Jorge Rios wasn’t thinking straight when he got the news.
The mother of his 15-year-old son, the woman he’d loved since high school, had been transferred to the hospital from Arizona’s Perryville Prison, where she was nine months into a two-year sentence for drug possession.
It was cervical cancer.
Jorge, at 35 an athletically built man with a shaved head and a prickly goatee, didn’t know the name of the medical facility, what had happened to prompt the abrupt move, how she was holding up — anything.
He just knew he needed to see Nishma Kanabar. Immediately.
He started with St. Joseph’s Hospital in Phoenix.
The woman at the front desk couldn’t find Nishma in the registry. But, he reasoned, perhaps, because she was an inmate, they’d keep her whereabouts hush-hush.
He stopped a janitor. “Where would they send a prisoner from Perryville?” he asked.
He stopped a nurse. “Where would they send a prisoner from Perryville?”
He wound his way, frantic, through every hallway on every floor, poking his head in doors, searching.
Old men hooked up to heart monitors.
Young children awaiting surgery.
He headed to the Phoenix campus of St. Luke’s Hospital next.
“Do you have a Nishma Kanabar checked in?” he asked.
Up and down the hallways, he went, searching room after room after room. No Nishma.
Eventually, he found her at St. Luke’s Tempe campus. But, because he and Nishma had a complicated history (over the course of their relationship, they married, divorced, and then reconciled), and because he had done his own stint in prison, the security guard informed him he would have to file paperwork to request a visitation. It took weeks to get the green light.
When he finally saw Nishma, his sparkling, gregarious, life-of-the-party mate, she greeted him with a weak half-smile. She was just 33, but her raven hair had turned silver. Her plump cheeks were hollowed out. Trembling with pain, hands clenched into fists, twisting to look at him was a strain. Her head nearly was too heavy for her neck.
Doctors first noted abnormal cells growing in Nishma’s cervix — a common sign of cancer — during a physical exam administered when she was booked into Perryville.
But although Nishma, crippled by abdominal pain, rapidly losing weight, and bleeding out quarts of blood, begged repeatedly to see a doctor, it was more than eight months before she was administered a diagnostic test.
Even after the cancer was discovered, records show that weeks slogged by before Corizon, the private health-care organization Arizona hired to manage inmates’ medical needs, authorized her to begin chemotherapy.
Now Nishma is dead.
Her family, forced to watch helplessly as she withered away behind bars without treatment, is suing Corizon and the Arizona Department of Corrections.
It’s difficult to know exactly how Nishma’s story would be different had she been tested for cancer and started treatment right away (as she most certainly would have if she had not been incarcerated).
But prompt care, her lawyer, Scott Zwillinger argued, would have at least spared her more than a year of pain and suffering, and may have extended — or even saved — her life.
“It was obvious for a long time that there was something seriously wrong with Nishma,” he said. “It was Corizon’s duty to figure out what that was, and they didn’t bother.”
The tragedy of Nishma’s death, though, is greater than one family’s losing a partner, a mother, a sister, a child, a grandchild.
Horror stories of prisoners, like Nishma, receiving instructions to pray or drink energy shakes to alleviate cancer symptoms have poured out of the Arizona Department of Corrections for years.
And yet, even after the American Civil Liberties Union organized a class-action lawsuit and, in October 2014, managed to pressure the Department of Corrections to settle, diagnosis and treatment for chronic conditions remain abysmal.
The state has made so little progress on the goals outlined in the settlement agreement, which include, among other things, increasing the number of medical professionals serving prisoners and decreasing the wait time to see a doctor, that the ACLU in April demanded that a federal judge force the ADC to step up.
But the state is not just failing to meet agreed-upon benchmarks, said David Fathi, director of the ACLU’s national prison project. In an attempt to cover up the problems, officials also have adopted dishonest reporting tactics.
“There is no discernible plan to change anything,” Fathi said. “The attitude is not: ‘Yes, this is a problem, and here’s how we’re going to fix it.’ It’s: ‘There isn’t a problem.’”
Nishma was born in Tanzania in March 1980, the third of four children.
Mehendra Kanabar and Sheetal Patel, Indian immigrants, owned several businesses and lived a comfortable life in a large home with maids to make the beds and wash the dishes. But they gave it all up to start over in Arizona after Nishma was born, Sheetal said, because they were dissatisfied with the country’s health-care infrastructure.
