Requirements for certain groups of people to be vaccinated against COVID-19, known as vaccine “mandates,” have generated significant debate, including in institutions of higher education and health care settings in the United States. More mandates are likely to be instituted in the United States as vaccine manufacturers seek full approval from the Food and Drug Administration, virus variants drive surges, and vaccination rates plateau. We outline below six key points to consider when determining the human rights implications of COVID-19 vaccine mandates. These perspectives allude to the U.S. context, but many are applicable globally as vaccines become more widely available.

1. There is strong legal grounding in the United States for vaccine mandates in public and private settings.

Vaccine mandates have a long history as an important tool to ensure the public’s health. In the context of COVID-19, the question is less whether mandates can legally be instituted and more how they can be ethically and equitably structured to protect human rights.  

2. Mandates can be ethical and rights-respecting if availability, accessibility, and acceptability of high-quality vaccines are widespread and equitable.

Any entity contemplating a mandate must ensure that all people subject to the mandate can receive vaccination according to the four pillars of the right-to-health framework: Availability, Accessibility, Acceptability, and Quality (AAAQ). Steps that must be taken to adhere to the AAAQ framework for people subject to a COVID-19 vaccine mandate include:

• the opportunity to receive culturally sensitive, free, accurate, and detailed information from trusted sources in their preferred language to address vaccine-related concerns;
  • the option to receive free vaccination at a time that works for their schedule;
  • the offer of free childcare to facilitate receiving the vaccine and for any needed recovery time;
  • free transportation to a vaccination site; and
  • the guarantee of paid time off (where applicable) to receive the vaccine and to recover from any vaccine-related side effects.

3. Any entity instituting a mandate must provide reasonable accommodation for people for whom vaccination is not advisable.

Some people cannot receive vaccination for religious or medical reasons (e.g., allergic reactions to vaccine contents or specific underlying health conditions). These people must be offered alternative transmission mitigation strategies, such as regular COVID-19 testing and mask-wearing, and should not suffer any consequences from being unable to meet a vaccine mandate.

4. Mandates should never apply to people who are in detention.

People who are detained should be offered vaccines and provided accurate information from trusted sources to answer their vaccine-related questions, but vaccines should never be mandated for them while in detention, nor as a condition of their release. The disparate power dynamic for people in detention creates an inherently coercive situation in which mandating vaccination would be a clear rights violation. Anyone vaccinated in detention must be provided with their complete medical and vaccination records upon transfer or release to facilitate their ability to meet future proof-of-vaccination requirements.

5. People who have received vaccines that have been approved by the World Health Organization (WHO) should be considered to have satisfied any vaccine mandate.

Entities instituting mandates should accept all vaccines authorized for use by the WHO, even if the vaccine has not been approved by the country’s own regulatory body. An entity could offer an available higher-efficacy vaccine to people subject to its mandate who have previously received a lower-efficacy vaccine, provided that mixing vaccines is endorsed by medical and public health authorities. However, people in this situation should not be required to accept the offer to meet the mandate.

6. Any vaccine mandate should be reevaluated regularly as the circumstances of the pandemic evolve.

By observing the above points, mandates can respect rights while helping advance population health. But mandates should not remain in place longer than needed. As stated by the WHO, any mandate should be periodically revisited to “ensure it remains necessary and proportionate to achieve public health goals,” particularly in the rapidly evolving context of the COVID-19 pandemic.

Syria remains one of the world’s most complex humanitarian emergencies. Ten years of violence have resulted in more than 500,000 casualties, triggered one of the worst displacement crises of our time, and led to the widespread destruction of civilian infrastructure. Homes, schools, and health facilities have not been spared, and people have been deprived of essential services such as clean water and electricity. Despite the cessation of hostilities in many areas, the situation remains dire and is only worsening.

Few issues account more for the horrific toll of the violence in Syria than the impact of the conflict on health and access to health care. According to the United Nations, while 41 percent of Syrians suffer from non-communicable diseases, barely half of hospitals and primary health care centers in Syria are fully functional.

To avert an even greater humanitarian catastrophe in Syria, the Security Council must not only act to renew authorization for the existing Bab al-Hawa cross-border crossing, but also re-open two previously authorized crossings to ensure greater and urgently needed humanitarian access.

As the United Nations Special Rapporteur on the right to health, my responsibility is to assess the situation of this right throughout the world and contribute to its full enjoyment by all. The enjoyment of the right to health including the right of access to health facilities, goods, and services on a non-discriminatory basis under international human rights law as well as the norms on the protection of the wounded and the protection of medical facilities and personnel, which have been systematically violated throughout the conflict. Attacks on medical facilities, the killing and intimidation of medical personnel and obstruction of access to communities in need has decimated the health care system in Syria for a decade.

On July 10, Syria’s lone remaining UN-sanctioned international cross-border aid opening – through which life-saving medical and humanitarian supplies flows to civilians in dire need – is at risk of being closed, as a UN Security Council resolution permitting the crossing expires. To avert an even greater humanitarian catastrophe in Syria, the Security Council must not only act to renew authorization for the existing Bab al-Hawa cross-border crossing, but also re-open two previously authorized crossings to ensure greater and urgently needed humanitarian access.

