To say the work is difficult, amid rampant homophobia and a political climate that has led to the imprisonment of a record 1.5 million Americans, is to say the sun is hot. But Greenspan, who works under the auspices of Catholic Charities of the East Bay, expects the difficulties. She expects the raised eyebrows when she mentions caring and criminals in the same breath.
What she doesn't expect, she says, is what she believes is the stubborn illogic -- and questionable practices -- of prison officials and politicians, particularly when it comes to the 3,200 inmates at the California Medical Facility (CMF) in Vacaville.
More than 500 CMF inmates are HIV-positive. One of four prison hospitals in the state, CMF is the only such facility with a special AIDS hospice, a 17-bed unit that is typically considered a bright spot in the otherwise grim universe of jailhouse medical care.
But in the past few months, Greenspan says, the situation at CMF -- where every four days or so a man dies of an HIV-related illness -- has grown increasingly disheartening. Her concerns about Vacaville prisoners include everything from the health information they receive while alive to the autopsies they receive when they die. The troubles at CMF, she says, highlight a complex, often subtle set of realities that keep dying prisoners behind bars, deny them help, and turn convictions for even minor crimes into death sentences.
On Nov. 1, for reasons under dispute, Dr. Joe Bick, chief medical officer at CMF, shut down an internationally acclaimed HIV peer education program, in which prisoners counseled other prisoners on health matters and how to avoid HIV. The social worker who created and supervised the program, Scott Cozza, has been reassigned to a different prison job, says Greenspan.
Cozza declined to comment on the matter. But according to Greenspan and other prisoner advocates -- who were contacted by upset inmates and other sources -- the peer program was suspended after the prison scheduled flu shots for HIV-positive prisoners, and Cozza, in response, distributed fliers providing information about how those shots can sometimes be dangerous for people with weakened immune systems.
"What he handed out was a fact sheet that didn't recommend anything," says Ryan Clary of Project Inform, the AIDS treatment advocacy group that provided Cozza with the fliers. "All we do is present the information, and it's up to the individual and doctors to make choices," Clary says. "That's why we were kind of shocked that [Bick] would shut down the program."
"This is a cutting-edge program," adds Tish Levee, co-chair of the HIV/AIDS Commission for the Episcopal Diocese of Northern California. Cozza's work is so well-regarded, and his material in such demand, he's been invited to speak at AIDS and prison conferences in Israel and Japan, and at the upcoming "AIDS in Africa" conference in Uganda, Levee says. "Frankly, I don't understand why the prison isn't going around tooting their horn about him," she says.
Bick, meanwhile, says the program was not shut down because of the flu shot flier, but because "we had some breaches in security." The doctor declined to say what the breaches were, but likened them to "bringing in medical cutlery, or leaving outside phone lines unattended." Bick says the program will be reorganized and restarted, but apparently sans Cozza.
"Anything we can do to prevent HIV infection in prison, we want to do," Bick says. "But it has to be done in a way that security risks aren't created."
"There was no security risk," counters Greenspan, rarely one to back down. Before coming to the Bay Area four years ago, she worked for the American Civil Liberties Union National Prison Project in Washington, D.C. It's a time-honored excuse in prisons, she says, to declare something a security risk. "What this is about is control versus care," she declares.
The point/counterpoint, Greenspan vs. Bick, is nothing new. For years, Greenspan has fought Bick and prison officials in general for the compassionate release of prisoners whose terminal illnesses render them unlikely security risks. Allowing such prisoners to die at home not only makes moral sense, says Greenspan, but could save the state millions.
California, home of the largest prison population in the country, spends at least $372 million annually on inmate health care -- more money than the entire prison budgets of 36 other states combined. According to the state Department of Corrections, medical bills for prisoners sick enough to need outside hospitalization -- and, along with it, 24-hour guards -- can reach $4,000 per day. Even at CMF, with its hospital behind bars, sick inmates run up tabs of $75,000 a year.
The cost, which will only increase as prison populations both grow, and gray, led Assemblyman Antonio Villaraigosa, a Los Angeles Democrat, to sponsor a bill this year that would have streamlined the compassionate release process and allowed more inmates to die at home. The bill was vetoed by Gov. Wilson in October.
"What is happening is that nonviolent, first-time offenders who are HIV-positive are in effect getting sentenced to death," says Greenspan. Behind her, file cabinets overflow with statistics, case studies, appeals for help. "Some of these people have zero T-cell counts," she says. "Some are nearly in comas."
Under current law, all prisoners seeking compassionate release must first get a prison doctor to pronounce them likely to die within six months. Next, they must win approval from their prison warden, the Department of Corrections director, the sentencing judge, and the state parole board. The application gauntlet takes so long, prisoners sometimes die before it's half begun.
