It wasn't all because of Tommy Mae Flakes Ames's colostomy bag -- which jailers routinely refused to allow her to clean.
It wasn't only the shit and blood found on cell bars, mattresses, floors and ceilings. Or the beatings, the cockroaches and obvious fire hazards.
But the civil rights case that started with Ames more than 25 years ago exposed such abominable conditions at the city of Houston's work farm on Mykawa Road that it forced city officials to enact drastic changes.
The work farm was shut down and a new jail built. A director of hygiene was appointed and regular health screenings implemented. The last significant lawsuit over jail health care came a decade ago.
As last month's review of health care services at the two city jails confirms, things have improved drastically in city lockup.
But the mayor's office isn't satisfied and hopes to farm out jail health care operations this year. City attorneys are busily writing a draft of a three-year contract to entrust jail health services with the University of Texas Medical Branch at Galveston. The contract is expected to be presented to councilmembers this month.
However, a recent report of UTMB's handling of Dallas County jail operations suggests turning it over to the group could be a step back for the city. According to that report, health screenings are ineffective; services are understaffed; few of the inmates who need doctors ever see one; and negligence is likely to blame for some inmate deaths. And of deaths, there have been plenty. There were 12 in Dallas County jails last year, 13 the year before. And though UTMB didn't come into the system until October, 2002 saw 15 inmates die, according to the state attorney general's office.
"It got to where every time I looked up at my computer screen there was something about another custodial death," says Dallas County Commissioner John Wiley Price.
With that kind of record, why are we doing this?
Houston Councilmember Adrian Garcia says the city has been interested in getting out of the "jail business" for years. It's not so much a concern about medical practice as it is an interest of turning the program over to an expert, he says. That expert, ultimately, will most likely be Harris County. On-again, off-again conversations with the county could see city jail operations assumed by Harris County in three years, according to several sources.
Touted as a populist, Houston Mayor Bill White is not averse to more Republican affections like privatization. He had the city's building department turned over to private industry in his first year of service. City department heads got the message early on: White was seeking ways to either improve services or save the city money -- or both. It didn't take long for conversations to turn to jail health care.
While the police and health departments have been happy with the services as they exist, the mayor's office started to push for change. It didn't advertise for bids on the contract. Instead, quiet conversations began last summer that led to interviews with officials from the University of Texas, Baylor and UTMB.
Two of the three were quickly weeded out. UT, which operates some county jail programs around the state, didn't want to expand. And although Baylor was interested, it has no experience providing jail health care services.
That left UTMB.
Manuel Perez, chief of jail services for the health department, says he has "no idea" why the city is farming out the duties. Though he doesn't criticize the move, he defends his staff, saying: "They're providing medical care that inmates need at the time they need it." And though a city spokesperson says the department will try to find other jobs for these employees, one jail worker says staffers already have been informed they will soon be out of work.
"It was all of a sudden. That ax that cut down the jailers has fallen on us," the assistant says, referring to last year's mass firing of more than 200 civilian jailers.
Critics of the change say it is going to cost the city up to $1 million more per year, which Mayor White's health liaison Elena Marks denies. The actual cost -- something she can't pinpoint, saying only that it is being treated in continually changing "draft" contracts -- is expected to be "cost neutral."
"It's just a broader, deeper program," Marks says of UTMB's offerings. "We just have this one small program. They have about half of the inmates and jails and prisons in the state."
Actually, UTMB cares for 80 percent of those locked up in Texas prisons and jails. And it doesn't take much digging to find the bodies.
Up in Dallas County, where the county's decision to privatize was based on the bottom line, things haven't turned out well.
"My colleagues said it would save us some millions of dollars," says Price, who voted against the contract back in 2002. "In fact, it's done quite the opposite: It's going to cost us millions of dollars."
A number of lawsuits have been brought against the county because of the poor care provided inmates under UTMB's watch, Price says.
The wife of Frank Palo Jr. filed a lawsuit against the county in March, alleging the jail staff failed to provide her husband with the heart medicine he needed. According to the lawsuit, Palo "repeatedly asked nurses and officers for his heart medicine, but was either rebuffed or ignored." He was booked into jail on a Saturday. Five days later he was dead.
Another suit brought against the city tells the story of Clarence Lee Grant Jr., who had his medication confiscated by the nursing staff after he was transferred in from a mental hospital. Over the next month it was noted by various staff members that he appeared dehydrated and weak. But when family members called up to the jail, they were told he was "doing fine."
