Thousands of American prisoners spend 23 hours a day in solitary confinement

Gabriel Eber has no shortage of macabre tales of life inside the East Mississippi Correctional Facility, a notoriously violent and chaotic men's prison on the outskirts of Meridian. Assaults (staff on inmate, inmate on inmate) are frequent. According to accounts, cells are infested with rats that crawl over prisoners; some inmates tie leashes to the rodents and sell them to the mentally ill as pets. Men are kept in small, unsanitary isolation cells with scant human attention for months and years. Self-mutilation and suicide attempts are not uncommon.

But words alone, Eber says, can't bring home the facility's gruesome conditions. "I can show you a video of what I'm talking about, and I have some pictures," says Eber, dressed in a loose-fitting dark suit as he sits in his cramped Washington office at the American Civil Liberties Union. He clicks open a file to show footage shot by the private corporation that now manages the prison. Two corrections officers stand outside a cell in one of the EMCF's isolation units. (One such unit is known to inmates as the "dead zone" or "dead man's zone.") The officers are here for an unknown reason, perhaps to respond to a medical emergency, but if so, Eber says, they are already too late. One hears garbled shouts from other unit inmates, intermixed with a rhythmic, buzzing cacophony of machinery. The man inside, Eber says, suffers from asthma, which has likely worsened due to pepper spray in the air. Corrections officers routinely spray through a cell door's tray slot if the inmate refuses to close it. Inmates often leave the slots open as a cry for help to receive medical attention, food, or a shower, and such defiant acts are common. Some inmates flood their cells by cramming whatever they can into a toilet, or use damaged electrical sockets to set fire to their mattresses. Some cut themselves.

Eventually the door opens, revealing a tall, thin 40-year-old African-American man, hunched over with one hand on a wall splattered with blood. Eber conjectures the blood might be a symptom of forceful or long-term coughing. On the floor lie "fishing lines," a rudimentary mechanism for prisoners to pass messages or contraband—matches, a razor, a piece of glass—back and forth. Out of the cell now, the man coughs and shows signs of wheezing. After a few wobbly steps, he collapses. A sliver of pink phlegm shoots from his mouth. A small cadre of prison medical staff, yards away, looks on.

Cell visits in isolation units don't have to be so cruel, says Eber, SPH '02, a senior staff counsel with the ACLU's National Prison Project. The project investigates the nation's prisons and jails and advocates for compliance with the U.S. Constitution, domestic law, and international human rights principles. The investigators assert that prison inmates should be guaranteed proper medical and mental health care and basic human decency. There's no justification, Eber says, for intentional abandonment so that medical symptoms or pre-existing conditions go untreated or receive only rudimentary attention.

He details other cases at the East Mississippi Correctional Facility, all part of a class action lawsuit filed in May 2013 in a U.S. District Court on behalf of the 1,170 prisoners there. According to reports filed by the plaintiffs and expert witnesses involved in the case, a 25-year-old inmate was not granted timely access to a urologist following an abnormal ultrasound that showed a testicular mass, which later swelled to the size of a softball and metastasized to his abdomen. A 64-year-old patient with untreated diabetes reported losing his vision and has not, as far as Eber knows, received an ophthalmological evaluation or referral to a retinal specialist. A 43-year-old black male with a severe heart condition recently died in an isolation cell. His symptoms, as documented by an expert witness, indicated that his cardiac function was deteriorating. He spent several months in the medical observation unit but was then discharged back to isolation, where he died a month later. Two days before his death, he set fire to his cell, apparently in a desperate effort to get help. He had earlier been found putting a rope around his neck, and he'd been cutting himself. In a dated and time-stamped note in his chart, a registered nurse listed his vital signs as stable and said he was in no acute distress. At that point, however, the man had been dead for 10 hours. "That's indicative of the quality of care prisoners sometimes receive," Eber says. "I've seen a case where a nurse will document 'normal' exams a week or two after a patient has died, because they're being made up."

