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Don’t Get Cancer if You’re in Prison

07_31_Prisons_01
Wayne Rose, left, mops the floor in Robert Bryan's room as he lies in bed waiting to die behind the prison walls of Colorado Territorial Correctional Facility, November 08, 2012. Arrested more than 50 times since he was 18 years old, his current sentence—six years for second-degree assault—will be his last. He has liver cancer and was a patient of the Colorado Territorial Correctional Facility’s hospice program in Canon City. RJ Sangosti/The Denver Post

“I’m 76 years old. Please renew my wasting diet as soon as possible,” Manfred Dehe begged health care workers at the Arizona State Prison Complex-Eyman on September 28, 2012.

Dehe stood at 5 feet 11 inches and weighed at least 200 pounds, boasting a considerable paunch and a head of thick, white hair, when he entered Eyman in February 2012. But soon after, his weight began to plummet.

“My diet card [for the wasting diet, to help him put on weight] expired in September,” he again pleaded on another request form, in December. “I have been trying to get it renewed ever since. I submitted HNR [a Health Needs Request form] requests on 9/28/2012 and 11/6/12. It’s now 12/10/12, and my diet card is still not renewed. My weight continues to decline.” By February 2013, his body weight had dropped to about 150 pounds.

“I started noticing his clothing looked very loose,” says Dehe’s son Mark, who visited him regularly at Eyman, in Florence, Arizona. “It looked like he had borrowed clothes from somebody else, because they were too big for him.”

Dehe’s weight loss wasn’t a medical mystery. Almost immediately after he came to Eyman, a series of symptoms indicated he might have prostate cancer. Providers of Dehe’s medical care—first, a private, for-profit prison health care company named Wexford Health Sources, followed by another private, for-profit prison health care company named Corizon—were well-aware of these symptoms, according to records provided to Newsweek.

Lab results dated March 31, 2012, indicated Dehe had a prostate-specific antigen (PSA) level of 23.3 nanograms per milliliter. The lab report flagged this level as “high”—the range listed there for a healthy individual was 0.0 ng/mL to 4.0 ng/mL—and according to the National Cancer Institute, “the higher a man’s PSA level, the more likely it is that he has prostate cancer. Moreover, a sustained rise in a man’s PSA level over time may also be a sign of prostate cancer.” By June 2, Dehe’s PSA had shot to 31.4 ng/mL.

Despite that alarming bloodwork, as well as multiple hospitalizations and Dehe’s repeated requests for help, he didn’t undergo a prostate biopsy until August 9, 2013. The results came back a month later: metastatic prostate cancer.

Cutting Corners & Pointing Fingers

There is little hard data on the quality of medical treatment behind bars, says Dr. Marc Stern, a correctional health care consultant and former health services director for the Washington State Department of Corrections. Nor is there much regulation of correctional facility health care.

No one disputes that prison care saves lives and often treats people who might not otherwise be treated. Many who end up imprisoned are too poor to get adequate health care on the outside. Hepatitis C is a useful case in point: An estimated one-third of those infected with hep C in the U.S. pass through the prison system. Outside of prison, this is a population that is unlikely to seek professional help when experiencing symptoms of a disease like hep C, and probably couldn’t afford treatment ($25,000 to $189,000 for a full course of hep C drugs) if they did. In prisons with adequate health care services, these sick prisoners are more likely to be screened and diagnosed, and then are given the drugs at no cost to them.

However, after working in prisons across the country, Stern says his impression is that “the places that are excellent are more rare than the places that are not.” The problems tend to stem from underlying financial issues: There is little public investment in correctional health care systems, and generally speaking neither public nor private providers can offer competitive salaries to prison health care workers.

07_31_Prisons_02 A 73-year-old patient diagnosed with terminal colon cancer, takes his daily medication in the hospice care wing of California Medical Facility on December 17, 2013 in Vacaville, California. The prisoner, who asked to not be identified, is serving a 30 year sentence. He was diagnosed with cancer in April 2013; doctors currently expect him to live another three months. Andrew Burton/Getty

“The problem is a structure that creates incentives to delay and deny care,” says David Fathi, director of the National Prison Project at the American Civil Liberties Union (ACLU). “The reason to deny care is obvious—because you save money, particularly when you're talking about conditions like cancer, which can't be treated on-site by the prison doctor. Those patients have to be sent out to specialists. That gets very expensive. That's an area where we very often see private providers cutting corners.”

Managers of correctional institutions typically have a background in criminal justice and don’t have medical training, which exacerbates the situation, Stern says. “They don’t keep an eye on things closely enough.”

There are constitutional requirements for providing adequate health care to our incarcerated populations. In 1976, the U.S. Supreme Court decided in Estelle v. Gamble that “deliberate indifference to serious medical needs of prisoners constitutes the ‘unnecessary and wanton infliction of pain’...proscribed by the Eighth Amendment,” and ruled that correctional facilities must provide appropriate health care to prisoners. In 1993, in Helling v. McKinney, the court decided that prison officials cannot expose inmates to environments that “pose an unreasonable risk of serious damage” to their future health.

Since then, however, frequent reports and lawsuits charging negligent care of inmates—including numerous deaths—strongly suggest that many U.S. prisons and jails have ignored these rulings.

Allegations of subpar care in Arizona provide a good example of how correctional health care dysfunction puts cancer patients at extreme risk. In March 2012, the ACLU and allied prisoners’ rights groups filed a lawsuit against the Arizona Department of Corrections (ADC) and several state officials, alleging that “grossly inadequate” health care puts “all prisoners to a substantial risk of serious harm, including unnecessary pain and suffering, preventable injury, amputation, disfigurement, and death.” The suit points to several cases of what it describes as poorly treated, or untreated, cancer. (The ADC oversees the state’s 16 prisons, six of which are privately run.)