Despite the potentially catastrophic consequences, ongoing negotiations suggest that the Security Council will only re-authorize the lone existing channel rather than re-open the two previously closed crossings. And stunningly, the Security Council may only opt to extend authorization for the Bab al-Hawa crossing for a meager six months instead of the 12 months sought by many Syrian civilians, international aid groups, and some Member States. If only extended for six months, this would represent a callous and disastrous prioritization of political points over people’s lives in Syria.

The situation for women and girls is particularly dire. Since December 2019, 618,000 women and girls have been displaced due to ongoing hostilities, making their access to reproductive and other healthcare limited or impossible. Pregnant women may face unsafe procedures and even death due to complications if there are no hospitals nearby.

Since the beginning of the conflict, Physicians for Human Rights has documented 600 attacks affecting at least 350 medical facilities, as well as the killing of 930 medical personnel. These incidents, many of which may constitute violations of International Humanitarian Law, have devastated the capacity of the health system and deterred civilians from seeking health care. In March, the International Rescue Committee, together with the Syrian American Medical Society, released a report which found that 81 percent of Syrian health workers had a co-worker or patient who had been injured or killed due to an attack and 59 percent of civilians interviewed had been directly impacted by one during the course of the conflict.

Since the beginning of the conflict, Physicians for Human Rights has documented 600 attacks affecting at least 350 medical facilities, as well as the killing of 930 medical personnel.

The ongoing COVID-19 pandemic has further exacerbated the strain on the health system. Hospitals have been overwhelmed throughout the country, and there are ongoing shortages of PPE, ventilators, oxygen, and testing supplies. A vaccination campaign recently began and will expand in the coming months, making the need to increase the capacity of the health system even more important.

Despite the overwhelming humanitarian needs, the UN, NGOs, and their partners continue to provide lifesaving care to 4 million civilians in need in Northwest Syria. United Nations heads of agency have stated that a large-scale UN cross-border response for an additional 12 months remains essential to avert a humanitarian catastrophe in northwest Syria. This resolution is a vital lifeline and is critical that it not only be renewed, but also expanded based on the humanitarian needs on the ground.

The closure of Yarubiyah border crossing into North Eastern Syria in January 2020 provides a window into what can be expected in other parts of Syria if the remaining crossing is closed, where medical supplies became even scarcer, and malnutrition rose. Overcrowded hospitals that struggle to provide care, rising malnutrition, no available post-rape treatment kits for survivors of sexual violence – these all characterize the current, and future, Syria, in the absence of continued humanitarian access.

The Security Council must urgently renew the authorization for Bab al-Hawa crossing in Northwest Syria for 12 months  – not six – and, given the humanitarian needs on the ground, reopen the Bab al-Salam and Yarubiyah crossings. Greater humanitarian access is essential for providing life-saving humanitarian aid and increase the provision of COVID-19 vaccines. I further urge the continued engagement with all concerned parties to allow for cross-line aid convoys, which passes from Government of Syria-held territory into non-Government of Syria-held territory in the Northwest, while noting, as the UN has, that these convoys could not replicate the size and scope of the cross border operation.

Syrian people must remain our priority.  For this, I urge the Security Council to renew the resolution and re-open the two previous crossings.  Syrian civilians’ rights to enjoy the right to health, to have unhindered access to life-saving health-care and to live free from violence has been egregiously violated for more than a decade – the Security Council must not fail them again.

As the COVID-19 vaccine rollout continues and a renewed sense of normalcy is beginning to be restored in many places in the United States, a human rights crisis remains at the U.S. southern border: hundreds of thousands of people fleeing persecution in their home countries are being turned away without being allowed their legal right to seek asylum.

This high volume of expulsions is due to a Trump-era order based on U.S. Code Title 42, which uses public health grounds to authorize the U.S. government to immediately turn away and expel people seeking asylum at the border. In March 2020, at the start of the COVID-19 pandemic, the Trump administration imposed the Title 42 order as a way to deter immigration into the United States, despite objections from senior officials at the Centers for Disease Control and Prevention and criticism from medical experts.

“Title 42 was a public health law – it was never meant to authorize expulsions.”

Lee Gelernt

Despite assumptions that the Biden Administration would restore asylum at the border and cease to violate the human rights of people seeking refuge, the Title 42 expulsion order continues. To date, only an exemption for unaccompanied children, and a few other vulnerable groups, has been made. Between March 2020 and January 2021, more than 500,000 refugees and asylum seekers were expelled from the United States without access to due process, including more than 18,000 unaccompanied minors as young as four years of age. Meanwhile, the United States remains open to other international travelers.

The impact of the Title 42 order was the subject of an expert discussion in Physicians for Human Rights’ (PHR) webinar series on the health and human rights dimensions of COVID-19. The discussion was moderated by Amy Cohen, MD, a mental health and child welfare consultant to attorneys monitoring detention facilities, executive director of Every Last One, and member of PHR’s Asylum Network. Panelists included: Cynthia Pompa, PHR’s Asylum Program officer; Dr. Hannah Janeway, International and Domestic Health Equity and Leadership Fellow at the University of California, founder and co-director of Refugee Health Alliance, and an attending physician at UCLA-Olive View Medical Center and White Memorial Medical Center; Lee Gelernt, deputy director of the ACLU’s Immigrant Rights Project and Linda Rivas, JD, executive director and managing attorney of Las Americas Immigrant Advocacy Center.

