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Dying to Get Out 

Some inmates tell horror stories about healthcare at the women's prison in Vandalia. Some didn't live to tell their tales.

In 1995 Stephanie Rane Summers found herself, once again, standing before a Missouri judge. Not only had she forged two checks, the 45-year-old grandmother had done it while on probation for a 1989 conviction for doing the same thing. Present in the Jasper County courtroom in Joplin along with Summers was her older sister, Sara Ann Gilpin. Ever since their baby sister Lois Kay died when they were teenagers, Gilpin told the judge, Summers hadn't been the same. Now their mother was dying from breast cancer and she asked the judge to be merciful. Instead Summers got two twelve-year sentences -- one for each check -- to run consecutively. The first time she'd be eligible for a parole hearing would be April 1999.

Almost as soon as Summers was sent to the women's prison in Chillicothe, her health began to deteriorate. In December 1995 she was taken to Capital Regional Medical Center because she couldn't catch her breath. Lab tests showed that her white blood cell and platelet counts were low, so a doctor at the medical center recommended an infectious-disease screening. The screening wasn't done.

Her health problems continued. Gilpin says that on at least three occasions during the following year, doctors repeated the recommendation for an infectious-disease screening, to no avail. By early 1997 Summers was vomiting blood and bleeding from the rectum. Gilpin says that in August of that year, her sister was finally tested for infectious diseases. The diagnosis: liver disease from hepatitis B and C.

According to Gilpin, in early 1998 a doctor at a medical center in Chillicothe recommended, again to no avail, that Summers be placed on a waiting list for a liver transplant. In March of that year a Chillicothe prison physician addressed a memo to the state's Board of Probation and Parole, noting that Summers suffered from "multiple disorders, including chronic asthma, and end stage liver disease with cirrhosis. She required Lasix to flush the excess fluid from her body, and the doctor said she was showing early signs of encephalopathy, a side effect of cirrhosis that damages the brain.

"She will need full time infirmary care in the near future," the prison doctor concluded. "It is for this reason that I would like you to consider her for a medical parole."

In her own memo on the topic, a parole officer offered a different opinion, noting that the prison staff had reported "observing Summers on the yard and in the bay area of her dorm performing daily functions, as would any healthy inmate."Asserted the parole officer: "Subject is receiving full medical care as needed by staff at this facility. This officer is not convinced that Subject would be hindered in a way as to not commit other crimes."

Dr. Gary Campbell, one of the prison doctor's supervisors, received both reports. In a March 1998 fax to a colleague, Dr. Robert Hampton, Campbell agreed with the parole officer. "I am going to wait on this," he wrote. "I just don't feel she is at the level of illness yet that would make her a candidate for parole.... I'm not sure she isn't just overacting!"

Soon afterward Summers was transferred to the newly opened Women's Eastern Reception, Diagnostic and Correctional Center in Vandalia, about 100 miles northwest of St. Louis. Her health did not improve. In May 1999, Dr. Campbell wrote a letter to the Missouri Department of Corrections (MDOC) recommending medical parole. Summers had been to the infirmary several times to control her fluid retention, she'd been to the hospital, she still had periods of bleeding and her liver was failing, he wrote. "These problems have continued to worsen over time and will inevitably result in Ms. Summers' death unless she receives a liver transplant which is not medically advisable in a correctional setting because of long-term infection risks," Campbell's recommendation went on.

Though Summers had already been scheduled for regular parole in January 2000, the parole board denied Campbell's request without a hearing. By then it was clear to Summers that she likely would not live out the year. "I am sending this to say that I love you," she wrote in a letter to her daughter, Beverly Walker. "My medical parole was again denied. I may have to bleed to death. I made some pretty foolish mistakes....sometimes you learn a little too late. I hope to see you again, but if I don't, remember that I love you and your boys and all my family. I do believe in Jesus Christ our Heavenly Father and I know He has forgiven and at least I will see my sister Lois and my mother. Love always, your mother."

On August 26, 1999, Summers began to hemorrhage from the mouth and was taken by ambulance to the University of Missouri hospital in Columbia. "The Physicians at UMC Hospital have been unsuccessful in stopping her bleeding with the usual measures and are preparing to do a procedure to reduce pressure in the veins that are bleeding," Dr. Hampton wrote in a report to the MDOC the following day. "This is a last step measure to stop the bleeding and has a risk of death and of worsening her liver failure." The inmate's family, Hampton asserted, should be permitted to visit.

