Alors que le conflit dans l’est de la République démocratique du Congo (RDC) continue de s’intensifier, le partenaire médical de Physicians for Human Rights (PHR), HEAL Africa, fournit des soins intensifs aux survivants des violences sexuelles et sexistes. Nous avons échangé avec HEAL Africa pour en savoir plus sur la fourniture des services des soins de santé dans un contexte de conflit et sur leur approche innovante de prise en charge des survivants de violences sexuelles, notamment grâce à des outils co-développés par PHR. 

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Read English translation here.

En République Démocratique du Congo (RDC), la montée des niveaux de violence a fait basculer un contexte sécuritaire très précaire vers une crise de conflit meurtrier. Ces derniers mois, l’intensification des combats a provoqué des déplacements massifs de population ; selon l’Organisation Internationale pour les Migrations (OIM), le nombre de personnes déplacées à l’intérieur du pays (PDI) en RDC a atteint un niveau record de 6,9 millions de personnes. Les communautés de l’est de la RDC, comme celles du Nord-Kivu où travaille Physicians for Human Rights (PHR), ont été particulièrement touchées par des niveaux dévastateurs des violences sexuelles liées au conflit, dont plus de 90 000 cas signalés rien qu’en 2023. Les enfants, en particulier, ont été victimes d’horribles violences. 

“Ce que nous observons au Nord-Kivu est une crise totale, où les atrocités contre les civils se poursuivent en toute impunité”

Joyeux Mushekuru, coordinateur de PHR en RDC

“Ce que nous observons au Nord-Kivu est une crise totale, où les atrocités contre les civils se poursuivent en toute impunité”, a déclaré Joyeux Mushekuru, coordinateur de PHR en RDC.  

« Un nombre impressionnant de personnes ont été déplacées de force de leurs foyers, rendant leur accès aux soins de santé presque impossible. Cela est particulièrement préoccupant pour les personnes qui ont survécu aux violences traumatisantes dues au conflit, notamment les enfants, qui ont besoin de toute urgence de soins médicaux , d’un soutien psychosocial mais aussi des orientations des mineurs a risque de VBG. ” 

HEAL Africa : Une lueur d’espoir 

Pour fournir des soins aux survivants des violences sexuelles liées au conflit au Nord-Kivu, PHR s’est associé aux cliniciens de HEAL Africa, qui sert de one stop center pour fournir un soutien médical, psychosocial et juridique aux populations les plus vulnérables en RDC.  Travaillant au centre d’une crise où l’accès à la santé a été perturbé et où d’autres établissements de santé sont devenus non fonctionnels en raison du conflit, HEAL Africa est une lueur d’espoir et de guérison pour les survivants du conflit, y compris pour les survivants de violences sexuelles. 

“Il est impératif dans ce contexte d’assoir un progrmme de prise en charge holistique prenant en compte l’inclusion” a fait savoir Mr Ndungo Sakoul, directeur de programme à HEAL Africa. 

Le Dr Serge Kahawta, ancien medecin directeur de HEAL Africa, notait qu’en garantissant aux survivants des violences sexuelles l’accès à des soins complets dans un seul établissement, HEAL Africa contribue à éviter un nouveau traumatisme des survivants et encourage la collaboration entre les professionnels pour rendre disponible une prise en charge multisectorielle. 

« HEAL Africa a pour mission de prendre soin de chaque personne de manière holistique. Nous aidons les individus a retrouver leur dignité mais aussi à réintégrer la société, en leur donnant les outils nécessaires pour devenir indépendants et créer leurs propres moyens de survie », a déclaré Dr. Kahawta. 

Physicians for Human Rights (PHR) a commencé à travailler avec HEAL Africa en 2014 à travers des efforts de développement des capacités avec des cliniciens et des acteurs du secteur du droit et de la justice y compris la police pour perfectionner leurs compétences en matière d’examens médico-légaux et renforcer ainsi les capacités pour mieux utiliser ces preuves pour poursuivre les auteurs des violences sexuelles. Ensemble, PHR et HEAL Africa ont piloté avec succès des approches innovantes en matière de documentation et de collecte de preuves médico-légales, notamment via MediCapt, l’application mobile de PHR visant à soutenir la documentation de qualité, fiable et sécurisée des preuves médico-légales de violences sexuelles. 

Relever les défis de la prestation de soins de santé dans l’Est de la RDC 

Les installations de HEAL Africa restent une bouée de sauvetage cruciale pour des millions de personnes dans l’Est de la RDC qui restent déplacées par la récente escalade du conflit, mais en particulier pour celles qui se trouvent dans d’immense camps des personnes déplacées du Nord-Kivu. HEAL Africa s’est efforcé de surmonter les problèmes de sécurité croissants – et les défis logistiques et humains qui en résultent – afin de mobiliser des équipes des prestataires des soins de santé dans les zones qui en ont besoin. 

“Il est crucial pour tous ces enfants d’avoir un espace où des professionnels pourront recueillir leurs témoignages mais également, pour certains, les référer vers des structures de prise en charge médicale et sociale. Sans un espace dédié à leur accueil et à l’écoute, ils ne sauraient pas  aupres de qui obtenir un soutien holistique, une prise en charge et la justice pour les crimes qu’ils ont subis.”

Georges Kuzma, Consultant Expert en police et justice chez PHR

En tant que première ligne des soins pour les populations fuyant la violence, les cliniciens de HEAL Africa signalent des niveaux désastreux de violence sexuelle, touchant notamment les enfants. Dans le camp de Bulengo, à quelques kilomètres   de la ville de Goma, le personnel de HEAL Africa rapporte qu’en moyenne 5 à 7 survivants se présentent chaque jour pour recevoir des soins, dont une moyenne de 6 enfants survivants de violences sexuelles par semaine. C’est qui est alarment et inquiétant. Le personnel de HEAL Africa signale une détérioration croissante des conditions de vie des personnes déplacées chaque jour qui passe, en raison du manque de ressources matérielles, de la résurgence de maladies infectieuses (telles que le choléra, la rougeole et d’autres maladies diarrhéiques) et de la malnutrition due à un accès insuffisant à l’eau et à la nourriture.

Face à cette crise, HEAL Africa et PHR se sont associés pour répondre aux besoins des enfants survivants des violences sexuelles liées aux conflits. Des données en lien avec les survivant(e)s de viol par les différents groupes armés portent à croire que ces pratiques sont devenues très récurrentes et les mineuress sont les plus viséess. HEAL Africa a identifié des dizaines de cas au courant du mois de décembre 2023. En 2023, nous nous sommes associés pour répondre aux besoins urgents des enfants survivants des violences sexuelles, en créant un établissement dédié à leur soutien dans le camp de Bulengo. S’appuyant sur les meilleures pratiques fondées sur des preuves pour la conception d’espaces adaptés aux enfants dans les contextes humanitaires, sur les conseils des principaux protocoles d’entretien des enfants survivants de violences sexuelles et sur l’expertise des parties prenantes multisectorielles du Nord-Kivu et de la RDC, HEAL Africa et PHR s’efforcent de piloter cette initiative pour faciliter une documentation sûre de la violence traumatisante que ces enfants ont subie.  L’espace demeure une source de soutien continu pour les survivants.

“Il est crucial pour tous ces enfants d’avoir un espace où des professionnels pourront recueillir leurs témoignages mais également, pour certains, les référer vers des structures de prise en charge médicale et sociale” explique, Georges Kuzma, Consultant Expert en police et justice chez PHR. “Certains de ces adolescents sont devenus les soutiens pour leurs petits frères et sœurs, suite à la disparition des parents. Sans un espace dédié à leur accueil et à l’écoute, ils ne sauraient pas  aupres de qui obtenir un soutien holistique, une prise en charge et la justice pour les crimes qu’ils ont subis.” 

Construire un avenir meilleur  

Alors que la violence continue de croître dans l’Est de la RDC, les agents de santé tels que ceux travaillant avec HEAL Africa constituent une bouée de sauvetage pour les millions de personnes déplacées par le conflit. Qu’il s’agisse d’une collaboration pour soutenir les enfants survivants dans les camps des personnes déplacées ou de la poursuite d’autres innovations pour collecter et sécuriser en toute sécurité les preuves des violations, PHR est fier de son partenariat continu avec HEAL Africa. 

PHR en collaboration avec HEAL Africa s’inspire de la résilience des professionnels de la santé dans l’Est de la RDC et salue leurs approches innovantes pour atteindre les communautés qu’ils servent.  Néanmoins, d’énormes défis demeurent. Afin de fournir les soins nécessaires aux survivants, PHR appelle les parties prenantes nationales et internationales à apporter un soutien urgent au secteur de la santé en RDC, en particulier aux organisations qui peuvent atteindre les personnes les plus touchées par le conflit, comme HEAL Africa.. Les survivants ont droit à la santé, aux droits humains et à ce que justice soit rendue pour les atrocités commises dans le conflit. 

As the conflict in the eastern region of the Democratic Republic of the Congo (DRC) continues to escalate, Physicians for Human Rights (PHR) medical partner HEAL Africa is providing intensive care to survivors of sexual and gender-based violence. We spoke with HEAL Africa to learn more about the provision of health care services in a conflict context and the organization’s innovative approach to caring for survivors of sexual violence, including through the use of tools co-developed by PHR.

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French translation available here

In the eastern Democratic Republic of the Congo (DRC), rising levels of violence have shifted a very precarious security context into a deadly conflict crisis. In recent months, intensified fighting has led to massive population displacement. According to the International Organization for Migration (IOM), the number of internally displaced persons (IDPs) in the DRC has reached a record high of 6.9 million people.

Communities in eastern DRC, such as those in North Kivu, where Physicians for Human Rights (PHR) works, have been particularly affected by devastating levels of conflict-related sexual violence, including more than 90,000 reported cases in 2023 alone. Children in particular have been victims of horrific violence. 

“What we are seeing in North Kivu is a full-blown crisis, where atrocities against civilians continue with impunity… This is of particular concern for survivors of traumatic violence due to the conflict, including children, who are in urgent need of medical care and psychosocial support ”

Joyeux Mushekuru, PHR’s coordinator in the DRC

“What we are seeing in North Kivu is a full-blown crisis, where atrocities against civilians continue with impunity,” said Joyeux Mushekuru, PHR’s coordinator in the DRC. “A staggering number of people have been forcibly displaced from their homes, making it almost impossible for them to access health care. This is of particular concern for survivors of traumatic violence due to the conflict, including children, who are in urgent need of medical care and psychosocial support as well as minors at risk of gender-based violence.”

HEAL Africa: A glimmer of hope 

To provide care to survivors of conflict-related sexual violence in North Kivu, PHR has partnered with clinicians at HEAL Africa, which serves as a one-stop center for survivors to access medical, psychosocial, and legal support to the most vulnerable populations in the DRC. “It is imperative in this context to establish a holistic and inclusive care program,” said Ndungo Sakoul, Program Director at HEAL Africa. 

Dr. Serge Kahatwa, former medical director of HEAL Africa, noted that by ensuring survivors of sexual violence have access to comprehensive care in a single facility, HEAL Africa helps prevent further trauma for survivors and encourages collaboration among professionals to make multi-sectoral care available. 

HEAL Africa’s facilities remain a crucial lifeline for millions of people in eastern DRC who remain displaced by the recent escalation of conflict, particularly those in huge camps for internally displaced persons in North Kivu.

“HEAL Africa’s mission is to care for each person holistically. We help people regain their dignity and reintegrate into society, giving them the tools to become independent and create their own means of survival,” said Dr. Kahawta. 

PHR began working with HEAL Africa in 2014 through capacity development efforts with clinicians and actors in the law and justice sector, including the police, to hone their forensic examination skills and build capacity to better use this evidence to prosecute perpetrators of sexual violence. Together, PHR and HEAL Africa have successfully piloted innovative approaches to documentation and collection of forensic evidence, including through MediCapt, PHR’s award-winning mobile app to support the secure documentation of forensic evidence of sexual violence. 

Addressing the challenges of health care delivery in eastern DRC 

HEAL Africa’s facilities remain a crucial lifeline for millions of people in eastern DRC who remain displaced by the recent escalation of conflict, particularly those in huge camps for internally displaced persons in North Kivu. HEAL Africa has been working to overcome the growing security concerns – and the resulting logistical and human challenges – in order to mobilize teams of health care providers in areas that need them. 

“It is crucial for all these children to have a space where professionals can collect their testimonies and refer them to medical and social care structures… Without a dedicated space to welcome and listen, they would not know where to go for holistic support, care, and justice for the crimes they have suffered.” 

Georges Kuzma, expert consultant in police and justice at PHR

As the front line of care for populations fleeing violence, HEAL Africa’s clinicians report dire levels of sexual violence, especially affecting children. In the Bulengo camp, a few miles from the city of Goma, HEAL Africa’s staff report that an average of five to seven survivors arrive every day for treatment, averaging six child survivors of sexual violence each week. Dozens of cases were identified by HEAL Africa in December 2023 alone. HEAL Africa staff report an increasing deterioration in the living conditions of displaced people with each passing day due to lack of material resources, resurgence of infectious diseases (such as cholera, measles, and other diarrheal diseases) and malnutrition due to insufficient access to food and water.  

In response to this crisis, HEAL Africa and PHR have partnered to address the needs of child survivors of conflict-related sexual violence in the Bulengo camp. In 2023, PHR and HEAL Africa created a child-friendly interviewing facility dedicated to supporting child survivors living in the camp. Drawing on evidence-based best practices for designing child-friendly spaces in humanitarian settings; guidance from key interview protocols for child survivors of sexual violence; and the expertise of multi-sectoral stakeholders in North Kivu and the DRC, HEAL Africa and PHR are working to pilot this initiative to facilitate safe documentation of the traumatic violence these children have experienced. The space continues to be a source of ongoing support for survivors.  

“It is crucial for all these children to have a space where professionals can collect their testimonies and refer them to medical and social care structures,” explains Georges Kuzma, expert consultant in police and justice at PHR. “Some of these teenagers have become the support for their younger siblings, following the disappearance of their parents. Without a dedicated space to welcome and listen, they would not know where to go for holistic support, care, and justice for the crimes they have suffered.” 

Building a better future  

As violence continues to grow in the eastern region of the DRC, health workers such as those working with HEAL Africa are a lifeline for the millions of people displaced by the conflict. Whether it is collaborating to support child survivors in IDP camps or pursuing other innovations to safely collect and secure evidence of violations, PHR is proud of its continued partnership with HEAL Africa. 

We are inspired by the resilience of health care professionals in eastern DRC and commend their innovative approaches to reaching the communities they serve. Enormous challenges nevertheless remain. To provide the necessary care to survivors, PHR is calling on national and international stakeholders to provide urgent support to the health sector in the DRC, especially to organizations that can reach those most affected by the conflict, such as HEAL Africa. Survivors have the right to health, human rights, and justice for the atrocities committed in the conflict. 

Learn more about the work of HEAL Africa here. 

Executive Summary

The United States maintains the world’s largest immigration detention system, detaining tens of thousands of people in a network of facilities, including those managed by private prison corporations, county jails, U.S. Immigration and Customs Enforcement (ICE), U.S. Customs and Border Protection (CBP), and the Office of Refugee Resettlement (ORR). At the time of writing, ICE is detaining over 35,000 people, including long-term residents of the United States, people seeking asylum, and survivors of trafficking or torture. Instead of finding refuge, these people are held in ICE custody for extended periods, enduring inhuman conditions such as solitary confinement (dubbed “segregation” by ICE), where they are isolated in small cells with minimal contact with others for days, weeks, or even years. In many instances, such conditions would meet the definition of torture, or cruel, inhuman, or degrading treatment under international human rights law.

Solitary confinement causes a range of adverse health effects, including post-traumatic stress disorder (PTSD), self-harm, and suicide risks. Prolonged confinement can lead to lasting brain damage, hallucinations, confusion, disrupted sleep, and reduced cognitive function. These effects persist beyond the confinement period, often resulting in enduring psychological and physical disabilities, especially for people with preexisting medical and mental health conditions or other vulnerabilities.

In recognition of this well-documented harm, ICE issued a directive in 2013 to limit the use of solitary confinement in its facilities, especially for people with vulnerabilities. A 2015 memorandum further protected transgender people, emphasizing solitary confinement as a last resort. In 2022, ICE reinforced reporting requirements for people with mental health conditions in solitary confinement, highlighting the need for strict oversight. Despite these directives, however, government audits and whistleblowers alike have repeatedly revealed stark failures in oversight.

This report – a joint effort by Physicians for Human Rights (PHR), Harvard Law School’s Immigration and Refugee Clinical Program (HIRCP), and researchers at Harvard Medical School (HMS) – provides a detailed overview of how solitary confinement is being used by ICE across detention facilities in the United States, and its failure to adhere to its own policies, guidance, and directives. It is based on a comprehensive examination of data gathered from ICE and other agencies, including through Freedom of Information Act (FOIA) requests, first filed in 2017, and partly acquired after subsequent litigation. It is further enriched by interviews with 26 people who were formerly held in immigration facilities and experienced solitary confinement over the last 10 years.

The study reveals that immigration detention facilities fail to comply with ICE guidelines and directives regarding solitary confinement. Despite significant documented issues, including whistleblower alarms and supposed monitoring and oversight measures, there has been negligible progress. The report highlights a significant discrepancy between the 2020 campaign promise of U.S. President Joseph Biden to end solitary confinement and the ongoing practices observed in ICE detention. Over the last decade, the use of solitary confinement has persisted, and worse, the recent trend under the current administration reflects an increase in frequency and duration. Data from solitary confinement use in 2023 – though likely an underestimation as this report explains – demonstrates a marked increase in the instances of solitary confinement.

This report exposes a continuing trend of ICE using solitary confinement for punitive purposes rather than as a last resort – in violation of its own directives. Many of the people interviewed were placed in solitary confinement for minor disciplinary infractions or as a form of retaliation for participating in hunger strikes or for submitting complaints. Many reported inadequate access to medical care, including mental health care, during their solitary confinement, which they said led to the exacerbation of existing conditions or the development of new ones, including symptoms consistent with depression, anxiety, and PTSD. The conditions in solitary confinement were described as dehumanizing, with people experiencing harsh living conditions, limited access to communication and recreation, and verbal abuse or harassment from facility staff.

ICE oversaw more than 14,000 placements in solitary confinement between 2018 and 2023. Many people who are detained in solitary confinement have preexisting mental health conditions and other vulnerabilities. The average duration of solitary confinement is approximately one month, and some immigrants spend over two years in solitary confinement.

Analysis of FOIA data revealed persistent and prolonged use of solitary confinement and demonstrated significant inadequacies of current oversight and accountability mechanisms. In the last five years alone, ICE has placed people in solitary confinement over 14,000 times, with an average duration of 27 days, well exceeding the 15-day threshold that United Nations (UN) human rights experts have found constitutes torture. Many of the longest solitary confinement placements involved people with mental health conditions, indicating a failure to provide appropriate care for vulnerable populations more broadly.

Some solitary confinement placements lasted significantly longer, with 682 lasting at least 90 days and 42 lasting over one year. Many of these instances involved people with mental health conditions and other vulnerabilities, including 10 of those 42 placements lasting over a year in solitary confinement. Data provided by ICE also demonstrated a disproportionately harmful impact on people with vulnerabilities, particularly transgender people and those with mental health and medical conditions.

The treatment of people in immigration detention facilities and the excessive, punitive use of solitary confinement is not only contrary to ICE’s own policies and guidance but also violates U.S. constitutional law and international human rights law. The Fifth Amendment prohibits the deprivation of life, liberty, or property without due process of law, protection that extends to all persons within the United States, including people in immigration detention. The government has a duty to ensure the health and safety of people in immigration detention facilities, providing for their basic needs such as food and medical care. Persons in detention also have First Amendment rights, including the freedom to protest conditions or report issues without fear of retaliation.

International human rights law has also made clear that the detention of immigrants, especially in solitary confinement, should be a last resort, for the shortest time possible, and used only for limited purposes. The United States has signed and ratified the International Covenant on Civil and Political Rights (ICCPR), which prohibits arbitrary and unlawful detention. The use of prolonged solitary confinement, especially for people with mental health conditions, is prohibited under the UN Standard Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules). The United States has also signed and ratified the UN Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. The UN Special Rapporteur on Torture has highlighted the severe psychological and physical harm caused by prolonged solitary confinement, especially for people with mental health conditions.

ICE’s failure to adhere to domestic and international law and its own guidelines has created dangerous conditions in detention centers, particularly for people with mental and medical health conditions or other vulnerabilities. The persistent use of solitary confinement over the last decade underscores the need for radical changes in ICE policy and practice. The evidence of profound physical and mental health deterioration caused by solitary confinement, in combination with ICE’s inability to implement policies around its use that adhere to its own guidelines as well as constitutional and international law, necessitates an immediate commitment by ICE to end the practice entirely. Prior to publication, the authors of this report had the opportunity to present the findings to key personnel in DHS and ICE.

The report makes the following recommendations to the Secretary of the U.S. Department of Homeland Security (DHS) and to the Director of ICE, which serve as a road map to completely phase out the use of solitary confinement in immigration detention.

1. Publicly commit to ending the use of solitary confinement in all immigration detention facilities. As it abandons solitary confinement, DHS and ICE must express this commitment in the form of a binding directive. The directive should:

1. Require a presumption of release from ICE detention for people who have reported existing vulnerabilities, including, but not limited to, people with serious medical conditions, mental health conditions, disabilities, LGBTQIA+ people, and survivors of torture and/or sexual violence. These people should be released into the safety of their community with post-release care plans in place, per the 2022 ICE directive, in addition to providing resources and referrals for social, legal, and/or medical services as appropriate.
2. Mandate that any person in detention be afforded 24-hour access to qualified mental and medical health care professionals who respond in a timely manner and in compliance with the Health Insurance Portability and Accountability Act (HIPAA).
3. Require increased transparency from ICE’s Detention Monitoring Council by making properly redacted or deidentified reports and reviews related to solitary confinement publicly available on the agency’s website within 72 hours of the order to place someone in solitary confinement.

2. Amend the 2013 “Segregation Directive” to ensure that every immigration detention facility, public or privately contracted, is required to report concurrently to ICE Field Office Directors and ICE headquarters within 24 hours of placing someone in solitary confinement. ICE headquarters, in turn, must share this consolidated “segregation”/solitary confinement data with the DHS Office of the Secretary within 72 hours. This requirement must apply to every confined person, regardless of the duration of their confinement or whether they have a vulnerability. Additionally:

1. For those who are currently in solitary confinement, require a prompt and meaningful psychosocial and medical evaluation, undertaken by qualified medical professionals, who can assess the prevalence and extent of existing vulnerabilities;
2. For those scheduled for placement in solitary confinement, require a meaningful psychosocial and medical evaluation by qualified medical professionals who can assess the prevalence and extent of existing vulnerabilities prior to such a placement;
3. Mandate the reporting of race and ethnicity of each person in solitary confinement;
4. Mandate reporting of the justification provided for initial confinement; justification for continued confinement; duration of the confinement; any vulnerabilities identified; and a detailed description of the alternatives to solitary confinement that were considered and/or applied, as listed in 5.3.(2) of the 2013 “Segregation Directive.”
5. Require daily checks and regular monitoring and documentation by qualified and licensed health care professionals against a detailed checklist created in partnership with independent medical professionals, that includes reviewing vital signs, checking for signs of self-harm, and any other indicators of deteriorating mental and physical health; 
6. Require the routine sharing by ICE of deidentified data acquired from the above reporting mechanisms on its website every two weeks as part of its release of Detention Statistics, until it has ended the use of solitary confinement.

3. Revise current contracts and agreements with immigration detention facility providers and contractors to include stringent performance standards and clear metrics for compliance regarding the use of solitary confinement. Compliance should be assessed through regular and comprehensive inspections by the Contracting Officer. Additionally, to increase adherence to detention standards, ICE must:

1. Introduce a performance-based contracting model, where a portion of payment is contingent upon meeting certain performance and reporting indicators, including those listed in recommendations 1 and 2 herein; and
2. Impose immediate financial penalties for any violation of performance and reporting indicators, and contract termination for repeated or persistent violation.

4. Establish a task force led by the Office of the Secretary of DHS to develop a comprehensive plan including specific recommendations for phasing out the use of solitary confinement. The task force must include:

1. Members with knowledge of, or expertise regarding, the mental and physical health consequences of the use of solitary confinement;
2. Independent medical experts;
3. Independent subject matter experts from civil society (including those with expertise in the use of solitary confinement in criminal and civil custodial settings and human rights);
4. Formerly detained immigrants who have experienced solitary confinement in ICE custody; and
5. Employees of the following offices:

• Civil Rights and Civil Liberties (CRCL);
• ICE Health Services Corps (IHSC);
• Immigration Detention Ombudsman (OIDO);
• Enforcement and Removal Operations (ERO); and
• Office of Professional Responsibility (OPR).

The plan must be presented to Congress and publicly accessible on ICE’s website upon completion, which shall be no later than one year after formation of the task force. Finally, recommendations included in the plan should ensure the end of ICE’s use of solitary confinement in immigration detention within one year of presentation of the plan to Congress and the public.

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Introduction

The United States operates the world’s largest immigration detention regime. On any given day, tens of thousands of adults and children are detained in a vast network of facilities, including those operated by private prison corporations,[1] county sheriffs, U.S. Immigration and Customs Enforcement (ICE), U.S. Customs and Border Protection (CBP), and the Office of Refugee Resettlement (ORR). Immigration detention is legally considered civil rather than criminal custody, but many immigrants are held in correctional facilities, which means the conditions of confinement are often the same as criminal incarceration.

As of the writing of this report, ICE is currently detaining more than 35,000 people.[2] These include people who have built a life in the United States for decades as well as people who have recently arrived seeking asylum, including trafficking or torture survivors who fled their home countries for their own safety. Those hoping to find refuge in the United States are instead imprisoned, often for months or even years while they wait for their immigration applications to be resolved or to be deported. As they wait, they are frequently subjected to inhuman conditions, including, as this report details, the danger, indignity, and harm of solitary confinement – being held in small cells with little or no contact with other people for days, weeks, or even years at a time.[3]

Given the lack of oversight and transparency regarding the use of solitary confinement in immigration detention, Physicians for Human Rights (PHR), along with faculty and students at Harvard Law School (HLS) and Harvard Medical School (HMS), have sought to spotlight what is happening in the “black box” of solitary confinement in ICE detention centers. This report is the culmination of that work and reflects years of research, to uncover how many people have been held in solitary confinement, the conditions in solitary confinement, the sense of helplessness felt by those subject to solitary confinement – sometimes for months or even years – and the harmful impact of solitary confinement on people after their release from detention.

Much of the data in this report was obtained by faculty and students at HLS through Freedom of Information Act (FOIA) requests and subsequent litigation that builds on records previously obtained by the Project on Government Oversight (POGO) and the International Consortium of Investigative Journalists (ICIJ). This report also draws on dozens of personal interviews with survivors of solitary confinement conducted by faculty and students at HMS. This report details the abusive and excessive use of solitary confinement in immigration detention. For example, ICE oversaw more than 14,000 placements in solitary confinement between 2018 and 2023.  Many people who are detained in solitary confinement have preexisting mental health conditions and other vulnerabilities.[4] The average duration of solitary confinement is approximately one month, and some immigrants spend over two years in solitary confinement, [5] illustrating how concerns repeatedly raised by members of Congress and government auditors, and whistleblowers alike about the prolonged and excessive use of solitary confinement have been ignored.[6]

Background

Solitary Confinement in ICE Detention

Solitary confinement is generally defined as isolating someone in a cell for 22 hours or more per day without meaningful human contact.[7] However, ICE describes this practice euphemistically as “segregation” or “segregated housing,” using it as both punishment (termed “disciplinary segregation”) and ostensibly for safety (“administrative segregation”).[8] In this report, the term “solitary confinement” will be consistently used, unless directly quoting ICE or other official government records where the term “segregation” was applied. Notably, the need for medical isolation when no “designated medical unit exists” is one stated purpose of administrative “segregation.” However, this is in stark contrast to standard medical care of patients who need isolation for medical reasons. In the latter, isolation rooms are simply normal rooms with windows and regular furniture and bedding but the influx and egress of persons are controlled. Rooms are not locked, isolated persons do not lose most of their “privileges,” and while confined, one is made to feel like a patient, not a prisoner.

The adverse health effects of solitary confinement are well-documented and include post-traumatic stress disorder (PTSD) and increased risks of self-harm and suicide.[9] According to research, isolation can cause lasting brain damage and trigger symptoms such as hallucinations, confusion, heart palpitations, disrupted sleep, and reduced cognitive function.[10] These symptoms can extend beyond the period of solitary confinement and affect people after their release by causing enduring psychological and physical disabilities and impairments.[11] For people with preexisting medical and mental health conditions, solitary confinement can worsen existing conditions and even lead to suicide.[12] Solitary confinement thus exacerbates the well-documented high rates of suicide of immigrants in ICE detention.[13]

International law clarifies that prolonged solitary confinement “can amount to torture or cruel, inhuman or degrading treatment or punishment when used as a punishment … for persons with mental disabilities or juveniles.”[14] As such, in 2011 the UN Special Rapporteur on Torture called for an “absolute prohibition” on solitary confinement for more than 15 days.[15] Additionally, the Rapporteur recognized that shorter periods of solitary confinement for legitimate disciplinary reasons can constitute “cruel, inhuman or degrading treatment or punishment where the physical conditions of prison regime (sanitation, access to food and water) fail to respect the inherent dignity of the human person and cause severe mental and physical pain or suffering.”[16]

ICE Directives on Solitary Confinement

2013 “Segregation Directive”

After years of documentation and advocacy by civil society, ICE issued a directive in 2013 – over a decade ago – that mandates limiting and monitoring the use of solitary confinement in immigration detention. The 2013 “Segregation Directive” describes two forms of solitary confinement: administrative segregation and disciplinary segregation.[17] Before someone can be placed in disciplinary segregation, the directive states that there must be a hearing and a finding by a disciplinary panel.[18]

According to the 2013 “Segregation Directive,” administrative segregation is “a non-punitive form of separation from the general population” and is authorized “only as necessary to ensure the safety of the detainee, facility staff, the protection of property; or the security or good order of the facility.”[19] Consequently, the directive warns that placement in solitary confinement “is a serious step that requires careful consideration of alternatives” before it is used.[20] For people with special vulnerabilities, such as those with mental health conditions, serious medical conditions, disabilities, LGBTQ+ people, and torture, trafficking, and trauma survivors, the directive mandates that solitary confinement should be “only used as a last resort and when no other viable housing options exist.”[21] Facilities must notify the ICE Field Office Director (FOD) if someone has a special vulnerability as soon as possible but not more than 72 hours after placement in solitary confinement, or when anyone has been placed in solitary confinement for 14 consecutive days or 14 days in a 21-day period.[22]

Special Protections for Vulnerable Populations

2015 Memorandum: Transgender People in Detention

In 2015, ICE issued a memorandum emphasizing the need for additional protections for transgender people in detention. Like the 2013 “Segregation Directive,” the 2015 guidance emphasized that transgender people should be placed in solitary confinement only “as a last resort and when no other temporary housing option exists.”[23] Under the guidance, if a facility cannot meet this requirement or if there are concerns about the conditions of confinement, ICE is required to examine whether transferring the person to a different facility is a viable option.[24]

2022 Directive: “Individuals with Serious Mental Illness”

In 2022, ICE issued a further directive related to detained persons with serious mental health conditions that reiterated the heightened reporting requirements when placing such persons in solitary confinement.[25] The directive further echoed the 2013 “Segregation Directive” by specifically mandating that facilities notify the ICE FOD and the ICE Office of the Principal Legal Advisor within 72 hours of placing any immigrant with a serious mental health condition in solitary confinement. [26]

ICE Solitary Confinement Oversight Mechanisms

 The 2013 “Segregation Directive” requires FODs to collect data from facilities on their use of solitary confinement so that ICE headquarters can provide oversight. Specifically, immigration detention facility administrators are required to notify FODs within 72 hours of the use of solitary confinement on anyone who has medical or mental illness, has a special vulnerability and/or because the detained person is an alleged victim of sexual assault, is an identified suicide risk, or is on hunger strike.[27] The 2013 “Segregation Directive” also mandates reporting on the prolonged use of solitary confinement for any person with or without these vulnerabilities when they have been held “for 14 days, 30 days, and at every 30-day interval thereafter” or “for 14 days out of any 21 day period.”[28]

ICE’s oversight mechanism for solitary confinement has been described in more detail by the U.S. Government Accountability Office (GAO) in a 2022 report.[29] Per the report, ICE headquarters staff within “Custody Management” conduct reviews of all solitary confinement placements in what is known as a “Segregation Review Management System” (SRMS).[30] The staff review compliance with ICE detention standards and directives. Representatives of a select group of ICE offices, including Custody Management, Office of the Principal Legal Advisor attorneys, and ICE Health Service Corps, also conduct weekly reviews for compliance with detention standards.[31]

ICE also maintains a “Detention Monitoring Council,” comprised of management officials who meet quarterly to discuss overall detention-related issues, including solitary confinement. Headquarter officials from Custody Management present a report on solitary confinement statistics, which includes, among other things, length of solitary confinement, reasons for confinement, and how many [individuals] were considered members of vulnerable populations.[32]

In addition to oversight through the mechanisms described above, solitary confinement practices are also monitored through facility inspections and onsite monitoring of detention standards compliance, including by independent inspectors, and by the DHS Office of Inspector General (OIG).[33]

A process map of ICE’s oversight mechanism for solitary confinement, as described in the GAO report, can be seen in Graphic 1, below.[34]

Documentation of Noncompliance and Abuse

Despite these directives, whistleblowers and government investigators alike have documented the abuse and overuse of solitary confinement in immigration detention over the past decade, particularly among vulnerable groups such as people with mental health conditions, physical disabilities, LGBTQ+ people, and survivors of torture and domestic violence.[35] Oversight mechanisms have also been repeatedly flagged as failing to ensure compliance.[36] Indeed, current Homeland Security Secretary Alejandro Mayorkas has been on notice about these failures related to solitary confinement since 2014.[37] The OIG, which provides independent oversight of DHS, has expressed concern about ICE’s repeated failure to follow its own directives limiting the use of solitary confinement.[38] In a 2021 audit, OIG reiterated those concerns while flagging ongoing problems with complying with reporting requirements and record retention policies related to “segregation.”[39] Recognizing that solitary confinement can result in severe negative psychological effects, particularly for people with preexisting mental health conditions or people at risk of suicide, OIG also concluded that ICE had failed to document whether it properly considered alternatives before placing someone in “segregation.”[40]

Similarly, a 2022 report from the GAO again highlighted that ICE did not consider alternatives to “segregation” for most placements.[41]

Recent Developments and Persistent Failures

In September 2023, the Department of Homeland Security’s Office for Civil Rights and Civil Liberties (CRCL) and the DHS Office of General Counsel issued a memorandum documenting more than 60 complaints over the past four years regarding people with serious mental health conditions or a mental health disability held in solitary confinement in ICE custody across the country.[42] The seven examples provided in the memorandum reflected a range of issues, including immigrants held in solitary confinement while on suicide watch and with diagnoses such as chronic PTSD, major depressive disorder, bipolar disorder, and schizophrenia.[43] The memorandum also revealed that immigrants were reluctant to report suicidal ideation and mental health concerns because they feared being placed in solitary confinement.[44] According to the complaints, immigrants were often left without access to psychiatric medication, access to counsel or legal visits, or the ability to send or receive mail while in solitary confinement.[45]

These concerns are longstanding. In 2012, PHR, in partnership with the National Immigrant Justice Center, published a report on solitary confinement in ICE detention, “Invisible in Isolation: The Use of Segregation and Solitary Confinement in Immigration Detention.”[46] That report demonstrated how solitary confinement of people in ICE custody was applied arbitrarily, inadequately monitored, harmful to health, and a violation of their due process rights.

