We Can’t Overlook Reproductive Health Needs in Haiti

Sharon Camp

During this time of displacement, the health and lives of Haiti's women and girls are threatened by severe living conditions, including the virtual absence of reproductive health services.

Following
the devastating earthquake that struck Haiti on January 12, relief agencies,
multilateral institutions and governments are increasingly shifting their focus
from emergency response to longer term relief, rebuilding and development
efforts. Given the scale of the disaster, many thousands of Haitians will
likely be forced to live in camps or other makeshift arrangements for years, if
not decades, to come. During this time of displacement, the health and lives of
Haiti’s women and girls-many of whom were already in a precarious situation
because of poverty or low social status-are threatened by severe living
conditions, including the virtual absence of reproductive health services.

Most immediately,
there is an urgent
need
for clean delivery kits to ensure that childbirth is safe for mothers
and their newborns. Likewise, displaced women and girls are especially
vulnerable to sexual violence and exploitation, and proper care-including emergency
contraception and HIV prophylaxis-must be made widely available to any victims
of sexual violence. Also, the many Haitian women who find themselves cut off
from their usual sources for family planning services and supplies, including
condoms, must be provided with free contraceptives. A failure to address these
needs heightens the risk for unwanted pregnancy and botched abortion, HIV and
other STIs, and high-risk, life-threatening pregnancies and childbirth.

Fortunately,
with increased awareness over the last 15 years of the importance of
reproductive health for displaced people
, coordination and collaboration
among agencies working on these issues has grown, including through the work of
the Reproductive Health Response in Conflict
(Rewire) Consortium
. Additionally, increased research and documentation of
the specific needs of refugees and displaced people have been critical in
improving service delivery and strengthening advocacy efforts aimed at donors,
NGOs and policymakers.

The U.S.
government’s response to the Haitian earthquake has been both swift and strong.
But Haiti’s women also need the United States to reassert a leadership role in
ensuring that sexual and reproductive health care is a core component of the
humanitarian response to the crisis. As Secretary of State Hillary Rodham
Clinton said in her recent
speech on global reproductive health
: "Investing in the health of women,
adolescents and girls is not only the right thing to do; it is also the smart
thing to do. That is why we are integrating women’s issues as key elements of
our foreign policy agenda." It’s time to put these wise words to the test in
U.S. relief and rebuilding efforts in Haiti by prioritizing reproductive health
care.

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Analysis Human Rights

Erika Rocha’s Suicide Brings Attention to the Dire Need for Mental Health Care in Prison

Victoria Law

Erika Rocha's was the first suicide of the year at Corona's California Institution for Women (CIW), which is currently at 130 percent capacity. CIW's suicide rate, however, is more than eight times the national rate for women behind bars.

On April 14, 2016, one day before her parole hearing, Erika Rocha committed suicide. The 35-year-old had spent 21 years behind bars. But what should have been a day of hope for Rocha, her family, and her friends instead became a day of mourning.

Rocha’s was the first suicide of the year to rock Corona’s California Institution for Women (CIW), which is currently at 130 percent capacity. CIW’s suicide rate, however, is more than eight times the national rate for women behind bars. The prison had four suicides and 16 attempts in 2014. In 2015, it had two suicides and 35 attempts. And in the first two months of 2016, CIW had four additional suicide attempts.

These numbers, advocates say, display the consequences of the lack of mental health resources for women in prison, some of whom have been behind bars for decades.

The need for comprehensive mental health care has long plagued California prisons. In 1990, advocates filed Coleman vs. Wilson, a class-action civil rights lawsuit alleging unconstitutional medical care by the California Department of Corrections and Rehabilitation (CDCR). In 1995, a U.S. District Court ruled in Coleman that mental health-care access in the state prisons violated the Eighth Amendment prohibition against cruel and unusual punishment; the following year, it appointed a special master to review California’s prisons and to monitor mental health care. That special master is still monitoring CDCR’s mental health care.

