ROTTING AWAY

Thousands of New York inmates have hepatitis C. Only a few hundred
get treatment.

Jimi Hammerstein learned he was sick with hep C only after leaving
prison. photo: Cary ConoverIt's hard to imagine how a doctor could
miss Jimi Hammerstein's primary health risk. The graying Brooklyn
native spent most of the last 10 years upstate for slinging dope in
Park Slope--back when the neighborhood was still in transition. "I
remember when this neighborhood wasn't nothing like this," he says,
laughing as he sits in a drop-in center for ex-offenders on Fourth
Avenue, the Slope's still-gritty border with Downtown Brooklyn. "This
was like, dope land!"

Dope land's geography extended into the prison compounds Hammerstein
bounced between. His habit continued once he was inside, and just as
intensely. Most inmates snort heroin rather than inject it, but as
Hammerstein describes the scene, "You got the die-hard dope fiends
like I was, where there's only one way to fly. If you're going to do
any kind of substance, you might as well shoot it."

Hammerstein's commitment to the needle made him a textbook candidate
for two of the modern era's most aggressive communicable diseases:
HIV and hepatitis C--a deadly virus that, when left untreated, slowly
devours your liver. He tested positive for HIV back in 1989, before
he entered prison. He says he copped to the infection at the
beginning of his two bids, but he'd never heard of hep C and claims
no one-- certainly not corrections health officials--ever asked him about it.

Only after his release last year did the questions begin. "People
used to say to me, 'Oh, you're HIV; are you hep C too?' " Hammerstein
remembers. "I'd say no. And they'd say, 'Oh, that's unusual.' " He'd
shrug the idea off. "I'd been taking tests up north for years, and no
one mentioned anything about hep C." His doc on the outside finally
insisted he get tested, and in what should have been no surprise, he
was positive.

Like Hammerstein, thousands of prisoners around the country are
slowly dying from a wholly treatable disease because corrections
officials are doing everything possible to avoid caring for them. New
York is among the worst offenders, as by most estimates it boasts
more inmates living with hep C than any other state. But after years
of advocates and inmates fruitlessly lobbying for change, a series of
recent lawsuits, including a class action case now pending in federal
court, appears to have finally forced the state's hand.

Over the last three decades, hep C has been a stealthy but virulent
sidekick to its celebrity sister HIV. Nearly 3 million people
nationwide now have chronic infections--triple the HIV caseload. They
are uniquely concentrated in prisons: At least 14 percent of New
York's inmates are known to have hep C. And as these legions barrel
toward the disease's end stage, in which the inflamed liver turns
cirrhotic, they promise to collapse the teetering liver-transplant
market. Already, hep C is the number one reason for swapping out a
liver; the waiting list for transplants is 17,000 people deep and
growing. The sooner you start treatment, the less likely you'll need one.

In response to growing awareness about the epidemic--and its
concentration among drug users who cycle in and out of
incarceration--the state corrections department says it now offers
tests to all incoming prisoners whose profiles raise red flags, as
Hammerstein's should have. But even for those who get screened,
learning you've got the disease is where, for most, the process ends.
According to a Justice Department census, as of 2000, only about 300
of the state's estimated 10,000 hep C-positive inmates were being treated.

Prison health advocates charge this dismal rate is no accident.
Coincidentally or not, treating hep C is one of the more expensive
tasks in medicine. The multi-drug regimen can cost as much as $35,000
per patient. Corrections already spends almost $23 million a year on
AIDS meds, nearly 40 percent of its whole pharmacy budget.

Until mid October, when the department began revising its policies in
response to ongoing litigation, any inmate needing hep C treatment
who had a history of using drugs--as does almost everyone with the
virus--was required to first enroll in a six-month class for users.
The official approach, which has been slowly shifting over the last
couple of years, originally forced inmates to complete the course
before getting treatment. It was expansive and unbending: If you'd
ever done drugs or alcohol in your life, you had to take the class.

"You got guys that been in the system eight, nine, 10 years," scoffs
Rahiem (not his real name), a hep C-positive lifer at the
medium-security facility in Auburn who refused to take the drug class
and so hasn't gotten treatment. "They don't have no record of drug
use from disciplinary actions. But they're denied treatment." Rahiem
wears long gray dreadlocks and stares with measured intensity when
insisting that he last got high in 1973. But his old girlfriend once
got charged with smuggling whiskey into the visiting room, he says,
so now he's stuck with a user label.

