Brown v. Plata

delivered the opinion of the Court.

This case arises from serious constitutional violations in California’s prison system. The violations have persisted for years. They remain uncorrected. The appeal comes to this Court from a three-judge District Court order directing California to remedy two ongoing violations of the Cruel and Unusual Punishments Clause, a guarantee binding on the States by the Due Process Clause of the Fourteenth Amend-*500men! The violations are the subject of two class actions in two Federal District Courts. The first involves the class of prisoners with serious mental disorders. That case is Coleman v. Brown. The second involves prisoners with serious medical conditions. That ease is Plata v. Brown. The order of the three-judge District Court is applicable to both cases.

After years of litigation, it became apparent that a remedy for the constitutional violations would not be effective absent a reduction in the prison system population. The authority to order release of prisoners as a remedy to cure a systemic violation of the Eighth Amendment is a power reserved to a three-judge district court, not a single-judge district court. 18 U. S. C. § 3626(a). In accordance with that rule, the Coleman and Plata District Judges independently requested that a three-judge court be convened. The Chief Judge of the Court of Appeals for the Ninth Circuit convened a three-judge court composed of the Coleman and Plata District Judges and a third, Ninth Circuit Judge. Because the two cases are interrelated, their limited consolidation for this purpose has a certain utility in avoiding conflicting decrees and aiding judicial consideration and enforcement. The State in this Court has not objected to consolidation, although the State does argue that the three-judge court was prematurely convened. The State also objects to the substance of the three-judge court order, which requires the State to reduce overcrowding in its prisons.

The appeal presents the question whether the remedial order issued by the three-judge court is consistent with requirements and procedures set forth in a congressional statute, the Prison Litigation Reform Act of 1995 (PLRA). 18 U. S. C. § 3626; see Appendix A, infra. The order leaves the choice of means to reduce overcrowding to the discretion of state officials. But absent compliance through new construction, out-of-state transfers, or other means — or modification of the order upon a further showing by the State— *501the State will be required to release some number of prisoners before their full sentences have been served. High recidivism rates must serve as a warning that mistaken or premature release of even one prisoner can cause injury and harm. The release of prisoners in large numbers — assuming the State finds no other way to comply with the order — is a matter of undoubted, grave concern.

At the time of trial, California’s correctional facilities held some 156,000 persons. This is nearly double the number that California’s prisons were designed to hold, and California has been ordered to reduce its prison population to 137.5% of design capacity. By the three-judge court’s own estimate, the required population reduction could be as high as 46,000 persons. Although the State has reduced the population by at least 9,000 persons during the pendency of this appeal, this means a further reduction of 37,000 persons could be required. As will be noted, the reduction need not be accomplished in an indiscriminate manner or in these substantial numbers if satisfactory, alternative remedies or means for compliance are devised. The State may employ measures, including good-time credits and diversion of low-risk offenders and technical parole violators to community-based programs, that will mitigate the order’s impact. The population reduction potentially required is nevertheless of unprecedented sweep and extent.

Yet so too is the continuing injury and harm resulting from these serious constitutional violations. For years the medical and mental health care provided by California’s prisons has fallen short of minimum constitutional requirements and has failed to meet prisoners’ basic health needs. Needless suffering and death have been the well-documented result. Over the whole course of years during which this litigation has been pending, no other remedies have been found to be sufficient. Efforts to remedy the violation have been frustrated by severe overcrowding in California’s prison system. Short-term gains in the provision of care have been *502eroded by the long-term effects of severe and pervasive overcrowding.

Overcrowding has overtaken the limited resources of prison staff; imposed demands well beyond the capacity of medical and mental health facilities; and created unsanitary and unsafe conditions that make progress in the provision of care difficult or impossible to achieve. The overcrowding is the “primary cause of the violation of a Federal right,” 18 U. S. C. § 3626(a)(B)(E)(i), specifically the severe and unlawful mistreatment of prisoners through grossly inadequate provision of medical and mental health care.

