Ruiz v. Estelle

MEMORANDUM OPINION

JUSTICE, Chief Judge.

TABLE OF CONTENTS

Page

I. INTRODUCTION

A. Description of the TDC System ^74

B. Description of the TDC Inmate

Population 1274

C. Procedural History 1275

D. Outline of the Opinion 1276

II. OVERCROWDING

A. Findings of Fact

1. Compendium 1277

2. Description of Facilities 1277

3. Effects of Overcrowding 1281

4. Failure to Ameliorate Overcrowded Conditions 1283

B. Legal Analysis 1285

III. SECURITY AND SUPERVISION

A. Findings of Fact

1. Compendium 1288

2. Security Staff/Understaffing 1288

a. Background 1288

b. Training 1289

c. Staff duties and responsibilities; Understaffing 1290

3. Building Tender System 1294

4. Staff Brutality 1299

B. Legal Analysis 1303

Page

iv. health care

Medical Care

A. Findings of Fact

1. Compendium 1307

2. Staffing and Personnel 1307

a. Physicians 1307

b. Nurses 1309

c. Medical Assistants 1309

d. Inmates 1311

e. Dental Personnel 1312

3. Facilities 1313

a. Unit infirmaries 1313

b. Huntsville Unit Hospital 1314

c. John Sealy Hospital 1315

4. Interference Occasioned by Security and Work Concerns 1315

a. Diagnostic Unit Procedures 1315

b. Unit Medical Procedures 1318

c. HUH Hospital Procedures 1321

5. Medical Records 1323

6. Pharmaceutical Services 1324

7. Organization 1327

B. Legal Analysis 1328

Psychiatric Care 1332

A. Findings of Fact

1. Compendium 1332

2. Psychiatric Screening of Inmates 1332

3. Psychological and Psychiatric Care at the Unit Level 1333

4. TDC Treatment Center 1334

5. Treatment Staff in General 1336

6. TDC’s Defenses 1338

B. Legal Analysis 1338

Special Needs Inmates 1340

A. Findings of Fact

1. Compendium 1340

2. Physically Handicapped Inmates 1340

3. Mentally Retarded Inmates 1344

B. Legal Analysis 1345

V. DISCIPLINE 1346

Hearing Procedures

A. Findings of Fact 1346

B. Legal Analysis 1350

1. The

Wolff

Requirements

a. Notice 1351

b. Statement of reasons *352

c. Witnesses 1353

d. Counsel substitute 1355

2. Impartial Hearing Body 1355

3. Failure to Follow State Rules 1356

4. Vague and Overbroad Rules ^357

5. Relief 1358

Solitary Confinement 1359

A. Findings of Fact

B. Legal Analysis 1361

Administrative Segregation 1364

A. Findings of Fact

B. Legal Analysis 1365

VI. ACCESS TO THE COURTS 1367

A. Findings of Fact

B. Legal Analysis 1370

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Page

VII. OTHER CONDITIONS OF CON-

FINEMENT 1373

A. Findings of Fact

1. Fire Safety 1373

2. Sanitation 1374

a. Housing areas 1374

b. Water supply and plumbing 1374

c. Wastewater and soiid waste disposal 1375

d. Food service areas 1375

e. Food processing areas 1375

3. Work Safety and Hygiene 1376

B. Legal Analysis 1377

1. Pendent Jurisdiction 1377

2. Applicability of State Health and Safety Laws 1378

3. Constitutional Claims 1382

VIII. TOTALITY OF CONDITIONS 1383

IX. DEFENDANTS’

RIZZO

ARGUMENT 1384

X. GENERAL RELIEF 1385

A. Unit Size and Structure 1385

B. Prison Location 1389

C. Appointment of One or More Special Masters 1389

D. Development of Detailed Remedial Decree 1390

XI. CONCLUSION 1391

I. INTRODUCTION

The issues in this civil action relate to the constitutionality of certain operations of the Texas Department of Corrections (TDC), which is responsible for the confinement and management of adult convicted prisoners of the State of Texas. The plaintiffs are named TDC inmates, who represent a class of all past, present, and future inmates. Defendants are W.J. Estelle, Jr., Director of the Texas Department of Corrections, and the members of the Texas Department of Corrections. Jurisdiction is appropriate under 28 U.S.C. § 1343 (3) and § 2201. Before embarking upon a discussion of the numerous specific factual and legal issues posed by the evidence in this civil action, a general overview of the TDC system, a description of the inmate population, the history of the litigation, and a general outline of this opinion will be set out.

A.

Description of the TDC System

The Texas Department of Corrections currently operates eighteen prison unites in the state of Texas, sixteen for male prisoners and two for female prisoners.

1

All but one of these units are characterized by TDC as maximum security institutions. Most of the units are large; the smallest incarcerates eight hundred inmates, and the largest house some four thousand. On most of the prison units, extensive farming and industrial operations are carried on, with the use of inmate labor. Indeed, self-sufficiency is a trademark of the TDC system-prison inmates produce most of their own food and clothing, provide manpower for prison construction and maintenance projects, and produce a variety of manufactured goods (mattresses, brooms, furniture, etc.), which are used within the prison system or are sold to other state agencies. Responsibility for the management of the prison system, subject to the control and supervision of the Texas Board of Corrections, is vested in the TDC Director. Each unit has its own warden, who is responsible for the day-to-day management of the unit.

B.

Description of the TDC Inmate Population

The number of prisoners confined in the TDC system is very large and increases constantly. The inmate population includes persons of a variety of backgrounds and widely differing abilities, as well as many with acute physical and mental problems. A statistical profile of the TDC inmate population reveals pertinent information concerning persons immured in Texas prisons.

TDC’s 1978 Annual Statistical Report discloses that approximately ninety-six per

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cent of the 24,575 inmates in TDC system were male, and four percent were female. An ethnic breakdown showed that approximately forty-three percent of inmates were black, thirty-nine percent were white, and nineteen percent were of Mexican ancestry. Prior to the incarceration, almost twenty-seven percent resided in the Dallas-Fort Worth area, twenty-five percent in the Houston area, and seven percent in the San Antonio area. In general, a large majority of TDC’s inmates were convicted in urban areas.

The mean age of TDC inmates in 1978 was 29.58, with forty-one percent of the population twenty-five years old or younger. These figures represent slight overall increases from previous years in the age of TDC inmates. In 1978, more than sixty-one percent of the new admissions to the TDC system were first offenders.

The average maximum sentence of all inmates was 23.54 years. According to TDC’s classification of the offenses for which inmates have been sentenced, approximately twenty percent were incarcerated for “violent” crimes, sixty-five percent for “property” crimes, and fifteen percent for “other” offenses.

The mean intelligence quotient (IQ) for TDC inmates in 1978 was 93.92. Scores of seventy or below were exhibited by 1,609 inmates, or 7.05% of the TDC population. Another 2,157 inmates, or 9.45% of the population, had IQ scores between 71 and 89. Expert witnesses agreed that approximately ten to fifteen percent of the inmates were mentally retarded. It was further estimated that five percent of the inmates were acutely mentally ill, and that as many as sixty-eight percent were mentally or emotionally disturbed. Thirty percent had histories of serious alcohol abuse, and records of drug abuse and dependency were shown for thirty percent.

Fifteen percent of the inmate population were found to be illiterate. Eighty-five percent were school “drop-outs”, eighty percent had less that a seventh grade education, and fifty percent less than a fifth grade education. Average reading ability for TDC inmates was at approximately a sixth grade level.

C.

Procedural History

This civil action began in June 1972, when David Ruiz, an inmate of the Texas Department of Corrections, filed suit against the Director of TDC, pursuant to 42 U.S.C. § 1983 , seeking declaratory and injunctive relief for alleged violations of his constitutional rights. In the spring of 1974, the civil action instituted by Ruiz was consolidated with the suits of seven other TDC inmates

2

into a single civil action, styled

Ruiz v. Estelle,

550 F.2d 238 . Counsel was appointed to represent the indigent plaintiffs in the litigation, and the United States was ordered to appear in the case as

amicus curiae.

In December of 1974, the motion of the United States to intervene as a plaintiff was granted,

3

and the addition of members of the Texas Board of Corrections, as defendants, was also allowed. A further order was entered which permitted the action to be maintained as a class action, and all

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damage issues were severed for later considerations, as to all parties.

Beginning in 1974 and continuing through 1977, the parties engaged in substantial discovery efforts. During this period, several hearings were conducted to consider a variety of outstanding matters, including disputed discovery issues and requests by the named inmate plaintiffs for protection from retaliation by the defendants. On December 30, 1975, an order was issued which enjoined TDC officials from interfering with plaintiffs’ access to counsel and the courts, and from engaging in various other forms of harassment, retaliation and discrimination against the plaintiffs.

4

Trial on the merits was originally set for March 6,1978, in Tyler, Texas. The motion of the defendants for a continuance was granted, and the case was tentatively reset for trial on September 5, 1978. A preliminary pretrial conference was held February 3, 1978, in Tyler. On February 6, 1978, the defendants moved for a transfer to the Southern District of Texas. On May 30,1978, an order was entered transferring the civil action to the Southern District of Texas, pursuant to 28 U.S.C. § 1404 (a). The order cited “substantial logistical and security concerns generated by the prospect of transporting and housing” hundreds of inmate witnesses, most of whom were confined in the Southern District. On June 8, 1978, the Honorable Reynaldo G. Garza, then Chief Judge of the United States District Court for the Southern District of Texas, assigned the undersigned judge to preside over the trial.

Trial commenced in Houston, Texas, on October 2, 1978. After 159 days of trial, including one significant delay, the parties finally rested on September 20, 1979.

5

At the conclusion of the trial, the court had heard the testimony of 349 witnesses and had received approximately 1,565 exhibits into evidence.

D.

Outline of the Opinion

The named plaintiffs and the plaintiffintervenor, the United States of America, have alleged that a variety of conditions and practices in TDC prisons violate the eighth and fourteenth amendments to the Constitution of the United States. They have challenged the following aspects of confinement in TDC prisons: overcrowding, security and supervision, health care, discipline, access to the courts, and other gener

*1277

al conditions of confinement. Each of these areas will be considered separately, although many of the relevant factual and legal issues are applicable to several of the categories to be discussed. Within each section of the opinion, in nearly all instances, factual findings will be separately made, followed by a legal analysis of the claims raised. ,

Because the plaintiffs and plaintiff-intervenor have alleged systemic constitutional violations which adversely affect the entire plaintiff class, the findings of fact will, for the most part, have reference to practices and conditions generally prevalent in TDC prisons, as demonstrated by many reports of specific incidents and experiences which are in evidence. Where examples of particular happenings are referred to, they are used for illustrative purposes only, and they are not to be interpreted as a reflection of the totality of the evidence presented or considered in making the general findings. In reaching the conclusions here made, the trial testimony of the hundreds of witnesses has been considered, including inmates, TDC employees, and experts in a wide variety of fields. Because of the size and complexity of the record, specific citations to it are not included.

II. OVERCROWDING

A.

1.

Compendium

TDC has been, by the admissions of its own officials, severely overcrowded since at least March of 1977. The problem has reached crisis proportions. When Director Estelle testified in August 1979, he reported that approximately 1,000 of the system’s 26,000 inmates were sleeping on the floors of TDC institutions. These supernumerary inmates are housed in cells and dormitories already holding almost double the number of persons for which they were designed. The inmate population continues to increase-as of November 30, 1979, there were 26,392 inmates in the system

6

-and the current intolerable situation promises to become even more acute.

The overcrowding at TDC exercises a malignant effect on all aspects of inmate life. Personal living space allotted to inmates is severely restricted. Inmates are in the constant presence of others. Although some degree of regimentation and loss of privacy is a normal aspect of life in any prison, the high population density at TDC leaves prisoners' with virtually

no

privacy at any time of the day or night. Crowded two or three to a cell or in closely packed dormitories, inmates sleep with the knowledge that they may be molested or assaulted by their fellows at any time. Their incremental exposure to disease and infection from other inmates in such narrow confinement cannot be avoided. They must urinate and defecate, unscreened, in the presence of others. Inmates in cells must live and sleep inches away from toilets; many in dormitories face the same situation. There is little respite from these conditions, for the salient fact of existence in TDC prisons is that inmates have wholly inadequate opportunities to escape the overcrowding in their living quarters. The environment outside the housing areas is similarly strained by the demands of the increased prison population and can offer no substantial relief from the pressures and harms generated by living in such close proximity.

2.

Description of Facilities

With a few exceptions, such as unit infirmaries and disciplinary segregation cells, TDC maintains two types of housing, either traditional cells with barred doors or large dormitories. Most of the approximately 9,000 cells measure nine feet long, five feet wide, and seven feet high.

7

Originally de

*1278

signed to hold one inmate each, a second bed has been added to these cells in the last few years; almost invariably, they now house at least two inmates. Typical cells are equipped with two steel frame bunks (one above the other) attached like shelves to the wall, a sink, a toilet, a narrow shelf above the front bars, and a naked lightbulb. Inmates in the cells are provided nothing to sit on, except for the toilet-which has no seat-or bunks. No desk or other flat surface is made available to them for writing purposes. The small wall shelf and the space under the lower bunk are the only places to store personal possessions. An aisle about thirty to thirty-six inches wide separates the edge of the bunks from the opposite wall. The commode is situated at the back of the cell, near the end of the aisle. The usable, unobstructed space in the cell amounts to an area approximately seven and one-half feet long and three feet wide, totaling 22.5 square feet. So cramped is such a cell that two standing persons must squeeze by each other to pass, and an average man can stand in the center of the cell and touch both walls with outstretched arms. Barely enough room is present to do bodily exercises, such as push-ups or situps. Thus, inmates assigned to these forty-five square foot TDC cells can do little more than lie or sit on their bunks or the floor, or use the sanitary facilities.

When a total of three inmates are confined to a single TDC cell, as is all too often the case, the third must sleep on a mattress in the aisle. These mattresses, and often their occupants, are constantly stepped on by others in the cell attempting to reach the toilet, sink, or door. A third person will usually sleep lengthwise in the aisle, parallel to the bunks, with his head near either the toilet or the barred door. Inmates testified that they were fearful to sleep in the latter location, because they can be injured when the doors are opened. Occasionally, four-and sometimes even five-inmates are assigned to one cell. When four inmates are present, two of them must sleep on the floor, across the width of the cell, with their feet under the lower bunk. Since the cells are only five feet wide, these two cannot stretch out fully during the night. With five inmates, three must sleep on the floor, squeezed between the bars in front and the toilet in the rear of the cell. Inmates have been compelled to endure this latter type of confinement for days or even weeks at a time, most of them having been immured in the cells set aside for administrative segregation, TDC’s “non-punitive” detention status. There, inmates are ordinarily subjected to unremitting restriction to the cells assigned to them, for the entire period of their confinement in this status, with the exception of the brief times allotted for showering. At one unit, inmates being quarantined for possible exposure to gonorrhea were housed, four to a cell, in an administrative segregation wing for several consecutive weeks.

The dormitories at TDC units provide even less security and privacy than do the cells. TDC dormitories, sometimes called tanks, vary in size, each lodging between ten to 136 persons. A typical dormitory is a large rectangular room containing rows of narrow beds or double-decker bunks, recreation facilities, and a toilet area. None of the men’s

8

dormitories have partitions or screens. Because the aisles between the rows of beds are narrow and the beds are situated very close together, dormitory occupants are not easily visible to guards stationed in the halls or at the picket locations, which are outside the tanks.

