"The HIV+ men incarcerated in Limestone Prison's Dorm 16 were put there to be forgotten. Not only do Benjamin Fleury-Steiner and Carla Crowder bring these men to life, Fleury-Steiner and Crowder also insist on placing these men in the middle of critical conversations about health policy, mass incarceration, and race. Dense with firsthand accounts, Dying Inside is a nimble, far-ranging and unblinking look at the cruelty inherent in our current penal policies."
---Lisa Kung, Director, Southern Center for Human Rights
"The looming prison health crisis, documented here at its extreme, is a shocking stain on American values and a clear opportunity to rethink our carceral approach to security."
---Jonathan Simon, University of California, Berkeley
"Dying Inside is a riveting account of a health crisis in a hidden prison facility."
---Michael Musheno, San Francisco State University, and coauthor of Deployed
"This fresh and original study should prick all of our consciences about the horrific consequences of the massive carceral state the United States has built over the last three decades."
---Marie Gottschalk, University of Pennsylvania, and author of The Prison and the Gallows
"An important, bold, and humanitarian book."
---Alison Liebling, University of Cambridge
"Fleury-Steiner makes a compelling case that inmate health care in America's prisons and jails has reached the point of catastrophe."
---Sharon Dolovich, University of California, Los Angeles
"Fleury-Steiner's persuasive argument not only exposes the sins of commission and omission on prison cellblocks, but also does an excellent job of showing how these problems are the natural result of our nation's shortsighted and punitive criminal justice policy."
---Allen Hornblum, Temple University, and author of Sentenced to Science
Dying Inside brings the reader face-to-face with the nightmarish conditions inside Limestone Prison's Dorm 16---the segregated HIV ward. Here, patients chained to beds share their space with insects and vermin in the filthy, drafty rooms, and contagious diseases spread like wildfire through a population with untreated---or poorly managed at best---HIV.
While Dorm 16 is a particularly horrific human rights tragedy, it is also a symptom of a disease afflicting the entire U.S. prison system. In recent decades, prison populations have exploded as Americans made mass incarceration the solution to crime, drugs, and other social problems even as privatization of prison services, especially health care, resulted in an overcrowded, underfunded system in which the most marginalized members of our society slowly wither from what the author calls "lethal abandonment."
This eye-opening account of one prison's failed health-care standards is a wake-up call, asking us to examine how we treat our forgotten citizens and compelling us to rethink the American prison system in this increasingly punitive age.
Read an Excerpt
The HIV/AIDS Ward at Limestone Prison
By BENJAMIN FLEURY-STEINER CARLA CROWDER
The University of Michigan Press
Copyright © 2008
University of Michigan
All right reserved.
Chapter One Penal Health Care in Contemporary American Society
Sociologists of punishment have long recognized that inequalities in the broader society are mirrored in and through the prison population, beginning with such classic works as George Rusche and Otto Kirchheimer's treatise Punishment and Social Structure and Donald Clemmer's The Prison Community, a Depression-era case study of Illinois's maximum security prison at Menard. As a staff member of Menard's Mental Health Office and a coach of the prison football team, Clemmer had unparalleled access to conduct both an extensive prisoner survey and a detailed field analysis of the institution. Clemmer's major discovery was that the prison's social hierarchy closely approximated the outside community. Specifically, he discovered that the prison contained three distinct classes: an upper class; a middle class; and a lower, "Hoosier" class. Alternatively, Gresham Sykes's The Society of Captives, a case study of New Jersey's maximum security prison (written at the height of the cold war, in the 1950s), focused more on the prison as its own self-contained social system. Ironically, of all sociologists to conduct the earliest investigations of penal institutions in the United States, Sykes most poignantly articulated the similarities between prison and the broader society.
In reality, of course, the prison wall is far more permeable than it appears, not in terms of escape ... but in terms of the relationships between the prison social system and the larger society in which it rests. The prison is not an autonomous system of power; rather, it is an instrument of the state, shaped by its social environment, and we must keep this simple truth in mind if we are to understand the prison.