"These rules are barriers that they set up," complains Romeo Sanchez,
a hep C-positive ex-offender who organizes prison activism at the New
York City AIDS Housing Network, "because they don't want to pay for it."

But as Robert Hilton found out, even if you go along with the rules,
the outcome is often the same: no treatment. Hilton is the lead
plaintiff in the new class action, filed in federal court on August 17.

Hilton began treatment for hep C at Bellevue in 2002. But a few
months after starting, he became homeless, and his treatment was
interrupted. In August 2004, he was locked up on a parole violation
and shipped upstate to Altona. Upon intake there, he underwent a
routine exam at which he told doctors about his infection, the
resulting liver disease, and his treatment history.

But the medical staff waited two months to conduct its own tests,
according to the complaint, and a full seven months to recommend him
for treatment. Then Chief Medical Officer Lester Wright ruled Hilton
couldn't start until he took drug addiction classes, even though no
previous doctor in or out of the system had suggested it and even
though Hilton professed to have not used drugs in 13 years--much of
which time he spent passing drug tests as a parolee.

Hilton acquiesced and signed up for the class--only to be put on a
lengthy waiting list. He was then transferred to another facility,
where counseling staff again tried to enroll him in an addiction
class. This time, his enrollment was turned down because he would be
eligible for parole before the class finished. "As antiretroviral
treatment continues to be denied on the basis of this catch-22," the
class action complaint notes, "Mr. Hilton's liver continues to deteriorate."

The state declined to comment on this and other suits it now faces.

In previous suits, the corrections department has offered a
reasonable-sounding defense. Hep C treatment is no joke--at least a
shot a week and daily pills that can cause depression and flu-like
symptoms similar to those of heroin withdrawal. Even the regular
needle use can be traumatic for someone kicking an old habit. So the
department worries about triggering relapses. And all credible
medical guidelines stress that no one who's actively using drugs or
alcohol should start treatment without getting sober, lest they fail
to complete the regimen.

The stakes are high: If you start and don't finish, your virus will
likely mutate, developing the sort of drug resistance we've heard so
much about with HIV.

Critics, however, point out that all of the guidelines cited by
corrections warn only against treating active users. The concern over
relapse is the department's own.

In early November, the prison officials submitted a sweeping policy
change to the U.S. District Court for the Northern District of New
York, asking that a central part of Hilton's case be dismissed based
on that change. The new policy removes the drug abuse class
requirement but maintains an insistence that inmates have "no
evidence of active substance abuse" in the previous six months. Those
with evidence of such will be evaluated on a case-by-case basis.

Alexander Rienert, an attorney with Koob & Magoolaghan, which is
leading the Hilton class action and has led a number of previous hep
C suits, says that's not near good enough. He wants to see a far more
detailed portrait of how the system will scale up treatment--and how
it will get those it has previously turned away into treatment. "What
Dr. Wright is saying is, trust us, you don't have to be involved
anymore," scoffs Rienert. "But our experience is, the only time an
individual gets treated is when an attorney has stepped in."

Moreover, Rienert says he's already received at least one new
complaint from an inmate who has been denied treatment based on his
failure to take a drug abuse class.

Milton Zelermyer, a staff attorney with Legal Aid's Prisoners' Rights
Project, adds that there remain plenty of ways for corrections to
ration treatment. Already, the prisons only test certain inmates for
hep C, and as Hammerstein's experience shows, many likely candidates
slip through unscreened. But effective hep C screening and treatment
also require extensive diagnostics, including regular blood tests and
a liver biopsy--just the sort of thing the department delayed for
months before denying Hilton based on the drug class rule. So the new
policy looks like progress, Zelermyer says, but "how it works in
reality is another question."

Prison health advocates say the system's failure to deal adequately
with hep C is just the latest disaster to come from letting prison
guards control public health. Even as the narrow legal battle over
hep C intensifies, advocates are pressing a broader legislative
reform. Of course, for activists in Albany, reforms for guys like
Rahiem and Hammerstein and Hilton have been the most dead on arrival.

The corrections department's health care challenge is already
massive--it runs what amounts to the nation's largest HIV medical
practice, for instance. Yet it is exempt from Department of Health
oversight because state law considers its facilities more akin to
private colleges than public hospitals. The state assembly wants that
law changed, but neither the health department nor corrections wants
to be part of an arranged marriage; bills calling for it have twice
stalled in the senate.

And that leaves dying inmates' futures in the hands of the courts.
"There could be something out there for you--whatever medicine,
whatever program, whatever doctor you have to see--and they ain't
telling," Hammerstein complains, "because the facility don't want to
go for the money."