The forcible separation of migrant children from their families under the current United States (U.S.) administration’s “zero-tolerance” policy (Office of the Attorney General, 2018) and the prosecution of migrants crossing into the United States, even when exercising their legal right to seek asylum, have spurred a national outcry. Many medical professional organizations warn that children separated from their parents experience serious short- and long-term consequences (Kraft, 2018; Lopez, 2018). Subsequent media stories have highlighted the horrifying conditions to which these children are exposed in immigration detention facilities: inadequate nutrition, foil sheets intended to serve as blankets, substandard and delayed medical care, denial of meaningful social interactions such as hugging one another, and being held in cages (Merchant, 2018). In this Ethics Column, the authors discuss the background of the current immigration detention system and the integral role of nurses in immigration detention facilities across the US, apply a human rights and trauma-informed-care ethical framework to their discussion, analyze the ethical dilemma of dual loyalty, and conclude by sharing ways in which nurses and physicians can speak out together against the human rights violations occurring against this vulnerable, trauma-exposed population of immigrants and asylum seekers.
The disturbing realities of immigration detention reflect a larger policy trend toward the criminalization of immigration and privatization of immigration detention. The U.S. prison system is number one both in its prison system and in immigration detention (Gilman & Romero, 2018; Global Detention Project, 2018; & Prison Policy Initiative, 2018). This detention practice makes for a costly enterprise, with a profit motive that may overshadow the concern for individuals in these detention centers, be they detainees, healthcare providers, or other staff. Immigration enforcement is largely in the hands of the Immigration and the Customs Enforcement (ICE) and Customs and Border Protection (CBP). ICE alone spends around $2.5 billion annually, housing immigrants in private prisons and contracted local correctional facilities (GovTribe, Inc., 2018). Approximately three-quarters of the immigration detainee population are held in facilities run by private prison companies (Luan, 2018), which operate outside the purview of public oversight and accountability, and are incentivized to cut medical staffing and deny care to maximize profit.
In a recent visit to an immigration detention center in California, one of the authors (AS) heard stories from detainees that raise serious ethical concerns. One severely mentally ill detainee’s psychotropic medications were changed to cheaper alternatives, leading to his mental health deterioration. Additionally, a punitive approach to mental health distress was used, including pepper spraying for acutely, mentally ill individuals and segregation and isolation for multiple others, despite evidence to suggest this can exacerbate mental health symptoms. Detainees experienced delay in, or else inappropriate medical care. Examples included failure to give individuals with chronic health problems their medications; the denial of basic needs, such as glasses for impaired vision or dietary modifications for health or even religious reasons; and racist and stigmatizing verbal abuse by detention center staff, including words, such as “trash,” and “crazies,” among many other inappropriate behaviors (Disability Rights California, 2018; Saadi, personal communication, August 13-14, 2018). This pattern of dehumanization and grossly inadequate medical and mental healthcare for those detained was similarly witnessed on a tour of immigration detention facilities in Texas (Human Rights First, 2018; Saadi, 2018).
Role of Nurses in Immigration Detention Facilities
Nurses caring for ICE detainees are charged with a broad scope of responsibility. Despite nurses being the largest direct provider of healthcare to inmates nationwide (Blair et al., 2014), chronically understaffed corrections facilities are asking nurses to serve additional roles areas, such as administration, occupational and mental health, sexual assault, public health, crisis management, education, and infection control (Almost et al., 2013; Gerber, 2012). In privately operated immigration detention centers, the United States ICE Health Service Corps (IHSC) is tasked with providing direct patient care (ICE Health Service Corps, n.d.). IHSC is largely shaped by healthcare models used in the Federal Bureau of Prisons, where clinical staff, responsible for the supervision and direction of healthcare within the walls of the facility, report to the warden, ICE, or Department of Homeland Security (DHS) officials (Department of Justice Office of the Inspector General: Audit Division, 2008). Under the umbrella of IHSC, healthcare providers may be federal employees with additional professional scrutiny, but the majority of healthcare providers hired by detention centers are contracted.
Despite updated 2016 ICE protocols clearly delineating the role of healthcare providers in corrections facilities (U.S. Immigration and Customs, 2016, p. 261), there continue to be reports of correctional nurses pulled into roles which jeopardize their autonomy. Examples include being expected to work as guards when staffing is short (Ivory & Dickerson, 2018; Johnson, 2016; Johnson, 2018). In response to some of these issues, the National Commission on Correctional Health Care released a white paper in 2014 outlining the importance of the proper assignment of nursing personnel in correctional facilities based upon the applied scope of practice as defined by state boards of nursing (Blair et al., 2014). However, clinical oversight and quality reporting of medical care varies widely state-to-state and facility-to-facility (The Pew Charitable Trusts, 2017).
