After some time, the medical staff began to force-feed John Otieno.* “They put me on a bed and handcuffed me to an emergency medical stretcher,” he said. “[They] strap you on the chest, waist, legs, [with] hard restraints … there is no point in fighting back because you are there with six male, strong officers, and three nurses, and there is nothing you can do.” The doctor claimed to have a judicial order but declined to show it to him. Mr. Otieno saw two other hunger strikers who were also force-fed.* Pseudonym
Mr. Otieno, an asylum seeker from East Africa, is one of the many people in U.S. Immigration and Customs Enforcement (ICE) detention who began a hunger strike to protest poor conditions and seek release during the COVID-19 pandemic. Rather than listen to his pleas, ICE retaliated by locking him in a freezing cold room, force-feeding him through a nasogastric tube against his will, and transferring him to three different facilities. Only after subjecting him to all of this did ICE finally release him from detention in late 2020. Mr. Otieno, who lost 28 pounds and now takes medication for post-traumatic stress disorder (PTSD) and depression, described it as “an experience that I wouldn’t wish on my worst enemy.”
The decision to begin a hunger strike in immigration detention is not taken lightly. A detained person’s refusal to eat may be the last option available to voice complaint, after all other methods of petition have failed. Detained and imprisoned people worldwide have engaged in hunger strikes to plead for humane conditions of confinement or release from captivity and to bring attention to broader calls for justice.
Each day, the United States government unnecessarily locks up thousands of people in civil immigration detention, including children, in over two hundred immigration detention centers around the country. 
People may be locked up for many months — even years — as they await final adjudication of their cases or deportation. Trapped in a system marked by mistreatment and abuse, medical neglect, and the denial of due process, hundreds of people in immigration detention engage in hunger strikes as a means of protest each year. ICE’s failure to provide safe and humane conditions in detention during the COVID-19 pandemic has only raised the stakes for detained people. Although some detained people, on occasion, are able to bring outside attention to their hunger strikes, very little is known of ICE’s systemic response to hunger striking detainees.
This report provides for the first time an in-depth, nationwide examination of what happens to people who engage in hunger strikes while detained by ICE.
The report and its findings are based on an assessment of over 10,000 pages of documents…[relating to] hunger strikes by at least 1,378 people from 74 countries across 62 immigration detention centers in 24 states.
Data and Methods
The report and its findings are based on an assessment of over 10,000 pages of documents, including emails, case records, procedural directives, and court filings obtained under the Freedom of Information Act (FOIA), related to hundreds of hunger strikes in ICE detention from 2013 to 2017, spanning both the Obama and Trump administrations. These include hunger strikes by at least 1,378 people from 74 countries across 62 immigration detention centers in 24 states. The report is also based on a review of ICE’s current policies on hunger strikes in detention and on interviews with six formerly detained people who engaged in hunger strikes.
Force-Feeding and Other Involuntary Medical Procedures: ICE’s Dangerous and Unethical Approach to Hunger Strikes
The released records reveal that ICE has chosen to employ involuntary medical procedures on detained hunger strikers that violate ethical guidelines for medical personnel, including force-feeding, forced hydration, forced urinary catherization, involuntary blood draws, and use of restraints. These records confirm that ICE began seeking, obtaining, and executing orders for involuntary treatment years earlier than was previously known. The documents reveal a previously unknown force-feeding case from 2016 and government motions for involuntary medical procedures as early as 2012.
Force-feeding and forced hydration are medical procedures where food, nutrients, or fluids are administered to those in detention against their will via several invasive and painful procedures. These invasive procedures include:
- Force-feeding via nasogastric (NG) tube: a plastic tube is inserted through one of the nostrils and advanced through the back of the throat and the esophagus to the stomach. This can be a very painful procedure that causes gagging, skin and tissue irritation, and in rare cases, perforation of vital organs. The tube can also be misdirected and advanced into the airways instead of the esophagus, potentially causing serious infections. When officials insert an NG tube against a person’s will, they typically must forcibly restrain the individual by staff or via mechanical restraints.
