INMATES WITH KIDNEY DISEASE CALL TRANSPLANT POLICY CRUEL

OTISVILLE, N.Y.--David Lee Smith needed a new kidney, and his brother, a
proven match, was willing to give him one. But Smith delayed the transplant
surgery and then, as he put it, "I got in trouble."

A federal court in Texas found Smith guilty of selling crack cocaine and
condemned him to life in prison. In doing so, it also sentenced Smith, now
43, to spend years tethered three times a week to a kidney dialysis
machine. A transplant from his brother, Horace, that could prolong his life
is no longer an option under a federal Bureau of Prisons policy.

Smith and hundreds of other inmates in federal and state prisons across the
country are at the crux of a complex debate about medical choices within
the growing and rapidly aging prison population. State and federal
corrections systems provide medical care for ailing inmates and rely on a
network of prison hospitals, outside medical centers and private clinics to
do so.

But inmates with kidney failure and other life-threatening conditions
require constant monitoring and expensive specialized care. Most prisons
pay up to $40,000 a year per patient to keep such inmates on a
thrice-weekly program of hemodialysis, which cleans the blood of impurities.

Yet with advances in care, kidney transplants are now by far the preferred
medical treatment. The death rate for hemodialysis patients is
extraordinarily high -- about 23 percent a year. A successful transplant
using a living donor reduces that risk to about 3 percent per year.

A tangle of prison policies and budget constraints, combined with the
restrictive eligibility criteria of outside organ banks, has prevented most
inmates from getting kidney transplants. Even with family donors, prisoners
are unlikely to be considered for transplants unless they are perilously
near death or can pay the $80,000 to $120,000 initial medical costs of a
transplant -- plus the expenses of transportation and security.

Virginia is one of the few states that regularly refers patients for kidney
transplant evaluations and pays for the surgery, considering it
cost-effective and compassionate care. Three Virginia inmates have had
transplants since 1995 and another seven are waiting for organs, officials
said.

The federal Bureau of Prisons, which supervises 134 inmates on dialysis,
has not allowed a transplant in more than a decade and will not consider
transplant requests except in extraordinary situations, officials said. In
the outside world, federal Medicare insurance offers universal coverage for
kidney transplants, recognizing the surgery's cost and health benefits. But
federal prisoners lose that coverage while in custody. Inmates say high
surgical costs make it virtually impossible for them to foot the bills.

"We're aware of the statistics . . . regarding the benefits of
family-donated kidneys, but there are a lot of other considerations," said
David B. Good, national health services administrator for the Bureau of
Prisons (BOP). "Most of the inmates that we have on dialysis . . . came in
on dialysis. We still believe this is the appropriate care for them."

Some inmates -- their complaints backed by medical opinions -- say that
such restrictions are not just medically outdated and fiscally
shortsighted, but inhumane.

"The court sentences you to one thing. Then the Bureau of Prisons turns
around . . . and denies me access to a kidney transplant. They're virtually
sentencing me to a death sentence," said Michael Walker, another Otisville
inmate with kidney failure who is serving 14 years for bank robbery.

"I'm appalled" by the prison restrictions on transplants, said Juan P.
Bosch, chief of the division of renal medicine at George Washington
University Medical Center. "As far as I know, in the United States, every
patient who wants a transplant and is [medically] a candidate for
transplant should be registered" with a regional organ network to receive a
kidney.

BOP officials say the policy reflects the realities of kidney failure
treatment in the population as a whole. About 214,000 Americans are on
hemodialysis; only about 11,400 received transplants last year.

More than 38,000 people linger on donor waiting lists. Some dialysis
patients who can't find a living donor are forced to wait years for an organ.

Despite Medicare coverage for the procedure, blacks, women and poor people
are less likely to receive kidney transplants than whites, men and rich
people, according to a study published last week in the Journal of the
American Medical Association.

David Lee Smith is one of 19 kidney-failure patients incarcerated at the
federal prison here as part of a clustering concept that helps contain
prison medical costs. Only Otisville and two federal prison medical centers
- -- in Springfield, Mo., and Lexington, Ky. -- offer dialysis. Inmates with
kidney failure are housed in these locations, often so far from their
families that they rarely receive visitors.

Three times a week, the Otisville prisoners are strip-searched, shackled
and escorted onto a bus for a 35-minute trip to the Middletown Dialysis
Center, a private clinic under contract to treat up to 25 inmates a year at
a cost of about $40,000 per patient. Under the watchful eyes of guards,
each prisoner is hooked up to a machine for four hours, the blood pumped to
remove waste and excess fluid.

