At the California Medical Facility in Vacaville, Chief Medical Officer Joseph Bick, M.D., oversees the care of 3,200 patients, including more than 500 who are HIV positive. This is no ordinary hospital -- the guard towers, razor wire and electrified fences surrounding the 600-acre complex testify to that. And so will the patients, all inmates serving state sentences for crimes that will keep some of them locked up for life.
It's a strange setting for a man who says he had never known anyone who had been incarcerated before he started in correctional health care. When he arrived at California Medical Facility as an infectious disease specialist in 1993, Dr. Bick discovered a chaotic situation: years of neglect, medical staff demoralized, HIV-positive inmates in open rebellion against poor care and lack of access to treatment drugs.
In the years since, Dr. Bick and his reconstituted staff of dedicated professionals, have turned California Medical Facility around. It has become a model for prison treatment of HIV/AIDS and boasts the largest correctional transgender treatment program in the world, with 40 to 50 male-to-female preoperative transgendered patients at any given time. Still ...
"I believe too little attention has been paid to the challenges of providing quality HIV treatment in the correctional setting," insists Dr. Bick, noting restrictions on inmate possessions (including medications), regimented patient movement and institutional lockdowns that complicate care. Many inmates with HIV also are dealing with other illnesses. At California Medical Facility, three-quarters of the inmates have a history of drug abuse, 40 percent are infected with hepatitis C and 1 in 4 has tuberculosis.
Dr. Bick also points out that while new HIV medications have reduced mortality rates among HIV-positive inmates just as they have in the civilian population, infection rates for the incarcerated are still rising.
"In the correctional facility environment, we are prevented from providing people with the tools to protect themselves," he explains. "Though we know many engage in sexual activity while behind bars, we cannot, by law, even dispense condoms. The best we can do is try to educate them."
Dr. Bick and his staff work hard at that, even employing peer educators, HIV patients who they've trained to counsel fellow inmates. And they're dedicated to providing top-notch HIV treatment.
"We have a window of opportunity here in corrections heath care," he says. "We have people in a controlled environment. They're sober, not abusing drugs. They don't have to worry about rent, groceries or cab fare to get treatment. We can give people a chance to put aside things that brought them pleasure, but also got them in trouble; get treatment and focus on related issues like their mental and emotional health so that when they walk out of prison they have a shot at living healthy, productive, worthwhile lives."
Of course, not everyone agrees that convicted criminals deserve such concern. "Whether you care about prisoners or not," says Dr. Bick, "you should understand that you can't have a healthy society unless we provide inmates the best medical care possible -- especially with regard to HIV. First of all, they're still human beings, and most inmates are going to get out of prison someday." He notes that 20 percent of HIV-infected Americans and a third of those who are infected with hepatitis C or with active tuberculosis have been incarcerated.
"If they don't receive quality treatment and intensive education, they are only going to contribute further to the spread of disease. So, what better place is there than prison to focus our attention if we hope to improve the health of the nation?"
How long have you been practicing?
What's the best thing about your job?
Working with such a dedicated staff to bring quality whole-person treatment to patients who, because they are people convicted of crimes, are generally the last to be considered.
What's the worst thing about your job?
Dealing with bureaucracy. It can get very frustrating trying to provide quality health care in state organizations, especially in a corrections facility. There are so many rules and procedures to deal with.
What have been your greatest successes and failures in your work?
Success: Seeing a patient not only get better healthwise, but deal with the reasons that brought him to prison, go home and never return.
Failures: Seeing people we've treated get out and then return to prison. It's doubly disappointing because we find that the health gains those people have made while here have dissipated while they were out and they often return with more drug resistance, so they are actually sicker than before.
What is the biggest challenge you face as a clinician?
One big challenge is reaching every inmate who is HIV infected. There is no forced testing of inmates for HIV, so we only see the ones we diagnose or who disclose they are HIV positive. By most estimates, that means we see only one in three HIV-infected inmates. There are a lot of disincentives to disclosure. Admitting you have HIV may limit housing options, visitation privileges and work assignments, which is a really big deal because you get time off your sentence for working. But if you're too sick to work, what are you going to do? It literally changes your sentence. So many inmates don't disclose.
What do you think is the biggest problem people with HIV face today?
Overall, general lack of concern. I'd like to see correctional HIV care elevated to a public health issue, socially, governmentally and within medicine. Correctional public health is off the radar screen, and HIV in institutional settings is a big problem. I'd really like to see interns, residents and nurses all take rotations through prisons on their career path to being medical practitioners. It's there that you see the full spectrum of the medical, social, psychological and emotional issues that surround HIV.
Do you think prevention efforts are sufficient?
In the correctional facility environment, we are prevented from providing people with the tools to protect themselves. Though we know many engage in sexual activity while behind bars, we cannot, by law, even dispense condoms. The best we can do is try to educate them, and we work hard at that. We try to get them to engage in less risky sexual behaviors in prison, and try to convince them that when they get out they should take appropriate prevention steps. But a recent study by a group called Counterforce demonstrated that the majority of released prisoners are sexually active within a day -- and they don't use condoms. Perhaps if we accepted the reality of sex in prison and provided condoms, we could get at least some to exercise that option in and out of jail.