- Forced hydration: intravenous and PICC (peripherally inserted central catheter) lines are the most common means of providing hydration and parenteral nutrition. In both procedures, soft tubes are inserted into a vein in the arm, leg, or neck via needles. The procedures can cause local pain and bleeding, can cause damage to blood vessels, and increase risk of infections and other complications.
- Forced urinary catheterization: a tube is inserted into the urethra (the orifice through which urine travels out of the body). When cooperation or consent is not obtained, physical or chemical restraints have been used. Regardless of where a catheter is inserted, the risks include local injuries, pain, bleeding, infection, and damage to surrounding structures, including vital organs.
Involuntary medical procedures like force-feeding have been condemned by the American Medical Association as a violation of the “core ethical values of the medical profession” and described as cruel, inhuman, or degrading treatment or even torture by international human rights bodies and observers. As ethical guidelines for medical professionals have long recognized, participation in a hunger strike is not a medical condition, but rather, a political decision by the hunger striker, and people contemplating or undertaking a hunger strike are entitled to a relationship of trust with the health professionals providing their care.
In some instances, ICE used private prison medical staff to force-feed hunger strikers within a detention facility after nearby medical facilities refused to do so. In one instance at the Aurora Detention Center in Colorado, ICE officials could not find any local hospital staff who would agree to force-feed a hunger striker, due to ethical prohibitions. ICE officials finally turned to medical officers employed by the GEO Group, Inc., the private prison company that operated the detention facility, who offered to force- feed the hunger striker.
As noted in several court proceedings, ICE failed to consider alternatives to force-feeding, including resolving hunger strikers’ basic requests for improved conditions. In some cases, government attorneys sought—and received—force-feeding orders based on minimal evidence, sometimes without any specific detail or reference to the individual they sought to force-feed. Detained hunger strikers faced overwhelming challenges in defending themselves against force-feeding orders by ICE. In almost every instance we analyzed, detained hunger strikers lacked legal representation to defend themselves against the government’s pursuit of force-feeding orders.
ICE’s treatment of hunger strikers endangers lives. Since 2017, at least three former hunger strikers— Kamyar Samimi, Amar Mergensana, and Roylan Hernandez-Diaz—have died in detention, raising serious questions about medical neglect, lack of mental health services, and abuse during and after their hunger strikes. ICE’s failure to monitor people after they end their hunger strike may endanger and put them at risk of refeeding syndrome, a serious and potentially fatal complication. Refeeding syndrome is broadly characterized by metabolic abnormalities and severe electrolyte disturbances, leading to organ dysfunction, and respiratory and cardiac failure.
Solitary Confinement and Unlawful Retaliation Against Hunger Strikers
These records also reveal that ICE routinely placed hunger strikers in solitary confinement, which often amounts to cruel, inhuman, or degrading treatment, and, under certain conditions, even torture.
Although ICE claims that its policy to isolate hunger strikers is for the detained person’s well-being, there is no medical reason to place a hunger striker in solitary confinement, which can lead to additional serious physical and mental health consequences.
Placing detained hunger strikers in isolation as a result of their protected expressive conduct also violates the First Amendment. Compounding the harm, ICE also subjects hunger strikers who have concomitant mental illnesses to the same abusive solitary confinement policies. Conditions in solitary confinement units included impermissible punitive measures, such as cutting off water for toilets, washing, and drinking, which is contrary to ICE’s medical guidelines and of particular danger to detainees on hunger strikes.
ICE’s response reveals striking inflexibility to the underlying requests made by detained hunger strikers. ICE’s records, news reports, and interviews with former hunger strikers reveal numerous examples of unlawful retaliation by ICE, including involuntary transfer and excessive force. As one official at the Yuba County Jail in California, which detains immigrants for ICE, instructed: “move him to [another facility] and he will likely beg to come back here and mind his manners until he is removed.” In some instances, ICE moved to transfer or deport hunger strikers despite their physical or mental vulnerability and need for continued medical monitoring.
