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Acoca (1998) has noted the challenge of attracting medical professionals to work in correctional facilities, where the pay may be lower and the location of the facility may be undesirable — many prisons are located in rural areas where it is often difficult to attract professionals. In addition to the challenges of working in correctional facilities, medical professionals may find other aspects of the job undesirable. In Ammar and Erez’s (2000) study, nurses working in Ohio’s women’s prisons, faced the prospect of forced or mandatory overtime in the event that another nurse was unable to relieve them, sometimes requiring the duty nurse to cancel personal plans.

Furthermore, there appears to be a considerable stigma for individuals providing health care within correctional facilities. Dabney and Vaughn (2000, pp. 153-154) report that physicians who work in correctional health care are perceived by their peers as “inept,” and all medical professionals in this area are generally regarded as “less qualified.” On occasion, these negative perceptions of the qualifications and ability of the professionals employed by correctional facilities are accurate (Acoca, 1998; Dabney & Vaughn, 2000). Combined, these factors make the prospect of working as a medical care provider within a correctional facility for women highly undesirable.

Another challenge for medical care providers — one that is apparently experienced by many physicians — is the co-occurrence of health problems with mental health and/or substance abuse issues. According to Reed and Mowbray’s (1999, p. 74) study of non-correctional medical care, women with these combined mental health and substance abuse issues sometimes receive incomplete care from general practitioners “because they tend to ignore physical health problems once an individual has this label.” Additionally, substance abuse can mask symptoms and its related problems can occasionally be difficult to distinguish from neurological problems. This confusion may occur in correctional health care as well and impede care for inmates, a number of whom enter prison with mental health difficulties and substance abuse problems, as discussed above. A woman in Young’s (2000) study reported that her medical care provider dismissed her request for further examination by stating she felt the patient’s problem was imaginary. Reed and Mowbray (1999) also report a problem with negative gender stereotypes among some health care providers such as perceptions linking women with hypochondriasis or a failure of these practitioners to understand differences in the way women’s health could be affected by substance abuse. Similar perceptions may be held by correctional medical providers.

Provision of Care to Women Inmates
This section presents data that reflect the care and treatment that women report receiving in correctional facilities and the care and treatment that corrections officials report that their facilities provide.

In the end, the influence of the correctional facility on the overall health of an inmate is unclear. In their survey of free-world care versus that provided in prisons, Marquart et al. (1996, p. 345) tentatively suggest that “most inmates experience no change in their health status during incarceration.” The care they receive within a facility is better than they would have otherwise received, but the potential of this care to remedy their health problems is negated by the depth of their existing problems prior to admission. Vaughn and Smith (1999), however, dispute this view arguing that it disregards the effect of penal harm medicine on an inmate’s health. (Marquart and other colleagues (1997) do account for prison conditions in their evaluations.) Maeve (1999, p. 66), likewise, with regard to inmates, argues that inmates become “less healthy” in prison (see Murphy, 2003, for a discussion of rationed health care within the Bureau of Prisons). However, because Marquart et al. (1996) did not consider the health care of women inmates specifically, their findings may not be generalizable regarding this particular inmate population.

Health Care Received by Women Inmates
This section addresses the health care received by inmates. First, we examine challenges that exist to providing care to these women; this is followed by a discussion of what women and corrections officials report with regard to the health care that has been provided.

Challenges to Providing Medical Care to Women Inmates
The fact that women constitute a small portion of the correctional population has been used to justify a lack of adequate programming and treatment for them (Belknap, 2001). This is especially true with regard to their health care. Overall, scholars report that effective health care for inmates is insufficient, particularly in preventive care (Belknap, 1997). Ross and Lawrence (1998, p. 126) attribute the inability to provide sufficient health care to inmates to a “systematic denial to women of parity of services readily and regularly available to incarcerated men.”

