VI RESTRAINTS
 
 
 
 

"Chains or irons shall not be used as restraints. Other instruments of restraint shall not be used except in the following circumstances:
(a) as a precaution against escape during a transfer...
(b) on medical grounds by direction of the medical officer;
(c) by order of the director, if other methods of control fail, in order to prevent a prisoner from injuring himself or others or from damaging property....
(Instruments of restraint) must not be applied for any longer time than is strictly necessary."
Rule 33, United Nations Standard Minimum Rules for the Treatment of Prisoners

"Giving birth while incarcerated was one of the most horrifying experiences of my life. While enduring intense labour pains, I was handcuffed while being taken to the hospital, even though I was in a secured vehicle with a metal grating between the driver's and passenger's compartments and with no interior door handles on the passenger doors. With the handcuffs on, I could not even hold my stomach to get some comfort from the pain...At the hospital I was shackled to a metal bed post by my right ankle throughout seven hours of labour, although a correctional officer was in the room with me at all times. The shackles were not removed until 30 minutes prior to my delivery...Imagine being shackled to a metal bedpost, excruciating pains going through my body, and not being able to adjust myself to even try to feel any type of comfort, trying to move and with each turn having hard, cold metal restraining my movements. Not only was this painful, it was traumatizing, and very stressful for myself and also for my child...Even animals would not be shackled during labour, a household dog or a cow on a farm..The birth of a child is supposed to be a joyous experience, and I was robbed of the joy of my daughter's birth..Is it really necessary to handcuff and shackle mothers who are in labour? With all the other security measures that were in place, and with my minimum security status, did they really have to put me and my infant through that torture?"
Statement of Warnice Robinson, imprisoned in Illinois for shoplifting [ Warnice Robinson was speaking in Washington DC on 6 October 1998 at the launch of Amnesty International's report, United States of America - Rights for All, AI Index: AMR 51/35/98.].

1.    The use of restraints on pregnant and sick inmates

On 18 November, 1998, Amnesty International delegates visited Madera County Hospital in California. Prison officials took them through a ward where women are held when they are seriously ill or in labour and for a short period after giving birth. The ward is locked. Inside the ward are four armed guards. Yet every woman is chained by a leg to her bed. A woman showed the Amnesty International delegates her shackle. She could lie on her side but she could not roll over. Prison officials explained to the delegates that the shackle is removed only if a doctor informs them that it is interfering with medical treatment or is injurious to a woman's health. Shortly before Amnesty International's visit, the organization received a report from a lawyer that at the same hospital in 1998 she had seen a woman who was shackled having a seizure and that guards refused the request of nursing staff to remove the restraint.

The sick women chained to their hospital beds in California are not an exception. Around the USA, jails and prisons commonly use restraints on incarcerated women when the women are being transported to and kept in hospital. In Illinois in October 1998, a woman who was recently incarcerated in a prison in that state told Amnesty International that earlier in the year she had been taken handcuffed to a hospital for surgery and was shackled to her bed when she woke from the anaesthetic.

The same policy is in place in Chicago's Cook County jail. In November 1998, in relation to a lawsuit, an officer of the Cook County Sheriff's Department was asked about the Department's policy on the use of restraints on jail inmates in hospital. He described it as follows:
 

Q. (question from the lawyer seeking information): Once the medical staff has determined the (inmate) should be in Ward X, what, if any, arrangements are made to secure that person by the sheriff's department?
A. (answer by the officer): We would place an officer, individual officer, on an individual patient, and we would restrain the inmate via handcuff and leg shackle.
Q. Is that always the case or usually the case that you restrain them?
A. When there's a medical condition that precludes us from securing a patient, then there would be an exception.
Q. Okay. Can you give me an example?
A. If an inmate has no legs, we would not put a leg shackle on them.
Q. Okay. Let's say that the person was in a coma but alive. Do they get restrained?
A. Yes.
Q. Let's say a person has just had a heart attack and is recuperating but is so weak they can't get out of bed. Do they get restrained?
A. Yes [ Deposition of Daniel Thiesen relating to the case of Rivera v Sheahan et al, US District Court for the Northern District of Illinois, Eastern Division, No. 97 C 2735. The interrogation was conducted in relation to legal action over the use of restraints on a jail inmate with AIDS who was rushed to hospital for urgent treatment. Amnesty International has been informed that she died several months later.].
As these and other reports indicate, jails and prisons use restraints on women as a matter of course, regardless of whether a woman has a history of violence (which only a minority have); regardless of whether she has ever absconded or attempted to escape (which few women have); regardless of her state of consciousness [ Data concerning women's offences is presented in chapter 3. Concerning escapes, the State of New York Department of Correctional Services reports that in the period 1991-95 all escape and attempted escape incidents involved male inmates. In 15 years to 1997 there had been only three escapes or attempted escapes at female prisons - State of New York Department of Correctional Services, "Female Offenders: 1995-96," Albany, New York, 1997.]. While exceptions are made if a doctor asks on medical grounds, Amnesty International has received reports of cases where a doctor was not present to request the removal of restraints in circumstances where approval would generally have been given or a guard with a key was not immediately available. For example, Amnesty International received the following statement from "Maria Jones," a recent inmate of Cook County jail in Illinois [ Not her real name. The statement was made to a visitor and provided to Amnesty International.]. Maria Jones was charged with violating drug laws and stated that she had never tried to escape or been charged with a violent offence or been classified as dangerous. She had a prior conviction, in the 1980s, for shoplifting. Nevertheless, she was always placed in handcuffs and leg shackles when she was taken from the jail to hospital for pre-natal care and to give birth, as she describes:
 

