IV. Findings: Overarching Problems in the Medical System Affecting Women’s Care

In our interviews with currently or recently detained women, Human Rights Watch found that some issues arose repeatedly as impediments to proper care: delays in getting requested medical attention, compromised doctor-patient relationships, unnecessary use of restraints and strip searches, interruptions in care, unwarranted denials of testing and treatment, and ineffective complaint mechanisms. The following section outlines the difficulties women faced at each stage of their attempts to obtain appropriate care.

Delays & Denials of Testing and Treatment

I was starting to go blind. I had complained for 15 days about the blindness. I sent many sick calls. In June 2007 the officers called medical. I could only see shades of people. I couldn’t see numbers or letters. An officer asked me, “How come you are always sleeping? You’re not like that.” They called to inform the doctors (the doctors tell them whether to send us). The officer called and said I was diabetic and needed to be seen. Then the nurse saw me. I told her, “I can’t see. I’m blind. It has been 15 days.” They checked my sugars. They were 549. The nurse asked, “Why didn’t you tell us?” I was about to go into a diabetic coma or have a heart attack because my blood sugar was so high.

—Mary T., Texas, April 2008

Half of the women Human Rights Watch interviewed said they had experienced delays in receiving requested medical care and nearly as many were forced to make repeated appeals to obtain an appropriate response to their medical concerns. Official statements regarding the average response time for sick call requests at individual facilities bore little resemblance to the extended wait times women who spoke with us reported.[69] The length of the delays ranged from a few days to dispense ibuprofen for a headache to five-and-a-half months to follow up on an abnormal Pap smear. Some requests remained unfilled at the time of the woman’s release, including requests for prenatal care that never arrived in a woman’s month-and-a-half stay in detention. Giselle M., who could not remember the number of times she requested a sonogram to monitor a cyst that threatened her pregnancy, said the delay could not be justified: “I know everything is a process but to me there are some things they should be on top of.”[70]

Delays occurred at various points from the initial request to the scheduling of specialist visits to the arrival of medication, and affected treatment for problems of varying severity and complexity. Likewise, the delays resulted in a range of consequences, some of which were not manifest until after the period of detention. In several cases, the delays deterred use of the medical system by people who needed it. After waiting 10 days for an appointment to address burning urination and 15 days to see someone about a growing rash on her face, Meron A. gave up on the sick call procedure: “If I have a problem today, I need help today.... That makes me mad, I don’t like to write, I’m not going to say anything.”[71] Similarly, Raquel B. stopped trying to get the facility to dispense the anti-anxiety medication she took outside of detention, even though taking the substitute the facility provided caused her to tremble and prevented her from sleeping. “I’m already tired of asking [to change the medication]. Many times I’ve requested sick call.”[72]

While less common than delays, outright denials of requested care arose in circumstances of varying gravity, including in the case of a woman with an incapacitating spinal injury that ICE diagnosed as requiring surgery that it refused to provide.[73] None of the health service providers we spoke with reported difficulty working within the DIHS managed care system, which requires prior authorization for off-site, non-emergency treatment. However, at least two women were told explicitly by on-site providers that they believed they should receive a certain course of treatment but were prevented from providing it by authorization denials from the managed care unit at headquarters. “[The physician’s assistant] said, ‘We can’t do anything for you. Requests for care are denied by Washington.’ If it was up to him, ‘we would have approved it right away.’ They especially don’t want to provide care if you are awaiting deportation. They probably put my file aside. I can read between the lines.”[74]

Many more women complained about receiving inappropriate or inadequate care for their health concerns. These cases included a woman with gallstones whose symptoms nurses diagnosed and treated as related to depression until she collapsed,[75]as well as numerous women who were instructed to drink water for an assortment of maladies, such as intense menstrual cramps. “We call it the magic water,” said Elisa G.[76]

Obstacles to Obtaining Medical Care

In order to bring their health concerns to the attention of an appropriate medical provider, women described having to overcome numerous obstacles, including lack of awareness of available services and the sometimes obstructive role of security personnel and frontline medical staff.