Building on the insights of Clemmer and Sykes, one of the most sweeping sociological analyses of a prison is James Jacobs's study of the Illinois penitentiary at Stateville. Through archival analysis of fifty years of Stateville's institutional life and through rigorous observational analysis, Jacobs's book Stateville elucidates the rise and fall of various managerial approaches to prison governance that were shaped by and through broader societal developments. Most important for Jacobs was how Stateville had become shaped by the rise of "mass society"-that is, how the institution had been greatly influenced not only by officials but by social movements focused on creating a more socially inclusive, rights-based society.
The civil rights movement of the early 1960s served to politicize the prison minority's population which emerged as a solid majority by the 1960s. The trend toward mass society redefined the status and value of marginal groups in the polity. The demand by prisoners for fuller participation in the core culture was reinforced by the greater sensitivity of the elites to the moral worth of marginal citizens.
One of the most compelling contributions of Stateville is Jacobs's discovery that a more activist judiciary was responsible for major changes at the institutional level of penal institutions. Setting forth a whole slew of new mandates designed to ensure minority prisoners' equal protection under law and to ensure the rights of prisoners to openly practice religion, Stateville underwent important changes, especially greater tolerance on the part of prison officials and the racial diversification of staff. Most of all, however, Jacobs discovered how the new legal mandates of mass society resulted in greater bureaucratization-in this case, a kind of symbolic deference on the part of Stateville's elites to new, legally mandated rules and regulations-as opposed to an idealistic view of prisons as places that put individual rights on par with the institution's overriding security imperatives. Indeed, Jacobs discovered that, on the whole, legal interventions resulted only in modest reforms into the 1970s.
[T]ransformation was incompatible with the tenets of the authoritarian regime. It was also incompatible with the human relations model of management ... The reforms mandated by the courts can only be implemented by well-run organizations ... Whether rational administration and responsive grievance mechanisms will be sufficient to meet the press of inmate demands is a serious issue to be faced in the future. Understanding the authoritarian regime of the penal institution-what sociologist Erving Goffman, in the classic Asylums, formulated as the "total institution" (individuals living together twenty-four hours a day under a strict, depersonalizing climate of control)-is critical for understanding just how incompatible many of the court's mandates were rendered in the three decades after Jacobs's analysis of Stateville. Beginning especially in the 1980s (in the immediate years after Stateville was published), but accelerating in the 1990s, three trends occurred that greatly inhibited any movement toward a more humane and rehabilitative approach to incarceration: the near wholesale embrace of mass incarceration policies by a majority of American states, the attendant massive overcrowding and the relative entrenchment of penal institutions as human warehouses, and a powerful backlash against prisoner rights by a far more conservative judiciary. Although I will discuss these crucial trends in subsequent chapters of this book (indeed, they will be fundamental to the presentation of the current study), it is important to note from the outset that, with notable exceptions in a few states that have resisted mass incarceration policies, these trends resulted in a reformulation of now severely overcrowded penal institutions.
Many of today's penal institutions resemble, perhaps more than ever before, the amoral bureaucracies brought most vividly to public attention in the wake of New York's infamous Attica prison riots of the late 1970s. The New York State Special Commission on Attica captured this situation and how it pertained specifically to deficient medical care.
No examinations were given at sick call; there was not enough time and neither doctor felt it was necessary ... The approach was very businesslike, very direct, and very authoritarian. The time and effort necessary to explain, to help provide insight, to gain acceptance, to achieve confidence, were absent.
Despite some important gains made in the treatment of HIV+ prisoners in the courts and by contemporary prisoner activists, many of the institutional-level failures described by the New York State Special Commission on Attica remain a pervasive part of the delivery of medical services to prisoners in the United States today. Overcrowding and lack of adequate resources in most states has made it all but impossible for chronically ill prisoners to receive consistent and adequate care. Moreover, the quick, "businesslike" approach by prison doctors at Attica is also realized today by most penal systems' increasing failures to conduct adequate audits and to keep reliable medical records in order to implement adequate protocols of preventative care. The term businesslike has largely taken on a distorted meaning when describing penal health care in the United States today. With the concomitant explosion, beginning in the 1980s, of such dangerous and complex chronic illnesses as HIV/AIDS and hepatitis C, along with the continued pains of tuberculosis outbreaks behind bars, economically overwhelmed states and local municipalities have relied on inexpensive, for-profit health care providers to manage the dying on the cheap.
