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Prisons:3 6/7/07 2:57 PM Page 13 cluding a two-year stint at San Quentin during the roughest years there in the late 1970s, when riots erupted and violence was epidemic. In the end, she couldn't just walk away. Upland is driven by a personal and professional imperative to prevent medical neglect before it gets out of hand. She understands the system and what she has seen in her time both terrifies her and keeps her there. She's seen well-run healthcare plans within correctional walls and has also fought against shocking medical neglect. In addition to her regular job, Upland serves on the California Nurses Association Statewide Correctional Advocacy Group and is also one of a handful of nurses who works independently as a certified consultant and expert witness in correctional nursing, researching legal cases of medical negligence across the country. It's Upland's job to evaluate cases that have gone too far. "By the time [their cases] reach me, they're not suffering from neglect," she says. "I only see death cases." As she sits on the couch sipping cool water from a plastic bottle, she sinks deeper into the loveseat even though she knows she'll have to leave soon. She stares straight ahead, beyond the dining room table to the sharp fluorescent lights of the kitchen where a door leads to the garage and to her black SUV. It will take her back to the work she both loves and despises – back to nursing in the California prison system. y all accounts, the California Department of Corrections and Rehabilitation (CDCR) is in bad shape. Upland is just one nurse caught in the drama that has been raging within California prison healthcare system for decades, with tensions mounting over the past five years. Rampant medical neglect resulting in serious injury and death to prisoners in CDCR's care has compelled some nurses to leave. Others hang on for promised improvements to a system that is antiquated, ill-equipped, and out of control. Overall, registered nurses have been woefully sparse in the system. Until recently, prison RNs also earned about 25 to 30 percent less than nurses practicing in the private sector, with the most senior prison RNs topping out at about $75,000 annually. In 2002, U.S. Federal District Court Judge Thelton Henderson promised better conditions after hearing a landmark legal case filed by prisoners that rocked the state and revealed prison healthcare system abuses that had remained unexposed for decades. The largest-ever prison class action lawsuit, Plata vs. Schwarzenegger, alleged that the California Department of Corrections was violating the Eighth Amendment, which bars cruel and unusual punishment, by crippling and killing prisoners through gross medical neglect. According to the original complaint filed in 2001 by the advocacy group Prison Law Office, Marciano Plata, the lead defendant, endured medical neglect of injuries he sustained as the result of several falls. Despite severe head, neck, and back pain, Plata, who could not speak English, was repeatedly denied medical care and was forced to work until his knee buckled. Surgery was recommended by a physician but Plata did not receive surgery for 19 months. After Plata's operation, prison personnel forced him to walk back to his cell despite his medical history and the severe pain he endured. Plata continues to suffer from headaches, knee and back pain, but his story would prove to be just the tip of the iceberg. B M AY 2 0 0 7 Nine other named plaintiffs in the case suffered similar, and, in some cases, more severe abuse and neglect. Expert testimony during the hearing blew the lid off medical conditions inside the California Department of Corrections and Rehabilitation. Ample evidence was presented during the suit to indicate a significant rate of death in California prisons due to medical mismanagement. Widespread medical malpractice was revealed. Judge Henderson, who heard the case, delivered a stunning verdict, describing medical treatment in prisons as "horrifying" and "shocking." Henderson further found that the prison healthcare system was "broken beyond repair," causing an "unconscionable degree of suffering and death." The court also found that a California prison inmate dies every six to seven days due to grossly deficient medical care. In 2005, after years of issuing court orders to the state to compel them to provide constitutional standards of care to inmates but receiving little response, Henderson ordered that the California prison healthcare system be placed under the control of a courtappointed receiver who would oversee all aspects of prison healthcare. The appointment was unprecedented in the history of U.S. corrections. Henderson decided that the receivership would become the single most powerful post overseeing the medical actions of the California Department of Corrections and Rehabilitation. Charged with delivering constitutional care to inmates, the receivership was empowered to take any action to enforce the court order for constitutional care and an overhaul of the prison healthcare system. In all efforts to deliver care to prisoners, the receiver's orders, coupled with Henderson's rulings, would supersede the orders of the governor himself. In 2006, Henderson named Robert Sillen, the former administrator of Santa Clara County Medical Services, as the receiver. According to Upland and many prisoner rights activists, chief among the problems facing Sillen was the pervasive attitude that correctional functions be placed above the needs of patient care. In short, the well-being of the patient simply always came second to the system's mandate to punish and incarcerate the inmate. "If someone needs medication, but they want him in lock down, he's probably never going to get that medication," Upland says. Many of the problems in California's prisons would boil down to this conflict between corrections and care. Embodying the conflict was the role of the medical technical assistant, or MTA. The medical technical assistant classification soon became one of the most controversial issues in the history of the corrections department. Trained as both correctional officer and licensed vocational nurse, MTAs and other correctional classifications had been empowered by the system to direct care within the facility for the 70 years prior to the arrival of the receiver. Though laws had evolved outside of prisons to protect individuals and society, those protections did not reach inside corrections. For many years, correctional personnel had been working beyond their licensure and outside of accepted regulations governing the role of healthcare workers. Only registered nurses, nurse practitioners, and medical doctors are trained to assess patients and recommend a course of care. Licensed vocational nurses (LVNs) and medical assistants (MAs) are not permitted to assess patients. Prior to the Plata ruling, however, there were very few RNs working inside the California prison system. The healthcare system was predominantly run by doctors, a few nursing supervisors, correctional personnel, and MTAs in their dual W W W. C A L N U R S E S . O R G REGISTERED NURSE 13