[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]


 
            PROBLEMS WITH IMMIGRATION DETAINEE MEDICAL CARE

=======================================================================

                                HEARING

                               BEFORE THE

                      SUBCOMMITTEE ON IMMIGRATION,
                CITIZENSHIP, REFUGEES, BORDER SECURITY,
                         AND INTERNATIONAL LAW

                                 OF THE

                       COMMITTEE ON THE JUDICIARY
                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                              JUNE 4, 2008

                               __________

                           Serial No. 110-117

                               __________

         Printed for the use of the Committee on the Judiciary


      Available via the World Wide Web: http://judiciary.house.gov



                     U.S. GOVERNMENT PRINTING OFFICE
42-722 PDF                 WASHINGTON DC:  2008
---------------------------------------------------------------------
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpo.gov  Phone: toll free (866) 512-1800; (202) 512ï¿½091800  
Fax: (202) 512ï¿½092104 Mail: Stop IDCC, Washington, DC 20402ï¿½090001

                       COMMITTEE ON THE JUDICIARY

                 JOHN CONYERS, Jr., Michigan, Chairman
HOWARD L. BERMAN, California         LAMAR SMITH, Texas
RICK BOUCHER, Virginia               F. JAMES SENSENBRENNER, Jr., 
JERROLD NADLER, New York                 Wisconsin
ROBERT C. ``BOBBY'' SCOTT, Virginia  HOWARD COBLE, North Carolina
MELVIN L. WATT, North Carolina       ELTON GALLEGLY, California
ZOE LOFGREN, California              BOB GOODLATTE, Virginia
SHEILA JACKSON LEE, Texas            STEVE CHABOT, Ohio
MAXINE WATERS, California            DANIEL E. LUNGREN, California
WILLIAM D. DELAHUNT, Massachusetts   CHRIS CANNON, Utah
ROBERT WEXLER, Florida               RIC KELLER, Florida
LINDA T. SANCHEZ, California         DARRELL ISSA, California
STEVE COHEN, Tennessee               MIKE PENCE, Indiana
HANK JOHNSON, Georgia                J. RANDY FORBES, Virginia
BETTY SUTTON, Ohio                   STEVE KING, Iowa
LUIS V. GUTIERREZ, Illinois          TOM FEENEY, Florida
BRAD SHERMAN, California             TRENT FRANKS, Arizona
TAMMY BALDWIN, Wisconsin             LOUIE GOHMERT, Texas
ANTHONY D. WEINER, New York          JIM JORDAN, Ohio
ADAM B. SCHIFF, California
ARTUR DAVIS, Alabama
DEBBIE WASSERMAN SCHULTZ, Florida
KEITH ELLISON, Minnesota

            Perry Apelbaum, Staff Director and Chief Counsel
      Sean McLaughlin, Minority Chief of Staff and General Counsel
                                 ------                                

          Subcommittee on Immigration, Citizenship, Refugees, 
                 Border Security, and International Law

                  ZOE LOFGREN, California, Chairwoman

LUIS V. GUTIERREZ, Illinois          STEVE KING, Iowa
HOWARD L. BERMAN, California         ELTON GALLEGLY, California
SHEILA JACKSON LEE, Texas            BOB GOODLATTE, Virginia
MAXINE WATERS, California            DANIEL E. LUNGREN, California
WILLIAM D. DELAHUNT, Massachusetts   J. RANDY FORBES, Virginia
LINDA T. SANCHEZ, California         LOUIE GOHMERT, Texas
ARTUR DAVIS, Alabama
KEITH ELLISON, Minnesota
ANTHONY D. WEINER, New York

                    Ur Mendoza Jaddou, Chief Counsel

                    George Fishman, Minority Counsel



                            C O N T E N T S

                              ----------                              

                              JUNE 4, 2008

                                                                   Page

                           OPENING STATEMENTS

The Honorable Zoe Lofgren, a Representative in Congress from the 
  State of California, and Chairwoman, Subcommittee on 
  Immigration, Citizenship, Refugees, Border Security, and 
  International Law..............................................     1
The Honorable Steve King, a Representative in Congress from the 
  State of Iowa, and Ranking Member, Subcommittee on Immigration, 
  Citizenship, Refugees, Border Security, and International Law..     4
The Honorable John Conyers, Jr., a Representative in Congress 
  from the State of Michigan, and Chairman, Committee on the 
  Judiciary......................................................     6
The Honorable Lamar Smith, a Representative in Congress from the 
  State of Texas, and Ranking Member, Committee on the Judiciary.     8

                               WITNESSES

Ms. Julie Myers, Assistant Secretary, Immigration and Customs 
  Enforcement (ICE), U.S. Department of Homeland Security
  Oral Testimony.................................................    12
  Prepared Statement.............................................    15
Mr. Philip Farabaugh, Acting Director, Division of Immigration 
  Health Services, Immigration and Customs Enforcement (ICE), 
  U.S. Department of Homeland Security
  Oral Testimony.................................................    25
  Prepared Statement.............................................    27
Mr. Richard M. Stana, Director, Homeland Security and Justice 
  Issues, Government Accountability Office
  Oral Testimony.................................................    32
  Prepared Statement.............................................    34
Mr. Isaac Reyes, Washington Representative, U.S./Mexico Border 
  Counties Coalition
  Oral Testimony.................................................    62
  Prepared Statement.............................................    64
Mr. Edward Harrison, President, National Commission on 
  Correctional Health Care
  Oral Testimony.................................................    66
  Prepared Statement.............................................    69
The Reverend E. Roy Riley, Bishop of the New Jersey Synod, 
  Evangelical Lutheran Church in America
  Oral Testimony.................................................    72
  Prepared Statement.............................................    76
Ms. Gloria Armendariz, Wife of Isaias Vasquez, former detainee
  Oral Testimony.................................................    83
  Prepared Statement.............................................    84
Ms. Zena T. Asfaw, former detainee
  Oral Testimony.................................................    85
  Prepared Statement.............................................    87
Ms. Mary Meg McCarthy, Director, National Immigrant Justice 
  Center
  Oral Testimony.................................................    88
  Prepared Statement.............................................    90
Ms. Ann Schofield Baker, Partner, McKool Smith, and Attorney for 
  Amina Bookey Mudey, former detainee
  Oral Testimony.................................................    97
  Prepared Statement.............................................    99
Mr. Homer Venters, M.D., Attending Physician and Public Health 
  Fellow, Bellevue/NYU Program for Survivors of Torture
  Oral Testimony.................................................   141
  Prepared Statement.............................................   143

          LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING

Prepared Statement of the Honorable Zoe Lofgren, a Representative 
  in Congress from the State of California, and Chairwoman, 
  Subcommittee on Immigration, Citizenship, Refugees, Border 
  Security, and International Law................................     3
Revised and Extended Remarks of the Honorable Steve King, a 
  Representative in Congress from the State of Iowa, and Ranking 
  Member, Subcommittee on Immigration, Citizenship, Refugees, 
  Border Security, and International Law.........................     6
Prepared Statement of the Honorable John Conyers, Jr., a 
  Representative in Congress from the State of Michigan, and 
  Chairman, Committee on the Judiciary...........................     7
Prepared Statement of the Honorable Lamar Smith, a Representative 
  in Congress from the State of Texas, and Ranking Member, 
  Committee on the Judiciary.....................................     9
Prepared Statement of the Honorable Sheila Jackson Lee, a 
  Representative in Congress from the State of Texas, and Member, 
  Subcommittee on Immigration, Citizenship, Refugees, Border 
  Security, and International Law................................    10

                                APPENDIX

Material Submitted for the Hearing Record........................   161


            PROBLEMS WITH IMMIGRATION DETAINEE MEDICAL CARE

                              ----------                              


                        WEDNESDAY, JUNE 4, 2008

              House of Representatives,    
      Subcommittee on Immigration, Citizenship,    
   Refugees, Border Security, and International Law
                                Committee on the Judiciary,
                                                    Washington, DC.

    The Subcommittee met, pursuant to notice, at 2:05 p.m., in 
Room 2141, Rayburn House Office Building, the Honorable Zoe 
Lofgren (Chairwoman of the Subcommittee) presiding.
    Present: Representatives Lofgren, Conyers, Gutierrez, 
Waters, Sanchez, Davis, Ellison, King, Goodlatte, and Lungren.
    Also Present: Representative Smith.
    Staff Present: David Shahoulian, Majority Counsel; Andres 
Jimenez, Majority Professional Staff Member; George Fishman, 
Minority Counsel.
    Ms. Lofgren. This hearing of the Subcommittee on 
Immigration, Citizenship, Refugees, Border Security, and 
International Law will come to order.
    Without objection, the Chair is authorized to call a recess 
of the hearing at any time.
    I would like to welcome the Subcommittee Members, our 
witnesses, and members of the public to the Subcommittee's 
hearing on problems with immigration detainee medical care. 
This Committee held a hearing on this subject on October 4, 
exactly 8 months ago. At that hearing we examined serious 
concerns with the provision of medical care at immigration 
detention facilities across the country. News reports of deaths 
and the deficient care that may have led to those deaths 
triggered that hearing. Unfortunately, here we are again.
    As was the case 8 months ago, a string of recent news 
reports has severely shaken our confidence in the health care 
system used by ICE. The reports recount story after story of 
detainees who received inadequate care or no care at all, and 
they speak of suffering and death.
    But this time those stories are not just reports; The 
Washington Post and 60 Minutes support those stories with 
internal Government documents and what appear to be many 
interviews with Government whistleblowers who have uncovered 
severe problems and desperately want to see them fixed. Some of 
the witnesses today will deny that these problems exist, but I 
believe these claims are belied by Government officials who 
have reached out to the press and to us and by the documents 
that support their claims.
    The efforts of those whistleblowers tell me something, that 
there are people within our Government who really care about 
the medical and mental health care provided at ICE facilities. 
But their stories and documents also say something else: That 
their pleas and warnings have gone largely unheeded for far too 
long.
    Documents tell us that employees widely complained of 
severe staffing shortages of medical personnel. ICE tells us 
they are addressing these shortages now, but the documents 
indicate they ignored these warnings for years, failing to 
adequately address these shortages even as they ramped up 
enforcement and brought detention beds on line.
    Documents tell us that employees complained of certain 
policies that appear to be in violation of ICE's detention 
standards. For some time at the San Pedro facility, for 
example, the clinical director prohibited medical staff from 
doing any lab work for detainees no matter what their condition 
until they had been detained for more than 30 days. As 
indicated by an internal DHS document, this policy may have 
played a role in the death of a detainee with HIV who was 
denied medication during her first month in detention.
    Documents show that ICE's policy may be designed to deny 
care and save money rather than to provide care and save lives. 
Last October, Francisco Castaneda testified before our 
Committee concerning the medical care he received, or I should 
say failed to receive, during his detention. He is now dead. A 
quick review of his medical records shows that several on-site 
physicians recommended biopsy to rule out cancer, but it also 
shows that these requests were repeatedly denied over a 10-
month period by managed care coordinators here in D.C.
    Some might say this is just one case and does not signify 
anything. I disagree. When several doctors say that someone 
needs a simple biopsy, but this is denied not once, not twice, 
but repeatedly over 10 months by off-site bureaucrats, 
something is fundamentally wrong. No matter how it happened, 
there is no question that the system failed Mr. Castaneda over 
and over again. He paid with his life, and now the Government 
is on the verge of paying millions in a lawsuit pursued by his 
family.
    In any event, that necessary treatment is repeatedly 
delayed or denied by ICE is supported by many other documents. 
There are letters and affidavits from prison wardens expressing 
profound exasperation with the denials of care.
    And one document, which I can't even begin to reconcile 
with humane treatments, lists the amount of money ICE saved by 
denying requests for treatment. Such requests which were all 
submitted by on-site medical personnel were for such things as 
tuberculosis, pneumonia, bone fractures, head trauma, chest 
pain and other serious complaints. How an off-site bureaucrat 
can deny a request to treat tuberculosis or a bone fracture, I 
just don't know, but the document makes it seem as if ICE is 
proud of that fact.
    Putting aside the inhumanity of denying necessary health 
care, the $1.3 million savings that ICE brags about in this 
document is going to pale in comparison to the money that DHS 
will have to pay when courts begin to rule against it, as they 
already have.
    With the large increase of detainees in ICE custody, it is 
incumbent upon this Congress to ensure that ICE is properly 
executing its responsibility of providing safe and humane 
treatment. I hope that today's hearing will help us begin to 
find solutions to what appears to be a very serious problem.
    [The prepared statement of Ms. Lofgren follows:]

 Prepared Statement of the Honorable Zoe Lofgren, a Representative in 
Congress from the State of California, and Chairwoman, Subcommittee on 
Immigration, Citizenship, Refugees, Border Security, and International 
                                  Law

    This committee already held a hearing on this subject on October 4, 
2007--exactly 8 months ago. At that hearing, we examined serious 
concerns with the provision of medical care at immigration detention 
facilities across the country. News reports of deaths--and the 
deficient care that may have led to those deaths--triggered that 
hearing.
    Unfortunately, here we are again. As was the case eight months ago, 
a string of recent news reports has severely shaken our confidence in 
the health care system used by ICE. The reports recount story after 
story of detainees who received inadequate care, or no care at all. And 
they speak of suffering and death.
    But this time, those stories are not just reports. The Washington 
Post and 60 Minutes support their stories with internal government 
documents and what appear to be many interviews with government 
whistleblowers who have uncovered severe problems and desperately want 
to see them fixed.
    Some of the witnesses today will deny that these problems exist. 
But I believe these claims are belied by the numbers of government 
officials who have reached out to the press--and to us--and by the 
documents that support their claims.
    The efforts of those whistleblowers tell me something--that there 
are people within our government who really care about the medical and 
mental health care provided at ICE facilities. But their stories and 
documents also say something else--that their pleas and warnings have 
gone largely unheeded for far too long.
    Documents tell us that employees widely complained of severe 
staffing shortages of medical personnel. ICE tells us that they are 
addressing these shortages now. But the documents indicate they ignored 
these warnings for years, failing to adequately address such shortages 
even as they ramped up enforcement and brought detention beds on line.
    Documents tell us that employees complained of certain policies 
that appear to be in violation of ICE's Detention Standards. For some 
time at the San Pedro facility, for example, the clinical director 
prohibited medical staff from doing any lab work for detainees--no 
matter what their condition--until they had been detained for more than 
30 days. As indicated by an internal DIHS document, this policy may 
have played a role in the death of a detainee with HIV who was denied 
medication during her first month in detention.
    Documents show that ICE's policies may be designed to deny care and 
save money rather than to provide care and save lives. Last October, 
Francisco Castaneda testified before our committee concerning the 
medical care he received, or failed to receive, during his detention. 
He is now dead. A quick review of his medical records shows that 
several on-site physicians recommended biopsy to rule out cancer. But 
it also shows that these requests were repeatedly denied, over a 10-
month period, by managed care coordinators here in DC.
    Some might say that this is just one case and does not signify 
anything. I disagree. When several doctors say that someone needs a 
simple biopsy, but this is denied not once, not twice, but repeatedly 
over 10 months by off-site bureaucrats, something is fundamentally 
wrong. No matter how this happened, there is no question the system 
failed Mr. Castaneda over and over again. He paid with his life, and 
now the government is on the verge of paying millions in a lawsuit 
pursued by his family.
    In any event, that necessary treatment is repeatedly delayed or 
denied by ICE is supported by many other documents. There are letters 
and affidavits from prison wardens expressing profound exasperation 
with delays and denials of necessary care. And one document, which I 
can't even begin to reconcile with humane treatment, lists the amount 
of money ICE saved by denying requests for treatment. Such requests, 
which were all submitted by on-site medical personnel, were for such 
things as tuberculosis, pneumonia, bone fractures, head trauma, chest 
pain and other serious complaints. How an off-site bureaucrat can deny 
a request to treat tuberculosis or a bone fracture, I don't know. But 
the document makes it seem as if ICE is proud of the fact.
    Putting aside the inhumanity of denying necessary health care, the 
$1.3 million savings ICE brags about in this document will pale in 
comparison to the money DHS will have to pay when courts begin to rule 
against it--as they already have.
    With the large increase of detainees in ICE custody, it is 
incumbent upon this Congress to ensure that ICE is properly executing 
its responsibility of providing safe and humane treatment. I hope that 
today's hearing will help us begin to find solutions to what appears to 
be a very serious problem.

    Ms. Lofgren. I now recognize our Ranking Minority Member 
Steve King for his opening statement.
    Mr. King. Thank you, Madam Chair.
    This Subcommittee just had a hearing on the topic of 
immigration detainee medical care 8 months ago, and I am not 
sure that the recent media blitz alleging poor medical care in 
a few isolated instances warrants a second hearing.
    The risk of being murdered in some U.S. cities is higher 
than the risk of dying in an immigration detention facility. 
That means people on the streets of America are not as safe as 
some of the people that are incarcerated under ICE. For 
example--and these numbers are significantly lower than other 
data I have seen. For example, 2005 FBI statistics show in the 
statistical metropolitan area encompassing the city of Houston, 
712.6 residents per 100,000 were victims of violent crime, and 
9.1 residents per 100,000 were murdered or victims of homicide. 
That is Houston. In Houston alone there are 334 people murdered 
on the streets.
    In the statistical metropolitan area including Los Angeles, 
575.5 per 100,000 were victims of violent crime; 8.8 out of 
every 100,000 were victims of murder. In Los Angeles alone 
there were 489 people murdered in 2005.
    Some other examples would be the recent shootings in 
Washington, D.C. For example, my legislative counsel's 
neighborhood had four murders in a single 24-hour period right 
in the same neighborhood.
    And in the Chicago shootings that we know about, 32 
shootings over a weekend, at one time the death count was 6, 
and then it went to 12 or 13 in a single weekend. And we are 
here having a hearing about people incarcerated by ICE and 
getting medical care that is addressing their chronic illnesses 
as well that they come with. But during that same period of 
time, 2005, there were 6.8 deaths per 100,000 immigration 
detainees, many of whom were unhealthy when they arrived, and 
that is in ICE facilities. The number has dropped in subsequent 
years, and the data is getting stronger.
    I would submit that the constituents of the Members of this 
Committee would be better served if our focus was on the high 
risk of being murdered and violently victimized on the streets 
of their own cities and own communities rather than focusing on 
a media event that doesn't have the data to back up the 
necessity for this hearing.
    In any event, I am happy to use this opportunity to 
congratulate Ms. Myers for taking a lead role in reinvigorating 
ICE's worksite enforcement efforts, and that includes Iowa, and 
I thank you. All of us concerned about the impact of illegal 
immigration on American workers are grateful for your efforts. 
The death rate in our immigration detention facilities are low 
and dropping despite the fact that 25 percent of the detainee 
population already had a chronic illness such as hypertension, 
diabetes, tuberculosis, asthma, HIV/AIDS and seizure disorders 
when they came into ICE custody because they come from places 
where they don't get health care. That is why they are carrying 
chronic illnesses with them. This is the best and sometimes the 
first medical care that they have been exposed to in their 
lifetime.
    This is a fundamental difference between criminal 
incarceration and immigration detention. Prison inmates who 
have been sentenced to incarceration cannot choose when they 
are released. They are detained in order to provide punishment 
and rehabilitation to safeguard the community, and to deter 
other criminals.
    The medical care provided by the Bureau of Prisons ensures 
that inmates are not prevented from serving their full 
sentences, which average 9 years, because of illness. However, 
illegal immigrants and illegal aliens are in detention an 
average of only 37\1/2\ days, and they hold the keys to their 
own cells because immigration detainees can simply agree to 
their own deportations.
    Why should the American taxpayer be liable for providing 
Rolls Royce-quality medical care for aliens who are doing 
everything in their power to stay detained and therefore avoid 
deportation? ICE should not have to make up for a lifetime of 
poor medical care during this brief period of detention. Once 
they enter the ICE detention system, most immigration detainees 
are getting by far the best medical care they have had in their 
entire lives. It has cost the Federal taxpayers more than $360 
million to provide such care since ICE was created 5 years ago, 
$100 million in the last fiscal year alone.
    But let's not forget that the full cost to American 
taxpayers for the health care of illegal immigrants is far more 
than the cost incurred by ICE detention. The majority of 
illegal aliens do not have health insurance. As a result, 
hospitals in the southwest border counties of Texas, New 
Mexico, Arizona and California alone incur a cost of $190 
million for uncompensated emergency medical treatment to 
illegal aliens.
    The California Hospital Association worries that care for 
illegal aliens could tip some hospitals into bankruptcy; and, 
in fact, some have closed. The medical crisis caused by 
uninsured illegal immigrants clogging our emergency rooms and 
seeking free medical care is also compromising our citizens' 
accessibility to emergency health care. On top of all of these 
costs, it appears that some want to give detained illegal 
immigrants a blank check written on the account of the American 
taxpayer.
    Legislation introduced by Chair Lofgren seems to require 
American taxpayers to pay medical bills for immigration 
detainees even after they have been released or removed to 
their home country. That is not the taxpayer's responsibility.
    We need to make decisions in this Committee and in this 
Congress based upon data, not anecdotes, and to allege the 
inhumanity of denying necessary health care I don't think can 
be substantiated, and I don't agree with that statement, and I 
look forward to the hearing. I look forward to the testimony of 
the witnesses. Thank you, Madam Chair.
    [The revised and extended remarks of Mr. King follows:]

      Revised and Extended Remarks of the Honorable Steve King, a 
Representative in Congress from the State of Iowa, and Ranking Member, 
 Subcommittee on Immigration, Citizenship, Refugees, Border Security, 
                         and International Law

Replace this text:

    ``For example, 2005 FBI statistics show that in the statistical 
metropolitan area encompassing the city of Houston, 712.6 residents per 
100,000 were victims of violent crime and 9.1 residents per 100,000 
were murdered or victims of homicide. In the city of Houston alone, 
there were 334 people murdered in 2005. In the statistical metropolitan 
area including Los Angeles, 575.5 per 100,000 residents were victims of 
violent crime--with 8.8 per 100,000 murders and homicides. In Los 
Angeles alone, there were 489 people murdered in 2005.''

With the following paragraphs:

    ``For example, 13 homicides took place during one week of March 
this year in our nation's capitol, Washington DC. Not to be left 
behind, during a six-day period in April, Chicago suffered a shooting 
spree that left 12 dead. The 2005 U.S. Census Bureau statistics show 
that in Congressman Gutierrez's city of Chicago, there were 443 murders 
in 2005, or 15.6 deaths per 100,000. In the Chairman of the House 
Committee on the Judiciary John Conyers' city of Detroit, Michigan 
2,361 residents per 100,000 were victims of violent crime and there 
were 1,858 murders in 2005, or 41.4 deaths per 100,000. In 
Congresswomen Zoe Lofgren, Maxine Waters and Linda Sanchez' state of 
California, Los Angeles had 1,628 murders in 2005, or 12.6 deaths per 
100,000 and 821 per 100,000 residents were victims of violent crime. In 
Congresswoman Sheila Jackson Lee's city of Houston, Texas 1,173 
residents per 100,000 were victims of violent crime and there were 860 
murders, or 16.3 deaths per 100,000.
    While 15 detainees died while under ICE custody in 2005, and while 
the Members who represent the four cities I mentioned demanded we 
retreat from Iraq due to American loss of life, and while 676 brave 
American soldiers gave their lives in a just cause, 4,789 individuals 
were murdered on the streets of just four cities without a word of 
concern from the Members who represent many of the victims and their 
families. These statistics support the fact that residents of Chicago, 
Detroit, Los Angeles or Houston would be safer in an ICE detention 
facility than walking on the streets of these cities. Constituents of 
the Majority members of the House Judiciary Committee would be better 
served if our focus was on the high risk that they will be murdered or 
victimized by violent criminals in their own communities.''

    Ms. Lofgren. I would just note that on the bill I have 
introduced, it does not require provision of care after 
release, but I would be happy to discuss that off agenda.
    I would now recognize the Chairman of the full Committee 
Mr. John Conyers.
    Mr. Conyers. Thank you, Chairman Lofgren and Members. This 
is, I think, important.
    I want to agree to this extent with the opening statement 
of my friend Steve King. Maybe we are able, Steve, to do both 
things. We have to deal with the crime problem that you've 
reported in your statistics, which are accurate, and perhaps 
with this problem of how people who are brought into our 
custody are treated afterward. I want my statement to be 
included in the record.
    I just wanted to welcome the head of ICE, whom I hadn't met 
before, Ms. Myers. I wanted to welcome her, and I wanted to 
talk with the Committee about this sudden breakout of mass 
arrests, the largest in history, in Iowa last month, 300 
undocumented people arrested, going all over, raids everywhere, 
mass round-ups. Have we had a hearing on that yet?
    Ms. Lofgren. No, Mr. Chairman, but if you are suggesting, 
we can.
    Mr. Conyers. I would like to talk with Steve King about it 
first.
    I yield to the gentleman.
    Mr. King. I thank the Chairman. I think that would be a 
constructive thing to do, and I would be very interested in 
joining together for a request for a hearing.
    Mr. Conyers. Thank you very much.
    There is some kind of evenhandedness that ought to be 
required. Employers bring in all these people. They know who is 
illegal or undocumented or not. I think we have to start 
rounding some of them up, too. But that's a subject for another 
time.
    I figure it is pretty reasonable that we look at this 
subject matter again. As my friend pointed out, it was 8 months 
ago we did this, but things keep happening, and let's stipulate 
that a lot of people that have come here illegally need medical 
assistance, but the question is what do we do about it?
    And I will just close because I have been talking to some 
of my friends here in the Congress and on the Committee about 
universal health care, and a kind of similar issue that Steve 
raised comes up. Well, if you have universal health care, why 
include immigrants? Well, because they are going to spread 
disease and make it tough on all of us who might someday have 
universal health care.
    So these are the interesting questions that surround this 
hearing. You have brought together a great panel of witnesses, 
and I thank you for allowing my opening comments.
    [The prepared statement of Mr. Conyers follows:]

Prepared Statement of the Honorable John Conyers, Jr., a Representative 
in Congress from the State of Michigan, and Chairman, Committee on the 
                               Judiciary

    A very disturbing pattern appears to be developing at the 
Department of Homeland Security. First, there are revelations about 
medical abuses, problematic raids, misplaced emergency priorities, and 
inappropriate costumes. And, then--only after a formal Congressional 
inquiry--the Department either denies there's a problem or announces 
plans to correct it.
    Today, we are going to continue our efforts to address one of these 
recurrent problems, namely, the broken medical system in our Nation's 
detention facilities. As many of you will recall, this Subcommittee 
held a hearing on this issue last year where we heard the heartbreaking 
testimony of a woman who stood helpless as her sister died behind bars 
because ICE would not give her access to her medications.
    But the reports of grossly inadequate detainee medical care 
continue to surface. This callous disregard for detainee's medical 
conditions must stop.
    Accordingly, I want Assistant Secretary Julie Myers, and the other 
witnesses to respond to three specific concerns.
    First, I want to hear what concrete steps DHS has taken since our 
hearing last October, and what concrete steps are will be undertaken 
going forward. In the eight months since our last hearing, it appears 
little has changed. That is why I am a proud cosponsor of Chairwoman 
Lofgren's bill, the Detainee Basic Medical Care Act of 2008, which will 
address this problem.
    Second, I want hear what the DHS Inspector General has done and 
will do to investigate the deaths in custody, not just on a case-by-
case basis, but across the board as well.
    Third, I want to hear DHS's response to reports about a recent raid 
at a meatpacking plant in Iowa.
    In that raid, immigrants were penned up in a fairground and 
subjected to a new version of assembly-line justice, in which criminal 
charges and limited access to counsel replaced the normal 
administrative immigration charges.
    I want Ms. Myers and the other witnesses to tell us today what ICE 
is doing to address health care and humanitarian concerns when these 
mass raids are being undertaken. What kind of health care was provided 
in Iowa? Was anyone sent back home without receiving any treatment? Is 
this just an isolated incident or can we expect this to become the 
Department's ``standard operating procedure.''
    DHS should ensure that basic standards of life, safety, health 
care, due process, and Constitutional rights are maintained, not just 
in response to public scandal.

