Medical professionals are often on the front lines in conflict situations, providing life-saving health care to civilian communities suffering from violence, abuse, and deprivation. Nowhere has this been truer than in Syria. The targeting of civilians at the hands of the Assad regime and its Russian allies has played a very prominent role in the prosecution of the war, and medical professionals have all too often been violently prevented from carrying out their duties through persecution, arrest, disappearance, torture, and killings.

As first responders, medical personnel also see up close the wounds and evidence of violence and torture that their patients have endured. The government’s persecution of medical professionals is often part of oppressive governments’ intentional strategies of silencing these powerful witnesses.

PHR uses open-source data and field sources to document the deaths of medical personnel killed in Syria since March 2011. As of March 2024, thirteen years into the conflict, PHR has assessed that the Syrian government and their Russian allies are responsible for 92 percent of the deaths of medical personnel perpetrated by known actors throughout the conflict. Responsibility for the remaining seven percent lies with non-state armed groups: the self-declared Islamic State (IS), sometimes referred to as ISIS or ISIL, international Forces, and Syrian Democratic Forces. Three events with an unknown perpetrator resulted from attacks launched from areas controlled by both the Syrian government’s forces and the Syrian Democratic Forces. The attacks, which took place on June 12, 2021, targeted al-Shifaa hospital and other civilian targets in Afrin City, Aleppo. The targeting of medical personnel is a violation of international humanitarian law (IHL), and those responsible must be held accountable. When medical workers are killed, the human toll is not just the immediate loss of life, but also the exponential number of people who will suffer or die as a result of not having access to adequate or timely treatment.

Cumulative Deaths of Medical Personnel

Throughout the conflict in Syria, the Syrian government has systematically targeted medical facilities and personnel, killing doctors, nurses, and others as they care for the sick and injured in hospitals, clinics, and in the field. Health professionals have also been arrested, disappeared, imprisoned, tortured, and executed – often for upholding their professional commitment to treat all patients, regardless of political affiliation. PHR has documented the deaths of 949 medical professionals from the start of the conflict in 2011 through March 2024.

Medical Personnel Deaths Over Time

The beginning of the Syrian conflict was characterized by widespread killings of medical professionals, with 190 killed in 2012 alone. The highest number of killings occurred during the first four years, through shelling, aerial attacks, small arms fire, and the kidnapping and detention of medical workers that often resulted in death through torture or execution. In 2015 in Aleppo, it was reported that over 95 percent of the city’s doctors had fled, been detained, or been killed.

The dip in deaths of medical personnel after 2015 does not necessarily indicate a decrease in the intensity of the conflict, but rather likely reflects a decrease in the total number of medical professionals still in the country.

The targeting of medical personnel is a violation of international humanitarian law (IHL), and those responsible must be held accountable.

PHR recognizes that it cannot know of, let alone corroborate, all attacks on medical personnel. This is illustrated by the Syrian government’s continuous releases of lists of civilians who died in Syrian custody, indicating that there are potentially many more medical professionals who may have died in detention but whose deaths have not yet been made public.

Detention of health care providers has been a deliberate tactic of the Syrian government and part of a broader strategy to weaponize health care as a tool of war. PHR has studied the detention and ill treatment of health care providers in the first two years of the conflict. Our investigations showed that the risk of death in detention centers was higher among those who were detained due to their provision of health care to opposition-affiliated individuals or sympathizers compared to those who were involved in political activities against the government. The data on killed medical personnel shows that 94.3 percent of such deaths were due to detention, kidnapping, torture, and extrajudicial executions perpetrated by the Syrian government from 2011-2015, with a peak in 2012. The strategy then shifted toward targeting health care facilities with shelling and aerial attacks. This resulted in 480 deaths, 81.5 percent of which took place between 2012 and 2016.

Detention of health care providers has been a deliberate tactic of the Syrian government and part of a broader strategy to weaponize health care as a tool of war.

The territorial gains of Syrian government forces since the spring of 2018 have meant a reduction in front lines, and fewer attacks on medical facilities. But even with the changing dynamics of the conflict, medical personnel continue to be targeted for a variety of reasons, including the perception that they are economically advantaged and can be held for ransom. Between 2020 and 2022, 18 medical professionals were assassinated by ISIS and other unknown actors due to the deteriorating security situation, especially in northeast Syria.

Medical Personnel Killed by Governorate

Aleppo, Idlib, and Rif Dimashq represent the governorates with the highest recorded death rates of medical personnel. Spikes in the number of medical personnel killed have tended to coincide with major Syrian government offensives in these governorates.

For example, Aleppo was relentlessly targeted with barrel bombs from 2013 to 2015. In 2016, the Syrian government launched a military campaign to control the city, and by December 22, 2016, it had declared the city “liberated.” During this time, the number of medical personnel killed in Aleppo dropped from a high of 29 in 2016 to five in 2017 and two in 2018 and 2019 combined.

Similarly, in Rif Dimashq, the governorate surrounding Damascus, the Syrian government had been on the offensive since 2013. In April 2018, government forces regained full control over the suburb of eastern Ghouta after a brutal military campaign that killed 20 medical personnel in less than four months. Since then, the number of killed health workers has decreased.

In Idlib, the last rebel enclave in Syria, 85 medical personnel have been killed since 2012. The number increased significantly after 2014, when the Syrian government intensified its military action against various rebel groups who control the majority of Idlib’s countryside. Since the Syrian government and Russia escalated their offensive on the northwest in April 2019, 31 medical personnel have been killed in Idlib, northern Hama, and western Aleppo.

Death of Medical Personnel by Profession

PHR’s definition of “medical personnel” includes doctors, nurses, paramedics, pharmacists, dentists, veterinarians, lab technicians, and health professional students. They must be civilians to be included in the PHR dataset, as medical workers who engage in combat lose their protected status under IHL during such time as they are engaged. As this graph shows, the most affected medical professionals are doctors and nurses, followed closely by paramedics.

PHR chose to include nontraditional medical categories such as veterinarians, dentists, and students because it has received credible reports that these personnel often treat patients due to the lack of licensed physicians and nurses in many localities. The Syrian conflict forced many untrained and under-qualified civilians to step up and take on life-saving roles; according to the recent PHR report, those who volunteered to provide health care among non-physicians were at higher risk of being killed under detention.

The variety of Syrian medical professionals killed across the board points to the systematic destruction of the medical sector and the depletion of medical skills and services throughout the country.

Cause of Death of Medical Personnel

The largest causes of death of medical personnel are aerial bombardment, shelling, and small arms fire. These attacks can be deliberate or indiscriminate, both of which are violations of IHL when directed at medical facilities. As a result of such systematic attacks, many medical professionals died in the line of duty. Many others died after being detained and then tortured and executed.

Due to restrictions in access and limited information, this number is likely to be larger and may continue to increase as families learn that their loved ones died in prisons. In addition, there are many medical professionals who are believed to be alive in detention facilities. These detentions, as well as the concealment of the fate of those who were killed, are gross violations of human rights and humanitarian law.

For Medical Workers in Syria, Impossible Circumstances

For doctors, working in Syria is a triumph of will and determination over impossible conditions. They have been tortured, kidnapped, shot, and shelled. Many have fled while others have stayed behind, placing the lives of their patients ahead of their own. “The obstacles were everywhere,” said Dr. Rami Kalazi, a neurosurgeon who worked in eastern Aleppo city until the summer of 2016. “Massive bombardment everywhere, direct targeting of health facilities, a huge shortage of medical equipment and supplies, especially modern diagnostic devices, a demand for ambulances, a huge lack of medicines, a huge gap in medical experts, very few well-equipped ICUs, few beds in ICUs and wards – besides the enormous number of casualties. Could you imagine the circumstances that physicians in Syria are working under?”

Doctors in the Crosshairs

On March 22, 2011, government forces entered Daraa National Hospital, cleared it of non-essential staff, and positioned snipers on the roof. The snipers remained for two years, firing at the sick and wounded to ensure that only government supporters could enter the hospital. On April 8, a nurse trying to rescue an injured person was shot and killed by government forces in Daraa city. This was just the beginning of the government’s brutal and ongoing campaign of deliberate attacks on medical personnel and facilities as a weapon of war. Read more.

Learning Surgery as the Bombs Fall

In the Syrian government’s relentless assault on health care, nowhere was hit as hard as Aleppo. By the time the city fell to government forces in December 2016, more than two-thirds of the hospitals no longer functioned and roughly 95 percent of doctors had fled, been detained, or killed. Amidst this acute shortage of medical personnel, physicians had to learn to perform new operations on the spot. Dr. K, a dentist who was never trained in maxillofacial surgery, was the only doctor available one day to operate on a patient whose jaw was completely destroyed by a sniper shot. “I had to do deep sutures of the muscle, which was my first time, so I learned by doing that. I closed the patient and hoped that I had done a good job,” he said. Read more.

Conclusion

After thirteen years of death and destruction, the landscape for human rights, justice, and accountability looks bleak. As of the end of 2023, approximately 15 million people across Syria required health assistance. Many of the health facilities impacted by the conflict remain non-functional. The flight, death, or continued detention of large numbers of health professionals only add to the crippled condition of Syria’s health care system. Furthermore, the devastating earthquake that hit northern Syria last year exacerbated the existing crises endured by Syrians. Addressing the impact of the targeting of health care must begin with justice and accountability for these documented violations of human rights and IHL. Justice must be delivered for medical personnel who were targeted and killed for upholding their civic and moral duty and for those who remain in detention or who have fled Syria and remain too afraid of reprisal to return to their homes and country. 

Justice must be delivered for medical personnel who were targeted and killed for upholding their civic and moral duty and for those who remain in detention or who have fled Syria and remain too afraid of reprisal to return to their homes and country. 

PHR Methodology for Collection of Data on Attacks on Medical Personnel

PHR utilized open-source data and field sources to document the killing of medical personnel in Syria since March 2011. PHR drew primarily upon the Violations Documentation Center of Syria’s (VDC) English-language website, Syria Network for Human Rights website, media accounts, and social media, corroborating and supplementing this information with data gathered from PHR’s network of physicians in and surrounding Syria. PHR chose to exclude from our data set any documented death identified as a “non-civilian” medical worker, as medical workers engaged in combat lose protected status under IHL.

PHR’s research team collected data from a wide variety of open sources, including United Nations, government, and local and international NGO reports; local, regional, and international news sources; journal articles; Facebook and blog posts; Twitter feeds; and YouTube videos. PHR also conducted interviews and received information and photographs from individuals and organizations involved in providing medical services in Syria and neighboring countries with refugee populations. PHR’s English- and Arabic-speaking analysts reviewed materials in both English and Arabic.

From March 2011 through March 2024, PHR corroborated 604 attacks on at least 400 separate medical facilities and documented the killing of 949 medical personnel. Check out our map of attacks on medical facilities in Syria.

This project is funded in part by ifa (Institut für Auslandsbeziehungen) with resources provided by the German Federal Foreign Office.

Executive Summary

On July 10, 2022, the United Nations Security Council Resolution 2585, which authorizes the use of the one remaining border crossing for humanitarian aid into Syria, Bab al-Hawa, will expire. If the United Nations Security Council (UNSC) allows it to lapse, the closing of this border will force six million Syrians to face grave uncertainty regarding the protection of their human rights, including basic needs essential for survival.

To inform this policy brief, PHR interviewed 20 health and humanitarian professionals and met with six humanitarian organizations who work in the region to gain insight into how life-saving aid currently flows to at-risk communities in Northern Syria, as well as how the potential closure of the lone remaining border crossing would impact Syrians’ health and wellbeing. The brief builds on PHR’s 11 years of rigorous research documenting the destruction of the Syrian health system.

Physicians for Human Rights (PHR) urges UNSC Member States to renew the Bab al-Hawa border crossing authorization for at least 12 months. PHR also calls on the UNSC to reauthorize the Bab al-Salaam and al-Yarubiyah crossing points, in order to ensure equal and adequate access to humanitarian aid for populations in need across all of northern Syria.

Introduction

In the 11 years since the Syrian conflict began, more than 14 million Syrians who remain in the country have required humanitarian assistance. More than four million people in northern Syria alone need regular humanitarian aid and, among those, 2.8 million are internally displaced persons. Without the lifelines represented by the UN cross-border operations, it will be challenging for millions of Syrians to access health care or become food secure. Currently, 80 percent of the population (12.4 million individuals) is food insecure, meaning they lack access to regular sources of safe and nutritious food. Among those 12.4 million people, 4.1 million are in northwest Syria, while 97 percent live below the global poverty line.

In 2014, the UNSC adopted resolution number 2165, which authorized the UN agencies and humanitarian partners to deliver humanitarian aids across conflict lines within the country (Cross-line) and by international border crossings (Cross-border) at Bab al-Hawa, Bab al- Salam, and al-Yarubiyah in northern Syria, and Al-Ramtha in the south.

Physicians for Human Rights urges UNSC Member States to renew the Bab al-Hawa border crossing authorization for at least 12 months.

The closure of the al-Yarubiya and Bab al-Salam border crossings in January and July 2020, respectively, resulted from Russia and China’s veto of draft resolutions to renew cross-border operations. At the moment, the Bab al-Hawa border crossing along the Syria-Türkiye frontier remains the only entry point for UN humanitarian aid to directly reach populations in northern Syria, which make up nearly a quarter of the Syrian population. Without the reauthorization of this crossing, Syrians in the northern part of the country will struggle to access humanitarian aid, exacerbating an already dire situation. Also, health organizations will lose access to essential medical supplies that are only available from the World Health Organization (WHO), including COVID-19 vaccines and other essential medications and medical equipment.

Physicians for Human Rights (PHR) urges UNSC member states to renew the Bab al-Hawa border crossing authorization for at least 12 months to offer certainty to NGOs and other humanitarian organizations to plan their programs in Syria. Failure to do so would have a devastating impact on a fragmented health system and will make it more challenging for Syrians to access health services in northern Syria. PHR also calls on member states to reauthorize the Bab al-Salaam and al-Yarubiyah crossing points in order to ensure equal and adequate access to humanitarian aid for populations in need across northern Syria. The closure of both these crossing points in 2020 has made major contributions to the near collapse of the public health care system in the northeast of Syria.

A Lifeline for North Syria

“The crossing point [in Bab al-Hawa] for millions of Syrians in the north is like the umbilical cord for a baby. It is vital for their survival.”

A physician and the mission director of a Syrian Medical NGO

Currently, northern Syria relies exclusively on the Bab al-Hawa border crossing to get all UN humanitarian aid and medical supplies to civilians. This crossing point is the key corridor through which the WHO can deliver COVID-19 vaccines and other essential supplies to millions in the northwest. Furthermore, Bab al-Hawa has been used by international and local NGOs to support the health system in northwest Syria with trauma care kits, surgical equipment, and medications.

According to the United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA), 53.8 million beneficiaries have received health aid through the UN cross-border operations under the UNSC resolutions since the authorization of the operations in 2014. Of those, 46.5 million were reached from Türkiye through Bab al-Hawa and Bab al-Salaam, the latter of which was shuttered in 2020.3 The cross-border operations allowed children to receive their routine vaccines and facilitated the implementation of multiple rounds of polio campaigns. Following the declaration of COVID-19 as a global pandemic in 2020, the UN agencies have reached 18.5 million beneficiaries with medical supplies. If the UN Security Council votes to abruptly end the cross- border aid in northern Syria, an already catastrophic situation will be further exacerbated. Without these border crossings, there is no other well-equipped means to provide critical aid supplies at scale.

Weaponizing Health care

“If [the Syrian government] controls [the humanitarian aids], it will be a disaster. How should we expect the government that killed and displaced millions of people and used chemical weapons against civilians to distribute life-saving supplies?”

A physician from Afrin, North Syria

Resolution 2585, through which the UN Security Council extended by six months its previous authorization of the Bab al-Hawa crossing point, requested a special focus on different aid delivery modalities including crossline operations. Yet, according to UNOCHA, only five convoys have been deployed to northwest Syria since the Security Council’s most recent vote on this issue in July 2021.* These supplies were only sufficient for fewer than 200 thousand residents out of 2.9 million living in Idlib alone.

Health care providers in northwest Syria interviewed by PHR researchers voiced skepticism about claims that cross-line operations could or should substitute for the cross-border operations. An interviewee who previously volunteered with the Syrian Arab Red Crescent reported that the Syrian government has been selective in terms of the supplies that are allowed to enter the non- governmental-controlled areas. The interviewee noted, for instance, that surgical kits were not allowed to be delivered to the region. Also, a primary health care provider described that the Syrian government manipulated reports about vaccination rates in non-governmental controlled areas and deprived children of the right to access routine vaccines.

These views underscore a larger reality: for more than a decade, the Syrian government has systematically targeted health care workers, while using the health care system to brutalize and oppress the civilian population. Since March 2011, the Syrian government with the support of the Russian allies carried out at least 542 attacks on health care facilities, killed more than 850 health care providers, and arrested thousands of medical professionals. The Syrian government has routinely obstructed and denied access to health care to people living in areas of Syria it considers to be disloyal, even after retaking these areas, such as Daraa in southern Syria. As these statistics illustrate, allowing the Syrian government full control over the flow of humanitarian aid will have a devastating impact on the lives of millions of Syrians.

Lessons Learned from the Northeast

“Cross-line operations were covering 1% of the need and UN agencies in Damascus have been trying to increase the coverage by 35%. So, now 1.35% of the need will be covered.”

The head of a medical mission NGO in northeast Syria

In January 2020, the al-Yarubiyah crossing point was closed under UNSC Resolution 2504. Since then, the health system in northeast Syria has been struggling to meet the needs of affected populations, most recently evident in the unavailability of COVID-19 essential supplies.

Furthermore, relying on cross-line operations in the northeast has proven to be an inefficient alternative, as numerous local actors and medical professionals have reported to PHR and to the international news media. The WHO office in Damascus responded late to the COVID-19 pandemic in the northeast, which left the region with only one laboratory for PCR testing in the first six months of the pandemic.

Furthermore, prior to the closure of the al-Yarubiyah crossing, humanitarian organizations could receive humanitarian funds from the Türkiye Hub and implement health projects in the northeast through the border crossing. Currently, organizations can only receive funds directly from the Damascus Hub, which currently blocks most of the organizations from receiving such funds since they are required to be registered in Damascus to meet the eligibility criteria. Today, most organizations are not able to register in Damascus while maintaining their operations in northern Syria. Also, registering in Damascus requires that an NGO go through the Syria Trust for Development, which is founded by the First Lady Asma al-Assad, who remains under US sanctions as a result of the Caesar Syria Civilian Protection Act. Further, working in governmental-controlled areas requires working with the Syrian Red Crescent (SARC). PHR’s report on access to health in Daraa, southern Syria, shows that SARC has directed aid to areas within Daraa more firmly under the government control, withholding aid from areas that remained “opposition-minded.”

Medical supplies delivered by the Syrian government to the northeast have been grossly insufficient for the needs of the population, and they have not been distributed equally. In interviews with PHR, health care providers reported receiving medical supplies every five or six months that can barely cover their needs for a few days. In April 2022, the UN Secretary General estimated that cross-line operations provided around 850 thousand treatment courses for health facilities in the northeast. But these operations cannot fully replace the critical supplies that were delivered by the cross-border operations; NGOs supporting more than 100 health facilities in the region are still facing delays in securing essential medications, laboratory supplies, and treatment kits for communicable and non-communicable diseases due to barriers to access.

Obtaining necessary permissions from the Syrian government is also one of the challenges that delays the delivery of humanitarian aid to the region. According to the UNSC’s review of the UN’s humanitarian operations, the WHO delivered only two shipments by means of road convoys, both weighing 50,981 kg. Of those shipments, 67% were allocated for Qamishli National Hospital, which is run by the Syrian government, and the remaining 33% were distributed to 52 hospitals and medical centers. In short, the current situation in northeastern Syria illustrates the devastating, inequitable impact that the closure of operations at the Bab al-Hawa crossing point would have in the northwest.

Corruption and Retaliation

“When requesting supplies from Türkiye, these supplies enter Syria from the northwest and then are transported to the northeast, where different controlling parties impose high fees and taxes, and sometimes abduct part of the convoy. So, we end up receiving a portion of these supplies but at a very high cost.”

A physician working in northeast Syria

The health system in northeast Syria relies heavily on importing medical supplies and medications from government-controlled areas and on receiving supplies from Türkiye through the Bab al- Hawa crossing point, but both modalities are inefficient due to security reasons and logistical challenges. Health care providers in the northeast reported the impact of corruption at checkpoints between the government-controlled and the non-government-controlled territories, which has nearly tripled the cost of medical supplies compared to the prices in other governmental-controlled areas. This increase is due to the high fees and bribes that need to be paid, which can range from 10,000 to 15,000 US dollars per shipment, according to a director of a health care facility and a health care provider, who were interviewed by PHR researchers.

Regarding supplies arriving from the northwest, local NGOs and health care providers reported that shipments from the northwest are usually subjected to lengthy vetting procedures and/or theft while being transported through different areas of control. This is due to the political tension between the Syrian Democratic Forces and the opposition forces in the northwest and the Turkish-controlled territories. The Syrian government has used aid as a leverage to gain military wins in Aleppo, Homs, and Eastern Ghouta. The northwestern region, which remains the last standing opposition-controlled area in Syria and a vital refuge for millions of civilians who are afraid of and refuse to be in government-controlled areas, will face similar deprivation and retaliation if it is made to depend on cross-line humanitarian operations only.

According to the Humanitarian Needs Overview, the United Nations and its partners delivered humanitarian aid to 2.4 million individuals monthly, which falls short of meeting the needs of 3.4 million people in the northwest. Multiple modalities were used to scale up aid delivery, such as increasing the humanitarian aid flow through the cross-border and delivering through the cross- line operations. Still, even with this increase, the full needs of the population could not be met. Without a comprehensive strategy to implement a fair and equitable cross-line aid delivery that is adequate in size and scope, the cross-line cannot serve as an alternative to cross-border operations.

Recommendations

The health workers and experts interviewed by PHR emphasized that, for planning and staffing purposes, long term strategies that provide permanent solutions to the lack of medical supplies and services in northern Syria are necessary to ensure regular availability of, and access to, adequate health care in the region.

Given the shortcomings of cross-line humanitarian assistance between the Syrian government and non-government-held territory, comprising northwest Syria, northeast Syria, and Turkish- controlled areas, efficient delivery of humanitarian assistance to northern Syria must continue through the cross-border to meet population needs. Unless a holistic plan is designed that allows gradual and monitored integration of cross-line aid in the northwest, as well as mobilization of international humanitarian organizations, closing the Bab al-Hawa border in July will have dire consequences on the health of millions of Syrians.

PHR calls on the parties concerned to take the following actions:

To UNSC Member States:

• Authorize the renewal of cross-border resolution 2165 to maintain the Bab al-Hawa border crossing in northwest Syria beyond one year;
• Reopen the Bab al-Salam and al-Yarubiya border crossings to meet the demonstrated need of the population, considering Syria’s failing health system and the gravity of COVID-19 pandemic; and
• Call upon the Syrian government to ensure the delivery of aid and allocation of health services so that the WHO and other UN agencies, as well as humanitarian organizations and local actors, can reach populations in a neutral, effective, and equitable manner.

To the Syrian Arab Republic:

• Comply with minimum standards for coordination of humanitarian health system rehabilitation to avoid inequitable access to health care;
• Adopt transparent measures to prevent diversion of assistance;
• Provide donors with accounts of aid distribution in areas under the control of the Syrian government, including COVID-19 access to training, testing, PPE, equipment, treatment, and vaccines; and
• End attacks on health care workers, facilities, and transports.

*The number of UN inter-agency cross-line convoys was updated on June 14, 2022.

Physicians for Human Rights (PHR) welcomes and congratulates Dr. Ashish Jha on his new position as the White House Coronavirus Coordinator, which he began this month. PHR is grateful for Dr. Jha’s service on our Board of Directors and wishes him well in this critical role.

Dr. Jha takes up this new role at a pivotal moment, as the United States is again seeing an increase in new COVID-19 cases and the total US death toll from the pandemic nears the one million mark. The recent shortsighted decision by a federal judge to strike down federal mask–wearing mandates risks undermining the Centers for Disease Control and Prevention’s (CDC) authority, as well as the ability of the federal government to respond to the evolving pandemic.

In that context, PHR takes this opportunity to present six key COVID policy positions and recommendations for the U.S. government:

“Follow the Science”

From the earliest days of the pandemic, PHR has urged political leaders to “follow the science” to ensure that administration policy is rooted in the best possible public health and scientific data. We encourage the Biden administration to stand firm in support of public health data and expertise when crafting administration policies on any future updates to recommendations regarding mask-wearing, social distancing, or contact tracing as the pandemic continues to evolve.

Global Vaccine Equity

While PHR applauds the Biden administration’s efforts thus far to promote widespread access to and adoption of COVID-19 vaccines, it is clear that more work is needed to secure global vaccine equity. As of now, just over 65 percent of the U.S. population is vaccinated, and vaccination rates have been declining over the last two months. The United States must also leverage its political influence with other vaccine-producing countries to support the World Health Organization’s (WHO) international COVAX effort to vaccinate the world, while also emphasizing an equity lens to prioritize access to developing countries, countries or regions in conflict, and displaced or marginalized populations.

PHR urges the Biden administration to continue to engage vaccine-hesitant communities with any and all tools at its disposal and to develop new initiatives to address vaccine hesitancy and the low uptake of the recommended booster shots.

Vaccine Production and Distribution

With the immense public financial backing behind COVID-19 vaccine development, the U.S. government has unique leverage to push major pharmaceutical companies to waive intellectual property restrictions, share their know-how, and help boost global vaccine production capacity.  PHR encourages the White House to champion global efforts toward building the greatest possible global vaccine production capacity and the equitable and urgent distribution of vaccine doses around the world.

Disinformation

Despite the wealth of data and scientific consensus around the key pillars of the public health response to the pandemic, a small but vocal group of health professionals continues to sow fear and doubt through the promotion of misinformation or disinformation about COVID-19 and its impacts, vaccines, and public health measures to curb the spread of the virus. PHR calls on leading public health officials and the White House to combat disinformation in all its forms publicly, through new federal government initiatives, and via collaborative work with states, professional organizations, and experts in the field.

Threats to Public Health

PHR is gravely concerned about steps taken by some judges, as well as state and local governments across the United States, to weaken public health institutions and funding and to muzzle or restrict scientists and public health officials. This destructive effort against public health more broadly, which extends beyond efforts to combat the COVID-19 pandemic, poses a significant, long-term threat to public health in the United States. PHR urges the Biden administration to safeguard public health professionals and institutions across the country and to continue funding public health departments and initiatives. We further urge the White House to support the reversal of restrictions that have recently been enacted, such as efforts in some states to undermine or resist vaccine mandates, andother legislative efforts to restrict public health officials’ authority during future pandemics or public health emergencies.

Title 42 Expulsions

For more than two years, the CDC and successive White House administrations have used the Title 42 public health order to justify expelling asylum seekers along the U.S. southern border without properly evaluating their fear of being returned to persecution, as required by international and U.S. asylum law. While we welcome the CDC’s recent announcement that it will terminate the Title 42 order on May 23, PHR is deeply concerned about proposals already being presented in Congress to re-institute a Title 42-like policy to categorically block migrants and asylum seekers on baseless public health grounds.

The United States has the tools in place to mitigate public health concerns while safely, humanely, and efficiently processing asylum seekers at ports of entry through mask wearing, hand washing, social distancing, testing, vaccination, and avoiding congregate settings. The Biden administration should take steps to present a comprehensive plan to ensure safe, orderly, and just processing of asylum seekers in the weeks leading to the conclusion of Title 42, utilizing the full range of public health tools and support from both government bodies and civil society.

The COVID-19 pandemic remains far from over and the U.S. government must continue to play a leadership role in this consequential time. As Dr. Jha begins his new role, PHR hopes that these six policy priorities will continue to inform the Biden administration’s policy for the ongoing U.S. response to the pandemic. PHR stands ready to advise and support meaningful progress in these critical policy areas.

Executive Summary

When the news broke in 2018 that the U.S. government was forcibly separating thousands of parents and children as young as infants at the U.S.-Mexico border, nationwide outcry ensued due to the evident trauma caused by the separations. Physicians for Human Rights (PHR) found that the cases of forcible family separation by the U.S. government that we documented constituted torture. PHR’s torture finding was cited by the Biden campaign during the 2020 U.S. presidential election. However, as the election passed, uproar and outrage around family separation abated, but parents and children who were eventually reunited struggle to recover from severe psychological effects of the trauma they endured. Parents who were deported and separated from their children for three or even four years continued to suffer and wait in desperation for the moment when they could be with their children again. 

This study documents the longer-term psychological impact of this inhumane policy of forced separation on parents who were deported by the United States government, most of them separated from their children for three to four years. The persistent and damaging psychological effects documented by PHR call out for acknowledgement, accountability, redress, and rehabilitation. This study also seeks to make visible the desires of the parents who were interviewed regarding means of redress owed to them by the U.S. government. In the context of a broad discussion about redress, it is essential that the views of affected communities be directly incorporated into research and policy recommendations.

Reparation is not a policy choice; it is the fulfilment of the U.S. government’s obligation owed to victims as a result of its unlawful breach of international and domestic law.

PHR researchers conducted a content analysis of 13 psychological evaluations by PHR-affiliated expert clinicians who interviewed parents deported after being forcibly separated from their children by the U.S. government in conjunction with the “Zero Tolerance” policy. These forensic evaluations are conducted in accordance with the principles and methods of the UN Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (known as the “Istanbul Protocol”). The parents were all clients of a collaborating partner, Al Otro Lado, a civil society organization based in Tijuana, Mexico that provides legal representation to refugees, asylum seekers, and other migrants. At the end of the evaluation interview, the clinicians asked a few additional questions concerning parents’ wishes regarding accountability and redress.

According to the affidavits reviewed by PHR, all 13 parents interviewed had arrived with their families to seek asylum in the United States and were forcibly separated from their children, almost all in unexpected and chaotic ways. U.S. immigration officials conducted the separations in a brusque and cold manner and did not offer information about the reason for the separation or the process, causing great distress to both parents and children. In 10 out of 13 cases, parents describe not being given proper information, or any information at all, about why they were being separated, where their children would be taken, or for how long. In all but one case, the government initially failed to provide information to parents about where their children were, for weeks or even up to two months. Most of the parents were deported to dangerous situations. Over half of the parents (7 out of 13) reported that they continue to live in constant fear of persecution and hiding from gangs or cartels who threatened them before.

Although in most cases the separation had taken place several years before, the parents’ despair was evident in the reporting of current symptoms at the time of the PHR evaluation. Almost universally, parents noted continued disturbances in sleep, nightmares, loss of appetite, loss of interest, fear for the future, constant worry, hopelessness, and loss of the ability to concentrate. One mother said, “I don’t know if I will ever be able to recover from what I have experienced.” 

For parents and children, the trauma is ongoing and the possibility of healing remains elusive, as, despite many promises of change, policies of the Trump administration are still being enforced.

Almost all of the affidavits documented a diagnosis of post-traumatic stress disorder (PTSD) (11/13), which means that their symptoms persisted for more than a month and continue to interfere with their daily life, while the remaining two parents displayed symptoms of PTSD just below the clinical level.  Other diagnoses, according to PHR clinicians, included: major depressive disorder (10/13), generalized anxiety disorder (5/13), trauma related disorder (1), and adjustment disorder with mixed anxiety and depressed mood (1). Indications that the forced separation event played a significant role in mental health outcomes included symptoms directly related to the separation event, such as nightmares and flashbacks about the separation event, crying or other forms of distress when describing the separation or talking about their children, or being triggered by related stimuli. Many parents subjectively described the separation event as the worst thing they had ever experienced, even compared with other severe forms of trauma, such as assault. In virtually every case encountered, PHR’s expert evaluators noted that the trauma suffered by the parents and the children warranted further intervention and ongoing therapeutic support, because the events were causing “significant distress” and ongoing functional impairment.

As in the 26 cases documented in PHR’s 2020 report on family separation, PHR concludes that each of the 13 cases documented for this study constituted torture and temporary enforced disappearance. In response to these U.S. government abuses and subsequent psychological effects, parents called for a formal public apology by the government, an investigation such as a truth commission, financial compensation and funding for rehabilitation expenses, legal reforms to prevent repetition, and, importantly, permanent immigration status in the United States, to ensure that they would not be separated from their children again. These measures are all strongly supported in international human rights law, which requires states that inflict torture to ensure prompt and effective remedies for victims and survivors. Reparation is not a policy choice; it is the fulfilment of the U.S. government’s obligation owed to victims as a result of its unlawful breach of international and domestic law. International treaties ratified by the United States require that states provide remedy, rehabilitation, and redress to survivors of torture and enforced disappearance and to their affected family members.

Key Recommendations

The U.S. Administration, Department of Justice, and Department of Homeland Security should: 

Provide redress to victims who suffered harm through forced separations in line with U.S. law and international treaty obligations:

• Immediately reunify all families separated by the U.S. government and prohibit the separation of families arriving together at the U.S.-Mexico border;
• Work closely with Congress to ensure that families have a pathway to remain permanently in the United States with their children so they will have security from the traumatization of another separation, and because the harm they suffered should qualify them for immigration status as a form of restitution;
• Provide redress through prompt, fair, and adequate monetary compensation as damages for the physical and mental harm families suffered, for medical and rehabilitation expenses, and for legal assistance, and ensure that reparations are timely by returning to global settlement negotiations;
• Fund rehabilitation of family members according to the World Health Organization definition as including medical, social, educational, and vocational measures for restoring the individual to the highest possible level of functional ability; and
• Recognize the illegality and unconstitutionality of the forced family separations, in court and in a formal public apology, and consult with families regarding a full investigation to document what happened.

---

Introduction

When the news broke in 2018 that the U.S. government was forcibly separating thousands of parents and children as young as infants at the U.S.-Mexico border, nationwide outcry ensued due to the evident trauma caused by the separations. Physicians for Human Rights (PHR) found that the cases of forcible family separation by the U.S. government that we documented constituted torture. The cruelty of the separations as a response to families seeking asylum in the United States was a searing example of immigration enforcement abuses and galvanized public discussion demanding humane reforms. Indeed, PHR’s torture finding was cited by the Biden campaign during the 2020 U.S. presidential election. However, as the election passed, uproar and outrage around family separation abated, even though likely in excess of one thousand children remain separated from their parents at the time of this writing.^[1] Parents and children who were eventually reunited struggle to recover from severe psychological effects of the trauma they endured, while parents who were deported and separated from their children for three or even four years continue to suffer and wait in desperation for the moment when they can be with their children again.

Post-election, the political discourse in the United States shifted from compassionate campaign promises to vicious backlash against any support being offered to separated families. Right-wing media outlets and politicians blamed victims, showering vitriol on families as though they had deserved those abuses and castigating the government for even considering settling for damages.^[2] Meanwhile, an administration which campaigned on a pledge to bring justice to the families turned against them in federal court, arguing that the families were not entitled to any compensation.^[3] A central question at the heart of these discussions is: What does a state that commits torture owe its victims under domestic and international law? The persistent and damaging psychological effects documented by PHR call out for acknowledgement, accountability, redress, and rehabilitation.

This study documents the longer-term psychological impact of this inhumane policy of forced separation on parents who were deported by the United States government, most of them separated from their children for three to four years. The extreme suffering of the victims of these policies has largely disappeared from the public eye, especially the trauma of those deported to other countries, even as their children remain in the United States. For parents and children, the trauma is ongoing and the possibility of healing remains elusive, as, despite many promises of change, policies of the Trump administration are still being enforced. This study also seeks to document and make visible the desires of the parents who were interviewed regarding means of redress owed to them by the U.S. government. In the context of a broad discussion about redress, it is essential that the views of affected communities be directly incorporated into research and policy recommendations.

Background

Presidential campaign promised family reunification

In the wake of the Trump administration’s drastic changes to the immigration system, the Biden campaign ran on a message of restoring humanity to U.S. immigration policy, pledging to “welcome immigrants in our communities” and “secure American values.”^[4] Condemning the cruelty of the Trump administration during the final presidential debate, then-candidate Joseph Biden stated that forced family separation “violates every notion of who we are as a nation,” saying, “it’s criminal.”^[5] The Biden campaign cited PHR research findings that the forced family separations documented under the Trump administration constituted torture,^[6] and pledged to end those practices.^[7] One of the Biden campaign’s concrete promises was to issue an executive order to establish a White House task force on family reunification.^[8]

Reunification Task Force faces challenges

The Biden administration fulfilled its campaign promise to establish an Interagency Task Force for the Reunification of Families. The Task Force’s mandate is to identify all children separated from their families at the U.S.-Mexico border pursuant to the Trump administration’s “Zero Tolerance” policy and related policies which were in effect between January 20, 2017 and January 20, 2021.

As a first step, the Task Force undertook a review of government records to assess how many families were separated and what happened to them. By September 2021, the Task Force, relying on the information from the ACLU’s Ms. L class action lawsuit that ruled that the government must reunite families, identified at least 3,951 children who had been separated from their families between July 1, 2017 and January 20, 2021.[9] Due to systemic U.S. government failure to provide translation into non-Spanish languages,[10] indigenous families are especially at risk of family separation and delayed reunification.[11] However, because the U.S. government does not recognize citizenship of indigenous nations, it records nationality only by nation state and not indigenous territory; it is therefore difficult to know exactly the total number of indigenous children and parents who were separated.[12]

Progress towards reunification has been slow. As of December 2021, according to the Family Reunification Task Force, only 100 children have been reunited with their parents in the United States by the U.S. government.[13] Some 132 individuals have registered for reunification consideration, and 94 cases are under review for eligibility, but at least 1,841 children have still not been reunified with their parents, according to the Task Force. Some 2,187 children were independently reunified with their parents in the United States pursuant to the court order in Ms. L.[14] However, the fate and whereabouts of all children and parents, and even the complete tally of affected family members, cannot be confirmed. Challenges in the reunification process have included poor record keeping by the Trump administration and limited funding for government efforts, as well as deep parental mistrust of the reunification process after their traumatic experiences with U.S. immigration authorities.[15] There is also not yet a long-term immigration option for deported parents, who have thus far only been offered three years of humanitarian parole in the United States to reunite with their children.

At least 1,841 children have still not been reunified with their parents, according to the Family Reunification Task Force.

Through negotiations with the ACLU to settle the Ms. L lawsuit, the Task Force has launched a website for families to make contact with the U.S. government and a reunification hotline in partnership with Kids in Need of Defense and the United Nations High Commissioner for Refugees (UNHCR), funded by the State Department.[16] UNHCR and local NGOs are partnering to contact families in their home countries and visit local communities for outreach. For now, the International Organization for Migration is assisting some deported parents and children with travel arrangements to the United States, although gaps still remain for some family members who do not qualify.

The Task Force has stated that it is working with various Congressional offices to establish a long-term immigration status option, as yet undefined. Thus far, there is no solution, leaving parents vulnerable to deportation when their three-year grant of humanitarian parole ends. A Congressional bill proposes to provide a pathway to permanent residence for separated and reunited families; it was introduced in May 2021 and has yet to come to a vote.[17] 

The Justice Department defends the family separation policy in Federal Court

Advocates were shocked and heartbroken when, after months of talks with legal counsel for the families, on December 16, 2021, the Biden administration abandoned settlement negotiations with separated families on their claims for damages in civil court. Families are entitled to file suit under the Federal Tort Claims Act and to ask the court to award damages for the severe psychological suffering the government caused by the separations.

Confidential details from the negotiations regarding a possible settlement amount were leaked to media outlets and were met with an immediate backlash from anti-immigrant groups and Republican lawmakers. When asked about the possibility that separated families could receive payments of several hundred thousand dollars, President Biden said that the news reports were “garbage” and “never going to happen” – assertions later walked back by White House staff, who nevertheless confirmed that the government preferred a lower dollar figure.[18] President Biden later stated that the separated families “deserve some compensation, no matter the circumstances.”[19] However, instead of reaching a unified joint settlement agreement with the affected families, the administration has opted to defend the separations in court, even though many parents do not have the money to pay for attorneys to represent them and the trials will force them to relive their trauma in protracted, adversarial court proceedings.[20] Contrary to its campaign rhetoric, since January 2022, the Biden administration has argued – seemingly for political reasons – that the families are not entitled to any compensation and that reasonable officials would not have understood at the time that the family separations were unconstitutional.[21]

Parents who were deported and separated from their children for three or even four years continue to suffer and wait in desperation for the moment when they can be with their children again.

Prior court rulings requiring the government to reunify families[22] and to provide mental health services to affected families[23] are still in effect. A California-based nonprofit, Seneca Family of Agencies, was awarded a federal contract to contact separated families and connect them with mental health counselors; thus far, they have connected with more than 1,300 families, and linked them to more than 540 mental health providers across 39 states.[24]

Inhumane treatment of immigrants and family separations continue

Progress on restoring access to asylum at the border has also been slow or non-existent. The administration has touted statistics showing that it has reduced the number and duration of unaccompanied children in U.S. Customs and Border Protection (CBP) facilities, reopened the Central American Minors program[25], and sought to end the Migrant Protection Protocols (MPP), or “Remain in Mexico” policy, by processing more than 11,900 people to reenter the United States so that they might pursue their immigration cases. However, in August 2021, a federal court ruled that ending MPP without a public comment period violated administrative law and ordered the administration to resume the policy, although its implementation has already resulted in 1,544 publicly reported cases of murder, rape, torture, kidnapping, and other violent assaults against migrants, including children, and has also been associated with traumatic family separations.[26] As of publication, summary expulsions based on a misapplication of a U.S. health law, Title 42, continue to deny asylum without due process to hundreds of thousands of migrants at the border, using the pretext of public health imperatives in response to the COVID-19 pandemic, although the Centers for Disease Control and Prevention has stated that it will stop authorizing expulsions on May 23, 2022.[27] Public health professionals have roundly condemned the policy as lacking a public health basis. Title 42 expulsions have also been linked with traumatic forced family separations by the U.S. government.[28]

Asylum seekers, traditionally, have been a hard-to-reach population when it comes to research, particularly those in detention centers or waiting in make-shift camps across the U.S. border. Even harder to reach are those who have been deported to another country, as they return to their homes and are not easily traceable.

Our research team sought to understand the experiences of former asylum seekers who have been separated from their children and deported by U.S. authorities: their perceptions of being separated for a prolonged period from their children, their treatment by U.S. government officials, their mental health status, and their thoughts about what the government owes them as a form of redress for their suffering. This approach puts the personal beliefs of victims of these U.S. government policies at the heart of our analysis and recommendations regarding redress.

Contrary to its campaign rhetoric, since January 2022, the Biden administration has argued – seemingly for political reasons – that the families are not entitled to any compensation.

Methodology

Physicians for Human Rights (PHR) researchers conducted a content analysis of 13 affidavits written by PHR-affiliated clinicians who interviewed parents deported after being forcibly separated from their children by the U.S. government in conjunction with the “Zero Tolerance” policy, as well as asking some additional questions about redress during the evaluation interviews. The research team included PHR staff and volunteer experts, including a family medicine physician, a pediatrician, a child and adolescent psychiatrist, and immigrant rights practitioners.