The population density of inmates confined in dormitories is shocking. At the Central Unit, for example, two rows of double-decker bunks, directly adjacent to

*1279

each other, run down the middle of the dormitory. The scene was described as resembling one giant bed. Except for his bed, an inmate in this dormitory has no assigned space. Even while asleep, an inmate so confined is within easy and immediate reach of three other inmates (those sleeping at his side, at his head, and at his feet), and he is directly above or below a fourth inmate. In the less crowded dormitories, where single narrow beds are used instead of double-decker bunks, individuals have but little more personal space-their beds and, in addition, their footlockers. In such dormitories, the head of each inmate’s bed ordinarily backs up against a wall. Each side of the bed is only a few inches from the sides of those adjacent to it, and its foot is only a few feet away from the bed across the aisle. Under both of these living arrangements a total deprivation of privacy is insured, since every inmate is in full view of dozens of others at all times. Not even the urinals or toilets are screened or partitioned from the rest of the space.

The sanitary and recreational facilities in TDC dormitories are wholly inadequate for the numbers of inmates who use them.

9

Such a paucity of passive recreational area or common space exists in a typical dormitory that the television set is placed on a ledge above the toilets. A few game tables, seating four persons, and a small number of benches placed close together are situated in front of the television set. During popular television programs, the space around the toilet facilities is crowded with inmates, and only one toilet can be used. While this toilet is farthest from the television set, it is, nevertheless, in the midst of the beholders. For this reason, the inmate viewers sometimes do not allow

any

toilet to be used during well-liked programs.

The critical crowding which has resulted in “triple-celling” has also made its impact felt on the dormitories. Extra beds have been crowded in wherever possible, cutting into the already small recreational space. Inmates without beds sleep on mattresses placed on wall ledges (often above the toilets) or are wedged between the mattresses of two inmates whose bed frames have been pushed together

(i.

e., mattresses for three inmates are placed on two bed frames).

During the 1976 inspection of TDC facilities by expert witnesses, the space available for each inmate in TDC dormitories ranged from seventeen square feet to sixty square feet. The average was forty square feet. At the time of trial, TDC’s population had increased by approximately 5,000 inmates from the 1976 level, and square footage per inmate in the dormitories had generally decreased.

10

TDC’s defense against the extreme overcrowding of inmate living quarters includes two propositions. The first is that inmates spend so little of their time in the cells or dormitory sleeping areas that the high population density of living quarters, in itself, does minimal damage. The second is that TDC’s future building plans will alleviate whatever overcrowding exists within a short period of time.

The former proposition fails for several reasons. Initially, inmates do, in fact, remain in their living quarters a great portion of their time. Those who work regularly, and thereby put in the least amount of time in the housing areas, are still in their cells or dormitory sleeping quarters upwards of ten hours a day; many inmates are in the living areas much more frequently.

11

In

*1280

mates on cell restriction

12

occupy their “leisure” time in their cells. Unassigned inmates and those on medical lay-in status pass the greater part of their time in the living quarters.

13

Inmates in administrative segregation or solitary confinement are kept within their cells virtually twenty-four hours daily.

14

Furthermore, virtually all inmates are exposed to, and many are victimized by, the concomitants of unguarded, overcrowded cells and dormitories-the ever-present risk of assaults, rapes and other violence-for every day of their incarceration at TDC. In the present state of conditions at TDC, no amount of outside activities assigned to inmates can shield them from these dangerous potentialities for harm.

Even when they are away from the housing areas, inmates are confronted with the inescapable reality that overcrowding is omnipresent within the prison confines. For example, virtually all cellblocks are occupied at double, and some at even triple, their design capacity; hence, it follows that the adjacent dayrooms, designed for recreational purposes, must serve double and even triple the number of inmates for which they were conceived. Similarly, the inmates’ access to the indoor gymnasiums, the outdoor playing fields (which are located at only some of the units), the craft shops, and libraries are ever more limited, because an increasing number of inmates must use them in turns. Consequently these facili- . ties are available on only restricted bases to inmates, sometimes being accessible solely to building tenders or other privileged groups of inmates. Moreover, the dining rooms are nearly always crowded, with inmates waiting in long lines and eating in shifts.

Most of the inmates at TDC have job assignments and spend a significant amount of time working. But the conditions under which the greatest number of inmates work in no way relieve or compensate for the overcrowding of their living quarters. The main part of the inmates labor in uncomfortable surroundings, as components of a fairly large group. To illustrate, in the agricultural jobs, inmates are assigned to squads that must move down the field in unison, performing whatever activity (hoeing, thinning, or harvesting) as may be seasonal. Many other inmates toil in such areas as the laundries or kitchens, or perform construction work. All of these assignments involve physical activity in either hot, steamy indoor facilities or in outdoor settings which are subject to the vagaries of the elements. Giving consideration to these conditions, the expert witnesses testified that, at the end of the day, an inmate who has performed the drudgery accompanying much of the work at TDC has a great need for a relatively quiet, peaceful place, individually assigned to him, so as to achieve a respite from the stresses associated with the prison environment.

TDC officials’ contention that future building plans will eventually alleviate the aggravated conditions that now exist is extremely suspect. Originally, TDC officials had expected to eliminate douMe-celling upon the completion of the new Beto Unit, which is currently under construction. An unprecedented surge in inmate population undercut any realistic expectation of achieving that objective, and TDC officials’ most optimistic goal is now the elimination of triple-celling. Director Estelle testified that it was TDC’s “hope and intention” to get all inmates off the floors of the TDC units by April 1, 1980. However, population figures made available by the defendants in December of 1979, and judicially

*1281

noted by the court,

15

show a more rapid population increase than defendants had projected, thus leading to the conclusion that a great many inmates continue to sleep on the floors throughout the TDC system. It appears that, under TDC’s own plans, the elimination of triple-celling will not be achieved in the near future and overcrowding will only get worse.

TDC’s future plans encompass, for the most part, the construction of large maximum security institutions in rural areas, on lands extensive enough to maintain farming and ranching operations. Such a facility is the Beto Unit. TDC officials plan for it to house 4,000 inmates when completed, which will be several years from now.

16

Legislative authorization has been given TDC to begin site studies and to purchase land for a new prison unit, to be located in southern or western Texas, and a location for large-scale agricultural activity is now being sought. It is conceded by TDC officials that it will be many years before this projected unit will be ready for inmate habitation. Temporary housing facilities are also under construction at some of the existing units; and the remodeling and use of facilities at Gatesville, Texas, which were formerly used by the Texas Youth Council, is also contemplated.

The TDC prison system is uniform by design; the defendants have chosen to confine all inmates in massive, high-security institutions which vary only slightly from each other. Construction of such facilities is extremely expensive. For example, even with most of the labor being performed by unpaid inmates, construction of the Beto Unit is expected to cost $43,000,000.

17

In addition, these large maximum-security institutions take years to build, and simply cannot be constructed fast enough to overtake the soaring prison commitment rates. Despite these facts, TDC has chosen not to utilize other types of institutions. It has no minimum security facilities, no honor farms or work camps, no halfway houses or urban work release centers-in short, practically no alternative levels or styles of custody. Moreover, TDC officials have not indicated that construction or use of any such facilities is even under consideration.

All told, the evidence makes it clear that TDC’s construction plans-geared as they are toward huge maximum-security facilities which take years to build-promise little hope in the foreseeable future of significant relief from the overcrowding which permeates Texas prisons.

3.

Effects of Overcrowding

The present extreme levels of overcrowding at TDC are harmful to inmates in a variety of ways, and the resultant injuries are legion.

The constant threat to the inmates’ personal safety posed by overcrowded living conditions in both the multiply-inhabited cells and the packed dormitories presents the most obvious harm. Penologists who testified at trial were virtually unanimous in their condemnation of double and triple celling. Director Estelle himself noted the exigent problems associated with doublecelling, making reference to the increased opportunity for predatory activities and the enhanced difficulties respecting supervision and control. TDC inmates are routinely subjected to brutality, extortion, and rape at the hands of their cellmates. Some of the most heinous examples have occurred in triple-celling situations, where two-on-one confrontations practically guarantee the capitulation of the abused third cellmate. However, the problems of violence also occur all too frequently in double-celling situations, where one inmate often dominates the other. The evidence made it clear that, even if inmates were doubled up in cells large enough to accommodate two persons, the effects of violence and the climate of fear would remain. This is because of two

*1282

factors: (1) TDC’s rudimentary system of inmate classification is totally inadequate properly to assure the peaceful compatibility of cellmates;

18

and (2) TDC’s security and supervision capabilities fall far short of being able to protect inmates from potential violence at the hands of cellmates.

19

Inmates who live in dormitories are exposed to the same threats of violence endemic to the cells. In several ways, the risks dormitory residents encounter may be greater than those faced by inmates confined in cells. Potentially assaultive inmates are present in great numbers in every dormitory, and since the dormitories are practically unsupervised, violent inmates have free access to their fellows. The record indicates that these risks frequently turn into the repulsive actualities of sex malpractices, barbarous cruelties, and ex-tortions, all of which have been shown to be commonplace in the dormitories. Indeed, some of the correctional experts who testified are of the opinion that abusive violence is inherent and largely uncontrollable in the prison dormitory.

A number of highly qualified expert witnesses presented persuasive testimony relating to the incremental negative physical and psychological effects of inmates’ continued close confinement in too-intimate proximity with their fellows. Included among the consequences were the spread of disease and the enhancement of stress, tension, anxiety, hostility and depression. Among the distinguishable manifestations of hostility and depression, the experts found, were increased blood pressures, aggressive behavior, and extreme psychological withdrawal. These expert witnesses also concluded that overcrowding at TDC has substantially contributed to increased rates of disciplinary offenses,

20

psychiatric commitments, and suicides. Not surprisingly, they additionally concluded that all of these effects are counter-productive to rehabilitation and are creative of serious behavioral and disciplinary problems.

Finally, as already noted, the overcrowding at TDC translates into a total dearth of personal privacy for its inmates, as well as extreme physical discomfort to them, resulting from packing human beings together, in excessively close proximity, for long periods of time, day in and day out.

The serious harm caused by the confinement of two or more persons in a forty-five or sixty square foot cell are recognized; such overcrowding violates the recommended or required minimum standard of every organization that has promulgated criteria for the design of prisons and jails. Indeed, many of the standards recommended a minimum space of greater than forty-five square feet to house

one

person.

21

Similarly, the deleterious effects of

*1283

overcrowded dormitories are recognized by penologists and correctional facility designers, who generally disfavor dormitories altogether because of the security and privacy problems they pose. It is notable, in this connection, that several experts testified that they had never seen dormitories as crowded as those at TDC. In contrast, if dormitories at TDC were populated according to American Public Health Association (APHA) and American Correctional Association (ACA) standards, which call for seventy-five square feet of living space per inmate, the maximum number of inmates who could be housed in each dormitory would be nineteen instead of the current average of sixty-six to sixty-nine. Furthermore, if requirements for providing thirty-five square feet of dayroom space per inmate were included in calculations for dormitory space, the maximum allowable number of inmates v ould drop to fifteen.

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4.

Failure to Ameliorate Overcrowded Conditions

It was repeatedly stated by TDC officials that they can do nothing about the number of prisoners sent to TDC by the courts. But TDC officials have, within their power, a number of means for quickly reducing the prison population, none of which they have chosen to exercise to the extent of significantly ameliorating the overcrowding. Complete control over which prisoners earn “good time,” and, within statutory limits, how much they earn is in the hands of TDC officials.

23

Likewise, they have the authority, which they occasionally exercise, to restore good time which has been forfeited and to back-date changes in status in such manner as to maximize earned good time. By the use of these means, release dates for inmates can be advanced. If these official prerogatives were exercised in behalf of all inmates, hundreds of persons could be im

*1284

mediately discharged from TDC institutions, which would have the effect of removing a significant number of persons from the floors. Moreover, if TDC undertook a continuing practice of liberalizing good time credit awards, the release rate would accelerate, thereby keeping closer pace with the admission rate. These actions would not pose a threat to society, for Director Estelle testified that one-third or more of TDC’s inmates could be released immediately with no risk of harm to the public.

24

TDC officials also have a direct influence over the number of inmates eligible for parole consideration by the Board of Pardons and Paroles. It is the Board’s policy to decline to interview inmates in certain categories: (1) those who have less than a specified number of “PIP” points

25

(2) those who have an outstanding forfeiture of good time, and (3) those who are in Class III good time status. TDC officials have the full right and responsibility for determining the composition of each of these groups. They also prepare “institutional adjustment” reports, which the Parole Board relies upon. Thus, although TDC officials do not make actual parole decisions, they make many judgments which affect inmates’ chances for parole. A more generous employment of acceleration evaluations and status determinations by these officials would expand the pool of potential parolees.

TDC’s failure to take available steps at its disposal to alleviate overcrowding is most clearly demonstrated by its failure to operate more than a token work release program, although it has a statutory mandate to put it into effect. In 1969, the Texas Legislature enacted a statute authorizing the establishment of a work release program for selected TDC inmates.

26

TDC’s implementation of this statute has been half-hearted and unimaginative at best. The statute directs TDC to endeavor to place prisoners on a work release status, subject to certain enumerated conditions, none of which would have prevented TDC from making greater use of the program. Several years ago, when TDC had a much lower population, as many as 200 prisoners were on a work release status. The program was then in operation at four separate TDC units. Now, however, TDC officials generally oppose the operation of a work release program. Instead of a substantial percentage of the prison population being in a work release situation, as is the case in other states,

27

TDC permits less than fifty inmates (or two tenths of a percent of its inmate habitancy) to participate. Only fifty beds are set aside for the program participants, and at the time of trial, a third of these were vacant. Supervisors at TDC’s industrial operations are not even asked to identify work release candidates, and these overseers know little or nothing about TDC’s work release program.

Work release has the great advantage of being far more economical to the taxpayers than full-time incarceration. The Texas work release statute provides that the prisoner earning wages while in a work release status must reimburse the TDC for his maintenance. It also provides that the TDC director can disburse funds for the support of such an inmate’s dependents,

28

and even to make restitution to the victim of the inmate’s crimes. Community corrections, in general, cost less than one-seventh

*1285

of the amount required for TDC confinement, as Director Estelle testified. It is to be noted that the Texas statute does not require work-release inmates to be confined in existing TDC facilities. Other prison systems have rented, bought, or modified Y.M.C.A. facilities, inner city motels, or halfway houses, as residences for work release participants. By following similar methods, the TDC could quickly acquire or build suitable housing for inmates classified for work release.

B.

A number of recent cases have found unconstitutional violations which, in whole or in part, were the product of overcrowding comparable to that existing within Texas prisons.

Williams v. Edwards,

547 F.2d 1206 (5th Cir. 1977);

Gates v. Collier,

501 F.2d 1291 (5th Cir. 1974);

Pugh v. Locke,

406 F.Supp. 318 (M.D.Ala.1976),

aff’d sub nom. Newman v. Alabama,

559 F.2d 283 (5th Cir. 1977);

McCray v. Sullivan,

399 F.Supp. 271 (S.D.Ala.1975);

Battle v. Anderson,

564 F.2d 388 (10th Cir. 1977);

Chapman

v.

Rhodes,

434 F.Supp. 1007 (S.D.Ohio 1977),

aff’d

624 F.2d 1099 (6th Cir. 1980);

Ramos v. Lamm,

485 F.Supp. 122 (D.Colo. 1979);

Capps v. Atiyeh,

495 F.Supp. 802 (D.Oregon 1980). Many of these cases evaluated the constitutional propriety of overcrowding in light of the related consequences of inadequate security and frequent violence.

Gates v. Collier,

349 F.Supp. 881, 894 (N.D.Miss.1972),

aff’d

501 F.2d 1291 (5th Cir. 1974);

Pugh v. Locke,

406 F.Supp. at 323, 325 ;

Williams v. Edwards,

547 F.2d at 1211 . While the present opinion contains a separate section on inadequate security, any analysis of overcrowding must keep in mind the intolerably grievous effects upon inmates who live in such close proximity to violent and brutal fellow prisoners.

