THE PRISON HOSPITAL
The Prison Hospital is a three hundred seventy-five-bed private facility offering acute, sub-acute, skilled, intermediate and end-of-life care for conditions such as HIV, cancer, cardiovascular disease, kidney dialysis and mental health for inmates. The Hospital serves state and federal agencies throughout the U.S.
This hospital was designed to provide cost effective detention healthcare. In a prison population of ten thousand, approximately four hundred are medically or mentally dependent. When compared to the usual cost of providing healthcare in community hospitals, this hospital provides substantial savings. Inmates do not participate in Medicare or Medicaid programs. Pay source is the admitting state or federal government agency, ultimately funded by taxpayers’ dollars.
In addition to providing inmate healthcare, the hospital evaluates recently arrested individuals to determine whether they are competent to stand trial or are not guilty by reason of insanity. I am often asked to do a nutritional evaluation while this determination is made. Here I often identify B12, iron, folate, thiamine and/or carnitine deficiency, all of which can cause psychological imbalance. These deficiencies are caused primarily by a very poor diet prior to arrest, often combined with alcohol and/or drug abuse.
Support services such as dietary and housekeeping are contracted to “for profit” companies who receive a predetermined fee. These companies determine the department’s budget. The dietary department is budgeted at $1.11 per meal. This amount might be compared to a nursing home or public hospital budget of $2.50 per meal. In the six years I have worked in this facility the budget has never increased, although food costs have gone up.
As a dietitian, I am expected to verify that the prearranged menu meets the “Dietary Guidelines for Americans” issued by the U.S. Department of Health and Human Services. These guidelines suggest the amount of calories, protein, fat, vitamins and minerals. The guidelines do not consider the quality of the food. For example, soy protein, beef protein, bean protein, and protein powder are valued equally as long as protein content is the same in all instances. Vitamin and mineral requirements are ultimately met by synthetic vitamin and mineral supplementation in food.
Recent changes to a more “heart healthy” menu were welcomed by this contracted company, not because it is purportedly better for those who will be fed by these guidelines or even because it may help the company look good in the public eye, but because the change decreases its food costs. This is a common theme in most institutions. Here are the “heart healthy” changes that decrease food costs:
• Margarine replaces butter.
• Animal protein serving size is decreased to decrease fat.
• Skim milk replaces whole and lowfat milk.
• Cheese is removed from sandwiches and other foods.
Other recent cost cutting measures include:
• Substituting real milk with powdered milk or fortified milk substitutes.
• Elimination of coffee, sugar, sweeteners, salt, jelly, salad dressings.
• Changing from meat to meatless entrées using soy or beans as the protein source.
The department performs with inadequate staff, allowing little time for proper food preparation. Expensive convenience foods are used, further decreasing monies available for higher quality foods. Inadequate staffing is a result of difficulty in hiring. Applicants are few, and most fail background checks and/or drug screens. Employment is usually short-term because applicants work only the time necessary to reinstate their unemployed status. Applicants that pass the background check and drug screen and present with a true desire to work do not carry proper immigration status.
Efforts to increase the dietary budget have failed. I present studies to demonstrate how good nutritional practices decrease overall hospital costs but it is difficult to get a response from this contracted company, which most certainly is more interested in its profits than the inmates’ care or hospital-wide costs.
Ensure® and other nutritional supplements are not part of the dietary department’s budget, and their use is not restricted. Ensure® is “ordered” by the physician as a medication might be. Many inmates rely on these supplements to maintain weight and protein status. I am unable to serve an inmate more food due to dietary budget constraints, but can provide Ensure®-type supplements in any quantity. The products are well accepted by inmates because of the sweet taste.
THE PRISON SYSTEM
I recently assumed nutrition responsibility for forty-five state inmates who receive dialysis. The inmates reside in one of twenty-seven South Carolina state prison facilities totaling approximately twenty-seven thousand inmates. The system ultimately reports to the governor, with many levels of administrators, guards and wardens to total close to six thousand employees. These six thousand employees receive seventeen paid holidays a year, including two Memorial Days: Federal and Confederate. Pay scale is the same as other healthcare facilities. The system is completely supported by state tax dollars because inmates do not participate in Medicaid or Medicare programs.
Meals at these state facilities are prepared and served by inmates. As with the prison hospital, meals must follow the guidelines of the U.S. Department of Health and Human Services. Food cost is fifty cents per inmate per meal. As compared to other state and federal correctional systems, this facility is found to have the lowest food costs in the country and administrators speak very proudly of this fact.