The parents were all clients of a collaborating partner, Al Otro Lado, a civil society organization based in Tijuana, Mexico that provides legal representation to refugees, asylum seekers, and other migrants. At the time, Al Otro Lado was one of the only legal services providers representing separated parents and families who had been deported. Al Otro Lado partnered with PHR to identify clinicians who are experienced in conducting medical-legal evaluations for their clients as part of ongoing immigration legal proceedings. Nineteen Al Otro Lado clients considered participating in this project. Two clients decided that they did not want to participate and four evaluations assigned to PHR clinicians did not take place due to logistical challenges, such as illness or poor internet connections. In total, 13 clients consented to participate in the evaluation interviews. Clinicians included two psychiatrists, a neurologist, a clinical psychologist, a licensed professional counselor, a pediatrician, an internal medicine and pediatrics physician, an internal medicine physician, a family physician, a family nurse practitioner, a licensed clinical social worker, and a doctoral-level social worker.

These forensic evaluations are conducted in accordance with the principles and methods of the international standards of the UN Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (known as the “Istanbul Protocol”[29]). They are typically requested by legal representatives to document and assess physical and psychological evidence of their clients’ accounts of alleged ill-treatment, persecution, or torture. PHR received anonymized and de-identified copies of those affidavits from the clinicians. 

At the end of the evaluation interview, the clinicians asked a few additional questions concerning parents’ wishes regarding accountability and redress. The interview questions about redress were developed by the research team and included eight questions on a scale that elicited attitudes about forms of reparations, asking if each type of remedy is “not important,” “somewhat important,” “important,” “very important,” or “absolutely necessary” and then providing an option to explain why they assigned that rating to each measure. The additional questions included all the measures of reparation from the UN Basic Principles and Guidelines on the Right to a Remedy and Reparation for Victims of Gross Violations of International Human Rights Law, including restitution, guarantee of non-repetition, financial compensation, rehabilitation, and satisfaction.[30] Translation of the additional questions into Spanish was reviewed by a native Spanish speaker on the research team and a native Spanish speaker who is a forensic psychologist to ensure that the wording was clear, accurate, and also understandable to people with different levels of education.

The psychological evaluations and the answers to the additional questions about redress were intrinsically linked in the analysis because the psychological suffering, and the manner in which it was inflicted, underscore the legitimacy of the parents’ claims and inform the nature of the appropriate remedy. A content analysis methodology was selected to identify themes and sub-themes in the clients’ narratives, quantify and count types of trauma experiences of the deported asylum-seeking parents, and examine their perceptions of the impacts of deportation and separation on their family members and separated children. The affidavits analyzed included content related to experience pre-migration, during their journey to the United States, while seeking asylum, and following their deportation, as well as the reported experiences of their separated children. Mental health assessments and diagnoses followed common screening and diagnostic instruments and criteria. The parents’ explanations in response to the additional questions about redress were also analyzed using a content analysis approach to explain and interpret the scale results.

A codebook was developed by the research team based on previous experience with qualitative data analysis and codebook creation. The researchers’ experience with migrant parents and children, including those who had been separated, facilitated the creation of the codebook through pre-defining a set of content categories for coding. These included: demographics; harm experienced in their country of origin, during migration, upon arrival in the United States, during detention, and following deportation; and clinical diagnoses, health and mental health conditions, and resilience factors. The database also contained a number of free text boxes to capture any themes that emerged outside of these categories as well as notable quotes from the affidavits.

All evaluation interviews were carried out by PHR volunteer clinicians remotely due to the interviewees’ location in countries outside of the United States. Interviews took place in March and April of 2021. The clinicians were all based in the United States and the deported parents were located in El Salvador, Guatemala, Honduras, and Mexico. Most of the evaluations (10/13) were conducted solely in Spanish with the clinician and client both fluent in Spanish. Two evaluations were conducted with a Spanish-language interpreter and English-speaking clinician. One evaluation was conducted in Spanish with a Maya K’iche’ interpreter who provided interpretation as needed. It was up to the parent to decide which language they wished to use in the evaluation. Evaluations were written up in English, based on clinician or interpreter translation.

PHR received the de-identified affidavits from the clinicians electronically, and the documents were stored in a password-protected folder accessible only to select PHR research staff. PHR staff worked with two external evaluators, both experienced clinicians. The data accessible to the research team was de-identified and anonymous.

The accounts below are taken from the clinicians’ expert affidavits. Direct quotations from parents are only included if present as direct quotes in the clinician’s evaluation. Citations from the written affidavit are represented as direct quotes from the clinician.

This research plan was reviewed by the University of Michigan Institutional Review Board and designated as exempt as defined by Title 45 CRF part 46 provisions for protection of human subjects. It was also approved by the Physicians for Human Rights Ethics Review Board.

Limitations

Our study has several limitations. This is a secondary analysis of pre-written affidavits, and the research team did not interview the separated and deported parents themselves. Second, the interviewing clinicians did not use structured or standardized forms to collect the information, as the evaluations were conducted according to general Istanbul Protocol principles. As a result, the type of information at times varied between evaluators, meaning that the data set is not uniform. Finally, none of the researchers or clinician evaluators were indigenous and there was no indigenous representation in the University of Michigan Institutional Review Board or PHR Ethics Review Board.

Importantly, the parent cohort is not a representative sample of all deported and separated parents. It is a self-selected intensity sample[31] of affected individuals who were receiving legal services from Al Otro Lado, and who were referred for physical or psychological evaluations for the purpose of this research project. The sample included mostly Spanish speaking individuals, only one of whom asked for translation into Maya K’iche’ language. It is possible, therefore, that this is a cohort of individuals with higher needs or more apparent trauma. It is also a group that includes only individuals with legal representation, and, as such, they may not be representative of the larger cohort who may not have access to legal representation or community-based resources. However, given the characteristics of this population – hard-to reach individuals dispersed across a large geographical area, across several countries, who are highly traumatized and living in hiding – the affidavits and answers to questions about redress, though relatively small in number, afforded PHR the opportunity to analyze rich content, to explore in depth the lived experience of people harmed by the United States’ policy of family separation and subsequently deported, and to deepen our understanding of the experience of people affected by this inhumane policy and what they now seek by way of reparation. 

Findings

Demographics

The medical-legal affidavits involved 13 separate family separation cases, from evaluating eight mothers and five fathers. Most of the parents (11/13) were not reunited with their children at the time of evaluation and had been separated for extended periods, for three years (9/13) or four years (2/13). Two of the parents were separated from their children for a number of months while in U.S. government custody (five months and eight months) and then were deported together with their children.

At the time of the evaluation interviews in March and April 2021, the parents reported a variety of living situations; some were living with family and some were living alone after deportation. One father reported moving between relatives’ houses to avoid being found by drug traffickers, a mother reported living with an aunt in another town to avoid detection by gang members, and one mother stated that she was living in a group shelter for migrants. By the time of writing, through the work of the families’ legal counsel, 10 of the parents have since been reunited with their children and are now living in the United States.

[One] mother recalled agents showing up at her cell and saying, “We are taking the children away.” It has been three years since that day and she still recalls vividly how her son cried, terrified, “Where are they taking me?” That was the last time she saw her son.

Out of the 13 parents, 11 reported that they had been threatened, extorted, or otherwise harmed by gang or cartel members, including gang members working as smugglers or drug traffickers, which had caused them to flee to the United States along with their children. Two women reported having experienced intimate partner violence in addition to gang violence. The remaining two mothers mentioned having been sexually harassed or assaulted, and threatened against reporting the violence, by community members (a taxi driver and a neighbor). In most cases, parents described targeted threats having been made against their children, including threats of kidnapping or sexual violence at gunpoint. In a handful of cases, children actually had been kidnapped or assaulted before parents had decided to flee to the United States, in one case a “near murder,” and in another case gang members approaching in cars had opened fire on a father and his son in a field where they were farming. Three of the parents identified as belonging to indigenous groups (one of whom was a farmers’ collective advocate). An indigenous father’s family had already fled Maya K’iche’ territory in Guatemala to seek refuge in Yucatec Maya territory in Mexico where they had continued to be persecuted. Three of the parents were small business owners (dental practice, bus company). Some of the parents had relatives in the United States which put them at risk of being targeted for kidnapping for ransom. After having fled these harms in their country of origin with their children, they had then been separated from their children by the U.S. government and eventually deported.

Other demographics are shown in Table 1.

Table 1: Demographic statistics

Dimension	n
Country of origin
Honduras	5
Guatemala	4
El Salvador	1
Mexico	3
Parent age ranges
Female (32-50)	8
Male (33-52)	5
Separation
Age of children they were separated from	Range from 6 to 20 years old
Duration of separation	Range of 5 months to 4 years

Manner of the Separation

According to the affidavits reviewed by PHR, all 13 parents interviewed had arrived with their families to seek asylum in the United States and were forcibly separated from their children, almost all in unexpected and chaotic ways. U.S. immigration officials conducted the separations in a brusque and cold manner, which increased the trauma inflicted, and did not offer information about the reason for the separation or the process, causing great distress to both parents and children. A mother recalled how she was woken up at 3 a.m. to answer questions about her daughters, was ordered by the agents to sign documents in English that she didn’t understand, and 15 minutes later was taken to a detention center and separated from her daughters. She begged them not to separate her from her children, but they only said “No, we are going to send you to jail.”  Another mother interviewed recalled agents showing up at her cell and saying, “We are taking the children away because the children can’t be here per orders.” It has been three years since that day and she still recalls vividly how her son cried, terrified, asking “Where are they taking me?” That was the last time she saw her son.

In another instance, a father and his son were told to get in different lines, one for adults and one for children. No explanation was given, they were only told that was the way apprehensions were processed, and they had no choice. He recalled seeing his son crying through a window of his cell, which broke his heart, as his son rarely cried. This father had no idea that would be the last time he would see his son, so he never got to say goodbye.

No Explanations Were Given to Parents at the Time of Separation

In 10 out of 13 cases, parents describe not being given proper information, or no information at all, about why they were being separated, where their children would be taken, or for how long.

During one of the interviews, a mother recalled crying the moment she was being separated from her two daughters: “I saw them one last day and then they were taken away.” Immigration officials told her she could not have information about her daughters, only that she was going to be deported. “They would not tell me anything,” she said.

A father spoke about not being able to get any information from detention facility guards, despite asking them about his son multiple times every day.

A mother described how a detention officer noticed her crying after the separation and reprimanded her for “putting her child in danger.”

Three out of 13 of the parents interviewed noted that, at the time they were separated from their children, immigration agents only made a vague reference to changes in policy.

One mother shared with the clinician who interviewed her how she was in shock and speechless, unable to believe what she was being told to do. At that moment she began to cry and asked the agents “Why are you going to separate me from my daughter?” The agent reportedly responded, “The one who gives orders is the president. There is nothing I can do.” She pleaded, “There must be something I can do. My daughter has been suffering her whole life, and now she will suffer even more!”

When another mother asked agents why they were separating families, an agent only responded, “Don’t you watch the news?”

A third parent reported only being told that the “law had changed” and so they were going to separate her from her children.

In another case, the parent was told she would be separated from her daughter until the issue of her prior deportation could be investigated.

Three of the 13 parents reported being given papers in English to sign at the time of separation which they did not understand. When one father asked for a translation, wanting to know what the paper said, the agent only said, “Just sign it! Just sign it!” He then told another officer “Dude, this guy doesn’t want to sign it. Separate him from his kid. This guy is not following the rules.”

Unknown Locations of the Parents and Children

In all but one case, the government initially failed to provide information to parents about where their children were. In the one instance where a mother had been told that her two children were being sent to a separate detention facility, she was also told that her brother would be able to pick them up the next day. It turned out that one of the children did end up with that uncle in Illinois, but the other child was held for months in detention, as he had a medical condition requiring surgery and they would not release him until this surgery was complete. The mother reported that the child cried on the phone to her that he did not want the surgery.

In all of the cases where the locations of parents and their children were eventually disclosed, the children ended up in the United States with relatives and the parent was initially detained for some period before being deported. There was a notable lack of commentary in the affidavits on the initial location of the children, likely because the children never knew where they were initially taken and so the parents were unable to report it in the affidavit.

Lack of Contact between Parents and Children

A defining point in each affidavit reviewed was when the parents reported the lack of contact with their children after being separated and their subsequent feelings of despair. Six out of 13 affidavits mention that when parents in immigration detention asked guards or immigration officials about the whereabouts of their children, they didn’t receive answers for weeks – in one case, they had no contact or information for two months. One mother explained that the authorities could not tell her anything about where her children were. She continued to ask questions, but then eventually stopped asking “because they were angry with me.” In another instance a mother said, “I was detained, they did not tell me anything about him, I thought I would never see him again, I could not do anything else but cry, I felt I was going crazy.” She noted that she was detained for one month and “every day was the same. They told me my son was OK, but they did not let me talk on the phone.”

One mother reported feeling “desperate and terrified” that her children were not well. In two out of 13 cases, parents contemplated taking their lives. One father reported that he had contemplated suicide because of extreme anxiety from the lack of contact and from worry, and when he was finally able to speak with his son on the phone, the first few times he could not understand anything his son said because the child was crying too much.

In one instance, a mother reported how the distress she felt due to the separation impacted their legal cases. This mother had a “credible fear” interview by telephone.[32] The interview only lasted about 20 minutes and she did not have an attorney. She felt that she was barely able to explain what had happened to her because the interview was so short. She emphasized to the asylum officer that “she needed to know where her daughters were, that she felt desperate and terrified that they were not well.” She found it hard to focus on explaining her case because she wanted to learn about her daughters. When she wanted to add information about her own case, the asylum officer did not give her the time to do so.

Separated Parents Lose Hope after Extended Detention and Lack Access to Representation

After facing months of detention under poor conditions and deteriorating mental and physical health, three of the parents evaluated by PHR clinicians reported accepting their deportation. One parent described having to navigate the U.S. immigration system without legal representation: he told the clinician that he did not want to represent himself at his bail hearing, but his legal representative was asking the “exorbitant” fee of $10,000 and he could not afford it. In immigration court proceedings, asylum seekers have the right to an attorney, yet the U.S. government is not obligated to provide one for those who cannot afford to pay. After approximately a year in detention in poor conditions and worsening mental health, a father recalled, “I spoke with my daughter, and told her I am going to leave so you can get out. She said ‘No, keep trying, keep fighting’ but I felt stuck. I felt scared.” Another mother reported to PHR that she wanted to appeal the judge’s denial decision, but she was told by an officer that if she wanted to appeal the denial, it would take months and she would have to stay in jail in the meantime. She said that the guards treated her so rudely and the conditions in the jail were so terrible that she lost hope.

One father reported that he accepted deportation because he was so filled with “worsening fear and dread” at not knowing his son’s whereabouts and thought he might have a better chance in Mexico finding out where his son was, rather than in U.S. immigration detention.

According to the narratives captured in the affidavits, in some instances (3 out of 13), U.S. authorities gave some parents deportation documents to sign in English without translations. Not knowing what the documents stated, parents ended up signing their own deportations, often not aware of what they were agreeing to or the consequences. In one case, a parent described being given a series of papers to sign while in detention, as the clinician wrote in the affidavit, “he kept thinking the papers he was signing were leading to his early reunification with his son and possible early deportation back to Guatemala.” Instead, he continued to be separated for a period of eight months before eventually being deported together with his child. Another mother interviewed shared how, days after requesting an appeal before the judge, a guard came with papers for her to sign sent by the judge. As described by the clinician, “the papers were in English, and she was told they were related to the appeal process. She learned after signing that she had signed her own deportation papers as she was being returned to her home country.”

Parents Feel Desperate and Helpless upon Return to Home Countries

In three of the cases reviewed by PHR, clinicians reported the parents feeling helpless, disoriented, stressed, and alone after arriving back to their countries of origin. One mother recounted how “her daughter was angry that she returned to Guatemala without her.” The mother could not bear the separation from her daughter, and in an attempt to join her daughter in the United States she crossed the border again, but was again apprehended and deported to Guatemala to travel back to Maya K’iche’ territory.[33] Another mother described spending much of her time feeling that she had given up on her children. In her words, “I surrendered. I miss my children so much. I feel very stressed, very alone. I ask God to help me. I feel that every moment that passes I am missing being with them. We try to speak twice a week but it is hard because the internet is very expensive.”

Parents Continue to Live in Fear of Persecution and Face Threats from Gangs

More than half of the parents (7 out of 13) reported that they continue to live in constant fear of persecution, and to live hiding from gangs or cartels who have threatened them before. Five of those parents were not able to return to their hometowns and have internally relocated, while the others have restricted movement and are too scared to leave their houses. As a father recounted, “I am afraid to go back to my town. Here in Guatemala, once [gangs] have threatened you, they always carry out those threats. I am afraid that they will learn that I am here, they will come and hurt me.” He continued, “I have constant nightmares that I am drowning in a river, that something bad is happening to my children.” Another parent reported that when he returned home, his house had been ransacked. Not daring to live there, he has since moved between relatives’ houses, where he hopes the drug traffickers will not find him.

Two of the parents interviewed by PHR clinicians describe receiving threats from gangs again after having been deported back to their home countries. One mother shared that because she was afraid of the threats she had received at her former office and home, she went to live with her father in another part of town. Afraid gangs would find her, she did not go back to her previous job. Months later, her husband, by then at a new job, began to receive threats demanding money and goods, just as they had experienced before seeking asylum in the United States. Another parent from Guatemala shared that he and his son are still not safe, as every day he continues to be targeted by people who are trying to kill them and he has had to move in an attempt to find safety within the country.

Physical and Psychological Distress Reported by Parents Due to Separation

A large majority of parents evaluated by PHR experts reported physical and psychological distress that occurred around the time of separation from their child. Commonly reported symptoms included loss of appetite and trouble sleeping. Some parents described feeling weak, while others reported experiencing trembling or “body shaking.” Other physical symptoms reported included headaches, stomach problems, and fainting, all of which can be commonly seen as reactions to stress and anxiety. One woman reported a return of heavy vaginal bleeding, which was previously well controlled; she did not seek medical care due to fear of the kind of treatment she would receive while in detention.

The most commonly reported psychological symptoms around the time of separation from their child included anxiety, sadness, and desperation. As one father described, “[Separation] was so hard. I had never been separated from my child before. It was very painful to be separated from my daughter who had always been at my side.”

Some parents recalled their child yelling and crying while being separated. One parent reported not knowing where her child was for about a week and then learning that the child was crying the entire time. Upon reconnecting with their children via phone or video calls, some parents recalled being unable to have conversations due to their children’s excessive weeping.

The affidavits describe a few physical symptoms during the time of separation – somatic symptoms described were mostly headaches and stomach aches, and one person reported fainting from anxiety – but were remarkably consistent in the psychological symptoms described, both at the time of separation and persisting through to the time of the evaluations. At the time of separation, nearly every participant described feeling anxious, sad, and worried, and most of them reported having decreased appetite along with insomnia. One mother noted that being separated from her daughter felt like something “choking me from the inside.” Another parent stated that the separation felt like physical pain because his son was “part of my heart that was torn away from me.” The despondency was evident through many of their symptoms. One parent said, “I gave up without my children.”

Although in most cases the separation had taken place several years before, the parents’ despair was most evident in the reporting of current symptoms at the time of the PHR evaluation. Almost universally, parents noted continued disturbances in sleep, nightmares, loss of appetite, loss of interest, fear for the future, constant worry, hopelessness, and loss of the ability to concentrate. These symptoms seemed most tied to concerns regarding the effects of the separation on their children’s well-being, as well as worries about their continued safety and future together. One father noted, “The beatings of childhood become scars for life. I know that the government is taking measures to help, but how will they return the years of parental love that my child has missed out on?” Another mother said, “I don’t know if I will ever be able to recover from what I have experienced.”

One father lamented that his child, upon reunification, was a changed person. He reported that he used to be a sweet, soft boy, but after the separation, he is now angry and agitated and does not trust his parents. The father’s feelings of sadness, worry, and hopelessness were very much connected with the effects of the separation on the child’s personality and the toll that it took on their relationship.

Diagnoses Observed and Recorded

All parents were diagnosed by PHR expert clinicians as meeting diagnostic criteria for at least one mental health condition associated with the trauma of family separation, compounded by additional traumatic experiences in their home country, before and after deportation, and during the migration process. Almost all of the affidavits documented a diagnosis of post-traumatic stress disorder (PTSD) (11/13), which means that their symptoms persisted for more than a month and continue to interfere with their daily life, while the remaining two parents displayed symptoms of PTSD just below the clinical level.

To be diagnosed with PTSD, someone must have at least one symptom that causes them to re-experience the trauma, such as flashbacks, one symptom related to avoiding thinking about the traumatic event, two symptoms related to being more highly reactive, such as being easily startled or having difficulty sleeping, and two symptoms related to cognition and mood, such as negative thoughts or memory loss.  The majority of the cases (9/13) had a comorbid diagnosis of major depressive disorder (MDD) in addition to the PTSD diagnosis. Other diagnoses, according to PHR clinicians, included: MDD (10/13), generalized anxiety disorder (5/13), trauma related disorder (1), and adjustment disorder with mixed anxiety and depressed mood (1). Clinicians compared symptoms with criteria from the Diagnostic and Statistical Manual of Mental Disorders and/or used validated Spanish versions such as PCL-5, GAD-7, and PHQ-9, which are used to preliminarily diagnose disorders and assess severity of symptoms.

One clinician also noted concern regarding the impact on a parent’s physical health, stating, “She is also at risk of hypertension and cardiac disease due to family history. These are both conditions that worsen with acute and chronic stress exposure and she would have increased risk of developing these conditions if re-exposed to the triggers listed above [separation and U.S. detention].” Another clinician noted that a mother’s diagnosis of fibromyalgia was “consistent with her reports of stress and her history of trauma.”

The vast majority of clinical assessments determined that the respondents’ mental health symptoms were persistent, due to both ongoing family separation and threats to parental safety in their home country after deportation. Indications that the forced separation event played a significant role in mental health outcomes included symptoms directly related to the separation event, such as nightmares and flashbacks about the separation event (“She has vivid nightmares during which she sees herself back inside detention, separated from her kids again”), crying or other forms of distress when describing the separation or talking about their children, or being triggered by related stimuli, such as feeling distressed when seeing other parents with their children or hearing the word “mother.” As one clinician explained,

“The symptoms of PTSD are necessarily related to the inciting trauma (e.g., the intrusion symptoms consist of intrusive memories of the inciting trauma). Thus, it is typically possible to say with confidence whether or not a given case of PTSD is caused by a particular trauma exposure. Because the cognitive content of Ms. X’s PTSD symptoms are most related to her separation from her children, it is highly likely that her current symptoms are primarily related to the trauma of forcible separation from her children at the border. Because PTSD can be cumulative, it is also likely that the earlier trauma of threats of gang violence in her hometown in Guatemala continue to contribute to her symptoms.”

The other main indications that mental health issues are linked with the separation are the timing of symptom onset and progression or change in severity pre- and post-separation. As one clinician wrote,

“It is my strong clinical opinion that Mr. X has suffered great psychological ill health effects because of the trauma of violence in Mexico, which was exacerbated and changed with the separation of his son.”

Many parents subjectively described the separation event as the worst thing they had ever experienced, even compared with other severe forms of trauma, such as assault. The separation is also an on-going source of trauma, as worries about their children’s current and future well-being are also a source of significant distress, observable during the interviews as parents cried, looked sad, or put their heads in their hands when speaking about their children. The distress is compounded by the dangers that parents face post-deportation in their own countries. One clinician stated,

“It is my professional opinion that based on her presentation and her history, her distress has been a direct result of her adverse experiences in detention and prolonged separation from her child and is further perpetuated by her deep concern for her son’s emotional wellbeing and a fear of potential murder, were her presence discovered.”

Consistency and credibility

The medical experts who evaluated the parents noted that all the individuals they interviewed and observed reported symptoms that would be expected, given the traumatic experiences reported by these parents. Based on the in-depth assessments following evaluations often lasting more than two hours, the experts described the parents as, for example, “entirely credible,” with “no suggestion of having been practiced or coached.”  Their reporting of symptoms was found to be, for example, “consistent with what would be expected as a result of the violence and trauma he suffered,” “highly consistent with the traumatic events she reports,” “no evidence of defensive behavior and no over-endorsement of symptoms,” “described in a fashion that he would not have been able to express had he not actually experienced them,” and “he did not, as in the case of malingering, exaggerate the expression of his distress.”

Gender	Age	Country of Origin	Time between separation and evaluation	Mental Health Diagnosis
Female	32	Maya K’iche’ territory (Guatemala)	2017 to 4/11/2021, 4 years [now reunited and in the United States]	Post-traumatic stress disorder (PTSD) with dissociative symptoms, major depressive disorder (MDD) severe without psychotic features
Female	38	Honduras	2018 to 3/22/2021, 3 years [now reunited and in the United States]	PTSD, MDD
Male	46	Honduras	2018 to time of eval, 3 years [now reunited and in the United States]	PTSD, MDD with anxious distress
Male	53	Honduras	2017 to 4/2021, 4 years [now reunited and in the United States]	Adjustment disorder with mixed anxiety and depressed mood, PCL-5, GAD-7 and PHQ-9 are elevated but do not signify presence of diagnosis
Male	33	Honduras	11/2017 to 3/25/2021, 3 years [still not reunited]	PTSD, positive PHQ-9
Female	30	Guatemala	6/18/2018 to 3/8/2021, 3 years [now reunited and in the United States]	PTSD, screened positive on PHQ-9 and GAD-7-MDD severe, GAD
Male	49	Honduras	3 years [now reunited and in the United States]	“Sub-threshold PTSD” or trauma-related disorder, MDD moderate, mild anxiety on GAD-7
Male	35	Guatemala	8 months [now reunited and in the United States]	PTSD, MDD
Female	41	El Salvador	6/2018 to 4/1/2021	PTSD
Male	38	Yucatec Maya Territory (Mexico)	Still separated at time of evaluation [still not reunited]	PTSD, MDD
Female	48	Mexico	4 years [now reunited and in the United States]	PTSD based on clinical interview, MDD moderate, generalized anxiety disorder (GAD) mild
Female	42	Maya K’iche’ territory (Guatemala)	3 years [now reunited and in the United States]	MDD, PTSD, GAD
Female	45	Mexico	5 months, deported together [now reunited and in the United States]	PTSD, MDD, GAD

Clinical Recommendations

In virtually every case encountered, PHR’s expert evaluators noted that the trauma suffered by the parents and the children warranted further intervention and ongoing therapeutic support, because the events were causing “significant distress” and ongoing functional impairment. The interventions most frequently recommended included “trauma-focused psychotherapy” and supportive therapy, and for psychiatric care to consider treatment with medications. Additionally, multiple experts recommended primary care to address screening health measures that have not been given attention or other medical concerns likely exacerbated by multiple factors such as stress and trauma symptoms, not living in their own communities, fear of accessing services, and unavailability of services in their home country, among others.

Some of the parents and children were able to access mental health services, but many families were not. Said one father, “My family trusted me and I failed them. I want to take my child for psychological counseling, but I don’t have the money or resources. How will he get through this extreme suffering?” A mother in Honduras stated that she cannot afford to see a mental health counselor or psychiatrist despite enduring psychological symptoms. In other cases, the therapy was not helpful due to the ongoing separation. One father described being required to attend therapy in U.S. immigration detention but said his symptoms did not improve because he was so anxious about being separated from his child.

PHR experts commented in all of the cases that symptoms of trauma were unlikely to improve due to continued parental separation from their children, causing reliving of the index traumatic experience, and ongoing safety concerns for the parents in their home countries. For example, an expert commented that a client’s trauma symptoms that “had their origins in this same dangerous environment [client’s home country], are highly unlikely to improve in this context.” In some cases, the medical experts commented that failure to reunify the family could result in further deterioration of mental health conditions, with the risk of suicidal ideation and behaviors in at least one case. In other cases, experts noted that deporting the children back to their home country could pose a tremendous risk to the children’s and parental mental health, due to ongoing risks of violence in their home country.

On a more hopeful note, clinicians noted that reunification with family would be supportive of improved health outcomes. One clinician said, “With treatment and the reunification of his family, Mr. X’s prognosis is good. This is based on factors such as his positive identification as a partner and father; work history; specific goals for the future; and ability to rebound from a dire psychological state over time.”

Parents’ perspectives on reparations and redress

In addition to the documented trauma of these 13 parents, the evaluations conducted also afforded the unique opportunity to engage them on what they thought were important forms of reparation and redress and to provide their reasoning for ascribing that level of importance. This study sought the perspective of 13 affected parents regarding all the main measures of reparation: reunification and immigration status in the United States as a form of restitution and guarantee of non-repetition, financial compensation, medical and mental health treatment as rehabilitation, and measures such as a public apology, investigation, and criminal prosecutions as measures for satisfaction and guarantees of non-repetition.

Long-term immigration status in the United States

All parents expressed that it was essential for them to have long-term immigration status in the United States, with 7/13 parents stating that long-term immigration status is very important and 6/13 saying that it is absolutely necessary. Parents consistently said that being free of the fear of deportation and re-separation was essential for their healing and sense of peace and safety, while being in precarious immigration status would leave them feeling insecure and unsafe, at risk of being returned to danger in their home countries. Said one parent, “Being illegal is not the same. One needs to be calm. If citizenship or legal status could be given so that we can live in peace, and be able to see each other and be together. What happened cannot be forgotten. But if we can be together – me and my daughter – little by little we will be able to forget. There is a possibility of being together if we get legal status.”

Physical and mental health treatment

All parents also put a very high value on provision of physical and mental health treatment for themselves and for their children, with 9/13 stating that it was very important and 4/13 saying it was absolutely necessary. Parents emphasized that they needed resources to ensure their children’s physical and psychological wellbeing, especially after all they had suffered due to the separation. “Physically and mentally, we are in very bad shape due to everything we went through there. I came back with anxiety and depression. I think my children, too.” Parents stated that medical care is very expensive and that they did not have adequate resources to access the care they need, saying that “health is everything” and “health care is a human right.”

Guarantee of non-repetition

All parents agreed that it is essential to ensure non-repetition and to establish laws or mechanisms to prevent forced family separations from ever happening again, with 7/13 stating that this is very important and 5/13 calling it is absolutely necessary. Most of the parents said that they did not want anyone else to go through what they have gone through, a unique and unimaginably painful experience; they also expressed their concern for other separated families, especially for the children. Said one parent, “Unless you have lived through this, you can’t know how unbearable it is. I want to be sure nobody else ever suffers what I have suffered. I hope God touches the heart of the authorities to let us all be together, but in a situation where we are safe.” Another parent said, “Families that come to the border have already suffered, but I never imagined this kind of trauma. My child was 13, but others were 5, 6 years old. I can’t even begin to imagine the trauma they will have for their whole lives. We will never forget. We need to prevent this from even happening again.”

Public apology by the U.S. government

All but one of the parents evaluated felt that a public apology by the government, which acknowledges how inhumane the separations were, was very important (7/13 parents) or absolutely necessary (5/13 parents), because separations violated the sacred bond between parent and child and because the government’s actions were disproportionately harsh, wrong, discriminatory, inhumane, and severely damaged children. One father told a PHR clinician about seeing a separated three-year-old child in detention, chained at the waist, wailing and flailing, while a U.S. government official dragged the child into a bathroom, hitting his head against a glass window. However, one parent said that a public apology by the government is not important because an apology does not make up for the harm done.

Investigation such as a truth commission

Most parents (12/13) believed that a full investigation to document what happened during the forced separations, such as through a truth commission where they could tell their story, was important to some extent. Parents stated that it was somewhat (3/13) or very important (5/13), or absolutely necessary (4/13). Several parents said an investigation is needed to ensure that separations do not happen again, because an investigation would expose the extreme suffering family separation causes; said one parent, “So that it won’t be repeated again, so more parents won’t be separated from their children, so no more children will be separated from their parents, which creates great trauma. It’s a very immense pain. I don’t know if I will be able to ever recover from what I have experienced.” Other parents said that an investigation would compel officials to acknowledge why they carried out the separations and fill an evidence gap, because the separations were not caught on “cameras or tapes;” they said an investigation would provide an opportunity for parents to describe what really happened “through our own words and our own mouth.” One parent felt that an investigation was less important than an apology from the government, in part due to his concern about the re-traumatizing nature of sharing their experiences: “People will not believe how horrible it is unless they experience it themselves. We would have to tell our stories and suffer from telling it, but it would not have much effect. A public apology from the government would be more effective.”

Possibility of criminal prosecution of U.S. officials

Within this small group of parents, there were different perspectives about the possibility of criminal prosecution for those responsible for the family separation policy. Some parents found value in prosecution, with 3/13 saying criminal prosecution was somewhat important, 2/13 saying it was very important and 2/13 saying it was absolutely necessary. Parents in favor said that prosecution would reveal government officials’ reasons for separating families, would make these officials an example, and would force them to face the consequences of their actions, thereby upholding the state obligation to ensure due diligence and justice. Other parents said that said criminal prosecution was not important at all (4/13) or not very important (1/13), or that they were not sure (1/13). Parents told PHR clinicians that they did not want to seek revenge, to “play God,” or to treat others like criminals, especially since being treated harshly themselves had been so painful. Said one parent, “I wouldn’t want to do that – be on trial, fighting. I wouldn’t want people to go through what I went through – being in jail.”

Financial compensation

Almost all parents (10/13) stated that financial compensation as damages for the harm they suffered was important to them (absolutely necessary (5/13), very important (3/13) or somewhat important (2/13)). Parents stated that the money could be used for necessities, to provide for their children, to pay for therapy for their children, and as a form of justice and an acknowledgement of their deep suffering. A couple of parents mentioned their destitution as a result of leaving everything they had in order to seek asylum, being detained for long periods in the United States, and then being deported, making compensation an urgent matter for them. As one parent said, “I’ve been left with nothing – I have nothing now. I need to take my son to get help and I need help, too.” Others highlighted the importance of financial compensation to help their children progress after years of deprivation. As one parent said, “Money could help my son have a future and be successful. He has been separated from me for so long and I haven’t been able to support him.” A few parents said financial compensation was not very important (2/13) or that they were not sure (1/13), mainly because they stated that reunification with their children is the most important.

Hopes for the future

Although every parent interviewed by PHR researchers revealed feeling heartbroken, having profound despair, and being in agony over being separated from their children, several parents (5/13) explicitly displayed an inspiring amount of hope for the future as well as tenacious resilience. These parents revealed that despite feeling constantly worried that they would never see their children again, they remained hopeful that they would one day be reconnected and they took solace in knowing that their children were safer in the United States than in their home countries. One mother, who has been separated from her daughter for more than four years, told researchers that she constantly feared the possibility of being murdered in Maya K’iche’ territory and admitted, “If something happens to me, at least I know that my daughter is safe with my sister in the U.S.” Since being connected with lawyers who are advocating for her right to be reunited with her daughter in the United States, she has glimmers of hope. Yet, she frequently feels that she is powerless and without recourse to fight for their reunion.

Additionally, several of these parents spoke about the pride they felt knowing their children were still able to thrive in school, despite experiencing the trauma of family separation. One father emphasized that he remained hopeful that his 14-year-old daughter would continue to excel in school and do “good things in the future.” Two of the parents shared that they placed their faith in God to reunite them with their children. One father, who was separated from his son, emphasized throughout the interview that his faith in God helped him get through his days and he has largely put his future in God’s hands. One mother, speaking of her son whom she still has not seen since the separation, said, “I have faith in God that I will be with him again.” 

Each of these five more hopeful parents spoke about how the most important thing to them, and their sole motivation for focusing on staying safe and making a decent living in their countries, was to be reunited with their children. One mother, who has been separated from her four daughters for three years, said, “There is nothing more valuable for me than being united with my daughters.” Another father, separated from his 14-year-old daughter, described the possibility of being reunited with her: “Not even knowing that it would be possible, I can’t even put words to how that would feel in my heart. It would be an enormous joy.”

Legal framework

Forced separations constituted torture and enforced disappearance

These 13 evaluations by PHR clinicians were conducted according to the principles of the Istanbul Protocol, the UN manual for documenting torture and ill-treatment. As in the 26 cases documented in PHR’s 2020 report on family separation,[34] PHR concludes that each of the 13 cases documented for this study constituted torture and temporary enforced disappearance.

Torture is defined in the UN Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (CAT) as “any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining … information or a confession, punishing him … or intimidating or coercing him … at the instigation of or with the consent or acquiescence of a public official.”[35] In other words, torture is an act which 1) inflicts severe physical or mental suffering, 2) is done intentionally, 3) is committed for the purpose of coercion, punishment, intimidation, or for a discriminatory reason,  and 4) is carried out by a state official or with state consent or acquiescence. Torture and cruel, inhuman, and degrading treatment violate foundational human rights and are prohibited under domestic and international law in any and all circumstances. In the cases that PHR documented, U.S. officials forcibly separated parents and children, causing extreme pain and suffering, in order to punish, coerce, and intimidate asylum seekers to give up their asylum claims. PHR concurs with other human rights experts who have found that the forced family separations implemented in the United States during the Trump administration meet the legal definition of torture.[36]

Enforced disappearance is defined as any deprivation of liberty by the state where there is concealment of the fate or whereabouts of the disappeared person.[37] In all 13 cases, parents reported that for an extended period of time, as long as two months, they had no idea of their children’s whereabouts or well-being and did not have any means of contacting their children, despite repeated requests to U.S. officials for information. Refusal of U.S. officials to provide information to parents about the location and well-being of their children over an extended period of time constituted intentional and prolonged concealment and amounts to temporary enforced disappearance.[38]

State obligations to provide redress to victims of torture and enforced disappearance

In addition to the absolute prohibitions on torture and enforced disappearance in international law and the state obligation to take measures to prevent torture and enforced disappearance from occurring, international treaties ratified by the United States also require that states provide remedy, rehabilitation, and redress to survivors of torture and enforced disappearance and to their affected family members.[39]

The CAT requires that states parties ensure that torture victims obtain redress and compensation, stating “Each State Party shall ensure in its legal system that the victim of an act of torture obtains redress and has an enforceable right to fair and adequate compensation, including the means for as full rehabilitation as possible” (Article 1(1)).  The Committee Against Torture, the body of independent experts that monitors the implementation of the CAT, has clarified that “redress” in Article 14 includes the full scope of measures for redress, including restitution, compensation, rehabilitation, satisfaction, and guarantees of non-repetition, with restoration of the dignity of the victim as the ultimate aim of redress.[40]

The International Convention for the Protection of All Persons from Enforced Disappearance requires states parties to provide reparations to disappeared persons and to “any individual who has suffered harm as the direct result of an enforced disappearance” (Article 2).[41] The rights of victims include the right to know the truth about the circumstances of the disappearance (Article 24(2))[42] and the right to reparation and “prompt, fair and adequate” compensation (Article 24(4)), defining reparation as material and moral damages, including restitution, rehabilitation, satisfaction, restoration of dignity and reputation, and guarantees of non-repetition (Article 24(5)). The Convention particularly notes the special rights of children affected by enforced disappearance, conferring a state obligation to search for and identify separated children and to return them to their families (Article 25(2)), stating that, in all cases, the best interests of the child shall be a primary consideration, and that children’s views should be given due weight in the proceedings, depending on their stage of development (Article 25(5)). Restoration of children to their parents may be understood as a form of restitution, seeking to restore the victim to their original situation, including in regard to their family life.[43]

Though the International Convention on the Rights of the Child is not ratified by the United States, there is widespread U.S. support for the objectives of the Convention.[44] The Convention affirms the right of children not to be separated from their parents against their will – unless as part of a comprehensive best interest determination process – and the right to maintain direct contact with their parents, further stating that if parents and children are separated due to detention, they have the right to know the whereabouts of their family members.[45]

States must ensure full and effective redress tailored to the needs of the victim and proportionate to the gravity of the violation.[46] Over time, harm from torture can increase without appropriate support, thus it is critical that redress is timely and prompt.[47] Measures for redress and reparation must also be victim-oriented, gender-sensitive, and comprehensive.[48] Legal and administrative systems should take measures to prevent re-traumatization during proceedings, while ensuring victim participation.[49] These obligations also apply to asylum seekers and refugees who have been tortured.[50] States should also give children age-appropriate and trauma-sensitive opportunities to express their views during the reparation process, prioritize the best interests of the child, and ensure that reparation measures are child sensitive and “foster the health and dignity of the child.”[51]

Compensation and rehabilitation for torture survivors

Compensation and rehabilitation for torture victims are rooted in a fundamental recognition that the victims’ dignity, health, and self-sufficiency may never be fully recovered due to the severe and persistent effect of torture.[52] Compensation for torture victims should be “prompt, fair and adequate;” the committee emphasizes that victims should be compensated for damages resulting from torture, including medical or rehabilitation expenses, damage for physical and mental harm, loss of earning or earning potential, and loss of opportunities, as well as compensation for legal assistance and costs for bringing the claim to court.[53] States are obligated to ensure timely compensation, including by addressing informal barriers to obtaining redress, such as inadequate procedures for quantifying damages.[54]

Rehabilitation likewise is described by the committee as a holistic concept, including medical and psychological treatment as well as legal and social services, for the “restoration of function” and “maximum possible self-sufficiency” for victims in order to ensure their full return to active participation in society.[55] Since torture has such clearly harmful physiological effects, torture rehabilitation should be understood to be long term and to require specialist services.[56]

The World Health Organization (WHO) defines rehabilitation as “the combined and co-ordinated use of medical, social, educational and vocational measures for training or retraining the individual to the highest possible level of functional ability.”[57] The WHO further defines in detail what is meant by different forms of rehabilitation: medical rehabilitation seeks to restore functional and psychological abilities and compensatory mechanisms, social rehabilitation focuses on reintegration into society and adjusting to demands of family, community, and work, and vocational rehabilitation enables the affected person to maintain suitable employment.[58] A definition of rehabilitation for torture survivors would not be complete without including the critical importance of restoring their essential human dignity as the central objective.[59]

Rehabilitation measures should be based on a comprehensive clinical evaluation, conducted according to international standards such as the Istanbul Protocol, which can point to the need for not only medical, physical, and psychological treatment, but also for social, community, and family services and vocational training or education.[60] A comprehensive clinical evaluation should include indigenous perspectives and health alternatives and should be conducted by individuals with experience in cultural humility when working with indigenous families.^{.[61], [62], [63]} Importantly, the victim should not have to obtain a judicial remedy in order to access rehabilitation.[64]

Satisfaction and guarantees of non-repetition for torture

Satisfaction for torture victims can take the form of public apologies or declarations which disclose the truth of the full extent of the violations and take responsibility for what happened, commemorate or pay tribute to the victims, and condone sanctions and criminal prosecution of those responsible.[65] Apologies must be victim-centered, respecting the victims’ perspectives on the wording and manner of delivery of the apology, and should be delivered sincerely, respectfully, remorsefully, and with sensitivity for the victimized.[66] Victims should never be forced to accept an apology. Apologies are one form of accurately recording the past; other forms of satisfaction include memorialization through location marking, museum exhibits, and renaming or designating commemoration days.[67] Victim participation in memorialization can increase the completeness and truthfulness of the historical record;[68] however, the safety, privacy, and best interests of the victims should be the first priority with regard to the content of public statements or disclosures.[69] Satisfaction is an important component of redress, because reparation measures must be undertaken as an acknowledgement of human rights violations, not merely as humanitarian gestures; this obligation remains in a successor regime.[70]

Ensuring fair and impartial judicial proceedings related to acts of torture, training and oversight for law enforcement and correctional officials, and reforming laws related to torture and nonrefoulement are critical for meaningfully guaranteeing non-repetition of torture or ill-treatment.[71] Systems should be in place for regular and independent monitoring for detention centers to prevent and to ensure accountability for torture and government officials should be trained in preventing re-traumatization during investigations.[72] Training in the Istanbul Protocol for health and legal professionals, and for law enforcement, judicial, and immigration personnel, will strengthen understanding of the physical and psychological impacts of torture, the needs of survivors, and the standards for effective investigation. In the case of separated families, provision of permanent immigration status will also be an important component of guaranteeing non-repetition of the forced separations.[73] Trauma counselling, discussed above as a part of rehabilitation, can also be understood as a mechanism for ensuring that institutional guarantees of non-repetition are effective at the individual level.[74]

Ultimately, all forms of redress (compensation, rehabilitation, satisfaction, restitution, and guarantees of non-repetition) are interrelated. For example, truth telling and accountability underscore that compensation is a justice measure, while compensation shows that symbolic actions and truth telling are not mere words.[75] Transitional justice measures recognize victims as rights holders, begin to rebuild trust in institutions, foster reconciliation, and strengthen the rule of law.[76]

Victim participation is essential for transformative reparations

The participation of victims throughout the redress process is important for respecting their agency and dignity and for ensuring appropriate outcomes.[77] Developing meaningful reparations policies and mechanisms requires in-depth consultation with affected groups, including by resourcing their participation.[78]  The United Nations Declaration on the Rights of Indigenous Peoples affirms the right of Indigenous peoples to participate in decision-making in matters which affect their rights and to choose the manner of their participation with due regard for their laws, traditions, and customs.[79] Ensuring meaningful participation of survivors is a sign of good faith and due diligence in state-led accountability processes; victim participation in bringing about justice also resists the power relationship between torturer and victim as it may live on in victims’ own psychology and in societal attitudes.[80] Given the risks of possible re-traumatization, provision of psychosocial support is a critical element to enable participation of victims, and may include measures such as physical accompaniment, prior briefings, and de-briefings to process their experience.[81]

The separated parents’ perspectives and wishes have shaped the policy recommendations in this report. These small scale consultations should be emulated on a national and international level, as only through consultation with affected groups can transitional justice measures capture the survivors’ sense of justice and effective redress, take their felt needs and cultural context into account, and broaden the range of measures considered for redress, ultimately contributing to the legitimacy of transitional justice measures.[82] The transformative and catalytic power of reparations to bring about meaningful reform and healing is only possible with the recognition of the violation and the suffering it caused, as well as the recognition of the systemic discrimination which is often its root cause.[83]

Conclusions

This study found that, similar to PHR’s previous research, the parents interviewed had arrived with their families to seek asylum in the United States and were forcibly separated from their children. U.S. immigration officials conducted the separations pursuant to policies that completely disregarded the children’s well-being and officials did not offer information about the reason for the separation or the process, causing great distress to both parents and children. Families experienced abject despair and trauma due to the lack of contact and information in the initial weeks and months of separation. At the time of the interview, more than half of the deported parents interviewed by PHR clinicians continued to live in constant fear of persecution and in hiding from gangs or cartels from whom they had previously fled. At the time of writing, two parents are still separated from their children.