"I told the nurse that my water broke, and the officer took off the handcuffs so that I could put on the hospital gown. I was placed on a monitoring machine with the leg shackles still on. I was taken into the labour room and my leg was shackled to the hospital bed. The officer was stationed just outside the door. I was in labour for almost twelve hours. I asked the officer to disconnect the leg iron from the bed when I needed to use the bathroom, but the officer made me use the bedpan instead. I was not permitted to move around to help the labour along.
 

"I was given an epidural, and I carefully moved into a sitting position while dealing with the leg iron. While the needle was still in my back, I felt a strong contraction and I knew that the baby was coming. When I told the nurse, she told me not to push and said that the baby wasn't coming yet. I asked for the doctor and worked the leg chain around so that I could lay down again.
 

The doctor came and said that yes, this baby is coming right now, and started to prepare the bed for delivery. Because I was shackled to the bed, they couldn't remove the lower part of the bed for the delivery, and they couldn't put my feet in the stirrups. My feet were still shackled together, and I couldn't get my legs apart. The doctor called for the officer, but the officer had gone down the hall. No one else could unlock the shackles, and my baby was coming but I couldn't open my legs.
 

Finally the officer came and unlocked the shackles from my ankles. My baby was born then. I stayed in the delivery room with my baby for a little while, but then the officer put the leg shackles and handcuffs back on me and I was taken out of the delivery room.

I was in the hospital for about three days, with one hand and one foot shackled to the bed. There was a heavy blue box connecting the cuff with the bed, which left me no room to move. My handcuffs were removed when I was eating or holding my baby, but the leg irons were always on. My leg was disconnected from the bed only when I used the bathroom. Otherwise I was handcuffed and shackled, with one hand and one foot shackled to the hospital bed. Since I went back to the jail, every visit with my baby has been through the glass. I have not been permitted to hold my baby since my release from the hospital."
Amnesty International also received reports that six women were restrained while in hospital waiting to give birth in New York City in 1998. The women were reportedly restrained despite the fact that none of them had a history of violence or had attempted to escape from custody: the policy of the New York City Department of Corrections prohibits the use of restraints on pregnant inmates admitted to hospital for delivery "unless the inmate attempts to escape at the hospital or the inmate engages in violent behaviour at the hospital which presents a danger of injury," [ City of New York Department of Corrections Directive 4202 (19 June 1989).The women were interviewed by Reverend Annie Bovian, of the Women's Advocate Ministry in Courts and Jail, an organization assisting incarcerated and recently released women in the State of New York. ]. According to the reports, one of the women gave birth while handcuffed to her bed in the labour room, unattended, screaming for assistance. Another was put into handcuffs while labour was being induced. The report continued:

"They took the handcuffs off when the baby was about to be born. After the baby was born she was shackled in the recovery room. She was shackled while she held the baby. Had to walk with shackles when she went to the baby. She asked the officer to hold the baby while she went to pick something up. The officer said it was against the rules. She had to manoeuvre with the shackles and the baby to pick up the item. In the room she had a civilian roommate and the roommate had visitors and she had to cover the shackles, she said she felt so ashamed....She said she was traumatized and humiliated by the shackles. She was shackled when she saw her baby in the hospital nursery (a long distance from the room). Passing visitors were staring and making remarks. She was shackled when she took a shower; only one time when she was not."

A third woman reported that she was shackled to the bed after the birth of her baby by caesarian section even though a doctor had requested that, because of her surgery, she be allowed to walk around. A fourth woman said she was shackled in the recovery room and while she held her baby. She said she felt traumatized and humiliated by the shackles when she went to see her baby in the nursery which is located in a public area.

