Moving on to ‘stage-two Zionism’ – Zionism Version 2.0

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‘Make a decision – are you citizens of Israel, or of the Palestinian Authority?” Yisrael Beitenu MK David Rotem challenged the Arab citizens of Israel in a recent Israeli news interview. Sadly, on the eve of Israel’s 60th celebration of independence, ongoing Israeli policy is pushing almost one-fifth of our citizenry – the Arab Israelis, or Palestinian citizens of Israel – into the corner of choosing between being Israelis or being Palestinians; when, in fact, they are both. This impossible choice plagues not only the million Palestinian Arab citizens of Israel – living in Ramle, Lod, the Galilee and the Negev. Rather, it poses an existential dilemma to the basic vision of our country.

I IMMIGRATED to Israel, in 1980, to be part of building a society of which I, a liberal Jew from America, could be proud. Often, I am proud of being an Israeli. When my kids and I push through the Hebrew Book Week crowds, eagerly choosing from among thousands of works of fiction, non-fiction and poetry, written in a language that was unspoken 100 years ago. When I go to my Kupat Holim HMO in Jerusalem, and my doctor is Armenian, our pediatrician is a Mizrahi Jew, and the eye doctor is a Russian immigrant. When I walk through the Knesset, and see ultra-Orthodox MK Eli Yishai, secular-Jewish MK Zahava Gal-on, and Muslim Arab MK Jamal Zahalka – all legislating for the State of Israel.

Today, Israel stands among the developed nations as a world leader in health care and technology. There is a lot to be proud of in Israel. A lot to be ashamed of, as well.

In the Negev, the Israeli government continues to refuse 70,000 Beduin citizens the right to settle on lands they have inhabited for centuries. In Israel’s mixed Jewish-Arab cities, building permits are denied to rehabilitate Arab homes, while adjacent Jewish neighborhoods flourish. In the Galilee, rather than investing in developing Arab towns, the government continues to constrict their lands in order to expand Jewish towns. As a result, in modern, successful Israel, over 50% of Israeli Arab families live under the poverty line.

SIXTY YEARS ago, the young State of Israel, using the Absentee Property Law, appropriated hundreds of thousands of dunams of land, owned by Arabs who had fled their homes – in the Galilee, the Negev, the mixed cities of Ramle, Lod, Jaffa, Haifa and Acco. Over the coming decades massive government (and international Jewish) investment gave birth to scores of new Jewish development towns, kibbutzim and moshavim throughout the country – consolidating possession of the land. Meanwhile, the Arab towns and neighborhoods that remained continued to be restricted, receiving little public investment, and facing labyrinthine planning systems designed to limit their development, or even re-allocate their remaining lands.

In 2008, this ethnic approach – draconian, yet necessary in the 1950s and 1960s – still dominates national land use and development policy in Israel. Today, if we continue this approach to building the “Jewish democratic state” we doom ourselves to a non-democratic state, known to the world as “Jewish.” But such a state will not be Jewish in ways of which we can be proud.

the gaza strip occupied terrorities 2003 map

AFTER 60 years, it is time to re-design our current path, with the aim of building a society that fully belongs to both its Jewish and Arab citizens. This aim is not only just; it is in the overall Israeli interest. It also affects, and is affected by, any effort to achieve a two-state solution.

First, despite Yisrael Beitenu’s demand to choose, Arab citizens of Israel are Palestinians. In some cases, they are the sisters or cousins of those who left in 1948, who are now living in Jordan, in Lebanon, and in Gaza. In all cases, one million Palestinian citizens of Israel maintain a constant balancing act – between their identification with their Israeli citizenship, and their identification with their Palestinian peoplehood. When their attempts to build a legal home or develop their neighborhood are rebuffed, their identification with Israel weakens. When their country bombs or shoots their people the balancing act becomes intolerable.

Second, failure in building a two-state future increases the national conflict among citizens inside Israel. Since the beginning of the Oslo process in 1993, until its violent interruption in October 2000, most Arab citizens of Israel sought their own civic aspirations in achieving equality in the state in which they lived – Israel. They sought, for their stateless Palestinian brethren, a Palestinian state alongside Israel.