    Ms. Lofgren. I now recognize the distinguished Ranking 
Member of the full Committee, the gentlemen from Texas, Mr. 
Smith.
    Mr. Smith. Madam Chairman, recent news reports detail cases 
of severe injury and even death in DHS detention facilities. 
Each of the instances as reported is heartbreaking to family 
members and of concern to all of us. However, we should not 
rush to judgment based on one-sided media accounts about the 
reported deficiencies in health care received by a few illegal 
immigrant detainees. Congress has a responsibility to rely on 
the facts in order to determine if there is a serious problem 
with the medical treatment provided to these detainees.
    Since 2004, 71 individuals out of over 1 million detained 
have died while in DHS custody. Many of these individuals enter 
detention facilities with prior medical conditions that can 
cause injury or death.
    About one-quarter of all immigration detainees are 
diagnosed as having chronic illnesses when they enter the 
detention facility. Many of these individuals are being 
diagnosed for the first time, and many of them have infectious 
diseases such as tuberculosis, which poses a serious health 
threat to Americans. Immigrants, at over 12 percent of the 
population now, account for more than half of all tuberculosis 
cases in the U.S. That means that immigrants are over four 
times more likely to carry that contagious disease than native-
born Americans.
    Last year, ICE spent nearly $100 million on detention 
immigration health care, double the funding level that existed 
just 5 years ago. Medical facilities at all ICE-managed and -
contracted detention centers are required to meet or exceed 
normal accreditation standards. Immigration detainees are 
provided extensive free health care far beyond that available 
to many of the American taxpayers who pay for the detainees' 
health care.
    In a recent series, The Washington Post alleged that there 
is ``a hidden world of flawed medical judgments, faulty 
administrative practices, neglectful guards, ill-trained 
technicians, sloppy recordkeeping, lost medical files and 
dangerous staff shortages.'' Yet according to ICE, the Post 
reporters made no requests to tour a single ICE detention 
facility.
    A July 2007 Government Accountability Office report on 
alien detention standards found no systemic problems in health 
care delivery or any pattern of noncompliance with applicable 
standards.
    Substantiated allegations of improper medical care to 
immigration detainees should be fully investigated. If it is 
determined in a particular case that a detainee was denied 
appropriate treatment, was not properly monitored or received 
negligent care, then corrective measures must be taken.
    Congress should be clear that it is not the responsibility 
of ICE, or the American taxpayer, to pay for or ensure the 
medical care of aliens after they are removed from our country. 
Nor is it the responsibility of ICE, or the American taxpayer, 
to keep aliens in detention solely for the purpose of providing 
them care.
    Today ICE and the Division of Immigration Health Services 
have an opportunity to present their side of the story.
    Holding hearings on this issue is important, but we must 
have reasonable and realistic standards. Medical care is not 
always perfect regardless of whether it is administered in a 
detention center prison or even the emergency room of a 
hospital.
    I thank you, Madam Chair, and I yield back the balance of 
my time.
    Ms. Lofgren. Thank you, Mr. Smith.
    [The prepared statement of Mr. Smith follows:]

 Prepared Statement of the Honorable Lamar Smith, a Representative in 
Congress from the State of Texas, and Ranking Member, Committee on the 
                               Judiciary

    Recent news reports detail cases of severe injury and even death in 
DHS detention facilities. Each of the instances as reported is 
heartbreaking to family members and of concern to all of us.
    However, we should not rush to judgment based on one-sided media 
accounts about the reported deficiencies in health care received by a 
few illegal immigrant detainees.
    Congress has a responsibility to rely on the facts in order to 
determine if there is a serious problem with the medical treatment 
provided to these detainees.
    Since 2004, 71 individuals--out of one million detained--have died 
while in DHS custody. Many of these individuals enter detention 
facilities with prior medical conditions that can cause injury or 
death.
    About one-quarter of all immigration detainees are diagnosed as 
having chronic illnesses when they enter the detention facility. Many 
of these individuals are being diagnosed for the first time. And many 
of them have infectious diseases, such as tuberculosis, which pose a 
serious health threat to Americans.
    Immigrants at over 12 percent of the population now account for 
more than half of all tuberculosis cases in the U.S. That means that 
immigrants are over six times more likely to carry that contagious 
disease than native-born Americans.
    Last year, ICE spent nearly $100 million on immigration detention 
health care, double the funding level that existed five years ago. 
Medical facilities at all ICE-managed and contracted detention centers 
are required to meet or exceed normal accreditation standards.
    Immigration detainees are provided extensive free health care far 
beyond that available to many of the American taxpayers who pay for the 
detainees' care.
    In a recent series, the Washington Post alleged that there is ``a 
hidden world of flawed medical judgments, faulty administrative 
practices, neglectful guards, ill-trained technicians, sloppy record 
keeping, lost medical files and dangerous staff shortages.'' Yet, 
according to ICE, the Post reporters made no request to tour a single 
ICE detention facility.
    A July 2007 Government Accountability Office (GAO) report on alien 
detention standards found no systemic problems in health care delivery 
or any pattern of non-compliance with applicable standards.
    Substantiated allegations of improper medical care to immigration 
detainees should be fully investigated. If it is determined in a 
particular case that a detainee was denied appropriate treatment, was 
not properly monitored, or received negligent care, then corrective 
measures must be taken.
    Congress should be clear that it is not the responsibility of ICE--
or the American taxpayer--to pay for or ensure the medical care of 
aliens after they are removed from our country. Nor is it the 
responsibility of ICE--or the American taxpayer--to keep aliens in 
detention for the purpose of providing them with care.
    Today, ICE and the Division of Immigration Health Services have an 
opportunity to present their side of the story.
    Holding hearings on this issue is important. But we must have 
reasonable and realistic standards. Medical care is not always perfect, 
regardless of whether it is administered in a detention center, prison 
or even the emergency room of a hospital.

    Ms. Lofgren. In the interest of proceeding to our 
witnesses, and mindful of the schedule, I ask other Members to 
submit their statements for the record. Without objection, all 
opening statements will be placed into the record.
    [The prepared statement of Ms. Jackson Lee follows:]

       Prepared Statement of the Honorable Sheila Jackson Lee, a 
    Representative in Congress from the State of Texas, and Member, 
 Subcommittee on Immigration, Citizenship, Refugees, Border Security, 
                         and International Law

    Madam Chair, thank you for your leadership in convening today's 
very important hearing concerning the problems with immigration 
detainee medical care. I would also like to thank the ranking member, 
the Honorable Steve King. This hearing will explore recent reports 
about inadequate medical care for immigrant detainees and deaths while 
in custody.
    The hearing will also examine the quality of medical and mental 
health care provided in detention facilities under ICE's jurisdiction. 
The Subcommittee will study ICE's medical and mental health care 
standards and procedures, and it will specifically look into the deaths 
of the growing number of immigration detainees that have died during or 
as a result of ICE custody, seeking to resolve the extent to which 
policies, procedures, or practice caused these deaths. Finally, the 
Subcommittee will seek recommendations to address any potential 
problems.
    The Bureau of Immigration and Customs Enforcement (ICE) within the 
Department of Homeland Security (DHS) is responsible for the arrest, 
detention, and removal of deportable non-citizens. In 2006, ICE 
detained nearly 300,000 men, women, and children--most of whom had no 
criminal history. This was three times the amount of immigration 
detainees held by ICE in 2001, when less than 100,000 were detained. 
ICE holds its immigration detainees in one of over 300 detention 
facilities across the country. A small percentage of these detainees 
are housed in 8 ICE-owned and operated service processing centers 
(SPCs), including the Krome SPC in Miami, the Florence SPC in Arizona, 
and the Port Isabel SPC in Texas. ICE also houses a small percentage of 
its detainees in 6 contract detention facilities (CDFs), which are 
operated by private contractors specifically for ICE. The majority of 
detainees are held with general population inmates in about 300 
federal, state, and local jails and other facilities, which operate 
through intergovernmental service agreements (IGSAs) with ICE. In 
addition to these adult detention facilities, ICE contracts for the 
operation of 19 juvenile and 3 family detention facilities.
    In carrying out its detention and removal responsibilities, ICE is 
charged with ensuring that conditions are safe and humane in all 
detention facilities used to hold immigration detainees. These 
responsibilities include the provision of adequate medical and mental 
health care to detainees.
    On October 4, 2007, the Subcommittee held a hearing on medical care 
in detention facilities after a New York Times article uncovered that 
at least 62 people had died in ICE custody between 2004 and 2007. Since 
that hearing, major media outlets have reported additional deaths and 
have released documents indicating that some of these deaths were the 
result of deficient medical care. A four-part series recently released 
by the Washington Post raises similar concerns about the medical and 
mental health care system at ICE detention facilities. This series, 
founded on internal ICE documents and interviews with detention 
facility employees, asserts severe staffing shortages of medical 
personnel, long and routine delays in the provision of medical 
treatment, frequent denials of necessary medication for chronic 
illnesses, and a system geared to deny care rather than provide it.
    In July 2007, the U.S. Government Accountability Office (GAO) 
issued a report detailing additional problems with detention 
conditions. The GAO report noted that when off-site medical care for 
detainees appeared necessary, ICE determined whether to authorize such 
care in conjunction with a DIHS Managed Care Coordinator (MCC). 
According to the report, officials at some detention facilities 
reported difficulty caring for detainees who required off-site medical 
and mental health care because they were unable to get authorization to 
provide that specialty care.
    In addition, numerous media outlets--including the New York Times, 
The Washington Post, and 60 Minutes--have reported stories suggesting a 
lack of proper medical care for detainees. On June 13, 2007, the 
Washington Post reported on a number of cases involving immigration 
detainees who allegedly received inadequate medical care. That same 
day, a class action lawsuit was filed on behalf of all immigration 
detainees at the San Diego Correctional Facility (SDCF). The lawsuit, 
Woods v. Myers, No. 07-cv-1078 (S.D. Cal.) charged ICE, DIHS, and the 
Corrections Corporation of America, Inc. with failing to provide 
adequate medical and mental health care to SDCF detainees. According to 
the complaint, the 11 named plaintiffs suffered from mental illness, 
chronic health conditions, and serious injuries that had not been 
appropriately treated while in ICE custody.
    Later in June 2007, the New York Times reported that at least 62 
immigrants had died in ICE custody since 2004. In July, the editorial 
board of the Miami Herald called upon Congress to investigate this 
issue and require ICE to publicly report each death that occurs in 
custody and to adopt legally binding healthcare standards.
    Since the Subcommittee hearing in October, numerous reports from 
major media outlets have raised additional concerns with the medical 
and mental health care provided in immigration detention centers. On 
May 5, 2008, the New York Times revealed a list of 66 individuals who 
had died in ICE custody, reporting details on several of the deaths 
that raised serious concerns about the quality of the medical care they 
received.
    This article was followed by an extensive, four-part series on 
detainee medical care by the Washington Post in May. According to the 
Washington Post, this series of articles was based on an extensive 
investigation involving the review of thousand of internal ICE 
documents and interviews with numerous ICE and DIHS personnel. The 
articles--as well as the internal ICE documents produced along with the 
articles--reveal serious staffing shortages of medical personnel, 
regular delays in the provision of medical treatment, and frequent 
denials of necessary treatment. In the first part in the series, System 
of Neglect, the Washington Post summarized their investigation as 
follows:

        The most vulnerable detainees, the physically sick and the 
        mentally ill, are sometimes denied the proper treatment to 
        which they are entitled by law and regulation. They are locked 
        in a world of slow care, poor care and no care, with panic and 
        coverups among employees watching it happen, according to a 
        Post investigation.

        The investigation found a hidden world of flawed medical 
        judgments, faulty administrative practices, neglectful guards, 
        ill-trained technicians, sloppy record-keeping, lost medical 
        files and dangerous staff shortages. It is also a world 
        increasingly run by high-priced private contractors. There is 
        evidence that infectious diseases, including tuberculosis and 
        chicken pox, are spreading inside the centers.

    By statute and regulation, the U.S. Public Health Service (PHS) may 
provide medical, surgical, psychiatric, and dental care to immigration 
detainees around the country. However, PHS provides on-site health care 
to only a small percentage of ICE detainees. PHS officers provide on-
site medical and mental health care at ICE-run service processing 
centers (SPCs) and several of the contract detention facilities (CDFs) 
and intergovernmental service agreement facilities (IGSAs). At all 
other facilities, including virtually all state and county jails 
operating under IGSAs with ICE, on-site medical care is provided either 
by the county or a private company that owns or operates the facility, 
or by private, for-profit companies that specialize in correctional 
health care.
    ICE holds its immigration detainees in one of over 300 detention 
facilities across the country. A small percentage of these detainees 
are housed in 8 ICE-owned and operated service processing centers 
(SPCs), including the Krome SPC in Miami, the Florence SPC in Arizona, 
and the Port Isabel SPC in Texas. ICE also houses a small percentage of 
its detainees in 6 contract detention facilities (CDFs), which are 
operated by private contractors specifically for ICE.
    I look forward to hearing from today's witnesses. I truly hope that 
we can understand the problems with immigration detainee medical care 
and that we can also develop some solutions. I look forward to the 
testimony of today's witnesses. Thank you, and I yield the balance of 
my time.

    Ms. Lofgren. We have two distinguished panels of witnesses 
here today to help us consider the important issues before us. 
Seated on our first panel is Ms. Julie Myers, Assistant 
Secretary for U.S. Immigration and Customs Enforcement (ICE). 
Previously she served as Assistant Secretary for Export 
Enforcement at the Department of Commerce, Chief of Staff for 
the Criminal Division at the Department of Justice, and Deputy 
Assistant Secretary for Money Laundering and Financial Crimes 
at the Treasury Department.
    Before entering Government service Ms. Myers was an 
associate at Mayer, Brown and Platt in Chicago, and she earned 
a bachelor's degree at Baylor University and a law degree from 
Cornell University.
    Next we have Dr. Philip Farabaugh, the new Acting Director 
of the Division of Immigration Health Services, or DIHS, which 
we understand was recently moved from Health and Human Services 
to the Department of Homeland Security. Prior to his position 
as Acting Director, Dr. Farabaugh was the clinical director at 
the Tacoma detention facility in Tacoma, Washington.
    And the final witness on our first panel is Mr. Richard 
Stana, Director of Homeland Security and Justice Issues for the 
U.S. Government Accountability Office. During his 32-year 
career with the GAO, he has directed reviews in a wide variety 
of complex military and domestic issues. Most recently he has 
managed GAO's work relating to immigration and border security 
issues. He is a graduate of Cornell University and Harvard 
University's JFK School of Government. He also earned a 
master's degree from Kent State University.
    Given the gravity of the issues we are discussing today and 
the key roles you all play, we would appreciate you taking an 
oath before you begin your testimony. Would each of you please 
stand and raise your right hand.
    [Witnesses sworn.]
    Ms. Lofgren. The clerk will note that all three witnesses 
have agreed to the oath.
    Your written statement will be made a part of the record in 
its entirety. We would ask now that you summarize your 
testimony in about 5 minutes. The little machine on the desk 
will flash a yellow light when you have 1 minute left, and when 
the red light goes on, we would ask you to conclude the 
testimony so we have time for our questions.
    Ms. Myers, we will begin with you.

TESTIMONY OF JULIE MYERS, ASSISTANT SECRETARY, IMMIGRATION AND 
CUSTOMS ENFORCEMENT (ICE), U.S. DEPARTMENT OF HOMELAND SECURITY

    Ms. Myers. Thank you very much.
    Good afternoon, Chairwoman Lofgren and distinguished 
Members of the Subcommittee. I appreciate the opportunity to 
appear before you today.
    Chairwoman Lofgren, you're right, people in Government do 
care. The men and women of ICE care. The men and women of the 
DIHS care, and we work every day to ensure that those in our 
custody are treated in accordance with the ICE detention 
standards.
    As you know, ICE was formed in 2003 with the broad mission 
that includes immigration and customs enforcement and 
management of the detention and removal processes for 
apprehended aliens. Indeed, with such an important mission, we 
had to look and see could we have additional oversight, 
additional oversight not only for medical care, but really for 
all of our detention, knowing that there are a large number of 
aliens in our custody.
    I think we have worked very hard over the past couple of 
years to see where there are places where we can improve 
detention oversight. To that end, I think the GAO has been very 
helpful, the IG, as well as Congress and NGOs, in giving us 
ideas and suggestions on how we can make sure that everyone in 
our custody is treated in accordance with the ICE detention 
standard.
    We have done a number of things. Just giving a few 
highlights of things that we have done for detention oversight 
overall, including but not limited to medical care, in February 
2007 we established the Detention Field Inspection Group, and 
that is a group that is an independent arm that reports to the 
Office of Professional Responsibility. They can go out and do 
an independent inspection of a detention facility to see if 
they are meeting up to the medical standard as well as all 
other standards in the ICE detention standard. Before that 
there was no such independent group.
    In addition, we looked at our overall reviews of 
facilities, and we recognized that previously under the old 
INS, they used detention and removal officers who tried to do a 
good job, but they were detention and removal officers who 
actually did the annual compliance inspections. We changed 
that. We contracted with outside groups to do annual reviews of 
our facilities in order to make sure that we were getting the 
best information, and if there were deficiencies, they could be 
corrected. These deficiencies would include anything we needed 
to work on with respect to medical oversight.
    In addition, we have hired quality assurance specialists at 
40 of our largest facilities. Their only job is to make sure 
that ICE is complying with the ICE detention standards. And we 
have also published our first Semiannual Report on Compliance 
with the ICE National Detention Standards.
    We created the first National Detainee Handbook, and we 
have undertaken a comprehensive review of the current National 
Detention Standards to see whether or not they could be 
improved. We think they could be, so we are working to make 
them more performance-based, working with the NGOs, the IGs, 
DHS, CRCL and so on.
    Turning specifically to detainee health care and oversight, 
let me begin with some context. ICE spent almost $100 million 
on detainee health care last fiscal year, double the funding of 
just 5 years ago. And this doesn't even include the funding 
providing for routine health care at IGSAs. During that same 
period, the number of detention beds managed by ICE has grown 
by approximately 30 percent, and since ICE was established, 
nearly 1.5 million individuals have passed through our custody. 
And although the ICE detainee population has increased by more 
than 30 percent since 2004, the actual number of deaths in ICE 
detention has declined from 29 in 2004 to 7 for the last 
calendar year, and there have been no suicides in the last 15 
months.
    But there is still more work to do. ICE law enforcement 
officers are not medical professionals, so we have historically 
relied on the independent medical judgment of the experts, the 
Public Health Service and DIHS.
    By way of background, all detainees are required to receive 
an initial health screening within the first 12 hours and a 
physical examination within 14 days. And as Representative King 
noted, last year nearly 34 percent of detainees were diagnosed 
with a chronic condition.
    Despite all of this, we recognize that there is need to 
take additional steps. Among them was the need to strengthen 
the suicide prevention process. The reality is since 2003, 
suicides have accounted for 18 percent of the 74 deaths of 
detainees in our custody. Even one preventable death is too 
many, so in the last 2 years ICE instituted an extensive 
suicide prevention program, and we have not had a single 
suicide in the last 15 months.
    We also are looking at the TAR process, and I believe there 
is room for improvement on the appeals of TARs, and so we are 
working with the Office of Health Affairs to see how we can 
strengthen the TARs process and provide for more oversight by 
independent individuals, as well as have the detainees have 
more of a role in that.
    We are also working with the DHS Office of Health Affairs 
to improve operations at DIHS. Already we have reduced the 
staffing issues from 30 percent vacancies down to 18. In 
addition, we have asked the Office of Health Affairs to assess 
all of DIHS's procedures to determine whether or not there are 
additional things we can do to strengthen oversight for those 
who are in our custody.
    The final thing we have done is respond to suggestions that 
we need to have more transparency in the reporting of deaths. 
And so we have talked with the DOJ, and we are going to begin 
reporting voluntarily pursuant to the Deaths in Custody 
Reporting Act so that the Bureau of Justice Statistics will 
have our information, and they can access it as appropriate.
    In closing, I want to say we are committed to working with 
you, outside groups and others to improve our processes and 
ensure that those in our custody are well cared for. Thank you.
    Ms. Lofgren. Thank you.
    [The prepared statement of Ms. Myers follows:]

                  Prepared Statement of Julie L. Myers





















    Ms. Lofgren. Dr. Farabaugh, we would be pleased to hear 
from you.

  TESTIMONY OF PHILIP FARABAUGH, ACTING DIRECTOR, DIVISION OF 
     IMMIGRATION HEALTH SERVICES, IMMIGRATION AND CUSTOMS 
    ENFORCEMENT (ICE), U.S. DEPARTMENT OF HOMELAND SECURITY

    Dr. Farabaugh. Good afternoon, Chairwoman Lofgren and 
Members of the Subcommittee, and thank you for allowing me to 
appear before you today.
    The Division of Immigration Health Services provides or 
arranges for health care and public health services in support 
of immigration law enforcement. As a unit within U.S. 
Immigration and Customs Enforcement, ICE, DIHS serves as the 
provider of medical and mental health care for detainees housed 
in DIHS-staffed detention facilities.
    DIHS oversees the financial authorization and payment for 
off-site specialty and emergency care for all detainees in ICE 
custody, whether in DIHS or Intergovernmental Service Agreement 
facilities.
    DIHS comprises medical professionals and support personnel 
detailed from the U.S. Public Health Service, General Schedule 
employees and contracted medical staffing services. The PHS is 
granted the authority to provide and arrange this care by 
virtue of section 322 of the Public Health Service Act ``Care 
and Treatment of Persons Under Quarantine and Certain Other 
Persons.''
    Each individual who comes through detention facilities 
receives an initial medical screening within 12 hours of their 
arrival into custody. Those remaining in ICE supervision at 
least 14 days receive a comprehensive physical examination. 
Many of these detainees initially learn of a medical ailment or 
receive medical care and treatment for the first time through 
this comprehensive screening. Each individual receives specific 
treatment, as medically necessary according to their illness. 
In fiscal year 2007, of the 184,448 screenings, approximately 
34 percent, or 63,000 individuals, were identified as having 
chronic conditions, most diagnosed with hypertension or 
diabetes.
    To address the needs of the growing number of detainees, 
DIHS mental health staff have provided over 31,000 patient 
encounters for psychological services since April 2007. These 
services include psychological assessments and followups, 
individual psychotherapy sessions, initial psychiatric 
evaluations, psychiatric medication and medication management 
followup, acute mental health hospitalizations, suicide risk 
assessment and follow-up. This list is not all-inclusive, and 
applies only to those detainees in facilities where DIHS mental 
health officers and staff are assigned.
    Individuals who have acute or chronic health care needs are 
referred to a primary care provider for evaluation and medical 
treatment. Those found to have an infectious disease are placed 
in the appropriate health care setting and receive treatment 
for their condition.
    Patients are treated in accordance with nationally 
recognized standards and guidelines. This care may be given off 
site or on site, as appropriate for the individual patient's 
clinical condition. Examples of such care include imaging 
studies like X-rays, CT scans, and MRIs; surgery for broken 
bones, heart conditions, gallstones, and appendicitis; and 
specialty consultation with urology for a bladder disorder, 
infectious disease for a patient with HIV, and gastroenterology 
for evaluation of stomach ulcers. Pregnant detainees are 
referred to community obstetricians to ensure the appropriate 
prenatal care is delivered.
    The DIHS medical staff and epidemiology branch monitor 
tuberculosis cases to ensure continuity of care, whether the 
detainee is to be released from custody into the United States 
or returned to his or her country of origin. Between January 1, 
2007, and May 31, 2008, ICE coordinated the repatriations to 
home countries of 156 individuals with active or suspected 
active tuberculosis. DIHS seeks to minimize stress to public 
health domestically and globally and prevent transmission of 
drug-resistant and multidrug-resistant tuberculosis.
    Each DIHS-staffed clinic has a written plan for delivery of 
24-hour emergency health care or immediate outside medical 
attention. All facilities have arrangements with nearby medical 
facilities or health care providers for health care not 
provided within the facility. These arrangements require 
appropriate custodial officers to transport and remain with the 
detainee for the duration of any off-site treatment or hospital 
admission. When an ICE detainee is hospitalized, the hospital 
assumes medical decisionmaking authority, including the 
patient's drug regimen, lab tests, et cetera.
    Each DIHS clinic has a mechanism that allows detainees to 
request health care services provided by a physician or other 
qualified medical officer in a clinical setting. Detainees, 
especially those who are illiterate or do not speak English, 
can receive assistance in filling out the request slip to 
access health care providers.
    Each detainee who is identified with a chronic care issue 
is treated and educated on self-care needs, and appropriate 
treatment and follow-up is coordinated.
    DIHS maintains accreditation from three nationally 
recognized accrediting bodies to ensure the quality of health 
care meets industry standards. This includes the American 
Correctional Association, the National Commission on 
Correctional Health Care, and the Joint Commission on 
Accreditation of Health Care Organizations, as well as the ICE 
National Detention Standards to evaluate the care provided to 
our detainees.
    All DIHS health care providers who care for detainees are 
required to be licensed and credentialed under the same 
guidelines as those serving the U.S. Bureau of Prisons and in 
other Federal or community facilities, and we have an ongoing 
credentials-monitoring program to identify and correct any 
noted deficiencies.
    Thank you once again for allowing me to provide testimony 
before your Committee today, and I am happy to answer any 
questions you may have.
    Ms. Lofgren. Thank you.
    [The prepared statement of Dr. Farabaugh follows:]

                 Prepared Statement of Philip Farabaugh











    Ms. Lofgren. We will turn to you now, Mr. Stana.

TESTIMONY OF RICHARD M. STANA, DIRECTOR, HOMELAND SECURITY AND 
        JUSTICE ISSUES, GOVERNMENT ACCOUNTABILITY OFFICE

    Mr. Stana. Thank you, Chairman Lofgren and Mr. King, for 
the invitation to testify at today's hearing on ICE's adherence 
to medical care standards in its detention facilities.
    As you know, ICE maintains custody of a highly transient 
and diverse population, with individuals from many countries 
with varying medical conditions and security risks; and 
includes males, females and families of every age group. The 
care and treatment of aliens while in detention is a 
significant challenge to ICE, as concerns continue to be raised 
by Members of Congress and advocacy groups about the treatment 
of the growing number of aliens while in ICE's custody.
    In response to a request from the House Judiciary and 
Homeland Security Committees, we reported last summer on ICE's 
adherence to its National Detention Standards to help ensure 
appropriate conditions of confinement.
    Of the 38 standards, we selected 8 for examination based on 
discussions with UNHCR, the ABA and the OIG. These dealt with 
telephone access, medical care, hold room procedures, use of 
force, food services, recreation, access to legal materials, 
and detainee grievance procedures. Our report did not 
specifically examine the quality of medical care issues, as 
that was the subject of a separate request from this Committee.
    I would like to discuss three main items that are germane 
to today's hearing. First, at the time of our visits, we 
observed instances of noncompliance with ICE's medical care 
standards at 3 of the 23 facilities we visited, but these 
instances did not show a pervasive or persistent pattern of 
noncompliance across the facilities like those we identified 
with the telephone system. Specifically, at the San Diego 
facility in California, an adult detention facility, ICE 
reviewers that we accompanied cited PHS staff for failing to 
administer the mandatory 14-day physical exam to approximately 
260 detainees. At the Casa de San Juan Family Shelter in 
California, we found that the facility staff did not administer 
medical screenings immediately upon admission. And at the 
Cowlitz County Juvenile Detention Center in Washington State, 
we found that no medical screening was performed at admission, 
and first aid kits were not available as required.
    Officials at some facilities told us that meeting the 
specialized medical and mental health needs of detainees was 
challenging. For example, officials at the York facility in 
Pennsylvania cited difficulties in obtaining ICE approval for a 
mammogram to evaluate a lump in a detainee's breast, and the 
facility ultimately paid for the medical service itself.
    On the other hand, we observed instances where detainees 
were receiving specialized medical care, such as special 
breathing equipment for a detainee at the Krome facility in 
Florida where we were told that the detainee had sleep apnea. 
And a detainee at the Hampton Roads facility in Virginia 
received treatment from a kidney dialysis machine.
    Second, ICE's own compliance inspections also showed 
noncompliance with medical standards. The most recently 
available annual inspection reports for 20 of the 23 detention 
facilities that we visited showed that ICE reviewers had 
identified a total of 59 deficiencies, 4 of which involved 
medical care. The Wakulla County Sheriff's Office in Florida 
had sick call request forms that were available only in 
English, whereas the population was largely Spanish-speaking. 
The Cowlitz County Juvenile Facility did not maintain alien 
medical records on site. The San Diego facility, in addition to 
the physical exam deficiency I just mentioned, failed to obtain 
informed consent from the detainee when prescribing psychiatric 
medication, and the Broward Transitional Center in Florida did 
not have medical staff on site to screen detainees arriving at 
5 p.m. and did not have a properly locked medical cabinet.
    I should also note, though, that we observed three ICE 
inspection teams reviewing facilities and found that one was 
very good, but the two others were less thorough.
    My last point relates to grievance procedures and the 
grievances and complaints filed by detainees at the facilities 
on a range of issues including the lack of timely response for 
requests for medical treatment. We found that ICE grievance 
standards were not followed at 4 of the 23 facilities we 
visited, and noncompliance ranged from issues like not having 
the grievance procedures in the handbook that is handed out to 
the persons upon entry, not having a grievance log at all, and 
not recording all grievances in the log. But the primary 
mechanism for detainees to file external complaints is directly 
with the IG, either in writing or by phone using the OIG 
complaint hotline.
    Our review of the approximately 750 detainee complaints in 
the OIG database showed that about 11 percent involved issues 
relating to medical care such as being denied access to 
specialized treatment. But in testing the phone system, we 
found that the OIG complaint hotline telephone number was 
blocked or otherwise restricted at 12 of the 23 facilities that 
we visited. So the number of reported allegations may not 
reflect all detainee complaints.
    Many complaints sent to the OIG were referred to ICE's DRO 
for action, but we could not determine the number, nature or 
disposition of these cases because DRO's complaint database was 
not sufficiently reliable for audit purposes.
    In closing, our work noted various deficiencies in 
compliance with ICE detention standards, but there was not a 
persistent or pervasive pattern regarding medical standards at 
the locations we visited. Importantly, it should be noted that 
our review did not examine quality of care issues or ICE 
decisionmaking on specific detainee medical cases. Nonetheless, 
our work showed the need for ICE to address a number of 
internal control weaknesses to help ensure that it is in a much 
better position to identify and address existing and potential 
deficiencies.
    This concludes my oral statement, and I would be happy to 
answer any questions that the Subcommittee Members may have.
    Ms. Lofgren. Thank you.
    [The prepared statement of Mr. Stana follows:]