In 2013, Lindsay Hayes, a suicide prevention expert, audited all of the state’s prisons for their suicide prevention plans. In 2015, he re-audited 18 of those prisons. In the report he released in January 2016, he noted that, while some prisons had made progress on the issue, “CIW continued to be a problematic institution that exhibited numerous poor practices in the area of suicide prevention.” These poor practices, Hayes wrote, included low completion of suicide risk evaluations, inadequate treatment planning, low compliance rates for annual suicide prevention training, and multiple suicides during the calendar year.

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“This Seemed To Be the Only Way”

No one will ever know what pushed Rocha over the edge. But others at CIW say that those who need mental health treatment there, both before and after their suicides, face a lack of preventive treatment, including counseling, and almost no follow-up.

Amber, who asked to be referred to by a pseudonym, noted that the prison lacks available mental health programming. She had already spent 14 years at another prison when she was transferred to CIW. There, she found that nearly every self-help and support group had a long waiting list.

In addition, mental health treatment was sparse. “I would only see mental health [staff] every 90 days, and that was only about five minutes,” she recalled in an interview with Rewire. “As time went on and I became more and more frustrated by the lack of anything to take my mind off my emptiness, I got more lonely and hopeless.” She stopped talking to her friends, stopped eating, lost interest in her appearance, and began losing weight. No one noticed these red flags. She told mental health staff that she wanted to stop taking medication. No one, she said, questioned her decision.

In July 2014, Amber and her friend Mindy (also a pseudonym) decided to end their lives together. Once they made their decision, Amber remembered feeling a sense of relief: “I was happy. I knew my misery and pain were ending. … This seemed to be the only way.” The two slit their throats, losing consciousness. But someone found them, alerted staff and they were transported to the hospital. How they were treated next, they said, didn’t make them feel any more hopeful about life.

After being released from the hospital, both women were placed in a mental health crisis bed, commonly referred to as “suicide watch” among people in prison. Amber described suicide watch as a place “where they strip you naked and put a hard gown on you, basically a life jacket. They give you a blanket made of the same material and have a bright light on with a nurse watching and recording [on paper] your every move. … You are not allowed anything for the first week. Then you can ‘earn’ a book. And maybe a muumuu gown if you are calm and cooperative. You aren’t even allowed a roll of toilet paper. When you need to use the toilet [in your cell], they hand you a tiny bit and watch you use it.”

Mindy spent 11 days in suicide watch; Amber was there for two weeks. Both were then placed in the prison’s specialty care unit, where they were able to have human interactions and access to group programming, which Amber described as 14 hours a week of coloring, watching movies, singing karaoke, and walking.

However, suicide watch is frequently full. In those cases, people are placed in an “overflow unit” in the prison’s Security Housing Unit (SHU), an isolation unit where people are locked in their cells for 23 to 24 hours each day. This kind of isolation can cause myriad mental health issues, including anxiety, panic, depression, agoraphobia, paranoia, aggression, and even neurological damage.

Krista Stone-Manista is an attorney with San Francisco-based Rosen Bien Galvan & Grunfeld, which co-litigated the Coleman case. She is also part of the team now monitoring compliance. She notes that, when a person reports feeling suicidal, she is supposed to be moved to a mental health crisis bed. But, because there aren’t enough mental health crisis beds, California prisons utilize what’s known as “alternative housing,” which might include isolation until a bed opens up. “What we’re seeing is that people are repudiating their suicidal ideation to get out of alternative housing,” she told Rewire. That means that they don’t receive counseling or any other type of mental health treatment.

But even when they are placed on suicide watch, the special master, in his 2015 review of CIW, found that “patients were discharged from the mental health crisis bed as soon as they reported they were no longer suicidal, with little effort to determine the underlying causes of their initial reports of suicidality.”

