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Every facility we visited offered basic medical services to detainees, and children at all facilities reported that they had received some sort of examination by medical staff shortly after their arrival. However, children frequently complained that they would have to wait a week or more to see a nurse or doctor if they became sick after receiving their initial medical examination; some youth reported that their requests for medical assistance were ignored altogether.

In at least one facility, we learned that medical staff did not regularly offer gynecological examinations, providing them to girls and women only upon request. Additionally, we learned that not all jails have separate medical facilities for female detainees, particularly for those on suicide watch. In the Washington County Detention Center, we saw an adult woman placed on observation in a cell at the front of the booking and intake section, in full view of the male guards and detainees who regularly passed by.

In Maryland and across the United States, detainees have a higher incidence of mental illness than the population as a whole. Accordingly, mental health services are a critical aspect of medical care in jails. In our tour of Baltimore's detention center, where Human Rights Watch's investigative team included a mental health professional, we were disturbed to find serious deficiencies in the mental health program.

General Medical Care

All of the jails Human Rights Watch visited had procedures in place to examine detainees upon their admission. All of the children we interviewed reported that they were screened by medical staff within several days of their arrival.

Nevertheless, children frequently told us that they had difficulty seeing medical staff when they were sick or needed dental care. "You got to write a lot of times," said Joey N., held in the Baltimore City Detention Center.5 Marlow P., a sixteen-year-old in Baltimore, told us, "I put out a sick call, but not been called yet. That was three weeks ago."6

"The amount of time it takes to see inmates depends," Montgomery County medical staff told Human Rights Watch. "It could be six days unless it's an emergency." Thomas C., a Montgomery County detainee, told us that he had made five requests to see the doctor during the nineteen months he had been at the jail;it usually took two weeks before he would be seen. He reported that another inmate contracted appendicitis but said that the corrections officer did not take the inmate seriously. Eventually, he told us, the inmate had to be taken out of the unit on a stretcher.7

Michelle R., a fifteen-year-old in Prince George's County, estimated that it takes a week or more to be seen after filling out a sick call slip. She stated that when she had an earache, it took six days before she saw the doctor. In addition, at the time of our interview in July 1998 she had been waiting for one week to see the dentist for a toothache. Jenile L. stated, "I've been waiting to go to the dentist. It says in the handbook that we can get temporary fillings. Mine fell out two and a half months ago. They not called me yet. I keep putting in requests for the dentist. It's ten or more slips I've put in." Similarly, Nestor S. told us that he had asked to see a doctor after becoming sick. "They told me, `okay,' but never got around to seeing me." However, Michael T., another Prince George's County inmate, reported that his cellmate saw the doctor four or five hours after putting in his request. "He has sickle cell, so it was faster than average," he said.8

These accounts raise questions about the responsiveness of medical staff to the needs of their juvenile and adult detainees. International standards call for detention facilities to provide children with "immediate access to adequate medical facilities" and provide that "[e]very juvenile who is ill, who complains of illness or who demonstrates symptoms of physical or mental difficulties, should be examined promptly by a medical officer."9

A jail's failure to attend to the medical needs of its detainees may subject it to liability under U.S. law. In Estelle v. Gamble, a case involving medical care in the Texas prison system, the U.S. Supreme Court held that deliberate indifference to the serious medical needs of prisoners is "unnecessary and wanton infliction of pain" in violation of the Eighth Amendment's prohibition of cruel and unusual punishment.10 A higher standard of medical care may apply to pretrial detainees, who are entitled under the due process clause of the Fourteenth Amendment to befree from all punishment; in any event, a pretrial detainee's rights should never be less than those of a convicted prisoner.11

Whether or not a jail's medical care is so deficient that it violates the U.S. Constitution, its failure to adhere to international standards and good medical practices carries the risk that serious medical conditions will go untreated, with potentially tragic consequences.

