regulation of environmentally-induced carcinogenicity will precede adequate scientific estimation of public health risk. The recent decision to ban saccharin is consistent with this trend. We do not challenge the responsibility of the federal government to make decisions regarding the acceptability of public health risks; however, we maintain that these decisions should rest upon stronger scientific risk estimates than are presently available. The continuity of public confidence in the combined process is at stake.


REFERENCE 1. Kuzma, R.J., Focade, C.M., Buncher, C.R. Ohio drinking water source and cancer rates. Am. J. Public Health 67:725-729, 1977.

Dr. Ibrahim is professor and chairman, Department of Epidemiology, and Dr. Christman is professor and chairman, Department of Environmental Sciences and Engineering, School of Public Health, University of North Carolina, Chapel Hill, NC 27514. Additionally, Dr. Ibrahim is Chairman of the Editorial Board, American Journal of Public Health, and Dr. Christman is Editor, Environmental Science and Technology, the American Chemical Society.

Public Health Professionals and Prison Health Care Needs Prison health care has been the subject of medical and sociologic concern for at least 150 years. De Tocqueville discussed the relative merits of American penal institutions in the 1830s.' The incredibly barbaric health conditions at Andersonville prisoner of war camp was one of the major complaints against Colonel Wirz in his notorious court martial following the Civil War.2 Goldberger's classic studies on pellagra and vitamin B deficiency3 were possible only because the nutritional service in North Carolina prisons during the early 20th century was so poor that a significant difference existed between the rates of illness among inmates and guards. Numerous studies over the past quarter century have emphasized the poor health services and increased risk of illness among prisoners as compared to other members of society.4-7 But not until prisoners themselves began to exert their constitutional rights through civil rights actions8-'1 was any effort made by governmental administrators to improve the deplorable state of health care in American correctional facilities. Through class action suits brought against the prison administration, inmates brought the attention of correctional officials and the general public to the major health care problems in American jails and prisons-and changes are now beginning to take place.

Medical administrators have since been employed in many states to organize systems of prison health care. Standards for health services were developed and published over a decade ago by the American Correctional Association.*"2 Other interested observers, including the American Public Health Association,'3 and the joint Committee of the *The Commission on Accreditation for Corrections, a project of the American Correctional Association, will publish a Manual of Standards for Adult Long-term Institutions in August, 1977; about 720

American Medical Association and the American Bar Association, have formulated standards and policy statements relating to prison health services. The federal prison system, a few states, and some cities have increased the fiscal resources available to improve the health services provided to prisoners. The program described by King, et al.,14 in this issue of the Journal is an outstanding example of the innovative programs now being developed by a few correctional systems around the country. Unfortunately, too few examples exist. Most prison systems, subjected to various constraints, have been unable to create a system of care designed to serve the health needs of prisoners. A patchwork of services, with a variety of providers, in numerous institutions with little or no medical communication is the rule rather than the exception in most correctional systems. Even in solitary facilities-like large city jails or singular state correctional institutions-the care provided is usually piecemeal and not part of any comprehensive or coordinated plan to assure even the most elemental aspects of a continuous system of service. In theory, a prison health care system differs very little from many other health systems: preventive services are a major concern; primary care services, including dental and psychiatric, must be provided efficiently, effectively, and equitably to the entire population; access must be assured to all inmates, and the services must be adequate to meet the population needs. As to secondary and tertiary care services, referrals to other medical specialists, hospitalization for acute care and 40 of the 500 standards to be published deal with medical and health care services in correctional institutions. Two manuals have been published to date and seven more are planned in the areas of jails, probation and parole field services, and all areas of corrections relating to juveniles.