The workload of medical care providers in correctional facilities is considerable. Maeve (1999, p. 51) notes that “health care for women in prison is largely an effort to ‘catch up’ in that considerable effort is most often necessary to raise women’s health status to legally mandated, acceptable levels.” Given the extent of problems many of these women have, catching up constitutes a massive undertaking. In addition to providing health care to a “very needy” population, the isolation and security concerns within prisons and jails makes inmates entirely dependent on care providers, which is especially cumbersome with inmates suffering from chronic conditions. For example, care providers must devote time simply to distributing medications to affected inmates, who would not require this outside the institutionalization context (Marquart et al., 1997), or providing other routine treatment. Care providers may also need to evaluate the well-being of inmates who are not ill, such as those confined to segregation or placed in restraints (Ammar & Erez, 2000).

Aggravating the workload for medical care providers in correctional facilities is the insufficiency of staffing and provision of resources for women’s correctional health care. Women inmates in state and federal prisons reported having medical problems after being admitted in higher percentages than men — 23 percent of women in state prisons compared to 16 percent of men and 25 percent of women in federal prison compared to 15 percent of men (Maruschak & Beck, 2001). Because the health care provided in women’s prisons and jails is often based on what is needed and provided in men’s correctional facilities (Ross & Lawrence, 1998), the estimate of staffing levels on the part of correctional officials can be inaccurate. A nurse reported this problem within Ohio’s women’s facilities, commenting that, “Staffing of the women prisons follows the male mode: 300 men to three nurses. But women in prison go to doctors two and a half times the rate of men. Women have problems that men do not have….” (Ammar & Erez, 2000, p. 20). A similar problem has been reported in California’s women’s correctional system, where resource needs are determined “using a healthy, young male as its model prisoner” (Hill, 2002, p. 232). The resulting lack of adequate staffing resources often translates into delayed care for the women who have difficulty being seen by a medical doctor, such as those studied by Belknap (1997) and Dobash, Dobash, and Gutteridge (1986). Problems of higher rates of utilization of health services by female inmates as well as difficulty in seeing doctors have been reported in Lindquist & Lindquist’s (1999) study of men and women’s use of health services in jails.

Individuals from several disciplines — law (Friedman, 2004; Nordberg, 2002; Stratton, 2004), medicine and social science (Berkman, 1995; Munetz & Teller, 2004; Ross & Lawrence, 1998), and journalism (Bernstein, 1999; Butterfield, 1992) — have discussed the role of prisons and jails as social safety nets, especially with regard to the mentally ill and homeless. Some observers relate this aspect of corrections to an increased willingness to spend tax dollars on incarcerating people, rather than providing them with adequate social services that might prevent their incarceration (Butterfield, 1992). Friedman (2004), for example, contrasts the social safety nets of other Western democracies, especially in their provision of health care, with the United States’ preference for criminal justice solutions to long-standing social problems such as concentrated poverty or addictions. According to one physician, “It is fatuous for politicians or social planners to deny the relationship between rising unemployment, deepening poverty, and the parallel growth in the prison population” (Berkman, 1995, p. 1617).

In correctional facilities, people in need of limited social services can receive shelter, food, and medical care that would either not be available to them or that is available only in very poor quality (Butterfield, 1992). Some social services — such as subsidized housing, treatment, and mental health treatment — have long waitlists that also put them out of immediate reach (Nordberg, 2002). Mentally ill individuals appear to have difficulty accessing certain resources in their communities, even where referrals and guidance have been provided prior to release (Bernstein, 1999). Marquart et al.’s (1997) notion that jails are sometimes the sole resource for a dealing with a community’s mentally ill is confirmed by a state supreme court justice, who has described correctional facilities as the “de facto mental health system of our day” (Stratton, 2004).

These views of correctional facilities as safety nets, however, largely disregard the particular circumstances of inmates. Essentially, it is a view of prisons and jails that works for men in a way that it cannot for women. Information about the socio-economic difficulties of inmates discussed above clearly demonstrates their need for social services. Incarceration can also provide relief to these women from poverty and violence (Bradley & Davino, 2002), yet with regard to health care, what is available to inmates is very limited, as discussed below. Furthermore, jails and prisons functioning as safety nets provides little for these women in their roles as mothers and nothing for the children they leave behind while incarcerated. In short, correctional facilities may be literally safer for women facing lives of violence, as has been claimed by some observers (Acoca, 1998; Bradley & Davino, 2002). But to claim that they provide social safety nets for women to the same degree as they might for men is inaccurate. This is especially true with regard to health care, when “some correctional systems… justify their often inadequate women’s health care services by comparing them to the nonexistent care the women were receiving on the street” (Acoca, 1998. p. 61).