Information

The ability to access information on health services is an obvious prerequisite to obtaining the services themselves, but proves to be far from a simple matter in the detention context. National Commission on Correctional Health Care standards stipulate that information on the availability of health services should be provided orally and in writing to detained individuals on their arrival at a facility, with care taken to ensure it is communicated in a form and language they understand.[77] The new ICE medical standard and the standard on the admission and release of individuals from detention describe an orientation process where the facility should inform individuals about the available services, including medical care.[78] As part of the orientation, a “detainee handbook” outlining facility procedures should be provided to each individual who enters custody[79]. In addition, the Division of Immigration Health Services (DIHS) standard intake form contains a check box for the intake examiner to indicate that the patient has been informed how to request medical care. The women who spoke with Human Rights Watch were by and large familiar with the general procedures for requesting care, although a few had received the information from other detained women and did not recall any official guidelines on how to seek care.

More commonly the information gap pertained to the nature and scope of the services available. Giselle M. spent several weeks in discomfort when she was detained during her pregnancy before one of the other women in her unit told her that she should have received an extra mattress pad for her bed, according to the facility’s standard practice. “You don’t know your rights,” she told Human Rights Watch.[80] This problem arose even more frequently in relation to services that were not routinely provided. In discussing various health concerns, including abortion, lactation, hormonal contraception, and services for survivors of recent sexual assault, health providers frequently stated that an issue had not come up at their facility, or that a procedure was not standard but could be made available if requested. Women we spoke with who had been released from detention, on the other hand, frequently said that they would have wanted the services had they known they could be obtained in detention.

At Eloy Detention Center in Arizona, for example, Health Services Administrator Lieutenant Commander Melissa George indicated that Tylenol and massage would normally be recommended to nursing mothers but that a breast pump also could be made available.[81] However, Ashley J., who was detained at Eloy while nursing, told Human Rights Watch that she was not told she could have access to a breast pump and so assumed it was not available. Unable to express her breast milk manually, Ashley experienced great pain when the ducts in her breast clogged. Speaking about the pump and other services, Ashley J. explained, “Sometimes we don’t ask. We don’t even know these things exist. You believe in part—you almost feel like you are a criminal and the crime is to be illegal.”[82]

This combination of ignorance of available services and inhibition inspired by detention dynamics points to why the legal onus is on the detention authorities to raise awareness and offer services to the individuals in their custody. Certainly, some individuals will come into detention with a ready knowledge of the services they are entitled to and will not shy away from asking for them, but others—especially those who have never experienced detention before and who may be traumatized or face linguistic or cultural barriers—may not be equipped to do so. Further, relying on the detention grapevine to inform women does not represent a satisfactory substitute for proactive education by facility staff and, in fact, may undermine efforts to provide care.

A key component to making individuals aware of services they need is identifying their medical concerns. DIHS officials told Human Rights Watch that their ability to respond to health concerns depends in large part on what information is conveyed during an individual’s initial medical screening and follow up appraisal. However, the new and currently binding ICE medical standards state that non-medical detention staff can conduct the initial medical and mental health screening.[83] Even though staff members receive training to perform this function, they will not be as well-equipped as certified medical professionals to identify and respond to pressing health concerns.

Gatekeepers

Limitations on their movement and a series of intermediaries between themselves and the appropriate health professionals may also impair women’s access to care. In most facilities women do not have the freedom of movement to present themselves at the facility medical unit when they feel the need. Rather, health services are accessed in two ways, through submission of a “sick call” slip or “kite” or by bringing the situation to the attention of the security personnel in the housing unit.[84] The health services personnel triage the sick call requests and nurses conduct initial patient evaluations, provide appropriate treatment within their range of expertise, and refer patients to a physician’s assistant or doctor when they deem it necessary. Although one health services administrator indicated that referral to a doctor becomes automatic after a patient has been seen a certain number of times,[85] some women told Human Rights Watch that they had difficulty reaching a doctor.[86]

In between sick calls, security personnel assume the frontline in receiving the health concerns of the women in their custody. This can prove problematic for two reasons. First, staff without advanced medical training are put in the position of evaluating a patient’s need for care, including in the event of an emergency. American Public Health Association standards require that “prisoners who complain of or display acute or emergency health problems must be referred to medical staff immediately.”[87] One health services administrator insisted that officers have an obligation to call if they are notified of an emergency because they are not qualified to make medical decisions.[88] This approach is reflected in the new and currently binding medical standards’ instruction that employees who are unsure whether emergency care is required should immediately notify medical personnel who can make the determination.[89] However, Rhonda U. told Human Rights Watch of her difficulties in appealing to security personnel for access to care in urgent circumstances:

Only one officer will advocate for women for medical; others will tell you to put in a request. When I say, “I’m sick, please let someone with medical knowledge check on me,” the officer, Mrs. [Name], says “Out there you wouldn’t get any better.” But I say, “You have alternatives. Our back is against the wall. [In here] you can’t do for yourself. Don’t make me feel this small. Like I just want to get into a medical facility. Please help me because I can’t help myself. That’s all I ask.”[90]

Indeed, determining the existence of an emergency may entail a medical judgment in itself and according to one woman at an Arizona facility, “there is no such thing as an emergency for them unless you are bleeding.”[91]

Secondly, testimony provided to Human Rights Watch suggests that the relationship of security personnel to the individuals in their custody may seriously undermine access to health care. In the most benign instances, some women said that they did not feel comfortable sharing private health information with the individuals with whom they interacted day in and day out. In other cases women alleged mistreatment by security staff in the course of requesting medical care or being transported for treatment. This included guards placing a woman on lockdown in response to repeated sick call requests during a protracted struggle between her lawyers and ICE over her medical care, and, in another case described below, guards saying that they could do whatever they wanted to a woman who they knew to have been on suicide watch because no one would believe her.[92]

Itzya N. described the way the guards’ knowledge of her mental health issues allowed them to frighten her to the point that she wanted to leave the facility to which she had been transported for better medical care:

The guards know about medical problems.... Nothing is a secret around here. In the past, I used to get very depressed and I thought about it and here you are laughing at me and I’m just trying to go forward. They [the guards] talk poorly about the women who are here. Instead of taking care of you they pretty much screw you over verbally. I don’t want to generalize but it happens with more than one. I do remember [one time] and it was at [the service processing center]. It was a woman and four men. They referred to me as the one who tried to kill herself. They said they could do anything they wanted to me because no one was going to believe me because I had done something stupid. I don’t want to remember the exact words they said. All I know is that night I told the doctor I didn’t want to be there for one more minute. All I remember is that that night I couldn’t sleep fearing what would happen to me. If I close my eyes I can see their faces. The first time it happened I lowered my head. But now every time I see them I raise my head because I see them and I know what they did.[93]

Distortions in the Doctor-Patient Relationship

The immigration detention healthcare system’s focus on crisis management compromised the doctor-patient relationship in multiple ways for women who spoke with Human Rights Watch. While some women spoke favorably of the medical staff, a number felt that the staff did not take their complaints seriously or lacked a genuine interest in helping them. Further, language interpretation deficiencies prevented some women from participating fully in their care, and we received four reports of health service providers insisting on medication against the express wishes of the patient.

 

 

Providers’ Narrow Approach to Care

While variation in the aptitude and zeal of individual providers may be hard to avoid, the government bears responsibility for the extent to which the detention system’s emphasis on stop-gap, deportation-oriented care at the policy level has influenced the outlook of its caregivers. The first rule of the Principles of Medical Ethics Relevant to the Protection of Prisoners Against Torture, adopted by the UN General Assembly in 1982, holds that “Health personnel, particularly physicians, charged with the medical care of prisoners and detainees have a duty to provide them with protection of their physical and mental health and treatment of disease of the same quality and standard as is afforded to those who are not imprisoned or detained.”[94]

 

However, some statements by health services personnel to Human Rights Watch reflected the Covered Service Package’s more narrow view of care. One service provider articulated the medical unit’s mission as “to maintain health and keep [the detained individuals] in a deportable state.”[95] This view is consistent not only with the declared intent of the Covered Services Package, but the package’s requirement that certain basic services, such as Pap smears and annual dental examinations, only be provided to individuals “with no indication of imminent removal.”[96] Another health service provider noted that “most people are here voluntarily because they are fighting their deportation case” when explaining the limitations in available services.[97] This assertion is only true in the barest technical sense since individuals face a choice of enduring detention or giving up their claims for legal status in the US, which would likely come at great personal cost and possibly great personal peril for individuals fleeing persecution.

