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Page Number: 26

20 

BROWN v. PLATA 

Opinion of the Court 

‘fact’  side.”  Lilly  v.  Virginia,  527  U. S.  116,  148  (1999) 
(Rehnquist,  C. J.,  concurring  in  judgment).  Because  the 
“district court is ‘better positioned’ . . . to decide the issue,”
our review of the three-judge court’s primary cause deter-
mination  is  deferential.    Salve  Regina  College  v.  Russell, 
499 U. S. 225, 233 (1991).

The  record  documents  the  severe  impact  of  burgeoning
demand  on  the  provision  of  care.  At  the  time  of  trial, 
vacancy  rates  for  medical  and  mental  health  staff  ranged 
as  high  as  20%  for  surgeons,  25%  for  physicians,  39%  for 
nurse  practitioners,  and  54.1%  for  psychiatrists.    Juris. 
App.  105a,  108a.    These  percentages  are  based  on  the
number  of  positions  budgeted  by  the  State.    Dr.  Ronald 
Shansky,  former  medical  director  of  the  Illinois  prison
system,  concluded  that  these  numbers  understate  the  se-
verity  of  the  crisis  because  the  State  has  not  budgeted 
sufficient  staff  to  meet  demand.5    According  to  Dr.
Shansky,  “even  if  the  prisons  were  able  to  fill  all  of  their 
vacant  health  care  positions,  which  they  have  not  been
able to do to date, . . . the prisons would still be unable to
handle  the  level  of  need  given  the  current  overcrowding.” 
Record  in  No.  2:90–CV–00520–LKK–JFM  (ED  Cal.),  Doc. 
3231–13,  p. 16  (hereinafter  Doc.  3231–13).    Dr.  Craig 
Haney,  a  professor  of  psychology,  reported  that  mental 
health  staff  are  “managing  far  larger  caseloads  than  is
appropriate or effective.”  App. 596.  A prison psychiatrist
told Dr. Haney that “ ‘we are doing about 50% of what we 
should be doing.’ ”  Ibid.  In the context of physical care Dr.
Shansky agreed that “demand for care, particularly for the 
high  priority  cases,  continues  to overwhelm  the  resources 

—————— 

5 Dr. Craig Haney likewise testified that the State had “significantly 
underestimated the staffing needed to implement critical portions of the 
Coleman  Program  Guide  requirements,”  that  “key  tasks  were  omitted 
when  determining  staffing  workloads,”  and  that  estimates  were  based
on  “key  assumptions”  that  caused  the  State  to  underestimate  demand
for mental health care.  App. 596–597.