Summers, meanwhile, lapsed into a coma. On September 1, Gilpin learned her sister was dying. When Gilpin and Beverly Walker drove up from Joplin, they were unprepared for what they saw.

Because Summers was an inmate, a security guard had been posted at the door to her hospital room. Inside, Gilpin recalls, her sister lay comatose in bed. Summers was bloated with 80 extra pounds of fluid, pushing her weight up to about 300 pounds. And her body was held hostage not only by medical monitoring equipment, but by a chain connected to shackles on each leg.

When Gilpin demanded that the chains be removed, she says, she was informed she'd first have to sign paperwork granting her custody of Summers, which was on its way. Her sister's medical parole had finally been granted.

It took three or four hours to free her sister from the physical constraints. Ten hours after that, Gilpin says, Stephanie Summers was dead, with the imprints from the shackles still embedded an inch deep in her legs.

Sara Gilpin had always assumed the doctors and nurses in the prison infirmary worked for the Missouri Department of Corrections. It wasn't until after her sister died that Gilpin learned that the caregivers were employed by a private company.

Correctional Medical Services, also known as CMS, is a St. Louis company founded in 1979 and headquartered on Olive Boulevard in Creve Coeur. Over the course of 24 years, CMS has become the nation's leading provider of prison medical care, with 6,000 employees and 450 independent contractors in 27 states looking after approximately 225,000 inmates. The company operates like a health-maintenance organization for the incarcerated, receiving a fixed amount of money per inmate to manage and provide for all medical needs. As a privately held firm, CMS isn't required to disclose financial information, but infoUSA, a service that compiles business data, estimates annual revenues at $500 million to $700 million.

"The doctors and nurses who choose to work in prisons and jails do so because they believe they can make a positive difference in the lives of patients," Dr. Louis Tripoli, chief medical officer for CMS, writes in a statement provided to the Riverfront Times for this story. "Over the past two decades, numerous enhancements have been made in correctional health care and CMS has served an important role in those efforts."

Of course, inmates don't comprise the healthiest segment of the population, especially when it comes to infectious diseases. States Tripoli: "In my experience as a physician working in corrections, it is clear that many patients come into correctional facilities not having had regular access to healthcare prior to their incarceration."

CMS landed its first five-year contract with the Missouri Department of Corrections in 1992. According to MDOC spokesman Tim Kniest, the state paid the company roughly $3.70 per inmate per day during the first year of that original contract, which was renewed on a year-to-year basis. In 1997 the contract was renewed for another five-year term, and a third five-year agreement was inked in December 2001. For fiscal year 2002, the state paid CMS nearly $51 million; in fiscal year 2003 the figure approached $80 million. For the current fiscal year CMS is charging the state $7.84 per day to cover the medical, dental and mental-health needs of each prisoner.

Kniest says the contract has worked well for MDOC. "We were not able to compete with the private sector in paying salaries, so we had a lot of vacancies and a lot of deficiencies in our medical services," he explains. "We felt that entering into a contract with a private concern would offer us better medical coverage for the offenders."

One advantage is that the budgeting process is streamlined. "We pretty much know how much money we're going to spend in a given year on medical services," says the MDOC spokesman. "If you're on the HIV protocol for drugs, it costs the Department of Corrections the same amount as if you were getting aspirin for a headache. If an inmate has to go out to a hospital for any special surgery or test or anything like that, it is all covered."

CMS has received its own share of coverage, in the form of critical news coverage and lawsuits. In 2001 the state of Virginia canceled its contract with the company after fining CMS $900,000 for a number of violations, including failure to provide timely care to inmates. Over the past several years, news stories detailing allegations against CMS have appeared in the St. Louis Post-Dispatch, the Columbia Daily Tribune and the Des Moines Register, among others; most recently, the August issue of Harper's magazine contained a story that took the company to task for its care of inmates suffering from hepatitis. and earlier this year, an Illinois jury hit CMS with a $1.75 million verdict after an inmate committed suicide. The victim's family had alleged that the medical staff had failed to place him on suicide watch even though he'd indicated to numerous employees that he was suicidal. (The verdict is being appealed.)

