Aging inmates, hard cases and a violent environment contribute.
In his solitary confinement cell at Florida State Prison, Titus Smoaks was screaming and cursing and throwing his lunch around.
He urinated on the floor, defecated in his prison clothes and smeared feces on the cell door. When guards finally got him in the shower, he began spraying them with water.
A prison doctor said Smoaks was faking, so, over the next few days, a team of guards gassed him, off and on. To extract him from his cell, they doused him with pepper spray, jolted him with an electric stun shield, pinned him to the wall, knocked him to the ground, twisted his arms, shackled his feet and strapped him to a restraint chair.
The 25-year-old burglar ended up in the infirmary, where nurses stitched up a 2-inch gash on his right eyebrow. Finally, he was sent to a psychiatric prison where his mental crisis stabilized.
As Florida's inmate population gets meaner, crazier, sicker and older, health care workers scramble to meet the needs of more hard cases like Titus Smoaks.
They are locked in a system of contradictions:
The Department of Corrections tries to provide just enough medical care to avoid lawsuits, but that can mean giving inmates the best AIDS-fighting drugs available _ drugs that aren't affordable to many people on the street.
Florida spends millions each year on prison mental health professionals, while maintaining a solitary confinement system at maximum security prisons that some researchers say exacerbates, even causes, mental illness.
Doctors have performed surgery on death row inmates as little as two months before their execution. The last killer to die in the electric chair, 344-pound Allen Lee "Tiny" Davis, was put on a diet to help him get to his execution on time, then given a last meal of lobster tails with drawn butter.
"This place belongs to security and not to the doctor," said Dr. Victor Selyutin, who stood in the death chamber as Davis bled, then died. "I cannot change that; only Tallahassee can change that."
In the past two years, the corrections department has cut 200 health care jobs and is preparing for a new round of consolidations. Among other things, Corrections Secretary Michael Moore is recommending eliminating the Correctional Medical Authority, a semi-independent board that helps ensure adequate prison care and avoid costly lawsuits.
Even after the cuts, the state's prison care will remain above the standard of "necessary" care required by the Eighth Amendment ban on cruel and unusual punishment, said John Burke, Florida's deputy director of prison health services.
"We're providing more than Medicaid," Burke said. "The problem with the costs is what everybody in the health care industry is facing."
Prison leads to "early aging'
This year, 65,000 Florida prisoners will get $232-million in health care. And with an increase in the number of mandatory life sentences and an elderly inmate population expected to double in 10 years, there is no end in sight.
"If the trend continues as we all believe it will, we're going to have problems of all kinds," Burke said. "A 25-year-old diabetic who may cost us $5,000 a year today may cost us $40,000 a year 30 years from now. When he's 55, he may have vision problems, cardiac problems, amputations."
What's more, prison leads to "early aging" for inmates like "Tiny" Davis, 54, who developed high-blood pressure, arthritis and hearing loss during his 16-year death row stay. He was rolled to his execution in a wheelchair.
Early aging comes because many prisoners have long engaged in high risk behavior, including alcohol and drug abuse and a lack of preventive care.
"You take a 30-year-old kid paraplegic who was on the wrong end of a gunfight with police," Burke said. "Today he may cost $35,000 a year. After 20 years, you put a lot of prison stress on his body _ he's wheelchair-bound _ he may be costing us $80,000."
Already, the pressure is on. Prison caregivers _ the lifeline to inmates _ complain about bare-bones staffing, a violent environment and custodial concerns that sometimes make treatment tough.
Inmates have told auditors they fear retribution from corrections staff if they ask for medical or mental health care. During its survey of Okeechobee Correctional Institution in July 1997, for example, Correctional Health Authority staffers said guards allegedly impeded access to health care by threatening inmates and harassing nurses.
Elsewhere, auditors reported that prisoners talked of being slapped with punishment _ disciplinary reports, lockdown and even beatings _ for asking to go to a doctor.
Corrections administrators say some inmates lie for attention and others use insanity or medical excuses to get transferred to an air-conditioned prison. But they acknowledge that the medical staff at Charlotte Correctional Institution was counseled for inadequate care in an inmate's brutal death in 1997.
After John Edwards was beaten repeatedly by guards, he slashed his arms with a sharpened ID card. Then he was strapped naked to a bed and bled to death after nurses allegedly failed to stitch his wounds, take his vital signs or tell supervisors that he suffered trauma or possible abuse.
"It was an aberration," Burke said.
In July, convicted guard-killer Frank Valdes died after a fight with corrections officers at Florida State Prison. The Florida Department of Law Enforcement is investigating the death as a murder, and said last week it is looking into whether nurses helped corrections officers cover up the extent of Valdes' original injuries.
Where it started
The prisons' medical emergency dates back to the 1970s, when federal courts found many inmate health systems so primitive that they violated the Eighth Amendment ban on cruel and unusual punishment. Burke, a former Marine and health care risk manager, remembers the days when prison doctors could barely speak English and were willing to work for $55,000 a year.
In 1972, two inmates sued. Florida found itself entangled in a health care mess that would lead to 21 years of costly litigation. The state invested vast sums to bring its system up to constitutional snuff. Finally, Florida lawmakers _ in the midst of a hardening of national sentiment against parole and a lively debate about how much jail care is too much _ created the Correctional Medical Authority. The nine-member board, appointed by the governor, is aimed at helping administrators deliver care as cheaply as possible _ without triggering lawsuits or a riot.
In 1993, Judge Susan Black closed the lawsuit, returned control of prison health care to the state and put oversight responsibilities in the hands of the CMA.
