It takes more than good intentions to transform the South. It takes money.
What the hell is a Scalawag?
People in Louisiana prisons are dying painful deaths under the care of ill-equipped physicians, according to multiple lawsuits filed against the Louisiana Department of Public Safety and Corrections.
One major flaw, according to prison reform activists, is that medical care in the state's carceral system falls overwhelmingly in the hands of doctors whose licenses were formerly suspended. When a doctor's medical license is reinstated after a suspension, there can still be limitations on how they can and can't practice medicine, meaning many of these doctors aren't able to perform some of the most basic functions of health care, from administering pain management to writing prescriptions.
The result puts the 34,000 people currently incarcerated in Louisiana at risk of preventable suffering from treatable conditions or illnesses—or worse, dying an unnecessary or excessively painful death.
"[I have] patients telling me that they've been complaining about back pain for four years, five years," said Dr. Anjali Niyogi, founder of the Formerly Incarcerated Transitions Clinic. Niyogi is a hospitalist at University Medical Center in New Orleans, where she sees critical care patients who transfer from care of the corrections department. For some patients, she said, their pain had escalated to the point that they couldn't walk.
The hospice facility at Angola Prison in 2011. Photo by Frank McMains.
The difficulty in understanding poor medical outcomes in Louisiana prisons, Niyogi said, is that it is very hard to pin down one root cause. There's bureaucracy, and there's bias against incarcerated people. But like others pushing for prison reform, she's critical of hiring a majority staff of physicians with restricted licenses, particularly those who've broken the Hippocratic oath—and thereby the trust of their patients.
Doctors working in Louisiana prisons have restrictions on their licenses for widely varying reasons. Some sanctions stem from legitimate, lasting harms done to patients and their communities. Others have restrictions for off-the-clock substance use and/or disorders not currently recognized by the American Psychological Association or the Diagnostic and Statistical Manual of Mental Disorders, like "sex addiction."
These doctors' histories also include sexually assaulting patients, writing under-the-table narcotic prescriptions, possessing child pornography, and drinking alcohol on-duty.
The practice of hiring physicians with disciplinary histories works as a mechanism to keep prison health units staffed. Because of social stigma surrounding working for a prison (and lower pay), these positions are harder to fill.
Today, the practice runs all the way up the chain of command.
According to records obtained by Scalawag in October 2020, 10 out 11 of doctors on staff at the Louisiana Department of Public Safety and Corrections have a previous disciplinary action on their record. Of the 10 physicians in the department of corrections with restricted licenses, seven are medical directors of state facilities. Medical directors make decisions about standards of care, maintain records, and admit patients to infirmaries or hospitals. They are also involved in clinical supervision of fellow providers.
"There's this common understanding that having no doctors in prisons is probably worse than having some doctors in prisons who have disciplinary records. And I would agree. We need doctors," said civil rights attorney Jamila Johnson, managing attorney at the Promise of Justice Initiative in New Orleans.
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Reformers aren't looking to retry the physicians who've served time in prison or on disciplinary probation, but the practice of medicine gives these providers an incredible amount of power in prisons. People currently incarcerated in Louisiana receive no other option for their health care. With a rapidly aging population confined in overcrowded spaces during a pandemic, these are fiercely vulnerable people. Reformers are calling for higher scrutiny to protect patient's rights and build clinical relationships founded on trust, which is the standard of medical care outside prisons.
"When almost everyone working within your facility has limitations on the type of care they can provide, based on their previous medical history," Johnson said, "you can imagine that is not going to be an appropriate level of care."
Because of the cost to replace physicians working with restrictions, prison reform advocates face an uphill battle with the conservative-held State Legislature, which has historically pointed to the budget's bottom line rather than the benefits of better health care for people behind bars.
Controlled by Republicans in each chamber, the Legislature oversees the Louisiana State Board of Medical Examiners, which maintains licenses for all physicians in the state. Legislators create policies for the medical board, which in turn has the power to interpret those policies. The medical board also oversees disciplinary actions for all physicians in the state, using a system based on complaints and formal investigations.
"We try and keep them out of vulnerable populations," said Dr. Vincent Culotta, Executive Director of the board. But, "just because they're in a vulnerable population doesn't mean that they would abuse the privilege of practicing medicine in that vulnerable population."
The medical board does not monitor how providers behave unless they receive complaints, and they no longer take anonymous complaints. This means if a patient wants to report their doctor for sexual aggression, they must go on public record and give their identity in order to file a complaint and trigger an investigation.
