Human rights at Rikers: Dual loyalty among jail health staff

New York City’s Departments of Health and Mental Hygiene (DOHMH) and Correction (DOC) have a collaborative relationship within the City's jail system; DOC oversees security, while DOHMH is responsible for all inmate health care services through the Bureau of Correctional Health Services (CHS). In 2012, CHS integrated a human rights framework into its medical mission. One effort was to start a dialogue with staff around their dual loyalty burden, a human rights concept describing the pressure the security setting places on the health mission. An interactive survey containing vignettes based on jail scenarios was presented, followed by questions regarding how a respondent might react. Following the close of the survey period, the intervention is now conducted with all incoming providers.

Six scenarios were presented, each followed by asking whether respondents had encountered or heard of similar scenarios in their work setting; affirmative responses ranged from 16% to 93%. The first scenario involved a patient who reports asthma but is not being front cuffed as required by medical policy to ensure access to his inhaler; only 6% of respondents indicated they would refuse to issue the order for front cuffing. In the second scenario, a transgender patient reports having sex while in jail and requests condoms (allowable by CHS policy); 4% responded that patients should never receive condoms and 27% responded they would report the patient to security staff for infraction purposes. In the third scenario, a provider walks away from a patient requesting help; 100% of respondents indicated they would take measures to address the patient’s needs. In the fourth scenario, mental health staff are asked to ‘clear’ a patient into solitary confinement despite recent self-harm; 7% of respondents indicated they would have no concerns for the patient’s welfare if he returned to solitary confinement. In the fifth scenario, a patient disputes the contents of an injury report written by security staff; nearly half of respondents (47%) would take direct action, while the remaining would ask for guidance. In the sixth scenario, as a patient is brought, unscheduled, to the clinic by multiple security staff to be seen for injuries, the provider witnesses them striking the patient; 77% of respondents said they would try to get security staff to stop beating the patient. The training was reported as helpful by 91% of respondents and 95% reported that more energy and time should be dedicated to identifying and addressing dual loyalty concerns.