Medical Care for Female Detainees

The jails we visited appeared to make some effort to provide basic medical services with appropriate examination procedures for female detainees, but not all offered regular gynecological examinations. For example, Washington County Detention Center policy provides that if the examining doctor is male, a female nurse must be present during examinations of female detainees. However, the medical staff told us that gynecological examinations are offered only "as needed, if a female makes a specific complaint. They're not offered on a routine basis."12

The National Commission on Correctional Health Care notes that

Research regarding the provision of gynecological services for women in correctional settings has been limited, but it consistently has indicated that such services are inadequate. Annual gynecological exams are not done routinely in either jails or prisons, nor are they regularly performed upon admission. Appropriate initial screening questions about a woman's gynecologic history may not be asked, and in many correctional facilities, there are no physicians who are trained in obstetrics and gynecology, leading to inadequate and inappropriate gynecologic care.13

The commission recommends that jails and other confinement facilities provide "comprehensive services for women's unique health problems"; in doing so, "[c]onsidering the unique developmental needs of female adolescents, special attention should be given to their needs" in providing these health services.14

While the larger detention centers had separate medical and mental health facilities for female detainees, separate facilities are not always the rule in small jails, raising the concern that female juveniles may be housed with males while receiving medical or mental health treatment. Although we did not see any instances in which female juveniles were commingled with males, in Washington County we observed one adult woman in a cell in the holding area, the only female inmate in a group of cells otherwise occupied by males. She lay on a plastic bed set at floor level, with a single sheet to cover her. The officer accompanying us explained that she had been placed in that cell, plainly visible to the guards and to anybody walking through the holding area, because she was a danger to herself. The officer told us, "It's the best place for her right now because she's right up in front where the officers can see her. We don't like holding females in this area. It's really the lesser of two evils."15

Mental Health

While we made no attempt to evaluate the mental health needs of individual juveniles, some children identified mental health services as one of their most significant needs. James S., a seventeen-year-old held in the high security pod of the Montgomery County Detention Center, repeatedly told a Human Rights Watch representative that he wanted treatment to assist him to rehabilitate himself and to help with his mental state. "I just be depressed most of the time," he said. "On lockdown for four months, haven't seen my family since I been here. I overreactto the situation, to the lockdown. I'd like to see if I could get some type of treatment, some help. I want to change."16

"There are a lot of mental health needs among the people now coming to the jail. We are not in a position to handle these people at all," Commissioner Flanagan of the Baltimore City Detention Center observed to us.17 While there has been no systematic study of the mental health needs of children detained in Maryland's adult detention centers, a 1998 study of youth in the state's juvenile justice system estimated that 24 percent are in need of mental health services.18

Mental health experts generally concur that youth in the justice system have a higher incidence of mental disorder than the juvenile population as a whole.19 For example, a 1995 Virginia assessment "revealed that more than three-quarters of all youth in the states's seventeen detention facilities exhibited at least one diagnosable mental disorder. Of that number, 8 to 10 percent had mental health needs in the severe/urgent range and 40 percent were assessed as having needs in the moderate range."20 Nationwide, the General Accounting Office estimates that between 6 and 14 percent of the incarcerated population, juvenile and adult, may have a major psychiatric disorder.21

The Human Rights Watch delegation that toured the Baltimore City Detention Center in May 1999 included a mental health specialist, enabling us to evaluate the mental health services available at that jail. Human Rights Watch researchers were not accompanied by a mental health professional on our visits to the other facilities.

Mental Health Services in the Baltimore City Detention Center

Mental health services in the Baltimore County Detention Center are minimal to nonexistent for juvenile and adult detainees alike, with no services designated specifically for juveniles. Baltimore's mental health staff comprises three full-time professional service providers. One of these, a clinical social worker, provides intake assessments for the approximately 87,000 annual admissions at the central booking facility. One masters'-degree-level psychologist works with the women, a population of up to 528 at any given time. A doctorate-level chief psychologist, assigned to work with the men, serves up to 2,428 inmates.

In addition to these staff members, the education program has two part-time mental health workers who provide case management services, but these professionals do not coordinate with either the jail's mental health staff or its corrections staff. The corrections staff includes several social workers, who provide access to the phones for legal and some social calls, coordinate aftercare planning, and otherwise serve as case management staff. The mental health staff with whom we spoke reported that they did not feel that the social workers on the corrections staff worked with them as part of a collaborative team. The failure of staff in all programs to coordinate is a lamentable failure to maximize the effectiveness of available resources.22

The paucity of service providers results in the complete absence of mental health programming at the jail-there are no therapeutic groups, no individual counseling, and no aftercare planning efforts.23 In practice, the only detainees who are able to access mental health services in the detention center are those who are in crisis. Troubling under any circumstances, such limited access to mental health services is alarming when the physical environment of the detention center is taken into account. As described in detail in previous sections of this report, detainees are housed in areas that are largely dark, dreary, run down, poorly ventilated, and infested with roaches and other vermin.24 Confined in these inhumane conditions,detainees-particularly those placed in segregation without appropriate monitoring-are likely to suffer acute exacerbations of preexisting mental health disorders.25

