**PUBLISHED** UNITED STATES COURT OF APPEALS FOR THE FOURTH CIRCUIT

**No. 15 -**  **1587**

PAUL SCINTO, SR., Plaintiff

- Appellant,

v. WARDEN PATRICIA STANSBERRY, FCI

- Butner

- Low; SUSAN MCCLINTOCK, Camp Administrator, FPC

- Butner; R. HOLT, Senior Officer Specialist ; DR. PHILLIPS ; OFFICER COORS , Defendants

- Appellees , and FEDERAL BUREAU OF PRISONS, a division of the U.S. Department of Justice; HARLEY G. LAPPIN, Director, Bureau of Prisons; KIM WHITE, Mid Atlantic Regional Director , Defendants.

Appeal from the United States District Court for the Eastern District of North Carolina, at Raleigh. James C. Dever III , Chief District Judge. (5:10

- ct

- 03165

- D )
Argued: September 23 , 2016 Decided: November 4, 2016

Before NIEMEYER , MOTZ, and WYNN, Circuit Judges

. Affirmed in part and reversed in part by published opinion. Judge Wynn wrote the opinion, in which Judge Niemeyer and Judge Motz joined.2 **ARGUED** : Adam H. Farra, COHEN MILSTEIN SELLERS & TOLL PLLC, Washington, D.C. , for Appellant. Robert J. Dodson, OFFICE OF THE UNITED STATES ATTORNEY, Raleigh, North Carolina , for A ppellee s . **ON BRIEF** : Paul J. Zidlicky, SIDLEY AUSTIN LLP, Washington, D.C. , for Appellant. John Stuart Bruce, Acting United States Attorney, G. Norman Acker, III, Assistant United States Attorney, OFFICE OF THE UNITED STATES ATTORNEY, Raleigh, North Carolina, for Appellee s .3 WYNN, Circuit Judge: Plaintiff Paul Scinto, Sr. (“Plaintiff”), a former federal prisoner, sued several federal prison officials pursuant to Bivens v. Six Unknown Named Agents of Federal Bureau of Narcotics , 403 U.S. 388 (1971), alleging a number of violations under the Fourth, Fifth, Eighth , and Fourteenth Amendments. Defendants are Dr. Derick Phillip (“Dr. Phillip”) ; Patricia Stansberry, former Federal Prison Camp Butner Warden (“Warden Stansberry”) ; and Susan McClintock, former Butner Camp Administrator (“Administrator McClintock” ). Collectively, these Defendants successfully moved for summary judgment on all of Plaintiff’s c laims. On appeal, Plaintiff limits his arguments to the district
court’s dismissal of three claims that Defendants were deliberately indifferent to his medical needs , in violation of the Eighth Amendment

. Plaintiff argues that, in dismissing these claims, the district court made credibility determinations and weighed the parties’ evidence, thus violating the summary judgment standard. For the reasons that follow, we reverse the district court’s disposition of the two Eighth Amendment claims against Dr. Phi llip and Administrator McClintock but aff irm its resolution of the claim against Warden Stansberry.4 I. The Eighth Amendment prohibits the infliction of “cruel and unusual punishments.” U.S. Const. amend. VIII. This prohibition “proscribes more than phy sically barbarous punishments.” Estelle v. Gamble , 429 U.S. 97, 102 (1976). It also encompasses “the treatment a prisoner receives in prison and the conditions under which he is confined

. ” Helling v. McKinney , 509 U.S. 25, 31 (1993). In particular, the Eighth Amendment imposes a duty on prison officials to “provide humane conditions of confinement .

. . [and] ensure that inmates receive adequate food, clothing, shelter, and medical care.”
Farmer v. Brennan , 511 U.S. 825, 832 (1994). To that end, a pri son official’s “deliberate indifferen ce to serious medical needs of prisoners constitutes the unnecessary and wanton infliction of pain pro scribed by the Eighth Amendment

. ” Estelle , 429 U.S. at 1 04 (internal quotation marks and citation omitted)

. Prisone rs alleging that they have been subjected to unconstituti onal conditions of confinement must satisfy the Supreme Court’s two

- pronged test set forth in Farmer v. Brennan , 511 U.S. 825 (1994). First, Farmer ’s “ objective ” prong requires plaintiffs to demonstrate that “the deprivation alleged [wa s], objectively, ‘sufficiently serious.’” Farmer , 511 U.S. at 834 (quoting Wilson v. Seiter , 501 U.S. 294, 298 (1991)). To be5 “sufficiently serious,” the deprivation must be “extreme”

-- meaning that it poses “ a serious or significant physical or emotional injury resulting from the challenged conditions, ” or

“ a substantial risk of such serious harm resulting from .

. . exposure to the challenged conditions.” De’Lonta v. Angelone , 330 F.3d 630, 634 (4th Cir. 2003 ) ( internal quotation marks and citation omitted). In medical needs cases , like the case at bar, the Farmer test requires plaintiffs to demonstrate officials’ deliberate indifference to a “serious” medical need that has either “been diagnosed by a physici an as mandating
treatment or . . . is so obvious that even a lay person would easily recognize the necessity for a doctor’s attention.” Iko v. Shreve , 535 F.3d 225, 241 (4th Cir. 2008). Second, under Farmer ’s “ subjective ” prong , plaintiffs must show that prison official s acted with a “sufficiently culpable state of mind.” Farmer , 511 U.S. at 834 (internal quotation marks omitted) (quoting Wilson , 501 U.S. at 297) . In conditions of confinement cases, the requisite state of mind is deliberate indifference