The use of restraints on women who are about to give birth endangers the woman and her child, as described by physician Dr Patricia Garcia:
 
 

"Women in labour need to be mobile so that they can assume various positions as needed and so they can quickly be moved to an operating room. Having the woman in shackles compromises the ability to manipulate her legs into the proper position for necessary treatment. The mother and baby's health could be compromised if there were complications during delivery, such as haemorrhage or decrease in fetal heart tones. If there were a need for a C-section (caesarian delivery), the mother needs to be moved to an operating room immediately and a delay of even five minutes could result in permanent brain damage for the baby. The use of restraints creates a hazardous situation for the mother and the baby, compromises the mother's ability post-partum to care for her baby and keeps her from being able to breast-feed." [ Dr Garcia is an obstetrician and gynaecologist at North Western University's Prentice Women's Hospital; her statement was provided to Amnesty International by Chicago Legal Aid to Incarcerated Mothers, December 1998.].
Amnesty International welcomes the fact that a growing number of corrections departments acknowledge that special attention is required for pregnant prisoners. In a recent national survey, 20 of the 52 state, city and federal corrections departments that responded reported that they have specific policies or procedures for the physical control and transportation of pregnant inmates [ They are: Colorado, Connecticut, Delaware, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Mississippi, New Hampshire, New Mexico, New York, New York City, North Carolina, Ohio, Oklahoma, Rhode Island, Utah, Washington, Wisconsin and the US Bureau of Prisons: US Department of Justice National Institute of Corrections Information Center, Current Issues in the Operation of Women's Prisons, National Institute of Corrections, Colorado, 1998.]. In 38 systems, medical personnel are involved in evaluating individual cases prior to the restraint of pregnant women. However, policies for pregnant women that Amnesty International has seen still permit the routine use of restraints without consideration of the necessity for restraints to be employed.

For example:
 
 

*    Ohio The state correctional authority informed Amnesty International that pregnant inmates are scheduled to deliver their babies at the Ohio State University Hospital and "are treated as any patient would be treated regarding procedures during labour and childbirth. The exception is one arm or leg is secured to the bed during labour unless the doctor requests the restraints be removed. During delivery, there are no restraints on the inmate." [ Letter to Amnesty International from L Jones, Human Services Administrator, Ohio Department of Rehabilitation and Correction, March 26, 1998, emphasis added.].
 
 

*    Massachusetts The policy of the correctional authority provides that during their second and third trimester, pregnant inmates are to be transported to hospital only in handcuffs. The policy prohibits the use of restraints on inmates in hospital who are in active labour unless they are disruptive[ Letter of 11 June 1998 from W Saltzman, Senior Litigation Attorney, Massachusetts Department of Correction with departmental policy, to Amnesty International.].
 
 

*    Kentucky In contrast, the policy of the Kentucky correctional authority is that pregnant inmates may not be restrained from the time they enter labour and the delivery area until they leave the recovery room. However, after leaving the recovery area, "one leg may be restrained." [ Memorandum from George Million, Deputy Warden/ Security, 1 February, 1996.].
 
 

*    Michigan Women who gave birth while in prison in Michigan told Amnesty International in October 1998 that they were transported to the hospital secured by belly chains and handcuffs, and were kept in restraints at the hospital even though they were constantly supervised by prison guards. One woman reported that she was handcuffed to the hospital bed until she was close to delivery, and that the cuffs were removed at the request of a doctor. A second woman reported that, at the hospital, her legs were chained together until shortly before she gave birth. She told Amnesty International that the restraints were removed at the request of a doctor and only after the guard had obtained approval by telephone from a superior officer. Both women reported that they were cuffed to their beds shortly after giving birth. In November 1998, Detroit City Council passed a resolution calling on state governor, John Engler, to ban the use of restraints on pregnant women before and during labour. The head of the Michigan Department of Corrections has stated that he is not aware of cases where prisoners who were shackled while giving birth [ Letter to Amnesty International from Kenneth L McGinnis, Director, Michigan Department of Corrections, 1 November 1998.]. Amnesty International is seeking a detailed account of the Department's policy.
In March 1998 the Illinois Department of Corrections informed Amnesty International that all pregnant prisoners were restrained when being transported to hospital and kept in restraints while in hospital, even when in labour, unless a doctor asked for them to be removed and a correctional officer approved. During the course of 1998, legislators drafted proposed laws to prohibit the use of restraints on pregnant women when they were being transported and in hospital, and on women in hospital after giving birth. In January 1999, the Department of Corrections informed Amnesty International that it was preparing a new policy to stop the use of restraints on pregnant women while being transported and in hospital. The policy will apply only to prisons. It will therefore not apply to Cook County jail, the policy of which was described at the beginning of this chapter.

In October 1998, Amnesty International wrote to the US Attorney General, Janet Reno, requesting an inquiry into the use of restraints on pregnant women prisoners. The letter was referred for response to the section of the US Department of Justice that is responsible for enforcing federal criminal civil rights laws. The chief officer of the section informed Amnesty International that the section was unable to authorize an investigation because the information concerning shackling "does not disclose a prosecutable violation of federal criminal civil rights statutes." [ Letter to Amnesty International from J Mott, Acting Section Chief, Criminal Section, Civil Rights Division, US Department of Justice, 22 October 1998, emphasis added.]. Amnesty International acknowledges that the routine use of shackles on pregnant women does not violate criminal laws. It considers that an inquiry is warranted because the practice violates internationally recognized human rights standards which the USA should respect.

