1.

Nation

Careless detention

System of neglect

AS TIGHTER IMMIGRATION POLICIES STRAIN FEDERAL AGENCIES, THE DETAINEES IN THEIR CARE OFTEN PAY A HEAVY COST
By Dana Priest and Amy Goldstein

Washington Post
May 11, 2008
Page A1

Near midnight on a California spring night, armed guards escorted Yusif Osman into an immigration prison ringed by concertina wire at the end of a winding, isolated road.

During the intake screening, a part-time nurse began a computerized medical file on Osman, a routine procedure for any person entering the vast prison network the government has built for foreign detainees across the country. But the nurse pushed a button and mistakenly closed file #077-987-986 and marked it "completed" -- even though it had no medical information in it.

Three months later, at 2 in the morning on June 27, 2006, the native of Ghana collapsed in Cell 206 at the Otay Mesa immigrant detention center outside San Diego. His cellmate hit the intercom button, yelling to guards that Osman was on the floor suffering from chest pains. A guard peered through the window into the dim cell and saw the detainee on the ground, but did not go in. Instead, he called a clinic nurse to find out whether Osman had any medical problems.

When the nurse opened the file and found it blank, she decided there was no emergency and said Osman needed to fill out a sick call request. The guard went on a lunch break.

The cellmate yelled again. Another guard came by, looked in, and called the nurse. This time she wanted Osman brought to the clinic. Forty minutes passed before guards brought a wheelchair to his cell. By then it was too late: Osman was barely alive when paramedics reached him. He soon died.

His body, clothed only in dark pants and socks, was left on a breezeway for two hours, an airway tube sticking out of his mouth. Osman was 34.

The next day, an autopsy determined that he had died because his heart had suddenly stopped, confidential medical records show. Two physicians who reviewed his case for the *Washington Post* said he might have lived had he received timely treatment, perhaps as basic as an aspirin.

Privately, Otay Mesa's medical staff also knew his care was deficient. On Page 3 of an internal review of his death is this question: "Did patient receive appropriate and adequate health care consistent with community standards during his/her detention ...?"

Otay Mesa's medical director, Esther Hui, checked "No."

Osman's death is a single tragedy in a larger story of life, death, and often shabby medical care within an unseen network of special prisons for foreign detainees across the country. Some 33,000 people are crammed into these overcrowded compounds on a given day, waiting to be deported or for a judge to let them stay here.

The medical neglect they endure is part of the hidden human cost of increasingly strict policies in the post-Sept. 11 United States and a lack of preparation for the impact of those policies. The detainees have less access to lawyers than convicted murderers in maximum-security prisons and some have fewer comforts than al-Qaeda terrorism suspects held at Guantanamo Bay, Cuba.

But they are not terrorists. Most are working-class men and women or indigent laborers who made mistakes that seem to pose no threat to national security: a Salvadoran who bought drugs in his 20th year of poverty in Los Angeles; a U.S. legal U.S. resident from Mexico who took $50 for driving two undocumented day laborers into a border city. Or they are waiting for political asylum from danger in their own countries: a Somali without a valid visa trying to prove she would be killed had she remained in her village; a journalist who fled Congo out of fear for his life, worked as a limousine driver and fathered six American children, but never was able to get the asylum he sought.

The most vulnerable detainees, the physically sick and the mentally ill, are sometimes denied the proper treatment to which they are entitled by law and regulation. They are locked in a world of slow care, poor care and no care, with panic and coverups among employees watching it happen, according to a Post investigation.

The investigation found a hidden world of flawed medical judgments, faulty administrative practices, neglectful guards, ill-trained technicians, sloppy record-keeping, lost medical files, and dangerous staff shortages. It is also a world increasingly run by high-priced private contractors. There is evidence that infectious diseases, including tuberculosis and chicken pox, are spreading inside the centers.

Federal officials who oversee immigration detention said last week that they are "committed to ensuring the safety and well-being" of everyone in their custody.

Some 83 detainees have died in, or soon after, custody during the past five years. The deaths are the loudest alarms about a system teetering on collapse. Actions taken -- or not taken -- by medical staff members may have contributed to 30 of those deaths, according to confidential internal reviews and the opinions of medical experts who reviewed some death files for the *Post*.

According to an analysis by the Post, most of the people who died were young. Thirty-two of the detainees were younger than 40, and only six were 70 or older. The deaths took place at dozens of sites across the country. The most at one location was six at the San Pedro compound near Los Angeles.

Immigration officials told congressional staffers in October that the facility at San Pedro was closed to renovate the fire-suppression system and replace the hot-water boiler. But internal documents and interviews reveal unsafe conditions that forced the agency to relocate all 404 detainees that month. An audit found 53 incidents of medication errors. A riot in August pushed federal officials to decrease the dangerously high number of detainees, many of them difficult mental health cases, and caused many health workers to quit. Finally, the facility lost its accreditation.

The full dimensions of the massive crisis in detainee medical care are revealed in thousands of pages of government documents obtained by the Post. They include autopsy and medical records, investigative reports, notes, internal e-mails, and memorandums. These documents, along with interviews with current and former immigration medical officials and staff members, illuminate the underside of the hasty governmental reorganization that took place in response to the attacks of Sept. 11, 2001.

The terrorist strikes catapulted immigration to a national security concern for the first time since World War II, when 120,000 Japanese residents and their American relatives were locked away in desolate internment camps.

After Sept. 11, the Bush administration transferred responsibility for border security and deportation to the new Department of Homeland Security, which gave it to Immigration and Customs Enforcement (ICE) -- a reconfiguration of the decades-old Immigration and Naturalization Service -- in 2003, the year the Post used as the starting point for counting detainee deaths. Each year since, the number of detainees picked up for deportation or waiting behind bars for political asylum has skyrocketed, increasing by 65 percent since July 2005.

Government professionals provide health care at 23 facilities, which house roughly half of the 33,000 detainees. Seven of those sites are owned by private prison companies. Last year, the government also housed detainees in 279 local and county jails. To handle the influx of detainees, ICE added 6,300 beds in 2006 and an additional 4,200 since then. They too are nearly full.

These way stations between life in and outside the United States are mostly out of sight: in deserts and industrial warehouse districts, in sequestered valleys next to other prisons, or near noisy airports. Some compounds never allow detainees outdoor recreation; others let them out onto tiny dirt patches once or twice a week.