. Id. T o prove d eliberate indifference , plaintiffs must show that “the official kn[ew] of and disregard[ed] an excessive risk to inmate health or safety. ” Id. at 837. Put differently, the plaintiff must show that the official was “aware of facts from which the inference could be drawn that a substan tial risk of serious harm exist[ed] , and
. . . dr[ew ]6 th[at] inference.” Id. (emphasis added). Deliberate indifference is “more than mere negligence,” but “less than acts or omissions [done] for the very p urpose of causing harm or with knowledge that harm will result.” Id. at 835. It “lies somewhere between negligence and purpose or knowledge: namely, recklessness of the subjective type used in criminal law.” Brice v. Va. Beach Corr. Ctr. , 58 F.3d 101, 1 05 (4th Cir. 1995) (citing Farmer , 511 U.S. at 835)
. Under this standard, mere “[d]isagreements between an inmate and a physician over the inmate’s proper medical care” are not actionable absent exceptional circumstances. Wright v. Collins , 766 F.2d 841, 849 (4th Cir. 1985) (citing Gittlemacker v. Prasse , 428 F.2d 1, 6 (3d Cir. 1970)). In deliberate indifference to medical needs cases, Farmer ’s subjective prong requires proof of the official’s “actual subjective knowledge of both the inmate’s serious med ical condition and the excessive risk posed by [the official’s] action or inaction.” Jackson v. Lightsey , 775 F.3d 170, 178 (4th Cir. 2014) (citing Farmer , 511 U.S. at 837

– 39)
. A plaintiff can meet the subjective knowledge requirement through direct evid ence of a prison official’s actual knowledge or circumstantial evidence tending to establish such knowledge, including evidence “that a prison official knew of a substantia l risk from the very fact that the risk was obvious.” Makdessi v.7 Fields , 789 F.3d 126, 133 (4th Cir. 2015) (quoting Farmer , 511 U.S. at 842).
A plaintiff also makes out a prima facie case of deliberate indifference when he demonstrates “that a substantial risk of [serious harm] was longstanding, pervasive, well

- documented, or expressly noted by prison officials in the past , and the circumstances suggest that the defendant

- official .

. . had been exposed to information concerning the risk and thus must have known about it .

. . .” Parrish ex rel. Lee v. Cleveland , 372 F.3d 294, 303 (4th Cir. 2004) ( first alteration in original) (internal quotation marks omitted) (quoting Farmer , 511 U.S. at 842) . Similarly, a prison official’s “[f]ailure to respond to an inmate’s known medical needs raises an inference [of] deliberate indifference to those needs.” Miltier v. Beorn , 896 F.2d 848, 853 (4th Cir. 1990) , overruled in part on other grounds by Farmer , 511 U.S. at 837 . However, even officials who acted with deliberate indifference may be “free from liability if they r esponded reasonably to the risk

. ” Farmer , 511 U.S. at 844.8 II. Plaintiff entered federal custody at Federal Prison Camp Seymour Joh nson in October 2002

. 1 At that time, he suffered from myriad medical conditions , including hepatitis C, a knee infection, insulin

- dependent diabetes, and high blood pressure. In the years that followed, Plaintiff was confined in various federal prison fa cilities. In particular, f rom June 2005 to March 2006 , Plaintiff was incarcerated at Federal Prison Camp
Butner in Butner, North Carolina. During that time, several incidents purportedly occurred and gave rise to a number of constitutional claims

. Follo wing a circuitous journey through the federal judicial system, the present appeal addresses only a subset of these claims. On February 28, 2008, Plaintiff filed a Bivens action pro se in the United States District Court for the District of Columbia. Plain tiff’s original complaint sought relief for alleged violations of his rights under the Fourth, Fifth,
E ighth, and Fourteenth Amendments, naming as defendants various federal officials , including the Bureau of Prisons, then

- Bureau Director Harley Lappin, Regional Director Kim White, Warden

1 After pleading guilty to maintaining a place for the purpose of manufacturing, distr ibuting, or using phencyclidine, Plaintiff was sentenced to 78 months’ imprisonment. The nature of his conviction and sentence are irrelevant to this appeal.9 Stansberry, Administrator McClintock, and Butner Correctional Officer Richard Holt (“Officer Holt”)

. After dismissing a number of these claims on jurisdictional and sovereign immunity grounds, the district court transf erred Plaintiff’s remaining claims against Warden Stansberry, Administrator McClintock, and Officer Holt to the United States District Court for the Eastern District of North Carolina. Scinto v. Fed. Bureau of Prisons , 608 F. Supp. 2d 4, 10 (D.D.C.), aff’ d , 352 F. App’x 448 (D.C. Cir. 2009). Following a second appeal in this Circuit, Plaintiff successfully amended his complaint to include additional Eighth Amendment claims against defendants Dr. Phill i p and Butner Correctional Officer Lawrence Coor (“Offi cer Coor”). Scinto v. Stansberry , 507 F. App’x 311 (4th Cir. 2013) (per curiam). Cross

- motions for summary judgment followed and,

o n September 9, 2014 , the district court denied Plaintiff’s motion for summary judgment and granted summary judgment to the defendants on each of Plaintiff’s claims. Plaintiff appeals only three of the claims dismissed on summary judgment , each arising under the Eighth Amendment