Some of these investigations end in the suspension of a license, temporarily or indefinitely. Many cases result in restrictions related to the criminal statutes or ethical boundaries the physician broke.
"Each one of them is subtly different, so it would depend upon the uniqueness of the case," Culotta said.
While there is no public website with a list of restricted physicians working in the department of corrections, physicians' license restrictions (present and past) are available on the medical board website. In cases where physicians served time in prison, the medical board reflects that in their documentation.
But because the medical board has a wide range of reasons to restrict doctors, there's no one way to describe "all restricted doctors." Offering a specific reason for each physician's restrictions means airing their criminal history. Even if that history caused harm (assault, malpractice), reformers and abolitionists believe in individual reconciliation.
However, these are not doctors who have one infraction, fulfil probation, and move forward without issue.
One such doctor is Robert Cleveland, the medical director for the B.B. Rayburn Correctional Center near Angie, Louisiana. Cleveland's first investigation under the medical board focused on a medical equipment scheme. While on probation for that infraction, Cleveland wrote prescriptions for OxyContin out of his home office with incorrect and incomplete documentation. Today, he still cannot prescribe any Schedule 2 or 3 controlled substance. Rayburn Correctional houses more than one thousand people.
A month into Louisiana's COVID-19 lockdown, the medical director of the Louisiana Department of Public Safety and Corrections, Dr. John E. Morrison, resigned. His replacement was later confirmed to be Dr. Randy Lavespere, who previously worked as the medical director of Louisiana State Penitentiary (known as Angola). Under Lavespere's direction, Angola was, according to a 2016 report filed by correctional medicine experts, one of the worst prisons they'd reviewed in their collective 60 years of medicine.
"You've got one of the worst medical directors of one of the worst medical systems in the prisons now in charge of all of the medical systems in prison," Niyogi said.
In 2006, Lavespere purchased $8,000 worth of crystal meth from an informant in a Home Depot parking lot. He was suspended and served two years for an intent to distribute conviction. His license was reinstated with restrictions in October 2009. In those restrictions, the medical board revoked his ability to prescribe all controlled substances and ruled that he couldn't practice medicine in the state "other than in an institutional, prison or other structured setting" pre-approved by the board. Two other physicians currently working in the corrections department also have this restriction in their history. Hired in 2010, Lavespere practiced medicine at Angola with those restrictions on his license.
"When doctors have limitations on their abilities to provide pain medication because of their past disciplinary history, that really limits their ability to provide good treatment," civil rights attorney Johnson said.
Lavespere's license was reinstated without restrictions in 2014, and in the following year, the Southern Poverty Law Center and the Promise of Justice Initiative filed a class-action lawsuit against the department of corrections administration and Angola Medical. Lavespere is a defendant in Lewis v. Cain, with extensive depositions and testimony. Johnson provided counsel on the case.
In court, Lavespere shared he believes nearly half of all the patients he sees are lying to him about their medical complaints. Lavespere also claimed that patients commonly refused medical services, not that he denied them treatment, but could not supply documentation of these refusals.
There were reports that Lavespere dismissed symptoms and requests for assistance, particularly when it came to people with incredibly painful conditions.
During discovery, plaintiff's lawyers uncovered the story of "Patient 18." In 2013, Patient 18 had a positive HIV test result and saw Lavespere in Angola Medical. There are no records of Lavespere relaying the test result to Patient 18. They died of pneumonia weeks later. Before that, in 2011, under Lavespere's watch, a patient was confined to an isolation room for three days with a 103 degree fever, before he was returned to the general population without medical follow-up and collapsed in his cell. Lavespere then ordered EMTs not to move the patient or provide emergency medicine for hours following the collapse. The patient died the next morning.
Lavespere made decisions about the care of patients, evaluated the severity of their symptoms, their needs for treatment, and importantly, made system-wide decisions at Angola. And it was those decisions that led to dangerous care for people who had no other system to turn to.
There are more issues of record-keeping concerning Lavespere. Multiple times in testimony, Lavespere claimed he did not require taking notes on the more than 70 patient interactions he had a day. Between 2009 and 2014, one of Lavespere's license restrictions was to submit regular reports to the medical board written by a medical supervisor. At the time, this would have been former department of corrections medical director Dr. Raman Singh.
Lavespere isn't just a bad apple. Through the discovery process of Lewis v. Cain, the plaintiffs' legal team found only one instance of professional review by Singh submitted to the medical board over four years.
