                    United States Court of Appeals
                            FOR THE EIGHTH CIRCUIT
                                 ________________

                                    No. 06-1534
                                 ________________

Barbara Alberson, as Special        *
Administrator of the Estate of      *
James Alberson,                     *
                                    *
             Appellant,             *     Appeal from the United States
                                    *    District Court for the Eastern
       v.                           *     District of Arkansas.
                                    *
Larry Norris, Director of the       *
Arkansas Department of Correction; *
Correctional Medical Services; Kay *
Howell, Warden of Wrightsville      *
Unit; John Byus; James Branch, MD; *
Ella Casady; Betty Leatherwood,     *
                                    *
             Appellees.             *
                               ________________

                             Submitted: June 14, 2006
                                 Filed: August 15, 2006
                               ________________

Before SMITH, HEANEY and GRUENDER, Circuit Judges.
                         ________________

GRUENDER, Circuit Judge.

      Barbara Alberson, on behalf of her deceased son James Alberson and as special
administrator of his estate, appeals an adverse grant of summary judgment on her 42
U.S.C. § 1983 claim. Ms. Alberson alleges that the appellees acted with deliberate
indifference with respect to the medical treatment of Mr. Alberson, who died from
complications arising from Goodpasture Syndrome while in the custody of the
Arkansas Department of Correction (“ADC”). For the reasons discussed below, we
affirm the judgment of the district court.1

       Mr. Alberson began a twelve-month sentence at the ADC on May 16, 2003 for
a driving-while-intoxicated conviction. At all times relevant to this action, Larry
Norris was the Director of the ADC; Kay Howell was warden of the Wrightsville Unit
of the ADC; John Byus was the Medical Administrator of the ADC; Correctional
Medical Services (“CMS”) was under contract to provide medical services to the
ADC; Dr. James Branch was a physician employed by CMS; and Betty Leatherwood
was a registered nurse employed by CMS (collectively, “Appellees”).

       Mr. Alberson began suffering from earaches before arriving at the Wrightsville
Unit on August 11, 2003 and filed numerous medical service requests after his arrival.
Between August and October 2003, Mr. Alberson complained of his earaches and
other afflictions in letters to Ms. Alberson. Ms. Alberson in turn called Howell
approximately thirty times to demand that her son receive medical treatment. Ms.
Alberson alleges that Howell told her repeatedly that “there’s nothing wrong with
your son” and that her son was “a faker and an actor.” Ms. Alberson also called Byus
in late September 2003 and received a similar response. Nonetheless, Mr. Alberson
received treatment by a physician at the Wrightsville Unit Infirmary on six separate
dates between August 21 and October 29, including a two-night stay in the infirmary
ward. He received multiple rounds of antibiotics and other treatments for ear
infections, acid reflux, edema of the legs, bilateral knee pain, erythema and purpuric
rash, and hypersensitivity vasculitis.




      1
       The Honorable William R. Wilson, Jr., United States District Court for the
Eastern District of Arkansas.

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       On November 7, 2003, Mr. Alberson returned to the infirmary with complaints
of joint pain, shortness of breath and a sore throat. Dr. Branch made a preliminary
diagnosis of streptococcus infection, prescribed new antibiotics and ordered additional
diagnostic tests. On November 11, Dr. Branch called Mr. Alberson to the infirmary
for a follow-up examination, noted a chronic cough and persistent sore throat and
ordered a chest x-ray and a series of laboratory tests. On November 12, when Mr.
Alberson’s condition failed to improve, he was prescribed a different antibiotic. On
November 14, Mr. Alberson produced blood in his cough and was admitted to the
infirmary ward. The chest x-ray ordered three days earlier had not yet been
performed. When Mr. Alberson’s condition had not improved the following morning,
Dr. Branch suspected pneumonia and transferred Mr. Alberson to Southwest Hospital
in Little Rock, Arkansas. Mr. Alberson lapsed into a vegetative state on November
18 and died the next day.