. These include : (1) Plaintiff’s claim against Dr. Phillip for allegedly denying Plaintiff insulin to treat his diabetes; (2) Plaintiff’s claims against Dr. Phillip and Administrator McClintock for allegedly failing to provide aid in a medical
emergency ; and (3) Plaintiff’s claim against Warden Stansberry10 for her alleged failure to provide Plaintiff wi th a diabetic diet during Plaintiff’s incarceration in administrative segregation ( the “ Special Housing Unit ”)
. We address t he facts relevant to each claim below.
III . “We review the district court’s grant of summary judgment de novo, viewing the facts and the reasonable inferences therefrom in the light most favorable to the nonmoving party.” Bonds v. Leavitt , 629 F.3d 369, 380 (4th Cir. 2011). Summary judgment must be granted “if the movant shows that there is no genuine dispute as to any material fa ct and the movant is entitled to judgment as a matter of law.” Fed. R. Civ. P. 56(a). To survive summary judgment, “there must be evidence on which the jury could reasonably find for the [nonmovant].” Anderson v. Liberty Lobby, Inc. , 477 U.S. 242, 252 ( 1986).
A . 1. Plaintiff’s first claim alleges that Dr. Phillip violated Plaintiff’s Eighth Amendment rights by denying Plaintiff insulin to treat his diabetes. Dr. Phillip was Plaintiff’s prison doctor at Federal Prison Camp Butner and treated several of Plaintiff’s medical conditions, including his diabetes. On June 5, 2005, shortly after Plaintiff’s arrival at Butner, Dr. Phillip prescribed Plaintiff morning and evening insulin11 injections, as well as supplemental insulin injections based upon a “slidin g scale” keyed to his blood sugar. According to that sliding scale, Plaintiff was prescribed two units of insulin when his blood sugar was between 141 and 150 milligrams (“mg”) per deciliter (“dL”) , four units when his blood sugar was betwee n 151 and 200m g/dL, and so on. On June 14, 2005, Plaintiff requested from Dr. Phillip and other medical personnel at Federal Medical Camp Butner a supplemental insulin injection because his blood sugar was 200mg/dL. Based on the sliding scale Dr. Phillip prescribed,
P laintiff should have received four units of insulin. At the time of his request, Plaintiff admits that he was “angry”

-- at least in part because his blood sugar was high. The parties agree that, r ather than providing four units of insulin as dictated by P laintiff ’s prescription , Dr. Phillip terminated Plaintiff ’s visit to the medical clinic and declined to provide him with insulin . Instead, Dr. Phillip developed an alternative plan to monitor Plaintiff ’s blood sugar levels at mealtimes and
to “cover each meal with short acting insu lin” if Plaintiff desired. J.A. 521. 2

2 Citations to “J.A. __” refer to the Joint Appendix filed by the parties in this appeal.12 According to Plaintiff’s evidence, the June 14 incident was not the first time Dr. Phillip denied Plaintiff prescribed insulin injections. Nor, according to Plaintiff , was it the last. Although medical records reflect Dr. Phillip’s plan to monitor Plaintiff ’s blood sugar and provide supplemental insulin at mealtimes , Plaintiff filed two Inmate Request to Staff forms (“cop

- outs”) that suggest this plan was never follow ed. First, on June 22, 2005, Plaintiff directed a cop

- out to Dr. Phillip “request[ing] insulin coverage whenever my blood glucose levels rise above 200mg/dl.” J.A. 88. And on July 27, 2005, Plaintiff addressed another cop

- out to Dr. Phillip referencing his June 22 request for supplemental insulin (along with several other , unrelated requests for medical attention) and stat ing that his conditions “remain untreated [and] uncured.” J.A. 82. Dr. Phillip admits that he did not provide Plaintiff with insulin during the June 14 appointment, but asserts that the denial was justified based on Plaintiff’s threatening behavior and that his treatment of Plaintiff’s diabetes before and after this incident was appropriate. Plaintiff claims that Dr. Phillip’s alleged repeated denials of supplemental insulin resulted in an unhealthy increase in Plaintiff’s blood sugar and his hemoglobin A1 C levels , which rose from approximately 7 (within the normal range for diabetics) to 9 .8 (an unhealthy level for diabetics) from13 January to September 2005
. More generally, Plaintiff claims that the inadequate treatment of his diabetes resulted in “unnecessary exacerbation of his serious diabetic .

. . condition[], causing serious harm to the Plaintiff [that] resulted in damag e to the Plaintiff’s kidney’s [sic], eyesight, nervous system, . . . and psychological well being.” J.A. 165. 2. Contrary to the district court’s holding, Plaintiff adduced sufficient evidence to establish a genuine dispute of fact as to both Farmer ’s obj ective and subjective prong s . Regarding the objective prong, Plaintiff ’s evidence established that he suffers from a serious medical condition: in sulin

- dependent diabetes. This medical condition was diagnosed by a medical professional, and Dr. Phillip pro vided treatment for the condition by prescribing Plaintiff’s insulin regimen. Moreover, Plaintiff has created a genuine issue of material fact regarding whether Dr. Phillip’s failure to provide him with insulin was an “extreme deprivation” resulting in “a serious or significant physical or emotional injury” or “a substantial risk” thereof actionable under the Eighth Amendment.
See De’Lonta , 330 F.3d at 634. Dr. Phillip admits that he denied Plaintiff a supplemental dose of insulin on June 14, 2005, at a time when Plaintiff’s blood sugar was 200mg/dL. This may be sufficient alone to meet the objective test set forth in14 Farmer . See, e.g. , Lolli v. Cty. of Orange , 351 F.3d 410 , 420 (9th Cir. 2003) (“Leaving a diabetic .

