“If we’re not here to make them better, then why am I even here?”

Tanyatta Woods knows very little about the agonizing last days of her son’s life. She didn’t get to comfort 19-year-old Deundrez when his hallucinations reached a fever pitch, or to see him one last time before his mind shut down. In June 2013, he was a healthy all-city wrestler at Alabama’s Huntsville High School, and he was an avid sketcher, with dreams of going to art school in Georgia. Less than two months later, he was huddled on the floor of a jail cell with a gruesome infection — incoherent, unconscious, and unable to recognize his own mom.

What happened? Effectively, an unpaid speeding ticket landed a teenager a death sentence in a county jail.

In the summer of 2013, Deundrez was arrested for allegedly shoplifting Star Wars DVDs and using a fake $100 bill at a local Walmart, and he had a warrant out for an unpaid speeding ticket. The charges earned him a two-month sentence in Alabama’s Madison County Jail. After about a month in the jail, Deundrez’s behavior started to change dramatically — by early August, he had dropped dozens of pounds and was barely lucid. He was suffering from a badly infected wound on his right foot — gangrene — that was not treated by the jail’s medical staff, despite his obvious and rapid deterioration. A lawsuit filed against the county by his mother, Tanyatta, alleges that Woods spent five days in a medical observation cell in front of jail staff, naked and hallucinating in a gangrene-induced haze. He didn’t eat or drink during that time, according to the lawsuit: He just rolled around and withered away on the hard cell floor.

Meanwhile, Tanyatta had no idea how disastrously Deundrez’s health had declined. She didn’t get a glimpse of her son until his August 15 court hearing. By then, she says, her son was barely recognizable. He couldn’t talk, walk, or even stand — the formerly powerful athlete was rolled into court on a wheelchair — and perhaps most disturbingly, he couldn’t register who she was.

“He wasn’t himself,” Tanyatta told ThinkProgress. “There wasn’t nothing normal about him… It looked like he had lost about maybe 60, 70 pounds… his mouth was crusted, his eyes were like dry, glazed over… He thought he was back to a child stage. He kept saying that his granddaddy was pushing him in a wheelchair and in a swing. But he wasn’t in a swing, he was in a wheelchair. And I kept on asking, did he know who I was, and he said ‘no.’ I said, ‘are you sure you don’t know who I am?’ And he said ‘no ma’am.’… There’s not a child that doesn’t know their mother’s voice.”

Tanyatta repeatedly asked the correctional officers at the hearing to take Deundrez to the hospital, but they didn’t heed her calls, instead blaming his behavior on preexisting mental health issues, she said. Over the next several days Deundrez’s conditions deteriorated, but medical staff never checked his temperature, blood pressure, and blood sugar, according to her suit (the defendants denied these claims). On August 19, they found Deundrez in his cell completely unresponsive and finally sent him to the Huntsville Hospital.

It was too late. The infection that started in Deundrez’s foot made its way through his body, and he was septic, dehydrated, and suffering multi-organ failure and acute renal failure. On August 21, Tanyatta visited the hospital with her mother, who made the trip from Mississippi to see her grandson one last time.

“When I got there they acted like I was a mad woman,” Tanyatta said. “They had all about 10 guards [there]. He was already brain dead. Both of his hands were handcuffed to the bed; so were his feet.”

Deundrez’s suffering didn’t last much longer: the 19-year-old died later that day. The precise cause of his death remains unclear. The company responsible for his health care in the jail told ThinkProgress that the gangrenous infection was not what killed him, and medical experts who testified in the case had conflicting conclusions about which of Deundrez’s numerous conditions ultimately led to his death.

But was is indisputable is what Deundrez left behind — his one-year-old son, Jailyn, who Tanyatta is now helping raise. She can’t look at him without thinking of his father. “He walks like him, he smiles like him, he looks like him, he acts like him,” she said, her voice catching. “He knows his dad’s pictures… When I take him to the cemetery he’ll say ‘that’s my dad’s stone’ and when I put flowers on his dad’s grave, he says ‘I wanna go see my dad.”