Watch the discussion here:

Asylum-Seekers Impacted by Inhumane Border Practices

During the webinar, panelists reflected on the health consequences and human rights implications of the Title 42 order, the Biden administration’s lack of action to repeal it, and steps necessary to protect refugees and asylum seekers during the COVID-19 pandemic.

“Title 42 was a public health law – it was never meant to authorize expulsions,” said ACLU civil rights attorney Lee Gelernt, pointing out that the policy violates international and U.S. law. “It has never in its history throughout the worst pandemics ever been used to send people back…. Even if it could somehow be construed to authorize deportation, it cannot override asylum laws.”

In many instances…asylum seekers and their families who are being expelled from the United States are lied to about their whereabouts and suddenly find themselves being forced back over the international bridge into Mexican border towns, leaving them even more vulnerable and exposed to violence.

Panelists addressed the harm of turning people back from the border, citing the harrowing experiences that drive people and families to seek refuge in the United States in the first place. Many of these cases have been extensively documented by PHR, including the stories of individuals fleeing gang and domestic violence.

“The stories that I heard in 2019 are the same that I hear today,” said PHR Asylum Program officer Cynthia Pompa. She described what she has heard throughout the years documenting human rights abuses among asylum seekers, “‘I’ve been persecuted for being a trans person,’ or ‘for being a woman’; ‘my child was being harassed daily if they didn’t join a gang’ or ‘the gang demanded money regularly or they would kill my family.’”

The panel also emphasized the inhumane and deceptive tactics being used by the U.S. Customs and Border Protection agents, including Border Patrol. In many instances, for example, asylum seekers and their families who are being expelled from the United States are lied to about their whereabouts and suddenly find themselves being forced back over the international bridge into Mexican border towns, leaving them even more vulnerable and exposed to violence.

Despite widespread acknowledgement from civil society and public health officials that the Trump administration was using specious public health arguments cloaked in Title 42 as a way to close the border to asylum seekers, the Biden administration did not make its repeal an early priority.

“We’re still seeing a lot of cruelty. On the ground, by DHS [Department of Homeland Security] – we’re seeing these families essentially being lied to,” said Linda Riyas. “It almost feels like the Border Patrol didn’t throw away their script from MPP.” Implemented by the Trump administration in 2019, the Migrant Protection Protocols (MPP), also known as the “Remain in Mexico” policy, forced asylum seekers to wait in dangerous Mexican border towns while their cases were pending review in U.S. immigration courts. Not only was this legislation cruel, but it was also in violation of U.S. and international law. MPP was terminated on June 1, 2021, following an executive order by President Biden.

However, despite widespread acknowledgement from civil society and public health officials that the Trump administration was using specious public health arguments cloaked in Title 42 as a way to close the border to asylum seekers, the Biden administration did not make its repeal an early priority. Due to public pressure and litigation efforts, the federal government has indicated a willingness to review this policy but has not provided details.

PHR has been working in partnership with a broad coalition that is actively campaigning to repeal the Title 42 expulsion policy, elevating the voices of those impacted and pushing for humane asylum laws to be restored. Please, join us today to demand an immediate end to Title 42 border expulsions and protect the right to seek asylum at the U.S. border. As the United States continues to reopen after the pandemic, it is imperative that the Title 42 expulsion order be seen for what it is: a cruel and illegal measure using public health grounds to further harsh Trump-era immigration policies.

On President Biden’s 100th day in office, Nilson Barahona-Marriaga joined demonstrators who greeted the president at a rally in Atlanta. “End detention now!” they chanted. “Communities are afraid!”

A 39-year-old immigrant from Honduras, Nilson had been recently released from Immigration and Customs Enforcement’s (ICE) Irwin County Detention Center in Ocilla, Georgia. The Irwin detention center, which remains open despite the Biden administration’s promise to end its contract with the facility, had most recently gained attention due to multiple allegations of involuntary hysterectomies performed on women at the facility.

When Nilson was detained at Irwin last year, he learned through his lawyer that coronavirus was present at the facility. ICE officials had failed to alert or protect staff and detainees. Facility staff regularly failed to wear masks and ensure disinfection.

Out of desperation, Nilson participated in a hunger strike with other detainees. Their group made common-sense demands that ICE follow public health guidelines, provide them with masks and cleaning supplies, and release medically vulnerable people from detention. Instead, facility officials threw Nilson and his fellow hunger strikers in solitary confinement. ICE cut off the water in their cells, so they could not drink, wash, or flush the toilets. Officials also restricted Nilson’s communications with his lawyer and family. Only nine days later, when Nilson realized that a person detained in the room next to his had COVID-19, did he end his hunger strike.

In the last year, hundreds of detained immigrants like Nilson have participated in a growing number of hunger strikes nationwide, seeking protection from COVID-19. ICE officials and detention staff have met these hunger strikes — protected speech under the First Amendment — with extreme measures, including increased use of force such as pepper spray, physical force, and rubber bullets. Today, detained immigrants are currently on hunger strike for the same reason at a number of facilities, including the Northwest Detention Center in Tacoma, Washington, and Bergen County Jail in New Jersey. After several months of declines,  ICE has again begun to increase the number of detained people in custody. COVID-19 cases in ICE detention are again on the rise.