Psychological Coercion: ICE’s Attempts to End Hunger Strikes
These records and interviews with formerly detained hunger strikers also shine a light on the many forms of day-to-day psychological coercion ICE employs to try to break hunger strikes, including denying access to basic privileges, restricting water access, and threatening prosecution. ICE officers used dehumanizing language to describe hunger strikers. In one instance an officer noted, “I really feel that we should stop neglecting these poor innocent fruit flies. I mean really, why should they have to go without fruit? Maybe a protest is in order.” While ICE officers were unwilling to consider hunger strikers’ requests, they often attempted to leverage traditional foods (such as curry dishes or Bengali tea) or members of the hunger strikers’ faith communities to pressure them to break their fast. In one alarming case, ICE reportedly brought in a Bangladeshi consular official to meet with hunger striking asylum seekers who had fled persecution by the Bangladeshi government.
Separating Families, Hiding Stories: ICE’s Treatment of Hunger Strikers at Family Detention Centers
Other documents reveal how ICE officials took pains to hide hunger strikes from public view, including those at family detention centers that detain immigrant children and their parents. While discussing a hunger strike by several mothers at the Berks Family Residential Center in Pennsylvania, an ICE physician noted that “we are using the food protest (or meal refusal) label rather than hunger strikes for a couple of reasons. Since this is a family facility, we don’t want the messaging going out that there is a hunger strike going on. The optics just look bad. Then people wonder if the kids are on strike too and starving.” The same physician proposed family separation as a response to the strike: “If it appears they really are on a hunger strike, we will need to separate the mother and children—send mom to an IHSC [ICE Health Service Corps] facility to address the hunger strike.”
In other instances, documents revealed that ICE officials recommended misrepresentation or omission of key facts related to hunger strikes to evade oversight reporting requirements. In one case at the Pulaski County Detention Center in Kentucky, an ICE representative recommended that a nurse remove information about suicide risks from a former hunger striker’s health summary. In email correspondence with staff at the Northwest Detention Center (NWDC) in Washington, the ICE Western Regional Communications Director/Spokesperson asked for an update on the number of detainees who were going to be placed on formal hunger strikes protocols. The NWDC representative estimated 12 people but asked the ICE spokesperson to hold off while they confirmed the numbers. The ICE spokesperson replied, “OK … but the wolves are at the door. Maybe I can come up with something fuzzy … using a round number.”
Violations of Medical Ethics: The Role of ICE’s Health Professionals in Abuses Against Hunger Strikers
The documents reveal that ICE’s health professionals helped facilitate and enable abuses against hunger strikers, in contravention of their ethical obligations and international human rights norms. They lent their names and credibility to medical declarations in support of motions for force-feeding and other involuntary medical procedures. In some cases, they failed to ensure that even the most basic standards for adequate medical monitoring were met.
“You cannot compare being in immigration [detention]; it’s like something out of a horror story.”
A New Opportunity: Ending a System of Abuse
ICE’s treatment of hunger strikers reflects the broader context of harm and abuse endemic to the immigration detention system — which hunger strikers themselves are protesting. As a formerly detained hunger striker, Luis Yboy Flores, noted, “You cannot compare being in immigration [detention]; it’s like something out of a horror story.”
Hunger strikes continue in ICE detention as of this writing, as detained people at risk of contracting COVID-19 make pleas for basic sanitation, safety, and the ability to practice social distancing behind bars. ICE officials and detention officers have responded with extreme measures, including use of pepper spray, physical force, rubber bullets, and facility- wide lockdowns, in addition to force-feeding and retaliatory punishment for those who are singled out as instigators.