This Court now holds that the PLRA does authorize the relief afforded in this case and that the court-mandated population limit is necessary to remedy the violation of prisoners’ constitutional rights. The order of the three-judge court, subject to the right of the State to seek its modification in appropriate circumstances, must be affirmed.

I

A

The degree of overcrowding in California’s prisons is exceptional. California’s prisons are designed to house a population just under 80,000, but at the time of the three-judge court’s decision the population was almost double that. The State’s prisons had operated at around 200% of design capacity for at least 11 years. Prisoners are crammed into spaces neither designed nor intended to house inmates. As many as 200 prisoners may live in a gymnasium, monitored by as few as two or three correctional officers. App. 1337-1338, 1350; see Appendix B, infra. As many as 54 prisoners may share a single toilet. App. 1337.

The Corrections Independent Review Panel, a body appointed by the Governor and composed of correctional consultants and representatives from state agencies, concluded that California’s prisons are “ ‘severely overcrowded, imperiling the safety of both correctional employees and in*503mates.’ ”1 App. to Juris. Statement, O. T. 2009, No. 09-416, p. 56a (hereinafter Juris. App.). In 2006, then-Governor Schwarzenegger declared a state of emergency in the prisons, as “ ‘immediate action is necessary to prevent death and harm caused by California’s severe prison overcrowding.’” Id., at 61a. The consequences of overcrowding identified by the Governor include “ ‘increased, substantial risk for transmission of infectious illness’ ” and a suicide rate “ ‘approaching an average of one per week.’ ” Ibid.

Prisoners in California with serious mental illness do not receive minimal, adequate care. Because of a shortage of treatment beds, suieidal inmates may be held for prolonged periods in telephone-booth-sized cages without toilets. See *504Appendix C, infra. A psychiatric expert reported observing' an inmate who had been held in such a cage for nearly 24 hours, standing in a pool of his own urine, unresponsive and nearly catatonic. Prison officials explained they had “ 'no place to put him.’ ” App. 593. Other inmates awaiting care may be held for months in administrative segregation, where they endure harsh and isolated conditions and receive only limited mental health services. Wait times for mental health care range as high as 12 months. Id., at 704. In 2006, the suicide rate in California’s prisons was nearly 80% higher than the national average for prison populations; and a court-appointed Special Master found that 72.1% of suicides involved “some measure of inadequate assessment, treatment, or intervention, and were therefore most probably foreseeable and/or preventable.”2 Id., at 1781.

Prisoners suffering from physical illness also receive severely deficient care. California’s prisons were designed to meet the medical needs of a population at 100% of design capacity and so have only half the clinical space needed to treat the current population. Id., at 1024. A correctional officer testified that, in one prison, up to 50 sick inmates may be held together in a 12- by 20-foot cage for up to five hours awaiting treatment. Tr. 597-599. The number of staff is *505inadequate, and prisoners face significant delays in access to care. A prisoner with severe abdominal pain died after a 5-week delay in referral to a specialist; a prisoner with “ ‘constant and extreme’ ” chest pain died after an 8-hour delay in evaluation by a doctor; and a prisoner died of testicular cancer after a “failure of MDs to work up for cancer in a young man with 17 months of testicular pain.”3 California Prison Health Care Receivership Corp., K. Imai, Analysis of CDCR Death Reviews 2006, pp. 6-7 (Aug. 2007). Doctor Ronald Shansky, former medical director of the Illinois state prison system, surveyed death reviews for California prisoners. He concluded that extreme departures from the standard of care were “widespread,” Tr. 430, and that the proportion of “possibly preventable or preventable” deaths was “extremely high,” id., at 429.4 Many more prisoners, suffering *506from severe but not life-threatening conditions, experience prolonged illness and unnecessary pain.

