Wall Street Journal - October 22, 1997
Mitchel Benson

But it's not the infected men and women behind the towering concrete walls and razor wire who worry her. It's the unknowing, the innocent and the not-yet-infected on the outside.

"I'm not on a mission to save prisoners," says Ms. Craig, a 45-year-old administrative assistant from Irvine who became a patient advocate after being diagnosed with hepatitis C in 1995. "I do not have a passion for who they are and what their issues are. But most of these people will be paroled. And most of these people will continue to spread the disease" upon their release from prison.

It is that concern -- that what is now largely an institutional epidemic could erupt into a full-blown public-health crisis -- that has driven Ms. Craig and others to attack the commitment of state Corrections officials to contain the spread of the deadly disease.

Their criticism comes at a time when one survey by state health officials suggests that more than 41% of the system's 155,000 inmates are infected with hepatitis C -- and there is no indication that the rate of infection is slowing down.

The fact that the outbreak of hepatitis C "shows no signs of diminishing is going to raise some serious questions with respect to their strategy at this point," says Chris Flammer, consultant to Sen. Richard Polanco, a Los Angeles Democrat who has scheduled a hearing on the issue for next week.

At the hearing, Ms. Craig is one of several witnesses who are expected to question why the Department of Corrections spent only $240,000 of the more than $2 million it requested and received last year to test and treat inmates infected with hepatitis B and C.

To make matters worse, Corrections had to return the unspent $1.8 million to the state's general fund after it failed to report back to legislators by last December's deadline on the number of inmates it had screened and treated and the costs of doing that work.

Corrections had identified only 765 inmates as having chronic hepatitis B or hepatitis C -- and conceded that the number was undoubtedly low. Of that total, the report said, a mere 24 inmates were being treated, the majority for hepatitis C. (Today, that number is 40.)

With an estimated 90,000 inmates being paroled from state prison every year, Ms. Craig is outraged that officials are not doing more. "The blame is within the Department of Corrections," she says. "I don't think they followed through on their own findings."

But Susann Steinberg, one of Corrections' top health officials, defends the department's actions, saying it has been hamstrung by confusion and disagreement within the medical community over the best ways to attack the disease. The expectation was that experts were going to lay out a precise regimen for combating hepatitis C. But "that didn't happen," explains Dr. Steinberg, an acting assistant deputy director in Corrections' Health Care Services Division.

What's more, Dr. Steinberg says she takes personal offense to the charges that Corrections isn't taking hepatitis C seriously. After all, she played a role in the survey of inmates that showed their ranks could be infected by more than 41%. And it was Dr. Steinberg and her staff who then followed up and prepared the formal request for the $2 million appropriation.

Corrections is trying to be "very proactive so that, to be perfectly honest, we wouldn't be criticized for the reverse," she says.

Robert Gish, a doctor familiar with Corrections' efforts, also believes the department is committed to tackling hepatitis C. But he says officials have encountered several complicated logistical problems, including some of their own making. For example, he says Corrections underestimated the size of the staff needed and the security risks involved in performing the large number of liver biopsies it proposed. Biopsies are a valuable pretreatment screening procedure.

"The logistics of getting liver biopsies of 40% of the prison population is a big deal," says Dr. Gish, a Corrections consultant and the medical director of the liver-transplant program at the California Pacific Medical Center in San Francisco. "I don't know that they sat down and did their math."

In addition, the protocol for treating inmates for hepatitis C -- which Dr. Gish and Corrections officials eventually wrote on their own -- requires prisoners to be drug- and alcohol-free for at least 12 months.

"They may be afraid" to do so many drug tests, Dr. Gish says, "because they may have to recognize another problem: What if a third of the people come up with positive screens for" drugs like cocaine, heroin, marijuana and methamphetamine? Drug use in prison, he adds, is "something they're going to eventually have to deal with."

Dr. Steinberg maintains that in prison today, "the use of injectible drugs -- I'm not saying it's zero, but it is extremely, extremely low."

Across the country, hepatitis C continues to be a conundrum for public-health officials and medical researchers. Nearly four million Americans -- 1.8% of the population -- have hepatitis C, including about 500,000 Californians.

