Unjust Medicine
Why health care in juvenile justice facilities is often atrocious,
and what's being done about it.
By Martha Shirk

By all accounts, 17-year-old Omar Paisley died an excruciating death.

For three days, Omar lay on a concrete bunk, weeping and moaning and begging for help. "Ain't nothing wrong with his ass," a licensed practical nurse proclaimed after a cursory examination.

By the time the nurse agreed to summon an ambulance, Omar was delusional. By the time the ambulance was actually called, Omar was dead of a ruptured appendix. No one who watched him die even tried to resuscitate him.

Omar's death would be tragic in any setting. The fact that it occurred while he was locked up in the state-run Miami-Dade Regional Juvenile Detention Center was indefensible, a grand jury concluded after a nine-month investigation. "We were appalled at the utter lack of humanity demonstrated by many of the detention workers charged with the safety and care of our youth," the grand jury declared in an investigative report.

Omar's death in June 2003 brought attention to the quality of health care in juvenile justice facilities, a topic that historically has received little scrutiny. A grand jury, a select legislative committee and a state inspector general have investigated the staff missteps that preceded Omar's death, along with the general state of the medical care that the Florida Department of Juvenile Justice provides to the 52,000 youths admitted to secure detention each year.

Omar's death has also spurred a bout of self-examination at other juvenile institutions around the country. "We all worry about something like that happening on our watch," said one detention facility doctor, who asked not to be identified.

From October 1999 through September 2000, the latest period for which data are available, 47 youth died while in custody in the United States. No one knows how many deaths could have been prevented with better medical care. But Earl Dunlap, executive director of the National Juvenile Detention Association (NJDA), says: "I can say to you with no equivocation that health care in juvenile detention and corrections, as a whole, is extremelyinadequate." Although many juvenile facilities around the country provide exemplary health care, evidence is mounting that many others do not:

• Less than a year before Omar died, state quality control inspectors had labeled health care at Miami-Dade as "minimal." Many detainees never received physicals, recordkeeping was haphazard, and requests for care were often ignored, the inspectors reported. In 2000, a girl suffered a miscarriage and went more than a day without medical attention, despite severe bleeding and acute pain. At the time, the center's policy gave staff up to 72 hours to respond to a request for medical assistance.

• At the California Youth Authority, several teams of outside experts reported last year that health care was "not commensurate with community standards of care" and that the agency's mental health services actually made most youths worse. Youths sometimes waited two weeks for treatment of fractures. At one facility, narcotic pain medication was never prescribed, even for excruciating conditions.

• For two years, Connecticut's attorney general and its appointed child advocate have been pressing for improvements in health care and other services at the new state-operated Connecticut Juvenile Training Facility. After violence erupted in May, they called for a team of juvenile justice and mental health experts to oversee the facility. "We are gravely concerned that we have reached a point where something catastrophic is going to occur," they said.

• Louisiana is reinventing its health care system for juvenile inmates as a result of a settlement reached in 2002 of civil rights lawsuits challenging conditions of care. The suits, filed in 1998, alleged a pattern of diffident or cruel care, particularly for residents with mental problems, who were sometimes hog-tied or isolated rather than being offered treatment.

• Cook County, Ill., is working on a plan to improve health care at its detention center, the nation's largest, after the settlement in 2002 of a lawsuit alleging that youth had difficulty accessing medical and mental health care and other services.

Injuries, Addictions and STDs

As a group, teens are generally healthy. But that's not as true of the 330,000 who spend time in detention and the 100,000 who are sentenced to correctional institutions each year.

The Coalition for Juvenile Justice says that 50 to 75 percent of those youth have diagnosable mental disorders, and up to half of those also abuse drugs. A national survey of detention facilities in 1994 found the rate of gonorrhea to be 152 times greater among confined males and 42 times greater among confined females than among unconfined youth. A study published in Pediatrics in 1985 reported injury rates five times the rates for youth on the outside. Each month, nearly 1,000 incarcerated youth commit "suicidal acts," says Physicians for Human Rights. The National Center on Institutions and Alternatives says that 108 killed themselves between 1995 and 1999.