. . without proper food or insulin w hen it is needed creates an ob jectively, sufficiently serious risk of harm.” (internal quotation marks omitted)). Even without drawing this conclusion, however, Plaintiff raises a genuine dispute of material fact as to whether the deprivation of his prescr ibed insulin caused serious injury or a substantial risk of serious injury as required by the objective prong. He does so by pointing to his deposition testimony and medical records showing an increase in his blood sugar and hemoglobin A1C values from January to September 2005, which encompasses the period from June to August 2005 during which Dr. Phillip was assigned to treat Plaintiff’s diabetes. Viewing these facts in the light most favorable to Plaintiff, there are genuine disputes of material fact as to whether (1) this increase is itself a serious injury and (2) the act of withholding insulin from an insulin

- dependent diabetic alone creates a serious injury or a substantial risk of such injury. Plaintiff’s evidence also created a genuine dispute o f material fact as to Farmer ’s subjective prong . As Plaintiff’s prison doctor, Dr. Phillip knew of Plaintiff’s serious medical condition. Indeed, Dr. Phillip prescribed the insulin regimen under which Plaintiff was to receive supplemental insulin15 injecti ons when his blood sugar was above 140mg/dL. This evidence establishes that Dr. Phillip was aware of facts

-- Plaintiff’s diabetes and his blood sugar value at the time of his request for insulin

-- giving rise to an inference that failing to provide insulin could result, at least, in a substantial risk of serious harm. Moreover, viewed in the light most favorable to Plaintiff , Plaintiff’s lengthy prison medical records show that his diabetes diagnosis was “longstanding, pervasive, well

documented, [and] expre ssly noted by prison officials , ” Parrish , 372 F.3d at 303

- - including by Dr. Phillip himself

. T his is sufficient to prove a prima facie case of deliberate indifference. Id. Furthermore, as in Miltier , Dr. Phillip knew of Plaintiff’s medical need for insu lin at the time of the request and failed to respond to that known need, raising an inference of deliberate indifference. 896 F.2d at 853 , overruled in part on other grounds by Farmer , 511 U.S. at 837
. The district court erred in failing to apply the Par rish presumption and infer deliberate indifference from Dr. Phillip’s knowledge of Plaintiff’s diabetes and disregard of his own prescription designed to manage that condition. Notwithstanding the factual disputes outlined above, the district court granted Dr. Phillip’s motion for summary judgment for two principal reasons. First, the court found fault with16 Plaintiff’s failure to o ffer medical expert testimony ( a ) that his blood sugar level during the June 14 appointment “created a substantial harm” under the objective prong of Farmer and ( b ) that Dr. Phillip’s failure to provide insulin during the appointment “resulted in some substantial harm” sufficient to satisfy the objective prong. 3 J.A. 956. Second, the district court concluded that Dr. Phillip had no obligation under the Eighth Amendment to provide Plaintiff, “an angry and hostile patient,” with the requested insulin

. J.A. 956. Accordingly, the district court held, Dr. Phillip satisfied his constitutional burden by ordering staff to monitor Plaintiff’s condition and provide supplemental insulin at mealtimes. We disagree with bo th conclusions

. Regarding the absence of expert medical testimony, plaintiffs alleging deliberate indifference must, “[a]t a

3 We emphasize that the correct standard to apply when considering the objective prong of deliberate indifference claims is whether there is an “extreme deprivation” and “a serious or significant physica l or emotional injury resulting from the challenged conditions or .

. . a substantial risk of such serious harm resulting from .

. . exposure to the challenged conditions.” De’Lonta , 330 F.3d at 634. The district court’s reference to a “substantial harm” requirement does not change this analysis substantively, but does alter unnecessarily the language set forth in Fourth Circuit precedent. We caution that the “serious or significant” injury or “substantial risk” standard, not the district court’s “substa ntial harm” standard, should be used when instructing the jury on the objective prong of the Farmer test.17 minimum, .

. . specifically describe not only the injury but also its relation to the allegedly unconstitutional condition.” Strickler v. Waters , 989 F.2d 1375, 1381 n .9 (4th Cir. 1993). There is no requirement, however, that a plaintiff alleging deliberate indifference present expert testimony to support his allegations of serious injury or substantial risk of serious injury. Rather, the Federal Rules of Evidence app ly, and expert testimony is necessary

-- indeed, permissible

-- only when it will “help the trier of fact to understand the evidence or to determine a fact in issue.” Fed. R. Evid. 702(a). When laypersons are just “as capable of comprehending the primary fac ts and of drawing correct conclusions from them” as are experts, expert testimony may properly be excluded. Salem v. U.S. Lines Co. , 370 U.S. 31, 35 (1962). As a result , when the seriousness of an injury or illness and the risk of leaving that injury or illness untreated would be apparent to a layperson, expert testimony is not necessary to establish a deliberate indifference claim. See, e.g. , Blackmore v. Kalamazoo Cty. , 390 F.3d 890, 899

– 900 (6th Cir. 2004); Boring v. Kozakiewicz , 83 3 F.2d 468, 473 (3d Cir. 1987). Recognizing that it is a “[w]ell

- known” fact that diabetes is a “c ommon yet serious illness that can produce harmful consequences if left untreated for even a short period of time,” several of our Sister Circuits have denied defendants summary18 judgment on Eighth Amendment claims alleging that prison officials deprived diabetic inmates of insulin, even when those claims were not supported by expert testimony. Lolli , 351 F.3d at 419

– 20 (concluding, based on the plaintiff’s testimony, that a diab etic person who is “unable to take insulin .