Experts know that the disease attacks the liver, and that the virus is spread through contact with mucous and blood, especially from the sharing of injection-drug needles, cocaine paraphernalia, tattoos, body piercing and, in extremely rare instances, blood transfusions. The spread from sexual transmission is inconclusive.

And there is still no known vaccine to inoculate against the disease (unlike its better-known cousin, hepatitis B). While 20% of those infected with hepatitis C somehow clear the virus and cure themselves, the state-of-the-art Interferon drug therapy now being used helps no more than another 20% of infected individuals, in part because the virus mutates quickly and often.

An estimated 8,000 to 10,000 people will die from hepatitis C this year, and if current trends continue, deaths from the disease will surpass those from AIDS by 2000. The American Liver Foundation calls it the silent killer because symptoms -- including liver damage, lethargy and depression -- may not show up for 10 or 20 years, and by then it might be too late for treatment or even a liver transplant.

Despite the perplexing nature of the disease, some people familiar with the Department of Corrections say its stumbling over the inmate hepatitis C epidemic reflects a much broader problem: the department's anachronistic approach to health matters.

Officials with the nonpartisan Legislative Analyst's Office describe Corrections as a massive $3.5 billion-a-year institution that is being dragged ever so slowly into the modern medical era of managed care.

Consider this: At this time, there are no computerized medical records for inmates, who are spread throughout 33 prisons. That means they are tracked by nothing but reams of paper and cabinets full of manila folders in a medical, dental and mental-health-care system that will spend $462 million this year on its patients, or an average of $3,100 per prisoner.

In fact, until about three years ago, an inmate's health-care file didn't even follow him or her from one institution to another.

Corrections officials don't expect to assemble a complete, computerized Health Information System database until 2000 -- at the earliest. In the meantime, "I cannot tell you the total number of broken bones suffered [by inmates] last year, or even the total number of sick calls" to prison infirmaries, says Clifton Curry, who tracks inmate health care for the Legislative Analyst's Office.

And it's for that very same reason, Mr. Curry says, that neither he nor anyone else can say with certainty how many of the state's prisoners really suffer from chronic hepatitis C.

In its own hepatitis report, Corrections acknowledges that the estimate of 765 afflicted inmates was derived by cobbling together "four distinct databases that were not specifically designed for this purpose, and therefore we believe it is incomplete."

The controversy over Corrections and hepatitis C was prompted by a study of thousands of randomly chosen inmates who entered the state penal system between August and October 1994. That study, a joint project of the Department of Corrections and the state Department of Health Services, found that 1,972 of the 4,764 men and women tested, or 41.4%, had hepatitis C.

In turn, Corrections made its $2 million request to do further screening and then treat inmates. But Corrections didn't issue its long-awaited follow-up report until sometime last spring -- months after the deadline. The precise timing is unclear because the report is undated and unsigned and was delivered to legislative staffers without a cover letter.

Even then, its details were sparse. The report promised that a more thorough paper would come out in March -- even though that date had already passed by the time the original document was released. Dr. Steinberg now says that new information won't be ready until next month.

In the spring report, officials couldn't say how many liver biopsies had been performed on inmates. And they included no cost figures or estimates on treatment or screening.

It is omissions like these that have Ms. Craig, the patient advocate, worried and angry. If the disease isn't attacked more aggressively, she warns, "this isn't going to be the Department of Corrections' problem. It's going to be ...the whole state's problem."

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Inmate Epidemic

Inmates entering the California correctional system infected with Hepatitis C

Race/Ethnicity Number Tested Number Infected Percentage

Infected

MEN

Latino 1,425,574 40.3%

African-American 1,299,380 29.3

White 1,235609 49.3

Native American 52 30 57.7

Asian 23 6 26.1

Other 106 33 31.1

WOMEN

SUBTOTAL 4,140 1,632 39.4

White 227,132 58.1%

African-American 214 81 37.9

Latino 148,103 69.6

Native American 16 14 87.5

Asian 3 0 0.0

Other 16 10 62.5

SUBTOTAL 624,340 54.5

TOTALS 4,764 1,972 41.4

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Notes: The results are based on tests administered to inmates between August and October 1997 by the state Dept. of Health Services and the Dept. of Corrections. The Asian category includes Pacific Islanders; the Native American category includes American Indians and Alaskan natives.

Source: California Department of Health Services, Office of AIDS, 1996

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