B

These conditions are the subject of two federal cases. The first to commence, Coleman v. Brown, was filed in 1990. Coleman involves the class of seriously mentally ill persons in California prisons. Over 15 years ago, in 1995, after a 39-day trial, the Coleman District Court found “overwhelming evidence of the systemic failure to deliver necessary care to mentally ill inmates” in California prisons. Coleman v. Wilson, 912 F. Supp. 1282, 1316 (ED Cal.). The prisons were “seriously and chronically understaffed,” id., at 1306, and had “no effective method for ensuring . . . the competence of their staff,” id., at 1308. The prisons had failed to implement necessary suicide-prevention procedures, “due in large measure to the severe under staffing.” Id., at 1315. Mentally ill inmates “languished for months, or even years, without access to necessary care.” Id., at 1316. “They suffer from severe hallucinations, [and] they decompensate into catatonic states.” Ibid. The court appointed a Special Master to oversee development and implementation of a remedial plan of action.

*507In 2007,12 years after his appointment, the Special Master in Coleman filed a report stating that, after years of slow improvement, the state of mental health care in California’s prisons was deteriorating. App. 489. The Special Master ascribed this change to increased overcrowding. The rise in population had led to greater demand for care, and existing programming space and staffing levels were inadequate to keep pace. Prisons had retained more mental health staff, but the “growth of the resource [had] not matched the rise in demand.” Id., at 482. At the very time the need for space was rising, the need to house the expanding population had also caused a “reduction of programming space now occupied by inmate bunks.” Id., at 479. The State was “facing a four to five-year gap in the availability of sufficient beds to meet the treatment needs of many inmates/patients.” Id., at 481. “[increasing numbers of truly psychotic inmate/patients are trapped in [lower levels of treatment] that cannot meet their needs.” Ibid. The Special Master concluded that many early “achievements have succumbed to the inexorably rising tide of population, leaving behind growing frustration and despair.” Id., at 489.

C

The second action, Plata v. Brown, involves the class of state prisoners with serious medical conditions. After this action commenced in 2001, the State conceded that deficiencies in prison medical care violated prisoners’ Eighth Amendment rights. The State stipulated to a remedial injunction. The State failed to comply with that injunction, and in 2005 the court appointed a Receiver to oversee remedial efforts. The court found that “the California prison medical care system is broken beyond repair,” resulting in an “unconscionable degree of suffering and death.” App. 917. The court found: “[I]t is an uneontested fact that, on average, an inmate in one of California’s prisons needlessly dies every six to seven days due to constitutional deficiencies in the *508[California prisons’] medical delivery system.” Ibid. And the court made findings regarding specific instances of neglect, including the following:

“[A] San Quentin prisoner with hypertension, diabetes and renal failure was prescribed two different medications that actually served to exacerbate his renal failure. An optometrist noted the patient’s retinal bleeding due to very high blood pressure and referred him for immediate evaluation, but this evaluation never took place. It was not until a year later that the patient’s renal failure was recognized, at which point he was referred to a nephrologist on an urgent basis; he should have been seen by the specialist within 14 days but the consultation never happened and the patient died three months later,” Id., at 928 (citations omitted).

Prisons were unable to retain sufficient numbers of competent medical staff, id., at 937, and would “hire any doctor who had ‘a license, a pulse and a pair of shoes,' ” id., at 926. Medical facilities lacked “necessary medical equipment” and did “not meet basic sanitation standards.” Id., at 944. “Exam tables and counter tops, where prisoners with . . . communicable diseases are treated, [were] not routinely disinfected.” Ibid.

In 2008, three years after the District Court’s decision, the Receiver described continuing deficiencies in the health care provided by California prisons:

“Timely access is not assured. The number of medical personnel has been inadequate, and competence has not been assured.... Adequate housing for the disabled and aged does not exist. The medical facilities, when they exist at all, are in an abysmal state of disrepair. Basic medical equipment is often not available or used. Medications and other treatment options are too often not available when needed. . . . Indeed, it is a misnomer to call the existing chaos a ‘medical delivery system' — it is *509more an act of desperation than a system.” Record in No. 3:01-cv-01351-TEH (ND Cal.), Doc. 1136, p. 9.

