Thomas J. Dart, sheriff of Cook County, Ill.—and overseer of what he says is the  nation's largest jail—believes that posterity will gaze back 100 years from now and know that we were "horrible people."

This is because our country incarcerates mentally ill individuals in overwhelming numbers for minor violations instead of steering them into appropriate treatment, Dart said via teleconference to a group of health care providers, bioethicists, sociologists and advocates recently gathered at the University of Pennsylvania.

"I can't think of anything that is more morally reprehensible than what we do to this population," Dart told the ethics in correctional psychiatry group.

Funded by the Leonard Davis Institute of Health Economics and part of the Scattergood Ethics Program for Applied Ethics in Behavioral Health Care at Penn's Perelman School of Medicine, the team launched a pilot project six months ago to research the shadow health care system that exists behind bars. As I wrote in a post three months ago, the group aims to draft policy proposals about how to improve correctional mental health care and will publish scholarly research on its findings.

"The field of bioethics has been negligent in addressing these issues," said Penn bioethicist Dominic Sisti, the director of the Scattergood Program, who is also spearheading the prison ethics group. "I want to encourage the field to be looking at these issues in a very systematic way," Sisti said.

"There's no one in this system who feels that we're doing this well," said Cyndi Rickards, assistant professor of criminology and justice studies at Drexel and one of the organizers of the prison ethics group, referring to maltreatment experienced by those with mental illness who cycle in and out of jail and prison.

"These issues are fixable if you have folks who are focused on them and understand the moral issues involved," Dart said, adding that they "sort of blew up the whole model" of incarceration at Cook County.

Of the 730,000 individuals sitting in the nation's jails each day, roughly 9,000 – most of them awaiting trial—are under Dart's supervision. He says he has turned the Cook County Jail into a "health care model," which Sisti's group thinks might become a template for others  around the country.

"We hold their hands," Dart said about those suffering from mental illness in his jail. "We case manage them out the door. Once they leave me, I stay in contact with them. We connect with all these people so they now call us when they need rides to their doctors' appointments."

But Dart, a former prosecutor and Illinois state senator, is the first to say that he is not a clinician.

"I shouldn't be running the largest mental health hospital in the state of Illinois. But I am."

And because so many people suffering from mental illness on the inside are under his care, Dart said he feels a sense of "urgency." He has diverted funds from other, less important areas—such as graffiti control—toward hiring mental health providers who evaluate every inmate when he or she enters the Cook County Jail.

During their time behind bars, those struggling with mental illness receive services, such as therapy and career advice, as well as follow-up attention after release.

"I just kept asking myself how I would want to be treated if this was me," Dart said.

This summer, the prison ethics group is conducting focus groups with administrators, clinicians and correctional officers at the George W. Hill Correctional Facility, the privately managed Delaware County jail in Thornton, Pa.

The team is still awaiting approval to include inmates in focus groups to find out more about their experience with mental health care inside.

Sisti's group plans to hold a daylong conference in October—co-sponsored by Penn's Perelman School of Medicine and Drexel's Lindy Institute for Urban Innovation—at the National Constitution Center, with interdisciplinary panels of clinicians, ethicists, criminologists, correctional staff and returning citizens.

Courtenay Harris Bond is a freelance writer and journalist in residence at the Scattergood Ethics Program. Contact her via email or Twitter @CHarrisBond

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