Systemic indifference: Dangerous & substandard medical care in US immigration detention

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On April 6, 2015, Raul Ernesto Morales-Ramos, a 44-year-old citizen of El Salvador, died at Palmdale Regional Medical Center in Palmdale, California, of organ failure, with signs of widespread cancer. He had entered immigration custody four years earlier in March 2011. He was first detained at Theo Lacy Facility, operated by the Orange County Sheriff’s Department, and then at Adelanto Detention Facility, operated by the private company Geo Group, both of which had contracts with US Immigration and Customs Enforcement (“ICE”) to hold non-citizens for immigration purposes.

An ICE investigation into the death of Morales-Ramos found that the medical care he received at both facilities failed to meet applicable standards of care in numerous ways. Two independent medical experts, analyzing ICE’s investigation for Human Rights Watch, agreed that he likely suffered from symptoms of cancer starting in 2013, but that the symptoms essentially went unaddressed for two years, until a month before he died.

Throughout this time, Morales-Ramos repeatedly begged for care. In February 2015, he submitted a grievance in which he wrote, “To who receives this. I am letting you know that I am very sick and they don’t want to care for me. The nurse only gave me ibuprofen and that only alleviates me for a few hours. Let me know if you can help me.” At the time of ICE’s report on its investigation, the final cause of death had not yet been determined, but as detailed below, the facts revealed in the ICE investigation show that systemic indifference to his suffering and systemic failures in the healthcare system spurred his death.

The number of people held in immigration detention in the United States has grown significantly over the past decade. It hit a record high under President Obama, over 400,000 people per year, and is likely to grow even higher under President Trump, who soon after his inauguration signed executive orders calling for increased detention, both through changes in detention policy and increased construction of or contracts for detention centers along the US-Mexico border. Trump’s enforcement priorities, which now encompass people who have no criminal convictions but have committed a “chargeable offense,” are also likely to lead to a substantial increase in the number of people detained.

Medical care in the US immigration detention system, and the poor system of oversight that allows substandard care, has long been the target of criticism by investigative journalists and human rights advocates. This is the third report Human Rights Watch has released on medical care in immigration detention since 2007, and one among many reports by civil and human rights organizations on conditions in such facilities nationwide.

Gaining access to immigration detention facilities is difficult and information on conditions there is hard to obtain. ICE took an important, if limited, step forward in June 2016 when it publicly released detailed reports of its investigations into 18 deaths in custody (death reports) that occurred in such facilities between May 2012 and June 2015. (A total of 21 people died in US immigration detention during that period.) To better assess the evidence and gain insight into health care practices and responses to serious illnesses in immigration detention facilities, Human Rights Watch and Community Initiatives for Visiting Immigrants in Confinement (CIVIC) asked independent medical experts to analyze the recently released reports. We also asked experts to review the medical records of a dozen other individuals, none of whom died in custody, recently held in 10 different facilities across the country.

As detailed here, the experts identified repeated, clear-cut instances of subpar medical care, including inadequate care that contributed to seven deaths in detention. They also found numerous examples of systemic substandard and dangerous medical practices in other cases—such as overreliance on unqualified medical staff, delays in emergency responses, and requests for care unreasonably delayed. The cases examined represent a small but not necessarily representative sample—though many of them point to much larger, systemic failures of healthcare provision and government oversight that have likely put many more thousands of other detained individuals at risk.

Manuel Cota-Domingo, detained at Eloy Detention Center, died of untreated diabetes and pneumonia after numerous delays, including a policy that placed restrictions on which staff could call 911, resulted in eight hours passing between the moment he started to have trouble breathing and his arrival at an emergency room. Tiombe Carlos died by suicide in York County Prison after being detained for two-and-a-half years. The mental health care she received was deemed “woefully inadequate” by an independent expert. Santiago Sierra-Sanchez, detained at Utah County Jail, died of a staph infection and pneumonia. A correctional health expert said of the care he received, “Medical staff essentially abandoned this patient by not properly assessing him or following up.”

Medical experts identified numerous and significant delays in the care “Jose L.” received while detained at Adelanto Detention Facility for three years, including a failure to act quickly to address vision problems that likely led to him becoming legally blind in his right eye. “Carlos H.” tore his ligament while detained at Yuba County Jail in California, but it was not properly diagnosed for three months because he kept seeing licensed vocational nurses who did not refer him to a doctor, and then ICE further delayed his scheduled surgery repeatedly without providing any clinical reason. “Luke R.,” detained at Orange County Jail in New York, had been diagnosed previously with schizophrenia. The facility not only failed to provide adequate mental health care—at one point changing a prescription for an anti-hallucinogen to Benadryl, an anti-histamine—it also disciplined Luke and put him into solitary confinement for actions that were clearly related to his mental health condition.

As noted above, these are not new problems. ICE has been receiving reports of such substandard medical care for years but has failed to take meaningful action. The Obama administration implemented several new programs meant to improve oversight, but these monitoring procedures remain inadequate, and the Trump administration has already announced plans to reverse many of these reforms, including not including the most recent detention standards for contracts with county jails. The Government Accountability Office has faulted ICE for its failure to track and analyze its oversight mechanisms and grievances from detained immigrants. ICE’s response to Human Rights Watch’s requests under the Freedom of Information Act have been uninformative and in some cases appear to indicate that the agency lacks important baseline information about the provision of healthcare services to people in its custody.