2.    Other concerns about the use of restraints

The use of restraints on women who are pregnant and women who are ill is part of a pattern of the use of restraints in prisons and jails and by police agencies that Amnesty International considers constitutes cruel, inhuman and degrading treatment in contravention of international standards. Some authorities in the US use chains or leg irons, restraints that are expressly prohibited by international standards [ Rule 33 of the United Nations Standard Minimum Rules for the Treatment of Prisoners specifies that "chains or irons shall not be used as restraints."]. In a recent report on human rights violations in the USA, Amnesty International described human rights concerns about the use of restraints because of the nature of the restraint or the manner in which it was being used [ United States of America - Rights For All, AI: Index AMR 51/35/98.].

(i) The restraint chair

Some of the most serious abuses have involved a mechanical restraint chair which allows prisoners to be immobilized with four-point restraints securing both arms and legs, and straps which can be tightened across the shoulders and chest.

Amnesty International's concerns include reports that the chair was used to torture and ill-treat more than a dozen inmates in Sacramento County Jail, California, between 1995 and 1997. According to a lawsuit filed against the Sacramento County Sheriff's Department, a disproportionate number of the victims were women and members of racial minorities. The complaints allege that unresisting detainees, most of whom had been arrested for minor offences, were strapped into the chair for hours as a punishment [ The chair was used after the detainees had reportedly exhibited only mildly challenging behaviour, such as complaining about their treatment; failing to respond quickly enough to commands and, in one case, asking for a lawyer.]. Many of the victims had masks held over their faces while being placed in the chair or were hooded. They were denied bathroom facilities, food and water, and were subjected to taunts and sexually derogatory remarks by guards. Some of the victims are reported to have suffered serious injuries as a result of being held in the chair in straps and shackles which had deliberately been pulled too tight. Cases include:
 
 

*    A 32-year-old Caucasian woman with a heart condition was held in the chair for eight and a half hours in December 1995. She was allegedly forced to urinate on herself after pleading repeatedly to use the bathroom and was cursed at and taunted by guards. She is reported to have suffered cuts to her shoulders and damage to her wrists, feet and ankles from the tight leather straps and metal cuffs.
 
 

*    A 38-year-old woman from the Dominican Republic was strapped into the chair in May 1996 after a guard overheard her complaining to a nurse about her treatment. Despite suffering from asthma, she was bound, temporarily hooded, and left in a restraint chair for five hours during which period she reportedly had breathing difficulties and was taunted by guards. She is reported to have suffered numerous bruises, swellings and pain as a result of being held in the chair.
 
 

*    A 30-year-old African-American woman with a thyroid complaint, was stripped naked by male and female guards and strapped into a restraint chair where she was left with a hood over her head for eight and a half hours in May 1997. The chair was placed in the centre of an illuminated room with a floor-to-ceiling window through which she was allegedly stared at and jeered at by male guards and other employees, including outside contract workers. She was forced to sit in her own urine which deputies later made her clean up using only her jail-issue T-shirt and bare hands.
Negotiations to settle the lawsuit in these and other cases were underway in February 1999. Meanwhile, the chair continues to be used in the jail. Amnesty International has received reports of misuse of the restraint chair in other US prisons and detention facilities and several inmates have died after being placed in the chair (see USA: Rights For All, 1998). Other cases include that of Annette Romo, who alleged that she was brutalized and placed in a restraint chair while in pre-trial detention in Estrella Jail, Maricopa County, Arizona, in June 1997, after she complained to guards about conditions in her jail unit and asked to be transferred. This was two months after she had lost her baby due to alleged medical neglect in the same jail.

Amnesty International has called for the chair to be banned in the Sacramento County Jail pending a full, independent inquiry. It has also called on the federal authorities to institute an urgent national inquiry into use of restraint chairs, in US prisons and jails[ See United States of America - Rights For All, AI Index: AMR 51/35/98.].

(ii) Electro-shock devices

Other forms of restraint about which Amnesty International is concerned are electro-shock devices. In one case, Amnesty International received a report that at Muncy Prison, Pennsylvania in 1996, an "Electronic Body Immobilizer Shield" (EBID) was used against a prisoner who was in distress after she was informed of the scheduled date of her execution. Amnesty International wrote to the Pennsylvania Department of Corrections expressing concern that an electro-shock device had been used against a female prisoner who, according to reports, was not threatening other people. The authorities responded that the device was used because the woman "was displaying significant injurious behaviour and was refusing all orders given by the supervising commissioned officer." [ Letter from M Horn, Secretary of Corrections, September 18, 1998.]. As well, the head of the Department of Corrections explained:
 

"The EBID shield was utilized as the least amount of force necessary to gain control of the inmate and have her comply with the orders. This shield is a non-lethal defensive device and was used in compliance with Department of Corrections Use of Force Policy, including appropriate documentation and review."
On 17 March 1998 and 14 August 1998 Amnesty International asked the Department of Corrections for a copy of its policy on the use of the device. The Department has not provided a copy. In its correspondence to Amnesty International concerning this case, the Pennsylvania Department of Corrections has not asserted that the woman was threatening staff. Amnesty International therefore considers that the description of the device as "defensive" and as a "shield" is inaccurate. In the incident described above, it was used as a weapon to secure compliance with orders, not to protect staff from attack.