As the prospect of a Palestinian state dims, and Israeli government policies and proclamations continue seeking to “Judaize” the Galilee and the Negev, Arab citizens of Israel turn increasingly to the idea of achieving Palestinian self-determination within the State of Israel. The more that mainstream politicians regard Arab citizens as a foreign element to be contained and later jettisoned in a “land swap,” the more these same citizens withdraw from participation in Israeli democracy, and seek their future through increased autonomy – as a national minority within Israel.

AS WE celebrate Israel’s 60th birthday, we need to make a paradigm shift, and to re-envision our society. Sixty years after the founding of the state, we must declare an end to stage one of Zionism – state-building – and move to stage two of society-building. We need to redefine our Israeli civic enterprise, not as a Jewish State, but as a Jewish Homeland, in a state with shared citizenship. Otherwise, in clinging to the visions that have guided Israel in the past, we will destroy what has been built.

Israel – within its pre-1967 lines – is a shared home. It is a Homeland for the Jewish people; but it also a home for the descendants of the Arabs who were living here and became citizens in 1948. Over these 60 years they, too, have worked, paid taxes, and built their future and their children’s future here in the land of their birth.

At the same time, if our Homeland is to be genuinely democratic, with a Jewish majority, a viable Palestinian Homeland must be established alongside ours – with its own Palestinian majority and law of return for Palestinians. As Prime Minister Ehud Olmert said at the Annapolis conference in November 2007: without the two-state solution, Israel is “finished.” As long as only one state exists in this Land (between the Mediterranean Sea and the Jordan River), our Jewish national home will not be sustainable. Sixty years after achieving statehood, our national home awaits this completion.

The immediate steps on the path to this vision are clear. Jettison the settlement enterprise – both within the Green Line (“Judaizing” the Galilee, the Negev, and the mixed cities of Ramle, Jaffa, Acre and Lod), as well as beyond it (in east Jerusalem and the West Bank). Dismantle institutional discrimination – particularly in land-use, planning, and resource allocation – and develop the country for all citizens equally. Teach Hebrew and Arabic as the official languages they are; and teach the histories, narratives and poetry of both peoples in our schools. Pursue “complete equality of social and political rights to all inhabitants” – as proposed in Israel’s Declaration of Independence.

After 60 years of independence, it is time to recognize that an Israel that attempts to neglect, dispossess or exclude its Arab citizens is not Jewish; and is not sustainable. It is time to stop defining the Jewishness of the state by the amount of land controlled by Jewish towns or citizens, but by the justice of our society. It is time to be guided by the vision of Israel as a decent, fair, democratic society for all Israelis -Arab and Jewish – as we pursue a two-state solution that will allow national fulfillment for both peoples.

The writer won the 2002 Prize of the Speaker of the Knesset for Contributing to the Quality of Life in Israel – for founding and co-directing the Center for Jewish-Arab Economic Development. She is currently writing a book based on 25 years of experience in the field of Jewish-Arab relations in Israel.

This article can also be read at /servlet/Satellite?cid=1208870524513&pagename=JPost%2FJPArticle%2FShowFull

US Solider David Motari Likes to Throw Puppies for Fun

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Us soldier throws puppy off cliff (Graphic Video Content)

If this is how US Soldiers treat puppies in Afghanistan and Iraq, what are they doing with the locals?

What else have these psychopaths brave men in uniform been doing that has not been caught on tape?

Calling people terrorists when your own government orchestrated and planned the entire 9-11 hoax. Welcome to the United States of Amnesia. Does this country feel any shame, guilty or responsibility for its actions, or it is always someone else’s fault?