It became hard for Grant to speak.
When a jailer stopped at his cell, knocked on the glass and asked if he wanted to see a nurse, Grant jumped at the sound but did not answer. The jailer asked the nurse about the behavior and was told to record it as "a refusal to see the nurse."
Grant died in his cell later that day.
"From the beginning of the UTMB contract difficulties with providing mental health and medical services to mentally ill inmates arose," the suit alleges.
Dallas County has since brought the Galveston-based system into one of those suits as a third party. When problems became too obvious to ignore, commissioners hired Health Management Associates to review UTMB's performance.
Those results, released in a February report, found ineffective screening that bordered on the chaotic, with only about one in four chronically ill inmates ever being seen by a health professional after intake. Tuberculosis screenings are "basically non-existent," investigator Dr. Michael Puisis wrote, noting UTMB had reduced the TB screening program staff from 13 to three. More than 35 percent of those with medical problems and up to 30 percent of the mentally ill are never even identified.
And you'd be out of luck if you got a toothache in lockup. UTMB's only treatment in Dallas County is to pull the tooth. And that is done the old-fashioned way: with hand tools only, in a dirty room. From the lone chair, inmates at this "dental clinic" find there aren't even sinks to spit out the mouthfuls of blood.
"My position is, they're still on a learning curve according to Dr. Puisis and the HMA study," Price says. "There's no way in two years to say all of a sudden 'We've learned.' I don't think that's the case."
UTMB officials counter that they were brought into an ineffective system in Dallas County, one they weren't charged with fixing.
"They did not approach us to come in and redesign the jail health program," says John Allen, executive director of operations of UTMB's correctional health care.
And Allen rejects any "apples to apples" comparisons.
After all, Dallas County, with its 6,500-bed capacity is a far different program from Houston's mere 500-bed arrangement. Houston's two jails are more a detention turnstile where the most important health care concern is not long-term care (with average stays of presentenced detainees running only 23 hours, there is hardly the chance) but rather the critical initial screenings.
While Allen blames screening problems in Dallas County on the fact that jailers perform that step -- not UTMB staffers -- there are several reasons to be concerned about the Dallas experience.
UTMB launched itself into the prison health care business back in 1983, with the opening of a prison hospital on campus in Galveston. But it got a rocket boost ten years later when the Texas legislature, responding to an exploding jail population, turned health care services for one of the largest correctional systems in the Western world over to UTMB and Texas Tech.
High hopes were held out for UTMB, which at the time was developing an extensive telemedicine network, whereby rural doctors (and now, increasingly, prison nurses) could get specialized assistance from doctors in other parts of the state.
With its move into prison health, UTMB began treating one of the demographically sickest populations in the nation. A report by the U.S. Department of Justice found that the average offender coming into prison has a "95 percent chance of needing medical care" and 60 percent of the time the prison doctor or nurse is the inmate's first exposure to a health care professional.
With four million documented patient encounters per year, UTMB doctors, nurses and med school students get unlimited access to conditions they'd never dream of encountering in a typical suburban practice.
For some students, that's a thrill.
"I had the chance to see diseases that other medical students just read about," UTMB graduate Chad Conner was quoted as saying in one higher-education journal. (In an interesting bit of spin, the same article suggests that med school-run prison health care programs have "increased patient satisfaction by decreasing the time inmates spend away from their prison.")
Helga Dill has formed a different opinion of UTMB as she has worked to help her husband, a heart patient, survive a 20-year stint at the Michael W. Powledge Unit in Palestine, Texas.
"He has been forced to take medication he was allergic to and at one time went into cardiac arrest because of that and had to be airlifted to Hermann Hospital," Dill says. "Last week, he tried six times to go see the nurse to have his nitroglycerin refilled. If he doesn't have it, it can kill him."
While her husband's care has improved, Dill says it is only because of her involvement. As chair of a prisoners' rights group called Texas Citizens United for Rehabilitation of Errants, Dill regularly receives letters recounting horror stories from inmates about the state of health care in state prisons.
She says the Dallas County story is the rule -- not the exception.
"It's the biggest farce you can imagine," Dill says. "I mean, they're getting three hundred-plus million dollars a year for health care that isn't provided."
It can be difficult to get an objective view of UTMB's performance. The Texas Department of Criminal Justice itself has limited oversight of the health care network inside its facilities. The schools are charged with the self-serving task of reporting on themselves, Dill says.