Recommendations on the use of restraints

In prisons and jails around the USA, restraints are commonly used when they are not essential to prevent escape or to protect people and property. This is evident in the cases of women who are in labour or who have just given birth, or who are seriously ill. Restraint chairs and electro-shock devices have also been used in circumstances which appear to violate the prohibition on the infliction of torture and other forms of cruel, inhuman or degrading treatment and punishment.

Amnesty International recommends that jails and prisons adopt policies on the use of restraints that accord with international standards, as follows:

3.    Restraints should be used only when they are required as a precaution against escape or to prevent an inmate from injuring herself or other people or damaging property. In every case, due regard must be given to an inmate's history and physical condition. Restraints must never be used as punishment.
 
 

*    Policies on the use of restraints should prohibit their use on

*    pregnant women when they are being transported and when they are in hospital awaiting delivery
*    women who have just given birth
*    seriously sick inmates when they are being transported to and when they are in hospital.
 
 

*    Policies on restraints should specify that the types of restraints and the circumstances of their use must not be hazardous to the health and safety of inmates.
 
 

*    Four-point restraints should only be used when strictly necessary as an emergency short-term measure to prevent damage or injury, and in accordance with international and US medical standards. The federal authorities should institute an urgent national inquiry into the use of restraint chairs in prisons and jails.
 
 

*    Jails and prisons should suspend the use of electro-shock weapons pending the outcome of a rigorous, independent and impartial inquiry into the use and effects of the equipment.
 
 

*    Authorities that are responsible for jails and prisons should monitor the use of restraints to ensure strict compliance with policies.

VII HEALTH

"A proper medical examination shall be offered to a detained or imprisoned person as promptly as possible after his admission to the place of detention or imprisonment, and thereafter medical care and treatment shall be provided whenever necessary. This care and treatment shall be provided free of charge."
Principle 24, UN Body of Principles for the Protection of all Persons Under Any Form of Detention or Imprisonment

"Law enforcement officials shall ensure the full protection of the health of persons in their custody and, in particular, shall take immediate action to secure medical attention whenever required."
Article 8, UN Code of Conduct for Law Enforcement Officials [ Adopted by the United Nations General Assembly, 17 December 1979.].

"On the night of April 20th I started spotting (bleeding). I told the guard and she said medical was not in at that time of night and there was nothing she could do. As the night went on the bleeding got worse and so did my stomachache. I didn't sleep at all that night and when the guard passed by me I was crying and I told her the bleeding was getting worse and that I couldn't stand the stomach cramps I was having.." [The following day Annette Romo continued to bleed and in the afternoon she collapsed and was taken to hospital and immediately scheduled for surgery]. "...I still to this day have dreams about what happened. I will never forget it. It was the worst thing I have ever experienced. If they would have only helped me when I first asked all this would not have happened nor would I have had to lose my baby. It was an awful experience and one that will be with me forever. I thank God everyday that I'm alive and I pray this never happens to anyone else."
Annette Romo, writing of her experience in an Arizona Jail in 1997 [ Letter to Amnesty International, 22 February, 1998.]

1. Introduction

Many women who enter prison and jail are ill or pregnant, and many experience the need for medical attention while they are incarcerated. International standards specify that medical care must be provided whenever necessary, free of charge. The US Supreme Court has also ruled that inmates have a right to adequate medical care for serious medical needs [ Estelle v Gamble 429 US 97 (1976).]. Despite these international and national legal obligations, many prisons and jails have not met the required standards.

The following reports illustrate the struggle of many incarcerated women to secure adequate health care.

California In 1995, women at two prisons in California (Central California Women's Facility and California Institute for Women) began legal action to obtain improved health care services [ Shumate v Wilson, US District Court, Eastern District of California, No CIV S-95-0619 WBS JFM.]. The lawsuit cited a number of cases of poor medical treatment including:
 
 

*    Clarisse Shumate, who was suffering from sickle cell anaemia, heart problems, pulmonary hypertension and asthma, experienced delays and interruptions in the provision of medication;
 
 

*    Beverly Tucker, who had long-standing blood-clots in her legs, was not given prescribed medication for the condition. As a result, she had to have a foot amputated;
 
 