Torture Still Doesn’t Work

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Torture Still Doesn’t Work

By Robert Fisk, The Independent UK,
Posted on February 4, 2008, Printed on March 3, 2008

“Torture works,” an American special forces major — now, needless to say, a colonel — boasted to a colleague of mine a couple of years ago. It seems that the CIA and its hired thugs in Afghanistan and Iraq still believe this. There is no evidence that rendition and beatings and waterboarding and the insertion of metal pipes into men’s anuses — and, of course, the occasional torturing to death of detainees — has ended. Why else would the CIA admit in January that it had destroyed videotapes of prisoners being almost drowned — the “waterboarding” technique — before they could be seen by US investigators?

waterboarding torture

Yet only a few days ago, I came across a medieval print in which a prisoner has been strapped to a wooden chair, a leather hosepipe pushed down his throat and a primitive pump fitted at the top of the hose where an ill-clad torturer is hard at work squirting water down the hose. The prisoner’s eyes bulge with terror as he feels himself drowning, all the while watched by Spanish inquisitors who betray not the slightest feelings of sympathy with the prisoner. Who said “waterboarding” was new? The Americans are just apeing their predecessors in the inquisition.

Another medieval print I found in a Canadian newspaper in November shows a prisoner under interrogation in what I suspect is medieval Germany. In this case, he has been strapped backwards to the outer edge of a wheel. Two hooded men are administering his agony. One is using a bellows to encourage a fire burning at the bottom of the wheel while the other is turning the wheel forwards so that the prisoner’s feet are moving into the flames. The eyes of this poor man — naked save for a cloth over his lower torso — are tight shut in pain. Two priests stand beside him, one cowled, the other wearing a robe over his surplice, a paper and pen in hand to take down the prisoner’s words.

Anthony Grafton, who has been working on a book about magic in Renaissance Europe, says that in the 16th and 17th centuries, torture was systematically used against anyone suspected of witchcraft, his or her statements taken down by sworn notaries — the equivalent, I suppose, of the CIA’s interrogation officers — and witnessed by officials who made no pretense that this was anything other than torture; no talk of “enhanced interrogation” from the lads who turned the wheel to the fire.

waterboarding torture

As Grafton recounts, “The pioneering medievalist Henry Charles Lea … wrote at length about the ways in which inquisitors had used torture to make prisoners confess heretical views and actions. An enlightened man writing in what he saw as an enlightened age, he looked back in horror at these barbarous practices and condemned them with a clarity that anyone reading public statements must now envy.”

There were professionals in the Middle Ages who were trained to use pain as a method of inquiry as well as an ultimate punishment before death. Men who were to be “hanged, drawn and quartered” in medieval London, for example, would be shown the “instruments” before their final suffering began with the withdrawal of their intestines in front of vast crowds of onlookers. Most of those tortured for information in medieval times were anyway executed after they had provided the necessary information to their interrogators. These inquisitions — with details of the torture that accompanied them — were published and disseminated widely so that the public should understand the threat that the prisoners had represented and the power of those who inflicted such pain upon them. No destroying of videotapes here. Illustrated pamphlets and songs, according to Grafton, were added to the repertory of publicity.

waterboarding torture

Ronnie Po-chia Hsia and Italian scholars Diego Quaglioni and Anna Esposito have studied the 15th-century Trent inquisition whose victims were usually Jews. In 1475, three Jewish households were accused of murdering a Christian boy called Simon to carry out the supposed Passover “ritual” of using his blood to make “matzo” bread. This “blood libel” — it was, of course, a total falsity — is still, alas, believed in many parts of the Middle East although it is frightening to discover that the idea was well established in 15th century Europe.

As usual, the podestà — a city official — was the interrogator, who regarded external evidence as providing mere clues of guilt. Europe was then still governed by Roman law which required confessions in order to convict. As Grafton describes horrifyingly, once the prisoner’s answers no longer satisfied the podestà, the torturer tied the man’s or woman’s arms behind their back and the prisoner would then be lifted by a pulley, agonizingly, towards the ceiling. “Then, on orders of the podestà, the torturer would make the accused ‘jump’ or ‘dance’ — pulling him or her up, then releasing the rope, dislocating limbs and inflicting stunning pain.”

waterboarding torture

When a member of one of the Trent Jewish families, Samuel, asked the podestà where he had heard that Jews needed Christian blood, the interrogator replied — and all this while, it should be remembered, Samuel was dangling in the air on the pulley — that he had heard it from other Jews. Samuel said that he was being tortured unjustly. “The truth, the truth!” the podestà shouted, and Samuel was made to “jump” up to eight feet, telling his interrogator: “God the Helper and truth help me.” After 40 minutes, he was returned to prison.

