'Deadly inadequacies' plague inmate wards
Gaps in evaluating care let some mistakes go unnoticed

First of four parts By Mike Ward and Bill Bishop American-Statesman Staff Sunday, December 16, 2001

BEAUMONT After prison officials allowed Cadarell Freeman to fester in his jail cell with ulcers eating through his throat and his feet swelling to the size of hiking boots, after yanking Freeman on and off prescriptions so often that he grew resistant to advanced HIV medications and dependent on a wheelchair, after a nurse asked Freeman if he would donate his organs when he died, which, she implied, would be soon, and after prison officials called Freeman's mother at 4 a.m. to say her son "probably wouldn't make it through the morning" only after all of that did Cadarell Freeman suffer the last-ditch indignity of the Texas prison system.

Larry Kolvoord/American-Statesman When he left prison last year, Cadarell Freeman returned to Houston with medical records he collected while he was imprisoned at the Stiles Unit near Beaumont.

A bus driver told Freeman that if he wanted out, he'd have to crawl.

This is a story about people you don't like.

They've passed bad checks, stolen cars, robbed banks and worse. They don't eat their salad with the proper fork, and they don't make donations to the United Way. They are in jail, most of them, for doing wrong. Almost all of the 134,000 people in Texas prisons will be set free one day. Eighty percent of those sent to prison in 2000 will serve less than 10 years. They'll move to Lockhart or Travis Heights, Round Rock or Circle C. They'll come out changed by the time they spent in prison. The question their future neighbors might ask is whether these changes will be for the better or for the worse.

Texas has proved it's good at building prisons. The state is less successful at caring for the people it puts in these new lockups. Some convicts come out of the state's 105 prisons sicker than they went in. Too frequently, they take strains of drug-resistant HIV into what inmates call the free world.

How bad is health care in Texas prisons?

It's better than it once was, good enough that the federal courts found that medical care in Texas prisons was no longer "deliber- ately indifferent" to inmates' medical needs. Still, a federal judge wrote in 1999 that he had hard evidence of "significant, even deadly, inadequacies" in the medicine practiced on inmates. Prisoners have been left to die in their cells. They've starved in infirmaries, languished in their own feces before dying. Care in the prisons is so bad, inmates say, that they join experimental drug trials at a university hospital in Galveston to avoid the care offered in jailhouse infirmaries.

It's impossible to know whether these instances of poor care are exceptional or common. The state has made it that way. The Texas Legislature in 1993 created a little kingdom in the prisons (see LITTLE KINGDOM). Instead of providing care itself, the prison system ceded that job to the University of Texas Medical Branch in Galveston and Texas Tech University in Lubbock. It has become a $297 million-a-year business, paid for with public money but immune from any meaningful public scrutiny a system built for secrecy, if not for care. "Being a prison doctor is an honorable profession, despite what people may think because of the way it has been portrayed in the media a special bond develops between the medical providers and the patients," said Dr. Ben G. Raimer, a vice president at UTMB. "As with any large system, you can find some problems. But they have not been malicious, and not because people did not care. . . . There have been some bumps along the way, but we have an excellent system that is continuing to improve."

Larry Kolvord/American-Statesman In prison, Cadarell Freeman says, his HIV drugs were sometimes withheld. As a result, he grew weak and had seizures that confined him first to a wheelchair and then to his bunk. Freeman's health improved after he was paroled last year, and now he gets checkups at Houston's Thomas Street Clinic.

Cadarell Freeman was to leave prison in September 2000. He had walked into prison, but now he was deathly sick. He had lost 60 pounds. The inmate's legs were so weak that he slumped in a wheelchair at the Stiles Unit near Beaumont as he waited for the bus that would ferry him to Huntsville and his freedom. The vehicle came. From his chair, Freeman eyed the steps into the bus. The driver told Freeman that if he wanted out, he could crawl. A nurse eventually helped the dispirited inmate onto the bus. The next day, a guard pushed him through the front door of the prison in Huntsville, where Freeman's mother was waiting. He was free. Luckily, his mother brought a wheelchair. The state kept the one Freeman had been issued by the prison's medical system.

Lester Allen was a cross-dressing bank robber in Houston who bedeviled police with his array of high-fashion Escada outfits and getaways ingeniously accomplished on city buses. Police caught the lady bandit in 1991, and the courts sent Allen away for 10 years.

Larry Kolvoord photos/American-Statesman Lester Allen worked as a hospice aide during his stint at the Stiles Unit, helping fellow prisoners who he said needed help but didn't get it.