Now CMS' performance in its own backyard is being challenged as concerns -- and deaths -- mount at the women's prison in Vandalia. Family members, inmates and religious activists who volunteer at the facility allege that long delays for medical tests, treatment and medication have caused unnecessary and agonizing deaths. In May of this year the U.S. Department of Justice announced it had opened an investigation into the Vandalia prison; at the same time, the American Civil Liberties Union of Eastern Missouri is looking into more than 50 claims of inadequate healthcare at the facility. Neither the Department of Justice nor the local ACLU will discuss the ongoing probes in depth, but from medical records and interviews with former inmates and with the families of deceased prisoners, Riverfront Times has learned the following:

· Since March, three Vandalia inmates -- Crystal Smith, Al'Deana Simmons and Sharon Kroll -- have died while in custody, raising allegations of medical neglect. Additionally, the deaths of Vandalia inmates Cheri Rose, Ellen "Honey" Ross and Lavenia Populus during the past four years have spurred accusations of inadequate healthcare.

· In July a CMS nurse gave approximately fifteen Vandalia inmates the wrong antidepressant; as a result, about a dozen prisoners were sent to the hospital.

· Two other cases have resulted in medical malpractice lawsuits against CMS and the MDOC. One was filed in 2001 by the family of Stephanie Summers. The other was filed by recently paroled Vandalia inmate Vicki McElroy, who claims that a hepatitis C treatment plan she was given while in prison in another state was ignored when she was transferred to Missouri.

· Another Vandalia inmate, Vera Jones, claimed CMS failed to monitor her for side effects from a tuberculosis medication. Jones, who also suffered from hepatitis C, was medically paroled this past summer and died soon after.

"A fair review will show that healthcare professionals at the prison do an excellent job meeting the needs of inmate patients," asserts CMS' Dr. Louis Tripoli.

Sister Frances Buschell, prison coordinator for the Jefferson City Roman Catholic Diocese, views the situation differently. "My biggest concern is with timeliness and follow-through," says Buschell, who has ministered to Vandalia inmates for almost six years. "It is really a problem to see neglect or to see somebody with cancer sitting there waiting two or three or four months to get diagnosed."

Sara Gilpin is blunt in her assessment of the company that provided medical care for her late sister, Stephanie Summers. "It is the most corrupt corporation based on greed that I've ever seen," Gilpin says of CMS. "Not only do they keep getting wealthier, lots of people are losing their lives from corporate greed."

On August 31, 1999, as Stephanie Summers lay in a coma, state representative Glenda Kelly, a Democrat from St. Joseph, convened a meeting of the state's Joint Committee on Correctional Institutions and Problems, which she chaired. Gathered in the Senate Lounge for the public hearing along with Kelly and eight fellow committee members were former inmates and family members, prison-rights activists, representatives from CMS and then-prison superintendent Dora Schriro.

The inmates and their advocates didn't get the warmest reception. "In the eighteen years that I have served here in the Missouri Senate, I probably had four complaints against Corrections on medical treatment," said Senator Danny Staples, who had formerly chaired the committee. Staples is an Eminence Democrat whose district southeast of Jefferson City is home to four prisons. "For you to sit there in the witness chair and explain to me after I have driven 150 miles today and 150 miles tonight that this is happening today -- I want documentation of that," he said.

Republican representative Jon Dolan of Lake St. Louis was likewise impatient. "What I get from you is that there is this existence of this Dateline-styled scandal out there," he scolded. Dolan wasn't interested in what he called "just the vague references" that in "many ways may insult the former chair's management of this committee." He wanted specifics, such as medical records.

Peter DeSimone, executive director of the Missouri Association for Social Welfare, was testifying at the time. When DeSimone pointed out that he didn't have access to medical records, Dolan replied, "That's a cop-out."

Barbara Ross, who works for the Roman Catholic Diocese of Jefferson City, also testified. "The common experience of women and men in prison in Missouri is that the medical staff does too little too late and that they treat the symptoms rather than look for the deeper causes of sickness and death," said Ross, who then told the committee about a 29-year-old Vandalia inmate named Cheri Rose. For nine months, Ross said, Rose had claimed she felt weak and suffered from headaches and blotchy skin that were diagnosed as spider bites. The actual culprit, however, was leukemia. Rose went nine months without a diagnosis, Ross told the committee. Once her illness was discovered, she was given a week's chemotherapy -- while in shackles. After a second week of chemo Rose was medically paroled and died shortly thereafter.