TDC prisons are strained beyond their limitations, currently housing over 200% of their original design capacity.

Battle v. Anderson

found a constitutional violation where the institution held 191% of capacity.

Chapman v. Rhodes

found a violation with the prison at 138% of capacity.

Indeed, every known standard for prison living conditions requires more distinct, severable room for individual inmates than is made available in TDC institutions.

29

Although recommended standards alone may not be said to establish constitutional mini-ma,

Bell v. Wolfish,

441 U.S. 520, 543-44, n.24 , 99 S.Ct. 1861, 1875, n.24 , 60 L.Ed.2d 447 (1979), many courts have used such standards as one of the factors to analyze the adequacy of an institution’s housing facilities.

Battle

v.

Anderson; Chapman v. Rhodes; Gates v. Collier,

390 F.Supp. 482 (N.D.Miss.1975),

aff’d

525 F.2d 965 (5th Cir. 1976);

Williams v. Edwards; Newman v. Alabama.

In

Gates v. Collier,

the district court observed that “generally accepted correctional standards require a minimum of 50 square feet of living area for every prison inmate” to ensure a minimum level of decency. 390 F.Supp. at 486 . The Fifth Circuit continues to cite the

Gates

standard with approval,

Jones v. Diamond,

594 F.2d 997, 1012 (5th Cir. 1979),

reh. granted

602 F.2d 1243 (1979); however, it has warned that a “simple mathematical calculation of total square feet of space divided by a standard of square feet per man may not necessarily be appropriate or practicable.”

Williams v. Edwards,

547 F.2d at 1215 . In

Williams ,

the Fifth Circuit remanded the district court’s determination of prison capacity based on an eighty square feet per inmate standard and ordered a “recomputation of the proper inmate population . .. [taking into account] [t]he functions and characteristics of each building ... in arriving at the capacity of each.” 547 F.2d at 1215 . The

Williams

court noted that the prison’s existing cells contained forty-eight square feet, while correctional standards call for a minimum of fifty square feet per inmate. The Fifth Circuit has further cautioned that design standards, without more, do not amount to a

per se

constitutional limitation on the number of prisoners which may be housed in a particular prison facility.

Newman v. Alabama,

559 F.2d at 288 .

*1286

The

Newman

court affirmed the district court’s requirement that inmates in existing facilities, whose conditions the court had evaluated, must be confined in single cells, and remanded for further consideration a requirement that all new prison construction provide sixty square feet of space for each prisoner.

These opinions, read together, provide useful criteria for evaluating whether the amount of individual space in inmate living areas is constitutionally sufficient. It is clear that confinement of inmates in spaces of less than fifty square feet should occasion great concern and careful judicial scrutiny. However, no hard and fast rule is appropriate; in each case, the court must consider all of the existing circumstances surrounding the overcrowding.

Space allocations for TDC inmates are so far below the fifty square foot level that little doubt exists as to their constitutional inadequacy. Inmates double-celled in forty-five foot cells have twenty-two and a half feet apiece; those who are housed three, four, or five to a cell are consigned to much less space. Prisoners living in the dormitories are accorded, on the average, less than forty square feet of space per person.

None of the other conditions of confinement related to overcrowding at TDC alleviate its deleterious effects or mitigate the conclusion that it violates the Constitution. As noted in the factual description of overcrowding, inmates spend a substantial amount of their time in the closely-packed living quarters. Even when away from the housing areas, they get no relief, for other facilities in the prisons are likewise intensively crowded.

The record makes plain the rampant violence associated with overcrowding, and none of the other conditions in TDC alleviate its appalling consequences. Security is so inadequate

30

that inmates in multiply populated cells and packed dormitories cannot be properly supervised or prevented from brutalizing each other. Similarly, there is nothing at TDC which serves to ease the severe psychological harm and physical discomfort which inures from extreme overcrowding and living in the constant presence of countless others.

31

All of the relevant factors being considered, it is clear that the severe overcrowding at TDC contravenes the eighth amendment.

Defendants have steadfastly maintained that crowding cannot be found to violate the eighth amendment, unless there is a showing of “a concrete injury prescribed by the Eighth Amendment that is directly caused by crowded conditions.” Defendants argue for an exceedingly strict standard of proof on these points; they criticize plaintiffs’ evidence, for its alleged failure to demonstrate with a high degree of specificity and certainty that harms have been caused to the inmates by overcrowding.

It is clear from a reading of cases in which overcrowded conditions have been found unconstitutional that the defendants’ characterization of the plaintiffs’ burden of proof is erroneous. Detailed, scientifically exact proof of harm has never been required. Courts have reached conclusions concerning the extent of harm from overcrowding based on common sense reasoning

*1287

from observable facts, such as population levels, space per inmate, incidence of violence and staffing levels. See, e.

g.,

the facts relied upon in

Pugh v. Locke,

406 F.Supp. 318 (M.D.Ala.1976),

aff’d in relevant part sub nom. Newman v. Alabama,

559 F.2d 283 (5th Cir. 1977) (population well over design capacity; sanitation and security impossible to maintain; mattresses on floor and next to windows; inadequate number of toilets; no hot water; foul odors; violation of public health standards; bad effects heightened by dormitory style living);

Williams v. Edwards,

547 F.2d 1206 (5th Cir. 1977) (“terribly overcrowded” living areas; not enough space to segregate dangerous inmates; a large number of stabbings; general lack of security; accumulations of sewage);

Gates v. Collier,

349 F.Supp. 881 (N.D.Miss.1972)

aff’d

501 F.2d 1291 (5th Cir. 1974) (lack of sufficient guards; high number of assaults; inadequate sewage and water systems; inadequate number of toilets; lack of adequate firefighting equipment; poor medical care).

At trial, testimony was received from dozens of inmates and TDC employees (whose descriptions of the overcrowded conditions did not substantially vary), and also from a large number of extremely well qualified experts, the like and number of which have never been assembled in any other prison case of which this court is aware. This wealth of evidence supports the conclusions here drawn as to the effects of overcrowding. Furthermore, most of the deleterious results of overcrowding found to exist at TDC are discoverable as a matter of common sense and would be apparent to any logical judicious observer.

See Battle v. Anderson,

447 F.Supp. 516, 521 (E.D.Okla.1977),

aff’d

564 F.2d 388 (10th Cir. 1977) (Many of the problems “are self evident or intuitive in nature.”).

Finally, mention must be made of

Bell v. Wolfish,

441 U.S. 520 , 99 S.Ct. 1861 , 60 L.Ed.2d 447 (1979), where the Supreme Court refused to find unconstitutional the housing of two pre-trial detainees in seventy-five square foot cells designed for one person. Although the Court stated that there was no “ ‘one man, one cell’ principle lurking in the Due Process Clause”, 404 U.S. at 542, 99 S.Ct. at 1875 , the Court specifically reserved judgment on cases presenting different facts. 404 U.S. at 544, n.27, 99 S.Ct. at 1876, n.27 . The jail involved was a short term facility from which virtually all inmates were released within sixty days. Detainees generally were locked in their rooms from eleven at night until six in the morning, and for brief periods during the afternoon and evening head counts. During the rest of the day, they were free to move about between their rooms and the common areas. In addition, the

Wolfish

jail was designed according to the most contemporary correctional and architectural standards and complied with all fire safety codes and provisions. Finally, rooms had direct access to sunlight and were equipped with doors, not bars.

The

Wolfish

facility undoubtedly presents quite a different perspective to the prisoners confined there than does the grim prospect faced daily by TDC inmates. First, the floor area of the average cell at TDC is closer to forty-five than sixty-five square feet. Next, a substantial proportion of the inmates are not free to move about; some are unassigned, others in a medical lay-in status, and more are in lockup (administrative segregation). These inmates typically are confined to their cells for a large portion of both their waking and sleeping hours. The movements of the inmates who work are highly regimented, and even these inmates spend an average of ten hours a day in their cells on working days, and much more on weekends. Significantly, many inmates at TDC must endure their overcrowded quarters for months or years on end.

Recognition of the potential hardship caused by overcrowded prison conditions led the

Wolfish

court to state that

confining a given number of people in a given amount of space in such a manner as to cause them to endure genuine privations and hardship over an extended period of time might raise serious questions under the Due Process Clause as to whether those conditions amounted to punishment....

Id.

at 542 , 99 S.Ct. at 1875 . The evidence shows that the overcrowding to which TDC

*1288

inmates are presently subjected is of such magnitude as to amount to severe punishment.

This conclusion is fully undergirded by both the facts and the prior case law. It will, therefore, be a part of the relief accorded to the plaintiff class that defendants take immediate action to end overcrowding at all TDC facilities. The relief to be granted will include,

inter alia,

the following: (1) a prompt and expeditious end to triple-celling of inmates; (2) the elimination of routine double-celling of inmates in the forty-five and sixty square foot cells; and (3) alleviation of the intense overcrowding in the dormitories.

III. SECURITY AND SUPERVISION

A.

1.

Compendium

All persons in a penal institution are entitled to physical safety. The nature of the safety afforded them is largely dependent upon the persons employed by the institution-their training, their number, their deployment, and the duties assigned to them. When analyzed on these bases, the TDC security staff reveals serious inadequacies. Training is brief and fails to provide new guards the skills needed for the effective, safe performance of their duties. A high turnover rate results in virtually perpetual vacancies in low-level guard positions. More importantly, there are simply too few civilian guards adequately to supervise inmate activity. These deficiencies in the security staff have either created or exacerbated many other security and safety problems.

32

In essence, TDC has failed to furnish minimal safeguards for the personal safety of the inmates. Primarily because the civilian security force is insufficient in number and poorly deployed, inmates are constantly in danger of physical assaults from their fellow prisoners. To compensate for the serious understaffing, TDC has institutionalized the use of certain inmates as auxiliary guards, to assist the civilian security forces in controlling the units. This “building tender” system maintains picked inmates in positions of authority over other inmates, despite the mandate of state law to the contrary.

33

Moreover, these chosen inmates often brutalize their fellow prisoners, with the tacit approval or direction of civilian prison personnel. The civilian security officers augment the violence themselves, frequently indulging in acts of brutality against inmates.

2.

Security Staff/Understaffing

a. Background

TDC security officers

34

are primarily white males from rural communities. Some have had military or college training prior to their employment, but this preparation is not a prerequisite for a position. Many guards aspire to careers in law enforcement, and their TDC jobs are simply a means to obtain practical knowledge before

*1289

moving on to more desirable and higher paying positions in this field. A number of TDC employees attend college when not at work, usually at Sam Houston State University. Pursuit of a higher education is encouraged by prison officials, but TDC encounters difficulties in keeping its best educated guards. Also, problems in recruiting and retaining minority employees have repeatedly been manifested.

35

Minority recruital is difficult, because most TDC units are located in isolated rural communities not having significant minority communities and often lacking adequate housing, particularly for families. These same factors hamper recruitment of persons accustomed to life in urban areas. Further, persons who might otherwise be disposed toward a career in TDC are deterred by the inadequate pay for low-level correctional officers.

36

W. J. Estelle, Jr., Director of TDC, testified that most of the employees with promising futures leave in a relatively short time. Those who remain and are eventually filtered upward into higher ranking positions characteristically have strong personal ties to TDC or to the communities in which they work. Virtually all of TDC’s high level employees have, to some extent, come through the ranks; persons from without the system are almost never hired directly for such positions.

A substantial percentage of inmates are from urban areas, chiefly the cities of Dallas and Houston. The combined total of black and Mexican-American inmates constitutes a majority of the TDC inmate population. Both groups are from subcultures radically different from that of the rural whites who typically supervise them. Given the racial, ethnic, cultural and regional differences separating them, mere communication between inmates and guards is not easy. Empathy and understanding, the latent corollaries of truly comprehensible dialogues, are exceedingly difficult to realize.

b. Training

Newly employed security officers attend a TDC training school before assuming positions inside the prisons. To more quickly supply needed manpower, the training program, which formerly lasted four weeks, was reduced to two weeks. Even though the syllabus for the training school includes a comprehensive list of topics, many complicated and important topics are covered in a short period of time.

37

The ambience of TDC prisons is one of generally felt tension and discord, attributable to such factors as the contrarieties of guards and inmates and the omnipresent overcrowding. Violent clashes frequently

*1290

erupt among the inmates and between the guards and inmates. Regardless of these conditions, guards are not given any actual physical training or practice in the appropriate uses of limited physical force for the restraint of inmates or the proper utilization of riot batons or mace. At most, trainees view a film which discusses such subjects. Similarly, they receive but little instruction as to verbal, non-physical means of calming these crises. In other institutional settings, the evidence showed, such programs have lessened the frequency of overreaction and physical violence.

When a new training school graduate initially arrives at a unit, he is usually assigned to accompany an experienced guard engaged in the performance of his duties. This serves to familiarize the new guard with the nature and extent of his functions and responsibilities before he undertakes them alone. The tine so spent may vary from a day or two to two weeks. All further training is received on the job, until the employee reaches a higher ranking position. Several former correctional officers, who were worthy of belief, testified that the policies and practices they learned on the job differed markedly from those learned at the training school. For example, these officers were taught at training school that all inmates should be treated equally and fairly. At the units, however, they were directed to keep an especially close watch on “writ writers”

38

and to deal harshly with their infractions, while at the same time awarding special privileges to, and largely ignoring violations by, favored inmates such as “politicians” and “building tenders.”

39

Indeed, for the first several months of employment, new correctional officers must unlearn the policies taught at the training school. This casts doubt upon the validity of TDC’s formal descriptions of its training programs and procedures and lends credence to allegations that its prisons are run according to unwritten rules which are inconsistent with the officially expressed policies.

(See

Sections V and III A.3.)

c. Staff Duties and Responsibilities; Understaffing

TDC prisons are severely understaffed, a fact essentially undisputed by TDC officials.

40

The evidence shows that during the years 1973, 1974 and 1977, TDC had the worst staff/inmate ratio of any state prison in the United States. During the summer of 1979, TDC employed approximately one uniformed guard for every 12.45 inmates, one of the most unfavorable, if not the worst, staff/inmate ratios in the nation. The Texas Legislature authorized appropriations for staffing at a ratio of one guard to eleven inmates, beginning September 1, 1979.

41

Nationally, the average guard-to-inmate ratio is .one to five.

42

*1291

Director Estelle recognized that the TDC guard-to-inmate ratio is the lowest in the country. Indeed, in 1976, he characterized a ratio of one to twelve as “extremely dangerous”. He and other defense witnesses insisted, nevertheless, that TDC prisons are being safely managed at current staffing levels, contending that TDC’s physical design and its management methods require fewer security officers than might be necessary in other systems. TDC officials also asserted that computations of guard-to-inmate ratios should include non-uniformed staff members, although their primary functions are not related to security.

As to the latter claim, it is clear that non-uniformed employees, such as medical personnel, vocational and industrial supervisors, teachers, and food service stewards, are primarily concerned with providing services and programs to inmates and have little to do with secuity

per se.

Computing their presence would thus be irrelevant to an assessment of security effectiveness at TDC. The national guard-to-inmate average, referred to above, and the comparable statistics from other prison systems do not take account of non-uniformed, non-security prison employees.

The defendants’ argument that fewer security officers are required at TDC than in other prison systems must be evaluated by an examination of TDC’s actual deployment of its disproportionately underpopulated staff. TDC security officers perform three basic functions: (1) patrolling the security perimeters of the institutions, to prevent or detect escapes, (2) supervising inmates at their work or school assignments, and (3) managing and controlling inmate movement and activities into, out of, and within the main building of each unit (where housing, eating, medical, and recreational facilities are located). Perimeter security guards work in the outside pickets (gun towers) and radio patrol units, hence they rarely come into direct contact with inmates. Most of the security officers who supervise work activities are assigned to the agricultural fields. Because these fields are beyond the prisons’ security perimeters, inmates in the agricultural lines are closely supervised by armed officers on horseback. The overall shortage of security staff has meant that fewer inmates are dispatched to the fields on a given day than would be the case otherwise, and those who are not assigned to work on that day remain idle in the housing areas.