Some of the prisoners have been told by doctors that they are good
transplant candidates and have relatives willing to give them kidneys.

But their dealings with prison officials have been disheartening. Inmate
Sylvester Clay, 39, said he inquired about a transplant in a letter to BOP
officials several years ago but lost hope when he received their answer.

"The policy says unless I am willing to cover all the costs -- for security
and everything -- that's the only way I could get it," he said.

Michael Walker, a tenacious man with a scholarly manner, has filed several
unsuccessful lawsuits and has written dozens of letters to federal
officials concerning his care. Medicine bottles, boxes of correspondence
and a thick law journal vie for the scant storage space in the 8-by-12-foot
cell he shares with another prisoner.

Walker came to Otisville in 1994 from the U.S. Medical Center for Federal
Prisoners in Springfield, Mo. Shortly after his arrival, he suffered an
episode of pericarditis -- an accumulation of fluid around the heart -- for
which he blamed inadequate dialysis at the Springfield facility. He
underwent surgery and recovered but said his ability to exercise remains
impaired.

Inmate Abdullah Saubar, 50, twice received kidney transplants through organ
networks while a state prisoner in Massachusetts, where he says his
operations were paid for by the state. He was forced to go back to dialysis
after the transplants failed.

Saubar said he does not want another transplant -- but he may need one to
survive. After 21 years on dialysis, blocked blood vessels have made it
increasingly difficult for nurses to hook up the dialysis machine. A thin,
frail-looking man, Saubar during an interview wore a bandage on his neck,
covering an intravenous catheter that doctors placed there for dialysis.

In recent months, the Otisville prisoners say their situation has seemed
more perilous because of the deaths of two inmates who were on dialysis.
Inmate Ernest Baker, 53, collapsed in front of the others in January while
getting off the bus at the dialysis center.

Walker said Baker had been hospitalized with heart problems three days
earlier and complained that he had received no dialysis during his hospital
stay. Kidney failure patients ordinarily need dialysis three times a week
and sometimes more often when they are sick.

As the bus was unloaded, Baker was taken out in a wheelchair, his legs
shackled, Walker said. "He was moaning and groaning and couldn't sit up
straight," Walker recalled. "As he was getting off the bus, I and several
others watched him. His eyes rolled back in his head."

Paramedics could not resuscitate Baker. "We were informed . . . that night
that he had expired," Walker said.

Inmate Ernest Gordon suffered for several years from low blood pressure and
dizziness, both occasional side effects of dialysis. In June, the inmates
said, Gordon, 44, passed out at the dialysis unit and died at a nearby
hospital.

Robert Kirschner, the kidney specialist who owns the clinic, said autopsies
showed that neither death was caused by the dialysis treatment.

"They're getting good care, whether they appreciate it or not," he said of
the prisoners.

Nevertheless, Kirschner said, he has written letters for some inmates
recommending them as good medical candidates for transplants. He said he
does not know the reasons for the bureau's restrictions on transplant surgery.

Kidney experts say that simply being on long-term dialysis puts life at
risk. Cardiovascular disease produces blocked blood vessels in the heart
and elsewhere in the body, and causes 60 percent of deaths in people on
dialysis, said Garabed Eknoyan, a professor of medicine at Baylor College
of Medicine and president of the National Kidney Foundation.

This is partly because many people with kidney failure also have high blood
pressure or diabetes, which are risk factors for cardiovascular disease.
However, dialysis itself appears to increase their risk of heart and blood
vessel disease, Eknoyan said.

The best candidates for kidney transplants are relatively young patients
who are in good shape except for their kidney disease, said Bosch of George
Washington University. People with severe heart disease or diabetes often
are eliminated as transplant candidates, as are patients infected with the
AIDS virus or chronic carriers of the hepatitis B virus.

A history of drug abuse -- which is common in prison populations, and
sometimes causes kidney failure -- also may exclude a person from
consideration for a transplant.

BOP spokesman Todd Craig said that under the agency's policy, a prisoner
judged likely to die within six months to a year without a transplant may
be considered for "compassionate release" so that the surgery could be
performed outside. When a prisoner is released, the surgery qualifies for
Medicare coverage.

But doctors say the bureau's policy makes little sense given the optimum
conditions for a successful transplant. The longer the surgery is delayed,
the less hopeful the prognosis, they say.