A report by the Receiver detailed the impact of overcrowding on efforts to remedy the violation. The Receiver explained that “overcrowding, combined with staffing shortages, has created a culture of cynicism, fear, and despair which makes hiring and retaining competent clinicians extremely difficult.” App. 1031. “[0]vercrowding, and the resulting day to day operational chaos of the [prison system], creates regular 'crisis’ situations which . . . take time [and] energy . . . away from important remedial programs.” Id., at 1035. Overcrowding had increased the incidence of infectious disease, id., at 1037-1038, and had led to rising prison violence and greater reliance by custodial staff on lockdowns, which “inhibit the delivery of medical care and increase the staffing necessary for such care,” id., at 1037. “Every day,” the Receiver reported, “California prison wardens and health care managers make the difficult decision as to which of the class actions, Coleman ... or Plata they will fail to comply with because of staff shortages and patient loads.” Id., at 1038.

D

The Coleman and Plata plaintiffs, believing that a remedy for unconstitutional medical and mental health care could not be achieved without reducing overcrowding, moved their respective District Courts to convene a three-judge court empowered under the PLRA to order reductions in the prison population. The judges in both actions granted the request, and the cases were consolidated before a single three-judge court. The State has not challenged the validity of the consolidation in proceedings before this Court, so its propriety is not presented by this appeal.

The three-judge court heard 14 days of testimony and issued a 184-page opinion, making extensive findings of fact. The court ordered California to reduce its prison population *510to 137.5% of the prisons’ design capacity within two years. Assuming the State does not increase capacity through new construction, the order requires a population reduction of 38,000 to 46,000 persons. Because it appears all but certain that the State cannot complete sufficient construction to comply fully with the order, the prison population will have to be reduced to at least some extent. The court did not order the State to achieve this reduction in any particular manner. Instead, the court ordered the State to formulate a plan for compliance and submit its plan for approval by the court.

The State appealed to this Court pursuant to 28 U. S. C. § 1253, and the Court postponed consideration of the question of jurisdiction to the hearing on the merits. Schwarzenegger v. Plata, 560 U. S. 964 (2010).

II

As a consequence of their own actions, prisoners may be deprived of rights that are fundamental to liberty. Yet the law and the Constitution demand recognition of certain other rights. Prisoners retain the essence of human dignity inherent in all persons. Respect for that dignity animates the Eighth Amendment prohibition against cruel and unusual punishment. “‘The basic concept underlying the Eighth Amendment is nothing less than the dignity of man.’” Atkins v. Virginia, 536 U. S. 304, 311 (2002) (quoting Prop v. Dulles, 356 U. S. 86, 100 (1958) (plurality opinion)).

To incarcerate, society takes from prisoners the means to provide for their own needs. Prisoners are dependent on the State for food, clothing, and necessary medical care. A prison’s failure to provide sustenance for inmates “may actually produce physical ‘torture or a lingering death.’” Estelle v. Gamble, 429 U. S. 97, 103 (1976) (quoting In re Kemmler, 136 U. S. 436, 447 (1890)); see generally A. Eisner, Gates of Injustice: The Crisis in America’s Prisons (2004), Just as a prisoner may starve if not fed, he or she may suffer or die if *511not provided adequate medical care. A prison that deprives prisoners of basic sustenance, including adequate medical care, is incompatible with the concept of human dignity and has no place in civilized society.

If government fails to fulfill this obligation, the courts have a responsibility to remedy the resulting Eighth Amendment violation. See Hutto v. Finney, 437 U. S. 678, 687, n. 9 (1978). Courts must be sensitive to the State’s interest in punishment, deterrence, and rehabilitation, as well as the need for deference to experienced and expert prison administrators faced with the difficult and dangerous task of housing large numbers of convicted criminals. See Bell v. Wolfish, 441 U. S. 520, 547-548 (1979). Courts nevertheless must not shrink from their obligation to “enforce the constitutional rights of all ‘persons/ including prisoners.” Cruz v. Beto, 405 U. S. 319, 321 (1972) (per curiam). Courts may not allow constitutional violations to continue simply because a remedy would involve intrusion into the realm of prison administration.

