‘Just Let Him Kick’

Ashley Dixon first met Jonathan Salada when he was kicking his cell door.

It was spring of 2017 and Dixon had just started working as a correctional officer at CoreCivic’s Trousdale Turner Correctional Center in Tennessee. It was her first, and would be her last, job in corrections.

“What’s wrong with him?” Dixon asked the officer who was training her.

The officer told her “he wanted his insulin but they haven’t called for insulin yet,” Dixon recalled in a recent interview with The Appeal. The officer’s response? “Just let him kick.”

He continued kicking for two more hours. Dixon kept asking the officer what they could do. Finally, she told Dixon to call the infirmary if she wanted to. Dixon did and learned that people with insulin-dependent diabetes had already been called out of their cells to receive insulin injections hours earlier. They let Salada out to receive his shot.

From then on, Dixon said, she tried to make sure Salada received his insulin when she was working.

About a month later, on May 24, 2017, she heard an emergency medical call for Salada over the prison radio.   

According to an incident report Dixon later submitted to a captain at the prison, Salada “was in extreme pain and screaming for help.” The nurses initially refused to enter his cell; when they finally did, they checked his vitals and left. “I just can’t figure out what his game is,” one of the nurses said to a lieutenant, according to Dixon’s incident report.

Three days later, Salada would be pronounced dead.  

The Appeal requested but has not yet received his autopsy report. His official cause of death, according to a local media report, was an overdose of buprenorphine, a prescription opioid painkiller, with diabetes listed as a contributing factor.

Spotty, erratic, and dangerous

We all need insulin to survive, and most people produce it regularly on their own. But in Type 1 diabetics like Salada, the body doesn’t produce insulin. To stay healthy, Type 1 diabetics and some Type 2 diabetics must check their blood sugar with a finger prick and receive insulin via injection or an insulin pump multiple times a day, carefully timed with the consumption of carbohydrates.

Missing even a single dose of insulin can be harmful, explained Sarah Fech-Baughman, director of litigation for government affairs and advocacy at the American Diabetes Association (ADA). “If a patient goes without insulin for hours to days, he or she could develop a condition called diabetic ketoacidosis—which is life-threatening.” If a patient receives inadequate insulin and has chronically high blood glucose for a sustained period of time, she added, it can also cause serious complications like blindness and cardiovascular disease.

The legal advocacy program at the ADA receives roughly 200 requests per year from incarcerated people who are receiving inadequate medical care, according to Fech-Baughman. The care of people with diabetes held in Trousdale is the subject of a class-action lawsuit by the ADA against CoreCivic (formerly Corrections Corporation of America) and the Tennessee Department of Correction. There are at least 60 Type 1 diabetics or Type 2 diabetics incarcerated at Trousdale who require insulin injections, according to the ADA’s complaint.

[T]hey did not bring me any insulin for two days and I got really sick. … I could not stop throwing up.

Douglas Dodson plaintiff in ADA suit

According to the lawsuit, blood sugar checks and the delivery of insulin—both of which should be coordinated with meals—are sporadic, erratic, and at times nonexistent.  Meals, blood sugar checks, and insulin injections are given at irregular times during the prison’s frequent lockdowns, the suit explains, forcing diabetic prisoners to choose between their health and their hunger. “Such unconscionable delay in receiving basic diabetes care is the functional equivalent of receiving no care at all,” the lawsuit alleges.

Firsthand accounts from prisoners with diabetes inside Trousdale detail their own metaphorical kicks at the door for insulin:

“[T]hey did not bring me any insulin for two days and I got really sick,” Douglas Dodson wrote in a handwritten note submitted as an exhibit in the ADA suit. “I could not stop throwing up.”

Another note from Dodson included with the ADA suit refers to a day he didn’t get any insulin until two hours after he had already eaten breakfast: “[M]y blood sugar was 476 at this time and we are still lock down.” (A normal blood sugar reading for an adult diabetic is between 80 and 130 before a meal, and less than 180 one to two hours after a meal begins.)

“I haven’t got any insulin at all today. It’s almost 1 pm,” Tazarius Leach writes in a grievance attached to his pro se complaint against the prison. “I’m not trying to cause a problem but its my health … I’m getting force to miss shots I have no control over.”

Central to the ADA’s lawsuit is the claim that CoreCivic prioritizes profits over care. This, ACLU of Tennessee executive director Hedy Weinberg explains, is precisely why the ACLU opposes prison privatization.

“Handing control over to private prison companies is clearly a recipe for abuse and neglect,” said Weinberg. “A private prison is most concerned about their stockholders.”

Both CoreCivic and Correct Care Solutions, LLC, which handles all medical care at Trousdale, deny all wrongdoing. In response to a request for an interview, Steven Owen, managing director of communications for CoreCivic wrote in an email, “While we can’t speak to the specifics of pending litigation beyond our court filings, CoreCivic is committed to providing high-quality healthcare to those entrusted to our care.” The Tennessee Department of Correction did not respond to a request for comment.

Beyond Trousdale

Negligent medical care isn’t confined to for-profit prisons, notes Gabriel Eber, senior staff counsel with the ACLU National Prison Project. “I’ve seen bad care in state-run prisons,” he said. “I’ve seen bad care in private prisons.”