Our new report, Behind Closed Doors: Abuse and Retaliation Against Hunger Strikers in U.S. Immigration Detention, by the ACLU and Physicians for Human Rights, reveals that the scope and scale of ICE’s cruelty in response to such hunger strikes is much broader than previously known. Based on an assessment of over 10,000 pages of previously disclosed documents, the report analyzes hundreds of hunger strikes in ICE detention from 2013 to 2017, as well as the testimony of recent hunger strikers. The report finds that abuse and retaliation against hunger strikers is commonplace and dates back to President Biden’s time as vice president. ICE has responded to hunger strikes with involuntary medical procedures, solitary confinement, retaliatory deportation and transfer, and use of force — responses which are in violation of constitutional protections, international human rights law, and medical ethics.

Our report also shines a light on the many forms of day-to-day psychological coercion ICE employs to try to break hunger strikes, including denying access to basic privileges, restricting water access, and threatening prosecution.

Rather than safeguarding their patients’ health, medical professionals played a disturbing role in these abuses. During an August 2016 hunger strike of 22 mothers at the Berks County family detention center in Pennsylvania a family detention, an ICE physician sought to downplay the situation. The ICE physician also proposed family separation and force-feeding as responses to the hunger strike, noting that “If it appears they really are on a hunger strike, we will need to separate the mother and children – send mom to an IHSC facility to address the hunger strike.” 

Doctors and nurses employed or contracted by ICE also violated medical ethics by supporting government motions for invasive and involuntary medical procedures, including force-feeding, forced hydration, forced urinary catherization, involuntary blood draws, and use of restraints. Our report identifies at least 14 separate ICE medical declarations supporting government motions for such involuntary procedures, in violation of physician’s ethical obligations to preserve the autonomy of mentally competent individuals, as well as international human rights law.

Our report reveals the lengths to which ICE will go to punish and deter hunger strikers rather than engage with their legitimate demands. Changing the response to hunger strikes will require addressing their underlying cause: an abusive and dangerous civil immigration detention system.

President Biden – who oversaw these abuses when Vice President — should reverse course and end the U.S. reliance on a mass immigration detention system and invest in community-based social services as alternatives to detention. Health professionals should refuse to participate in violations of medical ethics in their provision of care to detained immigrants, and government lawyers should refrain from pursuing cases for force feeding and other involuntary medical procedures.

Originally published by the Los Angeles Times on May 21, 2021

In a steadily growing encampment mere yards south of the U.S.-Mexico border, we are led to a little girl with a fever. She lies dehydrated and wrapped in her parents’ possessions inside a water-logged tent. Recently deported from the United States under a Trump-era pandemic policy, the family is camped next to the border wall with thousands of others who have nowhere to go.

In recent months, much attention and political outrage has focused on unaccompanied children crossing into the U.S. and being detained in government custody. But less scrutiny has been given to the mass deportations of migrant families and vulnerable adults expelled with no due process during the pandemic under a U.S. health law called Title 42, which allows the government to bar people from countries where communicable disease exists.

For more than a year — and in the name of public health — the U.S. has been summarily expelling migrants arriving at the U.S.-Mexico border, ignoring epidemiologists and health experts, violating the migrants’ human rights and creating a critical situation in Tijuana and other border towns.

As medical professionals who provide care in encampments and shelters in Tijuana, we’ve seen how this expulsion policy has caused a humanitarian emergency in northern Mexico. Even as these encampments become increasingly overcrowded and unsafe, many migrants and their families are still being denied entry or quickly deported by the U.S. government. The Biden administration has carried out roughly 350,000 expulsions, including nearly 50,000 families.

Migrants in Tijuana are subjected to targeted violence by cartels, squalid conditions in encampments and shelters, and despair after the U.S. lied to many of them about their expulsions.

The administration, as part of a legal settlement, recently agreed to process up to 250 asylum seekers a day deemed vulnerable by advocacy groups so they may continue to pursue their asylum cases in the U.S.

However, this is nowhere near sufficient to address the widespread human rights violations and humanitarian crisis we see every day in Tijuana. There are still many thousands of asylum seekers along the border who were previously subjected to inhumane detention and expulsions — and who are now grappling with the subsequent fallout and trauma.

Migrants in Tijuana are subjected to targeted violence by cartels, squalid conditions in encampments and shelters, and despair after the U.S. lied to many of them about their expulsions. Some asylum seekers have reported Border Patrol agents telling them they were being transferred to a shelter in another U.S. city when, in fact, they were sent to Mexico.

As co-founders of an organization providing healthcare to migrants stranded in Tijuana, we have been working around the clock to provide them medical care.

The Title 42 expulsion order has been used by the U.S. to essentially eliminate asylum at the border and put thousands of people in immediate danger by either returning them to their countries of origin or to Mexican border cities, even if the asylum seekers are not Mexican or do not speak Spanish.

We have seen increasing dehydration, malnutrition and infectious diseases associated with overcrowding. At an encampment in Tijuana that shelters some 2,000 asylum seekers, there are no formal sanitation facilities; gastrointestinal illnesses are causing severe illness in newborns and young children. Chronic diseases and mental health disorders, left untreated, could become death sentences. The migrants have been forced to camp amid very cold temperatures at night during winter months.

Disease is not the only threat. Families fear cartel activity and kidnappings since vulnerable migrants are often targeted for violence. More than 80% of LGBTQ refugees in Baja California reported surviving an assault in Mexico from mid-February to March. Last month, we received a late-night phone call from a lawyer asking for our help. The client — a transgender woman — had been stabbed, forced into hiding and was afraid to go to the local hospital in Tijuana because they are often unsafe places for sexual minorities. We were able to provide her basic medical care, but many others are not as lucky.

