By Amy Goldstein and Dana Priest
Washington Post Staff Writers
Monday, May 12, 2008
FLORENCE, Ariz. -- Underneath her baggy jail-issue pants, Yong Sun Harvill feels the soft lump just below her left knee. Sometimes it tingles. Sometimes it is numb. Like her cancer felt when it arrived behind the knee a few years ago.
She noticed the lump under the thin, blue cotton in August, five months after federal immigration officers, to her amazement, took her into custody to try to deport her for buying stolen jewelry more than a decade ago. The lump grows slowly. It is now three inches across. And though she keeps asking, no one has done a test to see whether her sarcoma has come back.
Her leg is painful and swollen from hip to foot, damaged by past surgeries and radiation treatments. Some nights, liquid seeps through cracks in her distended skin. Her left ankle is three times as big as her right. For years, she relied on a leg pump to boost her circulation and keep the swelling in check. But as an immigration detainee in this desert prison town, Harvill, 52, has been unable to persuade anyone to get her a pump, or to let her family back in Florida send hers from home.
Nor has she gotten the biopsy that a doctor has told her she needs to determine whether the spots on her liver might be tumors. And it remains uncertain whether her frequent crying spells are part of bipolar disorder, as some records suggest, or a flare-up of old anxieties -- heightened now by chronic pain, bewildering medical problems, and the fact that, three decades after she arrived from South Korea as a teenage Army bride, she is in a jail far from home with the government trying to eject her from the United States.
Harvill is one of 33,000 immigration detainees in the custody of the Department of Homeland Security's Immigration and Customs Enforcement agency, known as ICE, on any given day. They are locked up in a patchwork of out-of-the-way federal detention compounds, private prisons and local jails. This unnoticed prison system was built for a quick revolving door of detainees -- into custody, out of the country. But often, people linger in detention for months or years.
These detainees, like other prisoners, are by law and regulation entitled to medical services if they are sick. But Harvill's journey through immigration detention provides a glimpse into a medical system that often fails those who need it most. It is an upside-down world where patients have no say, doctors and nurses on site have little power to administer timely treatment, and a managed-care system in Washington operates from a rulebook that emphasizes what is not covered rather than what is.
Two months after ICE agents seized Harvill in Florida, they transferred her to Arizona last May, saying a federal compound called the Florence Service Processing Center was better suited to handle her medical care. Four weeks later, they moved her, without explanation, a few miles down a cactus-lined highway to a county jail that hasn't had a full-time staff doctor since she arrived.
At Pinal County Jail, Harvill is 2,132 miles from her family outside Tampa, and even farther from her Miami lawyers. To see her, they crowd around a closed-circuit TV in an immigration courtroom in Miami, where the judge to whom her case is assigned convenes "video hearings" about once a month.
Seated at a scuffed oak table in a small courtroom in Florence for one recent hearing, facing a television screen with a video camera on top, Harvill looked older than her age. Her thick, long hair was streaked heavily with gray. Her brown eyes, sparkling in a 1999 wedding photo, were now dull. Arthritis had bent her fingertips.
On days when her hands are too stiff, Harvill dictates as other detainees write her entries in the journal that her lawyers have asked her to keep, as best she can, with the five pieces of paper the jail doles out each week. The entries tell of her leg pain, of missing her husband and her Florida cancer doctors, of wondering whether God still loves her. One entry tells of a dream in which she peered into a coffin and saw herself inside.
Her medical records, inches thick, document countless visits to jail nurses and to a public hospital in Phoenix. But many of the visits have been frustrating and unproductive.
One morning in late February, she was led from her cell at 5:15 a.m. and driven the 66 miles to the hospital to have an operation to remove polyps that were causing bleeding in her uterus. When she arrived, three workers in green scrubs told her that the doctor couldn't perform the surgery because the hospital was out of hot water.
Even with hot water, they said, she couldn't have had the procedure that day: As usual, no one at the jail had told her ahead of time that she would be having a medical appointment, so she didn't get the instructions not to eat or drink after midnight the day of surgery. When the guards woke her at 5 a.m., she ate a honey bun, a treat she had been saving from the jail canteen.