The lack of mental health services is especially problematic for juveniles. Youth face greater challenges in adjusting to institutional life, difficulties that are compounded by antagonisms from the street. Because juveniles are a minority population with fewer housing options in the jail, youth at odds with each other may of necessity be housed together, resulting in further need for mental health services. Finally, the lack of mental health services for juveniles is of particular concern because juveniles have longer periods of detention than do adults. Nevertheless, the chief psychologist appeared to minimize the need for mental health services among the juveniles. "They're normally not here based on mental illness," he told us. "Mostly they're very fearful for their own safety on the juvenile section. They feel very safe here. Some get arrested to get back on E Section."26

We found that the lack of mental health coverage extends to psychiatric care. On the day of our May 1999 visit, we observed an adult male waiting to be admitted to the Men's Detention Center's inpatient mental health unit. Although jail staff had told us that the facility had psychiatric coverage on Tuesdays, no psychiatrist was on site on the Tuesday we visited. Staff told us that they had not been able to obtain a phone order for medication from the psychiatrist, who was unwilling to prescribe medication for a patient he or she had not seen and was unable or unwilling to visit the jail for a face-to-face consultation. Our observations raise questions about the extent of psychiatric coverage, either on site or on call, that is really available for detainees in Baltimore.

There is no acute care unit for women or juveniles comparable to the men's inpatient mental health unit, which has fourteen beds. The psychologist overseeingservices for adult men stated that when juveniles must be placed on suicide watch or provided with other acute care services, "certain statuses are forgiven,"27 meaning that juveniles are housed alongside adults when they are in need of acute mental health services at the jail.

Detainees with acute mental health conditions are housed in deplorable conditions in a series of dormitories. The patients we saw were naked, with some making an effort to drape their paper blankets over their bodies. Joey N., age seventeen, told us that he was placed in one such dormitory when he was put on suicide watch:

They took me to the suicide room. That's the butt-naked room. It's a dorm, they got about seven people in it. You don't get no clothes when you're there. I think there was five people including me when I was there. They kept me there for two or three days, then they took me to another dorm where I got my clothes back, then they discharged me and took me back to lockup.28

There is no medical justification for this dehumanizing practice, and the fact that juveniles are housed among this group is cause for extreme concern. Moreover, upon inspecting the cells designated for suicide watches, we found that they lacked important safety elements and contained numerous objects and protrusions to which a detainee could anchor a sheet or blanket in order to hang himself.29

The absence of a mental health program has likely contributed to the detention center's extensive reliance on lockdowns and similar security directives to address institutional unrest. On the day of our May 1999 visit, children reported that they had been locked down for six weeks, prohibited from taking recreation, making phone calls, receiving visits, or ordering goods from the commissary.

Such harsh security measures are frequently counterproductive, contributing to further disciplinary problems and increasing the need for mental health services. Severe measures that are imposed for a protracted period of time and that punish groups rather than individuals only serve to make the detainee population embittered and recalcitrant.

5 Human Rights Watch interview, Baltimore City Detention Center, February 9, 1999.

6 Human Rights Watch interview, Baltimore City Detention Center, May 11, 1999.

7 Human Rights Watch interviews, Montgomery County Detention Center, July 30, 1998.

8 Human Rights Watch interviews, Prince George's County Correctional Center, July 23, 1998.

9 U.N. Rules for the Protection of Juveniles, Article 51.

10 429 U.S. 97, 104 (1976).

11 See Ingraham v. Wright, 430 U.S. 651, 671-72 n.40 (1977); Martin v. Gentile, 849 F.2d 863, 870 (4th Cir. 1988) (noting that the due process rights of a pretrial detainee are at least as great as the protections offered to a convicted prisoner under the Eighth Amendment); Michael J. Dale, "Lawsuits and Public Policy: The Role of Litigation in Correcting Conditions in Juvenile Detention Centers," University of San Francisco Law Review, vol. 32 (1998), pp. 719-20. The U.S. Court of Appeals for the Fourth Circuit, whose jurisdiction includes Maryland, has applied the "deliberate indifference" standard of Estelle v. Gamble to cases brought by pretrial detainees. See Martin, 849 F.2d at 871; Whisenant v. Yuam, 739 F.2d 160, 164 n.4 (4th Cir. 1984); Loe v. Armistead, 582 F.2d 1291, 1294 (4th Cir. 1978).

