Robert Misson MD, Director of Infection Control, California Men’s Colony

Needle sharing is surely the great hepatitis C transmission modality in California. Present policy finds it useful to imprison illegal drug users. Needle sharing goes on in prison, both for drugs and tattoos. You can imagine the authorities' response to the suggestion that needle exchange programs work. The necessary consequence is that the prevalence of hepatitis C in the inmate population of our state prisons is vastly greater than in the public at large. Whereas perhaps 2% of the general population is infected, about 35%-40% of inmates are. Most are, and still feel, fairly well, but many are chronically ill. A smaller but increasing number have cirrhosis, end-stage liver disease, or liver cancer. California Men's Colony is host to almost seven thousand men. The arithmetic is simple, and makes clear the enormity of the problem. We have thousands of infected men in our local prison, hundreds of whom are already ill, many seriously so. CMC hospital always has two or three end-stage liver disease patients in its beds.

The financial burden is huge. Each inmate with laboratory-test evidence of Hepatitis C antibodies (or liver inflammation discovered incidentally) must be evaluated. This involves nurse and physician time, a fairly extensive - and expensive - series of tests perhaps including a liver biopsy. Treatment with interferon alpha and ribavirin for either six or twelve months is offered where appropriate. This frequently leads to serious side effects, and patients must be seen and tested often, especially early in the treatment course. A 24-week course of therapy costs roughly $15,000 dollars for the two primary medicines alone. So figure one and a half million dollars for each one hundred inmates treated - just for the interferon and ribavirin. And this in one prison.

There is a human cost behind the dollars-and-cents stuff. The prison is overcrowded. Each cell provides barely sufficient living space for one man, but houses two. The "half bath" in a typical "two-and-a-half-bath" house is about the same size. Those who would have you believe prison is a holiday resort need a reality check. There can be few more hostile environments for the chronically unwell. To be frail is to be marked for exploitation. There is no privacy. Telephone access is severely limited - one phone call per month is typical. None for those who refuse to work. Contact with family and friends is minimal, until death is imminent, but by that time liver failure clouds the mind enough to stifle love, and joy and all the feelings that give meaning to life. The hospital employs inmate "porters" who funnel information and rumor back to the "quads" where the general population lives. Every one with Hep C knows when someone is dying in the hospital from the same illness. The newly diagnosed naturally wonder when their turn is coming. Thus much of our time is spent educating, reassuring and dispelling unrealistic fears as best we may. Too much of it is spent trying to comfort those without hope. What about liver transplantation? Should convicted felons with a self-inflicted illness have access to scarce donor-organs? The Department of Corrections has no formally articulated policy regarding organ-transplantation for its wards. Presumably the legislature and the courts will address this difficult ethical dilemma.

Prison - like war - is hell. By clear intent, the War on Drugs visits much of its fallout on prisoners. This is not to say it should be abandoned - the consequences of that are unfathomable. But in compounding the miseries attendant on the criminal life it has produced a singular plague in our midst. Is it time to rethink?