Student/Faculty Collaboration Leads to NEJM Publication

In a recent perspective published by the New England Journal of Medicine (NEJM), Stanford Law student Alexandra Daniels analyzed a growing body of federal litigation brought by prisoners with the hepatitis C virus (HCV) who are seeking access to treatment for their condition.

Another public health crisis in prisons

With co-author and mentor, Professor David Studdert, Daniels documented the dire public health problem of HCV in prisons. “People incarcerated in prisons account for approximately one third of HCV cases in the United States” the authors wrote, and nearly one in five prisoners are infected, compared with 1 percent of the general population. 

HCV is a slow-moving disease, but left untreated it eventually leads to cirrhosis, cancer, liver failure, and death.  

A new wave of “miracle” drugs for treating HCV appeared in 2014. Direct-acting antivirals–or DAAs–are far more effective than anything previously known. The catch–they are extremely expensive, upwards of $50,000 for a course of treatment.  This creates a far higher price tag for universal treatment than most prison systems can afford. The result is that, even though prisons are the epicenter of the HCV epidemic, only a small minority of prisoners have gained access to DAAs.   

Rationing meets constitutional rights

“To address the cost problem, most prisons have turned to rationing,” Daniels explained. “They use protocols to limit treatment to inmates with the most severe disease. These protocols essentially require inmates’ chronic HCV to get worse before they can be eligible for treatment. This violates the standard of care for HCV treatment and can result in serious health consequences for those who are left untreated.” 

The United States Supreme Court has interpreted the 8th Amendment of the United States Constitution, which prohibits cruel and unusual punishment, to guarantee prisoners a minimum basic level of health care. Does that right extend to access to DAAs? More than 250 lawsuits have been filed in the last few years asking courts to resolve that question. In the perspective, Daniels and Studdert review how courts have responded. 

“There is a split here,” Daniels said. “Some courts have found denying DAA treatment for no medical reason is a violation of the 8th Amendment, while other courts have found that no violation exists because inmates who were denied DAAs received an alternative treatment in the form of periodic lab tests. Courts have also rejected 8th Amendment challenges where the plaintiff’s condition had not worsened as a result of the withheld treatment.” 

A possible solution

“We know that the root cause of limited access to DAAs in prisons is their high cost,” said Daniels. “The good news is that several states are pursuing innovative strategies to fix this issue. Washington and Louisiana, for instance, have initiated fixed-price plans with drug manufacturers to bundle access for the states’ Medicaid and correctional populations. This option could provide a win-win for everyone; a guaranteed purchase for the drug company every year and access for all who need treatment, potentially reducing the healthcare cost of the illness for the state.”

Medical journal vs. law journal

While a typical publication path for a law student would be a law journal, Daniels and Studdert decided to seek publication in a high-profile medical journal. 

“Policymakers and public health and legal practitioners are crucial audiences for this kind of scholarly work,” said Studdert. “It can be difficult to reach them through conventional law journals, so we took a different path.” 

“Stanford Law encourages interdisciplinary learning and I was lucky enough to take Professor Studdert’s health law class where I was able to align the research required with my interests in prisoners’ rights litigation,” said Daniels. “Professor Studdert worked with me for a year to develop my class research paper into an article that might reach people who could actually impact healthcare in correctional facilities.”

While medical journals require a more concise and policy-focused form of writing than law journals, Studdert recognized that Daniels had a talent for conveying complicated legal concepts. 

According to a 2013 study published in QJM, an international journal of medicine, only about 2.5 percent of the articles in the medical journals studied had a student as the lead author. “For a law student to lead-author a piece in the world’s leading medical journal is beyond rare. Ally has accomplished something very special,” said Studdert.

During her undergrad years and while at Stanford Law, Daniels volunteered in jails and prisons, most recently at a San Francisco County jail where she provided basic legal services for inmates. “After law school, I hope to practice law in this arena, and I’m very grateful for the opportunity I’ve had to work with Professor Studdert and address conditions of confinement through a health policy lens.”