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Correctional Health Care
"It is but just that the public be required to care for the prisoner, who cannot, by reason of the deprivation of his liberty, care for himself."

-Spicer v. Williamson Supreme Court of North Carolina (1926)

Correctional health care is the area of health care as it applies to the system of corrections, and is concerned with the treatment and prevention of sickness in the incarcerated population of a society. This article will address the development, role and application of correctional health care in the United States.

In the absence of incarcerated persons' capacity to seek health care or prevent or remedy illness on their own behalf, prisons and jails are obligated by social norms and by the Eighth Amendment rights of inmates as U.S. citizens to provide health care services for them (see Eighth Amendment to the United States Constitution). The cost of health care in the United States has ballooned in recent years and continues to expand at an astounding rate. As the baby boomer generation ages, the number of elderly and potentially ailing citizens grows, as does the burden on the health care system and on society. The United States incarceration rate--as well as the percentage of those incarcerated within the overall population--already rivals that of any other country in the world: "Tough sentencing laws, record numbers of drug offenders and high crime rates have contributed to the United States having the largest prison population and the highest rate of incarceration in the world, according to criminal justice experts." Prisons and jails, already feeling the strain of a growing incarcerated population, are not exempt from the increasing demands that plague the larger health care system. This makes the field of correctional health care more relevant now than ever before, and the ongoing maintenance of and struggle towards a better standard of health care in corrections requires an ever-expanding number of doctors, nurses, and professionals in the field of healthcare administration.

Origins of Correctional Health Care
Illness and disease have existed in jails and prisons as long as jails and prisons have been around. But it has not been until recently that a system of health care that would address prisoners' mental and physical health needs was established: “Correctional health care as a separate field of endeavor is a relatively new phenomenon. It was not until the early 1970s that anyone focused on the type of health care and level of services provided to those who were incarcerated. In the 1970s, the primary problem was that few prisons or jails had a system of care in place."

Perhaps it was the catalyst of the Civil Rights Movement during the 1960s and its accompanying focus on the struggle for human rights and equality under the law that cast a spotlight on the needs of this segment of the population. Whatever the cause, the field of correctional health care has grown a great deal in the decades since its inception, and it continues to expand and evolve from the days when the concept of correctional health care as a functioning standardized system did not exist. Now, "virtually every state department of corrections and large jail system has a health delivery system in place."

It is perhaps not surprising that, for years, no real standard of care existed for prisoners. After all, out of sight of the general population tends to mean out of mind as well. For most people--those not involved with corrections in some way--any knowledge of prison life or correctional health care is based on cinematic portrayal of potentially dubious origins. Such representations leave a lasting impression nonetheless; recall the perfunctory and casual reference in the movie, The Shawshank Redemption, to the new inmate who dies after being left unattended all night in the prison infirmary). Stories abound of prisoners caring for one another in the absence of qualified--or any--medical personnel on staff at detention and correctional facilities, or worse, of prisoners being denied treatment despite the presence of qualified medical professionals, though this has changed in recent years: "Now, it is rare to find any system where inmates serve as caregivers...correctional staff are far less apt to impede inmates' access to health care or deny it overtly as punishment...." For a long time, even laying claim to being a medical professional employed in corrections tarnished one with the suggestion of illegitimacy: "Because corrections has had a history of offering second-rate health care, it was often assumed that the people who chose to work in this environment were second rate as well. To the extent that that may have been true in the past, it no longer characterizes the professionals who work in corrections." Now, unlike in the past, "almost all health workers in corrections are appropriately licensed, registered, or credentialed."

Organizations in Correctional Health Care
The concept of correctional health care was born and grew up hand in hand with the organizations that would help define, validate, nurture and improve it; it is doubtful that the endeavor of establishing a field of correctional health care would have been taken so seriously without the support of organizations created to oversee it, nor is it likely that such organizations would have come into existence had it not been generally felt by social organizations and by those persons involved in corrections that there was a real need and a social obligation to provide health care to the incarcerated population. There are four main organizations that are related to the oversight and development of the field of correctional health care: The National Commission on Correctional Health Care (NCCHC), the American Correctional Association (ACA), the Joint Commission, formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and to a lesser degree, the American Public Health Association (APHA). Though these oranizations all play or have played valuable roles in the corrections community, NCCHC is the organization that has been most integral to the evolution and establishment of the field of correctional health care, as well as the one that continues to develop and refine the standards applicable to it. It has been noted: "In the opinion of many...the dominant organization in correctional medicine today is NCCHC--in part because it consolidates the efforts of so many professional associations and in part because it offers many diverse activities aimed at helping correctional institutions upgrade their health services.

National Commission on Correctional Health Care
The National Commission on Correctional Health Care (NCCHC)[www.ncchc.org] is an independent, non-profit organization dedicated to improving the standard of care in the field of correctional health care in the United States: "With support from the major national organizations representing the fields of health, law and corrections, the National Commission on Correctional Health Care is committed to improving the quality of health care in jails, prisons, and juvenile confinement facilities."

