When Incarceration Kills

US prisons are horrific — so horrific, in fact, that a former top physician at Rikers Island insists in a new book that we treat incarceration itself as a cause of harm to the imprisoned.

A man enters the road to Rikers Island on March 31, 2017 in New York City. Spencer Platt / Getty Images

“Incarceration harms health,” Homer Venters declares at the outset of Life and Death in Rikers Island. Venters worked for almost a decade administering health care in the New York City jail system — the bulk of which is clustered on Rikers Island — including as chief medical officer and assistant commissioner of Correctional Health Services for the New York City Department of Health (DOH). In Life and Death, Venters draws from his experience in the highest echelons of the DOH, numerous clinical studies on Rikers Island, and a background in public health that includes examining asylum seekers for evidence of torture. His conclusion: incarceration itself must be treated as a cause of harm to incarcerated people.

Life and Death is at once measured and scathing, a fitting combination for a staid medical professional navigating a brutally authoritarian environment. Venters casts himself as neither a whistle-blower nor a score-settler, focusing instead on interpreting the information available in the public domain through the lens of his professional experience and ethical perspective.

Much of the book will be nothing new to those who follow highly publicized Rikers scandals like the deaths of Christopher Robinson, Bradley Ballard, and Kalief Browder; the growing chorus of state-sponsored and private investigations into abuses on the island; and employee memoirs like former Rikers social worker Mary Buser’s Lockdown on Rikers. The novelty of Venters’s account is not so much the stories he tells as the framework he brings to understanding them. The result is a damning indictment of the Rikers Island penal colony — and the conditions of jails across the country.

The Complicity of Medical Professionals

Venters introduces a variety of categories to help us understand the horrors of the US prison system.

The first is “jail-attributable deaths”: jail itself, Venters argues, can be treated — and measured — as a cause of death. Jail-attributable deaths include fatalities from violence, suicide, substance withdrawal, and overdoses upon release (a silent epidemic, Venters says). Criticizing the incomplete and often nonexistent data measuring harm inflicted upon incarcerated people, Venters argues for a systematic quantification of jail-attributable deaths, which he expects would shed light on particularly egregious facilities like those on Rikers.

Next is “nosocomial rape” — a medically derived term (a nosocomial infection originates from the hospital setting and is therefore attributable to hospitalization) that Venters uses to describe sexual assaults that would not have occurred if a detainee were not in jail. Tellingly, the cases Venters spotlights are not between detainees, but between guards and detainees, with the former taking advantage of their unchecked power to terrorize their prey — and their families — on both sides of the bars.

Finally, there is Venters’s notion of “dual loyalty”: the often contradictory allegiances medical professionals hold between their patients and the security dictates of the jail environment. Venters writes that medical professionals have become complicit in both human rights abuses and their erasure from the record. They struggle to provide the level of care their profession demands as detainees are denied medical appointments and medicine, held in torturous conditions like solitary confinement, and subjected to a brutal regime of discipline.

The complicity of medical staff in the violation of detainees’ rights is multifaceted. In his own investigation into prisoner injuries at the hands of guards, Venters found more than half had been threatened by guards and told to lie about the origins of their injuries — 80 percent of which were sustained, at least in part, after the prisoner was restrained. Venters re-creates scenes, familiar to readers of Buser’s Lockdown on Rikers, of guards brutalizing prisoners in full view of medical staff and then intimidating the clinicians into keeping quiet. Even as a high-ranking city official, Venters recalls being threatened at times, once by a group of guards in the notoriously violent solitary confinement building who told him point blank: “That ID badge won’t help you here.”

A thornier form of dual loyalty comes less from external threats than from medical providers’ internalization of the “security” perspective pushed by the guards. In a review of hundreds of medical staff’s notes written on detainees, Venters finds 12.2 percent were “not in the patient’s interest,” meaning they were not simply detrimental to the patient but rather something no medical professional should do ethically. Most commonly, this meant leaving medical observation to parrot the contention, hurled by guards at pretty much any detainee requiring medical assistance, that the prisoner was lying in order to improve their situation in the jail.

Venters also draws on his experiences to cast doubt on the validity of a popular category used by medical providers in jails: “excited delirium.” According to Venters, this is a pseudoscientific diagnosis that can cover just about any behavior that occasions violent treatment by guards. Often, it exculpates death.

Similarly, the widespread practice of mental health professionals approving prisoners for solitary confinement on the grounds they are fit to withstand the punishment is not only baseless in its medical pretense, it also “violates basic ethics principles, because, of course, that patient is supposed to suffer.” Venters furnishes his own data that shows black detainees are twice as likely to land in solitary confinement at Rikers as white prisoners, who make up roughly 10 percent of the island’s population.

