HEALTH CARE IN PRISONS.   Term Paper ID:22977 Click to get this paper

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Paper Abstract: Services available, views of public, politicians & administrators, AIDS, gender issues, examples, TB, public health, costs. Paper Introduction: The purpose of this research is to examine the current status of health care within the American state and federal correctional systems. The plan of the research will be to set forth the context in which prison-related health care takes place, and then to discuss the administrative environment in which treatment takes place, the availability of primary, maintenance, and rehabilitative health-care services for the varieties of both major and minor medical problems and where they are provided, the quality of care and how it is monitored, and the economic aspects of health-care services in prisons. In 1971, describing prisons as "factories of crime," Ramsey Clark (1971, pp. 212-13) wrote that "ninety-five per cent of all expenditure in the entire corrections effort of the nation is for custody--iron bars, stone walls, guards. Five per cent is for hope--heal Text of the Paper: The entire text of the paper is shown below. However, the text is somewhat scrambled. We want to give you as much information as we possibly can about our papers and essays, but we cannot give them away for free. In the text below you will find that while disordered, many of the phrases are essentially intact. From this text you will be able to get a solid sense of the writing style, the concepts addressed, and the sources used in the research paper. Crime and violence insideor outside prisons would not decrease, but addiction would. Yarbrough (1985) also cites the Alabama prison-conditionscase, noting that federal judges who mandated the reform of conditions inAlabama based on the concept of violation of civil rights essentiallychanged the entire relationship between the judiciary and executive oradministrative arm of the correctional system. Kleber, H. Just as sheer availability of health treatment varies frominstitution to institution, so does the location where treatment may bedelivered. Weiner and Anno (1992) summarize the principal areas of health-careconcern in correctional facilities in the current period as AIDS,tuberculosis, substance abuse, mental disorders, and distinct complaintsof female inmates. The political world of federaljudges as managers. (1992)analyze a survey of male inmates of older than 5 in the Iowa prisonsystem, noting that most of those surveyed (97%) had missing teeth, and7 % were smokers. (1994) recommendthat inmate transfers be evaluated with reference to the need to controlinfection and prevent the spread of TB. Another key issue for Thorburn is theinevitability of health issues that arise owing to the aging of thepopulation of prisoners, a point to which we shall return. A1. S. 1988 update: AIDS in correctional facilities.Washington, DC: U.S. (1989, December 4). Longand Rickman call for public-health education that will help preventdisease, placing prisoners and correctional officers at the top of theirlist. Types of medical services available to prisoners varies widely withindividual institutions, but most who have studied the phenomenon appearto agree that the services are inadequate. Further, Sowder makes the casethat such a failure has implications for the legal status of prisoners,in this way, that it amounts to cruel and unusual punishment, which isspecifically prohibited by the 8th Amendment. Prisons are widely believed to have failed in their punitiveapproach to dealing with prisoners on a whole range of issues, includingbut hardly limited to health-related issues. Prison health: the breaking point. Ms. Reno and the jail glut. Dicataldo, F., Greer, A., & Profit, W.E. Further, disproportionate numbers ofinmates, relative to the general population, are afflicted with AIDS. (1994, July). Sources disagree, however, on the consequences of suchnumbers. Further, what masquerades ascounseling often takes the form of psychological intimidation, a bigissue if the young person enters the facilities with a preexisting butundiagnosed emotional or physical disability. (1994, October 28). The one constant in this whole scheme has been thatprison populations have not decreased but have continued to set recordsfor increasing. (1994, June). AIDS education and incarceratedwomen: a neglected opportunity. Hammett (1988)describes such strategies as AIDS education and training, HIV antibodyscreening, and so-called precautionary measures to protect prisonpersonnel and fellow inmates from infection by AIDS prisoner-patients.However, as a practical matter, the major AIDS-related strategy appearsto be to isolate the known infected from the supposedly uninfected(Coughlin, 1988). (1994, February 12). JAMA, The Journal of the American Medical Association, 262,3258-6 . The purpose of this research is to examine the current status ofhealth care within the American