People incarcerated at CIW report that its environment has not improved in the two years since Amber and Mindy attempted to take their lives. In March 2015, Stephanie Feliz hung herself. Mindy, who was in the mental health unit at the time, said that Feliz walked in and requested services for a mental health crisis. Despite having a history of suicide attempts and self-mutilation, Mindy said staff told her that she had already been seen the day before. According to Mindy, Felix returned to her cell, where she was found dead two hours later. This treatment is not unusual, Mindy noted, writing to Rewire in a letter that she too has requested mental health services only to encounter delays and, at times, outright dismissal.

But no matter what changes the institution makes, Stone-Manista pointed out, “There’s only so much CIW can do for someone who is chronically suicidal. They’re not a hospital.”

CDCR did not respond to queries about the numbers of suicides and suicide attempts at CIW or about its suicide prevention practices.

Rocha’s Years in Prison

When Rocha was 14 years old, she and several older teens were arrested for an accidental shooting. Rocha was charged as an adult and, without a parent or guardian present, questioned by police and, according to advocates, pressured to plead guilty by the prosecutor. She did and was sentenced to 19 years to life. Rocha was initially sent to a juvenile prison, where she spent two years. At age 16, she was transferred to the adult Valley State Prison in Chowchilla. There, prison officials placed her in solitary, ostensibly for her own protection due to her age. She stayed in isolation for one year.

Windy Click is now program coordinator for the advocacy group California Coalition for Women Prisoners (CCWP). She was imprisoned at Valley State when Rocha arrived and met the girl shortly after she had turned 19. Rocha was looking for something positive to do and asked how to get to the prison library. While Click, then in her 30s, and Rocha never became close friends, each time Rocha was released from solitary, she sought the older woman out.

“She was a funny girl,” Click recalled in an interview with Rewire. “She liked to joke and be light-hearted.” One of the topics that Rocha frequently joked about was growing old in prison. “She’d say she would be an old lady in prison.”

Other times, however, the girl had a hard time coping with prison. “She would be very shaky, trembling almost,” Click recalled. “‘I can’t do this no more,’ she’d tell me.” During those times, Click said, Rocha would tell prison staff that she was afraid for her life and request to be placed in administrative segregation, a form of isolation commonly known as ad-seg, where she would be locked in a cell for 23 to 24 hours each day. Prison staff obliged and Rocha would be placed in isolation. When she returned to general population, Click remembered that the girl would seem better but “after a day or so, she’d be back to that shakiness.”

Click recalled one conversation in which she told Rocha, “This place isn’t the last place you’ll ever be.” But, she remembered, the younger woman couldn’t see the light at the end of the tunnel.

It didn’t help that Rocha spent more than a decade without seeing her family, who lived nearly 300 miles in the Los Angeles area. Lacking a car, they could not make the trek to Central Valley. It was not until Rocha was moved to CIW, 15 minutes from their home, that they could visit. By then, Rocha’s father had died; her stepmother Linda Reza brought her three daughters as soon as Rocha was allowed to receive visits.

“She was still the same little kid that left us,” Reza remembered of that first visit in an interview with Rewire.

That was how Geraldine, Rocha’s half-sister, saw it as well: “She’s nine years older than me. But it was like I was the big sister.”

Rocha got along best with her teenage sister Freida, who was born after her incarceration and whom she met for the first time in the CIW visiting room. When the family visited, Reza remembered that Rocha and Freida would head to the visiting room’s play area and play on the swings. Reza recalled that, when Rocha received news of her upcoming hearing, she and Freida made plans to share a room at Reza’s house, clipping magazine pictures and envisioning how to decorate the room.

Colby Lenz, a volunteer legal advocate with CCWP, saw a different, more vulnerable side, one that Rocha did her best to keep from her family. “She was the most fragile and traumatized person I had ever met in prison,” Lenz recalled about their first meeting less than two years ago. It was only partway through the legal visit that Rocha began to open up. “She went back to [age] 14 or 15 and talked about her early years—how much time she had done in solitary, how they treated her.”