Sometimes the harm that results from medical care is at the hands of the medical care providers themselves. However, placing excessive blame on this group is inappropriate and misleading. Penal harm medicine also occurs at the hands of correctional officers when they undertake tasks intended for medical professionals (Vaughn & Collins, 2004). Penal harm may also be the result of correctional facility policies (for example, those addressing security concerns), such as when officials override the suggestions and needs of medical personnel (Ammar & Erez, 2000). Penal harm medicine may be a consequence of a correctional system’s decision to provide treatment in a managed care model, in which cost-savings measures may compromise inmate care (Robbins, 1999). Ross and Lawrence (1998, p. 128) argue that poor quality health care for these women is not the fault of staff, but rather “a manifestation of pervasive and insidious attitudes, behaviors and beliefs which influence government policy.” Thus, not all penal harm medicine can be attributed to medical care providers themselves.

How widespread the practice of penal harm medicine may be is not clear. Maeve and Vaughn (2001, p. 58) report that “penal harm medicine and nursing have become so routinized, mundane, and banal that they pass for standard operating procedure.” However, their research has often focused on single facilities (Maeve, 1999; Vaughn & Smith, 1999) or judicial decisions (e.g., Dabney & Vaughn, 2000; Vaughn & Collins, 2004) which, by their adversarial nature, cannot reflect the full range of medical care provided in correctional facilities. On one hand, studies relying on judicial decisions obviously would not reflect provision of good medical care. On the other, they may underrepresent instances of poor medical care, owing to a number of factors including the limits federal legislation has placed on inmate lawsuits (Schlanger, 2003) or the fact that inmates may be less likely to bring lawsuits challenging the conditions of their incarceration (Aylward & Thomas, 1984).

Other sources indicate that penal harm medicine is not typical of all institutions. Ammar and Erez (2000) describe medical care providers who are very concerned about the women they care for in the Ohio prison system. Prison nursery programs that address the needs of pregnant and post-partum women are examples of thoughtful care within the correctional context (Fearn & Parker, 2004). In Todaro v. Ward (1977, pp. 1159-1160), the first case to address the health care of inmates specifically, the presiding judge, even while finding deliberate indifference, nevertheless complimented the Bedford Hills prison medical staff for their “concern…with the well-being of the inmates they served.”

Subsequent Supreme Court decisions have refined what must be demonstrated to establish that correctional officials have been deliberately indifferent to an inmate’s health care needs. Chief among them is Farmer v. Brennan (1994, p. 837); here, the Court stated that a plaintiff must show that an official “knows of and disregards an excessive risk to inmate health or safety.” This requires a showing of a corrections official’s “state of mind” (Robbins, 1999, p. 221).

Theoretical Views of the Role of Correctional Facilities
Correctional facilities have been described as the “social safety net of last resort” (Ross & Lawrence, 1998, p. 128) and also as institutions that implement penal harm. These seemingly contradictory descriptions can be seen as complementary, however, when corrections is understood both as a means of managing “disruptive and unsightly members of the underclass” and as “an emergency service net for those who are in the most desperate straits” (Feeley & Simon, 1992, p. 468). Familiarity with both concepts is critical to an understanding of the health care expected by and delivered to women in correctional facilities.