Photos from Deundrez’s funeral bulletin. Courtesy of Hank Sherrod.

The lawsuit Tanyatta filed against the jail settled recently, but that’s hardly a consolation for her. She’s still looking for answers — not just about what happened, but about how the situation could have spiraled so disturbingly out of control. “I raised my child, and to lose him like this, it took a lot out of me,” she said. “I read that he was dragged from one cell and held like a dog, it got tears in my eyes. To act like my son was an animal. And he wasn’t even a violent criminal…[They] knew there was something wrong, but just let him lay in there and die. That’s basically what they did…I’m still not content with it. We went to court, we settled, but it’s still a piece of me that’s gone.”

Cutting health care costs—but at what cost?

At the time of Deundrez’s death, the Madison County jail contracted out its medical services to an Illinois-based, for-profit correctional health care company called Advanced Correctional Healthcare (ACH). The company, one of the country’s most-contracted inmate medical providers for jails, participates in a lucrative and growing market for a range of correctional services.

Companies like ACH appeal to cash-strapped governments by offering to save them money through lower administrative fees. “Our commitment to addressing cost concerns has saved the county over $2.9 million during our tenure,” ACH boasted in a 2013 contract proposal presented to Madison County just a few months after Deundrez died in jail.

But critics worry that these cost-cutting measures can fall directly on inmates’ well-being. In the same year Woods’ case was heard in court, two other inmates in the Madison County Jail died: Nikki Listau, of injuries allegedly caused by alcohol withdrawal; and Tanisha Jefferson, of bowel obstruction.

These incidents aren’t confined to Madison County’s borders. In Tennessee, an ACH nurse working at Anderson County jail pleaded guilty to charges of falsifying the medical records of an inmate who died of a drug and alcohol overdose. The nurse didn’t check on the inmate as required, and instead used a different inmate’s vital signs to cover up for his error. In Kentucky in 2013, Danny Ray Burden, a diabetic, collapsed and died in Grant County jail after staff ignored his numerous pleas for insulin. Burden died just months after the U.S. Department of Justice (DOJ) wrote a long letter to the County Attorney expressing concern over “an ongoing lack of prisoner access to qualified clinical staff… and mental health services in general.” In the jail, the letter concluded, “unqualified staff are serving as gatekeepers to medical care.”

A medical expert who testified in the Woods case went a step further. “Advanced Correctional Healthcare deviated from standard of care correctional medicine and was deliberately indifferent in the care of the Inmate Deundrez Woods,” he said. “This deliberate indifference led to his death.”

In a statement provided to ThinkProgress, ACH reiterated its commitment to serving inmates — and added that the many lawsuits filed against the company aren’t a source of concern. “People who work in corrections understand that incarcerated patients file a disproportionately high number of lawsuits,” the company’s senior counsel wrote. “Just because someone may be named as a defendant in a lawsuit, does not make them guilty. Unfortunately, the allegations made by plaintiffs are often reported as facts, and reporters rarely dig deeper than the allegations of the complaint.”

Finding new ways to profit from incarceration

The U.S. jail and prison population has risen dramatically in recent decades: There were more than 2.2 million people behind bars in state and federal prisons and local jails in 2013, up from less than 530,000 in 1986. That’s largely due to a series of “tough-on-crime” laws and harsh sentencing policies — a reaction to the so-called ‘War on Drugs’ and concerns over rising crime rates — enacted in the 1980s and 1990s. These laws, which included mandatory minimum sentences for low-level crimes, as well as “three strikes, you’re out” for recidivists, resulted in a massive overall increase in the number of people ensnared in the criminal justice system. The U.S. now incarcerates more people than any other country in the world, including the much more populous China, and has the globe’s highest incarceration rate. Today, roughly one in every 100 adults in the U.S. is behind bars; for black men between the ages of 20–34, that number surges to one in nine.

