Weekly Update: December 12, 2023
Medical Experimentation On Incarcerated People: What Does Consent Mean In A Correctional Environment?

COCHS WEEKLY UPDATE: December 12, 2023

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Highlighted Stories

Editor's Note
Today's highlighted stories shed light on the complexities of incarcerated people giving consent for medical procedures and whether it constitutes fully informed consent. In other words, are incarcerated people aware of the possible harmful side effects of what they have consented to?

The first story from The New York Times is a case in point. A group of surgeons at Bellevue Hospital in New York City are reported to have established a Medicaid coverd bariatric surgery assembly line. Some incarcerated people from Rikers Island were recruited to undergo this procedure (Medicaid coverage is allowed when an incarcerated person becomes an inpatient in a hospital setting for more than 24 hours). However, unlike other patients, these individuals had no means of maintaining the post-surgery dietary requirements within a correctional environment. This lack of follow-up care has resulted in reports of malnourishment and regret for having undergone the surgery.

In healthcare settings outside correctional environments, where primary care practitioners coordinate care, a patient might have received better guidance. Lacking this type of care, an incarcerated person’s consent could be said to have been given in an information void.

The bariatric surgery incident echoes broader concerns about consent in incarcerated healthcare, as evidenced in the second article from Pennsylvania. This piece illustrates historical instances of incarcerated people becoming subjects of medical experimentation when financial incentives are present. A "tampon test" led to a woman undergoing a hysterectomy due to inadequate instructions for tampon use.

The third and fourth articles from JAMA explore the complexities of consent and medical interventions within prisons and jails. One study suggests that clinicians should be aware of the limited decision-making available to incarcerated patients. However, reviewing the stories from New York and Pennsylvania, limited decision-making might have been one of the motivating factors for why those procedures and tests were allowed to be performed in the first place.

The final story is a COVID-19 study from Berkeley Public Health. This study underscores the role of inadequate ventilation in correctional settings, rendering prisons and jails effective vectors of transmission. In conjunction with the previous stories, this report emphasizes the significant disadvantage in which incarcerated people find themselves regarding their health: the very environment is harmful, and at the same time, when an incarcerated person might think they are providing consent to medical intervention, it might be just the means to enable predatory practices.

Experimentation, Consent & Facility Conditions
New York Times: A Famed Hospital Churns Poor Patients Through Weight-Loss Surgery
This investigation found that the bariatric program at New York’s Bellevue Hospital, led by surgeons with financial incentives to perform more operations, has become a high-speed assembly line that has endangered some patients and compromised urgent care for others. And because most of the hospital’s patients are on Medicaid or uninsured, taxpayers foot the bill. The program has even recruited patients from New York City’s Rikers Island jail complex who have virtually no chance of maintaining the required diets after surgery. Two prisoners told The Times that they had become malnourished and regretted having the operation.

Prism: University of Pennsylvania-led medical experiments harmed incarcerated women
The infamous experiments by University of Pennsylvania dermatologist Albert Kligman at Philadelphia’s Holmesburg Prison are facing renewed scrutiny, with former participants sharing their experiences. However, the full scope and consequences of Kligman’s experiments remain incompletely explored, and a less-acknowledged aspect involves a "tampon test." In this test, female subjects were given tampons based on their menstrual flow. Dorothy Alston, who had never used tampons before, experienced complications during the experiment, with a part of the tampon becoming dislodged in her body. Despite discrepancies in the tampon weight, no immediate investigation occurred until she started experiencing severe pain.

JAMA: Decision-Making for Hospitalized Incarcerated Patients Lacking Decisional Capacity
Incarcerated patients admitted to the hospital face threats to their rights to privacy and self-determination in medical decision-making. Little is known about medical decision-making processes for hospitalized incarcerated persons who lack decisional capacity. During the 20-year study period, 462 patients from the prison were admitted to the hospital, totaling 967 unique admissions. Of these, 131 admissions (14%) involved patients with a loss of capacity and 43 admissions (4%, representing 34 unique patients) required surrogate decision-making.

