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1600 John F. Kennedy Boulevard, Suite 1800 Philadelphia, PA 19103-2899 ISBN-13: 978-0-323-03265-0 Clinical Practice in Correctional Medicine ISBN-10: 0-323-03265-6 Second Edition Copyright 2006, 1998 Elsevier, Inc. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior permission of the publisher (WB Saunders, 1600 John F. Kennedy Boulevard, Suite 1800, Philadelphia, PA 19103-2899). Notice Knowledge and best practice in this field are constantly changing. As new research and experience broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of the practitioner, relying on his or her own experience and knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the Editor assumes any liability for any injury and/or damage to persons or property arising out or related to any use of the material contained in this book. Library of Congress Cataloging-in-Publication Data Clinical practice in correctional medicine/[edited by] Michael Puisis.–2nd ed. p. ; cm. Includes bibliographical references and index. ISBN 0-323-03265-6 1. Prisoners--Medical care. I. Puisis, Michael. [DNLM: 1. Health Services–United States. 2. Prisons–United States. HV 8833 C641 2006] HV8833.C53 2006 365’.66–dc22 2005052246 Editor:Rolla Couchman Editorial Assistant:Dylan Parker Marketing Manager:Laura Meiskey Printed in United States of America. Last digit is the print number: 9 8 7 6 5 4 3 2 1 To Sam and Coral To Armond Start and Bernard Harrison and to all others have worked and continue to work to improve the quality health care to the inmate population v Associate Editors B.Jaye Anno,Ph.D.,CCHP-A Lambert N.King,M.D.,Ph.D. Partner, Consultants in Correctional Care Director of Medicine, Department of Medicine Santa Fe, New Mexico Queens Hospital Center Jamaica, New York Robert L.Cohen,M.D. Principal Investigator, Searching for Common Ground Project Assistant Professor, Social Medicine and Clinical National Commission on Correctional Health Care Epidemiology Chicago, Illinois Albert Einstein College of Medicine Attending Physician, Department of Medicine Catherine M.Knox,R.N.,M.N.,CCHP St. Vincent’s Hospital Director of Nursing, Health Services New York, New York Washington Department of Corrections Board Member, National Commission on Correctional Olympia, Washington Health Care Chicago, Illinois Madeleine LaMarre,M.N.,A.P.R.N.,B.C. Representative, American Public Health Association Correctional Health Care Consultant Washington, District of Columbia Atlanta, Georgia Joe Goldenson,M.D. Jeffrey L.Metzner,M.D. Assistant Clinical Professor, Family and Community Medicine Clinical Professor of Psychiatry, Department of Psychiatry University of California, San Francisco University of Colorado School of Medicine Director/Medical Director, Jail Health Services Denver, Colorado San Francisco Department of Public Health Medical Staff, Family and Community Medicine John M.Raba,M.D. San Francisco General Hospital Chief Operating Officer, Cermak Health Services San Francisco, California Cook County Department of Corrections Attending Physician, Departments of Medicine and Family Robert B.Greifinger,M.D. Practice Consultant in Correctional Medicine John H. Stroger Hospital of Cook County Dobbs Ferry, New York Chicago, Illinois Newton E.Kendig,M.D. Ronald Shansky,M.D. Medical Director, Federal Bureau of Prisons Consultant in Correctional Medicine Department of Justice Chicago, Illinois Washington, District of Columbia vii Contributors Frederick L.Altice,M.D. H.Blair Carlson,M.D.,M.S.P.H. Associate Professor of Medicine, Director of Clinical Research, Clinical Professor of Medicine and Director of the HIV in Prisons Program University of Colorado School of Medicine Yale University School of Medicine Fellow, American Society of Addiction Medicine and American Section of Infectious Diseases, AIDS Program College of Physicians Attending Physician, Department of Internal Medicine Past Member, Board of Directors Yale-New Haven Hospital National Commission on Correctional Health Care New Haven, Connecticut Denver, Colorado Harold Appel,M.D.,CCHP Michael D.Cohen,M.D.,FAAP Neurologist, Neurology Clinic Medical Director, Bureau of Health Services Bellevue Hospital New York State Office of Children and Family Services Neurologist Rensselear, New York Specialty Clinics, Rikers Island Prison Health Services, Inc. Joseph N.Costa,D.D.S. Neurological Consultant, Correctional Health Services Dental Director New York City Department of Health and Mental Hygiene Dwight