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Spring 2014
BMM Current Issue
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Patient Prisoners
Medicine at the cellular level.
From a health care perspective, there are ways in which jail doesn’t look that bad. I spend one day each week in an outpatient setting—one half in the resident continuity clinic at Rhode Island Hospital and the other half at the women’s prison at the Adult Correctional Institute (ACI) in Cranston. The clinic contains gray metal file cabinets that line the walls, with stacks of papers and charts piled precariously on top. The windows don’t open, and the heat is turned up so high that the air conditioner remains on all year long. Until recently, the examination table was missing half a leg. The gynecologic stirrups have no padding, so they are covered with oven mitts. In spite of these meager resources, the patients receive high quality, comprehensive care.

In my clinic at the hospital, where almost all my patients lack health insurance, it can take months to get them an appointment with a specialist. Psychiatrists are in particular demand. At the ACI, a psychiatrist is on site several days a week. If I have a patient who needs mental health services, I can walk into the next room and talk to the psychiatrist directly. If he or she is unavailable, a mental health worker will see the patient that day. Dentists and ophthalmologists have regularly scheduled clinics. There is on-site physical therapy, and extensive contraceptive counseling and services. There is a guaranteed supply of medication, without co-pays, that is brought daily in “med line.” There is the security of drug- and tobacco-free housing, and three meals per day.

Certainly, all of this comes at a monetary cost to taxpayers and a social and emotional cost to inmates. Many of the women are separated from their children. Some report being treated harshly by other inmates. Punishments are doled out, justly or unjustly, with little recourse for appeal. However, while none of my patients would elect to stay if given the choice, many say they fare better with the stability that prison affords.

For a number of women, prison is the only way they have been able to access substance abuse services. I have one patient who was diagnosed with hepatitis C while at the ACI. She underwent a liver biopsy and is now scheduled to begin treatment, something she would not have accessed easily outside. Another underwent genetic testing for Huntington’s disease and was connected to a neurologist when the test came back positive. Pregnant women receive scheduled prenatal care, and diabetics take their medications and have their blood glucose levels checked regularly. Many women survive outside as sex workers; many suffer physical and emotional abuse. For them, jail is safer. One could even view prison as a Patient-Centered Medical Home: women are cared for by a multidisciplinary team, electronic medical records are used, and follow-up is timely and guaranteed.

I am not advocating increasing the already high incarceration rate. I do not think that jail is the solution to society’s problems. On the contrary, I am suggesting that services be put in place outside of jail so that people can be cared for without being incarcerated. There is something wrong with the fact that my patients in prison have access to more comprehensive care than do my patients in continuity clinic. Health care is a right to which all people, incarcerated or otherwise, are entitled. The question is not why prisoners receive such good health care, but why the rest of our citizens do not.

Joanna D’Afflitti is in her third year of Brown’s general internal medicine residency training program.
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