JAMA: Quality of Surgical Care Within the Criminal Justice Health Care System
Individuals who are incarcerated represent a vulnerable group due to concerns about their ability to provide voluntary and informed consent, and there are considerable legal protections regarding their participation in medical research. Little is known about the quality of surgical care received by this population. This study evaluates perioperative surgical care provided to patients who are incarcerated within the Texas Department of Criminal Justice (TDCJ) and compare their outcomes with that of the general nonincarcerated population. The study suggests that patients who are incarcerated have equivalent rates of mortality and readmission compared with a general academic medical center population.

Berkeley Public Health: Berkeley Public Health team reports on prison ventilation conditions during COVID-19 outbreaks; wins grant for related research
A paper, posted November 7, 2023 in PLOS ONE, found that despite the fact that COVID-19 infections in prisons were five times the rate in non-incarcerated people, there is little understanding of successful mechanisms for reducing transmission. They concluded that ventilation was often subpar, and suggested that improvements become a central component of emergency respiratory pandemic preparedness and response plans. The researchers recommended that California and other states adopt their assessment methods to identify high-risk areas and monitor the impact of mitigation methods designed to improve ventilation.


BMC: “The COVID-19 pandemic and operational challenges, impacts, and lessons learned: a multi-methods study of U.S. prison systems”
This study examines how the COVID-19 pandemic changed U.S. prison operations and influenced the daily work of prison staff. Using a framework of bounded rationality, it was found that daily operations were strained, particularly in the areas of staffing, implementing public health policy efforts, and sustaining correctional programming. Meaningful reductions in the prison population, changes in physical infrastructure, and expansions of hiring and retention initiatives are critical for positioning prisons to manage future emergencies.

Mental Health
Wiley: Early phase psychosis and criminal conviction in United States adults
Individuals experiencing early phase psychosis (EPP) are at increased risk for legal involvement. In prior studies, between 14% and 75% of individuals with EPP reported a history of criminal offending behavior, criminal charges, or criminal convictions. Criminal cases that occurred during adulthood and resulted in convictions of three or more traffic offences, ordinance violations, misdemeanors, and felonies were recorded for analysis. These data highlight the need for specialty clinics to partner with professionals with expertise in the prevention and management of criminal behavior.

Solitary Confinement
Psychiatrist.com: Solitary Confinement in Prison Systems and Future Psychopathological Effects
Solitary confinement is a severe type of incarceration that has been linked to long-term psychological harm and poor post-release outcomes. While the data for short-term solitary confinement are minimal, prolonged segregation, mistreatment by correctional staff, and preexisting psychological vulnerabilities can lead to negative mental health outcomes for prisoners. Evidence suggests that social isolation may contribute to the development of mental illnesses, including schizophrenia. Prisoners with preexisting mental illnesses are particularly vulnerable to the negative psychological effects of solitary confinement. It is estimated that more than half of prisoners in solitary confinement have mental disorders, while only about 5% of the general prison population has a psychiatric illness.

Plos One: History of incarceration and age-related neurodegeneration: Testing models of genetic and environmental risks in a longitudinal panel study of older adults
The interplay between history of incarceration as a risk factor and more traditional risk factors for age-related diseases (e.g., genetic risk factors) has not been studied. This study focuess on cognitive impairment, a hallmark of neurodegenerative conditions like Alzheimer’s disease, as an age-related state that may be uniquely impacted by the confluence of environmental stressors (e.g., incarceration) and genetic risk factors.

Opioid Epidemic

Spectrum News: Justice Department, jail reach settlement that ensures inmates' rights to opioid medications
Inmates at an eastern Kentucky jail are guaranteed access to medication for opioid use disorder under a settlement between the U.S. Justice Department and the Big Sandy Regional Jail Authority, U.S. Attorney Carlton S. Shier announced. The Americans with Disabilities Act protects people in recovery from the disorder and the settlement requires Big Sandy Regional Detention Center to ensure that medically appropriate treatment with any FDA-approved medication is available.

LAPPA: 2023 State of the States
A comprehensive review of the evidence suggests that there are several strategies that can assist state leaders and other stakeholders in preventing overdoses, often by increasing access to treatment. This guide provides state leaders with the most effective approaches to addressing the opioid and other drug epidemic by identifying 10 evidence-based policy approaches to reduce overdoses. It is a roadmap that can also be used to monitor states’ adoption and implementation of different strategies.