At the time of the interviews, parents almost universally reported continued disturbances in sleep, nightmares, loss of appetite, loss of interest, fear for the future, constant worry, hopelessness, and loss of the ability to concentrate, such was their concern for their children’s well-being and their continued safety and future together. All parents were diagnosed as meeting diagnostic criteria for at least one mental health condition associated with the trauma of family separation, compounded by additional traumatic experiences in their home country, before and after deportation, and during the migration process. Almost all of the affidavits documented a diagnosis of post-traumatic stress disorder. Indications that the forced separation event played a significant role in mental health outcomes included intrusive symptoms about the separation event and triggering by related stimuli. PHR’s expert evaluators noted that the trauma suffered by the parents warranted trauma-focused psychotherapy and psychiatric care, due to their acute distress and ongoing functional impairment. Due to living in hiding or lacking resources, most parents interviewed were not able to access mental health services at the time of the interviews. Currently, those who have been reunited with their children in the United States are accessing mental health services as mandated by a court ruling, though it is uncertain how long these services will continue.

In response to these U.S. government abuses and subsequent psychological effects, parents called for a formal public apology by the government, an investigation such as a truth commission, financial compensation and funding for rehabilitation expenses, legal reforms to prevent repetition and, importantly, permanent immigration status in the United States, to ensure that they would not be separated from their children again. These measures are all strongly supported in international human rights law, which requires states that inflict torture to ensure prompt and effective remedies for victims and survivors. Reparation is not a policy choice; it is the fulfilment of the U.S. government’s obligation owed to victims as a result of its unlawful breach of international and domestic law.[84]

Policy Recommendations

The U.S. Administration, Department of Justice, and Department of Homeland Security should:

Provide redress to victims who suffered harm through forced separations in line with U.S. law and international treaty obligations:

• Immediately reunify all families separated by the U.S. government, through consultation with indigenous-led groups and other family advocacy organizations, and with legal counsel for the families;
• Work closely with Congress to ensure that families have a pathway to remain permanently in the United States with their children so they will have security from the traumatization of another separation, and because the harm they suffered should qualify for them for immigration status as a form of restitution;
• Provide redress through prompt, fair, and adequate monetary compensation as damages for the physical and mental harm families suffered, for medical and rehabilitation expenses, loss of earning, or earning potential, and as compensation for legal assistance and costs for bringing the claim to court. – 
• Ensure that reparations are timely by returning to global settlement negotiations to settle the lawsuits with the families; and
• Fund rehabilitation of family members according to the World Health Organization definition as including medical, social, educational, and vocational measures for restoring the individual to the highest possible level of functional ability. Rehabilitation should be based on a baseline clinical evaluation, conducted in accordance with international standards such as the Istanbul Protocol. Rehabilitation should take a strengths-based approach, protect victims’ confidentiality, be tailored to their cultural background and personality, and allow them to participate in selection of the service provider. The government should consult with indigenous groups on technical assistance for mental health assessments and interventions.

Ensure accountability for rights violated through forced family separations:

• Recognize the illegality and unconstitutionality of the forced family separations both in court and in a formal public apology issued by the White House, and immediately end all legal defense of the prior administration’s practice of forced family separation;
• Consult with families regarding their wishes to support a full investigation that would document what happened during the forced separations, such as through a truth commission and possibly through criminal prosecutions, in order to prevent repetition and to ensure full acknowledgment of government actions; and

• Train health and legal professionals, and law enforcement, judicial, and immigration personnel to use the Istanbul Protocol to strengthen understanding of the physical and psychological impacts of torture, the needs of survivors, and the standards for effective investigation, including training in preventing re-traumatization during investigations and adjudication.

Protect families from future violations through reforming policies and practices:

• Prohibit the separation of families arriving together at the U.S.-Mexico border and hire child welfare experts and health professionals to handle the majority of intake and processing needs at the border, especially those of families and children, as the United States has done with refugee resettlement;
• Ensure that any lawful separation in extreme cases, solely for the safety and well-being of the child, takes place through a trauma-informed process which ensures interpretation in the child’s and parents’ primary language, provides a written decision and opportunity to appeal in court; and ensures interagency record-keeping for reunification or release to a sponsor; and
• Avoid costly, inhumane, and unnecessary immigration detention by using legal authority, including parole, to release people seeking asylum to live with family and community while their cases are pending; scale up effective, appropriate community-based case-management services operated by trusted nonprofit service providers.

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Acknowledgements

This report was written by PHR staff members Brittney Bringuez, MA, program associate, Asylum Program; Kathryn Hampton, MSt, MA, deputy director, Asylum Program; Ranit Mishori, MD, MHS, senior medical advisor; Cynthia Pompa, former program officer, Asylum Program; and PHR Asylum Network Members Vidya Ramanathan, MD, MPH, medical director of the University of Michigan Asylum Collaborative, and Barbara Robles Ramamurthy, MD, Founder and CEO of Saagara Consulting and Teku.

Interviews were conducted by Monica Alzate, MA, PhD, LCSW; Eddy Ameen, PhD, LPC; Amelia Averyt, MD, MPH; Leslie Davis, PhD; Michele Heisler, MD, MPA; Carol Kessler, MD, Mdiv; Laura Miller, LCSW; Charles Mitchell, MD; Juliana Morris, MD, EdM; Vidya Ramanathan, MD, MPH; Altaf Saadi, MD, MSC; and Maggie Sullivan, FNP-BC, DrPH. Elsa Raker, former PHR asylum associate, coordinated the logistics of the remote evaluations and contributed to the data collection. Dahlia Fateen, medical student at Georgetown University School of Medicine, provided input to the research design. Hannah Houpt and Emily Mei, PHR asylum interns, formatted the citations and references.

The report benefitted from review by PHR staff, including Christian De Vos, JD, PhD, director of research and investigations; Michele Heisler, MD, MPA, medical director; Karen Naimer, JD, LLM, MA, director of programs; Michael Payne, deputy director, advocacy; and Jennifer Sime, MA, chief operating officer and interim executive director.

The report also benefited from external review by PHR Board Members Susan M. Blaustein, MMA, DMA and Gail Saltz, MD; Carol Anne Donohoe, JD, MS, managing attorney, Family Reunification Project, Al Otro Lado; and by Comunidad Maya Pixan Ixim staff and experts Lucero Gonzalez Alvarado (Maya Q’anjob’al), MA, BSW, human rights researcher; Domingo Alvaro (K’anjob’al Community) indigenous rights advocate and paralegal; Astrid Josefina Gomez (K’iche’ Maya), LMSW, CADC, social worker; Carolina Martin Ramos, JD (Mexica Mestiza/Cherokee Kin), co-executive director; and Cindy Toledo (Maya Q’anjob’al), indigenous human rights advocate.

The report was edited and prepared for publication by Claudia Rader, MS, PHR senior communications manager, with assistance from Samantha Peck, PHR executive assistant. Hannah Dunphy, PHR digital communications manager, prepared the digital presentation.

PHR is grateful to the parents who shared their stories with us, and for the partnership with Al Otro Lado, whose staff continues to zealously represent these families on the pathway to justice.

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Endnotes

[1] United States Department of Homeland Security, “Interagency Task Force on the Reunification of Families Interim Progress Report,” Nov. 29, 2021, https://www.dhs.gov/sites/default/files/2021-12/21_1129_s1_interim-progress-report-family-reunification-task-force.pdf

[2] Monique Beals “McConnell blasts potential payments to separated migrant families,” The Hill, Nov. 1, 2021, https://thehill.com/policy/international/579531-mcconnell-blasts-potential-payments-to-separated-migrant-families; Niall Stanage, “The Memo: Much-criticized Trump policy puts Biden in a vise,” The Hill, Nov. 9, 2021, https://thehill.com/homenews/administration/580646-the-memo-much-criticized-trump-policy-puts-biden-in-a-vise.

[3] Miriam Jordan, “Justice Department Halts Settlement Talks With Migrant Families,” New York Times, Dec. 16, 2021, https://www.nytimes.com/2021/12/16/us/biden-migrant-family-separation-settlement.html.

[4] Joe Biden for President: Official Campaign Website, “The Biden Plan for Securing Our Values as a Nation of Immigrants,” Aug. 5, 2020. https://joebiden.com/immigration/.

[5] Narea, Nicole, “Trump Showed No Regret over Family Separations during the Presidential Debate,” Vox, Oct. 22, 2020, https://www.vox.com/2020/10/22/21529710/trump-debate-family-separations.

[6] Hajar Habbach, Kathryn Hampton, and Ranit Mishori, ““You Will Never See Your Child Again”: The Persistent Psychological Effects of Family Separation”, Feb. 2020, https://phr.org/wp-content/uploads/2020/02/PHR-Report-2020-Family-Separation-Full-Report.pdf.

[7] YouTube. Joe Biden for President, Oct. 28, 2020. https://www.youtube.com/watch?v=PevJComISV0&feature=youtu.be.

[8] Arlette Saenz, “Biden If Elected Will Form Task Force to Reunite 545 Separated Immigrant Children With Family, Campaign Says,” CNN, Oct. 29, 2020, https://www.cnn.com/2020/10/29/politics/biden-immigrant-children/index.html.

[9] Of the affected families, 1,710 parents were returned to their countries, with or without their children, and 410 children were returned to their countries, with or without their parents. U.S. Department of Homeland Security, “Reunification of Families Interim Progress Report.”

[10] Denise N. Obinna, “Alone in a Crowd: Indigenous Migrants and Language Barriers in American Immigration,” Race and Justice, Mar. 31, 2021, https://doi.org/10.1177/21533687211006448.

[11] Tristan Ahtone, “Indigenous immigrants face unique challenges at the border: Language barriers mean Indigenous families may be more likely to be split up,” High Country News, Jun. 21, 2018, https://www.hcn.org/articles/tribal-affairs-indigenous-immigrants-face-unique-challenges-at-the-border.

[12] Interview on March 7, 2022, with Comunidad Maya Pixan Ixim experts, Cindy Toledo, Astrid Josefina Gomez, Lucero Gonzalez and Carolina Martin Ramos.

[13] Caroline Vakil, “Task Force Has Reunited 100 Children With Families Separated Under Trump,” The Hill, Dec. 23, 2021, https://thehill.com/homenews/administration/587206-task-force-has-reunited-100-children-separated-under-trump-with/.

[14] U.S. Department of Homeland Security, “Reunification of Families Interim Progress Report.”

[15] Myah Ward, “At Least 3,900 Children Separated From Families Under Trump ‘Zero Tolerance’ Policy, Task Force Finds,” Politico, Jun. 8, 2021, https://www.politico.com/news/2021/06/08/trump-zero-tolerance-policy-child-separations-492099.

[16] Together.gov, https://www.together.gov.

[17] 117^th Congress (2021-2022), “H.R.2766 – Families Belong Together Act,” Apr. 22, 2021, https://www.congress.gov/bill/117th-congress/house-bill/2766?s=1&r=75

[18] Nick Niedzwiadek, “W.H. Softens Biden’s Opposition to Family Separation Settlements,” Politico, Nov. 4, 2021, https://www.politico.com/news/2021/11/04/white-house-biden-separation-settlement-519589.

[19] Zeke Miller and Colleen Long, “Biden: Families of separated children deserve compensation,” ABC News, Nov. 6, 2021, https://abcnews.go.com/Politics/wireStory/biden-families-separated-children-deserve-compensation-81010134.

[20] Ben Fox, “US Pulls Out of Settlement Talks in Family Separation Suits,” AP News, Dec. 16, 2021, https://apnews.com/article/immigration-lawsuits-american-civil-liberties-union-c1a672b1210fb47c469506ac075c4757.

[21] Wilpur P.G. et al v. United States of America, No. 4:21-cv-04457-KAW (N.D. Cal. Jun. 10, 2021).

[22] Ms. L, et al. v. U.S. Immigration and Customs Enforcement, et al., No. 18cv0428 DMS (MDD) (S.D. Cal Jun. 26, 2018).

[23] Ms. J.P. et al. vs. Jefferson B. Sessions, et al., No. LA cv18-06081 JAK (SKx) (C.D. Cal Nov. 5, 2019).

[24] “Todo Por Mi Familia,” Seneca Family of Agencies, https://senecafoa.org/todopormifamilia/.

[25] The CAM refugee and parole program enables some children from El Salvador, Guatemala, and Honduras to apply in their home country for refugee status to rejoin their parents or legal guardians in the United States. See “Central American Minors (CAM) Refugee and Parole Program,” USCIS, September 14, 2021. https://www.uscis.gov/CAM.

[26] Kathryn Hampton, Michele Heisler, Ranit Mishori, Joanna Naples-Mitchell, Elsa Raker, Rebecca Long, Madeleine Silverstein, et al., “Forced Into Danger: Human Rights Violations Resulting from the U.S. Migrant Protection Protocols,” Jan. 19, 2021, https://phr.org/our-work/resources/forced-into-danger/.

[27] Camilo Montoya-Galvez, “CDC orders Title 42 to wind down, saying expulsions of migrants are no longer needed”, CBS News, April 1, 2022, https://www.cbsnews.com/news/cdc-orders-title-42-wind-down-saying-expulsions-of-migrants-are-no-longer-needed/.

[28] Kathryn Hampton, Michele Heisler, Cynthia Pompa, and Alana Slavin, “Neither Safety nor Health: How Title 42 Expulsions Harm Health and Violate Rights,” Jul. 28, 2021, https://phr.org/our-work/resources/neither-safety-nor-health/.

[29] UN Office of the High Commissioner for Human Rights (OHCHR), Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (“Istanbul Protocol”), 2004, HR/P/PT/8/Rev.1.

[30] UN General Assembly, “Basic Principles and Guidelines on the Right to a Remedy and Reparation for Victims of Gross Violations of International Human Rights Law and Serious Violations of International Humanitarian Law: resolution,”, Mar. 21, 2006, A/RES/60/147, https://www.refworld.org/docid/4721cb942.html.

[31] Lawrence A. Palinkas, Sarah M. Horwitz, Carla A. Green, Jennifer P. Wisdom, Naihua Duan, and Kimberly Hoagwood, “Purposeful Sampling for Qualitative Data Collection and Analysis in Mixed Method Implementation Research,” Administration and Policy in Mental Health vol. 42, ed. 5 (2015): pp 533–514, https://doi.org/10.1007/s10488-013-0528-y.

[32] A credible fear interview is a preliminary screening by an Asylum Officer to assess if an immigrant at the border has a significant possibility of being persecuted if they are returned to their country. See “Questions and Answers: Credible Fear Screening,” USCIS, Jul. 15, 2015, https://www.uscis.gov/humanitarian/refugees-and-asylum/asylum/questions-and-answers-credible-fear-screening.

[33] Email communication from CMPI co-executive director Carolina Ramos on March 8, 2022 reminds that Maya people who are removed from the United States are deported back to the Guatemalan state, an occupying, colonial government that committed genocide against Maya peoples and continues to persecute them today. After processing by Guatemalan authorities, they are finally allowed to travel to the Maya territories where their families live.

[34] Habbach, “You Will Never See Your Child Again”: The Persistent Psychological Effects of Family Separation.

[35] UN General Assembly, “Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment,” Art 1(1), Dec. 10 1984, https://treaties.un.org/pages/ViewDetails.aspx?src=IND&mtdsg_no=IV-9&chapter=4&clang=_en.

[36] UN General Assembly, “Convention Against Torture”, Art. 1; “‘You don’t have any rights here’: Illegal Pushbacks, Arbitrary Detention and Ill Treatment of Asylum-seekers in the United States”, Amnesty International, 2018, https://www.amnesty.org/en/latest/research/2018/10/usa-treatment-of-asylum-seekers-southern-border/; Beth Van Schaak, “The Torture of Forcibly Separating Children from their Parents,” Just Security, Oct. 18, 2018, https://www.justsecurity.org/61138/torture-forcibly-separating-children-parents/; Redacted GJC et al. v. Whitaker, Nielsen, Price, and the US Department of Homeland Security, “Brief Amici Curiae,” Feb. 2019, https://chrgj.org/wp-content/uploads/2019/02/Redacted-GJC-et-al-Brief-Amici-Curiae-Feb-2019.pdf.

[37] UN General Assembly, “International Convention for the Protection of All Persons from Enforced Disappearance,” Art. 2, Dec. 20, 2006, https://www.ohchr.org/en/instruments-mechanisms/instruments/international-convention-protection-all-persons-enforced.

[38] UN General Assembly Human Rights Council, “Report of the Working Group on Enforced or Involuntary Disappearances,” A/HRC/36/39/Add.2, Jul. 28, 2017, https://documents-dds-ny.un.org/doc/UNDOC/GEN/G17/229/15/PDF/G1722915.pdf?OpenElement.

[39] The International Convention on the Elimination of All Forms of Racial Discrimination (art. 6), the Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (art. 14), the Convention on the Rights of the Child (art. 39) and the International Covenant on Civil and Political Rights (art. 2 and ICCPR General Comment 20 (1992)), International Convention for the Protection of All Persons from Enforced Disappearance (art 24).

[40] UN Committee Against Torture (CAT), “General comment no. 3, 2012: Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment: implementation of article 14 by States parties,” Dec. 13, 2012, https://www.refworld.org/docid/5437cc274.html; UN General Assembly “Basic Principles and Guidelines.”

[41] Although the United States has not ratified the Convention, enforced disappearance represents a violation of other U.S. treaty obligations in the ICCPR such as the right to life, right to protection from arbitrary deprivation of liberty and security of the person, the right to humane treatment, and the right to recognition as a person before the law. See also María Fernanda Pérez Solla, Enforced Disappearances in International Human Rights (Jefferson, NC: McFarland & Company, Inc., 2006).

[42] See also UN Commission on Human Rights, “Human Rights Resolution 2005/66: Right to the Truth,” E/CN.4/RES/2005/66, Chap. XVII, 20 April 2005, https://www.refworld.org/docid/45377c7d0.html.

[43] UN General Assembly, “UN Basic Principles and Guidelines on the Right to a Remedy and Reparation for Victims of Gross Violations of International Human Rights Law and Serious Violations of International Humanitarian Law”, Official Records of the General Assembly, Sixtieth Session, Supplement No. 49 (A/60/49), A/RES/60/147,  354, 2005.

[44] Congressional Research Service, “The United Nations Convention on the Rights of the Child,” Jul. 27, 2015, https://crsreports.congress.gov/product/pdf/R/R40484/25

[45] UN Commission on Human Rights, “The United Nations Convention on the Rights of the Child”, E/CN.4/RES/1990/74, Article 9, Mar. 7, 1990.

[46] UN General Assembly, “UN Basic Principles and Guidelines on the Right to a Remedy and Reparation for Victims of Gross Violations of International Human Rights Law and Serious Violations of International Humanitarian Law”, Official Records of the General Assembly, Sixtieth Session, Supplement No. 49 (A/60/49), A/RES/60/147,  354, 2005.

[47] Ibid.

[48] IP, para 185

[49] UN General Assembly, “UN Basic Principles and Guidelines on the Right to a Remedy and Reparation for Victims of Gross Violations of International Human Rights Law and Serious Violations of International Humanitarian Law”, Official Records of the General Assembly, Sixtieth Session, Supplement No. A/RES/60/147,  354, 2005.

[50] Ibid.

[51] Ibid.; see also Dyan Mazurana and Kristopher Carlson, “Children and Reparation: Past Lessons and New Directions: Innocenti Working Paper,” UNICEF Innocenti Research Centre No. 2010-08,  2010.

[52] UN General Assembly, “UN Basic Principles and Guidelines on the Right to a Remedy and Reparation for Victims of Gross Violations of International Human Rights Law and Serious Violations of International Humanitarian Law,” Official Records of the General Assembly, Sixtieth Session, Supplement No. A/RES/60/147,  354, 2005.

[53] Ibid.; see also UN General Assembly, “UN Basic Principles and Guidelines on the Right to a Remedy and Reparation for Victims of Gross Violations of International Human Rights Law and Serious Violations of International Humanitarian Law,” Sixtieth Session, Supplement No. 49, 2005, A/60/49, A/RES/60/147, 354, para. 20.

[54] UN General Assembly, “UN Basic Principles and Guidelines on the Right to a Remedy and Reparation for Victims of Gross Violations of International Human Rights Law and Serious Violations of International Humanitarian Law,” Official Records of the General Assembly, Sixtieth Session, Supplement No. A/RES/60/147, 2005.

[55] UN General Assembly, “UN Basic Principles and Guidelines on the Right to a Remedy and Reparation for Victims of Gross Violations of International Human Rights Law and Serious Violations of International Humanitarian Law,” Official Records of the General Assembly, Sixtieth Session, Supplement No. 49 (A/60/49), A/RES/60/147, 354, 2005.

[56] Ibid.; United Nations Resolution adopted by the Human Rights Council 22/21, “Torture and other cruel, inhuman or degrading treatment or punishment: rehabilitation of torture victims,” A/HRC/RES/22/21, Apr. 12, 2013.

[57] World Health Organization, “WHO Expert Committee on Medical Rehabilitation: Second Report,” World Health Organization Technical Report Series 419, (1969): 6.

[58] Ibid.

[59] Clara Villalba, “Rehabilitation as a Form of Reparation Under International Law” Redress, no. 10 (Dec. 2009), http://www.redress.org/downloads/publications/The%20right%20to%20rehabilitation.pdf

[60] HRC General Comment No 3, Para 13; United Nations Resolution adopted by the Human Rights Council 22/21, “Torture and other cruel, inhuman or degrading treatment or punishment: rehabilitation of torture victims,” A/HRC/RES/22/21, Apr. 12, 2013.

[61] Interview with Comunidad Maya Pixan Ixim experts, Cindy Toledo, Astrid Josefina Gomez, Lucero Gonzalez and Carolina Martin Ramos. Mar. 7, 2022.

[62] CAT General Comment 3, Paras 13, 15 and 32 United Nations, “UN Basic Principles and Guidelines on the Right to a Remedy and Reparation for Victims of Gross Violations of International Human Rights Law and Serious Violations of International Humanitarian Law,” Official Records of the General Assembly, Sixtieth Session, Supplement No. 49 (A/60/49), A/RES/60/147, 354, par. 13, 15, 52, 2005.

[63] Juanita Cabrera Lopez et al., “Policy Position and Proposal on Technical Assistance for Separated Children and Families” The National Council of Indigenous Peoples in the Diaspora (CONPID), (Aug. 23, 2021), https://docs.google.com/document/d/1akXjkt6tzR1uXvPHmsfcqRM-X3xRN6_3/edit.

[64] General Comment No 3, Para 32.

[65] CAT General Comment 3, Paras 13, 15 and 32 United Nations, “UN Basic Principles and Guidelines on the Right to a Remedy and Reparation for Victims of Gross Violations of International Human Rights Law and Serious Violations of International Humanitarian Law,” Official Records of the General Assembly, Sixtieth Session, Supplement No. 49 (A/60/49), A/RES/60/147, 354, par. 17, 2005.

[66] Fabián Salvioli, “Report of the Special Rapporteur on the Promotion of Truth, Justice, Reparation and Guarantees of Non-Recurrence,” Human Rights Council resolution 36/7, A/74/147, Jul. 12, 2019.

[67] Public International Law and Policy Group, “Core Elements of Reparations: Legal Memorandum,” Jun 2013, https://syriaaccountability.org/wp-content/uploads/PILPG-Reparations-Memo-2013_EN.pdf.

[68] Juan E. Méndez, “Victims as Protagonists in Transitional Justice,” International Journal of Transitional Justice, vol. 10, issue 1, (Mar. 2016): 1–5, https://doi.org/10.1093/ijtj/ijv037.

[69] UN General Assembly, “UN Basic Principles and Guidelines on the Right to a Remedy and Reparation for Victims of Gross Violations of International Human Rights Law and Serious Violations of International Humanitarian Law,” Sixtieth Session, Supplement No. 49, 2005, A/60/49, A/RES/60/147, 354, par. 22.

[70] CAT General Comment 3, Paras 13, 15 and 32 United Nations, “UN Basic Principles and Guidelines on the Right to a Remedy and Reparation for Victims of Gross Violations of International Human Rights Law and Serious Violations of International Humanitarian Law,” Official Records of the General Assembly, Sixtieth Session, Supplement No. 49 (A/60/49), A/RES/60/147, 354, par. 37, 2005.

[71] CAT General Comment 3, Paras 13, 15 and 32; UN General Assembly, “UN Basic Principles and Guidelines on the Right to a Remedy and Reparation for Victims of Gross Violations of International Human Rights Law and Serious Violations of International Humanitarian Law,” Sixtieth Session, Supplement No. 49, 2005, A/60/49, A/RES/60/147, 354, par. 18. UN General Assembly, “UN Basic Principles and Guidelines on the Right to a Remedy and Reparation for Victims of Gross Violations of International Human Rights Law and Serious Violations of International Humanitarian Law,” Sixtieth Session, Supplement No. 49, 2005, A/60/49, A/RES/60/147, 354, par. 23.

[72] CAT General Comment 3, Paras 13, 15 and 32 United Nations, “UN Basic Principles and Guidelines on the Right to a Remedy and Reparation for Victims of Gross Violations of International Human Rights Law and Serious Violations of International Humanitarian Law,” Official Records of the General Assembly, Sixtieth Session, Supplement No. 49 (A/60/49), A/RES/60/147, 354, par. 19, 30, 35, 2005.

[73] Letter to the House and Senate, Aug. 21, 2021, https://docs.google.com/document/d/1ZJmJco9OBQkHVkd_uET3yfaFITrLb6fuffcUdOpHLFc/edit.

[74] Pablo de Greiff, “Report of the Special Rapporteur on the Promotion of Truth, Justice, Reparation and Guarantees of Non-Recurrence,” A/HRC/30/42, Sep. 7, 2015.

[75] Pablo de Greiff, “First Annual Report Submitted to the Human Rights Council by the First Special Rapporteur on the Promotion of Truth, Justice, Reparation and Guarantees of Non-Recurrence,” A/HRC/21/46, Aug. 9, 2012, par. 24.

[76] Ibid.

[77] CAT General Comment 3, Paras 13, 15 and 32 United Nations, “UN Basic Principles and Guidelines on the Right to a Remedy and Reparation for Victims of Gross Violations of International Human Rights Law and Serious Violations of International Humanitarian Law,” Official Records of the General Assembly, Sixtieth Session, Supplement No. 49 (A/60/49), A/RES/60/147, 354, par. 4, 2005.

[78] Public International Law and Policy Group, “Core Elements of Reparations: Legal Memorandum,” Jun 2013, https://syriaaccountability.org/wp-content/uploads/PILPG-Reparations-Memo-2013_EN.pdf; Pablo de Greiff, “Report of the Special Rapporteur on the Promotion of Truth, Justice, Reparation and Guarantees of Non-Recurrence,” 27/3, A/71/567, Oct. 25, 2016.

[79] UN General Assembly, “United Nations Declaration on the Rights of Indigenous Peoples: Resolution Adopted by the General Assembly,” A/RES/61/295, Article 18, Article 27, Oct. 2, 2007.

[80] Juan E. Méndez, “Victims as Protagonists in Transitional Justice,” International Journal of Transitional Justice, vol. 10, issue 1, (Mar. 2016): 1–5, https://doi.org/10.1093/ijtj/ijv037.

[81] Pablo de Greiff, “The Report of the First Special Rapporteur on the Promotion of Truth, Justice, Reparation and Guarantees of Non-Recurrence,” Human Rights Commission, pursuant to Council Resolution 27/3, A/HRC/34/62, 27, Dec. 2016, par. 67-69.

[82] Pablo de Greiff, “The Report of the First Special Rapporteur on the Promotion of Truth, Justice, Reparation and Guarantees of Non-Recurrence,” Human Rights Commission, pursuant to Council Resolution 27/3, A/71/567, Oct. 25, 2016.

[83] Michelle Bachelet, “15th Anniversary of the Basic Principles and Guidelines on the Right to a Remedy and Reparation for Victims of Gross Violations of International Human Rights Law and Serious Violations of International Humanitarian Law ‘The catalytic power of reparations’,” UN High Commissioner for Human Rights, Dec. 16, 2020, ttps://ohchr.org/EN/NewsEvents/Pages/DisplayNews.aspx?NewsID=26615&LangID=E.

[84] Fabián Salvioli “Special Rapporteur on the Promotion of Truth, Justice, Reparations and Guarantees of Non-Recurrence,” Report on practical experiences of domestic reparation programs, A/HRC/42/4511 July 2019, par. 28.

This article was originally published by The New Humanitarian, a news agency specialised in reporting humanitarian crises.

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Many Syrians are experiencing heart-wrenching flashbacks as we watch the mounting devastation in Ukraine and the millions of refugees fleeing. As a Syrian physician who provided medical care amid the war in my country, it’s especially painful when clinics or hospitals are bombed.

I’m haunted by the escalating attacks on healthcare facilities in Ukraine, which leave me feeling that I have been here before.

Since the Syrian conflict began in March 2011, my colleagues at Physicians for Human Rights have documented 601 attacks on 400 healthcare facilities there. In Ukraine, it’s happening again: At least 119 attacks on health facilities, workers, and transports like ambulances have reportedly been perpetrated since Russia’s invasion began in late February, according to the World Health Organization.

Even after 11 years of such attacks on healthcare targets in Syria, no perpetrator has been held accountable for these crimes.

Things can be different for Ukraine. While Russia has blocked multiple attempts by the UN Security Council to refer the Syria conflict to the International Criminal Court, with Ukraine the ICC does not need the Security Council’s go ahead. Last month’s unprecedented referral by 41 ICC member states, combined with Ukraine’s declarations that it accepts the ICC’s jurisdiction (despite not being a state party), means that the court can proceed.

If just one positive development emerges from the ongoing horrors there, let it be a wake-up call: Global leaders must no longer stand by passively as war crimes such as attacks on civilians and “civilian objects” (like hospitals, schools, theatres) continue unabated.

This begins by actively supporting efforts to hold perpetrators of war crimes and crimes against humanity accountable for the bloodshed. It means ensuring that the ICC has the political and financial support it needs to do its work, while also supporting accountability efforts in other jurisdictions. Such investigations have already been launched by domestic prosecutors in countries like Germany, France, and Sweden.

What I witnessed

Last month, as I watched the videos and saw the photos of a maternity hospital in Mariupol, Ukraine that had been bombed by Russian forces, I was thrust back to a painful memory from a hospital in the al-Sakhour neighbourhood of Aleppo, Syria where I was working in 2014.

I had noticed a young woman enter the health clinic, looking excited for her final pre-natal check-up. While waiting for the doctor to call out her name, an aerial bombardment suddenly blasted the hospital, injuring three staff members and killing two patients. Shrapnel penetrated the pregnant woman’s stomach. With smoke still thick in the air, we rushed her into emergency surgery. She survived. Her baby did not.

“When you kill a doctor, you harm her patients. When you bomb an ambulance, you terrorise a community and intimidate residents from seeking the medical care they need.”

As a Syrian doctor, I can imagine Ukrainian medics scanning the sky for fighter jets while moving a patient out of an ambulance. I know the feeling of trying to focus on hearing your patient’s concerns, when your ears are instead listening for the distant roar of aircraft.

I can envision Ukrainian doctors pausing mid-surgery to ask their colleagues about new threats of shelling, even amid the overwhelming flood of war injuries that many have never seen before.

A war strategy

Attacks on healthcare are not only catastrophic, but they are also illegal under international humanitarian law. The Geneva Conventions and its Additional Protocol I, to which both Russia and Ukraine are parties, prohibit the targeting of those providing or receiving healthcare in armed conflicts.

These horrific attacks don’t just happen in Syria or Ukraine: Violence against healthcare workers and facilities is a particularly abhorrent feature of some armed conflicts around the world. They are also a signature of Russia’s brutal war strategy.

In Chechnya, the Russian military levelled healthcare facilities as part of its scorched-earth tactics and crackdown on civilians. Many parties to the conflict violated medical impartiality and attacked healthcare targets, but witnesses reported that the greater volume of abuses was perpetrated by Russia’s federal forces, including the bombing of medical facilities. Russia’s federal forces destroyed or damaged at least 24 different medical facilities.

According to data collected by Physicians for Human Rights, some 244 of the 601 total attacks on healthcare targets in Syria occurred after the Russian military entered the conflict on the side of the Syrian government in 2015, and can be attributed to either Syrian or their allied Russian forces.

April 27 marks the six-year anniversary of two bombs hitting the front of al-Quds Hospital in Aleppo, where several of my friends – including Dr Hamza Al-Khataeb, depicted in the Oscar-nominated documentary For Sama – toiled in what became known as “the last hospital standing in Aleppo”.

In total, Syria and Russia have carried out around 90 percent of all attacks on healthcare targets in Syria, including the killing of 942 health workers.

In one illustrative case, the Russian military bombed four hospitals in one town in just over 12 hours in May 2019, as The New York Times meticulously documented.

These attacks are not only profound tragedies for health workers who are killed, and their families. They also cripple entire health systems. When you kill a doctor, you harm her patients. When you bomb an ambulance, you terrorise a community and intimidate residents from seeking the medical care they need.

Civilians pay the price. When being in a hospital becomes more dangerous than staying home, people will naturally avoid medical care for fear of becoming targets. The long-term impacts are also devastating, and communities subjected to violence against healthcare targets don’t just see conflict-related injuries. War can also exacerbate chronic and noncommunicable diseases; women are less likely to see reproductive and neonatal doctors; and indicators of maternal and newborn health decline.

In Syria’s case, a decade-plus of destruction, obstruction of aid, and neglect has caused a near-collapse of health systems in parts of the north not controlled by President Bashar al-Assad’s government.

Sowing fear

While we will never know exactly what Vladimir Putin or al-Assad – or other leaders whose armed forces attack healthcare targets, like Min Aung Hlaing of Myanmar or Mohammed bin Salman of Saudi Arabia – are thinking, to me it’s clear that sowing fear is the point. Attacking healthcare is a way of shattering the resilience of the community. It is a devastating but grimly effective strategy.

With the ICC unavailable in Syria, a few universal jurisdiction trials in Europe are helping to provide a small measure of justice for some victims and survivors of the Syrian government’s atrocities. But to date, no one has ever faced accountability for bombing a hospital or torturing a medic.

Ukraine now offers an opportunity for the ICC to investigate the same types of brutal tactics that Russia honed in Syria.

I hope my Ukrainian medical colleagues never have to experience what is the most disturbing part of my experience in Syria: Despite volumes of comprehensively documented evidence and years of courageous activism by Syrians, impunity pervades.

So let the international community hear this loud and clear: We cannot fail the besieged health workers and patients in Ukraine the way that Syrians were failed by the global community.

Standing up for justice means robustly supporting the ICC’s work and pushing for accountability in domestic jurisdictions as well. It means working more vigorously to implement UN Security Council Resolution 2286, which was meant to ensure better protection for medical and humanitarian personnel in armed conflict. It means continuing to isolate Russia politically and financially. And it means upholding the legal right to seek asylum and welcoming those fleeing the ravages of war, no matter the colour of their skin.

Whether a hospital is bombed in Mariupol or Aleppo, in Sana’a or in Kunduz, those responsible must be held to account.

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This article was originally published by The New Humanitarian, a news agency specialised in reporting humanitarian crises.

Executive Summary

On December 23, 2020, Bella Quinto-Collins called 911, seeking help for her 30-year-old brother, Angelo Quinto, who was agitated and exhibiting signs of a mental health crisis at their home in Antioch, California. When two police officers arrived, they pulled Quinto from his mother’s arms onto the floor. At least twice, Quinto’s mother, Cassandra Quinto-Collins, heard him say to the officers, “Please don’t kill me.” Bella and Cassandra then watched in disbelief and horror as the two officers knelt on Quinto’s back for five minutes until he stopped breathing. Three days later, Quinto died in the hospital.[1]

It was not until August 2021 that the family learned the official determination of cause of death: a forensic pathologist testified during a coroner’s inquest that Quinto died from “excited delirium syndrome.”[2]

Angelo Quinto, a Filipino-American Navy veteran, is one of many people, disproportionately people of color, whose deaths at the hands of police have been attributed to “excited delirium” rather than to the conduct of law enforcement officers. In recent years, others have included Manuel Ellis, Zachary Bear Heels, Elijah McClain, Natasha McKenna, and Daniel Prude.^[3] “Excited delirium” even emerged as a defense for the officers who killed George Floyd in 2020.^[4]

The term “excited delirium” cannot be disentangled from its racist and unscientific origins.

An Austin-American Statesman investigation into each non-shooting death of a person in police custody in Texas from 2005 to 2017 found that more than one in six of these deaths (of 289 total) were attributed to “excited delirium.”^[5] A January 2020 Florida Today report found that of 85 deaths attributed to “excited delirium” by Florida medical examiners since 2010, at least 62 percent involved the use of force by law enforcement.^[6] A Berkeley professor of law and bioethics conducted a search of these two news databases and three others from 2010 to 2020 and found that of 166 reported deaths in police custody from possible “excited delirium,” Black people made up 43.3 percent and Black and Latinx people together made up at least 56 percent.^[7]

Watch: Debunking “Excited Delirium”

When did the term “excited delirium” evolve to describe a distinct type of “delirium?” How did the corresponding term “excited delirium syndrome” become a go-to diagnosis for medical examiners and coroners to use in explaining deaths in police custody? What is the evidence that it is indeed a valid diagnosis? This report traces the evolution of the term from when it appears to have first been coined in the 1980s to the present. Physicians for Human Rights (PHR) reconstructed the history of the term “excited delirium” through a review of the medical literature, news archives, and deposition transcripts of expert witnesses in wrongful death cases. We evaluated current views and applications of the term through interviews with 20 medical and legal experts on deaths in law enforcement custody. Additionally, we spoke to six experts on severe mental illness and substance use disorders to better understand the context in which the term most often arises. Finally, we interviewed members of two families who lost loved ones to police violence for a firsthand account of the harms of the term’s continued use.

This report concludes that the term “excited delirium” cannot be disentangled from its racist and unscientific origins. Dr. Charles Wetli, who first coined the term with Dr. David Fishbain in case reports on cocaine intoxication in 1981 and 1985,^[8] soon after extended his theory to explain how more than 12 Black women in Miami, who were presumed sex workers, died after consuming small amounts of cocaine.^[9] “For some reason the male of the species becomes psychotic and the female of the species dies in relation to sex,” he postulated.^[10] As to why all the women dying were Black, he further speculated, without any scientific basis, “We might find out that cocaine in combination with a certain (blood) type (more common in blacks) is lethal.”^[11]

After a 14-year-old girl was found dead in similar circumstances but without any cocaine in her system, Wetli’s supervisor, chief medical examiner Dr. Joseph Davis, reviewed the case files.^[12] Davis concluded that all of the women –19 by that point – had actually been murdered, pointing to evidence of asphyxiation in many of the cases.^[13] Investigators eventually came to hold a serial killer responsible for the murders of as many as 32 women from 1980 to 1989.^[14]

The year after the suspected killer’s arrest, Wetli continued to assert that at least some of the women had died from a combination of sex and cocaine: “I have trouble accepting that you can kill someone without a struggle when they’re on cocaine … cocaine is a stimulant. And these girls were streetwise.”^[15] He also continued to promote a corresponding theory of Black male death from cocaine-related delirium, without any scientific basis: “Seventy percent of people dying of coke-induced delirium are black males, even though most users are white. Why? It may be genetic.”^[16]

Wetli’s grave mischaracterization of the murders of Black women in Miami – and the racism and misogyny that seemed to inform it – should have discredited his other equally racialized and gendered theory of sudden death from cocaine. Instead, the use of the term “excited delirium” grew.

A small cohort of authors, many working as researchers or legal defense experts for TASER International (now Axon Enterprise) – a U.S. company that produces technology products and weapons, including the “Taser” line of electroshock weapons marketed as so-called “less-lethal” “stun” weapons – increased the broader use of the term by populating the medical literature with articles about “excited delirium.” In 2007, TASER/Axon purchased many copies of a book entitled Excited Delirium Syndrome written by one of its defense experts, Dr. Vincent Di Maio, and his wife Theresa Di Maio, that built on Wetli’s description of “excited delirium” by describing an “excited delirium syndrome.”[17] They distributed the book for free and also gave out other materials on “excited delirium” at conferences of medical examiners and police chiefs.[18] Seven years later, during a deposition, Dr. Di Maio acknowledged that he and his wife had “come up with” the term “excited delirium syndrome.”^[19] The term has come to be used as a catch-all for deaths occurring in the context of law enforcement restraint, often coinciding with substance use or mental illness, and disproportionately used to explain the deaths of young Black men in police encounters.[20]

“Excited delirium” is not a valid, independent medical or psychiatric diagnosis. There is no clear or consistent definition, established etiology, or known underlying pathophysiology.