Correctional Facilities as Devices of Penal Harm and Penal Harm Medicine
An emerging trend in corrections is that of “new penology,” which focuses on “techniques to identify, classify, and manage” offenders rather than explain their behavior or address their rehabilitation (Feeley & Simon, 1992, p. 452). It is described as being more concerned with actuarial aspects of penology and how to manage efficiently the probabilities that different risks present. Marquart et al. (1999) have suggested that health risk be considered amid other criteria used for evaluating offender risk — some groups may present more of a health risk than a criminal risk and that this consideration will affect their management within the criminal justice system. Another concept emerging from discussions of the new penology is that of penal harm, in which punishment is a tool for harming offenders — harm justified because it is offenders being affected and harm that is easier to justify in the atmosphere of “depersonalized efficiency” which critics attribute to the new penology’s emphasis on management and probability (Cullen, 1995, p. 339). Penal harm concepts have come to affect the health care provided in some correctional facilities, such as when medical care is withheld or delayed or used to humiliate inmates (Vaughn & Smith, 1999). According to Vaughn and Smith (1999, p. 217), it is the “collective demonization” of the inmates that permits medical care providers to violate their ethical obligations. Vaughn (1999) has also argued that the treatment capabilities of medical care professionals in some correctional systems have been excessively confused with custodial concerns, as when the Federal Bureau of Prisons provides basic correctional training to its medical staff without any distinction between their role and that of other correctional officers. Medical care as a device of harm within correctional facilities is not new (Butler, 1997). Estelle v. Gamble ameliorated the situation in 1976 by mandating a minimum level of medical care below which facilities could not fall. However, medicine remains a tool for deliberate harm in some facilities. Schlanger (2003) for instance, reported that issues of medical care are the number one cause of litigation in jails or prisons.

The range of self-reported health problems for many inmates is considerable. Treatment for these issues operates against a background of legal and penal concerns, which are discussed in the following section.

Roughly 40 percent of the inmates surveyed while incarcerated were first-time offenders while almost 60 percent were recidivists. More than one-third of these women reported being previously incarcerated. Many of these women were reluctant (or refused) to speak about their offenses; however, approximately one-third of women reported that they were under the influence (of drugs and/or alcohol) at the time of their offense. One-quarter of women reported drinking alcohol at the time of the offense while one-quarter reported committing the offense in order to get money for drugs. Almost one-third of the women reported that their offense was a drug-related offense, 16 percent stated that they had committed a violent offense, and 18 percent reported having engaged in a property-related offense. Finally, more than 80 percent of these inmates stated that they had pled guilty to the offense for which they were currently serving time. These women illustrate a series of life course characteristics which makes them much more susceptible to poor health—including unmet medical needs, drug/alcohol use, and mental health issues — that have the potential to be treated, or exacerbated, by incarceration.
The range of self-reported health problems for many inmates is considerable. Treatment for these issues operates against a background of legal and penal concerns, which are discussed in the following section.

Underlying Concerns Regarding Women’s Health Care in Prison Legally Required Standard for Medical Care in Correctional Facilities

The United State Supreme Court’s decision in Estelle v. Gamble (1976) is central to evaluating legal requirements for the medical treatment of incarcerated individuals. Because the decision turns on considerations of the 8th Amendment’s prohibition of cruel and unusual punishments, Estelle and its progeny directly affect those who have been convicted of crimes. It indirectly affects those awaiting trial, who although incapable of being punished, may still be subjected to certain deprivations so long as they do not rise to the level of punishment. Precisely what this class of inmates is entitled to is unclear, but must at least satisfy what is required by the 8th Amendment (see Parker forthcoming).
According to the Court, the government has an obligation to provide medical care to inmates and accordingly, Estelle (1976, p. 104) holds that “deliberate indifference” on the part of correctional officials with regard to an inmate’s “serious medical needs” is impermissible. Indifference could manifest itself in denying or delaying care or the interference with treatment. However, the Court was clear in limiting what might be considered deliberate indifference, specifically excluding negligence and medical malpractice.

Roughly 40 percent of the inmates surveyed while incarcerated were first-time offenders while almost 60 percent were recidivists. More than one-third of these women reported being previously incarcerated. Many of these women were reluctant (or refused) to speak about their offenses; however, approximately one-third of women reported that they were under the influence (of drugs and/or alcohol) at the time of their offense. One-quarter of women reported drinking alcohol at the time of the offense while one-quarter reported committing the offense in order to get money for drugs. Almost one-third of the women reported that their offense was a drug-related offense, 16 percent stated that they had committed a violent offense, and 18 percent reported having engaged in a property-related offense. Finally, more than 80 percent of these inmates stated that they had pled guilty to the offense for which they were currently serving time. These women illustrate a series of life course characteristics which makes them much more susceptible to poor health—including unmet medical needs, drug/alcohol use, and mental health issues—that have the potential to be treated, or exacerbated, by incarceration.