What Allen didn't know when he first entered the Texas prison system, but soon learned, is that no matter what a judge orders, any term in Texas can be a life sentence.

The man who taught Allen this lesson was Harold Fields. Allen knew Fields from Dallas, where both had lived. They met again at the Ramsey Unit in Brazoria County, one of Texas' oldest prisons.

"I watched Harold die slowly," Allen recalled recently. "If you're positive with HIV or AIDS and you can't get the treatment you know you need, you can't get help, you can't get anyone to care, you feel like you're hanging on at the end of a rope, and after a while your hands get tired and you just let go."

Before 1993, the prison system hired its own doctors, bought its own medicine and ran its own clinics. The Legislature took that job away from the prison system and gave it to the University of Texas Medical Branch in Galveston and Texas Tech. The reasons were to save money and to appease a federal court judge.

UTMB provides care in the eastern portion of the state, where 80 percent of the inmates are housed; Texas Tech works with the mostly newer prisons to the west. The new system saves money. But there are few public checks on the quality of care the universities provide and, until recently, no penalties if the universities practice poor medicine.

Four hundred fourteen people died of natural causes last year in Texas prisons. UTMB or Texas Tech doctors review the medical charts for each dead inmate and rate the care as proper or improper.

Chart reviews are one way to monitor the quality of medical care. Florida publishes the results of chart reviews on the Internet as one public accounting of health care in its prisons.

In Texas, the state's chart reviews of deceased inmates are secret by law but events in 1996 were an exception.

Prisoners at the Stiles Unit that year began filing large numbers of complaints about medical care at the facility. Many of the system's sickest inmates were housed at Stiles. Prison system doctors, relegated by then to administrative functions, took notice and began an emergency audit of the medical charts of the inmates who had died that year. The doctors reviewed 24 charts and concluded that 16 dead inmates had received improper care. One was Lester Allen's friend, Harold Fields, who had been transferred from Ramsey to Stiles a few days before he died. Another was Alexander Oris, who "starved to death in infirmary," according to the Texas Department of Criminal Justice's internal review. Michael Anderson vomited for three days and had no bowel movements for six days before he died and "appeared to have been neglected in his cell." Another man died a few days after he had been found covered in feces. Another was "left to die." Another "appears to have suffered from neglect."

UTMB reacted to the Stiles audit. The university shifted people to other units or jobs. Doctors were dispatched from Galveston to provide "minifellowships" and "retraining" for Stiles medical personnel, according to testimony from a university health care official.

The Legislature took no public notice of the Stiles study, nor did the committee of prison system and university officials given the job of overseeing prison health. When reporters asked about the report, however, UTMB officials said the system had been much improved.

But had it?

In 1998 an attorney representing Texas convicts in a long-running federal lawsuit over prison conditions hired corrections system doctors from other states to conduct another review of prison deaths.

In the 1998 study, these doctors came to conclusions strikingly similar to those in the prison system's own study two years earlier at Stiles (see 1998 STUDY). They examined 59 deaths from across the state and found that 20 of the inmates received poor or very poor care. Sixteen of those 20 deaths were either "preventable" or "possibly preventable." Ophelia Rangel was left "lying in feces, menstrual fluid and urine" until she died of "severe dehydration," the doctors concluded. Robert Lee Brown died of a stroke and a heart attack after prison health officials ordered medicine to treat hypertension that caused a "precipitous lowering of blood pressure." The federal Food and Drug Administration had warned against this method of treating hypertension in 1985. Three weeks before Arthur Hines died of heart failure, his medical chart said he "appears in good health." The prisoner repeatedly had complained of chest pains and shortness of breath, but he received "no particular treatment" in the weeks preceding his death, doctors hired in the court case testified.

In court, the state disputed those conclusions by finding fault with the way the study was conducted. Dr. David Smith, a Texas Tech official and then-chairman of the committee in charge of prison health care, testified that the studies were "not recognized as an effective way of analyzing data." He also revealed that in the case of Rangel, a physician and two nurses were fired.

Dr. Jason Calhoun, who headed UTMB's prison medicine program, responded to the '98 study in court documents, saying the university had improved its care. "Although hindsight will always identify specific cases where different treatment could have produced a different outcome," Calhoun said, "UTMB has made significant progress since 1994 in areas of access to care, evaluation and treatment at the unit level."

If these accounts of prison health care are harsh, they are mild compared with the way things were a generation ago.

In the 1970s, convicts acted as doctors. They pulled teeth, stitched lacerations and dished out pills. In 1974, Texas employed just one doctor for 40,000 prisoners in a brutal and unconstitutional system of health care largely run by prisoners.