PHR’s review leads to the conclusion that “excited delirium” is not a valid, independent medical or psychiatric diagnosis. There is no clear or consistent definition, established etiology, or known underlying pathophysiology. There are no diagnostic standards, and it is not included as a diagnosis in any version of the International Classification of Diseases, the international standard for reporting diseases and health conditions, currently in its tenth revision (ICD-10), or in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for psychiatric illness. Neither the American Medical Association nor the American Psychiatric Association currently recognize the validity of the diagnosis. In general, there is a lack of scientific data, and the body of literature supporting the diagnosis is small and of poor quality, with homogenous citations rife with conflicts of interest.

The foundations underpinning the diagnosis of “excited delirium” have been misrepresented, misquoted, and distorted. The ICD-10 and DSM-5 acknowledge delirium and its subtypes as valid, but these do not align with purported criteria for “excited delirium” and are described as stemming from underlying causes. It seems that “excited delirium” as a diagnosis and standalone cause of death was originally brought about by one or a few people’s subjective opinions. The term has since taken on a meaning and life of its own, with a deleterious impact.

In our interviews with clinicians and scientists across disciplines, there was no consensus on the definition of “excited delirium.” A review of the medical literature further confirms that the syndrome is not well defined or understood. The term is therefore scientifically meaningless because of this lack of consensus or rigorous evidentiary basis. Many of the studies that have been used to support the diagnosis have serious methodological deficiencies and are laden with conflicts of interest with law enforcement and TASER/Axon. Moreover, the use of “excited delirium” to explain agitated behavior raises the concern that underlying causes of these behaviors, such as a mental illness or substance intoxication, are not being diagnosed or treated. Most significantly, it is disturbing that “excited delirium” as a diagnosis has been used to justify aggressive and even fatal police tactics.

It is also concerning that “excited delirium” has come to pervade law enforcement policies and training manuals, at least in part due to the continued acceptance of the term by the American College of Emergency Physicians (ACEP) and National Association of Medical Examiners (NAME). Officers in many law enforcement agencies are trained to respond to an array of medical emergencies as “excited delirium,” which in practice have included conditions that may not all warrant the same medical response, including heart attacks, drug or substance overdoses or withdrawals, acute psychosis, and oxygen deprivation. “Excited delirium” has also gained international reach, having received attention in the wake of in-custody deaths in Australia, Canada, and the United Kingdom, among other countries.[21]

The diagnosis of “excited delirium” has come to rest on racist tropes of Black men and other people of color as having “superhuman strength” and being “impervious to pain,” while pathologizing resistance to law enforcement, which may be an expected or unsurprising reaction of a scared or ill individual (or anyone who is being restrained in a position that inhibits breathing). Presently, there is no rigorous scientific research that examines prevalence of death for people with “excited delirium” who are not physically restrained.

The term has come to be used as a catch-all for deaths occurring in the context of law enforcement restraint … and disproportionately used to explain the deaths of young Black men in police encounters.

People who present with symptoms and signs such as agitation, confusion, fear, hyperactivity, acute psychosis, sweats, noncompliance with directions, tachycardia (rapid heart rate), and tachypnea (rapid breathing), which are too often classified by medical examiners and coroners as “excited delirium,” must be recognized as having an underlying diagnosis. The specific underlying condition should be identified and treated. Too often, law enforcement officers are called as the sole first responders to medical emergencies and then use violent methods to forcibly restrain people manifesting these signs, methods – such as those that induce asphyxia from prone and other forms of restraint – that themselves may cause death. Consequently, “excited delirium,” rather than law enforcement actions, is cited as the cause of death, or as a factor contributing to death, in autopsy reports.

PHR holds that “excited delirium” is a descriptive term of a myriad of symptoms and signs, not a medical diagnosis, and, as such, should not be cited as a cause of death. It is essential to end the use of “excited delirium” as an officially determined cause of death, particularly in cases of deaths in police custody. This is one critical step among many to stop these preventable deaths.

Introduction

As Minneapolis police officer Derek Chauvin knelt on George Floyd’s neck in May 2020, fellow officer Thomas Lane said, “Roll him on his side?… I just worry about the excited delirium or whatever.” Officer Lane’s comment in the midst of George Floyd’s murder is indicative of the extent to which the concept of “excited delirium” has come to pervade U.S. law enforcement training and practice.

This report traces how “excited delirium” has evolved from a description in case reports of people with cocaine intoxication into a term that is used by law enforcement, forensic pathologists, emergency physicians, and in courts. Others have already described the troubled history of “excited delirium.”[22] Yet since the term persists, this report reviews the origins, history, medical literature, and views of experts and affected family members in order to evaluate the underlying validity of the diagnosis.

It is essential to cease the use of “excited delirium” as an officially determined cause of death, particularly in cases of deaths in police custody. This is one critical step among many to stop these preventable deaths.

Background

In the United States, people of color are far more likely than white people to be killed by police.[23] The American Medical Association, American Public Health Association, National Medical Association, and many other groups recognize this as a public health crisis.^[24] In addition, a significant percentage of police killings – anywhere from 25 to 50 percent – occur while responding to mental health, behavioral health, or substance use disorder crises.[25]

The in-custody killing of George Floyd by Minneapolis police in May 2020 ignited an unprecedented wave of national and global demonstrations in support of the Black Lives Matter movement and against police brutality and systemic racism across many areas of law enforcement. Protesters called for accountability for police killings and reforms, with many urging the reallocation of funding from law enforcement to social and community services, including mental health services. Protesters also drew attention to the ways in which certain health emergencies all too often receive a law enforcement rather than a medical response, which can result in serious harm or death.

In Many Areas, the United States Lacks Appropriate Systems to Respond to Mental and Behavioral Health Crises

In 2020, the Substance Abuse and Mental Health Services Administration (SAMHSA), a branch of the U.S. Department of Health and Human Services, reported that more than one in every five American adults (21 percent) experienced a mental illness.[26] Additionally, in 2020, more than one in every 20 adults (5.6 percent) experienced a serious mental health condition, such as schizophrenia or bipolar disorder.[27] Both of these estimates were higher than annual estimates from 2008 through 2019.[28]

Despite the increasing prevalence of mental health conditions in the United States, there remains a lack of appropriate emergency response systems for people in crisis. Moreover, the deinstitutionalization movement, beginning in the 1950s, left many people with severe mental illness with neither proper treatment nor resources. This has led to a number of people finding themselves homeless or in contact with the carceral system rather than appropriate treatment.[29] The norm when someone is experiencing a mental health crisis is to call emergency services through 911, where, in most jurisdictions, the police often respond. Using armed police as first responders in these cases can result in an escalation of the situation while criminalizing or further endangering the person in crisis. Introducing people with mental illness in crisis first to the carceral system by proxy of a police officer, instead of a trained mental health counselor or clinician, can and has led to deaths at the hands of law enforcement.[30] A 2015 report by the Treatment Advocacy Center found that people with untreated mental illness are 16 times more likely to be killed during a law enforcement encounter than other civilians.[31]

A significant percentage of police killings – anywhere from 25 to 50 percent – occur while responding to mental health, behavioral health, or substance use disorder crises.

In a 2021 report, the Office of the United Nations High Commissioner for Human Rights (OHCHR) observed that law enforcement officers frequently violate the rights of Black people experiencing mental health crises to protection from discrimination on the basis of both race and disability. OHCHR reviewed more than 190 reports of deaths of Black people in law enforcement custody worldwide, including in the United States, finding that one of the three contexts that accounted for 85 percent of the cases that occurred was “the intervention of law enforcement officials as first responders in mental health crises.” The report stated:

“Several incidents analyzed by OHCHR occurred after calls to emergency services seeking assistance for a person experiencing a mental health crisis. According to the analysis, when acting as first responders, police interventions often aggravate the situation including due to the use of restraints, while crises de-escalation protocols may not provide for appropriate crisis support services. Further, police often fail to identify the victims as individuals in distress and in need of rights-based mental health support. Instead, racial bias and stereotypes compounded with disability-based stereotypes appear to lead law enforcement officials to perceive the victim as “dangerous”, overriding considerations of the individual’s safety and well-being and of delivery of the appropriate care and basic life support.”[32]

“When you’re dealing with severe mental illness, and especially when you’re a Black family or a brown family, you pause before you call the police.”

Sabah Muhammad, attorney and legislative and policy counsel, Treatment Advocacy Center

Standards for Death Investigations in the United States Vary by Jurisdiction

In the United States, official processes for investigating and establishing cause of death vary by state and local jurisdiction. Each state has different requirements for which kinds of deaths require investigations or autopsies.[33] Death investigation systems are highly variable, including both medical examiner systems and coroner systems. In most systems, it is a coroner or medical examiner’s responsibility to lead an investigation to determine the circumstances of a person’s death in cases of homicide or when there is suspicion of crime or foul play, including police violence.[34] Coroners in most states do not have to be physicians.[35] Medical examiners are physicians but are not always forensic pathologists. Forensic pathologists are physicians that specialize in pathology (study of injured organs, tissues, and cells) and work at the intersection of law and medicine to determine the cause of death. Twenty-three (23) states and Washington, D.C. have appointed medical examiner and/or coroner systems, 11 states have elected coroners and appointed medical examiners, four states have a combination of elected and appointed coroners, and 12 states have a combination of elected and appointed medical examiners.[36]Although there is a lack of national standards and of a universal definition, the consensus for defining deaths in custody is “deaths of persons who have been arrested or otherwise detained” by law enforcement officials.[37]

In 2009, the National Academy of Sciences (NAS) recommended, “Congress should authorize and appropriate incentive funds to the National Institute of Forensic Science (NIFS) for allocation to states and jurisdictions to establish medical examiner systems, with the goal of replacing and eventually eliminating existing coroner systems.” NAS further held, “All medicolegal autopsies should be performed or supervised by a board certified forensic pathologist.”[38]

Law Enforcement-Related Deaths Are Under-Counted

There is strong evidence that deaths after or during interaction with law enforcement are not always appropriately reported, monitored, or investigated. A 2017 Harvard study found that more than half of all police killings in 2015 were incorrectly classified as not the result of police officer interactions.[39] Coroners and medical examiners were found to regularly report results that minimized the accountability of police officers.[40] The study compared data from The Guardian’s “The Counted,”[41] an investigative project on police killings, to data from the National Vital Statistics System (NVSS), a U.S. federal government system that gathers death certificate data, identifies law enforcement-related deaths, and assigns a corresponding diagnostic code: “legal intervention.”[42] This same study found that there were significantly more law enforcement-related deaths in The Guardian’s data set compared to the NVSS. They further discovered that the NVSS had misclassified 55.2 percent of all police killings, and that deaths in low-income areas were disproportionately underreported.[43]

A 2021 study found that the National Vital Statistics System, the most comprehensive mortality database in the United States, failed to report “55.5 percent of all deaths attributable to police violence,” missing about 17,100 deaths from 1980 to 2019.

Similarly, a 2021 Lancet study compared data from the NVSS to “The Counted” and two other media-based databases on police violence, “Fatal Encounters” and “Mapping Police Violence.” The results showed that the NVSS failed to report “55.5 percent of all deaths attributable to police violence,” missing about 17,100 deaths from 1980 to 2019.^[44] The study also found that the age-adjusted mortality rate due to police violence grew by 38.4 percent from the 1980s to the 2000s, and mortality rates due to police violence were highest in non-Hispanic Black people, followed by Hispanic people of any race, non-Hispanic white people, and finally non-Hispanic people of other races.^[45]

System Flaws and the Ability to Manipulate the Reporting System Contribute to Under-Counting of Law Enforcement-Related Deaths

Several factors contribute to under-counting of law enforcement-related deaths. One oft-cited reason is the lack of independence of coroners and medical examiners. In a 2011 survey of National Association of Medical Examiners (NAME) members, 22 percent reported experiencing political pressure from elected or appointed officials to change the cause or manner of death listed on death certificates.[46] Conflicts of interest built into many systems include having medical examiners and coroners work for or be part of police departments.[47] A second contributor to under-counting is the lack of well-established standards and guidelines. There are no standards or explicit instructions to note whether there was police involvement in many death certificates’ open-ended sections to “describe how the injury occurred,” or to assure correct coding that there was law enforcement involvement, even if the certificate notes police involvement. Moreover, lack of standards to ensure sufficient knowledge and training of coroners and medical examiners further contributes to errors in classification. For example, some medical examiners face difficulty in having to determine whether a restraint case, such as a “hog-tying incident,” should be classified as “homicide,” “accident,” or “undetermined.” There is no national definition on manner of death for these police custody killings.[48] Lastly, fear of litigation resulting from problematic conduct also influences accurate documentation. In another NAME survey with 222 medical examiner respondents, 13.5 percent acknowledged modifying their forensic findings because of previous threats of litigation, and approximately 32.5 percent revealed that these considerations would impact their decisions in the future.[49] Thirty (30) percent expressed that “fear of litigation affected their diagnostic decision-making.”[50] In this way, a lack of standards is compounded by a lack of independence of forensic scientists to act without undue pressure from law enforcement or political officials.

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Methodology

Physicians for Human Rights (PHR) sought to understand the complex origins, history, current usage, and validity of “excited delirium” by pursuing multiple strands of inquiry.

Documents

As part of PHR’s work to systematically document the origins, history, and evolution of the term and concept of “excited delirium,” PHR partnered with civil rights attorney Julia Sherwin, who, through nearly two decades of work, has compiled an extensive library of news archives, deposition transcripts, court documents, and articles related to the origins and history of “excited delirium.” PHR obtained additional deposition transcripts and court documents from civil rights attorneys John Burton and Ben Nisenbaum.

Medical Literature Review

To examine the extent and quality of evidence for “excited delirium” as a diagnosis and potential cause of death, physician members of the PHR team conducted a scoping review of and analyzed peer-reviewed medical literature.[55] On August 19, 2021, PHR conducted a PubMed/MEDLINE search using the key words “excited delirium” without filters. Two hundred twenty-six abstracts (226) were found between the available date range of January 1956 and August 2021. Titles and abstracts were screened for information on diagnostic criteria for “excited delirium,” origins of the term, pathophysiology, and evidence for the syndrome. If the abstract was not available or if the article was unclear after a review of the abstract alone, a full review of the article was performed.

Articles were excluded if they were not peer reviewed, not in English (due to a lack of capacity to translate), or did not provide any of the following: 1) historical information on the origins of “excited delirium;” 2) a definition or description of “excited delirium,” which may have included pathology or pathophysiology; or 3) a discussion of evidence for or against “excited delirium” as a distinct syndrome. Articles were also excluded if they focused solely on a case report or series, drugs, or treatment without significant discussion of “excited delirium” as an entity itself. Of the 226 articles, 180 did not meet the above criteria and were excluded from our analysis, leaving 46 peer-reviewed articles. A secondary search was performed on the same database using the term “excited delirium syndrome,” which yielded 95 results, all of which had already been captured in the primary search. (Of note, alternate search terms were not employed, such as “Bell’s mania,” “agitated delirium,” “positional asphyxia,” “restraint asphyxia,” “in-custody deaths,” or “police use of force.”)

Between August 19, 2021 and October 20, 2021, PHR team members read and abstracted articles that met inclusion criteria. To provide important context to the 46 peer-reviewed articles, other literature, such as letters to the editor and commentary, secondary references, consensus and position papers, and non-peer reviewed material, were also considered and incorporated in this report when germane.

To check for saturation and consistency, results were compared to a general literature review performed in July 2021 by a different PHR team during the concept design stage of this report. The references and conclusions of these two independent literature reviews were complementary and consistent.

Interviews

In light of the continued use of “excited delirium” as a cause of death among medical examiners and coroners, PHR explored the experiences and perspectives of forensic pathologists and other medical and legal experts on deaths in custody. After obtaining exemption from PHR’s Ethics Review Board, given the low risk to interviewees, PHR conducted individual semi-structured interviews with 20 experts on deaths in police custody regarding their knowledge and perspective on the use of “excited delirium” as a cause of death. The interviewees included nine forensic pathologists (across the United States, Canada, Chile, and New Zealand, one of whom also trained in Italy and Scotland), one forensic epidemiologist, two emergency physicians, one surgeon who is also a certified medico-legal death investigator, four plaintiff’s attorneys, two prosecutors, and one law enforcement trainer.[56] We used snowball sampling to connect with experts and continued reaching out to prospective interviewees until we reached thematic saturation (i.e., no new themes emerged during analysis of interview transcripts). Although the focus of our research was the use of “excited delirium” as a cause of death in the United States, we also interviewed forensic pathologists based outside the United States considering the global reach of the medical literature on “excited delirium.”

In the interviews with physicians, we sought to identify areas of consensus and ongoing discussion regarding “excited delirium” and to learn about their introduction to the term and the evolution of their understanding. We interviewed the attorneys to inform the report background and to seek their views on the prevention of deaths in custody that are attributed to “excited delirium.” PHR also held conversations geared toward preventing such deaths with experts on mental health and substance use crisis response, including staff at the Treatment Advocacy Center, National Harm Reduction Coalition, Crisis Assistance Helping Out On The Streets (CAHOOTS), and Portland Street Response.[57]

Finally, PHR received approval from PHR’s Ethics Review Board to interview members of families who had lost loved ones to deaths in police custody in the United States where “excited delirium” was designated by medical examiners as the cause of death. We connected with civil rights attorneys who represent families in wrongful death lawsuits against law enforcement officers and asked the attorneys whether any of their clients were interested in speaking with us for our report. Two families conveyed through their attorneys their interest in speaking with PHR, and their attorneys were present for the subsequent interviews.

All interviews took place via video or audio conferencing due to the SARS-CoV-2 public health emergency and wide geographical location of interviewees. All participants gave verbal consent to the interview, and for the interview to be recorded. Notes were also typed during the interviews.

Interviewees were informed of the purpose and voluntary nature of the interview. They were told that they could stop the interview at any time and that all possible measures would be taken to keep their identity confidential unless they wanted to disclose it. They were given the option of remaining anonymous and using a pseudonym in this report. Interviewees received no compensation for participating in interviews. The interviewers used an interview guide, previously agreed upon by the research team. Interview materials and transcripts were stored securely on PHR computers. Team members reviewed the written notes and transcripts to identify key themes across the interviews and pull illustrative quotes.

Limitations

PHR’s interviews with forensic pathologists, emergency physicians, lawyers, and others are not intended to be a representative sample of the field. Rather, we sought to speak to experts both in the United States and internationally to gauge areas of consensus and ongoing discussion regarding the continued use of “excited delirium.”

The medical literature review was not exhaustive and used one biomedical literature database (PubMed/MEDLINE). Only “excited delirium” and “excited delirium syndrome” were searched and may have not resulted in a comprehensive selection of relevant articles. After articles meeting inclusion criteria were identified and reviewed, a pragmatic research approach was adopted: references of included articles were explored for context and history.

Findings

Origins and History

Key Definitions

A syndrome consists of a group of signs and symptoms that occur together and characterize a discrete abnormality or condition.^[58] The cause, pathophysiology, and/or course of a “syndrome” is often not clearly understood. Once medical science identifies a clear causative agent or underlying pathophysiologic process, the group of signs and symptoms are then referred to as a “disease.” What are considered diseases change over time as a result of advances in technology, diagnostic ability, and expert consensus determinations, among other factors. In psychiatry, maladaptive mental and behavioral disturbances that impair functioning are often referred to as disorders. There are well-defined criteria for diagnosing psychiatric disorders, even though some have criticized these criteria as unreliable.^[59]

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) defines delirium as a neurocognitive disorder characterized by a “disturbance in attention and awareness that develops over a short period of time and is not better explained by another preexisting, evolving, or established disorder.”^[60] Additional features may include hypo- or hyperactivity and emotional disturbances such as fear, agitation, or euphoria, as well as reduced awareness of the environment. The pathophysiology of delirium is poorly understood, but it is generally accepted as a sign of an underlying disease process, such as organ failure, infection, lack of oxygen, metabolic imbalance such as low blood sugar levels, drug side effects, intoxication, or withdrawal, among others. Delirium is medically treated by finding and treating the underlying cause, along with supportive behavioral modifications and medical care such as hydration, psychopharmaceuticals, and pain control.

Restraints in the medical context are actively discouraged and avoided in the management of delirium, never include prone or neck restraints, and are monitored by an independent medical oversight organization (the Joint Commission on Accreditation of Healthcare Organizations). Delirium is not itself considered a cause of sudden death.

Bell’s Mania

In 1849, Dr. Luther Bell, a Massachusetts physician at the McLean Asylum for the Insane, described cases of primarily female psychiatric patients who experienced symptoms and signs such as overactivity, delusions, transient hallucinations, sleeplessness, and fevers, typically over days to weeks, and in some cases resulting in death.^[61] This constellation of signs and symptoms has been called Bell’s Mania, delirious mania, acute maniacal delirium, lethal catatonia, and, later, chronic “excited delirium.”^[62] The Bell’s Mania description occurred long before other diagnoses like schizophrenia,[63] bipolar mania, or autoimmune encephalitis were described in their current formulations, and the signs and symptoms of Bell’s Mania are consistent with these diagnoses, among others. The disappearance of case reports using these descriptions between the 1950s and 1980s has been attributed to the rise of relatively effective antipsychotic medications and treatment and greater psychiatric diagnostic precision.^[64]

Wetli and Fishbain

The introduction of the term “excited delirium” in the 1980s has been attributed to Drs. David Fishbain and Charles Wetli. In the early 1980s, at the University of Miami, Fishbain was director of psychiatric emergency services, and Wetli was a forensic pathologist. In 1981, Wetli and Fishbain co-authored a case report of cocaine intoxication in a person who swallowed packets of cocaine in order to store them within their body, termed “bodypacker.”^[65] Wetli and Fishbain described the resulting delirium as a medical emergency characterized by a disturbance of attention with impaired perception. They characterized this “acute excited delirium” as reversible, transient, and with an array of possible causes. They elaborated that there are “two types of delirium: stuporous … and excited.” Notably, they stated that the treatment of delirium is of the underlying illness and concluded that the delirium presentation hides the “medical nature.”

In 1985, Wetli and Fishbain published a case series on cocaine-induced psychosis.^[66] This series described seven cocaine users (six men and one woman) who exhibited fear, panic, violent behavior, hyperactivity, hyperthermia, and/or unexpected strength. All of them had been restrained (six by police, in some cases with the assistance of bystanders, and one by emergency room staff) and all died suddenly with respiratory arrest, with five of them reportedly dying in police custody.

Autopsies did not reveal any “anatomic cause of death.” In this publication, Wetli and Fishbain again described “excited delirium” as a “medical emergency but with a psychiatric presentation” and noted that the “prognosis depends on the underlying cause of the delirium.”

Four of the seven people had been either hog-tied (had their hands and feet fastened together) or put into a hobble restraint (a nylon strip that ties a person’s ankles together and links them to their wrists handcuffed behind their back) in a prone position, which can impair breathing. Other than mentioning the prone restraint in passing, Wetli and Fishbain did not discuss the role restraint may have played in these victims’ deaths.

In both these 1981 and 1985 case reports, Wetli and Fishbain reference the Comprehensive Textbook of Psychiatry, 3rd edition, chapter 20, pages 1359–1392.^[67] This section was written by Dr. Zbigniew J. Lipowski. (PHR obtained the same edition and reviewed these pages.) Wetli and Fishbain cite Lipowski when defining delirium, including the description of a hyperactive and hypoactive delirium: “There are two major types of delirium: stuporous (dull, lethargic, hypoactive, mute, somnolent, and apathetic), and excited (thrashing, shouting, hyperactive, fearful, panicky, agitated, hypervigilant, and violent).”[68] Lipowski does not use the term “excited delirium.” It is our conclusion that Wetli and Fishbain initially used “excited” as an adjective to portray the hyperactive form of delirium.

A short time later, Wetli, as will be discussed below, began using “excited delirium” as a cause of death, diagnosis, and unique disease. There is, however, no indication in his writings that he had access to new scientific evidence underpinning this change.

Serial Murders of Black Women in Miami

In the years that followed his publications on cocaine-induced “excited delirium,” Wetli began to seek new applications of his theories in his work as deputy chief medical examiner in Miami.

Between September 1986 and November 1988, 12 Black women who were presumed sex workers were found dead, one after the other, in the same geographic area of Miami.[69] Wetli and several of his colleagues found that almost all had low levels of cocaine in their systems and classified the majority of the deaths as accidents from cocaine intoxication.[70] On November 24, 1988, Wetli began to publicize his theory that the women had died from combining sex with cocaine use, claiming that autopsies had “conclusively” shown they had not been murdered.^[71]

Wetli speculated that while the women were working as sex workers, they consumed small amounts of cocaine and then died from sexual excitement, which he described as the female manifestation of the “cocaine psychosis” he had previously identified in men.[72] “For some reason, the male of the species becomes psychotic and the female of the species dies in relation to sex,” he said.[73]

As to why all the women dying were Black, he further speculated, without any scientific basis, “We might find out that cocaine in combination with a certain (blood) type (more common in blacks) is lethal.”[74]

The following month, he said, “We know that the deaths are related to crack, but we still don’t know the mechanism.”[75]

On December 12, 1988 – less than a month after Wetli began to publicize this theory – 14-year-old Antoinette Burns was found dead.[76] Wetli, who performed the initial autopsy, believed that she, too, had died from a combination of sex and cocaine use.[77] For weeks, Burns’ family pushed back against this theory, but it was not until the toxicology report came back negative that authorities began to take them seriously.[78]

In March of 1989, police investigators confronted Wetli’s supervisor, chief medical examiner Dr. Joseph Davis, with evidence they believed pointed to homicide.^[79] Davis began to reexamine the case files.^[80] In May, a newsweekly reported that the number of Black women found dead had reached at least 17.^[81] The article noted that Burns had died without cocaine in her system and cited investigators’ beliefs that a serial killer was actually responsible for the women’s deaths.^[82] Burns’ mother told the paper, “I’m always wondering who killed her and how did she die. I want justice to be served.”^[83]

The article described Wetli’s sex-cocaine theory for women as the counterpart of his “excited delirium” theory about men. “The women may be dying after sexual activity,” Wetli said. “The men just go berserk.”

Wetli, meanwhile, continued to promote his theory that cocaine combined with orgasm produced lethal results: “We still really don’t know what’s going on. My gut feeling, though, is that this is a terminal event that follows chronic use of crack cocaine affecting the nerve receptors in the brain. I think it’s a type of neural exhaustion.”[84] The article described Wetli’s sex-cocaine theory for women as the counterpart of his “excited delirium” theory about men. “The women may be dying after sexual activity,” Wetli said. “The men just go berserk.”[85]

Later that month, Davis announced his conclusion that the deaths of all of the women – 19 by that point – were homicides.[86] He reclassified the 14 that had initially been ruled accidents or left unclassified.[87] Only nine women’s bodies had been found soon enough to identify concrete signs of strangulation and/or asphyxiation.[88] In those women’s cases, Davis found evidence of neck pressure in seven and pressure to the mouth in four, as well as evidence of hemorrhaging in the eyes.^[89] He noted that in some of the women’s cases, the signs of asphyxiation were so pronounced that one could see them from “ten feet away, it’s that clear.”^[90]

All but one of the women were believed to have the same killer.[91] Police soon identified Charles Henry Williams, a convicted rapist, as the primary suspect.[92] Arrested in 1989 on an unrelated rape charge, he was eventually believed to be responsible for the deaths of as many as 32 women since 1980.[93] Later charged with one of the murders, he died before he could stand trial.[94]

One year after Davis’s reclassification of the deaths as homicides, Wetli continued to assert that at least some of the women had died from a combination of sex and cocaine: “I have trouble accepting that you can kill someone without a struggle when they’re on cocaine … cocaine is a stimulant. And these girls were streetwise.”[95]

Wetli also continued to promote a corresponding theory of Black male death from cocaine-related delirium, without any scientific basis: “Seventy percent of people dying of coke-induced delirium are black males, even though most users are white. Why? It may be genetic.” ^[96]

Wetli’s grave mischaracterization of the murders of Black women in Miami – and the racism and misogyny that seemed to inform it – failed to discredit his other equally racialized and gendered theory of sudden death from cocaine.[97] Instead, the use of the term “excited delirium” grew.

NAME Position Paper (2004)

More than a decade later, Wetli coauthored a 2004 National Association of Medical Examiners (NAME) position paper that continued to link cocaine use to “excited delirium.”[98] That position paper, in a single reference, noted briefly “a catecholamine-mediated excited delirium, similar to cocaine” that was “becoming increasingly recognized and has been detected in patients with mental disorders taking antidepressant medications, and in psychotic patients who have stopped taking their medications.” It provided as a citation for this claim the abstract of a presentation by Wetli.[99] Yet, in discussing “sudden death related to police actions,” the paper only discussed assessing the involvement of cocaine as a cause of death and asserted that “other obvious causes of death must be carefully ruled out through a careful scene investigation, meticulous forensic autopsy, and a review of the medical information.” The paper also delineated criteria for a diagnosis of “cocaine-induced excited delirium,” requiring a “clinical history of chronic cocaine use, typically bizarre and violent psychotic behavior, and the presence of cocaine or its metabolites in body fluids or tissues.” It did not discuss at all criteria for diagnosing “excited delirium” from causes other than cocaine use.[100]

In its 2017 position paper on recommendations for the investigation and reporting of deaths in police custody, NAME referenced “excited delirium” in passing, noting, “the more difficult cases are those where the individual is observed to be acting erratically due to a severe mental illness and/or acute drug intoxication. These cases have been defined in the literature as excited delirium and often result in a law enforcement response and restraint of the decedent.”[101]

Publication of Excited Delirium Syndrome

In 2005, Theresa Di Maio, a psychiatric nurse, and her husband, Dr. Vincent Di Maio, a forensic pathologist who was serving as the chief medical examiner of Bexar County, Texas and editor of the American Journal of Medicine and Pathology, published a book on  “excited delirium syndrome.”^[102] They defined the term as “the sudden death of an individual during or following an episode of excited delirium, in which an autopsy fails to … explain the death.”^[103] They defined “excited delirium” as “delirium involving combative or violent behavior” caused by “normal physiologic reactions of the body to stress gone awry.”^[104] The Di Maios discussed the history and origins of “excited delirium” via summarized case reports from primarily the 1930s and 1940s, in most cases describing women in psychiatric institutions. In a 2014 deposition in a restraint death case, Dr. Di Maio noted that he and his wife had coined the term “excited delirium syndrome.”^[105]

Prone Restraint Studies

At the same time that the Di Maios were promoting the concept of “excited delirium syndrome,” others were conducting research on the safety of prone restraint tactics. Among the studies most widely used to exonerate law enforcement officials in cases of deaths in custody are those conducted by emergency physicians Theodore Chan and Gary Vilke. Drs. Chan and Vilke are part of what the New York Times in a December 26, 2021 investigative report described as a “small but influential cadre of scientists, lawyers, physicians and other police experts whose research and testimony is almost always used to absolve officers of blame for deaths.”^[106] Forming a “cottage industry of exoneration,” many of the dozen or so individuals in this group, including Chan and Vilke, have ties with TASER/Axon and/or work as defense experts in death-in-custody litigation.[107]

In 1997, Chan and Vilke sought to determine whether the “hobble” or “hog-tie” restraint position results in clinically relevant respiratory dysfunction. Fifteen healthy volunteers – a small sample size with a questionable ability to generate valid or reliable results – were hogtied. Measurements of lung function decreased by up to 23 percent, which were statistically significant, but the authors deemed them not clinically significant.[108]

In the early 2000s, Chan and Vilke conducted a study in which they placed 25 pounds and 50 pounds on the backs of 10 participants – again a very small sample size – while they were in a prone position.^[109] They obtained Institutional Review Board (“IRB”) approval from the University of California’s Human Research Protection Program for this study.[110]

In 2001, Vilke served as a plaintiff’s expert in a restraint asphyxia case when a man with schizophrenia in psychiatric crisis was restrained in a prone position while officers put their weight on his back. At that time, in his deposition, Vilke opined that the weighted restraint killed the decedent. In referring to his studies involving the placement of 25 and 50 pounds on people’s backs, he stated that these were preliminary studies only and seemed to suggest that experimenting with greater weights would be unethical due to the possible danger. He noted, “We don’t want to put 200 pounds on people and kill them.”^[111]

After appearing in that case, Vilke took on work as a defense expert in several wrongful death cases against TASER/Axon and law enforcement. Vilke acknowledged in a 2018 deposition that he had worked as a defense expert on behalf of TASER International in “certainly a number of cases” and said he believed that whenever he had testified in cases involving the use of a Taser, he had always testified on behalf of the defense. [112] Further evincing his defense sympathies, Vilke even told a journalist in 2021 that it was “doubtful” that Minneapolis police officer Derek Chauvin had killed George Floyd by pressing his knee on his neck.[113] The New York Times reported that in a deposition in summer 2021, “Dr. Vilke said it had been 20 years since he had last testified that an officer was likely to have contributed to a death.”[114]

Likewise, in a 2014 deposition, Chan acknowledged that he had been retained by the defense in cases involving the use of a Taser “probably four or five times.”[115]

In 2007, Vilke and colleagues published an article titled “Ventilatory and Metabolic Demands During Aggressive Physical Restraint in Healthy Adults,” in which they put up to 225 pounds (102.3 kg) on the backs of 30 healthy adults who were restrained in a “hogtie restraint” prone position, with 27 participants told to “struggle vigorously” for 60 seconds.[116] The authors found no clinically significant impairments in breathing (ventilatory function) among participants who were either prone or struggling. The authors reported that they received IRB approval from San Diego State and the University of California San Diego (UCSD) Human Research Protection Program for the study. However, repeated efforts by Julia Sherwin to subpoena IRB materials related to this study produced no evidence of a completed IRB review or approval. This raises concerns about whether this study that has since been used as evidence for the safety of prone restraint law enforcement tactics ever passed the ethical and safety hurdles needed to obtain IRB approval.[117]

In two recent restraint death cases handled by Julia Sherwin, the defendant police officers hired Vilke to testify on their behalf.[118] In both cases, Vilke testified that the officers beating and restraining the decedents in a prone position, putting weight on the victims’ backs, and even choking one decedent did not cause or contribute to their deaths.[119]

Role of TASER

TASER/Axon is a U.S. company that develops technology products and weapons for the military, law enforcement, and civilians, including “Taser,” a line of so-called “less-lethal” electroshock “stun” weapons. In 2007, TASER purchased 1,000 to 1,500 copies[120] of Di Maio’s book on “excited delirium syndrome” and distributed free copies. [121] They also gave out other materials on “excited delirium” at conferences of medical examiners and police chiefs.[122] Since there are only about 500 full-time forensic pathologists in the United States,[123] TASER purchased enough copies of Di Maio’s book in 2007 alone to easily cover the entire forensic pathology community, ensuring widespread familiarity with his theory on “excited delirium syndrome.”^[124] 

Di Maio has acknowledged testifying as a paid expert for TASER/Axon multiple times and stated in 2014 that in the cases in which he was deposed, he always gave the opinion that the Taser did not cause or contribute to the person’s death.[125]

Since there are only about 500 full-time forensic pathologists in the United States, TASER purchased enough copies of Di Maio’s book in 2007 alone to easily cover the entire forensic pathology community, ensuring widespread familiarity with his theory on “excited delirium syndrome.”

American College of Emergency Physicians (ACEP) White Paper

In 2005, TASER’s national litigation counsel,[126] Michael Brave, co-founded a corporation entitled the Institute for the Prevention of In-Custody Deaths (IPICD) with another TASER defense expert and consultant,[127] John Peters.[128] In October 2008, IPICD held its “3rd Annual Sudden Death, Excited Delirium & In-Custody Death Conference.” IPICD advertised the conference as “the first consensus conference that focuses upon excited delirium,” and promised that “attendees will help make law enforcement, medical, and legal history … focused on arriving at a ‘consensus’ about excited delirium.” IPICD stated that the “findings from this seminal event will then be published in leading medical, legal, and law enforcement journals.”[129]

The conference speakers included TASER and/or restraint death defense experts and consultants such as Chan, Di Maio, Vilke, and Wetli, as well as Dr. Steven Karch[130] and Dr. Deborah Mash.[131] The results of the 2008 IPICD conference were published as the “White Paper Report on Excited Delirium Syndrome” by the American College of Emergency Physicians on September 10, 2009.^[132] The co-authors of the white paper included Chan, Mash, and Vilke, as well as TASER’s medical director, Dr. Jeffrey Ho.[133] Despite the close links between the paper’s co-authors and TASER, PHR has been unable to find conflict-of-interest statements or disclosures in connection with the conference or the resulting white paper.

The White Paper Report acknowledges that the pathophysiology of “excited delirium syndrome” is not understood, that there are no tests or standard diagnostic criteria, and that the medical treatment for the “syndrome” is unknown. Regarding the term “excited delirium,” the authors assert that the “issue of semantics does not indicate that excited delirium does not exist” and provide similar ICD-9 (International Classification of Diseases, Ninth Revision) codes such as manic excitement, delirium of mixed origin, agitation, delirium, and abnormal excitement which “describe the same entity as excited delirium syndrome.” They fail to consider that if manic excitement, delirium of mixed origin, agitation, and abnormal excitement (among other ICD-9 codes listed) are the same entity as “excited delirium,” then “excited delirium” cannot be a unique entity. Their Report also does not consider that the forms of delirium or manic excitement in the ICD-9 are not considered lethal. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the main diagnostic tool used by clinicians for psychiatric diagnosis, in fact, recognizes “delirium” as a clinical entity, with “hyperactive,” “hypoactive,” and “mixed” delirium subtypes, but these do not align with “excited delirium.” The Task Force elaborates: “In most cases, the underlying disease will be untreated at the time of [excited delirium] presentation,” which suggests that “excited delirium” is a presentation or manifestation of another cause.[134]

The White Paper Report offers 10 specific features suggesting the presence of “excited delirium” (pain tolerance, agitation, not responding to police presence, superhuman strength, rapid breathing, not tiring despite heavy physical exertion, naked/inappropriately clothed, sweating profusely, hot to the touch, and attraction to/destruction of glass/reflective surfaces). However, it provides no direct citations to the medical literature as to the origins or accuracy of these 10 features in predicting or diagnosing “excited delirium,” nor does it comment on the validity of these features as a screening tool. The descriptions of certain symptoms and signs also play into racist tropes that people of color possess “superhuman strength” and are “impervious to pain.”[135] This is doubly concerning given that Wetli had asserted without evidence 18 years prior that 70 percent of people who died of cocaine-induced delirium were Black men and that “it may be genetic.”^[136]

In 2011, the same group of authors published a reiteration of the White Paper Report in the academic, peer-reviewed literature, titled, “Excited delirium syndrome: defining based on a review of the literature.”^[137] Based on a review of 18 articles, 10 written by the paper’s authors, the authors again identified 10 features of “excited delirium.”^[138]At no point did the authors discuss the lack of and consequent need to develop and test screening tools for “excited delirium” that are valid (able to accurately identify diseased and non-diseased individuals) or reliable (repeat measurements yield the same result). They also provided no statements of conflicts of interest or disclosures.

A 2008 National Institute of Justice (NIJ) report defined “excited delirium” as a “State of extreme mental and physiological excitement, characterized by extreme agitation, hyperthermia, euphoria, hostility, exceptional strength and endurance without fatigue.” Of note, the report was written by the then director of the NIJ but included the disclaimer that “Findings and conclusions of the research reported here are those of the authors and do not reflect the official position and policies of their respective organizations or the U. S. Department of Justice.”[139]

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The Death of Martin Harrison

On August 13, 2010, Martin Harrison was arrested for jaywalking in Oakland, California.[140] A warrant check revealed an outstanding warrant for failing to appear in court on a “driving-under-the-influence” charge, and the police arrested Harrison and took him to the Alameda County Santa Rita Jail.[141] During the intake medical screening process, which occurred at approximately 3:00 p.m., Harrison was visibly intoxicated and smelled of alcohol.[142] He told the licensed vocational nurse (LVN) who conducted the intake medical assessment that he drank every day, that his last drink was that day, and that he had a history of experiencing alcohol withdrawal.[143] The LVN determined Harrison needed no medical care and sent Harrison to the jail’s general population without instituting any alcohol withdrawal treatment protocols.[144]

Three days later, Harrison experienced severe alcohol withdrawal, or delirium tremens, hallucinating that he was in his apartment and holding his mattress over his head because he perceived people were trying to shoot him. Ten deputies arrived at Harrison’s jail cell, Tased him, severely beat him, put a spit hood on him, and forced him into a prone position with officers on top of him, until he died.

Alcohol withdrawal and delirium tremens are considered treatable by medical professionals, yet no medical management was offered at any point during Harrison’s stay in jail, including in response to deterioration of his medical condition.

The defendants hired both Di Maio and Wetli as their expert witnesses.

In 2014, Di Maio and Wetli gave sworn deposition testimony in the Harrison case. There was no dispute between the parties that Harrison was experiencing delirium tremens – which, unlike “excited delirium,” has an International Classification of Diseases code – at the time he was severely beaten, Tased, and restrained. Yet Wetli testified in his deposition that Harrison died of “excited delirium” and “is a classic example of death due to excited delirium or the resuscitation that has taken place.”^[145] Di Maio testified that Harrison’s “presentation is of somebody in excited delirium” and “you could argue” that Harrison’s death was “a pure excited delirium case.”^[146]

Despite their assertions regarding “excited delirium,” Di Maio and Wetli’s depositions confirmed these facts:

• “Excited delirium” has no International Classification of Diseases (ICD-9 or ICD-10) code, which means it cannot be assigned as a diagnosis or as a cause of death for statistical purposes; [147]
• “Excited delirium” has never appeared in any version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the main diagnostic tool for mental health problems used by physicians and mental health workers in the United States, which is now in its fifth edition; [148]
• “Excited delirium” is not recognized by the American Medical Association, American Psychiatric Association, or American Psychological Association.[149]

The Harrison case settled in 2015 after the first week of an eight-week trial, for $8.3 million, along with changes to policies and training in the fifth largest jail in the United States.[150]

“Excited delirium” has no International Classification of Diseases (ICD-9 or ICD-10) code, which means it cannot be assigned as a diagnosis or as a cause of death for statistical purposes.

Medical Literature Review

The PHR team explored two main areas of controversy in the peer-reviewed medical literature on “excited delirium”: 1) the underlying pathophysiology of “excited delirium;” and 2) “excited delirium” as a cause of death.

Consensus in the Literature that the Pathophysiology of “Excited Delirium” Is Unknown

There is consensus across reviewed articles that the pathophysiology of “excited delirium” is unknown, and that there are no telltale or characteristic autopsy findings.^[151] Many possible causes of the symptoms associated with “excited delirium” are hypothesized. These include a fight-or-flight response (catecholamine surge) resulting in cardiac arrhythmia, disturbances of dopamine and/or dopaminergic pathways, and restraint-related asphyxia or other use of force.^[152] Several systematic reviews of the literature on “excited delirium” conclude that the levels of evidence for any postulated etiology are low to very low, and that the overall quality of the studies is poor.^[153] For example, a 2018 systematic review found that 65 percent (n = 43) of the articles were retrospective case reports, case series, or case-control studies, all weaker forms of medical evidence.^[154]

Hypothesized Roles of Cocaine Intoxication and Neurotransmitters in Symptoms and Signs of “Excited Delirium”

The consensus among the articles included in the review was that Wetli and Fishbain in 1985 introduced into the literature and medical community the concept of “excited delirium” in the context of cocaine use. The authors reported that “excited delirium” was secondary to cocaine intoxication. Therefore, “excited delirium” is a presentation with an underlying cause.^[155] Wetli et al. cite the Comprehensive Textbook of Psychiatry, chapter 20, written by Dr. Zbigniew J. Lipowski, when defining delirium: “There are two major types of delirium: stuporous … and excited….” Lipowski does not use the term “excited delirium.” In fact, cocaine is only referenced in the context of “substance-induced organic mental disorders.”^[156] It seems that Wetli et al. initially used “excited” as an adjective to portray the hyperactive form of delirium in their case report.