12 Human Rights Watch interview, Washington County Detention Center, July 22, 1998.

13 National Commission on Correctional Health Care, "Position Statement: Women's Health Care in Correctional Settings," in Standards for Health Services in Jails (Chicago: NCCHC, 1996), p. 206.

14 Ibid., p. 208. In particular, female detainees report a high incidence of past physical or sexual abuse. According to the Bureau of Justice Statistics, 37 percent of female inmates in jails nationwide said that they had been physically abused, compared to 11 percent of male inmates. Similarly, 37 percent of women and 6 percent of men reported that they had been sexually abused. See Bureau of Justice Statistics, Profile of Jail Inmates 1996 (Washington, D.C.: Bureau of Justice Statistics, April 1998), p. 11. Because of the high levels of sexual and physical victimization within the female detainee population, the National Commission on Correctional Health Care recommends that medical services for women and girls include counseling and other appropriate services to address abuse issues. See "Position Statement," p. 208.

15 Human Rights Watch interview, Washington County Detention Center, July 22, 1998.

16 Human Rights Watch interview, Montgomery County Detention Center, July 30, 1998.

17 Human Rights Watch interview with LaMont Flanagan, commissioner, Division of Pretrial Detention and Services, Maryland Department of Public Safety and Correctional Services, Baltimore, Maryland, September 23, 1998.

18 Deborah Shelton, "Estimates of Emotional Disorder in Detained and Committed Youth in the Maryland Juvenile Justice System," March 1998, pp. 6, 28 (cited with permission of the author); Human Rights Watch telephone interview with Deborah Shelton, assistant professor, University of Maryland School of Nursing, Baltimore, Maryland, June 10, 1999.

19 See John F. Edens and Randy K. Otto, "Prevalence of Mental Disorders Among Youth in the Juvenile Justice System," Focal Point: A National Bulletin on Family Support and Children's Mental Health, Spring 1997, p. 7. See generally J.J. Cocozza, ed., Responding to the Mental Health Needs of Juveniles in the Juvenile Justice System (Seattle, Washington: The National Coalition for the Mentally Ill in the Criminal Justice System, 1992).

20 Susan Rotenberg, "Responding to the Mental Health Needs of Youth in the Juvenile Justice System," Focal Point: A National Bulletin on Family Support and Children's Mental Health, Spring 1997, p. 1.

21 General Accounting Office, Mentally Ill Inmates: Better Data Would Help Determine Protection and Advocacy Needs (Washington, D.C.: GAO, 1991).

22 We found a similar lack of coordination between the disciplinary hearing officers and mental health staff. In the absence of a protocol requiring mental health staff to be present during disciplinary hearings, a detainee who engages in self-injurious behavior may be dealt with punitively and without regard for underlying health issues. See Part VI, "Disciplinary Hearings."

23 Article 62 of the Standard Minimum Rules states that "[t]he medical services of the institution shall seek to detect and shall treat any physical or mental illnesses or defects which may hamper a prisoner's rehabilitation. All necessary medical, surgical and psychiatric services shall be provided to that end."

24 See Part IV, "Living Conditions."

25 "[L]eaving a psychotic or seriously depressed inmate along in a cell to suffer for long periods of time . . . is quite cruel and is likely to cause significant deterioration in their mental condition over time." Declaration of Terry Kupers, M.D., Coleman v. Wilson, No. CIV S 90-0520 LKK-JFM (E.D. Cal. Feb. 16, 1993), p. 41. In recognition of the dangers posed by prolonged periods of segregation, the National Commission on Correctional Health Care (NCCHC) requires that all inmates segregated from the general population should be "seen by qualified health personnel a minimum of three times a week to determine the individual's health status." NCCHC, Standards for Health Services in Jails (Chicago: NCCHC, 1996), p. 54. NCCHC recommends that juveniles "be checked daily by a health care worker." NCCHC, Standards for Health Services in Juvenile Detention and Confinement Facilities (Chicago: NCCHC, 1995), p. 37.

26 Human Rights Watch interview, Baltimore City Detention Center, September 23, 1998.

27 Human Rights Watch interview, Baltimore City Detention Center, May 11, 1999.

28 Human Rights Watch interview, Baltimore City Detention Center, February 9, 1999.

29 For example, a suicidal individual would have no difficulty tying one end of a paper blanket to the legs of the cell beds, the other end around his neck, and then leaning backward over the opposite end of the bed.

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