state and federal correctional systems.The plan of the research will be to set forth the context in which prison-related health care takes place, and then to discuss the administrativeenvironment in which treatment takes place, the availability of primary,maintenance, and rehabilitative health-care services for the varieties ofboth major and minor medical problems and where they are provided, thequality of care and how it is monitored, and the economic aspects ofhealth-care services in prisons. Most prisoners, for example, need dental care. 212-13) wrote that "ninety-five per cent of all expenditure inthe entire corrections effort of the nation is for custody--iron bars,stone walls, guards. Bulletin of the American Academy ofPsychiatry and the Law, 23, 573-585. In otherwords, leaving aside the psychosocial issues associated withtransitioning prisoners from correctional facilities to the generalcommunity, the correctional community is faced with the (all toopractical) fact that the prison system cannot afford to keep its currentprison population locked up or indeed maintain that population at itshigh level. Thorburn, K.M. Health-status of older male prisoners--a comprehensive survey.American Journal of Public Health, 82, 881-884. Thorburn's view that prison officials responsible for health carework with health professionals in nonprison public-health venues issuggestive to the degree it reflects a lack of well establishedcoordination between prison and nonprison health care delivery. The implication of such figures can bediscerned in Ramsey Clark's analysis of the connection between adequatehealth care, which the general population takes for granted, and socialintegration: "Simple physical illnesses are poorly treated in prison iftreated at all. Accordingly, one policy recommendation was that pilot programsaimed at encouraging family unity be set up by the National Institute ofCorrections so that inmates who fall into these categories in particularbe considered for alternative-to-incarceration programs (U.S. B. Health-care in correctionalfacilities. E. The NewYork Times, 143, p. AIDS in prison: judicial indifference to the AIDSepidemic in correctional facilities threatens the constitutionality ofincarceration. Shogren (1994) points to a reduction in crime relative to thehigh levels of incarceration in state and federal facilities; Hurst andMorain (1994) say that in the California state prisons the population isso high that overcrowding is itself a feature of punishment andconfinement; Broder (1993) contrasts figures of prison population withfigures for crime, saying that the increased prison population provesthat tougher crime prevention measures do not discourage criminalbehavior. There are, however, problems with screening and preventivestrategies. F. Weiner and Anno argue that correctional health careshould be linked to public health issues and that more resources shouldbe given to aggressive screening for disease and other problems wheninmates enter the prison population and disease-prevention strategiesthereafter. Government Printing Office. The figures indicate that health care provision has beenof relatively poor quality. Treatmentprograms in prisons, meanwhile, should deal with the special needs ofthose in prison, with a view toward guiding them to alternatives toprison, therapy. U.S. (1993, January 15). Managed careappears to be the delivery system of choice for such providers, which canbe taken to mean that cost controls and guidelines potentially have morestanding than medical issues where marginal situations of health-caredelivery are concerned. (199 , February 16). (1995, December). The Washington Post, 117, p. An AMA committee (Council,199 ) says that youth offenders are at particular risk for developingphysical and emotional problems while incarcerated at overcrowded andunclean facilities but that youths--even those not being charged withserious crimes--are often restrained physically, including with drugsthat affect perception and concentration. Hammett, T. In the past, the focus forcorrectional-facility health care has been on controlling drugs andpunishing offenders. Hard judicial choices: federal district courtjudges and state and local officials. The American Journal of Public Health, 8 , 1479-8 . C7. Five per cent is for hope--health services,education, developing employment skills." One might reasonably expectthat, between 1971 and 1996, conditions had changed. According to Weiner and Anno, the health problemsaccompanying this influx of inmates have overwhelmed the state's capacityto properly deliver health care for them. Golden years behind bars: special programsand facilities for elderly inmates. What makes the California and New York cases disquieting is that,as the medical literature indicates, the high incidence of TB in prisonpopulations (three times greater than the general population) has beenwell known for some time. When that loss is but one of many disadvantages and part of adehumanizing