Between 2012 and 2014, experts submitted reports to DHS’s Office of Civil Rights and Civil Liberties documenting deaths of people detained in solitary confinement, where the deceased had presented signs of mental illness, ranging from depression to schizophrenia. Despite having special vulnerabilities, they were nevertheless subjected to solitary confinement without consideration of more appropriate care or medication.[47]

Over 10 years later, little has changed. Recent complaints filed by advocates continue to highlight the arbitrary and excessive use of solitary confinement in immigration detention. In a Colorado facility, for example, advocates documented escalating misuse of solitary confinement, including its use as a retaliatory threat. One person was placed in solitary confinement more than 10 different times for reasons ranging from eating “too slowly” and speaking “too loudly” to having suicidal thoughts and being upset about deportation.[48]

Methodology and Limitations

A two-pronged approach guided the data collection for this report. First, faculty and students at HLS collected and analyzed data that they obtained from ICE and other federal agencies, including through litigation under FOIA. This data included reports, excel spreadsheets, e-mails and other documents from ICE and other federal agencies concerning the use of solitary confinement in immigration detention. Second, HMS faculty and students conducted qualitative, structured interviews with formerly detained immigrants who had experienced solitary confinement. While the aim with the ICE data was to generate aggregate statistics on people detained in solitary confinement in facilities nationwide, the goal of the interviews was to explore personal experiences in confinement.

ICE FOIA Data Analysis

With some limited exceptions, FOIA requires federal agencies like ICE to disclose previously unpublished or unreleased information pursuant to public records requests. In November 2017, HIRCP submitted FOIA requests to several federal agencies, including ICE, to obtain previously unpublished communications, records, training materials, evaluation reports, and memorandums documenting ICE’s use of solitary confinement in detention facilities.

After the agencies failed to adequately respond to these requests, HIRCP successfully sued ICE and other federal agencies in federal court. In July 2023, the U.S. District Court for the District of Massachusetts ordered ICE to respond to many of HIRCP’s requests.^[49] In October 2023 – six years after HLS filed its original FOIA requests – ICE finally produced records detailing its use and misuse of solitary confinement in immigration detention.

ICE uses the SRMS to track solitary confinement placements. HIRCP received a redacted SRMS spreadsheet from ICE detailing, among other things, the reasons for placing people in solitary confinement, the dates those people were placed in solitary confinement, the duration they were held in solitary confinement, and the names of facilities that placed people in solitary confinement.^[50] The spreadsheet is similar to records obtained by POGO and ICIJ,^[51]but the information obtained by HIRCP includes more recent data on solitary confinement placements with release dates between September 4, 2018 and September 13, 2023. This data came from 125 facilities throughout the United States that are run by or contract with ICE.^[52]

HLS faculty and students analyzed the data using Microsoft Excel and Stata to determine the average length of time that people were held in solitary confinement as well as the total number of solitary confinement placements. Further analysis was conducted to compare this data across years and facilities. Additionally, HLS assessed some of the reasons listed for why immigrants were placed in solitary confinement. The code and data to reproduce these analyses are available online at Harvard Dataverse, https://doi.org/10.7910/DVN/AT7YFA.

HLS faculty and students also reviewed several ICE quarterly reports as well as medical expert reports commissioned by CRCL that were produced in response to the FOIA litigation.^[53] The medical expert reports focused on assessing mental health conditions of people detained, as well as assessing mental health resources at the Henderson Detention Center, Nevada; Etowah County Detention Center, Alabama; Clinton County Correctional Facility, Pennsylvania; and Houston Contract Detention Center, Texas.^[54]

Despite the significant disclosures obtained through the FOIA process and litigation, several limitations restricted HIRCP’s analysis. By the time of this report, ICE had still not released all the data the district court ordered it to produce.

Limitations of FOIA Data Analysis

ICE has consistently provided inaccurate information about the use of solitary confinement in immigration detention facilities via its SRMS. Firstly, the SRMS data documented far fewer placements of people in solitary confinement than calculated by the OIG in its 2021 report, in which OIG obtained records directly from detention facilities for a sample of 474 individual “segregation” placements from fiscal years 2015 to 2019.[55] Specifically, the SRMS dataset for these chosen placements lacked about 16 percent of the solitary confinement placement records that the detention centers reported for the same time period.[56]

Second, comparing ICE’s SRMS data with vulnerable population data trackers, a 2022 report from the GAO revealed underreporting.[57] To reach this conclusion, GAO compared data produced by ICE to available vulnerable population data trackers and found serious discrepancies with the SRMS data.[58] For instance, it found that only about 76 percent of people with a mental health condition and only about 12 percent of the people with a serious mental health condition were actually reported by SRMS.[59]

Inconsistencies with SRMS data continue as data that ICE has only made publicly available for 2022 and 2023 reflects. Comparisons between publicly published quarterly ICE aggregate statistics from 2022 and 2023[60] and data HLS obtained through FOIA litigation[61] revealed a substantial underreporting in the number of placements and length of solitary confinement of vulnerable populations reflected in the FOIA SRMS data.[62] According to the publicly available ICE data, there are up to twice as many placements of vulnerable immigrants in solitary confinement during 2022 and 2023 than reflected in the FOIA SRMS data.[63] In addition, the publicly available ICE data for 2022 and 2023 show that the number of placements of vulnerable immigrants in solitary confinement is increasing at a faster rate than the number reflected in the FOIA-obtained SRMS data.[64]

Similarly, the average length of time in solitary confinement of vulnerable immigrants was much longer in ICE’s publicly available quarterly statistics than reflected in the FOIA SRMS data. With an increasing trend, the duration of solitary confinement ranged from one to 10 days longer in the ICE publicly available reports than the FOIA-obtained estimates.[65] These publicly available quarterly aggregates of vulnerable populations suggest a strong possibility of longer solitary confinement durations for people with mental illnesses than this report shows.

Lastly, CRCL evaluations also revealed that immigration facilities misrepresented their use of solitary confinement.[66] One CRCL evaluator encountered an “especially disturbing” incidence of misreporting at the Houston Contract Detention Facility in 2014.[67] Though ICE policy requires staff to offer programs in a comparable fashion to detained persons in administrative “segregation” and those in the general population – and the staff at the Houston facility actively assured the evaluator that they had complied with this – the evaluator reported that “none of this turned out to be true.”[68] The evaluator found that immigrants in administrative “segregation” were denied access to programs, shackled, and locked in their cells for approximately 22 hours a day.[69] The staff’s offering of misinformation “compromised the integrity of [the] facility review.”[70] Without accurate ICE reporting, other immigrants may similarly suffer in silence. Due to a combination of these issues, this report may in fact underrepresent the total number of immigrants placed in solitary confinement, their mental statuses, and their durations in confinement.

Structured Interviews with Formerly Detained People

From March 6 to August 17, 2023, the HMS research team conducted 26 interviews with people formerly detained in immigration detention using a standardized questionnaire developed by the research team. All study participants were 18 years of age or older, had been released from immigration detention, and had experienced at least one period of solitary confinement during detention in the United States after September 4, 2013. This date corresponds to the day in which the ICE “Segregation Directive” was published that ordered limits on the usage of solitary confinement in detention centers and contained a pledge to “ensure the health, safety, and welfare of detainees in segregated housing.”[71] All interviews were conducted by WhatsApp or standard telephone call, in languages in which participants were fluent (English or Spanish). While the study was open to speakers of any language, all participants spoke either fluent English or Spanish, so no outside interpreters were necessary. Interviews lasted approximately one hour. Participation was voluntary, and all participants provided verbal informed consent to participate in the study. A $40 electronic gift card was offered to participants as reimbursement of a standard meal and phone minutes. This study was reviewed by the HMS Institutional Review Board and determined to be exempt from further review. The study was also reviewed and approved by PHR’s Ethical Review Board. 

Structured interviews were based on a questionnaire (see Appendix A) that was designed to assess the implementation of ICE’s National Detention Standards (NDS) (Version 2.0, 2019).^[72],[73] The questionnaire included three sections: 1) Demographics; 2) Solitary Confinement Conditions; and 3) Solitary Confinement Experiences. The data collected during the interviews were both quantitative and qualitative in nature. All quantitative data were statistically analyzed in Excel (Version 16.40).

Participant Recruitment

Participants were recruited through outreach to immigration attorneys. Attorneys were asked to present information about the study to clients released from immigration detention who met inclusion criteria using a standardized script and flyer. Additionally, participants were able to refer other potential study participants.

Attorneys and participants were notified that this study did not include a language restriction. All referral information was placed into an anonymous, secure REDCap referral form. Referral information included the participant’s phone number, time availability, preferred language, and preferred mode of contact (WhatsApp or telephone). Names of participants were not requested or collected via the referral form to ensure anonymity and protect participants. Thirty-two potential participants were referred to the study and contacted by research staff. Six referred persons either decided not to participate or were unable to be reached to schedule the interview. Twenty-six people participated in the study and completed the entire questionnaire verbally. All participants accepted the electronic gift card.

Human Subjects Protections

Most participants were contacted through WhatsApp, which provides end-to-end encryption. For participants who did not have or prefer WhatsApp, a regular telephone line was used to conduct the interview. Prior to initiating the interview, the consent form was verbally reviewed with participants in its entirety, and verbal consent was obtained. Written consent forms in participants’ preferred language were also sent prior to the interview or offered. Participants were assured that their interview was confidential, that no identifying information would be collected, and that none of their responses would be communicated to their attorney or affect their pending immigration case (if they had one – many had already been deported). During the interview, quantitative and qualitative data was collected in real time in a secure REDCap database. No identifying information was collected or stored. Participant information (including the participant’s phone number) was collected in a separate REDCap database that could not be linked to participants’ survey responses. Finally, participants who accepted the electronic gift card for participation were sent the electronic gift card through WhatsApp, short message services, or, if preferred, e-mail. Any e-mail communication with lawyers and participants was conducted through a Harvard Medical School delegated-access e-mail account used exclusively by study staff, and all correspondence was deleted 30 days after completion of the study. The study staff’s WhatsApp accounts used to contact participants and conduct the interviews were also cleared of correspondence data after completion of all interviews. 

Limitations of the Interview Study

The data presented in the report represent the reported experiences of 26 people held in immigration detention in a limited number of facilities across the United States. Given the study’s modest sample size, we do not capture the full range of experiences of ICE-detained people experiencing solitary confinement in the United States. Additionally, some facilities were only known to the participants by their state location rather than the city, so it was not possible to know how many distinct facilities were represented. The interview portion of this study may also suffer from sampling bias in that attorneys may have only referred specific participants whom they felt would be comfortable participating. Participants sometimes referred friends they had made while in detention together, representing additional sampling bias. Although this study did not include a language restriction, lawyers may have been more likely to refer clients with whom they could communicate more easily without the use of an interpreter. This data was also subject to potential recall bias, as responses were based on participant memory of detention conditions. There was potential for variation in interview style among interviewers, but care was taken to minimize this variability through extensive interviewer training before and during the study period and by including at least two staff members per interview (one interviewer, one recorder) for each interviewer’s first interview. The use of a structured questionnaire with consistent wording was designed to reduce interviewer bias. Prior to publication, the authors of this report had the opportunity to present the findings to key personnel in DHS and ICE.

Key Findings

View from Government Records

Immigration Detention Facilities Used Solitary Confinement Extensively

One of ICE’s directives recognizes that the use of solitary confinement “is a serious step that requires careful consideration of alternatives” and calls on facilities to limit their use of solitary confinement only to situations where it is “necessary.”[74] Despite this standard, ICE documented well over 14,000 solitary confinement placements in the past five years alone.[75] These placements lasted 27 days on average, well in excess of the 15-day period that constitutes torture, as defined by the Special Rapporteur on Torture. Indeed, with a median length of confinement of 15 days, nearly half of the recorded placements exceeded 15 days and many placements lasted far longer: 682 solitary confinement placements lasted at least 90 days, while 42 lasted over a year.[76] In almost 30 percent of solitary confinement placements lasting over 90 days and 25 percent of placements lasting over 365 days, the people placed in solitary confinement suffered from a mental health condition.[77]

Additionally, the FOIA data reveal numerous egregious examples of facilities holding people in solitary confinement for years at time:[78]

• Just under two years (727 days) (Denver Contract Detention Facility, CO)
• Over a year and a half (759 and 567 days) (Otay Mesa Detention Center, CA)
• Over a year and a half (652 days) (Buffalo Service Processing Center, NY)
• Over a year and a half (637, 559, and 550 days) (Northwest ICE Processing Center, WA)
• Just under a year and a half (526 days) (Eloy Federal Contract Facility, AZ)

Strikingly, for-profit corporations operate all five of the facilities with the longest periods of detention.[79]

The Northwest ICE Processing Center also had one of the highest (ninth out of 125) average lengths of solitary confinement stays on record (average length at this location was 55 days).[80] Conditions at the Denver Contract Detention Facility were also poor overall: the average length of stay at this facility between 2018 and 2023 was 52 days.[81] The American Immigration Council and other groups have documented the repeated misuse of solitary confinement at the Denver facility and in July 2023 filed an administrative complaint with DHS’s Office of Inspector General, CRCL, Office of the Immigration Detention Ombudsman, and ICE’s Office of Professional Responsibility.[82]

Data Spanning Several Years Shows No Improvement

In every year between 2019 and 2022, there were several thousand new solitary confinement placements (between 2,000 and 3,300), reported in immigration detention.[83] As of September 2023, there were already 2,301 reported placements.[84] In light of the recent uptick in immigration enforcement,[85] and assuming a similar number of new solitary confinement placements in each of the remaining four months of 2023, the total number of placements in solitary confinement for 2023 likely surpassed 3,000 people.

The proportion of people in solitary confinement in ICE, out of the total number of those in ICE detention overall, has varied over time.[86] This number spiked in 2020 in conjunction with COVID-19 because immigration detention facilities used “solitary confinement under the guise of medical isolation.”[87] While the number of people held in solitary confinement has declined from its peak in 2020, there has generally been an upward trend in the percent of people detained who are held in solitary confinement since its lowest point in mid-2021.[88]

*ICE released this graph of 2023’s third quarter solitary confinement statistics on October 16, 2023.

According to ICE’s own quarterly reports, there were 1,106 solitary confinement placements in the third quarter of 2023.[89] This represents a 14.6 percent increase from the previous quarter, and a 61 percent increase from a year ago, based on the most recent data that ICE had released at the time this report was written.[90]

Also, the average length of solitary confinement placements remained well above 15 days in each of the past five years.[91] For 2023, this average was already at 23 days by September.[92] The average length of placements was 65 days for people who were placed in solitary confinement but were not released by the date ICE produced the SRMS data. As it is unknown when and if they were released, this is an underestimate.

Solitary Confinement Used Arbitrarily and as Punishment

Immigration detention facilities are authorized to use solitary confinement only as a last resort.[93] Yet facilities often placed immigrants in solitary confinement to punish minor disciplinary infractions. For example, FOIA documents indicate that on at least one occasion an immigrant was placed in solitary confinement for 29 days for “using profanity” and two immigrants were placed in solitary confinement for 30 days because of a “consensual kiss.”[94] In another record, ICE documented that an immigrant was placed in solitary confinement for 38 days because they “refused to get out of bunk during count.”[95]

This pattern of arbitrary solitary confinement placement is reflected in the administrative complaint filed regarding the Denver Contract Facility, where the facility put one person in solitary confinement for “eating too slowly.”[96] This same person faced solitary confinement 10 more times, for similarly groundless reasons: “If I climbed on top of a table to get a guard’s attention, solitary [confinement]. If I had suicidal thoughts, solitary [confinement]. When the guards would tease me about being deported back to my home country and make airplane sounds at me and gesture like a plane was taking me away, I would become upset and then get solitary [confinement] for being upset.”[97]

In other cases, immigration detention facilities appear to have deliberately discriminated against immigrants identifying as transgender.[98] In 2014, a CRCL evaluation of the Houston Contract Detention Facility found multiple incidents of facility discrimination against transgender immigrants.[99] The evaluator stated that transgender immigrants were disproportionately subjected to security measures typically used for immigrants placed in solitary confinement for aggressive behavior, such as “lock-down in their cells[,] use of cuffs for movement within the facility [and] inability to attend groups available to general population inmates.”[100] CRCL further noted that this treatment can “cause mental trauma and distress that resulted in avoidable suffering, depression, and suicidality.”[101] The FOIA data included 62 detainees that were placed in confinement for the following reason: Protective Custody: Lesbian, Gay, Bisexual, Transgender (LGBT). The average length of stay for these detainees was 57 days, with a median of 34 and maximum of 286 days. In addition, a recent ICE report with quarterly statistics on solitary confinement reveals that the number of transgender immigrants in solitary confinement more than doubled (increased by 114 percent) in the third quarter of 2023, the most recent quarter of available data shared by ICE.[102]

Unsafe Detention Facility Conditions Exacerbated the Misuse of Solitary Confinement

Immigration detention facilities often placed people in solitary confinement to purportedly address issues such as overcrowding and threats to harm staff and/or other people in detention. In 2016, a facility put one person in administrative “segregation” “due to no available [bed] space” elsewhere in the detention center.[103] The facility’s staff left this person in administrative solitary confinement for 372 consecutive days because she requested to remain there “due to being afraid of being around other detainees.” Yet she was diagnosed by the facility psychologist as having multiple severe mental health conditions: PTSD and Major Depressive Disorder (MDD).[104] Though this person was not the only person to request solitary confinement in detention, solitary confinement is not an appropriate solution to a lack of safety among the general detention center population.

When people requested solitary confinement or facilities put them in it for other non-disciplinary reasons, they have been unable to “make any legal calls, have legal visits, [and] have access to [their] legal documents.”[105] Solitary confinement under the guise of protection can also be life-threatening. In one person’s words, “[the staff] told me solitary kept me safe and helped me, but it was only ever a punishment . . . I have tried to kill myself three times already because of this endless nightmare and the consistent torture of solitary confinement.”[106] Another person felt that the stress of returning to solitary confinement was “too much for him to bear,” and he also attempted suicide.[107]

People with Mental Health Conditions Unfairly Discriminated Against

According to the UN Special Rapporteur on Torture, people with mental health conditions should not be held in solitary confinement.[108] ICE’s 2013 “Segregation Directive” mandates that its facilities must not place vulnerable populations in solitary confinement unless as a “last resort.”[109] Yet many of the people placed in solitary confinement in immigration detention between 2018 and 2023 had documented mental health conditions and it was unclear what alternatives, if any, to solitary confinement were considered.[110] Among the 8,788 records for this period where ICE’s SRMS reported the mental health status of immigrants in solitary confinement, over 40 percent had documented mental health conditions.[111] In the redacted SRMS spreadsheet produced in the FOIA production,[112] ICE reported immigrants’ mental health status in only 62 percent of its total solitary confinement records. Based on multiple findings of discrepancies with SRMS data,[113] the actual number of immigrants with mental health conditions who were placed in solitary confinement between 2018 and 2023 could be much higher.

The percentage of immigrants with mental health conditions placed in solitary confinement jumped from 35 percent in 2019 to 56 percent in 2023.[114] Additionally, while SRMS reported that 20 percent of the solitary confinement placement records for immigrants with mental illnesses in 2019 involved an immigrant with a serious mental health condition, close to 27 percent of immigrants with mental health conditions in solitary confinement in 2023 were classified as suffering from a serious mental health condition.[115] Among people whom SRMS labeled as suffering from a mental health condition, the average length of stay in solitary confinement was approximately 23 days; however, the average length in solitary for detained persons suffering from a serious mental health condition was 33 days.[116]

Some of the facilities with highest average confinement lengths for immigrants with mental health conditions included the Richwood Correctional Center (LA), Denver Contract Detention Facility (CO), Yuba County Jail (CA), Otay Mesa Detention Center (CA), and Henderson Detention Center (NV).[117] The average length of solitary confinement for immigrants with mental health conditions at these facilities ranged from three to six months.[118]

Immigration detention facilities also likely violated the 2022 ICE directive related to the treatment of immigrants with serious mental health conditions by denying immigrants with mental health conditions the “necessary and appropriate treatment and monitoring” that the directive requires.[119] For example, the 2023 CRCL memorandum reported how one immigrant was placed in solitary confinement even though they suffered from MDD, bipolar disorder, PTSD, and schizoaffective disorder or psychosis; their placement in solitary confinement caused “the delay or discontinuation of important mental health medications.”[120]

Immigration detention facilities also used mental health conditions as a justification for placing immigrants in solitary confinement despite the well-known negative effects of solitary confinement.[121] In one record, ICE reported that a “[s]ubject was placed in protective custody after he was not able to properly care for himself in general population. Subject has been diagnosed with schizophrenia.”[122] This person was held in solitary confinement for 56 days.[123] In another instance, an individual with a mental health condition was held in solitary confinement for 28 days because they reportedly responded to officers with “irrational answers” and were observed making “unusual body movements.”[124]

Substandard Medical Care in ICE Custody Caused Severe Health Consequences

ICE’s failure to ensure adequate medical resources in detention centers created life-threatening conditions for immigrants in solitary confinement. CRCL reported that between 2012 and 2014, some facilities left immigrants without any meaningful access to a mental health professional.[125] In least at one facility, mental health professionals stopped working altogether.[126] Another facility had nursing staff without psychiatric training performing suicide risk assessments, staff giving medications to immigrants without their consent, and medical forms lacking immigrants’ past medical histories.[127] These conditions can acutely impact immigrants in solitary confinement.[128] For instance, one of CRCL’s evaluations reported that an immigrant was “[u]nable to sleep” and “starting to have hallucinations due to being locked in cell all the time.”[129] This immigrant stated that his depression was “getting worse day-by-day.”[130]

Immigration facilities also punished suicidal immigrants with solitary confinement.[131] At one facility evaluated by CRCL in 2012, facility staff “actively discourage[d] [suicidal] detainees from seeking help.”[132] This hostile environment was created by staff that forced suicidal immigrants to undress except for a safety smock and remain in solitary confinement without access to counseling until they denied their “current suicidal thought[s]”.[133] These procedures humiliated and punished immigrants in critical need of medical care.[134]

In Their Own Words: Interview Findings of Experiences in ICE Solitary Confinement

Participant Demographics

Twenty-six participants were interviewed (questionnaire provided in Appendix A) in total; 23 identified as male (88 percent), and one each identified as female, agender, and transgender man (4 percent each). Interviewee ages ranged from 29 to 56 years old (average 36.2 years). Participants were originally from 19 different countries, including 31 percent who were from Mexico, 23 percent from Colombia, and 12 percent from Honduras. Eight percent of the people were multilingual, comfortably speaking more than one language. Thirty-one percent of the participants felt “uncomfortable” or “very uncomfortable” speaking English and would have very likely required translation services while in detention to easily communicate with non-bilingual staff members. A comprehensive list of countries of origin and languages spoken by participants is included in Appendix B.

These 26 participants were detained in at least 34 unique detention facilities in the United States – representing 11 county/public facilities, 22 private facilities, and one mixed-status facility – across 17 different states. Some participants could not recall the exact name or city of the facility in which they were held, so this list is not exhaustive of the locations where interviewees were detained and/or experienced solitary confinement. Of the private facilities, 12 were run by GEO Group, five by CoreCivic, and one facility each by Ahtna Support and Training Services, Immigration Centers of America, LaSalle Corrections, and Valley Metro Barbosa Group. One location, the Donald W. Wyatt Detention Facility, is publicly owned but privately operated. Of the 34 identified facilities, people experienced solitary confinement in 23 of them (68 percent).

Misuse of Solitary Confinement

Spending up to a Year in Solitary Confinement

Interviewees experienced an average of 3.6 separate stays in solitary confinement (range 1–30 stays). Each stay lasted an average of 32.2 days, with a median of 14 days. This is nearly six days longer than the average confinement in “segregation,” as seen in the FOIA data between 2018 and 2023. There was substantial variation in how long detained persons stayed in solitary confinement, as seen in Graphic 9.

Out of 55 described distinct placements in solitary confinement, a majority (61 percent) lasted longer than 14 days (what ICE defines as “extended segregation”), and 37 percent were greater than a month. One person stated that they were in solitary confinement for more than a year (32-year-old agender person, Etowah County Jail).

Solitary Confinement Was Often Misused as Punishment

The most commonly reported reason for solitary confinement placement was disciplinary “segregation” (n=16, 62 percent) (Graphic 10). ICE’s standards explicitly state that disciplinary “segregation” can only be used after receiving “a hearing in which the detainee has been found to have committed a prohibited act and only when alternative dispositions would inadequately regulate the detainee’s behavior.”^[135] However, only seven (44 percent) of those placed for disciplinary reasons received an official hearing for disciplinary “segregation.” The majority did not receive this due process. One person reported that intimidation was used to dissuade him from having hearings. Instead, he was encouraged to plead guilty to the charges, because, contrary to guidance and directives, he was told that if he went to a hearing, “they would often double the punishment or the time. So instead of 10 days, suddenly you would get 20–30 days” (30-year-old man, Kandiyohi County Jail).

“If you don’t listen to their rules, that’s a reason to go to the hole. If you don’t do anything they ask you, that’s a reason to go to the hole.”

35-year-old man, Caroline Detention Facility

Accounts from study participants conflicted frequently with the regulations as outlined in the aforementioned ICE “Segregation Directives.” Solitary confinement was commonly used to punish people who submitted complaints, organized protests, or required medical isolation. For instance, eight people (31 percent) reported being put in solitary confinement after participating in a hunger strike.

The decision to place someone in solitary confinement often relied on the discretion of correctional officers, leading to instances where detained persons were placed in solitary confinement as a punitive measure despite not having done something that would warrant disciplinary “segregation.” One participant shared that he was assaulted by one of the officers in the facility, which led to chest pain. He then tried to relay his medical concern: “I had chest pain [from the assault] but the correctional officer said I was lying so they put me in solitary confinement” (34-year-old man, Bristol County Correctional Facility). Solitary confinement was also abused for minor offenses, such as taking food from the cafeteria to their rooms. One respondent who spent nearly his entire time in detention inside of solitary confinement stated, “I would go on a walk without a uniform and that was enough to be put in solitary [confinement]. For any minimal thing, they would find an excuse to put me in solitary [confinement]. Even to use the stove to heat up coffee, they gave me 7days of solitary [confinement]” (37-year-old man, Orange County Jail).

One interviewee reported a common understanding that people exhibiting symptoms of serious mental health conditions would be placed in solitary confinement instead of being connected to care. One participant said he saw people placed in straitjackets and thought of solitary confinement as where “mentally and psychologically unstable” people were placed (32-year-old man, Richwood Correctional Center).

A Lack of Transparency

When people were put into solitary confinement, there was often uncertainty regarding how long their stay would last. Thirteen people (50 percent of interviewees) were never given an estimate of how long they were going to stay in solitary confinement, and if they were, this estimate would often change. One participant stated, “when you go to ‘the hole’ [solitary confinement] you don’t know how long you are going to be there.” (39-year-old man, Eloy Detention Center). Study participants noted that officials exploited loopholes to keep detained persons in solitary confinement longer, through either enforcing multiple separate solitary confinement stays or transferring persons in solitary confinement between facilities. “They just kept me there until they transferred me, because by the policy you can’t keep people for more than 2 weeks in solitary [confinement],” said one participant, “So when I complained about it, they just transferred me.” (33-year-old man, Caroline Detention Facility).

“They give you a paper saying what they say happened. If you don’t agree, they put you in longer.”

31-year-old man, Bristol County Correctional Facility

According to various directives, those in disciplinary “segregation” should have received reviews every seven days. However, only nine people (35 percent) remember being interviewed by a supervisor and only 14 people (54 percent) received a written review of why they were placed in solitary confinement. This suggests that there was a lack of transparency with people in solitary confinement, who may have had only brief interactions with supervisors overseeing their solitary confinement stay and did not have clear communication regarding this process.

Concrete Beds and 24/7 Lights Were Commonplace

Being placed in solitary confinement meant experiencing substantially worse living conditions than those in the general population at those same facilities. While specific descriptions of each cell differed, almost every participant described minimal furniture, uncomfortable bedding, small room sizes, and small windows. Eleven people (42 percent) reported having worse mattresses and bedding in solitary confinement compared to those issued in the rest of the detention facility. Specifically, seven people reported bedding was of poorer quality or described having no mattress at all, noting that the “bed was made out of cement with no cushion, only a blanket” (29-year-old man, unknown center in Louisiana) or just steel surfaces.

Interviewees described a lack of autonomy over basic control of their living conditions. One participant described how “the correctional officer (CO) had control of the light and flushing of the toilet; [I] had to bang the door and say ‘CO, bathroom! or CO, light!’”(34-year-old man, Bristol County Correctional Facility).

“The light is on 24 hours a day… the guards wouldn’t dim or turn them off at times… we went crazy, we tried to cover those lights with paper.”

30-year-old woman, Irwin County Detention Center

ICE standards require that all “cells and rooms used for purposes of “segregation” must be well-ventilated, adequately lit, appropriately heated/cooled, and maintained in a sanitary condition at all times, consistent with safety and security.”^[136] Despite these specifications, the lighting and temperatures of the rooms were controlled by the facility staff to create uncomfortable living conditions, leading to sleep deprivation and disorientation as to the time of day. For example, several people described the temperature in the rooms as being unbearably cold, with the air conditioner on at all times and not being provided blankets or jackets if they asked.

One person stated, “I lost all sense of time – lights were on all the time and there were no clocks on the walls or windows” (32-year-old man, Richwood Correctional Center). Twenty people (77 percent of interviewees) described having fluorescent lights in their room that were turned on either 24 hours per day or for prolonged periods, such as from five in the morning until midnight.

Keeping lights on for prolonged periods of time is known to cause sleep deprivation through dysregulation of the body’s natural sleep–wake cycles, or circadian rhythm, and may lead to cognitive disorganization, paranoia, and hallucinations.[137] These conditions included social isolation, constant bright lighting, and cold exposure are well-documented strategies for torture and interrogation designed to inflict psychological distress and have been described in immigration detention settings in the United States.[138]

Smaller and Worse Meals in Solitary Confinement

ICE’s own standards state that while in detention, people should be given “nutritious, attractively presented meals” and that “food rations shall not be reduced or changed or used as a disciplinary tool.”^[139]

However, eight people (31 percent) reported that their meals in solitary confinement were worse than those served to the general population. Three people said that the portions were smaller than usual – even half the size of normal. Although most participants reported being served three meals a day, three people reported that the facility sometimes only provided two meals (breakfast and dinner) a day to them while in solitary confinement. When one participant asked for water, he was told “to drink water from the toilet” (37-year-old man, Orange County Jail).

Meals could also be of such poor quality that the food was inedible, because it was either expired or unappetizing, such as resembling “vomit”(32-year-old agender person, Etowah County Jail) or “soggy tuna on bread” that looked like “cat food” (29-year-old man, unknown center in Louisiana).

Dietary restrictions for various medical conditions or religious exemptions were not always accommodated. One interviewee with food allergies said that he “told the kitchen [about the allergy], they told me to talk to the doctor. Then the doctor told me to talk to the kitchen. I couldn’t eat anything for months. I’m allergic to the turkey, I’m allergic to basically everything. So, I didn’t eat most of the time in there.”(41-year-old man, Golden State Annex). Another participant shared that, “I asked for a halal meal and the correctional officer was like ‘when you want to eat good food, go back to Africa.’ He said, ‘if you don’t eat this, I’m not giving you no food.’ But that’s my right to eat halal meals.”(34-year-old man, Bristol County Correctional Facility).

Access to Communication and Services

Restricted Legal and Personal Communications   

While people were held in solitary confinement, all communication outside of the detention center was closely monitored and restricted. Seven people (27 percent of the participants) were never able to call anyone on the telephone while in solitary confinement, and eight people (31 percent) could not write or receive letters. The remaining interviewees often had significant limitations on who they could talk to, even facing cases where “they blocked every number on my phone. It got to the point where I was only able to talk to my attorney”(38-year-old man, Montgomery Processing Center). These constraints meant that sometimes people could not let their loved ones know that they were in solitary confinement. There were also time limitations (as brief as five minutes per call), prohibitive costs (video calls cost $3 a minute), and sparse access to phones (sharing one telephone between 20 to 40 cells). Five people also said that their calls were monitored and recorded – especially calls to their lawyers or to the press – and that they could have their connections cut if they were heard discussing the living conditions inside detention or other complaints. The majority (65 percent) of participants also experienced staff violating their privacy by not keeping mail private, One in particular cited that facility staff would “open and read your letters and decide whether or not to send them; or keep them there”(34-year-old man, Bristol County Correctional Center).

“If I ever told my wife about mistreatment during a phone call or showed my wife the living conditions during a video call they would end my call immediately.”

50-year-old man, Northwest ICE Processing Center

These restrictions on people’s ability to communicate with the outside world also prevented interviewees from relaying information to their legal teams. Several people reported that the times they had to access the phone were at night, and they [facility staff]“only let me out after work hours so I couldn’t get in contact with anybody” (33-year-old man, LaSalle Processing Center). Even though the National Detention Standards (NDS) maintain that detainees in SMU (Special Management Unit) “may not be denied legal visitation,” people reported variable access to their lawyers.^[140] While some people could see their legal team once a week, others could only reach them on the phone and faced significant barriers to receiving legal advice.

Limited Access to Recreation, Hygiene, and Religious Services

Interviewees described frequent limitations to recreation and hygiene instituted as punitive measures. Even when these rights to participate in recreation and religious events were explicitly protected in ICE’s NDS guidelines,[141] people reported being unable to do so while in solitary confinement.

People in solitary confinement should be offered at least “one hour of recreation per day … at least five days a week.”^[142] While the remaining 23 hours were spent confined inside the cell, this one hour a day represented the only time people had to shower, talk on the phone, and use the recreational facilities. Seven people (27 percent) “rarely” or “never” received this much recreational time in solitary confinement. In these cases, the detained persons should have received a form of written correspondence about why and for how long their recreation was to be suspended.[143] Yet no interviewees received any such notice.