The Title 42 expulsion order has been used by the U.S. to essentially eliminate asylum at the border and put thousands of people in immediate danger by either returning them to their countries of origin or to Mexican border cities, even if the asylum seekers are not Mexican or do not speak Spanish. While the administration recently ceased cross-border expulsion flights — a reckless approach during the pandemic used to transfer and expel migrants to Mexico — officials have reserved the right to reinstate them as needed.

The policy has disproportionately affected Black migrants, who are often Haitian. They are deported without due process back to persecution in Haiti or to pervasive anti-Black violence in northern Mexico — leaving them without access to healthcare, psychological support, safety or asylum. More Haitians, over 1,200, were expelled in the first weeks of the Biden administration than during the 2020 U.S. fiscal year, and more than 60% of Haitian asylum seekers blocked from U.S. protection have been victims of crime in Mexico.

Title 42 undermines public health along the border — and must be withdrawn immediately.

Instead of unlawfully shutting down access to asylum, the administration should uphold American values and asylum laws, listen to the guidance from public health and refugee experts, and welcome migrants with dignity. Social distancing, masks and vaccines are the most effective measures to limit the spread of COVID-19 — not a discriminatory ban on at-risk asylum seekers.

A system of processing migrants safely is largely already in place, which has allowed thousands of individuals sent back under Trump’s “Remain in Mexico” policy to safely cross with the help of the United Nations and humanitarian organizations like ours.

While the interim changes from the Biden administration make a life-changing difference for the 250 per day now allowed to apply for asylum from the refuge of the U.S., thousands more at-risk families urgently need the same protections. Title 42 undermines public health along the border — and must be withdrawn immediately.

Psyche Calderon, Hannah Janeway and Ronica Mukerjee are medical providers and co-founders of Refugee Health Alliance.

After some time, the medical staff began to force-feed John Otieno.* “They put me on a bed and handcuffed me to an emergency medical stretcher,” he said. “[They] strap you on the chest, waist, legs, [with] hard restraints … there is no point in fighting back because you are there with six male, strong officers, and three nurses, and there is nothing you can do.” The doctor claimed to have a judicial order but declined to show it to him. Mr. Otieno saw two other hunger strikers who were also force-fed.

* Pseudonym

Executive Summary

Mr. Otieno, an asylum seeker from East Africa, is one of the many people in U.S. Immigration and Customs Enforcement (ICE) detention who began a hunger strike to protest poor conditions and seek release during the COVID-19 pandemic. Rather than listen to his pleas, ICE retaliated by locking him in a freezing cold room, force-feeding him through a nasogastric tube against his will, and transferring him to three different facilities. Only after subjecting him to all of this did ICE finally release him from detention in late 2020. Mr. Otieno, who lost 28 pounds and now takes medication for post-traumatic stress disorder (PTSD) and depression, described it as “an experience that I wouldn’t wish on my worst enemy.”

The decision to begin a hunger strike in immigration detention is not taken lightly. A detained person’s refusal to eat may be the last option available to voice complaint, after all other methods of petition have failed. Detained and imprisoned people worldwide have engaged in hunger strikes to plead for humane conditions of confinement or release from captivity and to bring attention to broader calls for justice.

Each day, the United States government unnecessarily locks up thousands of people in civil immigration detention, including children, in over two hundred immigration detention centers around the country. [1]

People may be locked up for many months — even years — as they await final adjudication of their cases or deportation. Trapped in a system marked by mistreatment and abuse, medical neglect, and the denial of due process, hundreds of people in immigration detention engage in hunger strikes as a means of protest each year. ICE’s failure to provide safe and humane conditions in detention during the COVID-19 pandemic has only raised the stakes for detained people. Although some detained people, on occasion, are able to bring outside attention to their hunger strikes, very little is known of ICE’s systemic response to hunger striking detainees.

This report provides for the first time an in-depth, nationwide examination of what happens to people who engage in hunger strikes while detained by ICE.

The report and its findings are based on an assessment of over 10,000 pages of documents…[relating to] hunger strikes by at least 1,378 people from 74 countries across 62 immigration detention centers in 24 states.

Data and Methods

The report and its findings are based on an assessment of over 10,000 pages of documents, including emails, case records, procedural directives, and court filings obtained under the Freedom of Information Act (FOIA), related to hundreds of hunger strikes in ICE detention from 2013 to 2017, spanning both the Obama and Trump administrations.[2] These include hunger strikes by at least 1,378 people from 74 countries across 62 immigration detention centers in 24 states.[3] The report is also based on a review of ICE’s current policies on hunger strikes in detention and on interviews with six formerly detained people who engaged in hunger strikes.

Force-Feeding and Other Involuntary Medical Procedures: ICE’s Dangerous and Unethical Approach to Hunger Strikes

The released records reveal that ICE has chosen to employ involuntary medical procedures on detained hunger strikers that violate ethical guidelines for medical personnel, including force-feeding, forced hydration, forced urinary catherization, involuntary blood draws, and use of restraints. These records confirm that ICE began seeking, obtaining, and executing orders for involuntary treatment years earlier than was previously known. The documents reveal a previously unknown force-feeding case from 2016 and government motions for involuntary medical procedures as early as 2012.