For example, an inmate named Ferdinand Dix complained for two years of lung cancer symptoms such as chronic cough and shortness of breath, and tested positive for tuberculosis—but never received proper treatment. The cancer spread “to his liver, lymph nodes, and other major organs, causing sepsis, liver failure, and kidney failure,” according to the suit. Dix’s liver “was infested with tumors and grossly enlarged to four times normal size, pressing on other internal organs and impeding his ability to eat.” The suit claims medical staffers didn’t “even [perform] a simple palpation of his abdomen. Instead, medical staff told him to drink energy shakes.” In February 2011, Dix fell into a “non-responsive state,” and “his abdomen was distended to the size of that of a full-term pregnant woman.” The prison brought him to an outside hospital, where he died a few days later.

The American Friends Service Committee-Arizona released a report in October 2013 titled “Death Yards: Continuing Problems With Arizona’s Correctional Health Care.” The Quaker organization found that some 105 prisoners died in custody from March 2012 to June 2013. The AFSC studied 14 deaths in depth, and the report said that they “raise a number of ‘red flags’ regarding conditions that, if treated in a timely manner, might have been resolved.” Of these 14 deaths, six involved metastatic cancers. “This clearly indicates that the conditions were long-standing and suggests that these deaths might have been preventable had the individuals received more timely care,” the report charges.

Asked about allegations of subpar health care in general, and Dehe’s case specifically, the ADC directed Newsweek to a press release that states: “Arizona’s inmate mortality rates, including incidents of suicide, are within the national average for corrections departments. In 2012, the most recent year for which statistics are available, Arizona reported 215 deaths per 100,000 inmates, compared to the national average of 254 per 100,000.”

In 2013, the ADC terminated its contract with Wexford and handed over prison health care to Corizon. The state alleged that Wexford improperly dispensed medication and wasted state resources. Wexford, however, says the decision to end the partnership was mutual—while pointing fingers at the prison system. “Once it began operating the program, the company discovered the (now publicly documented) dysfunctional nature of the ADC system,” Wexford told Newsweek in a written statement.

‘I Don’t Feel Right’

The prison renewed Manfred Dehe’s wasting diet several days after his December 10, 2012, request, but it did not address his request for prostate treatment until months later. Meanwhile, he started needing to urinate constantly. Sometimes, he had to get up four or five times at night, and each time it was a struggle to urinate. “I’m 77 years old & I don’t feel right,” he wrote in a Health Needs Request form.

By January 1, 2013, Dehe could barely pass urine. He was admitted to the hospital, where he was found to have a urinary tract infection and an enlarged prostate. The hospital staff inserted a catheter, prescribed a dose of antibiotics and then sent him back to Eyman.

07_22_CancerPrisons_02 Manfred Dehe allegedly received subpar cancer treatment in an Arizona prison, causing his death. Mark Dehe

But according to Dehe’s letters, his medication was cut off 10 days later and his catheter wasn’t changed for weeks. Finally, on March 19, Dehe was admitted to the hospital and diagnosed with urosepsis, a condition that develops when a urinary tract infection spreads into the bloodstream.

In May 2013, lab test results revealed that Dehe’s PSA had topped 100 ng/ml. By June 3, his PSA had soared to 174.4 ng/ml. “The patient needs a prostate biopsy,” an off-site urologist wrote on July 2. Dehe had his biopsy August 9. A month later, the doctor wrote in his report, “I am almost positive that he has widespread metastatic disease.” The urologist prescribed a testosterone suppressant injection every three months. (Male hormones encourage prostate cancer cell growth, according to the American Cancer Society.)

In February 2014, Mark visited his father. “He had to hold on to my arm for his support,” Mark recalls. “I knew he didn't have too much longer to live.” His care, Mark says, was consistently subpar. When Dehe went to the urologist on March 28, 2014, the doctor noted in his report, “His last known injection was 9/23/13.... His follow up injections should have been on 12/25/13 and 3/25/14.”

From April 2014 onward, Mark noticed that his father’s nose and ears had become overgrown with hair. He was too weak to take care of himself, and nobody was helping him groom. He had only two teeth and “ joked he looked like Bugs Bunny,” Mark says. His skin was blotchy and red with bruises, and bedsores had erupted on his feet and buttocks. Dehe, who had always loved to walk, spent his days lying motionless, too sick to leave his bed.

“It was very, very painful to see that—to watch somebody deteriorate in front of you, to see the nurses not care, like he was an inconvenience,” Mark says. He adds that one infirmary staffer said to him, “Why don't you just throw a sheet over him? Because he already smells like he's dead.”

On October 14, 2014, the ACLU and the ADC reached a settlement requiring that the state improve prison health care in publicly managed facilities and comply with continued monitoring and oversight by the prisoners’ attorneys, to make sure the department abides by the agreement. That same day, Dehe died from “complications of metastatic prostate carcinoma.”

Corizon says it’s barred by federal privacy laws from commenting on Dehe’s treatment, but “can affirm” that his oncology “met medical standards of care and was appropriate for his condition.... As health care providers, we are deeply saddened by any negative medical outcome. We take providing care for our patients very seriously. We extend our sincere condolences to Mr. Dehe’s family.”

This article is one in a series from Newsweek 's 2015 Cancer issue, exploring challenges and innovations in cancer treatment and research. The complete issue is available online and at newsstands.