                 Prepared Statement of Richard M. Stana

























    Ms. Lofgren. All of the witnesses, this is the time when 
Members of the Committee can pose questions. I will begin.
    Ms. Myers, I would like to ask about the managed care 
structure in the Department. It is my understanding that there 
are three nurses here in Washington who are charged with 
reviewing all medical treatment requests that are submitted by 
the physicians who are actually examining patients who are 
detainees at the various sites.
    I am not aware of any other system that permits nurses to 
overrule the judgment of the on-site physician who has actually 
examined a patient. Do you know of any other system that uses 
this?
    Ms. Myers. Thank you for that question. That will allow me 
to explain a little more about the TAR process and also about 
the independence that physicians have on site.
    As a point of clarification, the TAR process is not used 
for routine medications or other decisionmaking that is made by 
physicians or other officials on site. The TAR process is used 
when there is something that is nonroutine or nonemergency. The 
TAR process is used after an emergency just for reimbursement. 
It is not an authorization for emergency care. So if there is a 
particular thing that appears to be, where you need an outside 
provider, the managed care coordinators are the ones that 
review that to see whether it falls within the benefits 
package.
    I would say that ICE did not set up the managed care 
system. That is under the Public Health Service and DIHS, which 
has a managed care system not just for ICE, but also for the 
Bureau of Prisons and the United States Marshals Service which 
are also under that. They are the ones that placed that 
organization.
    Ms. Lofgren. If I may, there have been numerous complaints 
that have been brought to the Committee's attention not only by 
individuals, but through the press. For example, in The 
Washington Post series, which I assume you have read, there are 
several instances in which on-site medical personnel expressed 
their frustration by the refusal to authorize necessary medical 
care. And in the case of the York County prison, the county 
actual sued ICE for not authorizing care.
    In the July 2007 GAO report, the GAO wrote, ``Officials at 
some facilities told us that the special medical and mental 
health needs of detainees can be challenging. Some also cited 
difficulties in obtaining approvals for outside medical and 
mental health care as also presenting problems in caring for 
detainees.''
    Are you familiar with other facilities that have expressed 
concern about denial of care to detainees?
    Ms. Myers. The letter you referenced from the York County 
facility actually involved a 2005 letter, and it is our 
understanding Dr. Farabaugh and others just reached out to the 
York County facility yesterday, and maybe as soon as I finish 
my answer, I will have him go into more details with respect to 
that.
    On the TAR process, generally it is less than 10 percent 
that are denied. I believe we need to look at the 10 percent 
that may be denied. Some may be properly denied. We have 
instances where we get a submission for an individual who is 
not in ICE custody. It would not be a good use of taxpayer 
money to pay for that, or something that is obviously elective.
    Ms. Lofgren. Was Mr. Casteneda's biopsy denied under the 
TARs system?
    Ms. Myers. That case is in litigation.
    Ms. Lofgren. But the Government has admitted liability.
    Ms. Myers. The Government has admitted liability, but I 
believe there is room for improvement in the TAR appeal 
process, and that is why we have asked the Office of Health 
Affairs, working in conjunction with the Division of 
Immigration Health Service, to look at how does the TAR appeal 
process work, and how do we make sure the alien has a role in 
that process.
    Ms. Lofgren. Let me ask you about forced sedation. In its 
four-part series, The Washington Post cited what they said was 
250 medically unnecessary instances since 2003 in which ICE 
sedated a deportee against their will with what they called a 
``preflight cocktail,'' Haldol. It is my understanding on 
January 9 of this year, ICE headquarters issued a written 
guideline stating that the field offices may no longer request 
a medical escort from DIHS for involuntary sedation to 
facilitate deportation unless the Federal Government has 
obtained a Federal district court order authorizing sedation, 
and that there was to be no exception to this policy.
    The ICE memorandum, I understand, further recommends that 
the court appoint counsel for aliens who are not represented or 
who are unable to obtain counsel.
    Since this policy has been issued, how many Federal court 
orders have been issued authorizing sedation for deportation?
    Ms. Myers. If I can clarify just a little bit the 
information contained in your question, first of all, the 
policy directive that I requested be issued in June of last 
year said that we cannot do involuntary sedation absent a court 
order except in emergencies. And then in January of this past 
year, I said there is no emergencies, you know, court order, no 
matter what.
    It is my understanding, on information and belief, that 
since June of last year, I believe there are four applications 
that did go to court, and I believe they are all still pending. 
But I would request the opportunity to put that in responses to 
the record to make sure that I accurately describe the answers 
to your question.
    I will also add, I think this is just one of many areas in 
which ICE is examining decades-long practices and putting in 
enhanced oversight for things that have gone on for years, and 
where DIHS is very helpful.
    Ms. Lofgren. I am going to turn now to the Ranking Member 
Mr. King for his questions.
    Mr. King. Thank you, Madam Chairman.
    It occurs to me as I listen to the testimony and some of 
the comments made, including my own, that if someone is 
incarcerated in an ICE facility, one can self-deport and simply 
say, send me home; I am not satisfied with the food or the bunk 
or the medical care. Ms. Myers, have you ever had that happen?
    Ms. Myers. There are occasions in which an individual is 
going through immigration proceedings, and they decide to 
terminate the proceedings, and so that does happen, yes.
    Mr. King. Does it ever happen with a complaint about the 
facilities, the food or the health care, or anything that has 
to do with the environment that they are in other than the fact 
that they aren't free to travel?
    Ms. Myers. I have no specific knowledge, but I will get 
back to you in writing.
    Mr. King. I would very much like a response to that. It 
would be some interesting insight.
    If it is so horrible, has anybody asked to leave because of 
the conditions they are in rather than just to avoid the legal 
process?
    As I look at some memos that I have here, it shows that of 
the 27,500 ICE detention beds, 65 percent are located in State 
and local prisons or jail facilities; 19 percent commercial 
contract facilities; 14 percent are ICE-owned and operated; 2 
percent Federal Bureau of Prisons. Has anyone broken down the 
data on the deaths during incarceration with regard to those 
separate categories?
    The reason I ask the question would be, let's just say if 
it is a Federal prison or a State or a county, are they more 
likely to die in any of those facilities, or is it scattered 
across the board, or is there enough data for it to be 
significant? I ask you first, Ms. Myers.
    Ms. Myers. We would have to go back and make sure that we 
go through the statistics to give an accurate reporting.
    But we expect individuals, no matter where they are housed, 
we expect individuals to live up to ICE standards. If they 
don't, we will do just like we did last year: We will move 
individuals out of those facilities, and in some instances even 
shut facilities down if we can't ensure that individuals in our 
custody are being treated in accordance with the ICE detention 
standards.
    Mr. King. I appreciate that.
    Mr. Stana, could you discern any distinction between the 
data on let me say unhappy health results with regard to 
whether it would be a State or a local prison or a contract 
facility or an ICE-owned service?
    Mr. Stana. We didn't make that distinction. Every location 
we went to, we asked if there had been a death in the facility. 
And of the 23 we went to, I believe 2 had a death in the 
facility. We didn't do a whole lot of probing, but in one case 
the person died in their sleep apparently of natural causes. 
And the other case, I believe, was a heart attack.
    Ms. Myers. If I can add one point to that, we are starting 
this reporting under the Death in Custody Reporting Act. I 
believe the Bureau of Justice Statistics will be able to do the 
same kind of metrics that they do with other facilities in 
terms of looking at statistical deviances and so on. So that 
will be one measure going forward that I think will be useful 
on that front.
    Mr. King. I will submit that if we are dealing with between 
230,000 and 311,000 inmates a year, that there should be some 
statistical data that would point to a facility or a type of 
facility or something other than a random cross-section here. 
And one of these things I have here is our 2004 and 2005 
mortality rate in our U.S. jails and prisons at 550 deaths in 
2004 per 100,000; 540 deaths per 100,000 in 2005; and we are 
looking at ICE numbers of 10.8 or 6.8. Can you explain that, 
Ms. Myers?
    Ms. Myers. I am not a statistician, but we see that even 
the flat numbers of deaths that we are having, and any death is 
regrettable, the numbers of deaths we are having is going down, 
even though the number of detainees are going up.
    Some jails have very low lengths of stay, lower than in ICE 
custody, which is about 37\1/2\ days. Certainly there is a 
comparable thing there.
    But many more detainees may not have health insurance than 
individuals who come into other facilities. All of these 
statistics are reasons why we have asked the Bureau of Justice 
Statistics to look at this as we start reporting.
    We do have instances, unfortunately, like last year where 
someone was in our custody for about 72 minutes, and they had 
swallowed some cocaine while in State custody. It exploded 
within them, and they passed away.
    Mr. King. In your opinion would it be rational or 
irrational for this Congress to take action on a major policy 
change within ICE health care without answering these questions 
as to why there is a significantly lower death rate among ICE 
inmates than there are among inmates across the broad spectrum 
in other American prisons?
    Ms. Myers. I certainly think it makes sense to evaluate all 
of those things, and I think it also makes sense to consider 
whether or not in the proposed bill it is actually requesting a 
higher level of services than those provided to U.S. citizens 
or aliens who are detained in U.S. Marshals Service custody who 
have not yet primarily been convicted of a crime. I think it is 
important to look at those things, look at the costs, and get a 
sense of what kind of services are requested or expected.
    Mr. King. It is irrational to look at the data before 
making a decision.
    Ms. Lofgren. As I turn to Mr. Gutierrez, I want to correct 
for the record, under the Administration prior to the current 
Administration, there actually was a requirement that there be 
no sedation whatsoever on deportation, and that was changed.
    I yield now to Mr. Gutierrez.
    Ms. Myers. May I just respectfully ask to respond to that?
    Ms. Lofgren. No, but you will have an opportunity to 
respond.
    Ms. Myers. I would like to respond to that statement prior 
to the end of the hearing.
    Mr. Gutierrez. Thank you very much.
    I think once again what we see here is we have a hearing, 
and then we blame the victim, those detained by ICE. We hear 
again the demonization of immigrants. They are all sick; 34 
percent. Now we have an argument between Ms. Myers and the 
Ranking Member whether it is 34 or 25 percent.
    They talk about chronic illnesses, hypertension. I am not 
afraid of anybody with hypertension or diabetes. They then 
repeat ad nauseam tuberculosis, something that is a contagious 
disease, to make it appear after this testimony they are all 
dangerously ill coming to this country.
    I find it amazing that these very same people who are so 
dangerously ill are the same people who are taking away the 
jobs from Americans, showing up to work every day doing hard 
work, intense labor at meat-packing plants, picking up the food 
out in the fields under intense heat, and yet, well, a third of 
them have a chronic illness. I wonder if that is the way it is 
for the rest of the American population.
    It makes it feel like you offer, Ms. Myers, Rolls Royce 
health care. That is what we just hear from the Ranking Member, 
Rolls Royce health care. I almost feel after listening to the 
Minority that it is safer. I should maybe when I go to Chicago 
not check into my house, check into an ICE facility. It is 
probably safer there, according to the Minority, than it is on 
the streets of Chicago.
    Mr. King. Will the gentleman yield?
    Mr. Gutierrez. I will not yield.
    Mr. King. It probably is.
    Mr. Gutierrez. I said I will not yield.
    It appears it is safer for me. Again, the demonization, the 
criminalization, we hear it all the time.
    Let me ask Ms. Myers a question. How many people did you 
detain on the streets in work sites in America last year that 
you ultimately deported?
    Ms. Myers. I will have to get back to you in writing.
    Last year we arrested administratively in work site 4,667 
or so. In addition, we had 863 criminal arrests.
    We take our responsibility extremely seriously.
    Mr. Gutierrez. I know you want to control the hearing, but 
I have limited time, and I want to ask my questions.
    How many people did you detain on the streets of America 
and deport last year?
    Ms. Myers. We deported almost 300,000.
    Mr. Gutierrez. Three hundred thousand people, and you had 
more money to do that last year than you have had in previous 
years?
    Ms. Myers. Congress gave us more money to do that.
    Mr. Gutierrez. And you have more money for next year so you 
can increase the level of deportations?
    Ms. Myers. Our responsibility is to enforce the immigration 
laws.
    Mr. Gutierrez. Do you expect to have the capacity to deport 
more people next year than you did last year?
    Ms. Myers. Yes, I do expect that.
    Mr. Gutierrez. What increase--do you think you will go from 
300 to 330, so you have a 10 percent increase, a 20 percent 
increase? What do you think it is going to be?
    Ms. Myers. I will say that the number of aliens we charge 
in jail--we expect to charge over 200,000 aliens in jails this 
year.
    Mr. Gutierrez. Okay, 200,000 this year. So next year you 
expect to deport at least 300,000 people next year?
    Ms. Myers. Well, not all of the aliens who are in jail, who 
are charged, who are going through immigration procedures, will 
get out of jail this year. But once they get out, assuming 
their orders are removed and not allowed to adjust in any way, 
yes----
    Mr. Gutierrez. I know you want to emphasize on the 
criminalization of the population that you deal with. I am just 
asking you a general question, and I would really appreciate a 
specific answer to the question.
    How many--according to ICE, how many undocumented workers 
or illegally present people are there in the United States of 
America?
    Ms. Myers. You know, I don't believe----
    Mr. Gutierrez. You don't know.
    Ms. Myers [continuing]. There is a number on that.
    Mr. Gutierrez. You don't know. You have no idea. You have 
no idea, and there is no documentation in ICE, under oath, 
that--you have no idea, and you have never in ICE or at 
Homeland Security come up with a number of undocumented workers 
in the United States.
    That's your testimony?
    Ms. Myers. Well, certainly the Bureau of Immigration 
Statistics looks at----
    Mr. Gutierrez. And they say there are how many?
    Ms. Myers. You know, that's not within my agency, so I am 
going to have to reflect----
    Mr. Gutierrez. Fine. I will not comment on what has been 
statistically shown, since you don't know. You are the head 
person at ICE and don't have a number.
    You know, I would think that if I had a population of 
people that I needed to police, I would at least have an 
estimate of how many people it was I had to police and deal 
with as part of my Federal responsibilities.
    But it's your testimony here today that you cannot answer 
that question because you don't have a number.
    Ms. Myers. No, no, no.
    Mr. Gutierrez. And because my time--let me finish. And 
because my time is up, it begs the question once again. What 
are we doing?
    Ms. Lofgren. The gentleman's time has expired.
    Mr. Gutierrez. Because you know as well as I know that 
there have been estimates of between 12 and 20 million.
    Ms. Lofgren. The gentleman's time has expired.
    Mr. Gutierrez. And at a rate of 300,000 a year, which you 
have been doing with lots of gusto, it would take us 25--with 
not one more coming in, which begs the----
    Ms. Lofgren. The time of the gentleman has expired.
    Mr. Lungren. Privilege of the Chair, Madam Chairman.
    Ms. Myers. May I please respond to that question?
    Ms. Lofgren. The gentleman's time has expired.
    I am going to take the privilege of the Chair to give you a 
minute to comment on the Bush administration's policy of 
requiring a court order in every case to sedate, to deport, 
which I promise to give you an opportunity to comment on, as 
well as a very brief response, before turning to Mr. Lungren.
    Ms. Myers. I appreciate that very much.
    First, I will say upon information and belief--and we 
certainly would look forward to getting back to this in writing 
to you, I am not aware that that was the policy in the previous 
Administration and the former INS.
    That was not my experience, which was why I believed that 
it was important to issue the directive which I did last 
summer.
    If I could also respond to Congressman Gutierrez, what I 
said related to the U.S. for an estimate of individuals 
working, as opposed to an estimate of individuals who are 
currently here. Certainly the Office of Immigration Assistance, 
as well as the Pew Research Center--it does have--I can give 
those statistics to you.
    I am going to turn now to the Ranking Member, Mr. Smith. I 
will give you the White House memo that outlines the Clinton 
policy.
    Ms. Myers. Well, it does follow the question that I had.
    Ms. Lofgren. I turn now to the Ranking Member of the full 
Committee, the honorable gentleman from Texas.
    Mr. Smith. Thank you, Madam Chair. Before we get back to 
the subject matter at hand, Secretary Myers, I don't want the 
record to misrepresent your knowledge.
    Of course, you have a range of millions of people you know 
who are in the country illegally. Just because you can't give a 
precise figure actually points to a lack of a failure or a 
failure to enforce immigration laws; that's why we don't know 
how many people are coming into the country illegally.
    But if you were to be asked, you would probably agree that 
there are 12 to 20 million people who are here in the country 
illegally, would you not?
    Ms. Myers. I would.
    What I was responding to--his question was the individuals 
who were working. I believe there were some independent studies 
to talk about what percent of illegal aliens are working. They 
are not ICE studies.
    I can't vouch for the Pew Center's numbers, but certainly I 
am aware of that.
    Mr. Smith. There are no specific numbers. All we have is 
sort of orders of magnitude. But, again, that points to the 
failure or inability to enforce immigration laws.
    Let me get back to the subject at hand. You made the point 
earlier in your opening estimate that the number of deaths in 
detention facilities had traumatically declined over the last 
couple of years. What were those figures again?
    Ms. Myers. In calendar year 2007, there were seven deaths 
in our facilities. We had a detainee population of 323,000 
individuals.
    In calendar year 2006, there were 16 deaths in our 
facility.
    If you look back to calendar year 2004, there were 29 
deaths.
    Mr. Smith. The trend is dramatically down.
    Ms. Myers. The trend is dramatically down and the record-
keeping is up.
    Mr. Smith. Right.
    Ms. Myers. When I look back at the----
    Mr. Smith. Was that true or reported in any of the critical 
articles, the substantial reduction in deaths?
    Ms. Myers. You know, certainly we had challenges with 
respect to The Washington Post, the implications that were 
there. We disagree with a number of them. We have a long letter 
into the office----
    Mr. Smith. Would it have been a more balanced approach to 
show the progress you have been making and compared how few 
deaths there were compared to past years, would it not?
    Ms. Myers. I think it would. That's why we have a formal 
complaint in.
    Mr. Smith. What else does your complaint encompass? Were 
there other inaccuracies or omissions that should have been 
included?
    Ms. Myers. There are a number of those. If you read the 
article, it implies suicides are up. Obviously, as my testimony 
indicated, we haven't had a suicide in the last 15 months. We 
are working very hard to do what we can to ensure that we have 
quality medical care.
    The series didn't focus on the fact that we actually took 
over in a more direct fashion the administration of DIHS in 
order to ensure greater oversight. The Washington Post series 
failed to compare the treatment that DIHS provides with the 
Marshal Service system. Instead, it claimed that DIHS provided 
inadequate service and so on.
    We certainly have a 5-page letter which I would be happy to 
provide to the Committee, if you would like.
    Mr. Smith. I would like to have a copy of that. I would 
also like to make it part of the record. It seems to me at the 
very least you are owed a correction or retraction on the basis 
of that article.
    Ms. Lofgren. Without objection, we will put into the record 
the articles as well as the letter.
    Mr. Smith. Thank you, Madam Chairman.
    Mr. Stana, let me go back to your work at the GAO. You 
said, I think, that you only found examples of noncompliance, 
and I would say that some of them might be accurately described 
as minor in 3 of the 23 facilities that you visited; is that 
correct?
    Mr. Stana. That is correct.
    Mr. Smith. In only three did you find the noncompliance of 
standards.
    You also said they were not pervasive. Is that accurate as 
well?
    Mr. Stana. These were the medical care standards. There is 
a distinction between quality of care. I wanted to point that 
out. But this involves things like, was the proper equipment on 
site, did they have access to a doctor, did they have medical 
emergency procedures? Were inmates given the opportunity to go 
to a sick call? Were there suicide watch procedures? Those 
kinds of things.
    Mr. Smith. In those 3 out of 23 facilities, 13 percent of 
the facilities, would you describe the problems that you found 
as comprising a hidden world of faulty administrative 
practices, sloppy record-keeping and lost medical files; or is 
that a slight exaggeration as to what you found in those 23 
facilities?
    Mr. Stana. I can tell you what we found at the 23 
facilities.
    We found some differences between the large ones and the 
small ones as to how much equipment was on hand. We found that 
they were clean, they were well attended to.
    We did find there were some employee grievances--not 
employee grievances. There were detainee grievances. If there 
is an Achilles' heel to this whole process, it's the handling 
of those grievances.
    We are talking about what the scale of this problem is. One 
way to find out is to use the grievance and the monitoring and 
the compliance mechanisms as the canary in the coal mine, 
because it is not reliable.
    Mr. Smith. Right. Again, no systematic noncompliance in 
those facilities?
    Mr. Stana. We didn't find it, not at the facilities we were 
at.
    Mr. Smith. Great. Thank you very much.
    I will yield back the balance of my time.
    Ms. Lofgren. The gentleman yields back.
    I would now recognize my colleague from California, the 
gentlelady, Ms. Sanchez.
    Ms. Sanchez. I thank the Chairwoman. Again, I just want to 
start--before I start questioning, I just want to point out 
something.
    Much was made about the fact that detainees can voluntarily 
choose to leave if the food or the medical care treatment is 
that bad.
    I might point out to my colleagues on the dais, if they 
didn't already know this, that there are many countries with 
whom we don't have repatriation agreements. It would be pretty 
hard for somebody to allow--voluntarily allow themselves to be 
deported to a country that we essentially can't send them back 
to, and that there are many asylum seekers that end up in 
detention facilities. They are not exactly anxious to go back 
to war-torn places where they may be targeted for death or 
other kinds of threats.
    So I just wanted to make sure my colleagues on the dais 
understand it's not necessarily as easy as saying, well, pack 
me up and send me home because the medical care here is 
substandard.
    In terms of questions, Ms. Myers, both The Washington Post 
and the Office of the Inspector General have cited the 
debilitating shortages of medical staff at detention centers. 
And at some facilities, vacancies in medical positions range 
anywhere from 20 to 50 percent.
    Is that degree of lack of staff in compliance with the 
standards of the American Correctional Association or the 
National Commission on Correctional Health Care?
    Ms. Myers. Thank you for that question.
    We certainly agree that there were some concerns with 
respect to staffing, and we had some issues at ICE with respect 
to moving along as quickly as we would like with ICE and 
getting the staffing up. That's why in October of 2007 we 
actually took DIHS over more formally for--and the 
administrative side to really work on the staffing.
    Last January----
    Ms. Sanchez. But my question was----
    Ms. Lofgren. I am going to interrupt. We have just been 
notified that an alarm has gone off, that a tornado is heading 
for the Capitol, and that we should stay away from windows and 
stay inside.
    Since there are three windows right in back of us, I think 
that probably we should recess this hearing temporarily and 
move into that hallway.
    Thank you. We are in recess.
    [Recess.]
    Ms. Lofgren. That's the first time I have ever had to 
recess a hearing for a tornado. As a Californian, that's kind 
of a new thing for me.
    We are trying to find Congresswoman Sanchez to let her know 
we are back in session, and also the other Members who 
recessed, to let them know that we are back.
    So we will not use your time frivolously, I wonder, Mr. 
Davis, if you would like to begin your questioning while we 
notify other Members that we are back in session. Then we will 
let Ms. Sanchez resume her questioning when she returns.
    So I would turn now to Mr. Davis.
    Mr. Davis. Thank you, Madam Chairwoman.
    Ms. Myers, I am from Alabama so I am not scared of 
tornados. You notice these California folks ran. The Iowan and 
the Alabaman stuck around.
    Let me, Ms. Myers, try to get us refocused a little bit. I 
was reading your opening statement--didn't have a chance to 
hear you--but I was reading your opening statement or the 
transcript of it. And you talked for a moment about the quality 
assurance professionals who inspect the largest ICE facilities, 
and I want to ask you point-blank, how many of these quality 
assurance professionals are doctors?
    And, as they conduct their quality assurance review, are 
they evaluating the facilities for their medical quality?
    Ms. Myers. Thank you for that question. I am from Kansas, 
and I am scared of tornados, being from Kansas.
    But to be clear, the quality assurance professionals that 
are in our 40 largest facilities, those are focused on overall 
compliance with all our detention standards, so it's not solely 
on medical care. So these are individuals to make sure, if 
there is any issue with any particular detention center, they 
are there.
    We do have a detention field inspection group, which is 
this independent arm operating under the Office of Professional 
Responsibility. They have a medical professional within that 
group, so they are able to go out and do target reviews.
    But I think we can do more. That is the reason----
    Mr. Davis. Well, you frankly said what I thought you would 
say. My sense, from reading your testimony and from reading the 
testimony of the other witnesses, is that it's a quality 
assurance review that is far more generalized and the medical 
review so that----
    And, also, given your concession that we can do more, I 
make a proposal to you: Why not have the American Medical 
Association, a respected group of doctors, the equivalent of 
the ABA for lawyers, why not ask the AMA to appoint a panel of 
professionals to come in, review these facilities or to review 
at least perhaps 20 of them?
    Ms. Myers. Well, what--actually, what we have asked to do 
which is similar to that, but not precisely that, is to ask the 
Office of Health Affairs to look at--some experts that could do 
an overall review of all of DIHS processes. So they are finding 
experts, recognized medical experts, who can look and see, as 
DHS has taken over greater administrative control of the DIHS, 
what works, what doesn't work, where have things changed, where 
can we really do best practices?
    So this is our review that is starting now.
    Mr. Davis. Well, slow down for 1 second.
    Ms. Myers. Oh, sure.
    Mr. Davis. That's a perfectly reasonable suggestion, but 
what about my AMA suggestion? Good idea or bad idea?
    Ms. Myers. Well, I think--I thought that some sort of--some 
sort of review, once we took DIHS over, was appropriate. That's 
why we conducted a baseline review of our own----
    Mr. Davis. AMA, good idea or bad idea?
    Ms. Myers. What?
    Mr. Davis. AMA, good idea or bad idea?
    Ms. Myers. Yeah. I think that--the OHA review that is going 
on, I think really encompasses--and so I think that is 
sufficient to do the kinds of things that both you and I want 
to do.
    Mr. Davis. Not to be contentious, but I do want to try to 
get an answer because I mean it as a good-faith suggestion.
    The AMA is an enormously respected entity that I assume is 
the equivalent of the ABA. I certainly don't think they are 
known as a partisan or democratic leaning entity in any sense 
of the word.
    What's wrong with having the AMA come in and do a review?
    Listen to what I think the advantage would be: having 
somebody other than the Federal Government take a look at the 
Federal Government, having somebody outside the governmental 
process come in. Because I think--and I think this is the 
concern that others have driven home to you, I think, Ms. 
Myers--that we can go back and forth on what's the quality of 
care and all of that.
    I am going to ask you some questions about that in a 
moment, but if you are serious, and I take you at your word 
that you are serious about improving the quality of care at 
these facilities, it would seem that the best way to do that, 
is, frankly, not to have an intragovernmental review or even to 
have another Government agency conduct a review, but to frankly 
have an assessment by medical professionals.
    I am going to move on as my time is about up, but I would 
seriously encourage you to give some thought to the idea of an 
outside medical entity such as the AMA coming in and doing 
analysis.
    A final set of questions: Are you a lawyer, Ms. Myers?
    Ms. Myers. Yes, I am. Not a practicing lawyer.
    Mr. Davis. What do you believe is the standard of care for 
the individuals who are held in these facilities?
    Ms. Myers. I believe that DIHS has a responsibility to 
provide medically necessary health care while at the same time 
ensuring proper obligation of Federal funds, to ensure that we 
don't overpay for anything.
    Mr. Davis. Well, I would be curious in hearing--and perhaps 
in writing would be a better place for discussion on this, 
given the time limits, but I am seriously concerned about what 
DIHS considers to be the standard of care toward these 
individuals.
    Is it analogous, for example, to the standard of care for 
people who are in Federal prison?
    Ms. Myers. Well, I think you raise an excellent point. I 
believe it is analogous to the standard of care for U.S. 
Marshal Service prisoners, individuals who are coming into 
Marshal Service custody who have not yet been convicted of a 
crime.
    There may have been areas where it differs, but overall, it 
appears that that standard of care is very consistent. But, as 
I said, I am not a doctor.
    Mr. Davis. Is that current policy? Is what you just said 
current policy?
    Ms. Myers. That is my understanding. But let me say that's 
why we asked the Office of Health Affairs to actually consult 
with outside professionals--not just to do an intragovernmental 
review--but to consult with outside Government officials and 
look at all the DIHS system processes and see where there's 
room for improvement.
    I can see myself where there's room, but the doctors may 
have additional advice of counsel.
    Mr. Davis. I see my time has expired.
    Ms. Lofgren. The time of the gentleman has expired.
    We will turn now to the gentleman from Virginia, Mr. 
Goodlatte.
    Mr. Goodlatte. Thank you, Madam Chairman.
    Ms. Myers, I would like to ask about one of the provisions 
in H.R. 5950 that has been introduced by the Chairman to 
address some of the concerns. That bill appears to require the 
Department of Homeland Security to provide continuity of care 
for a reasonable period of time after removal.
    Do you read that to mean that the Department would be 
responsible for providing care to a detainee even after they 
are removed from the United States?
    Ms. Myers. Well, certainly. And I would caveat this with, 
obviously our lawyers are going to take a thorough assessment 
of the bill. The Administration will then take a position. But 
I do believe the language is vague in that it is just, you 
know, kind of what exactly is the continuity of care.
    By the way, we do already provide continuity of care in 
certain instances. But I think we need to look at the language 
and understand what is expected.
    Ms. Lofgren. Would the gentleman yield?
    Mr. Goodlatte. I would be happy to yield.
    Ms. Lofgren. I don't have a copy of the bill in front of 
me, but the intent, and if we get to a markup, it for example, 
the medical records should be provided to the person if they 
are removed, and things of that sort; that there should be 
planning, not just dumping somebody.
    Mr. Goodlatte. But you wouldn't be contemplating providing 
actual health care after they are no longer under the 
jurisdiction?
    Ms. Lofgren. No. In fact, we have strongly suggested that 
for those individuals who are in custody with serious health 
care problems, that they be provided alternatives to detention 
standards, so they could bill their own insurance, instead of 
the Federal Government.
    For example, if you have a chronic condition, and you are 
applying for a political asylum, why not put on an ankle 
bracelet and get your own care instead of being in detention?
    But I thank the gentleman for yielding so I could clarify 
that.
    Mr. Goodlatte. I thank the Chairwoman for that guidance. I 
hope the language in the bill will be clarified to make it 
clear we are not providing care to people after they have been 
deported from the United States.
    Ms. Myers, in your opinion, what is the maximum amount of 
time that would comply with the, quote, ``reasonable period of 
time'' requirement that's described in the bill during which 
the Department of Homeland Security must ensure continuity of 
care for detainees after release or removal?
    Ms. Myers. You know, I couldn't really provide a precise 
number at this time, but I think both points are very valid 
that we would need to look at kind of what is expected.
    Right now, in many instances we assist with follow-up 
appointments. We provide detainees, for example, with several 
days' worth of medication so that they could then go and find 
an additional doctor back in their own country or back in the 
United States.
    With respect to asylum seekers, very few asylum seekers are 
detained. Of course, we do have our parole policy which 
provides that after they go through the considerable peer 
process they are considered for parole.
    Mr. Goodlatte. I also have concern about the phrase, 
``serious medical or mental health conditions,'' which are not 
defined anywhere in the bill, that would raise some questions 
about how you would draw the line between serious medical or 
mental health conditions and nonserious conditions.
    Ms. Myers. I think that's exactly right. The bill also 
talks about more comprehensive dental care and vision care than 
is provided to prisoners in the United States Marshal Service 
custody.
    So I think there are a number of things that I think we 
should consider. What does the Congress want to find? We, as 
ICE, will implement, of course, whatever the Congress decides.
    Mr. Goodlatte. Let me ask you if the Department has 
considered the use of telemedicine to improve the quality of 
care that detainees receive while saving the taxpayer dollars. 
We have seen this utilized all across the country in prisons, 
in jails, and other places where having doctors immediately 
available, especially specialists, would be a considerable 
expense.
    Ms. Myers. I am going to have the doctor, if that's okay, 
respond to that.
    Dr. Farabaugh. We are actually actively pursuing a 
telemedicine system for our agency. This would mainly be 
utilized within DIHS facilities. Obviously we can't put 
equipment in every--you know, all 350 IGSA facilities out there 
that are used, but we can concentrate them with our own 
facilities to enhance the care that's provided.
    Mr. Goodlatte. Well, good. We hope you will do that, 
because I have seen it used very effectively in rural areas.
    Let me also say that I am stunned by the progress that you 
have made in reducing fatalities, deaths in your facilities, 
but even more so by the comparison of mortality rates in U.S. 
jails and prisons and in your facilities. I see 10.8 per 
100,000 a year in facilities and 550 in prisons. And in 2005, 
6.8 compared to 540.
    Is there some explanation for why your mortality rate is 
dramatically lower than it is in prisons?
    Ms. Myers. You know, I think certainly we are very pleased 
that we have been able to reduce the number of deaths, although 
absolutely any death is regrettable, I think. I am very proud 
of the care that DIHS provides the professionals that are there 
and the work that we do in order to make sure people get the 
best medical care.
    Of course, individuals in jails may be in for a much 
shorter period of time than individuals in ICE custody. 
Individuals in prison may be in there for a much longer period 
of time than individuals in ICE custody.
    So even--there are some variances, as well as the number of 
individuals with insurance; it may be much lower for 
individuals who come into our custody than for individuals who 
come into other custodies.
    There are a number of factors, but I am very proud of the 
work that they do.
    Ms. Lofgren. The gentleman's time has expired.
    Mr. Smith had asked to make a unanimous consent request to 
make a correction to his opening statement. I will recognize 
Mr. King for that purpose.
    Mr. King. Thank you, Madam Chairman.
    I appreciate being recognized on behalf of Mr. Smith, who 
wishes to correct a statistic he cited in his opening 
statement.
    The correct figure is that immigrants are over six times 
more likely to have tuberculosis than native-born Americans, 
not four times.
    He appreciates your indulgence. I yield back.
    Ms. Lofgren. Without objection.
    I understand that Ms. Sanchez would like to yield her 
remaining 3 minutes to Mr. Davis to continue his questions.
    We are going to have votes pretty soon, so we will have to 
say goodbye to this panel.
    Mr. Davis. Thank you, Madam Chairwoman. I will try to not 
take the 3 minutes.
    Let me pick up, conveniently enough, on the last question 
Mr. Goodlatte asked about the decreasing mortality rate, which 
you contend is a very low mortality rate. You made this point, 
but frankly, you made it at a rapid pace. I want to slow down 
and make sure that everyone gets this.
    I think it is enormously difficult to compare the ICE 
population with the prison population. One reason I suspect 
that people stay in American prisons a lot longer than people 
stay in ICE facilities: What's the average length of stay for 
someone at one of your detention facilities?
    Ms. Myers. The average length of stay in ICE facilities is 
actually between 33 and 37 days. Jails, in some American jails, 
the average length of stay is also in the 30 days--in that time 
period. But absolutely, in prisons it can be much longer.
    Mr. Davis. So that's one reason. Obviously, very few people 
get sentences of 30 days in the American prison system, so 
that's one comparison.
    You mentioned another having to deal with the level of the 
uninsured. I would suspect there are also some age differences. 
What's the average age of people in the ICE facilities?
    Ms. Myers. You know, I am going to have to get back to you 
on that in writing, so I can be positive.
    I have seen, in jails, the average age--I think--in the 
Bureau of Prisons, I believe, the average age is 38, so, you 
know, kind of midlife.
    But let me say, I agree with you that having a more robust 
analysis of the statistics would be useful. That's why we have 
asked the Bureau of Justice Statistics to take our statistics 
and look at them with all the other statistics under the Deaths 
in Custody Reporting Act. They can do the analysis, they have 
the statisticians. They can draw the comparisons that maybe we 
can't as effectively draw.
    Ms. Lofgren. Would the gentleman yield for a question?
    Mr. Davis. Yes.
    Ms. Lofgren. One of the differences between people in your 
ordinary, for example, State prison and ICE detentions, number 
one, the ICE detention people aren't criminals. But, number 
two, the ICE detention people are oftentimes moved around 
whereas the prison population tends to be sedentary.
    How do you--we have had a lot of complaints that medical 
files and medication don't get moved with detainees. How do you 
make sure that happens so that the medical care isn't deficient 
or, at the next facility, the person has to start over from 
scratch?
    Ms. Myers. Well, there are a couple of things that we do 
more generally, and a couple of initiatives, to make sure that 
we are comprehensively addressing this problem.
    I think more generally if we have specific instances that 
are brought to our attention, we address them, we look at them. 
Obviously, the detainee standard addresses this as well as some 
of the standards that apply to DIHS.
    But we are looking at our performance-based standards that 
are out for review by the Inspector General where we receive 
comments from the NGOs and other groups to make sure that the 
transfer standards make it clear about the transfer of the 
record----
    Ms. Lofgren. But there is a standard right now. Do you 
require that the files be sent with the inmate?
    Ms. Myers. A file--or in cases where we don't have access 
to a complete file, a summary of that information. Absolutely.
    Ms. Lofgren. And that their medication be transferred with 
them?
    Ms. Myers. That their medication be----
    Ms. Lofgren. That's what you require?
    Ms. Myers. That's what we require.
    I believe there is some room for improvement on some of 
these, certainly in the IT area, the--you know, the DIHS IT 
system has a lot of room for improvement.
    Ms. Lofgren. Okay. Our time has expired, and we are out of 
Members who want to ask questions. So we will thank this 
witness for your presentation today.
    The record will be open for 5 legislative days. There may 
be additional questions that we will forward to you in writing, 
and we would ask that those questions be promptly answered, if 
that happens.
    We will now ask the next panel to come forward. I would 
like to introduce all of them.
    First, I am pleased to welcome Dr. Homer Venters, Attending 
Physician at the Bellevue/NYU Program For Survivors of Torture, 
as well as a Public Health Fellow at New York University.
    As part of Doctors of the World, Dr. Venters sees detained 
asylum seekers who are victims of torture, and his research 
involves health care for detained immigrants. Dr. Venters first 
became involved with immigration health care as a health 
volunteer while in the Peace Corps in Togo. His most recent 
publications deal with public acceptance of torture in the 
United States and health care for detained immigrants.
    Next, I would like to introduce Ann Schofield Baker, a 
principal in the New York office of the law firm of McKool 
Smith, where she is the head of the firm's national trademark 
litigation practice. Along with her diverse practice, Ms. 
Schofield Baker maintains an active pro bono practice, through 
which she represented Amina Mudey, an asylee from Somalia who 
was detained at the Elizabeth Detention Center in New Jersey.
    She is admitted to the New York, Washington D.C., and 
Massachusetts bars, and to the Federal District Courts in the 
Southern and Eastern Districts of New York.
    Our next witness is Mary Meg McCarthy, Executive Director 
of the National Immigrant Justice Center, which she has led 
since 1998. NIJC serves approximately 8,000 asylum seekers, 
trafficking victims, unaccompanied immigrant children, detained 
adults, and other low-income immigrants each year, drawing on a 
network of 1,000 pro bono attorneys. Prior to joining NIJC, Ms. 
McCarthy practiced civil litigation at the law firm of Horvath 
& Lieber and served as a pro bono attorney for NIJC's asylum 
project.
    Our next witness is Zena Asfaw, a former immigration 
detainee. Zena was born in Addis Ababa, Ethiopia, where she 
worked for Ethiopian Airlines. Having endured persecution at 
the hands of the Ethiopian Government, she fled Ethiopia and 
made her way to the United States, where she applied for 
asylum.
    Upon arriving in the U.S., Zena was detained and held for 5 
months in an ICE detention center. She was finally released 
when an immigration judge granted her application for asylum. 
She currently lives in Los Angeles and is employed by the 
Sheraton Delfina in Santa Monica.
    Next, I would like to introduce Gloria Armendariz. Gloria 
is a U.S. citizen and is here to testify concerning her common-
law husband, Isaias Vasquez, a veteran of the Armed Forces, who 
was detained for about 18 months in several detention 
facilities. After his release, Isaias was granted U.S. 
citizenship based on his military service.
    Our next witness is the Reverend Roy Riley, Bishop of the 
New Jersey Synod of the Evangelical Lutheran Church in America, 
the largest Lutheran denomination in the United States. Bishop 
Riley serves on the board of directors of Lutheran Immigration 
and Refugee Services, which serves and advocates on behalf of 
refugees, asylum seekers, unaccompanied children, immigrants in 
detention, families fractured by migration, and other 
vulnerable populations.
    Next is Mr. Edward Harrison, President of the National 
Commission on Correctional Health Care, a not-for-profit 
organization that provides standards and independent 
accreditation of correctional health services. Mr. Harrison 
advocates for a better understanding of the importance of 
appropriate medical and mental health care in corrections 
facilities, and the relationship between correctional health 
care and the public's health.
    He has been employed by NCCHC since 1986 and has been its 
president since 1993. He earned his Master's degree from 
Northwestern University's J.L. Kellogg Graduate School of 
Management and his undergraduate degree from the University of 
Illinois.
    Our final witness is Mr. Isaac Reyes, partner with the 
government relations firm of Austin, Copelin & Reyes, which 
represents the U.S./Mexico Border Counties Coalition. Mr. Reyes 
spent 7 years working on Capitol Hill, most recently as policy 
adviser at the Senate Democratic Policy Committee, a leadership 
office of the former Democratic Leader of the Senate, Tom 
Daschle. Mr. Reyes received a Bachelor of Arts, with a major in 
political science, from California Polytechnic University at 
San Luis Obispo.
    Each of your written statements will be made part of the 
record in its entirety. We are going to ask you to give about 5 
minutes of oral testimony. But we are going to ask you to do 
this when we come back from voting.
    All of those bells and whistles mean that on the floor of 
the House right now there is a vote going on. We have about 10 
minutes left to get over there, and then I think there are four 
additional 5-minute votes. So what that means is at about 4:30, 
if we are lucky, we will be back here to hear your testimony.
    So, relax, I think there's a coffee shop down the stairs if 
you want. We will be back, we hope, about 4:30. We are in 
recess until that time.
    [Recess.]
    Ms. Lofgren. We have finished our voting for the next 2 or 
3 hours. I would like to wait for the Ranking Member to arrive 
before we begin the testimony.
    However, perhaps we could go through the formality of 
swearing each of you in. If so, would you stand and raise your 
right hands. I will read the oath, and you can say, yes, if you 
agree at the end.
    [Witnesses sworn.]
    Ms. Lofgren. We notice that all of the witnesses have 
indicated in the affirmative.
    Because several witnesses have transportation issues, I am 
going to ask that we get started, since the Ranking Member is 
on his way in. If we can start at the end with Mr. Reyes and 
then move right along, Mr. Harrison and the like.
    So we are going to start with Mr. Reyes.