Later, in 1996, Wetli et al. again discussed cocaine-associated delirium and concluded that, “When cocaine users with agitated delirium die, cocaine should be considered the cause of death, unless there is clear physical evidence that death is due to some mechanism other than cocaine toxicity, such as positional or mechanical asphyxia.”^[157]

The reviewed literature accepts that cocaine interacts with different receptors in the body, including the dopamine system in the brain, by increasing dopamine levels through various mechanisms.^[158] Increased release or transport of dopamine is hypothesized in some articles to lead to “excited delirium.”^[159] However, controversy remains about whether there is any evidence from autopsies that the dopamine system in the brain is associated with “excited delirium.”^[160]

Other articles have hypothesized that “excited delirium” may be part of a spectrum of other known medical conditions with other neurotransmitters and pathways involved.^[161]  No reviewed studies provide conclusive evidence for one hypothesized mechanism over another. Similarly, while death from “excited delirium” in reviewed case series were often attributed to acute myocardial dysfunction leading to cardiopulmonary arrest, exact mechanisms leading to this cause of death are not elucidated.

Debate in the Literature on Whether Prone Restraint Positions rather than “Excited Delirium” Are a Cause of Death in Police Custody

Bell and Wetli et al. defined positional asphyxia as the decedent being found in a position that does not allow adequate breathing and having been unable to free themselves.^[162]

In 2020, Strommer et al. conducted an extensive review of the literature and converted all relevant “excited delirium” or “agitated delirium” case reports and characteristics in the literature into a numerical dataset for quantitative analysis.^[163] They found that some form of restraint was described in 90 percent of all deaths in “excited delirium.” Restraint increased the odds of an “excited delirium” diagnosis by between 7 and 29 times.^[164]

A central debate has thus been whether restraint positions such as prone restraint can physiologically cause positional asphyxia and death. Some case reports have shown that prone restraint was used during sudden and unexpected in-custody deaths.^[165]  Studies have attempted reenactment of prone and prone restraint positions, including with compression, with no clear pattern of results.

One of the earliest studies evaluated blood oxygenation and heart rate after recovery from exercise while in a restrained and hogtied position.^[166] The study found that it took participants longer to recover in the hogtied position and questioned if this could be worsened during a violent struggle. Later, a different study monitored similar parameters for different types of restraint positions over a longer period of time after exercise, but in obese adults.^[167] This study concluded that there were no clinically significant effects. However, its data showed that carbon dioxide elimination was reduced in all restrained positions. None of the studies captured scenarios reflective of police encounters, i.e., involving people who may be struggling and agitated, as opposed to lying at rest, as were the participants in these studies.

Some studies have shown statistically significant decreases in lung function measures during prone restraint positioning, though whether these results were clinically meaningful is not clear.^[168] Researchers have found large decreases in lung function and/or other physiologic parameters, such as heart rate and blood pressure, and concluded that some prone restraint positioning should be considered a risk factor for sudden death.^[169] Other studies have shown that after applying weight to the torso of prone people, there were reductions in cardiac output, blood flow, and/or the diameter of the inferior vena cava (the large vessel which returns blood to the heart that is then pumped to the lungs to be oxygenated).^[170] One study measured the effects of prone positioning and restraint for 10 minutes on adults with chronic obstructive pulmonary disease; almost half were unable to complete the study due to uncontrolled respiratory symptoms.^[171]

A 2020 study found that some form of restraint was described in 90 percent of all deaths in “excited” or agitated delirium. Restraint increased the odds of an “excited delirium” diagnosis by between 7 and 29 times.

A 2021 study noted that four prominent factors – physical exertion, prone positioning, restraint, and body compression – had been tested in other studies.[172] The researchers used electrical impedance tomography (EIT) to measure the combined impacts of these parameters on ventilation in 17 healthy human participants. They found that under the combined effects of all these conditions, participants had significant and prolonged declines in lung reserve volumes over time, indicating increased work of breathing compared to the control posture of arms at the side.[173]

The researchers noted that these declines took place with an applied weight of 35 percent participant bodyweight, which the study described as “likely less” than the weight an officer would typically apply in an arrest-related encounter. They hypothesized that in true conditions of weighted restraint, the increasing effort needed to breathe while in a restraint posture would become more relevant to the survival of the participant the longer the weight is applied.[174]

The above studies demonstrated measurable hemodynamic and/or respiratory changes detectable in volunteers who were placed in a prone or prone restraint position in a controlled and mild setting. All of these studies had tiny sample sizes composed of primarily healthy volunteers in well-controlled environments. None of the study participants were intoxicated, fearful, or agitated, within or outside the context of mental illness, and none were being forcibly restrained. Therefore, none of the studies replicated an accurate police encounter with someone supposedly in “excited delirium” who may be struggling and agitated due to restraints, as opposed to laying in rest.

It is not known whether the use of prone restraint in conditions such as the forcible restraint of an agitated person could cause significantly worse hemodynamic or respiratory harms than what was found in these studies.

Regarding all forms of neck restraint, however, a 2009 study found that “A force of only 6kg is needed to compress the carotid arteries, which is about the average weight of a household cat or one-fourteenth the average weight of an adult male.”[175] For this reason, among others, the American Academy of Neurology (AAN) has held that neck restraints should be classified, “at a minimum, as a form of deadly force.”[176]

Whether Delirium Alone Can Be a Cause of Death

The DSM-5 recognizes delirium as characterized by “disturbance of consciousness” (i.e., reduced clarity of awareness of the environment), with reduced ability to focus, sustain, or shift attention. The three delirium subtypes are hyperactive, hypoactive, and mixed. Yet, some literature discussed that delirium alone cannot be a cause of death because, by definition, delirium requires an identifiable underlying organic cause that can be ascertained from the clinical presentation, diagnostic studies, or, in the case of death, by autopsy.^[177]

In their 2020 quantitative analysis on “excited delirium,” Strommer et al. discussed the overlap between restraint asphyxia and “excited delirium,” in that the characteristics used to describe “excited delirium” are likely to trigger the use of force and restraint, and that risk factors for “excited delirium” overlap with the risk factors for restraint-related asphyxia.^[178]This recent review further reinforces that “excited delirium” does not cause death in unrestrained people.

Delirium alone cannot be a cause of death because, by definition, delirium requires an identifiable underlying organic cause that can be ascertained from the clinical presentation, diagnostic studies, or, in the case of death, by autopsy.

Key Concerns Raised by Review of the Scientific Literature on “Excited Delirium”

The foundations for the diagnosis of “excited delirium” have been misrepresented, misquoted, and distorted. The authors credited with the creation of the term initially used “excited delirium” as a descriptive term for delirium and noted underlying causes. Our examination of the peer-reviewed medical literature on “excited delirium” found that those articles supporting this diagnosis were authored by a small group of people, many of them with ties to TASER/Axon and/or other conflicts of interest. Most of the studies cross-reference each other and highlight non-peer-reviewed sources, such as the Di Maio and Di Maio book Excited Delirium Syndrome, which is not a scientific or medical textbook, is not peer reviewed, and draws unsubstantiated conclusions.[179] For example, Di Maio and Di Maio discuss the 1997 study by Chan et al. multiple times. They describe this study as a “death blow” to the positional asphyxia theory and that believing positional asphyxia is possible “involves suspension of common sense and logical thinking.” Elsewhere, they state that Chan et al.’s study “disproved” the restraint asphyxia hypothesis. Di Maio and Di Maio are not reporting evidence-based conclusions. Chan’s single study with a small, non-representative sample size that does not replicate real-life conditions cannot deliver a “death blow.” 

Most of the reviewed literature suggests a relationship between “excited delirium,” death, and restraint. However, these studies have small sample sizes alongside other limitations. The extensive review conducted by Strommer et al. included studies up to April 2020 and summarized all “excited delirium” characteristics. It found that restraint was described in 90 percent of all deaths in the “excited” or agitated delirium medical literature.^[180] Notably, they report that asphyxia often lacks pathognomonic signs (clear signs that a particular disease is present) on autopsy.

Our review does not allow for conclusive determinations about whether or not restraint or positional asphyxia is the most likely true cause of death for people said to have died from “excited delirium” while agitated and forcibly restrained. All the studies discussed here, however, including those by authors who claim their studies refute restraint asphyxia and those that did not show clinically significant changes in cardiac or respiratory parameters, indeed did demonstrate measurable changes in cardiac and respiratory parameters. It is unknown if they would be clinically significant in a specific real-world situation, but it is notable that there were cardiopulmonary changes even among participants in calm and controlled settings. It is, therefore, reasonable to hypothesize that these cardiopulmonary changes could worsen and become clinically significant in real-world settings. We found no rigorous scientific research that examines the prevalence of death for people with “excited delirium” who are not physically restrained.

We found no rigorous scientific research that examines the prevalence of death for people with “excited delirium” who are not physically restrained.

Of note, in a December 26, 2021 investigation in the New York Times, the authors analyzed more than 230 scientific papers on restraints, body position, and “excited delirium” in the National Library of Medicine database published since the 1980s. They found that nearly three-quarters of the studies that included at least one author who was in the network of TASER/defense experts “regularly supported the idea that restraint techniques were safe or that the deaths of people who had been restrained were caused by health problems.” Meanwhile, “only about a quarter of the studies that did not involve anyone from the network backed that conclusion. More commonly, the other studies said some restraint techniques increased the risk of death, if only by a small amount.”[181]

Continued Use of “Excited Delirium” to Explain Deaths in Custody and as a Legal Defense to Exonerate Law Enforcement Officials

Despite the problems with its diagnostic underpinnings, “excited delirium” continues to be used to explain deaths in custody. An Austin-American Statesman investigation into each non-shooting death of a person in police custody in Texas from 2005 to 2017 found that more than one in six deaths (of 289 total) were attributed to “excited delirium.”[182] A January 2020 Florida Today report found that of 85 deaths attributed to “excited delirium” by Florida medical examiners since 2010, at least 62 percent involved the use of force by law enforcement.[183] A Berkeley professor of law and bioethics conducted a search of these two news databases and three others from 2010 to 2020 and found that of 166 reported deaths in police custody from possible “excited delirium,” Black people made up 43.3 percent and Black and Latinx people together made up at least 56 percent.^[184] Taser use was connected to 47 percent of cases.^[185] Similarly, a 2018 study found that the term “excited delirium” has been disproportionately used as a cause of death in cases concerning young Black men.^[186]

“Excited delirium” is also frequently asserted as a defense by police officers who kill people during the course of restraint.[187] With notable exceptions, such as the murder prosecutions of the Minneapolis police officers who killed George Floyd, law enforcement officers are usually not criminally prosecuted for restraint-related deaths,[188] and they frequently deploy the “excited delirium” causation defense in civil lawsuits brought against them by decedents’ families.[189]

Growing U.S. Medical and Psychiatric Association Opposition to “Excited Delirium” as a Diagnosis

The American Medical Association (AMA) and the American Psychiatric Association (APA) do not recognize “excited delirium” as a valid diagnosis. In 2021 and 2020, respectively, they released statements denouncing a concerning pattern where “excited delirium” is used as a justification for excessive police use of force, particularly when Black men die in law enforcement custody.^[190] The AMA elaborated that the term “excited delirium” has been used to justify inappropriate and discriminatory actions. The APA advocated for the U.S. Department of Health and Human Services to conduct a nationwide investigation of all cases labeled “excited delirium.” Both associations advocate for cessation of the use of the term “excited delirium” unless a clear set of diagnostic criteria can be established, rigorous studies undertaken, and data made available.

“Excited delirium” is frequently asserted as a defense by police officers who kill people during the course of restraint.

The American College of Emergency Physicians (ACEP), meanwhile, has yet to revise its position that “excited delirium” is a distinct type of delirium. In June 2021, ACEP released a new task force report on “Hyperactive Delirium with Severe Agitation in Emergency Settings” without rescinding the 2009 white paper.[191] The new report emphasized the necessity to “differentiate and treat life-threatening causes of hyperactive delirium,” outlined multiple potential underlying causes, and called for additional research to “more fully understand inciting pathways and distinct pathophysiology of individual causes of hyperactive delirium with severe agitation.” The report noted concerns about “potential bias” in the 2009 ACEP white paper on “excited delirium syndrome” and stated that since that report’s publication, “ACEP enacted a robust global conflict of interest policy, though notably not in direct response to critics of the 2009 white paper nor with specific concerns regarding the content of that paper or others generated before such a policy was in force.” Unlike in the 2009 position paper, ACEP this time appended conflict-of-interest disclosures for the members of the task force that produced this new report. However, the 2021 report specified that while its authors were “informed by” the 2009 report, the new report was “de novo and not to be construed as an update or refutation [emphasis added] of the 2009 paper.”[192]

In February 2022, PHR reached out to ACEP’s leadership to clarify their current position in light of their 2009 and 2021 publications.^[193] PHR received the following response from Sandy Schneider, ACEP associate executive director, clinical affairs: “We stand by the research presented in our ‘ACEP Task Force Report on Hyperactive Delirium with Severe Agitation in Emergency Settings,’ published on June 23, 2021.”^[194]

The American Medical Association and the American Psychiatric Association do not recognize “excited delirium” as a valid diagnosis and both advocate for cessation of the use of the term unless a clear set of diagnostic criteria can be established, rigorous studies undertaken, and data made available.

Equally of concern, the National Association of Medical Examiners (NAME) has not publicly released a statement refuting the validity of “excited delirium” as a diagnosis and cause of death. In February 2022, PHR reached out to NAME’s leadership to clarify its current position in light of its 2004 and 2017 position papers^[195] referencing the term.^[196]  PHR received a response from Dr. Kathryn Pinneri, the 2022 NAME president, who attached the 2021 ACEP task force report and said:

“‘Excited delirium’ is not recognized as a diagnosis in the World Health Organization International Classification of Diseases (WHO ICD-10).  It is a descriptive term used for what is known medically as an acute hyperactive delirium.  Acute delirium is a well-recognized diagnosis that is part of both ICD coding and the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) of the American Psychiatric Association. 

“A variety of diseases, intoxications, and injuries may result in an acute hyperactive delirium. … Deaths associated with an excited delirium component have also occurred in the absence of police involvement.  Forensic pathologists recognize that although a person may be experiencing a hyperactive or excited delirium, that does not mean they died from it. In fact, should a person die after experiencing acute delirium, the cause of death would be the underlying disease, injury or intoxication that caused the delirium.

“Though I suspect it is accepted among many NAME members, we have never issued any type of consensus statement on excited delirium, and as an organization have not formally ‘recognized the condition as a diagnosis.’ The NAME Position paper on the Certification of Cocaine-Related Deaths is no longer current and therefore does not reflect our position at this time. We do still support the position paper on in custody deaths.”^[197]

International Reach of “Excited Delirium”

“Excited delirium” has also received attention in the wake of in-custody deaths in Australia,[198] Canada,[199] the United Kingdom,^[200] and elsewhere. The international spread of the term is concerning, but it has far from widespread acceptance.

Australia

According to The Guardian, “No Australian medical association recognises ‘excited delirium.’”[201] The term has, however, been used by Australian forensic pathologists in specific cases of deaths in custody. Additionally, The Guardian identified at least one case in the last five years in which TASER/Axon sent an email to law enforcement the same day as a death that involved Taser use. Law enforcement shared the email with the forensic pathologist on the case, who disregarded it. The email read, “TIMELY AND URGENT AND REQUIRES ACTION WITHIN 24 HOURS OR LESS,” offering assistance with the investigation and inviting the police to send brain tissue samples to the University of Miami Brain Endowment Bank to “determine drug abuse and look for excited delirium markers.”[202]

Canada

In December 2007, the Commission for Public Complaints Against the Royal Canadian Mounted Police (RCMP) issued recommendations for the use of conducted energy weapons (Tasers), accepting the existence of “excited delirium” as a unique condition and warning that Tasers should not be used against people “experiencing the condition” unless “the behaviour is combative or poses a risk of death or grievous bodily harm to the officer, the individual or the general public.”[203]

In June 2008, an independent review of Taser use by the RCMP concluded that “excited delirium” “can be considered to be ‘folk knowledge’ when used by the police and should not be included in the RCMP’s operational manual unless subsequently formally approved by the RCMP after consultation with a mental-health-policy advisory body.”[204]

United Kingdom

In May 2016, the Royal College of Emergency Medicine in the United Kingdom issued guidelines for the management of “excited delirium,” which they also referred to as “acute behavioural disturbance” (ABD).[205] The term ABD was later added to the Maudsley Prescribing Guidelines in Psychiatry, a handbook for psychiatric medications, prompting the similarly named South London and Maudsley NHS Foundation Trust – the largest public provider of mental health and substance use services in the United Kingdom – to issue a statement noting that the Trust did not recognize either “excited delirium” or ABD as medical terms.[206] The term “excited delirium” is also not recognized by the European Society of Emergency Medicine, an association of emergency physicians from 30 countries.[207]

In 2020, the Royal College of Pathologists in the United Kingdom issued Forensic Science Regulator Guidance about “excited delirium,” noting concerns about its use and misuse as a cause of death. The regulator found that “‘Excited Delirium’ should never be used as a term that, by itself, can be identified as the cause of death. The use of Excited Delirium as a term in guidance to police officers should also be avoided.” The regulatory guidance applies in England, Wales, and Northern Ireland.^[208]

The Death of Elijah McClain

On August 24, 2019, 23-year-old Elijah McClain was walking home from a convenience store in Aurora, Colorado when he was unlawfully arrested, beaten, and placed in a chokehold. When paramedics arrived, they diagnosed him with “excited delirium” and injected him with ketamine, an anesthetic that can be fatal, in an amount indicated for someone almost twice his weight. McClain went into cardiac arrest in the ambulance on the way to the hospital and died four days later.[209] A forensic pathologist ruled that his death was undetermined but may have been the result of “excited delirium.”[210]

“Justice for Elijah McClain” became a rallying cry in the Black Lives Matter movement: a young Black man killed when he was simply walking home had been blamed for his own death at the hands of law enforcement and first responders.[211] McClain’s killing also drew nationwide attention to the inappropriate prehospital use of ketamine in response to supposed signs of “excited delirium.” A July 2020 investigation by KUNC, a Colorado public radio station, found that medics in Colorado administered ketamine to 902 people for “excited delirium” over 2.5 years, and about 17 percent of those people experienced complications.[212] Since then, there have been whistleblower complaints by paramedics reporting that police officers pressured them to administer ketamine against their medical judgment.[213]

In June 2020, the American Society of Anesthesiologists issued a statement opposing the use of ketamine for a law enforcement purpose.[214] In July 2021, Colorado Governor Jared Polis signed a bill prohibiting the use of ketamine by non-medical professionals and banning its use in response to “excited delirium.” In September 2021, a grand jury indicted three police officers and two paramedics for McClain’s death, charging them with manslaughter and criminally negligent homicide.^[215] In November 2021, the city of Aurora agreed to pay a settlement of $15 million to Elijah McClain’s family.[216] In December 2021, the Colorado Department of Public Health and Environment published a report from its independent ketamine review committee, which stated, “The panel rejected the condition or diagnosis of ‘excited delirium’ because it lends itself to discriminatory practices that result in systemic bias against communities of color, and because it lacks a uniform definition and specific, validated medical criteria.”[217]

“The panel rejected the condition or diagnosis of ‘excited delirium’ because it lends itself to discriminatory practices that result in systemic bias against communities of color, and because it lacks a uniform definition and specific, validated medical criteria.”

Colorado Department of Public Health and Environment, independent ketamine review committee

The Death of Daniel Prude [218]

Daniel Prude arrived at his brother Joe’s home in Rochester, New York on March 22, 2020, after his sister reported he had been behaving erratically. When Daniel jumped headfirst down the basement stairs, Joe called 911. Daniel was hospitalized but released later that day.^[219] In the middle of the night, Daniel left Joe’s home under the influence of phencyclidine (PCP).^[220] Joe jumped in his car to try to find Daniel, calling 911 for the second time. Police arrived and told Joe to go home or risk being jailed for violating the coronavirus lockdown.^[221]

Soon after, a Rochester police officer arrived at Joe’s home. Joe heard on the officer’s radio that they had found a man nearby, unclothed. Over the radio, Joe heard an officer at the scene asking the man if he was Daniel Prude, and Daniel responding “Yes.” This was the last word Joe heard his brother utter. The officer told Joe that everything was under control. Joe recalled telling him, “My brother doesn’t have any weapons on him. And if he’s naked, he’s no threat to anybody but himself. Don’t kill my brother.”^[222]

When the officers found Daniel, they ordered him onto the ground. He lay face down, putting his hands behind his back, and officers handcuffed him. Police body cameras recorded officers laughing while Daniel was on the ground. When he sat up, officers put a spit hood over his head and face. Soon after, they pinned him face down; he can be heard saying that the officers were “trying to kill me.” One officer assumed a three-point “pushup” position with both of his hands on Daniel’s head, stretching his legs out and focusing his weight onto Daniel’s head.^[223] He held that position for more than two minutes,while a second officer put his weight on Daniel’s back, and a third officer held Daniel’s legs down.^[224] Daniel vomited and became unresponsive.^[225] After about 18 minutes of resuscitation attempts, Daniel’s circulation returned, but he remained unconscious and unable to breathe on his own.^[226] He was transported to the hospital, where he was pronounced dead one week later.^[227]

The night of the police encounter, an officer falsely told Joe that his brother had died at the scene.  “It took seven days for me to find out that my brother was on life support,” Joe said.^[228]

One officer assumed a three-point “pushup” position with both of his hands on Daniel’s head, stretching his legs out and focusing his weight onto Daniel’s head. He held that position for more than two minutes, while a second officer put his weight on Daniel’s back, and a third officer held Daniel’s legs down. Daniel vomited and became unresponsive.

On May 5, 2020, the Monroe County medical examiner issued an autopsy report describing Daniel Prude’s manner of death as homicide but the cause of death as “complications of asphyxia in the setting of physical restraint due to Excited Delirium due to Acute phencyclidine [PCP] intoxication.^[229]

For months, the Rochester police chief and other city officials sought to delay the release of video footage from that night, knowing it would ignite public outrage.^[230] A Prude family attorney submitted a Freedom of Information Law request for the video footage in April 2020, but the city did not send him and his team copies of the video until August.^[231]

Grand Jury Proceedings and “Excited Delirium”

In September 2020, after the video became public, New York Attorney General (A.G.) Letitia James announced that she would empanel a grand jury to consider charges against the officers who restrained Daniel.^[232] The A.G.’s office retained as one of its prosecution witnesses the defense expert Dr. Gary Vilke to testify about “excited delirium,”^[233] unaware that Vilke had previously given multiple interviews in which he expressed doubt about the police officers’ responsibility for Daniel’s death.^[234] Vilke testified at the grand jury that Daniel died from “PCP induced excited delirium, leading to cardiac arrest.” He told the grand jury he “wouldn’t do anything differently” than what the officers had done. “My opinion is that none of the officers, their impact, individually or collectively, would have caused or contributed to that cardiac arrest.”^[235]

“This is something I’ve got to live with the rest of my life – seeing that video tape playing over in my head.”

Joe Prude, brother of Daniel Prude

On February 23, 2021, it was announced that the grand jury had decided not to indict the officers who had restrained Daniel, which James described as “very, very disappointing.”^[236] Almost two years after his brother’s death, Joe reflected on the pain of losing him in this way: “This is something I’ve got to live with the rest of my life – seeing that video tape playing over in my head.”^[237]

Training Recommendations and “Excited Delirium”

The same day that the grand jury decision was announced, the A.G.’s office released a report on its investigation into Daniel’s death, which included among its recommendations, “Law enforcement officers, emergency communications providers (dispatchers), and emergency medical service personnel must be trained to recognize the symptoms of excited delirium syndrome and to respond to it as a serious medical emergency.”^[238] The report acknowledged that “excited delirium” “can be controversial and for good reason,” noting that the purported symptoms “overlap with racist stereotypes of Black men,” which “continue to put Black people in danger.” Yet the report gave credence to the medical literature on “excited delirium” and the 2009 ACEP white paper, stating “we are unaware of any scientific studies in peer reviewed literature endorsing the notion that ExDS [Excited Delirium Syndrome] is a concocted, false finding that was generated to shield police misconduct.”^[239]

One month later, in the wake of media scrutiny related to the office’s decision to retain Vilke and its acceptance of “excited delirium” as a valid diagnosis,^[240] the A.G.’s office modified its training recommendations in a report of an investigation into the 2019 in-custody death of Troy Hodge. The office removed the term “excited delirium,” instead recommending that “law enforcement officers, dispatchers, and EMS personnel must be trained to recognize that when people display a unique constellation of symptoms, it can signal potential, imminent medical distress; response protocols and training must be structured accordingly.”^[241]

The A.G.’s office described this constellation of physical signs in the following manner:

“The most common type of presentment this office has observed involves individuals under the effect of a stimulant drug – most commonly cocaine. The individuals have generally been observed to be in a condition indicating some sort of detachment from reality and police have been summoned because of bizarre and/or violent and erratic behavior. Further, the individuals involved in our cases have often been highly sweaty or attired in clothing inappropriate for the existing weather conditions and/or surroundings. After police restrain these individuals, they have resisted the restraint and fought, seeming not to tire until, quite suddenly, they have become silent. The death is nearly always attributed to cardiac arrest or acute drug intoxication.”

Although this description appeared to be a re-packaging of some of the purported physical signs of “excited delirium,” the report appropriately noted the need for a “coordinated response” to medical emergencies.^[242]

However, the report also included the caveat:

“In addressing this issue, we are not suggesting that restraint does not contribute to the death of individuals experiencing this condition. To the contrary, our experience with cases over which we have had jurisdiction has informed us that individuals exhibiting these symptoms are particularly vulnerable to the stress and rigor of restraint, particularly when they struggle against it, are largely impervious to pain, and do not fatigue normally.”^[243]

While the report importantly noted the possible contribution of restraint to the observed deaths, PHR is concerned that the explanation above continues to pathologize a potentially normal and instantaneous human response (“struggle” against restraint) and uses language that reinforces racist tropes (“impervious[ness] to pain”).

The Death of Angelo Quinto^[244]

On December 23, 2020, Bella Quinto-Collins called 911 seeking help for her 30-year-old brother Angelo Quinto, who was exhibiting agitation and other signs of a mental health crisis at their home in Antioch, California.[245] When two police officers arrived, they pulled Quinto from his mother’s arms onto the floor. At least twice, Quinto’s mother, Cassandra Quinto-Collins, heard him say to the officers, “Please don’t kill me.” Bella and Cassandra then watched in disbelief and horror as the two officers knelt on Quinto’s back for five minutes until he stopped breathing. Three days later, Quinto died in the hospital.[246]

Cassandra recalled that shortly before paramedics arrived, the officers turned Quinto on his side, saw blood coming from his mouth, and asked if Quinto had taken any drugs.[247] PHR reviewed Cassandra’s video recording of the officers’ actions and observed that Quinto did not immediately get cardiopulmonary resuscitation (CPR), despite being unresponsive.[248]

Cassandra said that the paramedics’ report stated that law enforcement officers reported that Quinto was on methamphetamine and combative, that they had to restrain him, and that the paramedics had been told not to communicate with the family.[249] Later, however, a toxicology report found no methamphetamine in his system, and his mother said he did not use it.[250] “Angelo was not violent. He was not a threat to anyone. He was following all directions,” Angelo’s stepfather, Robert Collins, said.[251] The video recording confirms that Quinto was not combative.[252]

The police department obtained a felony search warrant and searched the Quinto-Collins residence. During the time the search was being conducted, the family was not allowed to reenter their home for eight hours.[253]

At the police station that night, Bella and Cassandra were each questioned separately. One of the officers asked if Cassandra had hit Quinto because he had a bloody nose. She said she had not. Cassandra recounted how the detective questioning her became visibly disturbed when he discovered she had recorded the police encounter in her home. The officer left the room, and Cassandra heard him cursing outside, insisting that police should not let her leave the station until they got a copy of the video, which Cassandra had already offered to share.[254]

Cassandra and Bella recalled how law enforcement officers deflected responsibility for Quinto’s condition, sought to place blame on him or his family, and blocked the family from receiving health status updates from Quinto’s medical team.

At one point that night, Cassandra got a call from Quinto’s doctor at the hospital. She took the call on speaker phone, and an officer rushed over and instructed her to ask for a call-back number and then get off the phone. The officer wrote down the number but never gave it to Cassandra. The family later learned that a detective at the Antioch Police Department had told the hospital not to communicate with the family.[255]

Cassandra and Bella recalled how law enforcement officers deflected responsibility for Quinto’s condition, sought to place blame on him or his family, and blocked the family from receiving health status updates from Quinto’s medical team.[256]

It was not until August 2021, eight months after Quinto’s death, that the family learned what was asserted to be the official cause of Quinto’s death: a forensic pathologist had testified during a coroner’s inquest that Quinto died from “excited delirium syndrome.”[257]

Robert Collins, Angelo’s stepfather, recalled a previous meeting with the family’s attorney: “He told us about ‘excited delirium’… when you have nothing else, you go with ‘excited delirium.’”[258]

“‘Excited delirium’ has to be debunked,” Cassandra said. She spoke about how painful it was not only to lose Angelo but to see law enforcement repeatedly deny the circumstances of his death. “We’re already suffering,” she said. To see law enforcement “lying about what happened” was “actually more hurtful.”[259]

After Quinto’s death, the Quinto-Collins family began working with the Justice for Angelo Quinto! Justice for All! Coalition, advocating for both accountability and legislative changes, focusing on positional asphyxia and mental health crisis response. “Justice for Angelo means it won’t happen to the next person,” Robert Collins said.[260] In September 2021, California governor Gavin Newsom signed the Angelo Quinto Act, which bans all forms of law enforcement restraints that can cause positional asphyxia, including the “knee to neck” restraint that killed George Floyd and Angelo Quinto.[261]

Key Themes from Interviews with Forensic Pathologists and Other Experts

Several key themes emerged from PHR interviews with nine forensic pathologists and four other physicians: 1) the debunking of the initial attribution of “excited delirium” as a cause of death in Miami in the 1980s; 2) the role of TASER/Axon in efforts to legitimize and increase use of “excited delirium” as a cause of death; 3) concern about the validity of prone restraint studies; 4) lack of meaning of the term “excited delirium;” 5) optimism about decreasing use of the term “excited delirium;” 6) use of the term “excited delirium” as a proxy for restraint asphyxia; and 7) use of the term “excited delirium” to exonerate law enforcement for deaths in custody. Additionally, interviews with many of these physicians, as well as legal, mental health, and substance use disorder experts, touched on recommendations for alternative responses to people in crisis.

Debunking of “Excited Delirium” after Misclassified Homicides in Miami in the 1980s

A number of forensic pathologists whom PHR interviewed were first introduced to the term “excited delirium” through Wetli’s work from the 1980s. Dr. Michael Pollanen, chief forensic pathologist for Ontario, Canada and professor of laboratory medicine and pathobiology at the University of Toronto, noted that Wetli’s original discussion of “excited delirium” “occurred in a context where there was a sharp rise of cocaine use in the U.S.”[262] He described its evolution from a “very classical clinical pathological description” of cocaine-related psychosis to a cause of death. “The root concept is highly useful and valid and helpful except it was extended too much beyond the original description,” he said. “Wetli described in a beautiful series of cases the concept of cocaine-related psychosis with a syndrome which included hyperthermia [high temperatures] and rhabdomyolysis [muscle breakdown]…. It was a very robust concept.” Pollanen observed, however, that “it has become overgeneralized to ‘excited delirium’ as a cause of death.”[263]

Dr. Joye Carter, forensic pathologist for San Luis Obispo County, California and the first Black American to be appointed chief medical examiner, described hearing the term during her forensic fellowship from 1987 to 1989 in Miami, where Wetli was deputy chief medical examiner. She recalled Wetli speaking about “excited delirium” quite often, although the chief medical examiner, Dr. Joseph Davis, did not use the term.[264] Carter, whose fellowship coincided with the office’s investigation of the series of deaths of Black women in Miami, said that she had performed the autopsy for one of the women.[265]

“During the time period in my training, there was a string of serial murders, which initially were classified as drug overdoses. While I was there, I remember attending a meeting. Dr. Davis had had a monthly homicide meeting with all the homicide detectives and all the police agencies.… During that meeting, they were discussing cases that had similarities. Through that discussion they realized they had a serial killer on hand.”[266]

“You literally get this letter threatening you if you say Taser was the cause of death.”

Dr. Joye Carter, forensic pathologist, San Luis Obispo County, CA

Wetli had described the cases using terms that were “very racialized” and “polarizing,” she said, referencing his comment, “For some reason the male of the species becomes psychotic and the female of the species dies in relation to sex.” In other words, Carter said, “This happened to Black men. Black women were dying because they were having sex with Black men.” Shortly after she left the medical examiner’s office, she recalled, Davis reclassified those cases. “I believe this was debunked in Miami because of the ways these cases were handled,” she said.

Carter questioned whether other forensic pathologists who view “excited delirium” as a cause of death “even know the origin of it.” “I was there,” she said. Those who promote the validity of “excited delirium” as a cause of death “don’t even acknowledge the fact that we had a string of homicides of Black women that were initially attributed to, ‘Oh now we have it in Black women.’”[267]

“I honestly think that we need to get to the historical reference of ‘excited delirium,’ where it came from, why it was debunked, and why it’s so harmful to just throw these categories on individuals,” she said.

The Role of TASER/Axon in Efforts to Legitimize and Increase Use of “Excited Delirium” as a Cause of Death

Interviewees described multiple efforts by TASER/Axon to promote the diagnosis of “excited delirium.” Dr. Roger Mitchell, chair of the department of pathology at Howard University and a forensic pathologist, recalled first seeing the term in Di Maio’s book and then hearing it at an IPICD conference in Las Vegas as a young forensic pathologist.[268] Several other interviewed forensic pathologists noted that Di Maio was well known in the field.[269] Mitchell described him as a “mainstay in forensics. At the time, he was one of the most visible forensic pathologists and productive forensic pathologists.”[270] Dr. Michael Baden, a forensic pathologist and former chief medical examiner of New York City, recalled attending an American Academy of Forensic Sciences annual meeting where TASER had a booth and was distributing free copies of Di Maio’s book.[271]

Dr. Martin Chenevert, an emergency medicine physician at UCLA Santa Monica Medical Center, only recently encountered the ACEP white paper. “It just seemed like kind of junk science.… There’s clearly a lot more work that needs to be done. However, it’s clear that it’s not a real syndrome, more just a collection of symptoms.… [The white paper] clearly had an agenda.” He said the paper described findings of lethal toxicity without any kind of clear biological mechanism. He also noted that many of the white paper authors’ TASER affiliations were a “huge red flag.”[272]

Multiple forensic pathologists referenced the chilling effects of TASER/Axon’s lawsuits over the years against medical examiners who had attributed in-custody deaths in part to Taser use.[273] Carter said, “You literally get this letter threatening you if you say Taser was the cause of death. They’re literally threatening the medical examiner with lawsuits.”[274] Dr. Judy Melinek, CEO of PathologyExpert Inc. and contract forensic pathologist for Communio Inc. in Wellington, New Zealand, also noted the “silencing effect” the lawsuits had on medical examiners: “Nobody wants to get sued.”[275]

Concern about the Validity of Prone Restraint Studies

Several forensic pathologists and other physicians expressed concerns about the validity of the studies on which Vilke and colleagues based their arguments that restraint was not dangerous. Dr. Michael Freeman, a forensic epidemiologist and associate professor of forensic medicine at Maastricht University in the Netherlands, described the studies as “blatantly unscientific research that proposes that it’s essentially impossible to kill somebody with restraint.”[276] He added, “That particular brand of science was developed for litigation support, in order to protect officers who may have been involved in the wrongful death of someone they were restraining.”[277]

Others emphasized the studies’ artificial conditions with healthy, non-stressed participants. As Dr. Kris Cunningham, the deputy chief forensic pathologist for Ontario, Canada and a cardiovascular pathologist, noted:

 “There are lots of problems with a number of the studies that have been done in the past, where they take a bunch of medical students and put them in prone positioning and restrain them. And, lo and behold!, they don’t become hypoxic. Well, that’s great, but you’re also not in pain and upset because a police officer is on your back. It’s a very artificial situation.”[278]

Pollanen also emphasized how dissimilar conditions in these studies were from real-life conditions:

“Part of the problem with the restraint asphyxia critique is that a lot of the experiments – all of the experiments – are done with healthy ambulatory people in prone restraint.… How is that medically or physiologically comparable to prone position restraint of someone who is under maximal adrenergic stimulation, whose oxygen demand is high?”[279]

Lack of Meaning of the Term “Excited Delirium”

While the physicians we interviewed did not agree about whether the term “excited delirium” should ever be used to describe signs and symptoms, those interviewed all agreed that there continues to be no consensus on its meaning. Some, such as Freeman, concluded, “‘Excited delirium’ is a contrived term. It doesn’t mean anything as a cause of death.”[280] Others described “excited delirium” as “a widely overused term that we don’t really have a meaning for” (Dr. Jared Strote, an emergency physician and professor of emergency medicine at the University of Washington), a “very nebulous concept” (Cunningham), and “an unfortunate mishmash of concepts when you view it from a critical point of view” (Pollanen).[281]

Pollanen did posit that there is a series of behavioral features that can be abbreviated in short form as “excited delirium,” but he concluded that this summary description should not be used for any causal conclusions:

“We do that all the time in medicine. We find denoting terms that describe something, and we use that. When we do that in medicine, we usually don’t attach causal relevance to it. It’s just a short form. The problem with ‘excited delirium,’ if you then apply a causal relevance, i.e., it can be a cause of death, the problem is there’s no way of differentiating someone with ‘excited delirium’ from someone who is just really agitated.”[282]

Pollanen, therefore, described the use of “excited delirium” as “almost a nomenclatural error”: “It goes without saying that the whole thing has just become progressively modified in an inappropriate manner. The concept has evolved in a way that the evidence does not support in fact.”[283] Others described the term as a “generic term that applies to a confluence of symptoms” (Melinek) and “a controversial theory that describes the final common path triggered by different substrates resulting in an increased level of catecholamines” (Dr. Enrico Risso, deputy chief medical examiner in Edmonton, Alberta, Canada).[284]

Regardless of their views on whether or not “excited delirium” should ever be used to describe any particular constellation of symptoms and signs, the majority of the experts interviewed held that “excited delirium” should not be considered a cause of death. As Chenevert said, “As a primary cause of death, I just can’t see it.”[285]

Optimism about Decreasing Use of the Term “Excited Delirium”

Some forensic pathologists and other physicians were optimistic that the term “excited delirium” was falling increasingly out of favor in recent years.[286] Cunningham characterized it as “a concept that had much more appeal in the past than for a lot of pathologists today.”[287]

Pollanen said, “‘Excited delirium’ as a cause of death is not fit for purpose in the 21st century, based on all the things we know now.”[288]

Several respondents speculated about possible reasons that the term may be less frequently used. Mitchell cited better research: “As we get more information, the medical community, particularly the forensic pathology community, needs to be able to adjust to the information in front of them versus being dogmatic in our diagnosis.”[289] Some attributed the increasing skepticism about the term to the rise of cellphone videos that capture the reality of police encounters, as Freeman has noted.[290]

Mitchell elaborated on this possible explanation:

“It’s a diagnosis that was used when you didn’t have cameras. We didn’t have direct objective evidence of the altercation with police or its severity. It is as if we are saying someone self-combusted. They started shaking, and they blew up, and now they’re dead. Now we’re seeing the actual footage of what is happening, law enforcement is standing on people’s backs. Imagine five grown men physically subduing an individual. Yes, he may have been intoxicated, but he would have gone home intoxicated, had he not been in that altercation.… It’s 2021. We have cellphone video … eyewitnesses. People are not scared to say what they’re seeing. It’s a different world.”[291]

Even forensic pathologists we interviewed who did not object to others using the term “excited delirium,” such as Risso and Dr. Soledad Martinez, a forensic pathologist with Chile’s Medical Legal Service, noted they would not use it themselves.[292] Risso said, “In the majority of cases, it is not provable at autopsy, and I prefer to describe the underlying pathologic findings.”[293] Martinez said, “I try to use not a single diagnosis: death in a man with cocaine, agitation, and physical restraint. [I’m] trying to show the complete spectrum of the death.”[294]

Other forensic pathologists also expressed a preference for a descriptive narrative and referring to the underlying disease or circumstances. Cunningham said that when he determines a cause of death, “It’s circumstance-dependent.”[295] Mitchell said, “I’ve been more descriptive of what my findings are. An example may be, blunt force trauma with acute cocaine toxicity during police restraint. Homicide …. I would rather describe the pathology than put it into a syndrome like excited delirium.”[296] Carter explained, “When you tell the story of death, you have an opportunity to put down the primary cause of death. Then you have underlying conditions.”[297]

“‘Excited delirium’ as a cause of death is not fit for purpose in the 21st century, based on all the things we know now.”

Dr. Michael Pollanen, chief forensic pathologist for Ontario, Canada

Use of the Term “Excited Delirium” as a Proxy for Restraint Asphyxia

Several forensic pathologists and other physicians criticized the use of “excited delirium” as a proxy for restraint asphyxia during law enforcement encounters. As Freeman said, “The evidence indicates that it’s used improperly or unknowingly as a proxy for restraint-related asphyxia.” He proposed that one should consider so-called “excited delirium” deaths through the lens of counterfactual causation, a concept borrowed from epidemiology. “Take away the restraint, what are the chances the conditions present in the restrained individual kill him at that discrete point in time?”[298] He added:

“There is this unproven hypothesis that ‘excited delirium’ is this unique pathophysiologic process that causes sudden death, and it’s the decedent’s fault because they took drugs, leveraged by the absurd theory that restraint can’t kill you if it is applied by law enforcement.”[299]

Many of the interviewed forensic pathologists linked use of the term “excited delirium” with maneuvers that could cause asphyxia. Cunningham said “excited delirium” “may be associated with certain things like chest compression, neck compression, prone positioning, restraint.”[300]

Carter said that if cocaine is present, but the person would not have died without the restraint, “I’d say call it what it is. It’s still a result of restraint asphyxia.”[301]

The interviewed forensic pathologists noted that it is still unknown but likely that a person exhibiting physical signs attributed to “excited delirium syndrome” would also have a heightened risk of death by restraint. Freeman described both the uncertainty and the possibility as follows: “The unknown variable is what that person’s oxygen needs are at that specific point in time.” A “person most likely to be adversely affected by restraint” is the “person with highest oxygen needs, person who is agitated, has been running around screaming.”[302] Strote also noted the possibility of increased risk of death for a restrained person who is agitated and under stress: “Is it more likely that an ‘excited delirium’ patient would die than one of the three of us [referring to himself and his PHR interviewers]?” Yes, he said, “But because they are already in a hyper-adrenergic state. Adrenaline going. Already a stress on their heart.”[303]

Mitchell provided an illustrative example to reinforce that predisposing conditions cannot be used to mitigate the responsibility of the perpetrator for a death: “We use an example in forensic pathology…. If an 87-year-old woman is walking down the street, and an assailant puts a gun in her face … and she dies [of fright], what’s the manner of death? Homicide.” [304]

“A cause of death that can only happen at the hands of cops is not a pathophysiologic process, but rather a semantic ploy designed to immunize police against scrutiny of deaths occurring during restraint.”