On March 31, 2021, Federal District Court Judge Shelly K. Dick ruled that Angola prison officials failed to provide constitutionally adequate medical care and accommodate disabilities, which resulted in sickness and death. The Court also found that the defendants had "been aware of these deficiencies in the delivery of medical care at LSP for decades." Specific relief after this victory is yet to be determined.
"Now we have a system to fix, not a person to fix," Johnson said.
An 'evolving' process
Lavespere's upward trajectory to Medical Director of the Louisiana Department of Corrections is a tacit endorsement that doctors who have harmed the communities they serve can and should work in prisons. His growing power in spite of his history could mean we will see more and more of it. In fact, Lavespere said he actively recruits physicians who are under medical board consent orders. According to documents obtained in 2019, at the time, 62 percent of doctors employed by the department of corrections had disciplinary histories. Today, because of deaths or resignations, doctors with those disciplinary records make up more than 90 percent of the department's physician staff.
But what creates this pipeline of restricted doctors to prisons?
There is no overall policy from the Louisiana State Board of Medical Examiners or the State Legislature regarding where physicians with restricted licenses can practice. The state's Medical Practices Act gives the medical board the ability to interpret standards of practice and create sanctions, which includes stipulations about where a provider can practice medicine.
"We do not prohibit people from practicing in the prison system if they are restricted, unless their work in the prison system would aggravate or put them in a bad position with regard to the reason they were disciplined," Culotta said.
Culotta shared one example during an interview: If a provider was sanctioned for sexual aggression or violence against cis women, they would only be allowed to provide care in facilities for assigned-male people. When asked about where trans people play into that reasoning, Culotta did not provide a response to the question. However, he stressed the the medical board approach to sexual assault by providers is "evolving."
In other words, the medical board does not assign providers a place to work, but it does maintain an approval process for the employment of restricted doctors. They do this either by explicitly adding a "Board Approval of Practice Setting" restriction or by making direct suggestions for care settings, like with Lavespere. That means the department of corrections must express interest in a provider and prove they are aware of the provider's history and restrictions. Then, the provider and employer (in this case, the department of corrections) go to the medical board for approval.
It took months of research and reviewing records from the medical board to understand this approval process.
When addressed with direct yes or no questions to understand this employment approval power, the agency declined to answer, citing exceptions and privileges under the state Medical Practice Act.
Other restrictions play a role in this as well. For example, if a provider has committed insurance fraud, it's likely the insurer from that incident will refuse to pay for that doctor's services again. Incidentally, correctional health units do not engage with private or state-sponsored insurance programs for reimbursement.
"The state Medicaid program itself is saying, 'Hey, if you have a restricted license, we're not going to honor your license…' and yet, our prisons feel that they can surpass that," Niyogi said.
In March 2019, Niyogi went before the medical board to discuss her concerns with this system in the department of corrections. The board suggested Niyogi introduce a bill in the State Legislature to assert that physicians with restricted licenses cannot work in correctional settings.
"This will be a hard one to push for, and may require more legal cases for medical complications," Niyogi said.
At one end, reforming this facet of Louisiana correctional healthcare is about blocking providers with harmful backgrounds from prisons, and at the other, how the department of corrections finds and hires doctors.
"We don't have to settle for filling-in just anybody, literally anybody," Niyogi said.
During testimony, Angola Warden Darrel Vannoy said that "primary care doctors with clear licenses are not going to work for the salary that is being offered." Another reform option could include raising salary pay for medical services to reflect treating a vulnerable population. This is common in other healthcare settings, and would attract a wider group of candidates. But, Niyogi recognizes that salary raises are unlikely.
Seeing a path forward takes some imagination. Niyogi shared strategies to attract doctors without disciplinary histories to work in prisons. Many newly graduating doctors leaving their residencies and other early-career programs will seek out fellowship positions to gain a foothold in the industry. Creating a fellowship within the department of corrections would provide access to doctors with up-to-date medical training at a lower cost per salary.
"We get people who are trained in trauma-informed care who really understand what it means to work with this vulnerable population," she said.
However reform may come, it would need to be done in a system that will still put more money into surveillance than into care. Niyogi said she sees that priority on security and punishment as a large part of the issue itself.
"If we work to divert money into actually providing care for people, we would decrease the amount of lawsuits we're having. That would be a great way for [the department of corrections] to save money, take money, and pay providers more."