*    Cynthia Martin, who required medical care for serious burns to more than half of her body; was denied physical therapy and was subsequently confined to a wheelchair.
In 1997 the women and the state of California agreed to settle the legal action on the basis of a number of undertakings by the state about health care services in the prisons [ The document containing the settlement states that the agreement is not to be construed as an admission of liability and that California does not admit that what it undertakes to do differs from the then current policy and practice. The women prisoners considered that the settlement required California to significantly improve health care provision.]. The state's compliance with the agreement is being assessed by an independent monitoring team. In 1998, the first assessment by the team found that of 57 substantive provisions of the settlement agreement, the state had failed to comply with 11, in whole or in part, at one or both prisons. Lawyers for the women contend that there are additional areas where the finding of compliance is in error [Assessment Report on the Compliance of the California Department of Corrections with the Settlement Agreement in Shumate v Wilson, 18 November 1998; Letter in response from E Alexander on behalf of counsel for the women prisoners, dated 5 January 1999.].

During 1998, Amnesty International received further reports of inadequate health care for women prisoners in California, including at Valley State Prison for Women. In November 1998, Amnesty International representatives visited the prison and spoke with prison officials, including medical staff, and prisoners. There is a substantial gulf between their accounts about issues such as continuity/interruption of previously prescribed medication for newly admitted women and delays in medical attention. A doctor at the prison acknowledged that women might have to wait weeks to be seen but stated that he screens requests daily to ensure priority is given to the most urgent cases. However several prisoners interviewed by Amnesty International said that they had experienced considerable delays before being seen for what they considered to be painful and pressing conditions.

Florida A recent study of medical care over a five-year period (1992-1996) in a Florida jail concluded that there was a persistent pattern of medical ill-treatment which in some cases amounted to torture under international law [ M Vaughn and L Smith, "Practising penal harm medicine in the United States: prisoner voices from jail," Justice Quarterly, 16(1), forthcoming, 1999.]. These are some of the cases reported by the study:
 
 

*    a pregnant prisoner who suffered a miscarriage at the jail waited six or seven hours before medical personnel sent her to the hospital although she was bleeding profusely;
 
 

*    a pregnant inmate with a history of prior pregnancy problems wrote to a court-appointed monitor of the jail, complaining that she had not been examined by a doctor after several weeks of incarceration. She said that the medical staff told her that they did not treat pregnant prisoners and that she was sometimes in so much pain that she could not eat and keep food down. She wrote that she was afraid of losing the baby, felt depressed and cried most of the time. Pleading for help, she wrote: "we are human beings, not animals, and...animals get better treatment than what we have been receiving."
 
 

*    another pregnant prisoner suffering from serious vaginal discharge wrote to the court monitor that she was seen by an obstetrician one month into her incarceration but a month later had still not received any treatment. She said that at sick call the jail doctor refused to see her. "I'm constantly having headaches, stomach cramps, and can't sleep," she wrote. "I'm very scared for my baby and myself....Please help me!! Help my baby!"

Virginia At the beginning of 1998, 40 women at the Virginia Correctional Center for Women signed a petition describing delays in getting access to emergency care, doctors, medication, and treatment for chronic illnesses. The complaints included that the facility, which housed around 800 women, did not have a gynaecologist on staff and that a woman who complained she was bleeding profusely from the rectum was told by staff to elevate her feet, and subsequently bled to death. Linda Dennett, the mother of a prisoner, reported that her daughter's psychiatric medication had been discontinued when she was transferred from jail to prison in July 1997. Six months later, the medication had not been restored. According to Linda Dennett, "I don't worry about trouble as much as I do about suicide." [ L LaFay, The Virginian-Pilot, January 26, 1998.] Prison officials denied claims that services were inadequate [ "Abysmal medical care reported by women at Goochland", press release from ACLU National Prison Project, January 21, 1998, Washington DC.].

"Females are secondary," the Chairman of the Virginia State Board of Corrections, Andrew Winston, reportedly stated in January 1998, acknowledging that prisons and inmate services were designed primarily for male prisoners [Associated Press, cited by American Civil Liberties Union media release, 9 February 1998.]. Later that month, Clifton Woodrum, the Chairman of the Virginia State Crime Commission (a correctional oversight body) wrote to the Inspector General of the Department of Corrections, expressing concern that long-standing problems in health care services for female inmates appeared not to have been successfully resolved. Mr Woodrum asked for a report on the Inspector General's investigations into inmate health care complaints and inmate deaths during 1997. At the end of 1998, the Crime Commission had not issued a report of its review. Amnesty International asked the Commission for information about the review on several occasions and at February 1999 had not received a response.

