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Health Policy Advisory Center No. 53 September 1973 HEALTH / PAC BULLETIN Editorial: PRISON HEALTH The fight for prison reform is an integral function. In other cities it may be a Health part of the struggle for social justice in Department, a hospital or a medical this society. A century ago prisons in this school. And while institutional interests, country incarcerated Irish immigrants, to be sure, may be self serving - , prisoners Blacks and other urban poor. Today Black can expect some health care improve- and Hispanic peoples inhabit the prisons ments since an outside agency is likely to in great numbers. Throughout recent his- focus on medicine rather than security. tory many, if not most, prisoners were in Moreover, this may begin to loosen the jail for crimes of economic necessity- total control which a prison exerts over its petty larceny and burglary, for example. inmates'lives. Prisons were not designed to rehabilitate The San Francisco experience further them, despite the pious rhetoric; they suggests that the agencies be community- were designed to punish and segregate based, such as public and private hos- those inside and intimidate their compa- pitals, free standing - clinics and commu- triots outside. They still are. nity mental health centers. For the mo- In this context, the delivery of good ment, most prison health care will be prison health care is difficult at best and impossible at worst. This BULLETIN pre- sents an overview of the problems of pris- delivered by these agencies within the prisons, but whenever possible it should be delivered outside the walls. Nowhere on health care, as well as case studies of the most far reaching - reforms to date those in New York City and San Francisco. The New York City experience suggests the impossibility of the Corrections sys- tem providing adequate health care to in- mates. The attitude of prison administra- tors toward health care and other prisoner needs is aptly summed up in their credo: " Our job is security and care of inmates- in that order. " With that attitude and a pe- renially inadequate prison budget, health care is bound to suffer. Any prison reform movement must insist upon an absolute separation between agencies responsible for security and those responsible for health care. Where such an independent is the old adage more true than in prison health facilities that separate care is in- herently unequal care. While independent prison health agen- cies and delivery of care by community health institutions suggest important di- rections for health care reforms, it is necessary, as the lead article points out, to understand at the same time how liv- ing conditions in prison, as well as the oppressiveness and meaninglessness of prison life mitigate with extraordinary force against both good health and good health care. Those who would improve health care cannot avoid these larger issues. They would do well to add their weight to the growing effort to " de- health agency does not exist, it must be populate " existing prisons by replacing created; where it does exist, its inde- them with small, community - based prison pendence from the Corrections Depart- ment must be maintained and extended. facilities and half way - houses, develop- ing extensive work and study release pro- In New York City the Health Services Ad- grams and abolishing the present dis- ministration serves such an independent criminatory bail system. MEDICINE BEHIND BARS In the last three years prisoners have been in revolt from coast to coast: from the Queens and Manhattan Men's Houses of Detention in New York City and Attica in upstate New York, to Lorton in Wash- ington, D.C., Walpole and Norfolk in Mas- sachusetts and Folsom and San Quentin in California. These rebellions have brought prison conditions to the attention of the nation in ways which could not be ignored. Prison rebellions can be seen as an extension of the 1960's ghetto rebel- lions. This could be expected, since black and Spanish speaking - people make up so disproportionate a percentage of the prison population. " Blacks born in the U.S. and fortunate enough to live past the age of 18 are con- ditioned to accept the inevitability of pris- on. For most of us, it simply looms as the next phase ir a sequence of humiliations, " wrote George Jackson. He and many others like him have spent their lives. shuttling back and forth between the ghetto of the street and that of the prison. Many of the oppressive conditions of prison have their counterparts in the op- pression of society. The inability to obtain essential services, the individual power- lessness and frustration plague ghetto and prison dweller alike. So too there are parallels between health care in poor communities and in prisons. Poor people, unable to pay the rapidly increasing costs, frequently cannot afford a doctor. The limited nature of public facilities in poor communities often means that no care is available. And if available, there are still long waits for short visits. Health professionals and workers in the public system are underpaid and overworked. Patients complain that they are " pro- cessed like meat through an inspection line. " Poor patients in public hospitals are considered appropriate teaching and re- search material. Emergency facilities, am- bulance service and emergency rooms 2 are overutilized. What is striking about the prison health system is the degree to which the problems of medicine in the community are reflected, indeed mag- nified, in prisons and jails. The most visible result of both ghetto and prison rebellions has been a spate of studies, both of those who rebel and of the conditions which cause them to rebel. And in prisons, where health care has consistently been a primary prisoner grievance, much attention has been fo- cussed on health services. Commissions, consultants, groups and individuals have investigated health care in Attica and the Tombs in New York, the local jails in San Diego and New Orleans, and the state prison systems in Massachusetts and Pennsylvania. Nor has the medical estab- lishment been far behind. In the last year both the American Medical Association (AMA) and the American Association of Medical Colleges (AAMC) have conducted national surveys evaluating prison health. care. What all of these studies share is their across - the - board indictment of prison health care delivery. The Problems of Prison Health Care Across the country there are some 400,000 inmates, half of whom are serv- ing long term - sentences in state and fed- eral prisons, and half of whom are await- ing trial and serving short - term sentences in local jails. The recent AMA survey in- dicated that in half of these local jails, there was no regular physician available. The consequences of this are severe: in 1971 in the California Bay Area alone, there were more than a dozen deaths in local jails mostly inmates who had never seen a doctor after their arrest. But even in prisons which provide physician cov- erage, medical care, from the moment the inmate steps in the door, is a hassle at best and impossible at worst. Initial Screening In most prisons and some jails, the prisoner's initial contact with the medical system is the entrance physical examina- tion. Examinations in the medical receiv- ing room of New York City prisons are primarily verbal. " Do you feel alright? Are you an addict? ", asks the doctor while casually checking the patient for VD, with- out, of course, touching him. In most prisons no blood test is performed. In the case of women prisoners, the " VD " exam frequently consists of an intra vaginal - exam, the main purpose of which is to discover contraband narcotics. The entire entrance physical rarely takes more than a minute or two. Blood pressures and pulses, to say nothing of urinalysis, rou- tine blood tests, tuberculin tests and chest X rays - are rarely performed. It is not, therefore, unusual for sick prisoners to be- gin doing time with undetected illnesses. And once inside, getting to see a doctor is no easy matter. Sick Call For an inmate, the port of entry for med- ical care is " sick call. " Both because of lack of medical resources and a tremen- dous demand for care (see below), pris- on sick call is oftentimes restricted. The means of restriction are myriad. Many prisons have inmates fill out sick call slips but then limit the number of slips accepted for sick call each day. " .. I fill out sick call each day and lots of guys just don't get on. ", reports a guard in San Diego's county jail. In some institutions nurses or physician's assist- ants limit clinic visits by " screening out " inmates they think are not really ill. Even worse is medical screening by prison cus- todial personnel. In New Orleans Parish Jail it is so bad that one prison health study reports that " prisoners sometimes have to pay off'hallboys and, indeed deputies to get their name on the [sick call] list. " In most instances these limita- CONTENTS 2 Medicine Behind Bars 9 New York City 17 San Francisco 23 Violence Center tions to sick call are done to enable the doctor to give more attention to the sick- est inmates by eliminating the trivial com- plaints. On the other hand, not infre- quently the doctor and custodial person- nel limit sick call to decrease their work- load. More maliciously, the restrictions have a " carrot and stick " function. Pris- oners who " make trouble " may be denied access to the doctor. There is one group of prisoners who ostensibly have no problem getting ac- cess to a doctor. They are the prisoners housed in segregation cells who in most cases must be visited daily by a physi- cian. But even here, according to the re- port on the Pennsylvania state prison system, " most visits entail a walk through the block or a chat with the block officer on duty to see if there are any apparent problems. Prisoners who are sleeping or too ill to call out may not secure the doc- tor's attention. " Conversely, when the doc- tors have asserted their right to examine a prisoner in segregation, they may be brought into direct conflict with prison guards. A doctor at a prison in Pennsyl- vania reported, for example, " that he was denied access by a guard to a mentally ill prisoner in Big Max, the segregation area. The guard asserted he was author- NEW STAFF Louise Lander is a lawyer who has worked with the Health Law Project in Philadelphia and MFY Legal Services in New York City. Published by the Health Policy Advisory Center, 17 Murray Street, New York, N. Y. 10007. Telephone (212) 267- 8890. The Health - PAC BULLETIN is published 8 times per year: January, February, March, April, May, Sept- tember, October and November. 3 special reports are issued during the year. Yearly subscriptions: $ 5 stu- dents, 7 $ other individuals, $ 15 institutions. Second - class postage paid at New York, N.Y. Subscriptions, changes of address and other correspondence should be mailed to the above address. New York staff: Con- stance Bloomfield, Oliver Fein, Nancy Jervis, David Kotelchuck, Ronda Kotelchuck, Louise Lander and Howard Levy. San Francisco staff: Elinor Blake, Thomas Bodenheimer, Judy Carnoy. San Francisco office: 558 Capp Street, San Francisco, California, 94110. Telephone (415) 282-3896. Associates: Robb Burlage, Susan Reverby, Morgantown, West Virginia: Desmond Callan, Kenneth Kimmerling, Marsha Love, New York City: Vicki Cooper, Chicago: Barbara Ehrenreich, John Ehrenreich, Long Island. 1973. 3 ized to determine who could enter a seg- regation cell... " When the prisoner finally gets to sick call, he may find that his luck stops there. Sick call is often handled by elderly, even senile physicians who cannot prac- tice in any other setting. Studies regularly report the duration of an average sick call patient contact to be from a few mo- ments up to perhaps two minutes. One in- stitution of 2,000 inmates reported 51,447 patient contacts in one year. The total number of prisoners requesting sick call on any given day varies between 10 and 30 percent of an institution's population. In some prisons doctor patient - contact is nothing more than a euphemism. In a few it would have to be called a parody. For example, in Attica, " prior to Septem- ber, 1971, the counter.. was equipped with a steel wire mesh grating from the top of the counter to the ceiling, and the contact between the inmates on the out- side of the grating and the doctor and the pharmacist on the inside, was verbal only, although the prisoner was visible through the inside wire mesh. No exam- ination at sick call, therefore, could take place. " Routine diagnostic procedures are often impossible. Reports the Massachusetts study: " Initial laboratory studies may consist of a gross urine examination and a blood serology [syphilis test]. Although supposedly a routine procedure, the se- rology is often overlooked. Routine chest X rays - are not always taken and skin testing for tuberculosis is variable. Elec- troencephalography is not done. Basic blood studies, such as hemoglobin or he- matocrit, are not generally performed and blood typing and routine immunization against tetanus are not done. " Specialty consultations are often entirely unavail- able and, even when supposedly avail- able, they are an immense hassle to ar- range. EKG's are often not available and even when they are, the doctors are fre quently too incompetent to interpret them properly. Often the most basic of medical equip- ment is not available to the prison doctor. For example, in the Tombs in New York there are no microscopes or X ray - ma- chines. And when equipment is available, more often than not there is no one to op- erate it or it sits in disrepair. In the Brooklyn Men's House of Detention it took over a month to find a light for the micro- scope, itself a recent addition. 