The documents reveal the architecture of abuse that underpins ICE’s response. They describe the routinization of the coercion and retaliation against hunger strikers that continue today. Rather than address the underlying circumstances that led to the hunger strike, ICE’s policy and practice is to intimidate detained people into ending their protests. Moreover, by applying the same hunger strike policies to people experiencing mental health crises, ICE puts already vulnerable people at greater risk.
Notably, newly elected President Joseph R. Biden was vice president during much of the period covered by the documents analyzed in this report. His administration now has an opportunity to acknowledge the abusive system that prompts so many immigrants to engage in hunger strikes, to end ICE’s cruel response to their protests, to heed hunger strikers’ urgent calls for humane treatment and release, and to begin phasing out the use of immigration detention entirely.
This section provides key recommendations to protect the rights of hunger strikers in ICE detention, as described below. A more detailed version is provided at the end of the report.
To the U.S. Department of Homeland Security (DHS):
- Phase out the use of immigration detention.
- Invest in community-based social services as alternatives to detention.
- End the use of solitary confinement in immigration detention.
- Issue a directive on the medical treatment of hunger strikers, consistent with national and international ethical norms, to ensure appropriate standards of care.
- Guarantee people in detention continued and regular access to independent health professionals, including licensed physicians and psychiatrists with provisions to ensure their clinical independence from the detaining authorities.
- Prohibit use of force and punitive measures against hunger strikers.
- Ensure greater transparency and accountability in the immigration detention system, including comprehensive facility inspections with safeguards for the participation of detained people, and meaningful consequences for failed inspections.
- Provide compensation for people who have been subjected to involuntary treatment and/or other forms of abuse while hunger striking.
To the U.S. Congress:
- Conduct robust oversight of ICE’s treatment of hunger strikers in detention.
- Request that the DHS Office of Inspector General (OIG) and Office of Civil Rights and Civil Liberties (CRCL) investigate and issue recommendations regarding the conditions documented in this report.
- Require that ICE publicly report data on hunger strikes by people in ICE custody.
- Prohibit the use of funds appropriated to the DHS to be used to force-feed or forcibly hydrate detained people engaging in a hunger strike who have been determined by an independent
- licensed physician to be competent in the refusal of treatment.
- Dramatically reduce funding for immigration detention and enforcement.
- Support and pass legislation that begins the process of phasing out mandatory detention and the use of detention entirely in our immigration system.
To the U.S. Department of Justice:
- Refrain from pursuing orders for force-feeding and other involuntary medical procedures.
- Refrain from retaliation against detained hunger strikers.
To Offices of the Federal Public Defender:
- Provide representation to people in detention on hunger strike who face court proceedings.
To State Medical Boards:
- Investigate for license suspension or revocation any medical or health professionals who authorize or participate in involuntary medical procedures on mentally competent individuals.
To Medical and Health Professional Associations:
- Censure and expel any medical or health professionals who authorize or participate in involuntary medical procedures on mentally competent individuals.
- Issue clear guidelines reinforcing that force- feeding and other involuntary medical procedures are unethical and inconsistent with professional norms.
- Lobby for stronger and comprehensive protections for health professionals who refuse to engage in unethical conduct, or act as whistleblowers.
To Individual Health Professionals:
- Advocate individually or through professional organizations against health professionals’ involvement in force-feeding and other involuntary procedures.
- Advocate for ICE to comply with ethical standards with respect to the treatment of detainees.
- Advocate for the censure of health professionals who have participated in force-feeding and other involuntary procedures.
To the UN High Commissioner for Human Rights, UN Special Procedures, UN Treaty Bodies, and the Inter-American Commission on Human Rights:
- Request official visits and unimpeded access to ICE detention facilities to monitor conditions and investigate ill-treatment of hunger strikers.
- Seek information from the U.S. government regarding the use of coercive measures against hunger strikers in immigration detention.
- Condemn the use of physical or psychological coercion against hunger strikers in ICE detention.