In response to questions from The Washington Post, ICE officials said last week that, "based on standard medical protocols," Harvill's records document that she has been "appropriately diagnosed and treated."
"I feel like I'm on a merry-go-round, round and round and you don't really get nothing done," Harvill said, her voice husky with just a trace of an Asian accent, during one of three interviews she gave The Post by telephone and in person, without the knowledge of federal officials. "I feel like an animal in a cage here. Sometimes I'm afraid I'm not going to wake up."
* * *
At night, to anyone driving southeast from Phoenix through the dark Sonoran Desert, the sky over Florence glows white with prison floodlights.
This county seat, once a center of copper mining and cotton, greets motorists today with road signs that say "State prison. Do not stop for hitchhikers." Every February, motorcyclists roar through town for the Hells Angels Florence Prison Run. And the first business along Butte Avenue, the main street leading into the small downtown, is E&E Outfitters, with its "UNIFORM" sign in the window and, inside, racks of guards' outfits in khaki, black and olive green. "Detention polo shirts from $28.50," says the sale sign over one circular rack.
Of the 25,500 people who live in Florence, about 17,000 are behind bars. The incarcerated included an average of more than 700 immigration detainees in fiscal 2007, divided among a federal compound, two private prisons and the county jail. An additional 1,500 were housed nearby in a compound outside the town of Eloy, giving Pinal County the largest concentration of foreign detainees in the nation.
At the town's northern edge, just beyond an RV park for retirees, rows of concertina wire surround the federal Florence Service Processing Center. During World War II, it was the site of a prison camp for Italian and German POWs. Now it is a tidy brown-brick compound with cactuses and giant crests of the Department of Homeland Security out front. This is where Harvill arrived last May after a flight from Florida, panicky, her nose bleeding, her stomach upset, an officer on each side.
The day after she arrived, Harvill saw a nurse and a doctor for a checkup that all new detainees are supposed to have, but don't always get. "Numerous issues," they wrote in her medical chart. History of sarcoma. Hepatitis C. High blood pressure. The nosebleeds. Panic attacks. "Borderline bipolar." And lymphedema, painful fluid buildup in her left leg.
Elizabeth Fleming, a lieutenant commander in the U.S. Public Health Service who was Florence's clinical director, showed concern about Harvill. She noted that Harvill needed a leg pump -- a compression device that inflates and deflates -- to help the circulation in her leg. She also requested records from Harvill's longtime cancer doctors in Tampa. And she managed to persuade administrators in Washington to let Harvill have three outside consultations at Maricopa Medical Center, the public hospital in Phoenix.
"Will likely need to order . . . pump and may require transfer to [another immigration detention center] with infirmary," the doctor wrote in her patient's chart.
The pump never arrived. Still, Fleming saw Harvill a dozen times over the next month, records show. By mid-June, the doctor wrote, her patient was "smiling, cheerful," and her nausea and leg pain were "much improved."
Harvill did not know that would be the last time Fleming would treat her. The next day, Harvill was moved down the road to the county jail. The government never explained the move, although she and her lawyers have asked repeatedly.
Last week, ICE officials told The Post: "Florence is not well equipped to provide long term medical care for female detainees. Female detainees are transferred from Florence to Pinal because of its better capability to provide long-term medical care to women. Ms. Harvill received appropriate medical care at Pinal with physician oversight."
Harvill lives in Cell 323 in Pod E300, part of a wing built for an eventual 600 detainees whom the federal government pays the county to house.
Her isolation at the county jail is almost complete. Her lawyers cannot call. Family members, if they came to visit, would not be allowed to see her in person, not even though plexiglass. The jail allows only "video visits," with visitor and detainee in separate parts of the building. Harvill, while longing for her family, has told them it is not worth the trip. She hasn't seen her husband in a year.
Most of her moments outside come when immigration officers take her in a white van on a three-minute ride to a little courtroom at the Florence federal compound for video hearings with her Miami immigration judge, and when they take her to the public hospital, an hour and 20 minutes away, where, as likely as not, little will get done.