4 When and if the physician does make a diagnosis, it may never be recorded. For example, in the New Orleans Parish Jail the records that did exist " did not record any diagnosis in almost 25 percent of the cases, and 42 percent of the records were not signed or identifiable in terms of the individual who treated the inmate. " Furthermore, in New Orleans two sets of medical records existed: " the prison rec- ord and the inmate's medical records from other sources of care. These two sets are not integrated and, more significantly, medical department personnel when pro- viding care do not as a matter of course check the non prison - source. " But worst of all, in a great many prisons, the only " medical record " is the sick call log. When the doctor recommends treat- ment, the prisoner faces yet another set of obstacles. Out date - of - and under- budgeted prison pharmacies do not stock many commonly prescribed medications. Legal Legacy Only recently have prisoners found legal recourse for improving prison conditions. Until then, most judges abided by a self imposed - " hands - off " policy alleging a " lack of subject mat- ter jurisdiction. " The real reason, however, was a profound reluctance by the courts to interfere with prison administration. In fact, the obligation of the State to provide medical and other essen- tial services was established as early as 1926, when a judge ruled that " It is but just that the public be required to care for the prisoner, who cannot, by reason of the privation of his lib- erty, care for himself. " More recently still, in a 1972 land- mark Alabama decision, a federal court ruled in favor of a class action suit alleging " cruel and unusual pun- ishment " of prisoners based on prison conditions, including medical condi- tions. Some decisions have gone fur- ther, determining that " prison physi- cians owe the same duty of care to prisoners as private physicians owe to patients who are free to choose. " These more recent decisions are based largely on the notion that per- sons are imprisoned for the " protec- tion " of society by the State and thus the State is responsible for their care. Often the demands of the prison regimen preclude administering medications more than once or twice a day, thus diminish- ing or destroying their efficacy. Prisoners complain that medications are often with- held for punitive reasons by guards or nurses. Other forms of treatment are even less likely to be available in a prison. Special diets for prisoners with ulcers, warm baths for inmates with hem- orrhoids, etc. are usually out of the question. Hospitalization Many larger prisons maintain their own hospitals. The federal prisons system maintains its own central medical facility at Springfield, Illinois. Most local jails and smaller prisons, however, must rely on community hospitals for acute inpa- tient care. Whether the facility is a cen- tralized prison hospital or a community hospital, transportation is a primary prob- lem. Many state prisons are located in iso- lated areas and transfer procedures are so poor that it may take days to transfer a sick inmate to the hospital. Pennsyl- vania, like many other states, maintains one central prison hospital, located at Western Penitentiary. Often the trip to Western is made in stages, taking several days. Several prisoners report the trans- port system caused them problems. One man with a fractured hip claims he was in severe pain; he received only aspirin enroute from Dallas Prison to WesternL a trip that took most of the day. Another prisoner claims he was transferred from Dallas to Western for tuberculosis treat- ment and spent a total of a week in tran- sit. He was held at Graterford Prison for five days. During the trip he was hand- cuffed; it was winter and the rear of the van was unheated. While the problem of distance does not ' exist in the case of community hospitals, prisons are hardly more willing to trans- fer patients. (Nor are community hos- pitals particularly happy to receive them.) Prisons claim they are too short staffed - to spare guards for this purpose. The situ- ation is compounded by the fact that once in the hospital, guards must usually be assigned around the clock to watch each prisoner - patient. When this is not the case, prisoners may find themselves shackled to the bed, as in Charity Hospital in New Orleans. In New York City and other large cities, there is usually a separate, locked and guarded prison ward in a lo- cal hospital. Often, however, the prison ward is located in an way out - of - the - place where busy doctors will not go. Emergency Care While the prison setting often makes routine care difficult to impossible, it is most adverse to the provision of emer- gency care. The rigidity of bureaucratic routine; the lack of personnel to transfer patients, adequate drugs and equipment, 24 hour - physician coverage in many prisons; the suspicion that until the last gasp, the prisoner is faking it all - are most devastating in the face of a med- ical emergency. When a prisoner collapsed in New York City's " Tombs " the doctor found to his dismay that the one resuscitator was broken and there was no adrenalin on hand. After running to his nearby office for adrenalin, he returned to find that the prisoner had died. Prisons are simply not geared to act quickly. A doctor at the Bronx Men's House of Detention reported that it took 45 minutes of trying to get a medical emergency transferred to a near- by hospital late at night, only to finally hear the warden's sleepy voice at the other end of a phone line, asking, " Now, what's this all about? " at which time the process of explaining began all over again. Again the patient died. Reasons for the Medical Disaster At first glance, the delivery of prison health services seems to be without rhyme or reason- a patchwork job performed by an often unsympathetic staff. On one level this is true: until recently very few health or other professionals paid serious attention to services to prisoners. But on another level, there is in fact a discern- able pattern to the reasons behind the medical disaster. In large part, the ex- planation lies in the complex interweav- ing of a number of elements. First there is a severe shortage of both money and prison health personnel. But even if there were no shortage of resources, the very nature of prisons - their purposes, policies and staff attitudes which result - make the delivery of good health care difficult, if not impossible. 5 Resources The lack of resources to staff and equip prison health services is typical of other medical backwaters of society. Money to establish an adequate formulary, to pur- chase needed equipment, to open suffi- cient salary lines for nurses as well as doctors, to upgrade and modernize facil- ities is simply not forthcoming from most state and local officials. The fact is that prisoners have very little political clout. While not the whole explanation, lack of money contributes to the inability of prisons to attract top notch - medical per- sonnel. Salaries are extremly low and facilities are unappealing to anyone who wishes to practice good medicine. The prison environment is hardly a drawing card. Who, then, is recruited? Prisons often attract physicians whose primary responsibilities lie elsewhere. In large urban areas, young, inexperienced house staff, " moonlighting " on hospital jobs, may find night or part time - work in prisons an easy " rip - off. " Even full time -, fully licensed physicians take this atti- " I just had too many mal- practice suits before I came here. " -Prison Physician tude: The Massachusetts study reported that " although the prison physicians (ex- cept currently at Walpole) are regularly salaried, time full - employees of the Com- monwealth, all evidence indicates that their actual working hours, which are not monitored, range from six to twenty hours per week. In one institution, in fact, the physician is known universally to the in- mates as '15 minute Charlie,'because of his reputed ability to come to the prison, carry out his daily medical responsibil ities and leave within 15 minutes after his arrival. " Most state prisons must rely on the services of a small town doctor who must fit prisoners into his regular practice. But prisons attract another kind of doc- tor those - who cannot practice in any other setting because they are senile, al- coholic or otherwise grossly incompetent. These physicians benefit from the closed nature of the prison institution: no one 6 knows or cares about the medical havoc that may be wreaked upon its prisoners. One prison physician frankly admitted to another, " I just had too many malpractice suits before I came here. " The secrecy of the prison has attracted still another type of doctor: those from medical institutions or large drug com- panies who wish to use prisoners as the subjects of medical research and experi- mentation. " There is something for every- one in prison research studies. The drug companies, operating through private physicians with access to the prisons, can buy human subjects for a fraction - less than one tenth, according to many med- ical authorities of what they would have to pay medical students or other'free world'volunteers. They can conduct ex- periments on prisoners that would not be sanctioned for student subjects - at any price because of the degree of risk and pain involved. Guidelines for human ex- perimentation established by HEW and other agencies are easily discarded be- hind prison walls, " says Jessica Mitford in her new book, Kind and Usual Punish- ment: The Prison Business. Of course, prisons are fertile research ground for another reason. Prisoners are usually eager to cooperate. They are lured by the promise of a favorable entry on a parole record or by the chance to earn a few dollars to purchase cigarettes and other amenities. Sometimes, in order to participate in the experiment, the prisoner gets a much desired - trip to a civilian hospital. In fact, some prisoners elect what may be unnecessary surgery in order to get transferred to the more pleasant environment of a hospital, where they end up as teaching material for resident surgeons. Institutional Constraints But money and staff aside, the very na- ture of prisons conflicts with the delivery of good health care. The purpose of prison, after all, is not the delivery of good health care but the punishment and warehousing of prisoners. These purposes are reflected in the policies, practices and attitudes of those who run the prisons. These, plus the necessity of maintaining a smoothly functioning institution, com- bine to create a set of formal and in- formal constraints on the practice of med- icine in prison. Often these constraints are couched in terms of " security. " " Lock - ins " when all prisoners must re- turn to their cells to be counted take place several times each day in most prisons. If a lock - in occurs during sick call, sick call is interrupted. When prisoners need to be transported to an outside medical facility, guards cannot be spared from the everyday administration of the prison- this might jeopardize " security. " And, if guards are available, the administration is reluctant to transfer a sick inmate any- way, since any excursion into the out- side world is considered " an escape risk. " Thus, when prisoners'health needs. come into conflict with what the prison administration terms the requirements of " security, " the prisoners'health is what gets sacrificed. We " are troubled, " write the authors of the Pennsylvania report, " by the apparent lack of analysis on the degree to which medical care is subject to security limitations. It seems that most health workers implicitly accept treat- ment methods and adopt some attitudes solely out of assumptions arising from no- tions