. . regularly” suffers a sufficiently serious risk of harm); Natale v. Camden Cty. Corr. Facility , 318 F.3d 575, 582

– 83 (3d Cir. 2003) (holding, in the absence of expert testimony, that a reasonable jury could c onclude that prison officials who knew the inmate was diabetic and needed insulin regularly were deliberately indifferent in denyin g insulin for nonmedical

reason s). We agree: a jury is capable of understanding, unaided, the risks of failing to provide in sulin to a diabetic and of a trained doctor’s denial of a diabetic’s known need for insulin. Accordingly, we reject the district court’s contention that Plaintiff was required to adduce expert testimony to demonstrate an objectively serious deprivation gi ving rise to a claim under the Eighth Amendment

. Regarding Dr. Phillip’s response to Plaintiff’s request for insulin, we agree that

-- even when both Farmer prongs are satisfied

-- a prison official who responds reasonably in the face of a known, serious ris k of harm to an inmate may be “free from liability” under the Eighth Amendment even if harm is not avoided

. Farmer , 511 U.S. at 844. But even assuming arguendo19 that it was reasonable for Dr. Phillip to decline to provide Plaintiff insulin in the face of his “angry” demands and, instead, to plan to monitor Plaintiff’s blood sugar and provide supplemental insulin at mealtimes, Plaintiff nonetheless has established a genuine dispute of fact as to whether Dr. Phillip followed through with that plan. In parti cular, Plaintiff’s June 22 and July 27, 2005, cop

- outs raise a reasonable inference that Dr. Phillip failed to provide supplemental insulin as proposed by his alternative plan. Therefore, the district court erred in concluding that there was no genuine di spute of fact as to whether Dr. Phillip reasonably responded to Plaintiff’s medical needs.
B . 1.
We now turn to Plaintiff ’s second Eighth Amendment claim , which arises out of Dr. Phillip ’s and Administrator McClintock ’s alleged failure to provide aid to Plaintiff during a medical
emergency. On August 24, 2005, Plaintiff was locked in his housing unit while prison officials conducted a “census count.” 4 During that time, the flow of water to Plaintiff ’s unit was discontinued because maintenance workers we re repairing the

4 During a census count, inmates must remain in place while prison officials conduct a count to ensure that all inmates ar e in their assigned locations.20 unit’s showers

. While locked down and unable to access water , Plaintiff began exper iencing “extreme [stomach] pain

. . . was throwing up vomit and blood .

. . [and] became incontinent.” J.A. 846. In this state, Plaintiff used an emerg ency phone in the unit to call for hel p by dialing a “deuces alarm” ( 2

- 2

- 2). The parties dispute Plaintiff ’s reason for using the emergency phone. Plaintiff claims that he used the phone to report his illness, saying “I’m sick. The water is off. I
can’ t get anything to drink. I can’t wash up. I’ve got bloo d all over me.” J.A. 848

– 49. By contrast, i n a n ow - expunged incident report arising from the phone use, prison officials recorded that Plaintiff used the phone to complain about the lack of water
. According to prison officials, Plaintiff complained that he “ha[d] to get a shower” before reporting to his work sh ift that afternoon. J.A. 327. Plaintiff asserts that the officials’ explanation is unfounded since prison records show that he worked only the morning shift on the day in question

. When prison officials responded to Plaintiff ’s emergency call, th ey offered no assistance even though Plaintiff points to several “outward signs” of his need for medical attention , including that his cell “reeked to high heaven” and that his21 face was covered with partially wiped

- up vomit and blood

. 5 J.A. 867

– 68. Despite his distressed state, Plaintiff claims that Dr. Phillip simply “looked at [ Plaintiff ] in disgust and turned his head and started to wal k away, ” providing no medical aid. J.A. 858. According to Plaintiff’s evidence, Administrator McClintock also failed to provide Plaintiff with treatment or call for medical assistance, instead ordering prison guards to

“ l ock him u p” in the Special Housing Unit . J.A. 858

– 59. Thereafter, prison officials removed Plaintiff to the Special Housing Unit, where he was conf ined for six months. Plaintiff ’s evidence indicates he did not receive medical attention until at least two days aft er the August 24 incident, with the only related entry in his medical record appearing on August 29 , 2005

-- five days after the purported emergency. In court documents, Plaintiff attributes his emergency to acute cholelithiasis ( gallstones ) , signs of which were first documented in his medical record on July 20, 2005, over one month prior to the incident

.

5 In recounting their version of events, prison officials make no mention of Plaintiff ’s physical appearance or medical condition.22 2. Again, Plaintiff’s evidence establishe s genuine disputes of material fact as to both Farmer prongs. First, there is a genuine dispute regarding whether Dr. Phillip ’s and Administrator McClintock ’s failure to provide aid to Plaintiff after he used the emergency phone constituted an “objectively, sufficiently serious” deprivation. Viewing the facts in the light most favorable to Plaintiff, as we mu st, P laintiff was suffering from a serious , visible medical need at the time Dr. Phillip and Administrator McClintock responded to his emergency call. In particular , Plaintiff was experiencing “extreme pain in [his] stomach, .