To counter the bad press the group has been receiving in recent years, UTMB paid the nonprofit Texas Medical Foundation for a six-month review of operations. What turned out to be a glowing review was compromised not only by the funding source, but by TDCJ's decision not to allow researchers to talk with inmates or observe jail practices because of "security concerns." It is for that same reason that city jails have a long-standing policy of not allowing tours by members of the media, a police spokesperson says, rejecting a request by the Houston Press to observe health screenings of inmates by health department employees. Such tours, however, have been allowed through the years for politicians, "visiting dignitaries" or lawyers investigating various potential abuses, according to another jail official.
It took media affairs representatives more than a week to return word from the police captain in charge of jail operations that "the city won't be giving tours of the jail anytime soon."
Access is another reason Puisis's report is so important. Even though UTMB keeps much of its operations secret, Puisis was granted access to Dallas County inmates as well as to jail and medical staff. The stories they told him reflect an overworked medical staff operating on a "survival mentality" in which staffers scramble from one emergency to the next without ever developing the ability to operate an actual health program, Puisis wrote.
Understanding just how the UTMB facilities are staffed is difficult, since the group has declared its budget "proprietary." But it is clear that UTMB's "cluster system," adopted in a partial response to budget reductions imposed by the state legislature, requires staff members to work in different positions for various prison networks. The Dallas County jail director, for example, is charged with overseeing 17,000 inmates at nine different facilities even though his position is funded by Dallas County.
And though UTMB has discussed increasing medical staff in Dallas County, Puisis says that the "general practice" of the group is to reduce staff -- something UTMB officials deny.
But perhaps most disturbing for the future of Houston's jails is the very thing that makes UTMB desirable to city leaders: its use of electronic record keeping and telemedicine.
Puisis found that technology in Dallas County jails had become a replacement for direct physician involvement.
"For most patients, their care involves physicians or nurses reviewing an electronic version of a scanned intake form written by a nurse who is seeing patients in a setting without privacy and not having performed a physical assessment," Puisis wrote.
Further, the reliance on telemedicine means that only one in four inmates with a chronic illness is ever physically seen by UTMB physicians. Instead, doctors are inundated with as many as 100 electronic records they must review each day. Medications are dispensed 12 months at a time without doctors ever seeing their patients. And nurses routinely underestimate the severity of diseases in their reports, enabling doctors to ignore what they believe are not serious cases.
The report suggests this is likely because of a lack of clinical staff.
Such shortcomings may have contributed to some questionable deaths at the Dallas County jail.
Puisis found that a suspiciously high number of these deaths were listed as "cardiac events." In the one case he reviewed, Puisis found the inmate more likely died from electrolyte abnormalities from liver disease complications -- something jail staffers knew about but failed to "treat in a timely manner."
Owen Murray, chief physician executive for UTMB, insists that "all those people are being taken care of by those nurses and triaged appropriately" and adds that, in any event, "talking about any patient's medical record is not something we can do."
Minus one spike in 1998, when 17 deaths were logged, inmate deaths in Dallas County since 1995 averaged seven per year until UTMB took over in the fall of 2002. While not all 15 deaths that year took place under its watch, UTMB was in total control the next two years, when there were 13 and 12 deaths.
It's been a long time since the Ames case. First filed in 1976, the complaint gathered plaintiffs until Houston officials finally agreed in 1989 to provide 24-hour medical screening services and a pharmacy at the city jails. It now spends $2 million a year maintaining about 40 full- and part-time medical staff.
To meet the terms of a federal consent decree, the work farm was shut down long ago. But one obvious lapse occurred in 1993, when a dying South Texas resident was arrested after being booted off an Amtrak train. The 19-year-old had stripped down on the train after crapping and pissing his pants. Booked in as a drunk, Max Perez was carried to jail on a stretcher. He died about ten hours later.
The family got $500,000; the city got a black eye.
And though complaints continue as they do at jails everywhere (these are, for good reason, unpopular places to spend one's time), and despite 14 custodial deaths in Houston's jails since 1995, the city has not had to shell out money to settle legal claims since the Perez case.
But screenings seem to continue to cause the city challenges.
New city inmates are supposed to be asked 14 questions before they are released into the general prison population. Do they have diabetes or hypertension? Are they pregnant? Do they want to die? The idea is to weed out those with conditions that need to be treated elsewhere, like a drunk tank, hospital or mental ward.