Once in Phoenix, the couple bought a dry-cleaning business. They slept in an apartment above the store, and during the day, Nishma and her older brother helped fluff and fold clothes while her younger brother, Sameer, napped inside a laundry hamper.
Business was good, and soon, Mehendra and Sheetal expanded, building more than 20 stores. They moved the children to a four-bedroom home in Madison Meadows and spoiled them, buying them fancy stereo systems and cars, and whisking them away on vacations to Bali, China, Indonesia, London, and Costa Rica.
Nishma was outgoing and popular. She loved fancy shoes, designer bags, and wearing flowers in her long, thick hair. She earned high marks in school. Those who knew her described her as a hard worker with “brilliant charisma,” the type of person who is “always ready to go the extra mile.”
Nishma, though, liked to party.
She and Jorge started experimenting with drugs in high school. At 19, Nishma got pregnant, and at 20, they married. Although they both earned high marks at community college, and Nishma was accepted into Arizona State University’s competitive fast-track nursing program, the two spiraled deeper and deeper into drug addiction.
Nishma dropped out of school. Jorge became violent, at one point fracturing Nishma’s skull and breaking her nose.
She pressed assault charges in 2007, and, while he was in jail, moved back in with her mother, enrolled in substance-abuse treatment, and landed a well-paying job as an administrative assistant at the real-estate investment firm Marcus & Millichap.
By all accounts, Nishma was getting her life back on track.
Then, on January 14, 2011, she was fired from her job for taking a sick day to care for her son, Sabian. She met with a friend to bemoan the situation over lunch and two vodka cranberries. On the drive home, she rear-ended someone on Missouri Avenue. A breathalyzer test put her blood-alcohol content at .154 — well above Arizona’s legal limit.
Nishma pleaded guilty to a misdemeanor DUI and was sentenced to 120 days in Maricopa County’s infamous Tent City Jail, where inmates are forced to wear pink underwear, eat meatless meals, and sleep in tents in 130-degree heat.
Because she had no prior convictions, she qualified for the work-furlough program, which allows employed prisoners to be released up to 12 hours per day, six days per week.
One evening, after she returned to jail from work, a corrections officer, claiming she was acting “suspicious,” had her strip-searched. They found a small plastic bag containing .1 grams (about $10 worth) of meth tucked under the padding of her bra.
Bawling to her brother Sameer, Nishma swore it was an accident. She was wearing an old bra from her drug-using days, she said, because Sameer had volunteered to do her laundry at one of the family dry-cleaning stores and hadn’t returned it.
“I believed her,” Sameer said. “I mean, I had her underwear in the trunk of my car.”
But prosecutors didn’t buy the story, and in June 2012, Nishma was sentenced to two years in prison for promoting prison contraband, a class-two felony, and drug possession, a class-four felony.
She was booked into Perryville on March 27, 2013, and, during a routine physical exam, was given a papanicolaou test (pap smear). On her record, nurses scribbled: “atypical squamous cells of undetermined significance.”
No follow-up was ordered.
During their weekly visits, as early as April, Sabian and Sheetal noticed Nishma’s cheeks hollowing out, the color draining from her face. But she kept up a cheery demeanor while they munched on ham sandwiches from the prison vending machine and played Scrabble, Sabian’s favorite game.
In June, she told her mother, softly, that her periods had grown heavy and that she was feeling tired. By July, she was bleeding almost nonstop. Complaining of fever and sharp abdominal pain that was so severe she couldn’t sleep, she filed a request for medical care with prison officials.
Nurses gave her birth-control pills and antibiotics, but neither the bleeding nor the pain subsided.
Her weight dropped from 172 to 165.
In August, she started vomiting up everything she ate. The pain increased. She felt dizzy and weak.
She filed several requests for medical care.
“I would like to see a doctor ASAP.”
“Please see me ASAP.”
Nursing staff in September noted in her clinical record that her symptoms were worsening and “urgent intervention” was required.
Her weight, they scribbled, was 156 pounds.
She tested negative for bacterial infection, but health staff prescribed her antibiotics anyway.
By October, the bleeding was so severe that she was using 10 feminine hygiene pads a day and passing clots the size of fists.
Sheetal and Jorge, who had reconciled with Nishma, peppered the ADC and Corizon with phone calls, begging them to do something.
A doctor canceled her pelvic examination because, he said, the bleeding was too severe. He told her to return in three weeks.