Detainees are not guaranteed free legal representation, and only about one in 10 has an attorney. When lawyers get involved, they often have difficulty prying medical information out of the bureaucracy -- or even finding clients, who are routinely moved without notice.

The burden of health care for this crush of human lives falls on an obscure federal agency that lacks the political clout and bureaucratic rigor to do its job well. The Division of Immigration Health Services (DIHS), housed in a private office building at 13th and L streets NW several blocks from ICE headquarters, had a budget last year of $61 million. ICE spent an additional $28 million last year on outside medical care for detainees.

Medical spending has not kept pace with the growth in population. Since 2001, the number of detainees over the course of each year has more than tripled to 311,000, according to ICE and the Government Accountability Office. Meanwhile, spending for the DIHS and outside care has not quite doubled, ICE figures show. ICE's conflicting population and budget numbers make the trends difficult to determine.

The agency is responsible for managing and monitoring detainee medical care, about half of which is provided by U.S. Public Health Service professionals and the rest by contracted medical staff. When doctors and nurses at the immigration compounds believe that detainees need more than the most basic treatment, they have to fax a request to the Washington office, where four nurses, working 9 to 4, East Coast time, five days a week, make the decisions.

A proud Statue of Liberty replica stands just beyond the glass doors of DIHS headquarters to remind visitors of the Public Health Service's historical role in screening and treating European immigrants arriving at Ellis Island at the turn of the last century. Its new role is to keep detained immigrants healthy enough to be deported.

The mission is accompanied at times by a sense of panic and complicity. Many documents obtained by the Post make clear that the people in charge know that the system is in trouble and that piecemeal fixes are not enough.

"The onus is on us if it hits the fan," one official complained during a high-level headquarters meeting about staff shortages late last summer, according to records of the conversation. "We're going to be responsible if something happens, because it's well documented that we know there's a problem, that the problem is severe."

"We are putting ourselves and our patients at risk," another official said.

Doctors express concerns about violating medical ethics and fear lawsuits. In July, Esther Hui at Otay Mesa sent a memo to DIHS medical director Timothy T. Shack, saying her colleagues were worried that they might be sued because of the substandard care they were giving detainees. The agency's mission of "keeping the detainee medically ready for deportation" often conflicts with the standards of care in the wider medical community, Hui wrote. "I know in my gut that I am exposing myself to the U.S. legal standard of care argument. . . . Do we need to get personal liability insurance?"

Nurses who work on the front lines see the problems up close. "Dogs get better care in the dog pound," said Catherine Rouse, a contract nurse at an Arizona detention center who quit after two months last year because she saw what she regarded as "scary medicine" in the prison: patients taken off medications they needed and nurses doing tasks they were not qualified to do. "You don't treat people like that. There has to be some kind of moral fiber," Rouse said.

In a statement responding to questions raised by the *Post*, Immigration and Customs Enforcement officials pointed out that the federal government spent nearly $100 million in fiscal 2007 on medical care for immigration detainees. About one in four immigrants in the detainee population has a chronic health condition, the statement said.

"Among ICE's highest priorities is to ensure safe, humane conditions of confinement for those in our custody," the statement said. "We make every effort to enforce all existing standards and, whenever possible, to improve upon them. When we find standards that are not being met, we take immediate action to correct deficiencies and when we believe that the deficiencies cannot be corrected, we relocate our detainees to other facilities."

By their calculations, officials said, the mortality rate among detainees has declined since 2004 to a level that is lower than that in U.S. jails and prisons. The deaths, the statement said, "highlight the tremendous responsibility and potential liability the government faces in providing medical care to a population that often did not have access to adequate health care before coming into our custody."

To this end, the agency recently increased its inspections of facilities and is creating an inspection group at headquarters to review serious incidents, including deaths or allegations that standards are not being met.

ICE declined to comment on specific cases, citing internal policies on patient privacy or pending litigation.

Neil Sampson, who ran the DIHS as interim director most of last year, left that job with serious questions about the government's commitment. Sampson said in an interview that ICE treated detainee health care "as an afterthought," reflecting what he called a failure of leadership and management at the Homeland Security Department. "They do not have a clear idea or philosophy of their approach to health care [for detainees]," he said. "It's a system failure, not a failure of individuals."

A new director for health services arrived six months ago, following a stretch when the agency was run first by Sampson and then by a second interim director. The new boss is LaMont W. Flanagan, who brought with him the credential of having been fired in 2003 by the state of Maryland for bad management and spending practices supervising detention and pretrial services. An audit found that Flanagan had signed off on payments of $145,000 for employee entertainment and other ill-advised expenditures. His reputation was such that the District of Columbia would not hire him for a juvenile-justice position.

"Another death that needs to be added to the roster," Diane Aker, the DIHS chief health administrator, tapped out in an e-mail to a records clerk at headquarters on Aug. 14, 2007.

Juan Guevara-Lorano, 21, was dead.

Guevara, an unemployed legal U.S. resident with a young son, was arrested in El Paso for driving illegal border-crossers farther into the city. He was paid $50.

An entry-level emergency medical technician, with barely any training, had done Guevara's intake screening and physical assessment at the Otero County immigration compound in New Mexico. Under DIHS rules, those tasks are supposed to be done by a nurse.

After two difficult months in detention, Guevara had decided not to appeal his case. He would go back to Mexico with his family. But on Aug. 4, he came down with a splitting headache, what he called a nine on a pain scale of 10, his medical records show. The rookie medical technician prescribed Tylenol and referred Guevara to the compound's physician "due to severity of headache . . . and dizziness," according to medical records.

But Guevara never saw a doctor. Eight days after the first incident, he vomited in his cell. The same junior technician came to help but was unable to insert a nasal airway tube. Guevara was taken to a hospital, where doctors determined an aneurism in his brain had burst.

His wife, pregnant at the time with their second child, recalled that she rushed to the hospital but ICE guards would not let her inside, until the Mexican Consulate interceded. Guevara's mother waited five hours before they let her in. By then he was brain-dead.

"My son is not coming back," sobbed Ana Celia Lozano months later, sitting in Guevara's small mobile home as her grandson played on the floor. "I want to know how he lived and died, nothing more."