existence, it adds its measure of brutalization" (Clark,1971, p. This strategy was specifically andprogrammatically not followed in the California case, although the risksof providing on-site health care for certain diseases are apparent.Further to this point, Bass (1995) says that the historic decline in TBcases was reversed from the mid-198 s onward, and that prisons have beenamong the most important centers of the increase of drug-resistantstrains of the disease. The implications ofsuch an analysis can be seen in the work of Sowder (1992), who arguesthat the New York penal system also failed its prison population, not somuch by failure to educate prisoners as by failing to screen for AIDS onone hand or to distribute condoms to prisoners who may engage in sexualbehavior that puts them at risk for AIDS. Along the same lines, Glaser andGreifinger (1993) say that the corrections system could play a positivehealth-care role, particularly in if it were more attuned to theepidemiology of such diseases as AIDS, TB, and venereal disease Thereason is that, because of prisoner demographics, most prisoners havelimited experience of medical care. The New York Times, 142, p. Los Angeles Times, 113, p. inmate count doubled since198 , Congress is told. III (1988, June-July). Kleber (1994) advocatesexpansion of drug treatment programs, while maintaining legalrestrictions against currently illicit drugs. There is also evidence thatstates may be lax or heedless in attending to health-maintenance needs oftheir prison populations, a problem that has become more visible as theprison population itself has become visibly older. Suicidemortality in the Maryland State Prison System, 1979 through 1987. J. Their view is that the state's prison system has by andlarge failed to systematically engage the prison population in what arefairly simple and straightforward health strategies. (1994, July 3 ). A similar situation occurred in the NewYork state prison system, where a drug-resistant strain of TB was foundamong more than 17 inmates between 199 and 1991 (Valway, & others,1994). The Progressive, 52, 18-22. Moore, W. (1993, April). (1994, March). AIDS in prisons: onecorrectional administrator's recommended policies and procedures.Judicature, 72, 63-6. However, the record of success with regard to health education(and hence, disease prevention) of prisoners, many of whom, as astatistical matter, come from educationally deprived backgrounds, isnevertheless spotty. Washington, DC:Superintendent of Documents. (1991). (1994, February 3). Skolnick, A. However, as a practicalmatter, there seem to be more proposals for education and training thanactual programs in effect in this regard. It does suggest,however, that Sowder believes that the correctional system incurs anaffirmative obligation to protect the health of inmates in its charge. Types of health-related services available in prison appear to varywith prevailing institutional and governmental culture, as well as withbudgetary realities, although certain minimum standards of care aremandated by constitutional guarantees against cruel and unusualpunishment on one hand and statutory regulation on the other.Rehabilitative health services would seem to be ideally available in acorrectional facility, where administrative control of inmates is agiven. Los Angeles Times, 113, p. Further to this point, Berkman (1995) notes that the femaleprison population is growing and in future years is likely to requiremore, not less, health care, and that care needs are likely to beamplified for the reason that prisoners come from lower socioeconomicgroups where general health care has never been particularly available.Berkman also cites the need for an increase in female-specific healthservices as more and more women are jailed. The result is that when healthdeterioration sets in for prisoners (especially AIDS patient-prisoners),they are forced to struggle for health and against death in environmentsthat lack compassion (Berkman, 1995). Yarbrough, T. He suggests areconsideration of health-service delivery in light of these facts,suggesting that prison administrators work with public health authoritiesfor technical assistance, as well as for rehabilitation and self-careprogram development. General Accounting Office,doubled in the 198 s (National Pages, 1989), and by 1994 it had increasedto more than one million (Thomas, 1994; Shogren, 1994), as a number ofsources report. Ogburn, K. Western Journal of Medicine, 163, 56 -564. Bloch, A.B., Onorato, I.M., Ihle, W.W., Hadler, J.L., Hayden, C.H., &Snider, D.E. One case assumed specialimportance in this regard. S. Making managed careprinciples work in the correctional setting. Alcoholism-Clinical and Experimental Research, 19, 3-5. Journal ofInfectious Diseases, 17 , 151-156. (1994, April 17). But the recordindicates that health-care issues for prisoners have not only not beenresolved but for a variety of reasons have become more complex. Officer extinguishes fire to rescue