   TESTIMONY OF ISAAC REYES, WASHINGTON REPRESENTATIVE, U.S./
                MEXICO BORDER COUNTIES COALITION

    Mr. Reyes. Thank you, Chairwoman Lofgren, Ranking Member 
King and Members of the Subcommittee, for inviting me for to 
testify about the U.S./Mexico Border Counties Coalition 
findings on the costs of providing medical care to undocumented 
immigrants.
    The Border Counties Coalition is a nonpartisan policy and 
technical forum comprised of the elected officials from the 24 
governments located on the Southwest border. Our efforts at the 
Federal level are focused on increasing the reimbursement 
levels for the costs associated with undocumented immigration 
resulting from the failure of the Federal Government to secure 
our borders.
    Because of their proximity to the border, our member 
counties bear a disproportionate share of these costs. My 
testimony this afternoon is about the cost to border counties 
for providing health care to undocumented immigrants.
    It is awkward to be discussing fiscal costs related to 
undocumented immigration when many of the witnesses this 
afternoon are addressing the loss of life and the horrific 
treatment of people in custody.
    The focus of this hearing, the treatment of immigrants in 
detention, most of whom were, up to the time of their jailing, 
working and contributing members of their communities, whose 
only crime was to be living and working in the U.S. without 
permission, is an issue that needs more congressional 
oversight, and I urge continued examination of this problem.
    Let me say clearly that our organization does not oppose 
the delivery of health care to undocumented immigrants. What we 
are saying is that the Federal Government should be responsible 
for these costs, not counties.
    The Federal Government controls our Nation's borders and 
has the sole responsibility for developing and enforcing the 
immigration policy. The Federal Government's success or failure 
in protecting the Nation's borders directly affects State and 
local governments, particularly Southwest border counties.
    Border counties receive pennies on the dollar when it comes 
to reimbursements from the Federal Government, whether we are 
talking about the State Criminal Alien Assistance Program, the 
Southwest Border Prosecution Initiative or Section 1011 Funds 
for Emergency Health Care reimbursement.
    These three pots of money, developed as reimbursement 
programs, did not come close to making border counties whole. 
From 1999 to 2006, the 24 counties along the border spent a 
cumulative $1.23 billion to process criminals, undocumented 
immigrants, through the law enforcement and criminal justice 
systems. During that same time border counties only received 
$54 million in reimbursements from the Federal Government. 
Again, the costs were $1.23 billion, and only $54 million in 
reimbursements from the Federal Government.
    In fiscal year 2006 alone the cost was 192 million. Of that 
192, border counties received only $1.47 million. These are 
staggering costs, considering the rural nature and poverty 
level of most of these border counties.
    Our 2002 study, entitled ``Medical Emergency: Who Pays the 
Price for Uncompensated Emergency Medical Care Along the 
Southwest Border?'' provides an estimate of the costs for 
providing emergency hospital and transportation services to 
undocumented immigrants. Our study determined that undocumented 
immigrants cost border hospitals $189.6 million in 
uncompensated emergency medical costs during 2000. To put this 
figure in context, total reported uncompensated costs at border 
hospitals were 831 million, meaning that costs attributable to 
undocumented immigrants comprised almost 25 percent of the 
uncompensated emergency room care.
    In addition, we estimate that emergency medical service 
providers had 13 million in uncompensated costs, bringing the 
total to more than 200 million in uncompensated emergency 
medical costs during 2000. Our study found that the former INS 
brought injured and ill-undocumented entrants to hospital and 
emergency rooms or called ambulances without arresting them, so 
that the Federal Government would not bear the cost of 
treatment.
    Although the Federal Government reimbursed the States and 
counties for part of the costs they incurred for providing 
federally mandated and mercy health care services to 
undocumented immigrants, Southwest border counties are 
absorbing a significant and disproportionate amount of the 
costs.
    The position of the Border counties Coalition is that the 
Federal Government should support the medical treatment of 
undocumented immigrants and pay for 100 percent of these costs. 
The Federal Government is responsible for the costs associated 
with undocumented immigration, not counties.
    The costs to process undocumented immigrants come at the 
expense of basic, vital services to county residents. The unmet 
needs include libraries, jails, courtrooms, parks and basic 
infrastructure to colonias' new developments, flood prevention, 
social service programs for abused children and women, child 
care and after-school programs, but the overwhelming needs 
expressed by our elected officials are related to health care.
    They need more ambulances, clinics, more indigent health 
care funding and more funding for comprehensive health care 
programs. These are basic services that lift the quality of 
life and communities. And the residents of border counties 
should not be asked to go without them because of the failure 
of the Federal Government to fully reimburse them.
    Thank you for the opportunity to present the findings of 
our report, and I will be happy to answer any questions.
    Ms. Lofgren. Thank you very much.
    [The prepared statement of Mr. Reyes follows:]
                  Prepared Statement of Isaac A. Reyes
    Chairwoman Lofgren, Ranking Member King, members of the 
subcommittee, thank you for inviting me to testify about the U.S./
Mexico Border Counties Coalition findings on the costs of providing 
medical care to undocumented immigrants. I am the Washington 
representative of the Border Counties Coalition, a nonpartisan, policy 
and technical forum compromised of the elected officials from the 
twenty-four county governments located on the U.S./Mexico border. Our 
efforts at the federal level are focused on increasing the 
reimbursement levels for the costs associated with undocumented 
immigration resulting from the failure of the federal government to 
secure our borders. Because of their proximity to the border, our 
member counties bear a disproportionate share of these costs.
    My testimony this afternoon is about the costs to border counties 
for providing health care to undocumented immigrants. It is awkward to 
be discussing fiscal costs related to undocumented immigration when 
most of the witnesses this afternoon are addressing the loss of life 
and horrific treatment of people in custody. The focus of this 
hearing--the treatment of immigrants in detention--most of whom were, 
up to the time of their jailing, working and contributing members of 
their communities whose only ``crime'' was to be living and working in 
the U.S. without permission--is an issue that needs more Congressional 
oversight and I urge continued examination of this problem.
    The federal government controls our nation's borders, and has sole 
responsibility for developing and enforcing immigration policy. The 
federal government's success or failure at protecting the nation's 
borders directly affects state and local governments, particularly 
southwest border counties. Border counties receive pennies on the 
dollar when it comes to reimbursements from the federal government, 
whether we are talking about the State Criminal Alien Assistance 
Program, the Southwest Border Prosecution Initiative, or Section 1011 
funds for Emergency Health Care Reimbursement. These three pots of 
money, developed as reimbursement programs, do not come close to making 
border counties whole.
    From 1999 through 2006, the 24 counties along the border spent a 
cumulative $1.23 billion on services to process criminal undocumented 
immigrants through the law enforcement and criminal justice system. 
During that same time, border counties received only $54.8 million in 
reimbursements from the federal government. In fiscal year 2006 alone, 
the cost was $192 million. Of that $192 million, border counties 
received one percent of the SCAAP appropriation--only $4.7 million came 
back to them. These are staggering costs considering the rural nature 
and poverty level of most of these border counties.
    Many members of this subcommittee are well aware of the problems 
associated with SCAAP and are trying to improve that program. The 
recent passage of H.R. 1512, sponsored by Representative Sanchez and 
approved by this subcommittee, will bring more SCAAP funds to our 
counties and we thank you for your efforts and recognition of the 
problem.
    Our 2002 study, entitled ``Medical Emergency: Who Pays the Price 
for Uncompensated Emergency Medical Care Along the Southwest Border?'' 
provides an estimate for the cost of providing emergency hospital and 
transportation services to undocumented immigrants. Our study 
determined undocumented immigrants cost border hospitals $189.6 million 
in uncompensated emergency medical costs during 2000. To put this 
figure in context, total reported uncompensated costs at border 
hospitals were $831 million, meaning that costs attributable to 
undocumented immigrants comprised almost 25 percent of the 
uncompensated emergency room care. In addition, we estimate that 
emergency medical service providers had $13 million in uncompensated 
costs, bringing the total to more than $200 million in uncompensated 
emergency medical costs during 2000. The $200 million broke down in the 
following manner: $79 million in California, $74 million in Texas, $31 
million in Arizona, and $6 million in New Mexico. Our study also found 
that the former Immigration and Naturalization Service brought injured 
and ill undocumented entrants to hospital emergency rooms or called 
ambulances without arresting them so that the federal government would 
not bear the cost of treatment.
    Yet, this $200 million figure does not represent the total costs 
borne by southwest border counties and local medical providers. Costs 
incurred for preventive, acute, extended or rehabilitative healthcare, 
and non-emergency medical transportation are not included in our 
estimate since these services fall outside the federal definition of an 
``emergency'' and were therefore beyond the scope of our analysis. 
Furthermore, services delivered by a physician in a hospital's 
emergency department that are not paid by or through the hospital are 
billed separately and cannot be captured by examining uncompensated 
hospital costs. As such, costs incurred by physicians attending an 
undocumented immigrant in a medical emergency also are not included in 
our cost estimate.
    The problem of uncompensated emergency services has far reaching 
implications beyond loss of hospital revenues. Health care costs and 
insurance premiums are rising, due in part to burgeoning levels of 
uncompensated care. Rising health insurance premiums are threatening 
business' ability, particularly small business, to offer employees 
affordable health care benefits. High liability costs and low levels of 
compensation are threatening the viability of emergency rooms and 
emergency transportation providers along the border. Some counties with 
high rates of uncompensated care can no longer afford to provide 
``charity'' care for local needy residents. In some instances, high 
levels of unpaid medical bills related to undocumented immigrants have 
forced local healthcare providers to reduce staffing, increase rates, 
and cut back services.
    The border counties health and health care systems face a much 
different set of issues than the rest of the nation. In 2007, the 
Border Counties Coalition released a report entitled, ``At The Cross 
Roads: U.S./Mexico Border Counties in Transition.'' This report 
provided an in-depth analysis of the 24 border counties and compared 
them to the 50 states in our country. In terms of health care, the 
report found that if the border counties were considered a 51st state, 
it would rank last in the presence of health care professionals. Border 
counties would rank as the 50th state out of 51 in insurance coverage 
for adults and children. The prevalence of tuberculosis per 100,000 
persons among residents of all border counties (10.4) is twice that of 
the United States (5.1) as a whole. Border county populations suffer 
higher rates of diseases, such as asthma, adult diabetes, and 
hepatitis, which are compounded by the low socioeconomic status 
characteristic of the population and a large migrating population 
between the United States and Mexico that relies heavily on public and 
charity health programs. As a significant segment of the population 
moves back and forth across the border, they become transfer agents of 
contagions and potential illnesses. It is clear that border counties 
could use the money spent on health care for undocumented immigrants 
for health care needs for their own residents.
    There has been a lot of heated debate about whether or not 
undocumented immigrants should receive free emergency medical care. Let 
me point out that Congress mandated this policy. In 1996, Congress 
passed two major laws that affect the delivery and financing of 
emergency services to undocumented immigrants. The first is the 
Emergency Medical Treatment and Active Labor Act (EMTALA), which 
requires hospitals and emergency personnel to screen, treat and 
stabilize anyone who seeks emergency medical care regardless of income 
or immigration status. The second law, the Personal Responsibility and 
Work Opportunity Reconciliation Act of 1996 (PRWORA), among other 
things, limits Medicaid benefits for undocumented immigrants to 
emergency health services and non-Medicaid funded public health 
assistance (e.g., immunizations, communicable disease treatment). In 
addition, PRWORA requires states that want to provide non-emergency 
medical assistance to ``non-qualified'' immigrants to pass affirmative 
legislation before providing such services, even if the state already 
had such a law in place prior to the federal Act's passage.
    Although the federal government reimburses states and counties for 
part of the costs they incur providing federally-mandated emergency 
health services to undocumented immigrants, southwest border counties 
are absorbing a significant and disproportionate amount of costs. The 
position of the Border Counties Coalition is that the federal 
government should support the medical treatment of undocumented 
immigrants and pay for 100 percent of the costs. The federal government 
is responsible for the costs associated with undocumented immigration, 
not counties. Few state resources are made available to help counties 
with this burden, so costs fall heavily on local taxpayers in these 24 
counties along the border.
    The costs to process undocumented immigrants come at the expense of 
basic, vital services to county residents. The unmet needs include 
libraries, jails, courtrooms, parks, and basic infrastructure to 
colonias, new developments, flood prevention, social service programs 
for abused children and women, childcare, and after school programs. 
But the overwhelming needs expressed by our elected officials are 
related to health care--ambulances, clinics, more indigent healthcare 
funding, and more funding for comprehensive healthcare programs. These 
are basic services that lift the quality of life in communities and the 
residents of border counties should not be asked to go without because 
of the failure of the federal government to fully reimburse them.
    Thank you for the opportunity to present the findings of our report 
and for giving you a glimpse into the situation facing border counties. 
I will be happy to answer any questions.

    Ms. Lofgren. Mr. Harrison.

TESTIMONY OF EDWARD HARRISON, PRESIDENT, NATIONAL COMMISSION ON 
                    CORRECTIONAL HEALTH CARE

    Mr. Harrison. Thank you. I am pleased to be with you today 
to describe our organization's standards setting and 
accreditation processes.
    The National Commission on Correctional Health Care is a 
not-for-profit organization that grew out of a project begun at 
the American Medical Association in the early 1970's. Our board 
of directors is made up of representatives of 38 major 
supporting organizations, including the AMA, the American 
College of Physicians, the American Nurses Association, the 
National Association of counties, the American Dental 
Association, the American Bar Association, the American Public 
Health Association and the National Sheriffs' Association. 
There was some comment earlier about getting the AMA or the ABA 
involved, and they are involved through our organization.
    We are solely and completely dedicated to improving health 
services in our Nation's jails, prisons and juvenile 
confinement facilities. Our pioneering work began even before 
the Supreme Court's position in Estelle v. Gamble that inmates 
have a constitutional right to health care. So we have watched 
this field evolve and improve over time and have helped the 
correctional systems and correctional health care professionals 
adapt to new challenges that were unheard of 30 years ago.
    Our standards are based on three basic principles: that 
inmates should have access to necessary medical and mental 
health care, that assessment and treatment should be done by 
competent health care professionals, and that health care 
ordered by clinicians should be delivered without undue delay 
or interference. These principles may seem obvious and simple, 
but adhering to the standards is often complicated by the 
institutional nature of corrections.
    Our standards are available to anyone. They have been used 
by State medical societies who have been contracted to review 
local correctional health care services. They have been used by 
the Department of Justice in its investigation into civil 
rights violations in correctional facilities, and by numerous 
consultants and other third parties hired by correctional 
systems to help evaluate and improve the quality of their care.
    Even correctional systems accredited by other 
organizations, when confronted with growing problems, have 
asked us to conduct a review of their own facility and to make 
recommendations for improvement based on the NCAC standards.
    Our organization advocates continuous quality improvements, 
CQI, as a great way for correctional systems to improve their 
operations. CQI, which is one of our standards, dictates that 
service staff actively seek out areas in need of improvement. 
The model embraces the discovery of problems as an opportunity 
to improve. From the thousands of correctional system reviews 
we have done over the past 30 years, I can say that what 
distinguishes the best systems from the mediocre is this 
culture of quality.
    We never come across a perfect system. Indeed, the whole 
notion of CQI is that there is always room for improvement.
    In the case of ICE facilities, ICE has taken the step of 
not only seeking accreditation from our organization, but from 
The Joint Commission on Accreditation of Health Care 
Organizations and others, and it is unusual in our field to see 
an organization take that step to seek multiple accreditations.
    Several years ago I had the chance to go into an ICE 
facility, and I saw tremendous cooperation between the custody 
staff and the health staff. And that interplay between custody 
and health is a key component in a good correctional health 
care system.
    Patient safety in this country, not just in corrections, is 
a huge problem. The Institute for Health Care Improvement 
estimates that each year as many as 15 million patient injuries 
occur in health care settings and between 100,000 to 200,000 
deaths fromunintended injury. This is more deaths than would 
occur if a 747 jumbo jet crashed each and every day. So within 
the profession of health care we are well aware that unintended 
problems arise when treating patients. Within the world of 
corrections, as I mentioned earlier, treatment can be more 
complicated and, therefore, more susceptible to problems in the 
community.
    I have read a number of press reports about the medical 
problems in some ICE detention facilities. It is always deeply 
troubling to hear about neglect and suboptimal care. Reports of 
these kinds require careful investigation and the warranted 
changes to improve the system. Some of the reported problems 
had to do with custody staff action or inaction, which is not 
my organization's area of expertise. If there were critical 
performances involved, we were very, very concerned.
    While we recognize that not every problem can be 
anticipated, we strongly believe that a correctional facility 
should be proactive in implementing patient safety systems to 
prevent near-miss and adverse critical events.
    There should be an error reporting system for health staff 
to report, to voluntarily report in a nonpunitive environment, 
errors that affect patient safety; and all deaths should be 
reviewed promptly, both administratively and critically. In the 
cases of suicide, a psychological autopsy should also be 
conducted. Importantly, treating staff should be informed of 
any review findings and necessary corrective actions needed to 
be implemented.
    Ms. Lofgren. Mr. Harrison, could you sum up at this point? 
Your 5 minutes are up and we have many witnesses.
    Mr. Harrison. Thank you very much. I appreciate the 
opportunity to be here. I understand that some of the steps 
that ICE has taken, and I think that making improvements in 
systems is always possible. We will be glad to help the 
Committee and ICE.
    Ms. Lofgren. We do very much appreciate that offer of help.
    Mr. Harrison. Thank you.
    [The prepared statement of Mr. Harrison follows:]

                 Prepared Statement of Edward Harrison











    Ms. Lofgren. I now turn to Bishop Riley.