Women had high praise for certain medical providers and strong criticism for others. Mercedes O. told Human Rights Watch how moved she had been when a provider took a personal interest in her situation: “That doctor was a good person and helped: I’m a Christian and she prayed with me and said she was going to do everything to help me get out of [the detention center].”[98] But others felt that the providers were indifferent to their concerns, did not take them seriously, or viewed their requests as bothersome.[99] One health services administrator who spoke with Human Rights Watch gave little cause to doubt these reports. Speaking about the prevalence of anxiety among the women in custody, she said, “You know us girls, we just want to go home, we want to look pretty,” and later commented, “I don’t spend a whole lot of time down there with [the women in custody] because they are difficult.”[100]

Some women recounted confronting a lack of compassion at a moment of intense vulnerability. Alicia Y. had to be hospitalized for kidney stones and an acute pancreatic infection that caused her to faint. At the hospital, she remembered a nurse bruising her with a needle, leaving her to bleed and letting the blood remain soaking through her sheets overnight. She overheard a nurse who thought she did not understand English comment to a colleague that, “She doesn’t have any options. She’s just a detainee.”[101] Beatriz R., whose physical and mental health had markedly deteriorated over the period of her detention, recalled, “I was talking to the nurse about how I feel and she interrupted, ‘You can’t be talking about your problems, you’re just here for a check-up.’”[102] Looking up from her hands in her lap as she recounted this incident, Beatriz R. appeared both hurt and puzzled. “They treat us like we don’t have a life out there, like we don’t have a family, like we didn’t exist in the world.”[103]

Confidentiality & Privacy

Breaches of confidentiality in the handling of medical information and intrusions into the privacy of the exam room concerned several women who spoke with Human Rights Watch and led at least one woman to decline to seek care. According to the currently binding ICE medical standard, healthcare providers are expected to protect the confidentiality of medical information to the degree possible “while permitting the exchange of health information required to fulfill program responsibilities and to provide for the well being of detainees.”[104] The new ICE medical standard states that privacy of medical information will be protected in accordance with “established guidelines and applicable laws.”[105] Three women reported that guards, some male and some female, commonly have knowledge of the women’s health concerns, while two health services administrators explained that although they did try to limit security personnel’s exposure to individual medical information, the guards would also be bound by medical privacy laws. Nonetheless, Maya Z. insisted, “They talk about other patients. Everyone always knows why you went to the doctor.”[106] Women may find their confidential medical information exposed to other detained women as well, including in the communication of pregnancy test results which is not always done individually.

                                                                  

According to the new ICE medical standard, detention facility medical units should have sufficient space to allow patients to be seen in private while ensuring safety.[107] However, on visits to off-site providers, security measures vary between facilities and by the security classification of the woman detained. In some cases these measures can include having a guard stationed inside the exam room. This practice, as implemented in cases described to Human Rights Watch, is inconsistent with standards issued by the National Commission on Correctional Health Care which maintain that all clinical visits should be conducted in private “without being observed or overheard.”[108] The NCCHC recognizes exceptions for the presence of security personnel only where a patient poses a probable safety risk to a health care provider or others. In the instances described to Human Rights Watch, the women whose care was observed had no history of violent behavior.

One woman confessed that she had multiple issues she had not raised after hearing that another woman received a Pap smear in the presence of a guard. “The doctors outside treated me okay but it was uncomfortable for me because the guard has to be in the room. If I have to show where I have pain, the guard has to see it too. The CO [corrections officer] was there when they did the Pap smear on [other woman in custody]. I haven’t told them [that I am due for a Pap smear] because I don’t want to go through what she went through... I have breast implants, I didn’t tell them. By the end of last year I was supposed to get them checked. I haven’t told them about the breast implants because I don’t want the officers to see me naked.”[109]

 

Language & Consent

Under the American Public Health Association’s standards, “It is the institution’s responsibility to maintain communication with the prisoners; therefore, personnel must be available to communicate with prisoners with language barriers.”[110] Each facility Human Rights Watch visited insisted that language differences did not impede access to care, generally because the staff spoke multiple languages and interpretation for less commonly encountered languages could be obtained by phone. However, inconsistencies in the use of interpretation services compromised care for several women Human Rights Watch interviewed. Meron A. said that she informed the facility health providers that her English “was not good” only to have them dismiss her concern, saying they understood her, neglecting to consider that she in fact did not understand them.[111] Medical records for Nana B., whose interview with Human Rights Watch required French interpretation, indicate that facility personnel repeatedly conducted her medical visits in English, perhaps contributing to the fact that the date of birth in her records was off by 18 years.[112] Suana Michel Q., hospitalized during her time in ICE custody, reported being asked to sign consent forms for treatment without the opportunity to consult with a translator.[113]

