• Twenty-Five Years Behind Bars: Treating Patients Inside Massachusetts Prisons

    I’m not going to tell you stories about the terrible things that may happen inside the prisons … although you do hear and see a lot over a 25-year period. I’m not going to tell you how difficult the inmates are … because most are not. I am not going to tell you how scary it is inside a prison … because I don’t feel scared when I am there.

    The story I have to tell is about a grateful population of patients, and a team of correctional officers and medical staff that make it possible to care for inmates in a prison ophthalmology clinic. I hope what follows will answer some of the questions I have been asked through the years about working within the prison system.

    Jean E. Ramsey, MD, MPH

    First of all, I am the on-site prison ophthalmologist in Massachusetts. I don’t go to the jails, just prisons. Most people in jail are awaiting trial or have been convicted of minor crimes. I go to prisons where people have been tried and convicted of more serious crimes. Consequently, many of the inmates have lengthy prison sentences and I have managed their eye care for many years.

    I remember well the first time I entered the prison. I had to wait to be allowed entry into the institution, as I was unknown to security staff. I was not able to proceed into the facility until the clearance authorization was verified and the paperwork completed. Once cleared, I was herded through security with a large group of staff and correctional officers who were about to start their shifts. I learned that day that you don’t refer to the correctional officers as guards. Good to learn that early.

    I was then subject to a visitor search: the officer went through a detailed inspection of my exam bag and personal belongings. I was patted down and instructed to walk through the metal detector. I then had to wait for someone to escort me through the grounds to the health service unit. They gave me a visitor ID tag, which I attached to my jacket. I was instructed to never lose that tag or else “something” would happen. ”Something” was later described to me as a shutdown of the entire prison site as all visitor tags needed to be accounted for. Maybe the officers just wanted to get the point across to a newbie, but it worked. The importance of securing that tag left a lasting impression on me. 

    As I entered the prison site I was struck by the number of locked doors and gates I had to walk through in order to reach my destination. I would count them. There were between six and eleven locked doors/gates between the entry point and my final destination. The exact number varied depending on where I was going. Traveling to the disciplinary unit, for instance, inevitably added at least six additional doors/gates to that final number. I found myself thinking that a prison is probably not a good place for someone who suffers from claustrophobia.

    The grounds were well-kept but barren. There was a large area with multiple identical block buildings for inmate housing. I did not walk past that area. But I did walk past the culinary area for staff and inmates with the unmistakable smell of breakfast being cooked. The inmates were in single file as they prepared to enter the “chow hall.”  The line of inmates obstructed the walkway, but as I approached the inmates would clear a path for me to walk through. Officers were positioned throughout the area, and regularly patted down the inmates.

    Upon entering the health service unit, I was dismayed by the grayness of it all: the gray floors, walls, clothing, the disheveled men in the inpatient ward, some in bed, some in wheelchairs, some walking around, and the emaciated patients patients dying of AIDS. I remember thinking, “Where are the colorful get-well cards?” It seemed like a terrible and lonely way to die. But these AIDS patients were the reason I was there. The Department of Corrections’ health care team had sought me out to examine the eyes of these very sick HIV patients.

    That was 25 years ago. Things have changed since then. My responsibilities quickly expanded from AIDS patients to comprehensive ophthalmology services, and from one prison site to nearly all prison sites throughout the state of Massachusetts. I no longer have to routinely wait for entry into the facility. I now possess a Department of Corrections ID, and I go through security like other staff and correctional officers, with no special modifications. The exception is if I happen to be the “search of the day.”

    In that case, I would be subject to a more detailed security clearance process, similar to what I experienced in the early days. I have learned the rules, and there are a lot of them: rules specifying what types of bags can be carried into the facility, what size coffee cup is allowed entry, what is considered “contraband” such as paper clips, binder clips and pens. Cell phones are typically not allowed in the institution. Rules vary somewhat by prison site, and they often change, so you learn to be flexible and patient. I no longer need to be escorted through the facility. I know the facility, the staff, correctional officers, and they know me. They call me “doc.” I don’t need a visitor pass, so I don’t have to worry about losing the pass. (It is funny how some things stick in your mind.)

    Nearly all of my scheduled patients will typically show up for their appointments with me. There are 15 to 30 patients scheduled. The inmates are held in the health unit “cage” until I call for them. The correctional officer assigned to the clinic does a “pat down” on each inmate prior to entering the exam room. The hours for clinic are limited as the inmates need to return to their units in time for “count,” which occurs at a regular time each day. No movement is allowed throughout the institution during count time until “count clears,” indicating that all prisoners are accounted for.

    Some people are surprised to learn that I spend most of my exam time alone with the inmates and that generally they are not in restraints. After all, when inmates are seen in the outside hospital clinics, they are likely to be in restraints and accompanied by multiple officers. Inside the prison, the correctional officers are immediately available should they be needed. Restraints are primarily placed on inmates from the disciplinary units, who are also escorted by multiple correctional officers. I have felt safe with my patients in prison.

    Although many of the inmates appear disheveled, it is not infrequent for an inmate to present to the on-site ophthalmology clinic freshly showered with clean clothes in anticipation of their visit with me. They are very respectful and express appreciation for my care. I have followed many of these patients for 10 to 20 plus years. The most common disease I see in prison is glaucoma. These patients are ready for my questions because I ask them every visit, “Are you having any trouble getting your drops?” and “Are you ever without drops?” Then I move to the more standard questions: “What drops are you using? How many times a day do you put them in? How often do you forget to put them in?” We have regular discussions about the importance of using eye drops.

    In any institutional setting, there is a lot that can go awry in the process of ordering, receiving and dispensing medications that is beyond the control of the patient. But prison adds an additional list of unpredictable obstacles: unit and cell searches, lockdowns, transfers, disciplinary unit admissions and more. Eye drops may get lost or be temporarily unavailable to the patient after a move, or during disciplinary segregation.

    All this can make it difficult for patients to strictly adhere to the medication plan. I typically schedule many patients to see me sooner than might otherwise be necessary for the sole purpose of checking on the status of their medications and their adherence to the medication plan. Taking care of prison patients necessitates interacting with numerous systems and processes that can be challenging and frustrating at times.

    People often ask me if I know what crimes an inmate has committed. I do not know because I choose not to know. Early in my prison work an event occurred while working in the prison dedicated to inmates who have been determined to be sexually dangerous.

    Once while waiting for a patient to arrive, I scanned a page of his paper chart that was opened to information about his criminal background. It outlined details of the inmate’s molestation of a young child. It was then that I made the decision to avoid any knowledge of a patient’s criminal background. I was concerned that my knowledge of an inmate’s crime could unwittingly affect my care of the patient. It is my firm ethical and professional belief that my job is to give these inmates, and all patients, the best possible care that I can.

    I do believe that the inmates are grateful for the care they receive. Although many start with a distrust of the system, I do my best to reassure them and hopefully a trusting relationship evolves. Recently, the inmates heard a false rumor that I might be leaving the position that allows me to visit prisons. Word of this apparently spread and one after another of the inmates expressed their gratitude, their concern and their fear. “What are we going to do without you?” was a common concern expressed, some with tears in their eyes.

    Over 25 years, I have learned a lot about the prison system, the inmates and the people that keep it running. The on-site ophthalmology clinic has allowed more inmates to get the eye care that they need. I hope my work may inspire others in ophthalmology to care for this special population of patients, a population that needs to be seen, even if they are often kept out of sight.