The NDS say that people in solitary confinement can “shower at least three times weekly” to maintain their personal hygiene.^[144] A majority (73 percent) of participants could shower between three to seven times a week; however, seven (27 percent) could only shower twice a week or never. For some in solitary confinement, showering was only allowed during their limited designated recreation time, forcing them to make difficult decisions about if they should allocate their time to shower or talk to others on the telephone.

While in detention, people are reliant on the commissary to purchase basic necessities such as soap, shampoo, and deodorant. However, 15 people (58 percent) were not able to use the commissary while in “segregation” at all.

Finally, although the NDS state that persons in solitary confinement “shall be permitted to participate in religious practices” unless there is an explicit safety concern,^[145] most people reported that they were not allowed to leave the cell to attend religious services and their requests to join were denied. A majority of participants (16 people; 62 percent) reported never being able to participate in religious practices while in solitary confinement. Two interviewed persons reported that they faced discrimination as Muslims: there were no specialized Islamic services, and the Qur’an was only available for purchase at exorbitant prices whereas the Bible was provided for free.

Medical Health Care in Solitary

Lack of Regular Medical Assessments in Solitary

“When you’re in solitary [confinement], you don’t get to see any doctors, nurses, dentists, anything .… There would have to be something really wrong with you .… But usually you don’t see any doctors, or nurses, dentists, or anything when you’re in seg.”

30-year-old man, Kandiyohi County Jail

Many interviewees had significant medical needs requiring attention during solitary confinement. Fifteen people (58 percent of interviewees) had a medical condition requiring care during solitary confinement, and 12 people had new medical conditions arising while in solitary confinement. Examples of these medical conditions and the time passed before seeing a provider are listed in Graphic 12 below.

ICE regulations outline that “[d]etainees must be evaluated by a health care professional prior to placement in an SMU (or when that is infeasible, as soon as possible and no later than within 24 hours of placement).”^[146] Yet, of the 26 participants included in this study, only 11 people (42 percent) reported being seen by a medical professional before being placed in solitary confinement and only nine people (35 percent) were screened for preexisting mental health conditions.

In addition to the initial assessment, there should also be frequent “face-to-face medical assessments at least once daily for detainees.”^[147] However, only 13 people (50 percent of the study’s respondents) remembered being routinely evaluated by a health care provider. Only those participating in hunger strikes or who were deemed suicide risks were consistently seen by a health care professional daily. Otherwise, the frequency with which people were seen by a health care professional varied from daily (four people) to approximately every three to four days for those in medical isolation (two people). Others, even those with chronic or acute medical conditions, were seen either intermittently or not at all over the duration of their confinement. Many recounted that it felt like staff were just going through the motions to fulfill detention center requirements and documentation.

Interviewees reported difficulty identifying the role of various health care professionals who interacted with them, suggesting that interactions were either unduly brief or that staff members failed to appropriately clarify their role during their care. As one person described, “[Health care professionals] come around, they make their rounds. But if you want to talk to them, you got to stop them. You got to be up at a particular time … Because they come by at 5, 6 in the morning. Otherwise you miss them” (38-year-old man, Montgomery Processing Center). When participants were able to identify the types of health care professionals, the majority (56 percent) reported being seen by a nurse, with a minority being seen by physicians, physician assistants, therapists, psychologists, or medical assistants. Multiple respondents reported that nurses were the primary health care providers in these facilities; doctors were either reserved for more serious concerns or entirely unavailable. One interviewee raised concerns about the licensure of health care staff employed by the detention center, relaying reports that the doctor where he was detained had had his license suspended.

Long Waits and No Medications

Of the 14 people who submitted requests to see a medical provider, only three people (21 percent) reported being seen within 48 hours. Of the remaining cases, eight (57.1 percent) waited one week or more to be seen. Notably, these cases included potentially serious complaints such as chest pain, lower extremity swelling, and head trauma. Despite placing multiple requests for conditions including migraines, insomnia, and dental pain, three people were never medically evaluated while in solitary confinement.

There was a high bar to receive medical care while in solitary confinement, and the burden to overcome that bar rested solely with the detained person despite ICE standards requiring routine evaluations by health care providers.[148] Multiple respondents reported that their medical issues were ignored unless they were persistent with requests: “The thing with immigration and with the medical, they’re just trying to give you the minimum. You gotta keep going and going, bugging and bugging, to get the help you need. You gotta keep bugging them, that’s the only thing. So, your medical issue might be ignored in the temporary time”(39-year-old man, Eloy Detention Center).

Medications were also difficult to access while in solitary confinement. Six of the interviewees (33 percent) who needed medications during solitary confinement did not receive them during at least part of their solitary confinement period, with three people denied medicine the entire time. Examples of medications people were denied included naproxen (for pain relief from chronic osteoarthritis), antibiotics (for a skin/soft-tissue infection at a surgical site), and an inhaler (for wheezing and trouble breathing from asthma). Interviewees reported that they were not provided medications for a variety of reasons including participation in hunger strikes and perceived overuse by detention facility staff. One participant with a known Tylenol allergy noted that detention facility staff failed to provide appropriate alternatives, so he was denied any analgesia (56-year-old man, Buffalo (Batavia) Service Processing Center). One person even mentioned that over-the-counter medications, such as ibuprofen, were only available to purchase.

Disturbingly, two participants reported being given unknown medications without being told their purpose and against their will. They reported side effects following the administration of these unfamiliar medications, including upper extremity swelling and slurred speech, with no further evaluation or follow-up care.

In addition to poor quality of medical care, several respondents reported being denied a sense of privacy in their interactions with health care workers. Although guidelines require that “the facility shall provide out-of-cell, confidential assessments and visits for detainees whenever possible, to ensure patient privacy and to eliminate barriers to treatment,”^[149] many interviewees reported that most evaluations occurred across their locked cell doors. One participant recounted, “The worst part is that they do that through the metal door, so you have to say loudly – everyone can hear your mental health conditions”(56-year-old man, Buffalo (Batavia) Service Processing Center). This treatment is in violation of the federal Health Insurance Portability and Accountability Act, which classifies peoples’ health information as protected data that cannot be disclosed to others without their consent.^[150]

Enough Done to Be “Kept Alive,” But Not Cared For

Multiple participants described substandard medical care while in solitary confinement, including denying detained persons of emergent care in life-threatening situations. One person described having to perform “CPR on another inmate while a guard stood there in shock …. A nurse came back later and said that there was no doctor and that they would have to wait until the next day to be seen” (50-year-old man, Northwest ICE Processing Center). Another participant recounted an incident when he had chest pain with electrocardiogram findings, which could have represented a heart attack or cardiac arrhythmia, but doctors refused to transfer him to a hospital because he was getting deported that same night. These findings are consistent with the recently published finding of potential underutilization of emergency medical service systems as compared to the number of ICE-documented medical emergencies in their detention facilities.[151]

“There are no doctors, just nurses. When there’s an emergency, they don’t know how to handle it. They come, and they bring a ton of pills to the person, but they don’t know what it’s for or why they’re using it.”

32-year-old agender person, Etowah County Jail

Interviewees described dehumanizing treatment while seeking medical care in solitary confinement. Three people reported being handcuffed and shackled prior to being brought to medical care, despite not being in criminal custody: “You could see a doctor if you put in a request … if there was an emergency, like if there was something really wrong. I’ve seen guys go back there, but you would have to be handcuffed and shackled. Then you could go back to the clinic area to see the nurses and doctor.”(41-year-old man, Joe Corley Detention Facility) Interactions with medical providers were often cursory, with one person noting that he “never felt like [he] was taken care of medically and providers will do the most they can to not spend time with you”(50-year-old man, Tacoma Northwest Detention Center).Another person reported that the prevailing attitude was “just keep him alive until they can get deported. They didn’t care about how you felt”(35-year-old man, Caroline Detention Facility).

Lasting Negative Impacts on People’s Physical Health from Solitary Confinement

Of the 15 people who required medical care during solitary confinement, 12 (71 percent) had a new medical problem while in solitary confinement. Some people attributed the development of their medical conditions to the poor sanitation in solitary confinement. As one participant described, “I got scabies from the solitary confinement room. All you got was a bottle of disinfectant. I sprayed and cleaned the room, but it was not good enough. It’s really disgusting” (35-year-old man, Caroline Detention Facility). Other conditions were not necessarily related to their confinement, such as viral and dental infections, but still required medical assessment.

“The numbness on [my] right hand due to prolonged handcuffs remains – it is a constant reminder. When you use a mouse, you feel the numbness.”

56-year-old man, Buffalo (Batavia) Service Processing Center

Other interviewees reported complications of existing conditions due to inadequate health care while in solitary confinement. For example, one person described an untreated leg wound that led to increased swelling and infection, which required two surgeries and put him at risk for an amputation.

The high levels of stress associated with solitary confinement could also have lasting physical impacts. “I would get so stressed out that there would be physical problems … lots of sweating, my blood pressure would be affected,” recalled one person (30-year-old man, Kandiyohi County Jail); another had worsening migraines “triggered by the light [and] constant worrying about when you will get out”(35-year-old man, Donald W. Wyatt Detention Facility).

In addition to stress and delayed medical care, others felt that the conditions within solitary confinement itself negatively impacted their health: “Because the room was very small, I was unable to exercise. With my eyes, I wasn’t able to see very clear(ly) because of the light. The bunk hurt me. Sometimes I had to lie on the floor. My skin, rash, dry skin – it was all because I didn’t have access to all the regular stuff that people in detention have access to. My back hurt, my kidneys. I was groggy all the time and tired” (31-year-old man, La Salle Detention Facility). One person noted that protracted time that he spent with his hands in either handcuffs or zip-ties led to lasting sensory damage, in the form of residual numbness and tingling.

Many interviewees testified to long-lasting ramifications of solitary confinement on their physical health. Some reported continuing pain or complications from injuries that went untreated during solitary confinement, including residual back pain, chest pain, and infections. Others discussed how they were denied access to their medical information, rendering them unable to seek appropriate follow-up care after being released.

Mental Health Care in Solitary Confinement

Mental Health Care Did Not Meet Basic Standards of Care

Fifteen interviewees (57 percent) had a condition requiring mental health care while in solitary confinement, five of whom had preexisting condition(s) and the other 10 who developed symptoms in solitary confinement. These conditions and related symptoms included: anxiety, depression, PTSD, and a variety of symptoms such as paranoia and hallucinations.

While in solitary confinement, access to mental health care was limited unless officially placed on “suicide watch.” Of the 15 people in solitary confinement who required mental health care assessment, 13 placed an official request to see a mental health care provider. According to ICE, people in detention are supposed to be evaluated within 24 hours after voicing a request.^[152] However, only two people (15 percent) were seen within this time period. Another four people (31 percent) had their requests fulfilled in less than a week. However, three people (23 percent) were never evaluated for their mental health concerns, which included depression and PTSD, and for another three people (23 percent), it took greater than a month. Notably, someone experiencing a dissociative episode – a period often associated with amnesia and a sense of detachment from their everyday experiences or actions, commonly associated with experiencing significant trauma and PTSD – waited approximately five months before being evaluated.

Even among those who ultimately received mental health care, interactions were often brief and inconsistent. Sometimes a mental health provider might be available for “maybe 5 minutes” at a time (34-year-old man, Bristol County Correctional Facility). Study participants described that some mental health providers would come for mental health checks, but these checks mostly occurred through the doors rather than taking the person out of the cell for a private conversation. This led one participant to state that one would “just sign this paper outside your door that they saw you, but as far as actually engaging you? They’re not engaging you” (38-year-old man, Montgomery Processing Center). Despite the increased stresses associated with solitary confinement, psychotherapy and access to medications were limited.

Solitary Confinement Created New Mental Health Illnesses

Research has shown that solitary confinement can exacerbate, cause a relapse, or lead to the development of new mental health conditions. “Security Housing Unit (SHU) Syndrome” is a term coined to describe symptoms resulting from stays in solitary confinement consisting of hyperresponsiveness to basic stimuli, delusions and hallucinations, panic attacks, and obsessional thoughts, paranoia, and impulse control.^[153]

“Being in solitary [confinement], that is like a whole other level of playing with your mind. To bother you, to hurt you, to offend you, to make you feel like less than nothing. Even your biology changes, how you view the world changes … your mind and your body break into little pieces.”

50-year-old man, Northwest ICE Processing Center

Our findings suggest that solitary confinement not only provided inadequate mental health care for those with existing mental health conditions, but also led to the development of new symptoms (with possible new diagnoses) for others. Of the 15 people who required care for a mental health condition during solitary confinement, 10 (67 percent) had new symptoms that developed during solitary confinement. The most commonly reported issues were anxiety (n=5) and depression (n=5), followed by PTSD, disassociation, and claustrophobia.

Depression was commonly reported, which interviewees attributed to forced prolonged loneliness and the prohibition of visitors or meaningful activities. One participant described wanting to “scream and cry” from not having visitors and not having anyone to speak with (32-year-old agender person, Etowah County Jail). Multiple participants noted that while regular detention was also demoralizing, the lack of access to books, video entertainment, and socialization opportunities drove their depression. Solitary confinement even led to suicidal thoughts. “I ended up losing my mind for two weeks, even talking to myself. I thought about suicide. I still have those thoughts in Senegal,” (34-year-old man, Bristol County Correctional Facility).

Solitary confinement also drove other serious mental health conditions in detained people, including psychosis, dissociation, and obsessive-compulsive tendencies; many participants reported that these symptoms were not present prior to solitary confinement. Participants shared many different types of psychosis-related symptoms, including amnesia, delusions, and hallucinations. These conditions could also manifest in self-harming behaviors such as one person who hit himself repeatedly with a cable, and another who felt so “crazy that I kept banging my head on the door,” which he perceived was the only way he would be able to see a mental health provider (30-year-old man, Kandiyohi County Jail).

Long-term Harms of Solitary Confinement

Solitary confinement not only affected people during their detention stays, but also created lasting impacts that followed them after decarceration. When asked how their time in solitary impacted their lives presently, many people discussed how they now have increased anger, fear of authority figures, and trouble socializing.

“Sometimes I feel like someone’s following me and I’m afraid they’ll take me to solitary confinement. Sometimes I’ll wake up and think that I’m in solitary confinement. I’ll have to look out of the window to remind myself I’m not there. I still have the same nightmares I did while in solitary confinement.”

33-year-old man, Caroline Detention Center

Several participants noted persistent symptoms of anxiety, agoraphobia, and recurrent nightmares. One person felt“a lot of anxiety right after solitary confinement, and couldn’t stop crying all the time,”which eventually led to an eating disorder (30-year-old woman, Irwin County Detention Center). Another reported continued claustrophobia whenever he is in elevators where he feels like he is“without oxygen like I can’t breathe”(36-year-old man, River Correctional Center). And yet another felt like the enforced boredom in solitary confinement led to persistent obsessive-compulsive tendencies, describing how “I used to rearrange stuff in my cell … and just cleaning, cleaning. There was nothing to do, so cleaning would kill time. Now I do the same thing” (30-year-old man, Kandiyohi County Jail).

Participants reported that they sought professional help for their mental health symptoms, with one person stating that he now suffers from “chronic PTSD, anxiety, and depression” (56-year-old man, Buffalo (Batavia) Service Processing Center).

Pervasive Humiliation and Violence

Solitary confinement was also associated with experiences of cruel, inhuman, or degrading treatment for many of the people interviewed. Twelve people (46 percent) said they experienced some form of verbal abuse, harassment, or physical violence while in solitary confinement by immigration detention staff.

Verbal abuse was the most common form of harassment reported, and commonly included racist or homophobic statements. One interviewee, who identifies as agender, was harassed by staff for being perceived as too feminine: “they called me slurs like f*ggot (“maricón”), bird (“pájaro”), b*tch (“puto”) that you call gay people” (32-year-old agender person, Etowah County Jail). Similarly, a detained person who identified as LGBTQ+, described hearing threatening statements: “in segregation, I was asked by the guards to ‘suck my d**k, you b***h,’ or perform oral sex on them” (56-year-old man, Buffalo (Batavia) Service Processing Center). Another interviewee experienced similar verbal prejudice based on race: “They [facility staff] made fun of me for not speaking English. They gave me the finger and spit at me. They said I was a thief and would make the country worse because I was Black” (29-year-old man, unknown center in Louisiana).

Interviewees reported physical violence and sexual misconduct by facility staff. Strip searches could happen in front of multiple guards and other detained people. One participant who had experienced a sexual assault discussed how being forced to undress in front of others led to a worsening of his anxiety (50-year-old man, Northwest ICE Processing Center). Individual privacy rights were unprotected, as one person said that while he was in solitary confinement, the “guard came in while I was showering and stared at me. When I complained, they charged me, they made me stay in solitary confinement longer” (33-year-old man, Caroline Detention Facility). Two participants described being filmed or photographed while naked, with one stating that “they [facility staff] tied up my feet and hands. They took pictures of me naked. They brought a camera and filmed in the bathroom with five or six officials in the bathroom” (37-year-old man, Orange County Jail).

People Held in Solitary Confinement Are Punished for Complaining

Many study participants spoke out about injustices related to solitary confinement via formal and informal channels but were faced with retaliation instead of change. The participants commonly did so through filing written complaints, communicating with their lawyers, or participating in hunger strikes.

In response, 12 people (67 percent) who reported issues related to solitary confinement faced some sort of punishment for their actions. The most common form of retaliation was an extension of solitary confinement (five people), followed by physical abuse such as pepper spray (three people), and verbal abuse (three people). One study participant was notably refused necessary accommodations for his religion – such as being denied a prayer rug and given non-halal meals – as punishment for his speaking out about the living conditions in solitary confinement (30-year-old man, Kandiyohi County Jail).

Legal and Policy Framework

The U.S. Government Must Safeguard the Lives of Immigrants in Detention

Immigrants in detention are protected under the Fifth Amendment of the U.S. Constitution, which mandates that no person shall be “deprived of life, liberty, or property, without due process of law.”[154] The Due Process Clause extends to “all ‘persons’ within the United States,” regardless of their immigration status and guarantees immigrants held in civil detention the right to be free from punitive conditions of confinement.[155] Under the Due Process Clause, the government has an obligation to protect the health and safety of people in civil immigration detention and to provide for their basic needs, including food and medical care.[156] The U.S. Supreme Court has recognized that people must be afforded greater constitutional protections and more considerate treatment in civil confinement than in criminal custody because civil confinement is – at least in theory – not intended to be punishment.[157]

Additionally, retaliation against immigrants who protest the use and misuse of solitary confinement or report issues with detention conditions violates basic First Amendment rights under the U.S. Constitution.[158] Furthermore, the facilities’ failures to accommodate people’s free exercise of religion while in immigration detention is a violation of basic First Amendment rights.[159]

Agency guidelines set forth specific procedures that detention centers must follow when placing immigrants in solitary confinement. ICE issued the 2013 ICE “Segregation Directive” to supplement preexisting detention standards, including the National Detention Standards (NDS) and the Performance Based National Detention Standards (PBNDS), that detention centers are obligated to follow.[160] ICE has periodically revised these standards to address safety-related concerns, including the use of solitary confinement and the provision of proper medical care.[161] In the 2019 NDS, ICE significantly weakened standards.[162] Furthermore, the required standards vary by facility as the terms in the individual contracts are set between ICE and each facility.[163] The 2013 “Segregation Directive,” however, sets the minimum standards that apply in all facilities.

Prolonged Solitary Confinement and the Solitary Confinement of People with Mental Health Conditions Constitutes Torture Under International Law

Under international law, detention of immigrants – especially holding them in solitary confinement – should be used only for limited purposes and as a last resort.[164] Arbitrary and unlawful detention is prohibited under the International Covenant on Civil and Political Rights (ICCPR), which the United States has ratified, and the UN Human Rights Committee has emphasized that detention of people seeking asylum must be subject to periodic review and that any detention of immigrants beyond a brief period must take into account alternatives to detention and impact on health.[165] The UN High Commissioner for Refugees Executive Committee has also noted that people seeking asylum should only be detained in limited circumstances to verify identity or travel documents, make preliminary assessments of claims, or based on an individualized risk and security assessment.[166] Yet the United States consistently flouts these international standards, detaining thousands of immigrants every day in inhuman conditions, including in solitary confinement for prolonged periods of time.

The UN Special Rapporteur on Torture and the UN Human Rights Committee have long recognized that prolonged solitary confinement may constitute torture or cruel, inhuman, or degrading treatment.[167] Under the UN Standard Minimum Rules for the Treatment of Prisoners (known as the Nelson Mandela Rules), prolonged solitary confinement – defined as confinement in excess of 15 days – is specifically prohibited.[168] Additionally, the UN Special Rapporteur on Torture has repeatedly emphasized that such prolonged solitary constitutes torture.[169] The Special Rapporteur has highlighted the debilitating effects of solitary confinement on people with mental health conditions, stating that “individuals with mental disabilities should never be subjected to solitary confinement.”[170]

The United States is subject to the absolute prohibition of torture under international law by having ratified the UN Convention Against Torture.[171] Despite these international obligations, the country continues to subject immigrants to torture and cruel, inhuman, and degrading treatment through the misuse of solitary confinement.

Indeed, when surveying detention conditions in the United States, the UN Special Rapporteur on Torture has cited numerous concerns about the country’s routine use of solitary confinement.[172] The former Special Rapporteur on Torture Nils Melzer explained in 2020 that the impact of such confinement includes “severe and often irreparable psychological and physical” harm, ranging from “progressively severe forms of anxiety, stress, and depression to cognitive impairment and suicidal tendencies.”[173] The Special Rapporteur concluded that such “deliberate infliction of severe mental pain or suffering may well amount to psychological torture.”[174] Regional human rights bodies such as the Inter-American Commission on Human Rights have also cited the “deeply troubl[ing]” use of solitary confinement in U.S. immigration detention, particularly “in the case of vulnerable immigration detainees, including members of the LGBT community.”[175]

Most recently, in November 2023, the UN Human Rights Committee, which monitors state compliance with the International Covenant on Civil and Political Rights, published its concluding observations on the fifth periodic report of the United States, in which it stated that the use of solitary confinement for “juveniles and persons with intellectual or psychosocial disabilities” in prison should be prohibited.[176] Regarding immigration detention, the Committee expressed grave concern over the prolonged use of solitary confinement for the treatment of immigrants, including refugees and people seeking asylum.[177]

ICE’s failures to follow domestic and international laws as well as its own guidance have created dangerous conditions for people who are detained – particularly those with mental health conditions and medical conditions, with no recourse to protect themselves from life-threatening harm due to the misuse of solitary confinement.

Conclusion and Recommendations

ICE’s pervasive use of solitary confinement – across over one hundred facilities at state and local levels – is alarmingly widespread and profoundly disturbing. This research, corroborated by findings from myriad sources, including the DHS Office of Inspector General and the U.S. Government Accountability Office, reveals the persistent and prolonged use of solitary confinement by ICE; the harmful, long-lasting impact on those exposed to such isolation; and the ongoing lack of meaningful oversight and accountability for violations of law and policy.[178]

Over 10 years ago, PHR, with the National Immigrant Justice Center, co-authored a seminal report on the use of solitary confinement in immigration detention centers. Since then, despite countless intervening and damning investigations, there has been no improvement: U.S. immigration detention remains inappropriately carceral and punitive, and solitary confinement is routinely used in a manner that meets the definition of torture, or to cruel, inhuman, or degrading treatment according to international human rights law. As stated by one DHS whistleblower, ICE uses solitary confinement as a “first and only option,”[179] rather than as a last resort, as required by ICE policy and guidelines as well as international law.

The persistent lack of oversight and accountability related to the use of solitary confinement in immigration detention has not only allowed abuses to continue unabated, but in fact to intensify over the past decade. The devolution in care for people in detention has resulted in egregious breaches of international and domestic human rights law, foundational principles of the U.S. Constitution, and ICE’s own directives.

In the last five years alone, ICE placed people in solitary confinement over 14,000 times, including those with preexisting mental health conditions and other vulnerabilities. Lasting nearly a month on average and sometimes for over two years, this persistent application of solitary confinement illustrates how concerns repeatedly raised by members of Congress, government auditors, and whistleblowers alike have been consistently ignored. The disproportionately harmful impact of solitary confinement on vulnerable populations, particularly transgender people and those with mental health and medical conditions, indicates a pattern of systemic discrimination and neglect that contravenes ICE’s own policies. 

ICE’s use of the “Segregation Review Management System” to monitor solitary confinement placements is deeply flawed, as evidenced by incomplete and erroneous data collection, faulty analysis, and the lack of accountability revealed in this report. These findings raise serious questions about the reliability and efficacy of the system’s quality assurance and reporting accuracy. 

The evidence of profound and lasting physical and mental health deterioration in people subjected to solitary confinement demands an immediate end to DHS’s use of this practice. There is overwhelming evidence and consensus that efforts at modest reforms such as improving data collection, retention and reporting, have done little to stop human rights violations in ICE detention.

The recommendations below serve as a road map for DHS to completely phase out the use of solitary confinement in ICE detention. Congress and state and local entities, as well as international bodies, must also advocate for the end of solitary confinement, as outlined below.

1. Publicly commit to ending the use of solitary confinement in all immigration detention facilities. As it abandons solitary confinement, DHS and ICE must express this commitment in the form of a binding directive. The directive should:

1. Require a presumption of release from ICE detention for people who have reported existing vulnerabilities, including, but not limited to, people with serious medical conditions, mental health conditions, disabilities, LGBTQIA+ people and survivors of torture and/or sexual violence. These people should be released into the safety of their community with post-release care plans in place per the ICE 2022 memo, in addition to providing resources and referrals for social, legal, and/or medical services as appropriate.
2. Mandate that any person in detention be afforded 24-hour access to qualified mental and medical health care professionals who respond in a timely manner and in compliance with The Health Insurance Portability and Accountability Act (HIPAA).
3. Require increased transparency from ICE’s Detention Monitoring Council by making properly (redacted or deidentified) reports and reviews related to solitary confinement publicly available on the agency’s website within 72 hours.

2. Amend the 2013 “Segregation Directive” to ensure that every ICE detention facility, public or privately contracted, is required to report concurrently to ICE Field Office Directors and ICE headquarters within 24 hours of placing someone in solitary confinement. ICE headquarters, in turn, must share this consolidated “segregation”/solitary confinement data with the DHS Office of the Secretary within 72 hours. This requirement must apply to every confined person, regardless of the duration of their confinement or whether they have a vulnerability. Additionally:

1. For those who are currently in solitary confinement, require a prompt and meaningful psychosocial and medical evaluation, undertaken by qualified medical professionals, who can assess the prevalence and extent of existing vulnerabilities.
2. For those scheduled for placement in solitary confinement, require a meaningful psychosocial and medical evaluation by qualified medical professionals who can assess the prevalence and extent of existing vulnerabilities prior to such a placement.
3. Mandate the reporting of race and ethnicity of each person in solitary confinement.
4. Mandate the reporting of the justification provided for initial confinement; justification for continued confinement; duration of the confinement; any vulnerabilities identified; and a detailed description of the alternatives to solitary confinement that were considered and/or applied, as listed in 5.3.(2) of the 2013 ICE “Directive on Segregation.”
5. Require daily checks and regular monitoring and documentation by qualified and licensed health care professionals against a detailed checklist created in partnership with independent medical professionals, that includes reviewing vital signs, checking for signs of self-harm, and any other indicators of deteriorating mental and physical health. 
6. Require the routine sharing by ICE of deidentified data acquired through the above reporting measures on its website every two weeks as part of its release of Detention Statistics, until it has ended the use of solitary confinement.

3. Revise current contracts and agreements with immigration detention facilities providers and contractors to include stringent performance standards and clear metrics for compliance regarding the use of solitary confinement. Compliance should be assessed through regular and comprehensive inspections by the Contracting Officer. Additionally, to increase adherence to detention standards, ICE must:

1. Introduce a performance-based contracting model, where a portion of payment is contingent upon meeting certain performance and reporting indicators, including those listed in recommendations 1 and 2 herein; and
2. Impose immediate financial penalties for any violation of performance and reporting indicators, and contract termination for repeated or persistent violation.

4. Establish a task force led by the Office of the Secretary of DHS to develop a comprehensive plan, including specific recommendations for phasing out the use of solitary confinement. The task force must include:

1. Members with knowledge of, or expertise regarding, the mental and physical health consequences of the use of solitary confinement;
2. Independent medical experts;
3. Independent subject matter experts from civil society (including those with expertise in the use of solitary confinement in criminal and civil custodial settings and human rights);
4. Formerly detained immigrants who have experienced solitary confinement in ICE custody; and
5. Employees of the following offices:
   1. Civil Rights and Civil Liberties (CRCL);
   1. ICE Health Services Corps (IHSC);
   1. Immigration Detention Ombudsman (OIDO);
   1. Enforcement and Removal Operations (ERO); and
   1. Office of Professional Responsibility (OPR).

The plan must be presented to Congress and publicly accessible on ICE’s website upon completion, which shall be no later than one year after formation of the task force. Finally, recommendations included in the plan should ensure the end of ICE’s use of solitary confinement in immigration detention within one year of presentation of the plan to Congress and the public.

5. Strengthen and expand the duties of the Office for Civil Rights and Civil Liberties to include integrating civil rights and civil liberties protections into all DHS programs and activities. Additionally, require that CRCL establish and publicize a system for staff and people detained in immigration detention facilities to file grievances about solitary confinement without fear of retaliation.

Further, make complaints filed available to the public and accessible online, redacting identifying information from those who have requested confidentiality. CRCL’s recommendations to ICE based on these grievances or any related inspections or evaluations must be regarded as compulsory, rather than optional, and subject to continuous monitoring and oversight to ensure full implementation of the recommendations.

To the U.S. Congress:

6. Pass binding legislation banning the use of solitary confinement in immigration detention and legislation that will significantly decrease the number of people in immigration detention, including the End Solitary Confinement Act (H.R. 4972 / S.3409) and Dignity for Detained Immigrants Act (H.R. 2760 / S.1208).

7. Pass binding legislation that strengthens and expands CRCL’s functions and authority, such as the Department of Homeland Security Office for Civil Rights and Civil Liberties Authorization Act (H.R. 4713).

7. Use funding bills to incentivize the end of solitary confinement and adopt community-based alternatives to ICE detention that are not funded by an enforcement agency such as ICE or CBP, are not surveillance-based, and that are contracted to community-based, civil society, and nonprofit organizations.

8. Conduct semiannual public hearings to hold DHS and ICE accountable for its use of solitary confinement in immigration detention, and track progress against the implementation of the recommendations herein.

9. Ratify the Optional Protocol to the UN Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment as a matter of priority to allow independent monitoring of all places of detention in the United States.

To State Governors and State Attorneys General:

10. End contracts with facilities that use solitary confinement in immigration detention.

11. Encourage states to pass legislation establishing state attorney general oversight of ICE detention facilities and prohibiting local governments from expanding or entering into contracts with the federal government or private companies for immigration detention.

The U.S. President must:

12. Sign the Optional Protocol to the UN Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment.

13. End solitary confinement and take steps to operationalize this prohibition in immigration custody.

To the UN Special Rapporteur on Health, the UN Special Rapporteur on Torture, the UN Committee Against Torture, the UN Human Rights Committee, the UN Working Group on Enforced or Involuntary Disappearances, and the UN Working Group on Arbitrary Detention:

14. Request an unconditional country visit to the United States and monitor conditions of immigration detention, including use of solitary confinement, as soon as possible.

15. Assess U.S. compliance with the UN Standard Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules) and where necessary, make recommendations for reform.

16. Raise concern about the U.S. government’s use of solitary confinement in immigration detention facilities in the context of its regular dialogue with U.S. authorities and urge its abolition.

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Acknowledgments

This report was written jointly by students and faculty of the Harvard Immigration and Refugee Clinical Program (HIRCP) and Harvard Law School (HLS), members of the Peeler Immigration Lab (PIL) at Harvard Medical School (HMS), and Physicians for Human Rights (PHR). 

The PIL writing and analysis team included Caroline H. Lee, MD, resident physician in the Department of Emergency Medicine, University of California San Francisco; HMS students Natalie Sadlak, Brian Benitez, and Anand Chukka; and senior author Katherine Peeler, MD, MA, Division of Medical Critical Care, Boston Children’s Hospital, assistant professor of pediatrics at Harvard Medical School, Justice, Health and Democracy Impact Initiative Fellow at the Edmond and Lily Safra Center for Ethics at Harvard University, and PHR medical expert.

Interviews were conducted by PIL students and faculty Caroline Lee, MD, Natalie Sadlak, Brian Benitez, Isaiah Baker, Julie Castro, Amina Rahimi, Anand Chukka, and Katherine Peeler, MD. 

The HIRCP writing and research team for this report included Harvard Law School students Felicia Caten-Raines (JD ‘25), Jiwon Kim (JD ‘24), and Ennely Medina (JD ‘23) under the supervision of Sabrineh Ardalan, Clinical Professor of Law and Director of HIRCP, and Philip L. Torrey, Assistant Clinical Professor of Law and Director of the Crimmigration Clinic. 

Dr. Arevik Avedian, Lecturer on Law, and Director of the Empirical Research Department at Harvard Law School conducted and supervised HIRCP’s statistical analysis in the report. This report would not have been possible without the work of numerous HIRCP clinical students, summer interns, and research assistants from 2017 to the present, who drafted, filed, and litigated numerous FOIA and state privacy act requests. 

The PHR writing team included PHR staff Tessa Wilson, senior program officer, Asylum Program. The report benefitted from review by PHR staff, including Christian De Vos, JD, PhD, director of research and investigations; Ranit Mishori, MD, MHS, MSc, FAAFP, medical advisor; Michele Heisler, MD, MPA, medical director; Madhuri Grewal, JD, interim deputy director of advocacy; Erika Dailey, MPhil, director of advocacy, policy, and communications; and Saman Zia-Zarifi, JD, LLM, executive director. The report benefited from contributions by Brittney Bringuez, former asylum program coordinator, and Anna-Theresa Unger, former research and case management intern

The report also benefited from external review by PHR board member and Publications Committee co-chair Adam Richards, MD, MPH, PhD and by Parveen Parmar, MD, MPH, professor, clinical emergency medicine, Keck School of Medicine, University of Southern California and PHR expert.

The report was edited and prepared for publication by Rhoda Feng, publications consultant, PHR. Hannah Dunphy, PHR’s senior communications manager, prepared the digital presentation.

The entire study team would like to thank Ellen Gallagher, DHS whistleblower and current Acting Deputy Chief of Staff at the DHS Office of Inspector General, who is represented by the Government Accountability Project; the current and former clients of HIRCP who were held in solitary confinement and willing to share their story; and local advocates who have been fighting these issues for decades. 

Additionally, we are immensely grateful for, and humbled by, the 26 participants in the interview portion of this study. Their generosity and strength in sharing their stories with us so that others may hopefully one day benefit from this information is unmeasurable.

Funding support for this study was provided by the Boston Children’s Hospital Division of Medical Critical Care IGNITE MCC grant. Dr. Peeler’s research time was also supported by the Edmond & Lily Safra Center for Ethics at Harvard University. HLS study benefited from the support of the Bellow Scholars Program and the HIRCP FOIA litigation from co-counseling with Jenner & Block LLP.