Dr. Michael Freeman, forensic epidemiologist and associate professor of forensic medicine, Maastricht University

Use of “Excited Delirium” to Exonerate Law Enforcement for Deaths in Custody

Several physicians noted the prevalence of “excited delirium” as an exculpatory term for police killings. Freeman said:

 “It is a term that allows us to ignore police use of force, no matter how extreme, because we have taken the possibility that the police caused the death out of the picture.… A cause of death that can only happen at the hands of cops is not a pathophysiologic process, but rather a semantic ploy designed to immunize police against scrutiny of deaths occurring during restraint.”[305]

Strote also expressed this view: “At some point, ‘excited delirium’ began to be used by police officers and pathologists to explain deaths in restraint, which can spare the officers a potential homicide diagnosis and pathologists the need to describe a clear cause of death.”[306]

Other forensic pathologists highlighted the implications of “excited delirium” mainly being used as a cause of death for deaths in police custody. As Baden noted, “If you have a condition or disease, it cannot be due to a boutique, unique condition that almost always causes a death only during a struggle between police officers and a civilian.”[307]

No National Standards for Death Investigations

“Right now, there’s no federal oversight to medicolegal death investigation in [this] country. It is a county-by-county, city-by-city, state-by-state construct, and it’s a milieu of sheriff-run organizations to politician-run organizations to forensic pathologist-run organizations. We need one system. Uniformity of practice should be our goal … [ensuring] accreditation and oversight of forensic pathology … and medicolegal death investigation.

“There has been no report [or data] from the Death in Custody Reporting Act passed in 2013 … and that’s mandated as law. My solution is … a checkbox on the U.S. standard death certificate … to allow physicians, whose job it is to sign a death certificate, to … identify deaths in custody. It’s so critically important for there to be an objective measure of deaths in custody, and that needs to happen at the level of the physician, in addition to circumstantial data from the law enforcement agency.

“Then there needs to be death-in-custody fatality reviews. We know as a public health construct how to research a problem and then set standards in place…. It’s time for the public health infrastructure … to define deaths in custody as a public health issue.”

— Dr. Roger Mitchell, chair of the department of pathology at Howard University

Recommendations for Alternative Responses to People in Crisis

Many interviewees – physicians, lawyers, mental health experts, and others – emphasized the need for a different kind of emergency response for individuals in crisis.

Changes in Police Procedures and Emergency Response Protocols

Some focused on the particulars of police training, such as the need to place individuals in a recovery position or to avoid prone restraint. According to Strote, the goal of the emergency response should be “to maximize the best balance of protection for others and minimizing harm to that person.”[308]

Melinek also advocated for changes to police procedures: “In many cases, police officers aren’t taught or aren’t trained that if they do a carotid hold, they can kill somebody.… During the lectures I was giving, I made a point of saying if the medical examiner is saying that something you have done has killed the patient/subject, that is another opportunity to ask: is there something in our procedures that needs to change?”[309]

Other interviewees discussed the need for better training and protocols for dispatchers and other first responders to mobilize appropriate resources beyond or instead of police to respond to an emergency call. Jack Ryan, a retired captain from the Providence, Rhode Island police department who now conducts trainings for law enforcement and policy and procedure audits for law enforcement agencies, recommended that Emergency Medical Services (EMS) dispatchers be trained to recognize signs that an individual is experiencing a health crisis and coordinate a multi-disciplinary response, where the objective is for the person to receive medical help as soon as possible.[310]

“Remember you can restrain somebody on the stretcher to the gurney rather than prone on their stomach and holding them down. And many times, these EMTs have soft restraints as opposed to some of our hard mechanical restraints.”[311]

He said that for these types of crises, “the plan should be similar. Can we slow this thing down?.… Let’s get sufficient resources there. Let’s try to diminish the prolonged struggle. Let’s try to turn them [over] to medical…. We don’t stabilize by putting a knee on someone’s neck or on someone’s back or crushing their heads into the ground.” He added, “I do think we should train officers on symptomology of crisis… But remember that symptomology seems to run across the board between mental health crisis, sometimes medical crisis, sometimes drug-induced crisis.”[312]

Ryan further noted that officers should be trained to avoid putting weight on an arrestee’s back while they are prone, and once the arrestee is handcuffed, officers should turn them on their side or sit them upright, to facilitate breathing. Ryan also stated:

“I think some of the issues go beyond law enforcement. We know with de-institutionalization … law enforcement has become the catchall at the end of the day. They say LA County Jail is the largest mental health institution in the U.S. I do some audits of jails. It is so disheartening to see the jail stuck with people because there’s no other place for them to go…. I think we should have a better system so that all of these folks don’t fall at the hands of law enforcement.”[313]

Medical and Behavioral Health Response Teams and Support Systems

Civil rights attorney Dale Galipo agreed with the need for medical responses to many requests for help that currently go to law enforcement: “One could argue when the police encounter someone that they claim is in this ‘excited delirium’ state, that’s a medical emergency, so that person needs medical treatment. That person doesn’t need force used against them. They don’t need to be held down. That is the worst thing you can do for someone in a medical emergency.”[314]

Others emphasized the limits of seeking to improve police training to respond to mental and behavioral health crises. Civil rights attorney Jim Davy observed, “The majority of violence and law enforcement-created injuries and civil rights violations I have seen primarily fall into two categories: someone was trained and did the thing they were explicitly trained not to do, or they did the thing they were trained to do, and they were trained to do things that violated people’s civil rights.” Police officers are not the best positioned to respond to a mental health crisis, he said. “I think we have responsibility as a society to be doing something better, different, more responsive.”[315]

A federal law passed in March 2021 allocated $25 million to states to support non-law enforcement mobile crisis teams.[316] To better understand what such other models could look like, PHR consulted experts at the National Harm Reduction Coalition, Treatment Advocacy Center, Crisis Assistance Helping Out On The Streets (CAHOOTS), and Portland Street Response.

Dr. Kimberly Sue, medical director of the National Harm Reduction Coalition, offered examples of alternative spaces to support people in substance use crises, including the new San Francisco Drug Sobering Center and the People’s Harm Reduction Alliance in Seattle, which provide drop-in spaces for people experiencing the effects of methamphetamine and other substances.[317]

Elizabeth Sinclair Hancq, director of research at the Treatment Advocacy Center, said that the organization’s stance is: “It shouldn’t be the situation where people are reaching a crisis point, and law enforcement has to intervene.” The goal should be “building up an adequate support system and mental health treatment system.”[318] As Sabah Muhammad, attorney and legislative and policy counsel at the Treatment Advocacy Center, noted, in supporting the need for systems to be in place to prevent crises: “Families with a loved one with untreated mental illness live with crisis every day…. What is being overlooked is our daily condition of crisis.”[319] A September 2020 Treatment Advocacy Center report found that in seven states, a person has to pose an “imminent threat” before they can be involuntarily hospitalized.[320] Muhammad spoke about the way that such state involuntary commitment statutes force families to call the police to get help for loved ones with severe mental illness. Changing such laws, she said, would help empower families to get treatment for their loved ones before their only remaining option was a potentially life-threatening police encounter.[321]

Hancq identified three types of crisis response models: Crisis Intervention Teams (CIT, law-enforcement-based response), co-responder teams (law-enforcement-based mental health response), and mental health crisis teams (mental-health-based response).[322] Muhammad said of the various models, “All of them are in an infancy. And they are very state-based. If certain models work in one area of the country, they don’t necessarily work in another.” She expressed hope that the more frequently clinicians and social workers are integrated into these models, the more families can access wraparound services or relationships of trust, and “something can be established that looks more like long-term treatment… because when you just sit around and wait for crisis, you are just expecting entire communities to suffer until they are going to be maimed or die.”[323]

Muhammad emphasized, “If it does turn into an emergency, police just should not be first. They can be part of the team if there is a weapon. Someone else with medical training, crisis training – clinician, doctor, social worker – needs to be informing police of their next step.”[324]

She explained, “We’re missing so many opportunities to be reasonable. To tap into our humanity. To take the time it takes to realize someone is in the middle of a delusion or hallucination. This is something that should not be done quickly. It is something that should be done to preserve the life of the person.”[325]

Tim Black, director of consulting at the White Bird Clinic, which runs the mobile crisis intervention program CAHOOTS in Eugene, Oregon, emphasized, “Any sort of mobile crisis system needs to be first informed by community and then providers.” In the context of limited resources, it is more important for the community to strengthen the social safety net than to “bring in mobile crisis teams” because crises are “directly tied to some unmet need.” He added, “It’s really easy and really popular to talk about mobile crisis [programs] but not about the resources that are needed …  rapid access and connection to those resources.” Such resources, he said, could include shelter, hygiene, food access, 24-hour mental health resources access, violence interruption, homeless outreach, street medicine, and harm reduction.[326]

Black further noted that the White Bird Clinic does not require its crisis workers to be licensed mental health or health care workers prior to their hiring, which would create impediments to staffing the positions, especially in smaller communities. Instead, the clinic is open to recruiting and then training and credentialing crisis response team members who have a variety of life experiences and educational backgrounds.[327]

Robyn Burek, program manager at Portland Street Response, said she has spoken to “probably 100 different cities” about their models for mobile crisis response. “Everybody has a slight variation in how they’re running this. I think that’s amazing.” She said that the “common thread” that flows through all these models is the need for funding streams at both the federal and state level to allow flexibility to have different models.[328] Black agreed. “There’s no one prescribed funding mechanism that works for each community.”[329]

Legal Framework

U.S. Law

Allowance of “Excited Delirium” as a Diagnosis in U.S. Courts – Despite No Consensus on its Meaning

A review of legal cases discussing “excited delirium” indicates that the term appears to be limited to cases involving interactions of individuals with law enforcement. Despite significant challenges to “excited delirium’s” validity within the medical community – and the limited context in which it arises – the term has been admitted in U.S. courts as a legitimate diagnosis, including as a direct cause of death.[330]

Given the lack of an underlying description of “excited delirium” in diagnostic manuals, legal cases have found a clear definition of the term to be elusive. Consequently, “excited delirium” in a police setting has been considered a reasonable medical diagnosis for an extremely broad array of signs and symptoms. It might be described as a state of agitation, excitability, or paranoia.[331] It might include bizarre behavior, confusion, delusions, hyperactivity, incoherence, or yelling.[332] It is often, although not necessarily, associated with drug use.[333] And, ultimately, it is so broadly defined that it might include the observable manifestation of almost every psychiatric or drug-induced behavior. Beyond even this, “excited delirium” has been described by courts to include superhuman strength and imperviousness to pain.[334] While this is generally asserted to be brought on by an underlying history of drug use or mental illness, it has also been described as being initiated by “physical stress.”[335] One court even found excessive “sweating” to be indicative of “excited delirium.”[336]

Admission of Expert Testimony on “Excited Delirium”

All courts perform some kind of “gatekeeper” function regarding the admissibility of expert testimony. At the federal level and in many states, in performing this “gatekeeper” function, courts make a preliminary assessment of whether the expert testimony’s underlying methodology is scientifically valid and can properly be applied to the facts at issue.[337] Important factors that have been considered in the context of “excited delirium” include whether the theory “has been subjected to peer review and publication” and whether it has attracted “widespread acceptance” within a “relevant scientific community.”[338]

After assessing those factors, courts often admit expert testimony on “excited delirium” as evidence at trial, finding that arguments against the theory should go to its persuasiveness as evidence, rather than to its admissibility. In cases in which plaintiffs have sought to exclude testimony on “excited delirium,” courts have pointed to three communities that “generally accept” it as a diagnosis: the American College of Emergency Physicians,[339] forensic pathologists and medical examiners,[340] and many police departments, which train their officers to interpret people’s behavior through a lens that assumes many medical or mental health conditions are “excited delirium.”[341] Admission of “excited delirium” has also been allowed because “the theory or technique has been published and subjected to peer review.”[342] Finally, courts cite the ACEP white paper.[343] One court even described the paper as resulting from ACEP “consensus” that “excited delirium syndrome” “is a unique syndrome which may be identified by the presence of a distinctive group of clinical and behavioral characteristics.”[344]

Notably, courts have admitted expert testimony on “excited delirium” even while acknowledging that “excited delirium” is not a validated diagnostic entity in either the International Classification of Diseases or the Diagnostic and Statistical Manual of Mental Disorders^[345] and is not recognized as a medical diagnosis by the American Medical Association, the American Psychiatric Association, or the World Health Organization.^[346]

The acceptance of “excited delirium” by U.S. courts underscores the harmful impact of ACEP’s 2009 white paper, which it has yet to refute. It also demonstrates the troubling reach of the academic literature on “excited delirium,” which persists despite its poor quality, homogenous citations, and embedded conflicts of interest.

Use of “Excited Delirium” as a Defense for Officer Conduct

Given courts’ admission of “excited delirium” theory into evidence, law enforcement defendants have also used it as a defense in civil rights cases claiming police brutality or wrongful death. Some courts have used the ever-broadening defense of qualified immunity to shield law enforcement officers from accountability for killing people in the course of restraint, based on claims that the decedent died of “excited delirium.” While in other circumstances an officer might be viewed as having used excessive force, the force employed may instead be deemed reasonable when dealing with an individual diagnosed with “excited delirium,” with its associations of being “impervious to pain” or having “superhuman” strength.[347] Similarly, deaths which might otherwise be attributed to asphyxiation as a result of excessive force may instead be explained away as natural or accidental due to the victim’s “excited delirium.”[348]

Impact of the Pervasiveness of “Excited Delirium” in Police Trainings

The pervasiveness of “excited delirium” within law enforcement policies and training manuals has resulted in a number of lawsuits against police officers for violating their training and mishandling a person claimed to be in “excited delirium.” In fact, a number of suits have been brought for not attending to the unique medical needs posed by “excited delirium.”[349] Plaintiffs have even gone so far as to state that defendant officers should have recognized that the plaintiff/decedent was experiencing “excited delirium,” including its purported “imperviousness to pain, great strength, bizarre behavior, aggression, and hallucinations.”[350] By introducing evidence that officers failed to follow trainings in this manner, plaintiff’s attorneys validate law enforcement protocols on “excited delirium,” perpetuating the term’s acceptance in courts at the expense of future victims of police violence.[351]

There are a number of underlying risks presented by the pervasiveness of “excited delirium” within law enforcement policies and training manuals. Myocardial infarctions (heart attacks), drug or substance overdose and withdrawal, oxygen deprivation, and acute psychosis have all been bundled by some law enforcement agencies or trainers under the diagnosis of “excited delirium.” Yet, these might require quite different medical interventions in an emergency situation, in contrast to the trained responses to “excited delirium.” In the case of Petro v. Town of West Warwick, for instance, the dispute as to whether the officers failed to render timely assistance hinged upon whether Mr. Jackson died from “excited delirium syndrome” or sudden cardiac arrest due to primary cardiac disease that had been left untreated.[352] In Estate of Hezekiah Harvey v. Roanoke City Sheriff’s Office, the defendants’ expert, the assistant chief medical officer of West Virginia, concluded that Mr. Harvey “died from natural causes – excited delirium due to chronic schizophrenia with a contributing cause of congestive cardiomyopathy.”[353] As such, the defense asserted that it did not matter whether emergency medical personnel had administered antipsychotic medication to Mr. Harvey, who had schizophrenia.[354]

When law enforcement officers are not held accountable for their actions based on a successful defense of “excited delirium,” the justice system is doubly hurt. Such a defense not only prevents accountability, it does so on the basis of a diagnosis that has no real medical underpinning. As Physicians for Human Rights explained in a brief to the United States Supreme Court:

“A civil action under 42 U.S.C. § 1983 is often the only way for a victim of official misconduct to vindicate … federally guaranteed rights. But qualified immunity often bars even those plaintiffs who can prove their case from remedying a wrong: harm, but no foul. Qualified immunity thus enables public officials who violate federal law to sidestep their legal obligations to the victims of their misconduct.”[355]

Indeed, the widespread belief in the existence of “excited delirium” among both law enforcement and the courts has resulted in a perverse paradox: a lack of accountability for police misconduct based on a medically nonexistent explanation for that conduct.

Finally, law enforcement agencies that train their officers on “excited delirium” are doing a disservice to their officers. The agencies are implicitly requiring the officers to diagnose a person’s condition, which is not their role. Officers who have concerns about the health status of a person they encounter should instead call for medical back-up.

International Human Rights Law

The United States is also bound by international human rights law, as are the countries to which the term “excited delirium” has spread – Australia, Canada, and the United Kingdom, among others. International law includes important standards related to the multiple contexts in which the term is used, addressing protection from excessive and potentially lethal force; protection from discrimination based on race or disability in encounters with law enforcement; protection from discrimination in accessing treatment for mental health or substance use disorder crises; the necessity of thorough, prompt, and impartial investigations of deaths in law enforcement custody; and the right to an effective remedy.

Right to Life and Protection from Excessive Force by Law Enforcement

The right to life is guaranteed by Article 3 of the Universal Declaration of Human Rights (UDHR)[356] and Article 6 of the International Covenant on Civil and Political Rights (ICCPR), which the United States has ratified and is bound to uphold.^[357] All are entitled to equal protection of this right without discrimination, according to Article 7 of the UDHR and Article 26 of the ICCPR.^[358]

People of color and people with disabilities, including mental illness or substance use disorders, have the right to protection from discrimination in encounters with law enforcement. Article 5 of the International Convention on the Elimination of All Forms of Racial Discrimination (ICERD), to which the United States is also a party, guarantees “without distinction as to race, colour, or national or ethnic origin … The right to security of person and protection by the State against violence or bodily harm, whether inflicted by government officials or by any individual group or institution.”^[359] Article 10 of the Convention on the Rights of Persons with Disabilities (CRPD) states, “States Parties reaffirm that every human being has the inherent right to life and shall take all necessary measures to ensure its effective enjoyment by persons with disabilities on an equal basis with others.”[360]

General Comment No. 36 of the Human Rights Committee, the treaty body that oversees implementation of the ICCPR, states, “The use of potentially lethal force for law enforcement purposes is an extreme measure that should be resorted to only when strictly necessary in order to protect life or prevent serious injury from an imminent threat.”[361]

The United Nations Basic Principles on the Use of Force and Firearms by Law Enforcement Officials (1990)^[362] stipulate that law enforcement agencies should adopt rules and regulations for the use of force within the following parameters:

• The use of force must be minimized, targeted, proportional, and directed at de-escalating violence.
• The use of “less-lethal” incapacitating weapons must be carefully controlled.
• Restraint must be shown in all use of force by law enforcement agents, with a view to minimizing injury and loss of life.

The Basic Principles further state that when the lawful use of force is unavoidable, law enforcement officials should ensure that assistance and medical aid are rendered to any injured or affected persons at the earliest possible moment.^[363] Additionally, “Governments shall ensure that arbitrary or abusive use of force and firearms by law enforcement officials is punished as a criminal offence under their law.”[364]

Right to Health

Article 12 of the International Covenant on Economic, Social and Cultural Rights (ICESCR) guarantees “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.”[365] The UN Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care further state, “All persons with a mental illness, or who are being treated as such persons, shall be treated with humanity and respect for the inherent dignity of the human person.”[366]

Article 5 of ICERD prohibits racial discrimination regarding the right to medical care.[367] Article 25 of the CRPD states that people with disabilities “have the right to the enjoyment of the highest attainable standard of health without discrimination on the basis of disability.”[368]

International Standards for Death Investigations and the Right to a Remedy

According to the UN Principles on the Effective Prevention and Investigation of Extra-legal, Arbitrary and Summary Executions:

“Governments shall prohibit by law all extra-legal, arbitrary and summary executions.… Such executions shall not be carried out under any circumstances including … situations in which deaths occur in custody.… There shall be thorough, prompt and impartial investigation of all suspected cases of extra-legal, arbitrary and summary executions, including cases where complaints by relatives or other reliable reports suggest unnatural death in the above circumstances.”[369]

The UN Manual on the Effective Prevention and Investigation of Extra-Legal, Arbitrary and Summary Executions, commonly known as the Minnesota Protocol and most recently revised in 2016,[370] sets international standards for the investigation of potentially unlawful deaths, including deaths in custody. It states:

“To discharge these responsibilities properly, forensic doctors, including forensic pathologists, must act independently and impartially. Whether or not they are employed by the police or the State, forensic doctors must understand clearly their obligations to justice (not to the police or the State) and to the relatives of the deceased, so that a true account is provided of the cause of death and the circumstances surrounding the death.”[371]

The right to an effective remedy for a violation of the right to life, including the right to judicial remedies, is guaranteed by the UDHR (Article 8), ICCPR (Article 2), ICERD (Article 6), and other international treaties and declarations.[372]

How the Use of “Excited Delirium” in Law Enforcement Protocols, Death Investigations, and Courts Violates International Law

As described above, the term “excited delirium” informs law enforcement responses to people experiencing an array of mental health and substance use disorder crises, as well as other medical emergencies. It is also used by forensic pathologists to explain deaths in law enforcement custody, disproportionately those of Black men, and has absolved officers from liability in both criminal and civil cases.

Some of the purported signs of “excited delirium” that law enforcement officers are trained to recognize (“superhuman strength” and “imperviousness to pain”) increase the risk that an officer will employ excessive or lethal force, violating human rights standards on the use of force or, indeed, the right to life itself. These same terms also put Black people and other people of color – in the United States and around the world – at greater risk of harm, given that they exploit racist tropes and perpetuate discrimination against people of color in law enforcement settings. Continued reliance on “excited delirium” thus violates international legal protections from racial discrimination.

People with mental illnesses or substance use disorders also face disproportionate risk of harm – in violation of protections from discrimination based on disability – given that their behavior may overlap with purported signs of “excited delirium.” For someone experiencing a medical emergency, an officer’s belief that the person is experiencing “excited delirium” could also mean denial of access to appropriate medical care – a potential violation of the right to health – and likely a violation of the right to non-discrimination on the basis of race or disability.

The term “excited delirium” is also used by forensic pathologists, medical examiners, and coroners to explain deaths in law enforcement custody, again disproportionately those of Black men. Continued use and acceptance of the term as a cause of death too often impedes a thorough, prompt, and impartial investigation of the death, given that the investigation may end prematurely when “excited delirium” is held to be the cause.

Finally, the allowance of “excited delirium” in courts as a defense for officers’ use of lethal force or as an explanation for deaths in custody may foreclose – and has foreclosed – avenues for criminal prosecution or civil liability, violating a core principle of international law: the right to an effective remedy. Black men are also more likely to have this core right infringed.

The allowance of “excited delirium” in courts as a defense for officers’ use of lethal force or as an explanation for deaths in custody may foreclose – and has foreclosed – avenues for criminal prosecution or civil liability, violating a core principle of international law: the right to an effective remedy.

Conclusion

“Excited delirium” is not a valid, independent medical diagnosis. There is no clear or consistent definition, established etiology, or agreed upon underlying pathophysiology. As a result, there are no diagnostic standards for “excited delirium.” In general, there is a lack of scientific data, and even the body of literature that mentions “excited delirium” is small and largely written by individuals with rarely disclosed conflicts of interest. Because “excited delirium” is not a valid diagnosis, it should not be used as a cause of death.

The term “excited delirium” cannot be disentangled from its racist and unscientific origins. In the 1980s, “excited delirium” was defined as hyperactive delirium, with aggressive behaviors, and associated with cocaine intoxication. A few years later, Dr. Charles Wetli extended his theory of sudden death from cocaine intoxication to explain the deaths of more than 12 Black women in Miami who, ,along with at least seven others who were found dead during the same period, were later found to have been murdered by a serial killer. Wetli’s grave professional error – and the racism and misogyny that seemed to inform it –should have soundly discredited “excited delirium” as a cause of death at the time, but instead its use grew.

Moreover, the diagnosis of “excited delirium” has been primarily applied to deaths occurring during encounters with law enforcement. If any other medical condition were only, or even mostly, occurring in a particular environment or context, a scientific approach would require interrogation of that environment as a contributing or causative factor – in this case, police custody.

PHR’s review of the literature and interviews with forensic medical and legal experts found that when the diagnosis of “excited delirium” has been advanced, it has almost always been by law enforcement and law-enforcement-affiliated organizations, such as TASER International (Axon Enterprise). To the extent that the diagnosis has been raised in the literature by physicians and scientists, they have often been paid by TASER/Axon or law enforcement agencies defending lawsuits arising out of a death, without disclosing these relationships. Interviewed forensic experts also described an alarming pattern of pressure from TASER/Axon when forensic pathologists and/or medical examiners describe law enforcement tactics as contributing to the cause of death.

A diagnosis of “excited delirium” also yields no actionable steps toward what treatment an individual might need. For a diagnostic system to establish itself as scientifically useful, the system itself must be created from reliable and valid definitions and criteria. In the case of “excited delirium,” this label certainly does not aid in treatment and has not invited or welcomed research that may better define it or aid in diagnosis, research, or treatment. That a person experiencing agitation, mental illness, or intoxication would need to be restrained, beaten, or choked rather than first treated medically is contrary to medical standards.

People presenting with agitation, confusion, rapid breathing, elevated heart rate, or sweats have an underlying diagnosis. Their signs and symptoms should be named as they are, and the underlying condition should be found and treated medically. Law enforcement should acknowledge that restraint asphyxia is highly possible, if not the most probable cause of death, and, consequently, law enforcement officials should make every effort not to put a person in a prone restraint or neck restraint.

PHR is concerned that the unscientific diagnosis of “excited delirium” has been used repeatedly over decades to mask deaths caused by inappropriate and often violent law enforcement responses to medical or mental health crises, and to exonerate perpetrators or cover up homicides.

“Excited delirium” is a descriptive term, not a medical diagnosis, and should not be used as a cause of death. PHR has concluded that it is essential to end the use of “excited delirium” as an officially determined cause of death in cases of deaths in police custody or in any other case. This is one critical step among many to stop these preventable deaths, which have to be acknowledged for what they are before a remedy can be found.

Recommendations

To the American College of Emergency Physicians (ACEP):

• Revise position on “excited delirium” based on the evidence, recognizing that it is not a valid medical diagnosis and cannot be a cause of death;
  • Note the racist origins and usage of “excited delirium” and the need for further study of racial disparities in its application;
• Rescind all previous white papers that support “excited delirium” as a distinct entity separate from other forms of delirium; and
  • Be transparent about conflicts of interest in previous position statements; implement clear policies on minimizing or eliminating conflicts of interest in future statements.

To the National Association of Medical Examiners (NAME):

• Issue a statement on “excited delirium” based on the evidence, recognizing that it is not a valid medical diagnosis and cannot be a cause of death;
  • Note the racist origins and usage of “excited delirium” and the need for further study of racial disparities in its application; and
• Conduct an investigation into structural, political, and other factors affecting the independence of medical examiners when investigating deaths in law enforcement custody, and report the findings publicly.

To Individual Medical Examiners, Forensic Pathologists, and Coroners:

• Ensure that “excited delirium” is not used as either a sole or a contributing cause in death certification.

To Other Medical and Health Professional Associations:

• Study how the involvement of law enforcement in the health context impacts the relationship between patient and health care provider; seek stakeholder input; and
• Establish best practices for communicating with families regarding injuries or deaths of loved ones in law enforcement custody.

To State and Local Governments:

• Address current use of the term “excited delirium:”
  • Instruct state attorneys general to review the use of the term “excited delirium” in all instances by police and correctional services to understand how and when it is applied;
  • Call on police associations and first responders to stop disseminating “excited delirium” protocols and collect data on how the term has been applied, including racial disparities in its use;
• Improve official responses to people experiencing mental and behavioral health challenges:
  • Bolster resources and social services to address community needs, including mental health and harm reduction;
  • Take steps to ensure that medically trained professionals are the primary responders and decision-makers in the management of acute medical emergencies, including mental health and substance use disorder crises;
  • Invest in alternative models of mental and behavioral health crisis response, led by health professionals and/or social workers, rather than law enforcement;
• Enact changes that strengthen oversight and independence of death investigations:
  • Strengthen qualifications and training for medical examiners, forensic pathologists, and coroners;
  • Strengthen institutional protections to ensure the independence of medical examiners, forensic pathologists, and coroners from law enforcement;
  • Establish independent oversight systems and mandate independent investigations of deaths in law enforcement custody;
  • If a death is indicated on the death certificate as a death in custody, institute rigorous death-in-custody fatality reviews with explicit guidelines;

• Ban the use of neck restraint and weighted or prolonged prone restraint by law enforcement; and
• Fund studies on how the involvement of law enforcement in the health context impacts the relationship between patient and health care provider.

To the Biden Administration:

• Enforce the Death in Custody Reporting Act of 2013 (Pub. L. No. 113-242) that requires law enforcement agencies to report to the Attorney General annually on all deaths in custody within their jurisdiction;
• Enforce the 21st Century Cures Act by requiring the Department of Justice (DOJ) and others to regularly collect and report data related to law enforcement encounters and mental illness;*
• Establish national standards across all federal law enforcement agencies for clear procedures in death investigations in federal custody;
• Work with Congress, and state and local governments, to unify national standards for investigations of deaths in custody, including well-supported independent accreditation, investigatory, and oversight mechanisms; and
• Establish a unit within DOJ to investigate all deaths in custody.

* We thank the Treatment Advocacy Center for its leadership on this.

To Congress:

• Exercise Congress’s oversight authority in the following ways:
  • Investigate the history and use of “excited delirium” in various jurisdictions across the United States in the context of deaths in police custody, systemic racism, and the pursuit of justice and accountability;
  • Call on DOJ to enforce the Death in Custody Reporting Act of 2013, which requires law enforcement agencies to report to the Attorney General annually on all deaths in custody within their jurisdiction;
  • Call on DOJ to enforce the 21st Century Cures Act, which requires the DOJ and others to regularly collect and report data related to law enforcement encounters and mental illness;*
  • Develop mechanisms for oversight and tracking of any aggressive tactics used to subjugate or control people in police custody;
• Pass legislation that seeks to direct national standards toward:
  • Quality assurance, and clear required procedures for death investigations and for documenting police violence on death certificates; and
  • Banning the use of neck restraint and weighted or prolonged prone restraint by law enforcement;
• Allocate funding for:
  • A mandated national database tracking law enforcement use of force, including data on mental illness, race, and ethnicity;*
  • New or expanded non-law-enforcement emergency mental health services and social services response programs on the state and local levels; and
  • Studies on how the involvement of law enforcement in the health context impacts the relationship between patient and health care provider.

*We thank the Treatment Advocacy Center for its leadership on this.

To the U.S. Centers for Disease Control and Prevention:

• Add a required checkbox on the U.S. standard death certificate to enable physicians to report deaths in custody;* and
• Undertake a review of deaths in custody as a matter of racial and other disparities in health, including deaths in which the term “excited delirium” was applied to describe the circumstances of death. In this review, analyze the demographics of the people to whom this term is applied, as well as the common situations in which it is invoked.

* This recommendation was suggested to PHR by Dr. Roger Mitchell, chair of the Department of Pathology, Howard University College of Medicine.

To UN Human Rights Mechanisms, including the Independent Expert Mechanism on Systemic Racism in Law Enforcement:

• As a function of state reporting and international oversight, study and report on the use of “excited delirium” worldwide to trace the geographic scope of the term’s use as an explanation for deaths in custody and its implications for human rights.

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Acknowledgments

Physicians for Human Rights (PHR) thanks the courageous survivors and families who have lost loved ones to police violence, without whom this report would not have been possible. In particular, we thank Robert Collins, Joe Prude, Bella Quinto-Collins, and Cassandra Quinto-Collins for their bravery in sharing their stories with us.

This report was written by Brianna da Silva Bhatia, MD, an internal medicine physician; Michele Heisler, MD, MPA, PHR medical director and professor of internal medicine and of public health at the University of Michigan; Joanna Naples-Mitchell, JD, PHR U.S. researcher; Altaf Saadi, MD, MSc, general academic neurologist at Massachusetts General Hospital and instructor of neurology at Harvard Medical School; and Julia Sherwin, JD, civil rights lawyer. PHR Advisory Council member Gerson Smoger, JD, contributed to the writing of this report, as did PHR interns Esther Choo, MA, Joshua Martins-Caulfield, and Olivia O’Leary. All medical analysis in the report was conducted by the physician team members, and all scientific conclusions were based exclusively on their analysis. The team members with legal expertise contributed to background, historical, and thematic analysis but had no influence over the medical findings or conclusions.

Interviews for the report were conducted by Brianna da Silva Bhatia, Michele Heisler, Joanna Naples-Mitchell, and Julia Sherwin. In addition to the report authors, Susannah Sirkin, MEd, former PHR director of policy and senior advisor, Rohini Haar, MP, MPH, PHR medical advisor, Joseph Leone, former PHR research and investigations fellow, Phelim Kine, former PHR director of research and investigations, PHR Advisory Council Members Jennifer Leaning, MD, SMH and Nizam Peerwani, MD, and Lindsey Thomas, MD, contributed to the research design. Homer Venters, MD, former PHR director of programs, originated the idea for a report on this topic. Esther Choo, Madelaine Graber, Riyana Lalani, Joseph Leone, and Olivia O’Leary conducted background research. Brian Hawkinson, JD, and Paulina Piasecki, JD, contributed legal research assistance.

This report has benefitted from review by PHR staff, including Christian De Vos, JD, PhD, director of research and investigations; Ranit Mishori, MD, MHS, senior medical advisor; Karen Naimer, JD, LLM, MA, director of programs; Michael Payne, deputy director of advocacy; and Susannah Sirkin. The report benefited from external review by PHR Board Member Deborah Ascheim, MD; PHR Advisory Council Member Monica Peek, MD, MPH, MS, FACP; and PHR Advisory Council Member Gerson Smoger, JD, PhD. It was also reviewed by; Joye Carter, MD; Michael Freeman, MedDr, PhD, MScFMS, MPH, DLM, MFFLM, FACE; Elizabeth Sinclair Hancq, MPH; Sabah Muhammad, JD; Abraham Nussbaum, MD, FAAP; Homer Venters, MD; and Alfredo Walker, MB.BS, FRCPath, DMJ (Path), MFFLM, MCSFS.

The report was reviewed, edited, and prepared for publication by Claudia Rader, MS, PHR senior communications manager, with assistance from Samantha Peck, PHR executive assistant. Hannah Dunphy, PHR digital communications manager, prepared the digital presentation.

Endnotes

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[1] Interview with Robert Collins, Bella Quinto-Collins, and Cassandra Quinto-Collins, Oct. 29, 2021. See also, John L. Burris, Ayana C. Curry, Ben Nisenbaum, Dewitt M. Lacy, James A. Cook, Kenneth Chike Odiwe, and Tonia Robinson, Law Offices of John L. Burris, “RE: Request for Endorsed Copy Verifying Administrative Claim Received – Law Offices of John L. Burris,” Feb. 18, 2021, https://johnburrislaw.com/Quinto-Claim.pdf; Jacey Fortin, “California Man Died after Police Knelt on Him for 5 Minutes, Family Says,” New York Times, Feb. 25, 2021, https://www.nytimes.com/2021/02/25/us/angelo-quinto-death-police-kneel.html; Claire Wang, “The Filipino American Family behind Calif.’s New Police Reform Laws Speaks Out,” NBC News, Oct. 15, 2021, https://www.nbcnews.com/news/asian-america/filipino-american-family-califs-new-police-reform-laws-speaks-rcna3030.

[2] Nate Gartrell and Rick Hurd, “Death of Angelo Quinto, Navy Vet Who Died after Struggle with Antioch Cops, Blamed on ‘Excited Delirium,’” The Mercury News, Aug. 20, 2021, https://www.mercurynews.com/2021/08/20/death-of-angelo-quinto-after-struggle-with-cops-blamed-on-excited-delirium-a-controversial-diagnosis-the-ama-says-is-used-to-shield-police-violence.

[3] Stacia Glenn, “‘Can’t breathe’: Tacoma police restraint of Manuel Ellis caused his death, medical examiner reports,” Seattle Times, Jun. 3, 2020, https://www.seattletimes.com/seattle-news/cant-breathe-tacoma-police-restraint-of-manuel-ellis-caused-his-death-medical-examiner-reports/; “Family rallies for man killed in 2017 Omaha police struggle,” Associated Press, Jun. 6, 2021, https://apnews.com/article/ne-state-wire-omaha-28d4820fecb111234d641f609db031f3; Anica Padilla, “‘Excited Delirium’: Elijah McClain’s Mother Talks To ’60 Minutes’ About Use Of Ketamine To Sedate Suspects,” CBS Denver, Dec. 14, 2020; Justin Jouvenal, “‘Excited delirium’ cited in dozens of deaths in police custody. Is it real or a cover for brutality?” Washington Post, May 6, 2015, https://www.washingtonpost.com/local/crime/existence-of-excited-delirium-ruling-in-va-womans-death-has-experts-split/2015/05/06/b1cc9499-ddaa-474c-9e8a-9ae89a9ae679_story.html; Kimberlé Williams Crenshaw and Andrea J. Ritchie, Say Her Name: Resisting Police Brutality Among Black Women (New York: African American Policy Forum, 2015) http://static1.squarespace.com/static/53f20d90e4b0b80451158d8c/t/560c068ee4b0af26f72741df/1443628686535/AAPF_SMN_Brief_Full_singles-min.pdf; Lisette Voytko, “Daniel Prude’s Autopsy Report Says ‘Excited Delirium,’ A Controversial Diagnosis, Contributed To His Death,” Forbes, Dec. 3, 2020, https://www.forbes.com/sites/lisettevoytko/2020/09/03/daniel-prudes-autopsy-report-says-excited-delirium-a-controversial-diagnosis-contributed-to-his-death/?sh=199868b61784.

[4] Alysia Santo, “As George Floyd Died, Officer Wondered About ‘Excited Delirium,’” The Marshall Project, Jun. 4, 2020, https://www.themarshallproject.org/2020/06/04/as-george-floyd-died-officer-wondered-about-excited-delirium; Steve Karnowski, “EXPLAINER: Why ‘excited delirium’ came up at Chauvin trial?” Associated Press, Apr. 19, 2021, https://apnews.com/article/health-death-of-george-floyd-trials-george-floyd-3b60b3930023a2668e7fc63f903fc3aa; Ja’han Jones, “3 ex-cops charged in George Floyd’s death try to blame ‘excited delirium’ as the cause,” MSNBC, Jan. 28, 2022, https://www.msnbc.com/the-reidout/reidout-blog/george-floyd-excited-delirium-rcna13990.

[5] Eric Dexheimer and Jeremy Schwartz, “In fatal struggles with police, a controversial killer is often blamed,” Austin-American Statesman, May 27, 2017, https://www.statesman.com/story/news/investigates/2017/05/27/in-fatal-struggles-with-police-controversial-killer-is-often-blamed/8339157007.

[6] Alessandro Marazzi Sassoon, “Excited delirium: Rare and deadly syndrome or a condition to excuse deaths by police?” Florida Today, Oct. 24, 2019, https://www.floridatoday.com/in-depth/news/2019/10/24/excited-delirium-custody-deaths-gregory-edwards-melbourne-taser/2374304001.

[7] Osagie K. Obasogie, “Excited Delirium and Police Use of Force,” Virginia Law Review vol. 107, no. 8 (Dec. 2021), https://www.virginialawreview.org/wp-content/uploads/2021/12/Obasogie_Book_107.pdf.

[8] David A. Fishbain and Charles V. Wetli, “Cocaine intoxication, delirium, and death in a body packer,” Annals of Emergency Medicine vol. 10, (Oct. 1981): 531–532, https://pubmed.ncbi.nlm.nih.gov/7283219/; Charles V. Wetli and David A. Fishbain, “Cocaine-Induced Psychosis and Sudden Death in Recreational Cocaine Users,” Journal of Forensic Sciences vol. 30, no. 3, (Jul. 1985).

[9] Adrian Walker and Heather Dewar, “Cocaine-Sex Deaths in Dade Probed,” Miami News, Nov. 24, 1988.

[10] Ibid.

[11] Ibid.

[12] Russ Rymer, “Murder Without a Trace,” In Health, May/Jun. 1990.

[13] Rosemary Goudreau, “Coroner: Somebody Killed 19 women,” Miami Herald, May 31, 1989; John Donnelly, “Suspect in Murder of Prostitutes Speaks Out,” Miami Herald, May 9, 1993; Donna Gehrke, “Missed Calls, Close Calls Mar Serial Killings Case,” Miami Herald, April 26, 1990; Donna Gehrke, “Cops: Rapist Top Suspect in Murders,” Miami Herald, Jun. 20, 1989.

[14] Donna Gehrke, “Both Sides Rest in Williams’ Rape Trial,” Miami Herald, Apr. 27, 1990.

[15] Russ Rymer, “Murder Without a Trace,” In Health, May/Jun. 1990.

[16] Ibid.

[17] Theresa G. Di Maio and Vincent J. Di Maio, Excited Delirium Syndrome: Cause of Death and Prevention (New York: CRC Press 2005).

[18]  Bernice Yeung, “Taser’s Delirium Defense,” Mother Jones, Mar./Apr. 2009, https://www.motherjones.com/politics/2009/02/tasers-delirium-defense; Gus Garcia-Roberts, “Is excited delirium killing coked-up, stun-gunned Miamians?” Miami New Times, Jul. 15, 2010, https://www.miaminewtimes.com/news/is-excited-delirium-killing-coked-up-stun-gunned-miamians-6367399?showFullText=true; interview with Michael Baden, Oct. 7, 2021.

[19] Deposition of Vincent J.M. Di Maio, M.D. at 159:19-21, Harrison v. County of Alameda, No. C11-2868 JST (N.D. Cal. Jan. 24, 2014).

[20] Philippe Gonin et al., “Excited Delirium: A Systematic Review,” Academic Emergency Medicine vol. 25, (May 2018): 552-565, https://doi.org/10.1111/acem.13330.

[21] See, e.g., Royce Kurmelovs, “‘Excited delirium’: how a disputed US term found its way to Australian deaths-in-custody inquests,” The Guardian, Jul. 3, 2021, https://www.theguardian.com/australia-news/2021/jul/04/excited-delirium-how-a-disputed-us-term-found-its-way-to-australian-deaths-in-custody-inquests; “Report of the Panel of Mental Health and Medical Experts Review of Excited Delirium”, Jun. 30, 2009,https://novascotia.ca/just/public_safety/_docs/Excited%20Delirium%20Report.pdf; Nazia Parveen, “‘Excited delirium’: term linked to police restraint in UK medical guide condemned,” The Guardian, Jul. 1, 2021, https://www.theguardian.com/uk-news/2021/jul/01/excited-delirium-term-linked-to-police-restraint-in-uk-medical-guide-condemned.