By this year, prison medical care was much different and much better. The federal courts in the long-running case named for inmate David Ruiz found that the prison system's medical care was constitutional (see DAVID RUIZ). Credit for these improvements was given to UTMB and Texas Tech.

Even so, U.S. District Judge William Wayne Justice warned that although prison health care in Texas may now be legal, it is still inadequate and "subpar." "As the law stands today," Justice wrote in 1999, "the standards permit inhumane treatment of inmates." Cadarell Freeman and Lester Allen would agree.

To gain a sure handle on the quality of care in Texas prisons is impossible. Records are not kept or are kept secret. The Legislature has prevented even prison authorities from fully monitoring the quality of care the universities provide.

Prison officials boast that the clinics in each of the state's 105 prisons are inspected and licensed by national prison health-care agencies. But even prison system doctors question whether these inspections adequately measure the quality of medical care. A

fter all, in 1996, when two-thirds of the men who died at the Stiles Unit had "improper" care, according to the state audit, the prison clinic earned passing grades from a national accrediting organization. Moreover, even these accreditation reports are kept secret under state law (see ACCREDITATION).

The details that can be discovered about prison health care are blips on a radar screen, tracks in the snow. That's all there is, because Texas has gradually developed a prison health-care system that is largely impenetrable not only to those outside the system, but to prison officials as well.

When information does emerge from this largely closed system, however, it often is disturbing:

The Texas Department of Health closed a prison dialysis unit in 1997 after finding "serious deficiencies," according to a state auditor's report. Even after the unit was reopened, prisoners needing dialysis treatment in 1998 would find chairs still bloody from earlier patients.

A 2000 study by two doctors at the University of Texas at San Antonio found that women and black inmates were prescribed more advanced, and more expensive, anti-psychotic drugs "less frequently than whites, implying that there may be bias in prescribing patterns in (Texas Department of Criminal Justice) Mental Health Services," according to a TDCJ analysis.

A 1997 study by UTMB pharmacists found that prison doctors treating diabetes "generally do not follow the guideline recommendations, and clinical markers were not improved."

As recently as March of this year, half of the prisoners discharged from clinics and prison hospitals had incomplete documentation, and one in every 10 required "emergency, acute care or readmission following discharge," according to a prison system report.

Convicts and prison employees complain of the same inadequacies: the poor care given at the units, as opposed to the excellent care they found at university hospitals; the messy dialysis units; the tendency of doctors at prison units to cancel or ignore orders issued by hospital specialists; the mix-ups in prescriptions; the checkups given seemingly without care or interest.

They also say, uniformly, that the two universities providing care have dramatically different results. Convicts well-traveled among Texas prisons say health care is better at West Texas units serviced by Texas Tech. That was also the conclusion reached by lawyers and doctors representing inmates in the federal Ruiz case.

"It was our belief based on the evidence that the most serious problems seemed to occur in the UTMB units as opposed to the Texas Tech units," said Donna Brorby, the San Francisco-based attorney who hired doctors to review the quality of medical care in Texas prisons. "We all agreed that Texas Tech did a better job."

A bus hauls inmates from the prison hospital in Galveston. Sick convicts advise each other to find reasons to be treated there, rather than risk inadequate care in the prisons.

Dr. John Robertson reviewed the medical charts of a sample of inmates who had died in Texas prisons. He agreed that "Texas Tech seemed to have less of a problem." Robertson, who is the medical director for the Alaska prison system, said recently that "based on our studies, I think the oversight and quality of care was better at Texas Tech than that provided by UTMB."

Because there is no independent agency monitoring the care given to Texas inmates, the universities are left to decide for themselves what care is proper. When prison system doctors found that two-thirds of the inmates who died at Stiles had received improper care, UTMB doctors reviewed each medical chart and they arrived at starkly different findings.

Prison system doctors concluded that Paul McGhee had been "essentially left to die in the infirmary." A team of UTMB doctors looked at the same chart and wrote, "There does not seem to be any problem in the care of this patient."

Alexander Oris "starved to death in infirmary," prison system doctors wrote. UTMB found "no lapse of care."

Jimmy Jones "received very little care at Stiles" and "appears to have suffered from neglect," according to the prison doctors. UTMB found "no lapse in the standard of care given this patient."

Raimer, of UTMB, said this difference of opinion is sometimes inevitable. "You can sit three doctors down together and have them review a case and get three different opinions on what should have happened," Raimer said. "The diagnosis can be correct, the medication can be correct, the treatment can be correct and still you can have an outcome that you didn't want or didn't expect. That's medicine."

