The long journey inside immigration detention centres in the USA

Immigrants escaping structural inequities

In our civilized world, geography is destiny. In all corners of the globe, political, economic and sociocultural forces promote inequalities in the distribution of wealth, health and opportunities. Unequal valuation of human lives produces oppressed, exploited, humiliated and disenfranchised people. To see this heart-rending problem here in the USA, we need to look no further than within our immigration detention centres.¹

But to even get to detention centres, immigrants first must escape home countries with issues that include food and housing insecurity, civil unrest and violence, persecution and exploitation.² Countless migrants make this heart-rending calculus, leave home, culture, language and family and undertake the treacherous journey to the US border. With scant life-savings hidden inside a tube of toothpaste or in a can of mayonnaise, and with few belongings, families, individuals and unaccompanied minors from war-torn and unstable locales around the world travel thousands of miles from South or Central America and across Mexico.² On their migratory route, men, women and children risk sexual and physical violence, extortion by smugglers and corrupt officials, snakebites, hunger and debilitating tropical infections. With a resilience born of repeated hardship and for the sake of reaching haven, they reach US soil. However, the cruel system enforced and expanded by the current US federal administration conveys a message that if you treat undocumented immigrants—including children—harshly enough, it will disincentivize others to come.³ For those able to cross the US border, many are placed in detention centres with incarceration-like conditions while they await immigration proceedings. Their length of stay ranges from <1 month to >4 years.³ The journey that most immigrants and asylum seekers undergo for the sake of improving their life conditions often turns into a long and perilous path that ends in detention centres, where the conditions that they endure are worse than the ones they were escaping from in the first place.

Insufficient medical care in detention centres

Once in detention, cascading human right abuses compound their often frail health.¹ The health profile of Mexican immigrants crossing the northern border of Mexico frequently has uncontrolled diabetes mellitus, hypercholesterolemia, untreated systemic arterial hypertension, cardiovascular disease and mental health disorders, particularly major depression and anxiety.^4–7 Many die from these underlying illnesses during detention.^6,8 Many have histories of repeated physical and emotional trauma and silent suffering.^2,7

In the USA, since 1995, the number of immigrants and asylum seekers in Immigration and Customs Enforcement (ICE) custody has increased from 7475 in 1995 to 37 311 as of early 2020 and distributed in ~137 detention facilities nationwide.⁹ The problem of inadequate medical care in immigrant detention is a well-known phenomenon and one i.e. growing.⁴ Most detention centres are private for-profit entities that are booming due to the progressive restrictionist immigration policies adopted over the last 3 years.³ Medical care of detainees depends on subcontractors who cut expenses to maximize profits.⁹ Facilities contract specialists to see patients with complex diseases, including those living with human immunodeficiency virus (HIV)-infection or with tuberculosis (TB) disease. However, public health organizations have been unable to assure detention centre compliance with providing and appropriately administering recommended medications with similar failures noted in the management of other chronic illnesses including diabetes mellitus, hypertension, depression and anxiety.^2,4 We have also noted instances of inadequate medical care, neglect and lack of oversight at our local, for-profit immigration detention centre, where hundreds of immigrant detainee adults are housed and staffed by one medical provider.

Observed medical neglect has included releasing detainees who were diagnosed with active TB, whereas still in treatment. Those patients were not linked for follow up at the local public health department to ensure TB treatment completion and side-effect monitoring. At detention centres across the country, there is no routine administration of influenza vaccination or other immunizations.¹⁰ An immigrant detainee with diabetes and uncontrolled blood sugar levels did not receive his insulin for several days. An immigrant detainee was not provided with his methadone developed severe opiate withdrawal and died.¹ Detention centre staff confiscated essential medication for an immigrant detainee with leprosy, which caused clinical worsening that left him debilitated and unable to walk. We also care for transgender women for whom gender-affirming care is rarely provided. Many patients living with HIV are receiving incomplete antiretroviral drug regimens or experience improper handling of drug side effects or interactions for prolonged periods before their referral to specialty care. Isolation and solitary confinement practices that many immigrants endure during detention promote the occurrence or exacerbation of mental disorders.^1–2 As a result, detainees experience high rates of anxiety, major depression and post-traumatic stress disorder.⁷

Immigration detention centres and the COVID-19 pandemic

Now, detained immigrants face the additional risk of becoming infected with the novel coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the conglomerate environments of detention centres. As the world is experiencing unprecedented anxiety and uncertainty with the coronavirus disease 2019 (COVID-19) pandemic, the fear and stress have reached the inside walls of these centres.⁷ The detention of any kind requires large groups of people to be held together in a confined space impairing the ability to curb the spread of the novel coronavirus inside immigration detention centres. Stress and anxiety disorders often found in immigration detainees can manifest in the human body as immunosuppression.⁷ This effectively places many detainees who are exposed to the novel coronavirus, and who may have other medical comorbidities such as diabetes mellitus and hypertension, prone to develop the severe manifestations of COVID-19.^4,7 Further expected to exacerbate the spread of the SARS-CoV-2 infection is the linguistic isolation, which occurs when a detainee cannot express their needs or symptoms to detention guards of the host country or even to other detainees. Such isolation regularly occurs with indigenous language-speaking detainees. Since the beginning of the COVID-19 pandemic in the USA, the number of detainees has declined to 27 908. This decline obeys mostly to reduced arrests and in minor degree due to early releases.⁸ As of 14 May 2020, there have been 965 confirmed cases of COVID-19 among detainees under ICE custody among 45 immigration detention centres. However, there have been 1804 tests performed in all ICE centres nationwide. For example, in Otay Mesa detention centre in California, there are 149 reported cases among ~2000 detainees. This number likely represents an underestimation of the true number of cases if broader testing strategies were to be employed. There are 152 employees within detention centres reported as confirmed COVID-19 cases.⁸

As healthcare providers of detained immigrants, we have personally witnessed the poor care that immigrants in detention face. We call on medical providers, state and federal policymakers to immediately address the silent suffering, medical neglect and unnecessary abuse of thousands of people in ICE custody. To achieve this goal, we recommend the end of corporations running detention centres whose incentive is profiting on cruelty.¹ Given the spreading number of outbreaks involving many detention centres,⁸ there is increasing benefits or reducing populations in these centres on the basis of humanitarian parole of all immigrants held for merely seeking asylum pending court cases. Furthermore, these interventions would allow for meaningful social distancing interventions. There is also a need of exposed individuals to resources that will allow appropriate medical follow-up, safe housing to avoid fueling household/community transmission and compassionate social distancing measures. Finally, there are improvements needed to ensure appropriate medical and mental health staffing of detention centres; and to promote transparency and measurable improvement in the provision of healthcare and overall conditions in these centres, there must exist a greater oversite of detention centres by state and local public health agencies.

Author contributions

C.F.P., Y.J., M.H., J.M.Y. and T.S. wrote the initial draught. G.B. and K.R. reviewed and analysed the literature. E.P., H.D. and A.H.M. edited the manuscript. All authors reviewed and approved the final version.

Conflicts of interest: None declared.

Financial support

None.