System of Neglect

Detainees are not guaranteed free legal representation, and only about one in 10 has an attorney. When lawyers get involved, they often have difficulty prying medical information out of the bureaucracy -- or even finding clients, who are routinely moved without notice.

The burden of health care for this crush of human lives falls on an obscure federal agency that lacks the political clout and bureaucratic rigor to do its job well. The Division of Immigration Health Services (DIHS), housed in a private office building at 13th and L streets NW, several blocks from ICE headquarters, had a budget last year of $61 million. ICE spent an additional $28 million last year on outside medical care for detainees.

Medical spending has not kept pace with the growth in population. Since 2001, the number of detainees over the course of each year has more than tripled, to 311,000, according to ICE and the Government Accountability Office. Meanwhile, spending for the DIHS and outside care has not quite doubled, ICE figures show. ICE's conflicting population and budget numbers make the trends difficult to determine.

The agency is responsible for managing and monitoring detainee medical care, about half of which is provided by U.S. Public Health Service professionals and the rest by contracted medical staff. When doctors and nurses at the immigration compounds believe that detainees need more than the most basic treatment, they have to fax a request to the Washington office, where four nurses, working 9 to 4, East Coast time, five days a week, make the decisions.

A proud Statue of Liberty replica stands just beyond the glass doors of DIHS headquarters to remind visitors of the Public Health Service's historical role in screening and treating European immigrants arriving at Ellis Island at the turn of the last century. Its new role is to keep detained immigrants healthy enough to be deported.

The mission is accompanied at times by a sense of panic and complicity. Many documents obtained by The Post make clear that the people in charge know that the system is in trouble and that piecemeal fixes are not enough.

"The onus is on us if it hits the fan," one official complained during a high-level headquarters meeting about staff shortages late last summer, according to records of the conversation. "We're going to be responsible if something happens, because it's well documented that we know there's a problem, that the problem is severe."

"We are putting ourselves and our patients at risk," another official said.

Doctors express concerns about violating medical ethics and fear lawsuits. In July, Esther Hui at Otay Mesa sent a memo to DIHS medical director Timothy T. Shack, saying her colleagues were worried that they might be sued because of the substandard care they were giving detainees. The agency's mission of "keeping the detainee medically ready for deportation" often conflicts with the standards of care in the wider medical community, Hui wrote. "I know in my gut that I am exposing myself to the US legal standard of care argument. . . . Do we need to get personal liability insurance?"

Nurses who work on the front lines see the problems up close. "Dogs get better care in the dog pound," said Catherine Rouse, a contract nurse at an Arizona detention center who quit after two months last year because she saw what she regarded as "scary medicine" in the prison: patients taken off medications they needed and nurses doing tasks they were not qualified to do. "You don't treat people like that. There has to be some kind of moral fiber," Rouse said.

In a statement responding to questions raised by The Post, ICE officials pointed out that the federal government spent nearly $100 million in fiscal 2007 on medical care for immigration detainees. About one in four immigrants in the detainee population has a chronic health condition, the statement said.

"Among ICE's highest priorities is to ensure safe, humane conditions of confinement for those in our custody," the statement said. "We make every effort to enforce all existing standards and, whenever possible, to improve upon them. When we find standards that are not being met, we take immediate action to correct deficiencies and when we believe that the deficiencies cannot be corrected, we relocate our detainees to other facilities."