When Rayford Burke, 63, lost his appetite in January, he knew something was wrong. Cases of Covid-19 had just reached a record high in North Carolina, though death row, where Burke has been incarcerated since 1993, had been spared due to its relative isolation. But it wasn’t long before Burke heard rumblings that the coronavirus was infecting people in his pod, so he started double masking and conducting his own rudimentary Covid tests, mixing a few drops of perfume oil with his lotion and every so often taking a whiff.

Burke’s loss of appetite wasn’t accompanied by a loss of taste or smell, and it closely matched a bad reaction he had two years earlier to hydrochlorothiazide, a blood pressure medication that so severely dehydrated him that he was taken by ambulance to an outside hospital for treatment. That’s what was happening again, he thought, as his lack of appetite led to weight loss and an even greater concern about his health. By the time he put in a sick call with prison staff in February, Burke estimates that he had lost between 30 and 40 pounds, down from his normal 285 or 290. He had also tested positive for Covid, as had 15 other people in his pod, he said.

“When I first tried to get them to take me to the doctor, I was so dehydrated, I couldn’t eat, couldn’t drink,” Burke told The Intercept. “I’d drink water and regurgitate it — I’d throw it back up. I’d take a bite of food — I’d throw it back up. And so I told them that. They wouldn’t do anything. They kept saying, ‘Well, we’re gonna do this. We’re gonna do that. We’re gonna get you to see somebody.’ About three days passed.”

Burke filed a grievance, and the next day he was taken to the emergency room at the prison hospital and placed on an IV. He regained his appetite a few days later and was sent back to isolate with his pod as Covid ran its course on death row. Given the circumstances, Burke was very lucky — but he’s worried that his luck will eventually run out.

Nearly two-thirds of the 135 people on death row in North Carolina, including Burke, are over the age of 50, which the state defines as “elderly.” Based on current trends, within the next 10 years, approximately 90 percent of people on death row will be considered elderly. Many have from chronic diseases and conditions such as high blood pressure, diabetes, cancer, and hepatitis C. With the passage of time, death row, in many ways, is transforming into an informal geriatric unit — one that has proved wholly unprepared to care for its aging population.

Marred by chronic understaffing; a slow, and sometimes ignored, sick-call process; a copay system that discourages people from seeking care; a utilization management program that must approve requests for specialized medical care; and the stalled implementation of a caretaker program that would teach incarcerated people how to effectively provide palliative care to their peers, the looming geriatric health care crisis on North Carolina’s death row provides a stark and dire warning for what lies ahead, especially when it comes to the economic and societal costs of incarcerating older people. North Carolina’s Department of Public Safety, or DPS, did not answer The Intercept’s questions related to medical care within the state prison system.

By the end of 2019, more than 21 percent of people incarcerated in state or federal prisons across the U.S. were age 50 or older, according to statistics from the U.S. Department of Justice. But death row is where the concentration of older people is highest: That same year, nearly 55 percent of people on death row in the U.S. were age 50 or older. Among state corrections departments, there’s no uniform definition as to what constitutes an “elderly,” “older,” or “aging” incarcerated person, though 50 or 55 are often used.

“Nationwide, every corrections department is facing an avalanche of elderly people,” Frank Baumgartner, a political science professor at the University of North Carolina at Chapel Hill, told The Intercept. “They’ve had 30 years to prepare for it, and naturally, they haven’t prepared.”

A photograph of Rayford Burke, currently on death row, as a young man in his case file in Durham, N.C.

A Self-Inflicted Wound

In “Throwing Away the Key: The Unintended Consequences of ‘Tough-on-Crime’ Laws,” a paper published recently in the journal “Perspectives on Politics,” Baumgartner and a group of co-authors predict a rapid rise in the number of geriatric prisoners in the United States. (Lyle May, one of the writers of this article, is a co-author of that report.) Many of these incarcerated individuals, like Burke, will endure chronic diseases diagnosed while serving a prison term they won’t outlive. The authors note that this impending crisis — a self-inflicted wound resulting from tough-on-crime laws adopted across the country in the 1980s and 1990s — will lead to serious human rights issues that many prison systems, like North Carolina’s, aren’t equipped to handle.