What appears to be the most incriminating document in Guevara's case has been partially blacked out. Still, what is left shows that he did not receive adequate care. "The detainee was not seen or evaluated by an RN, midlevel, or physician. . . . At the time of the incident on 8/12/2007, the detainee was seen and examined by EMTs."

Each immigration facility is allotted a different number of positions, and a shortage of doctors and nurses is not unusual at centers across the country. Records from February show that about 30 percent of all DIHS positions in the field were unfilled. ICE officials said last week that the current vacancy rate is 21 percent. Concern about the vacancies is voiced repeatedly at clinical directors' meetings. "How do we state our concerns so that we can be heard? . . . this is a CRITICAL condition. . . . We have bitten off more than we can chew," a physician wrote in the minutes of one meeting last summer.

In some prisons, the staffing shortages are acute. The Willacy County detention center in South Texas -- the largest compound, with 2,018 detainees -- has no clinical director, no pharmacist, and only a part-time psychiatrist. Nearly 50 percent of the nursing positions were unfilled at the 1,500-detainee Eloy, Ariz., prison in February. At the newly opened 744-bed Jena., La., compound, nurses run the place. It has no clinical director, no staff physician, no psychiatrist, and no professional dental staff.

Last August, Sampson, who was then DIHS interim director, warned his superiors at ICE that critical personnel shortages were making it impossible to staff the Jena facility adequately. In a vociferous e-mail to Gary Mead, the ICE deputy director in charge of detention centers, he wrote: "With the Jena request we have been re-examining our capabilities to meet health care needs at a new site when we are facing critical staffing shortages at most every other DIHS site. While we developed, executed, and achieved major successes in our recruitment efforts we have been unable to meet the demand."

The slow ICE security-clearance process forced many job applicants to go elsewhere, Sampson wrote. Of the 312 people who applied for new positions over the past year, 200 withdrew, he wrote, because they found other jobs during the 250 days it took ICE, on average, to conduct the required background investigations. Last week, ICE officials said the average wait had decreased recently to 37 days.

These shortages have burdened the remaining staff. In July 2007, a year after Osman's death in Otay Mesa, medical director Hui strongly complained to headquarters about workload stress. "The level of burnout . . . is high and rising," she wrote in an e-mail. "I know that I have been averaging approximately 2-6 hrs of overtime daily for the past 2 months. I will no longer be able to sustain this pace and will be decreasing the number of hours that I work overtime. This being said, more will be left undone because we simply do NOT have the staff."

The overcrowding has created a petri dish for the spread of diseases. One mission of the Public Health Service is to detect infectious diseases and contain them before they spread, but last summer, the gigantic Willacy center was hit by a chicken pox outbreak.

The illness spread because the facility did not have enough available isolation rooms and its large pods share recycled air, but also because security officers "lack education about the disease and keep moving around detainees from different units without taking into consideration if the unit has been isolated due to heavy exposure," noted the DIHS's top specialist on infectious diseases, Carlos Duchesne. The staff was forced to vaccinate the entire population in mid-July.

In one 2007 death, memos and confidential notes show how medical staff missed an infectious disease, meningitis, in their midst. Victor Alfonso Arellano, 23, a transgender Mexican detainee with AIDS, died in custody at the San Pedro center. The first three pages of Duchesne's internal review of the death leave the impression that Arellano's care was proper. But the last page, under the heading "Off the record observations and recommendations," takes a decidedly critical tone: "The clinical staff at all levels fails to recognize early signs and symptoms of meningitis. . . . Pt was evaluated multiple times and an effort to rule out those infections was not even mentioned."

Arellano was given a "completely useless" antibiotic, Duchesne wrote. Lab work that should have been performed immediately took 22 days because San Pedro's clinical director had ordered staff members to withhold lab work for new detainees until they had been in detention there "for more than 30 days," a violation of agency rules.

"I am sure that there must be a reason why this was mandated but that practice is particularly dangerous with chronic care cases and specially is particularly dangerous with . . . HIV/AIDS patients," Duchesne wrote. "Labs for AIDS patients . . . must be performed ASAP to know their immune status and where you are standing in reference to disease control and meds."

Given the frequency with which ICE moves people within the detention network, keeping track of detainees is critical to stopping the spread of infectious illnesses. The purchase of an electronic records system named CaseTrakker in 2004 was supposed to help. But according to internal documents and interviews, CaseTrakker is so riddled with problems that facilities often revert to handwritten records.

A study at one site found that it took one-third more time to use CaseTrakker than to use paper. Thousands of patient files are missing. Recorded data often cannot be retrieved. Day-long outages are common.

When detainees are transferred from one facility to another, their records, if they follow them, are often misleading. Some show medications with no medical diagnoses, or "lots of diagnoses but no meds," according to Elizabeth Fleming, a former clinical director at one compound in Arizona.

After Yusif Osman's death and the discovery of the problem with his computerized records, the DIHS ordered a review of all charts at the Otay Mesa center. During the review, auditors also found that 260 physical exams were never completed as required. The nurse responsible for the error in Osman's case was reprimanded, but the computer problem was not fixed.

The CaseTrakker system "has failed and must be replaced," Sampson, the DIHS interim director, wrote to his ICE supervisors in August.

In January 2008, medical director Shack told colleagues that CaseTrakker "is more of a liability than the use of paper medical record system," according to the minutes of a meeting. It "puts patients at risk."

ICE officials said last week that they are not satisfied with CaseTrakker and are working to replace it.

Along with being at the mercy of computer glitches, detainees suffer from human errors that deny or delay their care. And with few advocates on the outside, they are left alone to plead their cases in the most desperate ways, in hand-scribbled notes to doctors they rarely see.

"I need medicine for pain. All my bones hurt. Thank you," wrote Mexico native Roberto Ledesma Guerrero, 72, three weeks before he died inside the Otay Mesa compound.

Delays persist throughout the system. In January, the detention center in Pearsall, Tex., an hour from San Antonio, had a backlog of 2,097 appointments.

Luis Dubegel-Paez, a 60-year-old Cuban, had filled out many sick call requests before he died on March 14. Detained at the Rolling Plains Detention Facility in the West Texas town of Haskell, he wrote on New Year's Day: "need to see doctor for Heart medication; and having chest pains for the past three days. Can't stand pain."