Food quality is superior to the food at the prison hospital because it is prepared from “scratch.” The dietary department utilizes inmates to do the work and staffing is not a problem as in the prison hospital, where inmates are much too ill to work.
Inmates raise cattle for the production of beef and milk on state property. Beef and milk production was initiated to decrease food costs, but prison administration found it more profitable to sell the product to grocers and purchase food of poorer quality for the inmates.
No sugar or products containing sugar or corn syrup is served. Administrators feel this is poorly spent money on empty calories. Also, wardens fear inmates will hoard the sugar product and secretly make alcohol, something I find hard to believe.
Wardens frequently exert their petty positions of power and selfishness by initiating control of the food, often restricting meals to bologna or peanut butter sandwiches for weeks. This is initiated because one inmate may have said or done something which was “out of line” in the eyes of the warden. Sandwiches are delivered directly to the dormitories. Meals are served across the prison campus. The shift to sandwiches allows the warden “less work” because he does not have to supervise the inmates as they move across campus to eat. A regulation from South Carolina Department of Health states that cold food must never be served for more than three consecutive days, but the wardens assume their whim to overlook this regulation is acceptable, and it goes unchallenged.
Wardens, guards and other employees plan monthly organized fish fries on prison property for themselves. You smell the food cooking throughout the property and this day is known to be a violent one in the system, often with fights breaking out. I find this fish fry to be inappropriate when you consider that most of the men have not had any meat but poultry patty in many years and would love a piece of fish. I suggested that employees have their fish fry off prison property. Their answer was they would then have to “go off the clock” if they leave property and would rather do this while being paid, despite the problems it causes.
Because protein intake is poor and protein requirements for individuals on dialysis are high, the prior dietitian initiated use of Ensure® supplements for dialysis inmates. She found this to be the only way to provide required protein amounts without the ability to offer more food. All of these inmates found the Ensure® to be intolerable because it is too sweet. They are not used to eating sweets. Inmates who were recently admitted, and had been eating and drinking sugars, liked Ensure®.
Ground poultry product, prepared in various ways, is used as the protein source for approximately 95 percent of meals. This product is sold at low cost to the prison directly from the chicken processing plant. It is the ground remains of the chicken after all saleable parts are removed. The product contains good quality fat and protein and a small amount of bone and cartilage. I find the product to be healthy but not appealing, mostly because of the monotony and poor preparation methods. It is often undercooked and rarely seasoned. I found it to be inedible, as did all of the inmates I worked with in dialysis.
In most dialysis inmates I observed a very poor visceral protein status, reflected in a blood laboratory value called albumin. It has been well demonstrated that low albumin values lead to increased health problems in dialysis patients, something I presented in a letter written to the medical director and administrator of this system, shown opposite.
One week after I sent this letter, I was fired and my name placed on a list to no longer be admitted into any correctional facility in South Carolina. There was no communication by the medical director or administration, which I found to be highly inappropriate. I later found I was not the first dietitian who spoke up and was fired.
My suggestions are realistic. An additional two cents per inmate per day to the food budget would allow substantial variation and improved protein quality. The increase would cost the system approximately five hundred forty dollars per day but would decrease overall hospitalization and pharmaceutical expenses.
In comparison, an additional Memorial holiday for employees costs the South Carolina taxpayer approximately ninety thousand dollars. Seventeen paid holidays per year costs South Carolina taxpayers over twelve million dollars per year. This is not a realistic or appropriate use of our tax dollars.
This medical director and administration should be ashamed of poor treatment of an inmate and fellow man in so-called preference of “good stewardship” of our tax dollars. Perhaps a more a more humane budgetary constraint would be to eliminate a second Memorial holiday.
FOOD QUALITY AND HEALTH
In the prison hospital, I recognize a difference in the health of patients according to which prison system they were admitted from. Federal inmates are healthier; they also benefit from better nutrition practices of institutions offering real butter and whole meats.
Some systems provide meals based on refined convenience foods and have a cantina available for soda and snack products. These inmates present as unhealthy and laden with disease. The systems that provide unadulterated food, where prisoners prepare food mostly from scratch without sugar also have an overall healthier patient population.
It appears as if we either develop a desire or an intolerance for sugared sweet products. Our “sweet tooth” disappears as these foods are eliminated from the diet. In the prison hospital sweet foods are desired and requested. In the prison systems where sugar is eliminated, they are not only undesirable, but poorly tolerated.