Eber talks slowly and pauses often. He recounts these cases matter-of-factly, but his indignation simmers just under his stony expression. "I've never seen people treated quite the way they are in Mississippi prisons. The conditions there are horrific—the worst I've ever seen or heard of." Eber, an associate faculty member in the Department of Epidemiology at the Bloomberg School, is no neophyte. Since 2007, he has investigated large-scale class action lawsuits in five states, representing thousands of prisoners. He guesses he currently has somewhere in the neighborhood of 10,000 clients, probably more. His work at the National Prison Project focuses on cases alleging inadequate medical and mental health care, with a particular interest in solitary confinement.

Colleagues describe him as persistent and detail-oriented. Margaret Winter, the associate director of the project, says, "He bores in and gives a brilliant overview of what is broken and what needs to be done to fix it. He has an incredibly scientific mind combined with his passion for justice. It's not easy what he does. It takes a level of patience that not many have."

Eber, now 40 with a beard flecked with gray, grew up in Chappaqua, New York, an upscale hamlet in northern Westchester County. The son of an attorney, he occasionally visited his dad in court. He first toured the inside of a jail cell at age 5. He thinks the jail was in Yonkers, but all he can remember today was the unexpected sight of women behind bars. He attended Harvard, where he graduated in 1997 cum laude with a degree in social anthropology. For the next three years, he took course work in epidemiology and biostatistics at Harvard's school of public health, and then switched to the Bloomberg School, where he earned his MPH. He next enrolled at Georgetown University Law Center. After passing the bar, his interest in public health drew him to the National Prison Project, where he first served as a litigation fellow before becoming a staff counsel.

A sentiment that Eber and others in the same fight sometimes hear is: Why should we care about the health and well-being of inmates? These are convicted criminals. Some are serial rapists, murderers. They sell drugs to our children. They concoct fraud to steal money from our grandparents. Prison should be rough. That's what deters people from breaking the law, right?

Eber argues that we all should care what goes on inside prison walls. The system, he says, is built on a rehabilitation model, not a torture model. He tells people to ask themselves this: What kind of person do you want leaving prison? Someone who is healthy and rehabilitated? Or someone so damaged as to likely be a burden to society? The issue, he says, is clear and serious. In far too many U.S. prison systems, inmates who have serious medical needs are either ignored or get substandard care. The result, he says, can lead to unnecessary amputations, the spread of disease, suicides, and the exacerbation of pre-existing psychiatric disorders. Even basic care for treatable conditions, like diabetes, can be a challenge in prison. "We hear it all," he says. "It's heartbreaking. The system is sick."

Leonard Rubenstein, a senior scientist in the Bloomberg School's Center for Public Health and Human Rights, says the treatment that some inmates receive is unconstitutional and perverse. For the past 30 years, Rubenstein has been involved in the investigation and analysis of medical complicity in torture, medical ethics and human rights, and war crimes. Prior to joining Johns Hopkins, he served as a senior fellow at the United States Institute for Peace and executive director and president of Physicians for Human Rights. "There is a system of punishment in this country based on locking them up and taking away their freedom. That's it," says Rubenstein, who co-teaches with Eber a course on health in prisons at the Bloomberg School. "Your freedom is taken away. There is nothing in our system of law that authorizes harm, no matter how terrible a person you are. That is not part of constitutionalized civil order. And quite frankly, it's barbaric."

Eber's first ACLU case was from a women's prison in Wisconsin, where there were reports of medications administered by correctional officers, not nurses; in some instances, inmates were given the wrong medications or the wrong dosages. "It was a disaster. In fairness, the corrections officers wanted no part of this. It was just a practice that was allowed to continue. And it took a lawsuit to change," he says. "We eventually reached a settlement. I still go out there periodically to monitor conditions and make sure that what we asked for is being done."