Julie Castro and Brian Benitez graciously supplied written translation for the executive summary.

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[1] Eunice Cho, “Unchecked Growth: Private Prison Corporations and Immigration Detention, Three Years Into the Biden Administration,” last modified August 7, 2023, https://www.aclu.org/news/immigrants-rights/unchecked-growth-private-prison-corporations-and-immigration-detention-three-years-into-the-biden-administration.

[2] ICE Detainees, TRAC Reports, Inc., https://trac.syr.edu/immigration/detentionstats/pop_agen_table.html.

[3] See Inter-American Commission on Human Rights, “Report on Immigration in the United States: Detention and Due Process,” December 30, 2010; Jean Casella and James Ridgeway, “FAQs,” Solitary Watch, http://solitarywatch.com/facts/faq. [hereinafter FAQs, Solitary Watch].

[4] HLS FOIA: Spreadsheet Showing Solitary Confinement Stays Between September 4, 2018, and September 13, 2023, released by ICE on October 16, 2023 [hereinafter HLS FOIA: Spreadsheet]. The spreadsheet was produced in the midst of FOIA litigation, and at the time HIRCP wrote this report, HIRCP was still waiting for ICE to produce a more complete version of the spreadsheet as required by court order. See Harvard Immigr. and Refugee Clinical Program v. U.S. Department of Homeland Sec., 21-cv-12030, 2023 WL 4685961, (D. Mass. July 21, 2023).

[5] HLS FOIA: Spreadsheet.

[6] DHS OIG, “ICE Needs to Improve its Oversight of Segregation Use in Detention Facilities,” October 13, 2021, https://www.oig.dhs.gov/sites/default/files/assets/2021-10/OIG-22-01-Oct21.pdf.

[7] The United Nations Standard Minimum Rules for the Treatment of Prisoners, Rule 44 (2015) (https://www.unodc.org/documents/justice-and-prison-reform/Nelson_Mandela_Rules-E-ebook.pdf (defining solitary confinement  as confinement for 22 hours or more a day without meaningful human contact.”

[8] DHS OIG, “ICE Needs to Improve its Oversight of Segregation Use in Detention Facilities.”

[9] Peter Scharff Smith, “The Effects of Solitary Confinement on Prison Inmates: A Brief History and Review of the Literature,” 2006, Crime and Justice, 34(1), 441–528, https://doi.org/10.1086/500626; See also United Nations, “Special Rapporteur on Torture Tells Third Committee Use of Prolonged Solitary Confinement on Rise, Calls for Global Ban on Practice,” Oct. 18, 2011, https://www.ohchr.org/en/press-releases/2011/10/un-special-rapporteur-torture-calls-prohibition-solitary-confinement.

[10] Peter Scharff Smith, “The Effects of Solitary Confinement on Prison Inmates” 337, 441–528.

[11] Brinkley-Rubinstein L, Sivaraman J, Rosen DL, et al. “Association of Restrictive Housing During Incarceration with Mortality After Release,” JAMA Network Open 2019;2(10):e1912516. doi:10.1001/jamanetworkopen.2019.12516.

[12] New York Civil Liberties Union, “Boxed in: The True Cost of Extreme Isolation in New York’s Prisons” at 44, October 2, 2012, https://www.nyclu.org/sites/default/files/publications/nyclu_boxedin_FINAL.pdf; NIJC & PHR, “Invisible in Isolation” at 13-14, https://immigrantjustice.org/sites/immigrantjustice.org/files/Invisible%20in%20Isolation-The%20Use%20of%20Segregation%20and%20Solitary%20Confinement%20in%20Immigration%20Detention.September%202012_7.pdf; Stuart Grassian, “Psychiatric Effects of Solitary Confinement,” 22 WASH. U. J. L. & POL’Y 325 (2006) at 347-48, https://openscholarship.wustl.edu/law_journal_law_policy/vol22/iss1/24; Jose Olivares, “ICE Detainee Diagnosed with Schizophrenia Spent 21 Days in Solitary Confinement, Then Took His Own Life,” July 27, 2018, https://theintercept.com/2018/07/27/immigrant-detention-suicides-ice-corecivic/.

[13] Erfani et al, full reference available at: https://pubmed.ncbi.nlm.nih.gov/33575408/ (noting increased suicide rate in detention facilities); Terp et al, full reference available at: https://pubmed.ncbi.nlm.nih.gov/33575408/.

[14] United Nations, “Special Rapporteur on Torture Tells Third Committee Use of Prolonged Solitary Confinement on Rise, Calls for Global Ban on Practice,” October 18, 2011, https://www.ohchr.org/en/press-releases/2011/10/un-special-rapporteur-torture-calls-prohibition-solitary-confinement.

[15] Ibid.

[16] Ibid.

[17] U.S. Immigration and Customs Enforcement, 11065.1, “Review of the Use of Segregation for ICE detainees,” 2013 at 2, https://www.dhs.gov/sites/default/files/publications/segregation_directive.pdf [hereinafter 2013 ICE Segregation Directive]. Detention facilities across the country often use a range of euphemisms to refer to solitary confinement, including administrative or disciplinary “segregation,” special or restrictive housing. FAQs, Solitary Watch.

[18] 2013 ICE Segregation Directive at 2.

[19] Ibid.

[20] Ibid.at 1.

[21] Ibid.at 6.

[22] Ibid.at 4, 6.

[23] ICE, Mem. from Thomas Homan, “Further Guidance Regarding the Care of Transgender Detainees” at 4, June 19, 2015, https://www.ice.gov/sites/default/files/documents/Document/2015/TransgenderCareMemorandum.pdf.

[24] Ibid.

[25] U.S. ICE, ICE Directive 11063.2, “Identification, Communication, Recordkeeping, and Safe Release Planning for Detained Individuals with Serious Mental Disorders or Conditions and/or Who are Determined to Be Incompetent by an Immigration Judge,” April 5, 2022, https://www.ice.gov/doclib/news/releases/2022/11063-2.pdf.

[26] Ibid. at 5.

[27] 2013 ICE Segregation Directive at 6.

²⁸ Ibid. at 4.

[29] U.S. Government Accountability Office, Immigration Detention Actions Needed to Collect Consistent Information for Segregated Housing Oversight, October 2022, https://www.gao.gov/assets/gao-23-105366.pdf.

[30] Ibid. at 20.

[31] Ibid.

[32] Ibid. at 21.

[33] Ibid. at 21–22; see also DHS Office of Inspector General, “ICE Needs to Improve Its Oversight of Segregation Use in Detention Facilities,” OIG-22-01, October 13, 2021.

[34] U. S. Government Accountability Office, “Immigration Detention Actions Needed to Collect Consistent Information for Segregated Housing Oversight” at 19, October 2022, https://www.gao.gov/assets/gao-23-105366.pdf.

[35] See Maryam Saleh and Spencer Woodman, “A Homeland Security Whistleblower goes Public about ICE Abuse of Solitary Confinement,”The Intercept, May 2019,https://theintercept.com/2019/05/21/ice-solitary-confinement-whistleblower/;

Maryam Saleh,“Whistleblower ‘Helpless’ to Stop U.S. Immigration Solitary Confinement Abuses,” May 2019, International Consortium of Investigative Journalists, https://www.icij.org/investigations/solitary-voices/whistleblower-helpless-to-stop-us-immigration-solitary-confinement-abuses/; Nick Schwellenbach, Mia Stienle et. al, “ISOLATED: ICE Confines Some Detainees with Mental Illness in Solitary for Months,” Project on Government Oversight, August 2019,

https://www.pogo.org/investigation/2019/08/isolated-ice-confines-some-detainees-with-mental-illness-in-solitary-for-months; Spencer Woodman and Maryam Saleh, “40 Percent of ICE Detainees Held in Solitary Confinement have a Mental Illness, New Report Finds,” The Intercept, August 2019, https://theintercept.com/2019/08/14/ice-solitary-confinement-mental-illness/; Juan Mendez, Interim Report of the Special Rapporteur of the Human Rights Council on Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment ¶¶ 21, 26, U.N. Doc. A/66/268 August 5, 2011, https://digitallibrary.un.org/record/710177?ln=enA/66/268 (August 5, 2011), https://digitallibrary.un.org/record/710177?ln=en; Kenneth L. Applebaum, “American Psychiatry Should Join the Call to Abolish Solitary Confinement,” 43 J. Am. Acad. Psychiatry L. 406, 408 (2015), http://jaapl.org/content/jaapl/43/4/406.full.pdf; Human Rights Watch, “Do You See How Much I’m Suffering Here?”: Abuse against Transgender Women in US Immigration Detention” March 2016, https://www.hrw.org/sites/default/files/report_pdf/us0316_web.pdf [hereinafter Abuse against Transgender Women]; NIJC & PHR, “Invisible in Isolation” at 13-14, https://www.nyclu.org/sites/default/files/publications/nyclu_boxedin_FINAL.pdf.

[36] GAO Report, OIG Report, NIJC Policy Brief, https://immigrantjustice.org/research-items/policy-brief-beyond-repair-ices-abusive-detention-inspection-and-oversight-systemACLU; ACLU blog: https://www.aclu.org/news/immigrants-rights/ices-detention-oversight-system-needs-an-overhaul.

[37] Maryam Saleh and Spencer Woodman, “A Homeland Security Whistleblower.” (“In July 2014, on the advice of ethics counsel, Gallagher sent a detailed memo to then-Deputy Secretary of Homeland Security Alejandro Mayorkas, emphasizing that segregation was not in fact being used as a last resort in many instances, contrary to ICE policy. ‘Essentially, where a detainee’s behavior or characteristics are perceived to be disruptive, evidence of noncompliance, or a threat to the general population or ‘good order’ of the facility,’ she wrote, ‘segregation serves as a default remedy.’”); Memo of Ellen Gallagher, Senior Policy Advisor, Civil Rights Civil Liberties to Alejandro Mayorkas, Deputy Secretary, DHS, re The Use of Segregation for Immigration Detainees, July 23, 2014, https://www.documentcloud.org/documents/5998113-Mayorkas-Memo-07232014.html. Gallagher is a whistleblower who has publicly flagged issues concerning ICE’s use of solitary confinement for multiple years. She is represented by the Government Accountability Project.

[38] DHS OIG, “Concerns about ICE Detainee Treatment and Care at Detention Facilities,” OIG-18-32, December 11,  2017, https://www.oig.dhs.gov/sites/default/files/assets/2017-12/OIG-18-32-Dec17.pdf;   DHS OIG, “ICE Field Officers Need to Improve Compliance with Oversight Requirements for Segregation of Detainees with Mental Health Conditions,”OIG-17-119, September 29, 2017, https://www.oig.dhs.gov/sites/default/files/assets/2017-11/OIG-17-119- Sep17.pdf.

[39] DHS OIG, “ICE Needs to Improve its Oversight of Segregation Use in Detention Facilities,” October 13, 2021, https://www.oig.dhs.gov/sites/default/files/assets/2021-10/OIG-22-01-Oct21.pdf.

[40] Ibid.

[41] GAO Report.

[42] Mem. from DHS Office of Civil Rights and Civil Liberties and the Office of General Counsel to ICE, “Retention Memo: Segregation of Individuals with a Mental Health Disability and/or Serious Mental Illness,” September 1, 2023, https://www.dhs.gov/sites/default/files/2023-09/23_0901_crcl_retention_memo_to_ice_segregation_mental_health_or_illness_redacted_508.pdf.

[43] Ibid.

[44] Ibid.

[45] Ibid.

[46] “Invisible In Isolation: The Use Of Segregation And Solitary Confinement In Immigration Detention,” September 20, 2012, https://immigrantjustice.org/research-items/report-invisible-isolation-use-segregation-and-solitary-confinement-immigration.

[47] HLS FOIA: Evaluations Conducted by the Department of Homeland Security’s Office for Civil Rights and Civil Liberties on ICE Detention Facilities Between 2012 and 2014, released on October 25, 2023 [hereinafter HLS FOIA: CRCL Evaluations].

[48] American Immigration Council, “Press Release: Complaint Filed Against ICE As Misuse of Solitary Confinement in Colorado Facility Raises Concerns,” July 13, 2023, https://www.americanimmigrationcouncil.org/news/complaint-filed-against-ice-misuse-solitary-confinement-colorado-facility-raises-concerns.

[49] Harvard Immigr. and Refugee Program v. U.S. Dep’t of Homeland Sec., 21-cv-12030, 2023 WL 4685961, (D. Mass. July 21, 2023).

[50] HLS FOIA: Spreadsheet.

[51] POGO FOIA: Spreadsheet Showing Solitary Confinement Stays Between January 2016 and May 2018; ICIJ FOIA: Spreadsheet Showing Solitary Confinement Stays Between 2012 and 2017; HLS FOIA: Spreadsheet.

[52] HLS FOIA: Spreadsheet. The SRMS dataset included 14,264 cases, including 155 immigrants still in solitary confinement as of September 14, 2023. As these individuals’ stays in solitary confinement were still ongoing, they are not reflected in this report’s analysis of average length of solitary confinement.

[53] HLS FOIA: 2023 Q3 Segregation Metrics from ICE’s Detention Monitoring Council’s Quarterly Meeting on September 2023, released on October 16, 2023 [hereinafter HLS FOIA: 2023 Q3 Segregation Metrics]; HLS FOIA. The evaluations were conducted between 2012 and 2014 by doctors in response to complaints CRCL received about the adequacy of mental health services.

[54] HLS FOIA: CRCL Evaluations.

[55] DHS OIG, “ICE Needs to Improve its Oversight of Segregation Use in Detention Facilities,” October 13, 2021, https://www.oig.dhs.gov/sites/default/files/assets/2021-10/OIG-22-01-Oct21.pdf.

[56] OIG randomly selected a sample of 265 detention files, based on SRMS data. This resulted in 474 individual segregation placements, as some persons in detention were placed in segregation multiple times. Seventy-five of these placements were not required to be reported under ICE’s reporting requirements (see footnote 10 in the OIG report), which brings the total number of placements to be compared between SRMS and facilities to 399. Sixty-two placements were missing from the segregation placements that should have been recorded in SRMS according to ICE policy. The OIG report miscalculated the percentage of underreported placements, by including the placements that were not required to be reported, which resulted in a lower percentage.

[57] GAO Report.

[58] Ibid.

[59] Ibid., from 2017 to 2021. 1,436 (out of 5,907) detained immigrants with a mental condition and 3,541 (out of 4,017) detained immigrants with serious mental condition were not reported by SRMS (see Tables 6 and 7, pp. 35–36).

[60] ICE Detention Statistics, https://www.ice.gov/detain/detention-management.

[61] HLS FOIA: Spreadsheet.

[62] Two detention stats excel files were downloaded from the ICE detention management webpage, https://www.ice.gov/detain/detention-management, covering 2022 and 2023 fiscal years (no statistics on vulnerable populations were found in the earlier years). As ICE provides statistics based on federal government’s fiscal years (from October 1 to September 30), only aggregate statistics from the first quarter of 2022 to the third quarter of 2023 (October 2022-June 2023) were compared. The 2022 file (https://www.ice.gov/doclib/detention/FY22-detentionStats.xlsx) was used to obtain statistics for the first three quarters in 2022, and the 2023 file (https://www.ice.gov/doclib/detention/FY23_detentionStats.xlsx) was used to obtain statistics thereafter. These publicly available files reported a total of 2,314 placements of vulnerable populations during the observed seven quarters.

As ICE’s publicly shared statistics are not disaggregated by type of vulnerability (for example, mental illness, disability, suicide, and so on), necessary restrictions were made to construct aggregates comparable to the ICE’s quarterly statistics. According to the downloaded excel files, vulnerable population includes “reported facility-initiated segregation placements of noncitizens that self-identify as lesbian, gay, bisexual, transgender, and/or intersex (LGBTI); have a serious mental or medical illness; are conducting a hunger strike; or are on suicide watch.”

7,421 observations from 14,264 were removed to restrict the FOIA-obtained SRMS data to confinements placed from October 1, 2021 to June 30, 2023. Restricting the data to facility-initiated placements, dropped an additional 2,978 placements, resulting in a final sample of 3,865.

[63] FOIA-obtained SRMS variables indicating vulnerability were used to count 1,201 placements (variables included were MentalIll, SeriousMedicalIllness, SeriousDisability and SuicideRisk). There were an additional 706 placements that were not identified as vulnerable with any of the above-mentioned variables, but a reason for placement was coded as “Medical/Mental.” Without additional information on the severity of medical illnesses for these placements, it cannot be determined if ICE was required to report them as vulnerable. Therefore, assuming these cases were vulnerable could introduce bias. Even if, however, we assume that all these additional placements included vulnerable immigrants, the number of placements in our FOIA dataset was consistently underreported anywhere from 8 to 34 percent per quarter.

[64] HLS FOIA: Spreadsheet and ICE Detention Statistics, https://www.ice.gov/detain/detention-management.

[65] HLS FOIA: Spreadsheet and ICE Detention Statistics, https://www.ice.gov/detain/detention-management.

[66] HLS FOIA: CRCL Evaluations.

[67] Ibid.

[68] Ibid.

[69] Ibid.

[70] Ibid.

[71] 2013 ICE Segregation Directive.

[72] Of note, some facilities may be bound by the Performance-Based National Detention Standards or other versions of the NDS but the requirements regarding solitary confinement procedures, minimum standards of care, and procedures for implementing and carrying out solitary confinement are generally consistent across them.

[73] Appendix A for questionnaire.

[74] U.S. Immigration and Customs Enforcement, “Review of the Use of Segregation for ICE Detainees,” 2013, https://www.ice.gov/doclib/detention-reform/pdf/segregation_directive.pdf.

[75] HLS FOIA: Spreadsheet.

[76] Ibid.

[77] Ibid.

[78] Ibid. Seven of these solitary confinement placements were initiated in response to immigrants requesting solitary confinement. The longest lengths of solitary confinement placements that were specifically facility-initiated include: 637 days (Northwest ICE Processing Center , WA), 519 days (Adelanto ICE Processing Center, CA), 485 days (Imperial Regional Detention Facility, CA), 444 days (Nye County Detention Center, NV), 414 days (Northwest ICE Processing Center , WA), and 404 days (Central Louisiana ICE Processing Center, LA).

[79] CoreCivic, Detention Facilities, https://www.corecivic.com/facilities, last visited January 10, 2024 (listing Eloy Federal Contract Facility and Otay Mesa Detention Center); The Geo Group, Inc., Our Locations, https://www.geogroup.com/LOCATIONS, last visited January 10, 2024 (listing Denver Contract Detention Facility, Northwest ICE Processing Center); Detainees Leaving ICE Detention from the Buffalo Service Processing Center (Federal Detention Facility), Syracuse TRACImmigration, https://trac.syr.edu/immigration/detention/201509/BTV/exit/, last visited January 10, 2024.

[80] HLS FOIA: Spreadsheet.

[81] Ibid.

[82] Complaint Filed Against ICE As Misuse of Solitary Confinement in Colorado Facility Raises Concerns, July 13, 2023, https://www.americanimmigrationcouncil.org/news/complaint-filed-against-ice-misuse-solitary-confinement-colorado-facility-raises-concerns.

[83] HLS FOIA: Spreadsheet.

[84] Ibid.

[85] Eileen Sullivan, “Crossings at the U.S. Southern Border Are Higher Than Ever,” The New York Times, October 27, 2023, https://www.nytimes.com/2023/10/21/us/politics/cbp-record-border-crossings.html.

[86] HLS FOIA Spreadsheet and ICE Detention Statistics Excel files from 2018-2023 were used to derive the proportion, https://www.ice.gov/detain/detention-management.

[87] HLS FOIA: Spreadsheet; 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, 10.

[88] HLS FOIA: Spreadsheet.

[89] HLS FOIA 2023: Q3 Segregation Metrics from ICE’s Detention Monitoring Council’s Quarterly Meeting on September 2023, released on October 16, 2023 [hereinafter HLS FOIA: 2023 Q3 Segregation Metrics].

[90] HLS FOIA: 2023 Q3 Segregation Metrics.

[91] HLS FOIA: Spreadsheet.

[92] Ibid.

[93] U.S. Immigration and Customs Enforcement, Review of the Use of Segregation for ICE Detainees.

[94] HLS FOIA: E-mail from the Department of Homeland Security’s Office for Civil Rights and Civil Liberties, sent on April 22, 2016 [hereinafter HLS FOIA: CRCL E-mail].

[95] POGO FOIA: Spreadsheet Showing Solitary Confinement Stays Between January 2016 and May 2018 [hereinafter POGO FOIA: Spreadsheet].

[96] “Complaint Detailing Abusive Overuse of Solitary Confinement and Mistreatment that Disproportionately Impacts Persons with Disabilities at the Aurora Contract Detention Facility,” American Immigration Council, National Immigration Project, and Rocky Mountain Immigrant Advocacy Network, July 13, 2023, https://www.americanimmigrationcouncil.org/sites/default/files/research/misuse_of_solitary_confinement_in_colorado_immigration_detention_center_complaint.pdf. [hereinafter American Immigration Council Complaint].

[97] American Immigration Council Complaint.

[98] HLS FOIA: Evaluations Conducted by the Department of Homeland Security’s Office for Civil Rights and Civil Liberties on ICE Detention Facilities Between 2012 and 2014, released on October 25, 2023 [hereinafter HLS FOIA: CRCL Evaluations].

[99] HLS FOIA: CRCL Evaluations.

[100] Ibid.

[101] Ibid.

[102] HLS FOIA: 2023 Q3 Segregation Metrics.

[103] POGO FOIA: Spreadsheet.

[104] Ibid.

[105] Dana Salvano-Dunn, “Retention Memo: Segregation of Individuals with a Mental Health Disability and/or Serious Mental Illness,” U.S. Department of Homeland Security, September 1, 2023, https://www.dhs.gov/sites/default/files/2023-09/23_0901_crcl_retention_memo_to_ice_segregation_mental_health_or_illness_redacted_508.pdf.

[106] American Immigration Council Complaint, at 15.

[107] Dana Salvano-Dunn, “Retention Memo.”

[108] United Nations, “Special Rapporteur on Torture Tells Third Committee Us of Prolonged Solitary Confinement on Rise, Calls for Global Ban on Practice,” October 18, 2011, https://press.un.org/en/2011/gashc4014.doc.htm#:~:text=The%20Human%20Rights%20Council’s%20Special,terror%E2%80%9D%20and%20%E2%80%9Cthreats%20to%20national.

[109] U.S. Immigration and Customs Enforcement, Review of the Use of Segregation for ICE Detainees, 2013.

[110] HLS FOIA: Spreadsheet.

[111] Ibid.

[112] Ibid.

[113] DHS OIG, “ICE Needs to Improve its Oversight of Segregation Use in Detention Facilities,” October 13, 2021, https://www.oig.dhs.gov/sites/default/files/assets/2021-10/OIG-22-01-Oct21.pdf, GAO Report, HLS FOIA: Spreadsheet and ICE Detention Statistics, https://www.ice.gov/detain/detention-management.

[114] HLS FOIA: Spreadsheet. This percentage is calculated from the number of people in solitary confinement with recorded mental health status.

[115] HLS FOIA: Spreadsheet.

[116] Ibid.

[117] Ibid.

[118] Ibid.

[119] U.S. Immigration and Customs Enforcement, ICE Directive 11063.2, “Identification, Communication, Recordkeeping, and Safe Release Planning for Detained Individuals with Serious Mental Disorders or Conditions and/or Who are Determined to Be Incompetent by an Immigration Judge,” April 5, 2022, https://www.ice.gov/doclib/news/releases/2022/11063-2.pdf.

[120] Memo from DHS Office of Civil Rights and Civil Liberties and the Office of General Counsel to ICE, “Retention Memo: Segregation of Individuals with a Mental Health Disability and/or Serious Mental Illness,” September 1, 2023, https://www.dhs.gov/sites/default/files/2023-09/23_0901_crcl_retention_memo_to_ice_segregation_mental_health_or_illness_redacted_508.pdf.

[121] Stuart Grassian, “Psychiatric Effects of Solitary Confinement.”

[122] POGO FOIA: Spreadsheet.

[123] Ibid.

[124] Ibid.

[125] HLS FOIA: CRCL Evaluations.

[126] Ibid.

[127] Ibid.

[128] Grassian, “Psychiatric Effects of Solitary Confinement.”

[129] HLS FOIA: CRCL Evaluations.

[130] Ibid.

[131] Ibid.

[132] Ibid.

[133] Ibid.

[134] Ibid.

^[135] “National Detention Standards for Non-Dedicated Facilities,” ICE, Revised 2019, https://www.ice.gov/doclib/detention-standards/2019/nds2019.pdf.

^[136] Ibid.

[137] John Leach, “Psychological factors in exceptional, extreme and torturous environments,” Extreme physiology & medicine 5 (2016): 1–15.

[138] Loran F. Nordgren, Mary-Hunter Morris McDonnell, and George Loewenstei, “What constitutes torture? Psychological impediments to an objective evaluation of enhanced interrogation tactics,” Psychological science 22, no. 5 (2011): 689-694; Peeler K, Hampton K, Lucero J, Ijadi-Maghsoodi R., “Sleep deprivation of detained children: another reason to end child detention,” Health and human rights journal 21, no. 1 (2019): 317-320, https://www.hhrjournal.org/2020/01/sleep-deprivation-of-detained-children-another-reason-to-end-child-detention/.

^[139] “National Detention Standards for Non-Dedicated Facilities.”

^[140] Ibid.

[141] Ibid.

^[142] Ibid.

[143] Ibid.

^[144] Ibid.

^[145] Ibid.

^[146] Ibid.

^[147] Ibid.

[148] “National Detention Standards for Non-Dedicated Facilities”; “ICE Health Service Corps,” Immigration and Customs Enforcement, accessed October 18, 2023, https://www.ice.gov/features/health-service-corps.

^[149] “National Detention Standards for Non-Dedicated Facilities.”

^[150] “The HIPAA Privacy Rule,” Office for Civil Rights, https://www.hhs.gov/hipaa/for-professionals/privacy/index.html.

[151] Dekker AM, Farah J, Parmar P, Uner AB, Schriger DL, “Emergency Medical Responses at US Immigration and Customs Enforcement Detention Centers in California,” JAMA Netw Open 6, no. 11 (2023):e2345540. doi:10.1001/jamanetworkopen.2023.45540.

^[152] “ICE Health Service Corps,” Immigration and Customs Enforcement, accessed October 18, 2023, https://www.ice.gov/features/health-service-corps.

^[153] Grassian, “Psychiatric Effects of Solitary Confinement.”

[154] U.S. Const, Amend, V.

[155] Zadvydas v. Davis, 533 U.S. 678, 693 (2001).

[156] DeShaney v. Winnebago Cty. Dep’t. of Soc. Servs., 489 U.S. 189, 199-200 (1989).

[157] Youngberg v. Romeo, 457 U.S 307, 322 (1982).

[158] Alina Das, “Immigration Detention and Dissent: The Role of First Amendment on the Road to Abolition,” Georgia Law Review 56, no. 4 (2022), https://digitalcommons.law.uga.edu/cgi/viewcontent.cgi?article=1215&context=glr.

[159] Aleksandr Sverdlik, “Border Patrol and ICE Routinely Violate Immigrants’ Religious Rights,” ACLU, March 20, 2019, https://www.aclu.org/news/immigrants-rights/border-patrol-and-ice-routinely-violate.

[160] 2013 ICE Segregation Directive, https://www.ice.gov/doclib/detention-reform/pdf/segregation_directive.pdf; Detention Management, “U.S. Immigration & Customs Enforcement,” https://www.ice.gov/detention-management; “Hearing Regarding Oversight of Detention Facilities Before the Subcomm. on Oversight, Management, & Accountability of the H. Comm. on Homeland Security,” 116th Cong. 2, 3, 2019 (statement of Tae Johnson

Assistant Director for Custody Management, Enforcement and Removal Operations, U.S. Customs and Immigration Enforcement) (hereinafter, ICE Testimony).

[161] “2019 National Detention Standards for Non-Dedicated Facilities,” https://www.ice.gov/detain/detention-management/2019; “2011 Operations Manual ICE Performance-Based National Detention Standards,” https://www.ice.gov/detain/detention-management/2011 (“PBNDS 2011 reflects ICE’s ongoing effort to tailor the conditions of immigration detention to its unique purpose while maintaining a safe and secure detention environment for staff and detainees …. PBNDS 2011 is crafted to improve medical and mental health services … [and] improve the process for reporting and responding to complaints.”).

[162] ICE, “2019 National Detention Standards for Non-Dedicated Facilities,” https://www.ice.gov/detain/detention-management/2019.

[163] ICE Testimony.

[164] Article 31(2) of the UN Refugee Convention (permitting states to restrict refugee freedom of movement only when “necessary” and only until their legal status is “regularized” or they are admitted to another country); Andreas Zimmermann et al., “The 1951 Convention Relating to the Status of Refugees and its 1967 Protocol: A Commentary,” Oxford Public International Law, January 2011, https://opil.ouplaw.com/display/10.1093/actrade/9780199542512.001.0001/actrade-9780199542512.

[165] UN Human Rights Committee (HRC), General comment no. 35, Article 9 (Liberty and security of person), December 16, 2014, CCPR/C/GC/35, para 12, 18.

[166] UNHCR ExCom, Conclusion No. 44 (1986).

[167] United Nations, “Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment,” Note by Secretary-General A/63/174, 77. Special Rapporteur on Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, Report on Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, Human Rights; Human Rights Committee, General Comment 20, Article 7, 44th Sess., U.N. Doc. HRI/GEN/1/Rev. 1 para 30 (1994).

[168] United Nations Standard Minimum Rules for the

Treatment of Prisoners (the Nelson Mandela Rules) A/RES/70/175, January 8, 2016, https://documents-dds-ny.un.org/doc/UNDOC/GEN/N15/443/41/PDF/N1544341.pdf?OpenElement.

[169] Juan Mendez, Interim Report of the Special Rapporteur of the Human Rights Council on Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment ¶¶ 21, 26, U.N. Doc. A/66/268 (August 5, 2011), https://digitallibrary.un.org/record/710177?ln=en.

[170] United Nations Press Release, Special Rapporteur on Torture Tells Third Committee Use of Prolonged Solitary Confinement on Rise, Calls for Global Ban on Practice, October 18, 2011, https://press.un.org/en/2011/gashc4014.doc.htm. NIJC & PHR, “Invisible in Isolation” (citing Interim Report of the Special Rapporteur of the Human Rights Council on Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, para 62 UN Doc A/66/268, August 5, 2011, [prepared by Juan Mendez]).

[171] Art. 10, ICCPR. Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, December 10, 1984. 1465 U.N.T.S. 85, 113; S. Treaty Doc. No. 100-20 (1988); 23 I.L.M. 1027 (1984).

[172] Office of the High Commissioner, UN Human Rights, Press Release, “United States: Prolonged solitary confinement amounts to psychological torture, says UN expert,” February 28, 2020, https://www.ohchr.org/en/press-releases/2020/02/united-states-prolonged-solitary-confinement-amounts-psychological-torture.

[173] Ibid.

[174] Ibid.

[175] Inter-American Commission on Human Rights, “Report on Immigration in the United States: Detention and Due Process,” at para 337, 2010, https://www.oas.org/en/iachr/migrants/docs/pdf/migrants2011.pdf.

[176] At para 45, https://tbinternet.ohchr.org/_layouts/15/treatybodyexternal/Download.aspx?symbolno=CCPR%2FC%2FUSA%2FCO%2F5&Lang=en.

[177] Ibid., para 54.

[178] The recommendations in this section draw on several different sources, including: Project on Government Oversight, “ISOLATED: ICE Confines Some Detainees with Mental Illness in Solitary for Months,” August 2019,

https://www.pogo.org/investigation/2019/08/isolated-ice-confines-some-detainees-with-mental-illness-in-solitary-for-months; Physicians for Human Rights, “Praying for Hand Soap and Masks,” January 12, 2021, https://phr.org/our-work/resources/praying-for-hand-soap-and-masks/.

[179] Maryam Saleh and Spencer Woodman, “A Homeland Security Whistleblower goes Public about ICE Abuse of Solitary Confinement,” The Intercept.

Campaign Zero (CZ) and Physicians for Human Rights (PHR) are partnering to raise awareness about the medically-baseless concept of “excited delirium,” which has been misused to explain deaths in police custody for decades, disproportionately those of Black men in the United States.

This jointly-led initiative challenges the baseless concept often cited to justify excessive force and obscure links between force and death, disproportionately affecting Black and Brown communities. The initiative’s launch is marked by a comprehensive resource hub at EndExcitedDelirium.org to help a wide range of audiences to understand the problematic history of “excited delirium” and to support the ongoing advocacy efforts underway across the country to end use of “excited delirium” once and for all. 

The website is based on the 2022 PHR report titled “Excited Delirium” and Deaths in Police Custody: The Deadly Impact of a Baseless Diagnosis. Since the report’s release, every major U.S. medical association has disavowed the concept of “excited delirium”. The state of California has banned the use of the concept, as has Colorado’s Peace Officer Standards and Training (POST) Board, the Bay Area Rapid Transit Police Department, and the police training company Lexipol. 

Using this momentum, PHR and CZ are collaborating to share resources to educate the public and support advocacy efforts to address police violence across the United States. Both organizations will continue to work with impacted families and communities to change medical practice, law enforcement policy, and state law in order to end “excited delirium.” 

“Excited delirium” is a non-scientific diagnosis used by law enforcement and first responders to justify use of force against civilians, and by medical examiners and coroners to obscure any connection between the cause of death and the use of force. The concept garnered national attention after one of the officers involved in the killing of George Floyd asked whether Mr. Floyd was experiencing “excited delirium.”

For more information, visit our website EndExcitedDelirium.org. Please email us at exciteddelirium@campaignzero.org to work with this campaign. If you or someone you know has been involved with an incident of “excited delirium,” please report it to us. 

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About Physicians for Human Rights

For more than 35 years, Physicians for Human Rights (PHR) has used science and the uniquely credible voices of medical professionals to document and call attention to severe human rights violations around the world. PHR, which shared in the Nobel Peace Prize for its work to end the scourge of landmines, uses its investigations and expertise to advocate for persecuted health workers and facilities under attack, prevent torture, document mass atrocities, and hold those who violate human rights accountable.

About Campaign Zero 

Campaign Zero is a data-driven organization started by activists to provide information and tools to end police violence. Campaign Zero encourages organizers, activists, and policymakers to focus on solutions with the strongest evidence of effectiveness at reducing police violence. 

January 22 will mark the 51st anniversary of Roe v. Wade, which established federal protection of the right to abortion in the United States. Since June 2022, when the Supreme Court reversed Roe, at least 14 states have adopted abortion bans imposing severe civil and criminal penalties on clinicians for providing abortion except in very narrow circumstances.  