   TESTIMONY OF THE REVEREND E. ROY RILEY, BISHOP OF THE NEW 
      JERSEY SYNOD, EVANGELICAL LUTHERAN CHURCH IN AMERICA

    Reverend Riley. I am E. Roy Riley, Bishop of the New Jersey 
Synod of the Evangelical Lutheran Church of America, the 
largest Lutheran denomination the United States, about 5 
million members, many good members in Iowa.
    I thank Chairman Lofgren and Ranking Member King for the 
invitation to be here today.
    Deeply woven into the Christian faith is love and concern 
for all of our brothers and sisters in the human family. The 
Bible is clear: Welcome one another just as Christ welcomed 
you. The bishops of the ELCA hold a special concern for the 
treatment of individuals held in the U.S. immigration detention 
system.
    In just the past month, seven of my fellow bishops have 
visited three detention facilities in the States of Virginia, 
Michigan and Washington. I personally visited the detention 
system facilities in Elizabeth, New Jersey, and in New York.
    Since the detention facility opened in Elizabeth, New 
Jersey, Lutheran Church members have been providing ministry to 
immigration detainees through weekly visits and have been 
providing ministry and pastoral care through a glass partition 
and over a two-way telephone as best they could.
    In the course of these visits, our visitors have become 
aware of the very serious lack of appropriate medical care for 
detainees. These reports are documented in my written testimony 
and supported in various media reports. In fact, this very week 
a woman who came to this country seeking asylum from Nigeria 
and who was released from the Elizabeth Detention Center with 
full asylum 9 months after detention reported to me her story 
of inadequate medical treatment.
    The reports of inadequate medical care for detainees and 
confiscation of needed medicines and medical equipment at 
arrest have foreshadowed the worst news of all that since 2003 
at least 80 persons have apparently died either in detention or 
as a result of the lack of appropriate medical care while they 
were in detention.
    Members of the synod I serve are troubled that it has 
required evidence of people dying to move Congress to take 
action. Of even greater concern to us is that a Nation that has 
so prided itself on the compassion expressed by that statue in 
New York Harbor could, by its own Government, treat immigrants 
and asylum seekers, our fellow human beings, in such a punitive 
way.
    Three years ago, in 2005, the New Jersey Synod Assembly 
passed a resolution decrying the treatment of immigrants. 
Tomorrow, on June 5, our synod will convene again in annual 
assembly and we will consider adopting a resolution expressing 
our grave concern about the growing number of ICE raids 
targeting immigrants and, especially, the devastating effect 
these raids have on families, children and communities.
    I fully expect the synod assembly to adopt that resolution, 
which will continue to provide guidance for thousands of our 
members and help them as they work with their own legislative 
representatives.
    Most of what is driving this discussion today is rooted in 
our own fears, primarily the fear for our own security and our 
own economic stability. When we are so driven by fear, it 
becomes something that is no longer helpful and, in fact, 
causes us to act in ways that are not true to our best selves.
    On May 12, in the little town of Postville, IA, Government 
agents stormed into a workplace and arrested hundreds of 
people, handcuffing them and herding them to the Cattle 
Congress yards in Waterloo. In the process, hundreds of 
children were left not knowing where their parents were. The 
children were traumatized, both the immigrant children and 
children whose families had lived in Iowa forever. At the end 
of the day, teachers and administrators and citizens looked at 
each other and said, What happened here? What country is this?
    It's time for us to act with common sense and good judgment 
and compassion, not just for the sake of immigrant men, women 
and children, but for our sake as human beings and citizens of 
a country that is supposed to be a model for human rights.
    In light of these serious, systemic problems, I urge the 
Subcommittee to consider the following.
    One, improve medical treatment and immigration detention. 
H.R. 5950 is a good step;
    Two, improve conditions of detention; and
    Three, cap expansion of detention and provide alternatives 
to detention. There are alternatives.
    What I have said today will make no difference at all for 
50-year Boubacar Bah, 35-year-old Francisco Castaneda, 45-year-
old Sandra Kenley or 50-year-old Abdolai Sall. They and others 
like them have died in ICE-sponsored detention or as a result 
of the lack of appropriate medical care while in detention. 
What I have said will make no difference for them.
    I have spoken today for the men and women and children who 
are still living, but being held in prison-like conditions as 
asylum seekers or immigrants without clear documentation. On 
behalf of the church I serve, I am lifting them up as brothers 
and sisters who need our help, the help of this Government.
    But I am lifting up before you also the citizens of this 
country, myself included. We all need help in finding a just 
and sensible solution to the issue of immigration.
    I thank you for your kind attention.
    Ms. Lofgren. Thank you, Bishop.
    [The prepared statement of Reverend Riley follows:]

              Prepared Statement of Reverend E. Roy Riley















    Ms. Lofgren. We would now be honored to hear from you, Ms. 
Armendariz.

                TESTIMONY OF GLORIA ARMENDARIZ, 
            WIFE OF ISAIAS VASQUEZ, FORMER DETAINEE

    Ms. Armendariz. I'd like to thank the Committee for 
inviting me. It's an honor for me on behalf of Isaias Vasquez.
    My name is Gloria Armendariz, and I am a United States 
citizen. I reside in San Antonio, TX, with Isaias Vasquez, who 
immigrated to the United States from Mexico when he was 2-years 
old, served in the United States Army during the Vietnam War, 
and recently became a naturalized U.S. citizen. I have lived 
with Isaias for over--for more or less 30 years.
    After many years of suffering from mental illness, he was 
diagnosed in 1990 with schizophrenia, was hospitalized over 18 
years at the Audie Murphy Memorial Veterans Hospital. He was 
also hospitalized and received treatment for schizophrenia at 
the North Texas State Hospital following an arrest for 
possession of marijuana.
    Isaias' conviction for drug possession led to the detention 
and removal proceedings in November of 2004 by the Department 
of Homeland Security. Until August 2005, he was detained in San 
Antonio at the GEO facility.
    I visited Isaias every week while he was detained in San 
Antonio, and a number of times I was concerned he was not 
receiving adequate medical attention. Isaias complained that he 
was having side effects from the medication he received and was 
fainting. He said that the detention staff did not believe him. 
He was mentally ill or fainted. On two occasions, I learned 
that he fell and hit his head. When I complained to the 
detention staff, I was told that Isaias was fine and did not 
need additional medical attention.
    In August of 2005, Isaias won his immigration case. When 
the immigration judge granted his application under the 
Convention Against Torture, the judge found that Isaias would 
likely suffer torture in Mexico due to the mental illness.
    DHS did not appeal from the judge's decision, but Isaias 
was not released and was, instead, transferred to the South 
Texas Detention Complex at Pearsall, TX. There his condition 
became much worse. I was unable to see Isaias as often because 
of the distance from San Antonio to Pearsall. It was a hardship 
for me. But Isaias complained that he was not receiving his 
medications and that he was not fed properly and that he was 
being punished and put in segregation.
    When I saw him, he was frail and undernourished. He seemed 
unstable and disoriented. A few times I tried to see Isaias, 
but I was told that he did not want to see me.
    In January 2006, I learned that the DHS believed Isaias did 
not have schizophrenia, and it was trying to get the 
immigration judge to rescind the order allowing Isaias to stay 
in the United States. Later I found out that in November 2005 
the medical staff at the detention center diagnosed Isaias with 
unspecified personality disorder and that thereafter they 
decided to take Isaias off his medication for schizophrenia and 
depression. Isaias became very sick and was put on suicide 
watch.
    He smeared feces and spit in his cell. He became very 
disoriented and refused his other medications for diabetes and 
high blood pressure. He was punished by the detention staff. 
They put him in solitary confinement and gassed him. This was 
like 6, 7 months in there.
    I tried the best I could to get help for Isaias. Our 
immigration lawyer made requests to DHS to release Isaias. I 
called Advocacy, Inc., an organization which helps individuals 
with disabilities. I spoke to the detention center warden. I 
contacted my congressman's office a lot of times. I filed 
complaints with the FBI, six, seven times. Suddenly, in May 
2006, DHS, our lawyer, was told that Isaias was being released.
    I drove to Pearsall, TX, to get him. I was stunned at his 
condition. And, when I got there, Isaias was very thin. His 
feet were swollen. He was covered with sores and was ranting. I 
was afraid of him because he was so sick, disoriented, and they 
also told me that he had TB.
    I asked the Dr. Johnson to transfer Isaias to the VA 
hospital to transport him, because I was afraid, and he refused 
and said Isaias was not sick. I don't have it here, but there 
was like a SWAT team all around me--the warden, a lady taking a 
videotape of us. And I was pleading to them, Don't, I am afraid 
to take him, but I still had to leave with him.
    So I drove him straight to the VA in San Antonio, I learned 
when I got there that Dr. Johnson had already called the VA and 
told them that there was nothing wrong with Isaias. So at first 
the VA would not admit him though for many years he had been 
treated for schizophrenia at that hospital.
    I refused to take him. When Isaias became violent, the VA 
staff had to subdue him. And several people on the staff, they 
had to subdue him and finally they admitted him to the 
psychiatric ward.
    Isaias remained there for about 2 months and was put on the 
medications which had been discontinued at Pearsall.
    On January 30, 2007, at a hearing with the immigration, DHS 
agreed to dismiss the removal case so Isaias could apply for 
naturalization. On September 27, 2007, Isaias was granted 
naturalization based on his military service.
    Now he has good and bad days, but he still suffers from the 
treatment memories of Pearsall.
    [The prepared statement of Ms. Armendariz follows:]

               Prepared Statement of Gloria A. Armendariz

    My name is Gloria Armendariz. I am a United States citizen and I 
reside in San Antonio, Texas with Isaias Vasquez, who immigrated to the 
United States from Mexico when he was 2 years old, served in the U.S. 
Army during the Vietnam War, and recently became a naturalized U.S. 
citizen. I have lived with Isaias for over 30 years. After many years 
of suffering from mental illness, he was diagnosed in 1990 with 
schizophrenia. Isaias was hospitalized over 18 times at the Audie L. 
Murphy Memorial Veteran's Hospital (VA) in San Antonio, Texas. He was 
also hospitalized and received treatment for schizophrenia at the North 
Texas State Hospital following an arrest for possession of marijuana.
    Isaias's conviction for drug possession led to his detention and 
removal proceedings in November, 2004 by the Department of Homeland 
Security (DHS). Until August, 2005, he was detained in San Antonio at 
the GEO facility. I visited Isaias every week while he was detained in 
San Antonio, and a number of times I was concerned that he was not 
receiving adequate medical attention. Isaias complained that he was 
having side effects from the medication he received and was fainting. 
He said that the detention staff did not believe he was mentally ill or 
had fainted. On two occasions I learned he fell and hit his head. When 
I complained to the detention staff I was told that Isaias was fine and 
did not need additional medical attention.
    In August, 2005, Isaias won his immigration case when the 
Immigration Judge granted his application under the Convention Against 
Torture. The judge found that Isaias would likely suffer torture in 
Mexico due to his mental illness. DHS did not appeal the judge's 
decision, but, Isaias was not released and was instead transferred to 
the South Texas Detention Complex at Pearsall, Texas. There his 
condition became much worse. I was unable to see Isaias as often 
because of the distance from San Antonio to Pearsall, but Isaias 
complained that he was not receiving his medication, that he was not 
fed properly and that he was being punished and put in segregation. 
When I saw him he was frail and undernourished. He seemed unstable and 
disoriented. A few times I tried to see Isaias, but I was told that he 
did not want to see me.
    In January, 2006 I learned that DHS believed Isaias did not have 
schizophrenia and it was trying to get the Immigration Judge to rescind 
the order allowing Isaias to stay in the United States. Later I found 
out that in November, 2005 the medical staff at the detention center 
diagnosed Isaias with ``unspecified personality disorder'', and that 
thereafter, they decided to take Isaias off his medication for 
schizophrenia and depression. Isaias became very sick and was put on 
suicide watch. He smeared feces and spit in his cell. He became very 
disorientated and refused his other medication for diabetes and high 
blood pressure. He was punished by the detention staff--they put him in 
solitary confinement and gassed him.
    I tried the best I could to get help for Isaias. Our immigration 
lawyer made requests to DHS to release Isaias. I called Advocacy Inc., 
an organization which helps individuals with disabilities. I spoke to 
the detention center warden, contacted my congressman's office, and 
filed complaints with the FBI
    Suddenly, in May, 2006 DHS our lawyer was told that Isaias was 
being released. I drove to Pearsall, Texas to get him and I was stunned 
at his condition when I got there. Isaias was very thin, his feet were 
swollen, he was covered with sores and he was ranting. I was afraid of 
him because he was so sick, and I asked the doctor, Dr. Johnson, to 
transfer Isaias to the VA hospital. He refused and said that Isaias was 
not sick. So, I drove him straight to the VA hospital in San Antonio. I 
learned when we got there that Dr. Johnson had called to the VA and 
told the staff that there was nothing wrong with Isaias. So, at first 
the VA would not admit him, even though for many years he had been 
treated for schizophrenia at that hospital. I refused to take him home, 
and when Isaias became violent, the VA staff had to subdue him and he 
was finally admitted to the psychiatric ward. Isaias remained at the VA 
hospital for several weeks and was put back on the medications which 
had been discontinued at Pearsall.
    On January 30, 2007 at a hearing with the Immigration Judge, DHS 
agreed to dismiss the removal case so Isaias could apply for 
naturalization. On September 27, 2007 Isaias was granted naturalization 
based on his military service. Now, he has his good and bad days, but 
he still suffers from the memories of his treatment at Pearsall.

    Ms. Lofgren. Thank you very much for sharing your story.
    Ms. Asfaw?

          TESTIMONY OF ZENA T. ASFAW, FORMER DETAINEE

    Ms. Asfaw. Good afternoon. My name is Zena Asfaw. I am a 
political refugee from Ethiopia.
    I arrived in the United States November 15, 2006, fleeing 
persecution from my home country. Upon arrival, I asked for 
political asylum in the United States. I was taken into custody 
by immigration officials and remained in custody for about 5 
months until the immigration judge granted my political asylum 
application on April 10, 2007.
    Because of the trouble and difficulty I endured in my 
country, I will never regret making the decision to leave. I am 
alive, safe, and I am grateful to the United States for giving 
me refugee.
    I was transferred to the immigration detention center in 
San Pedro, California, after complaining about being unable to 
sleep because I was nervous about being deported. I was seen by 
a psychologist. He prescribed medication that was supposed to 
relax me and allow me to sleep the night.
    One day, I had a near-death experience due to the 
negligence of the attending nurse. On this day, between 7 and 8 
p.m., the attending nurse gave me seven pills to take at the 
same time. In the evening, I was only supposed to take two 
pills.
    Also, the pills she was giving me were different in color 
and shape than my regular pills. I asked her if she was sure 
those were my pills. She became angry and told me loudly to 
swallow them. Then she instructed the security guard to check 
my mouth to make sure that I did not hide the pills in my 
mouth. The guard used a flashlight to examine my mouth. I 
believe I was forced to take the medication that I am not sure 
were not mine.
    Immediately my body started shaking. I feel so cold. I 
thought I was freezing to death, but at the same time I was 
sweating. I went to my bed to lay down. Within a minute, I had 
a seizure and my body began to shake so violently that I fell 
off the bed on the floor.
    I was taken to the immigration center medical unit where 
the same nurse who had given me the wrong pills examined me. 
She took my blood pressure, gave me another four pills, and 
ordered the guard to take me back to my bed. I spent the entire 
night shaking and sweating.
    In the morning, a different nurse came to give me my pills. 
She noticed that I was shaking and sweating, and she asked me 
what was wrong. I told her what happened the night before. The 
ICE officer immediately took me to the hospital. At the 
hospital, I had my stomach pumped. I was taken back to the 
detention center.
    The next day, I was still feeling sick. I was vomiting 
continuously. I lost control of myself and fainted. I start 
bleeding from my mouth and my private parts. A fire department 
ambulance came and took me to the hospital. I was still 
vomiting.
    At the hospital, numerous tests were done on me. The 
examining doctor came and informed me that the test results 
showed damage on my liver, and he said he needed to do more 
tests. He said ICE would be informed about the results.
    It took about a month for me to feel better. I needed help 
from other detainees to dress, bathe and walk. During this 
month, I was only given medication to manage my pain. I 
couldn't even go to the bathroom by myself.
    I had my attorney call ICE and request my medical record. 
He was refused and told that I personally had to request these 
documents. I have requested all of my medical record on 
numerous occasions. To date, I have not received any of my 
records to this day.
    I am not sure to what extent my health has been damaged. I 
was never officially told that I was given the wrong 
medication. It was only in passing that one of the male nurses 
told me that he was sorry that I had been given the wrong 
medication.
    I have repeatedly request that I be informed about my test 
result, especially regarding my liver. I have just recently 
obtained health insurance and have taken tests.
    Ms. Lofgren. It's all right. Take your time. Take a breath.
    Ms. Asfaw. I hope that those tests will finally allow me to 
find out what, if any, permanent damage was done to my health 
while I was in detention by ICE.
    I hope that my testimony helps this Committee to evaluate 
the state of medical care within the ICE detention centers. 
Thank you.
    [The prepared statement of Ms. Asfaw follows:]

                  Prepared Statement of Zena T. Asfaw

    Hello, my name is Zena Asfaw. I am a political refugee from 
Ethiopia. I arrived in the United States on November 15, 2006, fleeing 
persecution from my home country. Upon arrival, I asked for political 
asylum in the United States. I was taken into custody by Immigration 
officials, and remained in custody for about five (5) months until an 
Immigration Judge granted my political asylum application on April 10, 
2007.
    I had never considered coming to the United States until I was 
jailed, beaten, and sexually assaulted after being arrested by the 
Ethiopian government. In late June of 2005, after the May elections in 
my country, the government arrested me for what they believed was my 
participation in the opposition party. There were many demonstrations 
regarding the legitimacy of the elections. Many believed that the 
government had committed fraud to win the election and to retain power. 
The government began to crack down on opposition party members as well 
as anyone they believed might be involved with the opposition. I was 
arrested after a police officer grabbed my cell phone and found some 
messages that had been sent to me by someone who did not support the 
government.
    I was held for 12 days and released after I was forced to sign a 
document stating that I would not involve myself in any political 
movements. After I was released, I went to the hospital because I was 
having physical/female problems because of the sexual assault. I was 
given some medication for my symptoms.
    I tried to put what happened to me at the jail out of my mind. I 
tried to move on with my life, continuing to work. In late October of 
2005, there was a riot that happened after a demonstration. People were 
demonstrating once again against the government because of the 
fraudulent elections. The government began to arrest and detain 
opposition party members and anyone they suspected of being such. Soon 
after this, I received a letter from the police asking me to report for 
questioning regarding the riots. I decided to flee my country in order 
to save my life. I fled first to Kenya on October 27, 2005 and arrived 
in Los Angeles on November 15, 2006. It took me 13 months, traveling 
through 17 countries to arrive here.
    Because of the troubles and difficulties I endured in my country, I 
will never regret making the decision to leave. I am alive and safe and 
I am grateful to the United States for giving me refuge.
    Upon arrival in the United States, I was photographed, 
fingerprinted, X-rayed and then transferred to the Immigration 
detention center located in San Pedro, CA. Upon arrival at the 
detention center I went to the medical unit and reported having female 
problems. I was given some antibiotics, which did not help.
    After complaining about not being able to sleep because I was 
nervous about being deported, I was seen by a psychologist. The 
psychologist concluded that these problems were because of what I had 
experienced in Ethiopia, together with the stress of being under 
deportation proceedings. He prescribed medication that was supposed to 
relax me and allow me to sleep at night.
    After taking this medication for about four or five days I found it 
difficult to wake up and get involved in the daily activities of simply 
dressing and feeding myself. I told the attending nurse of the problems 
I was having because of the medication and informed her that I would no 
longer take them. I requested to see the psychologist. Within a couple 
of days I saw the psychologist and told him how the medication was 
affecting me. He changed the prescription. The new medications were 
working for me. I remained on them for over a month.
    One day I had a near death experience due to the negligence of the 
attending nurse. As is the procedure, it is the attending nurse that 
gives all the detainees their medication. On this day, between 7 and 8 
pm, the attending nurse gave me seven pills to take at the same time. 
In the evening, I was only supposed to take two pills. Also the pills 
she was giving me were different in color and shape than my regular 
pills. I asked her if she was sure that those were my pills and told 
her that I was supposed to only take two at night. She became angry and 
told me loudly to swallow them. Then she instructed the security guard 
to check my mouth to make sure I did not hide the pills in my mouth. 
The guard used a flashlight to examine my mouth. I believe I was forced 
to take medications that I am sure were not mine.
    Immediately my body started shaking. I felt so cold that I thought 
I was freezing to death, but at the same time I was sweating. I went to 
my bed and lay down. Within minutes I had a seizure and my body began 
to shake so violently that I fell off the bed onto the floor.
    The other detainees became alarmed and thought that I was dying. 
They yelled and made all kinds of noise to get the attention of the 
security guards. The guards, sensing the severity of the situation, 
cleared the room. I was taken to the detention center medical unit 
where I was seen by the same nurse who had given me the wrong pills. 
She took my blood pressure, gave me another four pills and ordered the 
guards to take me back to my bed. I spent the entire night shaking and 
sweating.
    In the morning a different nurse came to give me my pills. She 
noticed that I was shaking and sweating and asked me what was wrong. I 
told her what had happened the night before. She looked at my chart and 
immediately locked up all the medication she was going to dispense and 
called ICE officers. The officers immediately took me to the hospital. 
At the hospital, I had my stomach pumped so that I would throw up the 
medication that was inside me. The doctor asked me why I was taking so 
many medications. I told him that I was only taking medication for 
depression and for sleeping. I remember that he said there was some 
kind of allergy medication that had been given to me. I was then taken 
back to the detention center.
    The next day I was still feeling sick. I was vomiting continuously. 
I lost control of myself and fainted. Again, the other detainees 
started making noise and yelling as they had done before. Emergency was 
called and two nurses came. I was taken to the medical unit at the 
facility by wheelchair and examined. They gave me an I.V. and I started 
bleeding from my mouth and my private parts. The nurses noticed the 
severity of my situation and ordered a lock up of the detention 
facility. A fire department ambulance came and took me to the hospital 
again. I was still vomiting.
    At the hospital numerous tests were done on me. The examining 
doctor came and informed me that the test results showed damage to my 
liver and said he needed to do more tests and that ICE would be 
informed about the results.
    It took about a month for me to feel better. I needed help from 
other detainees to dress, bathe and walk. During this month I was only 
given medication to manage my pain. I couldn't even go to the bathroom 
by myself. The other detainees needed to help me with just about 
everything. Sometimes the guards would also help me. Also during this 
time the detainees and myself were told to sign some document which 
absolved the facility from liability for dispensing medications related 
to depression and difficulty sleeping. I refused to sign.
    I had my attorney call ICE and request my medical records. He was 
refused and told that I personally had to request these documents. I 
requested all my medical records on numerous occasions. To date, I have 
not received any of my records.
    To this day, I am not sure to what extent my health has been 
damaged. I was never officially told that I was given the wrong 
medication. It was only in passing that one of the male nurses told me 
that he was sorry that I had been given the wrong medication. I have 
repeatedly requested that I be informed about my test results, 
especially regarding my liver. I have just recently obtained health 
insurance and have taken some tests. I hope that these tests will 
finally allow me to find out what if any permanent damage was done to 
my health while I was detained by ICE.
    I hope that my testimony helps this committee to evaluate the state 
of medical care within the ICE detention centers around the country.

    Ms. Lofgren. Thank you so much. I know that your testimony 
was difficult to give.
    Ms. McCarthy?

           TESTIMONY OF MARY MEG McCARTHY, DIRECTOR, 
               NATIONAL IMMIGRANT JUSTICE CENTER

    Ms. McCarthy. Thank you, Madam Chairwoman and Members of 
the Subcommittee. I am grateful for this opportunity to testify 
in support of the Detainee Basic Medical Care Act of 2008. I 
have submitted my written testimony for the record, and I would 
like to offer the following prepared remarks and then take your 
questions.
    I think the testimony of my colleagues here has been very 
moving and powerful and illustrates so many of the issues that 
we see at the National Immigrant Justice Center.
    I am the director of the National Immigrant Justice Center, 
a program of Heartland Alliance For Human Needs and Human 
Rights, based in Chicago, Illinois. The National Immigrant 
Justice Center coordinates the largest network of pro bono 
attorneys in the country, providing legal representation to 
approximately 8,000 individuals each year, including low-income 
immigrants, refugees, victims of human trafficking, 
unaccompanied children and asylum seekers. Our diverse client 
base and firsthand observation of different detention 
facilities gives us a unique perspective on detainee health 
care.
    Across the country, U.S. Immigration and Customs 
Enforcement contracts with more than 300 local county jails to 
detain noncitizens held in administrative custody. Many of 
these facilities are located in remote, rural areas, far from 
lawyers and other service providers.
    In Illinois and Wisconsin, the National Immigrant Justice 
Center regularly visits county jails under contract with ICE to 
offer legal rights orientations, conduct individual intake, and 
accept individual cases for representation.
    In the thousands of detention cases that the National 
Immigrant Justice Center has handled during the past 10 years, 
we have witnessed a constant stream of complaints about the 
denial of adequate medical care. These complaints range from 
treating common colds to managing serious, permanent illnesses, 
such as issues relating to reproductive health care, to 
diagnosing and treating the physical and mental trauma 
resulting from torture.
    I think it is also very important that we look at the 
numbers of days that individuals are staying in detention. We 
have heard this afternoon that the average length of stay is 
approximately 37 days. However, as my colleagues have testified 
today, that is not always the case.
    In those cases where individuals are detained for longer 
periods of time, it is critical that those individuals have 
access to adequate medical care. In fact, the General 
Accounting Office statistics indicate that approximately 5,660 
detainees of the 283,000 who were deported in fiscal year 2006 
that were detained for more than 210 days, or roughly 7 months.
    And as my colleagues testified today, many of those 
individuals are not here illegally. They have legal claims. 
Many were granted relief. They were granted immigration status 
in the United States.
    I briefly want to talk about one particular case from the 
Midwest. My written comments explore a wide range of areas 
regarding health care, but the one particular case I will 
describe involved an Algerian asylum seeker, Ms. Hassiba 
Belbachir who came to the United States seeking asylum. She was 
taken into custody in McHenry County Jail in Illinois.
    She suffered from severe depression, she told a nurse of 
her desire to take her own life, and repeated this cry for help 
to a social worker shortly thereafter. Instead of scheduling an 
emergency appointment with a psychiatrist, the nurse put Ms. 
Belbachir on a list to see the psychiatrist at his routine 
weekly jail visit 4 days later. Ms. Belbachir committed suicide 
before that appointment. The jail-issued socks wrapped around 
her neck asphyxiated her.
    Ms. Belbachir's story shows what is wrong with our detainee 
health-care system. She was an asylum seeker with a serious 
mental health problem. Because she had no effective advocate 
and because, like the other 30,000 noncitizens detained by ICE 
on a daily basis, her case was all but invisible to the public 
and any number of civic organizations or even State agencies 
that might have come to her aid. In addition, the county jail 
did not comply with ICE detention standards. Staff did not 
conduct a comprehensive initial medical screening upon Ms. 
Belbachir's arrival. Her subsequent care was inappropriate.
    ICE authorities knew that this facility had a history of 
failing to provide adequate screening to immigrants and failed 
to adequately train staff. And while ICE has detention 
standards, it has steadfastly refused to codify them. Thus, the 
standards are legally unenforceable, leaving immigrant 
detainees and their advocates little recourse.
    How do we prevent future deaths and ensure that immigrant 
detainees receive proper medical care? The Detainee Basic 
Medical Care Act is a necessary first step. Among its 
requirements, each immigrant in ICE custody must receive a 
comprehensive medical and mental health screening upon arrival 
at a facility and a comprehensive examination. Appropriate 
personnel must have access to medical records to ensure proper 
treatment.
    Ms. Lofgren. Could you summarize at this point?
    Ms. McCarthy. Yes, I'll be happy to wrap up.
    In conclusion, adequate health care is a critical component 
of humane detention conditions. When lives hang in the balance, 
maintaining humane detention conditions will depend upon 
oversight, transparency and accountability, from Washington, 
DC, to local ICE contract facilities. Lifting the veil of 
secrecy shrouding the immigration detention system and starting 
an honest discussion about its humanity and fairness would be a 
great start.
    Thank you for this opportunity.
    [The prepared statement of Ms. McCarthy follows:]

                Prepared Statement of Mary Meg McCarthy

                            I. INTRODUCTION

    Thank you, Madame Chairwoman and members of the Subcommittee. My 
name is Mary Meg McCarthy. I have served as Executive Director of the 
National Immigrant Justice Center, a program of Heartland Alliance for 
Human Needs & Human Rights, for 10 years. Prior to joining the 
organization, I represented asylum seekers as a pro bono attorney. I am 
grateful for the opportunity to testify in support of the Detainee 
Basic Medical Care Act of 2008.
    Madame Chairwoman and members of the Subcommittee, medical care for 
people who are detained in this country is in critical condition. It is 
but one symptom of a dysfunctional immigration system.
    This afternoon, I would like to provide a brief overview of the 
broken health care system for immigrant detainees, detail examples of 
the battles fought by the National Immigrant Justice Center to obtain 
health care and urgent treatment for immigrants in detention, and make 
recommendations for reform. The Detainee Basic Medical Care Act will 
greatly improve the quality and delivery of care to detained asylum 
seekers and other men and women in administrative detention. In 
addition to this critical function, it will remove the veil of secrecy 
that shrouds the deeply flawed immigration detention system.
    The National Immigrant Justice Center, or NIJC, is a legal aid 
organization based in Chicago. In addition to direct service, NIJC 
litigates in the federal courts and advocates for systemic reform with 
policy makers. NIJC and its pro bono partners provide legal 
representation to approximately 8,000 individuals annually, including 
low-income immigrants, refugees, victims of human trafficking, 
unaccompanied minors, and asylum seekers. During the past 25 years, 
NIJC has developed the largest network of pro bono attorneys in the 
United States, totaling more than 1,000 attorneys from leading law 
firms.
    Throughout most of the nation, the U.S. Immigration and Customs 
Enforcement, or ICE, contracts with local county jails to detain non-
citizens held in administrative custody. Many of these facilities are 
located in remote rural areas, far from immigration lawyers and social 
service providers. Strict secrecy regarding the disclosure of 
information regarding administrative detainees keeps them further 
isolated.
    NIJC regularly visits the Illinois and Wisconsin county jails under 
contract with ICE to offer legal rights orientations, conduct 
individual intake, and accept cases for representation of non-citizens 
held in ICE custody. Immigration detention is administrative, not 
criminal, in nature. Unlike individuals held in criminal detention, 
immigrants in administrative custody have no right to court-appointed 
counsel. Despite the best efforts of NIJC and other legal aid 
organizations, only about ten percent of detainees obtain sufficient 
legal counsel.\1\ Thus, legal rights presentations are often the only 
opportunity for detained immigrants and asylum seekers to gain an 
understanding of their legal rights and the available avenues for 
complaint and redress.
---------------------------------------------------------------------------
    \1\ According to the Washington Post's recent series on health care 
in immigration detention, only one in ten detained immigrants have 
legal representation. Dana Priest and Amy Goldstein, ``As Tighter 
Immigration Policies Strain Federal Agencies, The Detainees in Their 
Care Often Pay a Heavy Cost,'' Washington Post, May 11, 2008. In fiscal 
year 2006, only 48% of all non-citizens were represented by counsel in 
immigration court proceedings. United States Department of Justice, 
Executive Office for Immigration Review, FY 2006 Statistical Year Book, 
G1 (2007).
---------------------------------------------------------------------------
    The government has broad authority to decide who is detained and 
for what duration, with little oversight and virtually no checks-and-
balances. As a result, the system is arbitrary and lacks transparency. 
NIJC's direct representation of detained clients and its regular 
presence in the jails gives it a unique, insider's perspective on ICE's 
persistent failure to provide basic health care, respond to urgent 
needs, conduct vigorous oversight, and take corrective action. Despite 
this insight, much of the data obtained by NIJC related to detention 
conditions is garnered through requests under the Freedom of 
Information Act and federal litigation.
    The medical staff and guards at ICE contract facilities have proven 
to be more open to communication with advocates and service providers 
than the federal agencies. In 2003-04, NIJC conducted a program under 
which it educated jail staff on the medical and mental health needs of 
the immigrant detainee population, and trained them to better 
understand the unique and often tragic experiences of asylum seekers, 
torture survivors, and victims of domestic violence in immigration 
detention. This project, which was implemented in Illinois, Michigan, 
and Wisconsin, was well received by medical staff and guards at the 
jails, who welcomed information on areas of medicine in which they were 
unfamiliar, such as tropical medicine and infectious diseases. The 
project also addressed practical issues, such as conducting medical 
exams through interpreters. Throughout this project, NIJC staff tried 
to work with the Division of Immigration Health Services (DIHS) to 
share our findings and seek its involvement, but to no avail. DIHS all 
but ignored our attempts to collaborate and improve conditions for 
these men and women.