medicalunit. To be sure, there is some evidence thatcorrectional officers are willing to engage in various forms of heroic,life-saving interventions; Ogburn (1993) gives an account of a guard wholiterally put out a fire in a prison hospital coming from the hot waterheater of the prison's health care unit (but the truth is that this storywas told chiefly to enhance the career of the guard, not to contribute tothe debate over prisoner health care!). (1996, January-February). Indeed, Weisbuch (1991) argues that such linkages areessential because inadequately cared for prisoners released from anenvironment disproportionately infested with such diseases as AIDS andinfectious hepatitis into the general population could pose a seriouspublic health risk. A21. Perhaps the most important feature of the New York case was thatthe epidemic was not confined to one inmate or to three prisonfacilities, as in the California. Hurst, J., & Morain, D. (1993, June). (1995). National Pages. JAMA, The Journalof the American Medical Association, 264, 15 9-1 . Multidrug-resistanttuberculosis in the New York State prison system, 199 -1991. In recent years, cost-management strategies for reliable healthcare in the market as a whole have been studied with a view towardtransforming the mode of primary delivery of medical services. Further, proactivemeasures against the physical or mental well-being of inmates have beeninitiated against prisoners, as in the case of intimidation of juveniles.Meanwhile, authorities themselves differ over whether the salutary oreconomic effects of tobacco use and manufacture are outweighed by thepernicious effects of tobacco. Correctionalhealth-care--a public-health opportunity, Annals of Internal Medicine, 118,139-145. A1. In particular, correctionalsystems do not appear to have adequate services, including counseling,available to pregnant prisoners or to prisoners who already havechildren. However, nearly a year later, an X-rayrevealed the presence of TB, and he was confined to the on-site prisoninfirmary. In 1993, a U.S.congressional committee found that as a group, correctional systems havenot responded particularly well to the health-related needs of femaleoffenders, vis-à-vis their male counterparts. A. In 1971, describing prisons as "factories of crime," Ramsey Clark(1971, pp. New York Law School Law Review, 37, 663-87. Berkman, A. (1989, July 21). (1992) note that correctional-industryguidelines for local jails mandate screening for venereal and otherinfectious or communicable diseases, but that because the screening testsare scheduled for the fourteenth day after admission to a given facility,some infected but asymptomatic prisoners slip through the cracks andenter either the general or prison population in an infected state andcan remain untreated, wherever they reside. Thorburn (1992) summarizes the multiple issuesthat emerge where health care in correctional institutions is concerned,arguing that, on the whole, correctional systems recognize theimplications of increasing prison and jail populations, particularly dueto offenses for drug use. It is as if thestructure of managed care, regulatory strategies achieve as much standingas the vicissitudes of a given medical case. Treatment programs are also recommended by Long andRickman (1994) in a discussion of the health risks of tattooing,particularly in prison settings, where risks for infectious transmissionof hepatitis B virus, HIV, tuberculosis, and other germs are high. Glamour, 92, 8 . When the prisoner was actuallyconfined to the infirmary, he was not put in isolation, with the resultthat tuberculin air escaped to various areas in the infirmary area andbeyond it, extending to a ward housing prisoner-patients with AIDS or pre-AIDS symptoms. In other words, the ultimate consequence of poor-qualityhealth care in prison settings could be visited on society once a poorlymaintained prisoner is released. According to Moore, the dramatic growth in prison construction inthe late 198 s and early 199 s, as well as tendencies in the judicialsystem toward longer sentences for offenders, implies an increase incosts to public-sector budgets allocated to health care for inmates.Longer sentences, as we have seen, imply an aging prison population.However, at this point, programs specifically geared to the needs ofelderly prisoners, including facilities and services, are either severelylimited or in the proposal and planning rather than implementation andadministration stage (Aday, 1994). This is thecase even though the public position of both judicial and legislativeofficials is that good prisoner health care is in the state's besteconomic interest over the long term. A36. Bass, J.B. Indeed, Block, et al. The availability of health-care services in prisons appears to varywith the sex of the prison population to some degree. (1994, October 28). Theprison population, as reported by the U.S. The new responsibility for prisonhealth: working with the public health community. TheAmerican