By 2006, DPS understood the economic and moral consequences that these tough-on-crime policies, including life without parole, three-strikes laws, and the expanded use of the death penalty, would have on prison health care in North Carolina. That year, DPS published a study on the prison system’s aging population. The study had several objectives, but its main purpose was to help DPS plan for the inevitable increase in the number of older people incarcerated under its watch and the rising costs associated with their incarceration.

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The study’s authors surveyed 245 older incarcerated people and found that nearly three-quarters of them were under medical care and taking prescription medications for a variety of chronic illnesses or diseases, ranging from heart disease and cancer to Parkinson’s and tuberculosis. They reported that medical issues and lack of adequate care topped their list of concerns, just above their fear of dying in prison.

The study included a list of recommendations, which ranged from releasing terminally ill, geriatric, and “severely disabled” people to hospice care or private facilities to tracking health care expenditures by age and type. According to a status update published the following year, only two people were released to a hospice or private facility during fiscal year 2006-2007, while most other recommendations were still under review.

In the almost 15 years that followed, the state has taken little action, while the number of older incarcerated people, and the costs associated with caring for them, have continued to increase. By 2018, nearly 9,000 people incarcerated in North Carolina prisons were 50 or older, according to Baumgartner’s paper — up 158 percent since 2005. And in a 2018 report to the state’s Joint Legislative Program Evaluation Oversight Committee, program evaluators found that the average health care expenditure for an elderly incarcerated person increased to $36,399 in fiscal year 2016-2017 — up nearly $31,000 since fiscal year 2006-2007. It cost the state an estimated $27,748 more per person annually to care for an elderly person as compared with their younger peers.

The state has made some efforts to provide better, more cost-effective care. In 2011, North Carolina completed a $153.7 million medical complex at Central Prison, where death row is located. According to news reports prior to its opening, the new hospital was predicted to save the state $40 million a year. In 2019, a new 46-bed palliative and long-term care unit was completed — an improvement with the potential to make a real difference for older incarcerated people. But it sits empty, awaiting additional funding from lawmakers. On Thursday, Gov. Roy Cooper signed a new state budget that provides the needed funds for staffing and operational costs. Lawmakers also allocated an additional $45 million this year, and $50 million per year from 2022 onward, to help close a budget shortfall related to the pandemic and the rising cost of health care for incarcerated people.

A bariatric bed is shown in the new Central Prison health care complex during a tour of the new facility in Raleigh, N.C., on Oct. 19, 2011.

Natural Deaths

Over the last 15 years, since the last execution in North Carolina, 17 older people on death row have died of “natural causes.” The average age of death was 65, 10 years younger than the average life expectancy for a man outside prison. According to medical reports from the North Carolina Office of the Chief Medical Examiner, at least 13 deaths were due to either cancer or heart disease, the leading causes of death in prison. But two people, Bernard Lamp and Malcolm Geddie, died from hepatitis C, a curable disease.

In May 2016, Lamp, 58, underwent a procedure to treat enlarged, bleeding veins in his esophagus, known as esophageal varices, that typically occur in someone with advanced liver disease. Ten days later, Burke, who was incarcerated in the same pod as Lamp, saw Lamp after he came back to the cellblock from the recreation yard. Lamp approached Burke and asked him if he looked pale, Burke said. Burke didn’t think so, but Lamp told him that he felt like he was losing blood.

Later that night, sometime between 11 p.m. and midnight, Lamp began vomiting blood, according to Andrew Ramseur, an incarcerated person who witnessed the event while working as the night janitor, and Burke, who heard gagging coming from Lamp’s cell. Others on the cellblock began yelling for help, Burke said, but it’s almost impossible to alert staff from behind a cell door in Central Prison. Two guards discovered Lamp lying in a pool of blood when they made rounds later that night, according to Ramseur and Burke. Burke witnessed Lamp vomit blood three times before he was removed from the cellblock.

According to the medical examiner’s report, Lamp, who had a history of cirrhosis and esophageal varices resulting from hepatitis C, vomited another liter of blood in the emergency room at UNC Rex Hospital. He was intubated and sent to intensive care, where he died later that morning. According to a DPS news release, he died of “apparent natural causes.”