Correctional Center Neurological Consultant Dwight, Illinois Medical Services, Manhattan Psychiatric Center New York, New York Nancy Neveloff Dubler,L.L.B. Director, Division of Bioethics Getahun Aynalem,M.D.,M.P.H. Montefiore Medical Center and Professor of Bioethics Epidemiologist, Sexually Transmitted Disease Program Albert Einstein College of Medicine Los Angeles County Department of Health Services, Public Bronx, New York Health Los Angeles, California Joel A.Dvoskin,Ph.D. Assistant Clinical Professor, Department of Psychiatry Ronald Bajuscak,D.M.D.,M.S. University of Arizona College of Medicine Associate Professor, Clinical Medicine Tucson, Arizona A.T. Still Health Sciences School of Oral Health Mesa, Arizona Richard L.Frierson,M.D. Associate Professor and Director, Forensic Psychiatry Marty Beyer,Ph.D. Fellowship Independent Juvenile Justice and Child Welfare Consultant Department of Neuropsychiatry and Behavioral Science Cottage Grove, Oregon University of South Carolina Director, Forensic Psychiatry Education Joseph A.Bick,M.D. Forensic Services Chief Medical Officer, California Medical Facility Williams S. Hall Psychiatric Institute California Department of Corrections Treating Psychiatrist, South Carolina Department of Assistant Clinical Professor, Division of Infectious and Corrections Immunologic Diseases Gilliam Psychiatric Hospital University of California, Davis Columbia, South Carolina Davis, California Theodore M.Hammett,Ph.D. Larry Burd,Ph.D. Vice President, ABT Associates Professor, Department of Pediatrics Cambridge, Massachusetts University of North Dakota Grand Forks, North Dakota Lindsay M.Hayes,M.S. Project Director Gayle F.Burrow,R.N.,B.S.N.,M.P.H.,CCHP National Center on Institutions and Alternatives Director, Corrections Health Mansfield, Massachusetts Multonomah County Health Department Multonomah County Detention Center Portland, Oregon ix CONTRIBUTORS Budd Heyman,M.D. Mary Ellen Lane,R.N.,M.B.A.,B.S.N.,CCHP Chief of Prison Health Services, Bellevue Hospital Center Clinical Program Consultant, Health Services Clinical Instructor, Department of Medicine Georgia Department of Corrections New York University School of Medicine Atlanta, Georgia New York, New York Thomas Lincoln,M.D. Daniel J.Hickey,D.M.D.,FAGD Assistant Professor of Medicine CDR, U.S. Public Health Service Tufts University School of Medicine Chief Dental Officer, Health Services Unit Boston, Massachusetts Federal Correctional Institution Attending Physician, Division of Geriatric Medicine and Morgantown, West Virginia Geriatrics and Brightwood Health Center Baystate Medical Center Riduan Joesoef,M.D.,Ph.D. Springfield, Massachusetts Division of STD Prevention Primary Physician, Hampden County Correctional Center National Center for HIV, STD, and TB Prevention Ludlow, Massachusetts Centers for Disease Control and Prevention Atlanta, Georgia Lannette Linthicum,M.D.,CCHP-A,FACP Director, Health Services Division Richard H.Kahn,M.S. Texas Department of Criminal Justice Division of STD Prevention Huntsville, Texas National Center for HIV, STD, and TB Prevention Centers for Disease Control and Prevention Mark N.Lobato,M.D. Atlanta, Georgia Medical Epidemiologist, Division of Tuberculosis Elimination, National Center for HIV, STD and TB Michael F.Kelley,M.D.,M.P.H. Prevention Instructor, Community Health and Preventative Centers for Disease Control and Prevention Medicine Atlanta, Georgia University of Texas Medical Branch Galveston, Texas Nicholas S.Makrides,D.M.D.,M.A.,M.P.H. Chief Dental Officer, Federal Bureau of Prisons Jane A.Kennedy,D.O. Department of Justice Assistant Clinical Professor of Psychiatry, University of Washington, District of Columbia Colorado School of Medicine Diplomate, American Board of Neurology and Fleet W.Maull,M.D.,Ph.D.Candidate Psychiatry with Added Qualifications in Addiction Adjunct Faculty, Religious Studies & Core College Psychiatry Naropa University Certified, American Society of Addiction Medicine Founder and President, National Prison Hospice Denver, Colorado Association Boulder, Colorado Peter R.Kerndt,M.D.,M.P.H. Associate Adjunct Professor, Department of Epidemiology John P.May,M.D. School of Public Health, University of California at Los Medical Director, Armor Correctional Heath Services Angeles Coconut Creek, Florida Associate Adjunct Clinical Professor in Medicine NOVA, Southeastern University College of Medicine Department of Internal Medicine, Division of Infectious Fort Lauderdale, Florida Disease University of