Since then, prison care has "improved dramatically," Burke said. He credits a consolidation effort that assigns the sickest inmates to special facilities, those with dental problems to special facilities and those with AIDS to special facilities.
How great is the fear of litigation? Because of an inmate lawsuit in Mississippi, Florida DOC officials decided in 1997 to give some of the state's 2,298 HIV-positive inmates state-of-the-art AIDS medications _ protease inhibitors costing $300 a month.
Treating the mentally ill
According to a Justice Department report released last month, the nation's jails and prisons house 283,800 mentally ill inmates _ one of every six persons incarcerated. Prisons are catching some of the spillover from closed hospitals. More than other convicts, according to the report, mentally ill prisoners are more likely to commit violent crimes, be repeat offenders and serve longer sentences.
And they are more difficult to treat. Thomas Provenzano, the next killer in line for the electric chair, has spent 15 years on death row, sometimes on pyschotropic medications. According to prison records, Provenzano, condemned for killing an Orlando bailiff and paralyzing two others, has suffered from depressions, delusions, hallucinations and a sleeping disorder.
At times, the records say, he believed he was Jesus Christ. The prison psychologists' had these goals for him: follow rules and regulations; "acknowledge that he has performed no recognized miracles for 90 days." Now, other state psychologists say he was faking it.
At Florida State Prison, many of the 1,300 prisoners spend days, weeks, months _ and until Valdes' death last month _ years in confinement cells. Some cells have metal doors and have been likened to coffins, space capsules and dungeons. Inside, most of what can be seen is another wall. Human contact is minimal. Inmates tap into the gossip mill by plunging all the water out of their toilet and shouting down the pipe.
As researchers study the effects of sensory-deprivation conditions on inmates' mental health, Burke said confinement units nationwide will come under increasing scrutiny. The jury is still out, he said.
But prison advocates say the verdict is in: Inmates in isolation experience audio and visual distortions, hallucinations, aggressive fantasies, paranoia, suicide attempts and violent outbursts.
Before he was allegedly beaten to death, Valdes spent years off and on in solitary confinement at FSP, said his family's lawyer, Stuart Goldenberg. He said guards repeatedly tried to provoke Valdes and break him down.
Though it is not clear whether he had any trouble understanding instructions, Susan Cary, a prisoner attorney, said the mentally ill are trapped in a prison system they can't comprehend.
"These seriously mentally disturbed people sometimes don't understand what officers are telling them to do," she said. "The assumption by people in the system is that the inmate is lying if he says he wants to commit suicide. The assumption is he's faking illnesses to get better housing. And that's just obscene."
Burke said psychologists often disagree on which inmates are "management problems" lying about mental illness and which are truly ill. "There is only a very little difference," he said.
In the case of Titus Smoaks, the inmate who smeared feces, it was the prison warden _ not the psychologist _ who thought the inmate was nuts. After officers repeatedly gassed Smoaks in April, Warden James Crosby started asking questions. "I'm not trying to play doctor," he told his senior psychologist. "But he isn't acting like any normal person I know."
Eventually, they shipped Smoaks to a prison psych hospital, where he was medicated and stabilized, but there are a limited number of beds there. Smoaks was eventually moved back to lockdown, and wound up in more crises.
At a "max" like FSP, caregiving is a day-to-day war where prisoners sometimes wait hours to see doctors and nurses. In the infirmary, one patient with an IV in his arm was shackled to a bed to keep him from hurting himself, according to documents. One unshackled self-mutilator _ under 30-minute observation in the infirmary _ still found a piece of metal and stabbed himself. He survived.
"It's a culture where people with the most extreme behavior are often seen as normal," said Murdina Campbell, who surveyed FSP in 1996 for the Correctional Medical Authority.
Doctors and nurses juggle their ethical duty to provide "proper and humane" care against the realities of working behind bars. Take Dr. Selyutin, a Russian-born gynecologist who came to this country nine years ago. He sees prisoners with asthma and seizures. He sees "pieces of meat" _ with broken clavicles, broken legs, broken skulls _ after officers use force on "very violent" inmates. He tries to stay clear of the "psychos unless they swallow a piece of metal or a razor blade."
Selyutin sometimes finds himself making decisions based on security concerns rather than on medical needs. Recently, he handled the case of Robert Stokes, who was in the clinic with blood on his chest, arms and hands.
X-rays showed Stokes, 36, who has a tattoo of "BS" on his right shoulder and one of a heart on his left hand, had foreign objects in his rectum. Selyutin thought it was a razor blade and a lighter. Ever mindful of the prisoner's violent streak, the doctor had the guards uncuff the inmate, who had cut his stomach and forearm. Then he told Stokes, who is serving 25 years for murder, to remove the items himself. Even though that worked, Selyutin later said he probably should have done the procedure himself. Stokes was given a disciplinary report for mutilating himself. He is now in a prison mental health facility.
Selyutin said many inmates in the cellblocks need medicine but "we don't have enough personnel. One nurse cannot possibly do everything. But who cares? If Tallahassee doesn't care, who does?"
Burke disagrees. Not only is there adequate staff at FSP, he said, but the system's 128 doctors are more competent than ever.
Burke also said the department's overall suicide rate is the best of the nation's 10 largest prison systems _ "better than the general population and the military."
Even so, the Correctional Health Authority has raised questions about care of inmates at Florida State Prison, including two who hanged themselves after an assortment of warning signs were overlooked.
The authority's Paul Cornish said prison health care is a growing public health issue, for even though some inmates will grow old and die behind the walls, others are scheduled for release. Titus Smoaks is due out in 2006.
_ Times staff writer Jo Becker contributed to this report.