Critical Diagnosis

If you think your HMO is bad, check out what Texas has created for its prison inmates

Granted, Texas taxpayers might feel little sympathy for inmates, but they still might want to know whether they're getting their money's worth. And despite the unquestioned savings, there are some questions about where the funds paid to UTMB actually go. Some $668,000, for example, went right into the pockets of 60 UTMB physicians last year as bonuses, despite the protests of the prison board. Some Texas tax money appears to have been spent helping UTMB bid on providing health services for jails in New York City and for prison systems in other states. And a quarter of a million dollars goes to two highly paid -- and apparently underworked -- administrators who were once employed by the prison system. [See sidebar, page 20.]

And then there is the question of fairness. The punishment for people who commit crimes is the loss of their liberty; lack of medical care is not supposed to be part of the penalty too. But inmates who have not been given a death sentence can nonetheless die in prison from medical incompetence. One former prison health care administrator still shakes his head about a south Texas inmate who died of a strangulated hernia, a relatively simple medical problem to fix. No matter what the inmate did, he said, "no one deserves to die of a strangulated hernia."

In June 1996, inmate Stephen Kadis heard some reassuring news from his physician at the Pack 1 unit near Navasota. Kadis had collapsed twice with chest pain during the previous two months, and had been sent to specialists at UTMB in Galveston for tests. The tests indicated a swelling of the lining of the heart, but, Kadis's unit doctor assured him, the problem wasn't serious. In fact, he could go back to work. Work would even make him healthier, the doctor said, especially the kind of work Kadis was going to be doing for the TDCJ: working on the hoe squad, chopping weeds.

Kadis took the news with a certain amount of relief. He was going to be all right. Then 38 years old, Kadis was not a typical Texas inmate. He was well educated, with a master's degree from Columbia University in New York. After a business failure, he had carried a package for some people that turned out to be cocaine. It was a mistake, and he ended up in jail. His first three years were relatively uneventful. But after he became ill, prison life became hell.

For the next nine months, Kadis tried to work on the hoe squad, a job that has changed little since the 19th century. The men are hauled in wagons to work under the supervision of mounted guards, who are instructed to shoot any inmate who tries to escape. Kadis wasn't much of an escape risk. He felt so weak and off-balance, he says, that he kept falling over, and blacked out several times.

Kadis says he filed grievance after grievance with the prison medical authorities during those nine months, but his unit doctor kept sending him back to work. In June 1997 he was sent back to Galveston, which boasts the most advanced maximum-security hospital in the country, where his neck was x-rayed and he was given an MRI. The diagnosis was myelomalacia, a degeneration of the spinal cord caused by a narrowing of the spinal canal. "The specialist," says Kadis, "really didn't tell me anything, just wrote 'myelomalacia,' and sent me back." He was transferred to Ramsey 1 unit at Rosharon with work restrictions that included no lifting of anything heavier than five pounds and no prolonged standing.

But doctors at individual prison units have the right to judge whether an inmate has recovered from his problem and is fit for work, and the doctor at Ramsey 1, just like the doctor at Pack 1, wanted Kadis back on the hoe squad. But this time Kadis refused to go.

"Every day the guard would come and ask me if I was going to work, and I told them, 'You'll have to punish me'," he says. "So they took away three years of good time I had built up."

Kadis kept getting sicker. Eventually, his mother sent his chart to a private doctor, who was immediately alarmed. Myelomalacia is a degenerative disease that can prove fatal without highly specialized surgery. Kadis's family and his lawyer started sending letters to TDCJ officials protesting his work assignment and pointing out that without surgery he would die. One of the letters reached Lannette Linthicum, TDCJ's assistant medical director.

Linthicum doesn't intervene often, but she has a reputation as a sensible and compassionate physician who says what she thinks. Linthicum visited Kadis, he says, "and said she would make sure I was assigned to something where I wouldn't get hurt, and she saw that I got surgery." Last September, in a 14-hour-long operation, specialists at UTMB replaced three of Kadis's neck vertebrae with bone from his hip. "The surgery was as good as can be done," Kadis says now. "The services are fine when you get them, but so many people get them so late that they're crippled or sick."

The question is whether Kadis was just a victim of an incompetent unit doctor who either didn't know what myelomalacia was or was obsessed with malingering -- or whether the specialists who originally examined him in Galveston were trying to avoid a costly surgery. Kadis himself has a very simple diagnosis: "They were trying to kill me."

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