When that appointment arrived, the bleeding had not stopped, so he deferred the exam another four weeks.
It wasn’t until November 14, eight months after her abnormal pap smear, that Corizon ordered Nishma’s first diagnostic test: a pelvic ultrasound.
Health-care providers discovered a large cyst on her grossly swollen right ovary and spotted questionable masses on her uterus. Her cervix, they wrote in her clinical record, appeared “hard, friable, and eaten up.”
Still, they did not schedule a biopsy until December 5.
Her weight was 140.
For much of this country’s history, the courts have taken a hands-off approach to health-care administration in prisons, which, well into the 20th century, was largely nonexistent.
As recently as 40 years ago, 25 percent of the country’s jails had no medical facilities, and 65.5 percent provided only rudimentary first aid, according to the American Medical Association. It was common, as a result, for inmates to perform surgery on or yank infected teeth from one another, then die in their own filth, crawling with maggots.
It wasn’t until 1976 that the U.S. Supreme Court recognized that inmates had a constitutional right to adequate medical care behind bars.
In the landmark case Estelle v. Gamble, justices expanded the Eighth Amendment’s prohibition against cruel and unusual punishment — previously understood to refer to barbaric torture methods such as beheading, public dissection, or burning alive — to include ignoring an inmate’s medical needs.
Because a prisoner must rely on authorities for treatment, they reasoned, failing to provide care, in the worst cases, “may actually produce physical torture or a lingering death” and, at the very least, may cause pain and suffering that “no one suggests would serve any penological purpose.”
By the 1990s, at least 40 states had been court-ordered to improve medical care for inmates, or had agreed to settle a lawsuit and make changes on their own.
During a five-week trial in 1993, in the case of Casey v. Lewis, a judge declared that Arizona was providing constitutionally adequate medical care to its inmates but ordered the ACLU, which had brought the suit, to monitor the situation until 2000 to ensure services remained up to par.
Conditions went “seriously downhill” after the case closed, Fathi said. One out of every four health-care positions with the Department of Corrections fell empty, causing serious backlogging. The wait time to see an outside specialist, such as a cardiologist or an oncologist, averaged 11 weeks.
Then, in 2009, the Republican-led Arizona Legislature, in an effort to cut costs, passed laws requiring the Department of Corrections to turn over inmate care to a private health-care organization. Another law drastically reduced the amount of money the state could pay outside specialists.
Within months, ADC officials reported at the time, doctors and nurses were quitting in droves. Many outside contractors, saying reimbursement rates were too low, severed ties with the department.
Arizona hired Wexford Health Sources Inc., a Pennsylvania-based correctional health-care services organization, to take over in July 2012. But, by that point, Wexford officials argued in legal documents, the system was in shambles.
In addition to being woefully understaffed, they wrote, the ADC was months to years behind in filing inmate medical records, making it impossible to identify what care had been completed and what care still needed to be administered.
One consequence: Patients with chronic conditions, such as cancer, HIV, and diabetes, were not receiving regular checkups or medication.
After media caught wind of a nurse who was reusing needles, causing a Hepatitis C scare, and a pregnant woman who was told to treat her C-section wound with McDonald’s sugar packets, Wexford in January 2013 asked to be released from its three-year, $349 million contract, arguing that it had signed on to “improve efficiency and quality of care in an already-functional correctional health-care delivery system,” not “rebuild a dysfunctional system.”
The state brought on the next-lowest bidder: Corizon.
The Tennessee-based, for-profit provider came on board with a dicey record.
Like most private contractors that provide prison-related services, Corizon, which operates on an HMO model, has a reputation for cutting costs by paying lower wages, providing fewer employee benefits, and hiring less-qualified workers.
In Florida, in 2012, after an inmate was paralyzed by an antibiotic-resistant staph infection, a jury concluded that the company was pressuring employees during staff meetings to delay or avoid sending inmates to the hospital to save money.
That same year, on Corizon’s watch, a 26-year-old in Indiana died after getting denied care for lupus; a prisoner who jumped from a building in Pennsylvania was not referred for medical care for a full day; and an Iowa inmate gave birth in a cell, assisted by another inmate, because nurses declined to take her to a hospital. An independent investigation into Corizon’s system in Idaho found that the health-care provider wasn’t regularly feeding, watering, or providing pain medication to chronically or terminally ill prisoners.
While Nishma was fighting for a diagnosis, the ACLU, with the help of the Prison Law Office, a nonprofit advocacy firm based in California, was investigating the state’s prison health-care system.
