For a doctor, there is nothing harder than seeing a patient with a treatable condition not receiving basic care. I recently met a woman in U.S. immigration detention. She said that although she had notified the corrections staff that she suffered from chronic hypertension, it took four days for her to be given her blood pressure medication. By then she was experiencing stabbing pains in her chest. Another individual, with a chronic condition that makes him prone to developing blood clots, was not allowed access to a physician for several days, though he complained of his head throbbing and his leg being swollen. He knew that these symptoms could mean life-threatening blood clots. Days later, when he finally saw a clinician, he was confirmed to have a blood clot in his leg. He was given blood thinners, but received woefully infrequent follow-up monitoring – well below medical practice standards.
Both encounters took place in Texas, where, in April 2018, I toured the South Texas Detention Center and the Laredo Processing Center. As a Harvard-educated neurologist, and an expert volunteer for Physicians for Human Rights’ Asylum Network, I conduct medical and psychological evaluations of asylum seekers. This trip was organized by Human Rights First, who recently released a report on detention conditions. The trip offered me the opportunity to hear first-hand accounts of conditions in immigration detention. What I discovered was a pattern of grossly inadequate medical and mental health care for those detained.
I felt like I was visiting a prison, with asylum seekers and other immigrants made to wear prison uniforms, separated from their families and denied outdoor recreation. Unlike criminal detention facilities, immigration detention is not governed by binding, codified standards for medical care – something that became painfully apparent as I heard detainees recount their experiences.
Throughout my visits, I was accompanied by agents from Immigration and Customs Enforcement (ICE) or correctional officers working for GEO Group, or CoreCivic – the latter two the largest private prison companies that contract with ICE. Being chaperoned or monitored by authorities as I do my work creates a barrier between me and those being treated, but it is something that has become all too familiar to me. Recently I performed a medical evaluation in a detention center where the patient was “no contact,” meaning I evaluated the client’s severe medical needs through a phone and across soundproof glass. At Laredo Processing Center, we heard from local lawyers that patients seeking medical evaluations are held in five-point shackles. Both these scenarios clearly limit any health professional’s ability to conduct a proper evaluation.
But it’s not just the access that poses a problem. The facilities themselves are examples of the lack of appropriate standards. The suicide watch room that I saw at Laredo Processing Center had a barred metal door to a darkened space without natural lighting. I could only imagine a detainee’s mental state deteriorating in this atmosphere of isolation, supervised only by a correctional officer, and devoid of a clinician. I was curious to assess the situation at the South Texas Detention Center, but we were denied access to their suicide watch room.
Despite being in the presence of guards, individuals in detention at both facilities shared stories with me, not only of gross medical neglect, but of outright harassment and hostility. Individuals were shouted at by guards for things such as being underneath a blanket for too long, not eating, or for making minor noises. They were threatened with having their paperwork and identification taken from them, or with being cut off from phone access – a crucial lifeline to the outside world for most, like one father whom I met whose wife and children were in two different cities, making phone calls his only precious connection.
Others were subjected to neglect and indifference in basic everyday needs, with negative health consequences. With no cleaning supplies provided to clean bathrooms, there was clogging or fungus growth in toilets which serve more than 100 individuals in a housing unit. Some detainees reported live worms found in food served. One woman suffered an eye infection after being denied contact lens solution or glasses. She was instructed to use tap water, or face the alternative: impaired vision for the duration of her detention. Multiple women reported frequent vaginal infections and urinary tract infections from poorly washed underwear. Others reported being denied tissues for coughs, runny noses, or nose bleeds.
Substandard care is not an accident, it’s a reflection of a system without clearly-defined standards or effective external oversight. Because immigration detention standards have not been codified into law, it is up to each facility to decide which standards it will abide by, according to its individual contract with ICE. Moreover, existing standards are not legally binding. True oversight requires external inspections, with real consequences for facilities which do not comply, such as ending a contract. There also needs to be formal protection within the system for immigrants who speak out to protest the treatment they are subjected to. At Laredo Processing Center, I witnessed that individuals with grievances had to ask correctional officers for a grievance form, even when their complaints were aimed at that very same correctional officer. At South Texas Detention Center, one individual reported being placed in solitary confinement during the “investigation” period after each grievance report he filed, with solitary confinement ranging from under 24 hours to several days. This system breeds silence, born out of a fear of retaliation.
The United States already has the largest immigration detention system in the world and is dramatically stepping up its use of detention centers. I saw holding cells with capacity for 160 people and dorms holding 82 people in cramped double bunk beds. Recent policy changes have included detention of pregnant women, asylum seekers, individuals without a criminal history, and long-term residents of the United States. This increase in detentions leads to overcrowding and strains the capacity of an already substandard system which is dominated by private prisons with a profit motive.
For me, certain policy recommendations are clear:
- Prioritize the use of detention alternatives, such as release on parole or bond;
- Disclose publicly any plans to establish a new detention standards framework, and develop detention standards through a transparent process involving stakeholder input;
- Terminate facility contracts if inspections evaluations are less than adequate;
- Ensure that the latest Performance-Based National Detention Standards (PBNDS) are applied in all immigration detention facilities through incorporation in formal contracts with detention centers;
- Support discussions with Congress regarding codification of PBNDS into law; and
- Establish independent medical oversight boards at the local level for each detention center and nationally. ICE relies on contracts with many local governments for detention, therefore states and local municipalities can play a vital role in improving medical care and detention conditions.
At every level of government, we must ensure that anyone who is detained receives adequate medical care, as enshrined in the U.S. Constitution and international law. This involves not losing sight of each individual immigrant’s humanity, resisting the dehumanizing rhetoric of current politicians, and upholding human rights standards.
Altaf Saadi is a neurologist, fellow at the National Clinician Scholars Program, and health sciences clinical instructor of medicine at UCLA. She is a member of the Physicians for Human Rights Asylum Network. She completed her neurology training at the Harvard Partners Neurology residency program at Massachusetts General Hospital and Brigham and Women’s Hospital, where she also served as chief resident. She is a graduate of Harvard Medical School and Yale College.