Washington DC On 2 June 1996, Debra Gant, a prisoner in the District of Columbia, began to experience vaginal bleeding and abdominal pain. She reports that she complained to prison staff but her condition was not assessed and she received no treatment. Her condition deteriorated and on July 6 1996, when her pain had become severe and she was semi-conscious, she was taken to hospital where she was diagnosed as having a ruptured ectopic pregnancy. She underwent emergency surgery to stop her bleeding to death; surgeons had to remove an ovary and her fallopian tube. Debra Gant subsequently sued, alleging that "it was the pattern, practice and policy of the District of Columbia to fail to have a system to ensure proper follow up visits for medical treatment, to fail to have sufficient access to medical specialists...to fail to train medical staff to diagnose or treat major medical conditions...and to fail to hire sufficient medical staff." [ Gant v District of Columbia, Complained filed for hearing by Superior Court of the District of Columbia, 3 April 1997.]. Amnesty International has been informed that in 1997 the authorities agreed to pay Debra Gant an undisclosed sum of money to settle the case.

2.    The health of women in prisons and jails

In a 1994-95 survey of women prisoners in California, Connecticut and Florida, half reported that they were experiencing a physical health problem that was interfering with their lives [ L Acoca and J Austin, The Hidden Crisis: Women in Prison, National Council on Crime and Delinquency, San Francisco, 1996, 73.]. Various studies show that the health of incarcerated women is generally worse than that of women in the general community, reflecting the fact that incarcerated women are more likely to be affected by factors such as poverty, harmful substance use, and the risks arising from exchanging of sex for drugs or money. As one study observes, "the struggles for survival that put women at risk for arrest also put them in the path of HIV." [ A De Groot, S Leibel, S Zierler, "A Standard of Care for Incarcerated Women: Northeastern United States Experiences," forthcoming, Journal of Correctional Health Care.]. In prisons, which hold more than 2000 HIV-positive women, the number of infected women has increased by more than 88 percent since 1991 [ L Maruschak, "HIV in Prisons and Jails", Bureau of Justice Statistics Bulletin, Washington DC, 1997. Women who were HIV positive constituted 4% of the prison population (2.3% of the male prisoner population was HIV infected) and 2.4% of the female jail population (2.1% of male inmates were HIV infected). The proportion of incarcerated women who are HIV positive varies greatly around the US. For example, in New York, more than a fifth (22.7%) of women prisoners were known to be HIV positive; in several states (eg Nebraska, Virginia) there were no known cases.]. Incarcerated women also tend to use health care services more than men for various reasons including pregnancy and a higher incidence of sexually transmitted diseases, including HIV [ For example, see L Acoca and J Austin, The Hidden Crisis: Women in Prison, National Council on Crime and Delinquency, San Francisco, 1996 at page 26: in Connecticut, the study found, 60% of men reported no health needs; in contrast, over 60% of women needed minimal medical assistance requiring access to health services on an outpatient basis. Nearly four times as many women as men required specialized placement in a housing area where they could receive 24-hour nursing coverage.].

The physical and mental health of many incarcerated women has also been adversely affected by a history of physical and mental abuse as children and as adults prior to their incarceration. According to a 1996 national jail survey, 48 percent of female inmates and 13 percent of male inmates reported having been sexually or physically abused, or both, prior to admission [ C W Harlow, Profile of Jail Inmates 1996, Bureau of Justice Statistics, US Department of Justice, Washington DC, 1998: 37% of female inmates and 11% of the male inmates said they had been physically abused; 37% of female inmates and 6% of male inmates reported that they had been sexually abused; 27% of female inmates and 3% of male inmates reported that they had been raped.]. Other surveys have found far higher proportions of women reporting a history of abuse [ For example, 80% of a sample of California prisoners interviewed in 1994 indicated that they had experienced emotional, physical or sexual abuse (or a combination) at some time in their lives: B Owen and B Bloom, Profiling the Needs of California's Female Prisoners - A Needs Assessment, National Institute of Corrections, US Department of Justice, Washington DC, 1995.]. A number of studies have identified a relationship between abuse and ongoing physical health problems, such as gynaecological trauma, and mental health problems such as post-traumatic stress disorder as well as to conduct that is directly or indirectly linked to the crimes committed by many women, such as drug use (and associated property crime) and prostitution [ In a study of women prisoners in Washington, nearly 40 per cent reported prior sexual or physical abuse; sexual abuse was found to be very strongly related to mental disorder, with the most impaired inmates reporting rates of sexual abuse more than five times as great as inmates with little or no mental disorder. The study explored various aspects of the women's lives, and found that sexual abuse was the element that was most highly predictive of the level of mental disorder: Bates, op cit.].

Various other factors have been cited as contributing to a large number of people with mental health disorders being incarcerated in jails and prisons in the USA. These include
 
 

*    insufficient mental health services in the community; [ For example, see "Offenders With Serious Mental Illness: A Multi-Agency Task Group report to the Colorado Legislature Joint Budget Committee," Colorado Department of Corrections, 1998, and E Torrey et al, Criminalizing the Seriously Mentally Ill - the Abuse of Jails as Mental Hospitals, Public Citizens' Health research Group and National Alliance for the Mentally Ill, Washington DC, 1992, iv. As these studies describe, a number of state and local authorities have established programs designed to divert offenders from incarceration and to prevent re-offending.].
*    the massive increase in the incarceration of women convicted of violating drug laws, many of whom have a history of drug abuse;
*    stresses associated with incarceration - as well as the deprivation of liberty faced by all inmates; many also are also subject to stressful circumstances such as loss of family contact, termination of parental rights and overcrowding.

