Despite decades of lawsuits and settlements aimed at forcing the Baltimore City Detention Center to provide proper health care to those recently arrested or serving short sentences, advocates for detainees returned to court because they say conditions remain inhumane.
Detainees were put at serious risk because of poor care, which might be linked to seven deaths since 2013, according to a review by lawyers for the American Civil Liberties Union and the Public Justice Center who filed a motion Tuesday in the U.S. District Court for Maryland.
"The number may be higher when we get complete medical records," said Debra Gardner, legal director for the Public Justice Center. "This is a system failure."
Problems found in a review of more than three dozen inmate cases included lack of timely medical assessments, interruptions of medications to control diseases such as HIV and diabetes, incomplete medical records, and shortages of supplies and equipment as fundamental as wheelchairs.
The assessment also found that some of the Baltimore buildings that make up Central Booking and the men's and women's jails had moldy showers, excessively hot and humid air, mattresses that could not be completely cleaned, and, at times, lacked working plumbing.
Many detainees were found to be washing their own underwear in buckets.
Such conditions fostered the spread of infections, and the lack of care often worsened chronic conditions, the assessment said. For example, detainees who had controlled HIV became sick again, diabetics suffered dangerous levels of glucose, and those with hypertension had spiking blood pressure.
"At the Baltimore city jail, the potential for infection is unacceptably high," said Elizabeth Alexander, a Washington civil rights lawyer who reviewed the detainees' medical records. "Broken toilets may not be fixed for weeks. Showers are often pest-infested and have black mold. Eating, sleeping and living in these conditions — particularly when health care is scant — is an extra and unconstitutional punishment for detainees."
The motion seeks to reopen a consent order issued in 1993 by the court and settled in stages over the years, with the last agreement in 2012. It asks the federal court to immediately require the state to improve the worst conditions.
Officials at the Maryland Department of Public Safety and Correctional Services, which operates the detention complex, said progress has been made, with an investment of $58 million to improve safety and security in the past decade.
Stephen T. Moyer, the department's secretary, said the Hogan administration had been in office for only four months and had met with attorneys for the detainees three times.
"I ... have only had four months to learn about these perceived issues," Moyer said. "I have high expectations of my staff to change the way we do business. I respectfully asked for time to address these concerns and was told no by plaintiffs' attorneys. We are committed to providing the best service to our clients and will remain committed to ensuring accepted standards are met."
Tuesday was the last day the ACLU could file to reopen the consent order under the terms of the prior agreements. The 1993 order, designed to resolve a case that dates to the early 1970s, required the state to clean up the jail facilities and revamp the way medical services are provided.
Those who study heath in prisons and jails say Baltimore is not alone in struggling to provide medical, substance abuse and mental health services.
Other big systems have been accused recently by advocates for detainees of failing to provide constitutionally guaranteed care, including a 10-facility jail complex on Rikers Island run by the New York City Department of Correction and the Illinois prison system, where Wexford Health Sources Inc. provides medical care.
In 2012, Pittsburgh-based Wexford also took over medical care for Maryland's corrections system under a five-year contract. The state is expected to pay the company $116.6 million for the services in fiscal year 2016, up from $107.6 million in fiscal 2013. Wexford, which was not named in the motion, did not respond to requests for comment.
Treating those who often go in and out of booking facilities or jails is particularly challenging because of the short stays and ill health of many detainees, the researchers said.
Up to 70 percent of the more than 43,000 people brought each year to Central Booking in Baltimore have a substance or alcohol abuse problem, according to state intake records. Up to 29 percent of inmates in all of the state's jails have a mental health problem.
According to national studies, detainees are known to have a higher incidence of chronic medical conditions.
There are about 11.8 million admissions to the nation's jails every year, the average stay is 36 hours and no one is supposed to stay longer than a year, said Liza Solomon, an HIV policy and research expert and principal associate at Abt Associates, an international research and consulting firm.
There has been more progress in stabilizing and treating offenders who go to prison for longer stays than for those who go to jails, she said.
"Jails are an intensely busy environment where people coming in and out may not have sufficient time to be assessed and treated," said Solomon, who added that there is often little effort made to link detainees to care upon release.
Missing medications for a couple of days is probably not an issue for HIV patients, for example, but any longer can be bad for the patient and the community as those infected can go home and more easily spread disease, she said. For other conditions, daily medication can be critical.
"The system still has a lot of holes," she said.
Some smaller corrections systems have the ability to focus more on medical and other conditions but still struggle with providing care, said Dr. Josiah Rich, a professor of medicine and epidemiology at Brown University's Warren Alpert Medical School and director of the Center for Prisoner Health and Human Rights at the Miriam Hospital in Providence, R.I.
That is true at the Rhode Island Department of Corrections, which employs a staff and contracts with Rich and other Brown physicians to provide medical care for all its prisons and jails. They take in 15,000 to 17,000 people a year, or less than 40 percent of those booked in Baltimore alone.
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Rich has run a clinic in the correctional system for 21 years and agrees that the population is tough to serve, with higher rates of infectious and chronic conditions, often untreated, than the population at large.
And jails and prisons are not meant to be hospitals for complex medical, mental health and substance abuse problems that are persistent in poor, largely black communities where people are arrested at higher rates, Rich said.
He said strong medical standards are lacking nationwide and compliance is largely voluntary, and often dependent on the courts for enforcement.
Within hours of detainees' booking, providers scramble to assess their health, make medical records, obtain copies of outside records, administer medications and "turn on a dime if we find an acute problem," Rich said.
"We do the best we can around the edges," he said. "It's not perfect here, not anywhere. To improve care, we really have to look at our heavy incarceration rate. We have no control over who comes in."