Banner by: Maya Puskaric

Medicine Behind Bars

by Ripal Sheth

In 1976, a man named J.W. Gamble was a prisoner at the Huntington Unit of the Texas Prison System. During his sentence, he was working at a textile mill when a bale of cotton fell on his back. He continued working, but soon experienced severe pain as a result of the accident. Gamble was initially treated with pain medication and received time off of prison work; however, he continued experiencing intense pain for months after and his refusals to work landed him in solitary confinement. After visiting the prison doctor over fifteen times with worsening symptoms, his condition was finally diagnosed. Gamble decided to take action against his unit and the case was eventually taken to the Supreme Court. The Supreme Court ruled the eighth and fourteenth Amendments of the Constitution were grounds for receiving healthcare in prison. The outcome of Estelle v. Gamble marked a turning point in medical care provided in prison, but the system continues to be a source of controversy when considering the economic strain that is placed on prisoners and the equivalent standard of care between prisoners and the general public.

    In the prison system, inmates get a commissary fund that can be earned through prison work or donated to them by family members; however, since most inmates come from disadvantaged communities, the contribution that is made by family members is often minute. This fund pays for basic necessities like toothpaste, soap, and snacks. Unfortunately, many prisons also charge inmates copays for healthcare. These copays are taken out of the prisoner’s commissary fund, which means inmates can be faced with the choice of paying for healthcare or for basic necessities that are not provided in prison. This often results in patients forgoing medical treatment, even though they are the population in greatest need of medical treatment and care.

Since many inmates come from disadvantaged communities, they often do not have access to basic healthcare outside of the prison system, so when they often arrive with severe, long-term medical issues that have not been treated. However, since inmates are forced to pay copays for healthcare in prison, the problems that they bring with them to prison tend to fester and their condition worsens. Since medical care is aimed at preventative care, which would end up being less costly, it would seem intuitive to provide inmates from disadvantaged communities the chance to escape the cycle of poverty by providing affordable healthcare. Unfortunately, as greater number of prisons charge copays, fewer inmates get the care they need to be healthy when they finally leave the system.

One obstacle to providing free healthcare to prisoners is rooted in the economic strain that prisons put on state budgets. Due to the skyrocketing population of incarcerated citizens, prisons need to spend an unprecedented amount of money on healthcare. Most prisons get a portion of the state budget to fund for things such as prison healthcare, but many states are in a continual cycle of state debt, which makes it more difficult to sustain this growing population. This means, regardless of whether or not it would cause individual poverty, prisons are forced to charge copays for healthcare for prisoners in order to be able to provide healthcare to inmates at all. States are facing the dilemma of whether to continue the cycle of state debt or perpetuate the cycle of poverty in disadvantaged communities. There is not one “correct” solution, but it is increasingly apparent that the current economic system is unsustainable for the future.

The second controversy presents itself in the principle of equivalence of care, which states that people in prison should get the same quality of healthcare as the general public. However, the prison system inherently renders many aspects of this principle violated. The most prevalent violation is rooted in the rate of occurrence of mental illness and drug dependence. Many prisoners suffer from one or both of these issues, especially since the rate of incarceration for drug related offences is so high. However, the prison system is often unconducive to recovery from either of these issues. This is because prisoners are often forced to undergo withdrawal and are often deprived of necessary aspects of recovery such as a strong support system and personal liberties. The principle of equality principle is also violated due to deprivation of liberty, which goes hand in hand with the lack of autonomy that prisoners experience. They are often not given a choice in doctors or are unable to seek medical care due to other aspects of the correctional system, such as mandatory punishment for infractions and solitary confinement.

Even though prisoners are often deprived of liberties and are put in environments unconducive to recovery, an alternative perspective of the principle of equality is that the prison system is so different from the general public that equivalence of care might not be possible. Doctors who work in prisons often have to regulate the demand for medical care. This is because resources are limited and healthcare professionals have to prioritize what must be immediately addressed. In addition, healthcare professionals must be wary of the risk of malingering and manipulation while they are practicing medicine, especially when dealing with the administration of drugs or with the possibility of inmates pretending to be ill in order to  escape punishment or even the prison system altogether. Although the equivalence of care between prison healthcare and general public healthcare is a point of contention, the vast differences between the two systems often render equivalence of care impossible or impractical.

The prison system has come a long way in terms of healthcare since the pivotal Supreme Court case decision, Estelle v. Gamble, but controversies in the prison healthcare system still remain, especially with regard to the economic obligations that inmates have towards paying for their own healthcare and the imbalance in equivalence of care between inmates and the general public. Just as these issues will continue to plague the prison healthcare system if they are not directly addressed, the debate on prison healthcare will continue to be highly contested unless something gives.