Informed consent arose as an issue on several different occasions.[114] The new and currently binding ICE medical standards state that “as a rule, medical treatment shall not be administered against a detainee’s will.”[115] However, some women reported that they did not have the option to refuse medication when the staff came through to distribute it at “pill call.” Itzya N. recalled, “I started to stick the pills under my tongue ... because I didn’t want to take the pills. But some nurses look under your tongue.”[116] Serafina D. reported that the facility would not permit her to stop taking anti-seizure medication, even after tests confirmed her ailments were not seizure-related: “They just kept giving it to me.... They said since I was under their rules, if didn’t want to take it, I still have to take it.... Medicine would make me tired and drowsy. My body was feeling heavy, my eyes were heavy. I felt drugged up.”[117]

Detrimental and Unnecessary Use of Restraints and Strip Searches

ICE detention standards impose few definitive limits on the measures available to security personnel to control the individuals in their custody, with the result that women find their safety and their dignity subject to the inclinations of those charged with their supervision. Women interviewed by Human Rights Watch said this undermined their physical and psychological health.

The failure to categorically prohibit the shackling of pregnant women in ICE custody has drawn considerable criticism, as it is a practice condemned by health professionals and international bodies.[118] Under ICE policy, security staff may use restraints on pregnant women with the consultation of a medical provider.[119] Officials from the American College of Obstetricians and Gynecologists have declared their disagreement with the practice of shackling pregnant women, stating that “physical restraints have interfered with the ability of physicians to safely practice medicine by reducing their ability to assess and evaluate the physical condition of the mother and the fetus ... thus, overall putting the lives of women and unborn children at risk.”[120] In July 2008 a coalition of over one hundred women’s rights and immigrants’ rights groups wrote to ICE to request that the agency’s policy be changed to prohibit the routine restraint of pregnant women during medical appointments, transport to appointments, labor, delivery, and post-delivery.[121] ICE declined to make any revisions to the existing policy, stating in a response that it “properly balances the safety of the public, detainees and ICE personnel.”[122]

Women who were pregnant while in ICE custody told Human Rights Watch that they were not shackled during medical examinations, but that the use of restraints was typical during transportation between detention facilities and to and from off-site medical providers.[123] Both the new and currently binding ICE detention standards on land transportation indicate that as a rule women should not be restrained, but in addressing the shackling of pregnant women ICE has stated that “[its] policy is clear that any individual who has demonstrated violent behavior, criminal activity, or a strong likelihood of escape shall be restrained during transit.”[124] Giselle M., who was shackled while en route from one detention center to another, questioned the necessity of putting her pregnancy at risk: “What if I had fallen? How fast is a pregnant girl going to run?”[125] Recalling her experience with shackling, Katherine I. said, “When we went to the clinic in [city name], we were in a van without a way to hold on. There was a bench around and no way I could get myself so I couldn’t fall; I was pregnant and she was driving too fast. And I told the security who took us and they said they couldn’t do nothing about it.”[126]

Women who were shackled in the course of requesting medical care, whether pregnant or seeking care for other concerns, reported that the restraints took a psychological toll and presented a disincentive to seek care. Itzya N. said, “They only use shackles in transportation, but that is a trauma that lasts for three days. It’s just that on top of being chained you are being treated like an animal. It is more about the way they treat you, how they yell at you, how it’s like being caged.”[127]

Human Rights Watch spoke with women detained at facilities that also held criminal populations who were subjected to the facilities’ standard strip search procedures. The searches, which were imposed without apparent cause, constituted debilitating affronts to their dignity. Nora S. shook her head and closed her eyes as she recalled, “When the women from California first arrived, we were asked to strip down naked and walk around in circles in front of the women guards... I didn’t file a request for two whole weeks. All I could do was cry. I was in shock.”[128] Jameela E. was required to strip at each of the four county jails she was transferred between in Virginia. She described herself as devastated at the immodesty of being unable to wear her hijab, to say nothing of the requirement that she disrobe for inspection on multiple occasions.[129]

Discontinuity of Care

Women and healthcare providers alike identified lack of continuity of care as one of the greatest obstacles in the detention medical system.[130] Given the number of transfers between facilities and the short time that some individuals spend in the detention system, disruptions in care are an expected part of the detention system, as currently operated. Human Rights Watch interviews indicate that DIHS is failing to take sufficient steps to address this reality.

