Death on the Installment Plan

Medical neglect, chronic disease, a hepatitis epidemic. Some Colorado prisoners pay for their crimes with their lives.

Terry Akers, an inmate at the Colorado State Penitentiary, learned that he had hepatitis C when his liver enzymes checked out "high" in 1998. But he was told his body seemed to be "fighting the infection adequately," and his treatment was delayed for months pending additional tests. Then he learned about the required classes, which weren't even offered at the time at CSP, the state's supermax. As the months dragged on, Akers developed cirrhosis and began vomiting blood. The DOC then denied his request for treatment because the disease had reached such an advanced stage, making it less likely that interferon would help him ("The Needle and the Damage Done," December 14, 2000).

Akers has endured a stomach swollen like a beach ball with excess fluid and debilitating cramps that have left him curled up on his cot, unable to walk. Earlier this year, he suffered a bout of encephalopathy that left him disoriented and incoherent for weeks. "No one expected me to make it," Akers wrote in a recent letter. "But I am determined to beat this disease."

Along with David Jenner and several other prisoners, Akers is now suing the state over its hepatitis policy. Another one of the plaintiffs, Anthony Rodriguez, has been seeking treatment for the virus within the DOC since 1993. For years nurses told him no treatment was necessary, based simply on examinations of his skin and eyes. After a blood test finally revealed his elevated liver enzymes, he waited another eighteen months for a successful liver biopsy. Although he qualified for interferon therapy, the drugs weren't ordered for another two and a half years -- and then Rodriguez learned he was receiving only half of the dosage that had been prescribed. Last year, medical staff decided that his infection wasn't responding to the drugs and ceased treatment while denying his request for an alternative drug regimen recommended by outside doctors.

Mark Andresen
Roderic Gottula devised the DOC's first hepatitis treatment policies a decade ago.
Brett Amole
Roderic Gottula devised the DOC's first hepatitis treatment policies a decade ago.

The state's approach to the epidemic troubles Rod Gottula, who developed the DOC's initial hepatitis treatment policies a decade ago. "Back then, the treatment was in its infancy," Gottula recalls. "We didn't test routinely for hepatitis C. If we had someone who had an abnormal liver-function test, we would sometimes run a hepatitis profile on them and find it that way."

But the original policy didn't require a lengthy series of substance-abuse classes, either. Gottula is now the acting president of a national association of corrections health-care providers, and he says several states have adopted more "advanced" treatment programs than Colorado's, with fewer delays in detecting and treating the virus.

"Their treatment is more aggressive," he says. "Some of them require substance-abuse treatment, too -- but if they do, they make it available. From a physician's standpoint, it makes no sense to take a substance abuser with hep C and spend thousands of dollars on interferon and not treat the primary problem. The main issue I have with the recent DOC policy is that they required the substance-abuse program but didn't make it available; nor were people told that they needed the program to be eligible for interferon."

Gottula understands why some states are moving slowly in responding to the epidemic. "In many systems, just the cost of treating hep C is more than their whole health-care budget," he says. "So while they don't necessarily deny treatment, they don't go out actively looking for people to treat. When you get down to it, this is really a public health problem, and public health agencies don't want to fund it."

McGarry responds that his staff is diligent about informing patients that they have the virus and what their treatment options are; it's the inmate's responsibility, he insists, to take the necessary steps to qualify for drug therapy. "We're not dealing with a disease that can be spread innocuously," he notes. "You don't get hepatitis C from someone sneezing on you. The public health implications of this are different than they are for, say, tuberculosis. There's absolutely no downside to these people being involved in a drug or alcohol program, even if they aren't going to get [interferon] treatment."

But the current and threatened litigation surrounding hepatitis treatment appears to be exacting changes within the DOC. Hartley, the attorney representing Akers and Jenner in their lawsuit, declines to comment on the case other than to confirm that the litigants are in settlement negotiations. McGarry acknowledges that the department is in the process of revising its treatment protocol, with the aim of setting specific timelines for tests and biopsies and making drug therapy more readily accessible to qualified patients.

Even prisoners with advanced cirrhosis, such as Akers, can now qualify for the drugs, based on new research that suggests interferon can help stall the ravages of the disease. Akers reports that he started drug therapy a few weeks ago and felt immediate improvement. More recently, though, the drugs "caused my platelet and white blood cell counts to drop to critical levels," he says. He's now receiving injections to counter the side effects of the anti-viral drugs.

Treating hep C can be grotesquely expensive. But not treating it can be even more expensive. The virus is the primary reason for liver transplants in the United States. Last summer the DOC reached an agreement with the University of Colorado Health Sciences Center concerning inmates who might be candidates for transplants. Although no prisoner has yet been accepted for the procedure, which can cost around $250,000, McGarry acknowledges that it's probably only a matter of time until suitable candidates are approved. Death row inmates such as Rodriguez wouldn't be eligible, but dozens of others could conceivably meet the criteria.

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