43

It is there, in the housing areas-both during the day and at nighttime-, that the understaffing is most acutely felt.

The main buildings of most TDC units consist of cellblock and dormitory wings that intersect perpendicularly with long central halls.

44

Groups of prisoners are moved up and down the halls throughout the day, as they leave for work and school and return for food and recreation. During the day, building security personnel primarily function to coordinate and supervise these movements, and to keep track of unassigned inmates. On each shift, a specified number of security officers work in locked picket stations inside the buildings. These picket guards can observe activities in the halls, but they are forbidden to leave their stations. Many of the remaining guards are at specific posts along the central halls or within the dining rooms or writ rooms, although, if necessary, these guards have authority to go elsewhere in the building. These deployments leave few officers available to supervise the cellblocks and dormitories.

During the day, it is not uncommon for one guard to be responsible for supervising two to four cellblocks

45

or dormitories. Much of his time is occupied with perform

*1292

ing searches and shakedowns of inmates entering or leaving the cellblocks or dormitories and attending to the count. He is ordinarily stationed outside the cell area and usually can only see into the first four or five cells. Guards are never stationed inside the dormitories, although the evidence made it clear that activities inside the dormitories cannot adequately be observed from the outside.

Defendants’ witnesses repeatedly sought to point out that the housing areas are not full during the day. However, as already noted, on any given work day, a large percentage of inmates in the agricultural lines are idle; this, added to the fact that approximately ten percent of the inmate population is on an unassigned status every work day,

46

shows that the housing areas do, in reality, contain a substantial number of inmates during daytime hours. Also, some inmates are frje to return to their living areas before or after meals and in between working hours.

At night, most inmates are locked inside their cells or dormitories. Included among the principal tasks of the nighttime guards are keeping watch, handling such emergencies as may arise, and taking at least three nightly counts of the inmates in their charge. Each nighttime guard is assigned to supervise several hundred inmates, virtually all in doubly or triply occupied cells or cramped dormitories. A single guard will often be responsible for as many as four cellblocks, each of which contains three tiers. As previously noted, no guards are stationed inside the dormitories, and none will enter unless summoned from within. Additional burdens for these guards stem from the fact that movement through the prison halls is suspended for only a few hours during the nighttime. A final lockup is usually set at 10:00 p. m. Some inmates are awakened as early as 2:00 a. m., and many units begin serving their regular breakfast lines as early as 3:00 or 4:00 a. m. The resultant movement of prisoners creates even more responsibilities for the sparsely placed guards.

47

As an inevitable result of these staffing patterns, inmate activities within the housing areas are almost entirely unsupervised by civilian personnel. No security officers keep watch over the dormitory rooms. It is nothing short of impossible for one guard adequately to supervise two, three, or four cellblocks. The defendants themselves noted, in one of their exhibits, that “with only one officer assigned to two or four cell-blocks, the majority of inmates can do as they please when the officer is searching and counting those coming in or out.” At TDC units, two three-tiered cellblocks typically face each other across an open space. There are no crossover catwalks across these spaces; thus, to move from the second or third tier of one cellblock to the other, an officer must descend the narrow staircases between the tiers on one side, cross over on the ground floor level, and then ascend staircases to the appropriate level on the opposite cellblock. Since inmates cannot be seen from the stairways, this arrangement severely hinders the officers’ capability to respond quickly to disturbances or emergencies involving inmates in cells, and also limits their capacity to observe inmate activity in these locations. Indeed, it is extremely difficult for one guard safely to supervise even one cellblock, because inmates on more than one level cannot be observed simultaneously.

This lack of supervision means that aggressive and predatory inmates are free to do as they wish in the living areas, and their victims can be threatened, extorted, beaten, or raped, in the absence of protection from civilian personnel. No guards are present voluntarily to come to the aid of the victims or to prevent the attacks in the first place. Furthermore, inmates who feel threatened cannot necessarily communicate their fears to prison officials. A strong

*1293

prison code against informing exists among the inmates. Only an inmate having a special relationship with guards is able to make his straits known to officers without fear of being retaliated against by other inmates. If he remains in the general population, an inmate who violates this code increases his chances of being assaulted.

Simply put, inmates live in a climate of fear and apprehension by reason of the constant threat of violence. Indeed, to escape threatened physical attacks, several inmates have deliberately violated rules in order to be consigned to some form of punitive segregation. Self-mutilation being a disciplinary offense, some have gone to the extent of cutting their arms, legs, or heel tendons to achieve temporary transfers to administrative segregation, solitary confinement, or the hospital.

48

Numerous examples of the inability of TDC staff to protect inmates’ personal safety were graphically presented by credible testimony at trial. Three of the more shocking events, described by two TDC wardens, occurred within a twenty month period at two different institutions. The three incidents, described in the margin,

49

each involved physical torture and sexual abuse of inmates by their cell partners over a period of days. In each case, prison administrators concluded that individual guards had not been at fault in failing to discover these situations sooner, and no disciplinary action was taken against any of them. The wardens sought to characterize these incidents as regrettable, but rare, and not indicative of general security problems. It appears evident, however, that in a properly staffed maximum security institution, these types of prolonged torture would be quickly discovered.

In several cases, the official TDC incident reports of violent incidents include statements to the effect that, because of shortages in personnel, no officers were assigned to the areas where the incidents took place. The record also contains several examples of successful suicides which were not discovered until several hours after they occurred, although an officer was obligated to check the cells where the suicidal inmates were confined at least once every hour.

*1294

Although granting that assault rates

50

within their prisons are high, TDC officials maintain that the prisons are safe, citing statistics to the effect that escapes are virtually unheard of and homicides are uncommon. TDC’s record in these areas is somewhat impressive, although the statistics are subject to varying interpretations.

51

In any case, this does not end the inquiry into safety and security of TDC prisons. The fact that escapes are uncommon has little to do with the conditions of safety

within

the institution. The low escape rate demonstrates that TDC is fulfilling its duty to protect the safety of outside communities; it does not indicate whether TDC is discharging its obligation to defend the security of the confined inmates.

Similarly, while TDC’s relatively low homicide rate evinces that inmates do not often succeed in killmg one another, that fact is not necessarily inconsistent with the determination that TDC institutions are generally unsafe and that inmates live in fear of harm from other inmates. The comparatively low rate of homicides in TDC is attributable to a number of components, including routine strip searches of individuals, frequent shakedowns of entire cell-blocks to uncover lethal makeshift weapons,

52

and rather strict rules regarding visitation and inspection of incoming mail. However, those factors which decrease the availability of deadly weapons do not necessarily reduce the opportunities for nonhomicidal violence. While inmates may not be subject to murder at excessive rates, that does not relieve their well-founded apprehension of extortion, assault, and rape. Therefore, TDC’s low homicide rates do not preclude or modify the finding that TDC institutions are unsafe and charged with a climate of fear.

3.

Building Tender System

A Texas statute expressly prohibits the use of inmates in a supervisory or administrative capacity over other inmates and forbids any inmate to administer disciplinary action to another prisoner.

53

Disregarding this statutory provision, TDC has compensated for its chronic shortages of civilian security personnel by using inmates to perform security functions.

54

TDC officials agreed that a large number of inmates hold jobs in which they assist officers; notwithstanding, they deny that these inmates exercise supervisory authority over other inmates.

*1295

While these inmates now hold a number of different official job titles, in the past they were generally referred to as building tenders.

55

Most building tenders at a unit are selected by the warden, but the selection must receive the approval of the TDC State Classification Committee.

56

These are the only jobs assigned to inmates in the TDC system which require approval by the Classification Committee. Defense witnesses testified that the approval process is designed to insure that the inmates selected will not abuse their authority. It is evident, however, that the State Classification Committee exercises a very ineffectual check on the wardens’ selections for these positions, for under the procedures employed, violent, corrupt and brutal inmates-some particularly notorious-have routinely been approved.

57

TDC officials testified that the officially approved duties of building tenders, set out in the margin,

58

include only routine tasks that vary according to specific job assignments. However, conclusive evidence shows that,in reality, building tenders are allowed to do a great deal more than merely assist officers at routine tasks. For instance, building tenders are used by TDC officials to gather intelligence concerning the activities, expressions, and attitudes of other inmates.

59

More importantly, they quite often literally serve in the capacity of guards. In the words of one of the defendants’ expert witnesses, these inmates do the guards’ “dirty work,” serving as enforcers of the ranking officers’ will in the living areas, and harassing, threatening, and physically punishing inmates perceived as troublemakers.

60

*1296

Building tenders have unofficially been given such specific powers as issuing orders to other inmates, assisting in taking daily counts of the population, keeping track of inmate movements, escorting inmates to different destinations within the prison, and distributing correspondence and commissary scrip. Some are authorized to be in possession of keys outside the presence of civilian personnel, and others operate the automated opening devices which control access to cell blocks, day rooms, and other parts of the institutions. In the day rooms, building tenders are in complete control; e.

g.,

they enforce order and silence, operate the controls of television sets, and regulate the games that can be played.

The fact that building tenders work closely with civilian security personnel gives them several significant advantages, which they may readily abuse. Often, their greater contact with prison officials permits them the opportunity to arrange or influence job and housing changes, and to sell their influence over such matters to other inmates. Some have access to records concerning inmates’ financial resources, and others are authorized to assist in preparing and editing disciplinary reports. Certain building tenders are able to view general inmates’ files and use the information to operate extortion, prostitution, and usury schemes. Another common practice of building tenders is to “run stores”, that is, to sell to inmates, for exorbitant prices, commissary items in high demand. A free market situation does not prevail in these circumstances; building tenders have the power to punish inmates who refuse to deal with them on the demanded financial or sexual bases. The building tenders’ puissance in this respect extends to causing the loss of privileges (e.

g.,

the right to go to the commissary; favorable job or housing assignments) or even the infliction of physical punishment. Common inmates place themselves in extreme danger in any conflict with building tenders; the decisions of the latter concerning the inmates under their supervision are almost universally upheld by TDC officers. When such conflicts arise, the subordinate inmates are but rarely provided with protection from abuse by TDC officers. In point of fact, at some units, building tenders have and exercise more authority than low-level correctional officers. Several former TDC officers stated that they were taught their duties by building tenders, and learned quickly never to challenge them, particularly if the officer the building tender “worked for” was of high rank.

61

Of overriding significance is the fact that building tenders are often permitted to carry weapons,

62

which are employed to threaten and discipline other inmates. At some units, building tenders have routinely used such weapons, under the eyes and at the express direction of prison officers. At other units, the attitude toward possession and use of weapons by building tenders is one of deliberately kept ignorance; that is, guards willfully choose not to see that building tenders brutally enforce discipline on subordinate inmates by use of weapons. At still other units, the officials’ failure adequately to check building tenders’ rampant, callous utilization of arms results from lax supervision of these particular inmates, who are only infrequently subjected to searches and shakedowns.

63

This notorious

*1297

ability of building tenders to keep and use weapons is in marked contrast to TDC’s generally effective system of curbing the presence of arms and other contraband among the general inmate population, a disparity which supports the conclusion that the lapses of officials toward building tenders are not accidental.

The availability of weapons, as well as the other concomitants of power possessed by building tenders, allows them to engage in acts of marked brutality toward other prisoners. Of the many incidents of building tenders’ brutality shown by the evidence, those set out in the margin are merely illustrative.

64

In return for their assistance to the prison authorities, building tenders enjoy certain special privileges. They have greater mobility and access to facilities than do other inmates. Their cells are unlocked for more hours each day (professedly to perform their janitorial duties), thus enabling them to roam the building or parts of it-or, in certain instances, the institution-at will. The cells set aside to some building tenders are never locked. They may also elect when to eat within the several hours allotted to serving meals, and frequently they have been permitted to get late-night snacks from the kitchen after regular serving hours. Freer access than other inmates to indoor recreational facilities, as well as first priority in their use, is also granted building tenders. In many instances, these favored inmates are also permitted their choice of cell location;

65

or they may opt to have a single cell-even with other cells have one or more inmates sleeping on the floor. Building tenders have also been permitted to keep extra furniture in their cells, to keep pets, and to wear extra clothing, all being privileges not permitted the general inmate population. Low-level correctional officers are often directed by their ranking superiors not to bother to “shake down” building tenders; hence, they are seldom searched. Except for the most obvious, grievous offenses, building tenders ordinarily have actual or implied immunity for most disciplinary action, and a significant punishment for even their serious rule infractions is rare.

66

*1298

Expert witnesses for all parties have detailed some of the harms involved in the building tender system. According to their testimony, giving one group of inmates authority over others is an invitation for resentment, misunderstandings, physical confrontations, and clashes between the two inmate classes.

67

Their opinions were supported by numerous TDC incident reports revealing the enmity, rancor, and bitterness of spirit emanating from the inmates’ indignation at receiving orders from building tenders.

68

Frictions and tensions respecting building tenders are compounded at most units by the fact that they function with extended authority and are afforded the numerous privileges detailed above.

The overwhelming weight of the evidence demonstrates that abuses of authority are inherent in the buildi ng tender system, and that TDC officials are directly responsible for that system’s continuation. The prison officials’ arguments that abuses by building tenders are infrequent deviations, not in anywise sanctioned by them, contravene the clear implications of the testimony of their own witnesses. The very existence of the State Classification Committee approval process for sensitive jobs represents a recognition by defendants that close observation and study of the inmate appointees is a necessary accompaniment to the appointments. Clearly, any screening which has occurred has been grossly deficient; hence, partial blame for the abuses of building tenders appointed through this process lies with the approving officials. Similar culpability attaches to other high-level TDC officials, all of whom allow the building tender system, with its systemic abuses, to be perpetuated. This conclusion might be undercut if the record revealed that building tenders are frequently and systematically disciplined for abuses of their positions, but all evidence points to a contrary conclusion. As noted before, building tenders involved in serious incidents, documented in defendants’ official records, have retained their jobs after receiving either minimal disciplinary action or none at all.

In short, TDC officials have not adequately controlled the unlawfully maintained building tender system, and they have directly and indirectly permitted its abuses to be visited on the inmates of Texas prisons.

69

*1299

4.

Staff Brutality

Brutality by security officers is widespread in TDC prisons, the frequent use of physical force being one of the means employed by the overtaxed and sparsely placed security officers to keep control of the inmate population. Thus, inmates must live not only in fear of their fellow inmates, but of their keepers as well. Physical punishment is meted out by officers in a variety of situations and in a number of forms. The record is replete with credible evidence of inmates being unreasonably and unmercifully beaten with fists and clubs, kicked, and maced by the officers whose ostensible duty includes protecting them from harm. Many of the injuries so inflicted have required extensive medical care.

Indeed, the frequency of prison guard violence makes it apparent that brutality against inmates is nothing short of routine in the Texas prisons. Many of the incidents testified to by plaintiffs’ witnesses were unrefuted by the defendants. As to other incidents, the defendants conceded that rough actions were involved, but contended that the force exercised by the officers was not excessive. As noted later in this section, the evidence strongly imports that the force employed by guards was, in fact, intolerably excessive on many occasions.