In short, teens in detention and correctional facilities have "significant medical, dental and psychological problems," says Dr. Robert E. Morris, a pediatrician who has years of experience caring for confined youth in Los Angeles and, most recently, Louisiana. Aside from the moral and legal obligations to care for locked-up youth, Morris says, self-interest provides another compelling reason: A youth is less amenable to rehabilitation if he's battling physical or mental illness.

"If we are going to try to rehabilitate these kids, we need to provide both medical and psychiatric services," says Morris, who teaches at the medical school at the University of California at Los Angeles. "Otherwise it's not likely that they're going to get better."

But at many juvenile facilities around the country, the health care that's provided rarely rises above the level of "mom and pop-type care," says David W. Roush, former chairman of the National Commission on Correctional Health Care and head of the National Juvenile Detention Association's Center for Research and Professional Development.

"In a typical 50- to 75-bed juvenile facility operated by a county, you might find a part-time nurse who's there for maybe 20 hours a week," says Roush, who has observed health care in about 200 facilities. "There will be a part-time physician, who comes in two or three hours a week. A fever probably isn't going to be viewed as a concern until it hits 102. Of course, in some situations, that's pushing the envelope, and you've made a bad decision."

Some facilities strive to provide a high level of care. At the Santa Clara County juvenile detention center in San Jose, Calif., Medical Director Dr. Jerry R. Klein says he strives to "provide the preventive health care that most kids would get if they had their own private physician, which many of these kids don't."

While a youth is in custody, Klein and his staff make sure his or her immunizations are up to date. They screen for sexually transmitted diseases and provide advice about contraception. A dentist provides routine dental care, and each youth gets a mental health assessment and follow-up treatment if needed. Detainees get "all of those things that we would hope that all of our adolescents would get," Klein says.

More often than he would like, Klein discovers undiagnosed conditions that, left undetected, might cause serious health problems. He says he has diagnosed "everything from chromosome disorders to hypertension to thyroid disease to diabetes."

Because of poverty or chaos at home, many detained youth have a history of inadequate care. It's not uncommon for a teen to report that he last saw a physician for his pre-kindergarten physical. Many have never seen a dentist.

Barriers to High-Quality Care

A major barrier to improving care in juvenile facilities is the ban on the use of Medicaid funds to treat inmates, both juveniles and adults, which leaves counties and states to pay the whole bill. "You wind up with health care competing with all the other institutional needs, like security and guards' salaries," notes Sue Burrell, an attorney in San Francisco with the Youth Law Center, a public interest law firm. "Unfortunately, it sometimes takes a tragedy to get everyone's attention."

In fact, it was the death of a detained youth from pneumonia in 1981 that prompted Santa Clara County to beef up its medical services. Sixteen years later, after a near-suicide left a 14-year-old detainee in a persistent vegetative state, major improvements were made in mental health services for detainees.

In addition to inadequate funds, another barrier to good care is the desire of politicians to avoid being seen as coddling criminals. "We've often heard from juvenile administrators that they don't want Cadillac health care, that Chevy health care is just fine," Morris says.

The uneven quality of personnel also poses problems. "Several different types of people end up in correctional medicine," Morris notes. "Some really love it and do a great job. Some discover immediately that they don't like it and get out. And then some people don't like it and stay on and get broken down and don't do a good job. It's very difficult to attract good people on the cheap."

Another problem is the correctional culture, particularly if medical personnel view themselves as agents of the jailers, as Morris says they did in Louisiana, until recently. "The medical people need to understand that their job is care and not detention," says Morris, who served as medical director for Louisiana's juvenile system after the lawsuits were settled. "They need to worry about how the kid is doing and not about keeping the guards happy."

Klein, in San Jose, thinks Santa Clara County's setup is ideal, with the health professionals who care for detained juveniles employed by Valley Medical Center, the county-run hospital, rather than by the detention center. "The way I look at it is I work for the kids who are here," he said. "By being employed by an outside agency rather than probation, the services I provide are in the best interests of the minors. In situations where one is employed by the probation department or the correctional facility, one has a potential dual allegiance."