Under California’s SB 260, which passed in 2013 and went into effect in January 2014, Rocha became eligible for a youth parole hearing for youth sentenced as adults to long prison sentences. As part of the hearing process, she was given a psychiatric evaluation. But, said Lenz, no one explained to her why she was undergoing a psychiatric evaluation. The process brought her back to the police interrogations she had gone through at age 14 without a parent or guardian present. Frightened and retraumatized, Rocha not only waived her hearing, but also attempted to take her own life.

In 2015, Rocha learned she was scheduled for another youth parole hearing on April 15, 2016. In the weeks before, Reza recalled that Rocha was excited. The last time she called, Reza wasn’t able to answer her phone. The message Rocha left was hopeful. “Tell my sisters I know they’re going to kick my ass when I get home,” she said. “But that’s okay, I’ll take it.”

“In a Hopeless Place, Most Don’t Make It”

Since Rocha’s death, CCWP has reported that at least 22 people in CIW have been placed on suicide watch for attempting suicide or stating that they felt suicidal.

Mariposa, who asked to go by her stage name, is one of those 22 placed on suicide watch. She is the co-author of the one-woman play Mariposa and the Saint about her own time in solitary. She was also Rocha’s cellmate and fiancée. After Rocha was found hanging in their shared cell, Mariposa was immediately placed in suicide watch, where she was not allowed regular visits, phone calls, or mail. She was, however, allowed a legal visit with CCWP, but, advocates told Rewire, kept in a treatment cage the entire time.

Those inside the prison report that the lack of programs and activities contributes to the feeling of hopelessness. “People have way too much time to think and be in their heads,” wrote another woman at CIW to Rewire one month before Rocha’s death. “A lot of us are only hanging on by hope alone. In a hopeless place, most don’t make it.”

Krista Stone-Manista noted that CDCR is working on new policies and procedures to move people who need more care or longer-term care to inpatient care rather than keeping them inside the prisons, which are often inadequately staffed with mental health professionals. She also pointed to CDCR’s reduction of the use of solitary confinement, noting that studies have shown the damage to mental health and that suicides and suicide attempts often occur in segregation. In addition, she says, CDCR is working on how to respond to reports of suicidal thoughts before they become attempts or actual suicides.

All of these efforts are too late for Rocha. “When I get out, I want you to take me to the park,” Reza remembered her stepdaughter telling her and her sisters during one visit. “I want to play on the swings and the slide and run in the grass.”

Reza plans to honor that wish. “After her cremation, we’re going to have a reception in the park,” she said. “We’re going to put her on the swings.”

Analysis Law and Policy

State-Level Attacks on Sexual and Reproductive Health and Rights Continue, But There’s Also Some Good News

Rachel Benson Gold & Elizabeth Nash

Despite the ongoing attention to restricting abortion, legislators in several states are looking to expand access to sexual and reproductive health services and education.

State legislatures came into session in January and quickly focused on a range of sexual and reproductive health and rights issues. By the end of the first quarter, legislators in 45 states had introduced 1,021 provisions. Of the 411 abortion restrictions that have been introduced so far this year, 17 have passed at least one chamber, and 21 have been enacted in five states (Florida, Indiana, Kentucky, South Dakota, and Utah).

This year’s legislative sessions are playing out on a crowded stage. The U.S. Supreme Court is considering a case involving a package of abortion restrictions in Texas; that decision, when handed down in June, could reshape the legal landscape for abortion at the state level. Moreover, just as state legislatures were hitting their stride in late March, the U.S. Food and Drug Administration revised the labeling for mifepristone, one of the two drugs used for medication abortion. That decision immediately put the issue back on the front burner by effectively counteracting policies restricting access to medication abortion in a handful of states. (Notably, the Arizona legislature moved within days to enact a measure limiting the impact of the FDA decision in the state.)