The blame for the wrongs wrought by dual loyalty by no means falls on individual guards, nor on individual care providers. Venters describes how medical professionals are pushed from the heights of the jail hierarchy — and the very structure of the reporting process — to downplay the severity of prisoner injuries, which are classified by a rubric of A, B, C, or D. “A” injuries require notifying outside investigative bodies like the Department of Investigation, and the jail bureaucracy, Venters claims, does everything in its power to avoid those classifications: “Leadership in these jails place tremendous pressure on managers to keep these numbers down and limit external inquiries.”

It’s Not a Bug, It’s a Feature

Homer Venters has written a brave and potent book that puts a fine point on what we already know about the Rikers Island penal colony. It provides fresh analytic tools for understanding the jail’s unconscionable impact on the people confined there. But a central fault line running through Life and Death in Rikers Island makes the work simultaneously incoherent and all the more illustrative of the present historical moment.

On one hand, Venters insists that jails like Rikers “fail at basic management,” creating conditions where prisoners can be denied basic due process and controlled violently. On the other, Venters argues jails are “designed and operated to keep the truth hidden,” and thus defy opacity and accountable management. “As paramilitary operations,” Venters observes, “jails and prisons are designed to thwart transparency and undercut any priorities that come into conflict with ‘security,’” including the need for any rational management of prisoner health care, to say nothing of an honest documentation of the systems’ failure to provide it.

The contradiction recurs time and again. “The lack of connection between the rules and reality,” Venters writes of the “mismanagement” of Rikers, “leads naturally to the security authority selectively enforcing their rules.” But is this “mismanagement,” or simply how US jails and prisons are managed? “Striking someone after they’ve been restrained,” Venters argues, “represents the ultimate breakdown of correctional professionalism and indicates an absent or incompetent jail management.” But if violence is the rule of order structuring life in Rikers and nearly every other US jail facility — as Venters repeatedly claims — is such violence not the quintessence of “correctional professionalism”?

Likewise, Venters bemoans “a deeply ingrained ethos that relies on violence and intimidation to conduct the business of the jails.” While the specific nature of this business remains undefined throughout Life and Death, Venters never entertains the notion that violence and intimidation just might be all there is. The failure to consider these questions robs the book not only of internal coherence but, more important, of a political dimension that could seriously account for the experiences and phenomena Venters so deftly describes.

Life and Death does contain the seeds of a political analysis. Venters correctly notes the political power of the Correction Officers’ Benevolent Association (COBA), typified by the 1990 bridge blockade and brutal staff riot for which no guards were punished, as a key factor in the power imbalance between guards and civilian staff. Citing one COBA leader’s warning to a colleague in a different department — “Keep backing up health and we’ll go back to 1990” — Venters concludes dejectedly: “This threat . . . is the basic one that COBA and every jail staff can make, for which there isn’t much of an answer.” Similarly, he claims the task of systematic heath-care provision falls short “because these systems are subordinate to the interests of security forces and their political supporters.” This line of inquiry points to broader questions about the balance of power in New York City, namely the question of how police and jail guards got so politically powerful. If the query interests Venters, he is not willing to follow it here.

It is a merit of Life and Death that Venters considers abuse in jails “not just the actions of a few bad apples.” But as he rails against the “failure of institutions,” another question appears: failure to do what? Answering this would require engaging seriously with the history of mass incarceration in New York City and beyond, including the role of jails and prisons in aiding assaults on poor and working-class people. It would require engaging with the political-economic base of COBA’s power — that threat “for which there isn’t much of an answer” — with an eye toward undermining their political heft. It would mean staking out a clear argument about what jails and prisons are supposed to do and explaining why their current functioning is so aberrant from this putative purpose — if such divergence can be argued to exist.

In assuming a benevolent role for policing and jails from which present practices have simply departed, Venters thinks exhaustively through the symptoms of a problem without considering its root. Small wonder his proposed solution hinges on the erection of still more jails in New York City to replace Rikers Island, just as the facilities on Rikers replaced the hated facilities that came before.

The central contradiction running through the book — between notions of violent and unaccountable jails functioning poorly, rather than running by design — is symptomatic of a deepening crisis of legitimacy surrounding policing and mass incarceration in the United States, in which reform-minded people are being driven to ever more radical conclusions about the structural relationship between policing, prisons, and the country’s racialized class structure. It is a moment that has occasioned, within reform circles, space for the idea that policing, jails, and prisons in the United States are not mismanaged — they are doing exactly what they are supposed to do.

Holding these two contradictory positions as a kind of dual consciousness, Life and Death in Rikers Island may well endure as a relic of a historical moment grasping toward a more profound understanding of racist nightmares like the Rikers Island penal colony — and toward the political movement capable of bringing these nightmares to an end.