Spectrum News: Free Narcan vending machine at Louisville jail has dispensed nearly 270 units
In September, the Louisville Metro Department of Corrections (LMDC) announced that it placed a free Narcan vending machine in the exit lobby of the jail, accessible to people leaving the facility.


VT Digger: Vermont continues to send teens to controversial youth facility in Tennessee
A youth facility in Tennessee that Vermont has been using since 2020 is abusive, unethical and unsanitary, according to recent findings of New Hampshire’s Office of the Child Advocate, which described “a culture of shame, humiliation, and inhumane punishment endemic to the program.” The report prompted New Hampshire officials to remove two teenagers placed by that state with the Bledsoe Youth Academy and to decertify the facility, around the same time that Texas also stopped sending children there.


The New Yorker: Sentenced to Life for an Accident Miles Away
A sweeping and uniquely American legal doctrine, often couched in terms of justice for victims’ families, called felony murder. To engage in certain unlawful activities, the theory goes, is to assume full responsibility if a death occurs—regardless of intent. For prosecutors, the felony-murder rule offers an efficient path to conviction: winning a case is much easier if you don’t need to prove a person’s mens rea—“guilty mind”—or even, in some cases, to establish that the accused was at the scene of the crime. Forty-eight states now have some version of the statute.


Spectrum News: High-profile attacks on Derek Chauvin and Larry Nassar put spotlight on violence in federal prisons
Derek Chauvin was stabbed nearly two dozen times in the law library at a federal prison in Arizona. Larry Nassar was knifed repeatedly in his cell at a federal penitentiary in Florida. The assaults of two notorious, high-profile federal prisoners by fellow inmates in recent months have renewed concerns about whether the chronically understaffed, crisis-plagued federal Bureau of Prisons is capable of keeping people in its custody safe. Justice Department Inspector General Michael Horowitz, meanwhile, has issued a pair of scathing reports citing management failures, flawed policies and widespread incompetence.

Pharmacy Today: Pharmacists can provide care for psychiatric conditions within the prison system
Researchers of a study published May 4, 2023, in JAPhA investigated how pharmacists could fill gaps in care with a new inpatient psychiatric pharmacist service. The study found that integration of a pharmacist in the Federal Correction Center (FCC) at Butner Medical Center in North Carolina inpatient psychiatric program improved inmate treatment acceptance and drug monitoring, and reduced overall cost related to the treatment of psychiatric conditions. At the FCC at Butner Medical Center in North Carolina, over 60% of inmates have a mental health condition—more than double the prevalence for those who are not incarcerated.


National Council: SJLA December 2023 Learning Series Event - Community Connections: Working With Justice-involved Individuals
This webinar will explore the challenges faced by individuals who are justice-involved and by those working with this specialized population in behavioral health care settings. This event will highlight jail-based treatment and peer services, reentry, opioid treatment programs working in collaboration with jails and prisons, housing, and a program helping bridge the gap between drug and mental health courts and CCBHCs.

State Roundup

Danville San Ramon: Latest jail settlement orders improved mental health care at Santa Rita, despite similar orders in past
The death of 45-year-old Maurice Monk, who was found dead in his cell at Santa Rita Jail in Dublin on Nov. 5, 2021, prompted an investigation after it was alleged that he had lain dead in his cell for up to 72 hours before anyone noticed. Lawyers for his family have settled with the county for $7 million. One of these lawyers was quoted as saying: "We know multiple jail guards and medical staff from Wellpath -- which has a $250 million contract for medical services at the jail -- saw him lying face-down". U.S. Magistrate Judge Nathanael Cousins said that the treatment of inmates at the jail was unconstitutional.

The Independent: $81M for Mental Health Should Be Spent Outside Jail
About a dozen Alameda County residents last week protested a proposed $81 million expansion of mental health facilities at the Santa Rita Jail in Dublin, saying their tax dollars would be better spent on community mental health treatment centers to prevent people from ending up behind bars.

