"Hey, Doc. What's up with my eyes?"

A fellow inmate of the New Hampshire State Prison cornered me as we waited in the yard for the call to chow. I had grown used to curbside consults from those wanting advice or a second opinion. I looked him over. He was a robust middle-aged man, obviously a body-builder type. He pointed to his eyes. They were a dull yellow.

"They been like this for three or four days,” he said. “And, I've been pissin' blood, too. I went to sick call and they sent me back. They said it wasn't blood."

I sized him up and made an assumption. "Well, you have hepatitis C. Right?"

"No, Doc. They tested me a year ago and said I was negative."

I ran through a quick differential diagnosis of jaundice in my mind. Not likely alcoholic cirrhosis, I thought. Inmates will make hooch out of just about anything fermentable, but this guy didn't look chronically ill enough for end-stage liver disease. I considered chemical-induced jaundice.

"You on any meds?"

"No, nothin', Doc. I've been a healthy guy."

"Any belly pain?" I asked. Jaundice from cancer is usually painless.

"Yea, I been havin' a lot over the last few days."

"So, you say your urine's dark red?"

"Yea, like I said, I thought it was blood, but they said 'no."'

"Did they find something called “bilirubin” in your urine?" A routine dipstick urinalysis should have turned up something, I thought.

"They didn't say. They just said it wasn't blood."

"Well, it's got to be bilirubin that's making your urine red," I told him.

"What's that mean?"

"When your liver isn't working right, a chemical called bilirubin backs up into the blood. That's what's making your eyes yellow."

He nodded. I was down to the last two likely diagnoses on my mental list.

"Are your stools normal, or have they turned clay-colored?"

A blockage of the bile ducts with a gallstone can cause jaundice and abdominal pain. Bile is what gives the brown color to stool. When it's not getting through, the stool turns beige.

"No, they're normal color," he replied.

I nodded, and then ventured a probable diagnosis. "Well, then, I think you have viral hepatitis. In here, it's probably Hepatitis C, but it could be B, or even type A."

"No shit, Doc! So, what should I do?"

"Go back to sick call tomorrow. Let them look at you again. They can do a blood test to figure out what's going on."

"Why didn't they do that two days ago?" he asked, angrily.

I shrugged. It's always uncomfortable to second-guess another professional's reasoning. The inmate walked away shaking his head. I shook mine, too. Another case of viral hepatitis caught in prison. I hadn't bothered to ask him about his risk factors for Hepatitis C. I really didn't want to know. Many are illegal, though common, activities in prison: shooting up, tattooing or having unprotected sex. That's not always the case, though. Everyday activities like sharing nail clippers or razors with an infected cell-mate can spread hepatitis.

Any time human beings are forced to live in close quarters, the risk of disease increases. Prisons are high-risk places. It used to be tuberculosis was the big killer. It still is in most of the world. Here in the U.S., with nearly one percent of our country's population incarcerated, often in over-crowded prisons and jails, Hepatitis C is rampant. Only 2 percent of the non-incarcerated public is infected. Somewhere between 20 and 49-percent of prisoners have Hepatitis C. I've never seen statistics for New Hampshire. But it's big here. Many of those infected will progress to liver failure and death over the next twenty years. In the past, prison officials didn't think that Hepatitis C was their problem. After all, it's self-inflicted, and, other than supportive care for the dying, there wasn't much that could be done anyway.

That's all changed in the last decade. Now medicine is available. It's no quick fix. Drug treatment can cost up to $15,000 per inmate per year. Sometimes, for those in liver failure, the only treatment is a liver transplant. Treatment is more effective the sooner it's begun. Delaying treatment until an inmate is released from prison is no longer considered good health care. No wonder state lawmakers are pulling out their hair over the rising cost of prison health care. With longer sentences, virtually unlimited consecutive sentencing, and no good time credits, the state prison population is steadily rising. So is the number of inmates with Hepatitis C. There doesn't appear to be any end in sight.

Another inmate stopped me a few days later.

“Hey, Doc. Can we talk?”


"I just heard that my cell-mate has hepatitis. It's got me worried."

"It should," I said.