of security. No one has asked whether these practices and views are valid or necessary; no one has looked at the consequences or the quality of care provided under these circumstances. It is our judgment that, at the least, the estab- lished procedures for providing care re- quire review to see where security inter- ests properly outweigh concerns for med- ical treatment. Security should not be seen as a blanket excuse for giving inferior health care to prisoners. " And if medical treatment doesn't con- flict with the " security requirements " of a prison, often it conflicts with its punitive orientation. A hospital bed is viewed by Getting A Piece Of The Action Recently, several " establishment " medical groups have taken a new look at prison health. The American Medical Association (AMA) has embarked on a project to upgrade medical conditions in local jails. The AMA plan involves the setting of health and medical standards for jails, as well as actual upgrading of facilities in a sample of selected sites. The AMA envisions the collaboration of local county medical societies and, presumably, the contracting out of medical services to private physicians. The American Association of Medical Colleges (AAMC), the prestigious Washington - based medical school lobby, has conducted its own survey of over 100 medical colleges and teaching hospitals providing medical services to nearby jails and prisons. It also explored the prospect of promoting relationships between teaching facilities and correctional institutions. Meanwhile, Montefiore Hospital, a large voluntary teaching hospital in the Bronx, has just signed a three - year, 11.6 $ million contract with New York City for the provision of health services to several thousand New York City inmates (see article. Page 9). Since neither the AMA, the AAMC nor Montefiore Hospital has a longstanding interest in prison health, why are these groups suddenly so concerned with prison health care? Rank opportunism rears its ugly head. The AMA's interests most likely involve the extension of its authority as a regulatory and licensing body in the medical profession. Insofar as any " standards of medical practice " are to be set in prison health, the AMA wants to set them. No doubt it would also like to see its local private physician members get a portion of the prison health pie. The medical establishment is simply drifting over to where the money is. This is especially true of the big teaching and research centers which are being hard hit by the Nixon budget cuts in health. The AAMC expands upon its own interests in prison health in a memo to the Council of Deans (of medical schools): " The relationships between medical schools and prison systems are not without problems, but those schools involved suggest that along with the positive benefit to the community and to the prisons, these service relationships give valuable opportunities for teaching and research. " The implications of this for prisoners is clear. Medical schools, lured by the promise of federal, state and local money and new research and teaching populations, are ready, willing and able to get into the act. 7 the prison administration as " too soft " for the prisoner to lie in. And the same is true for special diets, baths, exercise, etc. Such special treatment is regarded by guards. as " coddling " and may not be carried out even if the facilities exist. If the facilities do not exist, they are hardly likely to be established. Even if these hurdles are overcome, the fact remains that the very essence of a prison sentence mitigates against good health care. Boredom, a sense of depend- ence and malaise are every prisoner's lot. For the prisoner, sick call is a break in the monotony and tedium of each day. It is often his only chance for contact with " civilians. " It means a change in routine, a ride on the elevator, perhaps also a chance to talk about problems he's hav- ing in prison. More than that, because every aspect of an inmate's life when - to smoke, how often to shower, what to eat Lis controlled by the institution, sick call also represents one of the few occasions when a prisoner can assert his own con- trol over at least this one aspect of his life. For all of these reasons, then, huge numbers of prisoners with no overt med- ical problems report for sick call. On any Prison Health: 1929 In 1929 the only lengthy study of prison health in this country - Health and Medical Service in America's Prisons and Reformatories - was writ- ten by Frank Rector, MD. It casts an interesting light on some of the " spe- cial problems " relating to prison health. Rector's remedy for dealing with " malingerers " still has a resonance today. "... Various methods are re- sorted to for the purpose of discourag- > ing repeated sick call visits by those who have no legitimate claim to such attention. In some instances nause- ating but harmless potions are ad- ministered and in others strong pur- gatories are given. In other cases the inmate at fault is severely repri- manded and discouraged from fur- ther visits. Again he may be deprived of some privilege, such as recreation for the day, or placed upon a re- stricted diet for a meal or two. Each case must be considered by itself... " given day as much as 10 to 30 percent of an inmate population will report itself sick. A former inmate of an upstate New York institution related this story: " There was one guy who went to sick call every day. He never missed a day. Everyone in the infirmary got to know him. The guards and the nurses all kidded him, asked him what was wrong this time, and so on. He did this for about four years. Then one day he didn't show. When he returned to sick call the doctor asked him, Where ' were you?'' I was sick,'was the reply. " For many of the same reasons that prisoners " over use " sick call, so do they also demand medications. Again it is a chance to assert independence. Obtain- ing medications is often regarded as es- sential to validate a prisoner's illness. Otherwise he may be considered a " ma- lingerer " by prison and medical staff alike. But most importantly, medication and especially psychotropic drugs repre- sent another chance to escape the prison environment by getting " high " or simply becoming detached from the grim prison reality. The result of such prisoner de- mands in many cases is overmedication. Also prison policies often conflict with sound medical practice. For example, the New York City prisons stock no strong pain medications - morphine, meperidine (Demerol) or pentazocine (Talwin). Thus if a patient breaks a leg, he must wait for relief of pain until he gets to the hospital. In many cases, however, it is not a question of prison policy, but of attitudes on the part of prison staff. A hostile guard or warden can turn on or turn off health care delivery altogether through his con- trol of the entire prison machinery. For example, antihistamines such as diphen- hydramine (Benadryl) are commonly prescribed outside of prisons. But diphen- hydramine also has a mild sedative ef- fect. Since prisoners will often attempt to get a prescription for a sedative from the doctor, the guards regard a doctor who prescribes " too much " diphenhydramine as a soft touch. The result may be the re- fusal to bring that doctor patients. Rather than an open refusal, however, this may take the form of " the elevator is broken today " or " we're too short staffed to bring any more inmates down. " These conflicts produce strange and oftentimes contradictory results. Mis med- - ication, as well as under- and over med- - ication, are all frequent occurrences. Doc- 8 tors may give in to prisoner demand and give medication when it is not indicated. Or, feeling manipulated by aggressive prisoners, they may refuse it when it is indicated. Or, doctors may feel compelled to placate guards quite aside from med- ical indications at all. Psychotropic drugs present one of the greatest difficulties to prison doctors, and both over- and under- medication are frequent. The blurring of the line, however, be- tween medicine and the dictates of the prison can produce even worse results than simply this rampant confusion. At its worst, medicine becomes a bludgeon in the hands of prison authorities. The use of medicine for punitive purposes has reached its most extreme form with the administration of strong tranquilizing drugs like prolixin (which lasts for two weeks and induces Parkinsonian - like symptoms) to political and other recal- citrant prisoners, even in the face of the prisoner's opposition to the treatment. (See Box, page 19). All of the aforementioned problems il- lustrate the impossibility of separating medical care from the social environment in which it is practiced. Any genuine at- tempt to deliver quality medical care to prisoners will, of course, have to take into account the incredibly limited re- sources available for prison health at the present time. But even a vast influx of re- sources would leave other basic problems untouched. While the practice of medicine is often regarded by the medical profes- sion as neutral and outside the realm of politics, the practice of medicine inside the prison challenges this assumption. Tackling the prison institution may be a necessary part of reforming the prison health system. -Nancy Jervis Selected Reports on Prison Health Unless otherwise noted, the reports were prepared for the local government agency with authority over prison health care: 1. Health and Medical Service in American Prisons and Reformatories, Frank L. Rector, MD. The National So- ciety of Penal Information, 1929. 2. Health Care and Conditions in Pennsylvania's State Prisons, The Health Law Project, University of Penn- sylvania Law School, 1972. 3. Report of the Medical Advisory Committee on State Prisons to the Commissioner of Corrections and the Secretary of Human Services of the Commonwealth of Massachusettes, 1971. 4. Report on the Medical Services Delivery System at Orleans Parish Prison, Seth B. Goldsmith, D.Sc., 1971. 5. Health Care Services in the San Diego County Jail, Rita Judd Stokes, 1973. 6. An Evaluation of Medical and Health Care Services at the Tombs Prison prepared for the Legal Aid Society of New York, E. D. Rosenfeld Associates, Inc., 1973. New York City: HSA Tries Harder Time Magazine hails New York City's two- year - old effort at reform of health care services in its prisons as representing the " greatest strides " taken by any prison sys- tem in the nation. The City's prison sys- tem, with over 10,000 people imprisoned on any given day and over 100,000 new admissions yearly, has become the Mecca for prison health officials seeking solu- tions to the problems that beset their own prison health programs. The changes in New York did not, of course, come about in a vacuum. In August, 1970 prisoners at the Man- hattan Men's House of Detention (the Tombs) seized five hostages in an eight- hour protest. The New York Times, no friend of anyone's rebellion, editorialized that everyone " acknowledges the validity of the prisoners'complaints. " A key in- mate demand was, " We ask that there be an improvement in the medical staff here. ... As the matter now stands, the doctors prescribe an assortment of pills for every individual ailment without adequate di- agnosis of the patient's complaint. " By October, 1970, full scale - rebellion had erupted in most of the City's nine prisons, but prison medical care still remained in the Dark Ages. As much as it pretended otherwise, the City government was affected by this tur- moil. Mayor Lindsay ordered a study of prison health care by the Health Services Administration (HSA), his superagency for health, a study that more than con- firmed the prisoners'complaints. Further- more, it set the stage for HSA to take con- trol of prison health care from the De- partment of Correction (DoC), a shift ef- fected by the Mayor in September, 1971. Subsequently many procedural and per- sonnel changes have been made in the delivery of health services to prisoners. The program, however, has been plagued with administrative problems that have limited its impact. And for the long haul the reforms have brought to the surface more serious conceptual problems under- lying the system, such as who should control prison health services. 