A prison doc’s mission to fix the system
As the Chief Physician at the California Correctional Medical Facility and Director of Hospice for incarcerated men, Dr. Michele DiTomas is charged with caring for some of the state’s most vulnerable people and helping to fix a broken system. When federal judge Thelton Henderson ruled in Plata v. Schwarzenegger more than a decade ago that a lack of appropriate medical care in California’s adult prisons was unconstitutional—citing “outright depravity” and egregious misconduct in the system—he ordered the federal government to enter the prison system into receivership. DiTomas was among the doctors hired to clean house. She now manages fifteen doctors who care for 2,800 inmates, at least half of whom are mentally ill or developmentally delayed. Her formal education (a Joint Medical Degree from UC Berkeley and UC San Francisco) and real-world experience have prepared her well. She was in the Peace Corps in Malawi in the early 1990s carrying out famine relief work during a massive drought, in the slums of Bangkok for her Human Rights Center Fellowship in 1997, and in poor and marginalized Bay Area communities for residency and beyond. Since 2006, she’s worked tirelessly within the state’s troubled mass incarceration system.
Note: The opinions expressed in this interview are those of the interviewee and do not necessarily reflect the views of the California Department of Corrections and Rehabilitation (CDCR) or the Federal Receivership.
Q. Although you worked in Malawi and Thailand, you ultimately did your medical residency in San Francisco. Why?
A. When you’re 35 and have three kids, you realize you’re probably not going to work in a Mozambican refugee camp with Doctors Without Borders. The residency I chose was UCSF family medicine and based at SF General. You’re working with people who have serious mental illness, substance issues, socio-economic challenges, immigration issues, poverty issues. It turns out that the people who I like to take care of most are these middle-aged, intermittently incarcerated homeless men. Every day I hear a story about an experience that is very different than what I encounter in my daily life.
Q. What did Plata v. Schwarzenegger say about health-care in California’s prisons?
A. Medical care in the prisons was found to be unconstitutional. People were dying unnecessarily in their cells. They were presenting with shortness of breath, told to go back to their cells for their asthma attack, and then died of asthma. There were egregious cases. Medical care was being given by people who were not necessarily qualified to give medical care. There has been a huge change since the receiver took over. Over the last 10 years, medical care inside the system has dramatically improved.
Part of why we have such overly aggressive sentencing in our criminal justice system is because as a society we tend to put things in categories. These guys are in prison, so they must be bad. That’s not what you learn when you spend time with people and hear their stories.
Q. Where did you begin?
A. I was hired as a Chief Physician and Surgeon—half clinical and half supervisory. The combination gave me time to do clinical work, but also work on system and quality improvements. I think it would have been too frustrating to go into such a damaged system and slog through the day and see the problems but not have any time to help make the system better.
Q. Does the California Correctional Medical Center feel like a prison or a hospital? Do you ever feel unsafe?
A. Part of why we have such overly aggressive sentencing in our criminal justice system is because as a society we tend to put things in categories. These guys are in prison, so they must be bad. That’s not what you learn when you spend time with people and hear their stories. When I’m walking down the main line and all of the guys from Unit 4 at 6:30 in the morning are walking out of their unit for chow, they say, “Hey, doc” or “Hey doc, thanks for helping me.” It feels safe to me. I have felt more unsafe at SF General because there you have very mentally ill patients who aren’t getting treated and you have no officers around if something goes wrong. Unfortunately, prison has become our nation’s de facto mental health treatment system. On the inside in California people have access to treatment programs, psychiatric medications, groups. It’s when we send them back out into society that they often do not have these supports.
Q. You also oversee the state’s hospice program for incarcerated men, with 17 beds. Hospice in prison must be a bit complicated.
A. Often people are estranged from family members. They haven’t seen them in many years. Sometimes they don’t even know if anybody is alive anymore. Many times family members were the victims of the crime. Often our incredible chaplain is able to track down family members. Recently he told three daughters that their father was here in hospice and that he wanted to see them before he died so that he could make amends for all of the pain and suffering he’d caused. And they said “No, we don’t want to ever see him again.” Click. The next day they all showed up at the front gate without any clearances or anything. This man had killed his wife in an alcoholic rage. They were kids when it happened and had been terrified of this man their whole life. He was a monster to them. They come in and here’s this little old man who says, “I’m so, so sorry.” He was able to have closure and to die in peace. Even more importantly these women who are now in their 30s and 40s will be able to live the rest of their lives knowing that he asked their forgiveness and that they forgave him the best that they could.
Unfortunately, prison has become our nation’s de facto mental health treatment system.
Q. Can we let out incarcerated men who have only a short time to live?
A. There is a process of compassionate release. If a doctor determines that a patient has less than six months to live, we can petition the courts to consider the individual for release. Since one of the criteria for hospice admission is a prognosis of less than six months, we request compassionate release for all of our hospice patients. Custody then reviews the case and if the patient is thought to not be a danger to society, they will forward the case to the court or the parole board for consideration. The problem is that the process typically takes four to five months and many of our patients have only weeks to months to live. This is an area of much needed reform so that the logistics of the process do not make the goal impossible.