Lax Oversight

No federal regulations dictate the level of health care that must be provided in juvenile facilities. The last time the federal government even examined the issue was

in 1992, in its Conditions of Confinement study. That study reported that almost half of detainees lacked daily access to a doctor or nurse.

Are conditions better or worse today? "Although a decade old, many of the findings associated with health care continue to exist," says Dunlap of NJDA. "Particularly in the last four years, youth in confinement have become less and less a priority, and along with that comes an erosion of adequate conditions of confinement."

In fact, just one year after the federal report was issued, critics complained that it had overstated the quality of health care because state and local budget cuts had caused staff reductions, a problem that has intensified in recent years.

One development that clearly merits scrutiny is the impact of privatization on quality of care. After adjudication, more and more youth are being committed to privately run facilities. "It's hard to know what the care is like in these, because there's no follow-up," Morris says. "You don't know anything until there's a disaster."

In 1998, Nicholaus Contrerez, 16, died of a massive lung infection while being forced to do push-ups at the privately owned Arizona Boys' Ranch, where he had been sent by a California judge. His death prompted California to stop sending youths to out-of-state programs for a while.

Even in facilities run by public agencies, medical care is often out-sourced to private contractors. Although that can work well, communications problems and incompetent personnel can easily undermine the benefits. The nurses who failed Omar Paisley were employed by Miami Children's Hospital, which had taken over medical care at the Miami-Dade facility in 2002, after state inspectors found fault with the previous private contractor.

Moving Toward Accreditation

Pressure to improve medical care in juvenile facilities comes primarily from two sources: public-interest litigators and advocates for voluntary accreditation.

For the past 25 years, American courts have consistently held that failing to provide incarcerated juveniles with professional medical care violates the Constitution. In the past few years, class-action litigation has forced improvements in health care in juvenile facilities in Louisiana, Kentucky, and Cook County, Ill., among other places. A 2003 lawsuit challenging conditions of confinement in the California Youth Authority, including medical care, is in settlement negotiations. [See sidebar.]

Though not intentional, the litigators' successes have helped propel the movement for voluntary accreditation. The National Commission for Correctional Health Care (NCCHC) lists 61 accredited health care systems within juvenile facilities, up from about 40 just five years ago. NCCHC is the only accrediting body that looks solely at health care, and NJDA's Dunlap considers its guidelines as the gold standard. (The Commission on Accreditation for Corrections, which lists 270 accredited juvenile facilities, assesses a facility's health services as part of a general accreditation process.)

Judith Stanley, NCCHC's director of accreditation, says that some facility administrators seek accreditation simply because "they want to do the right thing." Others do it for legal reasons. "Many of the suits try to prove that that facility is indifferent to health care," she says. "Having voluntarily sought accreditation helps protect the facility from that charge."

The accreditation requirements include intake screening, health assessments within a week of intake (and periodic reassessments thereafter), daily monitoring of segregated youth by health-care workers, a suicide prevention plan and readily available emergency services.

Although the accredited facilities represent only a minority of the more than 1,300 juvenile facilities nationwide, Stanley says interest is growing. "The word is getting out that you don't need a lot of extra money or staff to be accredited," she says. "Primarily, the standards help you do what you need to do to provide good care."

Omar's Aftermath

In Florida, the repercussions from Omar Paisley's death continue.

A grand jury indicted two licensed practical nurses for manslaughter, child abuse and third-degree murder. Both are free on bail while awaiting trial.

The top official at the state Department of Juvenile Justice (DJJ), William G. "Bill" Bankhead, retired, citing illness. Former New York City corrections chief Anthony Schembri, the model for the TV show "The Commish," took over on June 1.

Five mid- to high-level DJJ officials lost their jobs. Almost 20 detention center workers were fired or forced to resign.

The select legislative committee, the grand jury and DJJ's inspector general each issued recommendations for reform, many of which have been implemented, including the appointment of a new management team at the Miami-Dade detention center, installation of digital cameras throughout the facility, and system-wide training of staff in CPR and first aid. In addition, the telephones in the Miami-Dade center have been replaced so that employees can call 911, which they couldn't before.

In a statement marking the anniversary of Omar's death, Schembri said, "I pledge that I will zealously work to have safeguards in place so that no other families suffer such a grievous loss."

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