9 HSA to the Rescue The 1970 HSA survey, entitled " Study and Report on the Provision of Health Care in New York City's Correctional In- stitutions, " set the stage for the still raging - conflict between HSA and DoC for control of the prison health program. The report itself minced no words in detailing the horrors of medical conditions in the prisons: " Admission examinations were cursory and blood tests and X rays - not available. " Routine sick call was handled by elderly, even senile, doctors who were often in- competent and always unsupervised. No laboratory facilities were available. Treat- ment consisted of dispensing " one or more of 24 oral medications. " Medical practice was reversed so that, in the words of the officials, " ailments are speedily diagnosed to fit the range of chemical treatment available. " Very limited specialty consul- tations could be made at three municipal hospitals, but again, according to the re- port, " criteria for referral vary from insti- tution to institution and even doctor to doctor. " Moreover only a few inmates could be sent each day. Bad as things. were, they were getting worse. Over the past few years the number of physician hours had decreased by 40 percent while the inmate census had increased by 20 percent. If regular medical care was atrocious, mental health services were beyond the pale. HSA reported that " A very limited number of mental health personnel are available at all but one institution. About half of all mental health care (399 hours per week) is provided to the population on Riker's Island. Another 22 percent is provided at the Women's House of Deten- tion (WHD). The remaining 223 hours are provided at the remaining detention facilities; at a ratio of 2.4 minutes of care per patient per week. " Moreover, not all of this limited time was spent on the prisoners'behalf. Mental health " care " in the institutions largely involves staff par- ticipation in disciplinary hearings and pa- tient and staff examinations. Politically more interesting than the recitation of faults of the prison health system was whom HSA blamed for the medical debacle. The guilty finger was pointed directly at the DoC: " The Depart- ment of Correction has de facto super- visory responsibility and control of all health services delivered to its institutions. 10 --@ " The Medical Director (Correction); medical and paramedical personnel, all paid by the Department of Health; and nursing and clerical personnel, paid by the DoC, report principally to the Depart- ment's Director of Operations and to wardens in the various institutions, re- spectively. @ " While Correction officials seldom, if ever, interpose their judgment over that of a physician on purely medical matters, in cases of conflict in matters of a non- emergency nature, departmental require- ments generally prevail. @ " Clinic hours are set by the warden of the institution and are limited by other institutional needs. OE " Except in clearly emergency cases, whether prisoners receive care in other than their own institution depends upon Correction's capability to provide trans- portation and guard escorts. OE " Prisoners referred to hospital out- patient departments arrive at the conven- ience of the DoC which combines trans- portation to courts at irregular intervals. OE " Call - outs for mental health counsel- ing are also made as Correction schedules permit. " In September, 1971 the Mayor issued an executive order placing prison health services under the jurisdiction of HSA. This no doubt pleased HSA Administrator Gordon Chase, who saw in it an oppor- tunity to make much needed public rela- tions mileage for himself. He seized it with a vengeance. Almost immediately the press was bombarded with " progress " reports on prison health. A new head of prison psy- chiatry was appointed. It was claimed " Ailments are speedily diagnosed to fit the range of chemical treatments available. " " - HSA Survey (1970) that better admission physicals and sick- call procedures were started. A " mental observation " ward was opened at the Riker's Island Hospital. Later in the year HSA boasted a five fold - increase in the size of the prison mental health staff and an increased spending of about 1.5 mil- lion dollars. Older doctors were " retired " and younger doctors and additional nurses were hired. Overall, the money spent on prison health care doubled. Although the improvements fall a great deal short of the HSA's public relations department's claims, some real gains were registered: @ Blood tests for syphilis are routine. OE Smears for gonorrhea and Pap tests are routine for women prisoners. OE Pre natal - care for pregnant women prisoners has improved. --@ For the first time, eyeglasses can be routinely obtained for prisoners. OE Pre trial - competency exams are greatly expedited. M@ 24 hour - physician coverage exists in all the prisons except one smaller prison in Queens. OE The quality of dental care has im- proved and restorative procedures for the first time greatly outnumber tooth ex- tractions. OE Methadone detoxification is avail- able for all inmates requesting it. OE A system of drug inventory has been initiated, and, despite log jams - at the Cen- tral Pharmacy, represents some improve- ment. Some of the gains, however, are par- tial. For example, the results of the rou- tine blood tests for syphilis take many weeks to return from the laboratory. By this time 50 percent of the inmates have left the institution, and follow - up is no- toriously poor. And the older doctors have been replaced largely by more com- petent but scarcely more concerned " moonlighting " young hospital residents. Despite the many praiseworthy and substantial improvements, a recent study of health conditions at the Tombs, done for the Legal Aid Society by a private con- sulting firm, indicates how painfully small the real changes have been since 1970. Admission examinations are still cursory, and, except for the blood test for syphilis, no laboratory work or X rays - are done. Sick call is still chaotic and two minute - exams are the norm. Laboratory backup still does not exist. Drugs are often in short supply. And, finally, still very few patients can be referred for specialty consultation. Mental Health Under HSA Prison psychiatry has fared even worse. To the applause of the City's newspapers, a group therapy program was started at Riker's Island, and, better still, steel band and drama therapy programs were ini- tiated at the Brooklyn Men's House of Detention. The psychiatrist in charge of the program at Riker's Island Prison Hos- pital retrospectively gave a more accurate assessment of what the early days in July, 1972 were like. Dr. Frank Rundle ex- plains, " When I got there I found a com- pletely disorganized, chaotic conglomer- ate of services with no central direction, control, monitoring or planning. " By September, 1972 prison mental health para professionals - demonstrated in front of HSA headquarters. They charged HSA with " failure to follow through on its com- mitments to provide a basic workable sys- tem of mental health care in the prisons. " " They pressed for better job training and job upgrading. Their demands ignored, most have since quit in despair and disgust. In mid 1973 - prison and HSA officials noted that the prison suicide rate was in- creasing to an alarming degree. With six months still to go in the year, the num- ber of jail suicides (eleven) exceeded those for the entire previous year. In January, 1973 the head of Prison Psychiatry, Dr. Arthur Kaufman, quit and was replaced by Dr. Frank Rundle, who had earlier headed up the program at Riker's Island. Rundle's first task was to dismantle high visibility, PR valuable - , but otherwise worthless innovations and get down to delivering the essentials of prison mental health care. While Rundle admits that he has had insufficient time to change very much at most of the prisons, he points to accom- plishments at Riker's Island Hospital and the Women's House of Detention as future directions for all the prisons. In these insti- tutions, Rundle says, " inmates are screen- ed in an orderly way, receive a decent mental health evaluation, a treatment plan is developed, and follow - up is regu- larly provided. Inmates needing it are medicated in a practical and reasonable 11 # manner. Gradually, help is solicited from outside forces families - and em- ployers. Rundle sees helping the most seriously ill prisoners as the most pressing task. This common - sense conclusion is hardly revo- lutionary, but it represents a complete re- versal of the original HSA policy, which saw more to be gained from concentrat- ing on the less sick inmates where " therapy could really help. " Unfortunately, Rundle's primary method for implementing this common - sense ap- proach can only be described as regres- sive. Faced with a total inability to de- velop a mechanism within the prisons for preventing suicides or providing even minimal care for the estimated 500 acutely psychotic prisoners found in the system on any given day, Rundle's solu- tion is to open a prison psychiatric hos- pital. The site selected is the old Queens House of Detention, with a capacity of about 250 patients. Critics charge Rundle and HSA with creating an asylum and a dumping ground. Even those generously disposed to Dr. Rundle warn that, expedient as the solution may appear, it represents no long term - solution to the problem. At best, only a fraction of inmates needing such hospitalization can be accommodated. Even taking into account eventual plans to utilize other facilities soon to be aban- doned by various State agencies, bed space will be at a premium. There is, once again, potential space at City hospitals, but getting them to pro- vide the service is the rub. At the Bellevue Prison Psychiatric Ward, for example, the director boasts that he has slashed the patient census dramatically in recent years. The only notable effect this has had has been to make life a good deal pleasanter for the director while men con- tinue to rave and hang themselves at the Tombs. At Kings County Hospital the situ- ation is even worse. The Prison Mental Health Service reported in June, 1973 that " The overall conditions are appalling... Not only are there not adequate essential items of equipment, such as beds, but even more appalling is the fact that there is inadequate staff to provide even a sem- blance of an acceptable treatment pro- gram. " " With a little help from the City hos- pitals, their governing body - the Health and Hospitals Corporation - or the HSA, a humane, reform minded - director of 12 prison psychiatry is moving to implement the kind of warehousing program long discredited by mental health reformers (see BULLETIN, January, 1973). And even if this doesn't happen under his di- rection, many are concerned that it will happen once Dr. Rundle leaves. The fact that the new facility will, willy - nilly, be largely under the control of the DoC rein- forces the worry. Despite undoubted good intentions, it's likely that the new facility will in a short time exacerbate the very problems it was supposed to solve. On balance, then, HSA's reform pro- gram for prison health care has far to go before it can claim real success. But given the poor quality of the system it inherited, HSA has made substantial progress. It is easy for both critics and supporters of HSA to get mired down in squabbles over small details of the program. Unfor- tunately, this approach results in neglect of some of the larger questions, answers to which will have an important bearing on future directions for these programs: Who should control prison health services -HSA or DoC? and Is there a role for the private health sector? Who Controls Prison Health Care? Some of HSA's failures can be traced to its inability to wrest control of health services completely away from the DoC. The DoC may have lost fiscal and formal control of prison health care to HSA, but on a day - to - day basis it has been able to maintain power. Making use of its de facto administrative authority, it is DoC that limits clinic service to two hours each morning and afternoon; limits, to the de- light of the hospitals themselves, the num- ber of patients who can be referred for hospitalization; forbids inmates from hav- ing simple medications (e.g., aspirin) in their cells, and thus prevents appropriate use of antibiotics (which can now only be given twice a day); blocks new programs in mental health; denies inmates quasi- medicinal, quasi cosmetic - products in the Commissary (e.g., shaving powder and skin lotions). In sundry nit picking - ways DoC stands in the way of decent medical care for its hostages. DoC's adamant effort to control prison health services no doubt reflects the dis- dain that any bureaucracy feels toward another agency intruding on its turf. Cor- rections departments are notoriously hide- bound when it comes to clinging to es- tablished routines, and there is no ques- tion that " standard operating procedures " will have to change if inmates are to re- ceive better medical care. This alone is threatening to Corrections. Despite DoC's exaggerations, there may, in fact, be a small kernel of truth to DoC's concern over the delegation of health responsi- bility to HSA. The resulting division of authority contributes, at least in small ways, to the