Courts faced with the sensitive task of remedying unconstitutional prison conditions must consider a range of available options, including appointment of special masters or receivers and the possibility of consent decrees. When necessary to ensure compliance with a constitutional mandate, courts may enter orders placing limits on a prison’s population. By its terms, the PLEA restricts the circumstances in which a court may enter an order “that has the purpose or effect of reducing or limiting the prison population.” 18 U. S. C. § 3626(g)(4). The order in this case does not necessarily require the State to release any prisoners. The State may comply by raising the design capacity of its prisons or by transferring prisoners to county facilities or facilities in other States. Because the order limits the prison population as a percentage of design capacity, it nonetheless has the “effect of reducing or limiting the prison population.” Ibid.

*512Under the PLRA, only a three-judge court may enter an order limiting a prison population. § 3626(a)(3)(B). Before a three-judge court may he convened, a district court first must have entered an order for less intrusive relief that failed to remedy the constitutional violation and must have given the defendant a reasonable time to comply with its prior orders. § 3626(a)(3)(A). The party requesting a three-judge court must then submit “materials sufficient to demonstrate that [these requirements] have been met.” § 3626(a)(3)(C). If the district court concludes that the materials are, in fact, sufficient, a three-judge court may be convened. Ibid.; see also 28 U. S. C. § 2284(b)(1) (stating that a three-judge court may not be convened if the district court “determines that three judges are not required”); 17A C. Wright, A. Miller, E. Cooper, & V. Amar, Federal Practice and Procedure § 4235 (3d ed. 2007).

The three-judge court must then find by clear and convincing evidence that “crowding is the primary cause of the violation of a Federal right” and that “no other relief will remedy the violation of the Federal right.” 18 U. S. C. § 3626(a)(3)(E). As with any award of prospective relief under the PLRA, the relief “shall extend no further than necessary to correct the violation of the Federal right of a particular plaintiff or plaintiffs.” §3626(a)(1)(A). The three-judge court must therefore find that the relief is “narrowly drawn, extends no further than necessary . . ., and is the least intrusive means necessary to correct the violation of the Federal right.” Ibid. In making this determination, the three-judge court must give “substantial weight to any adverse impact on public safety or the operation of a criminal justice system caused by the relief.” Ibid. Applying these standards, the three-judge court found a population limit appropriate, necessary, and authorized in this case.

This Court’s review of the three-judge court’s legal determinations is de novo, but factual findings are reviewed for clear error. See Anderson v. Bessemer City, 470 U. S. 564, *513573-574 (1985). Deference to trial court factfinding reflects an understanding that “[t]he trial judge’s major role is the determination of fact, and with experience in fulfilling that role comes expertise.” Id., at 574. The three-judge court oversaw two weeks of trial and heard at considerable length from California prison officials, as well as experts in the field of correctional administration. The judges had the opportunity to ask relevant questions of those witnesses. Two of the judges had overseen the ongoing remedial efforts of the Receiver and Special Master. The three-judge court was well situated to make the difficult factual judgments necessary to fashion a remedy for this complex and intractable constitutional violation. The three-judge court’s findings of fact may be reversed only if this Court is left with a “ ‘definite and firm conviction that a mistake has been committed.’ ” Id., at 573 (quoting United States v. United States Gypsum Co., 333 U. S. 364, 395 (1948)).

A

The State contends that it was error to convene the three-judge court without affording it more time to comply with the prior orders in Coleman and Plata.

1

The parties dispute this Court’s jurisdiction to review the determinations of the Coleman and Plata District Courts that a three-judge court should be convened. Plaintiffs claim the State was required to raise this issue first in the Court of Appeals by appealing the orders of the District Courts. When exercising jurisdiction under 28 U. S. C. §1253, however, this Court ‘‘has not hesitated to exercise jurisdiction ‘to determine the authority of the court below,’” including whether the three-judge court was properly constituted. Gonzalez v. Automatic Employees Credit Union, 419 U. S. 90, 95, n. 12 (1974) (quoting Bailey v. Patterson, 369 U. S. 31, 34 (1962) (per curiam)); see also Gully v. Interstate *514Natural Gas Co., 292 U. S. 16, 18 (1934) (per curiam) (“The case is analogous to those in which this Court, finding that the court below has acted without jurisdiction, exercises its appellate jurisdiction to correct the improper action”). The merits of the decision to convene the three-judge court, therefore, are properly before this Court.

