Medical

AD AMS AFFIRMED,2 VA CA TED ,0

CROSSAN AFFIRMED,5 VA CA TED,5

NE WA Z AFFIRMED,5 VA CA TED,6

NE WA Z AFFIRMED,1 0 VA CA TED,1 1

MARTINEZ AFFIRMED ,0 VA CA TED,2

TI JERINA AFFIRMED,5 VA CA TED,4

TYR AK OSKI AFFIRMED,9 VA CA TED,1 3

AD AMS AFFIRMED,3 VA CA TED,1

MARTINEZ AFFIRMED, 5 VA CA TED,5

TI JERINA AFFIRMED,3 VA CA TED,9 O THER

CROSSAN AFFIRMED,3 VA CA TED,6

TYR AK OSKI AFFIRMED,1 1

VA CA TED,1 8

“THERE HAS NEVER BEEN A FULL-TIME PEDIATRICIAN ON SITE AT KARNES NOR IS THERE OBSTETRICS CARE AVAILABLE.” MEDICAL OUTCOMES

Medical care at Karnes is provided by GEO medical staff. For years, spanning multiple administrations, RAICES has heard complaints about the paltry medical care at Karnes from detained families and individuals. After federal Judge Dolly Gee in 2015 ordered that ICE must aim to release families after 20 days, lengths of detention hovered between a few weeks to a few months, but were relatively short. This circumstance resulted in an apparent culture of indifference among the medical staff at Karnes and a failure to invest in robust medical services. Families often reported that medical staff dismissed their complaints or flippantly told them that the Karnes medical services could not treat their ailment and that they would have to wait for release or deportation to seek care. For example, there has never been a full-time pediatrician on site at Karnes nor is there obstetrics care available. In 2019, ICE detained women in Karnes for an average of 51 days. Some, however, were detained for the entire six months that single adult women were in Karnes. Complaints about a lack of medical care only compounded with the population of adult women who on average were detained much longer than families.

The obligations of ICE to provide medical care are established by constitutional standards, federal law, state law, ICE standards and guidance, as well as the policies and procedures of individual prisons. Medical care is a fundamental constitutional right for incarcerated persons.53

ICE creates its own standards and procedures for the operation of its prisons. As mentioned previously, ICE implemented the 2011 Performance Based Detention Standards (“PBNDS”) in Karnes. The standards state that “Every facility shall directly or contractually provide its detainee population with … medically necessary and appropriate medical, dental and mental health care and pharmaceutical services.”54 Still, there is a growing amount of

53. Estelle v. Gamble, 429 U.S. 97 (1976) 54. Performance-Based National Detention Standards 2011, U.S. Department of Homeland Security (rev. Dec. 2016), at 260, sec. 4.3(V)(A), https://www. ice.gov/doclib/detention-standards/2011/pbnds2011r2016.pdf.

scholarship concerning poor medical conditions in immigrant detention. 55, 56, 57 Detained people have cited language access barriers, delays in receiving medical treatment, inadequate treatment for acute pain, failure to manage chronic illness, denial of adequate exercise and nutrition, and more.58 For instance, long wait times in accessing medical care are a well-documented complaint among clients at Karnes and many other detention centers.59 The 2011 Performance Based Detention Standards state that “Detainees shall be able to request health services on a daily basis and shall receive timely follow-up” and further, that all sick call requests are received and triaged by appropriate medical personnel within 24 hours.60

These deficiencies in care were reflected in the experiences of women detained at Karnes in 2019. In their initial intake meeting with RAICES, detained persons are asked about any chronic medical conditions or any medical conditions occurring as a result of detention. Many individuals report colds and fevers of varying severity while others report chronic and/or serious ailments. However, detained persons often do not report medical conditions until subsequent meetings, particularly those that may be more serious or that carry some sort of social stigma such as miscarriage or HIV. Given the high volume of potential clients and access to counsel issues, RAICES was unable to consistently follow up with many women after they were prepared for their CFI. As such, data on medical conditions and their treatment is incomplete. Given the lack of follow up and possible fear of retaliation for requesting services, there were likely more unaccounted for medical conditions, including those that developed during detention. This section includes stories from clients which RAICES has obtained permission to share.

