                                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.
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
Appellees.    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 Appellees.




                               2
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 claims.

      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.     Phillip         and    Administrator         McClintock      but        affirm    its

resolution of the claim against Warden Stansberry.



                                              3
                                             I.

     The Eighth Amendment prohibits the infliction of “cruel and

unusual        punishments.”          U.S.        Const.     amend.         VIII.          This

prohibition           “proscribes      more        than      physically             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

prison    official’s       “deliberate       indifference         to    serious       medical

needs     of    prisoners        constitutes       the     unnecessary         and     wanton

infliction       of      pain    proscribed        by      the    Eighth       Amendment.”

Estelle, 429 U.S. at 104 (internal quotation marks and citation

omitted).        Prisoners alleging that they have been subjected to

unconstitutional          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       [was],      objectively,

‘sufficiently         serious.’”       Farmer,       511     U.S.      at    834     (quoting

Wilson     v.     Seiter,       501   U.S.        294,     298     (1991)).           To    be

                                             4
“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    physician      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 officials 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.     To prove deliberate 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

substantial risk of serious harm exist[ed], and . . . dr[ew]

                                              5
th[at]     inference.”              Id.      (emphasis           added).             Deliberate

indifference is “more than mere negligence,” but “less than acts

or omissions [done] for the very purpose 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, 105 (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    medical

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   evidence       of    a    prison      official’s             actual       knowledge    or

circumstantial       evidence          tending      to    establish          such    knowledge,

including evidence “that a prison official knew of a substantial

risk from the very fact that the risk was obvious.”                                 Makdessi v.

                                               6
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 responded reasonably to the risk.”                   Farmer, 511 U.S. at

844.




                                           7
                                        II.

      Plaintiff entered federal custody at Federal Prison Camp

Seymour Johnson 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 facilities.             In particular, from 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.           Following 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.         Plaintiff’s     original     complaint     sought         relief    for

alleged    violations      of    his   rights     under     the    Fourth,          Fifth,

Eighth, and Fourteenth Amendments, naming as defendants various

federal officials, including the Bureau of Prisons, then-Bureau

Director    Harley     Lappin,     Regional      Director    Kim       White,       Warden



      1After pleading guilty to maintaining a place for the
purpose of manufacturing, distributing, or using phencyclidine,
Plaintiff was sentenced to 78 months’ imprisonment. The nature
of his conviction and sentence are irrelevant to this appeal.



                                           8
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   transferred      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.

Phillip and Butner Correctional Officer Lawrence Coor (“Officer

Coor”).     Scinto v. Stansberry, 507 F. App’x 311 (4th Cir. 2013)

(per curiam).        Cross-motions for summary judgment followed and,

on   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 Stansberry

                                            9
for her alleged failure to provide Plaintiff with a diabetic

diet     during         Plaintiff’s       incarceration            in     administrative

segregation (the “Special Housing Unit”).                         We address the 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      fact       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    insulin

                                             10
injections,         as    well    as     supplemental      insulin       injections       based

upon a “sliding 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

between 151 and 200mg/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,

Plaintiff 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,     rather      than    providing       four   units     of     insulin   as

dictated       by     Plaintiff’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      insulin”    if    Plaintiff

desired.       J.A. 521. 2




        2
       Citations to “J.A. __” refer to the Joint Appendix filed
by the parties in this appeal.



                                               11
      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 followed.                          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 stating 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      A1C

levels, which rose from approximately 7 (within the normal range

for diabetics) to 9.8 (an unhealthy level for diabetics) from

                                          12
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 damage 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 objective and subjective prongs.

       Regarding      the    objective           prong,        Plaintiff’s         evidence

established that he suffers from a serious medical condition:

insulin-dependent          diabetes.             This        medical     condition        was

diagnosed by a medical professional, and Dr. Phillip provided

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 in

                                            13
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       when     it      is        needed      creates          an     objectively,

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 prescribed 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     of

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          insulin

                                               14
injections       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] expressly noted by prison officials,” Parrish,

372 F.3d at 303--including by Dr. Phillip himself.                                           This 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      insulin       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     Parrish

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 with

                                                   15
Plaintiff’s failure to offer 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 both 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 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, 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
“substantial harm” standard, should be used when instructing the
jury on the objective prong of the Farmer test.




                                          16
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 apply, 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

facts     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, 833

F.2d 468, 473 (3d Cir. 1987).

         Recognizing that it is a “[w]ell-known” fact that diabetes

is   a    “common       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 summary

                                                 17
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     diabetic    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 conclude that prison officials who knew

the    inmate     was     diabetic        and    needed       insulin          regularly       were

deliberately       indifferent            in    denying       insulin          for    nonmedical

reasons).         We     agree:      a    jury       is   capable         of    understanding,

unaided, the risks of failing to provide insulin 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 giving 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 risk 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 arguendo

                                                18
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 particular, 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 dispute 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    were     repairing      the

       4
       During a census count, inmates must remain in place while
prison officials conduct a count to ensure that all inmates are
in their assigned locations.



                                             19
unit’s showers.         While locked down and unable to access water,

Plaintiff began experiencing “extreme [stomach] pain . . . was

throwing up vomit and blood . . . [and] became incontinent.”

J.A. 846.      In this state, Plaintiff used an emergency phone in

the unit to call for help 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 blood

all over me.”           J.A. 848–49.        By contrast, in a now-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 shift 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, they 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 his




                                           20
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 walk 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

“lock      him   up”   in   the   Special    Housing     Unit.     J.A.    858–59.