He first traveled to Mississippi five years ago to conduct routine monitoring. He volunteered to spend three days at the Mississippi State Penitentiary, also known as Parchman Farm, reading medical records. Nationwide, he says, substandard care is too often the norm, and the level of violence in prisons is disquieting. But the real horror, Eber says, can occur in the isolation units, where inmates are confined 23 hours a day—24 hours in many cases—to a cell the size of a small bathroom, behind a solid metal door with a small and narrow glass window and a narrow port for passing food trays. Human contact is limited to the few times during the day that staff come to the front of the cell to deliver a food tray or for brief mental health or medical rounds. At times, he says, the level of care borders on the absurd. He mentions a case of an inmate at East Mississippi who complained of chest pains and wouldn't close his tray slot until seen by a medical professional. A nurse had the inmate reach his hand through the door to take his blood pressure. "That was the extent of the exam," Eber says. "No other vitals checked. No questions asked. It's ludicrous."

Out-of-cell time for exercise occurs at best an hour a day a few times a week. Conversations with inmates in other cells are possible only by shouting. Prisoners might be deprived of the opportunity to shower for days at a time. A television is mounted on a wall at a distance across the dayroom, and it is often impossible to see or hear. Access to the telephone is almost nonexistent. Toilets frequently back up, so inmates are forced to defecate on their food trays and slide them through slots. One of the ACLUs experts in the Mississippi case, a sanitarian and dietitian from the Dallas County Jail, took photographs of various parts of the prison and found broken lights, dirty showers, congealed blood, rodent droppings, filthy kitchens, burned-out cells, and pills scattered on floors. In one isolation cell, she stood in a pool of blood left by an inmate who had gashed himself the day before.

Eber says the response from the Mississippi Department of Corrections and many in the prison system is, "It's not a problem." "They are fighting this lawsuit tooth and nail," Eber says of the Mississippi case. Many corrections officials, he adds, accuse his clients of lying, no matter how much evidence they present. "That is when we end up in litigation. And that is why we review medical records and conduct site inspections. We want to know the truth, and we want the public and the courts to know the truth."

Leonard Vincent, general counsel for the Mississippi Department of Corrections, says that although the East Mississippi Correctional Facility is not a state-run prison (it's operated by the private, Utah-based Management & Training Corporation), the state is the defendant in the case and has denied the allegations. Vincent also notes that EMCF has been accredited by the American Correctional Association in the past three years and received a "high score," although he admits that the level of health care is just one component of the accreditation. When asked about the significant gap between the state's and the ACLU's assessments, Vincent cites divergent philosophies. The standards and viewpoint of how a prison should be run are clearly not the same, he says. "These two sides come from different backgrounds and differ in their opinions for how this should be done."

For the better part of the 20th century, stays in solitary confinement were relatively short—days or weeks at a time. That changed in the 1980s and early 1990s when the U.S. prison population began to swell and so-called "supermax" prisons were built, facilities where thousands of inmates now spend years locked in small cells. America's prison population is the largest in the world and currently stands at around 2.3 million people—about one in every 100 American adults—incarcerated across federal, state, and local levels. The number denotes a fourfold increase from 1973. The tally of inmates held in some form of segregated housing is harder to come by because the definition varies from state to state and figures are often underreported. A 2005 report by the Bureau of Justice Statistics used a figure of 25,000 in isolation, but that only applied to those in supermax prisons. The real number, Eber and others assert, is likely closer to 81,000.

The prison system prefers terms such as "isolation" or "administrative segregation" or "restricted housing" to the more colloquial "solitary confinement" or "in the hole." Inmates are placed in wings called Special Housing Units or Special Management Units to maintain order. The most violent prisoners can be sequestered. Isolation can be used for discipline when an inmate disobeys prison rules. Eber says high-ranking gang members are often put in segregation. Corrections officials first turned to this strategy in response to growing gang violence inside prisons. Once gang members are placed in solitary, however, they rarely get out. "You're going to be deemed a threat forever," Eber says. Prisoners can be put into isolation units for an indefinite period, from days to decades. A 2012 report from the Colorado Department of Corrections found that prisoners spent a mean of 19.5 months in isolation. The federal Bureau of Prisons system currently confines about 7 percent of its 217,000 prisoners in isolation units for roughly 23 hours a day, according to a 2013 U.S. Government Accountability Office report. When they do get out, for exercise or a shower, prisoners are typically escorted by two or more high security officers. "But if there's a staffing shortage or unrest in another part of the prison that is demanding resources, then those prisoners are not going to be let out," Eber says. "That happens too frequently, so inmates might go weeks without getting out."