Where prison system doctors found 16 cases of improper care, UTMB doctors had questions about seven, and labeled none as improper care.

Lester Allen had gradually morphed from a college student to the bandit caught in a wig, black stockings and pumps after he robbed a Texas Commerce Bank on Houston's Main Street. In the steel halls of Texas' prisons, he changed again.

In 1995, Allen recalled, "I went to Stiles. I talked to the chaplain there and started working in the hospice program. I felt it was something I was called to do.

"It changed my life not the sentence, but what happened while I was in there. I saw lots of people dying, lots of people who were very sick, lots of people who needed help but weren't getting any. It was a horrible place. "I cared for people who were dying and who almost no one cared about. I saw the stages of my eventual death. It changed my outlook on life. I made my amends to God and myself."

At Stiles, Allen was known as an angel of mercy. As a hospice aide, he smuggled medication and food to sick prisoners. He brought them blankets in winter and ice in July, in defiance of guards' orders. Allen forged "hall passes" so that he could continue his work when he would otherwise be confined to his cell.

Lester Allen tried to give the care and the hope he was unable to provide his friend Harold Fields.

"At Stiles," prison system doctors wrote in 1996, "(Fields) was not assessed and managed properly although fevers, nausea, vomiting, weight loss and weakness were documented." UTMB doctors reviewed Fields' chart and wrote: "Standard of care met."

Bedsores ripened on Cadarell Freeman's backside. He contracted infections, fevers and diarrhea. An ulcer erupted in his throat that made it impossible to eat. His stomach churned.

Larry Kolvoord photos/American-Statesman The papers that Cadarell Freeman took with him when he was paroled last year provide a glimpse at the depths of his medical woes. In one bout with illness, Freeman was rushed to the prison hospital in Galveston, where workers called his mother to tell her he was near death. He recovered after he left prison.

When Freeman stayed on the drugs prescribed by doctors at UTMB's prison hospital in Galveston, he gained weight, got better. But a prescription in the Texas prison system is often just a piece of paper. Sometimes, Freeman said, the sacks of medicine he brought from Galveston were confiscated and not returned. Some weeks, according to Freeman's files, the inmate received only three of the 15 drugs he was supposed to be taking. For days at a time he would receive no medication at all.

A note written on Freeman's chart while the inmate was at the hospital in Galveston said the inmate was so "frustrated at his inability to get meds as prescribed that he is threatening to commit suicide to get to new unit." A doctor from the Galveston hospital wrote in December 1997 that Freeman "has had unacceptable lapses" in therapy, but that the inmate had been convinced "to continue to take meds despite obstacles at unit level."

An internal prison system report in 1999 found there were "multiple dosing errors on virtually every medication order" Freeman received. When Freeman complained, the report said, prison unit health-care workers "tended to roll their eyes and sigh at the mention of the offender's name." On drugs and then off again, Freeman began to have seizures; he was confined first to a wheelchair and then to his bunk. He lay watching as his disturbed cellmate plucked blades from safety razors, taped the metal strips to his fingers and, with bloodied hands, dubbed himself horror-flick villain Freddy Krueger.

In his diary, Freeman wrote on March 20, 1999: "This can't be a medical facility. This is a death camp. I hurt so bad." The same internal prison system report on Freeman's case stated, "There is further room for concern when treatment is given or withheld by a provider without actively putting hands, or even eyes, on the patient." In November that same year, guards found Freeman collapsed in his cell. He was rushed by ambulance to Galveston. Soon, a nurse asked if Freeman would donate his brain and other organs for scientific research. Freeman's mother received a call saying her son was near death.

After several weeks of care in Galveston, Freeman was taken back to Stiles. For a short while his health improved.

Then his drugs were withheld again. His health worsened. Freeman's pain bred hyperbole. In his diary he wrote, "I wonder did the Jews Hitler punished suffer this bad?" Freeman's question is easy to answer. There is no holocaust in the Texas prison system.

There is, however, a paradox. Freeman received some of the best health care in the world, and some of the worst. There were prison system workers who took up Freeman's case with a dogged, free-world ferocity and there were the medical personnel who wouldn't lay hands on the sick inmate, or even look at him.

For Cadarell Freeman, however, the bad overtook the good. He left prison and took with him into the free world limp legs, a check for $50 and a resistance to several HIV drugs.

You may contact Mike Ward at mward@statesman.com or (512) 445-1712 and Bill Bishop at bbishop@statesman.com or (512) 445-3634.