2

Before a three-judge court may be convened to consider whether to enter a population limit, the PLRA requires that the court have “previously entered an order for less intrusive relief that has failed to remedy the deprivation of the Federal right sought to be remedied.” 18 U. S. C. § 3626(a)(3)(A)(i). This provision refers to “an order.” It is satisfied if the court has entered one order, and this single order has “failed to remedy” the constitutional violation. The defendant must also have had “a reasonable amount of time to comply with the previous court orders.” § 3626(a)(3)(A)(ii). This provision refers to the court’s “orders.” It requires that the defendant have been given a reasonable time to comply with all of the court’s orders. Together, these requirements ensure that the “ ‘last resort remedy’” of a population limit is not imposed “‘as a first step.’” Inmates of Occoquan v. Barry, 844 F. 2d 828, 843 (CADC 1988).

The first of these conditions, the previous order requirement of § 3626(a)(3)(A)(i), was satisfied in Coleman by appointment of a Special Master in 1995, and it was satisfied in Plata by approval of a consent decree and stipulated injunction in 2002. Both orders were intended to remedy the constitutional violations. Both were given ample time to succeed. When the three-judge court was convened, 12 years had passed since the appointment of the Coleman Special Master, and 5 years had passed since the approval of the Plata consent decree. The State does not claim that either *515order achieved a remedy. Although the PLRA entitles a State to terminate remedial orders such as these after two years unless the district court finds that the relief “remains necessary to correct a current and ongoing violation of the Federal right,” § 3626(b)(3), California has not attempted to obtain relief on this basis.

The State claims instead that the second condition, the reasonable time requirement of § 3626(a)(3)(A)(ii), was not met because other, later remedial efforts should have been given more time to succeed. In 2006, the Coleman District Judge approved a revised plan of action calling for construction of new facilities, hiring of new staff, and implementation of new procedures. That same year, the Plata District Judge selected and appointed a Receiver to oversee the State’s ongoing remedial efforts. When the three-judge court was convened, the Receiver had filed a preliminary plan of action calling for new construction, hiring of additional staff, and other procedural reforms.

Although both the revised plan of action in Coleman and the appointment of the Receiver in Plata were new developments in the courts’ remedial efforts, the basic plan to solve the crisis through construction, hiring, and procedural reforms remained unchanged. These efforts had been ongoing for years; the failed consent decree in Plata had called for implementation of new procedures and hiring of additional staff; and the Coleman Special Master had issued over 70 orders directed at achieving a remedy through construction, hiring, and procedural reforms. The Coleman Special Master and Plata Receiver were unable to provide assurance that further, substantially similar efforts would yield success absent a population reduction. Instead, the Coleman Special Master explained that “many of the clinical advances ... painfully accomplished over the past decade are slip-sliding away” as a result of overcrowding. App. 481-482. And the Plata Receiver indicated that, absent a reduction in over*516crowding, a successful remedial effort could “all but bankrupt” the State of California. App. 1053.

Having engaged in remedial efforts for 5 years in Plata and 12 in Coleman, the District Courts were not required to wait to see whether their more recent efforts would yield equal disappointment. When a court attempts to remedy an entrenched constitutional violation through reform of a complex institution, such as this statewide prison system, it may be necessary in the ordinary course to issue multiple orders directing and adjusting ongoing remedial efforts. Each new order must be given a reasonable time to succeed, but reasonableness must be assessed in light of the entire history of the court’s remedial efforts. A contrary reading of the reasonable time requirement would in effect require district courts to impose a moratorium on new remedial orders before issuing a population limit. This unnecessary period of inaction would delay an eventual remedy and would prolong the courts’ involvement, serving neither the State nor the prisoners. Congress did not require this unreasonable result when it used the term “reasonable."