TDC officers habitually utilize physical force in a number of situations: (1) The administration of summary punishment, in the form of physical abuse, is a part of the standard procedures employed to control and supervise inmates. (2) Officers capriciously brutalize such inmates as writ writers, whose activities, although not in violation of any institutional rules, are insupportable to a great many TDC officials. (3) Security officers frequently respond with excessive force to violence or resistance by inmates, retaliating against the inmates by teaming up with other staff members or building tenders to inflict brutal beatings on them. Many of these beatings occur long after the situation which may have legitimately necessitated physical force has been eliminated. (4) Officers often meet what they perceive as major disturbances-attempts at escape and any concerted action or refusal to act by groups of inmates-with displays of force whose primary purpose and effect are clearly punitive rather than remedial. Each of these four situations shall be discussed in more detail.

As to the first, examples of the uses of physical punishment by TDC officers to assist in the day-to-day management of the prisons are numerous. A frequent practice of officers is to push and kick inmates whom they are escorting up and down stairs, and generally to use some form of physical prodding to keep inmates moving. In the agricultural fields, such practices are also common, and some have proved quite dangerous.

70

A separate problem is the frequent use of summary physical punishment, either before or in lieu of formal disciplinary charges, directed against inmates accused of disobeying rules or orders.

71

One of the more subtle forms of such punishment is the common practice of requiring inmates to “stand on the wall”. This procedure involves the inmate’s standing in one place in the hallway for long periods of time, sometimes in an awkward or humiliat

*1300

ing position, e.

g.,

having his nose and feet touching the wall. Several witnesses, including former officers, reported that inmates have been forced to “stand on the wall” for long periods of time, sometimes overnight or for several days running. Ordinarily, these inmates are not allowed to sit down, and they may be physically abused by officers, if it is discovered that they moved from their place “on the wall” without permission. In some cases, inmates who were too tired to stand at an assigned place were handcuffed to a bar or rail in an upright position.

72

The second situation involves the physical brutality often used by TDC officers against inmates who activities, while allowed by law and official TDC policy, are intolerable to a large number of TDC officials. The inmates most frequently singled out for abusive treatr lent are the writ writers. A few examples of the totally unwarranted and retaliatory violence employed against them are set out in the margin.

73

TDC officers frequently utilize excessive physical force against inmates who have allegedly attacked or threatened an officer or who have physically resisted efforts by officers to control their movements. It is unquestionably true that prison security officers are occasionally subjected to attacks from inmates. In such situations, quick and forceful physical responses by officers are essential to bring the attacking inmates under control and to protect the personal safety of the threatened officer and others. There is nothing objectionable about the use of physical force,

per se,

in such situations. It does not follow, however, that

any

degree of force is appropriate. The evidence revealed that, on many occasions, officers overreacted to the situations at hand or resorted to extreme amounts of physical force.

74

Even more disquieting then evidence of individual officers’ excessive responses to inmates’ aggression were the numerous incidents of needless, savage physical brutality against inmates who were already subdued or who had not participate in whatever confrontation had occurred. In these situations, the initial provocation by an inmate was used by the officers as an excuse for the administration of a severe beating.

75

*1301

Correctional officers often react excessively, and resort to unnecessary physical violence, in response to potentially serious security disruptions, such as group disturbances and escape attempts. It is not to be doubted that firm and speedy responses to potentially riotous conditions are necessary; however, the record discloses that TDC officials have not been content with merely quelling such disturbances. TDC’s official reports and eyewitness testimony established that, in various instances, unnecessary punitive physical force was used against rebellious inmates after the crucial situations had been brought fully under control.

76

*1302

Similar abuses have occurred when inmates attempted to escape. Not content with re-capture, TDC officers inflicted their own brand of punishment on these inmates. Several witnesses testified to an incident involving an inmate who was shot and slightly wounded as he attempted to break loose from the Eastham Unit. To avoid the dogs who were tracking him, the inmate climbed a tree. When the pursuing officers and dogs caught up with him, the inmate was ordered to climb down and fight the dogs. The “fight” continued for several minutes before the dogs were restrained. Afterwards, the inmate was beaten with the dog sergeant’s bullwhip. A TDC physician who subsequently treated the inmate testified that his various lacerations were characteristic of dog bites and bullwhip welts.

The defendants ha/e attempted to characterize the staff brutality at TDC as a mere collection of isolated and aberrant acts which are not characteristic of the institutions at large. Unfortunately, the evidence belies this assertion. The record in this case makes it perspicuous that violence by security officers is routine and is not restricted to dangerous situations. Nor is the brutality the sole province of a few low-level security officers; many vicious incidents of abuse implicate high-ranking TDC officials.

77

Furthermore, TDC’s systemic operations encourage staff brutality in two significant ways. First, TDC officials rarely investigate reports of violence and brutality involving civilian staff, and commonly fail to take corrective disciplinary action against officers whom they know to have brutalized inmates.

78

Second, TDC’s training program for guards fails to instruct the officers in the proper and reasonable use of limited physical force to quell inmate disturbances.

79

Both of these have the practical effect of allowing and even encouraging security officers to indulge in excessive physical violence in the performance of their duties.

State law

80

and formal TDC rules

*1303

prohibit physical brutality against inmates. That, however, does not absolve the defendants of responsibility for the actual existence of routine and unnecessary violence on the part of the TDC civilian staff. High-level TDC officials have allowed this violence to fester within TDC’s walls far too long, and have contributed to its perpetuation and exacerbation through their individual conduct and their direction of system-wide institutional operations.

B.

State officials have a duty to protect inmates from violence and the reasonable fear of violence.

While occasional, isolated attacks by one prisoner on another may not constitute cruel and unusual punishment,

Penn v. Oliver,

351 F.Supp. 1292 (E.D.Va.1972), confinement in a prison where violence and terror reign is actionable. A prisoner has a right, secured by the eighth and fourteenth amendments, to be reasonably protected from constant threat of violence and sexual assault by his fellow inmates, and he need not wait until he is actually assaulted to obtain relief.

Woodhous v. Commonwealth,

487 F.2d 889, 890 (4th Cir. 1973). Thus, a number of cases have found inadequate security to constitute or contribute to the existence of a constitutional violation.

Williams v. Edwards,

547 F.2d 1206 (5th Cir. 1977);

Gates v. Collier,

501 F.2d 1291 (5th Cir. 1974),

affirming

349 F.Supp. 881 (N.D.Miss.1972);

Pugh v. Locke,

406 F.Supp. 318 (M.D.Ala.1976),

aff’d sub nom Newman v. Alabama,

559 F.2d 283 (5th Cir. 1977);

Holt v. Sarver,

309 F.Supp. 362 (E.D.Ark.1970),

aff’d

442 F.2d 304 (8th Cir. 1971);

Alberti v. Sheriff of Harris County,

406 F.Supp. 649 (S.D.Tex.1975);

Withers v. Levine,

615 F.2d 158 (4th Cir. 1980).

The evidence makes it clear that the climate in TDC is one of fear and trepidation, engendered by the occurrence of frequent physical and sexual assaults, intimidation, bribery, and rule by threats and violence. A number of defendants’ practices have allowed this deplorable situation to develop. The defendants have failed to employ sufficient numbers of security officers to provide any systematic supervision of inmate activities, particularly in the extremely overcrowded housing areas.

81

This has produced practically unlimited opportunities for undetected assaults upon inmates by their cell or dormitory mates. Compounding the resultant sense of insecurity is the fact that the only order existent in the inmates’ living quarters is enforced through the abusive building tender system which TDC has fostered. Finally, TDC staff members have committed widespread, pervasive, and unwarranted acts of brutality upon many of the system’s inmates. All of these factors combine to create a situation of inadequate security which clearly transgresses the boundaries of the eighth amendment.

An unsafe prison environment resulting from the lack of adequate security staffing and reliance upon inmates as guards has been repeatedly condemned as unconstitutional by the courts.

See Williams v. Edwards,

547 F.2d at 1211 . In

Gates

v.

Collier,

349 F.Supp. 881 (N.D.Miss.1972), the conditions at the Mississippi State Penitentiary at Parchman were described as follows:

[T]he civilian guards assigned to the camps are insufficient in number to maintain control over the inmates. The one civilian watchman who is assigned to each camp is prohibited by penitentiary rules from entering the cages .... [Penitentiary employees have no control over inmates after the lights are turned out

*1304

and “there is no way that anyone can guard the safety of an inmate in the Parchman situation” because of the dormitory type system and the lack of free world personnel to guard and protect inmates.

349 F.Supp. at 889 . Parchman utilized a system of armed trusties to compensate for insufficient civilian guards:

The primary duties of guarding other inmates are performed by trusties who are selected by the sergeants without the use of objective criteria or uniform standards. * * * Inmates have, on many occasions, suffered injuries and abuses as a result of the failure to select, train, supervise, and maintain an adequate custodial staff .... The evidence indicates that the use of trusties who exercise authority over fellow inmates has established intolerable patterns of physical mistreatment.

Id.

The district court in

Gates

held that the lack of adequate protection from assaults and the assignment of custodial responsibility to untrained, incompetent inmates violated the eighth amendment. 349 F.Supp. at 894 . Affirming, the Fifth Circuit stated:

It is the obligation of penitentiary officials to insure that inmates are not subjected to any punishment beyond that which is necessary for the orderly administration of Parchman .... The infliction of these physical injuries is no less tolerable because accomplished by the inmates with the assistance and acquiescence of the prison authorities, then [sic] if perpetrated by the prison superintendent alone.

501 F.2d at 1309 .

Pugh v. Locke,

406 F.Supp. 318 (M.D.Ala. 1976),

aff’d, Newman v. Alabama,

559 F.2d 283 (5th Cir. 1977), found a constitutional violation in the Alabama prisons, where such a dearth of civilian staff existed that guards rarely entered the cell blocks at night. Accordingly, the maintenance of the order was left to inmate “cell flunkies” and opportunities for violence, blackmail, bribery, and extortion were the inevitable result.

In

Alberti v. Sheriff of Harris County,

406 F.Supp. 649 (S.D.Tex.1975), the county jail was found to be inadequately staffed when the guard to prisoner ratio was one to thirty. Inmate “goon squads” had developed, because of insufficient and inadequately trained staff, resulting in violent attacks by inmates upon other inmates, including homosexual assaults and rapes.

The use of custodial inmates was addressed in the landmark case of

Holt v. Sarver,

309 F.Supp. 362, 373 (E.D.Ark.1970),

aff’d

442 F.2d 304 (8th Cir. 1971), where the court noted that the practice is “universally condemned by penologists . . . [because] it breeds fear and hatred.”

By virtue of their positions of authority and the functions they perform trusties can make or break [other inmates]. They can make prison life tolerable or they can make it unbearably hard. They can and do sell favors, easy jobs, and coveted positions; they can and do extort money from inmates on any and all pretexts. They operate rackets within the prison, involving among other things the forcing of inmates to buy from them things like coffee at exorbitant prices. They lend money to [inmates] and then use force or threats of force to collect the debts.

309 F.Supp. at 375 .

Indeed, the potential for abuse in a building tender system has been recognized by the Texas legislature, which outlawed the placement of any inmate in a supervisory or administrative capacity over other inmates and the administration of disciplinary qction by any inmate to other inmates. Tex.Rev.Civ.Stat.Ann. art. 6184k-1 (Vernon Supp.1980). As the evidence makes apparent, both this Texas statute and the federal Constitution have been violated by the building tender system as operated at TDC.

The widespread, staff brutality at TDC is also in contravention of the Constitution. Brutalities similar to those found in the Texas prisons have, in other cases, been deemed cruel and unusual. In

Gates v. Collier,

501 F.2d 1291 (5th Cir. 1974), the record contained numerous examples of unwarranted physical punishments akin to

*1305

those which occur in TDC institutions. The Fifth Circuit found the existence of such widespread and unnecessary corporal punishment to run afoul of the eighth amendment, and stated that the district court was “unquestionably” correct in enjoining prison authorities from permitting the further use of certain methods of punishment. 501 F.2d 1306 .

Similarly, in

Morales v. Turman,

364 F.Supp. 173 (E.D.Tex.1973), 383 F.Supp. 53 (1974),

rev’d,

535 F.2d 864 (5th Cir. 1976),

rev’d,

430 U.S. 322 , 97 S.Ct. 1189 , 51 L.Ed.2d 368 ,

remanded

562 F.2d 933 (5th Cir. 1977), it was found that the repeated and unwarranted hitting, slapping, kicking and punching of juveniles detained in state youth homes was punishment of a cruel and unusual nature.

The Court of Appeals for the Second Circuit has held that retaliatory brutalities “wholly beyond any force needed to maintain order” are far in excess of “what our society will tolerate on the part of officers of the law in the custody of defenseless prisoners” and are, therefore, in violation of the eighth amendment.

Inmates of Attica Correctional Facility v. Rockefeller,

453 F.2d 12, 22-23 (2d Cir. 1971).

82

Courts have also condemned the unnecessary use of tear gas and chemical agents as violative of the eighth amendment.

Battle

v.

Anderson,

376 F.Supp. 402 (E.D.Okl. 1974);

aff’d

564 F.2d 388 (10th Cir. 1977);

Landman v. Royster,

333 F.Supp. 621, 649 (E.D.Va.1971);

Morales v. Turman,

364 F.Supp. at 173-74 ). In

Battle,

the court said:

[T]he use of chemical agents must never exceed that reasonably required to effect the legitimate ends of penitentiary officials. Accordingly, the use of chemical agents ... on the rationale that the actual situation is one which could develop into-although it has not yet become-one in which the use of such agents is permitted, constitutes the excessive use of physical force and is prohibited.

376 F.Supp. at 433 . As the evidence in the instant case has shown, tear gas has been unnecessarily employed on a number of occasions to brutalize TDC inmates.

83

Unwarranted staff brutality at TDC violates not only the eighth amendment, but the fourteenth amendment as well, inasmuch as it constitutes punishment devoid of the benefits of due process of law.

Hamilton v. Chaffin,

506 F.2d 904, 909 (5th Cir. 1975);

United States v. Stokes,

506 F.2d 771, 775 (5th Cir. 1975);

Tolbert v. Bragan,

451 F.2d 1020 (5th Cir. 1971);

Bruce v. Wade,

537 F.2d 850 (5th Cir. 1976).

In their attempts to remedy prisons and jails determined to be unconstitutionally unsafe, the courts have fashioned broad relief in the areas of screening, hiring, training and utilizing prison personnel. In

Williams v. Edwards,

the Fifth Circuit affirmed the district court’s order that two guards be present at all times in the open dormitories, stating that:

*1306

The number of prison guards necessary to assure a constitutional level of inmate safety must bear some reasonable relationship to the total number of inmates. A proper ratio should be established by reference to the various kinds of facilities at the prison, taking into account the capacity and purpose of each, thereby determining the number of guards required to provide security in each; or by proof showing usual adequate ratios established at other institutions where the level of prison violence is acceptable; by proof of learned studies, or by other proof acceptable to the District Judge.

547 F.2d at 1213 .

In

Gates v. Collier,

the district court ordered,

inter alia,

that adequate protection be provided to inmates confined in barracks, “including the assignment of additional employees to tl e cages and means for controlling the acquisition and possession of weapons by inmates.” 349 F.Supp. at 897-98 . It was further ordered that defendants produce a plan for “the rapid elimination of the trusty system as presently existing at Parchman and conversion of a system of civilian guards.” Further, it was required that the plan include “the means of hiring, training, and financing” additional civilian guards. 349 F.Supp. at 898 . Three civilian guards were to be assigned to each barrack during night hours, and floor-walkers and other inmates with custodial responsibilities were to be relieved of such responsibilities. The existing trusty system was to be dismantled in phases, with the trusties to be replaced by civilian guards. Moreover, lack of funds was not to excuse delay. 349 F.Supp. at 903 .

In affirming this order, the Fifth Circuit stated:

Not only do we agree that the totality of the present practices fosters cruel and unusual punishment, but we also conclude that none of the above measures ordered require burdensome implementation or is beyond the remedial jurisdiction of the district court.