Health and human rights advocates across the United States – including Physicians for Human Rights (PHR) – oppose these bans and the profound harm they cause, to patients and clinicians alike. Read on for a recap of PHR’s work on reproductive justice at the national and international arenas, and a look at how we’re gearing up for the year ahead. 

Exposing a Health and Human Rights Crisis in the United States 

Since Roe was overturned in 2022, PHR has worked with partners across the country to document the harm of abortion bans in the United Staes and bring evidence of the resulting health and human rights crisis to state legislatures, courts, the U.S. Congress and federal agencies, and regional and international human rights mechanisms. Our message is clear: State bans criminalizing abortion are incompatible with medical standards of care and the ethical practice of medicine, and therefore must be overturned.

Drawing on our research, including our groundbreaking April 2023 report “No One Could Say: Accessing Emergency Obstetrics Information as a Prospective Prenatal Patient in Post-Roe Oklahoma,” jointly published with the Center for Reproductive Rights and the Oklahoma Call for Reproductive Justice, we have called for recognition of the human rights violations caused by criminalizing abortion and the need for urgent reform. Our research revealed that due to abortion bans, no hospital in Oklahoma appeared able to articulate clear, consistent policies that empower clinicians’ to use their medical judgement nor support pregnant patients’ stated preferences and needs. The report was read into the Congressional record on April 27, 2023.

We continue to document clinicians’ and patients’ experiences under such bans and are pursuing accountability with key decision-makers. In November 2023, we submitted an amicus brief to the Texas Supreme Court in the case Zurawski v. State of Texas originally filed by the Center for Reproductive Rights on behalf of 20 people denied abortions under Texan law and two physicians. The PHR amicus brief argues that Texas statutes do not align with medical standards, thereby placing clinicians’ medical and ethical duties to their patients in direct conflict with the law; the penalties for performing an abortion, which a clinician deems medically necessary, can result in a jail term up to 99 years, $100,000 fines, and the potential loss of one’s medical license. Ultimately, this case will determine whether Texan clinicians are granted greater autonomy when deciding whether to provide care or will worsen the environment of fear and confusion within the medical community. 

Advocacy at the International Level 

PHR submitted evidence to the United Nations special procedures as well as the United Nations Human Rights Committee as part of its periodic International Covenant on Civil and Political Rights (ICCPR) review of the United States’ human rights record. The Committee found that abortion bans violate the rights to “life, privacy, and not to be subject to cruel and degrading treatment” and called on the United States to end the criminalization of abortion, remove barriers to care, and strengthen privacy protections for patients and clinicians.  

We also worked with partners to share the experiences of abortion patients and providers with the Inter-American Commission on Human Rights (IACHR), a regional human rights body in the Americas, in November. During the hearing, PHR and our partners called on the federal government to end the criminalization of abortion, strengthen privacy protections, and combat maternal morbidity and mortality. The commissioners strongly condemned state-level abortion bans as constituting ill-treatment and torture and expressed concerns that criminalizing abortion would exacerbate health inequities and maternal mortality rates, particularly for communities of color. By denying necessary health care to pregnant persons and imperiling their physical and mental health and safety, abortion bans rise to the level of torture and ill-treatment.  

By denying necessary health care to pregnant persons and imperiling their physical and mental health and safety, abortion bans rise to the level of torture and ill-treatment.  

We reiterated the concern that the costs of abortion criminalization disproportionately affect communities of color to various special mandates of the United Nations, including the Special Rapporteur on Contemporary Forms of Racism and the Expert Mechanism to Advance Racial Justice and Equality in Law Enforcement. Notably, communities of color in the United States already experience reduced access to quality reproductive health care and women of color are more likely to fall below the poverty line than white women, therefore feeling the costs of interstate travel for health care acutely. 

A Look Ahead 

The reversal of Roe v. Wade and 51 years of protection for abortion rights underscores the critical need for a holistic approach to enshrining sexual and reproductive health and rights. These rights remain under threat, including two looming legal challenges before the U.S. Supreme Court this year. Negative rulings on these cases would restrict Emergency Medical Treatment and Labor (EMTALA) guidance that protects the rights of patients in emergency rooms, and limit access to mifepristone for medication abortion. EMTALA guarantees all Americans emergency care at Medicare-participating hospitals with emergency departments and requires that hospitals stabilize patients when detecting a medical emergency.  

Ultimately, these broad attacks on abortion present an urgent health care crisis; clinician and patient autonomy is at risk, barriers in access to reproductive health care are increasing, and maternal mortality rates will likely rise significantly. As this crisis unfolds, PHR has been working with partners to interview clinicians at the state level in Louisiana to understand how medical personnel navigate bans in their practice and to assess the implications for human rights and health.  

This year promises to be another pivotal year for reproductive rights in the United States as the public goes to the polls to vote, including on state level ballot initiatives concerning reproductive rights. Other opportunities for reform, through state ballot measures, strengthening Health Insurance Portability and Accountability Act (HIPAA) protections that would safeguard the confidentiality of patient records, and more proactive measures from the Executive Branch, are all avenues available to reproductive rights advocates to use in the upcoming year. PHR is committed to building evidence of the health and human rights harms of abortion bans and will continue to push for reform.  

Press release available in English and Ukrainian.

Executive Summary

This case study expands on existing documentation of Russia’s widespread and systematic attacks on Ukraine’s health care system. It explores ways in which Russia has sought to systematically target health care as an apparent means of degrading resistance and, in Ukraine’s occupied territories, as a means of enforcing control over the civilian population, including by limiting and conditioning access to health care through a range of coercive practices. These practices include: (1) Russian forces misusing civilian health facilities for nonmedical purposes; (2) requiring forced changes of nationality as a precondition for gaining access to health care (otherwise known as “passportization”); and (3) threatening and harassing health care professionals as a way to further limit care and assert control over Ukraine’s health care system.

Based on a joint dataset, the study details a range of reported incidents that collectively suggest an apparent pattern of illegal attacks on health by Russia that both limit and violate the right to health of Ukrainian civilians. These attacks are violations of both international humanitarian law (IHL) and international human rights law. They also threaten the integrity of Ukraine’s health care system, which, while resilient, faces ongoing challenges following Russia’s full-scale invasion in February 2022.

The destructive impact of a compromised health care system threatens to impose long-lasting and severe hardship on Ukraine’s people. The Russian Federation must end its aggression, cease its violations, and return the administration of Ukraine’s health care system in the occupied territories back to the Ukrainian government. 

The destructive impact of a compromised health care system threatens to impose long-lasting and severe hardship on Ukraine’s people. Russia must end its war of aggression and return the administration of Ukraine’s health care system in the occupied territories back to the Ukrainian government. At the same time, there remains a pressing need to ensure accountability for violations of IHL with respect to health care, for which there has been almost complete impunity in both Ukraine and globally. All investigative and prosecutorial bodies with relevant jurisdiction – including the International Criminal Court’s Office of the Prosecutor, the Prosecutor General of Ukraine, the UN’s Independent International Commission of Inquiry on Ukraine, and other national prosecutors – must prioritize the investigation of attacks on health care as both war crimes and crimes against humanity, including the range of violations discussed herein.

Introduction

Since the onset of Russia’s full-scale invasion of Ukraine in February 2022, there have been a staggering 1,154 attacks[1] on the country’s health care facilities, workers, and medical infrastructure, amounting to approximately two attacks per day.[2] In 2022 alone, Ukraine’s health care system constituted more than one-third of all reported health-related attacks globally.^[3] Hospitals and clinics have been damaged or destroyed in over 500 incidents and at least 40 facilities were damaged more than once since February 2022.[4] The violence has not been limited to striking hospitals and clinics. It includes the shelling of ambulances, the looting of pharmacies, and acts of violence – killing, arbitrary detention, and torture – against health care personnel.[5]

The report “Destruction and Devastation: One Year of Russia’s Assault on Ukraine’s Health Care System” – published in February 2023 by eyeWitness to Atrocities, Insecurity Insight, the Media Initiative for Human Rights (MIHR), Physicians for Human Rights (PHR), and the Ukrainian Healthcare Center (UHC) – established a reasonable basis to believe that attacks on Ukraine’s health care system constitute war crimes and potentially crimes against humanity as well.[6] Drawing on 10 case studies and a joint dataset of attacks, it showed how Russian forces appear to be deliberately and indiscriminately targeting Ukraine’s health care system as part of a broader attack on its civilian population and infrastructure.

There remains a pressing need to ensure accountability for violations of International Humanitarian Law with respect to health care, for which there has been almost complete impunity in both Ukraine and globally.

The scale of such attacks underscores their destabilizing impact on Ukraine’s civilian population, from limited access to vital medicines to reduced access to critical health care services. While Ukraine’s health care system has shown resilience, it still faces enormous public health challenges, including fewer routine vaccinations, a rise in heart attacks and strokes, increased hospitalizations for infectious diseases in regions hosting many internally displaced persons, and growing financial barriers to obtaining necessary medicines.^[7] The primary health care system is in a state of deep crisis, struggling to meet the basic health care needs of the population.[8] The Russian invasion has also led to a significant increase in mental health issues and stress for all segments of the Ukrainian population.^[9] Notably, there is a particular need for systemic rehabilitation services for Ukrainian veterans and military service members.[10] Rebuilding facilities also demands substantial investments, with an estimated cost of $16.4 billion over the next decade for full reconstruction and recovery.^[11]

At the same time, ongoing attacks on health comprise more than physical acts of destruction. They also include other, less visible attacks often inflicted upon civilian populations and the community of health care professionals who labor amid conflict. In particular, in the Russian-occupied territories of Ukraine,[12] several patterns have emerged that profoundly affect civilians’ access to crucial health care services and medications as well as the health and safety of Ukrainian health care professionals.

This case study explores ways in which Russia has sought to systematically target health care as an apparent means of degrading resistance and, in Ukraine’s occupied territory, as a means of enforcing control over the civilian population, including through access to health care. It demonstrates what is happening to patients, providers, and the health system in these regions, where access remains exceedingly rare.

Covering the period from the start of the full-scale invasion in February 2022 to September 2023, the study explores these phenomena in the following ways:

1. The misuse of health facilities for nonmedical purposes: The use of Ukrainian hospitals by Russian forces for military purposes is a violation of their protected status under international law. It has also exposed patients and health care workers to a greater risk of violence. The repurposing of facilities for military medical care has severely limited civilian access to health care. The seizure of health infrastructure, including medical equipment, which often occurs during (or immediately after) occupation, further disrupts the provision of health care and likely violates the law of occupation as well.

• Forced change of nationality (“passportization”) of population through medical services: The practice of “passportization,” whereby civilian access to health care is conditioned upon a forced change of nationality, is increasingly used in Ukrainian territories currently under Russian occupation. This not only imposes an external identity on Ukrainians – a forced change of nationality – but also restricts their ability to access health care and other medical support.

• Threatening and harassing health care personnel: Health care workers in Ukraine’s occupied territories are laboring under immense duress. Local medical personnel face significant pressure as they are forced to work in occupied hospitals, compelled to operate under Russian law, and to deny care to Ukrainian citizens resisting “passportization,” pushed to undergo retraining in Russia, or even replaced by Russian doctors. The persistent risk of detention and other punitive measures creates a hostile and perilous environment for health care professionals, inflicting a range of physical, mental, and moral injuries.

Based on the dataset maintained by our organizations, there have been at least:

• 16 reported incidents where a health facility was repurposed for nonmedical purposes, including as a military base, to store weapons, or to otherwise plan military action;
• 34 reported incidents where civilian patients were forcefully evicted from a health facility or denied access to health care, and the facility was then reportedly repurposed for the use of wounded soldiers;
• 23 reported incidents where medical supplies were requisitioned by Russian forces;
• 15 reported incidents of “passportization” – denying medical care to people without a Russian passport or coercing civilians into obtaining one to access health care; and
• 68 health care workers who were detained in 17 separate reported incidents.[13]

Collectively, these incidents suggest an apparent pattern of conduct by Russia that both limits and violates civilians’ right to health and imperils their ability to access essential health services. They undermine not only the efforts of those interested in upholding care amidst conflict but serve to expand Russia’s coercion of and control over Ukraine’s civilian population.

In detailing these incidents, the case study also identifies some of their potential implications under international law, with reference both to international humanitarian law (IHL) and human rights law. Its conclusions underscore a grim reality but affirm a critical obligation in the context of Russia’s full-scale invasion of Ukraine: violations of the protected status of health care and health personnel must be prioritized for investigation and prosecution.

Methodology

The information cited in this study is based on reported incidents. It remains exceedingly difficult to access Ukraine’s occupied territories and data on health attacks – as well as their impact – remains limited and incomplete. The ability to physically document and verify attacks on the ground remains out of reach, constraining this study’s scope. To that end, the cited incidents should be understood as examples and not as representing a complete count of all incidents across Russian-occupied territories. Indeed, the examples are almost certainly an undercount.

This study has sought data from multiple sources, including audiovisual evidence, open-source research, and interviews with Ukrainian health care workers interviewed by MIHR, PHR, and UHC. It also draws upon reported incidents collected by Insecurity Insight from open sources and data provided by the World Health Organization (WHO).

Incident data was collected through collaborative efforts among the partner organizations as well as from UHC.[14] The dataset brings together individual incidents from a range of sources, including open-source research, the eyeWitness app, witness and victim accounts, site visits undertaken by UHC and PHR[15], and networks from organizations working on the ground. It has been compiled using an incident-based approach to evidence collection, where individual incidents are collected, verified, and combined to allow for an analysis of patterns of violence over time and in different locations.[16] All incidents were then reviewed, verified based on a range of criteria within the limits of research partners’ technical and resource capacity, and assigned an incident number. The dataset is regularly updated on a digital, interactive map at www.attacksonhealthukraine.org.

This study’s methodology was approved by PHR’s Ethics Review Board (ERB) to ensure compliance with U.S. requirements for human subject research.^[17] All interviews were conducted using a range of security precautions and protections. The incident data collection follows Insecurity Insight’s ethical guidelines on documenting and reporting incidents of attacks on health care. Certain incident data collected by other organizations like the WHO, however, remains unavailable for comprehensive analysis.[18]

As part of the methodology for this report, the research team submitted an official request for information to Ukraine’s Ministry of Health to confirm the number of health facilities in Ukraine’s occupied territories, which is discussed below.[19] It also submitted an information request for more detail on events reported by the WHO; however, at the time of publication, no response had been received.

For the purpose of this study, Russian-occupied territories were defined within the framework established by the Ministry of Reintegration of the Temporarily Occupied Territories of Ukraine, including territories that were occupied and have since been liberated by the Ukrainian forces and territories that are still under occupation.[20] A case-by-case decision as to whether an incident occurred in an occupied territory was taken based on the best available information at the time.

Applicable Law

Under IHL, a “territory is considered occupied when it is actually placed under the authority of the hostile army. The occupation extends only to the territory where such authority has been established and can be exercised.”[21] This case study references several towns, cities, and oblasts that are either currently, or were for a certain period, under the effective control of Russia. With regard to Donetska, Khersonska, Luhanska, and Zaporizka oblasts as well as Crimea, the study accepts the proposition that, consistent with international consensus,[22] these areas are only temporarily occupied and continue to remain part of Ukraine.[23] Given this context, IHL, and more specifically a subset of rules known as “occupation law,”[24] as well as human rights law, form the applicable legal framework for this study.[25] As supported by a wealth of international jurisprudence, human rights law does not cease to apply in situations of armed conflict,[26] and binds states even when they operate outside their territory, and “particularly in occupied territories.”[27]

Serious violations of IHL may constitute war crimes under international criminal law (ICL).[28] Specifically, the Geneva Conventions and Additional Protocol I establish that certain violations of IHL are to be considered “grave breaches” and must be prosecuted by state parties.[29] Individual criminal responsibility for other serious violations of IHL is established by customary international law and by international criminal law treaties, such as the Rome Statute of the International Criminal Court. Such violations, together with grave breaches, constitute war crimes. Some of these violations may also constitute crimes against humanity if they are committed “as part of a widespread or systematic attack directed against any civilian population, with knowledge of the attack.”[30]

Occupation law. The rules included within this specific branch of IHL rest on the fundamental premise that the Occupying Power – here, Russia – has not acquired sovereignty over the occupied territory and that the occupation is merely temporary. Existing laws and institutions should thus be respected and maintained as far as possible in order to preserve the status quo ante in the occupied territories.[31] In a balancing exercise between the Occupying Power’s purported military interests and those of the local population, occupation law fundamentally aims “to ensure the protection and welfare of the civilians living in occupied territories.”[32] In this sense, the Occupying Power must leave any local legislation in force provided that it does not constitute a threat to security or an obstacle to the application of the law of occupation.[33]

Right to health. Article 12 of the International Covenant on Economic, Social and Cultural Rights (to which both Ukraine and Russia are party) “recognize[s] the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.”[34] States have an obligation to maintain a functioning health care system in all circumstances, including during armed conflicts and in occupied territories. With regard to the situation in Ukraine’s occupied territories, IHL already imposes certain positive obligations upon the Occupying Power in relation to health.[35] The human rights framework goes further by clarifying that states have an obligation to take all necessary steps and use their resources to the maximum extent available to maintain, at the very least, essential primary health care, ensuring access to health facilities, goods, and services, as well as to the minimum essential amount of food, adequate supply of safe and potable water, basic shelter, housing, and sanitation. They should also provide essential drugs, while respecting the principles of nondiscrimination and equitable access.[36]

Health Care Under Occupation: Repurposing of Health Facilities and Seizing of Health Supplies

Applicable Law   Medical units are afforded specific, enhanced protection[37] under IHL due to “their primary importance during armed conflicts, both to maintain public health and to care for the wounded and sick caused by the armed conflict” and regardless of whether they are military or civilian.[38] They shall be respected and protected at all times by the parties to an armed conflict.[39] In occupied territories, the Occupying Power has the duty, to the fullest extent of the means available to it and in cooperation with national and local authorities, to ensure and maintain medical and hospital establishments, services, as well as public health and hygiene.[40] Additionally, it is also the responsibility of the Occupying Power to provide the necessary medical supplies for the population of the occupied territory, including by importing it into the area if the supplies in the region in question are inadequate.[41]

According to the most recent information provided to the research team by Ukraine’s Ministry of Health, as of October 2023, there were or are 364 health facilities registered on territories temporarily occupied by Russia,[42] out of a total of 3,555 health facilities in Ukraine.[43]

In 2023, the Ukrainian government has financially supported (at a cost totaling $48.5 million) 143 health facilities in the occupied territories through the National Health Service of Ukraine (NHSU),[44] with the declared intention of “[e]nsuring the preservation of human resources to provide medical care to the population in the temporarily occupied territory.”[45] The payment mechanism to support these facilities involves cross-referencing employee information from multiple sources, including official authorities like the Security Service of Ukraine, to determine access to health care funds, disconnecting health care facilities from the electronic system, and halting payments if irregularities are found.[46]

Based on the number of hospitals receiving financial support from Kyiv, it is estimated that up to 60 percent – or 221 health facilities – in the occupied territories remain disconnected from the Ukrainian health system. According to the International Organization for Migration’s GPS reporting, since December 2022, 28 percent of Ukrainians residing under current Russian occupation have insufficient access to medical services and medicines.[47]

Patients thus face the risk of significantly reduced access to health care. They may be less likely to seek access to care under occupation out of fear for their safety, particularly where health facilities have been repurposed for nonmedical purposes. Logistical hurdles – such as the inability to access transportation to travel to an available civilian hospital, or financial difficulties, including the inability to cover expenses for services from private health care facilities or providers – can further restrict patients’ access to medical services. Collectively, these obstacles can lead to an increased risk of health complications. Although NHSU receives reports from the contracted hospitals, the real picture of the health care situation in areas currently under Russian occupation is not fully known.

Repurposing Health Facilities for Nonmedical Purposes

Applicable Law

Based on the research team’s dataset, 16 health facilities in five of Ukraine’s oblasts were reportedly repurposed into military bases or for other nonmedical purposes. In all 16 cases, the health facility was fully functioning at the time of their repurposing. Most of these incidents were reported in Zaporizka oblast, where seven such cases were recorded. Five incidents took place during the first three months of the full-scale invasion, with cases being more frequently reported after November 2022. For instance:

• One former children’s hospital used as a COVID-19 hospital in Zaporizka oblast was reportedly repurposed into a military base in November 2022 (incident 35830).[52]
• A women’s hospital in Luhanska oblast was reportedly repurposed into a military base in January 2023 (incident 36931).[53] In March 2022, a psychoneurological boarding facility in Bucha, Kyiv was seized by Russian forces who fired artillery from its premises (incident 33352).[54]
• In March 2023, a hospital in Luhanska oblast was reportedly turned into barracks for Russian soldiers (incident 37605).[55]
• In July 2023, a hospital in Luhanska oblast was reportedly occupied by the paramilitary Chechen unit Special Rapid Response Unit (SOBR) “Akhmat” under the instruction of Russian authorities (incident 39938).[56]
• The repurposing of health facilities was also accompanied by other takeovers. For example, in Osypenko village, Zaporizka oblast, Russian military forces reportedly occupied the local hospital and civilian homes (incident 40276).[57]

Dr. Oksana Kyrsanova, an anesthesiologist at the Regional Intensive Care Hospital in the city of Mariupol, spoke to MIHR researchers about the occupation of the hospital by Russian forces on March 12, 2022[58], describing how doctors provided care during the occupation, and the conditions under which staff worked (incident 36432).[59]   “They made our hospital their headquarters. They had a rotation, first there were some, then others came. They occupied the entire building, completely surrounded and controlled the hospital, all entrances, exits, and stairs. They were on the roof of our hospital. We had a very big building, and they had a view of everything.”   “And indeed, we saw it all, they [Russian forces] set up their equipment and shot from the hospital buildings. Military equipment was placed around the perimeter of the hospital. Armored personnel carriers stood on all sides of the hospital. There were snipers on the roof and top floors. There were probably four soldiers on each floor. There were a lot downstairs, probably 10 [soldiers] and three armored personnel carriers. The soldiers would rotate; the armored personnel carriers hid, for example, between two houses right in front of the windows.”

Other incidents appear to have also involved repurposing for military use, but no details of how they were so used were provided. For example, in March 2022, a hospital in Slavutych city, Kyivska oblast, was taken over by Russian forces during their invasion of the city (incident 31988).[60] And in November 2022, an infectious diseases hospital in Melitopol city, Zaporizka oblast, was occupied by the Russian military (incident 35831).[61] 

There have also been nonspecific reports about the use of health care facilities by the Ukrainian forces.[62] However, our organizations have not been able to independently verify such misuse.

Reported locations of health facilities in Ukraine repurposed into military bases by Russian forces, February 2022 – August 2023

On at least 16 occasions, fully functioning health facilities were taken over by Russian forces and turned into military bases. Most of these incidents were documented in Zaporizka oblast.    

Military use of protected infrastructure is a violation of IHL, as it infringes the protected status of such sites and personnel. In addition to the risk that such “dual purpose” use of hospitals and health facilities poses to the civilian population – exposing them to greater risk of attack by combatant forces – the occupation of civilian hospitals also strains health care resources.

Olena Yuzvak, head of the Primary Care Center in Hostomel, Kyivska oblast, spoke to PHR about the occupation of the clinic (incident 41998)[63] from February through March 2022:[64]   “In the building of this primary clinic was the base of the Russian military, and in the basement of this building were children, civilians who were not even allowed to go outside and cook some food, because it was dangerous, no one allowed them to do so. And the people who tried to leave on their own because they were losing it and wanted to leave this hell, […] their cars were shot, they were civilians.”   Olena’s husband and son, both civilians, were taken prisoner by Russian forces. Her husband, who was shot when Russian soldiers entered their private house, has since been released in a prisoner exchange, but her son, Dmytro, remains in captivity.

Repurposing health facilities as military bases violates IHL and may constitute war crimes. The incidents narrated by doctors from Mariupol and Hostomel, in particular, raise concerns that merit further investigation.

Civilian hospitals repurposed as military hospitals

In 44 reported incidents, health facilities in seven of Ukraine’s oblasts were reportedly repurposed for the use of Russian soldiers. These takeovers of civilian facilities for military medical use were particularly frequent in February 2023 and the number of reported new takeovers increased between February and April 2023. In all 44 cases, the health facility was fully functioning at the time that it was repurposed from civilian use for the use of soldiers. 

Most of these incidents were documented in Luhanska oblast, where 18 cases were recorded, with most taking place between December 2022 and May 2023. Incidents were also common in Zaporizka oblast with 10 and Kherson with seven. Of note:

• Six women’s hospitals were reportedly repurposed for the use of soldiers, five of which were in Luhansk and one in Zaporizhzhia.
• Three children’s hospitals were reportedly repurposed for the use of soldiers: two in Zaporizhzhia and one each in Kharkiv.

In 34 of the 44 incidents, it was specifically reported that civilians were forcibly evicted from a health facility or denied access to health care, and the facility was then repurposed for the exclusive use of wounded soldiers. For example:

• In November 2022, Russian forces reportedly expelled patients from an emergency hospital in Melitopol, Zaporizka oblast (incident 35779).[68]
• In March 2023, a maternity hospital in Luhansk was allegedly taken over and turned into a military hospital by Russian forces. Women in labor were transferred to the two remaining maternity hospitals in the city (incident 37751).[69]
• Later in May, Russian forces reportedly handed the hospital over to the Russian-government–linked Wagner Group private military for the use of treating their wounded soldiers (incident 39079).[70] 

Reported locations of health facilities in Ukraine repurposed for the use of wounded Russian soldiers, February 2022 – August 2023

Fully functioning health facilities were repurposed from civilian use to soldiers by Russian forces at least 44 times. A great number of incidents was documented in Luhanska oblast between December 2022 and May 2023  

Based on available information, it is unclear whether these incidents satisfied the “urgent necessity” threshold of the Fourth Geneva Convention, nor is it clear if the health needs of specific patients, and access to health care for the civilian population as a whole, were adequately taken into account in these incidents. However, the way in which the use of beds and infrastructure were reportedly requested and taken over raises significant concerns about the equitable provision of care to all wounded and sick people.

The extent to which civilians were cut off from care as a result of requisitioning underscores the harmful health impacts of the continued occupation. Indeed, the reported medical needs within areas currently occupied by Russian forces are often so great that local health care capacities cannot cope with both Russian military and civilian populations. In Luhansk city, for instance, as well as in towns of the oblast, hospitals reportedly operate at full capacity. One person, whose father had a broken hip but was turned away at the hospital, reported that doctors “received an instruction from Luhansk to give hospital beds to wounded soldiers, and to send civilians back if they do not have a heart attack.”[71] Similarly, in Dovzhansk, a maternity ward was reportedly vacated to accommodate wounded Russian soldiers instead (incident 41997).[72]

The redirection of medical care to wounded combatants may have implications for civilians in the occupied territories. For instance, more than 450 wounded Russian military personnel were reportedly being treated in the city hospital of the occupied city of Dniprorudne, Zaporizka oblast, likely impacting the availability of medical services for civilians (incident 37004).[73] A similar situation is observed in Donetsk, where routine surgeries for civilian patients are reportedly being canceled (incident 42120),[74] making it increasingly difficult for the civilian population to access medical services across the region (incident 38618).[75] Additionally, in the occupied part of Khersonska oblast in January 2023, particularly in Kakhovka, a tuberculosis dispensary was transformed into a military hospital to treat Russian soldiers (incident 37667).[76]

In Crimea, increasingly more hospitals are reportedly being reoriented into military hospitals, restricting the civilian population’s ability to receive medical services.[77] The new Semashko Medical Center in Simferopol, with the capacity to treat 650 patients, was turned over to the Russian military (incident 39428).[78]

The conversion of civilian hospitals located in former or current occupied areas of Ukraine into military hospitals – such as the ones reported in Donetska, Khersonska, Luhanska, and Zaporizka oblasts – suggests a worrisome pattern by Russian forces. Further investigation is required, however, to confirm whether there was an “urgent necessity” in each instance and, if so, whether hospitals were restored to their normal use as soon as that urgency ceased to exist. There has also been no documented effort to expand the capacity of care for soldiers and civilians alike.

Seizure of Medical Supplies and other Forms of Appropriation

Applicable Law

The research team identified 23 reported incidents, in six of Ukraine’s oblasts, where Russian forces requisitioned medical supplies and equipment needed for the running of the health system, including computers, digital and medical equipment, hospital furniture, medicine and blood supplies, and, in one case, building supplies from a hospital under construction. While the details about the specific circumstances are not always clear, there is indication that requisitioning occurred in the context of armed threats, coercion, or harassment.

Such incidents were more frequently reported between October 2022 and March 2023, with three incidents reported as taking place during the first two months of the full-scale invasion.

• Nearly two-thirds of the incidents were reported in Khersonska oblast, where 15 cases were recorded. In June 2023, one women’s hospital in Luhansk oblast had reportedly all its furniture placed into military trucks and taken away after Russian forces converted it into a field hospital for wounded Russian soldiers (incident 39856).[83]
• In eight incidents, medical supplies were specifically reported to have been requisitioned and removed by Russian military vehicles. For example:
  • In October 2022, medical equipment was taken from a hospital in Bilozerka, Khersonska oblast, and transferred to Skadovsk and Henichesk (incident 35337).[84]
  • In March 2023, blood supplies were taken by Russian forces from transfusion centers in Sevastopol city, Crimea, to a military hospital, which caused a shortage in civilian institutions (incident 37907).[85] While there are few details available, it appears they were taken without proper procedures.
• In the remaining 15 incidents, medical supplies were removed from a health facility. However, it is unclear if they were removed to supply health care facilities they had repurposed to treat wounded soldiers or for other unspecified purposes.

Reported locations of medical supplies requisitioned from health facilities by Russian forces, February 2022 – August 2023

On at least 23 occasions, medical supplies and equipment needed for the operation of the health system were taken by Russian forces. A large number of incidents were reported in Khersonska oblast between October 2022 and February 2023.  

In Kharkivska oblast, Dr. Maryna Rudenko, director of the Balakliia Clinical Multiprofile Intensive Care Hospital, recounted living inside the facility until April 4, 2022, when Russian forces seized the hospital (incident 36559).[86] Upon her return five months later, Dr. Rudenko described the situation in this way:

“Almost everything was stolen. They took away everything that could be taken away. They couldn’t move the CT scanner, so they looted the electronics from it. … We had two surgical stands … We hid them in the basement, but they found them and stole them. All the tools were stolen. The diagnostic department: there is nothing at all, everything was stolen; they lived there. That is, all ultrasound machines, cardiographs, encephalographs; nothing. They took it out … We also had a generator for 100 kilowatts: disappeared. Out of 15 [ambulance] cars, 14 disappeared with them. Telephones, 37 washing machines, microwave ovens [were also removed].”[87]

Another doctor spoke to the MIHR researchers about the seizure of property in then-occupied Kherson before they left the city in July 2022 (incident 42145):[88]

“At the beginning of the spring of 2022, the occupation authorities banned the import of medicines into Kherson; this spurred an ‘underground’ trade in medicines throughout the city. From the start of the occupation, Russian ‘entrepreneurs’ appropriated Ukrainian pharmacies and started selling Russian medicines. They were of much lower quality than Ukrainian and European ones.”[89]

In addition to diminished access to medical services, property seizure and willful destruction have led to greater scarcity of medications and limited equipment to perform necessary tests or surgeries. Ukraine’s Ministry of Health has described the current supply levels of medicines to health care facilities and pharmacies in the areas currently occupied by Russian forces as “catastrophic,” as there are no deliveries to the occupied areas of Khersonska and Zaporizka oblasts, and the information from Donetska and Luhanska oblasts is scarce.[90]

Credible reports of medical supplies and equipment stolen by retreating Russian forces, such as the ones highlighted in Balakliia Clinical Multiprofile Intensive Care Hospital and in Kherson, require further investigation. They may amount to IHL violations and, possibly, war crimes of pillage and/or seizure of property.[91]

Forced Change of Nationality and its Consequences

Forced change of nationality – or as it is referred to in Ukraine, “passportization” – involves mandating the acquisition of Russian passports in the areas currently occupied by Russian forces, including by making access to health care conditional on one’s nationality. In this context, “passportization” refers to the coerced adoption of Russian nationality through control of access to several areas of civilian life, including access to health care.[92]

Applicable Law   Coercion of inhabitants in areas currently under Russian occupation to change nationality. One of the basic principles of occupation law states that “[i]t is forbidden to compel the inhabitants of occupied territory to swear allegiance to the hostile Power.”[93] It follows that no form of pressure can be exercised on the population to assume Russian nationality.[94]   Right to a nationality.[95] According to the Universal Declaration of Human Rights, “[e]veryone has the right to a nationality. No one shall be arbitrarily deprived of his nationality nor denied the right to change his nationality.”[96] The right to a nationality, also enshrined in other human rights treaties such as the International Convention on the Elimination of all Forms of Racial Discrimination and the International Covenant on Civil and Political Rights,[97] includes both the ability to freely change one’s nationality, without coercion,[98] and the prohibition against arbitrary deprivation of one’s nationality. This includes situations where people who were recognized as citizens of a state are subsequently stripped of that nationality.[99] With specific regard to protected persons in occupied territories, IHL provides that they “shall not be deprived, in any case or in any manner whatsoever, of the benefits of the present Convention by any change introduced, as the result of the occupation of a territory, […] nor by any annexation by the latter [the Occupying Power] of the whole or part of the occupied territory.”[100] Russian policies, witnessed first in Crimea and more recently in Donetska, Khersonska, Luhanska, and Zaporizka oblasts, instituting a procedure to forcibly issue Russian passports for residents that – if rejected – will ultimately render them stateless or “foreign” citizens, would likely violate these protections.   Adverse distinctions based on nationality. “Passportization” may likewise violate a range of IHL protections. The provision of medical supplies should be made “without any adverse distinction”[101] that is not based on medical or humanitarian criteria.[102] “Similarly, Article 75 of AP I would require humane treatment and fundamental guarantees to be accorded to all persons irrespective of ‘national […] origin,’ and would prohibit as discrimination all unfavorable treatment – including collective punishment –of persons compared to the treatment of persons of a different nationality (including own, enemy or third-country nationals) that has no reasonable and objective justification.”[103]   The prohibition of adverse distinction is the IHL counterpart to the concept of discrimination in human rights law,[104] defined by the UN Human Rights Committee as “any distinction, exclusion, restriction or preference which is based on any ground such as race, color, sex, language, religion, political or other opinion, national or social origin, property, birth or other status, and which has the purpose or effect of nullifying or impairing the recognition, enjoyment or exercise by all persons, on an equal footing, of all rights and freedoms.”[105] Distinctions based on nationality in the provision of medical supplies essential to the survival of the civilian population, resulting in nationals of the occupied state being subjected to less favorable treatment compared to nationals of the Occupying Power, would seem to openly violate the IHL provision referenced above.   Other violations. Using discriminatory methods to impose a change of nationality to the population of temporarily occupied areas may also result in other violations, such as the rules prohibiting forcible transfers or deportations of the population of the occupied territories,[106] and those forbidding the Occupying Power to pressure or force protected persons to serve in its armed or auxiliary forces,[107] as well as more generally depriving them of their fundamental rights.