Force-feeding and forced hydration are medical procedures where food, nutrients, or fluids are administered to those in detention against their will via several invasive and painful procedures. These invasive procedures include:

• Force-feeding via nasogastric (NG) tube: a plastic tube is inserted through one of the nostrils and advanced through the back of the throat and the esophagus to the stomach. This can be a very painful procedure that causes gagging, skin and tissue irritation, and in rare cases, perforation of vital organs. The tube can also be misdirected and advanced into the airways instead of the esophagus, potentially causing serious infections. When officials insert an NG tube against a person’s will, they typically must forcibly restrain the individual by staff or via mechanical restraints.

• Forced hydration: intravenous and PICC (peripherally inserted central catheter) lines are the most common means of providing hydration and parenteral nutrition. In both procedures, soft tubes are inserted into a vein in the arm, leg, or neck via needles. The procedures can cause local pain and bleeding, can cause damage to blood vessels, and increase risk of infections and other complications.

• Forced urinary catheterization: a tube is inserted into the urethra (the orifice through which urine travels out of the body). When cooperation or consent is not obtained, physical or chemical restraints have been used. Regardless of where a catheter is inserted, the risks include local injuries, pain, bleeding, infection, and damage to surrounding structures, including vital organs.

Involuntary medical procedures like force-feeding have been condemned by the American Medical Association as a violation of the “core ethical values of the medical profession” and described as cruel, inhuman, or degrading treatment or even torture by international human rights bodies and observers.[4] As ethical guidelines for medical professionals have long recognized, participation in a hunger strike is not a medical condition, but rather, a political decision by the hunger striker, and people contemplating or undertaking a hunger strike are entitled to a relationship of trust with the health professionals providing their care.

In some instances, ICE used private prison medical staff to force-feed hunger strikers within a detention facility after nearby medical facilities refused to do so. In one instance at the Aurora Detention Center in Colorado, ICE officials could not find any local hospital staff who would agree to force-feed a hunger striker, due to ethical prohibitions. ICE officials finally turned to medical officers employed by the GEO Group, Inc., the private prison company that operated the detention facility, who offered to force- feed the hunger striker.

As noted in several court proceedings, ICE failed to consider alternatives to force-feeding, including resolving hunger strikers’ basic requests for improved conditions. In some cases, government attorneys sought—and received—force-feeding orders based on minimal evidence, sometimes without any specific detail or reference to the individual they sought to force-feed. Detained hunger strikers faced overwhelming challenges in defending themselves against force-feeding orders by ICE. In almost every instance we analyzed, detained hunger strikers lacked legal representation to defend themselves against the government’s pursuit of force-feeding orders.

ICE’s treatment of hunger strikers endangers lives. Since 2017, at least three former hunger strikers— Kamyar Samimi, Amar Mergensana, and Roylan Hernandez-Diaz—have died in detention, raising serious questions about medical neglect, lack of mental health services, and abuse during and after their hunger strikes.[5] ICE’s failure to monitor people after they end their hunger strike may endanger and put them at risk of refeeding syndrome, a serious and potentially fatal complication. Refeeding syndrome is broadly characterized by metabolic abnormalities and severe electrolyte disturbances, leading to organ dysfunction, and respiratory and cardiac failure.[6]

Solitary Confinement and Unlawful Retaliation Against Hunger Strikers

These records also reveal that ICE routinely placed hunger strikers in solitary confinement, which often amounts to cruel, inhuman, or degrading treatment, and, under certain conditions, even torture.

Although ICE claims that its policy to isolate hunger strikers is for the detained person’s well-being, there is no medical reason to place a hunger striker in solitary confinement, which can lead to additional serious physical and mental health consequences.

Placing detained hunger strikers in isolation as a result of their protected expressive conduct also violates the First Amendment. Compounding the harm, ICE also subjects hunger strikers who have concomitant mental illnesses to the same abusive solitary confinement policies. Conditions in solitary confinement units included impermissible punitive measures, such as cutting off water for toilets, washing, and drinking, which is contrary to ICE’s medical guidelines and of particular danger to detainees on hunger strikes.

ICE’s response reveals striking inflexibility to the underlying requests made by detained hunger strikers. ICE’s records, news reports, and interviews with former hunger strikers reveal numerous examples of unlawful retaliation by ICE, including involuntary transfer and excessive force. As one official at the Yuba County Jail in California, which detains immigrants for ICE, instructed: “move him to [another facility] and he will likely beg to come back here and mind his manners until he is removed.” In some instances, ICE moved to transfer or deport hunger strikers despite their physical or mental vulnerability and need for continued medical monitoring.

Psychological Coercion: ICE’s Attempts to End Hunger Strikes

These records and interviews with formerly detained hunger strikers also shine a light on the many forms of day-to-day psychological coercion ICE employs to try to break hunger strikes, including denying access to basic privileges, restricting water access, and threatening prosecution. ICE officers used dehumanizing language to describe hunger strikers. In one instance an officer noted, “I really feel that we should stop neglecting these poor innocent fruit flies. I mean really, why should they have to go without fruit? Maybe a protest is in order.” While ICE officers were unwilling to consider hunger strikers’ requests, they often attempted to leverage traditional foods (such as curry dishes or Bengali tea) or members of the hunger strikers’ faith communities to pressure them to break their fast. In one alarming case, ICE reportedly brought in a Bangladeshi consular official to meet with hunger striking asylum seekers who had fled persecution by the Bangladeshi government.