Gates v. Collier,

501 F.2d at 1309-1310 (5th Cir. 1974).

In

Pugh v. Locke,

the district court ordered that, except for isolation units, one guard be inside and one outside each living unit at all times. “As to isolation units, guards must be stationed at all times so as to have visual and voice contact with the isolated prisoners.” The order further stated: “At no time shall prisoners be used to guard other prisoners, nor shall prisoners be placed in positions of authority over other inmates.” 406 F.Supp. at 333.

The supervision of inmates by inmate “corridor bosses” in the Dallas County Jail was enjoined by the district court in

Taylor v. Sterrett,

344 F.Supp. 411, 422-23 (N.D.Tex.1972),

aff’d in relevant part,

499 F.2d 367 (5th Cir. 1974),

cert. denied

420 U.S. 983 , 95 S.Ct. 1414 , 43 L.Ed.2d 665 (1975). There, it was ordered that enough jail guards be provided to maintain security without the assistance of inmates, and the use of “inmates as corridor bosses to enforce rules and preserve discipline” was prohibited. 344 F.Supp. at 423 .

In

Alberti v. Sheriff of Harris County,

406 F.Supp. at 691, the defendant sheriff was required to develop a comprehensive selection and in-service training plan for security officers, including psychological evaluations that would disclose personality defects rendering individuals unsuitable for work as jailers.

In addition to the instances noted above, courts mandated the hiring of additional security guards and the promulgation of specific requirements for the selection of training of personnel in

Miller v. Carson,

401 F.Supp. 835 (M.D.Fla.1975),

aff’d

563 F.2d 741 (5th Cir. 1977);

Hamilton v. Landrieu,

351 F.Supp. 549 (E.D.La.1972); and

Jones v. Wittenberg,

330 F.Supp. 707 (N.D.Ohio 1971),

aff’d sub nom. Jones v. Metzger,

456 F.2d 854 (6th Cir. 1972).

In

Holt v. Sarver,

the district court held that trusties should be under the full control and adequate supervision of civilian personnel and ordered an overhaul of the trusty system,' saying that the trusties must be “stripped of their authority over the lives and living conditions of other convicts.” 309 F.Supp. at 384 .

*1307

It is clear from the applicable law that this court has the authority, indeed the duty, to take the steps necessary to remedy the unconstitutional climate of fear and violence that permeates TDC institutions. This will require,

inter alia,

a significant increase in the quantity of civilian guards, improvements in selections and training procedures for security officials, the complete elimination of the building tender system, and the cessation of staff brutality toward prison inmates.

IV. HEALTHCARE

Plaintiffs and plaintiff-intervenor assert that TDC provides constitutionally insufficient health care for inmates incarcerated at all eighteen of the units. Within the term “health care”, they include medical and psychiatric therapy, and special treatment for handicapped inmates. These three areas will be discussed separately.

Medical Care

A.

1.

Compendium

Medical care for TDC’s overcrowded inmate population is provided almost exclusively at facilities which are operated by TDC employees and designed specifically for the care of inmate patients. Three basic levels of care are available. (1) Each unit has a small infirmary, which is managed primarily by medical assistants and inmates, with some degree of supervision by a physician. Unit medical personnel provide routine services, such as administration of medications. All inmate medical complaints are first evaluated by members of the staff, who determine whether to treat the inmates on the unit or to refer them elsewhere. (2) Relatively serious, but not critical, illnesses and injuries are referred to the Huntsville Unit Hospital (HUH), which is staffed by TDC doctors, medical assistants, and inmates. (3) Extremely serious medical conditions requiring intensive care or sophisticated surgery or treatment are referred to John Sealy Hospital (“John Sealy”), a part of a state medical school facility in Galveston. Some inmates are also taken to John Sealy for treatment on an outpatient basis. TDC inmates being treated at John Sealy are confined in a “discrete wing” of the hospital, where primary treatment is provided by regular hospital physicians. TDC medical support personnel and guards are also assigned to this unit of the hospital. A new, more complete hospital is currently being built exclusively for TDC inmates at the John Sealy facility. Also, TDC has a facility known as the Diagnostic Unit at Huntsville, where all new inmates are taken for initial processing and an evaluative medical examination before being transferred to a particular unit.

Major problems pervade all aspects of the medical care provided by TDC to its inmates. The personnel providing routine medical care are often unqualified; they are also wholly insufficient in numbers and deficiently supervised. The meager medical facilities, inadequately equipped and poorly maintained, do not meet state licensing requirements. Medical procedures are unsound and faulty at all levels of care. Initial processing, sick call methods, and transfer practices are all unnecessarily cumbersome, inefficient, and life-threatening. Proper medical treatment and practice is often sacrificed to exaggerated concerns about security. Medical records are so poorly maintained, and the entries made therein are so incomplete and inaccurate, as to be either useless or harmful in the day-to-day provision of medical care and in the review of care previously provided. Finally, the entire medical care “system” is marked by an absence of any organizational structure, plan, or written procedures for the delivery of medical care or for the instruction, supervision, and review of the personnel putatively providing it. These factors combine to produce a system that persistently and predictably fails adequately to provide for the legitimate medical needs of the prison population.

2.

Staffing and Personnel

a. Physicians

The number of physicians providing medical care for TDC inmates is woefully inadequate. In 1974, the report of the Tex

*1308

as legislature’s Joint Committee on Prison Reform noted that, to meet the American Correctional Association standards for its then 17,000 inmates, TDC needed nineteen full-time physicians. TDC has never begun to approach this figure. During most of 1974, TDC employed only one full-time physician for the entire system. On several occasions since then, only two or three full-time doctors were actually present in the system. Some improvement has occurred in recent years; at the time of trial, with an inmate population of over 26,000, TDC employed the equivalent of 12.6 full-time physicians. These physicians were apportioned between the HUH, the Diagnostic Unit, and the seventeen unit infirmaries. -A total of twenty positions for physicians were authorized for the budget year beginning September 1, 1979, but TDC experienced difficulty in finding physicians to take the jobs. Even if these vacancies were all filled, the physician staffs at HUH and the Diagnostic Unit would still be grossly insufficient,

84

and some units would continue to lack a full-time doctor. Correctional medical experts for both the plaintiff-intervenor and the defendants testified to an immediate, imperative necessity for more physicians, to meet adequately the authentic medical needs of TDC’s inmate population.

In consequence of the shortage of doctors, inmate patients are consistently treated by lay personnel. Important medical decisions relating to inmate patients are routinely left in the hands of non-physicians. Even at HUH (which primarily treats inmates for whom sufficient appropriate treatment cannot be provided at the unit level), patients frequently have been admitted, “treated”, and discharged without ever being seen by a doctor. At the unit level, where medical supervision is even more sparse, medical assistants and inmate helpers are regularly entrusted to make crucial decisions concerning the screening, treatment, referral, and medication of inmate patients reporting infirmities.

The scarcity of physicians in the TDC medical system causes those who are employed to suffer constantly from the frustrations accompanying overwork. In the TDC prison environment, this form of malaise has been the source of a callous indifference on the part of some physicians to the legitimate needs of the inmate patients.

85

In any case, the evidence made clear that even the most dedicated physicians have encountered disheartening difficulties in rendering adequate treatment under the conditions that exist in TDC.

Recruitment and retention of doctors in the TDC system has proven extremely difficult. Physicians, generally in high demand throughout the free community, understandably have little incentive to work in prison surroundings, especially when it is obvious that their lot will be overwork and lack of adequate facilities, equipment, and auxiliary staff. The fact that most TDC units are located in relatively small rural communities further limits TDC’s success in recruiting qualified physicians. In the face of such difficulties, Dr. Ralph Gray, TDC’s medical director, has, on several occasions, employed doctors who were not licensed to practice in the general community. These included foreign-trained doctors who had not yet passed the necessary examinations to permit them to practice in Texas, and also recent medical school graduates who were awaiting examination results before beginning residencies. Several of the li

*1309

censed physicians he succeeded in employing lacked relevant medical experience.

86

b. Nurses

An acutely grim and unwarranted lack of licensed nurses obtains in the TDC medical care system. At the time of trial, TDC was running the Huntsville Hospital with no registered nurses (RN’s). The only RN’s in the entire TDC system work in the women’s units. This situation results, in part, from TDC’s present policy of refusing to consider hiring female nurses to work at the male units.

87

Since male nurses comprise only one percent of all RN’s in the nation, this decision limits severely the pool from which TDC can attract applicants. In spite of the recruitment difficulties imposed by the all-male policy, TDC was able to employ five male RN’s and several male licensed vocational nurses (LVN’s) at HUH during the years 1975-77. Howf ver, these nurses, who were apparently competent, well-trained, and conscientious,

88

found conditions at HUH intolerable. By the end of 1977, all had relinquished their employment. One group, which resigned

en masse,

stated that they were prompted to take this action by the inadequacy of the physician staff, the absence of any formal procedures, and TDC’s lack of commitment toward improving the level of care. The nurses in question, trained to observe appropriate limitations of their roles and aware of the need to defer certain decisions to physicians, experienced particular difficulty in dealing with the hospital administrator and the medical assistants (MA’s). These functionaries did not share similar perceptions concerning the legitimate reach of the nurse s position, preferring instead that nurses and MA’s perform tasks properly entrusted only to physicians. Rather than attempting to correct the unsolved practical and ethical problems which caused the loss of these sorely needed nurses, TDC administrators effectively decided to function altogether without licensed nurses and ceased to request budget authorizations for RN and LVN positions.

89

TDC’s failure even to attempt to employ RN’sjí and LVN’s in its hospital and unit infirmaries vividly demonstrates its virtual abdication of responsibility for the provision of adequate health care for its inmates. In the free world, HUH certainly would not be permitted to function as a hospital without the presence of RN’s around-the-clock.

90

c. Medical Assistants

Medical assistants (MA’s) perform the vast bulk of medical care provided by civilians at TDC. TDC attempts to employ persons with military or civilian experience as medical technicians for these positions; however, neither this experience nor any character of state licensure or certification is absolutely required. Thus, of the MA’s working at TDC at the time of the inspections by expert witnesses in 1976 and 1978, only one or two had medically related licenses of any kind. Some of the persons employed by TDC as MA’s had no prior training as medical technicians nor any experience with direct patient care; the previous experience of others had ended many years before they went to work for TDC. TDC itself provides MA’s with no medical

*1310

training or instruction, since these individuals are expected to learn their trade on the job. Even if an MA desired to improve and expand his knowledge on a voluntary and independent basis, the lack of supervision by physicians and the absence of basic medical reference texts at the units would make this effort virtually impossible.

Although most MA’s are neither licensed, certified, nor trained to accomplish auxiliary health care functions at TDC facilities, they routinely perform procedures'¿¿that properly should be undertaken only jpy a registered nurse or a physician. Nearly all initial screening decisions are made by MA’s. They make the determination as to whether an inmate receives any treatment at all; if so, what medication to prescribe; when to hold the inmate for examination by a physician; and when to refer the inmate patient to HUH or John Sealy.

91

Thus, the typical inmate’s access to health care is regulated from the outset by persons who would be qualified to perform only orderly-type functions at a free world hospital. Furthermore, at the units, MA’s conduct sick call, diagnose ailments, prescribe and dispense medicine, and watch over inmates in solitary confinement. As previously alluded to, an almost total absence of supervision over the activities of the MA’s by qualified medical personnel compounds the problems. TDC has no policy or procedure for regularly investigating the MA’s performance of their duties, either through observation and supervision by physicians or by examinations of medical records. This lack of oversight permits MA’s constantly to make decisions and to take actions far beyond their capabilities.

Like physicians, MA’s at TDC are subject to unremitting demands for treatment. The consequent frustrations and tensions they experience results in insensitive, casehardened sentiments toward the complaints of inmates. Further aggravating these difficulties is the fact that TDC has never employed a sufficient number of MA’s to perform the duties demanded of them. The lack of doctors forces MA’s to carry the brunt of the workload at the units, and the too-few MA’s who are employed cannot adequately accomplish the immense, unending workload which is entailed. Even were TDC to employ the number of doctors necessary to serve its inmates, the sparse number of MA’s presently employed would be insufficient to fulfill a proper supporting role.

During the pendency of this suit, the number of MA’s assigned to the units steadily increased. If TDC is able to fill the new positions allocated in the 1980-1981 budget, it will have the equivalent of 93.5 full-time medical assistants on the units in future years; but even this number does not suffice to provide commensurate staff support. Obviously, then, the much smaller number of MA’s who were employed before the determination of this suit was grossly inadequate.

Through fiscal year 1979, TDC made no provision for MA’s to be on duty at its infirmaries on a twenty-four-hour basis, and only inmate nurses have been present at these facilities during the night. Both witnesses for the defendants and the plaintiffs agreed that the presence of civilian medical personnel at the infirmaries is essential at all times, since the evils inherent in a situation where inmates are responsible for the provision of medical care-detailed below-are magnified when they are the only medical personnel on duty. Moreover, the medical crises of inmates which arise during night hours are often of an emergency nature, junctures which demand immediate and skilled medical treatment by qualified personnel. Assuming that TDC

*1311

can employ 93.5 medical assistants in 1980-1981, it is conceivable that it could provide for medical assistants to be on duty, night and day, at each unit,

92

but only at the expense of leaving many units with only one MA constantly on duty. Even if every unit had a full-time physician, the unit infirmaries, nevertheless, could not properly serve their prisoner populations with only one day-shift MA for medical support.

93

d. Inmates

Inmates form the backbone of the TDC medical system. Disagreement existed among the doctors and other experts who testified as to whether inmates should be completely prohibited from participating in the delivery of health care or whether they should be merely restricted from participating in direct patient services. There is no dispute, however, that inmates must be properly qualified ard supervised in whatever job they are assigned, and that use of inmates creates special difficulties in a medical care system. Inmate “nurses” at TDC do not have the requisite and appropriate qualifications, training, or supervision to work in the infirmaries or hospitals, and their use necessarily creates deplorable obstacles to effective treatment of inmate patients.

An inmate assigned to work in TDC’s medical departments is not required to have any specific qualifications. Once assigned to the medical department an inmate is provided little formal training of any kind,

94

it being expected that he will learn his tasks by following and observing an experienced inmate nurse. Thus, even if such an inmate’s duties were restricted to orderly work, his training would be inadequate. The evidence revealed, however, that such inmates regularly perform a wide variety of medical functions, and consistently perform procedures for which they are not qualified. These procedures have included administering intravenous injections to inmates, performing Pap tests, dispensing drugs without the supervision of an RN or physician, suturing lacerations, and providing other emergency care.

95

Testimony has shown that inmate nurses often perform x-ray photography, conduct and interpret eye examinations, administer oral anesthesia, lance boils, and insert sutures. A few inmate nurses have regularly engaged in setting and casting broken bones, and one sutured heel tendons and performed a finger-tip amputation.

Inmate nurses have also been instructed or permitted to make entries in their patients’ charts. Deliberate falsifications in the charts are often made by these inmates; e.

g.,

patients’ liquid inputs and outputs have been improperly charted; spurious

*1312

temperature readings have been inserted; and fictitious administrations of medication have been shown (some entries having been registered up to twenty-four hours before the medicines were supposedly dispensed).

The defendants made no attempt to show that the inmate nurses are qualified by law, education, or training to perform these duties. While they admitted that they relied heavily on inmate personnel in the treatment and care of sick or injured inmate patients, the defendants asserted that efforts had been made recently to limit their roles. These efforts have been unavailing, and the harms and dangers of using unqualified inmate nurses remain. An attempt was made by defendants’ attorneys to elicit statements from plaintiffs’ witnesses that the inmates generally do adequate jobs. The evidence appears to be to the contrary.