[22] See, e.g., Arjun S. Byju, “Excited Delirium: How Cops Invented a Disease,” Current Affairs, Apr. 13, 2021, https://www.currentaffairs.org/2021/04/excited-delirium-how-cops-invented-a-disease; Royce Kurmelovs, “‘Excited Delirium’: How a Disputed US Term Found Its Way to Australian Deaths-in-Custody Inquests,” The Guardian, Jul. 3, 2021, https://www.theguardian.com/australia-news/2021/jul/04/excited-delirium-how-a-disputed-us-term-found-its-way-to-australian-deaths-in-custody-inquests; Jennifer K. Brody, Ayana Jordan and Sarah E. Wakeman, “Excited delirium: valid clinical diagnosis or medicalized racism? Organized medicine needs to take a stand,” STAT News, Apr. 6, 2021, https://www.statnews.com/2021/04/06/excited-delirium-medicalized-racism-organized-medicine-take-a-stand; “Police keep using ‘excited delirium’ to justify brutality. It’s junk science,” Washington Post, July 17, 2020, https://www.washingtonpost.com/outlook/chokehold-police-excited-delirium/2020/07/17/fe907ec8-c6bc-11ea-b037-f9711f89ee46_story.html; Amnesty International, “Amnesty International’s Continuing Concerns about Taser Use,” Mar. 2006, https://www.amnesty.org/en/documents/amr51/030/2006/en.

[23] G. Schwartz and J. Jahn, “Mapping fatal police violence across U.S. metropolitan areas: Overall rates and racial/ethnic inequities, 2013-2017,” PLOS ONE, vol. 15, no. 6, (Jun. 24, 2020), https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0229686; Frank Edwards, Hedwig Lee, and Michael Esposito, 2019, “Risk of Being Killed by Police Use of Force in the United States by Age, Race–Ethnicity, and Sex,” Proceedings of the National Academy of Sciences vol. 116, no. 34, (Aug. 20, 2019): 16793-16798, https://www.pnas.org/content/116/34/16793; Stephanie Woodard, “The Police Killings No One Is talking About,” In These Times, Oct. 17, 2016, https://inthesetimes.com/features/native_american_police_killings_native_lives_matter.html.

^[24] American Medical Association, “New AMA policy recognizes racism as a public health threat,” Nov. 16, 2020, https://www.ama-assn.org/press-center/press-releases/new-ama-policy-recognizes-racism-public-health-threat; American Public Health Association, “APHA Calls out Police Violence as a Public Health Crisis,” Jun. 4, 2020, https://www.apha.org/news-and-media/news-releases/apha-news-releases/2020/apha-calls-out-police-violence; National Medical Association, “NMA Calls for Open Dialogue on Police Brutality,” Jun. 2, 2020, https://www.nmanet.org/news/510933/NMA-Calls-for-Open-Dialogue-on-Police-Brutality.htm; see also Rachel R. Hardeman, Eduardo M. Medina, and Rhea W. Boyd, “Stolen Breaths,” New England Journal of Medicine vol. 383, no. 3, (Jul. 16, 2020): 197–199, https://www.nejm.org/doi/full/10.1056/nejmp2021072.

[25] According to a 2015 Treatment Advocacy Center report, anywhere from 25 to 50 percent of fatal law enforcement encounters end the life of someone with a serious mental illness; individuals with untreated serious mental illness are 16 times more likely to be killed when approached or stopped by law enforcement than other civilians. Doris A. Fuller et al., Overlooked in the Undercounted, Treatment Advocacy Center, Dec. 2015, https://www.treatmentadvocacycenter.org/overlooked-in-the-undercounted. A March 2016 study by the Ruderman Family Foundation found that up to half of all people killed by police in the United States have a disability. David M. Perry and Lawrence Carter-Long, “The Ruderman White Paper on Media Coverage of Law Enforcement Use of Force and Disability,” Ruderman Family Foundation, Mar. 2016, https://rudermanfoundation.org/media-missing-the-story-half-of-all-recent-high-profile-police-related-killings-are-people-with-disabilities. A June 2020 Mercury News study of 72 police killings in the Bay Area found that two-thirds of people killed had some kind of mental health issue. Thomas Peele, David Debolt, and Robert Solanga, “Exclusive: Blacks Are Only 7% of the Bay Area, but 27% of Those Killed by Police,” The Mercury News, Jun. 28, 2020, https://www.mercurynews.com/2020/06/28/110-deaths-police-killings-in-the-bay-area-since-2015-result-in-no-prosecutions-of-cops-and-little-discipline See also A. Saleh, A. P. Appelbaum, X. Liu., T. Scott Stroup, and M. Wall, “Deaths of people with mental illness during interactions with law enforcement,” International Journal of Law and Psychiatry vol. 58, (2018): 110-116 https://pubmed.ncbi.nlm.nih.gov/29853001/.

[26] Mental illness was defined as any mental, behavioral, or emotional disorder in the past year of sufficient duration to meet the diagnostic criteria of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), the main diagnostic tool used by clinicians for psychiatric diagnosis.

[27] A serious mental illness was defined as any mental, behavioral, or emotional disorder that substantially interfered with or limited one or more major life activities.

[28] Substance Abuse and Mental Health Services Administration (SAMHSA), “Key Substance Use and Mental Health Indicators in the United States: Results from the 2020 National Survey on Drug Use and Health,” Oct. 2021, https://www.samhsa.gov/data/sites/default/files/reports/rpt35325/NSDUHFFRPDFWHTMLFiles2020/2020NSDUHFFR1PDFW102121.pdf.

[29] Doris A. Fuller et al., Overlooked in the Undercounted, 2015.

[30] K. P.Rosenberg, J. DuLong, Bedlam: An Antimate Journey into America’s Mental Health Crisis (New York: Avery, 2019); C. Montross, Waiting for an Echo: The Madness of American Incarceration (New York: Penguin Press, 2020).

[31] Treatment Advocacy Center, “People with Untreated Mental Illness 16 Times More Likely to Be Killed By Law Enforcement,” https://www.treatmentadvocacycenter.org/key-issues/criminalization-of-mental-illness/2976-people-with-untreated-mental-illness-16-times-more-likely-to-be-killed-by-law-enforcement; see also David A. Paul, “The Death of Daniel Prude — Reflections of a Black Neurosurgeon,” New England Journal of Medicine vol. 383, no. 24, e135, https://www.nejm.org/doi/full/10.1056/NEJMpv2030234.

[32] United Nations High Commissioner for Human Rights, “Promotion and protection of the human rights and fundamental freedoms of Africans and of people of African descent against excessive use of force and other human rights violations by law enforcement officers,” Jun. 28, 2021, A/HRC/47/CRP.1, https://www.ohchr.org/Documents/Issues/Racism/A_HRC_47_CRP_1.pdf.

[33] Centers for Disease Control and Prevention (CDC), “Investigations and Autopsies,” Jan. 15, 2015, https://www.cdc.gov/phlp/publications/coroner/investigations.html.

[34] CDC, “Medicolegal Officers,” Jan. 15, 2015, https://www.cdc.gov/phlp/publications/coroner/medicolegal.html.

[35] Radley  Balko, “It’s time to abolish the coroner,” Washington Post, Dec. 12, 2017, https://www.washingtonpost.com/news/the-watch/wp/2017/12/12/its-time-to-abolish-the-coroner.

[36] CDC, “DC Medicolegal Officers,” Jan. 15, 2015, https://www.cdc.gov/phlp/publications/coroner/medicolegal.html.

[37] M. Hannan, I. Hearnden, K. Grace, T. Bucke, “Deaths in or following police custody. An Examination of the cases 1998/99 – 2008/09,” IPCC Research Series Paper vol. 17, (2010): 1-93.

[38] National Academy of Sciences, “Strengthening Forensic Science in the United States: A Path Forward,” Aug. 2009, https://www.ojp.gov/pdffiles1/nij/grants/228091.pdf.

[39] Harvard T.H. Chan School of Public Health, “More than half of police killings not officially documented on U.S. death certificates,” Oct. 10, 2017, https://www.hsph.harvard.edu/news/press-releases/documenting-police-killings; see also Jamiles Lartey, “US police killings undercounted by half, study using Guardian data finds,” The Guardian, Oct. 11, 2017, https://www.theguardian.com/us-news/2017/oct/11/police-killings-counted-harvard-study.

[40] Justin Feldman, “Want police reform? We need independent medical examiners and coroners,” Washington Post, Jun. 2, 2020, https://www.washingtonpost.com/opinions/2020/06/02/want-police-reform-we-need-independent-medical-examiners-coroners.

[41] “The Counted: People killed by police in the US,” The Guardian, https://www.theguardian.com/us-news/ng-interactive/2015/jun/01/about-the-counted.

[42] J. M. Feldman, S. Gruskin, B. A. Coull, N. Krieger, “Quantifying underreporting of law-enforcement-related deaths in United States vital statistics and news-media-based data sources: A capture–recapture analysis,” PLoS Med vol. 14, no. 10, (2017): 1-20, https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002399.

[43] Jamiles Lartey, “US police killings undercounted by half, study using Guardian data finds,” The Guardian, Oct. 11, 2017, https://www.theguardian.com/us-news/2017/oct/11/police-killings-counted-harvard-study.

[44] “Fatal Police Violence by Race and State in the USA, 1980–2019: A Network Meta-Regression,” The Lancet vol. 398, no. 10307 (Oct. 2, 2021): 1239–1255, https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)01609-3/fulltext.

[45] Ibid.

[46] S.A. Luzi, J. Melinek, W.R. Oliver. “Medical Examiner’s Independence is Vital for the Health of the American Legal System,” Academic Forensic Pathology – Sage Journals vol. 3, no. 1, (Mar. 1, 2019): 84-92, https://journals.sagepub.com/doi/abs/10.23907/2013.012.

[47] M. Singh, “How America’s broken autopsy system can mask police violence,” The Guardian, Jul. 3, 2020, http://www.theguardian.com/us-news/2020/jul/02/autopsies-police-killings-medical-misleading.

[48] L. Sathyavagiswaran, C. Rogers, T. Noguchi, “Restraint asphyxia in in-custody deaths – Medical examiner’s role in prevention of deaths,” Legal Medicine vol. 9, (2007): 88-93, https://doi.org/10.1016/j.legalmed.2006.11.007.

[49] William Russell Oliver, “The effect of threat of litigation on forensic pathologist diagnostic decision making,” American Journal of Forensic Medicine and Pathologyvol. 32, no. 4, (Dec. 2011): 383-386, https://journals.lww.com/amjforensicmedicine/Abstract/2011/12000/The_Effect_of_Threat_of_Litigation_on_Forensic.22.aspx.

[50] Ibid.

[51] R. Hanzlick, J. H. Hunsaker III, G. J. Davis, “A Guide For Manner of Death Classification,” National Association of Medical Examiners, 2002, https://name.memberclicks.net/assets/docs/MANNEROFDEATH.pdf.

[52] Ibid.

[53] Ibid.

[54] R. A. Mitchell Jr, F. Diaz, G. A. Goldfogel, et al., “National Association of Medical Examiners Position Paper: Recommendations for the Definition, Investigation, Postmortem Examination, and Reporting of Deaths in Custody,” Academic Forensic Pathology – Sage Journals vol. 7, no. 4, (Dec. 1, 2017): 604-618, https://journals.sagepub.com/doi/abs/10.23907/2017.051.

[55] H. Arksey and L. O’Malley, “Scoping studies: towards a methodological framework,” International Journal of Social Research Methodology vol. 8, no. 1, (2005): 19-32, https://doi.org/10.1080/1364557032000119616.

[56] The forensic pathologists PHR interviewed were Michael Baden, Joye Carter, Kris Cunningham, Soledad Martinez, Judy Melinek, Roger Mitchell, Michael Pollanen, and Enrico Risso. There were also contributions from forensic pathologists who preferred not to have quotes ascribed to them. The emergency physicians were Martin Chenevert and Jared Strote. The other physicians were Michael Freeman, doctor of medicine and forensic epidemiologist, and Suzan Marshall, surgeon and certified death investigator. The plaintiff’s attorneys were John Burton, Jim Davy, Dale Galipo, and Ben Nisenbaum. The prosecutors preferred not to have quotes ascribed to them. The police trainer was Jack Ryan. One additional attorney, Selwyn Pieters, provided written answers to our questions.

[57] PHR spoke to Tim Black, Crisis Assistance Helping Out On The Streets (CAHOOTS); Robyn Burek, Portland Street Response; Elizabeth Sinclair Hanc, Treatment Advocacy Center; Sabah Muhammad, Treatment Advocacy Center; Kimberly Sue, National Harm Reduction Coalition; and Greg Townley, Portland Street Response.

^[58] Merriam-Webster, “syndrome,” https://www.merriam-webster.com/dictionary/syndrome.

[59] R. Freedman, D. A. Lewis, R. Michels, D. S. Pine, S. K. Schultz, C. A. Tamminga, et al., “The initial field trials of DSM-5: new blooms and old thorns,” American Journal of Psychiatry vol. 170, no. 1, (Jan. 1, 2013): 1-5, https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2012.12091189?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed.

^[60] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, (Washington D.C.: APA Press, 2013).

[61] Luther Bell, “On a form of disease resembling some advanced stage of mania and fever,” The American Journal of Insanity vol. 6, (Oct. 1849): 97–127, https://ajp.psychiatryonline.org/doi/10.1176/ajp.6.2.97; M. Morrison, “Death of a Psychiatric Patient during Physical Restraint. Excited Delirium- A Case Report,” Medicine, Science and the Law vol. 41, (Jan. 2001): 46-50, https://doi.org/10.1177/002580240104100109; Amanda Truscott, “A knee in the neck of excited delirium,” Canadian Medical Association Journal vol. 178, (Mar. 2008): 669-670, https://doi.org/10.1503/cmaj.080210; Roger Byard, “Ongoing issues with the diagnosis of excited delirium,” Forensic Science, Medicine and Pathology vol. 14, (Aug. 2017): 149-151, https://doi.org/10.1007/s12024-017-9904-3; Deborah C. Mash, “Excited Delirium and Sudden Death: A Syndromal Disorder at the Extreme End of the Neuropsychiatric Continuum.” Frontiers in Physiology vol. 7, (Oct. 13, 2016): 1-9, https://www.frontiersin.org/articles/10.3389/fphys.2016.00435/full; Matthew D. Sztajnkrycer et al., “Cocaine, excited delirium and sudden unexpected death,” Emergency Medical Services, vol. 34, (Apr. 2005): 77-81, https://pubmed.ncbi.nlm.nih.gov/15900873/; M. Fink, “Delirious mania,” Bipolar Disorders vol. 1, no. 1, (Sept. 1999): 54-60, https://doi-org.offcampus.lib.washington.edu/10.1034/j.1399-5618.1999.10112.x; Sandeep Sekkon et al., “Excited Delirium,” StatPearls, Jul. 2021, https://pubmed.ncbi.nlm.nih.gov/31536280/; Philippe Gonin et al., “Excited Delirium: A Systematic Review,” 2018, https://doi.org/10.1111/acem.13330; Gary Vilke et al., “Excited delirium syndrome (ExDS): redefining an old diagnosis,” Journal of Forensic and Legal Medicine vol. 19, (Jan. 2012): https://doi.org/10.1016/j.jflm.2011.10.006; Maurice Lipsedge, “Excited delirium: A psychiatric review,” Medicine, Science and the Law vol. 56, no. 2, (Apr. 2016): https://doi.org/10.1177/0025802415579617; Gary Vilke et al., “Excited Delirium Syndrome: Defining Based on a Review of the Literature,” Journal of Emergency Medicine vol. 43, no. 5, (Nov. 2012): 897-905, https://doi.org/10.1016/j.jemermed.2011.02.017; Christopher Bond et al., “Hot Off the Press: SGEM #218. Excited Delirium: A Systematic Review,” Academic Emergency Medicine vol.26, (Jan. 2019): 106-108, https://doi.org/10.1111/acem.13487; J. R. Grant, P. E. Southall, J. Mealey, S. R. Scott, D. R. Fowler, “Excited Delirium Deaths in Custody: Past and Present,” American Journal of Forensic Medicine and Pathology vol. 30, no. 1, (2009): 1-5, https://journals.lww.com/amjforensicmedicine/Abstract/2009/03000/Excited_Delirium_Deaths_in_Custody__Past_and.1.aspx; David Ranson, “Excited delirium syndrome: a political diagnosis?” American Journal of Law and Medicine vol. 19, (Jun. 2012): 667-672, https://pubmed.ncbi.nlm.nih.gov/22908610/..

[62] M. Morrison, “Death of a Psychiatric Patient,” 46-50; Matthew D. Sztajnkrycer et al., “Cocaine, excited delirium and sudden unexpected death,”77-81; M. Fink, “Delirious mania,” 54-60; Gary Vilke et al., “Excited delirium syndrome (ExDS): redefining an old diagnosis,” 2012; Edith Samuel et al., “Excited delirium: Consideration of selected medical and psychiatric issues,” Neuropsychiatric Disease and Treatment vol. 5, (Jan. 21, 2009): 61-66, https://doi.org/10.2147/ndt.s2883; J. R. Grant, P. E. Southall, J. Mealey, S. R. Scott, D. R. Fowler, “Excited Delirium Deaths in Custody, 1-5; Di Maio and Di Maio, Excited Delirium Syndrome: Cause of Death and Prevention (New York: CRC Press, 2005).

[63] Psychiatric diagnoses, prominently schizophrenia, have also been used to stigmatize Black people. See, e.g., J. Metzl, The Protest Psychosis: How Schizophrenia became a Black Disease (Boston: Beacon Press, 2009).

[64] Gary Vilke et al., “Excited delirium syndrome (ExDS): redefining an old diagnosis,” 2012; J. R. Grant, P. E. Southall, J. Mealey, S. R. Scott, D. R. Fowler, “Excited Delirium Deaths in Custody, 1-5; David Ranson, “Excited delirium syndrome: a political diagnosis?” 2012, 667-672; Deborah C. Mash, “Excited Delirium and Sudden Death, 2016.

^[65] David A. Fishbain and Charles V. Wetli, “Cocaine intoxication, delirium, and death in a body packer,” Annals of Emergency Medicine vol. 10, (Oct. 1981): 531–532, https://pubmed.ncbi.nlm.nih.gov/7283219/.

^[66] Charles V. Wetli and David A. Fishbain, “Cocaine-Induced Psychosis and Sudden Death in Recreational Cocaine Users,” Journal of Forensic Sciences vol. 30, no. 3, (Jul. 1985): 873-880; Sandeep Sekkon et al., “Excited Delirium,” 2021; Roger Byard, “Ongoing issues with the diagnosis of excited delirium,” Forensic Science, Medicine and Pathology vol. 14, (Aug. 2017): 149-151, https://doi.org/ 10.1007/s12024-017-9904-3; Amanda Truscott, “A knee in the neck of excited delirium,” Canadian Medical Association Journal vol. 178, (Mar. 2008): 669-670, https://doi.org/10.1503/cmaj.080210.

[67] Z.J. Lipowsky, “Organic Mental Disorders: Introduction and Review of Syndromes,” in Comprehensive Textbook of Psychiatry, 3rd ed., eds. H.F. Kaplan, A. M. Freedman, and B. M. Sodock (Baltimore, Maryland: Williams and Wilkins, 1980), 1359-1392.

[68] Fishbain and Wetli, “Cocaine Intoxication, Delirium, and Death In a Body Packer,” 531-532.

[69] Adrian Walker and Heather Dewar, “Cocaine-Sex Deaths in Dade Probed,” Miami News, Nov. 24, 1988.

[70] Ibid.

[71] Ibid.

[72] Ibid.

[73] Ibid.

[74] Ibid.

[75] Adrian Walker, “Tainted crack suspected in deaths of 9 women,” Miami News, Dec. 8, 1988.

[76] Pete Collins and Bob McPhail, “Seventeen Dead So Far,” New Times vol. 4, no. 2, (May 3-9, 1989): 6-22.

[77] Donna Gehrke, “Missed Calls, Close Calls Mar Serial Killings Case,” Miami Herald, Apr. 26, 1990; Metropolitan Dade County Medical Examiner Department, “Investigation Report (Antoinette Burns. M.E. Case No. 7703575),” Dec. 12, 1988.

[78] Donna Gehrke, “18 Killings Leave Families Struggling with Uncertainty,” Miami Herald, Jun. 18, 1989; Barry Bearak, “Eerie Deaths of 17 Women Baffle Miami,” Los Angeles Times, May 14, 1989, https://www.latimes.com/archives/la-xpm-1989-05-14-mn-413-story.html.

[79] Russ Rymer, “Murder Without a Trace,” In Health, May/Jun. 1990.

[80] Ibid.

[81] Pete Collins and Bob McPhail, “Seventeen Dead So Far,” New Times, May 3-9, 1989.

[82] Ibid.

[83] Ibid.

[84] Ibid.

[85] Ibid.

[86] Rosemary Goudreau, “Coroner: Somebody Killed 19 women,” Miami Herald, May 31, 1989.

[87] Donna Gehrke, “Missed Calls, Close Calls Mar Serial Killings Case,” Miami Herald, April 26, 1990.

[88] Rosemary Goudreau, “Coroner: Somebody Killed 19 women,” Miami Herald, May 31, 1989.

[89] Ibid. John Donnelly, “Suspect in Murder of Prostitutes Speaks Out,” Miami Herald, May 9, 1993; Donna Gehrke, “Missed Calls, Close Calls Mar Serial Killings Case,” Miami Herald, April 26, 1990.

[90] Donna Gehrke,“Cops: Rapist Top Suspect in Murders,” Miami Herald, Jun. 20, 1989.

[91] Donna Gehrke, “18 Killings Leave Families Struggling with Uncertainty,” Miami Herald, June 18, 1989.

[92] Ibid.

[93] Donna Gehrke, “Both Sides Rest in Williams’ Rape Trial,” Miami Herald, Apr. 27, 1990.

[94] Tatiana M. With, “Absence of justice: case closed on suspected killer of 32,” Miami Herald, Sept. 25, 1994.

[95] Russ Rymer, “Murder Without a Trace,” In Health, May/Jun. 1990. Two decades later, Wetli still held to his theory that a combination of cocaine and sex might have killed the women. The Miami New Times reported, “Wetli, who is in private practice in New Jersey, initially downplays his theory. He had to make a diagnosis so that the bodies could be buried, he says. But then it becomes clear he still believes that death-by-sex might have killed those women 20 years ago. ‘It’s certainly a possibility,’ he says. ‘The guy never went to trial, so we’ll never know. The police had a commendable theory in suspecting him. But believing in something, and proving it, is another story.’” Gus Garcia-Roberts, “Is excited delirium killing coked-up, stun-gunned Miamians?” Miami New Times, Jul. 15, 2010, https://www.miaminewtimes.com/news/is-excited-delirium-killing-coked-up-stun-gunned-miamians-6367399?showFullText=true.

[96] Russ Rymer, “Murder Without a Trace,” In Health, May/June 1990.

[97] In a 2021 law review article on “excited delirium,” Professor Osagie K. Obasogie provides important additional context for Wetli’s theories: “it is imperative to highlight the role that race and, in particular, perceptions and anxieties regarding Black drug use and Black criminality play in giving legitimacy to an excited delirium diagnosis. … For example, the 1980s crack cocaine epidemic gave birth to horrific tropes about racial minorities and premature death, such as the so-called ‘crack baby’ myth suggesting that maternal drug use during pregnancy led to high rates of stillbirth and infants with lifelong health problems. … What connects this spectrum of belief and practice is the notion of pathologizing Blackness, where premature death is seen as a function of Black people’s inherent inferiority and is used to exculpate actions by others that may be the more proximate cause of death.” Osagie K. Obasogie, “Excited Delirium and Police Use of Force,” 2021.

[98] Stephens et al., “National Association of Medical Examiners Position Paper on the Certification of Cocaine-Related Deaths,” American Journal of Forensic Medicine and Pathology vol. 25, no. 1, (March 2004), http://www.charlydmiller.com/LIB04/2004namecocainedeaths.pdf.

[99] Charles V. Wetli, “Deaths due to cocaine induced excited delirium and psychosis,” American Journal of Clinical Pathology vol. 104, no. 329, (1995).

[100] Stephens et al., “National Association of Medical Examiners Position Paper,” 2004.

[101] R. A. Mitchell Jr., F. Diaz, G. A. Goldfogel, et al., “National Association of Medical Examiners Position Paper: Recommendations for the Definition, Investigation, Postmortem Examination, and Reporting of Deaths in Custody,” Academic Forensic Pathology vol. 7, no. 4, (2017): 604-618, https://journals.sagepub.com/doi/abs/10.23907/2017.051.

[102] Di Maio and Di Maio, Excited Delirium Syndrome, 2005.

[103] Ibid.

[104] Ibid.

[105] Deposition of Vincent J.M. Di Maio, M.D. at 159:19-21, Harrison v. County of Alameda, No. C11-2868 JST (N.D. Cal. Jan. 24, 2014). The transcript states:

Q. But excited delirium syndrome is something

you and your wife came up with, right?

A. Right. Yes.

[106] Jennifer Valentino-DeVries, Mike McIntire, Rebecca R. Ruiz, Julie Tate, and Michael H. Keller, “How Paid Experts Help Exonerate Police After Deaths in Custody,” New York Times, Dec. 26, 2021, https://www.nytimes.com/2021/12/26/us/police-deaths-in-custody-blame.html.

[107] Ibid.

[108] T. C. Chan, G. M. Vilke, T. Neuman, J. L. Clausen, “Restraint position and positional asphyxia,” Annals of Emergency Medicine vol. 30,(1997): 578-86.

[109] T. C. Chan, T. Neuman, J. Clausen, J. Eisele, G. M. Vilke, “Weight Force During Prone Restraint and Respiratory Function,” American Journal of Forensic Medicine and Pathology vol. 25, (2004): 185-189.

[110] This was necessary because such reviews are mandatory for all research with human participants to certify compliance with established safety and ethical standards.

[111] Deposition of Gary M. Vilke, M.D. at 55:20-21, Bonnie Keeney v. City of New London, No. 3:99-CV-2096 (JCH) (D. Conn. Apr. 5, 2001). [Charles Wetli was the defendants’ expert in the Keeney case.]

[112] Deposition of Gary M. Vilke at 13:22-14:5, Neuroth v. Mendocino County, No. 3:15-cv-03226-RS (N.D. Cal. Mar. 19, 2018).

[113] A.J. Lagoe, Steve Eckert, and Chris Vanderveen, “KARE 11 Investigates: Dueling experts about the danger of holding George Floyd down,” KARE 11, Apr. 10, 2021, https://www.kare11.com/article/news/local/george-floyd/dueling-experts-about-the-danger-of-holding-george-floyd-down/89-b4cecf93-0ec5-4b91-9a27-5271d1e77db6.

[114] Jennifer Valentino-DeVries, Mike McIntire, Rebecca R. Ruiz, Julie Tate, and Michael H. Keller, “How Paid Experts Help Exonerate Police After Deaths in Custody,” New York Times, Dec. 26, 2021.

[115] Deposition of Theodore C. Chan, M.D. at 22:25-23:1-9, Hesterberg v. USA., No. C13-1265 JSC (JCS) (N.D. Cal. Apr. 18, 2014).

[116] B.A. Michalewic, T.C. Chan, G.M. Vilke, S.S. Levy, T.S. Neuman, and F.W. Kolkhorst. “Ventilatory and metabolic demands during aggressive physical restraint in healthy adults,” Journal of Forensic Science vol. 52(1) (2007): 171-175, https://doi.org/10.1111/j.1556-4029.2006.00296.x.

[117] In the Neuroth case, Julia Sherwin subpoenaed the IRB materials only from UCSD and San Diego State. In Martinez v. City of Pittsburg, et al., she also subpoenaed IRB materials from Vilke and his co-authors; no one produced anything. San Diego State informed Sherwin they may have destroyed the information pursuant to their document retention policy. UCSD’s policy is to retain such documents “indefinitely wherever possible.” In accordance with FDA regulations, an IRB has the authority to approve, require modifications, or disapprove research. See U.S. Food & Drug Administration, “Institutional Review Boards (IRBs) and Protection of Human Subjects in Clinical Trials,” Sept. 11, 2019,  https://www.fda.gov/about-fda/center-drug-evaluation-and-research-cder/institutional-review-boards-irbs-and-protection-human-subjects-clinical-trials. Julia Sherwin subpoenaed all IRB materials related to all of Vilke et al. prone restraint studies from UCSD. The University produced IRB information for the earlier studies involving 25 pounds and 50 pounds but not for the study with 225 pounds. UCSD had no IRB documents or approval for the more recent study titled “Ventilatory and Metabolic Demands During Aggressive Physical Restraint in Healthy Adults,” nor did UCSD have IRB Committee meeting minutes from when the study was considered. Sherwin then subpoenaed all evidence or documents concerning IRB applications or approvals, even including correspondence and emails, for the 225-pound study from all authors of the study; these subpoenas produced nothing.  

[118] Depositions of Gary M. Vilke, M.D., Neuroth v. Mendocino County, et al., 3:15-CV-03226-RS, (N. D. Cal. 2018); Martinez v. City of Pittsburg, et al., 3:17-CV-04246-RS, (N.D. Cal. 2019).

[119] Ibid.

[120] Deposition of Vincent J.M. Di Maio, M.D. at 159:19-21, Harrison v. County of Alameda, No. C11-2868 JST (N.D. Cal. Jan. 24, 2014). Di Maio stated in this legal deposition in 2014:

Q. By 2007, TASER International had purchased

1,000 or 1,500 copies of your book to hand out free to

medical examiners, right?

A. Yes. That’s great.

[121] Gus Garcia-Roberts, “Is excited delirium killing coked-up, stun-gunned Miamians?” Miami New Times, Jul. 15, 2010; interview with Michael Baden, Oct. 7, 2021. As of December 1, 2021, a new hardcover copy was available for $123.47 and a digital copy for $229.95. https://www.amazon.com/Excited-Delirium-Syndrome-Cause-Prevention/dp/0849316111.

[122] Bernice Yeung, “Taser’s Delirium Defense,” Mother Jones, Mar./Apr. 2009; Gus Garcia-Roberts, “Is excited delirium killing coked-up, stun-gunned Miamians?” Miami New Times, Jul. 15, 2010.

[123]Scientific Working Group on Medicolegal Death Investigation (SWGMDI), “Increasing the Supply of Forensic Pathologists in the United States,” December 5, 2012, https://www.nist.gov/system/files/documents/2018/04/24/swgmdi_increasing_the_supply_of_forensic_pathologists_in_the_us.pdf.

[124] In 2017, TASER International changed its name to Axon Enterprise. See Laurel Wamsley, “Taser Changes Its Name To Axon And Offers Free Body Cameras For Police,” NPR, April 7, 2017, https://www.npr.org/sections/thetwo-way/2017/04/07/522878573/we-re-more-than-stun-guns-says-taser-as-it-changes-company-name.

[125] Deposition of Vincent J.M. Di Maio, M.D. at 159:19-21, Harrison v. County of Alameda, No. C11-2868 JST (N.D. Cal. Jan. 24, 2014).

[126] Tim Reid, Peter Eisler, Jason Szep and M. B. Pell, “As Taser warns of more and more risks, cities bear a burden in court,” Reuters, Aug. 23, 2017, https://www.reuters.com/investigates/special-report/usa-taser-legal/; Omar El Akkad and Jessica Leeder, “How Taser International wins in the courtroom,” Globe and Mail, Nov. 28, 2007, https://www.theglobeandmail.com/news/national/how-taser-international-wins-in-the-courtroom/article20406364/; Shahien Nasiripour, “Zapping Taser,” Reveal News, Dec. 1, 2008, https://revealnews.org/article/zapping-taser/; Jennifer Valentino-DeVries, Mike McIntire, Rebecca R. Ruiz, Julie Tate, and Michael H. Keller, “How Paid Experts Help Exonerate Police After Deaths in Custody,” New York Times, Dec. 26, 2021.

[127] In a 2018 deposition, Peters said, “On the consulting side I got paid from time to time retained by independent counsel on Taser associated death cases. And I probably did 15 or 20 of those over the course of six years. So using a flat rate approach of $7,500, that would be an approximate ballpark. Now whether those checks came directly from TASER or it came from counsel like you that TASER might have retained, that varied.” Deposition of John G. Peters, Jr. at 37:17-25, Neuroth v. Mendocino County et al., No. 3:15-cv-03226-RS (N.D. Cal. Feb. 15, 2018).

[128] Institute for the Prevention of In-Custody Death, Inc., “Initial List of Officers, Directors and Resident Agent,” Apr. 28, 2005. Courtesy of Julia Sherwin.

[129] Institute for the Prevention of In-Custody Deaths, Inc., “IPICD 3rd Annual Sudden Death, Excited Delirium & In-Custody Death Conference—LAS VEGAS,” Aug. 15, 2008, https://www.police1.com/police-products/training-products/press-releases/ipicd-3rd-annual-sudden-death-excited-delirium-in-custody-death-conferencelas-vegas-Ted0BlnrSeSTvzd3.

[130] Declaration of Steven B. Karch, MO, FFELM, Rosa v. TASER International, Inc., No. C-05-03577 JF/HRL (N.D. Cal. Jun. 1, 2009).

[131] Reuters reported in 2017, “Taser paid Mash around $24,000 for expert testimony in eight lawsuits filed from 2005 to 2009, court records show.” Jason Szep, Tim Reid, and Peter Eisler, “How Taser inserts itself into investigations involving its own weapons,” Reuters, Aug. 24, 2017, https://www.reuters.com/investigates/special-report/usa-taser-experts/.

[132] American College of Emergency Physicians (ACEP) Excited Delirium Task Force, “White Paper Report on Excited Delirium Syndrome,” American College of Emergency Physicians, Sept. 2009, https://www.ojp.gov/ncjrs/virtual-library/abstracts/white-paper-report-excited-delirium-syndrome.

[133] Andy Mannix, “After conflict-of-interest concerns, HCMC ends deal with Taser manufacturer,” Star Tribune, Jun. 19, 2019, https://www.startribune.com/after-conflict-of-interest-concerns-hcmc-to-sever-agreement-with-taser-manufacturer/511528142/; Curtis Gilbert, Angela Caputo, and Geoff Hing, “When Tasers Fail: Tasers are less reliable than their maker has claimed. The results can be deadly,” APM Reports, May 9, 2019, https://www.apmreports.org/episode/2019/05/09/when-tasers-fail.

[134] Ibid.

[135] Arjun S. Byju, “Excited Delirium: How Cops Invented a Disease,” Current Affairs, Apr. 13, 2021, https://www.currentaffairs.org/2021/04/excited-delirium-how-cops-invented-a-disease.

[136] Russ Rymer, “Murder Without a Trace,” In Health, May/June 1990.

[137] Gary Vilke et al, “Excited delirium syndrome: defining based on a review of the literature,” 2012, 43-45.

[138] Ibid.

[139] John H. Laub, “Study of Deaths Following Electro Muscular Disruption,” National Institute of Justice, May 2011, https://www.ojp.gov/pdffiles1/nij/233432.pdf. Other NIJ-funded but not endorsed reports on “excited delirium” include: “Special Panel Review of Excited Delirium,” Less-Lethal Devices Technology Working Group, Dec. 2011, https://nij.ojp.gov/library/publications/special-panel-review-excited-delirium; Cynthia Bir, “Physiological Model of Excited Delirium,” National Institute of Justice, Dec. 2011, https://nij.ojp.gov/library/publications/physiological-model-excited-delirium.

[140] Opposition to County Motion for Summary Judgment at 1:2-3:9, Harrison v. County of Alameda, No. 3:11-cv-2868-JST (N.D. Cal. Dec. 20, 2013), ECF No. 147; Opposition to Sancho Motion for Summary Judgment at 2:2-5:26, Harrison v. County of Alameda, No. 3:11-cv-2868-JST (N.D. Cal. Dec. 20, 2013), ECF No. 146.

[141] Ibid.

[142] Ibid.

[143] Ibid.

[144] Ibid.

[145] Deposition of Charles Wetli, M.D. at 106:17-19, 60:23-25, Harrison v. County of Alameda, No. C11-2868 JST (N.D. Cal. Jan. 15, 2014).

[146] Di Maio Deposition at 33:6-7. 32:23-24,Harrison v. County of Alameda, No. 3:11-cv-2868-JST (N.D. Cal. Jan. 24, 2014).

[147] Di Maio Deposition at 163:8-13, Harrison v. County of Alameda, No. 3:11-cv-2868-JST (N.D. Cal. Jan. 24, 2014).

[148] Wetli Deposition at 62:4-10, 63:23-64:1, Harrison v. County of Alameda, No. 3:11-cv-2868-JST (N.D. Cal. Jan. 15, 2014).

[149]Di Maio Deposition at 159:19-160:14, 162:5-17; Wetli Deposition at 62:7-10.

[150] Stipulation and Order of Settlement, Harrison v. County of Alameda, et al., No. 3:11-cv-2868 JST (N.D. Cal. Feb. 27, 2015), ECF No. 442.

[151] Sandeep Sekkon et al, “Excited Delirium,” 2021; Philippe Gonin et al, “Excited Delirium: A Systematic Review,” 2018; Gary Vilke et al., “Excited delirium syndrome (ExDS): redefining an old diagnosis,” 2012; Ellen Strommer et al., “The role of restraint in fatal excited delirium: a research synthesis and pooled analysis,” Forensic Science, Medicine and Pathology vol. 16, no.4, (Aug. 2020), https://doi.org/10.1007/s12024-020-00291-8; Jared Strote et al., “Medical conditions and restraint in patients experiencing excited delirium,” American Journal of Emergency Medicine vol. 32, (Sept. 2014): 1093-1096, https://doi.org/10.1016/j.ajem.2014.05.023; James Gill, “The syndrome of excited delirium,” Forensic Science, Medicine and Pathology vol. 10, no. 2, (Feb. 2014), https://doi.org/10.1007/s12024-014-9530-2; Sarathchandra Kodikara et al., ” “Excited delirium syndrome”: is it a cause of death,” Legal Medicine vol. 14, (Sept. 2012): 252-254, https://doi.org/10.1016/j.legalmed.2012.04.003; Christine Alison Hall et al., “Frequency of signs of excited delirium syndrome in subjects undergoing police use of force: Descriptive evaluation of a prospective, consecutive cohort, ” Journal of Forensic and Legal Medicine vol. 20, (Feb. 2013): 102-107, https://doi.org/10.1016/j.jflm.2012.05.008; William Bozeman et al., “Long QT syndrome unmasked in an adult subject presenting with excited delirium,” Journal of Emergency Medicine vol. 44, (Feb. 2013): 207-210, https://doi.org/10.1016/j.jemermed.2012.02.054; S. N. Kunz et al., “Arrest-related death on the basis of a drug-induced excited delirium syndrome,” Journal of Forensic and Legal Medicine vol. 77, (Jan. 2021): https://doi.org/10.1016/j.jflm.2020.102091.

[152] Christopher Bond et al., “Hot Off the Press: SGEM #218. Excited Delirium: A Systematic Review,” Academic Emergency Medicine vol.26, (Jan. 2019): 106-108, https://doi.org/10.1111/acem.13487; Solveig Baltzer Nielsen et al., “Can acute stress be fatal? A systematic cross-disciplinary review,” Stress vol. 22, (May 2019): 286-294, https://doi-org.offcampus.lib.washington.edu/10.1080/10253890.2018.1561847; William Bozeman et al., “Long QT syndrome unmasked in an adult subject presenting with excited delirium,” Journal of Emergency Medicine vol. 44, (Feb. 2013): 207-210, https://doi.org/10.1016/j.jemermed.2012.02.054; Ashwyn Rajagopalan et al., “Sudden death during struggle in the setting of heterozygosity for a mutation in calsequesterin 2,” Forensic Science, Medicine and Pathology vol. 12, (2016): 86-89, https://doi.org/10.1007/s12024-015-9733-1; Philippe Gonin et al., “Excited Delirium: A Systematic Review,” 2018; Ellen Strommer et al, “The role of restraint in fatal excited delirium,” 2020; A. J. Ruttenber et al., “Cocaine-associated rhabdomyolysis and excited delirium: different stages of the same syndrome,” American Journal of Forensic Medicine and Pathology vol. 20, (Jun. 1999): 120-127, https://doi.org/10.1097/00000433-199906000-00003.

[153] Christopher Bond et al, “Hot Off the Press: SGEM #218. Excited Delirium: A Systematic Review,” 2019; Philippe Gonin et al, “Excited Delirium: A Systematic Review,” 2018.

[154] Philippe Gonin et al, “Excited Delirium: A Systematic Review,” 2018.

[155] Charles V. Wetli and David A. Fishbain, “Cocaine-Induced Psychosis and Sudden Death,” 1985.

[156] Z.J. Lipowsky, “Organic Mental Disorders: Introduction and Review of Syndromes,” in Comprehensive Textbook of Psychiatry, 3rd ed., 1980.

[157] C. V. Wetli et al., “Cocaine-associated agitated delirium and the neuroleptic malignant syndrome,” American Journal of Emergency Medicine vol. 14, (Jul. 1996): 425-428, https://doi.org/doi:10.1016/S0735-6757(96)90066-2. The literature has often referred to “excited delirium” and agitated delirium as the same. Ellen Strommer et al., “The role of restraint in fatal excited delirium,” 2020.

[158] J. K. Staley et al., “High affinity cocaine recognition sites on the dopamine transporter are elevated in fatal cocaine overdose victims,” Journal of Pharmacology and Experimental Therapeutics vol. 271, (Dec. 1994): 1678-1685, https://pubmed.ncbi.nlm.nih.gov/7996484/; Deborah C. Mash et al., “D3 dopamine and kappa opioid receptor alterations in human brain of cocaine-overdose victims,” Annals of the New York Academy of Sciences, 877. (Jun. 1999): 507-522. doi:10.1111/j.1749-6632.1999.tb09286.x; J. K. Staley et al., “Adaptive increase in D3 dopamine receptors in the brain reward circuits of human cocaine fatalities,” Journal of Neuroscience vol. 16, (Oct. 1996): 6100-6106, https://www.jneurosci.org/content/16/19/6100; A. J. Ruttenber, “Fatal excited delirium following cocaine use: epidemiologic findings provide new evidence for mechanisms of cocaine toxicity,” Journal of Forensic Science vol. 42, (Jan. 1997): 25-31; B. G. Stephens et al., “Criteria for the interpretation of cocaine levels in human biological samples and their relation to the cause of death,” American Journal of Forensic Medicine and Pathology vol. 25, (Mar. 2004): 1-10, https://doi.org/10.1097/01.paf.0000118960.58334.a9; A. J. Ruttenber et al., “Cocaine-associated rhabdomyolysis and excited delirium,” 1999; Haresh G. Mirchandani et al., ”Cocaine-induced agitated delirium, forceful struggle, and minor head injury. A further definition of sudden death during restraint,” American Journal of Forensic Medicine and Pathology vol. 15, (1994): 95-99, https://doi.org/10.1097/00000433-199406000-00002.

[159] Kevin B. Gerold et al., “Review, clinical update, and practice guidelines for excited delirium syndrome,” Journal of Special Operations Medicine vol. 15, (2015): 62-69, https://pubmed.ncbi.nlm.nih.gov/25770800/; Deborah Mash, “Brain biomarkers for identifying excited delirium as a cause of sudden death,” Forensic Science International vol. 190, (Sept. 2009): e13-e19, https://doi.org/10.1016/j.forsciint.2009.05.012; A. J. Ruttenber, “Fatal excited delirium following cocaine use,” 1997; Gary Vilke et al., “Excited delirium syndrome: defining based on a review of the literature,” 2012, 897-905; Deborah C. Mash, “Excited Delirium and Sudden Death,” 2016; Deborah Mash et al., “Dopamine transport function is elevated in cocaine users” Journal of Neurochemistry vol.81, (2002): 292-300.