Harvill gets shuttled back and forth to the hospital in Phoenix because the jail does not have a doctor on its staff. There is no hospital within 30 miles of Florence, despite its thousands of prisoners. The Central Arizona Medical Center, on the city's outskirts, has been closed since 1999, and the small hospital building is empty. On a white sign out front, the blue lettering that says "clinic" has almost faded away.
One morning last summer, Harvill was taken up the road to the Florence compound for a repeat session to take photographs and fingerprints that immigration officers told her had gotten lost. Before she went inside, she later put in her journal, she noticed Fleming, the doctor who had treated her when she first arrived, going by "in a little golf cart."
I was glad to see her I had so much to ask her. Nurse here says that she is still my doctor and that all that happens to me goes to her. . . . I asked to talk to her for a minute. She told me that she was very busy, that she would try to talk to me later. I knew she wouldn't talk to me because she has not seen me for the last 2 months I was so sad. . . . Actually I felt as though she was angry with me. I stood there with tears in my eyes, but I had to go with the officer to get my fingerprints done.
The fleeting encounter with Fleming disturbed Harvill. The closest thing to a doctor she has seen at the jail during her 11 months there -- apart from a psychiatrist who has prescribed lithium and other drugs, but has not really diagnosed her -- was a physician assistant.
Fleming resigned days later.
According to internal government documents, one-third of the 29 medical positions at the Pinal County Jail were vacant as of February. The jail, the Florence compound and the large compound in nearby Eloy each had no full-time doctor.
In such an environment, complaints sometimes surface about the shortages and their effects. Last summer, two Eloy nurses sent a memo to headquarters in Washington, laying out the working conditions that were leading them to resign.
The checkups required for all arriving detainees were "never staffed with enough people," wrote the nurses, Catherine Rouse and Patricia O'Brien. Nurses would be told to expect five new arrivals, "but that could easily change to greater than 100 non-English speaking sick and injured frightened people," they wrote. The nursing shortage was particularly severe on nights and weekends. And one pharmacist and an assistant "process over 4,000 prescriptions a month. They try their best to have thing[s] complete before they leave on Friday. However, serving 1,500 people is an impossible task."
Last year, the Arizona State Board of Nursing heard that nurses at Eloy were being required, without enough training, to take the chest X-rays that new detainees are supposed to get to check for tuberculosis. The board sent ICE a terse, two-sentence letter. "Nurses are not radiologists," it said. "Taking X-rays is out of the scope of practice for a nurse, and a nurse who does so is violating the Nurse Practice Act and will be subject to discipline on his/her license."
The response from Washington: "Nurses working in federal government facilities are not subject to state licensing requirements."
* * *
At first, Harvill would get excited on the mornings of her trips to Maricopa Medical Center, but she learned soon that the visits usually were disappointments.
On July 26, she rode in the van to the hospital's cancer clinic. That same day, by coincidence, a doctor from the H. Lee Moffitt Cancer Center in Tampa, where she had been treated for more than a decade, wrote a letter at the request of Harvill's lawyers, warning that she "will need continued care at a facility familiar with [her] types of tumors, as they will continue to recur and progress. If not treated properly, they can become life-threatening."
It was from the Moffitt Center that Fleming had gotten records of Harvill's three previous episodes of cancer and her treatment. But no one had sent copies to Maricopa Medical Center. Starting from scratch, a doctor there ordered a CAT scan of her pelvis and her swollen left leg. The test, according to a radiology report, found a mass in an ovary and a cyst on her cervix, but there is no indication that her leg was scanned.
By late July, her records show, another Maricopa doctor had ordered a biopsy to determine whether unexplained "densities" on her liver might be tumors. But when Harvill went for the procedure a few weeks later, the records show, someone in the radiology department did an ultrasound as a first step and, when he saw cysts on her liver, cancelled the biopsy. "Liver Biopsy report received. . . . Biopsy not done," says a notation from a few days later in her jail records.
A month later, when Harvill saw the doctor who had ordered the biopsy, he asked whether it had been done.