Journal of Public Health, 85, 1616-19. argue thattimely treatment and testing for sexually transmitted diseases are likelycould be a form of public health implementation in "custody settings." Some correctional medical services are provided by outsidepersonnel who visit prison facilities on a regular basis. (1992, July 1). Becausethey are poor, they have never had any dental work, but few get adequateattention in prison. The fact that theinmate enters the system already sick means that correctional officersare confronted with expensive and increasing health needs. However, the record appears to be that the amount and qualityof health care is in many cases substandard. Colsher, et al. (199 , September 26). Specific recommendations for control of TB in the correctionalsystem included surveillance and containment, in addition to immediateisolation of persons with TB. Shogren, E. JAMA, The Journal of the American MedicalAssociation, 269, 978-9. S., & Brewer, T. The American Journal of Public Health, 82, 552-6. Meanwhile, inmate suicide hasbeen analyzed as a public health problem, although the focus of study ofthe problem appears to at least as much on generating more research intothe problem as on specific guidelines for health care professionals inevaluating the mental health of inmates (Salive & Others, 1989, 199 ). It was during this period that the guards and health-carepersonnel tested positive for TB. This indirectly argues that personal-development or socialrehabilitation programs, including education or community reintegrationtraining, can be seen as economically sound responses to a perceivedcrisis in the costs associated with providing health care in prison. 14. A similar point is made byShenson, et al. For example, King (1995)reports of the death of a man from AIDS in a Washington, D.C., jail, notonly with no medical care but also with no other form of care orrehabilitation available to him. The New England Journal of Medicine, 33 ,361-5. (199 , December). This fact achieves significance inview of the fact that, as Douglas and Mundey note, government agencies atlocal, federal, and state levels that are in charge of correctionalfacilities are increasingly privatizing health-care programs. The New York Times, 139, p. Now this does not mean that (unhealthy) prisoners who arereleased will achieve health by reason of their being released or thatsociety as a whole will benefit from such release. Something of an economic boom appears tohave been created by the expansion of prison facilities in general andthe attendant health-care environment of such facilities in particular.But the money is less likely to be spent on services to the prisonpopulation than on service providers or facilities as such. Locked in. Weiner, J., & Anno, B.J. Cohen, D., Scribner, R., Clark, J., & Cory, D. Long, G.E., & Rickman, L.S. Personalities are shaped by such factors as the lossof teeth. U.S. (1995, October). (1993, February 24).Probable transmission of multidrug-resistant tuberculosis in correctionalfacility--California. That is,instead of administering (and inevitably, regulating) day-to-day health-care delivery, government bodies are paying private-sector health-careproviders to deliver health care in correctional venues. An editorial in February 1994) in The New York Times points towhat it describes as a "jail glut," owing to the apparent overbuilding ofsome jails to accommodate rising prison population; curiously, writing inthe same publication less than one year earlier, however, Clines (1993)notes overcrowded conditions on the inside and the persistence of crimeon the outside. prison population, continuing rapidgrowth since '8 s, surpasses 1 million. Our current approach to drug abuse--progress, problems, proposals. Indirectly, therefore,Sowder is arguing that prisoners who have been failed by the system thatcontrols them should not be obliged to remain under the control of thesystem. (1985, November). Another question persistently arises regarding how health careeducation and training can be implemented. In theory, at least, andin general terms, judicial review appears meant to provide the rationalefor access to health care on the part of prisoners. (1994, October, 17). (1995, December). (199 ), who say that many prisoners bring the ill-healtheffects of drug abuse and poverty-related diseases (both physical andmental) with them when they enter the prison system. National Journal, 26, 1784-8. Federal Probation, 58, 47-54. Theimpact on public budgets as interpreted by Moore seems to arise from twodistinct, though related, sources--the health-care costs directly relatedto prisoners themselves, and the costs associated with supporting whatamounts to a publicly funded business opportunity environment forcommunities that seek out opportunities to provide well-paying jobslocally and for companies that exploit the opportunity to make clientsout of prison administrations. H. (1992). A. Cohen, et al. Moore (1994) argues that just ashealth