Former inmate Bonita Holley told the committee about fellow inmate Ellen "Honey" Ross. According to Holley, Ross was ignored when she insisted she was being given the wrong medications. And Ross' daughter told the panel that her mother had complained of severe headaches. After Ross suffered a stroke and died in prison, her family alleged that the corrections department refused to release her medical records unless they signed a release of liability.

"How do you sleep at night?" Holley asked. "Inmates are dying. I'm telling you today: Send help immediately to the Missouri Department of Corrections."

The committee didn't send any help that day. Kelly did, however, schedule a second hearing, which was held October 6, 1999. According to the transcript, neither Dolan nor Staples was present. But Sara Gilpin was there, and she was the first to testify.

Gilpin chronicled her sister's ordeal, blaming CMS and the MDOC for failing to test Stephanie Summers for hepatitis C when it was first recommended by an outside doctor, and for failing to evaluate her for a liver transplant or for interferon treatments.

Reminding those present that state law requires that corrections officials "shall arrange for necessary healthcare services" for inmates, she said, "I submit to you that surely this did not happen and [Summers] did not receive the proper medical care."

When she was finished, it seemed to Gilpin that she'd gotten through to at least some of the committee members.

"I think it is legitimate that people have concerns about whether they can trust the system," said Senator Larry Rohrbach, a California Republican.

Representative O.L. Shelton, a Democrat from North St. Louis, was more blunt. "What we need, we need a new team in this facility, in this state," Shelton proclaimed. "That's what we need. I think we need a new medical service for this state because I don't think that this is adequate for anybody."

But when the joint committee issued its annual report six months later, there was no call for a new medical service. Instead the committee made seven recommendations, many of which the MDOC agreed to implement. Among them: Regular meetings would be held between Correctional Medical Services, Representative Kelly and the Jefferson City Archdiocese; conflicting medical recommendations were to be referred to consulting physicians not employed by CMS; and family members would be allowed more access to inmates at off-site hospitals. At Vandalia, CMS would provide inmates with customer-service surveys and CMS staffers would attend every-other-week inmate council meetings where inmates could air medical concerns.

Buschell points to a few other changes that came out of the 1999 hearings: "We achieved a streamlined medical parole process, because it became clear with Stephanie Summers that other people had made decisions along the way so that it never made it to the parole board. And the infirmary was changed somewhat."

But when all was said and done, Buschell and others were disappointed. A prison medical system that they felt required major surgery had been treated with a Band-Aid. "I think it's gotten worse, rather than better," Buschell says today.

Peter DeSimone wasn't surprised with the outcome. "Most of the members of that joint committee have prisons in their district," says DeSimone, who has since retired from his post at the Missouri Association for Social Welfare. "For them, prison was not something to watchdog; it was something for jobs and patronage in their own districts, and economic activity."

One elected official who was attempting to watchdog prison healthcare was Representative Charles Quincy Troupe. For several years the north St. Louis Democrat had sponsored a bill to create an independent ombudsman position to give inmates access to an agency outside the MDOC and CMS that had the power to investigate, inspect and subpoena.

"It's not like it is so radical," DeSimone comments, noting that similar programs exist in 25 or 26 other states, including Kansas and Minnesota. But Troupe's bill never made it to the state house floor.

Troupe also tried to delve into inmate complaints himself. In January 2002 he wrote a letter to MDOC director Gary Kempker, requesting an investigation into the death of Vandalia inmate Lavenia Populus.

"Someone who cleans the infirmary witnessed Inmate Populus' death, and reported that the room looked like a slaughter house, that Ms. Populus has been crying and pleading for help all day, telling them she was in severe pain," Troupe wrote. "It is also reported that a doctor's answer was to prescribe Maalox. Apparently, Inmate Populus died in a pool of blood, hemorrhaging from every orifice, and there was blood on the walls and what was believed to be human tissue matter mixed with blood on the floor."

Troupe went on to say he'd been told Populus had been diagnosed with hepatitis C: "Is this a natural end to people who are infected with hepatitis C disease, and if this is the case, explain the blood on the walls and the lack of assistance for an obviously pleading and dying woman. Further, not being a medical person, I would like a medical explanation from the doctor as to how Maalox would help the pain from an obviously hemorrhaging person, and if death were imminent, then the humane thing to do would have been to make death as painless as possible.