Records

Having a complete medical history available and transferring it with the patient can help considerably in bridging the gaps in care between a facility in the community and one in the detention system, as well between different facilities within the detention system. Yet exchanging comprehensive records does not register as a priority in ICE policy. Although not required by the ICE detention standards, some health service providers who spoke with Human Rights Watch said that they would try to get a patient’s prior medical records from a community provider where necessary and feasible.[131] But several women reported that they had to resort to getting those records on their own in order to substantiate their healthcare needs.[132] Receiving no help from the facility to obtain her records, Lily F. tried repeatedly to reach the doctor in California who had originally put in her breast implants, which ruptured while she was in prison and remained deflated in her chest when she reached ICE custody. But Lily F. found the doctor had moved offices. She tried to follow up but had no money for phone calls and, not being literate, could not write letters. To get more money for the calls she worked in the detention center for the nominal wage (one or two dollars) the facility provided: “I worked for five-and-a-half months but I had to quit because I was not feeling good.”[133]

Individuals transferred from one ICE detention facility to another can encounter the same difficulties and experience disruptions in care, even though they remain in the custody and care of the same authority. American Public Health Association standards stipulate that a full medical record should accompany an individual transferred within the same correctional system, and a summary should only be used for transfers into another system.[134] Under ICE policy, a summary is used whenever ICE transfers someone to a facility where DIHS does not directly provide care.[135] The new non-DIHS facility does not receive the full medical record as a matter of course. This is problematic because, unlike transfers between correctional systems, transfers between DIHS and non-DIHS facilities happen frequently within the ICE system. ICE moved Antoinette L., who had a complicated medical history, from one facility to another located just across the street and still provided only an incomplete transfer sheet that did not include her list of medications, an omission that could further compound difficulties that can arise due to DIHS and non-DIHS facilities maintaining different formularies.[136]

For Jameela E., whom ICE shuttled between four county jails in Virginia, the impact of the policy on transferring records was palpable. “I had pain over half my body,” she said in describing what it was like to contend with an ovarian cyst without her pre-detention painkillers.[137] At the first detention center, the health authorities referred her to a specialist at a local hospital where it was determined that the cyst required surgery. Before the scheduled surgical appointment two weeks later, ICE transferred her to another jail. Not having received any records from the first facility, the health provider demanded, “Do you have any proof you have a cyst?” Jameela E. had records from prior to detention with her belongings: “I said I have it in my property but they won’t let me have it.... Finally I got it.”[138] But the jail kept saying it had to wait for records from the first facility, and before long ICE transferred Jameela E. again. She did not receive surgery for her cyst during her time in ICE custody.

The new and currently binding ICE medical standards do not provide for individuals to automatically receive their full medical record on release, but they are entitled to request it from the detention center.[139] Nonetheless, detained women and their lawyers report problems accessing medical records, with requests going unanswered or yielding only partial files. Serafina D. reported that the off-site specialists she saw refused to give her paper records because they said the tests had been ordered by ICE.[140] Despite provisions in federal law and the detention standards intended to ensure individuals’ access to their records, lawyers report that facilities often impose obstructive requirements.[141] Kelleen Corrigan of the Florida Immigrant Advocacy Center told Human Rights Watch that one facility she deals with regularly accepts record requests only from lawyers, effectively prohibiting unrepresented individuals from accessing their own medical information.[142]

Referrals and Discharge Planning

The Division of Immigration Health Service prides itself on its tuberculosis program, which includes not only screening and treatment at the detention facilities, but referral for continued treatment after detention, even in those cases in which the individual is being deported. Health services administrators told Human Rights Watch that they will provide individuals with a supply of medication and a referral to their nearest available clinic to receive follow up care. Although this level of continuity of care may be impracticable for all health concerns, the success with tuberculosis has shown that it is possible to provide useful medical advice and assistance to individuals leaving detention. Indeed, in standards issued by the American Public Health Association, it is expected that “correctional health care providers should work with government and non-government health care agencies to develop referral criteria and programs to ensure continuity of care for discharged prisoners with significant health care needs including medications and supportive care.”[143]

The issue of continuity of care arose most frequently in our research in relation to pregnancy, in part because women are likely to be released from detention through parole or another mechanism the further they progress into the pregnancy. Two officials Human Rights Watch spoke with described their commitment to identifying quality programs in the community to provide alternatives to detention for pregnant women: “Just because she’s out of detention doesn’t mean she is out of our responsibility.”[144] At another facility, however, Human Rights Watch asked whether the detention center would assist pregnant women who were about to be released with identifying appropriate health care providers in the community, and was told that those arrangements would be up to the women themselves.[145]