Ten days later he went to the clinic and became upset when he wasn't seen. He slugged the window, yelled, pointed at his wristwatch. He was escorted back to his cell.

Another of his sick call requests said: "Need to see a doctor. I have a lot of symptoms of sickness . . . as soon as possible!" The next was more urgent: "I have a emergency to see the doctor about my heart problems . . . for the last couple days and I been getting dizzy a lot."

The next day, Dubegel-Paez collapsed and died. His medical records do not show that he ever saw a doctor for his chest pains.

Hanna Boutros, 52, who came to the United States 30 years ago, waited seven months for surgery after receiving a diagnosis of "high-grade" prostate cancer, which his urologist urged be treated immediately. ICE officials sent him to Krome Service Processing Center in Miami because, they said, it could best deal with his condition.

But he was seen by nurses, not a doctor, until he found an outside lawyer to threaten a suit. Boutros finally got surgery just before Christmas, before he was deported to Lebanon, leaving two children and a wife in the United States. "I was miserable. I was very, very scared. It was always burning," he said.

Juan Guillermo Guerrero, 37, was denied his seizure medication and given an ineffective substitute. Suffering from one or two painful seizures a week, he told his lawyer to drop his case, saying he preferred to be deported than to die inside an immigration prison. A few days after he returned to Mexico, Guerrero died of asphyxiation during a seizure, according to his lawyers.

Sometimes, to save money, the government releases detainees instead of treating them. Martin Hernandez Banderas, a 40-year-old Mexican, was released from custody last year while he was in the hospital following surgery to amputate his leg. An internal review found that the system failed him before the surgery: Nurses and doctors at Otay Mesa did not appreciate the severity of his diabetic foot wounds, did not properly treat them or prescribe the correct course of antibiotics, and did not bring in a qualified surgeon to evaluate the problem.

Simon Reyes-Altimirano, 25, a Honduran, was diagnosed with chicken pox and sent back to his cell with Benadryl, only to be hospitalized a day later and diagnosed with an inoperable brain tumor. He died two weeks later.

Shack, the medical director, found that Reyes-Altimirano's care at the El Paso detention center had been "appropriate and timely." But a nurse at the center poured out her remorse in a typed note placed in Reyes-Altimirano's medical file. "We always have to listen to the patient and the reason I say this is because" when he first reported his problems, "one of the nurses said, 'I think he is faking his illness' . . . this is not just a medical learning experience but also an emotional one."

Three weeks after Reyes-Altimirano died, a nurse at the Krome Service Processing Center accused the Rev. Joseph Dantica of faking an illness, too. The 81-year-old Baptist minister had fled Haiti in the fall of 2004, fearing for his life after gangs set fire to the church overlooking Port-au-Prince where he ran a school, let people use computers for free and quietly handed out money to needy families.

As a younger man, Dantica listened to tapes to practice English every day, but he never wanted to live in the United States, said a niece, writer Edwidge Danticat, who was raised by him. He visited once a year, to see his brother in Brooklyn and raise money for his church.

But after U.N. peacekeepers and Haitian riot police seized the church to use as a base against gangs, and after the gangs retaliated by burning the altar, Dantica slipped on a woman's muumuu and wig and headed to the airport. He arrived in Miami with a valid visa but decided to seek asylum because he thought he might have to stay longer than his visa allowed. In an earlier time, Dantica would have been permitted to go on to New York while the government considered his claim. This time, he was detained.

Dantica and an immigration lawyer were sitting before an asylum officer when the minister began to vomit violently. The lawyer, John Pratt, said agents at the detention center had taken away his client's blood-pressure medicine.

Dantica "turned very cold. His eyes wandered around, and he appeared not to be conscious of his surroundings," the asylum officer, Miriam Castro, later told investigators, according to confidential documents. "Applicant assumed a rigid position with his legs stretched out and remained in this position."

Castro called for medical help. No one came for 15 minutes. When the public health nurse and a physician assistant arrived, the nurse said he believed that Dantica "was faking because Applicant kept looking at him randomly," Castro said. The nurse, Tony Palladino, "then went on to demonstrate that when he moved Applicant's head up and down, Applicant maintained his head rigid as opposed to limp, thus not allowing his head to fall back. [The nurse] stated that was another way he determined Applicant was faking symptoms."

Dantica died a day later in Miami's Jackson Memorial Hospital, shackled to a bed. Pratt had called the hospital repeatedly, trying to get information about the minister's condition and permission for his family to see him. "They never said anything but they were doing tests," Pratt said. Security reasons, hospital officials told him, prevented visitors.

The government's internal medical records say Dantica died of pancreatitis. A one-page death certificate in his file has "VOID" stamped across it. Two outside doctors who reviewed his medical records for the Post said he probably died of heart problems.

Yusif Osman had been living in Los Angeles as a legal resident for five years when he was detained crossing back from Tijuana in 2006 with a passenger, also from Ghana, who had a false ID. Osman was arrested on a smuggling charge, which he denied and was fighting while locked up at Otay Mesa. He seemed healthy to his friends and family who visited him or spoke to him by phone.

His girlfriend, Dorothy Weens, was stunned when she picked up the phone in late June and a stranger broke the news. "Yusif Osman passed away," the man said.

When Osman's lawyer called the compound to verify what had happened, he was told only that his client was no longer there. Weens and a cousin of Osman's called immigration officials several times for answers. They were told that the matter was under investigation. Eventually they stopped calling.

Osman's belongings from the prison arrived at his cousin's house one day by mail. Pants. Socks. Scraps of paper with prayer verses written in Arabic. His birth certificate. A letter from Dorothy: "Hey Babe! Hang in there. I'm trying everything I can do, to get you out of there. I love you and God love you. And that all you needs. I'm sending you $100.00. Love, Dot."

There was also an inventory of the rest of his personal property on the day he died: "4 yellow envelopes. 1 writing pad. 1 religious beads. 1 Chap Stick. 14 Ramen soups. 1 grape jelly. 1 jar peanut butter. 1 hot cocoa mix. 1 box Q tips."

The mortuary received a preliminary death certificate from the coroner's office. It noted Osman's cause of death as "pending," enough to release the body. His mosque collected money for a burial in a Muslim cemetery in the Mojave Desert. Male friends dug the grave. They laid his corpse, wrapped in white cloth, into the open earth and covered it with rocky dirt.