3.    Concerns about the adequacy of health care

A paper issued by national health care organizations in 1992 warned that standards of health care for incarcerated men and women were becoming increasingly difficult to meet because resources were not increasing in proportion to the increase in the number of inmates with significant health problems. According to the organizations, "the large increase in the number of substance abusers and sick and terminally ill inmates has rendered our nation's prisons and jails physically or financially unable to deal with their current populations, much less the explosive increases the future holds." [ American College of Physicians, National Commission on Correctional Health Care, American Correctional Health Services Association, "The Crisis in Correctional Health Care: The Impact of the National Drug Control Strategy on Correctional Health Services - Position Paper," Annals of Internal Medicine, Volume 117, Number 1, 1 July 1992. J Belknap surveyed an unnamed prison in 1992 and summarized the situation as indicating "a serious lack of effective health care for incarcerated women." One prisoner described the difficulty of seeing a doctor: "It's not easy at all unless you're dying." It had taken her 8.5 months "and by then I was over my illness." See J Belknap, "Access to Programs and Health Care for Incarcerated Women," Federal Probation, Vol 60, No.4, 1996.].

Subsequent reports indicate that the problems continue, and may have worsened, in many institutions. They include inadequate access to health services; failure to refer seriously ill inmates for treatment and delays in treatment or failure to deliver life-saving drugs for inmates with HIV/AIDS.

Human rights groups and health professional bodies consider that inadequate health care is one of the most pressing concerns in US prisons and jails today. According to a lawyer who has represented many women prisoners in legal action on health care matters:
 

"While the health care available to low-income women in the United States is generally poor, medical conditions for women in United States prisons and jails are appallingly bad...The inadequacy of medical care has had severe repercussions for women prisoners, leading in many cases to late-term miscarriages, untreated cancer and other life-threatening diseases, increased disability as a consequence of poor or nonexistent care and, in some instances, death." [ Ellen Barry, "Women Prisoners and Health Care", in K Moss ed, Man-made Medicine, Duke University Press, Durham 1996, 250-51.].
In 1994, the National Commission on Correctional Health Care (which establishes and monitors standards) issued a public statement recognising the growing number of female inmates and the increasing physical and mental health problems they present for correctional facilities. The Commission noted, for example, that research had consistently indicated that the provision of gynaecological services for women in prison settings was inadequate
[ National Commission on Correctional Health Care, "Women's Health in Correctional Settings," Position Statement adopted by Board of Directors, September 25, 1994.]. A recent survey of state prison systems found that all reported that they offer obstetric and gynaecological services, but does not report on their adequacy, for example, whether all women are screened to assess their health and how long women have to wait to be seen ["Inmate Health Care," Corrections Compendium, October 1998.]. In a survey a year earlier, only about half the systems stated that they offered additional female-specific services, such as mammograms and Pap smears ["Inmate Health Care, Part II," Corrections Compendium, November 1997.].

Lack of resources for health care

Perhaps the most commonly cited barrier to adequate heath care in jails and prisons is that there are too few health care staff to meet the physical and mental health needs of the rapidly growing number of incarcerated women. A number of reasons have been cited for staffing shortages, for example that the increase in the incarceration of women has been greater than authorities expected, compounded by difficulties in attracting and retaining medical staff to work in jails and prisons generally [L Acoca, "Defusing the Time Bomb: Understanding and Meeting the Growing Health Care Needs of Incarcerated Women in America." Crime and Delinquency, Vol 44 No.1 January 1998, 49-69, 62.]. As the following reports illustrate, the consequences that have been documented include lengthy delays in obtaining medical attention; disrupted and poor quality treatment and lack of counselling services for women who require treatment for substance abuse and other disorders.
 
 

*    In a national survey of jail inmates in 1996, fewer than half the women (47%) received a medical examination to determine their health status after they were admitted [ C Harlow, Profile of Jail Inmates 1996, Bureau of Justice Statistics, US Department of Justice, Washington DC 1998; 49% of men received a medical examination after admission.].
 
 

*    In a 1994-95 study of women in prison in California, Florida and Connecticut, 42 percent of women receiving medication for physical disorders, and 31 percent of those receiving treatment for mental health disorders reported that they were not receiving medical supervision. The effects of the lack of medical oversight, the study noted, included "physical deterioration of prisoners with chronic and degenerative diseases, such as kidney disease and cancer, and over medication of prisoners with psychotropic drugs, resulting in lethargy and/or problems with speech and gait (shuffling)." [ L Acoca, "Defusing the Time Bomb: Understanding and Meeting the Growing Health Care Needs of Incarcerated Women in America," Crime and Delinquency, Vol.44, No.1, January 1998.].