    II. OVERVIEW OF THE BROKEN HEALTH CARE SYSTEM FOR ICE DETAINEES

    The use of administrative detention for non-citizens has 
skyrocketed during the past 12 years. In 1996, the U.S. government had 
a daily immigration detention capacity of 8,279 beds. By 2006, that 
number had increased to 27,500, with funds appropriated for future 
expansion.\2\ In fiscal year 2007, more than 322,000 non-citizens were 
held in immigration detention facilities,\3\ with a daily average of 
approximately 33,000 detainees. According to ICE officials, 
approximately 350 facilities that hold immigrant detainees operate 
under Intergovernmental Service Agreements (IGSAs). An additional eight 
service processing centers (SPCs) are owned and operated by ICE, and 
seven contract detention facilities (CDFs) are operated by private 
contractors such as Corrections Corporation of America or the GEO 
Group.\4\ Most of the IGSA facilities are county jails that were not 
designed to hold a civil detainee population for what can be months or 
years.
---------------------------------------------------------------------------
    \2\ Jorge Bustamante, Report of the United Nations Special 
Rapporteur on the Human Rights of Migrants, Mission to the United 
States of America, A/HRC/7/12/Add.2, 5 March 2008, at 11.
    \3\ Testimony of Gary Mead, before the House Subcommittee on 
Immigration, Hearing on ``Problems with ICE Interrogation, Detention, 
and Removal Procedures,'' February 13, 2008.
    \4\ For a list of CDFs and SPCs, see ``Semiannual Report on 
Compliance with ICE National Detention Standards January-June 2007,'' 
U.S. Immigration and Customs Enforcement Office of Detention & Removal 
(released May 2008).
---------------------------------------------------------------------------
    The May 2008 reports by ``60 Minutes,'' The New York Times, and The 
Washington Post revealed the shockingly sub-standard conditions under 
which many asylum seekers and other non-citizens are held in federal 
custody. Eighty-three immigrants have died in custody in the past five 
years.\5\ Countless others have suffered immeasurably while they or 
their loved one begged ICE to provide care. The press has done an 
admirable job of educating the public and policy makers on the sorry 
state of this system. Sadly, these reports were not news to many 
advocates. In NIJC's extensive experience, immigration detainees 
frequently have to fight to obtain basic medical care and treatment for 
life-threatening conditions. Many never receive care, especially those 
with limited English language fluency and no legal representation.
---------------------------------------------------------------------------
    \5\ Dana Priest and Amy Goldstein, ``System of Neglect,'' 
Washington Post, May 11, 2008.
---------------------------------------------------------------------------
    ICE detention facilities are governed by the ICE Detention 
Standards, which were negotiated between the Immigration and 
Naturalization Service (INS) and the American Bar Association, to apply 
to facilities that hold non-citizens in ICE custody for 72 hours or 
more. ICE adopted these standards when it succeeded the INS, but it has 
steadfastly refused to codify the standards in statute or regulation, 
leaving the standards legally unenforceable. This is a fundamental 
point. Immigrant detainees and their advocates have little recourse 
when the government refuses to enforce its own rules.
    While ICE touts its expenditure of funds on immigrant health 
care,\6\ as described below, only a few DIHS nurses decide whether or 
not to authorize the thousands of requests for treatment that are 
submitted by on-site medical care staff in these jails.
---------------------------------------------------------------------------
    \6\ ICE has stated that it spent nearly $100 million in fiscal year 
2007 on medical care for detainees. ICE Statement for the Washington 
Post, May 7, 2008, available at www.ice.gov/pi/
detainee_health_wash_post_statement.htm.
---------------------------------------------------------------------------
           III. DOMESTIC AND INTERNATIONAL HUMAN RIGHTS LAW 
                     REQUIRES ADEQUATE HEALTH CARE

    The United States is a nation that values liberty and respects the 
rule of law. We do not deprive individuals of liberty without due 
process of law, regardless of their nationality or alienage. Our due 
process protections include the right to humane treatment while in 
custody. Of course, people in immigration detention are in 
administrative, not criminal custody. Many have no criminal record 
whatsoever, having arrived on our shores seeking asylum or protection 
from torture. Others have committed only minor civil infractions and 
have no serious or violent history. As a result, our immigration 
detention facilities are filled to a significant degree with immigrants 
who pose no threat to our communities and who should be released on 
parole, into secure alternative programs, or under orders of 
supervision.
    A host of constitutional principles and international laws govern 
the treatment of individuals in custody. All individuals in this 
country--regardless of their legal status--are protected by the Eighth 
Amendment (made applicable to the states by the Fourteenth Amendment), 
which prohibits cruel and unusual punishment. International human 
rights law also requires that all individuals in custody be treated 
humanely, regardless of citizenship status. For example, Article 10 of 
the International Covenant on Civil and Political Rights (ICCPR) states 
that ``all persons deprived of their liberty shall be treated with 
humanity and with respect for the inherent dignity of the human 
person.'' \7\ Torture and cruel, inhuman, and degrading treatment are 
outlawed by the Universal Declaration of Human Rights (UDHR) \8\ and 
the Convention Against Torture (CAT).\9\ The ICCPR and CAT were both 
ratified by the United States; the UDHR is accepted as universal law. 
In addition, United Nations guidelines call for non-discrimination 
while in custody, prompt medical care and attention, access to hygiene 
and sanitary conditions, and health care that meets national and 
community standards.\10\
---------------------------------------------------------------------------
    \7\ International Covenant on Civil and Political Rights art. 10, 
December 19, 1966, 99 U.N.T.S. 171.
    \8\ Universal Declaration of Human Rights art. 5, December 10, 
1948, U.N.G.A. res. 217 A(III).
    \9\ Convention against Torture, and Other Cruel, Inhuman or 
Degrading Treatment or Punishment arts. 2 and 16, December 10, 1984, 
1465 U.N.T.S. 85.
    \10\ See, e.g., United Nations Standard Minimum Rules for the 
Treatment of Prisoners, May 13, 1977, Economic and Social Council res. 
2076 (LXII); Body of Principles for the Protection of All Persons under 
Any Form of Detention or Imprisonment G.A. res. 43/173, annex, 43 U.N. 
GAOR Supp. (No. 49) at 298, U.N. Doc. A/43/49 (1988).
---------------------------------------------------------------------------
    The United Nations High Commissioner's Guidelines on Applicable 
Criteria and Standards Relating to the Detention of Asylum Seekers call 
the detention of asylum seekers ``inherently undesirable.'' \11\ The 
Guidelines recognize that there may be circumstances in which detention 
of asylum seekers becomes necessary.\12\ However, in those situations 
the Guidelines are unambiguous: ``Conditions of detention for asylum 
seekers should be humane with respect shown for the inherent dignity of 
the person.'' The Guidelines state that ``the permissible exceptions to 
the rule that detention should normally be avoided must be prescribed 
by law.'' \13\
---------------------------------------------------------------------------
    \11\ ``UNHCR Revised Guidelines on Applicable Criteria and 
Standards Relating to the Detention of Asylum Seekers,'' United Nations 
High Commissioner for Refugees (February 1999), Geneva, available at 
http://www.unhcr.org.au/pdfs/detentionguidelines.pdf. Although UNHCR's 
guidelines are not binding, they represent how UNHCR, the agency 
charged with supervising the application of the Refugee Convention, 
believes asylum seekers should be treated.
    \12\ Id.
    \13\ Id.
---------------------------------------------------------------------------
    Due process also affords detained non-citizens the right to 
counsel, which has proven to be a near prerequisite to obtaining basic 
health care in immigration detention. However, rights are meaningless 
if they cannot be effectuated by the individuals they are meant to 
protect. Because non-citizens in custody are not provided counsel 
(although they are entitled to it), the right to adequate health care 
is a battle that many are left to fight on their own from remote and 
isolated detention facilities, a battle not often won.

   IV. DIHS POLICIES VIOLATE APPLICABLE LAWS AND ICE'S OWN DETENTION 
                               STANDARDS

    The ICE Detention Standard on Medical Care, while far from perfect, 
requires that, ``All detainees shall have access to medical services 
that promote detainee health and general well-being.'' \14\ But because 
the standard is not enforceable, it remains, in effect, 
``aspirational.'' Unfortunately, the policy that seems to exercise 
greater influence over provision of medical care to ICE detainees is 
implemented by the Division of Immigration Health Services (DIHS) in 
Washington, D.C.
---------------------------------------------------------------------------
    \14\ See ICE Detention Standard on Medical Care, section I, 
available at http://www.ice.gov/doclib/partners/dro/opsmanual/
medical.pdf.
---------------------------------------------------------------------------
    As a matter of policy, DIHS errs on the side of refusing treatment 
to people who need care. The results are dangerous for detainees and 
frustrating to many jailers. In fact, the Deputy Warden of York County 
Prison in York, Pennsylvania, where federal immigration officials have 
held detainees for years, famously wrote to the local ICE office that 
DIHS had ``set up an elaborate system that is primarily interested in 
delaying and/or denying medical care to detainees.'' \15\
---------------------------------------------------------------------------
    \15\ Letter from Roger Thomas, Deputy Warden, York County Prison, 
to Joe Sallemi, D.A.D.D., ICE, regarding DIHS, dated November 28, 2005, 
at p. 3.
---------------------------------------------------------------------------
    In fact, the DIHS mission statement is contradictory to provisions 
of the ICE Detention Standard on Medical Care, which provides for at 
least basic medical care for the duration of detention. DIHS provides 
health services only for emergency care, defined as a ``condition that 
is threatening to life, limb, hearing or sight.'' In short, the DIHS 
mission, as revealed in a document obtained by The Washington Post, is 
to keep the detainee ``medically ready'' for deportation.\16\ This view 
was reiterated by Mr. Gary Mead, Acting Director of ICE Detention and 
Removal Operations, who questioned whether care was necessary as long 
as the detainee was ``medically capable'' of being removed.\17\
---------------------------------------------------------------------------
    \16\ Dana Priest and Amy Goldstein, ``System of Neglect,'' 
Washington Post, May 11, 2008.
    \17\ Transcript of The Diane Rehm Show, ``Medical Care of Detained 
Immigrants,'' WAMU Radio 88.5 FM, (a National Public Radio affiliate in 
Washington, D.C), May 13, 2008, available at www.wamu.org.
---------------------------------------------------------------------------
    Another significant barrier to obtaining health care is the fact 
that requests for treatment that are made by medical personnel on-site 
in the jails must be submitted to off-site DIHS Managed Care 
Coordinators (MCCs). These are three nurses, not doctors, who are based 
in Washington, D.C. These three MCC nurses currently receive and review 
the medical requests submitted by on-site staff in the jails, 
effectively serving all 33,000 individuals currently in ICE custody 
across the nation.\18\ According to The Washington Post, in one recent 
month, the MCCs received 3,000 requests for care.\19\ Working five days 
per week, at this rate, each of the three MCC nurses would have to 
review and respond to approximately 50 requests per day.
---------------------------------------------------------------------------
    \18\ We understand that previously a fourth nurse reviewed requests 
from hospitalized detainees across the nation, but that such requests 
are now spread among the three remaining staff. See, e.g., http://
www.icehealth.org/ManagedCare/ManagedCare.shtm.
    \19\ Dana Priest and Amy Goldstein, ``In Custody, In Pain,'' 
Washington Post, May 12, 2008.
---------------------------------------------------------------------------
    In a press conference on May 21, 2008, Chairwoman Lofgren described 
changes to DIHS policy that raise additional concerns about the quality 
of medical care provided under this system. Apparently, until 2007 an 
MCC nurse had the authority to approve requested medical care, but not 
to deny it. Cases that an MCC recommended for denial had to be reviewed 
by the Medical Director. As Chairwoman Lofgren described, a policy 
change now allows denial of requested treatment to be issued by the 
MCCs without review by the Medical Director. As a result, off-site 
nurses may deny care that was requested by on-site jail medical 
personnel--potentially endangering lives, and doing so with little to 
no oversight by doctors.
    Chairwoman Lofgren described another change to DIHS policy that we 
find alarming. DIHS previously allowed on-site physicians or medical 
personnel in the ICE facilities to effectively appeal a denial of 
treatment by asking that the request be reviewed by three DIHS 
physicians, not including the Medical Director who may have previously 
authorized denial of treatment. While not fully independent, this 
process at least allowed for review by additional physicians. 
Chairwoman Lofgren's comments in the May 21 press conference suggest 
that this process has been replaced with a grievance process that no 
longer permits independent or even quasi-independent review.
    Vigorous oversight by Congress and independent investigators must 
be conducted to measure the impact of these policy shifts with regard 
to the fairness of detainee access to treatment and the well-being of 
detainees. The Detainee Basic Medical Care Act corrects some of these 
problems by mandating that treatment decisions are based solely on 
professional clinical judgments and by mandating the continuity of 
care. These ensure that immigrant detainees are able to consistently 
obtain prescribed medicine that they were administered prior to 
entering ICE custody. Finally, the bill's establishment of an 
administrative appeals process for denials of medical or mental health 
care will help to correct the dangerous DIHS policy that is in place 
today.

   V. NIJC'S CLIENTS HAVE BEEN ROUTINELY DENIED ADEQUATE HEALTH CARE

    We all know that policies have consequences for real people. 
Policies that are carried out with a callous disregard for humane 
treatment, medical ethics, and international human rights standards 
lead to the horrific stories you have heard today and read in recent 
national press coverage.
    I would like to describe briefly several specific cases that 
reflect the persistent problems I have seen over a dozen years.\20\ The 
stories of these men and women illustrate the urgent need for systemic 
reform of the immigration detention health system to improve screening, 
comprehensive medical and mental health evaluations, access to medical 
records, and response to urgent treatment requests. Many of these 
problems can be addressed through enactment of the Detainee Basic 
Medical Care Act.
---------------------------------------------------------------------------
    \20\ To protect client confidentiality, most of these cases are 
described without using the client's name. NIJC will provide this 
information to the Committee upon request and with client permission.
---------------------------------------------------------------------------
A. Inadequate Screening
    Inadequate screening can fail to catch obvious medical conditions, 
including advanced stages of pregnancy, kidney stones, suicidal 
tendencies, and infectious disease. Early in my tenure at the National 
Immigrant Justice Center, a woman held in a county jail under contract 
to the INS, ICE's predecessor agency, gave birth in a jail bathroom. 
The INS and jail staff did not know she was pregnant. Granted, this 
case occurred several years ago, but little has changed. The same 
detention standards that were adopted by the INS in 2000 are still in 
place and frequently violated.
    NIJC represented an Afghan asylum seeker who was detained for more 
than eight months in a county jail in Wisconsin. He developed kidney 
stones and saw the jail nursing staff repeatedly. On rare occasions, he 
was provided with Tylenol or ibuprofen. It took the intervention of an 
attorney at NIJC to obtain medical tests to diagnose his serious 
condition. Then, this asylum seeker was transferred to another facility 
unexpectedly, before the test results were available.
    NIJC also represented a West African asylum seeker who suffered 
immeasurable harm after being kidnapped by soldiers and held for six 
months as a sex slave and laborer. She finally escaped her captors and 
reached the United States, where she was detained in a Detroit area 
jail. Even though she was an asylum seeker, she was held with the 
criminal population. She was unable to obtain adequate medical 
screening or access to health care, despite the fact that she suffered 
from pelvic pain and bleeding as a result of the torture she endured in 
captivity. After extensive negotiations with NIJC, the government 
agreed to release her. NIJC arranged for her to obtain the medical and 
mental health counseling she desperately needed. She eventually won 
asylum.
    In yet another case, a female client of NIJC exhibited signs of 
malaria that were not recognized by jail medical staff. The woman, an 
asylum seeker from Rwanda, recognized the symptoms and asked for 
medical care. She was provided with aspirin by the jail's medical 
staff. NIJC attorneys intervened and educated the jail physician, who 
had no experience or knowledge of tropical diseases. Malaria is easily 
treated, but can be fatal if misidentified or treated incorrectly. NIJC 
eventually convinced the government to release our client.
    The Detainee Basic Medical Care Act requires that each immigrant in 
ICE custody receive a comprehensive medical and mental health screening 
upon arrival at a facility, and a comprehensive examination within 14 
days of arrival. It also requires that appropriate personnel have 
access to medical records, an important step to ensuring proper 
diagnosis, prescriptions, and treatment.

B. Inadequate Treatment and Deaths in Detention
    In 2005, an Algerian asylum seeker, Hassiba Belbachir was detained 
at McHenry County Jail in Woodstock, Illinois.\21\ According to the 
complaint filed in a civil rights and wrongful death suit brought by 
her estate, on March 13, 2005, Ms. Belbachir, who suffered from severe 
depression and panic attacks, told a nurse of her desire to take her 
own life. The next day, she saw a social worker and again expressed her 
suicidal feelings. The social worker recommended she see a 
psychiatrist. But rather than scheduling an emergency appointment, the 
nurse placed her on a list to see the psychiatrist at his routine 
weekly jail visit a full four days later. Ms. Belbachir committed 
suicide before she had an opportunity to see the psychiatrist. To make 
the situation even more tragic, on the day of her death, jail staff saw 
her lifeless body motionless on the floor of her cell in the medical 
pod, but did not intervene for 40 minutes, when they finally called for 
emergency service. By the time jail staff entered her cell, it was far 
too late. Her face was purple. The jail-issued knee socks knotted 
together and wrapped around her neck had asphyxiated her.\22\
---------------------------------------------------------------------------
    \21\ The case of Hassiba Belbachir is discussed publicly because it 
is the subject of federal litigation. In addition, the attorneys for 
the Belbachir estate authorized the use of her name in this testimony
    \22\ Amended Complaint of the Estate of Hassiba Belbachir v. County 
of McHenry et al, Case 1:06-cv-01392, Filed Nov. 9, 2007 (N.D.Ill.)
---------------------------------------------------------------------------
    Significantly, ICE authorities knew from annual inspections, before 
Ms. Belbachir's death, that McHenry County Jail had a history of 
failing to provide adequate mental health and suicide screenings to ICE 
detainees, maintained no adequate written suicide prevention policy, 
and failed to adequately train staff to prevent suicides. Even so, 
according to the Belbachir complaint, ICE authorities did not enforce 
the Detention Standards until after Ms. Belbachir's death.\23\ Further, 
no one charged with overseeing her custody and care was disciplined in 
any matter related to this gross failure of medical and mental health 
care and supervision.\24\
---------------------------------------------------------------------------
    \23\ Id.
    \24\ Id.
---------------------------------------------------------------------------
    Such tragic and preventable cases call into question ICE's ability 
to monitor its facilities and conduct adequate, much less vigorous, 
oversight of its own operations. The Detainee Basic Medical Care Act 
requires ICE to report any death in detention to the Offices of the 
Inspector General of the Department of Homeland Security and Department 
of Justice within 48 hours. It also mandates reporting to Congressional 
oversight committees. These are critical measures long overdue. Only 
with greater transparency will we achieve accountability.

C. Failure to Transfer Medical Records When Detainees are Moved is a 
        Persistent and Dangerous Problem
    Over the lifespan of NIJC's project to educate health care 
practitioners in Midwestern facilities holding ICE detainees, NIJC 
spoke to dozens of jail staff and asked about their experience treating 
detainees. A common complaint from these nurses and other personnel 
included widespread failure to receive medical records when detainees 
were transferred from one ICE facility to another. In fact, in no case 
did a jail guard or medical professional tell NIJC that medical records 
were transferred to a new facility with an incoming detainee, despite 
the requirement in the ICE Detention Standards that records be 
transferred with each detainee.\25\
---------------------------------------------------------------------------
    \25\ See ICE Detention Standard on Medical Care, section III.N., 
``Transfer and Release of Detainees,'' which states, ``When a detainee 
is transferred to another detention facility, the detainee's medical 
records, or copies, will be transferred with the detainee.'' This 
standard was issued by the INS on September 20, 2000 and adopted by ICE 
along with the other Detention Standards when it succeeded the INS.
---------------------------------------------------------------------------
  VI. IN ITS HASTE TO DEPORT NON-CITIZENS, ICE CUTS CORNERS AND MAKES 
 RASH DECISIONS THAT HAVE THE POTENTIAL TO EXPOSE THE PUBLIC TO HEALTH 
                                 RISKS

    Last year, NIJC helped an African immigrant with infectious 
tuberculosis and AIDS seek much-needed medical treatment. This man was 
previously detained, but ICE released him on an order of supervision 
when it discovered he was HIV-positive. He was later diagnosed with 
AIDS. NIJC filed a motion for a stay of removal and expended 
extraordinary efforts to notify senior ICE officials that deportation 
would be inhumane in this case and could create a public health risk. 
The man was nonetheless put on a plane to Africa, an action that may 
have exposed other passengers to his infectious tuberculosis. NIJC 
strongly urges Congress to enact, and ICE to adopt, the provisions in 
the Detainee Basic Medical Care Act regarding continuity of care and 
development of discharge plans. As this case makes clear, such steps 
are not only critical for detainee health but also influence public 
safety.

    VII. FOR DETAINEES WITHOUT ATTORNEYS, SEEKING MEDICAL ATTENTION 
                        CAN BE A FRUITLESS QUEST

    ICE, DIHS, and congressional oversight committees must recognize 
that due to a chronic lack of legal counsel, most detained immigrants 
never know of their right to health care, much less how to exercise 
that right. When they do request treatment or complain about a lack of 
adequate care, detainees face insurmountable procedural obstacles and 
an accountability vacuum. A lack of transparency regarding who is 
detained, where, and for what purposes keeps claims related to health 
care and detention conditions beyond the reach of legal service 
providers and out of public view. Most of the stories you heard today 
have pierced the veil only because a lawyer, a social service provider, 
a volunteer with a religious organization, or a family member fought to 
hold the government accountable for the treatment of a particular 
individual in its custody. Like the cases revealed by Freedom of 
Information Act requests and the recent reports from The New York Times 
and the Washington Post cited above, they are powerful anecdotes that 
suggest broader violations.
    NIJC legal staff members routinely advocate for clients who need 
medical care and who cannot obtain it in ICE detention. Complaints 
about access to medical care are a constant theme in our conversations 
with detained immigrants. These grievances range from the denial of 
over-the-counter pain medication to a refusal to provide life-
sustaining medication for chronic illnesses. In addition to general 
medical conditions, NIJC has fought on behalf of asylum seekers who 
have been denied treatment for injuries sustained from the torture and 
the persecution from which they have sought refuge in the United 
States. Without an attorney or an advocate, these individuals would 
never have received appropriate care. How many other detained 
individuals are being denied critical medical care? How can we balance 
the use of detention with the humane treatment of detainees?
    Considering alternatives to detention would be a good start. It is 
inhumane to detain asylum seekers and other immigrants who have 
experienced trauma or other severe medical conditions. Alternatives to 
detention through non-governmental and private entities are proven to 
be secure and effective. Under these programs, an immigrant in removal 
proceedings is released to participate in an ``enhanced supervision'' 
program that requires regular check-ins with a caseworker, or in some 
cases, the use of an electronic ankle bracelet. Alternatives are less 
expensive than ICE detention, which averages approximately $95 dollars 
per day. Alternatives also provide a wider array of medical and mental 
health care options. The Detainee Basic Medical Care Act recognizes 
this humane and common sense approach by prioritizing the parole or 
bond of immigration detainees who have serious medical or mental health 
conditions.

                            VIII. CONCLUSION

    ICE and DIHS must provide screenings to all detainees in a timely 
manner and make decisions about treatment based on medical conditions, 
and not on the individual's immigration status. Providing adequate 
medical care is part of a broad range of detention conditions that the 
government must monitor and for which it must be accountable.
    Accordingly, decisions about health care must be made by on-site 
attending medical professionals, and not by a team of bureaucrats in 
Washington, D.C. An appeals process must be established for the review 
of request denials from detainees by on-site medical professionals in 
detention facilities. The medical and mental health requirements, 
appeal process for denial of care, and increased oversight in the 
Detainee Basic Medical Care Act will facilitate care for all detained 
immigrants. In many cases, alternatives to detention may be both the 
most humanitarian and fiscally responsible actions.
    Like any other area of government responsibility, where lives hang 
in the balance, maintaining humane detention conditions will depend 
upon oversight, transparency and accountability.
    Thank you for the opportunity to testify today. I request that my 
full statement be made part of the record and would be pleased to 
answer your questions.

    Ms. Lofgren. Thank you very much for your testimony.
    Ms. Baker, we would be pleased to hear from you.