Twenty years ago, when Annette Hanson began working in the Maryland correctional system, she expected to encounter reams of evidence in the medical literature about the bad effects of solitary confinement. Hanson, a clinical professor of psychiatry and behavioral sciences at the School of Medicine, has worked extensively in the Maryland correctional system as a psychiatrist, directly treating prisoners. "It was shocking how little evidence there was to the statement that segregation was damaging to a person's health," she says. "In my experience, the general claims and reports of the detrimental effects of incarceration on the physical and mental health of inmates has been somewhat overstated. I simply did not see what I've been reading in the news. Even in terms of medical isolation, in my experience their health did not deteriorate. In fact, some were relieved to have some peace and quiet, and be separated from the rest of the prison population where they might be harmed."

Segregation can be useful for medical purposes, Hanson says. An inmate might have tuberculosis or chickenpox and need to be isolated to protect the rest of the prison population. "It's not solely for disciplinary purposes," Hanson says. She balks at a ban on segregation practices. "I think it's a valuable tool for me and others in the correctional system," she says. "It can restore order. And it's a safe place. Let's say you are grieving for the loss of a family member. In prison, if you cry, you might as well paint a target on your chest."

A study published in 2013 in the Journal of the American Academy of Psychiatry and the Law examined administrative segregation involving Colorado prison inmates with and without mental illness. In the longitudinal study, researchers examined whether inmates in segregation showed greater psychological deterioration over time compared to those nonsegregated. The subjects, male inmates in both administrative segregation and the general population, completed a brief symptom inventory at regular intervals for one year. Results showed some differentiation between groups at the outset and small but statistically significant positive change over time across all groups. The study's findings were inconsistent with the hypothesis that inmates, with or without mental illness, experience significant psychological decline in solitary confinement. This study, however, has since been attacked on methodological grounds. Some critics say it relied too heavily on self-reports by inmates, with only marginal use of records and professional assessments, in circumstances where prisoners have disincentives to report psychiatric symptoms. Reports of psychiatric emergencies and medication changes were apparently not considered and, according to some critics, would have dramatically changed results.

A 2014 study published in the American Journal of Public Health, "Solitary Confinement and the Risk of Self-Harm Among Jail Inmates," analyzed the medical records of more than 134,000 New York City jail prisoners from 2010 to 2013. The study found that solitary confinement was strongly associated with increased risk of self-harm, which ranged from self-inflicted lacerations to headbanging on walls to suicide attempts. Of the 7 percent of inmates in solitary confinement, 53 percent committed acts of self-harm, and 45 percent committed acts of potentially fatal self-harm. For the total population studied, the absolute risk for self-harm during incarceration was 0.5 percent and for potentially fatal self-harm, .03 percent.

So what does happen to people deprived of social contact for months or years on end?

Gul Dolen, an assistant professor of neuroscience at the School of Medicine and an expert on social cognition in health and disease, has studied the impact of isolation-induced changes in the brain. Dolen says social isolation of animals causes all kinds of physical changes. Even after just one to three days, her research indicates that the plasticity of the brain and how it encodes memory are altered. A number of studies in rats and monkeys have shown that early-life social isolation leads to heightened aggression. Dolen also points out that in human studies of the general population, decreased social network size is known to be a huge risk factor for mortality, bigger than alcohol, smoking, obesity, high blood pressure, or air pollution. Although it's unclear how social isolation is causally related to increased mortality, studies have shown that the brain processes associated with social pain use the same circuitry that encodes physical pain. "Social pain is not only caused by isolation but also physical bullying, exclusion, and humiliation; these latter types of social pain induce a massive stress response, called social-defeat stress, which reorganizes the brain's response to pleasure, pain, and fear, and has been used in animal studies to model depression."

