Working in a prison clinic, I met a man named Walden. When he is called over the loudspeaker, he quickly pulls a ducat from his pocket and hands it to the custody officer before stepping inside. The nurse greets him kindly, though her posture remains guarded, a whistle hanging from her neck.
“How are you doing today?” she asks.
“I’m doing good,” he replies, hesitating at the end as if he might say something more. He doesn’t.
Sitting in his state blues, he tells me about the night before — how he woke clutching his chest to the sound of heavy metal doors unlocking down the hallway, unsure whether his racing pulse was from the sudden noise or from his arrhythmia. Walden is in his late 50s and clean-shaven. Wearing his thin-framed glasses, he carries himself with a quiet composure, glancing up occasionally as he speaks and choosing his words with care. He once told me that the closest he feels to freedom is while mopping the infirmary floors for ninety-some cents an hour. It isn’t the money that matters, but the routine – the clarity it brings.
I tell him that while the atrial fibrillation has resolved, a new rhythm, atrial flutter, has emerged and will require another ablation. There is some reassurance: the amiodarone-induced thyrotoxicosis has resolved. He exhales in relief. Then I begin the familiar list: reduce salt, exercise regularly, avoid drugs. As I speak, I find myself feeling almost duplicitous, advising him to make healthier choices while knowing how little control he has over what is available to him or how he spends his time.
What he looks forward to most is canteen day, one Wednesday each month, a small reprieve from the chow hall, where meals arrive with little description and even less choice. He rations carefully. For just a few dollars, the options are limited: honey buns, cup noodles, Doritos. This time, he chooses mackerel.
“At least it’s fish,” he says.
I find myself lingering on the unfairness of it. In a place where so little belongs to him, one of the few choices he gets to make is whether to spend those dollars on comfort or on trying to follow the advice I had just given him.
Unlike some of the others, he has no family sending packages — no omega-3s, no extra food. He has spent much of his life moving through juvenile hall and foster placements, carrying little with him from one place to the next. In the desert heat, even the medications meant to stabilize his heart, like beta blockers, can place limits on his daily activities, restricting when he can go to the yard and, at times, determining where he is transferred without his say.
Walden has tried to change. His parole date is set three decades away, but he has remained sober for six years, which is no small feat in a place like this. Even in a system meant to support rehabilitation, drugs remain rampant, making recovery less a matter of intention than one of constant vigilance. Two days a week, after his porter job, he tutors others in addiction recovery classes. In his free time, he cuts hair and talks with younger inmates about philosophy.
The limits I see around Walden are not entirely unique to this place. Outside, they take different forms. I think of the truck driver who spends long hours on the road, grabbing a fast-food burrito because it is what is available, and later being told he has not followed a healthy diet. Or the first-year law student, living on little sleep and takeout, gaining weight while trying to keep up with peers who seem effortlessly ahead. Their challenges are worlds apart, of course, but challenges nonetheless.
We document that we have counseled patients on lifestyle modification — at times reciting it, at times barely noticing it, the line already templated at the bottom of the note. But what does that advice mean when the choices it depends on are not fully within reach? Practicing medicine in prison has made those limits harder to ignore and changed the way I think about the freedom our recommendations assume. Incarcerated patients carry a disproportionate burden of chronic disease, substance use, and mental illness. In California prisons, roughly one in three people has an identified mental health treatment need, and many arrive carrying histories of trauma, addiction, and instability long before incarceration begins.
It is easy to give advice from the illusion of choice. Our counseling is often standardized, but the lives it is applied to are not. Some of these constraints are structural, from wages that limit what patients can afford to environments that restrict movement, and there is a role for broader change. But when the patient is in front of us, the responsibility feels more immediate. For me, that can mean taking one step further, when time allows, sometimes as simple as looking up the chow menu together to understand what choices are actually available.
Many of the decisions we ask patients to make are shaped long before they enter the room and often depend less on what they know than on what they can do. I tell Walden that an occasional glass of Kool-Aid after a long day is fine. Health is not simply a list of restrictions. Sometimes good care begins with understanding which choices truly belong to our patients, and preserving even the smallest ones. Sometimes, choice itself can be an act of care.