Most disturbingly, there is significant evidence that ICE does know about many of the deficiencies in its medical care system, but that it has failed to take swift and appropriate action. Its own investigations into deaths in detention have shown that it lacks the procedures necessary to take appropriate and timely corrective action. For example, Eloy Detention Center (EDC), run by the private company CoreCivic/CCA[1], has seen 15 deaths in detention since 2003, more than any other detention facility in the US. The ICE death report for Jose de Jesus Deniz-Sahagun, who died by suicide in 2015, flagged the lack of a suicide prevention plan at the facility “despite Deniz Sahagun’s suicide being the third at EDC since April 2013 and the fifth since 2005.”

Annual reports by the Office of Civil Rights and Civil Liberties at the Department of Homeland Security make clear that recommendations stemming from allegations of abusive conditions in detention facilities are regularly sent to ICE, but ICE often does not respond for years or responds in ways that are deemed completely inadequate to CRCL. In its 2015 report to Congress, CRCL states it sent ICE 49 recommendations regarding an unnamed facility in Arizona that mentions the number of suicides in recent years, making clear it is Eloy Detention Center. It took ICE two years to respond to these recommendations, concurring in 19, but CRCL stated it “[d]oes not believe that ICE responded appropriately to the other 30 recommendations.”

Over two-thirds of individuals in immigration detention are held in facilities operated by private prison companies, and these facilities in recent years have come under particular scrutiny by advocates, investigative journalists, and government bodies. The Bureau of Prisons (BOP), the federal prison system, also has private prisons run by the same companies.

In August 2016, a report by the Office of Inspector General at the Department of Justice found, “[I]n most key areas, contract prisons incurred more safety and security incidents per capita than comparable BOP institutions and that the BOP needs to improve how it monitors contract prisons in several areas.” Soon afterward, the Department of Justice announced it would phase-out the use of private prisons in its own federal prison system, “to ensure consistency in safety, security and rehabilitation services.” The US Department of Homeland Security then announced it would review its own use of private facilities.

The report of the Homeland Security Advisory Council, summarizing the results of the review, stated private detention would continue, but in the report’s release, the council voted 17-5 to support one member’s dissenting recommendation of a “measured but deliberate shift away from the private prison model.” At the same time, in October 2016, the Department of Homeland Security decided to reopen Cibola County Correctional Center, a private prison the Department of Justice had closed after a history of numerous citations for deficiencies in medical care, including deaths after inadequate medical care.

President Trump’s administration has since reversed the DOJ decision to phase-out the use of private prisons.

In researching this report, Human Rights Watch found significant problems with medical care in facilities operated by private companies, but it also found evidence of subpar care in county jails that contract to hold immigrants for Immigration and Customs Enforcement. It should be noted that in many privately-operated facilities, the medical care is provided by ICE’s Immigrant Health Service Corps (“IHSC”) and not by the private company. Although private facility staff and policy can affect the provision of medical care in IHSC-staffed facilities, including in responses to emergencies, the lack of appropriate medical care in public and private facilities, as well as those staffed by IHSC, underscore that problems with medical care are systemic.

The problem of poor medical care in immigration detention cannot be separated from the enormous and unwieldy nature of the system itself. At present, the US immigration detention system holds an average of 41,000 people on any given day. It holds asylum seekers and long-term residents of the US, including those with lawful permanent resident status. It holds men, women, and children, sometimes for days, and sometimes for months or years. Most are detained without an individualized hearing as to whether their detention is truly necessary.

The United States could meet its legitimate goals of ensuring appearance at removal hearings, protecting public safety, and effectuating removal by releasing many of the people who are currently detained and supervising them through community-based programs that provide case support. Several studies have shown such programs would be considerably less costly. A smaller detention system would also be more in keeping with international human rights principles. The United Nations Working Group on Arbitrary Detention has stated: “If there has to be administrative detention, the principle of proportionality requires it to be a last resort.”

The Trump administration, however, has signaled it will rapidly expand the use of detention. The challenges of adequately monitoring and holding accountable a diffuse and disparate system with numerous operators, including those with a strong incentive to reduce costs, will only be exacerbated in a system that rapidly expands.

The executive branch does not have unfettered power to expand the system: Congress must allocate the funding and thus is in a position to push back and insist on reforms, including increased use of alternatives to detention and measures to ensure effective oversight and adequate provision of health care for those who are detained.

Because ICE relies on contracts with many local governments for detention space, states also have a role to play in improving medical care and detention conditions more generally. In California, which detains more immigrants than any state except Texas, a bill is pending that could improve conditions. At the time of writing, Senate Bill 29, Dignity Not Detention, would end localities’ contracts with private companies to hold immigrants in detention; require localities that hold immigrants in detention for the federal government to adhere to the most recent Performance-Based National Detention Standards; and make these standards enforceable by the California Attorney General and local district and city attorneys. An earlier version of this bill passed the California legislature in 2016 but was vetoed by Governor Jerry Brown, who cited the then-pending review of private facilities by the US Department of Homeland Security.

Under the US Constitution and international law, anyone who is detained or incarcerated is entitled to adequate medical care. The Trump administration is obligated to ensure that all people in detention are treated humanely and with dignity, including through provision of appropriate medical care, and to provide sufficient funding to meet these obligations. Congress and state governments should work to limit the scope of detention to what is truly necessary and ensure that those who are detained are treated humanely.

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