Southern California Lawrence H.Mendel,D.O.,CCHP Director, Sexually Transmitted Disease Program Clinical Assistant Professor, Family Medicine Los Angeles County Department of Health Services, Ohio State University Medical Center Public Health Columbus, Ohio Los Angeles, California John R.Miles,M.P.A. JoRene Kerns,R.N.,B.S.N. Executive Director Programs, American Correctional Health Executive Vice President, Correct Care Solutions Services Association (ACHSA) Topeka, Kansas Senior Associate, McKing Consulting Corporation Atlanta, Georgia Seijeoung Kim,R.N.,Ph.D Editor, Journal of Correctional Health Care Postdoctoral Fellow, University of Illinois National Commission on Correctional Health Care School of Public Health, Division of Epidemiology and Chicago, Illinois Biostatistics Chicago, Illinois x CONTRIBUTORS Michael B.Nelson,D.O. Donna Marie Schwartz-Watts,M.D. Chief, Health Services Branch Associate Professor and Director of the Division of Forensic Health Services Division, Federal Bureau of Prisons Services of Neuropsychiatry and Behavioral Science Department of Justice University of South Carolina, School of Medicine Washington, District of Columbia Consulting Psychiatrist, Courtesy Psychiatry and Forensic Services Joseph E.Paris,Ph.D.,M.D.,CCHP,FSCP Palmetto Health Richland and Baptist Medical Director, Georgia Department of Corrections Treating Psychiatrist, Columbia Behavioral Health Atlanta, Georgia Treating Psychiatrist, South Carolina Department of Corrections Gilliam Psychiatric Hospital Becky Pinney,R.N.,M.S.N. Columbia, South Carolina Division Vice President, Rikers Island Contract Prison Health Services Steven Shelton,M.D.,CCHP-A Whitestone, New York Medical Director, Health Services Oregon Department of Corrections Steven E.Pitt,D.O. Courtesy Staff Clinical Associate Professor of Psychiatry, Department of Family Practice Psychiatry Salem Memorial Hospital University of Arizona Health Sciences Center Salem, Oregon Tucson, Arizona Hal Smith,M.P.S.,CCHP Mary Raines,R.N.,B.S.N.,CCHP Clinical Associate Professor, Forensic Psychiatry, Department Oregon Department of Corrections, Coffee Creek of Psychiatry Correctional Facility State University of New York, Upstate Medical University Wilsonville, Oregon Syracuse, New York Executive Director/CEO Stamatia Richardson,M.D. Correctional Mental Health Services Senior Physician, Women’s Health Care Central New York Forensic Psychiatric Center Cermak Health Services Marcy, New York Cook County Bureau of Health Consultant, Forensic Mental Health, Inc. Chicago, Illinois Schenectady, New York William J.Rold,J.D.,CCHP-A Leta D.Smith,Ph.D. Attorney at Law Director of Priority Initiatives and Mental Health New York, New York New York State Office of Children and Family Services (OCFS) Lee H.Rome,M.D. Rensselear, New York Director of Psychiatry and Mental Health Authority President, Forensic Mental Health, Inc. Wayne County Jail Schenectady, New York Detroit, Michigan Steven S.Spencer,M.D.,FACP,CCHP-A Elizabeth Sazie,M.D.,M.P.H.,CCHP Consultant, Correctional Health Care Oregon Department of Corrections, Coffee Creek Santa Fe, New Mexico Correctional Facility Wilsonville, Oregon Erin M.Spiers,Psy.D. Clinical Assistant Professor of Psychiatry, Department of Gordon D.Schiff,M.D. Psychiatry Associate Professor of Medicine, Department of Medicine Louisiana State University School of Medicine—New Orleans Rush University New Orleans, Louisiana Director of Clinical Quality Research and Improvement Department of Medicine Sandra A.Springer,M.D. John H. Stroger Hospital of Cook County Yale University School of Medicine Chicago, Illinois Section of Infectious Diseases, AIDS Program New Haven, Connecticut xi CONTRIBUTORS Bruce G.Trigg,M.D. Phillip D.Woods,D.D.S.,M.P.H. Medical Director, Public Health Program Lieutenant Commander, Dental Department Metropolitan Detention Center United States Public Health Service New Mexico Department of Health Federal Bureau of Prisons Clinical Associate Professor, Department of Pediatrics Department of Justice University of New Mexico Health Sciences Center National Periodontal Consultant, Bureau of Prisons Albuquerque, New Mexico Phoenix, Arizona Heather Villanueva,R.N. Ralph P.Woodward,M.D. Assistant Administrator—Health Services Division Director of Clinical Services, Health Services Unit Oregon Department of Corrections New Jersey State Department of Corrections Salem, Oregon Trenton, New Jersey xii Preface It is almost 7 years since the first edition of Clinical Practice in More