CT Mirror: CT’s incarcerated seek say in debate over assaults on prison staff
Referred to as the PROTECT Act, shorthand for Promoting Responsible Oversight, Treatment, and Effective Correctional Transparency, the bill followed years of testimony from incarcerated people and court rulings that exposed the agency’s “cruel and unusual” practices. There’s a belief among incarcerated people that some officers are attempting to push prisoners to violence. Recently, three correctional officers at Garner Correctional Institution in Newtown were charged with third-degree assault for allegedly beating an incarcerated person who they claimed threatened them and refused to follow their orders.

First Coast News: Judges ordered man who died in Duval County Jail to get mental health evaluation twice in 2022
A Duval County Jail inmate, 64-year-old Renae Ray Carter, was found dead in his isolated cell. It is believed he may have had a medical episode. A judge ordered him to go to a mental health facility for an examination. Carter is the 15th inmate to die in custody at the jail in 2023.

VT Digger: Corrections department asks judge to consider home detention for ailing 80-year-old double murder suspect
The state Department of Corrections is asking a judge to consider placing an 80-year-old double murder suspect on home detention at the rehabilitation facility where he has been closely monitored by corrections staff for months. The move would mean Michael Louise, who can’t stand or walk by himself, would be subject to electronic monitoring. That level of monitoring has cost the corrections department more than $220,000 as of Nov. 20, according to Haley Sommer, a corrections department spokesperson.

Continuing Stories From Local Jurisdictions

Los Angeles County
Vera: 44 People Have Died in LA County Jails This Year
Another person has died in Los Angeles County jails, bringing the total number of deaths of people in the system’s custody to 44 this year—an average of almost one death every week. That staggering number far exceeds that of New York City Department of Correction (NYC DOC) facilities, where the rising number of deaths at the Rikers Island jail complex has led to a mounting crisis that has received nationwide attention. The death toll in LA jails—the nation’s largest jail system—is driven by severe overcrowding, inadequate care inside jails, and a failure to offer robust alternatives to incarceration.

Yahoo New (Los Angeles Times): After a year in office, L.A. County sheriff talks deputy gangs, jail deaths, overdoses
Sheriff Robert Luna ousted his predecessor and became L.A. County’s top cop in late 2022. At that time, the half-century-old problem of deputy gangs had brought the sheriff’s department under increasing national scrutiny. Jail conditions were becoming increasingly dire, and the decades-old lawsuits about them seemed no closer to resolution. Critics say the new sheriff has little to show for his time in office. Still, the signs of change are unmistakable. After taking office, Luna opened up access to oversight officials. He created the Office of Constitutional Policing to help the county comply with four federal consent decrees, eradicate gangs and overhaul policies to reform the department.

San Diego County
San Diego Union-Tribune: Judge refuses to dismiss lawsuit over San Diego County jail death that sheriff called ‘natural’ in 2019
A federal judge in San Diego has refused to dismiss legal claims against San Diego County and a correctional healthcare provider related to the 2019 death of a man in sheriff’s custody. In a ruling, Judge Ruth Bermudez Montenegro rejected arguments from defense lawyers seeking to dismiss a lawsuit filed by the mother of Michael Wilson, after being held at the Central Jail in downtown San Diego. “Every reasonable medical staff member would understand that denying or delaying providing cardiac medications to an inmate-patient with a history of (heart conditions) who had missed several days of those medications was a constitutional violation,” the judge wrote.

Criminal Justice's Detrimental Impact On Mental Health

CT Mirror: My son was arrested during a psychotic break. He should not be in prison
A mother recounts how her son's psychotic break resulted in his incarceration, leading to his warehousing in isolation without immediate access to medication. Despite four years passing, her son has yet to be sentenced, and the prolonged confinement has worsened his mental health conditions.

ProPublica: Jailed for Their Own Safety, 14 Mississippians Died Awaiting Mental Health Treatment
Jailing people with no criminal charges during the civil commitment process is common in Mississippi because many county officials see no other option when publicly funded mental health facilities are unavailable. Since 2006, at least 14 Mississippians have died after being placed in jail during the civil commitment process, purportedly for their own safety. Nine of them, including those three men, died by suicide. Twelve had not been charged with a crime.