[160] Deborah Mash et al., “Brain biomarkers for identifying excited delirium as a cause of sudden death,” 2009; Magen M. Johnson et al., “Increased heat shock protein 70 gene expression in the brains of cocaine-related fatalities may be reflective of postdrug survival and intervention rather than excited delirium,” Journal of Forensic Sciences vol. 57, (Nov. 2012): 1519-1523, https://doi.org/10.1111/j.1556-4029.2012.02212.x.

[161] D. L. Ross, “Factors associated with excited delirium deaths in police custody,” Modern Pathology vol. 11, (Nov. 1998): 1127-1137, https://pubmed.ncbi.nlm.nih.gov/9831212/; Solveig Baltzer Nielsen et al., “Can acute stress be fatal?,” 2019; A. J. Ruttenber et al., “Cocaine-associated rhabdomyolysis and excited delirium,” 1999.

[162] M. D. Bell et al., “Positional asphyxiation in adults. A series of 30 cases from the Dade and Broward County Florida Medical Examiner Offices from 1982 to 1990,” American Journal of Forensic Medicine and Pathology vol. 13, (Jun. 1992): 101-107, https://pubmed.ncbi.nlm.nih.gov/1510056/.

[163] Ellen Strommer et al., “The role of restraint in fatal excited delirium,” 2020.

[164] Ibid.

[165] Charles V. Wetli and David A. Fishbain. 1985. “Cocaine-Induced Psychosis and Sudden Death,” 1985; D. T. Reay et al., “Positional asphyxia during law enforcement transport,” American Journal of Forensic Medicine and Pathology vol. 13, (Jun. 1992): 90-97, https://doi.org/10.1097/00000433-199206000-00002; Alain Michaud, “Restraint related deaths and excited delirium syndrome in Ontario (2004-2011),” Journal of Forensic and Legal Medicine vol. 41, (Jul. 2016): 30-35, https://doi.org/10.1016/j.jflm.2016.04.010; M. S. Pollanen et al., “Unexpected death related to restraint for excited delirium: a retrospective study of deaths in police custody and in the community,” Canadian Medical Association Journal vol. 158, (Jun. 1998): 1603-1607, https://pubmed.ncbi.nlm.nih.gov/9645173/; Patrick Joseph Maher, “Prehospital resuscitation of a man with excited delirium and cardiopulmonary arrest,” Canadian Journal of Emergency Medicine vol. 16, (Jan. 2014): 80-83, https://doi.org/10.2310/8000.2013.130824; Jami R. Grant et al., “Excited delirium deaths in custody: past and present,” American Journal of Forensic Medicine and Pathology vol. 30, (Mar. 2009): 1-5, https://doi.org/10.1097/PAF.0b013e31818738a0; S. J. Stratton, C. Rogers, K. Green, “Sudden death in individuals in hobble restraints during paramedic transportation,” Annals of Emergency Medicine vol. 25, (1995): 710-712.

[166] Donald T. Reay et al., “Effects of positional restraint on oxygen saturation and heart rate following exercise,” American Journal of Forensic Medicine and Pathology vol. 9, (Mar. 1988): 16-18, https://doi.org/10.1097/00000433-198803000-00005.

[167] Christian Sloane et al., “Evaluation of the ventilatory effects of the prone maximum restraint (PMR) position on obese human subjects,” Forensic Science International vol. 237, (Apr. 2014): 86-89, https://doi.org/10.1016/j.forsciint.2014.01.017.

[168] Gary M. Vilke et al., “Spirometry in normal subjects in sitting, prone, and supine positions,” Respiratory Care vol.45, (2000): 407–410; T. C. Chan et al., “Restraint position and positional asphyxia,” Annals of Emergency Medicine vol. 30, (1997): 578–586, https://doi.org/ 10.1016/s0196-0644(97)70072-6; Richard Barnett et al., “The physiological impact of upper limb position in prone restraint,” Medicine, Science and the Law vol.53, (2013): 161–165, https://doi.org/10.1258/msl.2012.012044; T. C. Chan et al., “Weight force during prone restraint and respiratory function,” American Journal of Forensic Medicine and Pathology vol. 25, (Sept. 2004): 185–189, https://doi.org/ 10.1097/01.paf.0000136639.69128.bc; Betty A. Michalewicz et al., “Ventilatory and metabolic demands during aggressive physical restraint in healthy adults,” Journal of Forensic Science vol. 52, (Jan. 2007): 171–175, https://doi.org/10.1111/j.1556-4029.2006.00296.x; Gary M. Vilke et al., “Spirometry in normal subjects in sitting, prone, and supine positions,”  407–410.

[169] John Parkes et. al., “Sudden death during restraint: do some positions affect lung function?” Medicine, Science and the Law vol. 48, (2008): 137–141; M. Roeggla et al., “Cardiorespiratory consequences to hobble restraint,” Wien Klin Wochenschr vol. 109, (May 1997): 359–361.

[170] Astrid Krauskopf et al., “Does weight force application to the lower torso have an influence on inferior vena cava and cardiovascular parameters?” American Journal of Emergency Medicine vol. 26, (Jun. 2008): 603-607, https://doi.org/10.1016/j.ajem.2007.08.017; Jeffrey D. Ho et al., “Effect of position and weight force on inferior vena cava diameter–implications for arrest-related death,” Forensic Science International vol. 212, (Oct. 2011): 256-259, https://doi.org/ 10.1016/j.forsciint.2011.07.001.

[171] Carolyn Meredith et al., “The cardiopulmonary effects of physical restraint in subjects with chronic obstructive pulmonary disease,” Journal of Clinical Forensic Medicine vol. 12, (Dec. 2005): 133–136, https://doi.org/ 10.1016/j.jcfm.2004.10.013.

[172] M. Campbell, R. Dakin, S. Stowe, et al., “Thoracic weighting of restrained subjects during exhaustion recovery causes loss of lung reserve volume in a model of police arrest,” Scientific Reports vol. 11, no. 15166 (2021), https://doi.org/10.1038/s41598-021-94157-w.

[173] Ibid.

[174] Ibid.

[175] J. M. Berkman, J. A. Rosenthal, A. Saadi, “Carotid Physiology and Neck Restraints in Law Enforcement: Why Neurologists Need to Make Their Voices Heard,” JAMA Neurology vol. 78, no. 3, (2021): 267–268. https://jamanetwork.com/journals/jamaneurology/article-abstract/2774482, citing S. Yamasaki, I. Takase, N. Takada, K. Nishi, “Measurement of force to obstruct the cervical arteries and distribution of tension exerted on a ligature in hanging,” Legal Medicine vol. 11, no. 4, (Jul. 2009): 175, https://www.sciencedirect.com/science/article/abs/pii/S134462230900217X?via%3Dihub.

[176] American Academy of Neurology, “AAN Position Statement on the Use of Neck Restraints in Law Enforcement,” Jun. 9, 2021, https://www.aan.com/policy-and-guidelines/policy/position-statements/aan-position-statement-on-use-of-neck-restraints-in-law-enforcement/.

[177] Maurice Lipsedge, “Excited delirium: A psychiatric review,” Medicine, Science and the Law vol. 56, no. 2, (Apr. 2016), https://doi.org/10.1177/0025802415579617; James Gill, “The syndrome of excited delirium,” Forensic Science, Medicine and Pathology vol. 10, no. 2, (Feb. 2014), https://doi.org/10.1007/s12024-014-9530-2; American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (Washington D.C.: APA Press, 2013).

[178] Ellen Strommer et al., “The role of restraint in fatal excited delirium,” 2020.

[179] Di Maio and Di Maio, Excited Delirium Syndrome, 2005.

[180] Ellen Strommer et al., “The role of restraint in fatal excited delirium,” 2020.

[181] Jennifer Valentino-DeVries, Mike McIntire, Rebecca R. Ruiz, Julie Tate, and Michael H. Keller, “How Paid Experts Help Exonerate Police After Deaths in Custody,” New York Times, Dec. 26, 2021.

[182] Eric Dexheimer and Jeremy Schwartz, “In fatal struggles with police, a controversial killer is often blamed,” Austin-American Statesman, May 27, 2017, https://www.statesman.com/story/news/investigates/2017/05/27/in-fatal-struggles-with-police-controversial-killer-is-often-blamed/8339157007.

[183] Alessandro Marazzi Sassoon, “Excited delirium: Rare and deadly syndrome or a condition to excuse deaths by police?” Florida Today, Oct. 24, 2019, https://www.floridatoday.com/in-depth/news/2019/10/24/excited-delirium-custody-deaths-gregory-edwards-melbourne-taser/2374304001.

[184] Osagie K. Obasogie, “Excited Delirium and Police Use of Force,” 2021.

[185] Ibid.

[186] Philippe Gonin et al., “Excited Delirium: A Systematic Review,” 2018.

[187] Alisa Chang, “Police Repeatedly Cite ‘Excited Delirium’ In Killings, But It Has No Real Definition,” NPR, Apr. 7, 2021, https://www.npr.org/2021/04/07/985128452/police-repeatedly-cite-excited-delirium-in-killings-but-it-has-no-real-definition.

[188] Katie Wedell, Cara Kelly, Camille McManus, and Christine Fernando, “George Floyd is not alone. ‘I can’t breathe’ uttered by dozens in fatal police holds across U.S.,” USA Today, Jun. 13, 2020, https://www.usatoday.com/in-depth/news/investigations/2020/06/13/george-floyd-not-alone-dozens-said-cant-breathe-police-holds/3137373001.

[189] See, e.g., Callwood vs. Jones et. al., 727 F. App’x at 556; Peppers v. Washington County, Tenn., 686 Fed. App’x. 328 (6th Cir. 2017); V. W. v. Nichelini, 2017 WL 34246 (E.D. CA Feb. 2, 2017); Pirolozzi v. Stanbro, F. Supp. 2d, 2009 U.S. Dist. LEXIS 42575, 2009 WL 1441070 (N.D. Ohio Mar. 13, 2009). See also Marquez v. City of Phoenix, 693 F.3d 1167 (9th Cir. 2012); Gregory v. County of Maui, 414 F. Supp. 2d 965 (D. Haw. 2006).

[190] American Medical Association, “New AMA Policy Opposes ‘ Excited Delirium ’ Diagnosis,” Jun. 14, 2021,https://www.ama-assn.org/press-center/press-releases/new-ama-policy-opposes-excited-delirium-diagnosis; American Psychiatric Association, “Position Statement on Concerns About Use of the Term ‘Excited Delirium’ and Appropriate Medical Management in Out-of-Hospital Contexts,” December 2020, https://www.psychiatry.org/File%20Library/About-APA/Organization-Documents-Policies/Policies/Position-Use-of-Term-Excited-Delirium.pdf.

[191] American College of Emergency Physicians (ACEP) Hyperactive Delirium Task Force, “ACEP Task Force Report on Hyperactive Delirium with Severe Agitation in Emergency Settings,” Jun. 23, 2021, https://www.acep.org/globalassets/new-pdfs/education/acep-task-force-report-on-hyperactive-delirium-final.pdf.

[192] Ibid.

[193] PHR, email to ACEP, Feb. 7, 2022.

[194] ACEP Associate Executive Director Sandy Schneider, email to PHR, Feb. 14, 2022.

[195] PHR, email to NAME, Feb. 7, 2022.

[196] Stephens et al., “National Association of Medical Examiners Position Paper,” 2004; R. A. Mitchell Jr., F. Diaz, G. A. Goldfogel, et al., “National Association of Medical Examiners Position Paper,” 604-618.

[197] 2022 NAME President Kathryn Pinneri, email to PHR, Feb. 10, 2022.

[198] Royce Kurmelovs, “‘Excited delirium’: how a disputed US term found its way to Australian deaths-in-custody inquests,” The Guardian, Jul. 3, 2021, https://www.theguardian.com/australia-news/2021/jul/04/excited-delirium-how-a-disputed-us-term-found-its-way-to-australian-deaths-in-custody-inquests.

[199] John Kiedrowski, Michael Petrunik, and Ronald-Frans Melchers, “An Independent Review of the Adoption and Use of Conducted Energy Weapons by the Royal Canadian Mounted Police,” Jun. 5, 2008, https://web.archive.org/web/20091231091631/http://www.rcmp-grc.gc.ca/ccaps-spcca/cew-ai/kiedrowski-report-rapport-eng.htm;  Gus Garcia-Roberts, “Is excited delirium killing coked-up, stun-gunned Miamians?” Miami New Times, Jul. 15, 2010, https://www.miaminewtimes.com/news/is-excited-delirium-killing-coked-up-stun-gunned-miamians-6367399?showFullText=true; “Report of the Panel of Mental Health and Medical Experts Review of Excited Delirium”, Jun. 30, 2009,https://novascotia.ca/just/public_safety/_docs/Excited%20Delirium%20Report.pdf.

[200] The Royal College of Pathologists, “The Use of ‘Excited Delirium’ as a Cause of Death,” Forensic Science Regulator Guidance vol. 231, no. 2: 3.

[201] Royce Kurmelovs, “‘Excited Delirium’: How a Disputed US Term Found Its Way to Australian Deaths-in-Custody Inquests,” The Guardian, Jul. 3, 2021, https://www.theguardian.com/australia-news/2021/jul/04/excited-delirium-how-a-disputed-us-term-found-its-way-to-australian-deaths-in-custody-inquests.

[202] Ibid.

[203] Commission for Public Complaints Against the Royal Canadian Mounted Police, “RCMP Use of the Conducted Energy Weapon (CEW): Interim Report,” Dec. 11, 2007, https://www.crcc-ccetp.gc.ca/pdf/InterimTaserReport.pdf.

[204] John Kiedrowski, Michael Petrunik, and Ronald-Frans Melchers, “An Independent Review of the Adoption and Use of Conducted Energy Weapons by the Royal Canadian Mounted Police,” Jun. 5, 2008, https://web.archive.org/web/20091231091631/http://www.rcmp-grc.gc.ca/ccaps-spcca/cew-ai/kiedrowski-report-rapport-eng.htm.

[205] Royal College of Emergency Medicine Independent Advisory Panel on Deaths in Custody, “Guidelines for the Management of Excited Delirium / Acute Behavioural Disturbane (ABD),” May 2016, https://rcem.ac.uk/wp-content/uploads/2021/10/RCEM_Guidelines_for_Management_of_Acute_Behavioural_Disturbance_May2016.pdf.

[206] Nazia Parveen, “‘Excited delirium’: term linked to police restraint in UK medical guide condemned,” The Guardian, Jul. 1, 2021, https://www.theguardian.com/uk-news/2021/jul/01/excited-delirium-term-linked-to-police-restraint-in-uk-medical-guide-condemned; South London and Maudsley NHS Foundation Trust, “South London and Maudsley NHS Foundation Trust categorically do not recognise ‘Acute Behavioural Disturbance’ and ‘Excited Delirium’ as syndromes or diagnoses,” Jun. 23, 2021, https://www.slam.nhs.uk/media/news/south-london-and-maudsley-nhs-foundation-trust-categorically-do-not-recognise-acute-behavioural-disturbance-and-excited-delirium-as-syndromes-or-diagnoses/.

[207] Royce Kurmelovs, “‘Excited Delirium’: How a Disputed US Term Found Its Way to Australian Deaths-in-Custody Inquests,” The Guardian, Jul. 3, 2021, https://www.theguardian.com/australia-news/2021/jul/04/excited-delirium-how-a-disputed-us-term-found-its-way-to-australian-deaths-in-custody-inquests.

[208] The Royal College of Pathologists, “The Use of ‘Excited Delirium’ as a Cause of Death,” Forensic Science Regulator Guidance vol. 231, no. 2:3.

[209] Claire Lampen, “What We Know About the Killing of Elijah McClain,”

The Cut, Sept. 1, 2021, https://www.thecut.com/2020/07/the-killing-of-elijah-mcclain-everything-we-know.html; Francie Swidler, “Elijah McClain’s death and what happened next: a timeline,” CPR News, Nov. 19, 2021, https://www.cpr.org/2021/11/19/elijah-mcclain-timeline; Ryan W. Miller, “Elijah McClain was injected with ketamine before he died. Is that legal?” USA Today, Jul. 1, 2020, https://www.usatoday.com/story/news/nation/2020/06/26/elijah-mcclain-ketamine-may-have-played-role-death-experts-say/3262785001.

[210] Allison Sherry, “The Adams County Coroner Met With Aurora Police Before Elijah McClain’s Cause Of Death Was Determined,” CPR News, Aug. 19, 2020, https://www.cpr.org/2020/08/19/elijah-mcclain-aurora-police-coroner-autopsy-report.

[211] Diane Carman, “Carman: A mother’s grief turns to long-overdue action in justice for Elijah McClain,” Colorado Sun, Sept. 5, 2021, https://coloradosun.com/2021/09/05/elijah-mcclain-aurora-police-opinion.

[212]Michael de Yoanna and Rae Solomon, “Medics In Colorado Dosed 902 People With Ketamine For ‘Excited Delirium’ In 2.5 Years,” KUNC, Jul. 21, 2020, https://www.kunc.org/news/2020-07-21/medics-in-colorado-dosed-902-people-with-ketamine-for-excited-delirium-in-2-5-years#stream/0.

[213] Josiah Hesse, “‘Weaponization of medicine’: police use of ketamine draws scrutiny after Elijah McClain’s death,” The Guardian, Dec. 17, 2021, https://www.theguardian.com/us-news/2021/dec/17/ketamine-law-enforcement-deaths-custody-elijah-mcclain; Krithika Varagur, “Minnesota Paramedic Speaks Out Against Police Use of Ketamine Injections,” The Intercept, Aug. 25, 2020, https://theintercept.com/2020/08/25/ketamine-police-use-minnesota/.

[214] American Society of Anesthesiologists, “ASA Statement on the Use of Ketamine for a Non-medical Purpose,” Jul. 15, 2020, https://www.asahq.org/about-asa/newsroom/news-releases/2020/07/asa-statement-on-the-use-of-ketamine-for-a-non-medical-purpose.

[215] Associated Press, “Officers and Paramedics are Charged in Elijah McClain’s 2019 Death in Colorado,” NPR, Sept. 1, 2021, https://www.npr.org/2021/09/01/1033289263/elijah-mcclain-death-officers-paramedics-charged.

[216] Jeremy Harlan, Lucy Kafanov, and Leslie Perrot, “Aurora, Colorado, to pay $15 million to Elijah McClain’s family to settle lawsuit over his 2019 death at the hands of police,” CNN, Nov. 19, 2021, https://www.cnn.com/2021/11/19/us/elijah-mcclain-and-aurora-police-settlement/index.html.

[217] Colorado Department of Public Health & Environment, “Final Report: Ketamine Investigatory Review Panel,” Dec. 1, 2021,  https://cdphe.colorado.gov/press-release/ketamine-review-committee-publishes-report-with-several-recommendations.

[218] In February 2022, Physicians for Human Rights interviewed Joe Prude about the death of his brother Daniel in police custody. The narrative in this section is based on that interview as well as media reports and other public records.

[219] Interview with Joe Prude, Feb. 12, 2022.

[220] Brett Dahlberg, “Rochester Hospital Released Daniel Prude Hours Before Fatal Encounter With Police,” NPR, Sept. 29, 2020, https://www.npr.org/sections/health-shots/2020/09/29/917317141/rochester-hospital-released-daniel-prude-hours-before-fatal-encounter-with-polic; Michael Wilson, ”Did This Police Maneuver Lead to Daniel Prude’s Death?” New York Times, Sept. 15, 2020, https://www.nytimes.com/2020/09/15/nyregion/daniel-prude-video-police-rochester.html; Steve Orr, “How Daniel Prude suffocated as Rochester police restrained him,” Democrat and Chronicle, Sept. 2, 2020, https://www.democratandchronicle.com/story/news/2020/09/02/daniel-prude-rochester-ny-police-died-march-2020-after-officers-restrained-him/5682948002.

[221] Interview with Joe Prude, Feb. 12, 2022.

[222] Ibid.

[223] Michael Wilson, “Did This Police Maneuver Lead to Daniel Prude’s Death?” New York Times, Sept. 15, 2020.

[224] Justin Murphy, “Doctor told grand jury that police restraint was ‘protective’ of Daniel Prude, who later died,” Democrat and Chronicle, Apr. 20, 2021, https://www.democratandchronicle.com/story/news/2021/04/20/daniel-prude-letitia-james-gary-vilke-grand-jury-restraint/7276344002/; Michael Wilson, “Did This Police Maneuver Lead to Daniel Prude’s Death?” New York Times, Sept. 15, 2020.

[225] Kim Bellware, “Daniel Prude’s death highlights dangers of ‘spit hoods’ and calls for regulation,” Washington Post, Sept. 5, 2020, https://www.washingtonpost.com/nation/2020/09/05/daniel-prude-spit-hood.

[226] New York State Office of the Attorney General, Special Investigations and Prosecutions Unit, “Report on the Investigation into the Death of Daniel Prude,” Feb. 23, 2021, https://ag.ny.gov/sites/default/files/oag_report_-_prude.pdf.

[227] Ibid.

[228] Interview with Joe Prude, Feb. 12, 2022.

[229] New York State Office of the Attorney General, Special Investigations and Prosecutions Unit, “Report on the Investigation into the Death of Daniel Prude,” Feb. 23, 2021, https://ag.ny.gov/sites/default/files/oag_report_-_prude.pdf.; Troy Closson and Ed Shanahan, “Black Man Died of Suffocation After Officers Put Hood on Him,” New York Times, Sept. 2, 2020, https://www.nytimes.com/2020/09/02/nyregion/daniel-prude-rochester-police.html.

[230] Interview with Elliot Shields, Feb. 12, 2022; Steve Orr and Justin Murphy, “Emails show Rochester officials’ attempts to conceal information about Daniel Prude’s death,” USA Today, Sept. 15, 2020, https://www.usatoday.com/story/news/nation/2020/09/15/daniel-prude-death-rochester-police-sought-delay-video-release-mayor-lovely-warren/5803252002; Evan Simko-Bednarski and Lauren del Valle, “Rochester officials intentionally delayed the release of Daniel Prude body cam video,” Sept. 16, 2020, https://www.cnn.com/2020/09/16/us/daniel-prude-rochester-emails/index.html; Michael Wilson and Edgar Sandoval, “Documents Reveal How the Police Kept Daniel Prude’s Death Quiet,” New York Times, Sept. 15, 2020, https://www.nytimes.com/2020/09/15/nyregion/rochester-police-daniel-prude.html.

[231] Ibid.

[232] “NY attorney general empanels grand jury in Daniel Prude case,” Associated Press, Sept. 5, 2020, https://www.wkbw.com/news/national/ny-attorney-general-empanels-grand-jury-in-daniel-prude-case; New York State Office of the Attorney General, “AG James Update on Prude Investigation: Moves to Empanel Grand Jury,” Press Release, Sept. 5, 2020, https://ag.ny.gov/press-release/2020/ag-james-update-prude-investigation-moves-empanel-grand-jury.

[233] Justin Murphy and Gary Craig, “Did AG’s choice ‘guarantee the outcome’? Expert in Prude grand jury draws scrutiny,” Democrat and Chronicle, Feb. 26, 2021, https://www.democratandchronicle.com/story/news/2021/02/26/excited-delirium-gary-vilke-letitia-james-daniel-prude-grand-jury-rochester-police-not-indicted/6813354002.

[234] Karen Pallarito, “Police Used a ‘Spit Hood’ While Arresting a Man Who Later Died of Asphyxiation—Here’s What That Is,” Health, Sept. 3, 2020, https://www.health.com/mind-body/health-diversity-inclusion/what-is-spit-hood-daniel-prude; Brandon Lowrey, “Amid Deadly Arrests, ‘Delirium’ Diagnosis Draws New Scrutiny,” Law360, Oct. 18, 2020, https://www.law360.com/articles/1320187/amid-deadly-arrests-delirium-diagnosis-draws-new-scrutiny.

[235] State of New York, “Day 5: Investigation into the death of Daniel T. Prude,” Transcript of the Proceedings held before the Monroe County Grand Jury, Dec. 16, 2020, https://ag.ny.gov/sites/default/files/session_five_-_december_16_2020.pdf.

[236] Justin Murphy and Gary Craig, “Did AG’s choice ‘guarantee the outcome’? Expert in Prude grand jury draws scrutiny,” Democrat and Chronicle, Feb. 26, 2021.

[237] Interview with Joe Prude, Feb. 12, 2022.

[238] New York State Office of the Attorney General, Special Investigations and Prosecutions Unit, “Report on the Investigation into the Death of Daniel Prude,” Feb. 23, 2021, https://ag.ny.gov/sites/default/files/oag_report_-_prude.pdf.

[239] Ibid.

[240] Justin Murphy and Gary Craig, “Did AG’s choice ‘guarantee the outcome’? Expert in Prude grand jury draws scrutiny,” Democrat and Chronicle, Feb. 26, 2021.

[241] New York State Office of the Attorney General, Special Investigations and Prosecutions Unit, “Report on the Investigation into the Death of Troy Hodge, Mar. 19, 2021, https://ag.ny.gov/sites/default/files/oag_report_-_hodge.pdf.

[242] Ibid.

[243] Ibid.

[244] Interview with Robert Collins, Bella Quinto-Collins, and Cassandra Quinto-Collins, Oct. 29, 2021.

[245] Ibid.

[246] Ibid. See also, John L. Burris, Ayana C. Curry, Ben Nisenbaum, Dewitt M. Lacy, James A. Cook, Kenneth Chike Odiwe, and Tonia Robinson. Law Offices of John L. Burris, “RE: Request for Endorsed Copy Verifying Administrative Claim Received – Law Offices of John L. Burris,” Feb. 18, 2021, https://johnburrislaw.com/Quinto-Claim.pdf; Jacey Fortin, “California Man Died after Police Knelt on Him for 5 Minutes, Family Says,” New York Times, Feb. 25, 2021, https://www.nytimes.com/2021/02/25/us/angelo-quinto-death-police-kneel.html; Claire Wang, “The Filipino American Family behind Calif.’s New Police Reform Laws Speaks Out,” NBC News, Oct. 15, 2021, https://www.nbcnews.com/news/asian-america/filipino-american-family-califs-new-police-reform-laws-speaks-rcna3030.

[247] Ibid.

[248] John Burris Law Offices, “Video of Angelo Quinto Incident,” YouTube, Feb. 18, 2021, https://www.youtube.com/watch?v=eB_tR-V9X-M.

[249] Interview with Robert Collins, Bella Quinto-Collins, and Cassandra Quinto-Collins, Oct. 29, 2021.

[250] Ibid.

[251] Ibid.

[252] John Burris Law Offices, “Video of Angelo Quinto Incident,” Feb. 18, 2021.

[253] Interview with Robert Collins, Bella Quinto-Collins, and Cassandra Quinto-Collins, Oct. 29, 2021.

[254] Ibid.

[255] Ibid.

[256] Ibid.

[257] Nate Gartrell and Rick Hurd, “Death of Angelo Quinto, Navy Vet Who Died after Struggle with Antioch Cops, Blamed on ‘Excited Delirium.’”

[258] Interview with Robert Collins, Bella Quinto-Collins, and Cassandra Quinto-Collins, Oct. 29, 2021.

[259] Ibid.

[260] Ibid.

[261] Claire Wang, “The Filipino American family behind Calif.’s new police reform laws speaks out,” NBC News, October 15, 2020https://www.nbcnews.com/news/asian-america/filipino-american-family-califs-new-police-reform-laws-speaks-rcna3030.

[262] Interviews with Pollanen, Sept. 20, 2021; Strote, Sept. 15, 2021; Carter, Sept. 23, 2021, among others.

[263] Interview with Pollanen, Sept. 20, 2021.

[264] Interview with Carter, Sept. 23, 2021.

[265] Ibid.

[266] Ibid.

[267] Ibid.

[268] Interview with Mitchell, Oct. 29, 2021.

[269] Interview with Freeman, Sept. 8, 2021; Risso, Oct. 5, 2021.

[270] Interview with Mitchell, Oct. 29, 2021.

[271] Interview with Baden, Oct. 7, 2021.

[272] Interview with Chenevert, Oct. 25, 2021.

[273] Eric Balaban, “How officials use a dubious medical condition to explain stun gun deaths,” The Guardian, Sept. 17, 2015, https://www.theguardian.com/commentisfree/2015/sep/17/dubious-medical-condition-stun-gun-deaths; Tim Reid and Paula Seligson, “Taser’s defense tactics include lawsuits against coroners and experts,” Reuters, Aug. 24, 2017, https://www.reuters.com/article/us-usa-taser-strikeback/tasers-defense-tactics-include-lawsuits-against-coroners-and-experts-idUSKCN1B4182.

[274] Interview with Carter, Sept. 23, 2021.

[275] Interview with Melinek, Sept. 16, 2021.

[276] Interview with Freeman, Sept. 8, 2021.

[277] Ibid.

[278] Interview with Cunningham, Sept. 16, 2021.

[279] Interview with Pollanen, Sept. 20, 2021.

[280] Interview with Freeman, Sept. 8, 2021.

[281] Interviews with Strote, Sept. 15, 2021; Cunningham, Sept. 16, 2021; Pollanen, Sept. 20, 2021.

[282] Interview with. Pollanen, Sept. 20, 2021.

[283] Ibid.

[284] Interviews with Melinek, Sept. 16, 2021; Risso, Oct. 5, 2021.

[285] Interview with Chenevert, Oct. 25, 2021.

[286] Interviews with Freeman, Sept. 8, 2021; Cunningham, Sept. 16, 2021; Pollanen, Sept. 20, 2021; Mitchell, Oct. 29, 2021.

[287] Interview with Cunningham, Sept. 16, 2021.

[288] Interview with Pollanen, Sept. 20, 2021.

[289] Interview with Mitchell, Oct. 29, 2021.

[290] Interviews with Mitchell, Oct. 29, 2021; Freeman, Sept. 8, 2021.

[291] Interview with Mitchell, Oct. 29, 2021.

[292] Interviews with Cunningham, Sept. 16, 2021; Martinez, Sept. 20, 2021; Baden, Oct. 7, 2021; Mitchell, Oct. 29, 2021.

[293] Interview with Risso, Oct. 5, 2021.

[294] Interview with Martinez, Sept. 20, 2021.

[295] Interview with Cunningham, Sept. 16, 2021.

[296] Interview with Mitchell, Oct. 29, 2021.

[297] Interview with Carter, Sept. 23, 2021.

[298] Interview with Freeman, Sept. 8, 2021.

[299] Ibid.

[300] Interview with Cunningham, Sept. 16, 2021.

[301] Interview with Carter, Sept. 23, 2021.

[302] Interview with Freeman, Sept. 8, 2021.

[303] Interview with Strote, Sept. 15, 2021.

[304] Interview with Mitchell, Oct. 29, 2021.

[305] Interview with Freeman, Sept. 8, 2021.

[306] Interview with Strote, Sept. 15, 2021.

[307] Interview with Baden, Oct. 7, 2021.

[308] Interview with Strote, Sept. 15, 2021.

[309] Interview with Melinek, Sept. 16, 2021.

[310] Interview with Ryan, Sept. 23, 2021.

[311] Ibid.

[312] Ibid.

[313] Ibid.

[314] Interview with Galipo, Sept. 27, 2021.

[315] Interview with Davy, Sept. 9, 2021.

[316] Joanne Zuhl, “Wyden takes Oregon street response model nationwide,” Street Roots, May 5, 2021, https://www.streetroots.org/news/2021/05/05/wyden-takes-oregon-street-response-model-nationwide.

[317] Interview with Sue, Oct. 14, 2021.

[318] Interview with Hancq, Oct. 7, 2021.

[319] Interview with Muhammad, Oct. 12, 2021.

[320] Lisa Dailey et al., “Grading the States: An Analysis of U.S. Psychiatric Treatment Laws,” Treatment Advocacy Center, Sept. 2020, https://www.treatmentadvocacycenter.org/storage/documents/grading-the-states.pdf; Sabah Muhammad, “Daniel Prude’s death is a nightmare scenario for Black families like mine,” Washington Post, Sept. 7, 2020, https://www.washingtonpost.com/opinions/2020/09/07/daniel-prude-death-policing-mental-illness.

[321] Interview with Muhammad, Oct. 12, 2021.

[322] Interview with Hancq, Oct. 7, 2021.

[323] Interview with Muhammad, Oct. 12, 2021.

[324] Ibid.

[325] Ibid.

[326] Interview with Black, Dec. 8, 2021.

[327] Ibid.

[328] Interview with Burek, Dec. 16, 2021.

[329] Interview with Black, Dec. 8, 2021.

[330] For this report, PHR’s legal team conducted an in-house review of legal cases. For a comprehensive review of law and legal scholarship on “excited delirium,” see Osagie K. Obasogie, “Excited Delirium and Police Use of Force,” 2021. Professor Obasogie performed a Lexis search for all federal court cases with the terms “1983” and “excited delirium.” He obtained 262 results, of which 195 qualified for the sample. He found, “89 of the 195 rulings (45.6%) contain language where the court, in its own voice, affirmatively asserted that excited delirium is a scientifically valid condition. … Fifty-four cases included this type of discussion [concerning whether or not law enforcement acted reasonably under the Fourth Amendment in restraining someone with this condition], where excited delirium was discussed in a manner that favored the police in twenty-three (almost half) of these cases. … there are twenty-two rulings in the sample where the court said that the presence of excited delirium requires an arresting officer to use more care or less force. … Thirty-seven cases in the sample that we reviewed involved claims regarding the deliberate indifference to medical need, in which thirty-three (89.1%) resulted in one or more defendants being found not liable.” He said his study, “highlights the malleable nature in which excited delirium is wielded by federal courts. In short, law enforcement is allowed to have their cake and eat it too. Excited delirium: (1) can be treated as a real entity that justifies the use of force that might be deadly; (2) can be questioned as a real disorder and therefore relieve officers of any duty to treat; and (3) can be used to shield officers from being held accountable for their actions, due to claims of officers’ inability to fully observe excited delirium’s full manifestations (yet nonetheless participate in questionable uses of force).”

[331] Mann v. Taser Int’l., Inc., 588 F.3d 1291, 1299 (11th Cir. 2009).

[332] Hoyt v. Cooks, et al., 672 F.3d 972, 976 (11th Cir. 2012).

[333] Goode v. Baggett, 811 F. App’x 227 (5th Cir. 2020).

[334] See e.g., Callwood v. Jones et. al., 727 F. App’x 552 (11th Cir. 2018); Hoyt v. Cooks, et al., 672 F.3d at 976; Batiste v. Theriot et. al., 458 F. App’x 351 (5th Cir. 2012).

[335] Davidson v. City of Statesville, 2012 WL 1441406, at *5 (W.D.N.C. 2012).

[336] Hoyt v. Cooks, et al., 672 F.3d at 976.

[337] Federal Rule of Evidence 702, which has been adopted by many states, governs the admissibility of expert testimony in federal courts. This rule followed a decision by the U.S. Supreme Court holding that trial courts are to perform a “gatekeeper” function regarding the admissibility of expert testimony. Daubert v. Merrell Dow Pharms., Inc., 509 U.S. 579, 589 (1993).

[338] Daubert. 509 U.S. at 593-594. For applications of the Daubert test to the admission of medical expert testimony on “excited delirium,” see, e.g., Galack v. PTS of Am., LLC, 2015 WL 5692327, *18 (N.D. Ga. 2015); Estate of Barnwell v. Roane City, 2016 WL 1457928, at *3-4 (E.D. Tenn. Apr. 12, 2016).

[339] Estate of Barnwell v. Roane City, 2016 WL 1457928, at *3.

[340] Mann v. Taser Int’l., Inc., 588 F.3d at 976; Estate of Barnwell v. Roane City, 2016 WL 1457928, at *3.

[341] See, e.g., Davidson v. City of Statesville, 2012 WL 1441406, at *10, *14 discussing the North Carolina Basic Law Enforcement Training Program training which includes “the recognition of the symptoms of excited delirium syndrome”; Carrier v. Mcknight,  2017 WL 2533529, at *8 (W.D. Tex. 2017), discussing Williamson County’s “Excited Delirium protocol”; Woodward v. City of Gallatin, 2013 WL 6092224, at *6-*7 (M.D. Tenn. Nov. 19, 2013) referring to “excited delirium” as part of TASER certification and recertification training.

[342] Silva v. Chung, 2019 WL 2195201, at *3; Estate of Barnwell v. Roane City, 2016 WL 1457928, at *3.

[343] Silva v. Chung, 2019 WL 2195201, at *3; Todero v. Blackwell, supra, 2021 U.S. Dist. LEXIS 188141, *5.

[344] Todero v. Blackwell, 2021 WL 4472550, at *2.

[345] Mann v. Taser Int’l., Inc., 588 F.3d 1291.

[346] Silva v. Chung, 2019 WL 2195201, at *2 (D. Haw. Feb. 5, 2020); Todero v. Blackwell, 2021 WL 4472550, at *2 (S.D. Ind. Oct. 7, 2021).

[347] See, e.g., Callwood vs. Jones et. al., 727 F. App’x at 556.

[348] Peppers v. Washington County, Tenn., 686 Fed. App’x. 328 (6th Cir. 2017); V. W. v. Nichelini, 2017 WL 34246 (E.D. CA Feb. 2, 2017); Pirolozzi v. Stanbro, F. Supp. 2d, 2009 U.S. Dist. LEXIS 42575, 2009 WL 1441070 (N.D. Ohio Mar. 13, 2009). See also Marquez v. City of Phoenix, 693 F.3d 1167 (9th Cir. 2012); Gregory v. County of Maui, 414 F. Supp. 2d 965 (D. Haw. 2006).

[349] See Mann v. Taser, 588 F.3d 1291; Davidson v. City of Statesville, 2012 WL 1441406; Cook v. Bastin, 590 F. App’x 523 (6th Cir. 2014); Mingo v. City of Mobile, 592 F. App’x 793 (11th Cir. 2014).

[350] Hoyt v. Cooks, et al., 672 F.3d at 976.

[351] A recent example is Estate of Aguirre v. City of San Antonio, 995 F.3d 395 (5th Cir. 2021). In Aguirre, the decedent was handcuffed and not resisting as officers forced him into a prone position with his legs crossed and pressed against his buttocks, similar to a hog-tie. Officers then put their weight on Mr. Aguirre’s back, buttocks, and neck for five and a half minutes until they noticed he had stopped breathing. One officer even noted that Mr. Aguirre’s lips turned blue, raising concern for hypoxia, and she decided it was because of drugs he was suspected of having consumed. 995 F.3d at 403-404. The autopsy found that Mr. Aguirre died of asphyxiation “[d]ue to the restraint by police,” and his death was classified as a homicide. 995 F.3d AT 404. The plaintiffs in Aguirre then introduced “excited delirium” into the case, criticizing the defendant officers for not following their training and properly managing the decedent’s claimed “excited delirium.” 995 F.3d AT 404. The district court granted qualified immunity to the officers on the plaintiff’s claims against them and also dismissed the claim against the city for constitutionally inadequate training. Ibid. The Fifth Circuit Court of Appeals reversed the grant of qualified immunity, but extensively relied on the “excited delirium” evidence submitted by the plaintiff, adding credence to this unscientific theory. Ibid. At 405, 413 n 10.

[352] Petro v. Town of West Warwick, 889 F. Supp. 2d 292 (D.R.I. 2012).

[353] Estate of Hezekiah Harvey v. Roanoke City Sheriff’s Office, 2007 BL 184012, at *5 (W.D. Va. Feb. 23, 2007).

[354] Ibid.

[355] Brief of Cross-Ideological Groups Dedicated to Ensuring the Public’s Trust in Law Enforcement, and Promoting the Rule of Law as Amici Curiae in Support of Petitioner at 5, Taylor v. Riojas, 141 S. Ct. 52 (2020), https://www.supremecourt.gov/DocketPDF/19/19-1261/143596/20200514193421509_Taylor%20v.%20Riojas%20cross-ideological%20brief.pdf.

[356] United Nations, “Universal Declaration of Human Rights (UDHR),” G.A. Res. 217A (III) at 71, art. 3, U.N. GAOR, 3d Sess., 1^st plen. Mtg., U.N. Doc. A/810 (Dec. 12, 1948) https://www.un.org/en/about-us/universal-declaration-of-human-rights.

[357] United Nations, “International Covenant on Civil and Political Rights (ICCPR),” Treaty Series vol. 999, (Dec. 16, 1966):171, art. 6, https://www.ohchr.org/en/professionalinterest/pages/ccpr.aspx.

[358] UDHR, art. 7; ICCPR, art. 26.

[359] United Nations, “International Convention on the Elimination of All Forms of Racial Discrimination (ICERD),” G.A. res. 2106 (XX), Annex, 20 U.N. GAOR Supp. (no. 14) at 47, art. 5, U.N. Doc. A/6014, 660 U.N.T.S. 195, (1966), entered into force Jan. 4, 1969, https://www.ohchr.org/en/professionalinterest/pages/cerd.aspx.

[360] United Nations, “International Convention on the Protection and Promotion of the Rights and Dignity of Persons with Disabilities (CRPD),”art. 10, G.A. Res. 61/106, (Dec. 13, 2006), https://www.un.org/development/desa/disabilities/convention-on-the-rights-of-persons-with-disabilities.html.

[361] United Nations, “United Nations Human Rights Committee, General Comment No. 36, Art. 6: right to life,” CCPR/C/GC/36 (Sept. 3, 2019) https://tbinternet.ohchr.org/_layouts/15/treatybodyexternal/Download.aspx?symbolno=CCPR/C/GC/36&Lang=en.

[362] United Nations, “UN Basic Principles on the Use of Force and Firearms by Law Enforcement Officials,” adopted by the Eighth United Nations Congress on the Prevention of Crime and the Treatment of Offenders, Havana, Cuba, (Aug. 27-Sept. 7, 1990), https://www.ohchr.org/en/professionalinterest/pages/useofforceandfirearms.aspx.

[363] Ibid., par. 5(c).

[364] Ibid.

[365] United Nations, “International Covenant on Economic, Social and Cultural Rights (ICESCR),” United Nations Treaty Series vol. 993, no.3, art. 12, (Dec. 16, 1966), https://www.ohchr.org/documents/professionalinterest/cescr.pdf.

[366] United Nations General Assembly, “Principles for the protection of persons with mental illness and the improvement of mental health care,” art. 2, G.A. res. 46/119, (Dec. 17, 1991), https://www.ohchr.org/EN/ProfessionalInterest/Pages/PersonsWithMentalIllness.aspx.

[367] ICERD, art. 5.

[368] CRPD, art 25.

[369] United Nations, “Principles on the Effective Prevention and Investigation of Extra-legal, Arbitrary and Summary Executions,” arts. 1 and 9, res. 1989/65, (May 24, 1989), https://www.ohchr.org/Documents/ProfessionalInterest/executions.pdf

[370] Office of the United Nations High Commissioner for Human Rights, The Minnesota Protocol on the Investigation of Potentially Unlawful Death (2016) (New York/Geneva: United Nations, 2017), https://www.ohchr.org/Documents/Publications/MinnesotaProtocol.pdf.

[371] Ibid.

[372] UDHR, art. 8; ICCPR, art. 2; ICERD art. 6. See also, UN Special Rapporteur on extrajudicial, summary or arbitrary executions, “International standards,” https://www.ohchr.org/EN/Issues/Executions/Pages/InternationalStandards.aspx; International Commission of Jurists, The Right to a Remedy and Reparation for Gross Human Rights Violations: A Practitioners’ Guide (Geneva: United Nations, October 2018), https://www.icj.org/wp-content/uploads/2018/11/Universal-Right-to-a-Remedy-Publications-Reports-Practitioners-Guides-2018-ENG.pdf