Surviving the process is no guarantee of success. Between 1991 and 1994, inmates or their families requested 270 compassionate releases. Only 87 were granted.
Doctors find it difficult to pronounce with any certainty that inmates will die in six months; judges and corrections officials find it politically inopportune to release convicts and appear "soft on crime." The results, notes Greenspan, are sometimes absurd.
* San Quentin inmate Albert Brown, serving a life term for second-degree murder, suffered a massive heart attack last October that left him near brain dead. The parole board refused the compassionate release requests made on his behalf. Brown spent the six months until his death in Marin County hospitals, his body guarded around the clock, though in his vegetative state he was incapable of going anywhere. The medical tab upon his death this spring: $882,709.
* Peter Hatzidakis, a first-time, nonviolent offender, began a four-year sentence at CMF last November after pleading guilty to burglarizing a Van Nuys storage facility. He has tuberculosis and full-blown AIDS, and his family, friends, and Greenspan have for months lobbied for his release. They have not met success.
* Regina Edwards, a San Diego heroin addict convicted under the three-strikes law -- which requires convicts to serve at least 80 percent of their sentences -- won a happier ending: the right to see her two children at home before she dies. Edwards had been given 32 months at the Central California Women's Prison in Chowchilla after pleading guilty to using an automatic teller machine card stolen from the purse of her drug recovery counselor. But Greenspan and a host of other advocates flooded the district attorney and sentencing judge with release requests: Edwards, they pointed out, was too weak to even attend her own court hearings. She was released this summer, and thought to have three months to live.
"What security risks could people like these possibly be?" Greenspan asks. Others, among them Assemblyman Villaraigosa, say they fear what will happen when the three-strikes bulge sets in. The current inmate population of 128,000 is expected to quintuple in the next few decades.
In response, what Greenspan wants is increased and speedier compassionate releases, particularly from CMF, home of so many ill inmates. Which brings her to her third worry about CMF -- a worry she is joined in by a Solano County supervisor. At CMF, say Greenspan and Supervisor Ed Schlenker, doctors are compiling statistics on inmates, aided by information they receive from the Coroner's Office. Bick has presented his findings at three recent professional forums, including an infectious disease conference in San Francisco and a Department of Corrections medical conference at Folsom Prison.
"The opportunities for research are enormous, and in fact we have already presented some information that we've obtained from these autopsies and we expect to increase that," Bick testified this June to the Solano County Board of Supervisors.
Bick was asked to appear because Schlenker wanted to question him about whether such research was appropriate, and, in addition, whether County Coroner Jim O'Brien should be ordering autopsies for every CMF inmate -- an unusual practice that Schlenker has described as a "cash cow" for pathologists. The costs of such autopsies -- more than 90 a year, at about $1,000 apiece, O'Brien told the Vacaville Recorder -- are totally reimbursed by the state.
Solano County is one of the few that orders autopsies for every inmate death. According to a recent study on the matter, most coroners only perform them if the death occurs under suspicious circumstances.
"The coroner has an absolute right to order autopsies, but where he does it on everybody who dies at CMF -- where men are dying of AIDS, and there's no mystery about it, then I think there's a problem," says Schlenker. What appears to be happening at CMF, he says, is that the Coroner's Office, which is supposed to act as a watchdog agency -- aggressively investigating abuses that might occur at the prison -- is instead working in concert with prison doctors to provide medical data.
Bick told supervisors as much himself. "I send fax information" to the coroner, describing "what we're actually looking for, with specific questions ... specific requests for what types of test we would like done," he testified.
Says Schlenker: "I think it is subverting the whole spirit of the thing, which is checks and balances. Everybody is winning. The pathologists are getting steady income, the coroner gets a bigger budget, Dr. Bick gets research findings. The only problem is, it's costing the state a lot of money."
There are also state laws prohibiting biomedical research on inmates, Schlenker notes. "There's a line here," he says, "and I think they're touching it."
Bick, however, says CMF doctors are not doing research: They're following their patients, as doctors should. "The autopsies help us understand why our patients died. Are there things we should be doing? Are there things we shouldn't be doing?" he says. "The goal is to figure out how to better treat the next patient."
At conferences, Bick says, he's presented information about CMF prisoners with less than 50 T-cells, who on average live more than 14 months, he says, whereas such men in the general population tend to live 12 months.
"Not to gloat about how we're doing a great job," Bick says, "but now we can say if somebody's had less than 50 T-cells for a year, based on our study here, the odds are they're not going to live another six months. So let's put them up for compassionate release."
Greenspan finds no solace in Bick's words, only more fuel for future battles, as the nature of these things so often go. "He's playing God, and he's doing it in the name of research," Greenspan says. "These are human beings, not laboratory rats. And they deserve to be able to go out and die with their families.