Progress on Several Fronts 

Despite the ongoing attention to restricting abortion, legislators in several states are looking to expand access to sexual and reproductive health services and education. By the end of the first quarter, legislators in 32 states had introduced 214 proactive measures; of these, 16 passed at least one legislative body, and two have been enacted. (This is nearly the same amount introduced in the year 2015, when 233 provisions were introduced.)

Although the proactive measures introduced this year span a wide range of sexual and reproductive health and rights issues, three approaches have received particular legislative attention:

  • Allowing a 12-month contraceptive supply. Legislators in 16 states have introduced measures to allow pharmacists to dispense a year’s supply of contraceptives at one time; these bills would also require health plans to reimburse for a year’s supply provided at once. (In addition, a bill pending in Maryland would cover a six-month supply.) Legislative chambers in three states (Hawaii, New York, and Washington) have approved measures. Similar measures are in effect in Oregon and the District of Columbia.
  • Easing contraceptive access through pharmacies. Legislators in 12 states have introduced measures to allow pharmacists to prescribe and dispense hormonal contraceptives. As of March 31, bills have been approved by at least one legislative chamber in Hawaii and Iowa and enacted in Washington. The measures in Hawaii and Iowa would require pharmacist training, patient counseling, and coverage by insurance; the Hawaii measure would apply only to adults, while the Iowa measure would apply to both minors and adults. The new Washington law directs the state’s Pharmacy Quality Assurance Commission to develop a notice that will be displayed at a pharmacy that prescribes and dispenses self-administered hormonal contraception. Under current state law, a pharmacy may prescribe and dispense these contraceptives under a collaborative practice agreement with an authorized prescriber. Oregon has a similar measure in effect. (California, the only other state with such a law, issued regulations in early April.)
  • Expanding education on sexual coercion. Measures are pending in 17 states to incorporate education on dating violence or sexual assault into the sex or health education provided in the state. A bill has been approved by one legislative chamber in both New Hampshire and New York. The measure approved by the New Hampshire Senate would require age-appropriate education on child sexual abuse and healthy relationships for students from kindergarten through grade 12. The measure approved by the New York Senate would mandate education on child sexual abuse for students from kindergarten through grade 8. And finally, in March, Virginia enacted a comprehensive new law requiring medically accurate and age-appropriate education on dating violence, sexual assault, healthy relationships, and the importance of consensual sexual activity for students from kindergarten through grade 12. Virginia will join 21 other states that require instruction on healthy relationships.

Ongoing Assault on Access to Sexual and Reproductive Health Services

Even as many legislators are working to expand access to services, others are continuing their now years-long assault on sexual and reproductive health services and rights. Restricting access to abortion continues to garner significant attention. However, last year’s release of a series of deceptively edited sting videos targeting Planned Parenthood has swept both the family planning safety net and biomedical research involving fetal tissue into the fray.