The final death certificate arrived in the mail sometime later. Under cause of death, it still read "pending." Osman's passing remains a mystery to his grieving relatives in Ghana and his adopted African community in Los Angeles.

An uneven, blank concrete headstone marks Grave 26. The truth of Osman's death is also buried, thousands of miles away, past the Statue of Liberty replica near the front door, inside a cabinet at the Division of Immigration Health Services, in file #077-987-986.

--Staff researcher Julie Tate and database editor Sarah Cohen contributed to this report.

2.

In Custody, In Pain

BESET BY MEDICAL PROBLEMS AS SHE FIGHTS DEPORTATION, A U.S. RESIDENT STRUGGLES TO GET THE TREATMENT SHE NEEDS
By Amy Goldstein and Dana Priest

Washington Post
May 12, 2008
Page A1

FLORENCE, Ariz. -- Underneath her baggy jail-issue pants, Yong Sun Harvill feels the soft lump just below her left knee. Sometimes it tingles. Sometimes it is numb. Like her cancer felt when it arrived behind the knee a few years ago.

She noticed the lump under the thin, blue cotton in August, five months after federal immigration officers, to her amazement, took her into custody to try to deport her for buying stolen jewelry more than a decade ago. The lump grows slowly. It is now three inches across. And though she keeps asking, no one has done a test to see whether her sarcoma has come back.

Her leg is painful and swollen from hip to foot, damaged by past surgeries and radiation treatments. Some nights, liquid seeps through cracks in her distended skin. Her left ankle is three times as big as her right. For years, she relied on a leg pump to boost her circulation and keep the swelling in check. But as an immigration detainee in this desert prison town, Harvill, 52, has been unable to persuade anyone to get her a pump, or to let her family back in Florida send hers from home.

Nor has she gotten the biopsy that a doctor has told her she needs to determine whether the spots on her liver might be tumors. And it remains uncertain whether her frequent crying spells are part of bipolar disorder, as some records suggest, or a flare-up of old anxieties -- heightened now by chronic pain, bewildering medical problems, and the fact that, three decades after she arrived from South Korea as a teenage Army bride, she is in a jail far from home with the government trying to eject her from the United States.

Harvill is one of 33,000 immigration detainees in the custody of the Department of Homeland Security's Immigration and Customs Enforcement agency, known as ICE, on any given day. They are locked up in a patchwork of out-of-the-way federal detention compounds, private prisons, and local jails. This unnoticed prison system was built for a quick revolving door of detainees -- into custody, out of the country. But often, people linger in detention for months or years.

These detainees, like other prisoners, are by law and regulation entitled to medical services if they are sick. But Harvill's journey through immigration detention provides a glimpse into a medical system that often fails those who need it most. It is an upside-down world where patients have no say, doctors and nurses on site have little power to administer timely treatment, and a managed-care system in Washington operates from a rulebook that emphasizes what is not covered rather than what is.

Two months after ICE agents seized Harvill in Florida, they transferred her to Arizona last May, saying a federal compound called the Florence Service Processing Center was better suited to handle her medical care. Four weeks later, they moved her, without explanation, a few miles down a cactus-lined highway to a county jail that hasn't had a full-time staff doctor since she arrived.

At Pinal County Jail, Harvill is 2,132 miles from her family outside Tampa, and even farther from her Miami lawyers. To see her, they crowd around a closed-circuit TV in an immigration courtroom in Miami, where the judge to whom her case is assigned convenes "video hearings" about once a month.

Seated at a scuffed oak table in a small courtroom in Florence for one recent hearing, facing a television screen with a video camera on top, Harvill looked older than her age. Her thick, long hair was streaked heavily with gray. Her brown eyes, sparkling in a 1999 wedding photo, were now dull. Arthritis had bent her fingertips.

On days when her hands are too stiff, Harvill dictates as other detainees write her entries in the journal that her lawyers have asked her to keep, as best she can, with the five pieces of paper the jail doles out each week. The entries tell of her leg pain, of missing her husband and her Florida cancer doctors, of wondering whether God still loves her. One entry tells of a dream in which she peered into a coffin and saw herself inside.

Her medical records, inches thick, document countless visits to jail nurses and to a public hospital in Phoenix. But many of the visits have been frustrating and unproductive. One morning in late February, she was led from her cell at 5:15 a.m. and driven the 66 miles to the hospital to have an operation to remove polyps that were causing bleeding in her uterus. When she arrived, three workers in green scrubs told her that the doctor couldn't perform the surgery because the hospital was out of hot water.

Even with hot water, they said, she couldn't have had the procedure that day: As usual, no one at the jail had told her ahead of time that she would be having a medical appointment, so she didn't get the instructions not to eat or drink after midnight the day of surgery. When the guards woke her at 5 a.m., she ate a honey bun, a treat she had been saving from the jail canteen.

In response to questions from the *Washington Post*, ICE officials said last week that, "based on standard medical protocols," Harvill's records document that she has been "appropriately diagnosed and treated."

"I feel like I'm on a merry-go-round, round and round and you don't really get nothing done," Harvill said, her voice husky with just a trace of an Asian accent, during one of three interviews she gave the Post by telephone and in person, without the knowledge of federal officials. "I feel like an animal in a cage here. Sometimes I'm afraid I'm not going to wake up."

At night, to anyone driving southeast from Phoenix through the dark Sonoran Desert, the sky over Florence glows white with prison floodlights.

This county seat, once a center of copper mining and cotton, greets motorists today with road signs that say "State prison. Do not stop for hitchhikers." Every February, motorcyclists roar through town for the Hells Angels Florence Prison Run. And the first business along Butte Avenue, the main street leading into the small downtown, is E&E Outfitters, with its "UNIFORM" sign in the window and, inside, racks of guards' outfits in khaki, black, and olive green. "Detention polo shirts from $28.50," says the sale sign over one circular rack.

Of the 25,500 people who live in Florence, about 17,000 are behind bars. The incarcerated included an average of more than 700 immigration detainees in fiscal 2007, divided among a federal compound, two private prisons and the county jail. An additional 1,500 were housed nearby in a compound outside the town of Eloy, giving Pinal County the largest concentration of foreign detainees in the nation.