Once broken, the Jewish prisoners, of course, confessed. After another torture session, Samuel named a fellow Jew. Further sessions of torture finally broke him and he invented the Jewish ritual murder plot and named others guilty of this non-existent crime. Two tortured women managed to exonerate children but eventually, in Grafton’s words, “they implicated loved ones, friends and members of other Jewish communities”. Thus did torture force innocent civilians to confess to fantastical crimes. Oxford historian Lyndal Roper found that the tortured eventually accepted the view that they were guilty.

Grafton’s conclusion is unanswerable. Torture does not obtain truth. It will make most ordinary people say anything the torturer wants. Why, who knows if the men under the CIA’s “waterboarding” did not confess that they could fly to meet the devil. And who knows if the CIA did not end up believing him.

© 2008 The Independent UK All rights reserved.
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Exposing John Yoo – The Torture Memo Mastermind

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Deconstructing John Yoo, Harpers Magazine

Once again, poor John Yoo, the author of the original torture memorandum and steady defender in public fora of waterboarding and crushing the genitalia of small children, feels he is being persecuted. This has been a steady theme of his writings in the Journal, in which he has lashed out against former Attorney General Ashcroft, the Supreme Court in its Rasul and Hamdan decisions, and his colleagues in academia. This time the victimizer is his own alma mater.

A Yale Law School clinic has supported a lawsuit filed against him in federal court in San Francisco seeking nominal damages ($1 plus attorney’s fees and costs) on behalf of Jose Padilla. The Wall Street Journal and other organs of the Neoconservative world (of which the soft-spoken Yoo is a card-carrying member) reacted promptly and in unison. This law suit is a ludicrous act of harassment, they say, blasting away against Yale Dean Harold Koh and a series of additional windmills who have nothing to do with it.

But John Yoo’s self-defense, published on Saturday, is extremely revealing. It merits a pause and careful read through. In it, Yoo is on the warpath. Moreover, he goes out of his way to describe the nature of his warpath. The war is all about politics, he tells us. Yoo very thoughtfully allows the inner Yoo to shine through. Read the rest of the article


Arnold’s Nazi Death Belt


For at least the second time now, Gov. Arnold Schwartzenegger has posed in trendy magazines bearing a Nazi-issue ‘deathshead’ belt buckle.

arnold deaths belt buckle

Arnold, the son of a high ranking officer in the Austrian Nazi Party, first made waves with the belt-buckle when he posed with Mayor Bloomberg on the cover of TIME (June 21, 2007).Now, Esquire has written a glowing– if not worshipful– piece on the Austrian-born Arnold as governor (transforming into a stately god?) that proclaims him the “president of 12% of us” while he grandstands in various poses with his cigar, the Nazi deathshead belt buckle and also a chair decorated with eagles.

This is anything but the first time propaganda has pushed the image of Arnold as President– not only was a full-bore campaign launched to convince the subjects of the U.S. to “amend for Arnold” circa 2004, but the 2008 GOP debates featured at least two canned questions where candidates were asked to ‘look Arnold in the eye’ and tell whether or not they would change the Constitution to acquiesce to Arnold’s thirst for power (McCain and Huckabee didn’t seem to mind). Even in 1993, the film Demolition Man‘ features a scenario where the Constitution is amended and Schwarzenegger becomes President.