Geddie, meanwhile, was admitted to UNC Rex in June 2017 and diagnosed with portal vein thrombosis, a clot that cuts off blood supply to the liver, and bowel ischemia, which reduces blood flow to the small intestine, according to a medical examiner’s report. Too unstable for surgery, Geddie became septic and died two days later. According to the report, Geddie had a variety of chronic illnesses and diseases, and his death, at age 70, was ultimately a result of complications of end-stage liver disease due to hepatitis C.

At the time of Lamp’s and Geddie’s deaths, hepatitis C treatment was not widely offered to incarcerated people. According to Geddie’s medical examiner’s report, he had begun treatment approximately a week before his death. It’s unclear whether Lamp had been treated or was even eligible for treatment, but Burke believes that Lamp had not received treatment. “If he had been getting it, he would have told me,” Burke said. In North Carolina prisons, medical records are kept confidential, even from the incarcerated people they concern.

“If you have hepatitis C, and there’s a cure, you have to give them the cure. Otherwise, you’re a monster.”

Treatment and testing protocols changed following a 2018 federal lawsuit filed on behalf of three people incarcerated in North Carolina prisons who had been diagnosed with hepatitis C. DPS had refused to treat the plaintiffs with direct-acting antiviral drugs, known as DAAs, according to court documents, noting that treatment was only approved if “significant liver scarring and the risks of further significant injury are higher” or if the patient had hepatitis B or HIV. According to the lawsuit, treatment could be denied if the patient’s life expectancy was less than 10 years or if the patient had a drug or alcohol infraction within the previous 12 months.

The lawsuit was settled earlier this year and ultimately expanded hepatitis C testing and DAA treatment to at least 2,100 people incarcerated in North Carolina’s prisons over a five-year period. At least 1,500 incarcerated people in North Carolina had hepatitis C in 2018, according to the lawsuit, though one estimate put that number at between 6,599 and 12,553. DPS will also be required to report how many incarcerated people are tested and treated every six months, though those requirements won’t begin until DPS resumes normal operations after the pandemic.

Ben Finholt, director of the Just Sentencing Project at Duke Law School’s Wilson Center for Science and Justice, believes that the complaints filed in the hepatitis C lawsuit were indicative of the greater problems related to health care quality and access within the North Carolina prison system. “If you have hepatitis C, and there’s a cure, you have to give them the cure,” Finholt told The Intercept. “Otherwise, you’re a monster.”

A sign and flowers commemorate Faye Brown, a 67-year-old victim of Covid-19, in front of the North Carolina Correctional Institution for Women on May 9, 2020.

An Impenetrable System

The pandemic has also demonstrated how the state’s prison health care system fails those incarcerated within it, with the gravest consequences faced by older adults and those with chronic diseases. As a result of a civil rights lawsuit that challenged the overcrowded, unsanitary conditions in North Carolina prisons, the state eventually agreed to release 3,500 prisoners over a six-month period.

When the pandemic hit North Carolina’s prison system, chronic care needs went unmet and sick calls were often ignored by the already limited medical staff, said Elizabeth Simpson, associate director of Emancipate NC, one of the groups that brought the lawsuit. All of that hit the older population the hardest. (According to a 2020 report to the state’s Joint Legislative Program Evaluation Oversight Committee, DPS had a 26 percent vacancy rate for nurses.)

Among the more than 29,000 people currently incarcerated in North Carolina’s prisons, those over 50 with underlying health conditions were, and remain, at the greatest risk from Covid. Despite strict safety protocols, testing, and vaccines mandated by the lawsuit, the virus still infected over 10,000 incarcerated people, many before the lawsuit was settled. According to the DPS Covid dashboard, 55 incarcerated people have died from Covid since the beginning of the pandemic, though news reports from Indy Week as well as an earlier investigation by North Carolina Health News and Vice News claim that DPS is underreporting the death toll.

“We got reports from people with cancer saying that DPS just stopped giving cancer meds to them during a global pandemic. … That’s just unconscionable.”