Health Care Crises Inside and Outside U.S. Penal Institutions
Mirroring the broader societal trend toward cost cutting as the primary imperative of managing the health of marginalized populations in the United States, chronically ill penal populations are, drawing on Clemmer's prescient insight, representative of a microcosm of the broader society. The trend toward profit-driven private sector appropriation of health care-a trend that expanded most dramatically in the Reagan years and whose legacy continues into the present-has led to broad public dissatisfaction with the U.S. health care system. In addition, a recent study found that "17.6 million Americans-one in six insured adults, largely from middle-class families and holding fulltime jobs-have substantial problems paying their medical bills." The study also found that those who were insured but in financial debt had health plans of far less quality. A growing majority of Americans are experiencing the negative effects of what sociologist Paul Starr, in the classic The Social Transformation of American Medicine, has called "zero-sum medical practice." In the context of deepening class and racial inequalities in the United States, the pains of for-profit medicine have been most acutely felt by the nation's marginalized populations. In their important, multivolume An American Health Dilemma, leading public health experts W. Michael Byrd and Linda A. Clayton observe, "Intentionally or not, the appropriation of the health system by capitalist market and corporate forces posed a clear and present danger to economically disadvantaged populations such as African Americans."
With exploding numbers of poor, uninsured African Americans being locked away in the last three decades, America's grossly overcrowded and underresourced penal institutions have been impacted in dramatic and dangerous ways. To be sure, in the wake of the AIDS epidemic, activist groups in poor communities and inside penal institutions have played vitally important roles in educating marginalized citizens about the virus and helping to improve the overall quality of care. But as sociologist Rachel Maddow observes in a compelling recent study of HIV activism in penal institutions in the United States and Britain, the widespread embrace of privatized prison and jail health care providers has made this work exceedingly difficult. A recent report from the National Institute of Justice counsels that saving money may very well be the overriding institutional imperative of jail and prison health care providers in the United States today.
Because prisoners lack the ability to consume all but the least expensive health services without the consent of prison officials, prison administrators have at least the potential to regulate prisoners' use of services very tightly. The ability to accomplish this depends in large part on the prison administration's success in controlling physicians' clinical decisions.
Going Beyond the "Prisoner Horror Story"
This study employs most closely what sociologist Michael Burawoy refers to as "the extended case method" (see appendix A for a fuller account of methods). However, by contrast to traditional ethnography, this analysis takes as its basis of inquiry one incident that has already happened: the deaths of forty-three HIV+ prisoners at Limestone prison in Harvest, Alabama, over a five-year period (1999-2003). Instead of casting the analytical net as wide as many previous studies of penal institutions have, I here explore these events as a means to investigate the world of contemporary penal practices in the context of the growing crisis of health care behind bars.
HIV/AIDS at Limestone Prison, 1999-2003
Early investigative reports of HIV+ prisoners held at Limestone prison provided important insights into the experiences of individual prisoners and their captors. However, based on these reports, one cannot help but be left with a rather narrow impression of the situation as an isolated "prison horror story"; that is, one is left to believe that this extreme situation of mistreated prisoners was driven by evil doctors and callous prison officials, without any documentation of the broader circumstances surrounding incarceration policies and prison health care at the time. By comparison, the words of the prison doctor who informed Daniel Ryan, "You have AIDS and are going to die from it" (quoted in the introduction to the present study), while callous, were uttered during the early years of the AIDS epidemic in the United States, a time when such overtly hysterical responses to those infected with the virus were commonplace in every region of the country. Moreover, in the early years of the epidemic, the mainstream media's use of a tragic and hopeless narrative that emphasized a desperate attempt to contain the virus was routinely employed in dozens of stories involving doctors outside the prison system and their patients.