What treatment regimen would you choose if you had to begin treatment today?
That's a really hard question. It would really depend. In correctional health care you have to take an especially hard look at each patient's life situation. For a lot of my patients, HIV isn't the worst thing that's ever happened to them. Many have been abused as children, endured terrible family situations, seen horrific violence, abused drugs, suffered from mental problems. They never expected to see age 30. So when I tell them they are HIV positive, they are like, "So?" They know it's treatable and they have a lot of other issues to deal with.
If you jumpstart treatment and they don't buy into the regimen by taking their medicines appropriately, then you risk drug resistance problems later on. In the correctional facility, you have more control over the treatment regimen. But if the patient is released on parole, for instance, that institutional control is lost and the patient is left to his own devices to follow a regimen. If he doesn't, problems with drug resistance may develop and complicate further treatment.
What's the key to a great healthcare provider/patient relationship?
Trust. That's a commodity that's hard to come by in a correctional facility. The people who reside there don't have a lot of faith that anyone related to the system, even health-care providers, has their best interests in mind. Clinicians also have to trust their patients to a large degree. It takes a lot of time to build that two-way belief system, more than just a 15-minute examination. Doctors have to talk to the patients, get to know them and accept them for who they are. You can't account for their crimes, there are too many uncontrolled factors that may have led to them, so you can't be judgmental. You just have to let them know you are going to treat them like any other human being, that you are going to give them the best care you can, and never, ever lie to them. You have to treat people with respect and let them know you'll respect whatever decisions they make.
How do you feel about patients who take a proactive role in their own treatment?
Some of our patients are very well educated, and I love it when they ask, "Why do you want to do that?" or "Have you ever heard about this or that?" They read a lot, and we have a Peer HIV Library they can use. They don't have access to the Internet, but they'll pass questions on to people on the outside to look up for them.
Who was your all-time favorite patient and why?
I couldn't pick one. But I'd like to mention the work of our patients in our Peer Education Program. We train them to educate other prisoners about HIV, the risks of contracting HIV, the availability of treatment. They talk to every new inmate at intake and they run the Peer HIV Education Library. They are a big part of our team. They form a bridge. And it works. The inmates respond better to a peer. They're someone to whom they can relate. Plus, the peer educators have an opportunity to take their training and experience with them when they get out of prison and turn it into a vocation by becoming counselors in their communities. It puts a value on their time in prison, gives their life outside meaning and provides service to society.
What is the most important thing you have learned from your patients?
To respect them and any decision they make.
How do you maintain a positive outlook and avoid burning out?
I love my work, even the parts I hate. If I were single, I'd probably set up a cot here in my office. But you've got to have balance in your life. I'm fortunate that my wife and two children provide me that in a very loving way.
Who would you like to dedicate this award to?
The people who make up the entire HIV treatment program at California Medical Facility, a state prison in Vacaville. You've got to have a certain something special to make prison health care a career. The pay is terrible, the physical plant is awful, you can't even take a walk outside during the day for a breath of air. But we've got a truly dedicated group here. Our program includes internists, HIV specialists, psychiatrists, psychologists, social workers, a chaplain and staff from the pharmacy and laboratory. Plus we have 10 inmate peer educators and more than 50 inmate pastoral care service workers who attend to the spiritual, social and psychological needs of our terminally ill inmates. Together, we have built a program that provides state-of-the-art treatment to the inmates who have been entrusted to our care.
And I don't want to forget our custodial colleagues. To succeed, you have to have a partnership between the medical people and the people in charge of keeping the inmates in custody. You can only provide quality health care in prison when the warden, or the sheriff in local jails, is committed to it.
We'd like our readers to get a sense of you as more than just a clinician. Where did you grow up?
Overseas, the South, and mostly the Midwest. My dad was in the military and we moved a lot.
What did you want to be when you were a kid?
Always a doctor. My mom was a nurse and I think she'd whisper to me in my crib, "You're going to be a doctor." I didn't really know what that meant when I was young. But my mom would come home and talk about her day, her patients, and I guess it got into my blood.
What kind of work do/did your parents do?
Dad: Army engineer, West Point graduate. Mom: nurse.
When did you decide on medical school?
Definitely by high school. I majored in biology in college.
What made you decide to go into HIV care?
As I went through my medical training, I took a particular interest in HIV care and after residency, I went for a fellowship in infectious diseases. I got into correctional health care because my wife, now a nurse, and I were both studying in Chicago when we met. She was a California girl and couldn't wait to get back. So, when it came time for me to find a job, she drew a circle on a map in California and said: "Look there." And here's where I ended up. Before that, correctional health care wasn't even on my radar and that's sad. Every person deserves quality medical care.
Can you tell us a little more about your family?
My wife is a nurse who is homeschooling our six-year-old son and eight-year-old daughter.
What's the biggest adventure you ever had?
What book would you say has had the most impact on you?
Herman Hesse's The Journey East.