Coerced adoption of Russian nationality began prior to the February 2022 invasion, when Russian citizenship was automatically granted to residents of occupied Crimea and simplified procedures for Russian passport applications were introduced for Ukrainian citizens of the occupied territories of Donetska and Luhanska oblasts.[108] On April 27, 2023, President Vladimir Putin of Russia signed a decree establishing a procedure to issue Russian passports to residents of the Russian-occupied territories of Donetska, Khersonska, Luhanska, and Zaporizka oblasts of Ukraine.^[109] According to the decree, residents have until July 1, 2024 to accept Russian citizenship; otherwise, they will be considered foreigners or stateless and can be detained or deported.^[110] As was the case in Crimea after Russia’s occupation in 2014, they may face threats and discrimination, including in accessing medical care and social services.^[111]

Concurrently, on June 20, 2023, Decree No. 186 was issued in the occupied territories of the self-proclaimed “Donetsk People’s Republic,” establishing a working group vested with executive authority to expel, deport, and detain all Ukrainians who did not obtain Russian citizenship in designated camps.[112]

Conditioning Access to Care on Change in Nationality

The research team documented 15 incidents of “passportization” through medical services between February 2023 and August 2023. Most incidents took place from March 2023 onwards, with one recorded incident in September 2022 in Donetska oblast. Cases were documented in four of Ukraine’s oblasts and were most frequent in Zaporizka oblast, where eight cases were recorded. Of note:

• Five incidents involved health care workers being affected by “passportization.” During these incidents, health care workers were reportedly ordered to deny medical services to people who did not hold a Russian passport or a receipt of application.
• In some hospitals, administration points were set up for civilians to then apply for a Russian passport.
• In other cases, health care workers were reportedly forced to hand over their Ukrainian passports and obtain a Russian passport within a strict time frame or face being dismissed from their positions if they refused and their positions filled by Russian staff.
• In one case in June 2023, Russian authorities reportedly closed a health facility in Zaporizka oblast after most of the employees refused to obtain Russian passports (incident 39417).[113]

In ten incidents, civilians carrying Ukrainian passports were reportedly unable to access medical services. Five of these incidents were reported in Zaporizka oblast.

Reported locations of “Passportization” of Population Through Medical Services by Russian forces, February 2022 – August 2023

Incidents became more frequent from March 2023 onward, with most taking place in Zaporizka oblast  

“Passportization”: Before and After February 2022

Before the 2022 invasion, human rights organizations in Ukraine had reported on limited access to medical services for civilians without Russian passports who were living in previously occupied territories.[114] In Crimea, for instance, medical services should have been provided free of charge, but after 2014, according to local practices these services were only available to holders of a compulsory health insurance policy for Russian citizens. Those who did not have such documentation could not obtain an appointment at a public hospital.^[115]

In the words of a patient from Crimea who spoke with the human rights organization ZMINA in 2017, “I was sick, I had a fever, a cough, I went to the receptionist at the seventh polyclinic. They did not give me a referral to a doctor because I did not have their insurance, and I did not have insurance because I did not have a passport. I had to go to a doctor I knew. As a result, it turned out that I had pneumonia, and I was treated at home, with the advice of a doctor I knew.”^[116]

Elsewhere, “passportization coercion is gaining momentum,” according to the advisor to the mayor of Mariupol Petro Andriushchenko.^[117] In Mariupol, the advisor reports that people are now “being denied treatment and/or examination […] without state health insurance. To get insurance, you need to have a Russian passport.”

Khersonska oblast is another area that has suffered devastating destruction –from the bombing of the Kakhovka dam in June 2023^[118] to incessant shelling of civilian infrastructure, including health care.^[119] According to a report by the Center for Investigative Journalism, a local resident in Hornostaiyivka reportedly died because doctors refused to provide him with medical care without a Russian passport (incident 42057).^[120]

In May 2023, the Russian government announced that all residents of areas occupied by Russian forces, including children, would need to obtain compulsory health care insurance available only for Russian citizens by the end of 2023.^[121] According to Yuriy Sobolevsky, first deputy chairman of the Khersonska Oblast Council, doctors have already refused to provide services to those who do not have a Russian compulsory insurance policy: “Fortunately, most of the doctors are our [Ukrainian] Kherson doctors, they are sabotaging this and quietly continue to provide medical services, but some health facilities already have managers and medical staff, partly people who came from Russia to Khersonska oblast, and they are putting the most pressure on our people.”^[122]

A similar situation obtains in Donetska and Luhanska oblasts. The Ukrainian government’s National Resistance Center reports that, to specifically control the process of “passportization” – and the provision of medical services based on one’s passport – the Russian “administration” is increasing the number of doctors brought in from Russia.^[123]

Russian officials and their appointees confirmed the existence of these policies. In Lazurne (Khersonska oblast), for instance, the Russian-appointed head of the town, Oleksandr Dudka, stated that Russian authorities would not provide medicines and humanitarian aid to Ukrainian citizens who rejected Russian passports. In his words, “Medicines purchased from the budget of the Russian Federation will not be distributed to Ukrainian citizens. This applies to insulin users who have already experienced what it is like to be a citizen of another country.” (incident 42060)^[124] Similar accounts of deprivation of access to insulin have also been reported from areas near Genichesk of Khersonska oblast.^[125] The Russian-appointed head of the occupation administration of Zaporizka oblast, Yevhen Balitskyy, said that residents of the Russian-controlled part of the oblast who do not have Russian passports will not be able to use medical services from 2024.[126]

Such barriers to access to lifesaving medicines are erected throughout many areas currently under Russian occupation, in addition to the unavailability of medical services. In Enerhodar of Zaporizka oblast, which hosts the threatened Zaporizhzhia Nuclear Power Plant, the largest nuclear power plant in Europe,^[127] the Russian administration prohibited the distribution of vital medicines to residents without a Russian passport. According to the mayor, Dmytro Orlov, all the pharmacies were seized and now refuse to provide vital medicines, including insulin and thyroid medicines, to citizens without Russian passports (incident 42062).[128] A resident of Enerhodar said that the occupation “administration” announced that an ambulance would not come “if you did not have a Russian passport. Then they warned us that they would not sign us up for scheduled surgeries, and before the urgent ones, they force [us] to sign a commitment to get this passport or at least to sign up for it.”[129]

Amid occupation, health care workers at public health facilities are often compelled to be the initial subjects for testing the newly implemented “passportization” policies. In Mariupol, for instance, health care workers were reportedly ordered to obtain Russian passports (incident 34715).[130] Meanwhile, they were also obliged to unconditionally hand over their Ukrainian passports, making it virtually impossible for them to leave the occupied city.

Impact of “passportization” on Children and Vulnerable Groups

These restrictions are particularly harmful to vulnerable groups, including people with disabilities, chronic diseases, critical conditions, the elderly, and low-income people. Women and girls may often struggle to access essential gynecological and reproductive health care in situations where health decisions are primarily shaped by scarcity, safety concerns, and ongoing conflict.[131] Patients may not seek necessary care, subjecting themselves to greater risk of health complications.

This is especially concerning for children, given reports of denial of access to insulin or hospitalization for children whose parents do not have Russian passports or who have resisted “passportization” (incident 42120).^[132] These practices are also occurring against the backdrop of mass deportations of Ukrainian children to Russia, with 150,000 to 300,000 children subjected to forcible transfer and/or deportation.^[133]

Russia’s “passportization” policy seeks to forcibly change the nationality of deported and forcibly displaced citizens of Ukraine, including orphans and children left without parental care. The latter are particularly vulnerable to the policy: as per the “passportization” laws, representatives from health care facilities,[134] as well as schools and social institutions in whose care these children are kept, can request to Russian authorities on their behalf that they no longer want Ukrainian citizenship. Human rights organizations have documented deportations of entire orphanages, with more than 2,000 orphans, children without status, and children deprived of parental care taken to Russia from boarding schools and orphanages in the occupied parts of Luhanska and Donetska oblasts alone since the beginning of May 2022.[135]

Ukrainian people are being forced to choose between their well-being, even their lives, and their citizenship in exchange for basic services, including health care; indeed, Russia appears to be aiming to expedite its “passportization” of the population in Ukraine’s occupied territories. Such violations urgently require further investigation.

Health Care Workers: At Risk and Under Duress

Applicable Law Under IHL, health care workers assigned to carry out medical duties or purposes must always be respected and protected, unless they commit, outside of their humanitarian function, acts that are harmful to the enemy.[136] They shall also be allowed to carry out their duties,[137] and must be exempted from any measures that may interfere with the performance of their professional ethical obligations including restrictions on their movements, and the requisition of their supplies, equipment, or vehicles.[138]   Cooperation between the Occupying Power and national/local authorities. The Occupying Power must ensure that hospital and medical services can work properly and continue to do so, with the cooperation of national and local authorities.[139] This means that the “burden of organizing hospitals and health services […] is above all one for the competent services of the occupied country itself.”[140] The level of involvement of the Occupying Power will vary based on the extent to which national authorities are able to look after the health of the population themselves.[141] As long as they are able to meet the needs of the population, staffing decisions would thus fall on national and local authorities. Deportations and Transfers. IHL provides that the protecting party shall not transfer part of its civilian population into the territory it occupies.[142] Similarly, there is also an absolute prohibition against the forcible transfer or deportation of one or multiple protected persons from the occupied territories to the territory of the Occupying Power or to that of any other country, regardless of the motive.[143] Both of these actions may also amount to war crimes.[144] Provisional evacuations for the security of the population or dictated by imperative military reasons are the only exceptions that can justify forcing the population of the occupied territory to move elsewhere.[145] To distinguish between unlawful forcible displacement and lawful evacuations, one must consider “[w]hether (a) the purpose is to protect civilians from the effects of military attacks, or (b) it is for an illicit purpose such as to change the demographic makeup of an area or indefinitely remove inhabitants as a security buffer;”[146] indeed, political motives cannot qualify as imperative military reasons to move a population in order to exercise more effective control over dissident groups or an area.[147] Health care workers also fall under this protection regime aimed at ensuring that the makeup of the population of an occupied territory is not reshaped.   Prohibition of arbitrary deprivation of liberty. Arbitrary detention is prohibited both under IHL and human rights law.[148] IHL lists lawful grounds for detention in all four Geneva Conventions. Regarding health care personnel, IHL distinguishes the treatment of civilian personnel from the ones of personnel who are part of the armed forces or work under their auspices. Civilian health care personnel may only be interned or placed in assigned residence if “the security of the Detaining Power makes it absolutely necessary”[149] or, in occupied territories, for imperative security reasons.[150] Military health care personnel, if exclusively engaged in medical activities, can be retained by the adverse Party “only in so far as the state of health […] and the number of prisoners of war require” and relieved where possible.[151] Auxiliary military health care personnel will instead be considered prisoners of war should they fall into the enemy’s hands, “but shall be employed on their medical duties in so far as the need arises.”[152] Detention that is not in conformity with IHL rules is defined as unlawful confinement and – when concerning civilians, including civilian health care personnel – amounts to a grave breach of the Fourth Geneva Convention.[153]   Prohibition of torture and cruel, inhuman, or degrading treatment. There are multiple definitions of torture under public international law. According to the Rome Statute, torture is the intentional infliction of severe pain or suffering, whether physical or mental, upon a protected person for the purpose of, among others, obtaining information, punishment, intimidation, or coercion.[154] Inhuman treatment does not require such purpose.[155] These acts are forbidden at all times, by all parties to a conflict.[156]

Doctors and other health care workers in conflict find themselves working in incredibly challenging conditions, often amid constant shelling. Many health care workers have become displaced, increasing the burden on the existing staff. The total health care workforce within Ukraine’s national health care system experienced a 13.7 percent reduction in 2022 compared to the previous year.^[157]

Since the onset of the full-scale invasion, 160 health workers have been killed and 119 have been injured in 185 incidents.

Doctors are often sources of support; in conflict and occupation, it is common for them to assume leadership roles in their communities. Dr. Yuzvak, who was the only active doctor in Hostomel during the occupation, described her role as follows: “People, civilians, kept coming to me for medical help. We were already running out of medicines, basic medicines, for hypertension, diabetes, and it was clear that there was nowhere to buy them, people were getting contusions from explosions, they were dying, and there was nowhere to bury them. They started turning to me because they knew I was a doctor. I had to take on some kind of a leadership role.”[158]

Precisely for these reasons, however, health care workers are often singled out and targeted during conflict, particularly in situations of occupation.[159] In relation to the Russian occupation of Balakliia, Dr. Rudenko stated that: “[t]he FSB [Russia’s Federal Security Services] came to us on April 3 in the evening. They gathered all the medical staff … and said, ‘Don’t even think about going anywhere, you have to live here, you have to work here. We need to establish communication with the local population, so we will not let the doctors leave the city.’”[160]

A doctor from the Kherson Regional Clinical Hospital spoke to MIHR about providing health care under occupation on the condition of anonymity:[161]   “On July 1, 2022, representatives of the Federal Security Service of Russia came to the Regional Clinical Hospital; they detained the director of medical affairs and the head of the hospital’s personnel department. In order to contain the doctors’ discontent, the Federal Security Service took some of the Ukrainian doctors away for “a conversation” or summoned them to the occupied Department of Health [to limit the spread of rebellion].”

Detention of Health Care Workers

During Russia’s invasion, hundreds of health care workers have been detained, arrested, or otherwise persecuted by Russian forces. Although the Russian Federation refuses to provide access to detention centers and confirm the exact numbers of civilians in captivity as well as prisoners of war, “Military Medics of Ukraine,” a nongovernmental organization that works to help free Ukrainian medics who are being held captive, indicates that, based on information from Ukrainian state bodies, approximately 500 medics, both military and civilian, are currently thought to be held captive by Russian forces.[162] MIHR researchers identified 42 places of detention in the Russian Federation – pretrial detention centers and penal colonies, located both in the regions bordering Ukraine and farther in the country. Some prisoners are also held in the occupied territories of Donetska and Luhanska oblasts.[163]

According to the research team’s database, at least 68 health care workers were detained by Russian forces or supporting forces in 17 incidents between February 2022 and August 2023. These arrests occurred in four of Ukraine’s 24 oblasts and were most frequent in Khersonska oblast, which documented eight incidents and Donetska which documented six incidents. Kharkivska, Kyivska, and Zaporizka oblasts each recorded one incident respectively. Of note:

• Health worker detentions were most common in 2022, with one incident reported in 2023 involving a female paramedic being taken from her home in Tarasivka village, Zaporizka oblast, in January by Chechen forces who threatened to deport her for refusing to cooperate (incident 36880).[164]

• Health workers were mostly detained in small groups (numbering between one and three) with one incident where 42 medics were arrested in April and May 2022 (incident 34716).[165] During that incident, and notwithstanding the special status afforded medics under IHL, Russia held an unspecified number of doctors of Hospital No. 555 as “prisoners of war” who were sheltering at the Ilyich metallurgical plant.[166]

Reported locations where health workers were arrested by Russian forces, February 2022 – August 2023

At least 68 health care workers were detained in 17 incidents by Russian or supporting forces. All but one arrest occurred in 2022, with incidents frequent in Donetska and Khersonska oblast and one each in Kharkivska, Kyivska, and Zaporizka oblasts.    

A doctor from the Kherson Regional Clinical Hospital in then-occupied Kherson, who was interviewed by MIHR researchers on the condition of anonymity, stated that, “It was dangerous for Ukrainian doctors to work under occupation, especially in small villages, as they could become victims of abductions. First, there are fewer witnesses to abductions in towns and villages; second, it is easier to pressure and force cooperation. The reason for the abduction could be the refusal to take Russian salaries or social assistance, or the compulsion to travel for retraining, which had been announced in June 2022.”[167]

During the occupation of Hostomel in Kyivska oblast in March 2022, Olena Yuzvak, head of the Hostomel Primary Care Center, was taken for interrogation by Russian soldiers where she had a plastic bag put over her head and was suffocated for up to 30 seconds (incident 42071): [168]   “On March 20, Russian soldiers came to our home in a private house. The Russian soldiers shot my husband in the knee and thigh with a gun, put him on the ground, and put the gun to his head. My son came out of the house [….] They put the three of us in an armored personnel carrier, blindfolded us and took us to their headquarters in Hostomel in the Yagoda residential complex. The interrogation was tough [….] Moreover, my husband was not provided with medical care, he was bleeding from the leg, he had two bullet wounds. During the interrogation, they asked me what I do, and I said that I am a doctor and that I have been working only in health care for more than 20 years. And after the interrogation, they put us in the corridor, put bags on our heads, tied our hands with tape, and started twisting and strangling us with tape around our necks.   [….] As a doctor, I understand that asphyxiation is an easy death [….] I accepted it, that that’s the way it should be. Then, when they saw that we started to suffocate, they cut holes in our bags and took us all to Antonov airport for further interrogation. They left my husband and son there. And I was brought back to this Yagoda residential complex, where I was held captive for a day.”

Health care workers, among many other prisoners held by Russia that return from captivity, report poor living conditions, torture, and ill-treatment.[169] A military medic, who was captured in Mariupol and later released as part of an exchange of prisoners, recounted:

“Upon arriving at the colony, we underwent an ‘admission’ procedure. As soon as we got off the bus, the jailers identified and continued to beat us: while we were saying our names, then again along a corridor they formed, and finally after they forced us to squat down. There was constant physical violence. They could have let this bus in without this ‘ritual,’ everyone knew the bus was carrying wounded people and doctors. But the wounded were not spared. There was a guy with a crutch; they took the crutch from him and beat him with it, even as he fell to the ground. A wounded prisoner of war, who survived two airstrikes and had facial burns, was beaten to death.” [170]

These reports, including that of Dr. Yuzvak, demand investigation, together with other allegations of torture and ill-treatment of doctors emerging from places of internment.[171]

Coercion of Doctors: Violations of Medical Ethics

Russian authorities have often forced health care workers to violate their professional and ethical obligations to their patients. As PHR has documented in other contexts, such circumstances could be characterized as “dual loyalty” situations, in which compliance with Russian demands conflicts with their professional and ethical obligations to their patients.[174]

Being coerced to deny medical care to persons who refuse to secure a Russian passport is one such example of direct interference with medical ethics. Furthermore, clinicians who refuse to obtain a Russian passport may also face sanctions or reprisals. In September 2023, Russian military reportedly abducted and killed 26-year-old Anastasia Saksaganska, a doctor from the village of Mali Kopani, Khersonska oblast, as well as her husband.[175] Their relatives stated that the reason for their death was their refusal to obtain Russian passports and submit to Russian demands. Another example was provided by a doctor from the Kherson Regional Clinical Hospital in then-occupied Kherson, who was interviewed on the condition of anonymity. They described medical personnel being commanded to transfer confidential patient data to Russian government authorities:

“The new occupation authorities demanded access to the electronic database of patients, ‘e-Health,’ from Ukrainian doctors; they asked which of my patients receive insulin and how much it costs. The database stores confidential information, accessible only to medical personnel. In addition to home addresses and phone numbers, it stores passport data and contact information. Special population groups are also indicated, including veterans of [Ukraine’s] Anti-Terrorist Operation. I was worried, because the week before, I had received a patient from the occupied city of Mykolaiv oblast; he was a former member of the Anti-Terrorist Operation suffering from diabetes. The Russians found out about his illness, arrested him, and waited for him to die slowly without insulin. The man somehow managed to escape. I gave him the contacts of acquaintances who [later] sheltered him.” [176]

Russian-controlled Health Service Delivery

The full-scale invasion has paralyzed the health care system in areas currently under Russian occupation. While exact numbers are unknown, in Mariupol alone, over 30 doctors were confirmed to have been killed during the first months of the invasion.[177] Increasingly, because of the shortage of medical personnel, Russian doctors are being brought into the occupied regions to replace Ukrainian doctors, work alongside them, and often lead health care facilities or departments. Working alongside doctors from an aggressor country is not only difficult on a personal level for many Ukrainian health care workers, but also poses logistical and administrative challenges: the health care systems of Ukraine and Russia are organized very differently. In addition, this often causes conflicts among medical personnel. As the doctor from the Kherson Regional Clinical Hospital explained:

“They [Russian doctors] said that we had destroyed the health care system, that we had few hospitals, few departments. They did not understand what electronic databases were, what confidentiality meant, that not everyone should see the data. [….] They did not communicate with our staff. Our staff were used only as servants. They cleaned up after the Russians, did laundry, and organized their everyday life. The Russians treated the Ukrainian workers with disdain.”[178]

In Mariupol, for example, Russian doctors reportedly came to work at the city emergency hospital led by the chairman of the State Duma Committee on Health, who publicly cheered Russia’s invasion of Ukraine and was later sanctioned by a number of states.[179] Russian doctors were also reportedly brought to Zaporizka oblast,[180] where, according to other reports, hospitals barely had a hundred employees instead of the required 500.[181]

A Ukrainian doctor from the Kherson Regional Clinical Hospital spoke to MIHR about providing health care under occupation. In their words:[182]   “Some of them [Russian doctors] came under duress, but there were also those who openly said that they came here to earn money. They were paid 200–300 thousand rubles, like the military. But there were also the ideologically driven who came to ‘help.’ The Russians forcibly gathered all the doctors [at the occupation administration]. The illegal director of the Skadovsk hospital was there, and someone else came from the medical directors of the left bank [of the river]. They were gathering us there to ask us to cooperate on documents. They wanted to appoint us to positions in the Russian occupation administration in the ‘Ministry of Health’ so that we could re-register as Russian doctors and undergo retraining. The meeting was chaired by the former Minister of Health of the [Russian] Republic of Tyva. He was appointed as a curator from Moscow.”

It is currently unclear what protocols are being followed, if any, in the health facilities of Ukraine’s occupied territories. A new Russian federal law regulating the health care system on the occupied territories mandates Ukrainian doctors and pharmacists to obtain accreditation in accordance with Russian health care laws by the end of 2025.[183] Particularly concerning is a provision of the law that allows medical care to be provided without taking into account clinical practice guidelines for the duration of the transition period until 2025, likely eroding the standards of an already weakened health care system in these areas. Such immediate rescission of administrative regulations would also appear to run afoul of IHL’s requirement that the status quo ante in Ukraine’s occupied territories be preserved to the extent possible. Moreover, the negative impact such Russian-imposed changes are likely to have on the broader civilian population’s access to health service delivery further underscores the coercive aspect of these regulations.

Accountability for Attacks on Health Care: An Urgent Priority

The destructive impact of a compromised health care system threatens to impose long-lasting and severe hardship on Ukraine’s people. The Russian Federation must end its aggression, cease its violations, and return the administration of Ukraine’s health care system back to the Ukrainian government. 

Pending such a return, protecting health care remains an obligation under international humanitarian law. This includes the protection of health care personnel, patients, and facilities from attack and ensuring the access of all populations in need of health care to adequate and timely care, with no adverse discrimination. Detained medics must also be released.

There remains a pressing need to ensure accountability for violations of IHL with respect to health care, for which there has been almost complete impunity in both Ukraine and globally. To that end, this study urges all investigative and prosecutorial bodies with relevant jurisdiction – including the International Criminal Court’s Office of the Prosecutor, the Prosecutor General of Ukraine, the UN’s Independent International Commission of Inquiry on Ukraine, and other national prosecutors – to prioritize the investigation of attacks on health care. This includes the unlawful repurposing of civilian hospitals and the ill-treatment of health care workers in Ukraine’s occupied territory, which may constitute war crimes, and the policy and practice of conditioning access to health care and other services on the forced change of nationality.

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Acknowledgments

This case study is a joint product of eyeWitness to Atrocities (eyeWitness), Insecurity Insight, the Media Initiative for Human Rights (MIHR), and Physicians for Human Rights (PHR).

It was researched and written by Christian De Vos, MSc, JD, PhD, PHR director of research and investigations; Anna Gallina, LLM, advanced LLM, eyeWitness associate legal advisor; the MIHR team; Uliana Poltavets, MSc, PHR Ukraine emergency response coordinator; and Christina Wille, MPhil, Insecurity Insight director. Will Jaffe, PHR advocacy coordinator, also contributed to the drafting and preparation of the study.

The case study was reviewed by the eyeWitness team; the MIHR team; and PHR staff members Erika Dailey, MPhil, director of advocacy and policy; Michele Heisler, MD, MPA, medical director; Karen Naimer, MA, JD, LLM, director of programs; Kevin Short, deputy director, media and communications; and Sam Zarifi, JD, executive director.

Interviews were carried out by staff members of the Ukrainian Healthcare Center (UHC) and published here with UHC’s permission; Uliana Poltavets, PHR; and by the MIHR research team.

The report received external review from Leonard S. Rubenstein, JD, LLM, distinguished professor of the practice at Johns Hopkins Bloomberg School of Public Health and chair of the Safeguarding Health in Conflict Coalition, as well as Ana Elisa Barbar, formerly of the International Committee of the Red Cross, and Rudi Coninx, MD, MPH, formerly of the World Health Organization.

The study was reviewed, edited, and prepared for publication by PHR’s senior publications consultant, Rhoda Feng.

Endnotes

[1] The World Health Organization defines an attack on health as “any act of verbal or physical violence, obstruction, or threat of violence that interferes with the availability of, access to, and delivery of curative and/or preventive health services during emergencies.” In this sense, attacks on health happen not only when hospitals and clinics are damaged and destroyed but also when access to health services is impeded or denied through an array of other methods, such as described below. “Attacks on Health Care Initiative,” World Health Organization, July 22, 2020, https://www.who.int/news-room/questions-and-answers/item/attacks-on-health-care-initiative.

[2] “Attacks on Health Care in Ukraine,” eyeWitness to Atrocities, Insecurity Insight, Media Initiative for Human Rights, Physicians for Human Rights, and Ukrainian Healthcare Center, last modified September 11, 2023, https://www.attacksonhealthukraine.org/.

[3] “Attacked and Threatened: Health Care at Risk,” Insecurity Insight, accessed September 4, 2023, https://mapaction-maps.herokuapp.com/health.

[4] “Attacks on Health Care in Ukraine,” eyeWitness to Atrocities, Insecurity Insight, Media Initiative for Human Rights, Physicians for Human Rights, and the Ukrainian Healthcare Center.

[5] The Independent International Commission of Inquiry on Ukraine deplored “that attacks continue to take place harming civilians and medical institutions which have protected status.” “Oral Update of the Independent International Commission of Inquiry on Ukraine,” United Nations Human Rights Council, September 25, 2023, https://www.ohchr.org/sites/default/files/documents/hrbodies/hrcouncil/coiukraine/20230923-Oral-Update-IICIU-EN.pdf; The UN Special Rapporteur on torture and other cruel, inhuman or degrading treatment also noted that the “volume of credible allegations of torture and other inhumane acts […] appear neither random nor incidental, but rather orchestrated as part of a State policy to intimidate, instill fear, punish, or extract information and confessions.” “Russia’s war in Ukraine synonymous with torture: UN expert,” United Nations Office of the High Commissioner for Human Rights, September 10, 2023, https://www.ohchr.org/en/press-releases/2023/09/russias-war-ukraine-synonymous-torture-un-expert#:~:text=%E2%80%9CThese%20grievous%20acts%20appear%20neither,an%20official%20visit%20to%20Ukraine.

[6] “Destruction and Devastation: One Year of Russia’s Assault on Ukraine’s Health Care System,” eyeWitness to Atrocities, Insecurity Insight, Media Initiative for Human Rights, Physicians for Human Rights, and Ukrainian Healthcare Center, February 2023, https://phr.org/our-work/resources/russias-assault-on-ukraines-health-care-system.

[7] “Healthcare at War: The Impact of Russia’s full-scale Invasion on the Healthcare in Ukraine,” Ukrainian Healthcare Center (UHC), April 2023, p. 3-4, https://web.archive.org/web/20230528004056/https://uhc.org.ua/en/2023/04/26/healthcare-at-war-eng/.

[8] UHC’s research indicates that the overall number of primary care encounters in Ukraine dropped by 28.8 percent since Russia’s full-scale invasion began – from 92.4 million in 2021 to 65.8 million in 2022. “Healthcare at War,” UHC, https://web.archive.org/web/20230528004056/https://uhc.org.ua/en/2023/04/26/healthcare-at-war-eng/.

[9] Ukraine’s current mental health situation is mirrored across other regions affected by protracted conflicts and war. One in five (22 percent) people who have experienced war or other conflict in the previous 10 years will have anxiety, bipolar disorder, depression, post-traumatic stress disorder, or schizophrenia. In applying these estimates to Ukraine, the WHO expects that approximately 9.6 million people in Ukraine may have a mental health condition. “Scaling-up mental health and psychosocial services in war-affected regions: best practices from Ukraine,” World Health Organization, December 16, 2022, https://web.archive.org/web/20230207062235/https://www.who.int/news-room/feature-stories/detail/scaling-up-mental-health-and-psychosocial-services-in-war-affected-regions–best-practices-from-ukraine. There is a high level of exposure to war-related stressors among parents living in Ukraine during the Russian war. Rates of ICD-11 PTSD and CPTSD were 25.9 percent and 14.6 percent, respectively. See Thanos Karatzias, et al. “War exposure, posttraumatic stress disorder, and complex posttraumatic stress disorder among parents living in Ukraine during the Russian war,” Acta Psychiatrica Scandinavica 147, no. 3 (March 2023): 276-285, https://archive.ph/L1AVg.

[10] “Scars on Their Souls: PTSD and Veterans of Ukraine,” GLOBSEC, September 5, 2023, p. 4-6, https://www.globsec.org/what-we-do/publications/scars-their-souls-ptsd-and-veterans-ukraine.

[11] “Ukraine Rapid Damage and Needs Assessment: February 2022 – February 2023,” World Bank Group, Government of Ukraine, European Union, and United Nations, March, 2023, p. 49-50, https://web.archive.org/web/20230829122318/https://documents1.worldbank.org/curated/en/099184503212328877/pdf/P1801740d1177f03c0ab180057556615497.pdf.

[12] Russian-occupied territories of Ukraine are referred to as “temporarily occupied territories of Ukraine” in the Law of Ukraine 1207-VII. “On ensuring the rights and freedoms of citizens and the legal regime in the temporarily occupied territory of Ukraine” from October 15, 2014 and are defined there as “parts of the territory of Ukraine within which the armed forces of the Russian Federation and the occupation administration of the Russian Federation have established and exercise actual control or within which the armed forces of the Russian Federation have established and exercise general control with the aim of establishing the occupation administration of the Russian Federation.” Cognizant of this nomenclature, this study also variously uses the terms “occupied territories” or “Russian-occupied territories.” “Ukraine: Law No. 1207-VII of 2014, on Securing the Rights and Freedoms of Citizens and the Legal Regime on the Temporarily Occupied Territory of Ukraine,” April 15, 2014, accessed November 14, 2023 https://www.refworld.org/docid/5379ab8e4.html.

[13] Several of the detentions are reported as “arrests”; however, there is insufficient information to understand the precise circumstances for these detentions and to what extent they might be considered lawful arrests or whether they were an unlawful deprivation of liberty.

[14] UHC participated in documenting attacks on health in Ukraine until October 2023.

[15] UHC’s research teams visited hospital sites in four different regions of Ukraine now under the control of the Ukrainian government – Chernihiv (Chernihivska oblast, July 14-15, 2022), Izium and Balakliia (Kharkivska oblast, November 18, 2022), Makariv (Kyivska oblast, May 23, 2022), and Trostianets (Sumska oblast, August 11, 2022). This study uses information and testimonies from their visit to Balakliia. PHR visited Hostomel (Kyivska oblast) on September 22, 2023.

[16] In its monitoring of attacks, Insecurity Insight uses established online data search methods, including both algorithms and manual searches. It then combines this information with confidential event contributions from long-term partner organizations to compile its dataset of attacks on health care in Ukraine. For more information on Insecurity Insight’s SIND database, used for the Safeguarding Health in Conflict Coalition, see SHCC methodology. “Methodology,” Insecurity Insight, accessed November 14, 2023, https://shcc.pub/2021Methodology.

[17] PHR’s Ethics Review Board provided guidance and approved this study based on regulations outlined in Title 45 CFR Part 46, which are used by academic Institutional Review Boards in the United States. All of PHR’s research and investigations involving human subjects are conducted in accordance with the Declaration of Helsinki 2000, a statement of ethical principles for medical research involving human subjects, including research on identifiable human material and data. For all interviews, the research teams obtained informed written consent from each subject after the subject received a detailed explanation of the partner organizations, the purpose of research, and the potential benefits and risks of participation.

[18] The WHO Surveillance System for Attacks on Health Care (SSA) reported “the militarization of a health asset” on 22 occasions for dates where this research project did not identify any reports of misuse of use for military medical care and “the removal of health care assets (e.g., transport, supplies and materials)” 37 times for dates for which this research did not identify any such incidents. In addition, the lack of any detail on the location or the nature of these incidents of “militarization” makes it impossible to determine if the facility was repurposed into a military base or for the use of wounded soldiers. Because these incidents were reported to have occurred on days where no open-source or private information available for this study suggested such repurposing, they are assumed to have happened in addition to the documented cases described above. “Surveillance System for Attacks on Health Care (SSA),” World Health Organization, accessed November 14, 2023, https://extranet.who.int/ssa/LeftMenu/Index.aspx. 

[19] Response І7-05/17/2624/ЗПІ-23//3360, Ministry of Health of Ukraine, November 2, 2023. This was in response to the official request by the coalition on October 5, 2023.

[20] “On the Approval of the Amendments to the List of Territories where Hostilities Are (Were) Conducted or Temporarily Occupied by the Russian Federation,” Ministry of Reintegration of the Temporarily Occupied Territories of Ukraine, December 22, 2022, https://minre.gov.ua/en/2023/10/03/on-the-approval-of-the-list-of-territories-on-which-hostilities-are-were-conducted-or-temporarily-occupied-by-the-russian-federation-2/. For up-to-date information on the changes in the situation on the frontline, see the following. “Territories State Map,” Ministry of Reintegration of the Temporarily Occupied Territories of Ukraine, accessed November 14, 2023, https://map.minre.gov.ua/en; “Deep State Map,” Deep State, accessed November 14, 2023, https://deepstatemap.live/en#6/49.438/32.053.

[21] Hague Convention IV: respecting the Laws and Customs of War on Land, Regulations, Art. 42, October 18, 1907.

[22] “Territorial integrity of Ukraine: defending the principles of the Charter of the United Nations,” UN General Assembly, October 12, 2022, https://press.un.org/en/2022/ga12458.doc.htm; “Statement by the Members of the European Council,” EU Council, September 30, 2022, https://www.consilium.europa.eu/en/press/press-releases/2022/09/30/statement-by-the-members-of-the-european-council/.