I have had to conclude from viewing hundreds of diet histories that diets from“outside” the system are poorer than any of the diets provided by the prison hospital or prison system. They tend to be laden with corn syrup, alcohol, refined foods and caffeine. Rarely is adequate protein, fruit or vegetables included in the diet. Nutritional deficiencies are common and are often resolved with supplementation and/or the diet served in the facility. See my comparison on page 48.
In order to control costs, food offered by the prison system and prison hospital is of substandard quality. What I find sad is that the diets are an improvement over the diets of most before admission. But before admission, the individual makes the choice to eat this way. Once in the system, inmates have no choice over what they eat or how they take control over their health. This power is unfortunately put in the control of heartless individuals who feel that healthy budgets are more important than these human lives.
I leave you with a thought from Matthew 25:40: Inasmuch as ye have done it unto the least of these my brethren, ye have done it unto me.
MY LETTER TO THE SOUTH CAROLINA DEPARTMENT OF CORRECTIONS
The importance of nutrition in the prevention of disease and the relationship between poor nutrition and increased medical costs is well documented.
In an effort to prevent needless medical costs, I would expect the SC Dept of Corrections to provide the nutrition necessary to keep the inmates nutritionally healthy.
Currently the SC Dept of Corrections works with the lowest food budget in the nation: $1.51/inmate/day. There has been no increase to coordinate with increased food costs over the past two years.
The average cost of food at comparable correctional facilities across the nation is $2.50/inmate/day. The average budget in local health care facilities is $2.50/meal. Meeting our low budget is accomplished in three ways:
1. Grits, eggs and milk are produced by the prisoners on three farms, the largest being 7000 acres at the Walden Correctional Facility in Sumter.
2. Costly processed foods and sugars are not utilized.
3. The protein source of most meals is an inexpensive low-grade ground poultry product. The product is the ground remains of chicken after all saleable pieces are removed. This includes cartilage/gristle.
My concern is that the prisoners are receiving but unable to ingest adequate protein.
After numerous complaints from dialysis inmates about a “poultry patty,” I went to see the product, how it was cooked and served in the Broad River Correctional Facility cafeteria. I concluded that the poultry product is intolerable. It has a strong stench, is very greasy and tastes foul. I also recognized at least 75 percent of the product is not eaten and goes to waste.
The product is prepared in various ways for most meals. Because its preparation in a regular diet is more tolerable than in a renal diet (using salt, etc.), we have changed many of our dialysis inmates to a regular diet to help them ingest more protein. We feel adequate protein is a more important component of the diet than the potassium, phosphorus and sodium restriction.
Perhaps in years past the poultry was more appealing. With increased hormones and antibiotics used in chicken production, taste worsens. Increased use of hormone and antibiotics in recent years is documented. The Department of Corrections constructs meals following the guidelines of the Dietary Guideline for Americans issued by the U.S. Department of Health and Human Services and the U.S. Department of Agriculture. The guidelines specify the required amount of nutrients but do not regulate the quality or frequency of the product served. For instance, you could serve 2-3 ounces of buzzard each meal and meet the guidelines for protein.
Protein is a particularly important nutrient, and protein needs are higher in dialysis patients than in any other group. There is a direct relationship between low protein intake and increased mortality/medical costs. You will receive but a few of the studies on this topic in the following e-mail.
Blood laboratory values are documented and analyzed monthly in dialysis. Most inmates have a low visceral protein status, which means they are not getting enough protein in the diet. I assume it would be the same for the rest of the SC state prison population if they receive this poultry product as their protein source.
Providing inmates with inadequate nutrition in an effort to reduce costs is a human rights violation. I find it both appropriate and necessary to replace this ground poultry product with a product that is edible.
Respectfully, I would like to share some ideas of ways to offer an acceptable protein product without greatly increasing costs:
1. Increase the budget slightly to allow purchase of low cost protein products such as liver, gizzard, turkey necks, canned mackerel, souse, spam, pork parts or spent hen products.
2. Purchase and serve half the product. It is more cost effective to serve half of something that is eaten than 100 percent of something that is not. Perhaps this will not meet the guidelines on paper, but it a more appropriate nutritional choice.
3. Instead of selling all of the beef produced by the prisoners in Watertree, keep some for prisoner consumption. Last year they produced close to 140000 pounds.
4. Initiate production of chicken, pork or turkey for inmate consumption.
5. Expand our sources of food donation or sale of product close to expiration date from local grocers.
6. Expand milk production into the production of cheese, cottage cheese, yogurt and kefir.
I appreciate your time and attention. Noel Franklin
This article appeared in Wise Traditions in Food, Farming and the Healing Arts, the quarterly journal of the Weston A. Price Foundation, Winter 2012.