I told him no because they told me it was just a cyst not a tumor. He was upset. . . . He still wanted a biopsy, she wrote in her journal.
By now, the soft lump had begun to grow under her knee, and her abdomen had started to swell and become hard. As an officer drove her to the hospital one day in mid-August, she hoped the appointment would address one of those problems. As it turned out, she was there to see a gynecologist, who wanted to do a Pap smear.
Harvill pointed out that she'd had one a month before.
I showed him my stomache, he told me he could not take care of that, that I needed to see a GI doctor. I told him about my leg swollen, and also he told me I had to see another doctor for that.
Still another runaround began when a different doctor said Harvill urgently needed a biopsy of her uterus lining to find out why, well after menopause, she was bleeding heavily. In early October, when an immigration officer took her back to the hospital for that test, a receptionist said it had been canceled and rescheduled for a month later. The officer, Harvill put in her journal, was stunned and told the receptionist that he "had the order for today." Instead, hospital workers did a CAT scan of her uterus.
She had already had a CAT scan of her uterus. I told them I had a lump on my knee, if they could do a scan on that and they said they didn't have an order for that. . . . We got out of hospital and the ICE officer said he felt bad for me, because he has taken me to the hospital 4 or 5 times and they never do anything for me.
It was early November when Harvill had the biopsy of her uterus, three months after it was ordered. She was told to come back for the results in two weeks, although the lab report was ready the next day, according to her medical records. Yet it wasn't until late January that she learned what was wrong: The bleeding was being caused by polyps that needed to be removed. The surgery, she was told, would be within two or three weeks. Four months later, it has not been done.
Late last week, after her attorneys gave them authorization to talk about her case, Maricopa hospital officials said that medical privacy law prohibited them from even confirming, without Harvill's personal consent, that she has been a patient. But she could not give consent because neither her attorneys nor anyone else is allowed to telephone her in the jail.
Over a weekend in mid-April, Harvill was told not to eat solid food for two days in preparation for a colonoscopy to try to find out why she had blood in her stool. First thing that Monday, she again boarded the van for the 66-mile drive to the hospital, where she was told that the procedure had been rescheduled.
Ten days later, she went to the hospital and had the test. It found a growth in her colon. The doctor said there was a chance it is cancerous and sent a sample for a biopsy. She does not know the result.
The liver biopsy still has not taken place. And no one has tested the lump below her knee.
* * *
Whether the gaps in Harvill's treatment are by accident or by design is difficult to discern. Yet it is clear that the obscure federal agency that oversees detainees' medical care, the Division of Immigration Health Services (DIHS), operates with a top priority of limiting care and saving money. Its medical mission is only to keep people healthy enough to be deported.
At Harvill's jail, and everywhere else immigration detainees are held, doctors and nurses must get permission from the agency's headquarters before treating patients. Except in emergencies or for the most routine care, they must send written requests to Washington, where, for the entire system of 33,000 detainees across the country, four managed-care nurses in a downtown office building decide what treatments to allow.
These care managers rule on what are known in the bureaucratic lexicon as treatment authorization requests, or TARs. In a recent month, they had to rule on 3,000 requests. They work five days a week, not on weekends, and are unavailable to handle requests that come in later than 4 p.m. Washington time, even though many large detention centers are in other time zones.
The agency touts this as an efficient form of managed care, similar to health plans familiar to patients in the outside world. But a 36-page manual that describes the "detainee covered services package" underscores how unusual it is, with rules designed to prevent people from getting too much help.
The health services division, the manual says, allows treatment mainly for emergencies that are "threatening to life, limb, hearing or sight." If a detainee has medical problems that "would cause deterioration of the detainee's health or uncontrolled suffering affecting his/her deportation status," treatment is not guaranteed. Instead, the manual says, the detainee "will be assessed and evaluated for care."
Instead of listing, as most health plans do, the services available to patients, the manual specifies services that are "usually not covered" for allergies, heart problems and other illnesses. Cancer is not mentioned at all.