“If I were to pick one broad topic where North Carolina prisons are the most out of bounds on the constitutional rights of the people in their custody, it’s a close call between their use of segregation and their medical care,” Finholt said. “It’s really horrendous. And Covid was a prime example of it. We got reports from people with cancer saying that DPS just stopped giving cancer meds to them during a global pandemic, where if you have a weakened immune system, you’re much more likely to die. That’s just unconscionable.”

Aside from their Covid-19 concerns, older incarcerated people on death row say they face structural obstacles to getting basic care.

To receive medical care — whether for an emergency or a routine physical or chronic care appointment — incarcerated people in North Carolina’s prisons must submit a sick call describing their need. Typically, a nurse sees the person within a week to screen them and take vitals. If the problem warrants being seen by a doctor, a nurse makes a note of it. Seeing a doctor takes two to three weeks. If a medical issue requires specialty care, it can take a month or more. Medications, X-rays, and lab tests usually occur within a week after that. As a result, it may take six weeks after submitting a sick call to receive treatment, which requires a $5 co-pay.

Requests for specialized treatment go through the utilization management program, which continues to make crucial medical determinations with an eye on cost, deciding who receives surgery for an ACL tear or ibuprofen and an ice pack, or nothing at all, with little recourse if a claim is denied.

DPS is required to conduct a physical on all incarcerated individuals 50 or older at least once a year, but just over half of 31 older people on death row informally surveyed by The Intercept said they had received a complete checkup within the last year. Only four of 17 people who said they needed treatment for chronic diseases — such as hypertension, diabetes, HIV, or sarcoidosis — reported being seen by a chronic care doctor in the last year.

This limited access to medical care will likely lead to suffering or premature death for many people on death row and serving life without parole, Baumgartner said.

“Our options are either paying for the kind of medical care that people deserve just as a human right or warehouse people until they die of old age after terrible suffering, forgotten, thrown away in a box without adequate medical care,” he said. “Is that the country we want to be?

Weeping Wounds

Two years ago, Allen Holman, a 62-year-old on death row since 1998, sat in the nurses’ station at Central Prison with a towel pressed against his stomach. Holman had been diagnosed with colon cancer a few years earlier, and doctors had removed his colon and rectum. After surgery, he was supposed to receive training on how to properly clean and change his colostomy bag, but his referral to an ostomy clinic was denied by the utilization management program, he said

Seated in the nurses’ station that day, Holman’s colostomy bag wouldn’t fill against his blistered, bleeding skin — the result of violent feces leaking from his stoma and a bad case of untreated eczema. Accompanied by three friends who provided much of his daily care, Holman waited silently while a nurse tried to reattach his colostomy bag without cleaning the site, much to the protest of his informal caregivers. The nurse, growing frustrated, finally called the prison’s urgent care.

Jason Hurst, Holman’s friend on death row who was with him that day, reflected on his role as a caregiver in a journal entry from September 2019.

“We have a routine where I stop in throughout the day and ask, ‘Are you alright?’” Hurst wrote in an excerpt he shared with The Intercept. “Usually he just responds with an unconvincing ‘Yeah,’ but this time, after a long silence, he whispered, ‘I’m tired.’ This drew me into his cell. I sat beside his bed and asked what he meant. He explained that he was ready to die, to be done suffering. At that point, both of us had tears in our eyes. In many ways I see him as the physical manifestation of the pain, sadness, and despair I fight to keep at bay, and that realization makes me fight for him as well.”

As people on death row create informal networks to care for one another, they also hope that the state will approve and fund a program that would train and better equip them to do so. In 2018, George Wilkerson, a 40-year-old man incarcerated on death row, submitted a proposal to Chad Lovett, the CEO of Central Prison’s hospital, calling for the creation and implementation of a caretaker program. According to Wilkerson, Lovett approved a pilot program, which would assign one trained incarcerated caregiver to each disabled person on death row. In February 2020, Wilkerson said he had been told by a DPS unit manager that the program was still moving forward. But then the pandemic hit, and there’s been no further word, Wilkerson said.

Meanwhile, Hurst and Holman’s other friends do their best to care for him, but without proper training, there’s only so much they can do. Had something as simple as a caretaker program been implemented, they might know how to effectively deal with Holman’s many needs — like changing out and securing his colostomy bag. Instead, they wing it for the sake of helping their friend.