96

However, even if defendants’ claim were true, alio- ving patently unqualified persons to have controlling influence over the lives and health of captive patients, who must accept whatever medical care is offered, is plainly unjustified.

While inmate nurses all too often improperly undertake treatment functions for which they are unqualified, the record reveals the irony that they have been reluctant to perform certain basic custodial duties. Grievous neglect of the personal care of patients at the HUH has resulted. Examples are numerous: on many occasions, routine preoperative enemas and urinalyses were not performed on time; urine bags were allowed to overflow (particularly on Monday morning, when no RN had been in the hospital all weekend); urine collections for urinalyses were either not accomplished or the specimens were not refrigerated, thus making them useless; intravenous solutions were allowed to run dry; bandages were not changed on time; incontinent inmates were allowed to lie in their own feces or urine for long periods; and inadequate hygienic care was administered to invalided patients generally. Decubitus ulcers (bedsores) were frequent among bedridden patients, as a result of the inattentive nursing. These open lesions are particularly troublesome at TDC, although they may usually be prevented simply by a systematic regimen of washing and turning the bedfast inmates.

In addition to improper medical treatment, other abuses are inherent in the use of inmates to provide direct patient care. In particular, TDC’s reliance upon inmate nurses places such inmates in positions of actual or potential authority over other inmates. These inmates, who distribute medicines, administer tests, process laboratory results, have access to medical records, and make appointments for consultations or treatment by physicians-all without the supervision of civilian personnel-are in a position to accept bribes in return for favors. The evidence showed that this abuse has been common and prevalent at TDC.

e. Dental Personnel

TDC lacks sufficient dental staff to provide suitable dental care to its inmates; as a result, only emergency care is provided. Inmates have little chance of receiving regular dental examinations or routine teeth fillings, and it is only when serious gum disease or tooth decay have progressed to the point where an extraction is necessary that an inmate is likely to receive care.

*1313

Even then, the dental treatment is slow, e.

g.,

several inmates testified that they had to wait several months for a set of dentures after all their teeth had been removed.

TDC’s Chief of Dental Services, Dr. James Tarver, estimated that TDC needs one dentist for every thousand prisoners, if anything is to be accomplished other than responding to the inmates’ dental crises (e.

g.,

relieving excruciating pain by pulling their aching or abscessed teeth). Other expert witnesses for the defendants also found dental care at TDC to be markedly deficient, estimating that one full-time dentist should be provided for every 750 prisoners (thirty-three for a population of 25,000), along with appropriate numbers of chairside and laboratory assistants. In 1979, TDC had the equivalent of 7.6 full-time dentists, one for every 3,289 prisoners. The 1980-1981 budget provides for seventeen positions for dentists. Although this increase constitutes an improvement, nonetheless, it does not provide for a sufficient aggregate of these posts adequately to serve the TDC population. Moreover, it was not demonstrated that TDC had succeeded in filling all of these openings.

Because of the lack of trained professional staff, TDC uses inmates to do work that should properly be performed only by licensed dental technicians or dentists. These inmates, without adequate qualifications or training, have been responsible for evaluating incoming inmates’ dental needs, a flagrantly improper practice, which has resulted in extensive suffering for those inmate patients whose dental problems have not been properly diagnosed or treated.

3.

Facilities

a. Unit Infirmaries

Each TDC unit has its own infirmary, supposedly equipped in such manner as to enable the unit medical staff to cope with the everyday minor ailments of inmates, to diagnose and determine the appropriate level of treatment for more serious medical problems, to render critical emergency care, and to arrange for the expeditious transportation of emergency cases to a hospital. The results of TDC’s severe overcrowding are also found here. Too many inmates are assigned to each unit for the infirmaries to serve these purposes effectively, since the exiguity of the examining rooms, office spaces, and beds in these facilities fall far short of meeting the demands placed upon them.

97

At least as late as the 1978 re-inspections by the expert witnesses who testified, suitable

emergency

equipment, laboratory equipment, and physical therapy facilities were still wanting.

98

The lack of reliable emergency transportation from the units to HUH, John Sealy, or community hospitals has been manifested repeatedly. On many occasions, breakdowns of ambulance equipment and related difficulties have resulted in inordinate delays in the transfer of emergency patients to hospitals.

99

To some extent, improved

*1314

equipment has been obtained, but a reliable alternative arrangement for ambulance service in the event of an ambulance breakdown is not available at every unit. Furthermore, most TDC ambulances are deficient of certain necessary equipment and competently trained para-medical personnel to operate them.

b. Huntsville Unit Hospital

It is highly questionable whether TDC’s “hospital” at Huntsville can be accurately labeled as such. HUH violates state hospital licensing requirements, and lost its Texas Hospital Association (THA) accreditation many years ago. It is obvious, then, that THA would not permit a comparable facility serving free world patients to operate in Texas. Notwithstanding the full, definite and longstanding knowledge of its gross inadequacies by TDC’s highest officials, HUH has been used as the system’s primary health care facility for many years. Antiquated, poorly designed, unacceptably equipped, and deficiently maintained, HUH is, in addition, extremely overcrowded. In 1974, reports by the Texas Joint Committee on Prison Reform were extremely critical of the conditions at HUH and made extensive recommendations for improvements. The THA, found,

inter alia,

that sanitary, safety, and privacy concerns necessitate extensive renovations and repairs of HUH. Its report added that, simply by better effort and organization of existent staff, substantial improvements in the housekeeping category could be achieved. Nevertheless, the evidence showed that by mid-1978 TDC had effected or begun only the most minimal changes at HUH. Many of the conditions criticized in 1974 and thereafter still exist, e.

g.,

lack of proper aseptic techniques in the isolation area, generally unsanitary conditions and inadequate cleaning methods, and shortcomings in the medical records and charts. Moreover, TDC apparently ignored the THA report in other respects: no evidence was found that the restroom facilities had been developed, that any efforts had been made to upgrade the electrical or plumbing equipment, or that the nurse’s station had been moved to afford better observation of patients. The primary accomplishments of TDC in the five year period since these reports were issued has been the improvement of surgical room facilities and the painting of the hospital.

Witnesses from both sides generally agreed that the facility was old, in disrepair, inadequately staffed, insufficiently organized and lacking in the most basic emergency equipment.

100

The most shocking deficiency is the continued absence of adequate firefighting equipment or safe means of exit from the hospital in case of a fire. With chilling indifference, TDC officials routinely permit seriously ill or injured inmates, a substantial number of whom are bedridden, to be placed in this facility that, since 1974, has been known to violate fire safety standards.

101

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In light of the overall deficiencies at HUH, Dr. Richard Della Penna and Dr. Kenneth Babcock, expert medical witnesses for the plaintiff-intervenor, recommended that the facility be immediately downgraded to an infirmary.

c. John Sealy Hospital

John Sealy Hospital (“John Sealy”) is a part of the University of Texas Medical Branch at Galveston. It is unquestionably a high-quality medical care facility. Indeed, it has a nationwide reputation for excellence. In the past, however, some difficulties attended its use for the treatment of TDC inmates. When TDC first began to send its seriously ill patients to John Sealy, they were placed throughout the hospital in regular hospital beds. It was believed by TDC security personnel that these placements necessitated the assignment of individual security guards for every patient-inmate. Even with this rigid surveillance, which sorely taxed TDC’s low staff resources, TDC officials felt that adequate security could not be provided. Hence, inmates considered to be high security risks were not permitted to go to John Sealy under any circumstances. In 1978, a “discrete” wing of the hospital was opened, which has beds reserved exclusively for TDC inmates. The inmates in this wing are treated primarily by the regular hospital staff. Housing the inmates together has the advantage of making it easier for TDC to provide security.

At present, plans are being prepared and funds have been appropriated for the construction of an entire hospital for TDC inmates, to be staffed by physicians and medical students from John Sealy. It is contemplated that the TDC facility will be used as a teaching hospital for the University of Texas Medical Branch at Galveston. All health care personnel employed in this institution will be from John Sealy and will be fully licensed, and a high staff-to-patient ratio is projected. It is also planned that TDC will provide security officers, together with a small contingent of inmates, all of whom will be assigned to the performance of housekeeping functions.

4.

Interference Occasioned by Security and Work Concerns

TDC officials are extremely conscious of security and discipline among the inmate work force, and many of the practices challenged by plaintiffs are said to be justified by these concerns. However, many TDC health professionals and security personnel testified that alleged security and work disciplinary measures often intrude upon the medical decisions made by doctors and adversely affect the treatment which inmate patients receive. As to this issue, the evidence clearly revealed that many of TDC’s practices attributed to such concerns are, in fact, unnecessary, unduly burdensome on inmates, and evince a deliberate indifference to inmates’ medical needs.

a. Diagnostic Unit Procedures

Each new TDC inmate is first taken to the system’s Diagnostic Unit at Huntsville, for initial processing and an evaluative medical examination, before being transferred to a particular unit. It has been a longstanding practice at the Diagnostic Unit to confiscate all medicines which inmates may bring with them from the free world. It is only

after

the medicine is confiscated, however, that TDC staff members communicate with the free world doctors whom the respective inmates may have listed as references, to determine if the medicine is, in actuality, legally prescribed and medically necessary. This process may take anywhere from a few hours to a week. Once the prescription is verified, the prescribed medication is issued to the particular inmate from TDC drug stocks. This policy was altered somewhat in 1974, following the death from epileptic seizures of an inmate whose anticonvulsant medicine had been confiscated pending verification. Under the modified policy, inmates with heart conditions, epilepsy, and diabetes are directed to notify Diagnostic Center officials immediately of their conditions, in order that prescribed medication may be verified promptly.

Although this procedure represents an improvement over the previous policy, it still permits much unnecessary suffering by

*1316

some inmates, and to that extent it is deficient. Expert witnesses for all parties were critical of an inquiry limited to only three conditions, since numerous other acute and chronic conditions (such as asthma or high blood pressure) also need prompt attention. However, under the existing policy, even inmates with observable conditions requiring immediate medical attention (e. g., gangrene) have been forced to wait several days for a routine examination before receiving treatment.

Despite the death of the epileptic inmate mentioned above, Diagnostic Center officials have since denied certain inmates needed anti-seizure medicines pending absolute confirmation of the condition. On at least two occasions, such inmates “proved” their conditions by having seizures. Similarly, asthmatic inmates must surrender and be deprived of their medicines, until a physical examination is conducted. When these inmates have protested that the medicines are urgently needed, they have been told that abstention from the drugs for a few days would allow them to more clearly exhibit the proper symptoms of their illness to an examining physician. Medical assistants who testified appeared totally indifferent to the fact that these practices result in acute distress, discomfort, and suffering by the affected inmates, and, moreover, carry with them a high potential of danger to the inmates. These witnesses merely asserted that if an inmate’s condition becomes critical before his medical examination (/. e., if he has an attack), medication will be given. Practices such as these, particularly in consideration of TDC’s inadequate supervision of inmates, are dangerous to the extreme and cannot be justified- as necessary for security. Whatever may be the drug control problems that exist at the Diagnostic Unit, it is irrefutably evident that they must be solved by some measure less drastic than confiscating all medicines and requiring inmates to go without them for several days after arrival.

102

Another disturbing intrusion of non-medical concerns into the initial medical processing of inmates is the inept and inappropriate manner in which medical classifications for work assignments are determined. The entire operation of the work classification system is characterized by indifference to inmates’ medical incapacities and a lack of any earnest consideration of their individual weaknesses and disabilities.

The primary purpose of the initial medical examination of an inmate is to determine his appropriate work classification.

103

Five classifications are employed, ranging from Class I (most fit) to Class V (least fit), which are designed to indicate various levels of physical fitness and, therefore, differing capacities to perform work. The standards for placement in the various classifications are fairly simple.

104

Examining

*1317

physicians at the Diagnostic Unit typically make an initial classification which is based upon their visual observations of the inmates, not waiting until free world medical records are received before making these decisions. As a result, a large degree of guesswork is involved, and inaccurate categorizations are frequently made.

105

Once inmates are so grouped, they are transported to the units to begin work.

Relying solely on the medical classification, unit officials assign inmates to jobs, without having any specific information about an inmate’s medical status except for his classification number. As a result of this system, inmates are frequently assigned to jobs which are incompatible with their condition of health or bodily impairments. For example, inmates with asthma have been assigned to work in environments such as the laundry or the textile mill, where humidity and dust aggravate their conditions; and inmates with severe allergies have been assigned to work in fields containing crops to which they are disagreeably sensitive or allergic. Inmates who have been inappropriately assigned must petition TDC physicians for an express exemption from assignment to a particular type of job, as hereafter explained. The recommendations of physicians in these respects may or may not be followed by TDC officials.

106

Work classifications are also inaccurate, because of TDC’s definition of the types of work appropriate for each class of inmates. By way of example, Class III inmates are assigned to work in the garden squads, a job which requires outdoor work in the large vegetable gardens at each unit. Some of the garden squads perform work substantially equal to that performed by inmates assigned to the regular agricultural field lines. Strenuous manual labor is involved in performing both garden and field work, and garden squad members are required to keep up with others in the group. The agricultural field force is composed

*1318

only of inmates in Class I or II, who are supposedly basically healthy, whereas the Class III inmates in the garden squad may suffer from asthma, mild arthritic problems, and inactive tuberculosis. No rationale for requiring Class III inmates to perform the equivalent of field work was offered by TDC.

107

Indications were present in the evidence, however, that assignments to the most unpleasant or strenuous job within a given classification are sometimes employed as a punishment for seeking a work classification change.

The procedure for changing a medical classification is complicated. Inmates submit requests for such changes to unit health personnel, who then schedule an evaluation by a physician. The examining doctor submits a recommendation to Dr. Gray, TDC’s medical director, who must approve all changes. These processes consume a large part of the physicians’ workday and further reduce the periods which they can devote to medical care.

TDC witnesses testified that they intend gradually to convert the medical classification system to a more precise silhouette or profile system, similar to that used by the United States Army. Under such a system, the examining physician indicates specific areas of the body that are impaired, rather than making non-specific overall classifications. While this process may provide some improvement in the initial classification determination, no indication was present from the evidence that the deficiencies already noted would be eliminated under this system,

i.

e., classification of inmates prior to receipt of medical records, lack of coordination between examining doctors and officials responsible for assigning work, physicians’ want of authority to order changes, and inappropriate placement of certain jobs in a particular classification.

b. Unit Medical Procedures

At TDC units, all aspects of medical care are compromised by security and disciplinary considerations. Security officers, building tenders, and other non-medical personnel frequently hinder inmates’ access to medical treatment, interfere with prescribed therapy, and countermand orders of medical officers. Additionally, many medical employees are instilled with a perception that' they are expected to perform more as security officers than as health care professionals.

Although sick call procedures vary somewhat among TDC units, the particular arrangement generally adopted is invariably unwieldy and tortuous. Inmates desiring nonemergency medical treatment must request permission to attend sick call. At some units, such requests must be made, in writing, the night preceding the morning sick call; thus, an inmate must predict the extent of his illness or incapacity several hours in advance or, if he is suffering during the night, ordinarily must endure the suffering until the morning. At other units, inmates desiring to report for sick call are assembled very early every morning.

108

Under either method, security officers or building tenders are in charge of releasing inmates for the purpose of attending sick call. The security officers can, and frequently do, refuse to honor the requests of some inmates to report for sick call. In other instances, an inmate is permitted to attend sick call but is later punished for exercising the right, if, in the guard’s untutored opinion, the complaint was not valid or substantive.