. . throwing up vomit and bl ood[, and] became incontinent.” J.A. 846. This is the sort of serious medical condition “so obvious that even a lay person would easily recognize the necessity for a doctor’s attention.” Iko , 535 F.3d at 241 (internal quotation marks omitted) (quoting
H enderson v. Sheahan , 196 F.3d 839, 846 (7th Cir. 1999))

. Further, Plaintiff ’s evidence creates a genuine dispute of fact as to whether the denial of medical attention during this emergency resulted in serious injury or a substantial risk of serious injur y. A juror could reasonably infer that f ailing to
treat , for two to five days, an inmate who is vomiting blood and experiencing evident physical distress creates a substantial risk that serious bodily injury will result or has already23 occurred. This conc lusion is supported by Plaintiff’s medical records, which indicate that , at the time of the alleged
emergency, he may have been experiencing complications arising from an earlier gallstone diagnosis. Plaintiff also has raised a genuine issue of material fa ct on the subjective prong of Farmer

-- whether Dr. Phillip and Administrator McClintock acted with deliberate indifference in failing to provide assistance in the face of Plaintiff’s alleged medical emergency

. In particular , there is sufficient circumstant ial evidence to suggest that Defendants were aware of facts giving rise to an inference that their decision to send Plaintiff to the Special Housing Unit without providing medical aid created a substantial risk of serious injury. Plaintiff’s testimony that his cell “ reeked ” and his face exhibited visible signs of illness , as well as his contempo raneous account of his symptoms create a genuine factual dispute about whether his need for medical attention was so obvious that an official observing the scene wou ld have both known of the facts giving rise to a risk of serious harm resulting from failure to provide medical attention and inferred that such a substantial risk was present. In addition, these outward signs of Plaintiff’s need for medical attention and Defendants’ contemporaneous failure to offer aid give rise to an inference of deliberate indifference sufficient for Plaintiff’s24 claim to survive summary judgment. See Miltier , 896 F.3d at 853 (“Failure to respond to an inmate’s known medical needs raise s an inference [of] deliberate indifference to those needs.”).
C . 1. Plaintiff ’s final Eighth Amendment claim is against Warden Stansberry and alleges a denial of a proper diabetic diet during his six

- month confinement in the Special Housing Unit. According to Plaintiff’s evidence, the only meals available to Plaintiff in the Special Housing Unit were those served to every other inmate in the unit

-- meals high in sugar and accompanied by a sugary drink. Plaintiff used several channels of communication to complain to Warden Stansberry about the unavailability of a diabetic diet. First, Plaintiff complained to the Warden during her weekly rounds in the u nit. Second, Plaintiff submitted cop

outs to Warden Stansberry seeking red ress for his complaints

. Third, Plaintiff wrote to his congressman, asking him to inquire with prison officials about the deficiencies in his diet . After the congressman forwarded this correspondence to the Bureau of Prison s , Warden Stansberry addressed the allegations in a reply letter. S he acknowledged that inmates in the Special Housing Unit d id not receive special diets but maintained that inmates25 we re educated about how to select foods appropriate for their medical conditions

. Because of the alleg ed deficiencies in the diet offered in the Special Housing Unit, Plaintiff claims to have suffered an increase in his blood sugar and A1C levels. Prison medical officials sought to combat these symptoms by increasing his insulin dosage

. This treatment pu rportedly “resulted in the loss of
. . . diabetic control .

. . and severe painful and destructive episod es of diabetic hypoglycemia and .

. . hyperglycemia.” J.A. 626.
T he district court assumed without deciding that Plaintiff raised a genuine issue of material fact on Farmer ’s objective prong: that the lack of a diabetic diet constituted a sufficiently serious deprivation

. T he court went on to conclude , however, that there was no genuine dispute regarding whether Warden Stans berry knew of and disregarded Plaintiff ’s need for a special diet

. T he court based its conclusion on Plaintiff ’s log of interactions with prison officials , which revealed that Plaintiff was “mainly focused on pursuing a collateral attack on his criminal c onviction and on defending against his disciplinary charge, rather than on informing Stansberry of the conditions” he considered unconstitutional

. J.A. 964. The court went on to note that even if there were a genuine dispute of material fact on this subj ective prong,26 Plaintiff ’s acknowledgement that he otherwise received adequate medical treatment for his diabetes while confined in the Special Housing Unit rendered a finding of deliberate i ndifference untenable. 2. We affirm the district court’s award of summary judgment in favor of Warden Stansberry on this cla im, but for a different

reason . Viewing the record in the light most favorable to Plaintiff , we conclude that Plaintiff failed to raise a genuine dispute of material fact regarding whether , in this case, the lack of a diabetic diet was a sufficiently serious deprivation to be actionable under the Eighth Amendment. Warden Stansberry conceded in her deposition and in her letter to Plaintiff ’s congressman that there was no diabetic diet provided to in mates in the Special Housing Unit. Even so, Warden Stansberry stated

on at least two occasions that all inmates were educated about how to select from the available meals foods appropriate for their medical conditions.
In Farmer , the Supreme Court stated that the Eighth Amendment imposes a duty on prison officials to provide inmates with “adequate food.” Farmer , 511 U.S. at 832. Several of our Sister C ircuits have reasoned , albeit in unpublished decisions, that this duty includes an obligation to provide a medically appropriate diet when necessary. For instance, the Tenth27 Circuit has stated that the Eighth Amendment “requires officials to provide inmates with a special diet if such an accommodation is medi cally necessary.” Frazier v. Dep’t of Corr. , No. 97

- 2086, 1997 WL 603773 , at *1 (10th Cir. Oct. 1, 1997) (citing Byrd v. Wilson , 701 F.2d 592, 595 (6th Cir. 1983)) . Simi larly, the Seventh Circuit has noted that the Amendment “assures prisoners a medicall y and nutritionally sound diet.” Jackson v. Hanlon , Nos. 89

- 2144, 89

- 2368, 1991 WL 3056 , at *1 (7th Cir. Jan. 14, 1991). Likewise, the Sixth Circuit has concluded that “officials must provide inmates with a special diet if such an accommodation is obviou sly medically necessary.” Miller v. Cleek , No. 99

- 5145, 1999 WL 1045156, at *2 (6th Cir. Nov. 9, 1999) (citing Byrd , 701 F.2 d at 594