Spectrum News: Some Californians released from prison will receive $2,400 under new state re-entry program
Hundreds of Californians released from prisons could receive direct cash payments of $2,400 — along with counseling, job search assistance and other support — under a first-in-the-nation program aimed at easing the transition out of incarceration and reducing recidivism. Recipients will get the money over a series of payments after meeting certain milestones such as showing progress in finding places to live and work. The governor's Workforce Development Board, devoted to improving the state's labor pool, is providing a $6.9 million grant to boost community-based organizations and expand so-called re-entry services for the formerly incarcerated.

Oaklandside: Homecoming Project matches people returning from prison to temporary homes with hosts
As homelessness continues to be one of the Bay Area’s most pressing issues, there is one, often-forgotten population that is 10 times more likely to be unhoused — people getting back on their feet after returning home from prison. The Homecoming Project is a first-of-its-kind program. It matches homeowners who have a spare room with individuals reentering their communities from prison. Homeowners get a monthly stipend, and participants get a place to stay, alongside a spectrum of reentry support.

New Jersey Monitor: High fees, long waits cast shadow over new criminal expungement laws
More states are making it easier for residents to clear or seal their criminal records. The effort has drawn bipartisan support, as lawmakers across the political spectrum say it will help people find jobs and housing, in turn boosting local economies and reducing reliance on social services. But the shift has created some new concerns. The surge in applications after lawmakers eased rules created a major backlog in several states. Some residents struggle to pay the required fees. And some prosecutors and legislators worry that people who commit additional crimes after their records are expunged may not be held fully accountable.

CoreCivic & GEO Group

The Lever: Private Prison Firms Set To Cash In On Immigrant Surveillance Boom
As the country’s immigration agency ponders a significant expansion of its vast, troubled immigrant surveillance regime, private prison companies are telling investors that the proposal could bring significant profits — and are deploying lobbyists to fight to fund it. In separate calls with investors last month, executives with two of the world’s largest private prison companies, the GEO Group and CoreCivic, said they were focused on a new proposal to radically expand an Immigration and Customs Enforcement (ICE) surveillance program.

Source NM: After sewage sickens incarcerated people, senator again asks Biden official to close ICE prison
When human waste flooded part of a U.S. immigration prison in central New Mexico last month, guards ordered incarcerated people to clean it up with their bare hands and put them in solitary confinement when they protested, according to a letter from Sen. Martin Heinrich to the U.S. Department of Homeland Security. On Wednesday the senator from New Mexico again asked U.S. Homeland Security Secretary Alejandro Mayorkas to close the Torrance County Detention Facility, an ICE prison in Estancia, and terminate his agency’s contract with CoreCivic, the company running the prison.

Correctional Health Care Vendors

Advanced Correctional Healthcare
Corrections 1: Ind. county pays $7.25M settlement over pretrial detainee’s death
Joshua McLemore — who was arrested during a mental health crisis at a hospital — barely ate, drank or slept at the Jackson County Jail in Indiana, where he was under constant video surveillance. He died after losing nearly 45 pounds in 20 days inside a windowless, solitary-confinement jail cell, according to a federal civil rights lawsuit. McLemore’s aunt Melita Ladner sued Jackson County, Sheriff Rick Meyer, jail staff members and the facility’s health care provider, Advanced Correctional Healthcare, Inc., over her nephew’s death. Jackson County has now paid $7.25 million to settle the lawsuit’s claims against them.

Southern Health Partners
Express Healthcare Management: Mental Health and Neglect in Detention Centers: Another Tragedy Unveiled
In a tragic turn of events, another family has come forward with a heartbreaking story of neglect and inadequate mental health care in a detention center. The Crow family recently filed a lawsuit against Southern Health Partners, the same medical company that operates in the Bamberg County jail, as well as the Aiken County Detention Center. Southern Health Partners denies all allegations made against them, but the mounting number of lawsuits filed against the company in Aiken County alone raises concerns about the quality of care provided in these detention centers.

Noozhawk: Grand Jury Reports on Jail Deaths Lead to Call for Broader Conversation About Mental Health
Five inmate deaths in the Santa Barbara County Jail prompted a series of Grand Jury reports investigating the deaths. In the reports, the Grand Jury found that each person’s mental health or substance abuse issues were ignored or not communicated across different agencies, contributing to the deaths. The Grand Jury also found that the medical contractor for the jail, Wellpath, didn’t communicate its findings to custody staff.