Requests for permission to seek treatment at the infirmary outside regular sick call hours are also appraised by untrained security officers, who often refuse consent. When leave is not granted, an inmate is forced to wait for a scheduled sick call or

*1319

until a convenient break in the work day, before he may receive any evaluation of his complaints by medical personnel. During the late night hours, when no medical assistants are on duty, security officers (with the assistance of inmate nurses) make the determination as to whether an alleged emergency medical condition is serious enough to justify calling off-duty MA’s or physicians. Officers make these judgments without any guidance from written policies, standing operating procedures, or instructions for the screening of emergency first aid complaints. Thus, at the outset, an inmate’s access to medical care can be, and with disturbing frequency is, blocked by medically untrained officers.

A widely-held perception among TDC employees is that inmates claiming to have medical conditions are actually malingerers attempting to escape their work assignments. This supposition also often acts as a barrier to prompt medical treatment for inmates; furthermore, it frequently leads TDC officials to hinder ongoing treatment. At each unit, the warden has ultimate authority over virtually all matters, including job restrictions, lay-ins (time off from work), and therapy ordered by medical personnel.

109

Often suspicious that inmates are exaggerating their complaints in order to avoid labor, and fearful that doctors may be overindulgent, the wardens and other prison officials frequently ignore, cancel, or prematurely terminate lay-ins ordered by medical personnel. As a result of these actions, inmates thus unwisely forced to return to work have occasionally suffered serious complications or re-injury.

110

Inmates have also been required to perform tasks which medical personnel had previously determined were not suitable, taking into account the inmates’ medical conditions.

111

While the imprecise work classification system

112

unquestionably contributes to these problems, the evidence also reflects that work supervisors and prison guards many times have forced inmates to perform work which, as they had been specifically informed, was beyond the several inmates’ medically determined capabilities. This hardened disregard of numerous inmates’ medical limitations has often inflicted upon them uncalled-for and distressing pain and

*1320

suffering. The policy, well established, which permits non-medical employees to ignore or countermand physicians’ orders,

113

further demonstrates the blind-walled indifference of many TDC officials to the medical needs of the inmates.

Security considerations are also used as an excuse for denying the use of medically prescribed physical aids. To illustrate, asthmatic inmates are not permitted to keep personal inhalers with them, because the inhalers are perceived by guards to pose potential security risks.

114

As a result, an inmate who needs an inhaler must request one from the guards; hence, when an asthmatic inmate is locked in his cell at night, his life may hinge on his ability, in the middle of an acute asthma attack, to attract the attention of, and receive immediate aid from, building tenders or guards. TDC’s shortage of security personnel, especially pronounced at night, offers no guarantee that such assistance can be provided quickly enough. TDC officials have also deprived inmates of the use of braces, canes, and similar devices at certain times, and have refused to permit, or have unreasonably delayed approval of, the use of special personal effects for inmates with a medical need for such items.

115

In short, defendants have frequently refused to countenance forms of prescribed medical treatment which necessitate variations from TDC’s highly structured and overly-regimented procedures. Their failure to permit individualized treatment of inmates is yet another indication of defendants’ willingness to sacrifice inmates’ constitutionally protected rights in the interests of security and work.

Medical personnel are sometimes similarly influenced by non-medical considerations. The record is replete with examples.

116

MA’s typically share the concept of many security officers that inmates with medical complaints likely qualify as malingerers.

117

Several medical assistants began their TDC employment as guards and later moved into medical positions, and all have been heavily infused with TDC’s emphasis on work and security.

118

Since the

*1321

poorly trained MA’s lack adequate and systematized supervision by physicians, it is thus entirely natural that they would tend to place an enhanced emphasis on the attitudinal structures prevalent among non-medical TDC officials at the units. Moreover, because unit wardens prepare performance ratings for the medical assistants, it is easy to infer that MA’s must submit to the wardens’ conceptions of appropriate medical care, if they wish to retain their employment.

Inmates who have been removed from the general population for security reasons find it especially difficult to obtain medical treatment. Those inmates in solitary confinement, administrative segregation, or hospital lock-up are not permitted to attend sick call; they must wait for medical officers to make their rounds. As will be discussed in the section of this opinion relating to discipline, TDC rules requiring medical surveillance of inmates in solitary confinement and administrative segregation, and policies restricting the placement of inmates with certain medical problems in solitary confinement, are frequently ignored. Even more ironically, inmates placed in “hospital lock-up”

119

have been denied medication, scheduled medical appointments, and other needed medical treatment.

Most severe is the treatment of inmates on death row. As Dr. Gray testified:

For some reason or other, people on Death Row are considered different from other people. They’re handled different. Security are afraid of them and all this sort of thing. I don’t understand it. They’re just people to me, but they do get different handling, and I guess it’s a rule of security, which I don’t understand.

The record confirms Dr. Gray’s insight. In one instance, a death row inmate with a serious stab wound in his lung was returned to his cell rather than being kept at the infirmary under close observation, because retaining him in the infirmary required too much paper work.

120

When the inmate’s lung collapsed during the night, he was directed to pack and carry his belongings to the ambulance which transported him to HUH. Because of his security status, he was kept in a hospital cell where access to emergency medical treatment was very limited. Furthermore, since they are viewed as extreme security risks, death row inmates, in several instances, have been denied important surgery and post-operative treatments.

In order to be treated at a free-world community hospital, an inmate must be granted a medical reprieve, which, in itself, is a complicated process.

121

At least partially as a result of this policy, inmates-even those suffering from serious emergency conditions-are rarely treated at nearby community hospitals. Instead, they are taken to HUH or John Sealy, regardless of the fact that these facilities are a substantial distance from the TDC units.

c. HUH Hospital procedures.

At the Huntsville Unit Hospital, an area on the first floor is referred to as the “cell-block area.” Contained within this area are

*1322

ten cells which are ostensibly used to house inmates classified as diabetics and self-mutilators, as well as inmates afforded “protection” and those undergoing discipline. The other cellblock area, referred to as “seven-row,” contains nine cells and is located below the second floor of the hospital.

122

Seven-row is generally used for isolation eases; however, it is also a common practice to house death row inmates at this location, regardless of the character of their medical conditions. Entry to these cells can only be gained by a key, which is kept by a security officer posted near the front door of the hospital, a location far distant from the cells.

Without the approval of a physician, inmate patients may be moved from their wards to one of the hospital cellbloeks at the direction of a medical assistant, a security officer, or the administrator. Numerous instances where inmates with serious medical conditions were assigned to the cellblock areas for punitive rather than medical reasons were referred to in testimony, the transfers being responses to the inmates’ complaints about the quality of the medical care they had received.

Former hospital employees testified that it was difficult to render appropriate care to inmates confined to the cells on seven-row. The inconvenience occasioned in obtaining the key to open the cells results in the performance of many medical services through the cell bars, such as “I — V” (intravenous) changes, bandage changes, administration of medications, and blood pressure readings. This type of procedure most frequently occurred in the treatment of death-row inmates, because it is a TDC policy that their cells may be opened only if two guards are present. On more than one occasion, the remote location of the cell door keys with reference to the cells in this area has caused serious delays in the rendering of emergency care to inmates confined there.

123

In addition, the seven-row area is not watched over adequately; at night, it is supervised by the same inmate who covers the entire second floor.

124

Civilian guards and medical assistants at HUH are affected by the same overemphasis on security which is so manifest in the unit infirmaries, and inmates suffer from the consequent insensitivity to their medical needs.

125

Some security officers at HUH

*1323

have specifically countermanded medical decisions and otherwise seriously interfered with medical care.

126

5.

Medical Records

Properly kept medical records serve many purposes: legal documentation of treatment is afforded; audits of the quality of treatment provided by particular doctors or by the institution as a whole may be accomplished; determination of the various needs of the institution are disclosed; and the major illnesses occurring there may be identified. Also, a physician who has had no previous involvement with the patient may examine a properly kept chart and, from the information contained on it, carry on with the care and treatment of the patient. However, the poor quality of TDC medical records renders it impossible to fulfill these objectives.

The typical record entry at TDC facilities consists of the complaint registered by the inmate and any medication which may be prescribed. No diagnosis by a physician is recorded. When inmates are admitted to HUH, no nurses’ entries are made on their charts to indicate the care provided, nor are there admission and discharge summaries. Further lacking are entries to indicate whether a particular test or procedure was, in fact, completed as ordered.

Additional serious shortcomings in the manner in which record entries are performed became clear from the evidence. Among these is the practice of signing an order with a physician’s name, followed by the name of an MA, nurse, or inmate nurse. From this kind of entry, it is impossible to determine whether the doctor gave the order orally to the co-signer or whether the patient was ever actually seen by a physician.

127

In some cases, the entries reflect a want of the most fundamental medical expertise, making it easily deducible that no physician participated in making them. Indeed, entries in TDC medical records are frequently made or transcribed by inmates, and numerous inmate workers have been given access to them. These practices not only result in inaccurate records, but also represent an invasion of the privacy of the inmate-patients concerned. The expert witnesses, therefore, recommended that immediate steps be taken to remove all inmates from positions in which they have access to medical records.

One additional inadequacy was presented. When an inmate is seen in the emergency room or at sick call on his unit, a diagnosis and evaluation are entered on his unit sick call record. At the time the inmate is admitted to the hospital, a separate in-patient record is made for him, which reflects that

*1324

the inmate is to be admitted and that further orders will be written on the floor. The in-patient record accompanies the inmate patient while he is in the hospital; but the original sick call record, which details the diagnosis pertaining to him and the reason for his admission, is not kept with it. Consequently, medical personnel examining the in-patient record are not apprised of the patient’s condition.

■ In view of these many deficiencies, it came as no surprise when the expert medical witnesses testified that patients could not be adequately treated by use of the records kept at TDC. Although TDC has had notice of the inadequacy of its medical records system for years, it has failed to implement necessary changes. While defense witnesses testified that some efforts have been initiated to organize HUH records and to standardize the record-keeping process, there was no indication from the evidence that these efforts have significantly affected the numerous deficiencies involved. Furthermore, TDC has apparently formulated no plans for improvement of the records maintained at the several unit infirmaries.

6.

Pharmaceutical Services

The control, prescription, dispensation, and administration

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of medications are important aspects of any medical care delivery system. In TDC, the medication needs of the inmates are served by a hospital pharmacy at HUH and by thirteen separate pharmacies (referred to as “pill rooms”) on the various units. A central pharmaceutical supply facility is located at the Walls Unit. TDC dispenses hundreds of thousands of doses of medicine every year, ranging from simple, over-the-counter remedies (e.

g.,

aspirin) to narcotics and other controlled drugs.

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The evidence disclosed that serious deficiencies are prevalent in the pharmaceutical practices and procedures at TDC, which jeopardize the inmates’ health and safety.

The inherently structured nature of confinement in a penal institution, as well as the need to prevent the development of a drug market within its confines, militate against inmates’ freedom to purchase nonprescription medications or to administer prescribed medicines to themselves. Hence, each time an inmate desires or needs a medicament at TDC, he must obtain and present a prescription or order for that medicine (referred to as a “pill pass”) to an authorized person in the pill room; moreover, he may submit the prescription only during the hours in which the medication line (“pill line”) is open. When the pill pass is presented, the person dispensing the medications examines and interprets it, selects the appropriate medicine, and delivers it to the particular inmate. It is required that the inmate be watched by a TDC employee, to insure that the drug is actually taken. The back of the inmate’s pill pass is stamped each time he receives a dose of medicine. At HUH, the procedure is similar to that in free-world hospitals: inmate patients are given individual doses of medications by hospital personnel, based upon orders written on their several charts. As will be detailed below, practices involving medicaments at the units and at HUH are deficient in a number of respects.

The most serious defect in TDC’s pharmaceutical services is attributable to the inadequate number of qualified professional

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staff. This exiguity contributes to and amplifies all other deficiencies. Although TDC has operated a pharmacy since 1934, it first hired a full-time pharmacist in October of 1976. Beginning September 1, 1979, a second full-time pharmacist was scheduled to begin work. These are the only persons employed by TDC with special training in pharmaceutical services.

The medical experts testified that pharmacists perform a crucial function within a health care system. The pharmacists’ knowledge of the properties, side effects, and appropriate dosages of the various medications enable them to supervise and verify drug prescriptions for accuracy, and to inform the prescribing doctors of any perceived irregularities in, or contraindications to a prescription. This function is particularly important, the expert witnesses testified, where the medical treatment of individuals is performed by a number of different persons, most of whom have no knowledge of a patient’s medication history. In TDC, the major prescription function of physicians concerns approval

vel non

of prescriptions written by inadequately trained, unlicensed medical assistants or inmates.

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A high volume of patients and medications makes thorough consideration of each inmate’s individual history and medication record impractical. A compelling necessity is manifested, therefore, for an adequate number of trained pharmacists to oversee the pharmaceutical services at each TDC unit and at HUH, since it is glaringly apparent that two pharmacists cannot effectively supervise the entire TDC drug dispensation program. Indeed, several medical experts who testified recommended that TDC employ a registered pharmacist at every unit dispensary.

The shortage of pharmaceutical professionals has led to the use of medical assistants, security officers, and even inmates to staff the pill rooms. These persons regularly perform duties that, in a free-world pharmacy, could only be handled by a licensed pharmacist. Unit medical assistants do not possess the necessary pharmaceutical training and lack the requisite qualifications to operate a pharmacy without the supervision of a trained, licensed pharmacist. The security officers who are on duty in many of the unit pill rooms have even less training and are more unqualified to handle medicines; furthermore, their deployment as pharmaceutical assistants depletes the already meager ranks of personnel performing true security functions. Even more egregious is the use of inmates to dispense medications, a practice universally condemned by the expert witnesses who testified. TDC claims to have taken steps to eliminate inmates from functioning in the pill room; but at the time of trial, this objective has not been achieved.

The major risk associated with use of unqualified personnel in the unit pharmacies is ascribable to the likelihood of errors, both in the interpretation of prescriptions and in the process of dispensation. The utilization of such personnel makes it verisimilar — indeed, ineluctable — that various inmate patients will receive incorrect medications, from which grave medical consequences will ensue. Expert witnesses testified that several persons whose task it was to dispense prescribed medications to inmates in the pill line could not identify the pills they were handling, and haphazard labelling procedures exacerbate the possibility of such mistakes. Deplorable harms to inmates have also been occasioned by errors in recording or transcribing prescriptions.

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Moreover, unqualified personnel often sub

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stitute an inappropriate drug for the one prescribed, either because the unit pharmacy does not stock the prescribed drug

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or temporarily runs out of it.

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Another evident deficiency in the unit pharmacies is the lack of systematized recordkeeping. Although some improvements and attempts at uniformity were instituted after the inspections made by the expert witnesses appointed by this court, unit pharmacies still fail to maintain records which memorialize the administration of each dose of medication to inmates. The only existent pharmaceutical record which relates to any individual inmate is the inmate’s copy of his pill pass. Since these records remain with the inmates rather than in the pharmacy, unit medical personnel have no way of determining whether given inmates have reported to the pill line and received their prescribed medications. This information can be extremely important in the treatment of specific cases, particularly where drugs which alter behavior have been prescribed. Furthermore, complete records of the dispensation of medications provide valuable information about overall medical practices at the institution.

An additional matter causing perturbation to the expert witnesses were unit pharmaceutical operations, where the tendency of TDC personnel to overmedicate inmates manifested itself most obviously. On a number of occasions, they testified, inmates were given larger doses of medication than were warranted, particularly in instances involving such powerful and potentially dangerous drugs as Thorazine.

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Additionally, medical personnel have shaken off importunate inmates voicing medical complaints, by prescribing for the latter medically uncalled-for drugs. The expert witnesses testified that this practice has negative implications for the quality of medical care, in that it functions as a substitute for careful diagnosis and evaluation of inmate complaints, results in inappropriate treatment for serious conditions, and increases the possibilities of drug abuse among the inmate population. Indeed, among the drugs routinely dispensed at TDC have been large quantities of be

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