problems for the general population increase with age, the samewill hold for the prison population. Cooper (1988) says that where government-run institutionsof any sort are concerned, the chain of discipline-specific command isnot necessarily located in professional staff. An investigation by the Centers for DiseaseControl (1993) in the early 199 s found that a single inmate in theCalifornia prison system may have been responsible for transmitting adrug-resistant strain of tuberculosis to both health care providers andguards. (1993, May 28). All locked up: some challenge thenotion that punishment is the best way to reduce crime. Clinical Infectious Diseases, 18, 61 -619. Salive, M. (1992,June). Even in prison, men get better treatment thanwomen. References Aday, R. Prevention and control of tuberculosis in correctional institutions:recommendations, advisory committee for elimination of tuberculosis. He cites controversy over whetherwithholding tobacco could lead to prison riots and other securityproblems or improve figures on health care, institutional sanitation, andfire safety. Prisons running out of cells, money andchoices. Tuberculosis in the 199 s. Corrections Today, 57, 98-1 . But we have already seen that TB, dental problems, and AIDS haveremained untreated in selected prison settings. 214). The sheer number of inmates inevitably has implicationsfor health-care delivery. This has potential consequences not only for the patients butalso for the rest of the prison population. Because prisons areviewed as repositories for criminals than as agents of rehabilitation andreintegration into society, administrators and legislators withjurisdiction over prison management programmatically resist maintenancehealth care or AIDS education. Notingthat such strategies, under the name managed care, appear to have beeninitiated in the correctional institutional settings, where cost controlshave always been at a premium, Douglas and Mundey (1995) describe theincreased use and application of managed-care structures as a response toeconomic constraints. (1993, June 29). Clines, F. Public Administration Review, 45, 66 -6. (1991, Summer). I., & Earp, J. (1989,December 15). Meanwhile, a few facilitiesappear to virtually foster poor health owing to long-term policies.Skolnik (199 ) says that the hazards of tobacco use are essentiallyignored by correctional facilities that sell cigarettes at deep discountsor have cigarette-manufacturing facilities on the premises as a means ofvocational training for juveniles. Upon being jailed, the prisoner was X-rayed and given a standardTB skin test that were negative. The crisis in correctionalhealth-care--the impact of the national drug-control strategy oncorrectional health-services. Nor are all disparities between health treatment of men and women,so to speak, sins of omission. Screening prisoninmates for mental disorder--an examination of the relationship betweenmental disorder and prison adjustment. Cohen, et al. Pregnant in prison; in onejail, 8 per cent lose their babies. A21. jail. According toSikka (1993), some facilities are located in remote areas, making ease ortimeliness of access to medical care sometimes difficult. However, this confinement (and the treatment to accompany it)did not occur until a month after the positive X-ray, which meant that hemingled with the general prison population until drug treatment started.Moreover, the prisoner was transferred to three separate prisonfacilities over a one-year period after having been diagnosed with TB andbefore any drugs could take effect. R. prisonercount past 1 million. A system strains at itsbars. Cooper, P. The dramatic increase in AIDS among the prison population in recentyears has led to special services in some prison settings. The committee cited 11 knowninstances of TB epidemics in prisons in eight states between 1985 and1988, noting that AIDS patients were particularly at risk for thedisease. In 1989, an American Medical Associationadvisory committee on TB reporting on its epidemiology in prisons citedovercrowding and poor ventilation as fostering the spread of the diseasein prison populations (Prevention, 1989). M. There are,however, disadvantages to this from an administrative point of view, asthe experience of the New York prison system indicates. (1996), say that 1986-1996has been unprecedented in the increase of TB and that prison populationsare among the highest risk groups for this disease. E., Smith, G. Rising health care costs in a period of diminishing funds to payfor them are also cited by Ruhren (1992) as part of the basis forencouraging parole of offenders from overcrowded prisons (andadministrative budgets) that, as a practical matter, are overburdenedwith the prospect of having to pay for health care of inmates. Thus the question of informationand training about disease prevention directed at inmates must be setbeside the documented failure of institutions holding the power to treata disease or not to intervene