SEE ALSO: Alex Jones’ Martial Law 9/11: Rise of the Police State (Pt. 3) which exposes Arnold’s Nazi ties and much more.
February 21, 2008

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Arnold’s Nazi Death Belt

Arnold’s Nazi Death Belt


Arnold’s Nazi Death Belt Bush Skull and Bones

Arnold’s Nazi Death Belt Bush Skull and Bones

9-11 Report Commissioner Zelikow Admits War was for “threat against Israel”

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The Israel Lobby (full text)

Key 9/11 Commission Staffer Held Secret Meetings With Rove, Scaled Back Criticisms of White House

“Third. The unstated threat. And here I criticise the [Bush] administration a little, because the argument that they make over and over again is that this is about a threat to the United States. And then everybody says: ‘Show me an imminent threat from Iraq to America. Show me, why would Iraq attack America or use nuclear weapons against us?’ So I’ll tell you what I think the real threat is, and actually has been since 1990. It’s the threat against Israel. And this is the threat that dare not speak its name, because the Europeans don’t care deeply about that threat, I will tell you frankly. And the American government doesn’t want to lean too hard on it rhetorically, because it’s not a popular sell.

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Philip D. Zelikow

Health Care Continuity in Jail, Prison and Community


Slide 1: Health Care Continuity in Jail, Prison and Community Hampden County Correctional Center Baystate Brightwood Health Center Springfield, MA 2006

Slide 2: Percent of Total Burden of Infectious Disease Found Among People Passing Through Correctional Facilities, 1996 Condition Estimated # of Total # in US Pop’n Releases as % releases w/ Cond’n w/ Cond’n of US Pop’n w/ Cond’n AIDS 39,000 229,000 17% HIV+ 98,000-145,000 750,000 13-19% HepBsAg+ 155,000 1-1.25 million 12-16% Hep C+ 1.3-1.4 million 4.5 million 29-32% TB disease 12,000 34,000 35% Hammett TM, Abt Associates, Nat’l HIV Prevention Conf. Aug 1999

Slide 3: Background • Health Needs – Infectious Diseases – Chronic Medical Disease – Mental Health Disease – Substance Addiction and Abuse • “33d state,” “But They All Come Back” (J Travis 2005) – Most return to core urban areas – ~ 650,000 releases from US prisons/yr – ~ 9 million releases from US jails/yr

Slide 4: Percentage of inmates reporting any physical, mental, alcohol and/or drug problem(s) and the percentage out of these inmates wanting help 100 Percentage of inmates 80 60 reporting problem 40 wanting help 20 0 Male Female Gender HCCC 1999 intake data in Conklin TJ et al. AJPH,

Slide 5: Chronic Medical Illness: Comorbidity 60% 50% 40% Psych 30% ETOH cage>2 >5 drinks 20% 10% 0% Psych ETOH cage>2 >5 drinks HCCC 2001

Slide 6: Viewed from whatever angle, whether social, economic, administrative, or moral, it is seen that adequate provision for health supervision of the inmates of penal institutions is an obligation which the state cannot overlook without serious consequences to both the inmates and the community at large.” National Society for Penal Information: Rector FL, editor. Health and Medical Service in American Prisons and Reformatories. New York: J. J. Little & Ives; 1929.

Slide 7: The Triad Corrections Public Health Public Safety Community Health

Slide 8: Model transitional programs: Searching for Common Ground Project • NCCHC, Dr. Lambert King, JEHT Foundation • 2 prison systems, 1 jail – Aftercare Planning Policy of North Carolina DOC – Accountability Model of Oregon DOC – Hampden County, MA Public Health Model

Slide 9: North Carolina DOC Aftercare Planning Program • 6 mo prior to release, inmate and social worker (along with institutional treatment team) complete an aftercare plan to coordinate the inmate’s mental health, medical care, and other social service needs post-release • Social worker completes form with referrals to relevant service agencies in the community • Host of community-based partners • Each person receives a copy of the aftercare planning form, medical record copy, packet includes information on other agencies, social security card, driver’s license, and records of programs completed

Slide 10: Oregon DOC Accountability Model • Six Components 1. Criminal Risk Factor Assessment and Case Planning 2. Staff-Inmate Interactions 3. Work and Programs 4. Children and Families 5. Reentry 6. Community Supervision and Programs

Slide 11: Oregon DOC Accountability Model: Reentry program features • Reentry Facilities: 7 prisons strategically located to encourage reach-in by the community. Transfer to facility closest to home 6 mo before release. • Criminal Risk Factors Identified and Mitigated through an enhanced assessment process leading to an automated corrections plan tracked through incarceration and supervision in the community. • Family Orientation through partnering with county community corrections agencies, Parole, and citizen Rehabilitation of Errants group (to Multnomah County– receives ~ 1/3 of all releases).