The range of self-reported health problems for many inmates is considerable. Treatment for these issues operates against a background of legal and penal concerns, which are discussed in the following section.

Roughly 40 percent of the inmates surveyed while incarcerated were first-time offenders while almost 60 percent were recidivists. More than one-third of these women reported being previously incarcerated. Many of these women were reluctant (or refused) to speak about their offenses; however, approximately one-third of women reported that they were under the influence (of drugs and/or alcohol) at the time of their offense. One-quarter of women reported drinking alcohol at the time of the offense while one-quarter reported committing the offense in order to get money for drugs. Almost one-third of the women reported that their offense was a drug-related offense, 16 percent stated that they had committed a violent offense, and 18 percent reported having engaged in a property-related offense. Finally, more than 80 percent of these inmates stated that they had pled guilty to the offense for which they were currently serving time. These women illustrate a series of life course characteristics which makes them much more susceptible to poor health—including unmet medical needs, drug/alcohol use, and mental health issues — that have the potential to be treated, or exacerbated, by incarceration.

Women intravenous (IV) drug users are also more likely to engage in risky sexual behaviors — such as having multiple partners, unprotected intercourse, and exchanging sex for money or drugs — which put them at increased risk for STDs/HIV and gynecological problems that include pelvic inflammatory disease and cervical cancer (Shearer, 2003). A study of women in a Texas correctional facility illustrates this point: 40 percent of women in the study self-reported having had an STD and 47 percent reported engaging in HIV risk behaviors (Marquart, Brewer, Mullings, and Crouch, 1999). Other health problems experienced by women with substance abuse issues include hepatitis, cirrhosis, higher risk for bone fracture, and anemia (Reed & Mowbray, 1999). Certain STDs—such as genital herpes and syphilis—make individuals more vulnerable to HIV infection (Marquart et al., 1999). HIV and tuberculosis are significant problems as well. Among state prisoners, three percent of inmates were HIV positive in 2002 (compared to 1.9 percent of male inmates) (Maruschak, 2004). In some states, however, this percentage was considerably higher, chiefly in New York (13.6 percent) and Maryland (12.1 percent). Wilcock, Hammett, Widom, and Epstein (1996) report that as many as 27 percent of female inmates in 1994 through 1995 had positive tuberculosis skin tests at intake (the mean was 6.7 percent). Although some of the correctional facilities they surveyed provided the number of male inmates who were both HIV positive and had positive TB skin tests, these facilities were largely unable to report this information for female inmates. However, AIDS mortality rates have decreased over time (see Maruschak, 2004).

These inmates were between 15 and 75 years of age, pretty equally divided among blacks and whites, and roughly 17 percent reported Hispanic heritage. Additionally, approximately one-third reported having either a high-school diploma or GED while a little more than half reported being employed prior to their prison admission. More than one-third of these women also reported receiving public assistance or welfare prior to admission while 12 percent reported being homeless, living on the streets, or living in a shelter. Although 43 percent reported never having been married, 20 percent were married and the remaining 37 percent were separated, divorced, or widowed. Additionally, almost 80 percent of the inmates reported having children. Approximately one-quarter of the inmates reported a history of physical and sexual abuse while 42 percent reported only physical abuse and more than one-third reported being sexually abused.

The health difficulties of inmates have long been a daunting challenge. Nineteenth-century inmates in the prisons of the American West, for example, often entered these facilities with chronic health problems and bodies scarred by evidence of rough lives (Butler, 1997). Some had substance abuse problems and/or sexually transmitted diseases (STDs) that were often in advanced stages. Tuberculosis (TB) was also a considerable problem among prisoners confined in dank, unhygienic conditions and weakened by inadequate diets. Existing physical and emotional problems were aggravated by being incarcerated in prisons unsuited for women.