AJPH August, 1977, Vol. 67, No.8


needed diagnostic evaluation, intensive care and specialized therapy must also be integrated into the preventive and primary care program to assure a comprehensive array of services to meet the needs of every patient. A system for follow-up care and the re-evaluation of prisoner health status as an adjunct to both the preventive programs and the medical care services is another essential element to assure continuity within the system. Prison medical programs in general fail to adhere to the theoretical construct. Linkage between the various elements and, indeed, an awareness that various elements are necessary are virtually non-existent. Prison medical records, an important linkage vehicle, are notoriously poor or non-existent. In my own experience in evaluating numerous prison systems, only a very few have been found to have any system for accumulating the incidence of disease and the frequency of service demand. Many reasons exist for deficiencies in the structure of the prison health care system; but two deserve special emphasis. The major reason is that the responsibility for providing adequate care in most prison systems rests with the prison warden or superintendent at each institution. Central responsibility and direct authority over health care by health professionals is found in only a very few programs. Physicians, nurses, and other professionals are hired by the superintendent to provide care but are rarely employed to administer the system. Where administrators are employed, their responsibilities are usually limited to services at one institution and generally do not include budgetary control or full responsibility for personnel management. In the numerous prison health programs evaluated by this author, no physician, including the directors of programs, has been identified who was familiar with and had authority over the health care budget for the prison program which he directed. A prison warden or superintendent, untrained in health care administration and unwilling to relinquish budgetary authority, cannot be expected to build an adequate health program for the prisoners under his charge. Faced with legion problems within his own institution, he is unprepared to address himself to the organization of a health care system involving other correctional facilities and outside medical care resources. As a corollary, the reluctance of superintendents to relinquish authority over any institutional service has resulted in few systems employing a director of health services who is anything more than a direct provider of health care. Such a provider-with insufficient knowledge of health care systems design, no authority over the system, and minimal administrative support-will be unable to bring together the disparate resources of the prison system into an integrated system of health care. Physicians and other health professionals employed to deliver medical care cannot be expected to assume responsibilities outside their own institution when authority to do so is elusive. So long as correctional administrators are satisfied that prison health care delivery can be provided simply by hiring a part-time physician and a few nurses or other providers, and making available a number of secure hospital beds within the walls, no major improvement in prison health care will occur. The thrust of most of the AJPH August, 1977, Vol. 67, No. 8

court cases to improve care is to mandate the employment of

health directors with authority over the health system. In fairness to correctional administrators and institutional superintendents, major constraints do exist in the prison system which militate against change: * The maintenance of security is a priority which may appear to compete directly with the provision of access to a full array of health services. Whenever a prisoner must go from one area of the facility to another, or from one institution to another, or from a "secure" facility to an outside medical institution, the question of preserving "security" is the primary concern of the correctional staff. In their view, granting authority to a medical director over a health care system could seriously jeopardize the system of security. * A second constraint faced by prison administrators is budgetary: health providers are expensive, medical care is expensive, prisoners demand a great volume of service, and prison budgets are notoriously underfunded. Correctional administrators argue that the release of budgetary authority for health services would restrict the limited resources currently available for the entire prison system. Neither constraint bears up under close scrutiny. An adequately organized health care system, with appropriate communication and record system linkages, modern treatment facilities, and qualified health care providers, would have fewer breaches of "security" than the disorganized system now in force. In a well organized system, the movement of patients is dictated by professional judgment of medical need; the hazards involved are communicated by providers in both the sending and receiving facility; knowledge of the disease process allows for a tailoring of the security coverage. In every case adjudicated by the court system, health needs were judged to take precedence over security requirements; and the individual's constitutional right to necessary health care may not be diminished by the requirements to provide security. Security can always be provided simply by increasing guard coverage or by building secure areas in qualified medical institutions. The economic constraint posed by correctional administrators is equally specious. King cites the cost per prisoner per year in correctional facilities as ranging between $700 and $1,000.14 In the Massachusetts system in 1973-74, the total cost was nearly $1,000 per inmate. After the development of a system of care, with a budget under the authority of the director of health services, the cost per prisoner decreased, and the volume of appropriate services increased; savings of health care dollars were found in many areas.t In the past, prison health programs have been inefficiently managed. When placed under the management of trained professionals, costs may be expected to drop and benefits grow, at least until an efficient steady state is achieved. In some systems where extremely low budgets for health services have been the rule, reorganization under a health director will necessitate increased expenditures in ortBased on data available to this author while serving as Director of Health Services for the Massachusetts Department of Corrections. 721