Slide 12: Oregon DOC Accountability Model: Reentry program features (2) • Information Network For Oregon (INFO): a resource directory used by a variety of other agencies providing info on resources and services available in each city and county in Oregon. Produced by inmates at Powder River Correctional Facility. • Oregon Trail/Offender Debit Card: built on the Oregon Trail Card for food stamps and other public assistance, inmates leaving receive “Offender Debit Cards” instead of checks for any monies in their trust accounts. • Smart Start: In partnership with Dept of Human Services, sexual health and family planning information delivered in last months before release. “Smart Start” packets on release: bag of over-the-counter birth control and personal hygiene items.

Slide 13: Community Integrated Correctional Health Care The Hampden County Community Health Model

Slide 14: Hampden Co. Community Integrated Model • 4 jail health teams integrated with 4 community (neighborhood) health centers • Patients assigned to health team by zip code or prior association with community health center • Dually based team members in 4 health centers and jail – Physician(s) and case manager in both community health center and jail – Nurse practitioner, primary nurse primarily jail based • Community corrections (probation/parole/DRC)

Slide 15: Drug-Related Arrests of Persons Residing in Specific Neighborhoods EForPk 40,000 16 Acres Median Family Income 35,000 Lib Pine Pt E Spf BosRd ForPk 30,000 Ind UppH McK 25,000 20,000 Bay Bri 6Cor 15,000 Met OldH S.End Mem 10,000 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Annual Rates of Arrest (per 1,000) Springfield Community Partnership and Prevention Alliance, 1995

Slide 16: Outcomes • HIV patient show rate: 84-90% • Cost effectiveness: $9-10/inmate-day, 10% of $44 million budget. ACA avg cost prisons 10%. Mass 12%. • Community opinion, family opinion, patient’s opinion. • Promotes county-wide cooperation and coordination. • Evaluation and research. • Absolute decrease in emergency room visits and hospitalizations after vs. before jail. • Multivariate analysis shows increase primary care follow-up with increase health care. • Scheduling appointments increases follow-up.

Slide 17: Public Health Model for Corrections • Education • Prevention • Early detection • Reservoir of Illness • Treatment • Proactive v. Reactive • Continuity of care • Sentinel function • Data • Public Health Department • Community-integrated model

Slide 18: Challenges/Opportunities Numbers

Slide 19: Bureau of Justice Statistics: Adult correctional populations 1980-2002

Slide 20: Corrections Statistics- USA • 2 million+ incarcerated. “33rd state”. World ~ 8 million. • Including probation and parole, 6.7 million persons involved with corrections- over 3% of all U.S. Adults • 13% of African-American men cannot vote • “Invisible population” • 25% of some neighborhoods • Incarceration rate has more than tripled since 1980

Slide 21: Annual Releases of Adults Sentenced to Corrections: Massachusetts, 1989-2000 25,000 20,000 15,000 10,000 5,000 0 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Hampden All County HOC State/DOC TOTAL Mass DOC; Community Resources for Justice, Inc.