– 95)
. We agree.
Yet t he Eighth Amendment’s requirement that prisoners receive special diets when medically appropriate is not without limit. C ourts have consistently held that prison officials comply with this mandate when they provide some food that the complaining prisoner is able to eat without compromising his health. For instance, in Frazier , the Tenth Circuit rejected a prisoner’s deliberate indifference claim when he “d[id] not contend that he [wa]s unable to eat any of the food provided by the correctional facility” and conceded that he was “able to eat certain items on the facility’s menu.” Frazier , 1997 WL 603773, at *1. The same was true in Miller , where the Sixth Circuit28 affirmed dismissal of an inmate’s inadequate diet claim based in part on the lack of “evidence that [he] could not maintain his health based on the diet provided and [the fact that he] d[id]
not contend that he was unable to eat any of the food provided by the jail.” Miller , 1999 WL 1045156, at *2. Likewise, c ourts have found that inmate s who are denied special diet s suffer no constitutional harm so long as they a re instead given instruction on how to eat the available meals in a way that satisfies their medical needs

. For example, the Tenth Circuit has found that an inmate who was served a universal, cafeteria

- style diet but could use “nutritional break down cards” to determine what foods were amenable to his medical condition could not claim deliberate indifference based on the lack of a special diet. Moore v. Perrill , No. 94

- 1377, 1995 WL 139407, at *1 (10th Cir. Mar. 31, 1995); see also Williams v.
Ha rtz , 43 F. App’x 964, 966 (7th Cir. 2002) (affirming the district court’s award of summary judgment when the complaining prisoner was not given a special diet , but was “instructed” on medically appropriate food choices and given “snacks” when necessary to raise his blood sugar). And a California district court held that a prisoner who received the “Heart Healthy” diet provided to all inmates in the
state prison system and failed to present evidence that he could not eat certain menu items or that the “overa ll percentage” of29 such items in each meal was significant could not survive summary judgment on hi s deliberate indifference claim. Baird v. Alameida , 407 F. Supp. 2d 1134, 114 0

– 4 1 (C.D. Cal. 2005)
. We find these decisions persuasive. O nly an “extreme dep rivation” is actionable under the Eighth Amendment. According to Plaintiff, the meals in the Special Housing Unit included “ a bread, a meat product[,] a vegetable[,] and a sweet dessert.” J.A. 279. Plaintiff has not offered evidence that there was no co mbination of foods in each meal that would have provided him with adequate sustenance without causing adverse medical consequences , instead asserting only that the meals were high in sugar and accompanied by a sugary drink

. Plaintiff also does not contrad ict prison officials’ claims that he was educated on how to eat the available meals (which were from the “national diet” “approved for all” inmates, J.A. 462, 539) in a way that would not exacerbate his diabetic condition

. 6 Accordingly, the district court properly awarded Warden

6 Because Plaintiff has not raised a genuine issue of material fact as to whether there was a sufficiently seriou s deprivation, we need not consider whether he has sufficiently established the subjective, deliberate indifference prong. See Celotex Corp. v. Catrett , 477 U.S. 317, 322

– 23 (1986) (requiring the nonmovant to “make a sufficient showing on” every essential element to survive summary judgment).30 Stansberry summary judgment on Plaintiff’s diet and nutrition claim. 7
IV . Having determined that Plaintiff’s claims against Dr. Phillip and Administrator McClintock should go forward, we must address Defendants’ argument that they are entitled to qualified immunity. Defendants raised qualified immunity before the district court , but because the court ruled for Defendants on the merits, it did not reach the question of Defendants’ entitlement to qualified immunity

. Qualified immunity may provide a basis for affirm ing the district court . R.R. ex rel. R. v. Fairfax Cty. Sch. Bd. , 338 F.3d 325, 332 (4th Cir. 2003) (“[W]e may affirm the district court’s judgment on any gr ound properly raised below.”) (citing Nw. Airline s, Inc. v. Cty. of
Kent , 510 U.S. 355, 364 (1994))
. Qualified immunity shields “government officials performing discretionary functions .

. . from liability for civil damages

7 Though we affirm the district court’s award of summary judgment on Plaintiff’s diet and nutrition claim, we reject the district court’s reasoning that because Plaintiff received some adequate treatment for his diab etes while in the Special Housing Unit he cannot complain about other aspects of that treatment. To the contrary, this court has held that “just because [prison officials] have provided [an inmate] with some treatment . . . it does not follow that they have necessarily provided h[im] with constitutionally adequate treatment.” See De’lonta v. Johnson , 708 F.3d 520, 526 (4th Cir. 2013).31 insofar as their conduct does not violate clearly established statutory or consti tutional rights of which a reasonable person would have known.” Harlow v. Fitzgerald , 457 U.S. 800, 818 (1982). In determining whether defendant government officials are protected by qualified immunity, the court considers both “whether a constitutional right [was] violated on the facts alleged” and “whether the right was clearly established” at the time of the conduct in question

. Saucier v. Katz , 533 U.S. 194, 200 (2001), overruled in part by Pearson v. Callahan , 555 U.S. 223 (2009). As explained previ ously, Plaintiff has alleged facts sufficient for a reasonable jury to conclude that his constitutional right s were violated when Dr. Phillip denied Plaintiff his prescribed insulin and when Dr. Phillip and Administrator McClintock failed to aid Plaintiff during a medical emergency. See supra Part s III.A, B . A lthough a jury may ultimately decide that Defendants’ version of events is more credible, we are barred from making such a determination when deciding whether to grant summary judgment based on quali fied immunity. See Meyers v. Balt. Cty. , 713 F.3d 723, 733 (4th Cir. 2013).
T o determine whether the right was clearly established, we first must define the right at issue. Occupy Columbia v. Haley , 738 F.3d 107, 118 (4th Cir. 2013). Dr. Phillip maintains that32 we should frame our analysis of qualified immunity as to Plaintiff’s insulin claim as whether it is “clearly established that a prison medical provider runs afoul of the Eighth Amendment when he does not give one single dose of insulin to a federal inmate, after the inmate becomes angry and hostile