than ever, public health plays an important role in Correctional Medicine. The incarcerated population has correctional medicine. Incarcerated persons most often leave increased unabated, albeit at a slower rate, since the first edition jails and prisons and return to society. Dr. Lincoln from the of this book. For the first time in the history of this country, over Hampton County Jail, along with John Miles who worked at 2 million persons are incarcerated on any given day with over 10 the CDC, contributed to an important new chapter that million persons discharged annually from local jails. The per- provides guidance on how to establish linkages between jails sistence of this population has resulted in a continued need to and prisons and public health institutions in establishing con- provide medical and mental health care and therefore a need for tinuity for inmates as they readjust to society. The dramatic this type of textbook. This edition contains 15 new chapters and increase in incarceration has been fueled in large part by incar- 24 others that have been extensively revised. We want to warmly cerating persons who use drugs. Treatment of this population welcome the 6 new associate editors and 46 new authors. has been neglected. Bruce Trigg from the New Mexico Correctional medicine is now established as a necessary and Department of Health provides details on opioid replacement important discipline of medicine. The various areas that differ- and other harm reduction strategies for incarcerated persons. entiate this discipline from other disciplines are described in the Nurses are essential members of the correctional health care first section that defines correctional medicine. Because this area team. New associate editors, Catherine Knox and Madie of medicine concerns a vulnerable population without a public LaMarre, along with six other nurse authors, provide guidance voice, we have added a chapter on health advocacy and the role to nurses on the practice of correctional nursing. Nurse sick call, physicians may play in protecting and caring for this popula- infirmary care, primary care, and nurse infection control chap- tion. ters provide nurse-specific information by nursing authors. Evidence-based practices continue to provide new data that Several new special areas have been added to this edition. Dr. make intake tests and annual health interventions more effective Ron Shansky and Dr. Gordy Schiff from Cook County Hospital in screening and intervening for health conditions. The intake give information on performance measurement as a means to chapter has been combined with a section on annual health improve outcomes in chronic illness and disease management. interventions so that intake evaluations are seen as the first of a Dr. Robert Greifinger describes how quality of care can be series of annual efforts to provide preventive health care for the improved through managed care systems. As the inmate popula- inmate. The sick call chapter now has a nurse co-author tion ages, more elderly inmates are dying in prisons. Fleet Maull, acknowledging and supporting the nurse in the sick call who previously helped establish a prison hospice program as an assessment effort. Chronic disease care has been revised to inmate, gives a unique perspective on how hospice care is support the concept of a team approach in providing chronic perceived by the patients it serves. Technology provides new tools disease care to the patient who is a partner to health care to support clinical programs. Drs. Ralph Woodward and Larry providers in managing his disease. Mendel describe how the electronic medical records and Infectious and contagious diseases remain a very important telemedicine can improve services to inmates utilizing these new part of correctional medicine. This section has a new associate technologies. Finally, Drs. Makrides and Costa, along with a editor, Newton Kendig, an infectious disease trained physician group of contributors, provide the first-ever chapter on establish- who is also the Medical Director for the Federal Bureau of ing a dental program in correctional centers. Prisons. The chapter on tuberculosis screening and management This book would not have been possible without the consid- has been updated and contains information that will be consis- erable assistance from all the authors and associate editors who tent with the new Centers for Disease Control and Prevention donated their time and knowledge to advance the field of correc- correctional