[23] Natasha Arnpriester, Laura Bingham, and James A. Goldston, “Written Comments of the Open Society Justice Initiative In the European Court Of Human Rights Application No. 29627/16 – Sentsov and Kolchenko v. Russia,” Open Society Justice Initiative, accessed November 14, 2023, https://www.justiceinitiative.org/uploads/96b60b45-eb97-4a5d-b2b6-942486d7ae5c/litigation-echr-sentsov-20190530.pdf.

[24] Provisions regulating occupation are contained in The Hague Regulations of 1907, the Fourth Geneva Convention of 1949, and Additional Protocol I of 1977, all of which have been ratified by both Russia and Ukraine, as well as customary international law.

[25] Ukraine and Russia are parties to most international human right treaties, including the following: International Covenant on Civil and Political Rights (ICCPR), December 16, 1966, 999 UNTS 171, http://www.ohchr.org/en/professionalinterest/pages/ccpr.aspx; International Covenant on Economic, Social and Cultural Rights (ICESCR), December 16, 1966, 993 UNTS 3, https://www.ohchr.org/en/instruments-mechanisms/instruments/international-covenant-economic-social-and-cultural-rights; International Convention on the Elimination of All Forms of Racial Discrimination (ICERD), December 21, 1965, 660 UNTS 195, http://www.ohchr.org/EN/ProfessionalInterest/Pages/CERD.aspx; Convention on the Rights of the Child (CRC), November 20, 1989, 1577 UNTS 3, http://www.ohchr.org/en/professionalinterest/pages/crc.aspx.  

[26] International Court of Justice (ICJ), “Legality of the Threat or Use of Nuclear Weapons, Advisory Opinion,” July 8, 1996, para. 25, https://www.icj-cij.org/sites/default/files/case-related/95/095-19960708-ADV-01-00-EN.pdf; ICJ, Legal Consequences of the Construction of a Wall in the Occupied Palestinian Territory, Advisory Opinion, July 9, 2004, paras 105-106, https://www.icj-cij.org/sites/default/files/case-related/131/131-20040709-ADV-01-00-EN.pdf; ICJ, “Armed Activities on the Territory of the Congo (Democratic Republic of the Congo v. Uganda), Judgment,” December 19, 2005, para. 216, https://www.icj-cij.org/sites/default/files/case-related/116/116-20051219-JUD-01-00-EN.pdf; Human Rights Committee, General Comment No. 31: The Nature of the General Legal Obligation Imposed on States Parties to the Covenant, CCPR/C/21/Rev.1/Add. 13, May 26, 2004, para. 11, https://www.refworld.org/docid/478b26ae2.html; Human Rights Committee, General Comment 29: states of emergency (Article 4), CCPR/C/21/Rev.1/Add.11, August 31, 2001, para. 3, https://www.refworld.org/docid/453883fd1f.html; Committee on Economic, Social and Cultural Rights, Concluding observation: Israel, U.N. Doc. E/C.12/1/Add.69 (August 31, 2001), para. 12, https://undocs.org/Home/Mobile?FinalSymbol=E%2FC.12%2F1%2FAdd.69&Language=E&DeviceType=Desktop&LangRequested=False. The General Assembly and Security Council have also condemned violations of human rights in armed conflict. General Assembly, Situation of human rights in the Democratic Republic of the Congo, U.N. Doc. A/RES/57/233, January 28, 2003, https://undocs.org/Home/Mobile?FinalSymbol=A%2FRES%2F57%2F233&Language=E&DeviceType=Desktop&LangRequested=False; Security Council, Resolution 1181 (1998), U.N. Doc. S/RES/1181, July 13, 1998, https://undocs.org/Home/Mobile?FinalSymbol=S%2FRES%2F1181(1998)&Language=E&DeviceType=Desktop&LangRequested=False.

[27] ICJ, “Democratic Republic of the Congo v. Uganda,” para. 216; ICJ, Legal Consequences of the Construction of a Wall in the Occupied Palestinian Territory,” para. 107-113, https://www.icj-cij.org/sites/default/files/case-related/131/131-20040709-ADV-01-00-EN.pdf; Human Rights Committee, Concluding Observations of the Human Rights Committee: Israel, CCPR/C/79/Add.93, August 18, 1998, https://undocs.org/Home/Mobile?FinalSymbol=CCPR%2FC%2F79%2FAdd.93&Language=E&DeviceType=Desktop&LangRequested=False; Committee on Economic, Social and Cultural Rights, Concluding observation: Israel, para. 11, https://undocs.org/Home/Mobile?FinalSymbol=E%2FC.12%2F1%2FAdd.69&Language=E&DeviceType=Desktop&LangRequested=False; Economic and Social Council, “Report on the Situation of Human Rights in Kuwait under Iraqi Occupation, prepared by Mr. Walter Kälin, Special Rapporteur of the Commission on Human Rights, in Accordance with Commission Resolution 1991/67,” U.N. Doc. E/CN.4/1992/26 (January 15, 1992), para. 55-59, https://digitallibrary.un.org/record/225886#:~:text=SymbolE%2FCN.4%2F1992%2F26%20TitleReport%20of%20the%20situation%20of%20human%20rights,Human%20Rights%2C%20in%20accordance%20with%20Commission%20resolution%201991%2F67; Loizidou v. Turkey, Application No. 15318/89, European Court of Human Rights (ECtHR), paras 62-64 (March 23, 1995), https://hudoc.echr.coe.int/fre?i=001-57920; Cyprus v. Turkey, Application No. 25781/94, ECtHR, para. 77 (May 10, 2001), https://hudoc.echr.coe.int/Eng?i=001-59454. The rationale of this rule can be found in the premise that “the Occupying Power is acting as the administrator of the territory and, as such, must abide by human rights obligations in its dealing with individuals in the territory under its control.” Noam Lubell, “Human rights obligations in military occupation,” International Review of the Red Cross 94 No. 885 (Spring 2012), 319, https://international-review.icrc.org/sites/default/files/irrc-885-lubell.pdf.

[28] ICRC, “Rule 156 Definition of War Crimes,” International Humanitarian Law Databases, accessed November 14, 2023, https://ihl-databases.icrc.org/en/customary-ihl/v1/rule156; Ryan Goodman, Michael W. Meier, and Tess Bridgeman, “Expert Guidance: Law of Armed Conflict in the Israel-Hamas War,” Just Security, October 17, 2023, section 4, https://www.justsecurity.org/89489/expert-guidance-law-of-armed-conflict-in-the-israel-hamas-war/.

[29] Geneva Convention I, Arts. 49-50; Geneva Convention II, Arts. 50-51; Geneva Convention III, Arts. 129-130; Geneva Convention IV, Arts. 146-147; Additional Protocol I, Arts. 11(4), 85.

[30] “Report on Violations of International Humanitarian and Human Rights Law, War Crimes and Crimes against Humanity Committed in Ukraine since 24 February 2022,” Organization for Security and Co-operation in Europe, April 22, 2022, p. 8-9, https://www.osce.org/files/f/documents/f/a/515868.pdf.

[31] Geneva Convention IV, Section III; Mikhail Orkin and Tristan Ferraro “IHL and occupied territory,” Humanitarian Law & Policy, July 26, 2022, https://blogs.icrc.org/law-and-policy/2022/07/26/armed-conflict-ukraine-ihl-occupied-territory/.

[32] “Contemporary challenges to IHL – Occupation: overview,” International Committee of the Red Cross (ICRC), June 11, 2012, https://www.icrc.org/en/document/occupation.

[33] Hague Regulations, Art. 43; Geneva Convention IV, Art. 64.

[34] ICESCR, Art. 12.

[35] Geneva Convention IV, Arts. 55-56.

[36] Committee on Economic, Social and Cultural Rights, General Comment No. 14: The Right to the Highest Attainable Standard of Health (Art. 12), U.N. Doc. E/C.12/2000/4 (August 11, 2000), para. 43, https://docstore.ohchr.org/SelfServices/FilesHandler.ashx?enc=4slQ6QSmlBEDzFEovLCuW1AVC1NkPsgUedPlF1vfPMJ2c7ey6PAz2qaojTzDJmC0y%2B9t%2BsAtGDNzdEqA6SuP2r0w%2F6sVBGTpvTSCbiOr4XVFTqhQY65auTFbQRPWNDxL.

[37] Additional Protocol I, Arts. 8(e), 12; ICRC, Customary International Humanitarian Law, Rule 28. Medical units are defined as establishments and other units, whether military or civilian, organized for medical purposes, be they fixed or mobile, permanent or temporary, including, for example, hospitals and other similar units, blood transfusion centers, medical depots, and the medical and pharmaceutical stores of such units.

[38] “Report on Violations of International Humanitarian and Human Rights Law,” p. 36.

[39] Geneva Convention IV, Art. 18; Additional protocol I, Art. 12.

[40] Geneva Convention IV, Art. 56(1).

[41] Geneva Convention IV, Art. 55(1), Geneva Convention IV, Commentary of 1958, Art. 55, https://ihl-databases.icrc.org/en/ihl-treaties/gciv-1949/article-55/commentary/1958?activeTab=undefined; Additional Protocol I, Art. 69(1).

[42] According to the Ministry’s official response to the research team’s public request, as of October 23, 2023, the Electronic Health Care System (EHCS) contains data on 364 health care facilities in the occupied territories in accordance with the order of the Ministry of Reintegration of the Temporarily Occupied Territories of Ukraine No. 309 dated December 22, 2022 (as amended by order 254 dated September 22, 2023). Health facilities from territories occupied prior to 2022 are likely not connected to EHCS, which was created in 2017; thus, the total number of health facilities in Russian-occupied territories might be higher. Elsewhere, Ukraine’s Minister of Health has mentioned 650 health facilities being on the occupied territories. “Almost 650 hospitals are located in the temporarily occupied territories, the Ministry of Health maintains contact with them and pays salaries to doctors – Liashko,” Ukrainian Radio, August 25, 2023, http://www.nrcu.gov.ua/news.html?newsID=99403.

[43] This figure was derived from data available on the National Health Service of Ukraine’s (NHSU) Dashboard, specifically the “Contracts for medical care of the population under the program of medical guarantees.” While this data encompasses health facilities under contract with the NHSU and may not include all private specialized health facilities, it provides the most comprehensive and current assessment of the health care system. This dataset allows for a comparison of the total number of health facilities in Ukraine with those presently funded in the Russian-occupied territories. “Contracts for medical care of the population under the program of medical guarantees,” National Health Service of Ukraine, accessed November 21, 2023,  https://edata.e-health.gov.ua/e-data/dashboard/pmg-contracts.

[44] The NHSU is a central executive body that was created in 2018 to facilitate state financial guarantees for contracting and payment arrangements for health care —this includes medical services, medicines, and medical supplies that the state guarantees to the population and pays for from the state budget at the same rates for all facilities. It consists of packages of medical services – a list of medical services, guaranteed by the state, which each person can receive in accordance with the grounds specified in these packages. “Guide to the Medical Guarantee Program for the Patient,” NHSU, October 2023, https://nszu.gov.ua/storage/editor/files/gid-dlya-patsientiv.pdf. The data was drawn from the NHSU’s Dashboard “Contracts for medical care of the population under the program of medical guarantees,” accessed November 21, 2023, https://edata.e-health.gov.ua/e-data/dashboard/pmg-contracts. The Ministry’s response to the research team’s inquiry states that, as of October 23, 212 facilities on the occupied territories have contracts for medical care for the population under the medical guarantee program for 2023.

[45] As of now, payments have been made to 146 health facilities for $43.9 million under the package “Ensuring the preservation of human resources to provide medical care to the population in the temporarily occupied territory.” “Contracts for medical care of the population,” NHSU; “Payments to healthcare providers under the medical guarantees program,” NHSU, accessed November 21, 2023, https://edata.e-health.gov.ua/e-data/dashboard/pmg-pay.

[46] Anna Levchenko, “Head of the National Health Service: The decision to suspend payments to healthcare facilities located in the occupied territories is not made by the NHS alone,” Interfax, April 24, 2023, https://interfax.com.ua/news/interview/905827.html.

[47] “Ukraine Internal Displacement Report: General Population Survey,” International Organization for Migration (IOM), December, 2022, https://dtm.iom.int/sites/g/files/tmzbdl1461/files/reports/IOM_Gen%20Pop%20Report_R11_IDP_final_Publ.13122022.pdf.

[48] Geneva Convention IV, Commentary of 1958, Art. 57, https://ihl-databases.icrc.org/en/ihl-treaties/gciv-1949/article-57/commentary/1958?activeTab=undefined.

[49] Geneva Convention I, Art. 19; Geneva Convention IV, Art. 18; Additional Protocol I, Art. 12(4).

[50] Geneva Convention, Additional Protocol I, Art. 12(4).

[51] Geneva Convention I, Art. 21; Geneva Convention IV, Art. 19; Additional Protocol I, Art. 13; Additional Protocol I, Commentary of 187, Art. 13, https://ihl-databases.icrc.org/en/ihl-treaties/api-1977/article-13/commentary/1987?activeTab=undefined; ICRC, Customary International Humanitarian Law, Rule 28; ICC, “Situation in the Democratic Republic of the Congo, Prosecutor v. Ntaganda,” ICC-01/04-02/06, July 8, 2019, para. 1147, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2019_03568.PDF. Note that certain domestic military manuals include an express rule providing that the improper use of privileged buildings, such as hospitals, for military purposes is a war crime. Refer tothe military manuals of Canada, New Zealand, Nigeria, United Kingdom, and United States. In this sense, see Jean-Marie Henckaerts and Louise Doswald-Beck, “Customary International Humanitarian Law Volume I: Rules”, ICRC, 2009, p. 96, https://www.icrc.org/en/doc/assets/files/other/customary-international-humanitarian-law-i-icrc-eng.pdf

[52] “Attacks on Health Care in Ukraine”, eyeWitness to Atrocities, Insecurity Insight, Media Initiative for Human Rights, Physicians for Human Rights, and the Ukrainian Healthcare Center; Victoria Kolomiets, “Ukrainian Armed Forces destroy occupants’ base in Vesele village, Zaporizhzhia region,” Hromadske, November 21, 2022, https://hromadske.ua/posts/u-seli-vesele-na-zaporizhzhi-zsu-znishili-bazu-okupantiv.

[53] “Attacks on Health Care in Ukraine”; “Russians set up “field hospital” in Luhansk Oblast, treating over 300 soldiers,” Ukrainska Pravda, January 20, 2023, https://www.pravda.com.ua/eng/news/2023/01/20/7385694/.

[54] “Attacks on Health Care in Ukraine”; “Borodianka psycho-neurological boarding facility may have been captured by occupiers firing artillery from there – local authorities,” Interfax, March 5, 2022, https://ua.interfax.com.ua/news/general/807853.html.

[55] “Attacks on Health Care in Ukraine”; Victoria Kolomiets, “Occupants decided to locate barracks in a hospital in Luhansk – General Staff,” Hromadske, March 7, 2023, https://hromadske.ua/posts/u-lugansku-okupanti-virishili-rozmistiti-kazarmu-v-poliklinici-z-paciyentami-genshtab.

[56] “Attacks on Health Care in Ukraine”; Natalia Kava, “In Lysychansk, occupants deployed Chechen ‘Akhmat’ unit in city hospital – General Staff,” RBC, July 18, 2023, https://www.rbc.ua/rus/news/lisichansku-okupanti-rozmistili-miskiy-likarni-1689696929.html.

[57] “Attacks on Health Care in Ukraine”; General Staff of the Armed Forces of Ukraine, “Update as of 06 AM on August 26, 2023 on the Russian invasion,” Facebook, August 26, 2023, https://www.facebook.com/GeneralStaff.ua/posts/pfbid023mJy3QDBKGnyMBeCEGrG5xUyrdBmp57ZHmStF5bAzZaAR7ebGubSLrYhHUZXNdxtl.

[58] The dates of the occupation differ: the witness first said, “around March 10”, then later clarified “on March 12.” Some other witnesses mentioned March 11; however, most accounts agree that it was March 12. See also “Armoury, Prison, Graveyard: Mariupol Intensive Care Hospital under Russian Occupation,” International Partnership for Human Rights, Truth Hounds, Global Diligence, November 2022, p.9, https://www.iphronline.org/wp-content/uploads/2022/11/Mariupol-report_for_distribution_final_1.pdf. The difference in dates can also be due to the fact that there were several squads entering the hospital in waves – first the assault squad, then, the ‘DPR’ squad. See Volodymyr Konoshevych, “I loaded the child’s body into the car myself – I wanted to protect the psyche of my colleagues.” Diary of a doctor from Mariupol”, Bird in Flight, April 29, 2022, https://birdinflight.com/nathnennya-2/dosvid/20220429-shhodennik-likarya.html; “Armoury, Prison, Graveyard: Mariupol Intensive Care Hospital under Russian Occupation,” International Partnership for Human Rights, Truth Hounds, Global Diligence, November 2022, p.9, https://www.iphronline.org/wp-content/uploads/2022/11/Mariupol-report_for_distribution_final_1.pdf.

[59] Attacks on Health Care in Ukraine”; Dr. Oksana Kyrsanova, “Interview with Dr. Oksana Kyrsanova,” Media Initiative for Human Rights (MIHR), March 19, 2022; Dr. Oksana Kyrsanova, “Interview with Dr. Oksana Kyrsanova,” MIHR, December 2, 2022 from “Destruction and Devastation.”

[60] “Attacks on Health Care in Ukraine”; Victoria Kolomiets, “Occupants invaded Slavutych and seized the hospital. They may have kidnapped Mayor Yuriy Fomichev (Update),” Hromadske, March 26, 2022, https://hromadske.ua/posts/okupanti-vtorglisya-v-slavutich-ta-zahopili-likarnyu-jmovirno-voni-vikrali-mera-yuriya-fomicheva.

[61] “Attacks on Health Care in Ukraine”; “Ukrainian Armed Forces destroy occupants’ base in Vesele village.”

[62] Oleg Chenysh, “Can the military use schools and hospitals?,” BBC, August 11, 2022, https://www.bbc.com/ukrainian/features-62503609.

[63] “Attacks on Health Care in Ukraine.”

[64] Clarissa Ward, et al., “This teacher was tortured by the Russians and held for six months before returning to her town in Ukraine in a prisoner swap,” CNN, October 21, 2022, https://edition.cnn.com/2022/10/21/europe/ukraine-civilians-kidnapped-filtration-russia-intl/index.html.

[65] Geneva Convention IV, Art. 57; Geneva Convention IV, Commentary of 1958, Art. 57.

[66] Ibid.

[67] Ibid.

[68] “Attacks on Health Care in Ukraine”; Tetiana Lozovenko, “Injured Russians taken to hospital in Melitopol after loud night in city of Vasylivka,” Ukrainska Pravda, November 17, 2022, https://www.pravda.com.ua/eng/news/2022/11/17/7376770/.

[69] “Attacks on Health Care in Ukraine”; Sergey Albul, “Occupants hand over maternity hospital to Wagner PMC in Luhansk, – Ukrainian Armed Forces General Staff,” Livyi Bereh, May 27, 2023, https://lb.ua/society/2023/05/27/557457_lugansku_okupanti_viddali.html. 

[70] “Attacks on Health Care in Ukraine”; Maria Iovova, “Occupants organized another military hospital in one of Luhansk’s hospitals,” Hronikers, May 19, 2023, https://hronikers.com/2023/05/19/okupanty-orhanizuvaly-cherhovyy-viyskovyy-shpytal-v-odniy-z-likaren-luhanska/.

[71] “Only wounded soldiers are admitted. Residents of the occupied Luhansk region tell about the work of hospitals,” Suspilne, January 15, 2023, https://suspilne.media/358912-prijmaut-tilki-poranenih-vijskovih-ziteli-okupovanoi-lugansini-rozpovili-pro-robotu-likaren/.

[72] “Attacks on Health Care in Ukraine”; Ibid.

[73] “Attacks on Health Care in Ukraine”; “Hundreds of wounded Russians treated in hospitals in occupied parts of Zaporizhzhia Oblast,” Ukrainska Pravda, January 24, 2023, https://www.pravda.com.ua/eng/news/2023/01/24/7386343/.

[74] “Attacks on Health Care in Ukraine”; “Donetsk hospitals are overcrowded with wounded occupants. Surgeries for civilians postponed indefinitely – General Staff,” Hromadske, December 4, 2023, https://hromadske.ua/posts/likarni-donecka-perepovneni-poranenimi-okupantami-operaciyi-civilnim-perenesli-na-neviznachenij-termin-genshtab.

[75] “Attacks on Health Care in Ukraine”; Evgenia Sokolenko, “In the occupied part of Donetsk region, most hospitals accept only invaders – the CNS,” Unian, April 23, 2023, https://www.unian.ua/war/na-okupovaniy-chastini-donechchini-bilshist-likaren-priymaye-lishe-zagarbnikiv-cns-12230445.html.

[76] “Attacks on Health Care in Ukraine”; Anastasia Gorbacheva, “Russians turn hospitals in the occupied territories of Ukraine into military hospitals”, Unian, January 16, 2023, https://www.unian.ua/war/viyna-v-ukrajini-rosiyani-peretvoryuyut-likarni-na-okupovanih-teritoriyah-na-viyskovi-shpitali-12111513.html.

[77] Victoria Veselova, “Servants of war. In Crimea, more and more civilian objects are being given to the Russian army,” Krym.Realii, July 5, 2023, https://ua.krymr.com/a/krym-armiya-infrastruktura-viyna-likarnya-vidpochynok-zemlya-transport-kursy/32489982.html.

[78] “Attacks on Health Care in Ukraine”; “CrimeaSOS: hospital in occupied Simferopol was given to the needs of the Russian military,” Crimea SOS, June 21, 2023, https://krymsos.com/krymsos-likarnyu-v-okupovanomu-simferopoli-viddaly-pid-potreby-vijskovyh-rf/.

[79] Geneva Convention IV, Art. 55(2).

[80] Ibid.

[81] Geneva Convention IV, Commentary of 1958, Art. 55. This includes a direct reference to the wording of Geneva Convention IV, Art. 147; Rome Statute, Art. 8(2)(a)(iv).

[82] Pillage is prohibited under Geneva Convention IV, Art. 33(2); ICRC, Customary International Humanitarian Law, Rule 52; Rome Statute, Article 8(2)(b)(xvi). Case law defines it as “all forms of appropriation, public or private, including organized and systematic appropriation, as well as acts of appropriation committed by combatants in their own interest.” ICC, Situation in the Democratic Republic of the Congo, Prosecutor v. Katanga (ICC-01/04-01/07), Judgment pursuant to Article 74 of the Statute, March 7, 2014, para. 905, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2015_04025.PDF; ICC, Situation in the Democratic Republic of the Congo, Prosecutor v. Ntaganda (ICC-01/04-02/06), July 8, 2019, para. 1028, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2019_03568.PDF; ICC, Situation in Uganda, Prosecutor v. Ongwen (ICC-02/04-01/15), February 4, 2021, para. 2763, https://www.icc-cpi.int/sites/default/files/CourtRecords/CR2021_01026.PDF. As such, the provision requires the perpetrator to appropriate certain property without the consent of the owner, for private or personal use. By contrast, seizing the enemy’s property (Article 8(2)(b)(xiii)) only covers property protected from seizure under IHL; Geneva Convention IV, Arts. 18, 21, 57. Aside from the nature of the property, the perpetrator’s intent to obtain the property for private or personal use is the main distinctive element between pillage and seizure of the enemy’s property, where such requirement does not need to be met; Law of the International Criminal Court, Article 8(2)(b)(xvi), last modified June 30, 2016, https://cilrap-lexsitus.org/en/clicc/8-2-b-xvi/8-2-b-xvi. Under both provisions, however, appropriations of property justified by military necessity do not constitute war crimes.

[83] “Attacks on Health Care in Ukraine”; “Russian forces loot maternity hospital in Luhansk region, set up field hospital there – General Staff,” Espresso, June 30, 2023, https://global.espreso.tv/russian-forces-loot-maternity-hospital-in-luhansk-region-set-up-field-hospital-there-general-staff.

[84] “Attacks on Health Care in Ukraine.”

[85] Ibid; Olha Hlushchenko, “Civilians in Crimean hospitals experience blood and medicine shortages due to Russian military being treated there,” Ukrainska Pravda, March 20, 2023, https://www.pravda.com.ua/eng/news/2023/03/20/7394156/.

[86] “Attacks on Health Care in Ukraine.”

[87] Dr. Maryna Rudenko, “Interview with Dr. Maryna Rudenko,” Ukrainian Healthcare Center, November 18, 2022 from “Destruction and Devastation.”

[88] “Attacks on Health Care in Ukraine.”

[89] “Interview with a doctor at the Kherson Regional Clinic Hospital [anonymous],” MIHR, October 23, 2022; “Interview with a doctor at the Kherson Regional Clinic Hospital [anonymous],” MIHR, October 28, 2022 from “Destruction and Devastation.”

[90] “Almost 650 hospitals are located in the temporarily occupied territories,” Ukrainian Radio.

[91] “Destruction and Devastation.”

[92] Dr. Kaveh Khoshnood, et al., “Forced Passportization in Russia-Occupied areas of Ukraine,” Humanitarian Research Lab at Yale School of Public Health, August 2, 2023, p.9, https://web.archive.org/web/20230804000628/https://hub.conflictobservatory.org/portal/sharing/rest/content/items/e280a7eeb7bf4dc588ed50ee655b9858/data; Neha Jain, “Weaponized Citizenship: Should international law restrict oppressive nationality attribution?,” EUI Global Citizenship Observatory, June 20, 2023, https://globalcit.eu/weaponized-citizenship-should-international-law-restrict-oppressive-nationality-attribution/. On the relationship between “passportization” and “Russification,” see also “Russification in Occupied Ukraine: An investigation by the EBU Investigative Journalism Network,” https://investigations.news-exchange.ebu.ch/russification-in-occupied-ukraine/index.html#:~:text=Passportisation%20is%20just%20one%20of,in%20every%20sphere%20of%20life.

[93] 1907 Hague Regulations, Art. 45.

[94] 1899 Hague Regulations, Art. 45.

[95] “Human Rights in the Context of Automatic Naturalization in Crimea,” Open Society Justice Initiative, June 2018, https://www.justiceinitiative.org/publications/human-rights-context-automatic-naturalization-crimea.

[96] Universal Declaration of Human Rights, Art. 15.

[97] ICCPR, Art. 24(3); ICERD, Art. 5; CRC, Arts. 7-8.

[98] “D.H. and others v. Czech Republic,” ECtHR Grand Chamber, November 13, 2007, para. 202-203, https://hudoc.echr.coe.int/fre?i=001-83256.

[99] “Report of the Secretary-General on Human rights and arbitrary deprivation of nationality,” Human Rights Council, U.N. Doc. A/HRC/13/34, December 14, 2009, https://undocs.org/Home/Mobile?FinalSymbol=A%2FHRC%2F13%2F34&Language=E&DeviceType=Desktop&LangRequested=False.

[100] Geneva Convention IV, Art. 47.

[101] Additional Protocol I, Art. 69(1), https://ihl-databases.icrc.org/en/ihl-treaties/api-1977/article-69/commentary/1987?activeTab=undefined.

[102] Ibid.

[103] George Dvaladze, “Unveiling claims of discrimination based on nationality in the context of occupation under international humanitarian and human rights law,” International Review of the Red Cross 105, no. 923 (2023): 961, https://international-review.icrc.org/sites/default/files/reviews-pdf/2023-06/unveiling-claims-of-discrimination-based-on-nationality-923.pdf.

[104] Ibid, 949 and 952. The use of different terminology in the different legal frameworks does not imply a difference in substance; terms can be used interchangeably.

[105] Human Rights Committee, “CCPR General Comment No. 18: Non-discrimination,” November 10, 1989, para. 7, https://www.refworld.org/docid/453883fa8.html.

[106] Geneva Convention IV, Art. 49 (1); Rome Statute, Art. 8(2)(b)(viii).

[107] Geneva Convention IV, Art. 51; Rome Statute, Art. 8(2)(a)(v). The Rome Statute lists the “compelling [of] a … protected person to serve in the forces of a hostile Power” as a war crime. The prohibition is absolute and admits no derogations. Its rationale is to protect the inhabitants of the occupied territory from attempts to undermine their allegiance to their own country or from actions against their patriotic feelings;Geneva Convention IV, Commentary of 1958, Art. 51, https://ihl-databases.icrc.org/en/ihl-treaties/gciv-1949/article-51/commentary/1958?activeTab=undefined.

[108] Dr. Kaveh Khoshnood, et al., “Forced Passportization in Russia-Occupied areas of Ukraine,” 9; “Report: Human Rights in the Context of Automatic Naturalization in Crimea,” Open Society Justice Initiative, June 2018, https://www.justiceinitiative.org/uploads/5ce04ddd-0fda-470c-9f94-eaa5bf928768/report-osji-crimea-20180601.pdf. The Open Society Foundation concludes that “a clear pattern of coercive and occasionally violent suppression of ethnic identity has emerged under Russian occupation.”

[109] President of the Russian Federation, “Decree No. 307: On the Specifics of the Legal Status of Certain Categories of Foreign Citizens and Stateless Persons in the Russian Federation,” April 27, 2023, https://web.archive.org/web/20230831113639/http://publication.pravo.gov.ru/Document/View/0001202304270013?rangeSize=1&pageSize=100&index=1.

[110] Dr. Kaveh Khoshnood, et al., “Forced Passportization in Russia-Occupied areas of Ukraine,” 9.

[111] Kseniya Kvitka, “Russia Threatens Ukrainians Who Refuse Russian Citizenship,” Human Rights Watch, May 16, 2023, https://web.archive.org/web/20230525215721/https://www.hrw.org/news/2023/05/16/russia-threatens-ukrainians-who-refuse-russian-citizenship.

[112] Head of the Donetsk People’s Republic “Oder No. 186, On the establishment of a working group,” June 20, 2023, http://npa.dnronline.su/2023-06-20/rasporyazhenie-vrio-glavy-donetskoj-narodnoj-respubliki-186-ot-20-06-2023-g-o-sozdanii-rabochej-gruppy.html.

[113] “Attacks on Health Care in Ukraine”; “Occupants close a hospital in Zaporizhzhia oblast,” Pershyi Zaporizkyi, June 15, 2023, http://1news.zp.ua/v-zaporozhskoj-oblasti-okkupanty-zakryli-bolniczu/.

[114] “List of the territories where military operations are (were) conducted or temporarily occupied by Russia.”

[115] Iryna Sedova, “How do Ukrainians in Crimea live without Russian citizenship?,” ZMINA, February 10, 2017, https://web.archive.org/web/20210423132513/https://zmina.info/articles/kak_zhivut_ukraincy_v_krymu_bez_rossijskogo_grazhdanstva-2/.

[116] Ibid.

[117] Petro Andriushchenko, “Mariupol. As of now,” Telegram, January 30, 2023, https://archive.ph/vaVOE.

[118] “The explosion at the Kakhovka Hydroelectric Power Plant Dam has caused Ukraine at least $2 billion in direct damages,” Kyiv School of Economics, June 30, 2023, https://web.archive.org/web/20230630104503/https://kse.ua/about-the-school/news/the-explosion-at-the-kakhovka-hydroelectric-power-plantdam-has-caused-ukraine-at-least-2-billion-in-direct-damages-according-to-the-initial-calculations-of-kse-institute/.

[119] “Kherson after occupation: Mapping Russian attacks on medical infrastructure,” Center for Information Resilience, September 19, 2023, https://www.info-res.org/post/kherson-after-occupation-mapping-russian-attacks-on-medical-infrastructure; Stanislav Pohorilov, “Ukraine’s Security Service tracks down resident of Kherson who guided invaders’ Shahed drones to medical institutions,” Ukrainska Pravda, August 28, 2023, https://web.archive.org/web/20230829022647/https://www.pravda.com.ua/eng/news/2023/08/28/7417365/.

[120] It remains unclear to what extent the doctors acted under order and duress. “Attacks on Health Care in Ukraine”; “In Hornostaivka, Kherson region, the occupiers deny medical care to residents without Russian passports and steal businesses of those who have left the occupation,” Center for Investigative Journalism, July 11, 2023, https://web.archive.org/web/20230712035006/https://investigator.org.ua/ua/news-2/256528/.

[121] Dr. Kaveh Khoshnood, et al., “Forced Passportization in Russia-Occupied areas of Ukraine,” 12.

[122] “In the occupied territory of Khersonska oblast, the occupation authorities are forcing local residents to take Russian passports,” Suspilne, September 21, 2023, https://web.archive.org/web/20230603154337/https://suspilne.media/421041-na-livobereznij-hersonsini-okupacijna-vlada-primusue-miscevih-ziteliv-brati-rosijski-pasporti/.

[123] Yurii Korogodskyi, “In the occupied Donetska oblast, most hospitals accept only Russian military personnel,” Livyi Bereh, April 23, 2023, https://lb.ua/society/2023/04/23/552862_okupovaniy_donechchini_bilshist.html.

[124] “Attacks on Health Care in Ukraine”; Lyudmila Zhernovska, “In Khersonska oblast, a gauleiter cynically threatens those who refused to give up their Russian passports,” Unian, August 11, 2023, https://web.archive.org/web/20230814063318/https://www.unian.ua/society/lazurne-gaulyayter-pogrozhuye-ukrajincyam-yaki-vidmovilisya-vid-pasporta-rf-12357855.html; “Diabetes patients with Ukrainian passports in the occupied territories will not be given insulin,” Protests in the world, Telegram, August 11, 2023, https://web.archive.org/web/20230823084821/https://t.me/worldprotest/33698.

[125] “‘The policy of pressure is centralized’: Kherson Regional Council tells about new options for coercion of occupants regarding Russian passports,” Espreso, August 15, 2023, https://web.archive.org/web/20230814164821/https://espreso.tv/politika-tisku-tsentralizovana-u-khersonskiy-oblradi-rozpovili-pro-novi-varianti-primusu-okupantiv-shchodo-pasportiv-rf.

[126] “Occupation authorities in Zaporizka oblast threaten to stop medical care for residents without Russian passports,” BBC News Russian Service, Telegram, October 6, 2023, https://t.me/bbcrussian/53377.

[127] Felipe Dana, “Land mines placed around Russian occupied Zaporizhzhia nuclear plant, UN says,” PBS, July 25, 2023, https://web.archive.org/web/20230726023822/https://www.pbs.org/newshour/world/land-mines-placed-around-russian-occupied-zaporizhzhia-nuclear-plant-un-says.

[128] “Attacks on Health Care in Ukraine”; “Mayor: Occupants in Enerhodar forbid to give out medicines to residents without Russian passports”, Espreso, August 15, 2023, https://web.archive.org/web/20230815110944/https://espreso.tv/okupanti-v-energodari-zaboronyayut-vidavati-zhitelyam-liki-bez-rosiyskogo-pasporta-mer. These medicines are subsidized categories of medication that Ukrainian citizens usually have the right to receive completely or partially free of charge.

[129] Ihor Burdyga and Anastasia Shepeleva, “What residents of the Russian-occupied territories of Ukraine say,” Deutsche Welle, September 30, 2023, https://web.archive.org/web/20230930155543/https://www.dw.com/uk/rik-pisla-aneksii-so-rozpovidaut-ziteli-okupovanih-rf-teritorij-ukraini/a-66951391.