NCCHC started as an area of interest within the larger health care-related sphere of the American Medical Association: "An outgrowth of AMA's Jail Program, NCCHC was incorporated in 1983 and began conducting business as NCCHC in January 1984. Its sole purpose is to improve health care in correctional institutions (prisons, jails, and juvenile facilities)...."

The National Commission on Correctional Health Care holds holds two conferences on correctional health care each year, the larger being the National Conference on Correctional Health Care, held each fall, as well as one seminar dealing specifically with correctional mental health care.

Early Court Actions
Eighth Amendment to the United States Constitution states that: "Excessive bail shall not be required, nor excessive fines imposed, nor cruel and unusual punishments inflicted."

Without the lawsuits that arose from a lack of proper health care and often unconstitutional treatment of inmates, correctional health care surely would not have advanced to the degree that it has (although it must be pointed out that such treatment was sometimes only established as unconstitutional by court ruling after the fact). Litigation was a major part of the catalyst that spurred the formation of a system of correctional health care: "In the 1960s, the judiciary began to scrutinize conditions in prisons and jails more assiduously and to enforce more strictly the precepts of the eighth amendment. With respect to health care, judges applied the amendment to prohibit not only the infliction of pain and suffering, but also the failure to relieve pain and the failure to restore function."

The court case considered to have had the greatest impact upon the development of correctional health care was the 1976 decision in Estelle v. Gamble. Though the outcome of this case did not favor the inmate filing the initial claim, it nevertheless proved to be a critical decision in terms of shedding light on an area that had until then not been the focus of much attention, as well as demonstrating a link between the Eight Amendment and its application to the criminal justice system: "The legal framework was established in the 1976 landmark decision of Estelle v. Gamble, in which the Supreme Court ruled that prisoners have a right to be free of “deliberate indifference to their serious health care needs.” Although there has been some fine-tuning, the legal landscape has remained largely unchanged for more than twenty-five years. In the hundreds of published cases following Estelle, three basic rights have emerged: the right to access to care, the right to care that is ordered, and the right to a professional medical judgment. The failure of correctional officials to honor these rights has resulted in protracted litigation, the awarding of damages and attorneys’ fees, and the issuance of injunctions regarding the delivery of health care services."

Estelle also introduced the notion of the role the court would come to play--beyond that of convicting--as occasional overseer of health care services within the corrections system: "the U.S. Supreme Court...ruled that, where constitutional rights are jeopardized, the courts have not only the right but the duty to intervene. According to Estelle, the eight amendment is violated when correctional officials are "deliberately indifferent" to an inmate's serious medical needs."

The Prison Litigation Reform Act
Litigation continues to provoke reform within the system of corrections. The existence of the court as a sort of monitor of the prison system can act as a line of defense against the mistreatment or lack of treatment of inmates as it relates to health care, and "once a health care professional orders treatment for a serious condition, the courts will protect, as a matter of constitutional law, the patient’s right to receive that treatment without undue delay. The easiest way for an institution to lose a lawsuit is to fail to provide inmate patients with the care that its own staff has ordered." But lawmakers and courts have to walk the line between protecting the rights of inmates and allowing the whole system to become embroiled in a litigation nightmare. To avoid the possibility of lawsuits becoming too prevalent in the world of correctional health care, Congress passed the Prison Litigation Reform Act:

The Prison Litigation Reform Act In 1996, Congress passed the Prison Litigation Reform Act. The legislation had two broad purposes: (1) to limit the role of the federal courts in the management of prison and jail operations; and (2) to reduce the number of civil rights lawsuits by prisoners that were thought to be without merit. To a significant degree, the Act has changed the landscape of federal court involvement in prison condition lawsuits (including those involving health care) and in individual prisoners’ claims for damages or injunctive relief."

Footnotes

1. Rold, William J., JD, CCHP-A, "Appendix." Standards for Health Services in Jails. Chicago: National Commission on Correctional Health Care, 2008, p. 135.

2. Vinci, James. US Has the Most Prisoners in the World." http://www.commondreams.org/headlines06/1209-01.htm. Article published on Saturday, December 9, 2006. Accessed on January 21, 2009.

3. Anno, B. Jaye, PhD. Correctional Health Care: Guidelines for the Management of an Adequate Delivery System. Chicago: U.S. Dept. of Justice, National Institute of Corrections; 2001 ed edition, 2001, p. 3.

4. Anno, p. 27.

5. Anno, p. 27.

6. Anno, p. 391.

7. Anno, p. 27.

8. Anno, p. 26.

9. NCCHC website. http://www.ncchc.org. Accessed on January 14, 2009.

10. Anno, p. 26.

11. Anno, p. 46.

12. Rold, p. 135.

13. Anno, p. 46.

14. Rold, p. 136.

15. Rold, p. 139.