Slide 22: Challenges to Continuity & Responses • Time (jails). – Community-based program. – In various locales sheriff’s dept agreed to only release participants in care program intervention between 8am-5pm Mon-Fri. • Distance (prisons). – Technology- telemedicine, EMR. – Transfer policy. – Use of jails for transitional programs

Slide 23: Models of Case Management release A B C D E

Slide 24: Challenges • Mindset • Costs • After release

Slide 25: HIV voluntary counseling and testing program: summary • Costs $6071 per new HIV infection identified • Should 0.46 cases and would save societal dollars • Savings (for the most part) do not accrue to corrections • Collaborations Varghese et al, HCCC, 2001

Slide 26: Barriers to Continuing Care In the Community after Release 1 month after release A Big Somewhat of Not a Not Problem a Problem Problem Applicable Not being able to pay for care 29 (23%) 18 (15%) 68 (55%) 9 (7%) or meds Not being able to get an 25 (20%) 20 (16%) 73 (59%) 6 (5%) appointment Not liking the care you get 11 (9%) 15 (12%) 88 (71%) 10 (8%) from providers Not having transportation 51 (41%) 21 (17%) 48 (39%) 4 (3%) Conflicts with work or other 18 (15%) 23 (19%) 78 (63%) 5 (4%) activities Chronic Illness Cohort, HCCC, 2001

Slide 27: Facilitators to Continuing Care In the Community after Release 1 month after release Very Somewhat Not Not Helpful Helpful Helpful Applicable Post-Release Medical 43 (35%) 5 (4%) 4 (3%) 72 (58%) Appointment Set Up in Advance 83% Dually-Based Providers 57 (46%) 29 (23%) 19 (15%) 19 (15%) 54% Health care in Jail 53 (43%) 55 (44%) 14 (11%) 2 (2%) 43% Health education in Jail 58 (47%) 43 (35%) 20 (16%) 3 (2%) 48% Drug/Alcohol Treatment in Jail 50 (40%) 30 (24%) 14 (11%) 30 (24%) 53% Chronic Illness Cohort, HCCC, 2001

Slide 28: Operational Elements for Promoting Continuity of Care • Discharge planning starts early • Case Management • Personally connect with health worker before reentry • Dually based health care workers • Schedule post-release appointments • Summary health record • Medical benefits • Medication • Holistic: mental health, addiction, family

Slide 29: Relationship of scheduling appointment and primary care follow-up, stratified by level of trust Trust of jail care n Risk Ratio (95%CI) Low 28 1.2 (0.6-2.6) Med 26 1.3 (0.7-2.6) High 47 1.9 (1.1-3.2) All 101 1.5 (1.1-2.2) • Correlation of appointment scheduled with going to doctor is most evident in group with higher trust of health care in jail • Trust in health care in community showed less modifying effect

Slide 30: Non-medical health needs 1. Food 2. Basic safety 3. Housing 4. Transportation 5. Income 6. Family role

Slide 31: Non-medical health needs 1. Food Other priorities: 2. Basic safety 2. Cigarettes 3. Housing 4. Transportation 5. Income 6. Family role

Slide 32: Invisible Punishments: “Collateral Sanctions” • Employment • Public assistance • Housing • Driver’s license • Voting • Education • Parental rights • Expunging criminal record

Slide 33: Contextual and Organizational Elements for Promoting Continuity of Care • Geography • “Bureaucratic simplicity” • Pre-existing collaborative relationships • Presence of a “champion” • Precipitating events • Public health worker in corrections • Information system

Slide 34: Geography: sites for reentry • Rhode Island • Oregon: DOC facility • Virginia: jails • Hampden County: jail, day-reporting, community corrections • Hawaii

Slide 35: Three Groups Benefit • Public • Individual patient – Reduction of disease – Unpopular to – Reduction of post- mention discharge medical costs • Less morbidity • Lower incidence • Jail – Enhanced public safety – Better environment • Decreased recidivism – Cost-effectiveness • Increased healthy behaviors

Slide 36: Some Key Points • Almost everyone returns. Temporarily displaced. • Triad of corrections, community and public health- collaboration needed for mission, expertise, expenses. Structure to maintain collaboration. • Jails and prisons differences • Geographic plan • Dually-based health care workers, personal connection • Schedule appointments

