The Violent Denial of Healthcare in Modern America

In 2019, a predictable pattern of medical neglect followed the outbreak of a deadly new virus, Covid-19, throughout women’s prisons across the United States. [1] As public health agencies worldwide emphasised the importance of disinfecting surfaces, washing hands, and keeping a social distance to prevent its spread, staff regularly denied women soap and other cleaning products and kept them confined in overcrowded, enclosed spaces. They also failed to ensure women’s continued access to prescribed medication and sanitary hygiene products. The prison system’s systemic denial of women’s health care needs—which put them at increased risk of not only contracting the Covid-19 virus but suffering from a series of other physical and mental health problems—mirrored their response to other health crises, including the outbreak of HIV/AIDS in the 1980s. [2]

By the end of the twentieth century, the health situation in women’s prisons had reached a crisis point. As the goal of women’s imprisonment shifted away from reformation and rehabilitation towards incapacitation in the post-war period, prisons began locking away women often with multiple health complications that arose from lifetimes of trauma and health struggles in new penal institutions that states had primarily designed for men. [3]

The shift in approach to women’s incarceration represented the punitive turn in American politics that followed the social, economic, and political changes of the 1960s and 1970s. Dovetailing with the dismantling of the welfare state and the privatization of healthcare, lawmakers who called for the state to “get tough on crime” framed the debate about social order. [4] This in turn led to the expansion of the types of  offences that warranted arrest and charge, including low-level, non-violent drug use and property offences. Mirroring women’s role in the expansion of punishment throughout US history, in the 1980s and 1990s, the broadening of chargeable offences brought increasing numbers of women who were more likely than men to commit these acts under the purview of the criminal justice system. [5] This shift significantly expanded the US carceral state. [6]

By the 1980s, state and federal governments were committing large amounts of money to building new prisons to accommodate increasing numbers of incarcerated people, with 936 prisons constructed between 1980 and 2004 up from 711 between 1811 and 1979. [7] Governments did not, however, equally commit to ensuring these spaces met women’s specific healthcare needs. Instead, the situation inside prison largely mirrored that of society at large in that women, and women of colour and gender non-conforming people in particular, faced debilitating and sometimes fatal medical neglect based on a series of prevailing racialised and gendered assumptions about health and welfare. These included that women’s health concerns came second to men’s, that women of colour experienced pain differently than white women, that profit was more important than human need, and that women lacked knowledge and authority over their bodies. While these historically rooted perceptions harmed all women, they proved especially dangerous for women living under the purview of a for-profit prison system, who, by virtue of their incarceration, authorities believed had forfeited their right to make claims on the state because they had broken the law. Although ‘violence’ is often interpreted as the use of force to cause harm, the testimonies and campaigning of women in prison in the late twentieth century underscores that gendered state violence takes both the form of physical interference as well as medical neglect. 

Across the country, the testimonies of women incarcerated in California prisons in the late twentieth century told a similar story of violent medical neglect. At the Central California Women’s Facility in Chowchilla (CCWF), a state prison which cost $141 million to build, women only received care when they requested it, demonstrating how the state directly undermined care to cut spending. Dating back to the nineteenth century, the military used the so-called ‘sick call’ system for young men in the army who are healthy and fit, not for women with multiple, reproductive, and often chronic health problems requiring regular care. 

This ‘sick call’ system created an atmosphere ripe for neglect. Women had to visit sick call and persuade a prison guard with minimal medical training, whom the California Department of Corrections and Rehabilitation (CDCR) renamed Medical Technical Assistants (MTAs), that the problem was serious enough to require medical attention. [10]

MTAs often ridiculed women and refused to take their health concerns seriously. To make matters worse, with little or no medical training, they also frequently misdiagnosed women and prescribed the wrong drugs. In 1989, aged 34, Charisse Shumate received a life sentence for defending herself against an abusive partner. Authorities moved her to CCWF, where MTAs frequently denied her the regular treatment needed to treat her sickle cell anaemia. Every month ‘like clockwork’ she went into crisis, forcing staff to rush her to the nearest community medical centre for emergency treatment. [11] In 1994, the California legislature passed a law allowing the CDCR to charge a $5.00 co-pay to request a medical visit through sick call, adding an additional financial barrier to care. [12]

The CDCR promoted the sick call and co-payment systems as ways to reduce medical requests and save money, rhetorically putting finance before human need. The fact that the co-payment system cost more to administer than the income it generated, that training an MTA cost more than hiring a professional nurse, and that the prison could save money by sending seriously ill people home demonstrates that an ideological commitment to destroy women trumped efficiency and humanity in the late twentieth century. Multiple women died in California prisons in the 1990s, including Charisse Shumate. The women did not accept mistreatment but met abuse with powerful activism, launching a major class action lawsuit against the state of California in 1995. [13] 

As philosopher Judith Butler has observed, violence takes many forms. This not only includes the use of physical force but economic and legal structures that play out on bodies. The US government has long justified inflicting different forms of violence on people of colour and all those deemed a threat to the national order, including simply existing in opposition to established sex, race, and gender norms. [14]

The experiences and activism of women in prison underscores that the withholding of medical care is a violent act that became an extension of the gendered carceral regime by the late twentieth century. It is important to note that men have also suffered from medical neglect at the hands of the ramped-up carceral system. Nevertheless, as prisons used health protocols and practices that authorities primarily designed to respond to emergency, rather than chronic and reproductive health problems, they posed a particular threat to women with higher rates of physical and mental health complications. Moreover, using MTAs and other prison staff as the gatekeepers to women’s care continued the historical practice of people in positions of power denying women adequate medical attention. Since the 1980s, coalitions of lawyers, activists, and advocates inside and outside prison have secured some important gains in reducing prison populations and challenging the political use of mass incarceration to solve social problems. This includes women in California prisons who in the 1980s and 1990s mobilised to address the fatal lack of care they were receiving for HIV/AIDS and a host of other chronic and reproductive health complications that were also affecting them. Nonetheless, the inadequate response to Covid-19 highlights that the gender-based violence of the prison system nevertheless persists. Women’s experiences underscored the life and death consequences of medical neglect, and the harmful, and sometimes fatal, consequences of using systems designed to punish to provide care. 