People with diabetes suffer in local jails and immigration detention facilities too—reflecting a broader inhumanity that snakes through the U.S. prison system.

In 2013, Carlos Mercado died of diabetic ketoacidosis about 15 hours after being taken to Rikers Island in New York. While at the jail, he carried around a bag of his own vomit and requested his insulin, which had been confiscated. Guards reportedly thought he was “dope sick.”

Also, in 2013, in Oklahoma’s McClain County jail, Kory Dane Wilson was not given insulin for three days—reportedly despite pleas from family, friends, and cellmates—and died of diabetic ketoacidosis.

Prison is punishment. But the punishment is the taking away of the liberty. It’s nothing more. It shouldn’t be a death sentence.

Gabriel Eber ACLU National Prison Project

In 2014, William Joel Dixon died after going without insulin for a week while in jail in George County, Mississippi. The day of his death, Dixon passed out in the shower. When a jailer asked the nurse to help him, she reportedly said she didn’t have time.  

“Prison is punishment,” said Eber. “But the punishment is the taking away of the liberty. It’s nothing more. It shouldn’t be a death sentence.”

Maintaining a healthy blood sugar is a daily challenge for people with diabetes even on the outside. In a prison healthcare system that may oversee thousands of patients, diabetics far too often fall through the cracks, said Eber.

At Trousdale, for instance, the medical staff consists of just four nurses and two nurse practitioners, according to a March 2018 filing in the ADA’s suit. As of July 5, 2017, 2,483 people were incarcerated at Trousdale.

“There is a sense of anger when I speak with insulin-dependent diabetics because they’re being wronged in a way that they know is going to affect their health,” Eber added. “And it’s not if or maybe. It’s certain.”

Type 1 diabetics are often well-versed in their own care—their lives depend on it, Eber explained. But their expertise, he said, can clash with the views of prison medical staff.

Brenda Menjivar Guardado, a 22-year-old Type 1 diabetic who had fallen into a diabetic coma at 13, knew to bring her insulin with her when she came to the United States seeking asylum from El Salvador. But when she was placed in ICE custody, her insulin was confiscated.

While Guardado was detained at CoreCivic’s T. Don Hutto Residential Center in Texas in 2017, she was provided with a different type of insulin than the one she had brought, causing her blood sugar to spike.

“They were giving Ms. Guardado what they were told was the best insulin treatment available, what most diabetic patients would want to receive,” said Robert Painter, director of pro bono programs and communications at American Gateways, which represented Guardado. “They were not hearing her when she was saying this type of insulin would not be effective for her.”

Eventually, Guardado was pushed into accepting the deportation, Painter told The Appeal. “Ultimately that was the only way she thought she could get the care she needed.”

ICE declined to address Guardado’s case specifically. In a statement to The Appeal, Nina Pruneda, a spokesperson for the agency said, “ICE is committed to ensuring the welfare of all those in the agency’s custody, including providing access to necessary and appropriate medical care.”

Salada’s final days

On the morning of May 25—two days before Jonathan Salada would be found unconscious in his cell—Dixon asked a nurse how Salada was doing; he had been admitted to the infirmary overnight. The nurse reported he was “sleeping like a baby” and that he was “likely doing this for attention,” Dixon wrote in her incident report. But a medical officer told Dixon that Salada had been “screaming in pain all night long.”

While it’s still unclear exactly what caused that pain, that morning a physician ordered Salada to be removed from the infirmary and returned to his cell, according to a lawsuit filed by Salada’s father. Salada’s father’s attorney stated via email that he prefers not to comment on active cases.

“[H]e continued to complain of pain and suffering and continued to request medical care but said requests were ignored and no further medical care or treatment was provided,” reads the complaint.

After his death, I was really haunted that my relationship had just been that of a guard and a prisoner, that I didn’t get to know him.

Ashley Dixon former correctional officer, Trousdale Turner Correctional Center

On the night of May 26, Salada was “still in horrible pain,” Dixon wrote in her incident report. The following morning he was “shaking and moaning in pain.”

That morning, May 27, the nurse did not bring insulin for Salada, Dixon said, despite her pleas. At the end of her shift, at about 8 a.m., she went to the infirmary to report that Salada had still not received his insulin.

“Well, we will get to it when we get to it,” one of the nurses told her, according to Dixon’s incident report.

At about 8:40 a.m., Salada was found unconscious in his cell. His blood sugar was 587, more than three times what it should have been. He was pronounced dead at 9:34 a.m. at Trousdale County Medical Center. He was 25. He had been at Trousdale less than a year.

“After his death, I was really haunted that my relationship had just been that of a guard and a prisoner, that I didn’t get to know him,” said Dixon. “I went to his funeral and saw pictures of his childhood trips and saw him as a person, which is something we’re not able to do working in the prison.”

Dixon said regardless of what caused his death, his health was neglected. She wishes she could have done more for him. “I wish I could have held his hand or done something that was more comforting than being there,” she said, “being a witness to his suffering, not being able to do anything.”

If you or a loved one with Type 1 diabetes have experienced difficulties with care while incarcerated or if you have worked in a prison and witnessed such issues, please contact the author through Twitter at @elizabethweill.