guidelines for TB control in correctional facilities. tional medicine. Acknowledgment must be given to Elsevier for Hepatitis C has become a significant challenge to correctional their commitment to this project and to this population. Rolla physicians. A chapter has been added to provide up-to-date Couchman and his assistant Dylan Parker along with the entire information on the management of viral hepatitis, including Elsevier team deserve special acknowledgment for their efforts to hepatitis C. A new chapter on infection control has been added coordinate this project in its many facets. This project would not to provide a clinical basis in establishment of an infection con- have been possible without their support and encouragement. trol program in prisons and jails. All of those involved in this project hope that readers will The mental health section has been significantly revised and find this edition useful for clinicians working in correctional updated. Jeffrey Metzner, nationally renowned as a correctional facilities to improve care for their patients as well as for those psychiatric expert, is the new associate editor for this section. In who have an interest in establishing a standard of care for the addition to significant revisions to previous chapters, a new incarcerated population. chapter was added to address the special population of behav- ioral disorder patients and those who commit self-harm. Michael Puisis, D.O. xiii Doctors, Patients, and the 1 History of Correctional Medicine Lambert N. King, M.D., Ph.D. The prison should, were the world not full of paradox, be a very A book, rather than a chapter, would be required to present paradigm of the rule of law. a complete history of correctional medicine. In this chapter, I have chosen to present six historical vignettes that illuminate the Norval Morris, 1974, The Future of Imprisonment1 story of correctional medicine. These vignettes carry us from 1775 to 2005 and from England to France to the United States. Each offers perspectives relevant to current conditions and issues in correctional medicine. In particular, I have selected vignettes ■ INTRODUCTION that address the following questions: The history of correctional medicine is the story of doctors car- • How have the history, culture, and purposes of correctional ing for people in jails and prisons, for good or for ill. Before institutions isolated and shaped the practice of medicine 1775, imprisonment was rarely used as a punishment for crime. within them? Since that year, however, rates of incarceration have grown dra- • Why is it important to collect and consider systematic data matically, and physicians working in correctional institutions about the health status and problems of incarcerated persons? have long struggled with conflicts between professional • Historically stigmatized and isolated, to what degree have covenants and the purposes and conditions of their patients’ physicians in correctional medicine moved toward profes- confinement. Like the history of public health, the story of cor- sional identity and autonomy, consistent with the mainstream rectional medicine consists of successive redefinitions of the of medical practice in the United States? unacceptable. As the number of people incarcerated in the • To confine and to punish are the most durable purposes of United States steadily escalated, correctional medicine assumed prisons, whereas concern for rehabilitation has waxed and greater importance for public health and the welfare of many waned. As members of a caring profession, what responsibili- individuals. Moreover, initiatives to build stronger connections ties do physicians in correctional medicine have to help foster between correctional health care and community-based health institutions or alternatives to incarceration that more effec- services are necessary to reduce marked racial and economic dis- tively rebuild lives, not simply punish and incapacitate? parities in health status and outcomes in the United States. • To what extent is it necessary and possible for correctional Understanding the history of correctional medicine also encour- medicine to be synchronized with health care systems and ages health care professionals to continue to push back walls of professional organizations in the larger community? inevitability and transform stringent limitations into human possibilities. ■ VIGNETTE 1:THE MEDICAL OFFICER Through their work caring for patients within the military serv- INVICTORIAN