der to bring the quality of service to an acceptable level; but the increase in services coupled with good management should outweigh the increase in cost. If the mandates from the courts continue to require that health services provided to prisoners be comparable to those health services available to free citizens, the pressure upon correctional systems to develop adequate health systems will mount. Correctional systems will be obligated to initiate programs similar to those described by King, et al.,14 by Della Penna and his co-workers,15 and organized by this author in the Massachusetts prison system.'6 Systems of health care which emphasize preventive programs, provide full access to primary, secondary and tertiary services, and assure comprehensive and continuous follow-up for all inmates in the system, regardless of the institution in which they are residents, will not be built by commissions of correction or institutional superintendents. Adequate programs for the delivery of health services will be developed by medical care professionals who are given full responsibility and full authority to implement programs. In the Cook County (Chicago) system described by King and his colleagues, the health care responsibility is carried out by the Cook County Department of Health and Hospitals under contract from the Department of Correction. The decision to hire hospital corpsmen to do a specific set of functions in the preventive area and in primary care was made by health care professionals, not prison administrators. That the system functions well is attested to by the fact that the correctional staff now works closely with the corpsmen, sick call demand has diminished, and medication use has declined. In other systems, the position of Director of Health Services has been created with responsibility and authority stemming directly from the Commissioner of Correction and/ or the Commissioner of Public Health. In New York City, for example, the Riker Island Prison Health System is provided by a local medical school under contract from the health department. Many options exist. But they all must include full health care responsibility and authority vested in a professional medical care administrator. Public health professionals have a necessary role to play in the development and maintenance of prison health care systems. The legal profession has lanced the boil; continuing treatment is up to the medical administrators and health care providers in all specialty areas. It is the responsibility of public health and preventive medicine to assure that the widespread, inadequate, unconscionable, and unconstitutional

prison health delivery system is relegated to the archives of history-never to return.

JONATHAN B. WEISBUCH, MD Address reprint requests to Dr. Jonathan B. Weisbuch, State Health Officer, North Dakota State Department of Health, State Capitol, Bismarck, ND 58505.

REFERENCES 1. DeBeaumont de la Bonniere, G., and De Tocqueville, A. On the Penitentiary System in the United States, and Its Application to France; with an Appendix on Penal Colonies. Reprint of 1833 ed. Augustus M. Kelley, Pub., Clifton, NJ. 2. Levitt, S. The Andersonville Trial. New York: Random House,

1960. 3. Goldberger, J. Etiology of pellagra: The significance of certain epidemiological observations with respect thereto. Public Health Reports, Vol. 29, June 26, 1914, pp 1683-1686. 4. Murton, T. Prison Doctors in Prisons, G. Leinwand, Editor. New York: Pocket Books, 1972. 5. Rector, F. L. Health and Medical Service in American Prisons and Reformatories. National Society of Penal Information, Inc., New York, 1929. 6. Report on the 1972 Survey of U.S. Jail System, American Medical Association, Chicago, 1973. 7. Whalen, R. P., and Lyons, J. J. A. Medical problems of 500 prisoners on admission to a county jail, Public Health Reports 77:497-502, June 1962. 8. Charles Street Jail Case: Inmates of Suffolk County Jail vs Eisenstadt, 360 F. Supp. 676 (D. Massachusetts, 1973) affirmed 494 F Second 1196 First Circuit 1974. 9. Alabama Prison Case: Newman vs State of Alabama, 349 F. Supp. 278 (MD Alabama 1972) affirmed 503 F Second 1320 Fifth Circuit 1974. 10. District of Columbia Jail Cases: (a) Gamble vs McGruder, 416 F Supp. 106 D.C. 1976; (b) Games vs Taylor, 416 F Supp. 100 D.C. 1976. 11. Oklahoma Prison Case: Battle vs Anderson, 376 F Supp. 402 1974. 12. The Manual of Correctional Standards, American Correctional Association, College Park, MD, 1966. 13. Standards for Health Care in Correctional Institutions, Jails and Prisons Task. Force, Program Development Board, American Public Health Association, Washington, DC, 1976. 14. King, L., Reynolds, A., and Young, Q. Utilization of former military medical corpsmen in the provision of jail health services. Am. J. Public Health, 67:730-734, 1977. 15. Della Penna, R., and Brecher, E. M. Health care services in local detention facilities (jails). Journal of the Indiana State Medical Association, Vol. 69, No. 8, pp 583-586, August 1976. 16. Weisbuch, J. B., Deposition, 1-31-77 and 2-1-77 (Bismarck, ND) Register vs Denton-The Ohio Prison Case, Case No. C75 355A, U.S. District Court, Northern District of Ohio, Eastern


The Image of Battered Women Concern about "stranger to stranger" crime has received public attention for years. Only recently has consideration been given to the victimization of people in their own homes. The study by Parker and Schumacher reported on 722

page 760 of this issue of the Journal1 is one more indication that violence in the home is a social problem of major proportions. Focus on violence intra-family began when the medical AJPH August, 1977, Vol. 67, No. 8

Public health professionals and prison health care needs.

EDITORIALS regulation of environmentally-induced carcinogenicity will precede adequate scientific estimation of public health risk. The recent decisi...
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