Originally published in Gambit

Ian Cazenave was an inmate at Louisiana State Penitentiary, more commonly known as Angola, when one day, he felt an intense stabbing pain in his back, stomach and knees.

Cazenave was born with sickle cell disease and recognized the symptoms. He was having a sickle cell crisis, which occurs when sickled cells cause a blockage in a blood vessel and prevent red blood cells from carrying oxygen to tissues and organs.

According to Cazenave, the prison doctor told the prison EMT to administer medicine to ease his pain. The doctor left the room, but Cazenave says he kept waiting and waiting for the EMT to give him the pain medication. While waiting, he remembers sobbing in pain.

“I’m hurting real bad,” he says. “I’m up in there crying.”

Cazenave estimates that after 20-45 minutes, the EMT pushed the bed out of the room and across the hall. He says when the EMT closed the door, she told him if he didn’t stop crying, she wouldn’t give him the medicine.

“It was like an hour and a half before she came and administered the medicine to me,” he says. “And after that, I still wind up having to go to New Orleans to the hospital.”

That wasn’t the only medical mistreatment of his sickle cell anemia and chronic leg wounds Cazenave says he experienced during his time at Angola, from 1999 to 2024, including a lack of regular blood tests and transfusions.

According to a class action lawsuit, he developed an infection in February 2016 and his hemoglobin dropped to dangerously low levels, putting his leg at risk of amputation.

Cazenave is one of more than 200 inmates that are part of Lewis v. Cain, an ongoing lawsuit brought forth in May 2015 by lawyers representing Angola inmates against the Louisiana Department of Public Safety and Corrections (DOC), former Louisiana State Penitentiary warden Burl Cain and other officials at the prison and DOC.

The inmates accuse the prison of denying appropriate health care to those behind bars, leading to “unnecessary pain and suffering, exacerbation of existing conditions, permanent disability, disfigurement, and even death.”

The complaint described the experiences of the inmates as “horror story after horror story.” The state DOC declined a request for comment, saying they were “unable to comment on pending litigation.”

All of the stories shine a light onto the practices of a place built on a site that was once a plantation with enslaved people. But those inmate experiences at Angola are a part of a larger national problem with health care for incarcerated people, which is often inadequate and at times horrific.

A prison system centered on cost and profit, staffing shortages, anti-prisoner biases and more deterrents all make it difficult to appropriately care for a prison population with complex needs.

“One, you don’t have sufficient staff. You don’t have sufficiently trained staff, particularly around mental health,” says Dr. Anjali Niyogi, who founded the Formerly Incarcerated Transitions Clinic to provide care for people with severe medical conditions after they are released from prison. “You don’t have enough of a budget to take care of people who are getting increasingly sick.”

A flawed design

In 1976, a ruling in Estelle v. Gamble stated that withholding health care from inmates is “cruel and unusual punishment” and violates the Eighth Amendment. But the ruling doesn’t say anything about the quality of care, forcing the precedent to be retroactive care, instead of preventative

The limits of the Gamble ruling can be seen in Lewis v. Cain.

The lawsuit accuses Angola workers of ignoring a wheelchair-bound inmate’s surgery requests multiple times for a procedure meant to repair a quarter-inch tear in his penis caused by a catheter.

It also alleges staff left inmate Kentrell Parker, who became paraplegic after being injured on Angola’s football field, alone for extended periods of time, laying in his own feces. In 2018, ProPublica reported he was left alone with flies crawling on his face, and in order to seek relief, he began to eat them.

According to a report by Prison Policy, roughly half of state prison systems have been court ordered to improve their mental and medical health care since 2000. The report found that prison management often treats incarcerated people’s symptoms as costly “nuisances.”

These health care systems function like a “cost control service for corrections departments, organized around limiting spending and fending off lawsuits rather than actually caring for anyone’s health,” the report said.

“It’s not a freebie. It’s not a handout,” says Bruce Reilly, a formerly incarcerated lawyer and the deputy director for Voices of the Experienced (VOTE). “You’ve chosen to invest $50,000 to $75,000, $200,000 on holding this person in a cage.”

In many places, like Louisiana, health care in prisons is overseen by the corrections department, not health department.

Niyogi says there are significant issues with such a model.

“Department of Corrections aren’t trained medical [professionals]. They do safety, and that is what their number one charge is,” she says. “It’s the Department of Public Safety and Corrections. There’s nothing about health in any of that.”

The budget for prison health care in Louisiana is stuffed into the DOC budget, and the Inmate Exclusion Act of 1965 banned prisons from using federal dollars on inmate health care.

However, Niyogi says, there is a small caveat. In Louisiana, if an inmate is admitted to a hospital for more than 24 hours, federal dollars can be used. This doesn’t apply to outpatient visits or things that happen in the prison, which comes out of the DOC budget.

People in prison — who are disproportionately poor and people of color — have higher rates of certain chronic diseases, including high blood pressure and diabetes, than those on the outside due to systemic issues, like increased exposure to pollution and lack of access to health care and healthy food.

According to Niyogi, the majority of people who enter the carceral system already have complex issues, such as histories of psychological, physical and sexual trauma.

In addition, the prison population as a whole has gotten older. According to research by Pew, the number of inmates 55 or older in state and federal prisons increased by 280% between 1999 and 2016.

“People are getting older. There are more medical problems. People have more medications that they need to take, procedures they need to have. And so all of that adds up to that budget,” Niyogi says.

Taking these factors into consideration, it’s not hard to see why incarcerated people have shorter life spans than non-incarcerated people. In fact, a 2016 study found that each year a person spends in prison takes two years of their life expectancy.