[1] Cary Aspinwall, Keri Blakinger and Joseph Neff, “Why women dying in prisons are the less visible victims of Covid-19,” The Guardian, May 14, 2020, https://www.theguardian.com/us-news/2020/may/14/women-prisons-coronavirus-victims; Daniel Moritz-Rabson, “‘A Living Hell’: Inside US Prisons During the Covid-19 Pandemic,” Al Jazeera, February 26, 2021, https://www.aljazeera.com/features/2021/2/26/a-living-hell-inside-us-prisons-during-the-covid-19-pandemic. 

[2] Vicki Prais, “The Impact of Covid-19 On Women Prisoners,” Human Rights Pulse, June 1 2020, https://www.humanrightspulse.com/mastercontentblog/the-impact-of-covid-19-on-women-prisoners; California Coalition for Women Prisoners (CCWP), “Advocates Demand Action as Largest Women’s Prison Experiences Covid-19 Outbreak,” CCWP Press Release, January 5 2021, http://womenprisoners.org/ccwf-covid-outbreak-demands/. 

[3] Angela Davis, Are Prisons Obsolete? (New York, 2003); Ruth Gilmore, Golden Gulag: Prisons, Surplus, and Opposition in Globalizing California (California, 2007); Emily Thuma, All Our Trials: Prisons, Policing, and the Feminist Fight to End Violence (Oxford, 2019). 

[4] Richard Nixon, “Remarks in New York City: ‘Toward Freedom From Fear,’” 8 May, 1968, https://www.presidency.ucsb.edu/documents/remarks-new-york-city-toward-freedom-from-fear; Ronald Reagan, “Radio Address to the Nation on Crime and Criminal Justice Reform,” September 11, 1982, https://www.reaganlibrary.gov/archives/speech/radio-address-nation-crime-and-criminal-justice-reform. 

[5] Jen Manion, Liberty’s Prisoners: Carceral Culture in Early America (Philadelphia, 2015). 

[6] Elizabeth Swavola, Kristi Riley, and Ram Subramanian, “Overlooked: Women and Jails in an Era of Reform,” Vera Institute of Justice, August 2016, https://www.vera.org/downloads/publications/overlooked-women-and-jails-report-updated.pdf. 

[7] German Lopez, “Watch the number of US prisons skyrocket after 1980,” Vox, July 14, 2014, https://www.vox.com/2014/7/14/5898267/prison-America-mass-incarceration-map-gif. 

[8] Assata Shakur, Assata: An Autobiography (London: Zed Books, 2014), 137. Harriet Washington, Medical Apartheid: The Dark History of the Medical Experimentation on Black Americans from Colonial Times to the Present (New York, 2006). 

[9] Shakur, Assata, 137. 

[10] Nancy Stoller, “Improving Access to Health Care for California’s Women Prisoners,” California Policy Research Center, January 2001, https://www.prisonlegalnews.org/media/publications/improving_health_care_for_ca_women_prisoners_2001.pdf, 36-37. 

[11] Nina Siegal, “Dying Behind Bars: Women in California Prisons are Facing Death Sentences for Lack of Basic Health Care. A Special Investigation by Nina Siegal,” San Francisco Bay Guardian, Feb. 5, 1997, 19. 

[12] California Department of Corrections and Rehabilitation (CDCR), “California Department of Corrections and Rehabilitation eliminates inmate copayments for health care services,” CDCR News Release, February 21 2019, https://www.cdcr.ca.gov/news/2019/02/21/california-department-of-corrections-and-rehabilitation-eliminates-inmate-copayments-for-health-care-services/. 

[13] Case: Shumate v. Wilson, https://clearinghouse.net/case/582/; CCWP, “Women Sue for Healthcare,” The Fire Inside Issue 01 (Summer 1996), https://www.womenprisoners.org/fire/000816.html. 

[14] Judith Butler, The Force of Nonviolence: An Ethico-Political Bind (London: Brooklyn, 2020). 

Emma Day is a Research Fellow in American History at the Rothermere American Institute, University of Oxford. Specialising in the histories of gender, sexuality, race, and health activism in the twentieth century United States, she completed her PhD in History at Oxford in 2020 and her first book, In Her Hands: Women’s Fight Against AIDS in the United States is forthcoming from the University of California Press in August 2023. Her work has also appeared in Modern American History, Theatre Annual: A Journal of Theatre and Performance of the Americas, Working Papers in Critical Disaster Studies: Historical Approaches to Covid-19, and the Washington Post.

Her book is available to pre-order here.

For more on her research on women’s HIV/AIDS prison activism, see: Day, E. (2022). 'The Fire Inside: Women Protesting AIDS in Prison since 1980,' Modern American History, 5(1), 79-100. doi:10.1017/mah.2022.3