 TESTIMONY OF ANN SCHOFIELD BAKER, PARTNER, McKOOL SMITH, AND 
        ATTORNEY FOR AMINA BOOKEY MUDEY, FORMER DETAINEE

    Ms. Baker. Thank you. I am Ann Schofield Baker. I am a 
principal at the law firm of McKool Smith in charge of their 
trademark litigation practice. Thank you to Congresswoman 
Lofgren and this Subcommittee for inviting me to testify today.
    As an intellectual property trial lawyer, I will admit I 
knew very little about asylum law or about the inner workings 
of detention centers until I agreed to represent pro bono Amina 
Mudey, a 29-year-old torture survivor from Somalia who sought 
asylum in the United States. Amina suffered unspeakable 
torture, abuse and loss in Somalia, as evidenced by her scars 
and four murdered family members.
    In April of 2007, Amina fled to America and sought asylum. 
She was incarcerated in the Elizabeth Detention Center in New 
Jersey, which is run by CCA.
    When I took Amina's case, I had no idea that I was destined 
to spend over 600 hours in the first 3 months focusing not on 
her asylum case but on battling DIHS, ICE and CCA to ensure 
that Amina didn't die in their care.
    Amina has authorized me to testify before you today.
    During Amina's 5-month ordeal in ICE custody, she 
experienced repeated incidents of medical mistreatment, 
incompetence and neglect that threatened her life, her health 
and her asylum case. In fact, there were two separate incidents 
in which her life was threatened because of poor medical 
treatment.
    When Amina first arrived at the CCA, she had a panic attack 
and fainted. She didn't speak English at the time, and DIHS 
medical staff examined her without an interpreter. They wrote 
in her medical records that, ``Patient complains that she has 
epilepsy and has seizures once or twice a week for 5 years.'' 
When I had the aid of an interpreter, I asked her, ``What's 
this all about?'' And she said, ``I don't have epilepsy. I was 
trying to tell them I've had headaches once or twice a week for 
last 5 years.''
    Then detention center doctors misdiagnosed her as being 
psychotic. They placed her on a powerful antipsychotic drug 
called Risperdal that had cataclysmic side effects on her, and 
they are telltale side effects of Risperdal. She started to 
lactate. She started to drool and convulse like she had 
Parkinson's disease. She fell off her chair. She stopped 
getting a period. She started to drool. You can't miss these 
side effects. She became dizzy and confused.
    Amina had no idea what was happening to her since no one 
ever gave her treatment with an interpreter. She showed the 
nurse that milk was coming out of her breasts, and she gave her 
a pregnancy test and gave her a cup to go get a urine sample. 
And since she couldn't speak English, she started giving them a 
milk sample from her breasts.
    Two weeks after this incident--it actually took 2 weeks for 
a doctor to evaluate her after she began to exhibit signs of 
lactation. What was his reaction? To increase her dosage of the 
Risperdal. She was still on Risperdal when I took her case 2 
months later.
    And I brought in two outside doctors to examine her on her 
underlying asylum case. Dr. Katherine Falk wrote in her sworn 
affidavit in the case, ``The diagnosis given to her by the 
doctor seeing her at the detention center is post-traumatic 
stress disorder, psychosis and depression. There is no evidence 
of psychosis, and there is absolutely nothing in the notes to 
indicate that she had any symptoms that would lead a medical 
doctor to be able to diagnose psychosis. She is not psychotic 
and should not be taking Risperdal.''
    Dr. Laurie Goldstein wrote in her affidavit, ``At the time 
of my exam of Ms. Mudey, I was alarmed at the side effects that 
I witnessed due to the medications she was being prescribed at 
the Elizabeth Detention Center. And I advised her to refuse the 
Risperdal.''
    Both doctors submitted handwritten notes to the detention 
center doctors explaining their credentials, explaining that 
they had given a full examination, that the Risperdal was 
wrong, ``Please contact me if you want to discuss the issue.''
    The doctor became angry at Amina and said, ``You need to 
keep taking this drug.'' Thankfully she refused, because the 
side effects she was exhibiting--if you go on Risperdal's Web 
site, they are all right there--the side effects were 
potentially permanent and life-threatening.
    Well, about 6 weeks later, as I was trying to prepare Amina 
to testify during my lawyerly duties, she developed symptoms of 
a serious abdominal illness that required immediate medical 
attention, but DIHS medical professionals ignored her pleas for 
help for weeks. A guard threatened to throw her in the SHU, 
CCA's solitary confinement chamber, if she continued to request 
medical attention and exhibit signs of sickness.
    She called me in tears, doubled over in pain, and asked me 
to intervene. I called the CCA and spoke to a medical 
professional and alerted them that she had someone inside the 
facility that needed to go to a hospital immediately or else I 
was going to call 911. And the person on the other end of the 
phone eventually said, ``Okay, fine, we will go and look in on 
her and see what is wrong with her.''
    Amina called me back 2 days later to say that nobody had 
had come to see her. And I didn't call 911 because the person 
on the other end of the phone told me, if you call 911, we 
won't let them into the facility.
    Well, after I found out that no one had come to see her, I 
prepared a Federal lawsuit to force them to take her to a 
hospital because I was afraid she would be dead by the end of 
the weekend. And the only reason they took her to a hospital is 
that they found out that I was going to file this complaint.
    To this day, they have refused to tell me what hospital 
they took her to, and I don't have her medical records, and I 
haven't seen medical records from her since June. I wonder why 
they don't want to give them to me. Can you figure it out?
    This is how ICE treated a torture survivor who fled to the 
U.S. in search of safety. Amina and other asylum seekers simply 
don't have the option to just go home.
    I look forward to taking your questions.
    [The prepared statement of Ms. Baker follows:]

               Prepared Statement of Ann Schofield Baker





















































































    Ms. Lofgren. Thank you very much.
    Finally, Dr. Venters?

   TESTIMONY OF HOMER VENTERS, M.D., ATTENDING PHYSICIAN AND 
  PUBLIC HEALTH FELLOW, BELLEVUE/NYU PROGRAM FOR SURVIVORS OF 
                            TORTURE

    Dr. Venters. Thank you, and good afternoon. My name is 
Homer Venters, and I am an attending physician at the Bellevue/
NYU Program for Survivors of Torture, as well as a public 
health fellow with the CDC and New York University. I would 
like to thank the Chairwoman and other Members of the Committee 
to speak here today.
    Together with my colleague, Dr. Allen Keller, I have 
conducted an analysis of the ICE health-care system for the 
last 8 months. Contrary to public statements by ICE, it is our 
conclusion that this health system and the care it allows for 
detainees may be getting worse, not better.
    The central thesis of my remarks is that, behind confusing 
and unreliable statistics concerning detainee deaths, the ICE 
health-care system contains key elements that may jeopardize 
detainee health. I will briefly review the flaws of the 
statistics provided by ICE, refer to several specific failures 
in the ICE health plan, and conclude with our specific 
recommendations for improving the system.
    ICE reports falling detainee mortality rates, but their 
figures are based on unreliable calculations. The most 
important failure is the lack of adjustment for average length 
of detention. Adjusting for risk exposure, such as length of 
detention, is a fundamental practice of both medicine and 
epidemiology, and failure to do so reflects flawed methodology.
    Figures for average length of detention are available for 
2006 and 2007. That is why I present these years. When 
appropriate adjustment is applied to ICE's own mortality 
figures, one sees that length-adjusted mortality has increased 
29 percent from 2006 to 2007.
    Other misleading statistics published by ICE include hollow 
comparisons between deaths among detainees and among prison 
populations and the general U.S. population without any 
adjustment for age, disease prevalence or, again, length of 
detention.
    ICE mortality figures reveal two important pieces of 
information. First, the length-adjusted mortality for detainees 
increased from 2006 to 2007. The cause of this increase is 
unclear, and mortality likely under-represents problems with 
detainee health care. Morbidity is a better marker. But it is 
certainly not the case the mortality has dramatically fallen 
during this time.
    Secondly, reliance by ICE on unsound statistical methods 
that consistently present a more positive picture of detainee 
health should generate concerns about the ability of ICE to 
adequately access and improve its own health-care system.
    This Committee has heard tragic and compelling testimony 
concerning the deaths of ICE detainees. I would like to mention 
four specific aspects of the ICE health plan that establish an 
unacceptable level of care for detainees and must be addressed 
if similar tragedies are to be averted.
    First, the ICE health plan was recently changed to 
eliminate chronic care visits every 3 months. This change will 
mean that less care and less consistent care is provided to the 
one-third of detainees who suffer from chronic medical 
problems. And this is in stark contrast to the proven medical 
standard of establishing system-wide protocols for chronic 
disease management.
    Another harmful practice is requiring the inclusion of 
nonmedical criteria in referring detainees for outside care, 
including whether or not failure to treat will impact 
deportation. This inappropriately limits cares for detainees, 
creates ethical jeopardy for ICE providers, and I will mention 
is different than the standard for the Marshals Service.
    A third problem pertains to health screening. The ICE 
health plan, again, was very recently changed to allow basic 
health screening tests, such as mammograms and pap smears, and 
I quote, ``on a case-by-case basis subject to clinical 
findings.'' Screening tests are, by definition, applied to an 
entire nonsymptomatic portion of a population. To wait until 
clinical suspicion or symptoms appear completely undermines the 
screening aspect of the test. It deprives detainees of the 
accepted medical standard of early detection and treatment, and 
it lets diseases such as cervical, breast and prostate cancer 
develop to the point of symptoms.
    A final critical point regarding the ICE health plan 
involves the treatment authorization request, or TAR. ICE has 
recently scrapped the TAR appeals process but has also given 
off-site nurses the ability to reject TARs by detention center 
physicians. So now physicians in detention centers may have 
their treatment authorization requests rejected by off-site 
nurses, and they have lost the ability to effectively appeal 
such decisions.
    We recommend the following specific changes to the ICE 
health plan as well as the larger infrastructure of ICE.
    The ICE health plan must be altered so that health 
screening tests and care for chronic disease are routinely 
available and reflect accepted medical standards. Nonmedical 
criteria must be eliminated from this health plan as part of 
thereferral process. And detention center providers should not 
have TARs rejected by off-site nurses without physician review 
and without possible appeal.
    Other changes to the larger ICE health system should 
include mandatory reporting of vital health statistics, 
including morbidity, not just mortality, to a body outside 
Homeland Security and routine consideration of parole for 
seriously ill detainees.
    Finally, the health-care system for ICE detainees must be 
guaranteed and defined as a matter of law. Many of the deaths 
reported among ICE detainees involve poor adherence to existing 
ICE guidelines.
    Unfortunately, the present response of ICE to the 
overwhelming evidence of inhumane health care for detainees 
shows that officials are more concerned with public relations 
than confronting a grim medical reality suffered daily by 
immigrants in detention.
    I thank you, and I'd be happy to take any questions.
    [The prepared statement of Dr. Venters follows:]

              Prepared Statement of Homer D. Venters, M.D.

    Good Afternoon. My name is Dr. Homer Venters. I am an attending 
physician at the Bellevue/NYU Program for Survivors of Torture as well 
as a Public Health Fellow with New York University. I am testifying 
today on behalf of the Bellevue/NYU Program for Survivors of Torture 
and the NYU School of Medicine Center for Health and Human Rights. I 
would like to thank Congresswoman Lofgren and members of the 
Subcommittee for inviting me to testify on immigrant detainee 
healthcare. My area of research as a Public Health Fellow is the 
medical care provided to Immigration and Customs Enforcement (ICE) 
detainees. Together with my colleague, Dr. Allen Keller (Director of 
the Torture Survivors Program and the Center for Health and Human 
Rights) I have conducted analysis of the ICE healthcare system, 
including the mortality statistics recently released by ICE and the 
specific provisions of the ICE health plan. My comments today focus on 
these two areas and I will provide recommendations for improvements of 
the ICE healthcare system. The central thesis of my remarks is that 
behind confusing and unreliable statistics concerning detainee deaths, 
the ICE healthcare system contains key elements that may jeopardize 
detainee health. Contrary to public statements by ICE, it is our 
conclusion that this health system, and the care it allows for 
detainees, is getting worse not better.

                   I. Misleading Mortality Statistics

    I would like to begin with the recent discussion of detainee 
mortality reported by ICE. I am referring to the ICE fact sheet on 
detainee deaths dated May 2008 \1\ as well as the Op-Ed by Assistant 
Secretary Myers in the Washington Post.\2\ In these documents, ICE 
relies on inappropriate use of basic epidemiologic terms and inaccurate 
comparisons between populations known to be radically different. The 
lack of standardized mortality or morbidity reported in these documents 
provokes grave concern for the welfare of ICE detainees and the ability 
of ICE to monitor the quality of its own health care system.
    ICE reports falling detainee 'mortality' rates but their figures 
are based on unreliable calculations. In Fiscal Year 2006 ICE detained 
approximately 250,000 people while in 2007, that number rose to 
310,000. Because the total number of detainee deaths dropped from 17 to 
11 during those periods, ICE claims that the mortality rate fell from 
6.7 to 3.5 per 100,000 detentions, a 49% decrease.\3\ However this 
conclusion neglects a very basic and essential issue, the length of 
detention. From 2006 to 2007, the average length of ICE detention 
decreased from 90 days to 37. Adjusting for risk of exposure (such as 
length of detention) is a fundamental practice of both medicine and 
epidemiology and failure to do so reflects flawed methodology. For 
instance, no physician would make conclusions about a patient's risk 
from smoking without including how long that patient had been a smoker. 
Taking ICE's same fiscal year numbers, but correctly adjusting for 
average length of detention, it is clear that the length-adjusted 
mortality actually increased between 2006 and 2007 from 27 to 34 per 
100,000 detention-years, a 29% increase (see Table 1 for side by side 
comparison).\4\ Consequently, the statistics presented by ICE tend to 
present an unduly rosy picture of detainee mortality.
    A second glaring weakness in the ICE statistics is found in their 
comparison between deaths of ICE detainees and those in a general 
prison population. Again, the lack of standardization for length of 
detention makes this a flawed comparison, since prisoners are typically 
held for a longer period of time in a given year than are ICE 
detainees. For example, imagine that ICE detained 300,000 people per 
year for one day each and U.S. prisons detained 300,000 people each for 
a full year. It would be incorrect to conclude that because fewer 
people died in ICE custody than in prison custody, the healthcare 
provided to ICE detainees was somehow superior. The fact that the 
average ICE detainee spends so much less time in custody than the 
average prisoner in a given year must be factored in to provide any 
meaningful results.
    Aside from lacking standardization over a given year, any 
comparison of ICE detainees to prisoner populations is dubious because 
prisoners are incarcerated for much longer periods of time in total 
than ICE detainees. Prison research has shown that mortality rates 
increase with time of incarceration, so even if ICE had standardized 
for time detained in a given year, prisoners who have accumulated years 
of prior detention are known to have higher rates of mortality.\5\ 
Also, when ICE favorably compares mortality of detainees to those of 
prisoners and the general population, there is no adjustment for age or 
disease prevalence. For example, U.S. prisoners have high rates of 
infectious disease, and the general U.S. population may be older, 
suffering from higher rates of heart disease and cancer than the ICE 
population. Without correct adjustment for these types of possible 
differences, the figures provided by ICE are unreliable.
    To be clear, mortality is an imprecise method for appraising 
healthcare in a transitional population. Because death is rare and 
detention is short, mortality likely under-represents problems with 
health care delivery among ICE detainees. Morbidity, which refers to 
sickness or having a disease, is a better measure of the efficacy of 
ICE healthcare since by ICE estimates, at least 34% of detainees suffer 
from chronic diseases.\6\ Consequently, complications from poorly 
controlled chronic disease, such as diabetes, HIV, asthma or 
hypertension are more sensitive health care measures. Unfortunately, 
ICE makes reports no specific information about morbidity of detainees. 
However, even morbidity may under-represent adverse effects of this 
system. As with mortality, shorter detentions will tend to produce 
fewer adverse events. In thinking of ICE detention as a risk factor, as 
ICE detention time shortens, the likelihood is that adverse events 
caused by this risk will occur afterwards. This may have been the case 
with Juan Guillermo Guerrero, 37, who was denied his seizure medicines 
while detained by ICE and died of complications from seizures shortly 
after being deported to Mexico.\7\
    This discussion of ICE detainee mortality reveals two important 
pieces of information. First, the length-adjusted mortality for 
detainees has increased from 2006 to 2007. The causes or significance 
of this increase are unclear but it certainly is not the case that 
detainee mortality is dramatically falling, as ICE has asserted. 
Second, the reliance by ICE on unsound statistical methods that 
consistently present a more positive picture of detainee health should 
generate concerns about the ability of ICE to adequately assess and 
improve its own healthcare system. Our review of the ICE health plan, 
including recent changes, suggests that ICE detainees are receiving 
medical care that is increasingly limited and inconsistent with current 
standards of medical practice.

 II. An Acute Care Health System for a Population in Need of Much More

    The healthcare provided for ICE detainees is directed by a set of 
rules under the Detention Management Control Program of the Department 
of Homeland Security (DHS). This program creates procedures for ICE 
detention operations but does not carry the force of law. Particular 
medical policies and reimbursement guidelines are determined by the 
Division of Immigration Health Services (DIHS), recently incorporated 
into DHS from the Health Resources and Services Administration of the 
U.S. Department of Health and Human Services. DIHS guidelines then 
become part of the overall set of ICE rules for detention 
operations.\8\ Despite acknowledging the substantial burden of chronic 
disease among detainees, the ICE health plan maintains a steadfast 
focus on an acute care model. The 1/3 of detainees with medical 
problems that require ongoing, skilled care for problems such as 
diabetes, hypertension, asthma and HIV find themselves in a medical 
setting geared towards addressing ankle sprains, cuts and bruises and 
calling 911 in case of emergency. Unfortunately, the ICE health plan is 
clearly not crafted to care for a population with significant chronic 
medical or mental health needs. The introduction of the ICE plan 
explains ``The DIHS Medical Dental Detainee Covered Services Package 
primarily provides health care services for emergency care. Emergency 
care is defined as 'a condition that is threatening to life, limb, 
hearing or sight.'' \9\
    This institutional aversion to caring for detainees with chronic 
disease is evidenced in recent detainee deaths. One year ago, a 23 year 
old transgender woman, Victoria Arellano was detained by ICE.\1\0 Ms. 
Arellano had AIDS and was taking a life saving medicine to prevent 
opportunistic infections that could quickly cause pneumonia and death 
were she to stop. These medicines are essential for people with AIDS 
and even a brief interruption risks sickness and death for a patient. 
Despite reporting her medical history and her medication when detained 
(and throughout her detention), Ms. Arellano was refused her medicine. 
Over the following weeks, Ms. Arellano developed a cough and fever, 
which should have prompted hospitalization and evaluation. Instead, Ms. 
Arellano was given an inappropriate antibiotic by the detention center 
medical staff, was still refused her needed medication, and returned to 
her cell. By the time Ms. Arellano's cellmates staged a protest to draw 
attention to her deteriorating condition, she had become very ill and 
died soon thereafter, comatose and shackled to her bed. Faced with a 
common chronic disease, ICE medical staff withheld the correct 
medicines, gave inappropriate medicines and failed to seek more 
competent care for Ms. Arellano. The care that Ms. Arellano required 
would be routine in almost any medical clinic or hospital in the United 
States.
    Among the most prevalent chronic diseases from which detainees 
suffer may be depression and anxiety. The prevalence of these 
conditions is difficult to gauge in part because detainee may fear 
being placed in segregation should they report mental health symptoms. 
This fear was documented in study conducted jointly by the Bellevue/NYU 
Program for Survivors of Torture and Physicians for Human Rights in 
2003 among asylum seekers (admittedly, a small subset of all 
detainees). This report found that ``the mental health of asylum 
seekers interviewed for this study was extremely poor and worsened the 
longer that individuals were in detention.'' In this study, symptoms of 
depression were present in 86% of the 70 detained asylum seekers, and 
anxiety was present in 77% and PTSD in 50%.\11\ The study also 
documented significant difficulties for immigrant detainees accessing 
health services for painful and sometimes dangerous health problems. 
Unfortunately, recent reports by the Washington Post and New York Times 
demonstrate that the problems with detainee healthcare documented in 
2003 are not new and have not been corrected. In fact the concerns are 
even greater today, given that current immigration policies continue to 
dramatically expand immigration detention.
    The fear of arbitrary and inhumane segregation is not hypothetical 
and has real bearing on the health of ICE detainees. In 2007, a 52 year 
old man from Guinea, Boubacar Bah, fell while in ICE custody and 
sustained a head injury.\12\ Mr. Bah was transferred to the medical 
unit of the detention center but when he became agitated, confused and 
vomited, Mr. Bah was written up for disobeying orders and transferred 
to segregation (a euphemistic term for solitary confinement) with 
approval of medical staff. The behavior that served as an excuse for 
disciplinary transfer to solitary confinement was in reality a sentinel 
sign of intracranial bleeding. The most shocking aspect of this case is 
that Mr. Bah was actually in the medical unit, under the care of ICE 
medical staff when the ill-conceived idea to place him in solitary 
confinement was approved. Mr. Bah's condition deteriorated steadily 
under the watch of ICE personnel until 14 hours after his fall, foaming 
at the mouth and unresponsive, he was transferred to a hospital. Mr. 
Bah was quickly diagnosed with a fractured skull, multiple spots of 
bleeding in his brain and ICE notified his family five days later of 
his condition. Mr. Bah died several months later without ever regaining 
consciousness and ICE medical staff originally reported his cause of 
death as 'aneurysm' without any mention of his fractured skull. While 
most detainees who are inappropriately placed in solitary confinement 
do not die, this case illustrates how very basic medical judgment can 
be abandoned in the detention setting. A man who had just fallen and 
lost consciousness, already inside the medical unit, was somehow judged 
to be 'disobeying orders' instead of manifesting a clearly recognizable 
sign of head trauma. Solitary confinement is obviously inappropriate 
for someone who is ill, but this case and others call into question the 
very practice of placing detainees in such a setting.

    III. Specific Weakness in the ICE Health Plan Imperil Detainees

    In addition to the broad institutional problems facing detainees 
who require medical care, there are very specific aspects of the ICE 
health plan that warrant concern. DIHS has altered the Covered Services 
Package several times in the past few years, limiting the scope of 
medical care for detainees. Publicly reported deaths of detainees have 
included cases in which persons with chronic diseases were refused 
access to care outside their respective detention centers.\13\ The 
refusal for this care comes in the form of a Treatment Authorization 
Request (TAR) submitted by local medical staff at a detention center 
and denied by DIHS. Before 2005, the Covered Services Package entitled 
detained with chronic medical problems to 'chronic care' visits every 
three months. In 2005, the Covered Services Package was changed in the 
following manner: ``we have clarified to providers that DIHS does not 
mandate the frequency a detainee is seen or what testing needs to be 
done by the onsite physician. The responsibility will lie with the 
provider.'' \14\ In stark contrast to these recent changes by ICE, 
there is clear and convincing evidence that establishing system-wide 
protocols for chronic disease diagnosis and treatment (including pre-
approved visits, tests and treatments) results in decreased mortality 
and morbidity.\15\,\16\,\17\ Because this change eliminated any notion 
of standard of care (such as a set protocol for treating specific 
diseases), and further increased the burden of securing prior approval 
for outside care, the net effect may have been to limit care for 
detainees with chronic medical problems. One tragic example is 
Francisco Castaneda, a 34 year old man from El Salvador, who was 
detained for 11 months by ICE with bleeding penile lesions. Despite 
numerous physicians documenting concern that his lesions were 
cancerous, DIHS refused the TAR for biopsy labeling the test 
'elective'. After being released from detention, Mr. Castaneda was 
finally able to receive appropriate evaluation and treatment. But by 
then it was too late and Mr. Castaneda died shortly after beginning 
treatment for metastatic penile cancer.\18\
    Another potential threat to detainee medical care is the 
requirement of the Covered Services Package that mandates that 
detention center medical providers include non-medical criteria in any 
potential referral for outside care. The Covered Services Package 
allows non-emergent care with the following explanation: ``Other 
medical conditions which the physician believes, if left untreated 
during the period of ICE/BP custody, would cause deterioration of the 
detainee's health or uncontrolled suffering affecting his/her 
deportation status will be assessed and evaluated for care.'' \19\ With 
these conditions, ICE simultaneously demands that a care provider 
estimate the length of detention for a detainee and assess whether or 
not deterioration of the condition might impact deportation. Both of 
these non-medical criteria potentially limit the care provided to 
detainees and likely create ethical (and potentially legal) jeopardy 
for ICE providers. In contrast, the U.S. Marshals Service relies on 
medical necessity alone in establishing criteria for outside 
referral.\20\
    A third problem with the care allowed under the Covered Services 
Package pertains to health screening. Originally (prior to the 2005 
changes), the plan approved basic health screening tests such as 
mammograms and pap smears only after one year in detention. This 
guideline was substandard because many detainees likely had little or 
no prior health screening and would have benefited from indicated 
health screening tests (as is the standard at Rikers Island Jail in New 
York City, where average length of stay is shorter than average ICE 
detention).\21\ But even this substandard coverage was further reduced 
in 2005 when the Covered Services Package substituted diagnostic 
criteria for what they continued to call screening tests. The new 
guidelines stated: ``screening for disease processes (e.g., breast, 
cervical, prostatic, colorectal cancer) are considered on a case by 
case basis, subject to clinical findings . . . In other words, clinical 
findings must support the need for the requested screening. This change 
will remove the impression that these tests are automatically approved 
for a detainee who is in custody for over 12 months.'' \22\ Screening 
tests are by definition, applied to the entire non-symptomatic portion 
of a population. For example, in discussing Pap smears, the U.S. 
Preventative Services Task Force recommends screening for cervical 
cancer in women who have been sexually active and have a cervix.\23\ 
There is no reference to symptoms or clinical suspicion in this, or any 
other screening recommendation and to wait until clinical suspicion or 
symptoms appear completely undermines the 'screening' aspect of the 
test. This difference is enormously important because while ICE 
continues to call these tests 'screening', they are in fact forcing 
tens of thousands of people to forgo some of the most beneficial and 
cost-effective measures of modern medicine. By waiting until detainees 
show symptoms or arouse clinical suspicion of a disease, ICE deprives 
detainees of the accepted medical practice of early detection and 
treatment in favor of letting diseases such as cervical, breast and 
prostate cancer develop to the point of symptoms.
    A final but critical problem with the ICE health plan involves 
changes in how each Treatment Authorization Request (TAR) is processed. 
Prior to changes in 2005, detention center medical staff could submit a 
TAR and if it was rejected by DIHS, they could appeal this refusal. 
These appeals were reviewed by a team of 3 DIHS physicians. This formal 
appeal process was scrapped in 2005 in favor of a 'grievance' process 
that eliminated the physician review component. In addition, in 2007 
ICE changed the guidelines for refusing TAR's so that DIHS nurses could 
reject a TAR without any input from the DIHS medical director. Such 
oversight by the medical director was required for rejection of TAR's 
prior to this change. The net effect of these two changes is that 
physicians in detention centers may have their TAR's rejected by off-
site nurses and they have lost the ability to appeal such decisions to 
a group of physicians.

                          IV. Recommendations

    We recommend several specific changes to the DIHS Medical Dental 
Detainee Covered Services Package as well as to the larger health 
infrastructure if ICE. Without these changes, we are concerned that all 
detainees held by ICE face an unacceptably low standard of medical care 
that will adversely affect their health.

    1.  The DIHS Medical Dental Detainee Covered Services Package must 
be altered in the following ways:

      A.
          Care for chronic disease must be routinely available and 
reflect community standards for the care of HIV, diabetes, hypertension 
and other common chronic diseases. Part of these improvements must 
include pre-approval for standard, foreseeable care.

      B.
          Health screening tests must be made available based on 
prevailing medical standards and any mention of 'clinical suspicion' or 
'symptoms' must be eliminated from criteria for these tests.

      C.
          Non-medical criteria must be eliminated from the process of 
detention center medical staff seeking a TAR for detainees. 
Specifically, the mandate that ICE providers balance a deteriorating 
condition and uncontrolled suffering against the ability to deport the 
detainee or estimate a detainee's length of detention must be 
eliminated from the health plan.

      D.
          TARs generated by physicians should not be rejected by nurses 
without review by a physician. Any TAR rejected by DIHS should be open 
to a genuine appeal, including review by physicians

    2.  ICE should be mandated to report vital health statistics 
(including deaths, disease complications, accidents and forcible 
medical actions against detainees) to a body outside DHS with expertise 
in public health and epidemiology. One possible solution would be to 
return DIHS to the Health Resources and Services Administration of the 
Department of Health and Human Services and include an ICE medical 
monitoring division.

    3.  Detainees with serious medical ailments requiring high levels 
of care should be routinely considered for parole. The correctional 
setting is an inefficient and inhumane venue for persons with medical 
problems requiring high levels of ongoing medical care.

    4.  Healthcare for ICE detainees must be guaranteed and defined as 
a matter of law. Many of the deaths reported among ICE detainees 
involve poor adherence to existing ICE guidelines. Greater 
accountability is needed to ensure compliance in healthcare standards 
across the wide spectrum of detention centers.

    These improvements will require substantial effort, including 
financial investment. Currently, ICE argues that the number of medical 
visits, procedures and overall medical budget ($100 million) 
demonstrate a high degree of care for detainees. But these details tell 
us nothing about key factors in care delivery, including delays in 
treatment and the nature of visits. Several detainee deaths involved 
delays in care and the explosive increase in immigration detainees has 
outpaced increases in medical spending. Moreover, $100 million may be a 
low health care budget for a system that detains 300,000 people per 
year. By comparison, Rikers Island Jail in New York City detains 
roughly half the people annually and on any given day that ICE detains, 
but has spent over $100 million annually on healthcare for over a 
decade for a population that is generally detained for less time than 
ICE detainees. Without transparency from ICE on basic health outcomes 
or costs, ICE's raw expenditures tell us little about the efficacy of 
this system of care.
    We believe that the most basic principles of decency and sound 
medical practice demand that an adequate standard of health care for 
detainees be legally mandated aggressively enforced and that basic 
health outcomes among detainees be reported for evaluation outside ICE. 
Unfortunately, the present response of ICE to the overwhelming evidence 
of inhumane healthcare for detainees shows that officials are more 
concerned with public relations than confronting the grim medical 
reality suffered daily by immigrants in detention.