Corene Kendrick, an attorney with the Prison Law Office, and Dr. Todd Wilcox, medical director of the Salt Lake County Jail System, toured Arizona prisons in Eyman, Florence, Perryville, Tucson, and Yuma, selecting patients from the states’ medical files to interview, and going cell-to-cell to collect stories.
As word about their project spread through the prison yard, inmates quietly approached them, lining up 75 at a time for the chance to air their ailments.
There was a man scooting around in a wheelchair, whose broken tibia had been protruding from his leg for months. There was a man who had swallowed the cap to his tracheostomy tube and was walking around with an open hole in his throat.
Many stories were eerily similar to Nishma’s.
One man had been diagnosed with colon cancer but, four months later, still had not received a treatment plan.
Another woman discovered a lump in her breast in February 2013 but didn’t get a mammogram until April. It then somehow took Corizon until July to get a biopsy. The clinical notes on her chart provide telling insight into the prison health-care bureaucracy:
May 15 — still waiting for approval for biopsy
May 21 — no biopsy yet
May 22 — verbal approval for consult
May 29 — official approval still pending
June 5 — still awaiting official consult approval
June 11 — doctor called and informed that patient was scheduled with surgeon
June 18 — patient sees surgeon for pre-op evaluation
June 20 — consult written to obtain biopsy per surgeon’s recommendation
July 1 — no biopsy yet
July 18 — patient has biopsy of breast mass
July 22 — patient informed she has breast cancer
The problem could be traced back to poor staffing, which declined even further under Corizon’s management, Wilcox would later write in an expert report for ACLU’s lawsuit, Parsons v. Ryan.
Wilcox wrote that Corizon considers a doctor to inmate ratio of 1-to-2,500 fully staffed. In Alabama, which has a prison system of comparable size, Corizon ensures a significantly higher ratio: 1-to-1,700.
During Nishma’s incarceration in 2013, the Department of Corrections official who headed up a team of state employees that monitors Corizon’s work acknowledged that just 53 percent of medical-provider positions were filled, meaning, at many prisons, the line to see a doctor could be 500 people long for those with chronic conditions.
There were not enough nurses to fill all the shifts without working overtime, so on some days, full cell blocks were unattended by medical personnel, the Department of Corrections’ monitoring bureau noted. Nurses were cutting corners. They weren’t taking patients’ vital signs. They weren’t updating patients’ medical records. They weren’t waiting until medications were administered before signing records indicating patients had been treated.
Often, because staffing shortages were particularly bad among higher-level providers, such as medical doctors and nurse practitioners, licensed practical nurses ended up taking appointments they weren’t equipped to handle.
“All they can do is hand out antibiotics or antacids,” Kendrick said. “In some cases, people who have cancer were going months and months without a diagnosis because they couldn’t get in to see a doctor who was licensed to do a biopsy. They just kept seeing a nurse, getting passed some Tums, and being told to reschedule.”
Sometimes, though, nurses simply tried their hand at procedures they hadn’t been certified to conduct, Wilcox wrote in his expert report.
At the Florence prison, for example, an LPN, who would ordinarily take vitals and provide bedside care, essentially was running the dialysis program, ordering labs, deciding what changes needed to be made on the dialysis prescription, and writing orders for post-dialysis management.
At the Tucson prison, Wilcox observed LPNs assessing patients, determining — falsely — that they didn’t need medical care, and sending them back to their units.
“The fact that the health-care system used LPNs out of scope virtually guaranteed a delay in diagnosis,” Wilcox wrote. “LPN’s are not taught to do physical examinations; they are not pathophysiologists; and they have no experience assessing sick patients, developing a plan to work up the problem, and pursuing a proper diagnosis.”
Wilcox and Kendrick, in their write-ups of the tour, also noted that patients were not referred to specialty providers, such as a rheumatologist, gynecologist, or oncologist, in a timely manner — or at all.
“In the Arizona system, all too often the providers make treatment decisions that are clearly substandard and endanger their patients,” Wilcox wrote.
Wilcox and Kendrick didn’t have time to talk to all the prisoners who approached them during the tour, so they took their names and prisoner-identification numbers and promised to follow up by mail.
Kendrick was so traumatized by the experience that she had nightmares for a week. “Arizona’s prisons are worse than anything I’ve ever seen,” she said.