PRISONS ices, Veterans Administration hospitals, and public health clinics, doctors have long functioned within the constraints of government With growth in the use of incarceration after 1775, hygiene and bureaucracy. However, the practice of medicine in prisons and problems became more visible in English prisons and other set- jails is probably the most enduring example of physicians caring for tings in which the poor were congregated. Among those seeking patients within institutional structures whose priorities subordi- reform was a wealthy philanthropist and devout ascetic, John nate those of the medical profession. Thus, the context of correc- Howard, who, in 1773 at age 47, left his country estate and tional medicine is of special interest today because growing began a career of prison and hospital reform throughout Europe. numbers of physicians practice within large public and private His quest cost him his fortune and, finally, his life in a typhus organizations that fundamentally shape relationships between ward in Russia in 1791. Among John Howard’s closest collabo- physicians and their patients. Furthermore, correctional health rators was a well-to-do Quaker physician, John Fothergill, programs in the United States have become ever more important whose involvement with prison reform was an outgrowth of his as providers care for people who lack health insurance, have interest in improving urban and institutional sanitation. Like received limited prior health care, and who often suffer from severe Howard, Fothergill was keenly interested in science, subsidizing mental illnesses and chronic diseases, such as hypertension and Joseph Priestley’s experiments and writing treatises on hygienic human immunodeficiency virus infection. burial practices. As Michael Ignatieff2 describes in his book, 3 SECTION I T AJust Measure of Pain, hygienic reform was both a moral and a The English prison medical officer was also responsible for H E medical crusade. Disease was seen as an outcome of vice to admissions to the prison hospital, which were much sought after C O which the poor were susceptible. Jail fever was attributed to by inmates, because the food there was more abundant and R R improper discipline as well as poor hygiene. Moreover, typhus palatable. One inmate wrote, when he was at last admitted to E C and other forms of jail fever were spreading to outside commu- the hospital, “Now that I lay stretched helpless on my back T IO nities. Prison magistrates became convinced that some form of everyone was gruffly kind to me, so kind indeed, that in my NA hygiene and medical supervision was needed to contain diseases. weakness I often cried softly into my pillow with gratitude.”6 L P The problem was to convince colleagues and government Inmates incarcerated in Victorian prisons wrote many H authorities that the introduction of basic hygiene, uniforms, accounts of their experiences, some terrible and some laudatory, Y SIC clean clothing, regular medical attention, and regimented diets with prison medical officers. Priestley7 synthesizes these experi- IA would not compromise the pain and humiliation for which pen- ences in an eloquent fashion: N itentiaries were intended. Physicians involved in the hygienic reform movement viewed These touching and sentimental scenes from institutional life do the sicknesses of the poor as manifestations of their lack of char- nothing to rescue the practice of Victorian prison medicine from the acter and worthiness. In 1795, John Mason Good, a physician consequences of its appointment to fundamentally disciplinary tasks. at Cold Bath Fields prison, wrote, “The poor are in general but The doctors patrolled the narrow straits that separate hunger from little habituated to cleanliness” and “feel not, from want of edu- starvation and punishment from outright cruelty, hauling aboard cation, the same happy exertion of delicacy, honour and moral the life raft of their dispensations this drowning soul or that, and sentiment which everywhere else is to be met with.” Ignatieff3 repelling, with brute force if necessary, the efforts of others to climb observes that Good and other 18th-century doctors were to safety. In doing so, they lent to the work of preserving their inclined to view physical illnesses as having “moral causes.” One employer’s reputations whatever dignity and authority their emerg- early hospital reformer, Jonas Hanway, described immorality as ing profession possessed—and lost it. an “epidemical disorder which