The two interrelated dimensions left out of early coverage of the Limestone situation were the concomitant explosion of jail and prison populations and the loss, in many American states, of public accountability of state social services (i.e., the move to for-profit service providers). Despite the media's failure to make this obviously important connection, the AIDS boom hit state penal institutions hard. A combination of extreme prison and jail overcrowding with soaring rates of HIV/AIDS set in motion a deadly chaos behind bars that was not relegated solely to Alabama. Yet the national media's focus on the sensationalistic nightmare of Limestone's "Thunderdorm" obscured these developments, which were important for understanding the crisis as more than an isolated incident.
The first glimpse at a more complex picture of the health care catastrophe at Limestone prison is presented in investigative reports written by Adam Liptak of the New York Times and Birmingham News reporter Carla Crowder. Both Liptak and Crowder framed their articles within the bigger picture of prison overcrowding and systemic problems associated with prison health care more broadly. One of the primary reasons for this is that journalists were given access to the report that Dr. Stephen Tabet prepared as a medical expert witness for the Leatherwood litigation. Two astonishingly detailed volumes of more than two hundred pages in length, Dr. Tabet's report provided journalists an open window into the treatment, living conditions, and details surrounding prisoner deaths.
Dr. Tabet reported staff shortages and the use of an outdoor pill line to distribute medications, forcing immune-suppressed prisoners to stand in the cold predawn air. Drawing on such details, recent journalistic accounts moved beyond earlier, more sensationalized coverage of an "AIDS colony." Moreover, one article, "Prison Medical Failures Seen in Suit," documents for the first time how cost cutting played a major role in explaining how the drive to be "tough on crime" resulted in a dramatically compromised system of medical care in Alabama's jails and prisons.
Providing a painstakingly detailed analysis of all forty-three HIV/AIDS-related prisoner deaths at Limestone between 1999 and 2003, Dr. Tabet's report provided journalists with a remarkably rich source of information. Indeed, the report gave journalists an account of the deaths documented by a recognized international expert on prison medicine. In contrast to the overwhelming majority of court opinions that rely on brief descriptions of broken prison health care systems, detailed reports that include prisoner death summaries are rarely made available to the press. Typically, prisoner death records are literally locked away from public view. Indeed, in recent years, few other state prison systems have made information regarding prisoner deaths widely available to the public. Dr. Tabet's report thus provided information-about health care and the treatment of the chronically ill behind bars-that had long been obscured from public view.
The report focused mainly on the two key sites of HIV+ prisoner deaths at Limestone prison: Dorm 16, where the HIV+ prisoners had been housed between 1999 and 2003; and the Health Care Unit (HCU), which consisted of both an inpatient and outpatient unit. His physical examinations of prisoners who had been living in Dorm 16 at the time of his visit and his evaluation of the institution's health care facilities provided a compelling commentary on the magnitude of the problem. However, Dr. Tabet's mortality reviews of the deceased would prove most crucial for understanding how the crisis at Limestone represented something far more than an isolated prison horror story.
Excerpted from DYING INSIDE by BENJAMIN FLEURY-STEINER CARLA CROWDER Copyright © 2008 by University of Michigan . Excerpted by permission.
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Table of Contents\rrhp\ \lrrh: Contents\ \1h\ Contents \xt\ Acknowledgments Introduction Chapter 1. Penal Health Care in Contemporary American Society Chapter 2. The Conflicting Imperatives of Mass Incarceration and Prisoner Health Chapter 3. The Conditions That Produce Catastrophic Penal Institutions Chapter 4. Courts, Legal Change, and Institutional Struggle Chapter 5. The Challenges of Leatherwood Chapter 6. Normalizing Catastrophic Loss of Life Conclusion Epilogue Appendix A. A Fuller Account of Methods Appendix B. The Institutional Lives of Catastrophic Jails and Prisons in the United States, 1990- --2007 Appendix C. Prisoner Activism and Advocacy Organizations in North America Notes References Index