 American Civil Liberties Union (ACLU), Human Rights Watch (HRW), and National Immigrant Justice Center (NIJC), Justice-Free Zones U.S. Immigration Detention Under the Trump Administration (2020), https://www.aclu.org/report/justice-free-zones-us- immigration-detention-under-trump-administration; Physicians for Human Rights, Praying for Hand Soap and Masks: Health and Human Rights Violations in U.S. Immigration Detention during the COVID-19 Pandemic (January 2021), https://phr.org/our-work/ resources/praying-for-hand-soap-and-masks; American Immigration Council, “Immigrants and Families Appear in Court,” July 30, 2019, https://www.americanimmigrationcouncil.org/ research/immigrants-and-families-appear-court.
 ACLU v. Department of Homeland Security, “Complaint for Injunctive and Declaratory Relief,” May 25, 2017, https://www.aclu.org/ legal-document/aclu-v-department-homeland-security-complaint.
 ICE Significant Event Notification (SEN) data (FOIA 2017-ICLI-0014, “SEN FOIA Request – May 2018 Reproduction.xls.”)
 Letter (dated April 23, 2013) from Dr. Jeremy A. Lazarus (president of the American Medical Association) to the Honorable Chuck Hagel regarding the treatment of hunger strikers at Guantánamo and force-feeding, http://media.miamiherald.com/ smedia/2013/04/30/07/58/FRs25.So.56.pdf.
 Brittany Freeman, “ICE review of immigration detainee’s death finds medical care deficiencies at Aurora facility,” Rocky Mountain PBS, May 20, 2019, https://www.rmpbs.org/blogs/ news/ice-review-of-death-in-aurora-immigration-detention- facility-finds-deficiencies-in-detainees-medical-care; Lilly Fowler, “New details of a death at Tacoma ICE facility raise questions over care,” Crosscut, December 3, 2020, https://crosscut.com/ news/2020/12/new-details-death-tacoma-ice-facility-raise-questions-over-care; Hamed Aleaziz and Adolfo Flores, “A Cuban Asylum-Seeker Died Of An Apparent Suicide After Spending Months In ICE Detention,” Buzzfeed News, October 16, 2019, https://www.buzzfeednews.com/article/hamedaleaziz/cuban-asylum-ice-death-suicide-louisiana-detention.
 Al Sharkawy, I., D. Ramadan, and A. El-Tantawy. “’Refeeding Syndrome’ in a Kuwaiti Child: Clinical Diagnosis and Management.” Med Princ Pract 19, no. 3 (2010): 240-3; Boateng, A. A., K. Sriram, M. M. Meguid, and M. Crook. “Refeeding Syndrome: Treatment Considerations Based on Collective Analysis of Literature Case Reports.” Nutrition 26, no. 2 (Feb 2010): 156-67; Eichelberger, M., M. L. Joray, M. Perrig, M. Bodmer, and Z. Stanga. “Management of Patients During Hunger Strike and Refeeding Phase.” Nutrition 30, no. 11-12 (Nov-Dec 2014): 1372-8; Crook, M. A. “Refeeding Syndrome: Problems with Definition and Management.” Nutrition 30, no. 11-12 (Nov-Dec 2014): 1448-55; Letter from Dr. Allen Keller and Dr. Parveen Parmar to Department of Homeland Security (February 7, 2021), https://1229c6da-0cea-441a-90c5-2c46bf07cdbd.filesusr.com/ ugd/5f6014_4bdf31b3e9c74f00a6d6948ecfa976ed.pdf.
 PHR, Praying for Hand Soap and Masks: Health and Human Rights Violations in U.S. Immigration Detention During the COVID-19 Pandemic (January 2021).
 Wynia, Matthew K. “Why It Is Important To Promote Clinical Independence Among Health Professionals Working In Prisons, Jails, and Other Detention Settings.” American Journal of Public Health 108, no. 4 (2018): 440. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5844422/