The Coleman and Plata courts had a solid basis to doubt that additional efforts to build new facilities and hire new staff would achieve a remedy. Indeed, although five years have now passed since the appointment of the Plata Receiver and approval of the revised plan of action in Coleman, there is no indication that the constitutional violations have been cured. A report filed by the Coleman Special Master in July 2009 describes ongoing violations, including an “absence of timely access to appropriate levels of care at every point in the system.” App. 807. A report filed by the Plata Receiver in October 2010 likewise describes ongoing deficiencies in the provision of medical care and concludes that there are simply “too many prisoners for the healthcare infrastructure.” App. 1655. The Coleman and Plata courts acted reasonably when they convened a three-judge court without further delay.

*517B

Once a three-judge court has been convened, the court must find additional requirements satisfied before it may impose a population limit. The first of these requirements is that “crowding is the primary cause of the violation of a Federal right.” 18 U. S. C. §3626(a)(3)(E)(i).

1

The three-judge court found the primary cause requirement satisfied by the evidence at trial. The court found that overcrowding strains inadequate medical and mental health facilities; overburdens limited clinical and custodial staff; and creates violent, unsanitary, and chaotic conditions that contribute to the constitutional violations and frustrate efforts to fashion a remedy. The three-judge court also found that “until the problem of overcrowding is overcome it will be impossible to provide constitutionally compliant care to California’s prison population.” Juris. App. 141a.

The parties dispute the standard of review applicable to this determination. With respect to the three-judge court’s factual findings, this Court’s review is necessarily deferential. It is not this Court’s place to “duplicate the role” of the trial court. Anderson, 470 U. S., at 573. The ultimate issue of primary cause presents a mixed question of law and fact; but there, too, “the mix weighs heavily on the '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 determination 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 prac*518titioners, 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 severity 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. 19 (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 available.” Id., at 1408.

Even on the assumption that vacant positions could be filled, the evidence suggested there would be insufficient space for the necessary additional staff to perform their jobs. The Plata Receiver, in his report on overcrowding, concluded that even the “newest and most modern prisons” had been “designed with clinic space which is only one-half that necessary for the real-life capacity of the prisons.” App. 1023 (emphasis deleted). Dr. Haney reported that “[ejach one of the facilities I toured was short of significant amounts of space needed to perform otherwise critical tasks and re*519sponsibilities.” Id., at 597-598. In one facility, staff cared for 7,525 prisoners in space designed for one-third as many. Juris. App. 93a. Staff operate out of converted storage rooms, closets, bathrooms, shower rooms, and visiting centers. These makeshift facilities impede the effective delivery of care and place the safety of medical professionals in jeopardy, compounding the difficulty of hiring additional staff.

This shortfall of resources relative to demand contributes to significant delays in treatment. Mentally ill prisoners are housed in administrative segregation while awaiting transfer to scarce mental health treatment beds for appropriate care. One correctional officer indicated that he had kept mentally ill prisoners in segregation for ‘“6 months or more.’” App. 594. Other prisoners awaiting care are held in tiny, phone-booth-sized cages. The record documents instances of prisoners committing suicide while awaiting treatment.6

Delays are no less severe in the context of physical care. Prisons have backlogs of up to 700 prisoners waiting to see a doctor. Doc. 3231-13, at 21. A review of referrals for urgent specialty care at one prison revealed that only 105 of 316 pending referrals had a scheduled appointment, and only 2 had an appointment scheduled to occur within 14 days. Id., at 25-26. Urgent specialty referrals at one prison had been pending for six months to a year. Id., at 30.

Crowding also creates unsafe and unsanitary living conditions that hamper effective delivery of medical and mental health care. A medical expert described living quarters in converted gymnasiums or dayrooms, where large numbers of prisoners may share just a few toilets and showers, as *520“‘breeding grounds for disease.’”7 Juris. App. 102a. Cramped conditions promote unrest and violence, making it difficult for prison officials to monitor and control the prison population. On any given day, prisoners in the general prison population may become ill, thus entering the plaintiff class; and overcrowding may prevent immediate medical attention necessary to avoid suffering, death, or spread of disease. After one prisoner was assaulted in a crowded gymnasium, prison staff did not even learn of the injury until the