       An autopsy determined Mr. Alberson’s cause of death to be pulmonary
hemorrhage and renal failure resulting from Goodpasture Syndrome. Goodpasture
Syndrome is a rare autoimmune disease that is difficult to diagnose because its
symptoms present a “confusing clinical picture.” 7 Ausman & Snyder’s Medical
Library (Lawyers’ Edition) § 14:32 (1999). “Patients who survive the initial
pulmonary hemorrhage usually progress to end-stage renal failure.” Id. § 16:16. No
definitive therapy exists. Id.

       Ms. Alberson sued the Appellees under 42 U.S.C. § 1983, alleging that the
Appellees were deliberately indifferent to Mr. Alberson’s serious medical needs. The
district court granted the Appellees’ motions for summary judgment because (1) the
undisputed evidence of medical treatment provided to Mr. Alberson foreclosed a
finding that the Appellees intentionally ignored Mr. Alberson’s suffering, and (2) Ms.
Alberson did not submit expert evidence to prove a causal connection between the
medical treatment provided by the Appellees and Mr. Alberson’s death.



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        We review the district court’s grant of summary judgment de novo and
examine the facts in the light most favorable to the party opposing summary
judgment. Revels v. Vincenz, 382 F.3d 870, 874 (8th Cir. 2004). A prison official’s
deliberate indifference to a prisoner’s serious medical needs constitutes cruel and
unusual punishment in violation of the Eighth Amendment. Estelle v. Gamble, 429
U.S. 97, 104-05 (1976). The claimant must show that “prison officials actually knew
of but deliberately disregarded” the prisoner’s objectively serious medical needs.
Dulany v. Carnahan, 132 F.3d 1234, 1239 (8th Cir. 1997). Given the extensive record
of medical treatment provided to Mr. Alberson in this case, we agree with the district
court that Ms. Alberson’s evidence does not support a claim that any prison official
deliberately disregarded Mr. Alberson’s suffering. Therefore, we analyze Ms.
Alberson’s claim as one that the medical treatment provided to Mr. Alberson was so
inadequate as to rise to the level of deliberate indifference.2



      2
        The dissent contends that certain “gaps” in Mr. Alberson’s treatment, in
combination with the inappropriate remarks made by prison officials to Ms. Alberson,
constitute sufficient evidence to create a jury question as to whether prison officials
deliberately disregarded Mr. Alberson’s suffering. However, to the extent the dissent
may be read to imply that Mr. Alberson developed an ear infection on July 31, 2003
but received no treatment for it until August 29, 2003, we note that Mr. Alberson was
examined at the ADC Diagnostic Unit on August 1, 2003, and was prescribed a course
of oral medication and ear drops for the ear infection. Notes from that visit also
reflect that Mr. Alberson was already taking Zantac twice a day at that time for his
heartburn. Mr. Alberson was reexamined on August 17, 2003, and the diagnosis
stated, “[H]as allergy problems[;] can’t hear out of ear – ears red[,] no swelling[,]
some drainage[;] will give ctm and Tylenol.” Mr. Alberson was also prescribed
further medication for his heartburn at that time. Similarly, to the extent the dissent
may be read to imply that Mr. Alberson submitted a medical request on October 15,
2003 but received no treatment until his admittance to the infirmary on October 27,
we note that Mr. Alberson was examined on October 17, was prescribed ice and a
sling and given a “no work” restriction. In short, the record makes clear that Ms.
Alberson’s evidence at best challenges the wisdom of the course of treatment provided
to Mr. Alberson, and does not suggest a deliberate disregard of his suffering.