Eber points out that prison populations differ greatly from the general population in prevalence of psychiatric illnesses. "People in prisons have a higher risk of psychiatric disease to begin with. Then you insert them into an environment that has the potential of bringing out those conditions. It's bad mix," he says. Experts say that American prisons are full, in part, because of the fallout from the underfunding and closing of psychiatric institutions. Prisons around the country have seen the numbers of mentally ill inmates increase as state hospitals have closed and community mental health services have been reduced by budget cuts. In California, more than 27 percent of male prisoners and almost 38 percent of female prisoners suffer from mental illness, according to state corrections department statistics. "What are these people doing in prison?" Dolen asks. "Even if you can show me evidence that this was necessary and good for our society, which has the largest prison population in the world, I'd be hesitant."

Dolen says social interaction is a good thing. We learn how to be tolerant. How to be compassionate. How to live in a society. People have to relearn how to be social after extended isolation. Dolen likens placing someone with an anti-social personality disorder into isolation to feeding only cheeseburgers to an obese person. Eber asks why solitary confinement has become the mental institution of last resort. "If you're seriously mentally ill and placed in solitary confinement, chances are you're going to be in there for a long time. Chances are you're not going to get quality care, and chances are you're not going to get better. In fact, you're going to get worse. Why do we consider this rehabilitation? What purpose are we serving? We need to make a decision as to how we're going to treat prisoners and how we want them to come out when it's time for them to be released. If we take a population that is sick to begin with, then throw them in a system not equipped to take care of them, they are going to get sicker. And they're going to die."

There is little oversight of American prisons compared to what occurs internationally. American prisons, Eber says, tend to be closed worlds where abuse is tolerated. "And it's only by shedding some light that we're even able to begin talking about change." Jean Casella, co-director of Solitary Watch, an advocacy group focused on human rights violations in the prison system, says that for years problems went unaddressed because prison systems generally are unregulated, unmonitored, and invisible, with no independent monitoring. She calls prisoner abuse the crisis that nobody has heard of. Correctional facilities have explained away any practice as necessary for safety and security. The National Commission on Correctional Health Care has since the 1970s offered a health services accreditation program and technical services to improve health practices in correctional facilities. But seeking such accreditation is voluntary unless the prison has been directed by law or a court. (The East Mississippi Correctional Facility is not an NCCHC-accredited facility.)

Prison reform, Eber says, is a painfully slow process. To build cases for change, advocates need detailed, rigorous assessments of the harm done, and they must demonstrate successful alternatives for maintaining order in prisons. Then there must be a change to the mindset inside the system. "They have gotten used to operating like this," he says. "It takes a lot of work to make sure things are actually improving, and that is why we don't bring legal cases lightly. If we win, it's huge. Enforcing the victory—that is another story."

Today, solitary confinement and prison health have become more mainstream issues. A coordinated hunger strike at California's maximum-security Pelican Bay State Prison in summer 2013 attracted national attention. The strike, started by four gang members in isolation units, protested indefinite long-term incarceration in solitary confinement and sought other demands like adequate food and expanded privileges like calendars and exercise equipment. One prisoner, Todd Ashker, had been held in the prison's Security Housing Unit for 23 years, devoid of any normal face-to-face human contact. On the first day of the strike, 30,000 prisoners across the state's prison system refused their meals. The strike lasted 60 days and resulted in some modest reforms, including the implementation of a "step-down" program that at least in theory makes it possible for inmates to leave segregation provided they follow a formal process and demonstrate good behavior.

Casella says her organization gets hundreds of letters from inmates about conditions inside prisons. She admits her group tends to hear the horror stories: suicide attempts, inmates throwing bodily fluids, teams of corrections officers donning riot gear to extract one inmate. "One of the things that is chilling for me to think of is that we are probably only hearing from a small representative sample," she says. "One-third of inmates are illiterate or have serious mental conditions, so they're not writing us. From what we observe, isolation never changes behavior for the better."