Separating Families, Hiding Stories: ICE’s Treatment of Hunger Strikers at Family Detention Centers

Other documents reveal how ICE officials took pains to hide hunger strikes from public view, including those at family detention centers that detain immigrant children and their parents. While discussing a hunger strike by several mothers at the Berks Family Residential Center in Pennsylvania, an ICE physician noted that “we are using the food protest (or meal refusal) label rather than hunger strikes for a couple of reasons. Since this is a family facility, we don’t want the messaging going out that there is a hunger strike going on. The optics just look bad. Then people wonder if the kids are on strike too and starving.” The same physician proposed family separation as a response to the strike: “If it appears they really are on a hunger strike, we will need to separate the mother and children—send mom to an IHSC [ICE Health Service Corps] facility to address the hunger strike.”

In other instances, documents revealed that ICE officials recommended misrepresentation or omission of key facts related to hunger strikes to evade oversight reporting requirements. In one case at the Pulaski County Detention Center in Kentucky, an ICE representative recommended that a nurse remove information about suicide risks from a former hunger striker’s health summary. In email correspondence with staff at the Northwest Detention Center (NWDC) in Washington, the ICE Western Regional Communications Director/Spokesperson asked for an update on the number of detainees who were going to be placed on formal hunger strikes protocols. The NWDC representative estimated 12 people but asked the ICE spokesperson to hold off while they confirmed the numbers. The ICE spokesperson replied, “OK … but the wolves are at the door. Maybe I can come up with something fuzzy … using a round number.”

Violations of Medical Ethics: The Role of ICE’s Health Professionals in Abuses Against Hunger Strikers

The documents reveal that ICE’s health professionals helped facilitate and enable abuses against hunger strikers, in contravention of their ethical obligations and international human rights norms. They lent their names and credibility to medical declarations in support of motions for force-feeding and other involuntary medical procedures. In some cases, they failed to ensure that even the most basic standards for adequate medical monitoring were met.

“You cannot compare being in immigration [detention]; it’s like something out of a horror story.”

A New Opportunity: Ending a System of Abuse

ICE’s treatment of hunger strikers reflects the broader context of harm and abuse endemic to the immigration detention system — which hunger strikers themselves are protesting. As a formerly detained hunger striker, Luis Yboy Flores, noted, “You cannot compare being in immigration [detention]; it’s like something out of a horror story.”

Hunger strikes continue in ICE detention as of this writing, as detained people at risk of contracting COVID-19 make pleas for basic sanitation, safety, and the ability to practice social distancing behind bars.[7] ICE officials and detention officers have responded with extreme measures, including use of pepper spray, physical force, rubber bullets, and facility- wide lockdowns, in addition to force-feeding and retaliatory punishment for those who are singled out as instigators.

The documents reveal the architecture of abuse that underpins ICE’s response. They describe the routinization of the coercion and retaliation against hunger strikers that continue today. Rather than address the underlying circumstances that led to the hunger strike, ICE’s policy and practice is to intimidate detained people into ending their protests. Moreover, by applying the same hunger strike policies to people experiencing mental health crises, ICE puts already vulnerable people at greater risk.

Notably, newly elected President Joseph R. Biden was vice president during much of the period covered by the documents analyzed in this report. His administration now has an opportunity to acknowledge the abusive system that prompts so many immigrants to engage in hunger strikes, to end ICE’s cruel response to their protests, to heed hunger strikers’ urgent calls for humane treatment and release, and to begin phasing out the use of immigration detention entirely.

Key Recommendations

This section provides key recommendations to protect the rights of hunger strikers in ICE detention, as described below. A more detailed version is provided at the end of the report.

To the U.S. Department of Homeland Security (DHS):

• Phase out the use of immigration detention.
• Invest in community-based social services as alternatives to detention.
• End the use of solitary confinement in immigration detention.
• Issue a directive on the medical treatment of hunger strikers, consistent with national and international ethical norms, to ensure appropriate standards of care.
• Guarantee people in detention continued and regular access to independent health professionals, including licensed physicians and psychiatrists with provisions to ensure their clinical independence from the detaining authorities.[8]
• Prohibit use of force and punitive measures against hunger strikers.
• Ensure greater transparency and accountability in the immigration detention system, including comprehensive facility inspections with safeguards for the participation of detained people, and meaningful consequences for failed inspections.
• Provide compensation for people who have been subjected to involuntary treatment and/or other forms of abuse while hunger striking.

To the U.S. Congress:

• Conduct robust oversight of ICE’s treatment of hunger strikers in detention.
• Request that the DHS Office of Inspector General (OIG) and Office of Civil Rights and Civil Liberties (CRCL) investigate and issue recommendations regarding the conditions documented in this report.
• Require that ICE publicly report data on hunger strikes by people in ICE custody.
• Prohibit the use of funds appropriated to the DHS to be used to force-feed or forcibly hydrate detained people engaging in a hunger strike who have been determined by an independent
• licensed physician to be competent in the refusal of treatment.
• Dramatically reduce funding for immigration detention and enforcement.
• Support and pass legislation that begins the process of phasing out mandatory detention and the use of detention entirely in our immigration system.

To the U.S. Department of Justice:

• Refrain from pursuing orders for force-feeding and other involuntary medical procedures.
• Refrain from retaliation against detained hunger strikers.