At the town's northern edge, just beyond an RV park for retirees, rows of concertina wire surround the federal Florence Service Processing Center. During World War II, it was the site of a prison camp for Italian and German POWs. Now it is a tidy brown-brick compound with cactuses and giant crests of the Department of Homeland Security out front. This is where Harvill arrived last May after a flight from Florida, panicky, her nose bleeding, her stomach upset, an officer on each side.

The day after she arrived, Harvill saw a nurse and a doctor for a checkup that all new detainees are supposed to have, but don't always get. "Numerous issues," they wrote in her medical chart. History of sarcoma. Hepatitis C. High blood pressure. The nosebleeds. Panic attacks. "Borderline bipolar." And lymphedema, painful fluid buildup in her left leg.

Elizabeth Fleming, a lieutenant commander in the U.S. Public Health Service who was Florence's clinical director, showed concern about Harvill. She noted that Harvill needed a leg pump -- a compression device that inflates and deflates -- to help the circulation in her leg. She also requested records from Harvill's longtime cancer doctors in Tampa. And she managed to persuade administrators in Washington to let Harvill have three outside consultations at Maricopa Medical Center, the public hospital in Phoenix.

"Will likely need to order . . . pump and may require transfer to [another immigration detention center] with infirmary," the doctor wrote in her patient's chart.

The pump never arrived. Still, Fleming saw Harvill a dozen times over the next month, records show. By mid-June, the doctor wrote, her patient was "smiling, cheerful," and her nausea and leg pain were "much improved."

Harvill did not know that would be the last time Fleming would treat her. The next day, Harvill was moved down the road to the county jail. The government never explained the move, although she and her lawyers have asked repeatedly.

Last week, ICE officials told the Post: "Florence is not well equipped to provide long term medical care for female detainees. Female detainees are transferred from Florence to Pinal because of its better capability to provide long-term medical care to women. Ms. Harvill received appropriate medical care at Pinal with physician oversight."

Harvill lives in Cell 323 in Pod E300, part of a wing built for an eventual 600 detainees whom the federal government pays the county to house.

Her isolation at the county jail is almost complete. Her lawyers cannot call. Family members, if they came to visit, would not be allowed to see her in person, not even through plexiglass. The jail allows only "video visits," with visitor and detainee in separate parts of the building. Harvill, while longing for her family, has told them it is not worth the trip. She hasn't seen her husband in a year.

Most of her moments outside come when immigration officers take her in a white van on a three-minute ride to a little courtroom at the Florence federal compound for video hearings with her Miami immigration judge, and when they take her to the public hospital, an hour and 20 minutes away, where, as likely as not, little will get done.

Harvill gets shuttled back and forth to the hospital in Phoenix because the jail does not have a doctor on its staff. There is no hospital within 30 miles of Florence, despite its thousands of prisoners. The Central Arizona Medical Center, on the city's outskirts, has been closed since 1999, and the small hospital building is empty. On a white sign out front, the blue lettering that says "clinic" has almost faded away.

One morning last summer, Harvill was taken up the road to the Florence compound for a repeat session to take photographs and fingerprints that immigration officers told her had gotten lost. Before she went inside, she later put in her journal, she noticed Fleming, the doctor who had treated her when she first arrived, going by "in a little golf cart."

"I was glad to see her I had so much to ask her. Nurse here says that she is still my doctor and that all that happens to me goes to her. . . . I asked to talk to her for a minute. She told me that she was very busy, that she would try to talk to me later. I knew she wouldn't talk to me because she has not seen me for the last 2 months I was so sad. . . . Actually I felt as though she was angry with me. I stood there with tears in my eyes, but I had to go with the officer to get my fingerprints done.

The fleeting encounter with Fleming disturbed Harvill. The closest thing to a doctor she has seen at the jail during her 11 months there -- apart from a psychiatrist who has prescribed lithium and other drugs, but has not really diagnosed her -- was a physician assistant.

Fleming resigned days later.

According to internal government documents, one-third of the 29 medical positions at the Pinal County Jail were vacant as of February. The jail, the Florence compound and the large compound in nearby Eloy each had no full-time doctor.

In such an environment, complaints sometimes surface about the shortages and their effects. Last summer, two Eloy nurses sent a memo to headquarters in Washington, laying out the working conditions that were leading them to resign.

The checkups required for all arriving detainees were "never staffed with enough people," wrote the nurses, Catherine Rouse and Patricia O'Brien. Nurses would be told to expect five new arrivals, "but that could easily change to greater than 100 non-English speaking sick and injured frightened people," they wrote. The nursing shortage was particularly severe on nights and weekends. And one pharmacist and an assistant "process over 4,000 prescriptions a month. They try their best to have thing[s] complete before they leave on Friday. However, serving 1,500 people is an impossible task."

Last year, the Arizona State Board of Nursing heard that nurses at Eloy were being required, without enough training, to take the chest X-rays that new detainees are supposed to get to check for tuberculosis. The board sent ICE a terse, two-sentence letter. "Nurses are not radiologists," it said. "Taking X-rays is out of the scope of practice for a nurse, and a nurse who does so is violating the Nurse Practice Act and will be subject to discipline on his/her license." The response from Washington: "Nurses working in federal government facilities are not subject to state licensing requirements."

At first, Harvill would get excited on the mornings of her trips to Maricopa Medical Center, but she learned soon that the visits usually were disappointments.

On July 26, she rode in the van to the hospital's cancer clinic. That same day, by coincidence, a doctor from the H. Lee Moffitt Cancer Center in Tampa, where she had been treated for more than a decade, wrote a letter at the request of Harvill's lawyers, warning that she "will need continued care at a facility familiar with [her] types of tumors, as they will continue to recur and progress. If not treated properly, they can become life-threatening."

It was from the Moffitt Center that Fleming had gotten records of Harvill's three previous episodes of cancer and her treatment. But no one had sent copies to Maricopa Medical Center. Starting from scratch, a doctor there ordered a CAT scan of her pelvis and her swollen left leg. The test, according to a radiology report, found a mass in an ovary and a cyst on her cervix, but there is no indication that her leg was scanned.