Solitary confinement, says the Bloomberg School's Rubenstein, who also on the faculty of the Berman Institute of Bioethics, creates an ethical dilemma for health professionals in prisons. If they are truly looking after an inmate's mental health, then solitary is never good. He testified last year before a Maryland Senate Committee on a solitary confinement bill that didn't pass. He started a review of state policies on the role of health professionals in solitary confinement. Some states say that if an inmate has a serious mental illness, that inmate should be excluded from solitary. Rubenstein says that although this policy keeps some inmates out of segregation, the involvement of mental health professionals—psychologists, nurses, and doctors—in this "gatekeeping" process raises serious ethical concerns. "The practice amounts to a tacit medical endorsement of the use of solitary confinement for the nonexcluded prisoner, thus involving health professionals in punishment," he says. "It also forces the health professional to ignore evidence that many mentally healthy prisoners placed in solitary confinement suffer serious psychological harm from the experience."

Rubenstein has initiated a dialogue with the Maryland Department of Corrections to better understand how the Bloomberg School could contribute to the improvement of inmate health. "The people in the corrections world are not evil," he says. "They are dealing with problems that they are concerned about— assaults on officers and staff, assaults on other prisoners. But once you have a system of punishment in place it perpetuates itself and takes on a life of its own. We need people to step back and look at this." To achieve some limitations on the use of solitary and the use of force in prisons, Rubenstein says, interested parties have to come up with alternatives. He was part of a group leading the American Public Health Association's resolution titled "Solitary Confinement as a Public Health Issue." The document recommends changes to federal, state, and local correctional policies on solitary confinement, including exclusion of prisoners with serious mental illnesses and those under 18. Prisoners also should be closely monitored and removed from solitary confinement if their health deteriorates or necessary medical or mental health services cannot be provided. They also want to ban solitary confinement for disciplinary purposes and create alternative means of discipline.

Eber does believe conditions will improve. As states begin to re-evaluate their criminal justice policies and make smarter decisions about who does and does not need to be in prison, the population will drop and take some of the pressure off the system. He says there is an increasing realization that the prison population has reached an untenable level, and recognition of the health impact on both the individual and communities when an inmate is denied adequate care. He notes that the ACLU just settled a statewide case in Arizona and has hopes for some reform there. New York City recently removed juveniles and people with mental disabilities from the list of those who can be placed in isolation. Corrections officials in California have announced significant changes in the use of solitary for mentally ill prisoners, revising decades-old policies.

Colorado Corrections Department Director Rick Raemisch has promised to reform solitary confinement policies in his state after he spent 20 hours in an isolation cell. The experience left him "feeling twitchy and paranoid" after just one night. In a newspaper editorial, Raemisch admitted that many prisoners who get thrown into solitary confinement already have mental problems, and isolating them only makes those problems worse. He wrote: "For a sound mind, those are daunting circumstances. But every prison in America has become a dumping ground for the mentally ill, and often the 'worst of the worst'—some of society's most unsound minds—are dumped in Ad Seg. If an inmate acts up, we slam a steel door on him. Ad Seg allows a prison to run more efficiently for a period of time, but by placing a difficult offender in isolation you have not solved the problem — only delayed or more likely exacerbated it, not only for the prison but ultimately for the public. Our job in corrections is to protect the community, not to release people who are worse than they were when they came in." Colorado has since begun to review its policies regarding administrative segregation.

Margaret Winter says now other prison systems need to engage in reform. "It's natural to be resistant when you're being criticized," she says. "But we do see change. There's been a dialogue. Now there needs to be more monitoring. There are people inside the system saying, 'Finally!' and who are glad to see changes. The people on the inside are not villains. There are many good, very well-intentioned people working under impossible conditions and circumstances. They long for people to come in and clean it up."

Eber envisions real movement on an issue that seemed hopeless a decade ago. "What we have is a system that can be quite cruel, and reforms are needed," he says. "We just need to make sure that those reforms go far enough. There is a lot of suffering."