Thereafter, prison officials removed Plaintiff to the Special

Housing Unit, where he was confined for six months.

       Plaintiff’s evidence indicates he did not receive medical

attention until at least two days after 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.




                                        21
                                            2.

       Again, Plaintiff’s evidence establishes 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 must, Plaintiff 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       blood[,   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

Henderson 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 injury.           A juror could reasonably infer that failing 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   already

                                            22
occurred.       This conclusion 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 fact

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

circumstantial 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

contemporaneous 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 would 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’s

                                             23
claim to survive summary judgment.           See Miltier, 896 F.3d at 853

(“Failure to respond to an inmate’s known medical needs raises

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 unit.          Second, Plaintiff submitted cop-

outs to Warden Stansberry seeking redress 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

Prisons, Warden Stansberry addressed the allegations in a reply

letter.    She acknowledged that inmates in the Special Housing

Unit did not receive special diets but maintained that inmates



                                       24
were educated about how to select foods appropriate for their

medical conditions.

       Because of the alleged 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 purportedly “resulted in the

loss   of    . . .       diabetic       control          . . .      and    severe      painful      and

destructive         episodes           of        diabetic          hypoglycemia          and    . . .

hyperglycemia.”          J.A. 626.

       The 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.                    The    court        went    on   to

conclude, however, that there was no genuine dispute regarding

whether Warden Stansberry knew of and disregarded Plaintiff’s

need for a special diet.                         The 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 conviction 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    subjective         prong,

                                                    25
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       indifference

untenable.

                                          2.

     We affirm the district court’s award of summary judgment in

favor of Warden Stansberry on this claim, 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 inmates

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 Circuits have reasoned, albeit in unpublished decisions,

that this duty includes an obligation to provide a medically

appropriate     diet     when    necessary.           For    instance,       the   Tenth

                                          26
Circuit has stated that the Eighth Amendment “requires officials

to provide inmates with a special diet if such an accommodation

is medically 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)).                       Similarly,

the   Seventh      Circuit     has   noted    that    the    Amendment      “assures

prisoners a medically 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    obviously    medically      necessary.”           Miller    v.

Cleek, No. 99-5145, 1999 WL 1045156, at *2 (6th Cir. Nov. 9,

1999) (citing Byrd, 701 F.2d at 594–95).              We agree.

      Yet    the    Eighth     Amendment’s     requirement         that    prisoners

receive special diets when medically appropriate is not without

limit.      Courts      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 Circuit

                                        27
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, courts have found that inmates who are denied

special diets suffer no constitutional harm so long as they are

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.

Hartz,   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 “overall percentage” of

                                         28
such       items    in    each   meal    was    significant       could     not    survive

summary judgment on his deliberate indifference claim.                            Baird v.

Alameida, 407 F. Supp. 2d 1134, 1140–41 (C.D. Cal. 2005).

       We    find     these      decisions      persuasive.        Only     an    “extreme

deprivation”             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 combination 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     contradict       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 serious
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).




                                               29
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 affirming 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 ground

properly raised below.”) (citing Nw. Airlines, Inc. v. Cty. of

Kent, 510 U.S. 355, 364 (1994)).

      Qualified immunity shields “government officials performing

discretionary functions . . . from liability for civil damages



      7Though 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 diabetes 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).



                                      30
insofar as their conduct does not violate clearly established

statutory or constitutional 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        previously,        Plaintiff      has    alleged       facts

sufficient       for     a   reasonable         jury      to   conclude      that     his

constitutional         rights    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 Parts III.A, B.               Although 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 qualified

immunity.       See Meyers v. Balt. Cty., 713 F.3d 723, 733 (4th Cir.

2013).

     To 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 that

                                           31
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 McClintock 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 incident report.

       But    “[f]or      a        constitutional             right         to     be     clearly

established, its contours ‘must be sufficiently clear that a

reasonable     official        would       understand         that     what       he    is   doing

violates that right.’”              Hope 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    conduct          violated     that      right.          Id.

Accordingly,      we      reject           Dr.        Phillip’s        and        Administrator




                                                 32
McClintock’s        invitations      to    define    the     rights     at   issue    in

accordance with the “very action[s] in question.” 8

       Rather, we define the right in question as the right of

prisoners to receive adequate medical care and to be free from

officials’ deliberate indifference to their known medical needs.

This        definition     is     consistent        with     previous        deliberate

indifference cases from this Circuit.                      For example, in Iko v.

Shreve--a case in which a prisoner alleged government officials

failed to conduct a medical evaluation after pepper-spraying him

to compel compliance during a cell removal--this Court defined

the right at issue as “the right to adequate medical care.”                          535

F.3d at 243 n.12.               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 Circuit since at least

1976       and,   thus,   was    clearly   established       at   the   time    of   the

       8We reject Dr. Phillip’s and Administrator McClintock’s
framing of the right 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.



                                           33
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   consistently   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 officials’ 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
again 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 Circuits 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)
                                           34
                                      V.

      For the foregoing reasons, we affirm the district court’s

disposition of Plaintiff’s deliberate indifference claim against

Warden Stansberry, reverse its resolution of the claims against

Dr.   Phillip   and    Administrator        McClintock,   and   reject   Dr.

Phillip’s   and       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 the 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 prong, “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-Capitol 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.”). But 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).



                                      35