440 SEVERE MEDICAL CASES REPORTED AT INTAKE

87

High Blood Pressure

21

Diabetes

74

OBGYN Issue

18

Thyroid Issues

65

Mental Health

16

Pain

51

Asthma

2

Cancer

22

Major Organ Issues

84

Other

55. N/A, Systemic Indifference: Dangerous And Substandard Medical Care in US Immigration Detention, Human Rights Watch, May 8, 2017. 56. Sola Stamm, et al., Detained And Denied: Healthcare Access In Immigration Detention, The Immigr. Learning Ctr., Feb. 2017, https:// www.immigrationresearch.org/report/other/detained-and-denied-healthcare-access-immigration-detention 57. N/A, Southern Border: Conditions at Immigr. Detention Ctrs., Am. Med. Ass’n., https://www.ama-assn.org/delivering-care/ population-care/southern-border-conditions-immigrant-detention-centers 58. Stamm, Supra note 56 59. Id. 60. Immigration and Customs Enforcement, “2011 Performance-Based National Detention Standards, Part 4.3 § S, “Sick Call”

INFORMED CONSENT

“There is a long list of people to be seen. . . I’m not sure how long it will take to be seen, but someone might get tired of waiting.”

The ICE standards require that informed consent standards shall be observed and adequately documented and that staff shall make reasonable efforts to ensure that detained people understand their medical condition and care. ICE defines informed consent as “an agreement by a patient to treatment, examination,or procedure after the patient receives the material facts about the nature, consequences, and risks of the proposed treatment examination, or procedure; the alternatives to it; and the prognosis if the proposed action is not taken.” 61

Missing from the ICE standards are explicit affirmative obligations on the caretaker to assess the patient’s ability to understand as well as to document the informed consent conversation in the medical record. RAICES is aware of many instances in which medical staff at Karnes provided medication to detained women without explanation of the type of medication or its function. Not only did this impede people’s ability to meaningfully consent to treatment, but could also inhibit future treatment of chronic medical illnesses.

Further, language access is often a severe barrier to fulfilling informed consent and accessing medical and mental health services in detention as the provision of medical services62 also requires interpretation and translation services.63 Notably, the 2011 Performance Based Detention Standards state that facilities shall provide appropriate interpretation and language services for detained people related to medical and mental health care. Where appropriate staff interpretation is not available, facilities will make use of professional interpretation services. Regarding the manner in which detained people request medical care, the standards require that paper slips to request care be provided in English and the most common languages spoken by the detainee population

61. ICE, Supra note 60 at Part 7.5, “Informed Consent”. 62. Stamm, Supra note 56 63. ICE, Supra note 60 at Part 6.1 § V(C), “Translations and Access for Limited English Proficient Detainees”

THE AMERICAN MEDICAL ASSOCIATION’S CODE OF ETHICS 2.1.1 DEFINES INFORMED CONSENT AS THE FOLLOWING:

“In seeking a patient’s informed consent (or the consent of the patient’s surrogate if the patient lacks decision-making capacity or declines to participate in making decisions), physicians should:

1. Assess the patient’s ability to understand relevant medical information and the implications of treatment alternatives and to make an independent, voluntary decision.

2. Present relevant information accurately and sensitively, in keeping with the patient’s preferences for receiving medical information. The physician should include information about:

• The diagnosis (when known)

• The nature and purpose of recommended interventions

• The burdens, risks, and expected benefits of all options, including forgoing treatment

3. Document the informed consent conversation and the patient’s (or surrogate’s) decision in the medical record in some manner. When the patient/surrogate has provided specific written consent, the consent form should be included in the record.”

of the facility.64 However, there is no apparent standard to determine what the “most common” languages are. Furthermore, paper slips pose problems for individuals who do not speak a written language, are unable to read or write, or speak a language not considered “common.” Indeed, RAICES is not aware of any client receiving a medical request form in a language other than Spanish or English.