Part of the problem facing the prisons is cost. Without Medicare coverage,
federal and state prisons pay the full cost of inmate health care. (In the
federal system, this breaks down to about $9.70 per day for each of its
120,000 prisoners.) Transplant surgery is costly and requires intensive
medical follow-up.

But George J. Annas, chairman of the health law department at Boston
University's School of Public Health, said transplants are less expensive
than dialysis in the long run.

"It's not as if they're going to save money" by denying transplants to
prisoners, Annas said. "If it is punishment, it would be cruel and unusual
punishment. That's not the penalty for any crime, being barred from getting
a transplant."

When prisoners have willing organ donors, he said, "then you don't even
have the problem of taking kidneys away from people who haven't committed
crimes."

But even if the bureau eased its restrictions, finding kidneys for
prisoners without family donors would be difficult, experts say. Some
transplant programs are reluctant to accept prisoners as candidates,
predicting that inmates will not follow the strict medical regimen required
to keep a transplanted organ healthy, said Eknoyan.

"A lot of these individuals are noncompliant," said Eknoyan. "We've had the
bad experience of people who . . . don't comply with the treatment [to
suppress the immune system], and reject the organ. It becomes a wasted
resource."

Other physicians argue that prisoners should be evaluated individually
rather than being categorically denied a treatment that clearly can prolong
survival.

Inmates with kidney failure in state prisons also rarely receive
transplants, according to interviews with officials of a number of state
prison systems.

In some cases, states refuse to pay for them. In others, prison policies
and the reluctance of transplant programs to consider prisoners combine to
prevent inmates from getting the treatment, said Bob Spieldenner, a
spokesman for the United Network for Organ Sharing.

To get on a kidney waiting list, a patient must be evaluated at a medical
center and accepted for a transplant program, he said, but some prison
systems are reluctant to even pay for an evaluation.

California's prison system, with 91 dialysis patients, last provided a
kidney transplant to an inmate in 1989, said Christine May, a spokeswoman
for the state's Department of Corrections. She said prisoners may be
evaluated for transplants but must meet standard eligibility requirements
to be placed on a waiting list. If they are allotted an organ, the state
will pay for the treatment.

Maryland, with about 30 state prisoners on dialysis, follows the federal
model. The state does not allow transplants for inmates, said Maxine
Eldridge, a spokeswoman for the state's Division of Correction. "If they
are in need of an organ, we would consider them for medical parole," she said.

Glen Castlebury, director of public information for the Texas Department of
Criminal Justice, recalled a case several years ago in which an inmate's
family had agreed to pay for a transplant. The prison system agreed to
provide transportation and security, he said.

"But it did not happen," he said. "The organ bank had a reluctance about it
because the offender recipient was . . . an IV drug abuser."

In Florida, with about 50 inmates on dialysis, "a couple of cases" have
been considered for transplants in recent years, said John Burke, deputy
assistant secretary for health services administration at the Department of
Corrections.

But the inmates either did not meet organ networks' criteria or their
health deteriorated before a transplant could be performed, he said.

Massachusetts Department of Corrections spokesman Anthony Carnevale said
decisions about transplants are made on a case-by-case basis.

He said he could provide no information about individual cases, such the
two transplants Saubar said he had at state expense.

Virginia has about 30 inmates on dialysis and was one of the few states
surveyed that routinely refers prisoners for transplant evaluations and
covers the cost of treatment.

"Just the same as on the outside, it is financially and socially better to
have a transplanted patient than a dialysis patient," said M.J. Vernon
Smith, chief physician of the Commonwealth of Virginia Department of
Corrections.

In three transplants since 1995, one kidney came from an inmate's relative
and two others from organ banks, said Smith. Seven more inmates are
awaiting calls from organ networks.

"That's the standard of care on the outside, to which I conform," said
Smith, a urologist who said he personally transplanted kidneys into eight
or nine state prisoners during 25 years of practice at the Medical College
of Virginia.

George Washington University's Bosch said that kidney transplants have
become relatively simple operations in recent years and that prisoners
shouldn't be denied access to a treatment the government provides to other
Americans.

"The idea that by giving it to them, you would restrict the kidneys
available to the honorable citizens of America is not a fair argument,
because many non-honorable citizens are getting kidneys outside" prisons,
he said. "Who is going to make the test of honorability ?"

Checked-by: Richard Lake