This column was originally published in AMA eVoice on October 25, 2007. Dr. Davis is president of the American Medical Association.
I recently had the privilege of meeting and speaking to attendees of the annual meeting of the National Commission on Correctional Health Care (NCCHC). Their work is important not only to those who are incarcerated in our nation's jails, prisons, and juvenile confinement facilities (from local detention facilities up to state and federal maximum security prisons), but also for every community.
Most inmates are poor and never had decent health care before being incarcerated. Therefore, those in correctional health care see a wide range of pathology. And since most inmates eventually return to society, from a public health viewpoint, we want them healthy when they come back to us.
The AMA was instrumental in the creation of the NCCHC. After the 1971 riots at Attica Correctional Facility in Attica, N.Y., the AMA commissioned a study to assess the overall health conditions in jails in the United States. This study revealed that facilities across the land had inadequate and disorganized health services, with no guiding national standards. That led the AMA, in collaboration with several other organizations, to establish a program that evolved into the now-independent NCCHC.
The NCCHC Standards for Health Services were developed in the 1970s, and the AMA is proud to be associated with this seminal effort in quality improvement. It delights me that, even after all these years, they are sometimes still referred to by old-timers as the "AMA standards." However, I was surprised to learn that fewer than half of the country’s correctional facilities are NCCHC-accredited, even when the standards are individually tailored for jails, prisons, and juvenile confinement facilities.
Every correctional facility should be accredited. These standards have unquestionably helped these facilities be more efficient at providing health services, strengthen their organizational effectiveness, reduce their risk of adverse legal judgments, and most importantly, improve the health of their inmates and the communities to which they return.
As a public health physician, I have long been interested in correctional health care, even more so after seeing the 2002 report to Congress, "The Health Status of Soon-To-Be Released Inmates." It contains essential recommendations on how to decrease risks to patients, staff, and our communities—by working harder to diagnose and treat inmates everywhere.
It’s exciting that one major recommendation of this report has been successfully adopted: the development and widespread use of clinical guidelines. NCCHC did this well, beginning with established guidelines from recognized leading organizations in a particular field, and then adding elements to help providers overcome barriers particular to correctional environments, and measure success in disease management.
Yet I am disappointed that much work remains to be done by government agencies with the other recommendations, especially in surveillance. And in planning for discharging inmates, it’s unfortunate that there often is no comparable mechanism on the outside (through community programs or local public health department services) to maintain former inmates’ access to health services once they are released. In part, this is because often they return to a predominantly poor area.
Jails have different challenges. Because they primarily house people who have not been convicted of a crime, their average length of stay is only a few months. Managing depression and infectious disease are the most pressing issues for correctional health care workers there, and suicide is perennially among the leading causes of prisoner death (PDF, 286KB).
Correctional facilities still face challenges in dealing with HIV. However, I was pleased to learn that because of dramatic improvements in detection and treatment during the last five years, AIDS is no longer the leading cause of death in state prisons. It is now responsible for 7 percent of all deaths in those facilities—surpassed by heart disease (27 percent of deaths), cancer (23 percent), and liver disease (10 percent).
Current AMA policy (H-490.915 Tobacco Use in Prison Populations) pushes for us to promote the same tobacco control policies for correctional facilities that exist in the outside community, work to stop the manufacture of cigarettes in prisons and jails, work to stop the subsidy of cigarette sales in correctional facilities, and ensure that the prohibition of smoking by minors is enforced. It also urges us to be committed to the availability of smoking cessation programs in correctional facilities, work through our NCCHC representative to ensure that smoking cessation counseling is made a national standard for correctional medicine, and support legislation that bans smoking in prisons and jails. The U.S. Supreme Court, in Helling v. McKinney (1993), ruled that exposure of prisoners to secondhand smoke can be considered cruel and unusual punishment under the Eighth Amendment.
A "correctional" issue that has been in the news in recent months is the role of physicians in capital punishment. AMA policy first adopted in 1980 and amended several times since then indicates that "A physician, as a member of a profession dedicated to preserving life when there is hope of doing so, should not be a participant in a legally authorized execution."
The unsung heroes in correctional health care are making a huge difference. Public servants all, there is no way they’re compensated enough for what they do. And their guiding light, the NCCHC, is the very model of a successful partnership, with an impressive diversity of organizations represented on its board. We should all recognize and laud their efforts, which ultimately benefit you, me, and society as a whole.
The lighter side
Prisons are a common feature in Hollywood movies. One database of prison films has more than 260 listings, including Cecil B. DeMille’s "Manslaugher" (1922); "Jailhouse Rock" (1957), starring Elvis Presley; and "The Shawshank Redemption" (1994), which was nominated for seven Academy Awards.
I showed images from several prison movies in my PowerPoint presentation at the NCCHC meeting. One image was from the scene in "Cool Hand Luke" (1967) when Luke, a chain-gang prisoner played by Paul Newman, ate 50 eggs in an hour. A video of that scene is available on YouTube.
I expressed my hope that egg gluttony was not occurring in real-life prisons, given the high cholesterol load in eggs. The yolk of one typical large egg contains about 213 milligrams (mg) of cholesterol, or 70 percent of the maximum daily cholesterol intake (300 mg) recommended by the American Heart Association.
In February, I had an interesting egg experience when visiting the hot springs in Hakone, Japan, near Mount Fuji (the day before I spoke at a symposium in Tokyo on immunization). A vendor was selling eggs that had been hard-boiled in the hot springs, whose sulfur content had turned the shells black. A sign on the shop promised that "If you eat one egg, longevity might be postponed for seven years," and two eggs might increase your life expectancy by 14 years.
I rarely eat eggs any longer, except for egg substitutes made from egg whites. But I did eat two of the blackened eggs, figuring that it was worth the risk of consuming 426 mg of cholesterol in order to add 14 more years to my life.
Please send comments, questions, and replies to amaprez@ama-assn.org.
Content provided by: Ronald M. Davis, MD