Do Jails Kill People?


There may be no worse place to live in New York City than on Rikers Island, and it is an even worse place to die—locked inside of a jail, forcibly separated from family and friends. Most people whose lives end on Rikers die of natural causes, but there is no doubt that some deaths there have been caused by the culture and conditions of Rikers itself. This tally of preventable deaths includes: Jason Echevarria, twenty-five, who swallowed a packet of soap in his cell, screamed in agony for hours, and died after guards refused to take him to the medical clinic; Carlos Mercado, forty-five, a diabetic in desperate need of insulin, who collapsed in a hallway his first day in jail; Ronald Spear, fifty-two, a kidney-dialysis patient, who died after being kicked in the head by a guard.

Every year, several thousand people across the country die while imprisoned. Local officials report the number of deaths to the Department of Justice, but very little attention is paid to the question of how many of these deaths could have been prevented. Several years ago, Homer Venters, a physician and the former chief medical officer for New York City’s Correctional Health Services, sought to answer this question. Between 2010 and 2016, there were a hundred and twelve deaths in New York City jails. Venters and his team found that ten to twenty per cent of those deaths each year were “caused by actions taken inside the walls” of a jail. He calls these “jail-attributable deaths,” and writes that some years the percentage of such deaths “rose to half or more.”

Reporters have virtually no access to the jails on Rikers Island, but, for many years, Venters had a rare vantage point from which to observe its inner workings. He started working on Rikers in 2008, overseeing health care for thousands of people imprisoned there. On an island known for abuse and violence, Venters became a legendary figure; he often spoke about human rights and was known for his persistent advocacy on behalf of inmates. He left the city’s jail-health service in 2017, and now he has written a crucially important book, “Life and Death in Rikers Island,” in which he examines one of the most overlooked aspects of mass incarceration: the health risks of being locked up.

Eight jails now operate on Rikers, each with its own medical clinics, where incarcerated people go if they feel sick or need follow-up care, often for diseases like diabetes or asthma. But part of what makes jails such health risks for the people confined there is the insidious way that the environment undermines the ability of medical staff to perform their jobs. In 2013, officials at Rikers stopped allowing incarcerated people to walk to clinics alone; now a guard had to escort them—and, suddenly, inmates were missing their appointments nearly half the time. Venters writes, “We would give security staff list after list of the ‘must see’ patients whom we feared might die without receiving care.” This strategy worked, but only temporarily. “We might make a brief improvement,” he writes, “and then a friendly deputy warden would be promoted, transferred, or fired, and we would fall back to half or fewer of our patients being produced.” Although the situation has improved, the problem persists.

The culture clash between guards and medical staff on Rikers was apparent even in the way that the two groups spoke about the people confined there: guards called them “inmates,” while medical workers called them “patients.” At times, medical staff found themselves caught in an ethical dilemma: Was their primary loyalty to their patients or to the system in which they work? This conundrum is known as “dual loyalty,” and Venters writes that, on Rikers, the “most dramatic and tortured aspect of dual loyalty” involves the role that medical staff play in sending people to solitary confinement. Jail managers who wanted to lock an individual in solitary first had to obtain “clearance” from a mental-health worker—assurance that the inmate would not harm himself if isolated for twenty-three hours a day. Venters is a fierce critic of the process. “Health clearance for solitary is not based on any reliable science and violates basic medical ethics because, of course, that patient is supposed to suffer,” he writes. “It’s punishment, after all.”

Rikers has long been notorious for its culture of brutality, and, soon after Venters started working there, he sought to determine exactly why so many inmates were being injured. The main cause of injuries was fights with other incarcerated people, but the secondary cause—accounting for about a quarter of injuries—was listed as “slip and falls,” according to official records. Venters and his team developed an injury-surveillance system, with drop-down menus where medical staff could document how and where the injuries had occurred. Soon a pattern of abuse by guards emerged—and the prevalence of slip and falls made more sense. If an incarcerated person had his nose broken by an officer’s fist, he was unlikely to tell the truth when brought to the medical clinic; fearing retaliation from guards, he might instead say that he had slipped in the shower.

Venters began combing this electronic database each week, identifying patients whose records showed that they had “sustained serious injuries during an interaction with correctional officers,” or whose stories of how they got hurt did not match their injuries (“like a jaw fracture from falling on a toilet”). “Then, at about 5:00 pm on Fridays, I would take my list and go to the jails where these patients were being held,” he writes. At that hour, he knew that he’d be able to move around with more freedom and less scrutiny, and he always made a point of wearing his stethoscope. But, he writes, “Within a few weeks of starting these Friday night encounters, the inmates and DOC [Department of Correction] staff alike came to recognize that I was coming to these housing areas and intake pens for reasons that went beyond simple checkups.” He continues, “Correctional officers would stiffen and slow-walk my requests to see patients. In some instances, officers would outright refuse to produce patients for me to see.”

Sometimes, Venters would encounter a patient whose injuries were more serious than the medical staff had initially thought, and he would try to correct the record. But when he would send an e-mail to D.O.C. officials asking to upgrade an injury, he recalls that he would get back “a flood of responses” intended to derail his efforts. Venters recounts one visit from a D.O.C. investigator “with zero clinical training” who “tried to poke holes” in his diagnosis. “Her challenging of my clinical assessment that a patient had suffered a nasal fracture was maddening,” he writes. “But had I been one of our hundreds of physician assistants or physicians”—instead of a senior official—“the message would have been clear: this isn’t a path you want to go down.”