With the exception of the Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), many of the health challenges faced by contemporary women — before and during their incarceration — are similar to those of their 19th century predecessors. According to Belknap (2001), incarcerated women have more challenging health issues than other women, due most likely to their increased exposure to poverty, insufficient nutrition, as well as substance abuse histories and a lack of knowledge about health generally. Another significant factor is that few inmates had access to health care prior to their incarceration (Kane & DiBartolo, 2002). This can be attributed to not being insured or coming from “medically underserved areas” (Marquart, Merianos, Cuvelier & Carroll, 1996, p. 334). This translates into their having had little or no preventive care, and for those who are ill, having received care later in the course of an illness (if care had been received at all). As a result, many women bring untreated health problems with them to correctional facilities, including STDs, high blood pressure, asthma, and diabetes (Maeve, 1999).

Women also bring unique health issues to correctional health care, such as a need for gynecological and obstetrical services. In 1998, for example, five percent of women admitted to state prisons and six percent of women admitted to jails were pregnant at that time (Greenfeld & Snell, 1999). Many of these pregnancies may be high risk if the mother has a history of substance abuse and/or sexually transmitted diseases (Hufft, Fawkes, & Lawson, 1993). The latest estimates indicate that approximately three-quarters of women in prisons are mothers (Center for Children of Incarcerated Parents, 2001; Snell & Morton, 1994).

Abuse histories present another gender-specific health challenge. Far more women than men inmates report having been physically or sexually abused at some time in their lives — 55.3 percent of women in jails (compared to 13.4 percent of men — see James, 2004) and 57 percent of women in state prisons (compared to 16 percent of men) (Harlow, 1999). Some women may have permanent injuries as a result of their abuse (Richie, 1996). Abuse is a factor that may also contribute to mental health and substance abuse difficulties, both factors themselves linked to having negative effects on women’s overall health (Reed & Mowbray, 1999). Among state prison inmates in 1998, for example, 24 percent of women were identified as mentally ill, and a large percentage of these women — 78 percent—had been abused at some time before their admission (Ditton, 1999). Because a number of incarcerated women are African-American — approximately 37 percent of women in jails or prisons at midyear 2004 (Harrison & Beck, 2005) — they can bring health issues to correctional facilities which either occur more frequently or exclusively among this population, such as diabetes, hypertension, and sickle-cell anemia (Acoca, 1998).

Some of the women’s poor health conditions are related to their life circumstances prior to being incarcerated. Inmates, both women and men, were more likely to have medical problems if they had been homeless or unemployed prior to their arrest (Maruschak & Beck, 2001). In a study of incarcerated parents, 18 percent of mothers reported having been homeless in the year before admission to state prisons (compared to eight percent of fathers) and 50 percent of mothers in state prisons were unemployed in the month before their arrest (compared to 27 percent of fathers) (Mumola, 2000).
Problems with drug and alcohol use are notable among inmates. Fifty-four percent of women in state prisons surveyed in 1991 had used drugs in the month prior their arrests (Snell & Morton, 1994). Among these women, 65 percent reported regular drug use and 41 percent reported using drugs daily. Nearly 54 percent of women in state prisons in 1998 reported having been under the influence of drugs and/or alcohol at the time of their offense (Greenfeld & Snell, 1999). Table 1 below provides specifics about the substances that inmates reported having used in the 1997 Survey of Inmates. Unsurprisingly, drug and alcohol abuse are harmful to women’s overall health (Reed & Mowbray, 1999), and some practices are more so than others. Among inmates those who had used needles to inject drugs or were alcohol dependent, health problems were more common (Maruschak & Beck, 2001). One-third of inmates studied by Snell and Morton (1994) had used injected illegal drugs, and an estimated 18 percent had shared needles. These women drank less frequently than their male counterparts. However, as Reed and Mowbray (1999) note, because women metabolize alcohol differently than men, they can develop more serious health problems despite less consumption.

Rapidly increasing numbers of women incarcerated in the United States have created an overwhelming need for appropriate health services for these inmates despite limited resources. This article outlines the key health care issues associated with women inmates. We begin by examining the challenges posed by this population of inmates. Additionally, we investigate the provision of health care to these women and then evaluate the perceptions of that care from the perspective of the women and their care providers. We conclude with a discussion of policy-relevant considerations and suggest that realism should be the underlying premise of any health-related policy for women inmates. Specifically, we suggest that education and the treatment of communicable diseases become the most targeted health-related goals for women inmates, as it is inevitable that most of these women will eventually be released.