Internal government documents obtained by The Post show that most requests are approved. But the documents also show that, when requests come in for people with serious problems, there can be pressure to cut costs. One chart, covering October 2005 to September 2006 -- seven months before Harvill became an immigration detainee -- is labeled "TAR Cost Savings Based on Denials."
The agency, the chart shows, saved $129,713 by denying 17 medical requests for people with HIV, $36,216 by denying seven requests for people with various forms of psychosis, $91,926 by denying 27 requests for people with chest pain and $9,545 by denying treatment for a case of blood in stool, one of the problems Harvill has had for months.
Asked about the chart, an immigration spokeswoman said that the vast majority of medical requests eventually are granted. Usually, she said, denials are "due to lack of information."
The supervisor of the managed-care nurses who rule on treatment requests sent a note once to a senior official about a 33-year-old detainee seen at a Nashville hospital for a recurrence of sarcoma, the same kind of cancer Harvill has had. "The process of re-diagnosis and treatment will be extensive and costly," that nurse wrote. She said she seconded the idea of releasing the detainee so the government would not have to pay for his care.
These sorts of machinations prompted the deputy warden at York County Prison in Pennsylvania, which houses many immigrant detainees, to fire off an angry letter about the health services division. "[I]n my opinion, they have set up an elaborate system that is primarily interested in delaying and/or denying medical care to detainees," the warden, Roger Thomas, wrote in late 2005. "There is nothing easy about working with DIHS. If something can be delayed, it is delayed. If it can be denied, it is denied. If it can be difficult, it is made difficult. Most importantly, if there is some bureaucratic procedure that will delay/deny treatment to a detainee . . . you can be assured that DIHS will do it."
Harvill's lawyers have tried to find out how many requests for treatment have been sent from Pinal County Jail on her behalf and how Washington has ruled on each one. They filed a Freedom of Information Act request last summer and, after two months, got an incomplete answer. In January, they left a phone message for the division's medical director. No one has called back.
But one page in Harvill's thick medical file hints at an answer. In late August, slightly more than a month before she would arrive at the hospital for a biopsy, only to be told it had been rescheduled, a jail nurse wrote this note: "TARs not approved for endometrial biopsy and lab draws. . . . Will continue to work on approvals and provide additional documentation as needed."
Finally, in early February, Harvill had a big week, riding in the van to the hospital three mornings in a row. A cancer doctor told her, yet again, that she needed a biopsy on her liver and one on the growing lump beneath her knee. A gynecologist talked with her about the surgery she needs on her uterus. A gastroenterologist spoke with her about the colonoscopy she should have.
Yet, after many months in immigration custody, Harvill understood that doctors' orders do not automatically produce tests. "It doesn't matter what the doctor says," she said in an interview.
Back at the jail after her three hospital trips, she asked a nurse what would be done with the doctors' requests. "She said she is going to send it up" to Washington, Harvill recounted at her next court hearing. "But she doesn't know when or how it is going to get approved. She doesn't know if it is going to get approved. She just said, 'Let's hope for the best.' "
* * *
Leon Harvill sat at his mother's kitchen table in Plant City, Fla., on a Sunday night, cradling the phone to his ear. "Baby, don't cry," he said softly into the receiver. "Come on, baby. Quit crying, all right?"
He had gone to an evening service at the Church on the Rock, the first time he had been in months. He hadn't felt much like reading the Bible lately. "I just don't understand it right now," he said. "I just can't understand things that are going on that are hard to believe. Her medical care -- I just can't understand that."
The thing that makes perhaps the least sense to him is that his wife is covered under a good health insurance policy that he gets through his union, the International Brotherhood of Boilermakers, and she and her lawyers have asked whether she could use that policy to pay for her treatment by private doctors while she is detained. They have been told no.
One more problem in a life full of them.
Yong Sun Harvill's immigration troubles began in March 2007, as she was finishing 13 months in prison on a drug-possession charge. One day, a prison official summoned her to his office and handed her a phone. On the line was a man who worked in Orlando for Immigration and Customs Enforcement. She would not be going home, he told her. She would be handed over to ICE agents, who planned to send her back to South Korea, a place she had not seen for 32 years.