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       To state a claim of inadequate medical treatment for § 1983 purposes, “a
prisoner must allege acts or omissions sufficiently harmful to evidence deliberate
indifference to serious medical needs.” Estelle, 429 U.S. at 106. The plaintiff “must
show more than negligence, more even than gross negligence, and mere disagreement
with treatment decisions does not rise to the level of a constitutional violation.” Estate
of Rosenberg v. Crandell, 56 F.3d 35, 37 (8th Cir. 1995). Where the complaint
involves treatment of a prisoner’s sophisticated medical condition, expert testimony
is required to show proof of causation. Gibson v. Weber, 433 F.3d 642, 646 (8th Cir.
2006).

      We agree with the district court that Ms. Alberson’s claim fails for lack of proof
of causation. For instance, in Robinson v. Hager, 292 F.3d 560 (8th Cir. 2002), a
prisoner suffered a stroke after prison officials failed to provide him with blood
pressure medication. We held that “although a person suffering from a stroke may
exhibit visible symptoms, the stroke itself is a sophisticated injury which could be
caused by numerous factors other than lack of medication. Therefore, expert medical
testimony is needed to prove causation.” Id. at 564.

       The instant case is similar. Goodpasture Syndrome certainly qualifies as a
sophisticated medical condition. Although Mr. Alberson suffered from visible
symptoms, a determination of whether CMS personnel should have provided different
treatment for Mr. Alberson or diagnosed his fatal illness earlier, or indeed whether any
treatment at all could have alleviated his suffering or arrested the progress of the
disease, “is not within the realm of lay understanding.” Id. (quoting Turner v. Iowa
Fire Equip. Co., 229 F.3d 1202, 1210 (8th Cir. 2000)). Therefore, Ms. Alberson’s
failure to produce expert testimony to prove that a lack of proper medical treatment
caused Mr. Alberson’s death is “fatal to [her] deliberate indifference claim as a matter
of law.” Id. Ms. Alberson’s evidence that administrators Howell and Byus expressed
skepticism about her son’s illnesses, while troubling, does not obviate the need for
expert proof of causation.

                                           -5-
     We conclude that the district court did not err in granting the Appellees’
motions for summary judgment based on the absence of expert proof of causation.
Accordingly, we affirm.

HEANEY, Circuit Judge, dissenting.

       I respectfully dissent in part. There is more than sufficient evidence of the
corrections employees’ deliberate indifference to James Alberson’s ongoing serious
health issues to require a trial. Thus, summary judgment was inappropriate and the
matter should be remanded. Although the present record does not directly link
James’s death to the corrections employees’ indifference, it clearly shows that he
suffered great pain prior to his death because the corrections employees denied him
appropriate access to medical treatment.

       Corrections officials are obligated, under the Eighth Amendment’s prohibition
of cruel and unusual punishment, to provide inmates with proper medical care.
Dulany v. Carnahan, 132 F.3d 1234, 1237 (8th Cir. 1997). To show a constitutional
violation, Alberson must show “(1) that [James] suffered objectively serious medical
needs and (2) that the prison officials knew of but deliberately disregarded those
needs.” Id. at 1239. “Whether a prison official had the requisite knowledge of
substantial risk is a question of fact subject to demonstration in the usual ways,
including inference from circumstantial evidence. . ., and a factfinder may conclude
that a prison official knew of a substantial risk from the very fact that the risk was
obvious.” Farmer v. Brennan, 511 U.S. 825, 842 (1994).

       The corrections employees’ actions and “callous comments” illustrate a culture
of deliberate indifference at the Wrightville Unit. See Dulany, 132 F.3d at 1244
(noting lack of callous comments or actions to support its conclusion that the prison
officials were not deliberately indifferent). The corrections employees’ minimal and
dismissive response to the decedent’s condition was clearly suspect. The record

                                         -6-
reveals that James had to submit a number of medical requests before receiving
medical attention and that his mother made several calls to prison officials, who
consistently discounted the complaints.