Introduction
The number of women inmates in the United States has grown dramatically in recent years (Unless otherwise specified, all references to inmates are to women inmates). Of the almost 1.4 million inmates incarcerated in state and federal prisons at midyear 2004, 103,310 were women (Harrison & Beck, 2005). This represents roughly a three percent increase in their numbers since mid-year 2003 (Harrison & Beck, 2005). In 2004 some 1,213,300 women were under supervision of criminal justice authorities (Glaze & Palla, 2004; Harrison & Beck, 2005). Most of these women — approximately 85 percent—were being supervised as probationers or parolees, while the others were incarcerated in prisons or jails. Provision of health care for this population has been insufficient according to scholars (Belknap, 1997; Ross & Lawrence, 1998). In this article, we first examine the challenges this population presents to correctional administrators. This is followed by a discussion of the perceptions these women and their care providers—both medical and custodial—have regarding the health care delivered in prisons. The article concludes with a discussion of related policy issues. We argue that the provision of care for inmates must be realistic in what it can accomplish and that given the limited means available for their care, education and treatment of communicable diseases should be the priorities in addressing their needs.

Health Needs of Women Inmates: Health Problems of Incarcerated Women
Marquart, Merianos, Hebert, and Carroll (1997, p. 186) suggest that the medical problems of incarcerated people be seen within the combined context of an inmate’s life prior to and during incarceration, which they call a “life course perspective.” Many of the health problems inmates experience in prison are often the result of factors — such as socio-economic status and lifestyle — that affect their wellbeing before incarceration. In writing about inmates, Ross and Lawrence (1998, p. 128) note, “Their health problems and needs do not arise in prison; rather, the women bring their health care problems to prison.”

The main goal of our paper was to empirically determine what factors were significantly responsible for increasing or reducing the likelihood and quantity of HIV testing performed in outpatient, community clinics. Since outpatient clinics are a primary access point for health care not only in California, but also in communities across the US, an understanding of these factors is an essential tool for constructing policies that are effective in controlling the US HIV/AIDS epidemic.

Our findings indicate several factors that may be useful at increasing HIV testing. First, our results show that HIV testing is responsive to the change in the AIDS population, but not the HIV-infected population. That is, people appear to want testing only when they see an increase in the number of people living with AIDS (which increases the potential for infection, and thus the need for testing) and a reduction in the number of AIDS deaths (which has a similar impact). As a result, policies promoting HIV testing may want to focus on these epidemiological factors, as opposed to HIV prevalence statistics.

Second, certain types of medical staff are positively associated with a higher amount and likelihood of HIV testing. Nurse practitioners, and to a lesser extent, physicians and physician’s assistants, are most effective at increasing HIV testing. This implies that HIV prevention and awareness policies should include these types of staff as an integral part of any such policy implemented at the level of the outpatient clinic.

Third, demographics play a crucial role in the demand for HIV testing. While this finding is not new, what we do find to extend this literature is that clinics play a unique role in HIV prevention by being able to target policies at specific sub-components of a population, most notably poor women and minorities. What makes this finding especially useful for policy makers is that these groups are extremely high-risk components of the population, and thus most in need of effective policy intervention.

Lastly, we do find evidence that outside sources of funding may be effective at increasing HIV testing in outpatient clinics. However, our results here are quite mixed. Some sources of funds increase the likelihood that a clinic offers HIV testing, but do not significantly impact the amount of HIV testing. Other sources of funds are only marginally significant determinants of funding, depending on how one estimates the demand for HIV testing. Thus, simply “throwing money at the problem” may not be an effective means of combating the epidemic.

While our results present some intriguing findings, they should also be viewed with caution. Our study only looks at California outpatient clinics in a single year. Future studies analyzing health care providers who have different operating characteristics, operate at different points in time, serve different socio-economic segments of the population, and who face different epidemiological conditions may find disparate results. We view this study as an initial step to spark discussion and future research about the effectiveness of these health care providers as a focal point in combating the spread of the HIV/AIDS epidemic.