One particularly busy night, "the medical screener came out to the prisoner line, held brief interviews with each prisoner and asked only one or two questions," wrote Gordon Kamka, a Looneyville, West Virginia-based auditor who has reviewed jail operations since the consent decree went into effect. "This does not suffice for a true medical interview. Improvement is needed in this area. All questions need to be asked."
But this sort of mismanagement, though pregnant with the potential for problems, falls limp when laid alongside the stories Dill has collected from inmates under UTMB's care.
Take, for instance, the tearful pleas expressed last year by a Jester III inmate housed in Richmond. Though it is unclear when Arnulfo Ramirez Sr. died, a recent letter makes it clear he died a Texas inmate living with an intense amount of pain.
A veteran of several heart operations and colon cancer treatments, Ramirez wrote Dill after being given six months to live and having his request for special-needs parole denied.
If the prospect of dying in prison wasn't bad enough, sloppy medical care and a lack of pain medication suggest other reasons Ramirez may have been eager to beat the Jester.
After one cancer surgery, Ramirez said, UTMB nurses at John Sealy Hospital were irritated because he kept sliding off his pillow. He complained of intense pain in his back, which was ignored. Finally, one nurse noticed that doctors had left the spinal tap in his back. When they tried to remove it, the needle broke off inside his spine. "Well," one doctor reportedly told him, "as long as it doesn't go into one of your lungs or your heart, you will be all right."
"All right," Ramirez quickly found, is a subjective state. The needle was never removed. And each day the pain increased. After he got back to Jester, his pain medication was taken away and he was given Tylenol instead. "I have not been taking anything to adequately control pain for two years," he wrote Dill on January 11, 2004. "I am always with chest pain." Numbness took over his left arm, and the pain in his spine quickened. He began to bleed from his mouth and rectum. A walking cane was the only aid the Jester staff offered.
A convicted sex offender, who apparently protested his innocence to the very end, Ramirez was hoping to die at home surrounded by his remaining family. He had lost both a son and a daughter during his time in lockup. He wanted "so much not to die in TDCJ," he said. "I do have a home to go to once released and medical care. Please help me go home to die."
It's budget season at City Hall. And the direction on jail health seems to be set. In the health department, the refrain is "We're not the bad guys." At the PD, no one seems to have been asked for an opinion in the first place. The police administrator says they are happy with city health services but would welcome UTMB just as well.
Draft contracts shuttling between city and UTMB offices are already nearing that middle ground where ink gets spilled, and techies from both camps have worked out which computer systems can be rigged up to make the hospital system's telemedicine practical here. Marks says such upgrades would be paid for by UTMB and that two more controversial elements in the draft contract -- a 90-day fee renegotiation and a monthly cap on intake screenings, either of which easily could have soaked the city for extra bills -- have been stripped.
Kamka, who did not return e-mail or phone calls, talked up the university system in his April report on city jail operations. "Privatizing health services at the Houston City Jail seems to make sense," he wrote. "UTMB is obviously qualified to provide these services." Whether he was aware of HMA's report on Dallas County or the fact that jail had been flunked by the Texas Commission on Jail standards for two years in a row is unclear. Marks said in two interviews on May 5 and 6 that not only did she not know about the Dallas County story -- despite heavy coverage by The Dallas Morning News -- but that it had never come up in staff discussions.
However, a series of e-mails shows that the matter was known and discussed.
An April 25 e-mail from the health department's Martha Engel to both department director Stephen Williams and Marks said Councilmember Carol Galloway's chief of staff had asked her about the jail program and the Dallas story.
"I told him I was aware of those articles and that problems sometimes arose in contracting," Engel wrote.
Ten days later, Marks wrote Engel back, saying "the "Houston Press has called about this -- obviously a setup since they want to know about 'privatization.' " Later that day Marks told the Press she was ignorant of Dallas County events.
"The issues I've seen in the paper surrounding jail health have to do with the privately contracted jails. I don't think it's UTMB," she said on May 5.
The next day, after she'd had a chance to "check it out," Marks told the reporter: "I appreciate the lead because I wasn't aware of it."
"So this wasn't something that had come up in the discussions?" the reporter asked.
Ass-covering aside, Marks said she does want to make sure Houston doesn't experience similar problems.
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"I think this is a very different situation," Marks said of Dallas. "However, we obviously want to make sure that the issues that they encountered up there don't occur here."
But she was obviously swayed by UTMB's argument.
"I think they learned some lessons there that will be applicable here."
In just a few months, the 118,000 inmates who cycle through Houston jails each year may have a chance to find out just what lessons those were.