Harvill had been barely 19 when she came to the United States in 1975, the new wife of an American soldier who had been stationed in Seoul. Within a year, she had a baby son and her first cancer diagnosis.
She divorced her first husband -- who hit her sometimes when he drank, according to Harvill, her lawyers, two friends and her medical records -- and then her second one, who hit her sometimes when he was high on drugs.
Nine years ago, she married Leon Harvill, a childhood friend of her second husband. He isn't much of a talker. She is loud and chatty. She felt protected by him. He loved how she cared for children and how her smile lighted up a room.
After all her years in Florida, she would still drive to Tampa once a month to buy rice at a Korean grocery, but she also loved collard greens and black-eyed peas, was a die-hard Tampa Bay Buccaneers fan, and knew the lyrics to all of Brooks & Dunn's country tunes.
In 2004, while she was riding with a friend, police stopped them for driving with expired tags. The car belonged to her friend, but the marijuana and methamphetamine on the floor were Harvill's.
She pleaded guilty to drug possession and served her time. Ordinarily, that would have been that. But ICE had begun scouring jails and prisons nationwide for people it might be able to deport, and a check of Harvill's criminal history turned up a decade-old felony conviction for buying stolen jewelry. Her lawyer insisted she'd had no idea it was stolen. A judge suspended the sentence and put her on probation, which was terminated early for good behavior.
A 1996 law had given the government new leverage to deport foreigners, including people living in the country legally as U.S. residents, if they had committed a crime at any time in the past, and the Bush administration was wielding that power aggressively. The law expanded the list of crimes defined as "aggravated felonies" that are grounds for deportation. It also for the first time required people to be locked up during their deportation cases -- including permanent legal residents such as Harvill, who is not a citizen but has had a green card ever since she came to the United States.
On March 22, 2007, instead of going home, Harvill was handed an orange uniform at the Palm Beach County jail to await deportation. Her parents are dead. She lost track of her sisters long ago. She has no idea where or how she would live in South Korea, particularly because she has not held a job for years because she cannot put weight on her leg for too long.
She has been fighting the deportation with the help of Cheryl Little and Kelleen Corrigan, lawyers at the Florida Immigrant Advocacy Center in Miami. They have applied for a visa available to foreigners with firsthand knowledge of crimes -- in Harvill's case, the abuse by her first two husbands. Meanwhile, they have repeatedly asked federal officials to let Harvill go home on bond because she is so ill.
Corrigan has a postcard on her office door with the words "Free Yong!" over a photo of a younger, happier-looking Harvill.
At church that Sunday night, Leon Harvill did not open the prayer book. But during the silent prayer, he leaned forward, his hands resting on the pew in front of him, and closed his eyes. He prayed for his wife to get medical treatment, to find peace, to come back.
He raced home after church, knowing she would call.
At 9:14 p.m. the kitchen phone rang. "I love you, too, baby," her husband said. "Things are going to get better. Come on, baby. Something is going to happen soon."
Before dawn the next morning, he would leave the house of his mother, Margaret Kersey, with whom he had been staying to save money, for the Tampa airport and a flight to Hawaii, where he had found a welding job with better pay. It had been hard lately to save, with work scarce in central Florida and money flowing out for his wife's phone cards and canteen treats, and for the "Free Yong!" postcards he'd printed so friends could mail them to the government. Most of all, he thought, he needed to save money so he would have some to send her if someday she were deported to South Korea.
Deportation had been on Yong Sun Harvill's mind, too. Sometimes, she is so depressed that she thinks about quitting her fight and signing the papers that would let the government send her out of the country. And she has been missing the one real friend she made in a jail, a younger Korean woman who would rub menthol ointment, when she could get some, on Harvill's swollen leg and write the journal entries when Harvill's hands stiffened too much.
A few weeks before this January night, her friend was deported.
But on this night, Harvill listened to her husband describe the path he would take to Hawaii the next day. "I have a layover in Phoenix," Leon Harvill said into the phone.
She told him to look at the desert as he landed.
"I'll get a look at it tomorrow," he told her. "We'll be that close."
Staff researcher Julie Tate contributed to this report.