Q. It’s probably not great for your mental health to be in prison. Are we doing all we can for mentally ill patients?
A. That’s what surprised me most when I started working there. I didn’t understand that we incarcerate people who are floridly psychotic when they commit their crime. One of the first years I was working I was reviewing my patient’s chart and saw his psychiatry note. When he committed his crime, he had this delusion that there were huge metal plates coming down from the sky trying to crush his car. The police were chasing him, he was speeding, crashed his car and hurt people. And he was put in prison. That was a wakeup call to me. He was running from something that he truly thought was a threat and yet he ends up inside a prison. Seems like there should be an alternative for cases like this. I also didn’t realize the degree of cognitive disability that people can have and still be incarcerated. I have patients who are so challenged that they have to be reminded daily to brush their teeth, shower and eat. And with the aging prison population we are spending extraordinary amounts of money caring for demented elders who need assistance with all of their activities of daily living.
No one intended for him to die in prison and certainly no one intended for his mother to have to live with that for the rest of her life.
Q. Do you consider your work human rights work?
A. This is my biggest internal conflict. Yes, I believe access to healthcare is a human right. But it also means working within a system that, in my opinion, is an unjust system.
Q. What’s the most unjust part of that system?
A. The sentencing laws are outrageous, often with sentences vastly out of proportion to the crime. They give much too long sentences. Many of our elderly patients are absolutely not a danger to society. The risk of recidivism is very low and yet we’re keeping them inside. And that feels wrong. Another area is the overuse of administrative segregation. A man gets caught with a bag of marijuana and a cell phone—these are potential security risks because people have called hits from prison and hurt other people—but no one deserves six months in solitary because of marijuana and a cell phone.
Q. Have your patients been further harmed by solitary confinement?
A. One man I remember well was my patient for about five years. He was a paraplegic. He had been shot in the spine in his early 20s, but was really fit with a sporty wheelchair. He had a history of depression but it was controlled. After he was sent to solitary confinement because he was caught with a marijuana and a cell phone, he became profoundly depressed. He was delusional. Paranoid. He gained 40 pounds. He would come in with these paranoid ideas that I knew weren’t happening. I attempted to advocate for him several times and custody did try to expedite the process. Human Rights Watch says more than two weeks in isolation is a human rights violation. There are challenges to being part of a system that does things like that. Sometimes I feel I should leave. But then somebody thanks me for helping them get the medical care that they needed. Or I have a small success, where I feel like my actions may have done something to change the culture for the better.
Q. Do you have an example of this?
A. We admitted a patient to hospice who had a few weeks left to live. He really wanted to speak to his daughter one last time before he died and say goodbye, but she was incarcerated as well at a woman’s prison and was in ad seg [administrative segregation, also called solitary confinement]. We worked with our Warden who got permission from the Warden at his daughter’s facility for a phone conversation. It was arranged that they would have a 15-minute conversation. Afterwards the daughter was taken to a session with her mental health provider to help her process the intense experience. Later, I got an email from a captain at the other facility thanking us for allowing him to take part in such a moving and compassionate experience. He said in 25 years as a correctional officer it was one of the most positive things he had been a part of. These sorts of experiences remind me why I continue this work.
Q. Is there any one case that really haunts you?
A. There’s one, a 35-year-old man who had been using some drugs, perhaps dealing, maybe some burglary, nothing incredibly violent. He ended up stealing his mother’s car. She was at the end of her rope and was worried she was enabling his behavior. So she called the police and he ended up getting five years, which wasn’t what she anticipated. As a child he had suffered from a rare cancer that he had survived and was thought to be cured. During his second year in prison, his cancer came back. He ended up coming to our hospice. His mother visited him all of the time and wanted nothing more than to have him come home with her. We applied for compassionate release but the cancer was aggressive and we slowly watched him go from a strong independent man to fully bed-bound. We did not think he was going to make it home and it was so hard to watch. Finally, he was granted release but custody had 14 days to let him out. I wasn’t sure he was going to make it until Monday, let alone 14 days. So Friday night at 4:55 PM we found someone to send us the official court documents and I got a promise someone would work on it over the weekend so he could leave on Monday. The most haunting part when I told him he could go on Monday was the profoundly sad look on his face. I thought he would be elated but his eyes said that he was not sure he would make it. Thankfully, he did make it until Monday and was able to go home with his mother. He died four days later. No one intended for him to die in prison and certainly no one intended for his mother to have to live with that for the rest of her life.
Q. Are you optimistic now that it seems more and more people are interested in fixing the mass incarceration system?
A. Sometimes I am optimistic and sometimes I’m not. Michael Romano is a civil rights lawyer who runs what used to be called the Three Strikes Clinic at Stanford and they advocate for people with life sentences. He played a huge role in putting together Prop. 36, which changed the [thee strikes] penalty so that the third strike had to be a serious or violent offense. And it passed overwhelmingly. I think people realized the pendulum had swung too far. Usually I don’t know my patient’s crimes. I had known this one woman for a long time, a lifer, when one day she saw me in the hall and came over excitedly and said, “I’m going home!” And I said, “What do you mean?” And she said, “My third strike was for stealing mascara!” She got life in prison for stealing mascara. And she got out. So thanks Michael Romano. There are movements to pull the pendulum back. There’s always hope.