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Arizona Prisons Called Medical Disaster Zones

PHOENIX (CN) - A year after an agreement was supposed to improve health care in Arizona prisons, doctors described an understaffed system in which an inmate died with infected lesions swarmed by flies, a man who ate his own feces was never seen by a psychiatrist, and a woman swallowed razor blades while allegedly under constant watch.

The two physician experts on Monday filed declarations detailing the Arizona Department of Corrections' (ADC) alleged lack of progress in implementing court-ordered reforms to its health care system.

Also Monday, plaintiffs in the class action alleging unconstitutional treatment in the state's prisons filed a motion to enforce the stipulated agreement approved by a federal judge in February 2015.

Inadequate health care in Arizona prisons still results in needless deaths from treatable diseases and preventable suicides by inmates who were not properly monitored, according to the experts' reports.

The biggest problem is a chronic shortage of qualified doctors and nurses, according to the statements from Dr. Pablo Stewart , a clinical professor at the University of California, San Francisco's School of Medicine, and Dr. Todd Wilcox , president of the American College of Correctional Physicians.

Both doctors spent time in Arizona prisons in late 2015, interviewing inmates and staff and reviewing patient records, in their roles as paid experts under the settlement agreement in Parsons v. Ryan .

"It is readily apparent that ADC has failed to comply with a number of critically important mental health performance measures," Stewart wrote. "This failure has already harmed a number of ADC prisoners ... and it creates a substantial risk of serious future harm to others."

A "recurrent theme" in Stewart's his reviews of mental health care in Arizona prisons since 2012 has been "that patients are not being seen by a psychiatrist as required by their clinical condition and by the performance measures."

"For example, in the ten full days I have spent inspecting mental health care in seven ADC prisons, I do not believe I have ever seen a psychiatrist," he wrote. "This is extraordinary and completely unprecedented in my professional experience."

Medical and mental health staffing levels are below the national standards, the experts found. The ADC provides seven psychiatrists and 11 mental health nurse practitioners for 35,000 prisoners - a ratio of 1,800 to 1. A similar prison health system in Colorado has a ratio of 531 to 1, according to Stewart.

Stewart found that since April 2015 no more than 52 percent of psychologist positions and 49 percent of mental health nurse practitioner positions have been filled in Arizona, and that the position of psychiatric director has been vacant since the settlement was approved.

"When you look at their own records, which show that for the last year they have never had more than 60 percent of their psychologist positions full; they've never had more than 50 percent of their mental health nurse practitioner positions full.

"When you see a problem going on for that long and not getting any better, it suggests that perhaps someone isn't trying very hard," said David Fathi, director of the ACLU's National Prison Project, in a telephone interview on Tuesday.


"This is a problem that all states face, and most of them have managed to overcome it in various ways," Fathi said. "One obvious way is that you pay people more money. If you are not getting quality applicants for what you are paying, you raise the salary. You make the position attractive in other ways, with flexible work schedules. ... This isn't rocket science, and I think if they were properly motivated they would find ways to fill these positions."

The shortage of mental health workers in Arizona prisons has led to tragic and troubling incidents, Stewart said in his declaration.

One 34-year-old prisoner, whose name was redacted, showed severe mental health issues in July and August of 2015. Staff found him naked in his cell, urinating and defecating on the floor and eating his own feces.

"Throughout this period of nearly four weeks, when [he] was displaying floridly psychotic behavior, there is no indication that he was ever seen by a psychiatrist, evaluated for medication changes, or considered for an inpatient level of care," Stewart wrote. "This is shockingly deficient and far below any acceptable standard of care."

Stewart also found that ADC did not prevent suicides even when an inmate was supposed to be on "constant watch." One female prisoner died after swallowing razor blades while reportedly being watched, which "indicates a serious and lethal defect in watch procedures," Stewart wrote.

Dr. Wilcox found similar, dangerous problems in medical care due to a chronic shortage of doctors and nurses.

The ADC, which has contracted with the for-profit company Corizon to provide health care in 10 of its prisons since 2013, has 14 staff physician positions, 12.8 of which were filled in December 2015, Wilcox found. There is one physician for every 2,500 inmates in Arizona. In a similar system in Alabama, the ratio is one physician to every 1,700 inmates.

Again, such seemingly inadequate staffing has resulted in needless death and suffering, Wilcox found.

A 59-year-old inmate died of liver disease in the Yuma prison, with flies swarming around his untreated lesions, after "the nursing staff repeatedly failed to respond to his desperate Health Needs Requests (HNR)," Wilcox wrote.

The inmate's "condition deteriorated and his fluid retention worsened to the point that his skin split open and became infected. ... [The] situation deteriorated to the point that he was being swarmed by flies, which he reported in a HNR," Wilcox wrote.

"The next day, 4/1/15, instead of investigating why this might be the case in a patient with split skin that oozes serum, the nurse instead decided that this problem did not need to be seen. The flies were attracted to his massively infected wounds and proved to be a harbinger of his death. He was ultimately transferred to the hospital more than a week later, on 4/9/15, where he died."

Wilcox found three men at a prison in Tucson who had suffered "unconscionable delays in screening and treatment for testicular cancer."

Testicular cancer is usually curable, but in these cases delays in care led to the death of a 42-year-old man, and the probable death within a year of a 30-year-old man. Another inmate with testicular cancer, 27, also received inadequate treatment and "may be the next victim," Wilcox wrote.

Fathi said that these and other cases uncovered by the physician-experts in Arizona are some of the most shocking he has seen in 25 years.

"I've seen a lot of prisons, and I've seen a lot of bad prison health care, and this is among the very worst I've seen," he said. "The bottom line is that they're still not getting adequate care and they are getting sicker and some of them are dying as a result."

ADC spokesman Andrew Wilder told Courthouse News that the plaintiffs were "cherry-picking a handful of cases from an inmate patient population in excess of 35,000, ignoring the overwhelming majority of inmate patients who are receiving excellent health care."

"Allegations are not evidence, and anecdotal incidents are not evidence of substantial non-compliance," Wilder said in an email.

In the motion to enforce the settlement filed Monday, along with the expert declarations, attorneys with ACLU Arizona and the Arizona Center for Disability Law asked the Federal Court to order the ADC to "develop and implement a plan to increase staffing to levels that will assure compliance with the stipulation's performance measures and thereby reduce the risk of serious harm to the plaintiff class."

The plaintiffs want the ADC to "immediately submit a plan that shows how they are going to reduce vacancies in all health care positions to no more than 10 percent," Fathi said, and to complete a comprehensive study of staffing needs.

If the ADC continues to fall short of the goals outlined in the settlement agreement, the plaintiffs could ask the court to order a federal takeover the state's prison system, Fathi said.

"I think that if ADC's intransigence continues, and if they continue to be unable or unwilling to fix their broken health care system, that that is a very possible outcome."

ADS spokesman Wilder called that an attempt to "sidestep the Parsons stipulation."

"The Department of Corrections is strongly committed to providing high-quality health care to its inmate population," Wilder wrote in the email. "We firmly disagree with the plaintiffs' allegations and attempt to sidestep the Parsons stipulation and re-litigate the lawsuit. We are confident that the court will agree when these issues are presented for judicial resolution."

The ADC budget for health care increased from $125 million in fiscal year 2015 to $142 million in 2016. This includes "$8,072,000 in FY 2016 for a $0.63 increase to the per diem to change the scope of the health care contract to meet the stipulation agreement for the Parsons v. Ryan lawsuit," according to the ADC's Fiscal Year 2016 Appropriations Report.

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