System of Neglect
As Tighter Immigration Policies Strain Federal Agencies, The Detainees in Their Care Often Pay a Heavy Cost
by Dana Priest and Amy Goldstein | Washington Post Staff Writers
Page A1; May 11, 2008
Near midnight on a California spring night, armed guards escorted Yusif Osman into an immigration prison ringed by concertina wire at the end of a winding, isolated road.
During the intake screening, a part-time nurse began a computerized medical file on Osman, a routine procedure for any person entering the vast prison network the government has built for foreign detainees across the country. But the nurse pushed a button and mistakenly closed file #077-987-986 and marked it "completed" -- even though it had no medical information in it.
Three months later, at 2 in the morning on June 27, 2006, the native of Ghana collapsed in Cell 206 at the Otay Mesa immigrant detention center outside San Diego. His cellmate hit the intercom button, yelling to guards that Osman was on the floor suffering from chest pains. A guard peered through the window into the dim cell and saw the detainee on the ground, but did not go in. Instead, he called a clinic nurse to find out whether Osman had any medical problems.
When the nurse opened the file and found it blank, she decided there was no emergency and said Osman needed to fill out a sick call request. The guard went on a lunch break.
The cellmate yelled again. Another guard came by, looked in and called the nurse. This time she wanted Osman brought to the clinic. Forty minutes passed before guards brought a wheelchair to his cell. By then it was too late: Osman was barely alive when paramedics reached him. He soon died.
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His body, clothed only in dark pants and socks, was left on a breezeway for two hours, an airway tube sticking out of his mouth. Osman was 34.
The next day, an autopsy determined that he had died because his heart had suddenly stopped, confidential medical records show. Two physicians who reviewed his case for The Washington Post said he might have lived had he received timely treatment, perhaps as basic as an aspirin.
Privately, Otay Mesa's medical staff also knew his care was deficient. On Page 3 of an internal review of his death is this question:
Did patient receive appropriate and adequate health care consistent with community standards during his/her detention ...?
Otay Mesa's medical director, Esther Hui, checked "No."
Osman's death is a single tragedy in a larger story of life, death and often shabby medical care within an unseen network of special prisons for foreign detainees across the country. Some 33,000 people are crammed into these overcrowded compounds on a given day, waiting to be deported or for a judge to let them stay here.
The medical neglect they endure is part of the hidden human cost of increasingly strict policies in the post-Sept. 11 United States and a lack of preparation for the impact of those policies. The detainees have less access to lawyers than convicted murderers in maximum-security prisons and some have fewer comforts than al-Qaeda terrorism suspects held at Guantanamo Bay, Cuba.
But they are not terrorists. Most are working-class men and women or indigent laborers who made mistakes that seem to pose no threat to national security: a Salvadoran who bought drugs in his 20th year of poverty in Los Angeles; a U.S. legal U.S. resident from Mexico who took $50 for driving two undocumented day laborers into a border city. Or they are waiting for political asylum from danger in their own countries: a Somali without a valid visa trying to prove she would be killed had she remained in her village; a journalist who fled Congo out of fear for his life, worked as a limousine driver and fathered six American children, but never was able to get the asylum he sought.
The most vulnerable detainees, the physically sick and the mentally ill, are sometimes denied the proper treatment to which they are entitled by law and regulation. They are locked in a world of slow care, poor care and no care, with panic and coverups among employees watching it happen, according to a Post investigation.
The investigation found a hidden world of flawed medical judgments, faulty administrative practices, neglectful guards, ill-trained technicians, sloppy record-keeping, lost medical files and dangerous staff shortages. It is also a world increasingly run by high-priced private contractors. There is evidence that infectious diseases, including tuberculosis and chicken pox, are spreading inside the centers.
Federal officials who oversee immigration detention said last week that they are "committed to ensuring the safety and well-being" of everyone in their custody.
Some 83 detainees have died in, or soon after, custody during the past five years. The deaths are the loudest alarms about a system teetering on collapse. Actions taken -- or not taken -- by medical staff members may have contributed to 30 of those deaths, according to confidential internal reviews and the opinions of medical experts who reviewed some death files for The Post.
According to an analysis by The Post, most of the people who died were young. Thirty-two of the detainees were younger than 40, and only six were 70 or older. The deaths took place at dozens of sites across the country. The most at one location was six at the San Pedro compound near Los Angeles.
Immigration officials told congressional staffers in October that the facility at San Pedro was closed to renovate the fire-suppression system and replace the hot-water boiler. But internal documents and interviews reveal unsafe conditions that forced the agency to relocate all 404 detainees that month. An audit found 53 incidents of medication errors. A riot in August pushed federal officials to decrease the dangerously high number of detainees, many of them difficult mental health cases, and caused many health workers to quit. Finally, the facility lost its accreditation.
The full dimensions of the massive crisis in detainee medical care are revealed in thousands of pages of government documents obtained by The Post. They include autopsy and medical records, investigative reports, notes, internal e-mails, and memorandums. These documents, along with interviews with current and former immigration medical officials and staff members, illuminate the underside of the hasty governmental reorganization that took place in response to the attacks of Sept. 11, 2001.
The terrorist strikes catapulted immigration to a national security concern for the first time since World War II, when 120,000 Japanese residents and their American relatives were locked away in desolate internment camps.
After Sept. 11, the Bush administration transferred responsibility for border security and deportation to the new Department of Homeland Security, which gave it to Immigration and Customs Enforcement (ICE) -- a reconfiguration of the decades-old Immigration and Naturalization Service -- in 2003, the year the Post used as the starting point for counting detainee deaths. Each year since, the number of detainees picked up for deportation or waiting behind bars for political asylum has skyrocketed, increasing by 65 percent since July 2005.
Government professionals provide health care at 23 facilities, which house roughly half of the 33,000 detainees. Seven of those sites are owned by private prison companies. Last year, the government also housed detainees in 279 local and county jails. To handle the influx of detainees, ICE added 6,300 beds in 2006 and an additional 4,200 since then. They too are nearly full.
These way stations between life in and outside the United States are mostly out of sight: in deserts and industrial warehouse districts, in sequestered valleys next to other prisons, or near noisy airports. Some compounds never allow detainees outdoor recreation; others let them out onto tiny dirt patches once or twice a week.
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, Immigration and Customs Enforcement 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."
By their calculations, officials said, the mortality rate among detainees has declined since 2004 to a level that is lower than that in U.S. jails and prisons. The deaths, the statement said, "highlight the tremendous responsibility and potential liability the government faces in providing medical care to a population that often did not have access to adequate health care before coming into our custody."
To this end, the agency recently increased its inspections of facilities and is creating an inspection group at headquarters to review serious incidents, including deaths or allegations that standards are not being met.
ICE declined to comment on specific cases, citing internal policies on patient privacy or pending litigation.
Key terms and acronyms from the Careless Detention series.
Read the original government documents related to the people and cases detailed in this story.
Based on confidential medical records and other sources, The Washington Post identified 83 deaths of immigration detainees between March 2003, when the federal Immigration and Customs Enforcement agency was created, and March 2008.