By late July, her records show, another Maricopa doctor had ordered a biopsy to determine whether unexplained "densities" on her liver might be tumors. But when Harvill went for the procedure a few weeks later, the records show, someone in the radiology department did an ultrasound as a first step and, when he saw cysts on her liver, canceled the biopsy. "Liver Biopsy report received. . . . Biopsy not done," says a notation from a few days later in her jail records.

A month later, when Harvill saw the doctor who had ordered the biopsy, he asked whether it had been done.

I told him no because they told me it was just a cyst not a tumor. He was upset. . . . He still wanted a biopsy, she wrote in her journal.

By now, the soft lump had begun to grow under her knee, and her abdomen had started to swell and become hard. As an officer drove her to the hospital one day in mid-August, she hoped the appointment would address one of those problems. As it turned out, she was there to see a gynecologist, who wanted to do a Pap smear.

Harvill pointed out that she'd had one a month before. "I showed him my stomache, he told me he could not take care of that, that I needed to see a GI doctor. I told him about my leg swollen, and also he told me I had to see another doctor for that."

Still another runaround began when a different doctor said Harvill urgently needed a biopsy of her uterus lining to find out why, well after menopause, she was bleeding heavily. In early October, when an immigration officer took her back to the hospital for that test, a receptionist said it had been canceled and rescheduled for a month later. The officer, Harvill put in her journal, was stunned and told the receptionist that he "had the order for today." Instead, hospital workers did a CAT scan of her uterus.

She had already had a CAT scan of her uterus. "I told them I had a lump on my knee, if they could do a scan on that and they said they didn't have an order for that. . . . We got out of hospital and the ICE officer said he felt bad for me, because he has taken me to the hospital 4 or 5 times and they never do anything for me."

It was early November when Harvill had the biopsy of her uterus, three months after it was ordered. She was told to come back for the results in two weeks, although the lab report was ready the next day, according to her medical records. Yet it wasn't until late January that she learned what was wrong: The bleeding was being caused by polyps that needed to be removed. The surgery, she was told, would be within two or three weeks. Four months later, it has not been done.

Late last week, after her attorneys gave them authorization to talk about her case, Maricopa hospital officials said that medical privacy law prohibited them from even confirming, without Harvill's personal consent, that she has been a patient. But she could not give consent because neither her attorneys nor anyone else is allowed to telephone her in the jail.

Over a weekend in mid-April, Harvill was told not to eat solid food for two days in preparation for a colonoscopy to try to find out why she had blood in her stool. First thing that Monday, she again boarded the van for the 66-mile drive to the hospital, where she was told that the procedure had been rescheduled.

Ten days later, she went to the hospital and had the test. It found a growth in her colon. The doctor said there was a chance it is cancerous and sent a sample for a biopsy. She does not know the result.

The liver biopsy still has not taken place. And no one has tested the lump below her knee.

* * *

Whether the gaps in Harvill's treatment are by accident or by design is difficult to discern. Yet it is clear that the obscure federal agency that oversees detainees' medical care, the Division of Immigration Health Services (DIHS), operates with a top priority of limiting care and saving money. Its medical mission is only to keep people healthy enough to be deported.

At Harvill's jail, and everywhere else immigration detainees are held, doctors and nurses must get permission from the agency's headquarters before treating patients. Except in emergencies or for the most routine care, they must send written requests to Washington, where, for the entire system of 33,000 detainees across the country, four managed-care nurses in a downtown office building decide what treatments to allow.

These care managers rule on what are known in the bureaucratic lexicon as treatment authorization requests, or TARs. In a recent month, they had to rule on 3,000 requests. They work five days a week, not on weekends, and are unavailable to handle requests that come in later than 4 p.m. Washington time, even though many large detention centers are in other time zones.

The agency touts this as an efficient form of managed care, similar to health plans familiar to patients in the outside world. But a 36-page manual that describes the "detainee covered services package" underscores how unusual it is, with rules designed to prevent people from getting too much help.

The health services division, the manual says, allows treatment mainly for emergencies that are "threatening to life, limb, hearing, or sight." If a detainee has medical problems that "would cause deterioration of the detainee's health or uncontrolled suffering affecting his/her deportation status," treatment is not guaranteed. Instead, the manual says, the detainee "will be assessed and evaluated for care."

Instead of listing, as most health plans do, the services available to patients, the manual specifies services that are "usually not covered" for allergies, heart problems, and other illnesses. Cancer is not mentioned at all.

Internal government documents obtained by the *Post* show that most requests are approved. But the documents also show that, when requests come in for people with serious problems, there can be pressure to cut costs. One chart, covering October 2005 to September 2006 -- seven months before Harvill became an immigration detainee -- is labeled "TAR Cost Savings Based on Denials."

The agency, the chart shows, saved $129,713 by denying 17 medical requests for people with HIV, $36,216 by denying seven requests for people with various forms of psychosis, $91,926 by denying 27 requests for people with chest pain and $9,545 by denying treatment for a case of blood in stool, one of the problems Harvill has had for months.

Asked about the chart, an immigration spokeswoman said that the vast majority of medical requests eventually are granted. Usually, she said, denials are "due to lack of information."

The supervisor of the managed-care nurses who rule on treatment requests sent a note once to a senior official about a 33-year-old detainee seen at a Nashville hospital for a recurrence of sarcoma, the same kind of cancer Harvill has had. "The process of re-diagnosis and treatment will be extensive and costly," that nurse wrote. She said she seconded the idea of releasing the detainee so the government would not have to pay for his care.

These sorts of machinations prompted the deputy warden at York County Prison in Pennsylvania, which houses many immigrant detainees, to fire off an angry letter about the health services division. "[I]n my opinion, they have set up an elaborate system that is primarily interested in delaying and/or denying medical care to detainees," the warden, Roger Thomas, wrote in late 2005. "There is nothing easy about working with DIHS. If something can be delayed, it is delayed. If it can be denied, it is denied. If it can be difficult, it is made difficult. Most importantly, if there is some bureaucratic procedure that will delay/deny treatment to a detainee . . . you can be assured that DIHS will do it."

Harvill's lawyers have tried to find out how many requests for treatment have been sent from Pinal County Jail on her behalf and how Washington has ruled on each one. They filed a Freedom of Information Act request last summer and, after two months, got an incomplete answer. In January, they left a phone message for the division's medical director. No one has called back.