[130] “Attacks on Health Care in Ukraine”; Petro Andriushchenko, “Mariupol. For now. Post-referendum,” Telegram, September 29, 2022, https://t.me/andriyshTime/3218.

[131] “She Pays the Highest Price: The Toll of Conflict on Sexual and Reproductive Health in Northwest Syria,” Physicians for Human Rights, March 2023, p.7-8, https://phr.org/wp-content/uploads/2023/03/REPORT-The-Toll-of-Conflict-on-Sexual-and-Reproductive-Health-in-Northwest-Syria_March-2023.pdf. 

[132] “Attacks on Health Care in Ukraine”; “Fedorov: Russians Are Endangering Children to Force Russian Passports on Residents of Zaporizka Oblast,” Dzerkalo Tyzhnia, June 03, 2023, https://web.archive.org/web/20230603195055/https://zn.ua/ukr/war/rosijani-stavljat-pid-udar-ditej-shchob-navjazati-zhiteljam-zaporizkoji-oblasti-pasporti-rf-fedorov.html.

[133] Veronika Bilkova, Dr. Cecilie Hellestveit, and Dr. Elīna Šteinerte, “Report On Violations and Abuses of International Humanitarian and Human Rights Law, War Crimes and Crimes Against Humanity, Related to the Forcible Transfer and/or Deportation of Ukrainian Children to the Russian Federation,” Organization for Security and Co-operation in Europe Office for Democratic Institutions and Human Rights, May 4, 2023, p.12-13, https://web.archive.org/web/20230707014607/https://www.osce.org/files/f/documents/7/7/542751_0.pdf. The National Information Bureau (NIB) of Ukraine for Prisoners of War, Forcibly Deported and Missing Persons, established by the Cabinet of Ministers of Ukraine in March 2022, maintains a registry of officially verified deported and/or forcibly displaced children on the territory of the Russian Federation. At the time of the report’s writing, this figure was 19,546 children. See “Children of War”, https://childrenofwar.gov.ua/en/.

[134] There are 36 such institutions (orphanages) in the health care system. “Report on the network and activities of health care facilities for 2022 (Form 47),” Center for Public Health of the Ministry of Health of Ukraine, accessed November 14, 2023, http://medstat.gov.ua/ukr/statdanMMXIX.html.

[135] “Deportation of Ukrainian citizens from the territory of active military operations or from the temporarily occupied territory of Ukraine to the territory of the Russian Federation and the Republic of Belarus,” 5 AM Coalition, February 2023, p.16, https://zmina.ua/wp-content/uploads/sites/2/2023/01/deportation_eng.pdf.

[136] Geneva Convention I, Arts. 24-26; Geneva Convention IV, Art. 20; Additional Protocol I, Art. 15; ICRC, Customary International Humanitarian Law, Rule 25.

[137] Geneva Convention IV, Art. 56(1).

[138] Geneva Convention IV, Commentary of 1958, Art. 56, https://ihl-databases.icrc.org/en/ihl-treaties/gciv-1949/article-56/commentary/1958?activeTab=undefined.

[139] Geneva Convention IV, Art. 56(1).

[140] Geneva Convention IV, Commentary of 1958, Art. 56.

[141] Ibid.

[142] Geneva Convention IV, Art. 49(6); ICRC, Customary International Humanitarian Law, Rule 130.

[143] Geneva Convention IV, Art. 49(1); ICRC, Customary International Humanitarian Law, Rule 129; Geneva Convention IV, Commentary of 1958, Art. 49, https://ihl-databases.icrc.org/en/ihl-treaties/gciv-1949/article-49/commentary/1958?activeTab=undefined.

[144] Rome Statute, Art. 8(2)(b)(viii).

[145] Geneva Convention IV, Art. 49(2); Geneva Convention IV, Commentary of 1958, Art. 49.

[146] Ryan Goodman, Michael W. Meier, and Tess Bridgeman, “Expert Guidance: Law of Armed Conflict in the Israel-Hamas War,” Just Security, October 17, 2023, Section 16, https://www.justsecurity.org/89489/expert-guidance-law-of-armed-conflict-in-the-israel-hamas-war/.

[147] Additional Protocol I, Commentary of 1987, Art. 17, https://ihl-databases.icrc.org/en/ihl-treaties/apii-1977/article-17/commentary/1987?activeTab=undefined.

[148] ICRC, Customary International Humanitarian Law, Rule 99; ICCPR, Art. 9.

[149] Geneva Convention IV, Art. 42.

[150] Geneva Convention IV, Art. 78.

[151] Geneva Convention I, Art. 28. For a definition of “permanent personnel,” see the following. Geneva Convention I, Art. 24.

[152] Geneva Convention I, Art.  29. For a definition of “auxiliary personnel” see the following. Geneva Convention I, Art. 25.

[153] Geneva Convention IV, Art. 147; Rome Statute, Art. 8(2)(a)(vii). Note that the definition of unlawful confinement under the Rome Statute is broader than the one found in the Fourth Geneva convention as it can refer to any protected persons under the Geneva Conventions, not only civilians.

[154] Rome Statute, Art. 8(2)(a)(ii). The definition of torture as a war crime, which requires that the victims be “protected persons” (as doctors and medics are), differs slightly from the definition of torture as a crime against humanity, which requires the victims to be in the custody of, or under the control of the perpetrator; Rome Statute, Elements of Crimes, fn. 35. Further, unlike the definition of torture under the United Nations Convention against Torture, the Rome Statute does not require the perpetrator to hold the status of a public official or to have acted in an official capacity; UN Convention against Torture, Art. 1.

[155] Rome Statute, Elements of Crimes, Art. 8(2)(a)(ii)-2.

[156] ICRC, Customary International Humanitarian Law, Rule 90.

[157] “Healthcare at War,” Ukrainian Healthcare Center, p. 34-36.

[158] Interview with Dr. Olena Yuzvak, PHR, September 22, 2023.

[159] “’My Only Crime Was That I Was a Doctor’: How the Syrian Government Targets Health Workers for Arrest, Detention, and Torture,” Physicians for Human Rights, December 2019, https://phr.org/our-work/resources/my-only-crime-was-that-i-was-a-doctor/. Ukrainian human rights organizations have documented similar patterns of harassment of health care workers. As told to the Ukrainian Helsinki Human Rights Union, the head of a hospital in Kherson was arrested and tortured: “Ilmiyev told everyone that I was a pro-Ukrainian person, cooperated with the SBU, helped the Armed Forces, so I was ‘not worthy of the position’ and should be suspended from work. He immediately offered me a choice: either I sign a paper on cooperation or I am arrested and taken to Perekopsk (to a pre-trial detention center). I replied that they could take me out to the yard and shoot me right away, but I would not sign any agreement with them“; “For refusing to cooperate, he was imprisoned: Kherson hospital chief doctor kidnapped by occupiers,” Ukrainian Helsinki Human Rights Union, May 26, 2023, https://www.helsinki.org.ua/articles/za-vidmovu-spivpratsiuvaty-potrapyv-do-kativni-holovnoho-likaria-khersonskoi-likarni-vykraly-okupanty/.

[160] “Interview with Dr. Maryna Rudenko.”

[161] “Interview with a doctor at the Kherson Regional Clinic Hospital [anonymous],” MIHR, October 23, 2022; “Interview with a doctor at the Kherson Regional Clinic Hospital [anonymous],” MIHR, October 28, 2022.

[162] Ed Holt, “Ukrainian medic prisoners of war speak out,” The Lancet 402, no. 10405 (September 9, 2023), https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)01885-8/fulltext; “Military Medics of Ukraine,” Military Medics of Ukraine, accessed November 14, 2023, https://military-medics-ua.org/en/home-en/.

[163] “In Russian captivity: what happens to Ukrainian soldiers behind the walls of Russian prisons,” Media Initiative for Human Rights, June 23, 2023, https://mipl.org.ua/v-rosijskomu-poloni-shho-vidbuvayetsya-z-ukrayinskymy-vijskovymy-za-stinamy-rosijskyh-tyurem/.

[164] “Attacks on Health Care in Ukraine”; Dmytro Romanov, “Ambulance nurse disappeared during deportation by Russians: what is known about her fate,” Telegraf, January 25, 2023, https://telegraf.com.ua/ukr/obshhestvo/2023-01-25/5776702-feldsherka-shvidkoi-dopomogi-znikla-pid-chas-deportatsii-rosiyanami-shcho-vidomo-pro-ii-dolyu.

[165] “Attacks on Health Care in Ukraine”; “42 doctors from the military hospital in Mariupol are in captivity. Some of them are on the verge of death,” 0629.com.ua, September 27, 2022, https://www.0629.com.ua/news/3469288/42-likara-z-vijskovogo-spitalu-v-mariupoli-perebuvaut-u-poloni-dehto-z-nih-na-grani-zitta-ta-smerti.

[166] Some of the detainees have since been identified by the NGO “Military Medics of Ukraine.” It has confirmed the identities of 54 military medics (53 men, 1 woman) held by Russia, including those from Hospital no. 555. Thirty six were subsequently freed in prisoner exchanges. “Military Medics of Ukraine,” accessed November 14, 2023, https://military-medics-ua.org/en/home-en/; Valerie Hopkins, “Ukrainian Medic’s Months in Russian Cell: Cold, Dirty and Used as a Prop,” New York Times, July 11, 2022, https://www.nytimes.com/2022/07/11/world/europe/ukraine-medic-russia-captive.html.

[167] Interview with a doctor at the Kherson Regional Clinic Hospital [anonymous], MIHR, October 23, 2022; Interview with a doctor at the Kherson Regional Clinic Hospital [anonymous], MIHR, October 28, 2022.

[168] Interview with Dr. Olena Yuzvak.

[169] Hopkins, “Ukrainian Medic’s”; “Russia’s war in Ukraine synonymous with torture: UN expert,” United Nations Office of the High Commissioner for Human Rights, September 10, 2023, https://www.ohchr.org/en/press-releases/2023/09/russias-war-ukraine-synonymous-torture-un-expert#:~:text=%E2%80%9CThese%20grievous%20acts%20appear%20neither,an%20official%20visit%20to%20Ukraine.

[170] “Interview with Dr. Y,” MIHR, November 24, 2022 from “Destruction and Devastation.”

[171] “Destruction and Devastation.”

[172] Additional Protocol I, Art. 16(1) and (2); ICRC, Customary International Humanitarian Law, Rule 26.

[173] Additional Protocol I, Art. 16(3).

[174] “Dual Loyalty & Human Rights in Health Professional Practice: Proposed Guidelines & Institutional Mechanisms,” Physicians for Human Rights and the School of Public Health and Primary Health Care, University of Cape Town, 2002, p.11-12, https://phr.org/wp-content/uploads/2003/03/dualloyalties-2002-report.pdf.

[175] “In the occupied Khersonska oblast, the Russian military abducted and killed the spouses Anastasia and Valery Saksaganski from the village of Mali Kopani,” Center of Journalistic Investigations, September 18, 2023, https://investigator.org.ua/ua/news-2/258612/.

[176] “Interview with a doctor at the Kherson Regional Clinic Hospital [anonymous],” MIHR, October 23, 2022; “Interview with a doctor at the Kherson Regional Clinic Hospital [anonymous],” MIHR, October 28, 2022 from “Destruction and Devastation.”

[177] Ihor Romanov, “Over 30 medics killed in active hostilities in Mariupol,” Mrpl.city, January 29, 2023, https://mrpl.city/news/view/pid-chas-aktivnih-bojovih-dij-v-mariupoli-zaginuli-ponad-30medikiv.

[178] “Interview with a doctor at the Kherson Regional Clinic Hospital [anonymous],” MIHR, October 23, 2022; “Interview with a doctor at the Kherson Regional Clinic Hospital [anonymous],” MIHR, October 28, 2022. By the time Russian doctors arrived in Kherson, the interviewed doctor has already escaped Kherson (on July 7, 2022) and received this information from his colleagues. His story is described in “Destruction and Devastation.”

[179] Yana Osadcha, “Occupants are building a medical center with a morgue in Mariupol and brought doctors from underdeveloped regions of the Russian Federation – city authorities,” Ukrainska Pravda, June 24, 2022, https://life.pravda.com.ua/health/2022/06/24/249249/; “Sanctioning Additional Members of Russia’s Duma, Russian Elites, Bank Board Members, and Defense Entities,” Department of State, March 24, 2022, https://www.state.gov/sanctioning-additional-members-of-russias-duma-russian-elites-bank-board-members-and-defense-entities/.

[180] Anastasia Gurin, “Invaders Rotate Medics in Occupied Territories of Zaporizhzhia – CNS,” Dzerkalo Tyzhnia, August 3, 2023, https://zn.ua/ukr/war/zaharbniki-proveli-rotatsiju-medikiv-na-okupovanikh-teritorijakh-zaporizhzhja-tsns.html.

[181] “‘You can’t go there for money. Fate will punish you.’ Who leaves Russia to work in the occupied cities of Ukraine and why,” BBC, April 1, 2023, https://www.bbc.com/ukrainian/features-65345635.

[182] “Interview with a doctor at the Kherson Regional Clinic Hospital [anonymous],” MIHR, October 23, 2022; “Interview with a doctor at the Kherson Regional Clinic Hospital [anonymous],” MIHR, October 28, 2022.

[183] Federal Law No. 16-FZ: “On the Specifics of Legal Regulations in Health Protection, Mandatory Medical Insurance, Medicine Circulation, and Medical Device Circulation in Connection with the Accession of the Donetsk People’s Republic, the Luhansk People’s Republic, Zaporizka Oblast, and Khersonska Oblast to the Russian Federation, Russian Federation,” February 17, 2023, http://publication.pravo.gov.ru/Document/View/0001202302170003?pageSize=100&index=1.

As we mark International Human Rights Day and the 75th anniversary of the Universal Declaration of Human Rights, we spoke with PHR Executive Director Sam Zarifi. In this Q&A, he reflects on the state of the human rights movement today, and provides a look ahead to how PHR is preparing for the next era of defending health and human rights around the world.

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Looking back at the past 75 years of the Universal Declaration of Human Rights, what do you see as some of the biggest successes of the human rights movement?  

The Universal Declaration was a response to the horrors of the Second World War and the First World War, the Holocaust, the various colonization and decolonization movements, the women’s rights campaigns, and of course the ongoing struggle against racism that we had seen in the first half of the previous century. As such, the Declaration was intended as guidelines and a set of restrictions for what governments and humans could do to one another, and in that sense we can say it has been successful.  

This is no less an effort at changing human culture, at disrupting human history, at setting boundaries on how states and people can treat one another based on the very revolutionary concept that all individuals everywhere have and are entitled to the same rights. Everywhere I have worked over the past 30 years around the world, on all continents, I have seen people, no matter their background or wealth or degree of education or awareness, point to those rights and demand those rights. I think that has been an amazing achievement for the Universal Declaration of Human Rights. 

“We think that the arc of the moral universe can bend toward justice, but this is not inevitable. It requires hard work and dedication to support the voices of those who are defending their own human rights.”

Sam Zarifi

What are the main challenges since the UDHR came into being? 

People look at the ongoing atrocities, the horrors, the violations that, unfortunately, are happening in so many different places on the planet and they ask, “Well what has the Universal Declaration ever done for us?” One of the great challenges is to work on improving and strengthening the implementation of the Universal Declaration while perpetuating its usefulness, and while asking the global community to still adhere to those principles that were declared 75 years ago. The violations that we now see are not an indication of the weakness of the Declaration, but rather that we are now seeing the world through the lens of violations and respect, or unfortunately lack of respect, for the rights embodied in that declaration. To me this is not a sign of the weakness of the Declaration, which, after all, is just a declaration. It’s not a binding treaty. It’s not a convention, it doesn’t have direct legal force. It’s a declaration of humanity and its aspirations. 

I would argue that another success of the Universal Declaration of Human Rights has been the growth of civil society across the world in almost every country. A lot of this has been significantly aided by developments in modern communication technology.  

What has been the role of health care workers in defending human rights and achieving accountability for human rights violations? How have they themselves been subjected to such violations? 

A crucial element that was codified in the Universal Declaration as well as in the Geneva Conventions was the notion that even in the most extreme conditions of warfare or emergencies, human rights must be protected. Health care workers in particular must be protected and health care facilities cannot be targeted. This is a reflection of the very beginnings of what we now call the laws of war – International Humanitarian Law – and it has been one of the foundational norms for human rights. In the past few years, we have seen a serious erosion in terms of respect for that right. That is a matter of real concern for Physicians for Human Rights (PHR), and it should be of concern to all of us.  

A central aspect of our work has been to protect members of the medical community in many places around the world. When they speak out about human rights or improving care for their patients, they can become targets of political attacks. We have also seen physical attacks on health care personnel and facilities, and a serious erosion of the foundational norm that health care providers must be protected. We have been working tirelessly to identify these attacks, to bring them to the attention of justice mechanisms and to provide what protection we can to our colleagues who are working in these very difficult conditions.  

Today’s headlines are pretty grim: From Gaza to Sudan to Ukraine, it is often easier to see the profound failures of the international human rights movement, than its successes. What gives you hope for the future of human rights? 

This is a moment to be sober about the promise made in the Universal Declaration. I think there are real reasons to question whether we could bring together the same constellation of actors of powerful states as we did 75 years ago, to make that declaration. At the same time, I think it is fair to say that the Declaration has found its way into global culture, into the hearts and minds of people everywhere. That is a huge success, but it is a victory that needs to be defended from challenges every day. 

We think that the arc of the moral universe can bend toward justice, but this is not inevitable. It requires hard work and dedication to support the voices of those who are defending their own human rights. A corollary to the Universal Declaration of Human Rights is that those who violate those rights should be held to account. This is the space that PHR has been working on for the last three decades, making sure that we push for accountability and that we are able to gather evidence to seek accountability, justice, and remediation for violations.  

An important advance in the last 75 years has been the development of mechanisms at the national, regional, and global levels for defending human rights. These instruments include the International Criminal Court, the European Court of Human Rights, as well as the use of universal jurisdiction in several countries around the world are really very new, about 20 or 30 years old. We have seen some successes and part of that success has been people demanding a lot more. They now ask, “Well, why can’t we put the perpetrators immediately on trial? Why can’t we take them to The Hague?” We have to work toward ensuring that expectations are reasonable but hopeful. 

One element of improving these justice mechanisms is ensuring that they have better evidence, better information. A great part of that comes from the kind of forensic and medical analysis and public health lens that physicians and health care professionals can provide. And in that regard, PHR occupies a fairly unique niche in providing that kind of analysis, that kind of evidence toward accountability and the search for justice. 

How is PHR looking ahead to meet the new era of human rights protection? 

Given our resources, we cannot address every situation that demands justice. But we have done quite a bit. And we are working to strengthen our ability to present and gather more evidence, and to use them more effectively in support of human rights, defenders of the people whose rights have been violated, working together with lawyers and prosecutors and academicians around the world. 

After 25 years of working in defense of human rights around the world I have been privileged and very excited to join PHR this year that marks the 75th anniversary of the Universal Declaration of Human Rights. I have seen what PHR can achieve by marshalling evidence, by using the power, frankly the prestige, of the medical community to defend, to promote human rights around the world. 

To take one example, the impact of PHR’s work on issues such as excessive use of force by the police around the world has been amazing to see. We have seen various UN mechanisms take note of the evidence provided by PHR, and respond to it. We have seen real reaction – from governments, for instance, in the United States, where PHR has been working to get rid of the false diagnosis of “excited delirium” – something that police still use to justify using excessive force. PHR has now worked with physicians’ organizations in the United States to ensure that they are clear that this diagnosis is not medically sound. And we are now starting to see state legislatures move to ban the use of this diagnosis by the police. That is real, concrete movement, inspired by the principles embodied in the Universal Declaration of Human Rights. This is just one of many examples of the impact PHR is having every day. 

The medical community and health care professionals play a unique role in defending and providing the basic rights that were embodied in the Universal Declaration of Human Rights: the right to life, the right to health and dignity all require functioning health care systems and require policies that are based on science and on medical evidence. That is why at PHR we say that we work at the intersection of law, medicine, and science, to defend human rights and to establish policies that support and promote human rights. The role of the medical community has been really highlighted, especially in the last few years with the pandemic and the ongoing effects of conflict, war, and climate change. We need to harness the expertise and evidence that can be provided by the medical community to respond to these huge challenges. 

On this Human Rights Day celebrating the 75th anniversary of the Universal Declaration of Human Rights, I hope that you will consider supporting the work of Physicians for Human Rights. 

This month, the United States received a stinging indictment of its human rights record spanning the Trump and Biden administrations. As a signatory to the International Covenant on Civil and Political Rights (ICCPR), the United States must periodically report to the United Nations Human Rights Committee on its efforts to respect, protect, and fulfill basic civil and political rights. In its Concluding Observations, the Committee found that the United States failed to uphold human rights obligations in over 30 distinct thematic issues.  

Several areas of concern include the human rights and health harms of U.S. immigration policies, violations of medical ethics and the right to health caused by abortion bans, and the excessive use of force by law enforcement against individuals in police custody and peaceful protestors.

Immigration 

Immigration policies adopted under the Trump and Biden administrations violate the human right to seek asylum, according to the Committee. Administrative rule “Circumvention of Lawful Pathways,” the CBP One mobile application, the “enhanced expedited removal” procedure, and the “Zero Tolerance Policy” were specifically criticized by the Committee for causing discrimination on the basis of nationality and risking the safety of asylum seekers, including their unlawful repatriation to potentially dangerous environments (refoulement). The Committee also flagged that reports of the U.S. government’s extensive use of solitary confinement and poor health conditions for detained asylum seekers violate international standards.

The Committee’s Concluding Observations align with evidence submitted by PHR that the “Zero Tolerance Policy” led to psychological trauma and constituted torture for asylum seekers. Our submission to the Committee highlighted that: 

More than 5,000 children were forcibly separated from their parents at the U.S.-Mexico border – 860 of whom remain separated from their parents – causing lasting physical and mental trauma for families. 

We also shared evidence of inhumane conditions, medical neglect, and abusive treatment in immigration detention, including during the height of the COVID pandemic in PHR’s report “Praying for Hand Soap and Masks: Health and Human Rights Violations in U.S. Immigration Detention during the COVID-19 Pandemic” and in our subsequent report “Behind Closed Doors: Abuse and Retaliation Against Hunger Strikers in U.S. Immigration Detention.” 

We urged the Committee to take a stronger stance toward the United States by calling for the end of immigration detention and adopting alternative, non-surveillance, community-based measures. We concur with the Committee that the United States also must improve accountability for excessive use of force and poor conditions in detention and provide reparations to families affected by family separation policies.

Reproductive Rights 

The assault on reproductive rights in the United States, particularly in the aftermath of the Dobbs v. Jackson Women’s Health Organization decision, was another area of concern for the Committee. In its Concluding Observations, the Committee stated that it  

“is alarmed at the increase of legislation, barriers and practices at the state level that impede women’s access to safe and legal abortion, inter alia, the criminalization of various actors linked to their role in providing or seeking abortion care, including health care providers.” 

These barriers, it explained, violate the rights to “life, privacy, and not to be subject to cruel and degrading treatment” which disproportionately impact women and girls with low incomes from vulnerable groups. Committee members cautioned that restricting access to reproductive health services will greatly exacerbate maternal mortality rates – a significant concern given that the United States already has the highest rate of maternal mortality among developed countries.

The Committee’s conclusions come as no surprise. PHR’s report “No One Could Say: Accessing Emergency Obstetrics Information as a Prospective Prenatal Patient in Post-Roe Oklahoma” found that state laws criminalizing abortion in Oklahoma have caused widespread fear and confusion among medical personnel when providing obstetric services and limit patients’ abilities to access information about care options. These findings reflect a growing trend across the United States and highlight the country’s backsliding on sexual and reproductive health and rights.

The federal government must take a more active role in challenging state bans and strengthening shield laws that protect cross-state travel and clinicians’ medical licenses across states. The United States should also redouble its efforts to prevent maternal mortality and eliminate health care disparities, particularly racial and ethnic disparities, as highlighted by the Committee.

Torture 

The Committee made it apparent that the United States has not fully reckoned with and ensured accountability for its use of torture. In 2019, PHR helped bring to light that in the Guantánamo Bay Detention Facility, detainees’ medical needs were regularly subordinated to security functions, medical records were incomplete and withheld from prisoners, and health services were often insufficient.

The Committee decried “the lack of specialist care and facilities to address the complex health issues of detainees” at the Guantánamo Detention Facility and called on the United States to hold perpetrators of torture in the Armed Forces criminally accountable. It recommended investigating allegations of torture using the Istanbul Protocol, the international standard for documentation of torture which PHR helped develop. It is alarming that the United States has no formal human rights mechanism to investigate these allegations as exists in many other countries.   

Policing 

The Committee also decried the United States’s policing practices that violate the rights to nondiscrimination and freedom of assembly. As noted by the Committee, racial profiling is still used by law enforcement and leads to the overrepresentation of racial minorities in the criminal legal system. PHR’s research has demonstrated that deaths in police custody, particularly of people of African descent, are undercounted across the country and that the use of excessive force against peaceful protestors is most pronounced against the same group of people.  

Similarly, the Committee called on the United States to comply with international standards on the use of force and to improve accountability by mandating that law enforcement agencies report all excessive or deadly use of force to the public. “Less lethal” crowd-control weapons used by law enforcement can cause serious health and human rights harms and can constitute collective punishment. Nonetheless, these weapons are often used indiscriminately against peaceful protestors in the United States and throughout the world. These demands for accountability align with PHR’s research and recommendations, such as in the 2023 report “Lethal in Disguise 2: How Crowd-Control Weapons Impact Health and Human Rights.” 

As raised in our submission to the UN Human Rights Committee, almost 40 percent of records sent to the U.S. Department of Justice by law enforcement bodies in 2021 did not include the required descriptions of the circumstances surrounding deaths in custody. Even when reported, the baseless medical diagnosis of “excited delirium” is often misused as a legal defense by law enforcement agencies despite being unscientific and rooted in racist stereotypes. While we align with the Committee’s calls for transparency and accountability, we further recommend that the United States support state efforts to ban “excited delirium” as a cause of death, as was achieved in California, and invest in alternative models of mental and behavioral health crisis response. 

Next Steps 

In conclusion, the United States urgently needs to improve its policies on immigration, reproductive rights, accountability for torture, and excessive force by law enforcement, among other areas. That is not to say that the government has made no efforts to rectify its human rights record – several initiatives shared with the Human Rights Committee represent promising, albeit limited, policy improvements. We encourage the U.S. government to take the Human Rights Committee’s concluding observations seriously to protect the health, safety, and rights of those currently neglected or abused. PHR will continue to monitor and document U.S. adherence to the ICCPR and other international human rights obligations in these crucial areas.

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Photo: PHR Medical Director Dr. Michele Heisler speaks at the 6th civil society consultation in advance of the October 17-18 ICCPR periodic review at the United Nations. Credit: United States mission in Geneva.

More than three years after the Black Lives Matter movement swept the United States and brought renewed attention to racial injustice, a UN human rights monitoring mechanism has issued a groundbreaking new report about excessive use of force and racism in policing. The report from the Expert Mechanism to Advance Racial Justice and Equality in Law Enforcement (EMLER), commonly referred to as the “George Floyd Mechanism,” lays out a detailed review of how systemic racism and inequality lead to harmful practices in law enforcement and the criminal justice system that disproportionately affect people of color across the United States.

What is the Mechanism?

The “George Floyd Mechanism” was established in December 2021 by the United Nations Human Rights Council in part as a response to the tragic murder of George Floyd in 2020 and the subsequent public calls to address systemic racism in law enforcement globally. Headed by commissioners Justice Yvonne Mokgoro (chair), Dr. Tracie L. Keesee, and PHR board member Professor Juan E. Méndez, the Mechanism is tasked with advocating for racial justice and equality in law enforcement, investigating governments’ responses to peaceful anti-racism protests, and ensuring accountability for victims of structural racism.

The commissioners completed their first country visit to the United States in May 2023, during which they met with community organizations and civil society in Atlanta, Los Angeles, Minneapolis, New York City, and Washington, D.C. The Mechanism’s visit and recently published report are important steps to promote criminal justice and racial justice reform by investigating the root causes and effects of systemic racism in U.S. law enforcement. This was the Mechanism’s first in-depth study of U.S. law enforcement practices, state laws, and other policies, and can serve as a basis for reform.  

The report from the “George Floyd Mechanism,” lays out a detailed review of how systemic racism and inequality lead to harmful practices in law enforcement and the criminal justice system that disproportionately affect people of color across the United States.

Key Conclusions from the U.S. Country Report

• The report speaks extensively about the need to demilitarize police departments and reduce excessive use of force, especially against protestors. As noted by the Mechanism, during the 2020 protests, law enforcement “confronted peaceful manifestations with riot gear as a first level response, rather than only in response to specific incidents of violence.” PHR’s report “Shot in the Head” was cited as evidence of the unjustified level of force used against peaceful protestors in violation of human rights law.

• The Mechanism encourages law enforcement to “reimagine policing practices” by adopting a human rights approach. According to the Mechanism, “this approach provides a framework for law enforcement institutions to build public trust and ensures confidence in the commitment of public officials to respect and protect the communities they serve.” The report lists several alternative methods that law enforcement can use in situations that have resulted in killings by police, noting that 59 percent of all killings by police in 2022 involved interactions at traffic stops, responding to mental health crises, or situations with people not alleged to be threatening others with a gun.

• The Mechanism calls on state and local governments to develop policies and oversight institutions for investigating and ensuring accountability for abuses by law enforcement. The Mechanism found that in the United States, “only 1.9% of all killings by police in the last decade resulted in police officers being charged with a crime.” The commissioners voiced concerns that police officers found responsible for misconduct have been able to assume posts in other agencies. The report also called for improvements to the reparations process for victims of police violence.

• The Mechanism also calls on law enforcement to address the ramifications of racial bias in police interactions that lead to over-incarceration and racial disparities. The report notes that the United States imprisons more people than nearly every other UN Member State and that “Black people are the most incarcerated and most criminally supervised persons in the United States.” According to a U.S. Department of Justice special report cited by the Mechanism, Black people were three times more likely to experience the threat of force, three times more likely to be shouted at by police, and 11 times more likely to experience police misconduct than white people in 2020. Similarly, Black people were four and a half times more frequently incarcerated, nearly three times more often under probation or parole, and more than three times more likely to experience criminal supervision than white people in the United States in 2021. “More than one out of six men of African descent between the ages of 25 and 54 years old are missing from daily life.”

• The report recommends that the United States institute international use of force standards at all levels of government. Standards such as the UN Human Rights Guidance on Less-Lethal Weapons in Law Enforcement of 2020 provide direction on the lawful and responsible use of less-lethal weapons (such as batons and chemical irritants) and outline pathways for states to ensure accountability. This is in stark contrast to the Mechanism’s concern that U.S. law enforcement practices “do not prioritize de-escalation and other less harmful methods of control.” PHR called for the United States to implement the 2020 UN guidance in our report Lethal in Disguise 2: How Crowd-Control Weapons Impact Health and Human Rights.

• The Mechanism joins other UN special procedures in stating that “the ‘war on drugs’ has been more effective as a system of racial control than as a tool to reduce drug markets.” Black people are more impacted by the use of military equipment in drug related raids, even though people of all races use and sell drugs at similar rates.

• Lastly, the Mechanism expressed grave concern about practices in places of detention. For instance, the commissioners received firsthand testimony from pregnant women who had been shackled during labor, some of whom lost their babies due to the restraints. Solitary confinement is also a commonly used practice – an estimated 80,000 prisoners are held in isolated confinement in the United States on any given day. This worsens the mental health of detainees and can amount to torture in severe cases. Finally, the report condemned the use of unpaid and poorly paid forced prison labor for its role in perpetuating slavery into the present day. As the Mechanism emphasized, these practices are an affront to human dignity and violate the UN Standard Minimum Rules for the Treatment of Prisoners (Nelson Mandela Rules).

“Only 1.9% of all killings by police in the last decade resulted in police officers being charged with a crime.”

PHR’s Concerns

PHR welcomes the work of the Mechanism as a vital forum for raising multiple concerns about racism and policing in the United States.

For instance, as noted by the “George Floyd Mechanism”, PHR has long condemned U.S. police departments’ use of policies that are rooted in systemic racism. One of these policies, the concept of “excited delirium,” was found by PHR to be an invalid medical diagnosis steeped in racist tropes that has become a catch-all explanation to explain and often excuse deaths in police custody. Nonetheless, physicians serving as legal defense experts or researchers for law enforcement agencies continue to use this medically baseless term, such as in the deaths of Daniel Prude, Elijah McClain, and Manuel Ellis. The last major medical association to support the concept, the American College of Emergency Physicians, recently publicly disavowed the term, and the state of California banned its use in death certificates and autopsy reports, police reports, and civil litigation, after concerted advocacy efforts from PHR, victims’ families, and many others.

PHR is also encouraged by the Mechanism’s condemnation of excessive force and misuse of crowd-control weapons by police departments in response to the 2020 George Floyd protests. PHR conducted several investigations about the unlawful use of force against peaceful Black Lives Matter protestors in New York City, Portland, and across the country; one of our investigations led to the establishment of a community reparations fund in New York City. PHR and INCLO also published an updated report on the health and human rights impacts of crowd-control weapons globally and offered recommendations for their safe use and accountability for abuses.

We also believe that the Mechanism can use its position to speak more generally about how criminalization of any form disproportionately affects Black, Indigenous, and people of color (BIPOC). As noted in our recent report on abortion bans in Oklahoma, abortion criminalization exacerbates health inequalities and is more likely to target BIPOC communities for detention and other penalties.

What’s Next

We encourage the “George Floyd Mechanism” to express its concern publicly about “excited delirium” to challenge the unscientific and racist legal defenses used to create impunity for killings by police.

Building on the findings of the report, U.S. lawmakers can combat structural racism and promote accountability for police abuses by passing the “End Racial and Religious Profiling Act”; ensuring better implementation of the “Death in Custody Reporting Act” of 2013; and creating an effective nationwide data base of people under investigation or found guilty for police misconduct. Law enforcement agencies should adopt a human rights-based approach to policing that limits the use of force and crowd-control weapons; strictly regulates practices in detention facilities like solitary confinement; and implements processes to prevent impunity for police misconduct.

PHR also joins the international Alliance for Torture-Free Trade in calling for the negotiation and adoption of a legally binding Torture Free Trade Treaty. As outlined in the UN Group of Governmental Expert’s 2022 report and reinforced days ago by the UN Special Rapporteur on Torture in her report to the UN General Assembly, such a treaty would help ban the trade and manufacturing of inherently abusive law enforcement equipment and regulate equipment that can be used to torture. We hope that the “George Floyd Mechanism” will voice public support for this initiative as well, and that the US government will robustly advance the effort as a member of the Alliance.