        On July 31, 2003, while in county custody, James developed an ear infection
that eventually resulted in hearing loss. At the time of his death, James was still
suffering from the infection, and the corrections officials had not yet provided him
with a hearing aid. From August 8 to August 29, 2003, James filed at least ten
medical service requests complaining of hearing loss, heartburn, and extreme pain in
his right shoulder, arm, and wrist. He received no medical attention until August 29,
2003. From August 2003 to November 2003, James’s mother called Kay Howell at
least thirty times complaining about her son’s condition and requesting that he receive
medical treatment. In response, Howell, apparently without verifying James’s medical
condition, told Alberson that James was “faking it.”

       From August 30 through September 24, 2003, James submitted at least four
medical service requests complaining of heavy pain in his ears, head, throat and teeth,
and an infected spider bite on his knee. He was not seen until September 24. In late
September 2003, James’s mother called John Byus who, again apparently without
verification, told James’s mother that James was “faking it.”

      On October 12, 2003, James submitted a medical request complaining of severe
headaches. He was not admitted to the infirmary until fifteen days later, on
October 27. He was released on October 29. That same month, James’s mother called
Larry Norris’s office to complain about the denial of medical treatment. She was told
that Norris was not available and transferred to another person who told her that there
was nothing wrong with James.

      On November 3, James submitted a medical service request complaining of a
constant cough, diarrhea, and aching pain in his body that affected his mobility. He

                                         -7-
was not seen until four days later on November 7 when he submitted an additional
medical service request. On November 9, James’s mother visited him, and he was
visibly distressed and walking with a limp. Later that night, James called her pleading
for her to help him get some medical attention. She called the Wrightsville Unit
requesting that someone check on him. She spoke with Lieutenant Tillman, who
worked in the diagnostic hospital, and requested that James be examined and
hospitalized. Tillman told her that only Byus could order James taken to the hospital
and refused to disturb Byus at home. He then also told her that James was “faking it.”
Two days later, James was seen by Dr. Branch, who diagnosed him as having a
chronic cough and persistent sore throat. On November 14, 2003, James was spitting
up blood and wheezing in both lungs. Although an x-ray had been ordered days
before, it had not yet been performed. James was finally admitted to the infirmary on
November 14, but treated only with Tylenol #3. On November 15, 2003, James was
still coughing and spitting up blood. He was diagnosed with pneumonia and
transferred to Southwest Hospital where he was placed on a mechanical ventilator.
At this point James had developed acute renal failure. On November 16, 2003, James
was transferred to Jefferson Regional Medical Center, placed on ventilator support,
and given dialysis. On November 19, 2003, James passed away.

        To receive medical attention, James was required to submit numerous medical
requests. When his mother pleaded with corrections employees to check on James’s
condition, her concerns were met with the callous response, without verification, that
James was “faking it.” There is sufficient evidence that the corrections employees
were aware that James was suffering from serious ongoing health issues, and yet they
were deliberately indifferent to his plight. Dulany, 132 F.3d at 1239. Alberson
testified that James was visibly distressed on November 9, and both James and his
mother notified prison officials about James’s declining health condition. According
to the record, James’s condition was “so obvious that even a layperson would easily
recognize the necessity for a doctor’s attention.” Phillips v. Jasper County Jail, 437
F.3d 791, 795 (8th Cir. 2006). The corrections employees’ continuing statement that

                                         -8-
James was “faking it” evidences a “deliberate inaction [by the corrections employees]
amounting to callousness.” See Bryan v. Endell, 141 F.3d 1290, 1291 (8th Cir. 1998)
(per curiam). The fact that James was not given a full and complete physical, though
not sufficient on its own, should be considered in determining whether he was
deliberately denied proper medical treatment. The rapid decline in James’s health
condition during his confinement could convince a jury to determine that
commonsense would have necessitated a thorough medical exam. There is sufficient
evidence in the record for a jury to hold that the corrections employees were
deliberately indifferent to James’s serious ongoing medical conditions. Thus, a
remand for trial is essential.
                        ______________________________




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