In practice, non-Spanish speaking clients commonly reported that GEO medical staff would attempt to triage medical issues without calling an interpretation service. In clients’ experiences, they describe that the medical staff acted inconvenienced when prospective patients did not speak Spanish. As aforementioned in the demographics section, about 7% of women did not speak Spanish. The next most common language was Creole, with about 46 speakers, followed by English (31 individuals), Garifuna (18 individuals), and French (15 individuals). As such, there were a minimum of 110 clients who potentially did not have access to the medical request process due to their language. This raises the question: What percentage of the population of non-Spanish speakers constitutes a significant enough portion to receive translation services so they are able to access medical care?

ICE and GEO’s refusal to provide medical interpretation has severe consequences. For instance, a RAICES client stated that the process of filling out the slip to request medical services was inadequate for people who spoke Creole as the Creole speaking women she knew could not read and write in English or Spanish. She stated that GEO medical services refused to treat her friend because her friend’s form was not filled out properly; she was not offered interpretation. The individual in question suffered from headaches, could not eat, and was experiencing weakness and dizziness that led to falling. Her symptoms had been ongoing for three weeks when her friend reported these conditions to RAICES.

It is important to reiterate that the people ICE detains do not have freedom to choose their medical provider. If medical providers in Karnes cannot meet the needs of the people they are intended to serve, then the people detained at Karnes have no option other than to endure. ICE’s inability to meet the medical needs of those it chooses to detain undercuts the integrity of every service it provides, medical or otherwise. Every human is entitled to quality medical care and that is only obtained through informed consent and language access. This is a burden ICE has placed upon themselves yet continually shirks.

DENTAL SERVICES

“The dentist said that there was nothing they could do . . . The pain has been so grand that I have trouble eating. I stopped eating for about two days because I couldn’t stand the pain.”

One client experienced pain so extreme from impacted wisdom teeth that it prevented her from eating. She underwent a dental screening when she first arrived that should have informed ICE/GEO of her condition, and she repeatedly sought care from the medical unit at Karnes, returning at least three times within her first week at the prison. Medical staff prescribed her ibuprofen and another unknown medication, which did nothing to relieve her pain. When she specifically inquired about tooth extraction, having gone days

64. ICE, supra note 60

without properly eating, Karnes medical staff told her that they would not be able to remove her teeth. The care that this client needed was beyond what could be provided at Karnes, and ICE took no steps to ensure that she accessed that care elsewhere while she remained in ICE custody. Seven days after arriving at the prison, she was able to meet with a dentist. He told her they were unable to take out her wisdom teeth because they lacked the necessary equipment to do so and recommended she continue taking the pain medication prescribed and wash her mouth out with water. The client reported that every time she washed her mouth out, she would spit up blood.

The 2011 PBNDS states that Emergency Dental treatment will be provided for immediate relief of pain, trauma, and acute oral infection. However, a following provision states that: “Routine dental treatment may be provided to detainees in ICE custody for whom dental treatment is inaccessible for prolonged periods because of detention for over six months, including amalgam and composite restorations, prophylaxis, root canals, extractions, c rays, the repair and adjustment of prosthetic appliances and other procedures required to maintain the detainee’s health.” The use of may in the second provision demonstrates that there is no affirmative obligation to provide routine dental care, despite detention length of at least six months. It is further troubling that ICE lists treatments they may offer only when someone has experienced detention for over six months--this seems inconsistent with the earlier provision that states that routine dental treatments may be provided for relief of pain, trauma, and acute oral infection. It is unclear what level of pain, trauma, or oral infection would be required to allow someone to access routine treatments.

CANCER

“I am feeling very tired. I do not sleep well. I usually do not get to sleep until 2 a.m. Then we have to get up at 4 a.m. My arm is swollen so much that it is hard for me to dress and shower.”

