Methods

Over the past 3 years, the CHHR has initiated a program of medical advocacy on behalf of detained immigrants that grew out of our systematic reviews of detainee medical care [3]. This program has utilized 4 physicians at 2 institutions (NYU School of Medicine and Montefiore Medical Center) in 77 cases thus far. These 77 cases involve detainees held in 7 states (NY, NJ, PA, AB, CA, AZ, LA). Most cases came to the attention of CHHR through attorneys or social workers. When CHHR was contacted about a case, the responding physician would speak with the attorney or whoever had knowledge of the detainee’s medical concerns. When possible, the responding physician would make an appointment to speak with the detainee by phone, using an interpreter if required. The responding physician would then determine what the detainees needs were and offer assistance that involved discussion, review of medical records or visit/evaluation at the detention center. The results of these evaluations we then used as the detainee wished, including for improvement of ongoing medical care, consideration of medical parole or towards support of some aspect of the detainee’s immigration case. The responding physician would write up the results of his/her work for submission to the detainee, the detention center medical staff, the detainee’s attorney or whomever else the detainee specified. These write-ups were generally between 1 and 4 pages in length, written to present an assessment and plan of each the detainee’s medical problems, and modeled after our evaluations of asylum seekers.

Results

Of the 77 cases that we have become involved in, 9 were limited to phone discussion with detainees, 57 involved medical records review and 11 involved visiting a detention center to evaluate a detainee. The discussion-only cases include detainee concerns about unaddressed symptoms, medications/side effects and procedures. One detainee had been sent multiple times from the detention center for a major cardiovascular surgery without having the procedure explained to him in his language, each time arriving at the hospital where medical staff refused to perform the procedure due to lack of informed consent.

The single largest category of cases within the CHHR detainee program involved the review of medical records. These records were obtained after the detainee’s attorney obtained consent from their clients and requested records from the current detention center or other medical settings including hospitals, clinics and other detention centers or jails. While some of these cases revolved around a discrete concern, they more often involved creating a timeline of diagnosis and treatment for complicated diseases such as cancer or persistent infection. We often found that diagnostic or clinical work done while at one detention center (including imaging and tissue biopsy results) was partially or completely ignored at subsequent detention centers.

For visits to detention centers, the attorney’s of detainees arranged visits in much the same manner they might for an asylum seeking client who needed a medical evaluation. In fact, the model for these visits was based on the experience of CHHR in visiting asylum seekers in detention and providing a complete history and physical in much the same manner. In the current CHHR program, the responding physician would obtain medical records and possibly talk with the detainee before visiting in detention. These visits would take place in a combination of visitation rooms and medical clinic examination rooms and included history taking, physical examination and mental status examination as indicated. When history taking was conducted in a visit room, the attorneys of detainees, without any correctional personnel, were generally present. Physical examinations took place in examination rooms of facility medical clinics and generally took place without the attorney present and involved the presence of correctional personnel outside the examination area.

Outcomes

Of the 9 discussion only cases, 7 concluded with the phone conversation while 2 resulted in a letter to the detainee’s attorney to be presented to detention center medical staff. Of the remaining 68 cases, 54 involved seeking some improvement in clinical care while detained while 10 involved seeking some sort of medical parole and 4 cases involved information that was use for another aspect of the detainee’s immigration case (not for medical parole). Examples of the clinical issues addressed for detainees include medications that were either withheld on intake (i.e. 7 days in detention without anti-seizure medications) or transfer (i.e. anti-retrovirals started at one detention center that were stopped upon arrival at a second). In extremely acute circumstances, such as the detainee who had not been provided anti-seizure medications, both local detention center medical staff and relevant ICE personnel in Washington D.C. were notified. In some instances, clinical issues were both apparent to the detainee and present in their records, but remained unaddressed by detention medical staff. Examples of clinical issues included untreated extrapulmonary tuberculosis, hematuria, schizophrenia, and angina. In all instances, both the detainee and their attorney had unsuccessfully attempted to have these issues addressed by detention center medical staff. The responding physician provided a written medical assessment of these cases to the detainee and their attorney. In some instances, such as the extrapulmonary tuberculosis case, the responding physician received follow up that the detainee was started on treatment. In many of these cases, however, the detainee was deported or transferred to an unknown facility and no clinical follow-up was available. The issue of detainee transfer amidst advocacy efforts, as well as ongoing medical treatment, has been identified as a serious challenge for detainees with medical needs [4]. In the cases where medical parole was sought, the responding physician worked to secure medical care for detainees once they were released from ICE custody. Three of these cases were initiated while the detainee was an inpatient at a hospital. Because detainees were undocumented, these placements were extremely time consuming, particularly when mental health services were required. Of the 11 medical parole cases, 7 were successful, resulting in release from detention while awaiting an immigration proceeding. A remaining 4 cases involved using the responding physician’s input for some aspect of the detainee’s immigration case, such as the need for specific care (i.e hemodialysis or cancer treatment) that would make removal from the U.S. highly problematic. One of these cases resulted in the detainee being granted permission to stay in the U.S.

Discussion

Our preliminary efforts to provide medical advocacy for detained immigrants reveals a pressing need for more medical providers to become involved in this work. During the time of this program (36 months), approximately 2 requests for assistance were received for every case that CHHR became involved with. We attempted to find medical advocates for cases that we did not become involved in but did not track these cases or their outcomes. However, it is our experience with the exception of the small percentage of detainees who are asylum seekers/survivors of torture, medical advocacy is essentially absent for detained immigrants. While we have attempted to involve many more attending physicians, fellows and residents in this program, the central barrier is the time required to review records (several hours) and visit detention centers (typically 1 day). Two of the responding physicians in this program are medical residents who are participating as part of residency projects focused on immigrant and community health. Because the number of requests for help far exceeds our ability to become involved, we have attempted several times to contact colleagues in other academic and medical settings for assistance. While there are several national human rights organizations that have trained and organized physicians to become advocates for asylum seekers (including the authors), these organizations and their members are generally not accessible to the approximately 95% of detainees who are not torture survivors or seeking asylum. Were those organizations to broaden their direct advocacy services to all detainees with medical concerns, they would be immediately overwhelmed. Across the United States, there are numerous clinicians who have become involved in medical advocacy for detainees, reviewing medical records and even visiting detainees on occasion. Our own experience replicates these efforts but with the goal of establishing a core of medical advocates who can respond to a large number of requests and develop the operational expertise to train others. We estimate that this type of medical advocacy can be undertaken with a 10% time commitment by a faculty member/team leader who then incorporates training and advocacy into the activities of residents and attending physicians who may contribute one half day session every 4–8 weeks. We are hopeful that this project may encourage other similar efforts elsewhere, with the ultimate objective of forming a national network of medical advocates working to ensure high quality medical care for detained immigrants (Fig. 1).

Fig. 1
figure 1

Preliminary case information

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Key Findings

  • Immigrant detainees can benefit from medical advocacy.

  • Tools developed by human rights organizations for asylum seekers can be adapted to advocate for all detainees.

  • Regional and national networks of medical advocates are needed to organize and promote detainee medical advocacy.

  • Medical residency programs with interests in community or immigrant health may prove valuable sources of medical advocates for detainees.