. . ., and the doctor implements a plan to monitor the inmate thereafter.” Appellees’ Br. at 44. Similarly, Dr. Phillip and Administrator McClint ock assert that we should consider their qualified immunity as to Plaintiff’s medical emergency claim based on whether a reasonable official would have known it violated a clearly established constitutional right to follow protocol by placing an inmate in administrative detention after he receives an incid ent report. But “[f]or a constitutional right to be clearly established, i t s contours ‘must be sufficiently clear that a reasonable official would understand that what he is doing violates that right.’” H ope v. Pelzer , 536 U.S. 730, 739 (2002) (quoting Anderson v. Creighton , 483 U.S. 635, 640 (1987)). There is no requirement that the “very action in question [must have] previously been held unlawful” for a reasonable official to have notice that his condu ct violated that right. Id. Accordingly, we reject Dr. Phillip’s and Administrator33 McClintock’s invitation s to define the right s at issue in accordance with the “very action [s] in question.” 8 Rather, w e define the right in question as the right of prison ers to receive adequate medical care and to be free from officials’ deliberate indifference to their known medical needs

. This definition is consistent with previous deliberat e indifference cases from this C ircuit. For example, in Iko v. Shreve

-- a case i n which a prisoner alleged government officials failed to conduct a medical evaluation after pepper

- spraying him to compel compliance during a cell removal

-- this C ourt defined the right at issue as “the right to adequate medical care.” 535 F.3d at 243 n.1 2. This definition also accords with Supreme Court jurisprudence, which has long dictated that the Eighth Amendment confers a duty upon prison officials to ensure that prisoners “receive adequate .

. . medical care.” Farmer , 511
U.S. at 832. A prisoner’s right to adequate medical care and freedom from deliberate indifference to medical needs has been clearly established by the Supreme Court and this C ircuit since at least 1976 and, thus, was clearly established at the time of the

8 We reject Dr. Phillip’s and Administrator McClintock’s framing of the rig ht at issue in Plaintiff’s medical emergency claim for the additional reason that it would require us to make a credibility determination inappropriate at the summary judgment stage of litigation.34 events in question. See, e.g. , Estelle , 429 U.S. at 104

– 05 (“We therefore conclude that deliberate indifference to serious medical needs of prisoners constitutes the ‘unnecessary and wanton infliction of pain’ proscribed by the Eighth Amendment. ” ( citation omitted) (quoting Gregg v. Georgia , 428 U.S. 153, 182

– 83 (1976) ) ) ; Farmer , 511 U.S. at 832 (“[P]rison officials must ensure that inmates receive adequate food, clothing, shelter, and medical care.”); Bowring v. Godwin , 551 F.2d 44, 47 (4th Cir. 1977) (“This circuit has consisten tly adhered to the prevailing view in requiring reasonable medical treatment [for inmates].” ) (citing authorities)

. Because we conclude that there is sufficient evidence that Plaintiff ’s Eighth Amendment right to adequate medical care and freedom from offi cials’ deliberate indifference to his medical needs was violated and that the right was clearly established, Dr. Phillip and Administrator McClintock are not entitled to qualified immunity

. 9

9 Although we need not reach the issue here, we note once a gain the “special problem” of “‘applying an objective qualified immunity standard in the context of an Eighth Amendment claim that is satisfied only by a showing of deliberate indifference’

-

- that is, a knowing violation of the law.” Cox v. Quinn , 828 F.3d 227, 238 n.4 (4th Cir. 2016) (quoting Rish v. Johnson , 131 F.3d 1092, 1098 n.6 (4th Cir. 1997)). Some C ircuits have resolved this problem by concluding that qualified immunity is unavailable when the plaintiff presents a genuine dispute of material fact regarding the defendant’s (Continued)35 V . For the foregoing reasons, we affirm the district court’s disposition of Plaintiff ’s deliberate indifference claim against Warden Stansberry, reverse it s resolution of the claims against Dr. Phillip and Administrator McClintock, and reject Dr. Phillip’s an d Administrator McClintock’s invocations of qualified immunity.
AFFIRMED IN PART AND REVERSED IN PART

deliberate indifference. The Seventh Circuit, for example, has held that the subjective prong of the Farmer test and the objective, clearly established prong of the qualified immunity test “effectively collapse into one” when th e plaintiff raises genuine factual disputes regarding the defendant’s deliberate indifference. Walker v. Benjamin , 293 F.3d 1030, 1037 (7th Cir. 2002). That court explained that when a plaintiff raises genuine disputes of fact on Farmer ’s subjective pron g, “a defendant may not avoid trial on the grounds of qualified immunity” even though qualified immunity protects covered government officials from suit, not merely from liability. Id. ; see also, e.g. , Beers

- Capito l v. Whetzel , 256 F.3d 120, 142 n.15 (3d Cir. 2001) (“[T]o the extent that the plaintiffs have made a showing sufficient to overcome summary judgment on the merits [of their deliberate indifference claim], they have also made a showing sufficient to overcome any claim to qualified immunity.”). B ut see Estate of Ford v. Ramirez

- Palmer , 301 F.3d 1043, 1049

– 50 (9th Cir. 2002) (rejecting the view that the deliberate indifference and clearly established inquiries merge).