ability of inmates to ma- neuver around, and between, competing authorities. In this way a prison reform movement is minimally enhanced. The DoC, shunning any concession on this front, therefore opposes this dual author- ity. This small advantage is partially, however, counterbalanced by the fact that the same divided authority permits buck passing - to occur, which deflects in- mate challenge. For example, it is virtu- ally impossible to determine exactly who sets the quotas for referral of inmates to hospitals. No matter though, whether based on real or fancied fear, DoC is chomping at the bit to rescue prison health back from HSA. Statements of prison officials at meetings with HSA support this belief. HSA insiders report that hardly a meeting passes without Commissioner of Correc- tions Benjamin Malcolm warning, " You'd better be careful. Remember, after the new Mayor is elected you will only be a guest in our house. " If, as is likely, the new Mayor is Abe Beame, Malcolm may be right. Beame is certainly not unsympa- thetic to " law'n'order " agencies. In April, 1973 the DoC released a 23- page report, entitled " Evaluation of Prison Health Services, " which alleges gross mismanagement on the part of HSA. Specifically, it criticizes the lack of regu- lar doctor coverage in the evenings, lack of workable standby procedures to re- place absent doctors and nurses, disap- pearance of doctors and other HSA per sonnel from the prison institution without " Our job is security and care of inmates- in that order. " _ A NYC Warden authorization, poor record keeping - , and improper maintenance of drug inven- tories. HSA has prepared a rebuttal, which, while marked by excessive self- praise, effectively counters almost all of DoC's criticisms, but which, inexplicably, HSA has chosen not to release to the public. One might wish to discount the DoC re- port as, at best, bureaucratic nit picking - . One might, that is, until one gets to Page 18 of the report, which reveals its real concern: " The major problem, however, tends to be one of a lack of accountabil- ity that exists between HSA Staff and Cor- rectional Staff. The legal responsibility for the care and custody of inmates defin- itively is that of the Department of Correc- tion. However, under the present structure of operations control of a major portion of such service is being handled by HSA operating on rules and regulations which are dramatically different from those of the DoC. Staff of HSA feels no responsibil- ity to DoC staff, and often when the insti- tutional staff requests information or reports they are told,'We do not work for you, we are not responsible to you.'Their response to rules and regulations estab- lished by the DoC is the same. " On Page 22 DoC's ultimate goal is more nakedly stated: " It would seem clear to this de- partment that more effective services, bet- ter quality and greater economy of re- sources could be achieved if the current resources were shifted over to the DoC and the department establish a Division of Health Services, headed by an Assist- ant Commissioner. " Should DoC succeed in regaining con- trol, the prospect for improvements in prison health will be nil. After all, there is no reason to suppose that after decades of rendering appalling medical care in the prisons, DoC will transform itself and do the job right the next time around. Wardens are fond of saying, " Our job is security and care of inmates - in that order. " Not perhaps a surprising per- spective for a warden, but surely an inap- propriate one for a health administrator. HSA would be delighted simply to ex- cuse itself from a confrontation with DoC. With the exception of its press release campaigns, which in the long run play havoc with its credibility, HSA has been reluctant to bring its case to the public and win for itself much needed - support. Indeed, some concerned individuals close to the situation feel that HSA has been 13 downright defensive and paranoid in this regard. It may be too late to remedy the situ ation. There is reason to believe that the new Mayor may dismantle HSA alto- gether. What will happen to its Prison Health Service is anybody's guess, but it's hard to imagine its role being en- hanced. And with DoC breathing down its neck, perhaps all HSA can hope for is a miracle. Some at HSA look to Montefiore Hospital as the Moses who will lead it out of the wilderness. Montefiore Hospital In perhaps its most far reaching - inno- vation to date, HSA has contracted with Montefiore, a private hospital in the Bronx, for the provision of prison health services at Riker's Island. At the very least this move adds Montefiore to HSA's presently nonexistent constituency for prison health services. The contract with Montefiore is modeled after the question- ably effective but unquestionably ex- pensive affiliation arrangement linking municipal and private hospitals. (See De- cember, 1971 and May, 1972 BULLETINS.) Under the terms of the contract, Monte- fiore will provide basic medical care and consultation services for all the inmates in Riker's Island's five institutions (total 6,000 prisoners). In exchange, Montefiore will receive a whopping $ 11.6 million The View From In New York city " the 18th floor " has come to symbolize the struggle for non- discriminatory mainstream prison health care in the face of stiff opposition from the power brokers of the private hospital sector and their allies in the public system. It also symbolizes the need for outside community groups to get prison issues into the light of day if their resolution is to be rescued from the clutches of those forces that benefit - to the prisoners'detriment - from the typical invisi- bility of the prison population. The floor in question is shell space located in the newly constructed - Bellevue Hospital, which is scheduled to begin admitting outpatients in November and inpatients next summer. Bellevue's prison health service, which treats inmates referred from several of the City's houses of detention, primarily the Manhattan Men's House of Detention (Tombs), is currently housed in one of the more rundown of the old hospital's buildings, which is scheduled for early demolition after the new facility opens. The New York University Medical Center (which provides physician staff for Bellevue) and its staunch ally, Bellevue Executive Director Bernard Weinstein, are the king - pin decision makers in this process. They thought they had persuaded the relevant decision - makers to re- locate the prison service in a " temporary " building erected five years ago to house the Adult Emergency Service. The City's health planners had a better idea. They argued that the most logical location was the new hospital's 18th floor. A maze of memos ensued, ostensibly concerned with considerations of logistics, long range - planning, and security. The real conflict that emerges, however, is that between the image of the new hospital vis vis - a - the middle - class constitu- ency it hopes to attract and the inevitability that prisoners'health care would be inferior to that of the general patient population unless it were delivered in the same facility. Critical to the success of the Weinstein - NYU strategy was that the issue be resolved behind closed doors. The opening of those closed doors began with a conference March 9 on the theme " Rx: Justice - A Call to Action " convened by the New York Urban Coalition and a number of unions, prisoners'rights groups, and assorted others. The next step was a two part - article on the issue in the Village Voice April 19 and 26 by Health / PAC staffers Howard Levy and Sandra Abramson. The scene then shifted to a series of meetings and other contacts by members of the Urban Coalition's Prison Health Committee and the Prison Com- mittee of Bellevue's formed newly - Community Board with decision - makers such as the City's Health Services Administration (HSA), its Commissioner of Correc- 14 over a three - year period. (At the present time, the budget for health services in the entire prison system is about $ 7.5 million yearly.) Excluded from Montefiore's obli- gation will be psychiatric care, dentistry, and in hospital - services. As affiliation con- tracts go, this one is pretty tightly drawn up. Reasonably specific services to be provided and personnel hours are spelled out. Still it's more than generous to Monte- fiore Hospital. In addition to the standard 10 percent overhead allowance, Monte- fiore stands to gain other hidden profits as well. For example, " time full - " for doctors is defined as four days at Riker's Island and one day at Montefiore. This repre- sents a 20 percent free load for Montefiore since it will not have to pay those doc- tors to do research and teaching at the Hospital. And if, as some suspect will eventually happen, Montefiore decides to employ lower - paid resident house staff at Riker's Island, its rake - off from the con- tract will soar astronomically. Moreover, laboratory tests unavailable at Riker's Island can be done at Montefiore, thus subsidizing the already inflated costs of the Hospital's laboratory facilities. The contract allows Montefiore to do research in the prisons, after obtain- ing the approval of HSA and DoC. While Hospital officials insist that no plans are afoot to carry out such medical experi- The 18th Floor tions and Board of Corrections, and members of the staff and Board of the Health and Hospitals Corporation (HHC) which runs the municipal hospitals. The results of these contacts were encouraging: On April 6 Frank Rundle, director of psychiatry of HSA's Prison Health Service, supported the 18th floor in writing. On May 1 Frank Schneiger, head of the Prison Health Service, and Corrections Commissioner Benjamain Malcolm followed suit. On June 16 Bellevue's Community Board voted 14 to 4 (with one abstention) to go on record in favor of the 18th floor location, with a consolidation of medical and psychiatric prison services. Also in June the Inmate Liaison Committee at the Tombs voted for the 18th floor. On July 27 Health Services Administrator and HHC Board Chairman Gordon Chase came out in writing for the 18th floor. And on August 7 the Capital Committee of the HHC Board voted unanimously in favor of the 18th floor. However impressive this alignment of forces may seem, it has not led the Weinstein - NYU alliance to roll over and give up. As a delaying tactic, creation of a joint Bellevue Medical Board Community - Board committee, ostensibly to study all issues relating to prison health care at Bellevue and the Tombs, was engineered a gambit that to date has not succeeded in putting off the HHC's decision - making process. Then Congressman Ed Koch (a man increasingly receptive to the law and order forces) was persuaded to put the issue on the agenda of the 18th Congressional District Democratic Caucus, a group of district leaders numbering among them the Associate Dean of NYU Medical School. This tactic backfired as well: Koch announced at the meeting that he had been deluged with phone calls urging him to support the 18th floor location, which he proceeded to do; support was also forthcoming from Democratic candidate for City Councilman - at - Large Robert Wagner, Jr. The final card in the hand of the 18th anti - floor coalition is the fact that the 18th floor and the three floors above it still require interior construction to become anything more than shell space. The fate of floors 19, 20, and 21 has been stalled for years in a dispute between the HHC and the state over a Community Mental Health Center projected for that location; the plan has been to let a single construction contract for all four floors. If the 18th floor forces don't succeed in disengaging completion of the 18th floor from completion of the other three, an alternate location for the prison service of about four years'duration is inevitable. And in four years, reasons Weinstein and Company, anything can happen. (In October Health / PAC will present an in depth - analysis of the Bellevue NYU / relationship.) 