"Was inmate Populus sentenced to death by the state? I await the results of your investigation," Troupe concluded.

The answer he received was hardly satisfying. "They explained to me that that's normal with hepatitis C," Troupe recounts. "My response to that is: That is total insanity."

Though it is by no means the only ailment they encounter, CMS doctors are undoubtedly well acquainted with the ravages of hepatitis C. According to the federal Centers for Disease Control and Prevention's recent report on hepatitis viruses in correctional settings, 15 percent of all inmates nationwide are infected with hepatitis C, while the infection rate in the general population is less than one-tenth of that: 1.3 percent.

Although people who contract hepatitis B usually fight off the disease and develop immunity to the virus, hepatitis C is far more insidious. Stubbornly resistant to attack by the body's immune system, the virus typically takes up lodging in the liver and lies dormant, sometimes for years. By the time symptoms surface, they've already progressed to advanced liver disease, with patients typically dying from cirrhosis of the liver and/or cancer. Death is painful, preceded by jaundice, fatigue, swelling, internal bleeding, vomiting blood or bleeding from the rectum.

Dr. Bruce Luxon, a liver specialist and associate professor at the St. Louis University School of Medicine, explains that the liver is the organ that makes most of the chemicals that allow blood to clot. "So if your liver is not working, your blood doesn't clot as well and your platelets -- a blood element -- are often low, so you're more at risk to have significant bleeding. If you've ever taken care of somebody that bleeds a lot because they have cirrhosis," Luxon adds, "it is a very scary thing."

Luxon, who says hepatitis C is known as "the silent epidemic," believes the best way to combat the spread of the disease is to root it out. "What we recommend is not to test on symptoms but to test on risk factors," he says. "So if you walked into my clinic and said, 'I have injected drugs,' or, 'I had a transfusion before 1991,' those things would cause me to test you." Luxon says that a decade or so ago, only about 5 percent of people with the virus could be cured; the figure is now up to 50 or 60 percent -- when the disease is detected before a person becomes cirrhotic. "It is a rough course of treatment with the interferons, which are shots and pills that people take for six months to a year," Luxon adds.

In January of this year, the CDC noted that screening inmates and, where possible, treating them with antiviral therapies such as interferon drugs helps to halt chronic liver disease and slows transmission.

"Each inmate with risk factors for hepatitis C is evaluated by a trained healthcare provider and offered appropriate diagnostic testing," responds CMS spokesman Ken Fields. "If the tests indicate chronic infection with hepatitis C, the patient receives an evaluation and treatment in a chronic-care clinic for liver disease."

But the August 2003 issue of Harper's contained a story about CMS that featured an internal memo from Dr. Gary Campbell circulated in February 1999: "Unless I have given you specific approval to do Hep C testing, do not do so unless the patient has obvious moderate to severe liver disease or has exposure as described by the exposure policy of the DOC. Remember, all Hep C testing has to be approved by me," the memo reads.

Fields calls the statement attributed to Campbell a "partial quote" that was "taken completely out of context" by the magazine. He declined, however, to furnish a copy of the memo in its entirety.

And the MDOC's understanding of CMS's current protocol at Vandalia would seem to give credence to the gist of what Campbell wrote back in 1999. "I don't think they specifically test for hepatitis C," says Kniest. "My understanding is that hepatitis C is an ailment that can lie dormant in an individual for many years. And if it is not an active case of hepatitis C, there really isn't any treatment to follow anyway. If someone starts suffering symptoms, then the medical staff make a decision as to what kind of treatment regimen we will follow for this individual."

Citing confidentiality regulations, CMS declines to discuss Lavenia Populus' death. Corrections spokesman Tim Kniest confirms that Populus died of cirrhosis of the liver. After investigating Troupe's allegations, the MDOC concluded they were unfounded. "There was no finding that that had occurred," says Kniest.

Owing to term limits, Troupe's 24-year career as a legislator ended in 2002.

Meanwhile this past March, Crystal Smith, who was serving a five-year sentence for drug possession, was found unresponsive in her cell at Vandalia. Kniest says an autopsy revealed the 46-year-old inmate died from cardiomyopathy, or heart disease.

