, and back into an already overburdened public health system. This is the spread of disease often neglected in our discussion of prison healthcare; these men return to “Free Society” with little hope of finding work or health care coverage, the perceived benefits of living a crime-free existence. This “revolving door” of the marginalized poor to prison, back to the same impoverished communities, and usually back to prison, again and again, can be observed. The costs are astronomical in dollars and unnecessary human suffering. One readily observes the overlap of the components and the necessity of using the dynamic biopsychosocial model. It is within this model that we place the truly relevant features that have led us down this road to the current health care crisis in U.S. prisons and that may now be a crucial part of bringing us back again. Using the ethnographic lens, we can delineate what these factors are and what the solutions will be. Ethnography: From Theory to Praxis Rhetoric is nice and makes for excellent presentations at conferences, yet we believe that research through an ethnographic perspective can lead to very real solutions. If we begin with the eyes of those who are in the midst of the system, we can begin to see new answers to . this pressing problem that have eluded us until now. The concept of using ethnographic techniques came to the fore with the New York Times article by Warren St. John, specifically, with relation to corrections and criminology (“Professor’s Past: Jail Time as Asset”, New York Times, August 9, 2003). With this impetus, we start to create unique tools to address advanced problems. Some of the tools to be produced will improve the quality of research, and some will be used as modalities to improve the prevention and treatment of disease. Researchers and administrators may consider tools such as frequent anonymous surveys about prison conditions and health care services, forming health care grievance committees made up of both staff and prison residents, facilitating responsive changes to policy‘, and insuring that retribution is not a factor in inhibiting complaints. Also, instituting random inspections of important areas of prison facilities by public health experts knowledgeable in prison health science. These areas include treatment rooms, living environment, bathrooms, grounds, etc. This is done with actual knowledge of how inmates live within these environs and what truly contributes to known disease processes within prisons. Another useful tool to be investigated for judging the quality of care may be the “IP for a Day” model, where regulatory bodies send prison health experts/investigators who will present themselves as lPs to the clinicians. They will present with clinical scenarios as well as criminal histories (the fact that these are not actual IPs is not known to the clinicians), will evaluate health staff on several levels, and will allow staff to read their evaluations. These reports should give the HCP and allied staff the necessary, objective feedback to improve delivery of healthcare services. Education is an obvious resource that cannot be ignored yet we believe it is rarely implemented frequently enough or appropriately. Routinely, upon orientation to the penal system, imnates are provided with pamphlets that briefly outline health concerns. Many imnates do not read, many are intimidated by words such as virus, bacteria, etc., and most simply toss the information without even considering reading it. As such, educational tools created through an ethnographic perspective for the general inmate population, the IP with specific diseases, and the health care staff must be implemented and updated frequently. The information must be relevant to the critical issues present in prisons today and delivered in an accessible format. One such format may be the peer-teaching model. First, peer teaching in GED and rehabilitation has been policy within corrections for many years. Furthermore, the use of inmate emergency medical technicians and nursing assistants has also been implemented. With this in mind, the use of imnates as peer leaders who teach important healthcare issues to other inmates may be an effective means to instill positive, healthy behavior, as well as educating patients about their disease and treatment. We should then determine the effectiveness of prevention and treatment of disease by means of these educational tools through quality epidemiological and biostatistical evidence. Those educational models shown to be most effective will be continued and improved, while like tools can be created, always keeping in mind the limited resources available to prison healthcare systems. Newer tools are being created by managed care systems. As these become known and are shown to be effective, they must be adapted to prison health care’s particular form of managed care. These tools must be constructed and implemented, not at a distance, but with accurate ethnographic knowledge of the dynamic that is prison. Conclusion V Finally, there must be support to create residency training programs and board certifications for MD, PA, and DO providers in prison medicine and master of nursing programs in prison nursing. The specialty field is already being created, whether we acknowledge it or not. We must insure that advanced training and education are available to those in the field. The rapid rise of prison populations compounded with understaffed facilities delivering low quality care, if any, to many IPs suffering from numerous diseases or likely to develop many conditions related to life in prison have unequivocally created a prison healthcare crisis. The problems invariably filter back into “Free Society” in various ways. Though many of us would like to believe that ethical considerations or even constitutional rights would be the impetus behind humane, quality health care, it may not be. Clearly, though, fiscal concerns are present, and we can demonstrate that it is sound business sense to treat IPs at the Front Door rather than at the Back Door of a presenting illness. Beyond the obvious necessity to attract and compensate high quality HCPS, we must begin to see the IP and his prison world through an ethnographic lens. Once we do that, the biopsychosocial model takes on new dimensions. We then begin to see the essential, not apparent, causes and transmissions of disease. We begin to understand the underlying reasons why treatments do not work and why some diseases elude early detection. Only then can we create practical research tools and discover new ways to implement quality treatment. We can make appropriate use of limited resources. As well as all of this, through the practice of medicine, nursing, and allied health, we may begin to instill the 11 values into our patients that we ourselves rediscover - health care in the first place. the very values that led us to the field of References Clear, T. 2003. Foreword. Convict Criminology. Belmont, CA: Wadsworth Krane, K., et al. 1998. “Intervening among the Invisible Population: The CDC Examines Correctional Health Care”. Corrections Today 60 (2): 124. Murphy, D. Chapter 12: “Aspirin Ain’t Gonna Help the Kind of Pain I’m in”. Convict Criminology. Belmont, CA: Wadsworth. Ibid. Ibid. Neuman, v. Alabama, 349 F. Supp. 285 (M.D. Ala. 1972); affd 503 F.2d 1320 (Sm Circuit), 1974); Ross, J ., Richards, S., et al. 2003. Convict Criminology. Murphy, D. Ibid.
