Fire in the belly
A model program stresses community involvement
By Stanya Kahn

Thunder rolls and cracks, darkening a bucolic Massachusetts landscape, where a winding road carved through manicured lawns resembles the spooky path through the woods to Oz. Although the setting here is green and quiet, it's just as mysterious: The road empties into a parking lot spread around a small maze of granite towers and low, metal rectangles. This is the Hampden County Correctional Facility, a calculated product of modern architecture and high-tech imprisonment, and one of 14 county jails in the state. Turns out the serpentine path is no mistake of nature but a well-planned roadblock to anyone trying to make a B-line out of the jail.

Ironically, Hampden County is one of a handful of jails in the country with an open door to the community. It has adopted a health care program based on the public health model that provides inmates with a community-based standard of care. Through links with local health centers, Hampden County's program defies the isolated grandeur of most prisons: Doctors, nurses, and case managers from the community come into the jail to deliver their services. And when prisoners are released, they continue with the same primary care providers they had inside, through a comprehensive discharge plan that includes Medicaid benefits and hookups with other supportive services.

"This is not a fortress in the woods," explains Richard McCarthy, Hampden County's public information officer, adding, "there is a sense of [the jail] being a positive player in the community." Thomas Conklin, M.D., the director of health services at the jail, adds, "We are the community. Our inmates are members of the community from which they came -- and to which they will return. We see ourselves as a point of entry into the health care system."

A physician of commanding stature and extraordinary height who towers over the armed officers at the jail, Conklin, with the support of the local sheriff Micheal J. Ashe Jr., helped found Hampden County's health program in 1992. The impetus included studies showing that more than 80 percent of Hampden County's prisoners have had no access to health care. They started the program for HIV-positive prisoners with a small grant from the Department of Public Health.

Many jails and prisons turn their backs on the health care of their prisoners, Conklin says, and on the burgeoning crises of HIV and AIDS, tuberculosis, and hepatitis that breed within their walls. Bent on punishment, prison officials elsewhere cite high medical costs and security issues as obstacles to decent care. In surveying other facilities, Conklin pored over death records and found that many deaths seemed preventable. "It's what I call the ostrich approach," he says. "They don't want to know, because once you make a diagnosis, [the illness] is expensive to treat." At Hampden County, they do just the opposite. Although many prisoners don't stay long, Conklin sees jail as an opportunity to intervene on their behalf.

Hampden County has organized its program around five basic tenets: detection, effective and prompt treatment, education, prevention, and continuity of care. Upon admission, prisoners undergo a three-day orientation, and are given a full physical exam, which includes a review of their medical history, and screening for diseases like tuberculosis, syphilis, chlamydia, and hepatitis A, B, and C. Women also receive gynecological care, including PAP smears and pelvic exams. During orientation, newcomers also attend an intensive peer-led educational session on HIV and AIDS. They are offered bilingual counseling and are encouraged to take an HIV test. Those who test positive are then offered viral load and CD4 T-cell tests, with T-cell test results coming within a few days, and viral load results within ten.

Conklin's statistics show that almost all of the prisoners choose to get tested for HIV at the end of orientation. Of the 2,000 prisoners at Hampden County, at least 75 are HIV-positive in any given month, a number based on the voluntary test results. Today at least three-quarters receive potent, triple-drug HIV therapy and are closely followed by primary care physicians. With average sentences of 18 months and average jail stays of 52 days, this orientation-at-admission guarantees a swift entry into the health care system and makes follow-up care easier once they get out.

Using community services as his reference point, Conklin begins by grouping prisoners according to residential zip code. He then assigns a medical team, which includes a primary physician, primary nurse practitioner, half-time nurse, and case manager from a health center in that area to care for those prisoners. He notes that these team members never change, so that patients and care providers actually get to know one other. This gives prisoners access to state-of-the-art HIV care and drugs-without compromising security.

Access to medication remains a huge obstacle within many U.S. prisons and jails. Most provide extremely limited medical care and inconsistent and impractical methods for distributing prescription drugs (see "Separate But Equal?"). At Hampden County, instead of long lines at a medication window that offer little or no privacy or regard for meal schedules, a pharmaceutical technician wheels a med cart through the living quarters, or "pods," four times a day. "It's like a localized med-line," says Priscilla Provencher, one of four primary care nurses on staff. The jail has a "keep-on-person" medication policy-except for capsules -- a privilege most facilities forbid out of concern that prisoners will sell the drugs. "I find the adherence is better when they keep [the medicine] themselves," says Provencher, stressing that prisoners can take their HIV meds with them when they go to court or to groups or programs. A 15-year veteran at Hampden County who was once the only primary care nurse on staff, she has been key in bringing about changes in the program that reflect the shifting demands of the epidemic.