To Offices of the Federal Public Defender:

• Provide representation to people in detention on hunger strike who face court proceedings.

To State Medical Boards:

• Investigate for license suspension or revocation any medical or health professionals who authorize or participate in involuntary medical procedures on mentally competent individuals.

To Medical and Health Professional Associations:

• Censure and expel any medical or health professionals who authorize or participate in involuntary medical procedures on mentally competent individuals.
• Issue clear guidelines reinforcing that force- feeding and other involuntary medical procedures are unethical and inconsistent with professional norms.
• Lobby for stronger and comprehensive protections for health professionals who refuse to engage in unethical conduct, or act as whistleblowers.

To Individual Health Professionals:

• Advocate individually or through professional organizations against health professionals’ involvement in force-feeding and other involuntary procedures.
• Advocate for ICE to comply with ethical standards with respect to the treatment of detainees.
• Advocate for the censure of health professionals who have participated in force-feeding and other involuntary procedures.

To the UN High Commissioner for Human Rights, UN Special Procedures, UN Treaty Bodies, and the Inter-American Commission on Human Rights:

• Request official visits and unimpeded access to ICE detention facilities to monitor conditions and investigate ill-treatment of hunger strikers.
• Seek information from the U.S. government regarding the use of coercive measures against hunger strikers in immigration detention.
• Condemn the use of physical or psychological coercion against hunger strikers in ICE detention.

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Endnotes

[1] American Civil Liberties Union (ACLU), Human Rights Watch (HRW), and National Immigrant Justice Center (NIJC), Justice-Free Zones U.S. Immigration Detention Under the Trump Administration (2020), https://www.aclu.org/report/justice-free-zones-us- immigration-detention-under-trump-administration; Physicians for Human Rights, Praying for Hand Soap and Masks: Health and Human Rights Violations in U.S. Immigration Detention during the COVID-19 Pandemic (January 2021), https://phr.org/our-work/ resources/praying-for-hand-soap-and-masks; American Immigration Council, “Immigrants and Families Appear in Court,” July 30, 2019, https://www.americanimmigrationcouncil.org/ research/immigrants-and-families-appear-court.

[2] ACLU v. Department of Homeland Security, “Complaint for Injunctive and Declaratory Relief,” May 25, 2017, https://www.aclu.org/ legal-document/aclu-v-department-homeland-security-complaint.

[3] ICE Significant Event Notification (SEN) data (FOIA 2017-ICLI-0014, “SEN FOIA Request – May 2018 Reproduction.xls.”)

[4] Letter (dated April 23, 2013) from Dr. Jeremy A. Lazarus (president of the American Medical Association) to the Honorable Chuck Hagel regarding the treatment of hunger strikers at Guantánamo and force-feeding, http://media.miamiherald.com/ smedia/2013/04/30/07/58/FRs25.So.56.pdf.

[5] Brittany Freeman, “ICE review of immigration detainee’s death finds medical care deficiencies at Aurora facility,” Rocky Mountain PBS, May 20, 2019, https://www.rmpbs.org/blogs/ news/ice-review-of-death-in-aurora-immigration-detention- facility-finds-deficiencies-in-detainees-medical-care; Lilly Fowler, “New details of a death at Tacoma ICE facility raise questions over care,” Crosscut, December 3, 2020, https://crosscut.com/ news/2020/12/new-details-death-tacoma-ice-facility-raise-questions-over-care; Hamed Aleaziz and Adolfo Flores, “A Cuban Asylum-Seeker Died Of An Apparent Suicide After Spending Months In ICE Detention,” Buzzfeed News, October 16, 2019, https://www.buzzfeednews.com/article/hamedaleaziz/cuban-asylum-ice-death-suicide-louisiana-detention.

[6] Al Sharkawy, I., D. Ramadan, and A. El-Tantawy. “’Refeeding Syndrome’ in a Kuwaiti Child: Clinical Diagnosis and Management.” Med Princ Pract 19, no. 3 (2010): 240-3; Boateng, A. A., K. Sriram, M. M. Meguid, and M. Crook. “Refeeding Syndrome: Treatment Considerations Based on Collective Analysis of Literature Case Reports.” Nutrition 26, no. 2 (Feb 2010): 156-67; Eichelberger, M., M. L. Joray, M. Perrig, M. Bodmer, and Z. Stanga. “Management of Patients During Hunger Strike and Refeeding Phase.” Nutrition 30, no. 11-12 (Nov-Dec 2014): 1372-8; Crook, M. A. “Refeeding Syndrome: Problems with Definition and Management.” Nutrition 30, no. 11-12 (Nov-Dec 2014): 1448-55; Letter from Dr. Allen Keller and Dr. Parveen Parmar to Department of Homeland Security (February 7, 2021), https://1229c6da-0cea-441a-90c5-2c46bf07cdbd.filesusr.com/ ugd/5f6014_4bdf31b3e9c74f00a6d6948ecfa976ed.pdf.

[7] PHR, Praying for Hand Soap and Masks: Health and Human Rights Violations in U.S. Immigration Detention During the COVID-19 Pandemic (January 2021).

[8] Wynia, Matthew K. “Why It Is Important To Promote Clinical Independence Among Health Professionals Working In Prisons, Jails, and Other Detention Settings.” American Journal of Public Health 108, no. 4 (2018): 440. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5844422/