I.
We wait for the metal gate to slide open. It is my first day at Mule Creek Prison. I feel anxious and nervous, but also excited. I have never been to a prison before. The prison complex is metal, concrete, and barbed wire set in the middle of rolling green pastures where deer and wild turkey roam and pine trees grow along the perimeters.
When I first heard about the opportunity to do medicine at Mule Creek Prison, I knew it was an opportunity that I could not miss. Believe it or not, correctional medicine is a very popular elective among my medical school classmates and all the spots were taken when I first tried to sign up. I emailed the course coordinator over several months to see if there was an open slot and one day, I got an email that someone had dropped the course and I was offered the spot. What appealed to me about this elective was the opportunity to work with a truly marginalized patient population and honestly a lot of it was pure curiosity.
We pass through the gate into E Yard. It is April 2021, the Covid-19 pandemic is waning but still lingering and we are all wearing masks and standing six feet apart. Prisoners are milling around, chit-chatting as they await their turn in line for medications. Guards stand by to keep order. Someone yells out, “Dr. Matharu! Did you order my x-ray?” Another voice, “Good Morning, Dr. Matharu! I think I have cancer in my leg! I’ma come see you.” Dr. Matharu answers all their questions with good humor. He is the attending physician who I will be working with during my four-week rotation at Mule Creek Prison.
We spend the morning seeing patients in the clinic. They come in for joint pains, stomach aches, allergies, and chronic conditions such as diabetes, high blood pressure, heart conditions, HIV, and hepatitis C. It does not feel much different from a community primary care clinic, except this is prison.
II.
Later in the week, Dr. Matharu gives me a tour of the prison. We go out into the yard. Someone yells “Matharu!” and “Best doctor ever!” They really like him. It is canteen time. All the prisoners line up at the canteen window. They fill their netted bags with boxes of mac and cheese, juices, crackers, candy bars which they bring to nearby round tables to eat. A few men are running around the track or doing pull-ups at the metal bars. Across the yard, some prisoners are training several dogs to be companions to wounded vets and seniors in the community. We walk past the cafeteria, which is locked and dark. It looks like a school cafeteria. Everything is concrete and gray. The sun reflects off the light pavement and the glare strains my eyes.
We enter one of the cell blocks. It is dark and cool inside. Two men are doing their homework for English 101. One of them shows us his essay. It is neatly handwritten in pencil on lined paper, double spaced. The cells are composed of pods of 6 men who sleep on bunkbeds. There is one toilet. A TV with local news is on. We next stop by the Mule Creek Post editing room. Some men are sitting around a table discussing an article. One is a man with white hair sitting in a wheelchair, another is a black man with dreads wearing a yamaka and Star of David around his neck, a third with glasses held together by tape is sitting at the computers working on graphs. On the whiteboard they have the topic layout for the next issue. They present me the last two issues of their paper. We talk about the new double-variant of Covid-19 in San Francisco. They ask me if I can write an article for them, perhaps about being a medical student rotating through the prison. They ask Dr. Matharu for updated Covid-19 statistics in the prisons.
III.
After a few days of getting oriented to the flow of clinic, I am ready to start seeing patients on my own. One of my first patients is a 68-year-old trans-woman in the process of applying for gender affirming surgery and waiting to transfer to a women’s prison. She talks about the challenges of being a trans person and how prison can be a microcosm of society where negative elements are magnified, concentrated. Yet, she says, despite all the tribulations she cannot deny who she truly is.
Later in the week, I meet Mr. T., a spritely 74-year-old man who uses a walker. We discuss his chronic conditions and his current medications. He tells me about the prison bible school and how he finds hope in prison, “I wake up and thank god for being alive every day. I am not happy to be in prison. No one should be happy in prison, but I have come to accept my condition and have found contentment. I think God saw that I was not doing well outside. I am here in prison for a time-out so I can think and find my way back.” Mr. T’s face starts to crumple, and I see some tears trickle down his leathery face. “I am so ashamed of what I did. I did something so terrible, and I feel so much shame.” I hand him a paper towel to dry his tears.
Later that day, I see Mr. G., a 39-year-old muscular, heavily tattooed man who towers over me. He hears ringing in his ears. We tell him this could be a sign of hearing loss. His face falls. “I can’t believe this ringing in my ears means I’m losing my hearing. I’m disintegrating in prison. I’ve been in prison for 15 years and I’m just disintegrating.”
Young men turn into old men in prison. Mr. L tells me, “I’ve been in prison since I was 20 and now, I’m near 60 years old, but I think I’m getting out soon. A long time coming is what I am becoming.”
IV.
We all make mistakes at some point in life. We do awful things that we regret. We can also change, and many of us do. This does not change the fact that society demands retribution for those mistakes. From the earliest days when humans started banding together, it became obvious that rules were needed to keep communities orderly and functioning and to protect the rights of all their members. Those not obeying the laws laid out by society were penalized. Jean Jacques Rousseau, in The Social Contract, his modern rework of Plato’s Republic, articulately explains the reciprocal obligations between society and the individual.
V.
People are sentenced to prison because they break the law, but poor diet and denial of quality health care is not and should not be part of their punishment. As a result of Plata v. Schwarzenegger (2001) the court ordered an overhaul of the California prison system to improve delivery of medical care. The correctional medical system is a work in progress.
It has been recognized that health care in the prison system was subpar in the past and continues to have deficits, but a new crop of health care providers, more dedicated and committed to primary care for the underserved, are responding. Physicians like Dr. Matharu obviously are making a huge difference in improving morale of the prison population under their care.
I am grateful to the patients at Mule Creek who allowed me to be part of their care and who spoke frankly to me about their life in prison. Medical school can be demanding and exhausting, but the joy of caring for patients, talking and learning from them, getting to know them, to me is the best reward. It is truly a privilege being invited into someone’s life, especially at a time which is not their best and when they feel most vulnerable. My attending physicians often remind me that patients are our greatest teachers. As Dr. William Osler, cofounder of Johns Hopkins, said, “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.”
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