Male incarceration rates by various demographic groups. Source: Pew Charitable Trusts

The result has been a growing market for companies which sell goods and services to prisons and jails. For-profit companies service a range of material needs, like jumpsuits or inmate restraints; they also now provide services, including prisoner transportation, probation services, medical care, and beyond. In recent years, the modern criminal justice system has seen greater and greater privatization, a trend rooted in the dramatic expansion of the nation’s prison and jail population in recent decades.

The specific rise in for-profit companies taking over inmates’ health care was the result of a demographic change: America’s prison population is getting older, and the cost of providing medical care to elderly inmates is greater than for younger, healthier inmates. A phenomenon known as the ‘graying’ of America’s prisons — the product of “tough on crime” policymaking, longer sentences, and demographic changes — means people age 50 and over now make up the fastest growing age group in the U.S. prison population, according to Bureau of Justice statistics. Many of these elderly prisoners are sick, with distinct — and costly — health care needs. From 2001 to 2008, the number of state and federal prisoners over the age of 54 increased by more than 90 percent, a 2014 Pew report found. During the same period of time, spending on correctional health care increased in 42 states of the 44 states Pew surveyed, with a median growth of 49 percent.

To offset the financial blow dealt by these demographic changes, many jails and prisons turned to private health care companies boasting lower administrative fees. Like ACH, many promised medical services at a lower cost, often through fixed-rate contracts based on daily inmate rates. These cost-saving promises have been a powerful lure for local and state governments eager to trim their budgets. Although data on private correctional health care is hard to come by, as of 2012, at least 20 states outsourced a portion of their health care to private companies, according to the Washington Post. Moreover, a June report by the Justice Department’s Office of the Inspector General found that federal prison spending on outsourced health care increased by nearly a quarter between FY 2010 and 2014, from $263 million to $327 million.

How this plays out in jails is even murkier. Dr. Marc Stern, a correctional health care expert and former assistant secretary for health services in the Washington State Department of Corrections, said that there’s no hard data on rates of privatization in jails, but guesstimated that around 50 to 60 percent of jails have outsourced some part of their health care to private companies. The decentralized, state-run nature of the jail system — with no federal oversight and only 27 states having independent oversight bodies with mandatory inspection duties — makes it even harder to know what’s happening inside our nation’s jails.

What we do know is that ACH has benefited greatly from the dynamics that have compelled correctional agencies to cut contracts with for-profit companies. In 2007, 2012, and 2013, the Illinois-based operation was listed as “one of INC. 5000’s fastest growing healthcare companies,” according to a review of company corporate records provided to ThinkProgress. The company, founded in 2002 by Dr. Norman Johnson, was established to “focus on providing care to the county jail systems.” From its inception in 2002, when it had just 9 contracts, the company now operates in 255 facilities and 17 states across the country.

Hank Sherrod is an an Alabama-based civil rights attorney who filed lawsuits against ACH for the deaths of Deundrez Woods, Nikki Listau, and Tanisha Jefferson in the Madison County Jail. Sherrod, who has since become a go-to litigator of sorts for wrongful death cases involving private correctional health care companies, says that inmates’ health treatment can vary from county to county. But, he noted, “what was going on at the Madison County Jail is among the worst I’ve ever seen.”

Sherrod partially attributes the poor treatment inmates receive to the basic structure of private correctional healthcare companies, which have strong for-profit motives without counterbalancing systems of accountability.

“They basically say, ‘You don’t harass us about the poor medical care we give, we save you money, and we protect you from liability,’” he explained. “What they really mean is, ‘We’ve got insurance, we’ll take it, we’ll save you money, and we’ll cover the inevitable lawsuits.’”

Deundrez Woods. Photo courtesy of Hank Sherrod.

“He told me he was dying.”

Hundreds of miles from Alabama’s Madison County Jail, in an Indiana jail, Timothy Kingston-Strayer also found himself in a life-threatening predicament under ACH’s care. In June 2011, Strayer was arrested on an outstanding warrant for marijuana possession with the intent to sell, and was sent to Indiana’s Dearborn County Jail. Strayer, in his late sixties at the time, suffered from a number of chronic health issues before arriving at the jail, including psoriasis, acid reflux, and heart disease. It didn’t take long for these conditions to worsen while he was behind bars, eventually leading to a health crisis that, without the intervention of Strayer’s brother, could have cost him his life.