diffuses its morbid qualities.” Although the views of the hygienic reformers toward the Some Victorian physicians did, however, become strong poor were judgmental, John Howard’s4 famous account of the advocates for the powerless individuals in their charge. Charles State of the Prisonsis a prototype for approaching social evils in Short was the visiting surgeon at Bedford Prison from 1810 terms of their consequences for the community’s health. For until 1844. In 1836, he drew public attention to the increasing every prison in the country, Howard recorded details about cases of petechial disease, which he thought was caused by expo- buildings, diet, inmate population, and even the weight of the sure to cold, poor living, silence, and solitary confinement. In chains used. Through his revelations of the relation between jails 1838, he told court justices that an improved diet was needed to and spreading of jail fever, Howard aroused and galvanized pub- correct the poor state of the prisoners’ health. In response to Dr. lic opinion and made improved conditions possible. Short’s advocacy, the home secretary issued minimum standards In early English prisons like Cold Bath Fields and for prison diets. The minimum diet was to include animal Pentonville, the customary entrance medical examination con- food for prisoners employed at hard labor, a considerable por- sisted of weighing and measuring, followed by a doctor’s exam- tion of the food was to be solid, and there was to be variety ination, and a rapid determination of prisoners’ fitness to be in the kinds of food provided. In 1845, however, inspectors assigned to labor, light labor, the hospital, or an observational found that Bedford prisoners were not getting the recom- cell. The doctor’s examinations were cursory, sometimes per- mended minimums.8 formed with the prisoner fully clothed. However, on entry into the Gloucester prison, convicts were stripped naked, probed and ■ IMPLICATIONS OF VICTORIAN examined by a doctor, and then bathed, shaved, and uniformed. PRISON MEDICINE Ignatieff2 writes that this purification rite cleansed inmates of vermin but also stripped them of defining marks of identity. In The paradoxical duties of physicians caring for individuals in his book, Victorian Prison Lives—English Prison Biography, 19th-century English prisons were emulated in early prisons in Philip Priestley5 writes about the role of the Victorian prison the United States, where they persisted, in whole or in part, well medical officer in performing the medical examination and into the 20th century. To be sure, institutional conditions, the making decisions concerning special diets and admission to the quality of nutrition, and the professionalism of the security staff prison hospital. Deep ambiguity exists, both professionally and are far better today than in the 19th century, but the physician ethically, in the work of the early English prison medical officer. working in correctional medicine must often try to balance the Victorian prison officials sought to avoid providing food that primacy of the doctor–patient relationship with the imperatives would be criticized as luxurious, while, at the same time, of security and institutional policies. In many jails and prisons attempting to avoid severe malnutrition in those in their charge. today, physicians still face conditions and deficiencies that com- An English public committee studying this issue in 1864 rec- promise the health of their patients, just as Dr. Short did in ommended that the existing dietary scales be reduced but added Bedford Prison in 1838. These dynamics continue to raise ques- the caveat that the prison medical officer see every prisoner on tions about whether physicians working in correctional medi- admission to certify his fitness for placement on the various cine are best employed under the aegis of the correctional diets. Priestley6 observes that the discretion placed in the doc- authority or should preferably be deployed at “arms length” tor’s hands raised tantalizing visions of better food in the eyes of through a health care agency or independent contractor. hungry prisoners and helped turn the practice of prison medi- Professional values, organizational structures, and administrative cine into a battleground between desperate and cunning con- control remain pivotal issues that will shape the future of cor- victs and suspicious and resentful physicians. rectional medicine. 4

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