Understaffing

Prisons are often understaffed. Many health care professionals don’t want to work in prison settings, due to lower pay and stigma, and the doctors and nurses who do take jobs in prisons are often stretched thin.

“You start doing the math on how many [health care workers] per patient. You’re just like, wow… they’re handling too many people,” says Reilly.

According to Niyogi, a prison typically has one medical director who oversees thousands of patients, far more patients than a medical director would be responsible for at a private clinic.

“No clinic has that many patients and one medical director … just from the baseline, that ratio is wrong,” she says.

This can lead to prison systems seeking staff from anywhere, either by outsourcing to private health companies or hiring doctors with a history of misconduct.

According to court documents, each of the five doctors on Angola’s staff when Lewis v. Cain was filed either had a restricted license or was restricted to practicing in certain institutional settings at the time they were hired.

A doctor’s license can become restricted when they are convicted of a felony, overprescribing drugs without a legitimate reason, sexual misconduct or unethical behavior, among other reasons. Doctors with restricted licenses are allowed to practice in certain “institutional” settings, one of those being prisons.

As of 2021, Scalawag Magazine reported, 10 of 11 doctors on staff at the DOC in Louisiana had restricted licenses.

Reilly says the state medical board “uses this as almost like [the doctors’] work release program.”

In 2016, 9 of the 15 doctors working in Louisiana prisons had been disciplined by the medical board. Of those nine, two had served federal prison sentences, two couldn’t treat patients under 18 years old and one required a chaperone when treating female patients under 60 years old.

Additionally, one doctor, Casey McVea, pled guilty to possession of child pornography. He had become the medical director at Raymond Laborde Correction Center in 2020 before dying from COVID-19.

“A lot of times, people are working in carceral settings not because they want to work with this population … or have an understanding of [this] population … it’s the only job they can get,” Niyogi says.

This essentially creates a situation where doctors with a history of unethical and illegal behavior have a great deal of power over people who have no options when seeking a health care provider.

And it can lead to issues for the formerly incarcerated once they are out of prison, since some pharmacists won’t fill prescriptions ordered by doctors with restrictions on their licenses.

And the problem goes all the way to the top. Randy Lavespere, the head of health care for the DOC since 2021 and the former Angola medical director, was convicted in 2006 of buying $8,000 of meth from an informant with the intent to distribute.

He is a defendant in Lewis v. Cain, with serious allegations of medical neglect against him.

Burl Cain, the warden of Angola from 1995 to 2015, quit during probes into his real-estate dealings. Since 2020, he’s led the Mississippi Department of Corrections.

Obstacles to seeking care

There are a number of reasons inmates might be hesitant to seek medical care. Often, prison staff don’t believe them. In fact, Lavespere in court said he believed close to half of patients were lying about their symptoms.

“A lot of times the first diagnosis is of malingering … [it] is always a diagnosis of exclusion,” Niyogi says.

The consequences can be severe and even deadly.

According to court documents, the lead plaintiff in Lewis v. Cain, Joseph Lewis, an 81-year-old with a history of chronic throat problems, submitted repeated sick call requests and grievances for two years. He was only ever prescribed over-the-counter medication. Once he was allowed to see a specialist in January 2015, it was discovered he had throat cancer.

Mississippi Today reported that when a Mississippi inmate broke his arm and asked the correctional officer to take him to the infirmary, the officer told him to go “sit his ass back down.” He later needed to have his broken arm amputated. In Colorado, a 22-year-old died from treatable infections after he was ignored by prison staff for a month.

Inmates may also be uncomfortable with the lack of privacy they have during appointments.

In cases where an inmate needs off-site treatment, and they have to make the nearly three-hour drive from Angola to the University Medical Center in New Orleans, they are followed by guards the whole time, including in the room when receiving treatment.

Costs can also be a major issue. Even small copays can dramatically impact inmates, who earn between two and 40 cents an hour, according to a 2022 ACLU report.

In 2021, the prices for medical care in Louisiana prisons were $3 for a sick call visit, $2 for a prescription visit and $6 for an emergency visit.

Seeking medical care can also put an inmate out of work for an extended period of time, wiping out their income entirely when they have a medical bill to pay.

Reilly’s group VOTE in 2022 pushed for a bill to cap copays and waive them for some inmates. He says they came to a compromise with the DOC, but a committee in the state legislature killed it in a 5-5 vote.

Where we go from here

Shelly Dick, chief judge of the Middle District of Louisiana, ruled in a 2023 opinion on Lewis v. Cain that the medical care at Angola was akin to “abhorrent cruel and unusual punishment,” adding that the human cost was “unspeakable.” She ruled Angola violated the Eighth Amendment, Americans with Disabilities Act and the Rehabilitation Act.

The state has decided to appeal the Cain ruling, citing the Prison Litigation Reform Act, which knee-capped a different but similar lawsuit against Angola close to 30 years ago. The far-right-leaning Fifth Circuit Court will hear the appeal.

The quality of care in Louisiana’s prisons is becoming even more strained as the state locks up more people due to the legislature’s reversal of its once bipartisan criminal justice reforms. According to the Louisiana Illuminator, Gov. Jeff Landry is looking to move an additional 688 inmates to Angola specifically.

So what can be done?

A report by Prison Policy recommends removing health care from the purview of corrections departments altogether, creating independent oversight bodies separate from prison systems and create performance measures for prison health care — similar to that of hospitals.

Reilly suggests marketing prison health care jobs similarly to much-needed public health work.

“Maybe if you just sort of change the job description and the outreach, you’d get a different class of people,” he says.

But until major changes are made, the same issues at Angola and beyond will persist, putting the roughly 2 million people incarcerated in U.S. state and federal prisons at risk.

“I think we need to understand the true cost of incarceration is keeping people alive and healthy,” Reilly says.

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