On August 3, Michael Strayer paid his brother a visit at the Dearborn County Jail, and was deeply disturbed by what he saw. “His physical condition was appalling. He was very frail, emaciated and pale and he was in obvious pain,” he wrote in a detailed written account of his visit. “His entire arms were a deep purple color with scales covering the entire area. He breathing was labored and could not speak above a whisper. He told me he was dying… I immediately went back to the general reception area and told the attendant that he had to be sent to a hospital immediately or else he would die.”

Panicked, Michael left the jail and sent a frantic letter describing his brother’s condition to county Sheriff Michael R. Kreinhop, as well as county prosecutor Aaron Negangard. “His medical condition was expressly noted upon his arrival and has deteriorated to the point that his life is in danger,” he wrote. “Without immediate hospitalization he well may not survive.”

Michael’s pleas were heeded later that day. Timothy was transferred to the Dearborn County Hospital with a perforated ulcer, and he would end up staying in a handful of hospitals over a series of months in recovery before returning to jail to serve his sentence. “Tim spent 196 days in 5 different hospitals in 3 different states,” his wife, Kelley Kingston-Strayer, told ThinkProgress. “Our medical bills climbed to almost $2 million.”

In 2012, the Strayers filed a federal civil rights lawsuit over Timothy’s treatment at the Dearborn County Jail. The lawsuit alleges serious negligence on behalf of the guards, nurses, and jail staff involved in Strayer’s detention. “As a result of the Defendants’ negligence and deliberate indifference to Tim’s serious medical needs, Tim very nearly died once he was transferred to the critical care unit of adjacent hospitals, was hospitalized for numerous weeks, and continues to suffer from serious, permanent, and life-threatening medical conditions.”

Dr. Ronald Davis was Indiana’s site physician for jails that contract ACH. On August 2, Davis was covering a shift for Dr. Nadir Al-Shami, the primary doctor with ACH at the Dearborn County Jail. Davis, it appears, knew little about the company despite his tenure there. At the time of his deposition in the lawsuit, in 2013, he had worked as a physician for ACH for nearly a decade. But when asked to explain what the company does, he answered: “They provide medical care for county hospitals throughout the midwest.”

Davis had to be corrected by his counsel: “county jails.”

According to the deposition, Davis saw Strayer after he filled out a medical request form over skin problems, a potential ear infection, and a hernia. “The ear infection was severe,” Davis said. “There was a lot of redness and swelling. I wasn’t able to fully visualize the eardrum, and that was causing him a lot of pain… His rash was all over his body, and it was very intensely itching pruritic. And his groin was really raw… So all of those were severe.”

Davis did not refer Strayer to a surgeon for the “large hernia” in his groin, however, because he didn’t think it was an emergency and didn’t believe Strayer was in a life-threatening situation.

Timothy Kingston-Strayer in the hospital. Photo courtesy of Kelley Kingston-Strayer

Dr. Lynn E. Eiler examined Timothy on August 6 and 7 when he was hospitalized at the Dearborn County Hospital in the intensive care unit. In an expert report accompanying the Strayers’ lawsuit, Eiler said Strayer was “critically ill” by the time he finally got to the hospital, and that the delay “greatly increased the severity of his illness with resultant increased morbidity to this patient.” Eiler concluded that Davis and the jail guards did not perform their duties as necessary. “I believe the failure of both the guards, who had the opportunity to observe Mr. Strayer, as well as Dr. Davis who saw Timothy Strayer on August 2, constituted deliberate indifference to a serious medical need by failing to immediately have Mr. Strayer sent to the hospital for treatment of his life-threatening illnesses. As to Dr. Davis, it constitutes a breach of the standard of care.”