 

Lack of Effective Remedies

I filled out a grievance a long time ago and didn’t get a response so I didn’t bother to grieve any more. The officers told me to put in a grievance because I was feeling bad. This was around September of 2007. I didn’t get a response until this January [2008]. They said it had gotten mixed in with a bunch of papers and they just found it. I don’t think so. I put a grievance against the medical treatment and they said, “Are you better now?” I told them, “You took so long to answer I could have been dead by now.”

—Mary T., Texas, April 2008

In the past year ICE has instituted a number of new oversight measures to assess facility compliance with detention standards; however, few include effective mechanisms for seeking feedback from or providing redress to detained individuals. The main mechanism for individuals in custody to register complaints about their care remains the local facility grievance systems, which to date have had limited input into ICE oversight programs.

Standard setting bodies such as the National Commission on Correctional Health Care state that a grievance process must be available to address complaints about health services.[146] Currently binding ICE detention standards require detention facilities to institute a grievance system whereby the individuals detained can file complaints that are reviewed and may be appealed up the chain of command to the officer-in-charge of the facility.[147] In addition, facilities must post the telephone number for the Office of the Inspector General’s (OIG) toll-free hotline where individuals can bypass the facility grievance process and report violations of their civil rights directly to the national-level authorities.[148] The new ICE standard on grievances, which will become binding on facilities in 2010, includes a separate process for addressing medical grievances in which ICE must be notified of appeals of medical grievances.[149] Also, ICE informed Human Rights Watch that it has begun screening correspondence to its field offices to identify communications raising pressing medical issues.[150]

These policy changes are positive signs, but their implementation will be essential to realizing actual progress. In interviews about the operation of the current grievance system, women indicated to Human Rights Watch that it was at the facility level of implementation that the process often failed them. Women interviewed for this report rarely found the available complaint mechanisms to be effective tools for obtaining redress. Even though information on the grievance system should be provided in an individual’s orientation upon arrival at the detention facility, some women never heard about the grievance system or seemed unclear on the availability of the grievance system for medical issues.[151] “When the doctor says no, it’s no. I don’t know about grievance,”[152] said Teresa W. Others said using the grievance system carried a risk of retaliation. “When you become such an advocate, you become a target. To them I’m threatening their job,”[153]said Nadine I. Serafina D., who said she did not shy away from advocating for herself or others, admitted, “One time I was going to file a complaint [about a non-medical issue] but then I was told if I file a complaint that they would do something to me and I never filed it.”[154] Facility procedures for the submission of complaints in some facilities amplified those fears. In one county jail, to file a grievance women needed to ask the guards for the form and return it directly to them after completing it.[155] Even the option of calling the OIG hotline was not perceived by women as being without risk, as women feared their calls would be monitored and their anonymity would be compromised.

For many of the women who spoke with Human Rights Watch, behind the decision to opt out of the grievance system or drop a complaint lay not fear but exhaustion and resignation. Having attempted to engage the system without success in other forms—filing sick call requests, asking guards for help, mentioning their concerns to deportation officers—women looked dimly upon the prospect of satisfaction through yet another bureaucratic process.

The women who did pursue the grievance process or another complaint mechanism reported mixed results. One woman reported that she convinced the facility to purchase new shower curtains for the women’s unit,[156] while another noticed a change for the better in the demeanor of a nurse after filing a complaint about her behavior toward patients.[157] Fewer appreciable results followed complaints about courses of treatment or the availability of particular medical services. One woman tried to call the Texas Health Department because a notice posted at the facility said that the Department accepted complaints, but could not get her call to connect.[158] Women who had the support of lawyers and family members who filed supporting letters and made follow up phone calls had more success, but it was inconsistent and delayed. Even with the backing of a team of zealous lawyers and attentive family members, Rose V. faced intimidation in pursuing her complaints regarding medical care. After advocacy efforts on her behalf graduated into a full-fledged campaign, Rose V. said that a senior official from the medical staff visited her and warned her, “I’m going to tell you right now, if your lawyers don’t stop it’s going to hurt your case. It’s going to make your judge mad; it’s going to make ICE mad... Call your lawyer.”[159]