15 mentation, prisoners could breathe easier if this right had been solidly denied Mon- tefiore in the contract. As was true of the earlier affiliation sys- tem in New York City, prison health care affiliations are likely to be copied else- where in the country. HSA itself is so convinced of the success of the program that even before it gets off the ground, it has begun negotiations with other med- ical centers for subsequent affiliations. There is, with all the necessary qualms aside, reason to believe that Montefiore will bring better health care to prisoners. For some years it has run a similar pro- gram with commendable results at the Spofford Adolescent Remand Shelter. But even with maximum success, few of the problems lurking in the shadows behind. HSA will be solved. Montefiore, HSA hopes, will do the messy confronting of DoC. This hope, however, may be vacuous. When asked what would happen if DoC interfered with its medical program, a Montefiore official replied, " We will inform HSA of the dif- ficulty and would expect them to run in- terference for us. We have no intention of battling with Corrections. " The truth is that rather than providing a solution to its problems, HSA's turning to the private sector is a symptom of larger problems. Not only has HSA been reluctant to confront DoC, it has even been timid in confronting the much less fero- cious Health and Hospitals Corporation. Indeed it is HSA's unwillingness to insist upon the City hospitals'meeting their re- sponsibility in caring for prisoners that has left it with no choice but to turn to the private sector. But affiliation with a private hospital for prison health care is merely a replay of a similar policy that was supposed to help the municipal hospitals these past ten years (see BULLETINS, December, 1971, and May, 1972). Most administrators of the City hospitals find no fault with either the affiliation contracts or the still deteriorating quality of the services at their hospitals. Indeed most of the admin- istrators owe their loyalties to the private sector anyway. A few administrators, how- ever, are furious. The director of the Outpatient Depart- ment at Kings County Hospital is fit to be tied. While his census goes up 10 percent each year, Dr. John Hong claims that not " one additional penny " is forthcoming to the hospital. A few of Dr. Hong's patients 16 are prisoners and mention of the Monte- fiore contract makes him livid. " I can un- derstand, " Dr. Hong remarks, " if the City really had no money available. But to turn around and give millions to the pri- vate hospital. Why? " Answering his own question, " Because they are better guys- No, I can't accept that! I say give the money to the City hospitals and if I still cannot improve health services, then fire me. " Even if Dr. Hong's lament is basically appropriate to the situation, it's unlikely to pierce HSA's insulated walls and its preference to get the City out of deliver- ing health services by paying the private doctor to do it. And if the result is tens of millions of dollars down the drain and still a second rate health system for the poor, that's of no concern to HSA or to any other City agency for that matter. It is pathetic but understandable then why a lower echelon - HSA official must confess, " We know Montefiore's ripping us off but what else can we do? " At this point, having failed to gain political mile- age early in the trip, HSA can probably do nothing except pay through the nose to private hospitals for the services that City hospitals are able but refuse to de- liver less expensively. At the root of HSA's difficulties are two major failings: an ultimate confidence in the ability and willingness of the private sector to perform more effectively than the municipal health system and an un- willingness to employ political, as well as technocratic, administrative tools to im- prove prison health care. This being the case, it's scarcely any wonder that HSA cannot plan beyond trying to fufill only the most elementary health needs for prisoners. Still, unless it does so, no prison medical program will adequately serve the real medical needs that tend to overwhelm the tremendously overutilized services it offers. The plain fact is that many prisoners besiege the health section of the prisons with minor complaints. If nothing else, this breaks the deadly tedium of 24 hour - - a - day cell life. If for no other reason than to preserve its own medical programs, HSA must concern it- self with the larger oppressive reality of life in New York City's houses of deten- tion. With all the other problems facing him, any HSA official would likely re- spond, " Are you kidding? " -Howard Levy San Francisco: Prison Health Care Makes A Break In San Francisco, California, two commu- nity based - programs in prison health have been developed in the last year which de- serve attention among prison reform activ- ists elsewhere. One is a Criminal Justice Unit, associated with one of the local Com- munity Mental Health Centers, which pro- vides mental health services to inmates upon request. The other is an innovative prison ward in San Francisco General Hos- pital (SFGH), the city's only public hospital. Like many progressive steps, both these community - based reforms were the result of a fortuitous combination of circum- stances: the right people in the right places at the right times. However, the important role that conscious political organizing played should not be minimized. The right people were in the right places at the right times for reason. State and local prison issues have been in the public mind since the late 1960's. In part this is due to the fact that the state prison system has been at the forefront of repressive social experimentation. The in- determinate sentence was developed to its fullest in California; the only psychosur- gery known to have been done on prison- ers was performed in California. Public pressure, much of it generated by the Medical Committee for Human Rights (MCHR), halted a behavior modi- fication and control project at the Califor- nia Medical Facility at Vacaville in 1972. Similar pressure has placed the funding of UCLA's Center for the Reduction of Vio - ` lence (using prisoner subjects) in jeopardy (see article, Page 23). The trials of the Soledad Brothers and Huey Newton added to interest in prison issues. George Jackson and Eldridge Cleaver, among others, articulated pris- oner discontent. The first prison rebellion occurred at Folsom in 1970 and inmate or- ganizing has gone on in the state ever since. Prisoners'unions exist in most of the state prisons - San Quentin being the most renowned and union storefronts have opened in numerous ghetto communities. In San Francisco itself, despite the city's liberal, free thinking - and progressive im- age, prison conditions and inmate treatment have been as scandalous as they are in local jails across the country. There are about 1,400 people incarcerated in the lo- cal jails. Of these, 300 are in the city prison -a detention center run by the city police department. The remaining 1,100 are in two county jails, run by the county Sheriff. (Despite their bureaucratic distinctions, both prison systems are under the aegis of the Mayor and the Board of Supervisors. And the community - based health pro- grams to be discussed below serve both prison populations.) The Conditions In 1968 and 1969, two reports were is- sued which exposed and documented San Francisco prison health conditions. One was issued by the local chapter of MCHR, and the second by a special Advisory Com- mittee appointed by the Mayor and headed by Dianne Feinstein, who later became a president of the Board of Supervisors. The Advisory Committee's report leaned heav- ily on the MCHR study. The issuance of the Advisory Committee's report put prison health on the city's political agenda. Both of these reports, plus affidavits filed in a federal court suit concerning health condi- tions in the county jails amply described the deplorable health conditions in San Francisco's prisons. Many of the deficiencies cited fall into one of three major areas: inadequate staff- ing, lack of appropriate mental health fa- cilities, and problems associated with hos- pitalization. OE Staffing Prisoners -a t San Bruno Jail (population 900), the largest of the county jails, in a list of grievances asked that more medical personnel be hired. At the time, there were two part time - doctors and only one nurse. Personnel shortages caused a number of problems, one of which con- cerned medication. At least two prison deaths were caused by accidental over- doses of insulin administered to diabetics by guards. Prisoners testified that medica- tions were frequently withheld for punitive reasons. About 20 prison deaths occurred in the San Francisco area, mostly of in- mates who never saw a doctor. The MCHR document, stating that " there is an obvi- ous need for amplifying the scope of medi- 17 cal responsibility at the prison, " pointed out that there is " little communication be- tween the prison doctor and the guards who are entrusted with the medical respon- sibility for the prisoners for the 22 to 23 hours of the day that the doctor is not there, as well as on Sundays and holidays. " @ Mental Health - In 1968, San Francis- co's Center for Special Problems withdrew its mental health services from the jails, citing " harassment by jail staff, " " failure of the sheriff to cooperate to provide ade- quate medical coverage, " harassment of patients who signed up for treatment, prob- lems dispensing medications, etc. The Cen- ter's two doctors felt that they were being used to tranquilize " troublemakers. " This left the prisons with no mental health personnel. The only mental health. " services " which remained were tranquil- izing drugs like diazepam (Valium), dis- pensed by the custodial staff. Hearsay re- ported up to 36,000 diazepam / month dis- pensed at San Bruno alone. Meanwhile, the more severely mentally ill were left to the whims of medically untrained corrections officers. This meant housing in the hole, or punishment cell, the only available isola- tion unit. The Advisory Committee's report cites the following case as an example: " On December 4, 1968, the Committee observed inmate ___________ in Isola- tion Cell # 3, County Jail # 1. The inmate's face and body were covered with excre- ment and he was pounding a spoon against a plate asking that the services of a min- erologist be obtained to determine the con- tents of the'oriental toilet.'The cell was dirty with feces and urine spread over the walls. " @ Hospitalization - A main prisoner de- mand at San Bruno was the assignment of additional guards to medical transport work. Patients who were scheduled for clinic visits never even got to the hospital, because the jail administration claimed it was too staffed short - to provide deputies to transport them there. patient In - hospi- talization at SFGH was difficult to arrange. Every hospitalized prisoner was either manacled to the bed, or required 24 hour - guard coverage. Shortages of custodial staff meant that prisoners had only limited access to hospitalization when needed. Initial Change Exposing conditions such as those in San Francisco's jails paved the way to put some reformers in a position of power in the San Francisco corrections system. One 18 such reformer who benefited from the pris- ons'bad press was Richard Hongisto, the liberal Sheriff who won office in 1972. Hongisto, however, was probably elect- ed as much by default as by design. His campaign was supported by a coalition of liberal Black politicians, gay liberationists, and prison reformers. The election also split the more conservative vote between two other candidates. Hongisto's ability to make reforms was greatly increased as a result of a recent federal court ruling. In 1973, a federal court judge decided in favor of the prisoners in a class action suit which alleged that denial of adequate medical care was " cruel and unusual pun- ishment. " The judge in that case ordered the Sheriff to consult with the Mayor (who controls the city and county purse strings) to bring the jails up to state minimum health standards. As a result, the budget for medication and supplies at San Bruno went from 4,000 $ in fiscal year 1971-2, to more than $ 14,000 in 1973-4. One of Hongisto's first tasks was to hire four new part time - doctors for the county jails. Among them was a young reform- minded physician, Dr. Gerald Frank. Frank has gradually taken greater initiative in coordinating medical care in the county jails. Since the summer of 1972, he has functioned as a de facto medical adminis- trator. Just recently, in the Spring of 1973, he was officially appointed Chief of Clini- cal Services in San Francisco's county jails. Hongisto's presence has created a cli- mate in which reformers have been able to operate effectively. Without Hongisto, a physician like Gerald Frank would prob- ably not have been attracted to work in the jails. He certainly would not have been able to accomplish much. Most of the reforms Frank has instituted are a concrete result of his assumption of the role of medical administrator. For ex- ample, in the past, the same prison health budget was submitted to the mayor every year. Now Frank adds additional items, based on present needs for staff supplies and equipment in the jails. With a medical administrator working out of the Sheriff's office, a combined and coordinated medi- cal records system is being set up. A new medical screening program will go into effect shortly, which will include chest X rays -, urinalysis, blood tests, tests for syphilis and sickle cell anemia. Perhaps most important, however, is that there is now someone in a position to oversee the Brave New World The new behavioral control techniques, says Dr. McConnell, " make even the hydrogen bomb look like a child's toy, and, of course, they can be used for good or evil. " But it will avail us nothing to " hide our collective heads in the sand and pretend that it can't happen here. Today's behavioral psychologists are the architects and engineers of the Brave New World. " For some convicts in California, those perceived as " dangerous, " " revolution- ary, " or " uncooperative " by the authorities, it has happened here, and Dr. McConnell's Brave New World is their reality. Signposts in this bizarre terrain may need translation for the auslander. OE Sensory Deprivation: Confinement (often for months or years) in the Adjust- ment Center, a prison prison - within - . OE Stress Assessment: The prisoner lives in an open dormitory where it is expected he will suffer maximum irritation from the lack of privacy. He is assigned to the worst and most menial jobs. In compulsory group therapy ses- sions staff members deliberately bait the men and try to provoke conflicts among them. The idea is to see how much of this a person can stand without losing his temper. -- Chemotherapy: The use of drugs (some still in the experimental stage) as " behavior modifiers. " including antitestosterone hormones, which have the effect of chemically castrating the subject, and Prolixin, a form of tranquilizer with extremely unpleasant and often dangerous side effects. @ Aversion Therapy: The use of medical procedures that cause pain and fear to bring about the desired " behavior modification. " OE Neurosurgery: Cutting or burning out those portions of the brain believed to cause " aggressive behavior. " The " behavior modification " programs are for the most part carried out in secret; they are not part of the guided tour for journalists and visitors, nor are outside physicians permitted to witness them. Occasionally word of these proce- dures leaks out, as in the autumn of 1970 when Medical World News ran an article titled " Scaring the Devil Out " about the use of the drug Anectine as " aversion therapy " in the California prisons. -Jessica Mitford Kind and Unusual Punishment (Alfred A. Knopf, N. Y., 1973) quality of medical care delivered in the jails. Incompetent doctors can and have been replaced. And inmates, as well as those who work in the system, have a med- ical line of authority to bring complaints to. By early 1973, then, there were at least three important gains in San Francisco prison health reform. Public awareness of conditions in the jails was at its height. A federal court judge had handed down a favorable decision in the class action suit, and one very good doctor had been put in charge of health services in the county jails. But any one of these isolated ele- ments by itself could not have brought the process of change much further. San Fran- cisco's prison health activists, groups like the prisoners'unions and outside prison support groups, like MCHR, community mental health workers, etc. were able to build on all these achievements combined. Recognizing that the nature of the prison itself often conflicts with the delivery of decent health care (see article, Page 2), they chose to move in the direction of in- creasing involvement with community- based health facilities for prisoners. Two important steps in this direction were the creation of the Criminal Justice Unit, and the establishment of a prison ward at SFGH. Criminal Justice Unit As of March, 1973, prisoners in both city and county jails had access to the mental health services of the Criminal Justice Unit. The Criminal Justice Unit is part of North- east Community Mental Health Services, one of the five community mental health centers (CMHC's) in San Francisco. 19 The idea for the Unit originated with sev- eral staff members of the Northeast CMHC, who became interested in setting up a proj- ect to deal with the special mental health needs of prisoners. The establishment of the Unit was further facilitated by Dr. Frank. When Dr. Gerald Frank took over increasing responsibilities for prisoner health, he was faced with an impossible situation: there were practically no psy- In a year and a half between 15 and 20 deaths occurred in the Bay Area mostly - among inmates who had never seen a doctor. chiatric facilities in San Francisco for pris- oners. Even SFGH's clinic and in patient - services had virtually no psychiatrists. Dr. Frank explained that he started to send all the psychiatric cases to Napa, the state mental hospital 80 miles away. This can legally be done for a three - day period with any mentally ill inmate. Since sometimes 15 were sent within one week, Napa could- n't handle either the load or the cost, so " that got the Criminal Justice Unit set up in a hurry. " At the moment, the Unit has set itself two main tasks: crisis intervention for medical emergencies and transfer of non emer- - gency cases to more appropriate medical facilities (including release into the com- munity). The philosophy of community- based treatment underlies its work. The Criminal Justice Unit's staff is, like that of the prison ward, composed entirely of paid staff who volunteered to work with prisoners. The professional staff consists of one psychiatrist, a psychologist, and several psychiatric nurses, counselors, ad- ministrative and clerical personnel, and considers itself a team. They have sev- 20 eral responsibilities: evaluating prison- ers psychologically at the order of the courts, and making recommendations re- garding treatment. They are in charge of all psychological services in the jails, in- cluding prescribing psychotropic medica- tions, and initiate follow - up treatment in the community upon release. This involves assigning outpatient treatment and follow- up of those released who then seek ther- apy. The Center also helps to get prisoners on Medi - Cal. In general, the ex prisoner - is assigned to one of the CMHC's for follow- up treatment. So far, the Unit has had one drawback. Because of their direct involvement with the courts, the Criminal Justice Unit psy- chiatrist and psychologists do not have " privileged communication " which tradi- tionally guards such relationships. Unless the initial psychiatric consultation is ini- tiated by the prisoner, with no referral by either medical or custodial staff, the men- tal health workers may be subpoenaed. As a result, all Criminal Justice Unit workers preface their initial interview with a warn- ing to the inmate. Because California law is so explicit in its denial of privileged com- munication, it brings out into the open the often hidden - contradictions inherent in prison psychiatry. The main contribution of the Criminal Justice Unit has been to establish and so- lidify relationships between prisoners and community treatment facilities. Through this work, it also hopes to prevent the cycle of bizarre behavior and imprisonment which affects many of San Francisco's prisoners. Toward this end, the Unit is ar- ranging meetings of its staff with various groups within the law enforcement branch- es police - , judges, etc. They now hope to get the mentally ill referred directly to community treatment facilities without having to go through criminal proceedings at all. San Francisco General Hospital In early 1973, a special ward was set up in San Francisco General Hospital (SFGH) for prisoners in the city and county system. This ward was first requested almost eight years ago by prisoners, in response to the problem of extremely limited access to in- patient care (see Page 18). Health activists at the hospital associated with MCHR had also become interested in prison health re- form, initially through their contact with prisoner - patients in the hospital's out- patient department. And other health workers in the hospital, many of them third world - , were attracted to prison health because they had themselves been in prison or had relatives or friends who had been in prison. Hongisto, the liberal Sher- iff, had economic motivations for wanting to get out of the business of transporting and guarding sick prisoners. All these forces combined to create the separate prison ward at SFGH. The prison Ward ward - 54 - is in an old, somewhat isolated section of the hospital. Its present capacity is 12 patients. How- ever, a newly renovated and larger ward, with a capacity of 20, is scheduled to open shortly. Eventually, when the new SFGH opens, the capacity will rise to 24. Ward 54's staff is headed by Dr. Richard Fine, an MCHR activist with a long history of involvement in prison health. Each pris- oner patient - , upon arriving at Ward 54, is assigned to a resident physician. The resi- dents then make daily visits to the prison ward. Part of Dr. Fine's job is to assure proper follow - up by the residents. Dr. Fine and the rest of the nursing and support staff (all of whom volunteered for work on " It's important for nurses to realize that it's not their responsibility to count knives and forks when trays are returned. " -Richard Fine, M.D. Head, SFGH Prison Ward the prison ward) hold weekly meetings to iron out any difficulties, establish commu- nication procedures both within the ward and hospital, and also between the hospi- tal staff and the corrections staff and Sher- iff's office, etc. The meetings also help separate out correctional responsibility from medical responsibility. The officers (Sherriff's and City) are responsible for security and discipline but they are in an obvious minority on the ward. Said one orderly, " Sometimes I disagree with the officer in charge. He says to a patient, ' You have to stay in bed,'perhaps to dis- cipline him, but I think it's medically im- portant for the patient to get some exercise, sit on the terrace in the fresh air. " Says Dr. Fine, " It's important for the nurses to real- ize that it's not their responsibility as med- ical personnel to count the knives and forks when the trays are returned. " In general, the medical staff are highly sympathetic to the prisoners, and enjoy talking with them. At first, the medical staff was somewhat hostile to the guards, but now this is changing. Contact between the two groups has increased as a result of the weekly staff meetings and, more re- cently, permanent guards have been as- signed to the ward. In fact, the guards themselves are becoming increasingly identified with the goals of the medical staff. The ward social worker, Sandra Bacon, has a MSW in psychiatric social work. Be- cause SFGH has such limited psychiatric facilities, she is also called upon to make preliminary psychiatric evaluation of prisoner - patients. Her job entails contact- ing lawyers, parole officers, and the fam- ilies of prisoners. She makes important phone calls for them, arranges for visits, helps families get financial assistance from the city or state, etc. One of the more important aspects of her work, however, is her function as a liaison for prisoners who are eligible for medical " modification " of their sentences. That is, those prisoners whose medical con- ditions are aggravated by prison condi- tions severe diabetes, hypertension and asthma as well as those prisoners with terminal diseases, are eligible for release upon the decision of a judge. The Sheriff's office has set up a special desk for prison- ers in this category (psychiatric cases may also apply) to facilitate the filing of pa- pers. In recent months, the courts have be- come somewhat more amenable to this approach. Although getting prisoners out of jail is generally seen as gratifying to the medi- cal staff and the social workers, it's not without its stickier side. Prisoners have be- come increasingly aware that getting sent to SFGH not only means literally a softer bed to lie in, but that it might even mean their release from jail if (they don't already know it, they learn as soon as they get to SFGH). Consequently, there are occasional problems for the medical staff, which is broached with, " Hey, Doc, can you get me modified out of here? " Too often, accord- ing to Ms. Bacon, the younger, less experi- enced doctors, in an effort to be nice, are 21 less than clear with their prisoner patients - , mumbling something like, " We'll see what we can do. " This in turn leads to the nurs- ing and support staff feeling the brunt of prisoner demands to be " modified out. " Says Ms. Bacon, " The patient needs to know what you can and cannot do for him. There has to be a lot of communication between all members of the medical staff. " To many prison health reformers, the establishment of a separate prison ward looks like backsliding. Shouldn't prisoners get their health care on the same ward as everyone else? For prisoners in San Fran- cisco, care on an open ward meant inade- quate care. But the SFGH prison ward was created by the initiative of those truly con- cerned with prisoners'health needs. Con- sequently, the ward not only provides good care, but has also extended the role of the medical staff beyond the narrower defini- tions of medicine. The ward staff, in fact, has increasingly seen its role as one of advocacy to the prisoner - patient. Whither Prison Health in SF? A number of essential improvements have come about in prison health care in San Francisco in the last year and a half. Care inside the county jails has improved markedly. More importantly, two model community - based programs have been es- tablished. However, neither prisoners nor their sympathizers on the outside believe that they have done all that needs to be done to improve the quality of prison health care. Not only are more reforms re- quired, but the two that have been made need protection from budget cuts, lethargy, and policy or personnel changes. Accomplishing concrete changes in prison health delivery requires working with agencies and bureaucracies which could easily be distasteful to some. In San Francisco, prison health reformers have been presented with a dilemma of sorts. They want community - based facilities- ones that are not under the control of the correctional officials because - community- Only in community - based programs can medical care be extricated from correctional control. 