On July 2 Vandalia inmate Al'Deana Simmons, who was serving a four-year sentence for forgery, died of an aneurysm at age 33. Her ex-husband, Jeff Simmons, says a Vandalia prison official called his home. "They told me that she was in the infirmary and that she ate breakfast and they went back and checked on her twenty minutes later and she was dead and they thought she might have choked on food," Simmons recounts. "Actually, she was in isolation and died of a brain aneurysm."

Al'Deana Simmons called her mother the day before she died. "She told me she was at the infirmary and she couldn't see and there was something wrong with her head -- it was sizzling," Virginia Terry recalls. "And she said the doctor saw her for ten minutes and said there wasn't nothing wrong with her." Before being incarcerated her daughter had been treated for bipolar disorder with medication that doctors said she'd have to wean herself from, Terry says, but Simmons wrote from prison saying she'd been switched to another medication. Terry also says she has met with the federal investigators in St. Louis who had questions about Simmons' death.

The day after Al'Deana Simmons died, a CMS nurse at Vandalia mistakenly administered the antidepressant Sinequan to about fifteen inmates who previously had been receiving Prozac. Thirteen of the inmates had to be sent to the hospital. "Two were kept overnight for further observation," says the MDOC's Tim Kniest. "Basically what happened was that when they took their medication, their blood pressure dropped significantly." Both women returned to Vandalia the next day, Kniest says. "None of the inmates suffered any long-term ailment because of that."

Adds CMS' Dr. Louis Tripoli: "The nurse did not try to cover up or deny her error. She immediately took action to protect her patients. On the heels of this incident, during the review, we received numerous letters and comments from inmates in support of this nurse and her noted dedication to her patients."

As a result of the medicine mix-up, Kniest notes, CMS has obtained new packaging for drugs that look alike. "For some of the drugs that look too similar, they have decided not to use those at all and replaced them with a different dosage, so they're a different color, different size or different shape."

Even before she started preaching the gospel of Jesus Christ, Jean Sullivan was accustomed to drawing a crowd. As a child she was one half of the dancing Wynn Twins and performed at the Starlight Theater in Kansas City. When she and her sister got older, they were members of the Kansas City Chiefs' Chiefettes. Sullivan went to college and pursued a career in social work, but that was cut short seventeen years ago by a long illness, which turned out to be Lyme disease. While she was bed-ridden, Sullivan says, she was saved. She became a chaplain and volunteered in the Kansas City prisons, ministering to female inmates.

Her ongoing battle with Lyme disease -- which continues to require Sullivan to give herself daily doses of medication through a tube inserted in her chest -- meant she had to give up a full-time ministry. But then Crystal Smith died. Sullivan heard about the death from a Vandalia inmate and went to see the family. A few months later, Al'Deana Simmons, who lived in a Kansas City suburb, also died. Before long Sullivan had become involved in the prison-activist community.

That's how she came in contact with Vera Jones. The 51-year-old inmate, who'd been sent to Vandalia in 2000 to serve a twelve-year sentence for stealing, had been medically paroled late this past summer; Sullivan found her in a nursing home and alerted investigators from the Department of Justice.

While in prison, Jones had been exposed to tuberculosis. She told Sullivan and others that CMS doctors compelled her to take medicine to prevent the disease from taking hold. This past February, court records indicate, she was diagnosed with hepatitis C and cirrhosis of the liver. She blamed the TB medicine, and a lack of follow-up exams, for spurring her liver condition.

CMS disputes Jones' allegations but declines to discuss the specifics of her treatment. Addressing the situation generally, CMS' Dr. Louis Tripoli says that "while the medication for exposure to tuberculosis can have short-term effects on the liver, monitoring of the patient's symptoms and the liver's function can help to prevent any long-term side effects. Patients taking the medication are told to immediately report any potential symptoms that can be associated with the side effects of the medication. And, they are told to stop taking the medication immediately if they notice such symptoms."

Vera Jones died on September 8. On September 15, Sullivan attended her funeral.

A week later, Sullivan is on hand at Vandalia to pick up another inmate, Vicki McElroy, who has been granted a medical parole. Sullivan has come to give McElroy a ride to St. Louis and put her on a plane to her hometown of Seattle. McElroy has been in prison for fourteen years, serving time for robberies she committed with her ex-husband in Washington, Arkansas and Missouri. In 1995, while incarcerated in Washington, McElroy was diagnosed with hepatitis C and cirrhosis of the liver. A doctor there put her on medications to help stabilize her blood counts and control swelling, she says.