The December 5 biopsy was unsuccessful because Nishma was bleeding too profusely.
The doctor wrote her an “urgent” referral to see a gynecologist, but before an appointment could be arranged, Nishma, weak and severely anemic, had to be rushed to Tempe St. Luke’s Hospital for an eight-pint blood transfusion.
There, more than five months after she started bleeding, she was informed that she had stage-four cervical cancer that had spread to her uterus, liver, colon, and bones.
Within days, her liver and kidneys were starting to shut down, and clinical staff was advising Nishma to “plan care for her child and family if the outcome is bad.”
Still, Nishma was transferred back to Perryville. It would be more than a month before Corizon would make a treatment plan and get her started on chemotherapy.
Her family, meanwhile, was calling, calling, calling, leaving voicemail after voicemail, getting no response. The doctor was out for the holidays, they were told. Wait until January.
“I couldn’t eat. I couldn’t sleep. I couldn’t work,” Sameer said. “All I could think was: ‘We have to get her out of there.’”
He frantically filed all the paperwork to get Nishma medical clemency so they could take control over her treatment, or, at the very least, bring her home to die.
The state denied the application, saying she wasn’t terminal.
So Sameer wrote Governor Jan Brewer, U.S. Senator John McCain, and Congressman Matt Salmon, begging for their help. Salmon, who lived near Sameer’s uncle, personally walked the clemency order to the governor’s office to collect Brewer’s signature.
Jorge, Sabian, and Sheetal picked her up from Perryville on February 28, 2014. A corrections officer pushed her out in a wheelchair, and Jorge helped her into Sheetal’s SUV.
Sabian peeled the Marvel Comics posters off the walls of his bedroom in the home he and Jorge shared, cleared out his skateboard and sword collection, and made up the bed with a pastel comforter. Nishma would sleep there; he would take the pull-out couch.
She put on light-blue Hello Kitty pajamas and black, fuzzy slippers, lounged on the couch, Sabian on one side, Jorge on the other, and watched television. They ordered pizza and wings because, Jorge said, if she couldn’t hold any food down anyway, “at least she was going to enjoy the taste of it.”
Sheetal drove Nishma to radiation therapy five days a week and chemotherapy seven. She was too weak to sit up in the car, so she curled up in a fetal position in the back seat.
By the end of March, she had been hooked up to a feeding tube and undergone surgery to remove part of her colon. She was in so much pain, Sameer said, that she just writhed and muttered “hospice, hospice, hospice.” The family decided to sign a do-not-resuscitate order.
She died April 20, 2014.
Within months, the ADC and Corizon would agree to settle the ACLU’s lawsuit, acknowledging more than 100 specific areas in need of improvement, such as care for pregnant prisoners and monitoring those with diabetes.
But, over the past year, the defendants have proven uncooperative.
In some areas where the ADC monitors noted progress, such as an improvement in access to specialty-care providers, lawyers discovered Corizon was hiding behind semantics to dodge scrutiny.
The ADC reported 100 percent compliance on this measure, but it wasn’t because Corizon did not deny any requests to see an outside provider, according to court documents. It was because, when Corizon rejected a request, it labeled the decision an “alternative treatment plan.”
“This willful misinterpretation of the word ‘denial’ does not demonstrate good faith,” a group of lawyers from the Prison Law Office wrote in a notice of compliance. “Defendants cannot nullify this requirement by using a different word.”
Still, even according to the ADC’s own measures, little has improved, and some conditions have gotten worse.
According to the settlement agreement with the ACLU, for example, patients should be triaged by a nurse within 24 hours of filing a request for medical care. Inmates should see a doctor within 14 days.
However, monitors with the ADC reported that, statewide, between March and July 2015, Corizon connected inmates with health-care providers in a timely manner only 64 percent of the time. At the prison’s Lewis complex, in July 2015, the wait time to see a doctor still averaged more than 75 days. The average wait time to see a nurse actually increased from 12 days in May 2015 to 17 days in July 2015. More than half of patients were not even scheduled to see a nurse at all.
It’s impossible for Nishma’s family to talk about the situation without getting emotional.
Sabian freezes. Sameer and Jorge swear. Sheetal openly weeps.
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“It just makes me so mad,” Sheetal says. “Nishma died, and it’s their fault.”
Fathi chalks the continuing problems up to a lack of commitment.
“Many other states have been in this position and have been able to fix the problem,” he said. “Arizona has no excuse.”