  • Abortion bans. Legislative attempts to ban abortion fall along a broad continuum, from measures that seek to ban all or most abortions to those aimed at abortions performed after the first trimester of pregnancy or those performed for specific reasons.
    • Banning all or most abortions. Legislators in nine states have introduced measures to ban all or most abortions in the state, generally by either granting legal “personhood” to a fetus at the moment of conception or prohibiting abortions at or after six weeks of pregnancy. Only one of these measures, a bill in Oklahoma that would put performing an abortion outside the bounds of professional conduct by a physician, has been approved by a legislative chamber.
    • Banning D&E abortions. Legislators in 13 states have introduced measures to ban the most common technique used in second-trimester abortions. Of these, a bill in West Virginia was enacted in March over the veto of Gov. Earl Ray Tomblin (D). A similar measure was approved by both houses of the Mississippi legislature and is being considered by a conference committee. (Kansas and Oklahoma enacted similar laws last year, but enforcement of both has been blocked by court action.)
    • Banning abortion at 20 weeks post-fertilization. South Dakota and Utah both enacted measures seeking to block abortions at 20 weeks during the first quarter of the year. The new South Dakota law explicitly bans abortions at 20 weeks post-fertilization (which is equivalent to 22 weeks after the woman’s last menstrual period). The Utah measure requires the use of anesthesia for the fetus when an abortion is performed at or after that point, something that providers would be extremely unlikely to do because of the increased risk to the woman’s health. In addition to these new measures, 12 other states ban abortion at 20 weeks post-fertilization.
  • Banning abortion for specific reasons. In March, Indiana enacted a sweeping measure banning abortions performed because of gender, race, national origin, ancestry, or fetal anomaly; no other state has adopted such a broad measure. The Oklahoma House approved a measure to ban abortion in the case of a fetal genetic anomaly; the state already bans abortion for purposes of sex selection. Currently, seven states ban abortion for the purpose of gender selection, including one state that also bans abortion based on race selection and one that also bans abortion due to fetal genetic anomaly.
  • Family planning funding restrictions. In the wake of the Planned Parenthood videos, several states have sought to limit funding to family planning health centers that provide or refer for abortion or that are affiliated with abortion providers. These efforts are taking different forms across states.
    • Medicaid. Measures to exclude abortion providers (e.g., Planned Parenthood affiliates) from participating in Medicaid have been introduced in five states, despite the clear position of the federal Centers for Medicare and Medicaid Services that such exclusions are not permitted under federal law. In March, Florida Gov. Rick Scott (R) signed a Medicaid restriction into law. By the end of the first quarter, measures had passed one chamber of the legislature in Arizona, Mississippi, and Missouri; a measure introduced in Washington has not been considered. (A related measure enacted in Wisconsin in February limits reimbursement for contraceptive drugs for Medicaid recipients.)

Similar attempts by six other states have been blocked by court action since 2010. These measures include laws adopted by Indiana and Arizona as well as administrative actions taken in Alabama, Arkansas, Louisiana, and Texas.

  • Other family planning funds. Legislators in 13 states have introduced measures to prevent state or federal funds that flow through state agencies from being distributed to organizations that provide, counsel, or refer for abortions; the measures would also deny funds to any organization affiliated with an entity engaging in these activities. Measures in three of these states have received significant legislative attention. In February, Wisconsin enacted a measure directing the state to apply for Title X funds (the state is not currently a grantee under the program); if the state’s application were approved, the measure would ban this funding from going to organizations that engage in abortion care-related activity. A measure that would deny funds to organizations engaged in abortion care-related activity passed the Kentucky Senate in February. A similar measure in Virginia, which would both prohibit an abortion provider from receiving funding and give priority to public entities (such as health centers operated by health departments) in the allocation of state family planning funds was vetoed by Gov. Terry McAuliffe (D) in March.
  • Related funds. In February, Ohio Gov. John Kasich (R) signed a measure barring abortion providers or their affiliates from receiving federal funds passing through the state treasury to support breast and cervical cancer screening; sex education; and efforts to prevent infertility, HIV in minority communities, violence against women, and infant mortality.
  • Fetal tissue research. The Planned Parenthood videos have also led to legislation in 28 states aimed at research involving fetal tissue. Measures have passed one legislative chamber in four states (Alabama, Iowa, Idaho, and Kentucky), and new laws have been enacted in four states (Arizona, Florida, Indiana, and South Dakota) in the first quarter alone. All four laws ban the donation of fetal tissue for purposes of research. These new laws are the first to ever ban the donation of fetal tissue. The Arizona law also bans research using fetal tissue, and the new South Dakota law strengthens the state’s existing ban by now considering fetal tissue research as a felony; four other states (Indiana, North Dakota, Ohio and Oklahoma) have similar provisions in effect.

Zohra Ansari-Thomas, Olivia Cappello, and Lizamarie Mohammed all contributed to this analysis.