Slide 37: Community health care after release At 1 month: • 46% had appointment set up • 60% went to first appointment. Comparing 6 months before and after incarceration: Intake (%) 6m (%) Went to regular doctor 64* 56* Went to ER 46 34 Admitted to hospital 24 10 * median visits 2 3 Chronic illness cohort, HCCC 2001

Slide 38: Self-reported health Intake 6 months (n=131) % % General Health Fair/poor 55 34 Good 24 33 VG/excellent 21 33 Pain (mod/severe) 40 20 Emotional problem 66 43 (mod/severe) Chronic illness cohort, HCCC 2001

Slide 39: In Jail Services and Post-Release Health Care Use (Physical)- instrumental variable multivariate analysis Following Release In jail service Doctor ER Hospital Doctor Visits ↑ 0.02 ↓ NS ↓ NS Case Management ↑ 0.02 ↓ NS ↓ NS Discharge Planning ↑ NS ↓ NS ↓ NS Appointment Made ↑ 0.01 ↓ NS ↔ NS Chronic illness cohort, HCCC 2001

Slide 40: Percent of Smokers Involuntarily Ceasing Smoking While Incarcerated Who Remained Cigarette Abstinent, by Length of Time Post-Release Chronic illness cohort, HCCC 2001

Slide 41: Hepatitis Program • Education, from admission, peer ed, groups. • Hep B vaccinate all. (? Target those •Education with known negative serology, age •Prevention above vaccine below 45. ( 18y- VFC) •Early detection • Voluntary counseling and testing, •Treatment includes HIV and hepatitis serology profile (A?, B, C) •Continuity of • ALT on admission care • Link to community health centers •Data • Collaboration with Dept of Public Health • Vaccination and PPD info wallet card and/or electronic health record

Slide 42: The health care system realizes net savings even when there is no incidence in prison, or there is no cost of chronic liver disease, or when only one dose of vaccine is administered. Thus, while prisons might not have economic incentives to implement hepatitis B vaccination programs, the health care system would benefit from allocating resources to them.

Slide 43: Multivariate model for predicting Hepatitis C % criteria % HCV detected % HCV+ Variables included 10.2 36.5 74.5 Shared needle 25.5 75.0 61.0 S. needle or ALT 29.2 81.3 57.7 S. needle, ALT or HxHep 35.6 90.1 52.7 S.needle/ALT/HxHep/HBc 19.4 57.3 68.7 ALT alone Definitions: Shared needles: Have you ever shared needles? ALT: above ULN. HxHep: Has a medical professional ever told you that you had hepatitis? HCCC 1999

Slide 44: Hepatitis B Seroprevalence- All Detainees by Age 50 40 1.9 Prevalence 30 4.8 40 20 37 0 27.9 10 4.2 16.7 7.3 7.9 0 <20 20-29 30-39 40-49 50+ Age anti-Bs only HCCC 1999

Slide 45: Vaccination needs of Hep C pts • Of inmates who tested positive for hepatitis C, 65% were negative for hepatitis A antibodies. • Likewise 39% of those positive for hepatitis C were negative for all hepatitis B serology. HCCC 1999

Slide 46: Medical Care Utilization and Coverage 200 patients with chronic health conditions • Hospitalized, past 6 months (24%) • ER Use, past 6 months (56%) • Medicaid coverage, past 6 months (68%) • No Coverage, (14%) • Sought care, but cost too much (19%) HCCC 2001

Slide 47: Economic Analysis in Public Health • Can aid in resource allocation process – determine program costs and benefits – determine cost-effectiveness of programs compared to alternatives • Can indicate important areas for research • Is increasingly required – for program evaluation – prior to program implementation

Slide 48: Economic Analysis in Correctional Health • Inmates often have comparatively high rates of health conditions • They are accessible • They can provide a link to non-incarcerated persons • Correctional health care programs often face severe budget constraints • Economic and cost-effectiveness analysis can quantify the cost and benefit (“production”) of correctional programs

Slide 49: Community Integrated Correctional Health Program •Health needs in their community Community •Community standard of care Health Centers : •CBO interactions •3% patients at HCCC

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