22 based facilities offer the best long range - opportunity for accountable, independent, quality health care. Only in community- based programs can medical care be ex- tricated from correctional control. How- ever, community - based programs fall un- der the administration of the Department of Public Health which runs San Francisco General Hospital and has authority over community mental health centers. It is a conservative, unsympathetic office. On the other hand, the correctional agency is headed by the County Sheriff, who for the time being is one of the reformers'closest allies. But there are obvious deficiencies in any plan which leaves prison health care in the hands of those whose primary con- cern is, after all, law enforcement and security. Both agencies would like to expand their domain. The Sheriff's office would like to take the city jail away from the Police De- partment. The Department of Public Health wants to take over prison health care in the county jails. What should the reformers do? The future of the prison health system in San Francisco will be determined by a number of contending forces. First, there are the prisoners whose voices are heard only in rebellions and occasionally in court. Then there's the Mayor and the Board of Supervisors; they would like to keep the budget down but are under court orders to improve health care. Then there is Sheriff Hongisto whose reputation is staked on changing the image of the pris- ons. There are his deputies, most of whom would prefer to return to the old security- conscious methods. In addition, there is the new breed of officers, many of whom are third world, who are attempting to be public minded - , and have a " serve the peo- ple " stance that is hard to reconcile with the uniform they wear. Lastly, there are the prison health reformers who have chosen to exploit the issues raised by all the other contenders. Given the present trend toward increasing reliance on com- munity health facilities, it seems clear that in the long run the health of San Fran- cisco's prison population is increasingly bound together with that of the wider San Francisco community. So, it makes sense for the Department of Public Health to eventually assume responsibility for pris- oner health care. One would hope, how- ever, that at the very least this would mean an improvement in health care rather than a reversal. -Nancy Jervis Jervis Brain Center For Violence California's prison system has the dubious distinction of pace setting - the nation in terms of the development of behavioral modification techniques and prisoner con- trol. In this context the attempt to establish a " Violence Center " at the University of California at Los Angeles (UCLA) assumes added importance. The first proposal for a " Center for the Prevention of Violence " at the UCLA Neu- ropsychiatric Institute (NPI) was issued on September 1, 1972. It focused on the vio- lent individual, referred mostly to biologi- cal causes of violence, included prospects for surgical treatment of violent individu- als, and included two proposed projects directed by a psychiatrist named Frank Ervin. The sixth draft of the proposal for a " Center for the Study and Reduction of Violence, " issued on June 25, 1973, includes a categorical denial that any surgery will be done in relation to the Center's func- tioning and does not mention Frank Ervin. The intervening events shed important light on the meaning of the establishment of such a Center. A research program on violence was first proposed by Dr. Louis Jolyon West, Director of the NPI, on June 21, 1972. Gov- ernor Ronald Reagan of California an- nounced the need for such a Center to deal with the increasing incidence of violence in his " State of the State " message in Jan- uary, 1973. One half of the approximately $ 1.5 million (first year) budget was to come from State Health and Welfare funds and ' one half was to come from the Federal Law Enforcement and Assistance Agency LEAA (), administered by the California Council on Criminal Justice (CCCJ). Dr. West expected no opposition to his proposal, and so was well on the way to implementing it without much public no- tice with the assumption that funding was assured. In early Spring, 1973, a public protest emerged around the question of psychosurgery. The proposal's focus on " violence prone " individuals, while ignor- ing or paying mere lip service to social aspects of violence, led many to suspect that the entire proposal, especially since it was being funded by the Justice Depart- ment (LEAA and CCCJ), was merely an attempt to give scientific credence to the rounding up, " diagnosing, " and " treating " of protestors and minority group members. The fact that Dr. Frank Ervin joined the NPI faculty and was originally included in the proposed Center made it obvious to many that psychosurgery would be a part of the " treatment. " Ervin, along with Drs. Mark and Sweet in Boston, had been advo- cating neurosurgical intervention in cases involving temporal lobe epilepsy and " un- " controllable aggression.'(See Violence and the Brain by Ervin and V. H. Mark, Harper and Row, N.Y., 1970.) Ervin had even suggested that ghetto rebellions (like that in Detroit) could be controlled by iden- tifying and dealing with individual " vio- lent slum dwellers " (see their letter in JAMA, September 11, 1967, p. 895). After all, they argued, since only some and not all ghetto dwellers participated in any given rebellion, the answer as to which people would participate could be found in individual studies of brain pathology. As public outcry against psychosurgery erupted, new drafts of the proposal were hastily written to specifically deny that such procedures would be included. Meanwhile on April 11 and May 9, 1973, the California State Senate Committee on Mental Health and Welfare held hearings on the proposed Center. A letter from State Senator Anthony Bielenson, Chairman of that Committee, to Robert Lawson, Director of the CCCJ, on May 21, 1973, summed up the Committee's reasons for deciding that approval of the proposed Center would be " advised ill -. " Questions regarding who would control the Center's activities, vague- ness of the proposals, lack of safeguards to " insure against the potential abuse of human subjects, " lack of provisions for peer review, and contradictory statements about the inclusion of psychosurgery in the proposal, all contributed to their nega- tive judgment. Additionally, no provision for the Center was included in the State budget so the funds would have to be taken away from other health and welfare programs. By this time, the opposition was no longer limited to concerns about psycho- surgery. Opposition included the Northern 23 California Psychiatric Society, the Los An- geles American Civil Liberties Union, the Medical Committee for Human Rights, the Los Angeles Federation of American Scien- tists, the Western Region of the NAACP, the Black Panther Party, the Mexican- American Political Association, the United Prisoners Union, the California Prisoners Union, the National Lawyer's Guild, the UCLA Coalition Against Psychosurgery, the Committee Opposed to Psychiatric Abuse of Prisoners and many others. The response of Dr. West and the grow- ing staff of the still merely proposed Vio- lence Center was to write more drafts, stressing ethics and controls while denying that psychosurgery, Dr. Ervin, and prisons were relevant to the Center's work. Law Professor Richard Wasserstrom and soci- ologist John Seeley were added to the staff, responsible for " Law and Ethics " and meth- odology, respectively - the two most criti- cal aspects of the proposal. The fact that so many drafts of the pro- posal have been written is construed by some to mean that the Center's designers are responsive to public opinion and flexi- ble in incorporating valid criticism. Dr. Isa- dore Zifferstein, a psychoanalyst and Asso- ciate Clinical Professor of Psychiatry at NPI feels otherwise. He has stated many times publicly that the successive drafts are merely " launderings " in order to make a dangerous proposal more palatable to the public. He cites the mere lip service given to social factors in later drafts while the projects themselves are still focused on individuals and biology. Also he claims that the inclusion of an Ethics Committee is not sufficient response to the criticism that the entire design of a Violence Center, focusing on the pathologically violent in- dividual, flies in the face of ethics and humanity.. In mid July -, just prior to a public hearing about the Center held at the CCCJ, the head of the Committee on Law and Ethics resigned. Professor Richard Wasserstrom wrote to the staff of the Center that he could no longer be a part of a center that had failed to adequately respond to the valid concerns raised by the opposition. Meanwhile, complications arose in the funding of the Center. As a result of the California Senate Health and Welfare Committee's concerns, a public hearing of the CCCJ was scheduled for July 27. The State budget passed by the legislature in 24 July contained the folowing provision: " No state funds from whatever sources are to be used to finance the proposed Center for the Study of the Reduction of Violence at UCLA without approval of the Legislature. " The stage was thus set. The CCCJ must have a public hearing before funding the Center. Since the funds are matching, the legislature must pass a bill or amendment providing for state funds to be used before any money could be released. The week prior to the public hearing, a meeting took place between Lawson of the CCCJ and the staff of the Center at UCLA. As a result of that meeting, and without consulting the opposition groups, Robert Lawson released to the press a re- port that the CCCJ staff had approved the Violence Center. Articles in the LA LA Times and SF SF Examiner reporting CCCJ approval of the Violence Center appeared July 26, the day before the public hearing! The hearing took place anyway, although the unanimous decision of the Council made up of law enforcement and judicial officials was clearly a foregone conclusion. Few of the questions raised by the many speakers opposed to the Center were even discussed. As the key test in the Legislature ap- proaches, many questions remain unan- swered. Peer review has still not been established. Community involvement and accountability has been refused. Although the proposals claim some form of commu- nity input will be part of the Center's system of review, a proposal for a Com- munity Advisory Council, accepted by the entire staff of the Violence Center, was vetoed on the day of the CCCJ hearings by Chancellor Young of UCLA, presuma- bly because such community accounta- bility would be a bad precedent for the University. In spite of the need to look at the disturb- ing incidence of violence in our society to- day, and in spite of several projects in- cluded in the Violence Center's proposal which seem potentially valuable, the entire proposal will soon enter a State Legislative debate to be confronted by opponents with grave concerns about its dangers. -Terry Kupers (Terry Kupers is a Los Angeles psychia- trist who has been a vocal opponent of the Violence Center. He formerly worked at UCLA's NPI and is presently at Martin Luther King, Jr. Hospital.)