To conceal the extent of the abuse toward inmates, Venters discovered, guards would sometimes hide individuals with suspicious injuries in remote jail cells. Venters describes receiving a call one day from a doctor who reported that guards had just beaten a patient in a waiting area at a clinic and that “the patient had been dragged away without receiving care and had not been seen since.” Venters went searching for him. “After failing to find him in any of the normal hiding spots in this jail, I went to another facility where ‘problematic’ patients were often sent,” he writes. “I found him in a remote part . . . and heard him sobbing before I saw him in his cell.”

Even more haunting is a story Venters recounts about a night, in December, 2012, when officers attacked incarcerated people inside a clinic. The next morning, Venters found a doctor there beginning her work shift by wiping blood off of cabinet doors. The night before, guards had brought in two young men, restrained on gurneys, then “yelled at the medical staff to get in the back of the clinic, after which the beatings began,” Venters writes. “I got the stories of several staff, some of whom made it clear they would not repeat their observations to others out of fear for their own safety.” But Venters did find one employee who was willing to relay details of the beatings to his boss, Dr. Tom Farley, who was then the commissioner of the New York City Department of Health. Venters writes, “She said something to Dr. Farley that revealed the normalization of abuse in jails: ‘I’m new here and I didn’t know that when this happens, we’re supposed to go in the back and stay out of the way.’”

The Times investigated the incident, in 2014, and the U.S. Attorney’s office for the Southern District of New York mentioned it in a report that year about Rikers, but no criminal charges were filed against the officers. Meanwhile, the worker who spoke up endured retaliation. “She was verbally harassed by DOC staff and started to receive calls from currently incarcerated patients to her cell phone,” Venters writes. “Despite our best efforts to create a safe work environment by transferring her to alternate facilities, she left her job shortly thereafter.” Medical workers told Venters that after speaking up about other incidents, they, too, faced retaliation, including “slashed tires” and “dead flowers on their computers.”

Late one night, during the same month that the clinic beatings occurred, Ronald Spear, a kidney-dialysis patient, at the North Infirmary Command repeatedly demanded to see a doctor. He was feeling ill and, around 5 A.M., he snuck out of his dorm to go to the medical office next door. A jail guard named Brian Coll stopped him. The doctor on duty said that he was busy and Spear would have to wait. Then Coll and Spear got into a scuffle. Two other guards pinned Spear to the floor, following the usual procedure. But the incident did not end there; while Spear was restrained, Coll repeatedly kicked him in the head. Spear died minutes later. When Venters arrived later that day, D.O.C. investigators and a homicide detective were present, and Spear’s body was still on the floor.

Venters doesn’t write about Coll’s subsequent criminal prosecution, but, at Coll’s trial, in 2016, three medical staff took the witness stand. Their testimony revealed Rikers’ unofficial rule about medical workers averting their eyes when guards have a physical altercation. Despite the commotion in the hallway outside the medical offices—which one person said sounded like “bodies hitting the ground”—the nurse on duty did not investigate. “I opened the door and I immediately closed it,” she said. The doctor on duty testified that he did not open his office door or peer out the window. Instead, he remained seated at his desk, where, he said, he was trying “to finish my paperwork” before his overnight shift ended. Eventually, a captain knocked on the door and asked the doctor to evaluate Spear, who was lying face down, wrists cuffed behind his back. “He was right in front of the door,” the doctor testified. “He has no pulse.”

The usual response to preventable deaths that occur inside a jail is to pin the blame on a few rogue guards (or incompetent medical workers), but Venters argues that the truth is far more complicated. “Because jails are chaotic and concealed from outside view, we only become aware of them when very bad outcomes occur, such as deaths,” he writes. “As a result, our periodic glimpses into this area miss the systemic failings of the systems we’ve designed, and we make the repeated error of blaming individuals for outcomes that we’ve essentially predetermined.”

According to Venters, these systemic failures include not only Rikers’ culture of brutality but also something more surprising: guards used “paper logbooks” to record when an inmate arrives and leaves a housing area, which meant that the medical staff did not always know where their patients were located. There were times when an incarcerated person would be “moved from one spot to another without any new information being entered into the security system,” Venters writes. As a result, “medical, mental health, pharmacy, and nursing staff” would be forced “to roam the halls of the jails every day physically looking for their patients.” Jail officials have begun trying to track inmates with wristbands, but the paper logbooks are still in use, and, in Venters’ view, this “archaic paper-based approach to information management . . . may be the single greatest contributor to abuse and neglect in the jails.”

Mayor Bill de Blasio has promised that Rikers Island will eventually be closed, and, in preparation, New York City has been working to reduce the number of people held in its jails. In January, de Blasio announced that the jail population “had dropped to less than eight thousand people for the first time in almost forty years.” Now the number of guards on the city’s payroll actually exceeds the number of incarcerated people. But Rikers’ culture of brutality persists, and many of its jails are falling apart. “The medical infirmary was literally the DOC bus garage before they decided to upgrade their bus fleet to another site and hand the space over to us for our sickest patients,” Venters writes. “I’ve often heard complaints about inmates who would file lawsuits about bits of the ceiling material falling down on them, but the scope of the problem became clear to me when we received a report that a rotting animal carcass had fallen into the patient area.”

In the end, Venters places the blame for the “slow-rolling disaster” of the city’s jails at the very top, with City Hall. New York City, “like many cities and counties,” he writes, “turned its back on jail conditions for years, and a culture of mismanagement and brutality took hold that has not been removed.” He makes few distinctions between de Blasio and his predecessor, Michael Bloomberg. “Having led the health service across two mayoral administrations, one a centrist Republican and the other a progressive Democrat,” Venter writes, “I have seen remarkable consistency in how the incompetence of the correctional service was not only tolerated but also supported.” Now, with “Life and Death in Rikers Island,” Venters reveals the true human cost of these colossal management failures.