These observations are not new. Human-rights abuses, medical negligence, and deaths in detention have been well documented by independent sources (American Civil Liberties Union, 2016; Code Red, 2018). The Table provides additional documentation of human rights violations. Even internally, red flags have been raised; for example the DHS Office of the Inspector General released a report in December of 2017 outlining significant failures in the treatment and care of ICE detainees, and another in June of 2018 outlining concerns over ICE’s system of oversight and compliance (DHS Office of the Inspector General, 2017, 2018). These are troubling findings, given that since ICE’s inception in 2003, there have been a total of 176 deaths of detainees while in custody (Kuang, 2018). An independent death review concluded that over half of all recent deaths in detention were preventable and due to inadequate medical care (Sullivan, 2018). To be clear, however, looking at mortality alone likely underestimates the provision of inadequate healthcare in this population. For example, interrupted care for chronic diseases, such as diabetes or hypertension, or substandard mental health or prenatal care, may not lead to death but still produces significant harm to individuals.
Table. Documentation of Human Rights Violations in United States Immigration Detention
American Immigration Council and the American Immigration Lawyers Association. (June 4, 2018). Complaint Demands Investigation Into Inadequate Medical and Mental Health Care Condition in Immigration Detention Center. Retrieved from https://www.americanimmigrationcouncil.org/sites/default/files/general_litigation/
Human Rights Watch. (2009, March 17). Detained and Dismissed: Women’s Struggles to Obtain Health Care in United States Immigration Detention. New York, N.Y.: Human Rights Watch. Retrieved from https://www.hrw.org/report/2009/03/17/detained-and-dismissed/womens-struggles-obtain-health-care-united-states#
Human Rights Watch. (2010, August). Detained and at Risk: Sexual Abuse and Harassment in United States Immigration Detention. New York, N.Y.: Human Rights Watch. Retrieved from https://www.hrw.org/sites/default/files/reports/us0810webwcover.pdf
Systemic Indifference | Dangerous & Substandard Medical Care in US Immigration Detention. (2017, May 8). Retrieved from https://www.hrw.org/report/2017/05/08/systemic-indifference/dangerous-substandard-medical-care-us-immigration-detention
Tovino, S. A. (2016). The Grapes of Wrath: On the Health of Immigration Detainees. Scholarly Works., Paper 953. Retrieved from https://scholars.law.unlv.edu/cgi/viewcontent.cgi?referer=https://www.google.com/&httpsredir=1&article=1977&context=facpub
Applying a Human Rights and Trauma-Informed-Care Framework
Many proposals have aimed to improve healthcare in detention facilities primarily from a legal perspective, by examining due process and constitutional and international human rights violations. Protecting detainees and prisoners from inhumane and degrading treatment, however, takes a multi-faceted and interdisciplinary approach. This approach needs to provide for procedural and legal safeguards, as well as actively involve healthcare providers who are trained and able to provide trauma-informed care within a human-rights framework. Such an approach is especially important because there is a high incidence of trauma reported in the detainee populations in immigration detention centers (Physicians for Human Rights, 2003).
In order to qualify for asylum in the United States, applicants must show that they have suffered, or have a reasonable fear that they will suffer persecution in their home country. The targets of torture and persecution can be those people who are obvious opponents to those in political power, or those who are under-recognized as targets: the poor, women and children; marginalized ethnic, cultural, religious, or sexual minorities; or accidental victims caught in the crosshairs of wars or conflicts across borders (United Nations, 2004). These marginalized groups constitute many of the asylum applications in the United States and many of those currently detained (Jordan, 2018).
As a Forensic Nurse Examiner (AP) and physician (AS), we have had the privilege to perform medical-forensic examinations of asylum seekers through Physicians for Human Rights since 2016 and 2017, respectively, corroborating claims of torture, physical abuse, and other forms of persecution for immigration proceedings. In my day-to-day professional practice (AP), I care for adults and children who are survivors of sexual and domestic violence. In my years working with victims of trauma, I have found immigrants to be the most vulnerable and the most victimized. Those protected by the rights and laws of no country are defenseless against the brutality that lurks in the world. I have personally cared for women who were repeatedly gang raped and tortured as they tried to flee fears of femicide in Honduras. I have cared for a child who was shot in the legs as she fled gang violence on her way to school and, who without medical care, suffered lifelong disability. I have sat with many women, beaten and raped, too afraid to ask for help for fear they will be deported and separated from their children. This is the reality of so many individuals in detention centers in the United States.
In a 2003 Physicians for Human Rights report on individuals in immigration detention centers, 59% reported having had a family member or friend murdered and 26% reported sexual assault prior to detention; consequently, they also reported high rates of depression in 86% of the detainees, anxiety in 77%, and post-traumatic stress disorder (PTSD) in 50% (Physicians for Human Rights, 2003). Many other studies similarly found high percentages of depression, anxiety, and post-traumatic disorders among immigrants and asylum seekers (Turrini et al., 2017). Additionally, studies note the lasting and traumatic nature of the immigration experience itself (Foster, 2001).