Denise, who asked that her real name be withheld to protect her identity, is a licensed clinical social worker who worked with ACH at Indiana’s Dubois County Jail for more than two years. She told ThinkProgress she wasn’t surprised when she heard about Timothy’s experience with the company. “I had quite a few inmates that were severely mentally ill and they did not get what they needed,” she said.

She recalled one situation she found particularly disturbing. After encountering a severely depressed inmate who refused to eat and sleep, Denise alerted her supervisor. “She said ‘I know this is probably going to sound bad to you, but our responsibility is not to improve their conditions but to keep them at the same level that they were when they came in.’ So basically, it’s not our responsibility to improve them.”

Denise found the response antithetical to the lessons she learned as a social worker, and she alerted the county sheriff. “I said, ‘If we’re not here to make them better then why am I even here?’ I didn’t feel like they were in it for any kind of desire to improve the lives of inmates or help them make changes that would help them result in a more positive outcome.”

That experience, among others, ultimately soured Denise’s time with the jail, and she stopped working with ACH altogether. But she still feels uneasy when she thinks about ACH offering crucial health services to inmates, both in the Dubois Jail and elsewhere. Based on what she’s seen, she doesn’t think ACH should be providing any health services in jails.

“I’ve said this before — I would not want a family member of mine to be in the jail and need help because I’m confident they would not give it,” she said. “It was like nothing was ever taken seriously. Nothing was ever a concern for the well-being of the inmates. It was always, do what you have to do legally.”

ACH, meanwhile, declined to comment on both Strayer and Woods’ individual lawsuits, but did note that the company recently received a workplace culture certification.

“This year, ACH was certified by Fortune Magazine as a Great Place to Work®, making us the first and only correctional healthcare company to receive the award,” the company’s senior counsel wrote. “This milestone was incredibly meaningful to us.”

“I feel that the system has failed.”

The first step in ensuring inmates get the care they need starts with in acknowledging the full scope of the problem, which extends beyond even the companies like ACH providing contracted medical care.

University of Washington’s Dr. Mark Stern will be the first to admit he’s “not a big fan of privatization.” But he believes the problems and fatal neglect for which many of the private companies have become notorious span beyond the for-profit industry itself — an issue rooted in a lack of funding and oversight. “In the work that I do, I see as many problems come up in facilities that are operated where the health care is provided by the government agency, not by a private company,” he pointed out. “The underlying problem to me is that we don’t spend enough money on correctional health care in the U.S… and that lack of money affects the quality of the care regardless of who delivers it.” As Hank Sherrod, Woods’ attorney, put it, “When you put in a system with incentives, it doesn’t bring the best out of people. If you have no accountability, then people tend to go astray.”

Stern believes there are reasons to invest in correctional health care beyond the moral and humanitarian arguments that animate some reformers. “More than 95% of all inmates return to their community.” he explained. “There’s more infectious disease and chronic disease in prisoners than there is in the community… So you have this window of opportunity when you have literally a captive audience and you can affect their health and change the risk that they bring back to the community when they inevitably are going to come back.”

Despite the broader public health links, it may take some prodding to get everyday people to care about investing in correctional health. Although the conversation around criminal justice has indeed changed — some politicians on both sides of the aisle have recognized the failures of the harsh sentencing policies that defined earlier eras — there are questions that need to be asked of the constituents as well. How much money are taxpayers willing to put into ensuring jails have the resources they need so they don’t have to cut corners with private companies?

Stern believes that might take an education campaign. “Until the public is informed and realizes the public health impact of jails and prisons on their own health, there’s not going to be a groundswell of interest to improve the conditions.”

Until that happens, the pushback will likely continue to come from a few lone voices — the family members, like Kelley Kingston-Strayer and Tanyatta Woods, who were forever changed by the neglect they say happened to loved ones behind bars.

“I think about him daily,” Woods said of her son. “I was cleaning a closet out two days ago, [and found] his letterman jacket from football. I was going through it, and it was like, it brought back tears.” She also has not forgotten the system that she believes cost her his son his life. “I don’t trust the medical staff,” she said. “I feel that the system has failed up there and they’re not treating anyone the way they need to be treated.”