In a screening at a border detention facility, a client was told she had high blood pressure and was transported to a nearby hospital for subsequent testing. After an examination and several tests, she was told she had cancer in her uterus, in addition to high blood pressure. She was provided medication for her high blood pressure but told she would need to see an OB/ GYN for her cancer. A doctor stated she needed to be released so she could see a specialist. Her medical records were transferred to the ICE officer who had custody of her and she was returned to the border detention facility. This information was collected by RAICES in September, two months after she was initially detained. At that time she had not yet been taken to a hospital nor examined by a doctor since her cancer diagnosis in July. This individual went to the medical center twice a day, every day, to take her blood pressure and pain medication until she was told there was no more blood pressure medication. She was not provided an explanation and was never asked about her stomach pain or her cancer diagnosis. As a non-Spanish and non-English speaker, she was unable to meaningfully communicate with medical staff. After speaking with an employee in the medical office who

65. Sarah Gardiner and Cynthia Galaz, Beyond Conditions: Immigration Detention is Psychological Torture, Freedom For Immigrations, Dec. 6, 2019, https://www.freedomforimmigrants.org/policy-updates/2019/12/6/beyond-conditions-immigration-detention-is-psychological-tortur 66. Angelina Chapin, “Women Are Being Denied Cancer Treatment, Psychiatric Help At ICE Detention Center,” HuffPost, Sept. 30, 2019, https://www.huffpost.com/entry/immigrant-women-denied-cancer-psychiatric-care-ice-detention-center_n_5d8d5880e4b0019647a5ebae

spoke her native language, she described pain in her arms, back, and lower abdomen and was told she would be taken to a doctor. Two months later, there was still no follow-up. The pain and subsequent swelling in her arm made daily activities painful and difficult, such as sleeping, dressing, and showering. She reported getting only two hours of sleep a night.

PREGNANCY

During this period, at least 23 pregnant women were detained in Karnes. On average, pregnant women were detained in Karnes for 32 days. Of these 23, eight were in their first trimester, seven in their second trimester, and one in her third trimester. The rest of the women did not report how far along they were. There is no on-site obstetrician available at Karnes. For more on pregnancy experiences at Karnes, see Black, Pregnant, and Detained.

MENTAL HEALTH

As other advocates have noted, detention is psychological torture.65 In detention, people are dehumanized by being referred to by their bunk numbers and infantilized by being forced to wear sweatpant uniforms. At least 1,200 women observed their birthdays while detained. Beyond this, people often have little to no access to information about the status of their cases, which can contribute greatly to anxiety. Additionally, people are woken up at frequent intervals throughout the night for so-called “safety checks.” These checks trigger fears of deportation as ICE regularly effectuates unannounced deportations by waking people and removing them in the middle of the night. While these are a few of the compounding factors that can contribute to mental health difficulties in detention, they are only the tip of the iceberg.

Naturally, many women reported mental health illness worsening or developing for the first time while detained at Karnes, including suicidality.66 Women’s mental health conditions included PTSD, schizophrenia, depression, and anxiety, among others. Many women additionally reported lack of appropriate mental healthcare when they sought assistance. Lack of trust in services and lack of language access exacerbated these conditions. Many women reported that meeting with the counselors in detention did not help. Some women even shared that they requested medication for their mental health but were denied.

In particular, RAICES met with several women who were threatened with solitary confinement because they were crying or because they were perceived to be suicidal. GEO or ICE threatened to lock the women in solitary confinement if they did not stop crying. In some cases, women were locked in solitary confinement against their will because guards erroneously perceived them to have expressed suicidality. Unfortunately, locking suicidal people in solitary confinement without further care is a common practice in immigration prisons despite solitary confinement being a risk factor for suicide.67, 68 Multiple women commented to RAICES that this practice discouraged them from seeking mental health care out of fear of being locked in solitary confinement. It is of note that the use of

67. N/A, The Walls Are Closing In On Me, HALTsolitary Campaign, May, 2020, http://nycaic.org/wp-content/uploads/2020/05/ The-Walls-Are-Closing-In-On-Me_For-Distribution.pdf 68. N/A, What are the effects of solitary confinement on health?, Medical News Today, Aug. 6, 2020, https://www.medicalnewstoday. com/articles/solitary-confinement-effects