Editorial

Citation

Hopkins, A.M. (2020), "Editorial", International Journal of Prisoner Health, Vol. 16 No. 2, pp. 93-94. https://doi.org/10.1108/IJPH-06-2020-075

When I shared my plans to rotate at the women’s prison obstetrics and gynecology (OB/GYN) clinic, a family member asked me “Why would they send you there?” Contrary to my family’s reservations, my rotation was a product of my own volition to gain direct experience with a patient population that had captured my attention during the early stages of medical school. Training at a large, public academic medical center, I have been exposed to many patients who have presently, or had previously, been incarcerated, and I was immediately drawn to these patients because of the sociocultural complexity accompanying their medical care. However, my early encounters with incarcerated patients were not consistent with the messages I had subconsciously internalized. Sensationalized narratives of criminality and punishment from popular media and messages to which I was exposed in childhood led me to assume prison to be a cruel, cold microcosm in which any kindness was fleeting in the context of formalized imprisonment. I realized that this conception of incarceration impeded my ability to truly understand the experiences of patients affected by the criminal justice system and those of their friends and family members. I plan to practice medicine as an OB/GYN, and incarceration will affect a large proportion of my future patients, as the rate of increase of female incarceration has been twice that of men since the 1980s, and an estimated one in four Americans will have a family member affected by the criminal justice system. I created a rotation at the women’s prison to better understand the realities and challenges of delivering OB/GYN care within the context of incarceration.

One specific motivation for my rotation was a profoundly influential experience with a former patient who I will call Denise. She had been admitted to the hospital from prison with uncontrolled type I diabetes and preeclampsia. I loved spending time with Denise, but my interactions were constrained by the bright red “no visitors” sign on her door and guard’s unwavering bedside vigil. My interactions were disguised as fact-finding missions or else I was asked to leave. Within these brief visits, we found ways to connect beyond her illness, pregnancy and incarceration. My emotional response to her situation was multifaceted – anger at guards who interpreted policies allowing shackling of pregnant patients to their beds as overriding our team’s medical orders, sadness that she would not get to care for her new baby after she left the hospital and embarrassment that my request for Denise to go outside briefly for fresh air was immediately met with roaring laughter from the officers. I felt distress at Denise’s restriction to a tiny room for the month until her scheduled delivery date, which for security reasons would not be revealed to Denise until the start of her labor induction. I grappled with deep discontent when various team members spoke to and about her, particularly when she asserted her capacity to make her own medical decisions, which were sometimes distinct from the team’s plans. I did not see her as a “manipulative” patient-prisoner as described by some of my colleagues. I saw Denise as a woman who valued her independence and who deeply loved her pregnancy. I saw her as someone who had been sucked into the sprawling penal system, an extensive mechanism of hyperregulating poverty. While at the prison, I often found myself subconsciously searching for Denise’s warm smile amongst the groups of women gathered in the central courtyard. I never did see her again, but I was able to briefly experience elements of the forces that shaped her life in prison.

During my rotation, I witnessed many examples of healing-centered care that will shape my future practice, and the first patient I met remains emblazoned in my memory. She was a middle-aged woman with vague lower abdominal pain. Prior evaluation in the OB/GYN clinic revealed no gynecological pathology. The patient was angry to be back in the clinic again, as she felt her pain was being ignored while she had been shunted around amongst various providers, ending up once again where she had started. The nurse jumped into the conversation, instructing the patient to quiet down and to be grateful to be seen by a doctor. The attending told the patient that she was right to be frustrated and to be angry that she was still hurting and subsequently placed the necessary referral for an MRI. Reflecting upon this encounter, the OB/GYN clinic appeared to be a place where women could freely advocate for themselves within a larger institution designed to deny autonomy.

It was regarding individual autonomy that I struggled with while articulating my reactions and experiences after my rotation ended. It was initially difficult to write of my experiences involving people who lacked the audience to voice their own stories. There are many feelings that I still cannot express today, and those that I can discretely identify cover a wide array of emotional territory. I learned how daily counts could place indefinite holds on clinic flow and how ice was a highly valued commodity. I learned that a small number of buildings in the prison complex were air-conditioned, while the medical clinic was one of these few, many of the dormitories housing pregnant women were not. I was appalled that women with Hepatitis C could not be treated without evidence of liver damage. I felt grief for a woman who could not conceive of continuing a pregnancy while she was incarcerated. I learned that maternity pants had been discontinued as some women had fashioned the elastic component of the pants into headbands. I felt heartbreak for the women who lost loved ones, both inside and outside of prison, whose full grieving processes were impacted by their incarceration. I felt shame as women shared that they avoided medical care on the outside owing to distrust of the health-care system. I felt a striking sadness as women shared past abuse and trauma just moments before a pelvic exam.

But I also felt contagious excitement from women with release dates in the near future who looked forward to life on the outside. I felt gratitude, as physicians with whom I worked took extra precautions to provide healing-centered care. The clashing enormity of these feelings indicated some larger contradiction about this work – how could we provide healing care in an inherently punitive space? Carolyn Sufrin theorized this incongruous sentiment in her description of jail health care and “the strangeness of folding medical routines into custody routines, of providing care to bodies labeled criminal.” I was part of a team of health-care providers operating as judicious healers providing what could have appeared as ordinary, standard medical care for women in the prison, but there was an emotional aspect of the experience that felt was unique. Amidst competing contradictions, I realized that a potential space exists within the prison where healing care can flourish and in which authentic benevolence not only survives but also endures.