Every "living pod" at the jail now has a regular triage nurse who visits daily and takes care of minor complaints on the spot, referring more serious ones, after private consultations with the medical team, to the medical department. That way inmates do not have to rely on the corrections officers (COs), the gatekeepers of medical care in many prison systems. Hampden County gives its COs HIV training.

HIV/AIDS education is a centerpiece of the program, with peer education the keystone of its prevention campaign. Esther Fletcher-Cruz, a fiery woman with blaze-red hair and metallic copper nails to match, came to Hampden County from a community service group in 1992 to direct HIV education. Fletcher-Cruz initiates inmates, COs, and other staff into her street-smart, scientific, and bilingual (Spanish) program. "I've got a handful of peer educators that work on this every day," Fletcher-Cruz exclaims. "They're wonderful! They take it on themselves-and it has helped to a great extent."

Keisha, smart, young and HIV-negative, acts as both an educator and confidant to fellow prisoners and braves the hard stares of those who piegeonhole her as an "AIDS carrier." She takes on everything from questions and fears about HIV testing to unsafe tattooing and the brutal "outing" of HIV-positive prisoners by fellow inmates. "Last week, it was this pregnant girl who comes to me," says Keisha, recalling a recent incident. "She keeps having yeast infections and she wanted to know should she get tested. She had risky behaviors. And I was like, 'Yeah, you really should.'" At Hampden County, Keisha believes, peer education has not only put the brakes on transmission and encouraged people to seek treatment but has also rolled back the stigmatization of people with HIV.

Economically, the program is also a winner. It has quickly proved cheaper than privatized health care or contracts with vendor doctors (see "Big Business"), while providing more services than the usual "shotgun" emergency medical treatment available to most U.S. prisoners. Instead of higher prison health costs, Hampden County's collaboration with local health centers and nonprofit community groups runs an average of $8 per prisoner per day, says Conklin, compared with an average $10 to $12 per prisoner per day in most correctional institutions. In his view, the program has slashed public health costs and stemmed transmission in the community at large. He even credits the program with curbing criminal behavior, citing the jail's recidivism rate, which, as of last year, had dropped to 4 percent annually. Spokesman McCarthy agrees: "We've got this Rolls Royce kind of jail/prison program in terms of effectiveness, [but] the costs are more like a Ford Fairlane."

As with any pioneering program, however, there are shortcomings still to be addressed. A glaring one is the lack of prevention materials available to prisoners, including condoms, safer-sex supplies, and bleach kits for cleaning needles or crude tattooing equipment. It's no news to the staff that these are the primary tools of prevention. Or that, prison policy aside, sex and drug use go on inside. "Oh no! It never happens!" jokes nurse Provencher. Other staff members stay mum on the subject. "A majority of the community is against it [harm reduction]," says Conklin, offering a defense for what he knows should be a key part of any model prevention program. "We have to pick and choose our battles. Right now, the proactive health care and educational program has got to be our main focus."

There is hope for change. According to Thomas Lincoln, M.D., a community physician working at Hampden County, "The facility blocked condom distribution a long time ago. Now we need to collect the data that show there is risk behavior going on inside. So far we don't have the data to prove it."

Even with critical prevention tools missing, their program far surpasses most in the country. A media-savvy trailblazer, Conklin has his press pitch down pat and tours the nation's corrections conferences, publicizing his model. After a recent meeting of the Large Jails Network and the Federal Bureau of Prisons, Conklin recalls, "One of those guys stood up and said 'We're ready, we want to change. Show us. Tell us what to do.'" Although the program may translate better for small county jail systems than large, isolated prisons, the essential elements of the public health model can be duplicated, he argues.

Others are buying it. Backed by heavy players like the Centers for Disease Control and Prevention and the Soros Foundation, and with others like the National Institute of Justice and the National Commmission on Correctional Health Care showing interest, Conklin and his team now plan extensive follow-up studies. It will take these hard statistics plus a good cost analysis to convince a conservative corrections system that a better alternative exists. That, and what Conklin considers the really critical element in creating change: "A humane impulse -- a fire in the belly."

Managing Editor Stanya Kahn wrote about global health activism in our September issue.