But one page in Harvill's thick medical file hints at an answer. In late August, slightly more than a month before she would arrive at the hospital for a biopsy, only to be told it had been rescheduled, a jail nurse wrote this note: "TARs not approved for endometrial biopsy and lab draws. . . . Will continue to work on approvals and provide additional documentation as needed."

Finally, in early February, Harvill had a big week, riding in the van to the hospital three mornings in a row. A cancer doctor told her, yet again, that she needed a biopsy on her liver and one on the growing lump beneath her knee. A gynecologist talked with her about the surgery she needs on her uterus. A gastroenterologist spoke with her about the colonoscopy she should have.

Yet, after many months in immigration custody, Harvill understood that doctors' orders do not automatically produce tests. "It doesn't matter what the doctor says," she said in an interview.

Back at the jail after her three hospital trips, she asked a nurse what would be done with the doctors' requests. "She said she is going to send it up" to Washington, Harvill recounted at her next court hearing. "But she doesn't know when or how it is going to get approved. She doesn't know if it is going to get approved. She just said, 'Let's hope for the best.' "

* * *

Leon Harvill sat at his mother's kitchen table in Plant City, Fla., on a Sunday night, cradling the phone to his ear. "Baby, don't cry," he said softly into the receiver. "Come on, baby. Quit crying, all right?"

He had gone to an evening service at the Church on the Rock, the first time he had been in months. He hadn't felt much like reading the Bible lately. "I just don't understand it right now," he said. "I just can't understand things that are going on that are hard to believe. Her medical care -- I just can't understand that."

The thing that makes perhaps the least sense to him is that his wife is covered under a good health insurance policy that he gets through his union, the International Brotherhood of Boilermakers, and she and her lawyers have asked whether she could use that policy to pay for her treatment by private doctors while she is detained. They have been told no.

One more problem in a life full of them.

Yong Sun Harvill's immigration troubles began in March 2007, as she was finishing 13 months in prison on a drug-possession charge. One day, a prison official summoned her to his office and handed her a phone. On the line was a man who worked in Orlando for Immigration and Customs Enforcement. She would not be going home, he told her. She would be handed over to ICE agents, who planned to send her back to South Korea, a place she had not seen for 32 years.

Harvill had been barely 19 when she came to the United States in 1975, the new wife of an American soldier who had been stationed in Seoul. Within a year, she had a baby son and her first cancer diagnosis.

She divorced her first husband -- who hit her sometimes when he drank, according to Harvill, her lawyers, two friends and her medical records -- and then her second one, who hit her sometimes when he was high on drugs.

Nine years ago, she married Leon Harvill, a childhood friend of her second husband. He isn't much of a talker. She is loud and chatty. She felt protected by him. He loved how she cared for children and how her smile lighted up a room.

After all her years in Florida, she would still drive to Tampa once a month to buy rice at a Korean grocery, but she also loved collard greens and black-eyed peas, was a die-hard Tampa Bay Buccaneers fan, and knew the lyrics to all of Brooks & Dunn's country tunes.

In 2004, while she was riding with a friend, police stopped them for driving with expired tags. The car belonged to her friend, but the marijuana and methamphetamine on the floor were Harvill's.

She pleaded guilty to drug possession and served her time. Ordinarily, that would have been that. But ICE had begun scouring jails and prisons nationwide for people it might be able to deport, and a check of Harvill's criminal history turned up a decade-old felony conviction for buying stolen jewelry. Her lawyer insisted she'd had no idea it was stolen. A judge suspended the sentence and put her on probation, which was terminated early for good behavior.

A 1996 law had given the government new leverage to deport foreigners, including people living in the country legally as U.S. residents, if they had committed a crime at any time in the past, and the Bush administration was wielding that power aggressively. The law expanded the list of crimes defined as "aggravated felonies" that are grounds for deportation. It also for the first time required people to be locked up during their deportation cases -- including permanent legal residents such as Harvill, who is not a citizen but has had a green card ever since she came to the United States.

On March 22, 2007, instead of going home, Harvill was handed an orange uniform at the Palm Beach County jail to await deportation. Her parents are dead. She lost track of her sisters long ago. She has no idea where or how she would live in South Korea, particularly because she has not held a job for years because she cannot put weight on her leg for too long.

She has been fighting the deportation with the help of Cheryl Little and Kelleen Corrigan, lawyers at the Florida Immigrant Advocacy Center in Miami. They have applied for a visa available to foreigners with firsthand knowledge of crimes -- in Harvill's case, the abuse by her first two husbands. Meanwhile, they have repeatedly asked federal officials to let Harvill go home on bond because she is so ill.

Corrigan has a postcard on her office door with the words "Free Yong!" over a photo of a younger, happier-looking Harvill.

At church that Sunday night, Leon Harvill did not open the prayer book. But during the silent prayer, he leaned forward, his hands resting on the pew in front of him, and closed his eyes. He prayed for his wife to get medical treatment, to find peace, to come back.

He raced home after church, knowing she would call.

At 9:14 p.m. the kitchen phone rang. "I love you, too, baby," her husband said. "Things are going to get better. Come on, baby. Something is going to happen soon."

Before dawn the next morning, he would leave the house of his mother, Margaret Kersey, with whom he had been staying to save money, for the Tampa airport and a flight to Hawaii, where he had found a welding job with better pay. It had been hard lately to save, with work scarce in central Florida and money flowing out for his wife's phone cards and canteen treats, and for the "Free Yong!" postcards he'd printed so friends could mail them to the government. Most of all, he thought, he needed to save money so he would have some to send her if someday she were deported to South Korea.

Deportation had been on Yong Sun Harvill's mind, too. Sometimes, she is so depressed that she thinks about quitting her fight and signing the papers that would let the government send her out of the country. And she has been missing the one real friend she made in a jail, a younger Korean woman who would rub menthol ointment, when she could get some, on Harvill's swollen leg and write the journal entries when Harvill's hands stiffened too much.

A few weeks before this January night, her friend was deported.

But on this night, Harvill listened to her husband describe the path he would take to Hawaii the next day. "I have a layover in Phoenix," Leon Harvill said into the phone.

She told him to look at the desert as he landed.

"I'll get a look at it tomorrow," he told her. "We'll be that close."

--Staff researcher Julie Tate contributed to this report.