Diabetes behind bars: challenging inadequate care in prisons

Abstract

Worldwide, more than 10 million people are held in prison or detention. In the USA, where various social and criminal justice policies have led to huge growth in the prison population since the mid-1970s, the current incarcerated population is well over 2 million, with a higher proportion of the national population imprisoned than in any other country. Data from 2011–12 show that prison and jail inmates are more likely than the general population to have chronic conditions or infectious diseases, while most inmates are overweight or obese and more than a quarter have high blood pressure. The proportion of inmates reporting having ever had diabetes or high blood sugar in 2011–12 was 899 per 10 000 prisoners, almost twice the rate reported in 2004 (483 per 10 000). On March 6, the American Diabetes Association (ADA) joined an ongoing class-action lawsuit against CoreCivic, the second-largest prison management firm in the USA. The suit relates to inmates with insulin-treated diabetes held at Trousdale Turner Correctional Center in Hartsville, TN, where it is alleged that severely inadequate health care constitutes “cruel and unusual punishment”, violating inmates' constitutional and other rights. The suit alleges poor or absent training of health-care staff, inadequate access to insulin, and lack of coordination of blood glucose testing and insulin administration with mealtimes. Unfortunately, this situation is far from unique. Previous media reports have highlighted many other examples of inadequate care or outright denial of needed intervention in imprisoned people with diabetes—including deaths associated with diabetic ketoacidosis or hypoglycaemia. For example, last year, a former jail administrator in Oklahoma was sentenced to more than 4 years in prison following his decision not to take an inmate with diabetes to hospital, resulting in his death in 2013. But even for patients who do not face acute crises and risk of death, suboptimal treatment of diabetes in prison can lead to poor glycaemic control, increasing the risk of complications. Last year also saw the filing of a suit by the American Civil Liberties Union and others regarding overcrowding in Nebraska prisons contributing to inadequate health care and other concerns, including one prisoner who lost their sight after reportedly being denied adequate treatment for diabetes. Appropriate training and resources to enable good quality care of incarcerated people with diabetes is essential. In 2011, the ADA published an updated position statement on diabetes management in correctional facilities, intended to help prisons to ensure care is provided in keeping with national standards. Recommendations include intake medical assessment, diabetes screening, uninterrupted continuation of treatment, and training of staff to recognise and respond to acute crises. The ADA also recommends provision of diabetes self-management education and availability of healthy food options, as well as consistent carbohydrate content of meals to enable nutritional management. Unfortunately, despite the existence of diabetes management guidelines from the Federal Bureau of Prisons, provision of such care is highly variable and often lacking. The use of private contractors and limited budgets creates incentives for cost cutting that can undermine the health of people with diabetes and other prisoners, including through low-quality food from outsourced contractors, formulated to cost as little as possible. Imprisoned people should not have to suffer from inadequate health care. In the US context, prisons are one of the few places where access to health care is guaranteed by law, thus representing a potential opportunity to improve the health of vulnerable populations. With proper funding and enforced regulation, the prison environment could be used to improve population health through disease screening, education, routine access to medical treatments, and lifestyle interventions including healthy foods and physical activity. In one recent example in Los Angeles, CA, an overhaul of the county jail system is intended both to improve health services and to use the short time inmates spend in the system to equip them to better manage their health—including chronic conditions such as diabetes—on returning to the community. However, such approaches need to be broader in scope, and be applied universally, including for people serving long-term sentences in the prison system. The ADA hopes that the lawsuit against CoreCivic, if successful, could help to establish a national standard of care for facilities across the country. This would be an important step, but improvements in funding and regulation will also be necessary to address these issues at a national level. For people with diabetes spending time behind bars, such system-wide changes cannot come soon enough.