when the health condition of a prisonercalls for it. J. JAMA, The Journal of the American MedicalAssociation, 263, 987-9 . (1988). Centers for Disease Control and Prevention. Colsher, P.L., Wallace, R.B., Loeffelholz, P.L., & Sales, M. A3. E., Smith, G.S., & Brewer, F. Senate,1993). Stein, L., & Mistiaen, V. Corrections Today, 55, 1 2. Some sources suggest that prisons might be a mechanism for haltingthe spread of a whole range of diseases. (1988, February). The issues of AIDS-related education or preventingstrategies directed toward those at risk for infection have been on thewhole placed into the background (Sowder, 1992). United States Senate Committee on the Judiciary. Valway, S.E., Greifinger, R.B., Papania, M., Kilburn, J.O., Woodley,C., Diferdinando, G.T., & Dooley, S.W. Their focus is on the highly structured philosophyof managed care, which is defined by a whole range of written guidelineswithin which limits of health-care delivery are set. Douglas, T., & Mundey, L. Meanwhile, 42% had major physical disabilities of onekind or another. Womenin prison: programs and alternatives: hearing. Instead, 12 prisoner-patients diagnosedwith TB (and with AIDS) were transferred through 2 of New York's 68prisons. (1988). Cost-effectiveness isimplied in such a structure because the situation is one in which qualityof medical care is assessed in terms of cost and not one in which cost isassessed in terms of quality care. Journal of Prison andJail Health, 1 , 3-18. Salive, M. Sowder, D. What wasalready an inadequate system of health care for prisoners has beenexacerbated by the fact that many new prisoners are the mentally ill, whoin former times might have been admitted to asylums but who end upcommitting crimes and being sent to prison because no other mental healthprograms or facilities exist to serve them. Infectious complications oftattoos. Thomas, P. I. King, C. Annals of Internal Medicine, 117, 71-77. As a practicalmatter, however, the record is less clear. Cooper cites cases inAlabama and Ohio in which district court judges and not medical staffdetermined the disposition of substandard health-related institutionalconditions. Citing the fact that the number of women in prison rose by afactor of 4 % from 198 to 1994 and that as a group women appear toserve longer sentences than men, a popular magazine faults poor andsometimes abusive management of women in prison and argues that basichuman services, including but not limited to health care and drugtreatment, are less widely available for women than for men (Editorial,1994). New York: Oxford University Press. Women and Health, 17, 1 5-17. Complicating the issue of thestigma attached to prisoners in general is the fact that the state of NewYork appears to have been unable to recruit a sufficient number ofphysicians able or willing to treat AIDS-infected or geriatric prisoners,both of which have special medical needs. Weisbuch, J. JAMA, TheJournal of the American Medical Association, 262, 365-9. Viadro, C. The WashingtonPost, 117, p. Editorial. Ironically, these needssurface at a time that the rhetoric of prison administration tends todehumanize persons who have been put in jailed. While some correctional facilitiesgo smoke-free, others appear to help inmates to light up. Death inprison: changing mortality patterns among male prisoners in Maryland, 1979-87. This is all the more ironic inview of the evidence that more and more public moneys appear to beallocated to prison culture. (1994, April). Broder, D. Glaser, J.B., & Greifinger, R.B. However, interventions on the part of medicalpersonnel after infections or health problems have arisen appear to havebeen inadequate because of the dramatic the increase in inmatepopulations. Health status ofdetained and incarcerated youths. D. The need for epidemic intelligence.Public Health Reports, 111, 26-31. Ideally, they say, a sentence periodcould be used to educate prisoners on health care both during and afterthe term. In this regard, Viadro and Earp (1991) report onwhat they see as the failure of the North Carolina medium-securitywomen's facility to either enable or encourage the education of prisonersregarding AIDS. Valway, et al. Council on Scientific Affairs. It mightbe assumed that health-care decisions for any category of patients wouldbe made by medical staff organized and authorized for that purpose.However, in the case of prison-related health care, this does not appearto be the case. Stein and Mistiaen (1988) describe thegreat disparity of health-care services available to women from facilityto facility, noting that in some jurisdictions, up to 8 % of all pregnantwomen who bear children while incarcerated stand to lose their childrenpermanently. (1995, July 15).Death without dignity in D.C. TheWashington Post, 118, p. X. (1995, February). Thepotential role of custody facilities in controlling sexually transmitteddiseases. Sterner penalties send U.S. Coughlin, T. Editorial. 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