(Note: This is Part 1 of a two-part series on initial health assessments.)
Nelson Mandela Rule #30 says something that to us might seem obvious:
A physician or other qualified health-care professional … shall see, talk with and examine every prisoner as soon as possible following their admission and thereafter as necessary.
The United Nations Standard Minimum Rules for the Treatment of Prisoners (unodc.org)
This is hardly a controversial point—health screenings on newly incarcerated individuals entering a correctional facility are necessary to identify special health issues, quarantine inmates with contagious diseases, and discover evidence of serious harm or of abuse. But like many of the Nelson Mandela Rules, this statement works as a general guideline and provides no specifics. What exactly should be done during an inmate’s first medical visit? What should the screener look for specifically? And, importantly, what happens after a screening identifies a problem?
How do we put this rule into practice?
A Note on Terms
We should first note that the terminology surrounding initial health assessments (IHAs) can be confusing. Different sources use different terms and concepts of what this first medical visit is—for instance, the National Commission of Correctional Health Care (NCCHC) uses the term “initial health assessment,” while the Convention against Torture Initiative (CTI) uses the term “initial medical assessment.” To avoid any confusion, we will be using the term “IHA” to refer to this first medical visit and health assessment.
An IHA is Not What It Sounds Like
Before we discuss how to screen new inmates, we have to emphasize here that screening is not as simple as a typical doctors’ visit. Facilities are often understaffed, and with new inmates constantly coming in, giving each one an in-depth assessment can easily overwhelm prison workers, who might then overlook inmates with serious health problems.
What, then, does screening realistically look like for a facility?
In 2021, a group of scientists from the University of Toronto, headed by psychiatrist Alexander Simpson, formed the STAIR model, a general five-step plan for how healthcare should be delivered in a correctional setting. The STAIR model took understaffing in prisons into account by separating a patient’s IHA into three parts before care is given:
- Screening: First, a new inmate would be given a quick evaluation to identify any immediate issues.
- Triage: If any serious issues are identified, the inmate is given a more thorough examination, called triage.
- Assessment: If needed, the inmate might be sent to a specialist for a more specific assessment.
These points definitely help guide IHAs, but again, we need specifics. How should an IHA actually be done on the ground level?
Step 1: Screening
According to the STAIR model, the purpose of a screening is to identify issues that could put the inmate in immediate danger. The NCCHC and CTI give several guidelines for this initial screening:
- New screenings must be done as soon as possible, but no later than seven days after entry.
- Healthcare staff should administer the screening, but trained nonmedical professionals like prison guards or social workers can also do screenings if there are no healthcare staff available. When this is done, however, they must be adequately trained and able to communicate with a health provider if needed.
- In some cases, another person must be in the room during the screening: For example, if the inmate being screened does not speak the language, an interpreter must be present.
Currently, there are no specific, universally-accepted standards on correctional health screenings—the NCCHC does not currently use the STAIR model, so there is little mention of what an initial screening should include. The Simpson study did, however, find two surveys that performed very well in identifying crucial health issues and needs in inmates: the Correctional Mental Health Screen (CMHS) and the Brief Jail Mental Health Screen (BJMHS). Whatever survey is used, screeners should evaluate for immediate health risks including:
- Severe mental illness, such as depression and psychosis
- Suicidal thoughts
- Alcohol or drug withdrawal
- Signs of bodily injury
A screening should also ask inmates what medicines they take and the doses. If the inmate cannot answer, the screener must ask for their prescribing psychiatrist or other provider, secure an ROI from the inmate, and find out immediately. This is imperative—inmates have died from not receiving their medications. In one especially egregious case, a man with a heart transplant was arrested in Florida in 2020. Dexter Barry told police, and then a nurse and a judge, that he needed his anti-rejection medicine to keep the transplant from failing. Barry never received his medicine, and he suffered a fatal heart attack just three days after his release from jail.
These initial surveys could mean the difference between life and death for inmates. However, they are not meant to be detailed health evaluations. If an inmate is flagged by a screening, they must be given a more in-depth examination by healthcare staff—and, just as importantly, care has to be given at some point.
What to do after an inmate screening? We’ll address that in our next post regarding Step 2: Triage and Step 3: Assessment.