In 1999 McElroy was transferred to Missouri to do time for her robberies here. Her doctor at the Washington prison worked out a treatment plan and sent it along with her, but she says MDOC officials and CMS doctors refused to follow it: Her medications were confiscated, she says, her grievances ignored. "Their response is always, 'We've reviewed the grievance and find that there is nothing to support your claim and you're receiving adequate care,'" McElroy says.

In January a Portland, Oregon-based lawyer filed a federal civil-rights suit on McElroy's behalf against the Missouri Department of Corrections and CMS. The suit, pending in the U.S. District Court for the Eastern District of Missouri, alleges that although McElroy's treatment plan was sent directly to CMS doctors, "Upon arrival in Missouri, plaintiff was immediately taken off her most critical medication.... As a result of being removed from the medication, plaintiff began experiencing swelling in the abdomen and stomach, bleeding from the nose and rectum, elevated ammonia levels which indicates onset of encephalopathic coma, and increased fatigue."

Alleging that McElroy "was denied her medication, regular review of her liver function tests, and monitoring of her ongoing deterioration," the suit goes on to claim that prison officials and CMS physicians were "deliberately indifferent to the serious, life-threatening medical needs of plaintiff including refusal to provide life-saving treatment and medication, refusal to recommend plaintiff for a transplant, falsifying medical records, assaulting plaintiff, and refusing to provide treatment which would ease her pain and suffering."

Spokesmen for CMS and the corrections department decline to comment on McElroy's case. But the defendants deny the allegations in court pleadings, deeming them "frivolous."

This past August, McElroy says, "I started throwing up blood." She was sent to a local hospital where, she says, a specialist found a mass on her liver but opted not to probe it for fear the patient would bleed to death. McElroy's subsequent request for a medical parole was denied at first; but after Sister Frances Buschell appeared before the head of the parole board on her behalf, the decision was reversed.

As McElroy leaves the prison on the morning of September 24, her hands shake but her gait is slow and steady. In the early going of the hour-and-a-half ride to St. Louis, she asks to stop at a gas station to buy crackers. Her stomach is upset -- not so much from the illness, but from nervousness: When she began serving her sentence, her daughter was two years old, she explains; McElroy hasn't seen her since.

While she awaits her flight at Lambert airport, McElroy is interviewed by a television reporter. Sullivan, standing a few feet away, begins to cry. "At least she is going home to die," the activist says. "But she's not the last one."

Sullivan is right. Five days later, on September 29, a 58-year-old Vandalia inmate named Sharon Kroll will die. According to MDOC spokesman Tim Kniest, the cause of death is listed as terminal cancer of the lungs and bone.

Denise Lieberman, legal director of the American Civil Liberties Union of Eastern Missouri, says her organization has fielded an unusually high number of calls about the women's prison at Vandalia. At present, Lieberman reports, the ACLU is looking into more than 50 complaints about the facility, ranging from allegations of wrongful death to grievances about botched medical care, failure to provide care, inadequate gynecological and reproductive healthcare and unsanitary conditions.

The complaints stood out to her in three ways, Lieberman says: "Their gravity, their consistency and the sheer number."

In May, as ACLU staffers were mulling whether to launch an investigation into Vandalia, the U.S. Department of Justice called with a question: Did the civil-liberties group have any information about the Women's Eastern Reception, Diagnostic and Correctional Center? It seemed the Justice Department, too, was interested.

"They asked for our cooperation and we've worked cooperatively with them on this," says Lieberman. "I can't answer anything for the Department of Justice," she goes on. "[But] we have an investigation, ongoing right now, concerning the conditions for women at the Vandalia prison, particularly as it relates to medical care."

The ACLU has worked to bring together prison ministry groups, advocates and volunteers. Investigators have made two trips to the prison, but Lieberman says the probe has hit some snags. "I can tell you that it is my understanding that the Justice Department has had difficulty obtaining medical records and has not been allowed to tour the facility," she says.