To accomplish the task of establishing trauma-informed care within a human-rights framework, healthcare providers must be equipped to recognize the signs and symptoms of trauma and promote practices and policies that actively resist re-traumatization. They must also have mechanisms established in their workplaces, whether in hospitals or in immigration detention, to report violations of these best practices. The American nursing experience is largely driven by the concept of patients’ rights within the context of our domestic healthcare system. Considering the healthcare of ICE detainees through a universal human rights lens, rather than through a domestic patients’ rights lens, requires us to examine the care of human beings in detention (and their healthcare providers) with a broader understanding of human dignity.
Ethical Dilemma of Dual Loyalty
Dual loyalty is an ethical dilemma encountered commonly by healthcare professionals caring for persons in custody (Pont, Stover, & Wolff, 2012). Dual loyalty refers to situations where healthcare professions feel caught between their obligation to help the individual under their care and a demand, whether formal or informal, to act on behalf of another entity (Fujio, 2011). Dual-loyalty circumstances can include, for example, imposing medical procedures that serve state interests rather than patients' interests. These procedures might include administering lethal injections to prisoners on death row; providing lower quality of care, such as lack of referral for treatment; remaining silent regarding human rights abuses vis-a-vis failing to report or document injuries; or keeping incomplete records. Nurses who work in immigration detention centers face this dual loyalty to patients and employers amid other challenges. These challenges might involve, for example, substandard working conditions that include large caseloads and constrained resources, and the tension between patient-centered medical practice and the prison rules and culture.
To address the reality of dual loyalty in correctional health, some correction health systems, such as the New York City jail system, embarked on dual loyalty training for all health staff, through clinical scenario discussion and strategizing on ways to mitigate the impact of dual loyalty on healthcare delivery (Glowa-Kollisch et al., 2015). Honest discussion about the entanglement of healthcare delivery and a penal immigration detention system in the US will allow for the health systems in these settings to serve their patients in a more ideal manner.
Conclusion: What Can be Done
Healthcare professionals need to be educated to recognize dual loyalty situations (Glowa-Kollisch et al., 2015) and advocate for establishment of independent ethics and/or oversight commissions, appeal processes, and protective mechanisms for those who speak up against abuse. Professional societies can also set internal standards, holding their members to the highest professional standards of commitment to the human rights and dignity of people whose lives they directly affect. For example, the International Council of Nurses (ICN) endorsed the United Nations Universal Declaration of Human Rights, the Geneva Convention of 1949, and also the additional protocols and United Nations Basic Principles for the Treatment of Prisoners, which asserts that prisoners and detainees have the right to healthcare and humane treatment regardless of their legal status (ICN, 2011). These protocols specifying rights can be publicized among the American nursing community, who, alongside physicians and other healthcare staff, can work with the primacy of their patients’ wellbeing at the frontline of their work. Other potential opportunities for change include advocating for robust, independent, and transparent monitoring of standards within immigration detention.
As individuals, health professionals have a moral and ethical obligation to speak out and act against the abuses of detainees’ human rights. There are ways for any healthcare professional to act simply as a citizen, such as contacting Congress, writing opinion pieces, and joining grassroots efforts. Since ICE relies on contracts with many local governments for detention, states and local municipalities can also play a vital role in improving medical care and detention conditions, opening up many opportunities for advocacy by healthcare professionals at local and state levels.
Recent policy changes to the use of detention and detention centers have only led to more people in detention, beyond children and asylum-seekers, including pregnant women, individuals without criminal history, and long-term residents of the US. Healthcare professionals, and especially nurses, who make up the largest segment of the detention workforce, must play a central role in ensuring that anyone who is detained receives adequate medical care that upholds current medical standards, alongside a trauma-informed and human rights framework.
Altaf Saadi, MD, MS
Altaf Saadi is a neurologist and fellow at the National Clinician Scholars Program at the University of California, Los Angeles (UCLA), where she has completed a master’s degree in health policy and management at the UCLA Fielding School of Public Health. A graduate of Yale College and Harvard Medical School, she completed her neurology training at the Partners Neurology Residency Program at Massachusetts General Hospital and Brigham and Women’s Hospital, where she also served as chief resident. Her research and advocacy concerns health inequities and disparities among racial and ethnic minorities, immigrants, and refugees, as well as enhancing diversity within the medical workforce. She is also an asylum evaluator for the Physicians for Humans Asylum network, having conducted medical and psychological evaluations for individuals in the community and in immigration detention centers.
Amanda Payne, RN-BSN, CCRN, SANE-A
Amanda Payne is a Forensic Nurse Examiner currently practicing with the Inova Forensic Assessment and Consultation Team (FACT) in Washington D.C. She is board certified in both Critical Care Nursing and Forensic Nursing. She was trained in the medical-forensic examination of asylum seekers through Physicians for Human Rights at the Yale Center for Asylum Medicine. Amanda has worked as a medical-forensic evaluator for the Physicians for Human Rights Asylum network since 2016. She is a member of the International Association of Forensic Nurses (IAFN) Social Justice Committee and has served as a representative on Georgia State Human Trafficking Task Force. She recently authored the paper SANE Forensic Examinations for Immigrant-Victims: A Case Study, published earlier this year in the Journal of Forensic Nursing.
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