"We've been very cooperative," counters Tim Kniest. According to Kniest, the Justice Department first contacted the MDOC about the Vandalia prison in November 2002. "They initially said they wanted to go to Vandalia and do an investigation which was a whole variety of issues that included food service, sewage. Medical was part of it," he says. According to Kniest, Missouri Attorney General Jay Nixon negotiated an agreement with the DOJ that limited the investigation to medical issues and specified how state and federal officials would communicate with one another. While he can't comment on the open investigation, Kniest says, "I can tell you that the Department of Justice has interviewed about 127 inmates to date, which we have facilitated and accommodated. They've also requested medical records; we've copied over 60,000 pages of medical records for them. My understanding is right now the Department of Justice and the Attorney General are working out a way to review those records."

As far as specific allegations about inadequate healthcare, Kniest says that when an inmate dies in custody, the institution's staff reviews the death and then a committee at MDOC's central office reviews the person's medical history. Independent autopsies are often performed. "In some situations, we also refer deaths to a physician that we contract with who is totally independent of CMS and the department," Kniest says. "They let us know if they believe there is anything missing in terms of treatment." No such problems, the MDOC spokesman says, have been found.

The department does not, however, review deaths of inmates who were medically paroled.

Regarding the deaths of Crystal Smith, Al'Deana Simmons, Lavenia Populus, Cheri Rose, Ellen "Honey" Ross and Sharon Kroll, CMS's Dr. Tripoli states, "We dispute the allegations, which are inflammatory and biased." Tripoli further cites a Vandalia executive council survey that polled inmates about medical care: "Over 70 percent of the population stated that there had been tremendous improvements. For every allegation that you have asked about, there are many examples of patients who are very pleased with the care they have received."

Sara Gilpin says that when she arrived at the hospital to see her sister in September 1999, the guard stationed outside Stephanie Summers' room was in tears: For days she'd wondered why the dying woman's family hadn't come.

In 2001 Gilpin, along with Summers' two children, filed a federal lawsuit against CMS and the Missouri Department of Corrections, alleging medical neglect and negligence, wrongful death and civil-rights violations. Among other things, the suit cites CMS doctors' initial failure to diagnose Summers for an infectious disease at a stage when she could have received "life-saving treatment," and its subsequent failure to evaluate her for a liver transplant.

As in the McElroy case, spokesmen for CMS and the MDOC decline to comment, and as in McElroy's case, officials from the company and the state deny the allegations in court pleadings, asserting that the lawsuit is "frivolous."

Gilpin has an undated medical summary CMS prepared about Stephanie Summers. "This patient had extensive medical and psychological problems while in the Department of Corrections," the summary reads. "She has seen more specialists, had more nurses and doctors visits, and for [sic] requests more acute care than anyone in my experience. Her medical care has been extensive and well managed since she has entered the DOC. Since 12-4-95, she has had 867 nurse encounters, including 53 self-declared emergencies and 275 physician encounters. I see no evidence of improper medical care by the attending physicians. In fact, I see continued concern and compassion for a patient who was deemed very difficult and manipulative."

To Richard Neely, Summers' son, CMS exhibited no concern or compassion for his mother or the family. When she got the call from prison officials informing her that Summers was dying, Gilpin had been unable to track him down at the golf course where he worked, and in the heat of the moment she opted to make the six-hour drive from Joplin without her nephew. When she got to the hospital, she called and told Neely it was best not to come. Seeing Summers would be too wrenching for him, she thought; besides, his mother would probably die before he could get there.

"Just try to imagine somebody that you love larger than life, and not getting to be there in their last times," Neely says today. "The worst thing is not knowing whether my mother's last thoughts in this world was ill of me because she didn't know we were coming. These are things that can never be answered for me, that I live with, that I keep swallowed every day."

Gilpin and Neely say they sued after CMS's contract was renewed and it became clear to them that changes in the correctional healthcare system were not forthcoming. When the defense questioned him at his deposition, Neely adds, one attorney asked what he'd do if he won the case: "I looked at him and said, 'Sir, I don't care nothing about your money.'"

"I know she did wrong and the law said she was where she needed to be," Gilpin puts in. But that was no excuse, she says, for denying her sister adequate medical care.

"She paid the ultimate price for a forged check," Gilpin says, her voice cracking. "I don't know any other way to make a change. I can't totally let her die in vain."

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More by Geri L. Dreiling

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