                               REFERENCES

 1.  Immigration and Customs Enforcement, Office of Public Affairs. 
Fact sheet: Mortality rates at ICE detention facilities. Office of 
Public Affairs, U.S. Department of Homeland Security; 2008.
 2.  Myers JL. Caring for immigration detainees. Washington Post. 5/20/
08 2008;A13.
 3.  mmigration and Customs Enforcement, Office of Public Affairs. Fact 
sheet: Mortality rates at ICE detention facilities. Office of Public 
Affairs, U.S. Department of Homeland Security; 2008.
 4.  If one were to use the calendar year deaths for 2006 and 2007 (16 
and 7), then the length-adjusted mortality does fall slightly from 25 
to 22 per 100,000 detention-years. However, this calculation is 
unreliable since it mixes fiscal and calendar year numbers at a time of 
rapid changes in numbers and length of detentions. Length of detention 
numbers were unavailable for years other than 2006 and 2007.
 5.  Mumola CJ. Department of Justice, Bureau of Justice Statistics. 
Medical causes of death in state prisons, 2001-2004. 2007; ncj216340.
 6.  Myers JL. Caring for immigration detainees. Washington Post. 5/20/
08 2008;A13.
 7.  Bernstein N. Few details on immigrants who died in custody. New 
York Times. May 5, 2008 2008;A.
 8.  Jawetz, T. (American Civil Liberties Union) 2007, Medical Care and 
Deaths in ICE Custody, House Subcommittee on Immigration, Citizenship, 
Refugees, Border Security, and International Law.
 9.  Government Accountability Office 2007, Alien Detention Standards, 
Governemtn Accountability Office, Washington D.C.
10.  Human Rights Watch 2007, Chronic Indifference: HIV/AIDS Services 
for Immigrants Detained by the United States.
11.  Physicians for Human Rights/Bellevue/NYU Program for Survivors of 
Torture 2003, From Persecution to Prison: The health consequences of 
Detention for Asylum seekers.
12.  Bernstein N. Few details on immigrants who died in custody. New 
York Times. May 5, 2008 2008;A.
13.  Lutheran Immigration and Refugee Service and Detention Watch 
Network 2007, Overview of U.S. Detention; Briefing materials for the 
United Nations Special Rapporteur on the Human Rights of Migrants, 
Detention and Deportation Working group.
14.  Division of Immigration Health Services (DIHS) 2005a, DIHS Medical 
Dental Detainee Covered Services Package, Division of Immigration 
Health Services (DIHS).
15.  Solberg, L.I., Asche, S.E., Pawlson, L.G., Scholle, S.H. & Shih, 
S.C. 2008, ``Practice systems are associated with high-quality care for 
diabetes'', The American Journal of Managed Care, vol. 14, no. 2, pp. 
85-92.
16.  Tsai, A.C., Morton, S.C., Mangione, C.M. & Keeler, E.B. 2005, ``A 
meta-analysis of interventions to improve care for chronic illnesses'', 
The American Journal of Managed Care, vol. 11, no. 8, pp. 478-488.
17.  ``Supplement 1. American Diabetes Association: clinical practice 
recommendations 2000'', 2000, Diabetes care, vol. 23 Suppl 1, pp. S1-
116.
18.  Priest, D. and Goldstein, A. System of neglect. Washington Post. 
May 11, 2008 2008;A1.
19.  Division of Immigration Health Services (DIHS) 2005a, DIHS Medical 
Dental Detainee Covered Services Package, Division of Immigration 
Health Services (DIHS).
20.  U.S. Marshalls Service 2008, Prisoner Health Care Standards. 
Available: 
http://www.usmarshals.gov/prisoner/standards.htm.
21.  Fein, E. September 19, 1997, Deal to Brink Rikers Inmates Managed 
Care, New York Times,A.
22.  Division of Immigration Health Services (DIHS) 2005b, Summary of 
Changes to the DIHS Detainee Covered Services Package, Division of 
Immigration Health Services (DIHS).
23.  U.S. Preventive Services Task Force. Screening for cervical 
cancer. 2003

    Ms. Lofgren. Thank you, Dr. Venters and all of the 
witnesses.
    This is a time when we have an opportunity to ask a few 
questions. I have several.
    First, Ms. Armendariz, your testimony is so hard to listen 
to due what occurred. He had been treated at the VA for years, 
because he was a veteran, and they had diagnosed him with 
schizophrenia.
    Ms. Armendariz. Fifteen years.
    Ms. Lofgren. Okay. So that is a Federal facility with 
Federal medical records. Were those records ever made available 
to ICE?
    Ms. Armendariz. I guess it didn't mean anything to them at 
that time. I told them--or his attorney told them.
    Ms. Lofgren. Okay. So that answers one question, that the 
medical records we were told this morning that always follow, 
there is a problem there, it appears.
    Ms. Armendariz. The first facility, because he was in San 
Antonio, the first facility, he fell down. And his face, I 
thought they had beaten him, and it was because they gave him 
strong Thorazine. It had side effects. And that is when I got 
advocacy involved.
    Ms. Lofgren. Right.
    Ms. Asfaw, you have been granted political asylum here in 
the United States. You received very abusive treatment in your 
home country. When you were put into custody after you made 
your indication to apply for asylum known, was there any effort 
to provide information or care to you to deal with the things 
that had been done to you that you had escaped?
    Ms. Asfaw. Yes.
    Ms. Lofgren. And what were those things?
    Ms. Asfaw. Back in my country?
    Ms. Lofgren. No, here in the ICE facility, did anybody in 
the ICE facility try to help you cope with the things that had 
been done to you in Ethiopia?
    Ms. Asfaw. Yes.
    Ms. Lofgren. And what were those things?
    Ms. Asfaw. I don't understand.
    Ms. Lofgren. Okay. That is all right. I will follow up in 
writing with you on that. That will be easier.
    Let me ask you, Ms. Baker, your testimony is very 
compelling. First, 600 hours is a lot of billable hours. I 
think it is pretty admirable that you have donated and your 
firm has donated that kind of time on a pro bono basis.
    You, I think, were here this morning to hear the testimony 
of Ms. Myers. How does her testimony compare to what you saw as 
an attorney with a client last year?
    Ms. Baker. You mean as opposed to the Rolls Royce of 
medical treatment?
    Ms. Lofgren. Correct.
    Ms. Baker. There are very clear systemic problems, as 
evidenced by my client's case and by a number of other people's 
cases who have testified here today.
    Number one, there are no interpreters. In the 5 months that 
Amina was in ICE detention, she didn't once have a medical 
examination or treatment with an interpreter.
    Ms. Lofgren. Did you offer to provide that for her?
    Ms. Baker. I offered to provide--as soon as I came into the 
case, I realized that there were glaring miscommunications, and 
I offered to provide them with an interpreter for months in 
writing, and no one ever called. They refused to do it.
    I still to this day, as I have said, have not seen her 
medical records. I think the medical care that she was 
provided, I mean, even if you can look the other way at a 
misdiagnosis in the first place and say they thought maybe she 
was psychotic but really wasn't, when you have the side effects 
that she was exhibiting, it's just inexplicable that none of 
the medical professionals got it.
    A gynecologist who I brought in instantly figured out that 
she was on an antipsychotic drug. And the psychiatrist figured 
out it was Risperdal, because at the time we didn't have her 
medical records, when Dr. Kathy Falk examined her. So the side 
effects were just catastrophic, and they completely either 
missed them or, worse, knew about them and increased the dosage 
anyway.
    Ms. Lofgren. Well, you provided them with a second opinion 
with outside physicians, right?
    Ms. Baker. Two second opinions. They actually wrote full 
letters to them. I didn't get to this in my testimony, but 
later on--and I started writing letters, too, saying, ``I'm 
Amina Mudey. I don't speak English. And I demand my medical 
records. My lawyer is writing this on my behalf.'' The inside 
doctor eventually gave all of the letters back, including at 
least one letter written by the doctor, told Amina, ``Tell your 
lawyer to stop writing me letters.''
    Ms. Lofgren. Ms. McCarthy, before my time runs out, your 
agency is in a lot of facilities doing pro bono assistance. You 
heard the testimony this morning from Ms. Myers. Does that, 
sort of, rosy picture that was given to us comport with what 
you are seeing in the facilities?
    Ms. McCarthy. Unfortunately, no. I think what is really 
alarming is the lack of attorneys available to represent 
detainees, the number of which is increasing dramatically.
    The three stories that we have heard today are stories of 
people who had legal representation and advocates. Just imagine 
what it is like for those individuals who do not have legal 
advocates. Unfortunately, Ms. Belbachir was one of those 
individuals. She was a suicidal asylum seeker who had no one 
from outside the ICE facility to advocate for her.
    There is no court-appointed counsel available for 
immigrants who are detained or placed in legal proceedings. 
Individuals are detained and deprived of their liberty and 
their only option for medical help, as the system is set up 
right now, is through Immigration and Customs Enforcement.
    Ms. Lofgren. Thank you very much.
    My time has expired, so I'll turn to the Ranking Member, 
Mr. King, for his questions.
    Mr. King. Thank you, Madam Chair.
    In listening to the testimony, I want to say that I surely 
don't doubt the testimony that's before us here, and I don't 
doubt that there are tragic human circumstances that take 
place. There are 300 million people in America and 6 billion 
people on the planet, and there are going to be many, many of 
these stories. And it is a small sampling that you have 
delivered here today.
    One of our jobs is to evaluate the policy that exists 
against the policy that's proposed and see where the data 
that's delivered to us matches up to that and also see where 
the anecdotes that are delivered to us matches up to that.
    And with that in mind, I'd turn first to Ms. Baker and ask 
you: What in Ms. Lofgren's bill, that is really part of the 
subject here today, even though it's not formally the bill 
that's before us in the hearing, what in that bill would have 
alleviated the circumstances that you testified with regard to 
today regarding your client, Ms. Mudey?
    Ms. Baker. The bill, as I understand it--and I have to 
admit that I only read it once about 2 weeks ago, so I'm not 
fully prepared to discuss the terms of it today--but that it 
creates a standard for the care that's provided. It's 
effectively like a bill of rights, as I understand it, that 
these kinds of situations just simply can't be swept under the 
carpet, that there needs to be some kind of standard set for 
the care provided to these people.
    Mr. King. And so, to summarize that answer, and I 
understand it this way too, that it provides a cause of action 
and perhaps a means of appeal. But it probably would have not 
have intervened before these circumstances took place. That's a 
point that I think we need to keep in mind here. And I 
appreciate the balance of your answer.
    And I'd turn to Bishop Riley. I'm, of course, very 
interested in your testimony and very respectful of you as a 
man of the cloth and the tone that you bring here as well.
    And I have a question that drifts in my mind with regard 
to, let's just say, human dignity. Human dignity is, in my 
judgment, a basic human right that should be provided to every 
human being regardless of their citizenship or whether they are 
lawfully present or whether they are not.
    Do you draw a distinction between human dignity and human 
rights in any way that you'd like to describe to this panel?
    Reverend Riley. I think that human dignity is a human 
right. It's one of the rights.
    Dignity--let me give you an example of a lack of dignity. 
One of the things that often happens is that when our detention 
facilities like the one in Elizabeth fills up, then folks are 
farmed out to the county jail. If you are farmed out to the 
county jail, such as Monmouth County, no matter what you're 
there for, if you're an asylum seeker or whatever, then you 
wind up being stripped searched for drugs with the rest of the 
criminal population.
    Mr. King. Reverend Bishop, wouldn't that also be true for 
someone who was, let's just say, someone who was lawfully or 
unlawfully present in the United States? Because that is the 
next piece of this question.
    Let me make it--there's four parts. I think there is a 
distinction between human dignity, which should be provided to 
all people, but then between that and human rights and between 
human rights and the distinction between those lawfully present 
and those unlawfully present in the United States, as well as 
the distinction between the rights of U.S. citizens.
    Those four definitions, do they have a distinction in your 
mind? And do you draw those distinctions, as far as supporting 
the laws of this Nation with regard to immigration?
    Reverend Riley. As you pointed out when you started this 
question, I come at this from a little bit different 
perspective, in that I look at all of the people as part of the 
family of God and the children of God. And so everyone in that 
vision is equal.
    I believe that the country has to have and maintain its 
laws, no question about that. And I think those laws need to be 
applied equally across the board.
    But I think it's also true that at the heart of our law is 
respect for human beings, wherever they come from, whoever they 
are. And I think that's at the crux of this matter, is that our 
own failed laws, frankly----
    Mr. King. Well, and I appreciate your point.
    Reverend Riley [continuing]. Put us in this situation.
    Mr. King. And so I'm asking you, do you believe that it's 
possible for ICE to enforce current immigration law and still 
provide for human dignity and still provide for the human 
rights that you and I believe in?
    Reverend Riley. If ICE is an extension of this Government 
that is me, because this Government is by the people, then I 
expect ICE to do this.
    I don't believe ICE is conforming to its own policies. I 
think that's why we are here today, is that law is going to 
have to be enacted to get ICE to respond to its own written 
policies in terms of its standards of care.
    Mr. King. But you do believe it is possible to enforce the 
law and still provide for human dignity and human rights under 
the current law?
    Reverend Riley. I would hope that it is.
    Mr. King. I would, too, Reverend. Thank you for your 
testimony.
    And thank you all for your testimony.
    I yield back the balance of my time.
    Ms. Lofgren. The gentleman's time has expired.
    I turn now to the Chairman of the Judiciary Committee, 
Chairman Conyers.
    Mr. Conyers. Thank you very much.
    I commend the witnesses.
    Steve King and I have agreed to send a letter to the lady 
that was the head----
    Ms. Lofgren. Ms. Myers.
    Mr. Conyers. Yes, Ms. Myers, with the testimony of Ms. 
Armendariz and ask her to respond to it so we can find out 
where she comes down on it.
    This is one of the times I would've liked to have had this 
panel go first and see how that might have affected her 
testimony or what comments she would've had about this at all. 
But anyway, I think this has to be continued.
    You know, this doesn't sound like this is in America this 
kind of thing is happening, to me. I mean, if you told me--I 
could name a number of countries that if you said this, I'd say 
it's awful and it's too bad they do things like that over 
there. But this is happening right under our nose.
    And I am beyond shock now, having been in this body enough 
years. But this is stunning testimony that needs to be followed 
up on.
    Now, could I ask anybody that knows what type of physician 
or physicians are on staff at the ICE facilities?
    Yes, sir?
    Dr. Venters. I have interacted with some of the medical 
staff when I do my evaluations. And so, generally, they're 
internists. I think Elizabeth Detention Center right now has a 
cardiologist who was trained as an internist and then has 
specialist care in cardiology. But, generally, internists or 
family practitioners, if they are physicians. However, a great 
many of the smaller facilities may have a physician's assistant 
or a nurse.
    I think the goal is to have a physician there during 
business hours, for a lot of these facilities, and then they 
have someone else to cover the evening and weekends.
    Mr. Conyers. Well, I guess the first thing the Committee 
might want to do is find out what kind of medical practitioners 
or health providers are at each facility. That would help us 
get off the ground.
    And dare I ask, are there any psychiatrists or 
psychologists at any of these facilities that we know of?
    Ms. Baker. I cannot state with certainty that my client was 
seen by a psychiatrist. However, in reviewing her medical 
records, it said something like ``seen by psych.'' But the 
person's name was never identified, as far as I can tell, so 
I'm not sure who prescribed the Risperdal to my client. There 
may have been a psychiatrist, but I can't say for sure.
    Mr. Conyers. Well, what else are we to make, Attorney 
Baker, of the way you were treated? I mean, for goodness sake, 
how many people, if they had counsel, would have people of your 
professional caliber making regular, logical interventions with 
questions and so forth? And they were shrugging you off like, 
please get out of my way.
    Ms. Baker. They were sick of me, I will tell you that much. 
They definitely were sick of me.
    But the thing that bothers me most in all of this--well, 
there are many, but one of the things that bothers me the most 
is the audacity of the person on the other end of the phone 
when I called and said, ``I'm about to call 911 because you 
have someone who is doubled over in pain, who has not been seen 
by a doctor for 2 weeks,'' and I had a doctor on the phone who 
prepared an affidavit who identified that this was a life-
threatening, potentially anyway, a life-threatening situation, 
as much as she could tell over the phone. And then 2 days went 
by before anybody went to see her. And they went to see her 
only after my colleague, Adam Pearl, and I got back to the 
phone and started saying, ``Hey, you told me someone was going 
to go and see what was wrong with my client,'' and nobody ever 
did.
    Mr. Conyers. Well, one last intervention here. Ms. 
McCarthy, Attorney Baker, how do we deal with this lack of 
legal representation problem? This isn't going to be cured by 
pro bono. There are not enough lawyers and law firms in America 
that they can produce the Bakers around here to provide--we are 
in a hell of a situation.
    What do you tell the Congress to do?
    Ms. McCarthy. Well, I think there are a number of issues, 
but I think the most significant issue, as I said in my 
comments, is the overuse of the immigration detention system. 
Is it necessary to have all of these individuals locked up at 
taxpayer expense? This is administrative detention; this is not 
criminal detention.
    I question whether it's necessary that we lock up men and 
women who are, many times, hardworking members of our 
community, need access to medical careoutside of the 
immigration detention system, or are asylum seekers merely 
seeking protection.
    Mr. Conyers. Do you have some studies or proposals or 
essays that suggest that the answer is, no, that we shouldn't 
be locking up so many?
    Ms. McCarthy. The Vera Institute of Justice has conducted a 
study in which it followed individuals who were released from 
detention to determine what the outcome of their immigration 
proceedings was. The study demonstrated successful results, 
because upon release from detention the immigrants were paired 
up with attorneys, they had access to health care, they had 
access to social services, and they had access to religious 
communities that supported them. So I think it's a very, very 
viable model.
    Mr. Conyers. Well, maybe King and I can work on analyzing 
this. The window of opportunity is closing here in the 110th 
Congress, but maybe we can work on getting some more 
information about what's going on and whether it is necessary 
or is this overkill.
    I mean, this sounds like we're in a country other than 
America about what's going on here.
    Ms. Baker. I would definitely support the notion of having 
more of these asylum seekers paroled, certainly.
    My client actually investigated trying to get parole, but 
this is an interesting fact, is that the document that her 
deportation officer or one of the deportation officers gave me 
to fill out included a very onerous financial statement and 
obligation on the part of the parolee that said they would----
    Mr. Conyers. That it would cost them?
    Ms. Baker. Yes. It was something to the effect that if you 
were going to sponsor someone for parole, you had to sign a 
document that said, I'm going to support this person for 10 
years.
    And I'm told--remember, I'm the newbie on the panel. This 
is my first asylum case. And if I get something wrong, I'm sure 
my colleague will correct me.
    But it's my understanding that the form I was given by the 
ICE official was created for a completely different purpose 
other than parole of an asylee.
    So she had someone who was willing to house her in the 
interim, but I couldn't get her out because that person didn't 
make enough money.
    Ms. McCarthy. I might just add to this discussion because I 
know Ms. Myers spoke today about the asylum parole process, but 
I think there are some serious flaws in that parole process. It 
needs to be reviewed and monitored. When ICE issues a decision 
to deny parole, that decision should automatically and 
immediately be reviewed by a Federal court judge. That review 
does not exist today.
    Mr. Conyers. Thank you very much.
    Ms. Lofgren. Thank you, Mr. Chairman.
    I'll turn now to my colleague, Mr. Gutierrez.
    Mr. Gutierrez. Well, thank you very much, Madam Chairwoman, 
for putting together this hearing. I think the testimony has 
been very eloquent and very clear.
    I'd like to say hello to Ms. McCarthy from Chicago, say a 
special hello to her, and like to thank the witnesses who have 
come forward, Ms. Armendariz, for their personal testimony in 
this case.
    Look, you were here, the witnesses were here, and I think 
the members of the panel were here. We heard the 
representatives of the Federal Government. I've been in 
Congress now for 16 years. I've had many witnesses, few of them 
as belligerent, as questioning of our authority as we've had 
here this morning.
    I would share with my colleagues on this panel that that 
has been my experience with ICE. In the Chicago area, when the 
head of ICE was asked, ``Did you actually pick up every Latino 
male between 18 and 35 regardless of any other information?'', 
she said yes, and she said she did it proudly, that that was 
her mission, enforcement. I mean, this is the police in the 
strictest sense of the word, and I won't go any further in 
terms of defining them.
    ICE works with our Justice Department. You think that they 
only hold the parolees? Then they call the Justice Department, 
and the Justice Department fights in the court to deport those 
parolees after they've asked for asylum.
    So I think we have a great problem here. The eloquence of 
the witnesses who have suffered so much here today at the hands 
of ICE and our justice system are but the tip of the iceberg. 
We receive cases like this almost every week that come into our 
office, people pleading.
    It is very difficult to believe that we can trust an 
agency--and I think there was a question asked earlier about 
the AMA and having an outside agency come in and intervene and 
use standards outside. It is very difficult to watch the 
Federal Government watch the Federal Government when the 
Federal Government's mandate almost is to deport as many people 
as quickly as possible regardless of the consequences.
    How do we take the testimony seriously about health care 
when--we are going to ask, Mr. Chairman--I think you and Mr. 
King should write that letter. We wrote a letter asking about 
ICE sitting across the country, outside of child care centers. 
That is where they put ICE agents. And we got a letter back 
from them basically telling us, ``Send us some more 
information.'' If there had been a little more time, I would 
have asked her: Did you actually ask the ICE agent if they are 
sitting outside?
    I mean, one of the purposes should be to make us safer, to 
make us more secure. I don't know that having ICE agents 
sitting outside of daycare centers makes us--I'll tell you who 
it doesn't make more secure. It doesn't make the moms and the 
dads that have to take their children to those daycare centers 
feel more secure. What they do, Mr. Chairman and Madam 
Chairwoman, is they take those children to work with them.
    I mean, we had this wonderful raid, and we should really, 
really have a hearing on this raid in Iowa because there were 
serious allegations of sexual abuse on the part of the managers 
and owners of the facility, not paying them wages, serious 
child labor infractions. And while one hand of the Federal 
Government, the Department of Labor, is investigating very 
serious allegations against the owners and the managers of a 
meat plant, guess what happens? ICE comes in, arrests 
everybody, deports over 145 people, and all of the witnesses 
are gone.
    I mean, you can exploit this labor as readily as possible 
as long as you have an ICE institution that will come in and 
cause a raid. I mean, 98 percent of the prosecutions that ICE 
conducted were against individuals, not against the owners of 
the factories, last year, but against the individual people.
    And let me just end with this. I would like to just join 
Bishop Riley in this sense. Not all of us think all human 
beings should be treated differently because they are American 
citizens or because of their legal status in this country. I 
have heard many of my colleagues speak eloquently about their 
great faith and their great faith in the Christian faith. And 
I'm not a theologian, but, you know, I went to Catholic school 
for a few years. I remember two fundamental lessons: to love 
God above everything else and to love my neighbor as I love 
myself.
    Now, when I go to church on Sunday, the undocumented sit in 
the pews. They receive the body and the blood of Christ with me 
as we go up, and we don't ask them. And if I really love my 
neighbor as I love myself, if I am an American citizen and I 
have guarantees of this country as an American citizen, and I 
love my neighbor as I love myself, then I want them to have 
better and greater guarantees than the ones that I have.
    And I think that that is really the mission of this panel 
and the Congress of the United States, to make sure we treat 
everyone as well as we expect to be treated, that is here in 
this country.
    And I thank the gentlelady, Chairwoman for the extension of 
the time.
    Ms. Lofgren. Thank you.
    I yield now to Mr. Ellison.
    Mr. Ellison. Let me join with my colleagues in thanking all 
of the very compelling, very informative testimony.
    And I also just want to add a very favorable support for 
the level of passion that the advocates possess. We need you to 
help our country run better, and I thank you for what you've 
done and what you've said today.
    You know, I practiced criminal law for 16 years. I never 
was an immigration lawyer, so I don't really know the process. 
I know that when I appear with a client, the prosecutor would 
argue that they were a flight risk or that they were a danger 
to public safety, and I would usually argue that they weren't, 
and the judge would make a decision.
    What are the criteria you use when a person who is in 
detention, when the question of their release is before the 
court? What's it like?
    Just I think it is good for the record and for people 
watching to know what kind of analysis the magistrate is going 
to apply in deciding to let a person be on parole or have a 
person stay in custody.
    Ms. McCarthy. This a very important point. The fundamental 
difference between criminal detention and the detention system 
of immigrants, is that immigration detention is an 
administrative process. So, unlike the criminal system, in the 
administrative detention system of immigrants there is no judge 
who reviews the individual's detention. Detention typically is 
an administrative decision initially reviewed by Immigration 
and Customs Enforcement.
    In some cases, an immigration judge may have an option to 
review that and set bond. But even if an immigration judge sets 
bond, the Government has the option to stay that bond if it 
chooses to do so.
    For example, I had a client for whom the immigration judge 
granted a $5,000 bond. The Government stayed that decision and 
the client remained detained for 3 years while seeking judicial 
review of the administrative decision.
    Mr. Ellison. So these are folks--I think it's important to 
be clear on the record, we are talking about people who are not 
even alleged to have harmed anyone or be a danger to the 
public. We are talking about people who are like Ms. Asfaw, for 
example, who had been a victim of political and physical 
torture herself, she is detained for, what, 5 months, was it?
    Did the fact that she hadn't hurt anybody or wasn't a 
threat or it would even be cheaper for the Government to just 
let her be in the community, does that come up when the 
decisions about detention are evaluated?
    Did that come up in your case, Ms. Asfaw?
    Could somebody help her?
    Ms. McCarthy. Yes, I can answer the question. I am not sure 
with respect to her case, but for asylum seekers in general the 
Government does have the option to review whether or not that 
individual should remain detained. So after the individual 
passes what's called a ``credible fear'' interview, the 
Government agency, ICE, could review whether or not Ms. Asfaw 
should have remained detained. And what ICE should consider is 
exactly what you mentioned: whether she's a flight risk or a 
danger to the community. But ICE has added another element to 
this review: whether or not it is in the public interest that 
the asylum seeker be released into the community. ICE added 
this irrelevant factor that makes it difficult for an asylum 
seeker to be released.
    As lawyers representing asylum seekers, we identify 
sponsors and individuals who the asylum seeker could possibly 
be released to, and then advocate for their release. But even 
in those situations, where the detainee meets the criteria, ICE 
denies release of the asylum seeker and there is no judicial 
review of the decision. ICE has complete discretion over the 
asylum seeker's release.
    Mr. Ellison. Does the question of extant medical need ever 
arise in the detention-release calculus? I mean, if somebody 
has a serious medical problem and it'd brought to the attention 
of the decision-maker, does that mitigate in favor of them 
being released into the community where they can get their 
medical needs met?
    Ms. McCarthy. It does, yes.
    Mr. Ellison. How often does that come up? It sounds like, 
based on the testimony we've heard, that it's not being very 
well heeded by the decision-maker. Am I wrong?
    Ms. McCarthy. I think your point is well-taken. Yes, I 
think that's one of the issues. And I think Ms. Armendariz's 
case is a very strong example of that. Her husband continued to 
be detained des[ote his medical conditions. This case 
illustrates that that medical humanitarian factors are not 
taken seriously into consideration by ICE.
    Mr. Ellison. If we had judicial judges doing the 
evaluating, would we probably get better outcomes?
    Ms. McCarthy. I think you're absolutely right. And, as Ms. 
Baker mentioned, she was ready to file a habeas petition in her 
client's case, which is an option, but there are many hurdles 
to habeas relief. So if we can build into the law some type of 
judicial review of the continued detention of the individual, I 
think that would be very valuable.
    Mr. Ellison. As Americans, we value liberty. We consider 
liberty an important value. It doesn't matter whether you are 
documented or undocumented. Whether you have a right to remain 
in the country is what is to be determined, right, later?
    Ms. McCarthy. Absolutely.
    Mr. Ellison. So it seems to me a somewhat strange anomaly 
in the law that when it comes to people who are trying to enter 
the country, that we would have even less discretion than a 
criminal defendant, who at least there is some probable cause 
for.
    Anyway, that's just my editorial.
    Let me ask you this. What are the implications for 
overcrowding? What about when we get into jails, county jails, 
other kinds of facilities when people can't be at a detention 
facility, which I would imagine is somewhat suited to meet the 
need that it's designed for, what about the overflow when--I 
mean, do we have people who are immigrants waiting to be 
determined about their status----
    Ms. Lofgren. I will give Mr. Ellison an additional minute 
so that question can be answered.
    Mr. Ellison. Thank you, Madam Chair--in the county jails?
    Ms. McCarthy. Well, Immigration and Customs Enforcement 
enters into contracts with county jails throughout the country. 
They have over 300.
    Mr. Ellison. Are they are mixed in?
    Ms. McCarthy. There are occasions when the immigration 
detainees are mixed in with the criminal detainees, although 
the detention standards provide that they should not be mixed 
in. But what happens in reality is that due to the increase of 
the number of detainees, there is a great deal of overcrowding. 
You hear about people sleeping on the floor, people not having 
access to proper hygienic materials, as well as adequate food 
and proper treatment.
    Mr. Ellison. Thank you for your testimony.
    Thank you, Madam Chair. I yield back.
    Ms. Lofgren. Thank you.
    And thanks to all of the witnesses.
    Mr. Harrison had to leave early to catch his flight, but we 
will certainly appreciate his offer of continuing help, Mr. 
Reyes as well, Bishop.
    Ms. Armendariz, yes, certainly you can speak.
    Ms. Armendariz. May I just make a point? Isaias had just 
served a year and a half in prison. I didn't see the point of 
keeping him in ICE. They could have saved money by him waiting 
for his hearing--he was on Social Security. Where was he going 
to go? They could find him. So I think it could have saved them 
money and wait for the process, and that shouldn't have 
happened. That could be one----
    Ms. Lofgren. Thank you. It would save the Government money 
and maybe be a little more respectful of that Vietnam-era vet.
    I thank you, Ms. McCarthy, Dr. Venters, for your excellent 
suggestions.
    Ms. Baker, it was fascinating to hear your story, and I 
hope that, in addition to doing IP litigation, you will have 
time to put your new knowledge of asylum cases to work again.
    The record will remain open for 5 legislative days. We may 
have additional questions for you. If so, we will forward them 
to you and ask, if at all possible, that you respond promptly 
if that occurs.
    With that, we will follow up with this hearing, as Mr. 
Conyers and Mr. King have agreed to solicit comments from Ms. 
Myers. We may need additional hearings, we don't know. But this 
is very serious to me, to hear these stories.
    The GAO was not able, actually, to go in and do the study 
because of the litigation involved. But, certainly, we have 
received substantial information that there is a substantial 
problem. Everybody in America is entitled to due process of 
law, and I have very serious concerns about whether that is, in 
fact, occurring in this area of the law.
    And, certainly, wherever we stand on the issue of 
immigration, we all need to know that there are civilized 
requirements for the Government when individuals are held in 
custody. Those people who are in custody don't have the option 
of going across town to their doctor any more than, you know, 
we have to feed them because they don't have the option of 
going across town to Burger King, too. So there are some 
obligations we undertake when we incarcerate. And, certainly, 
we need to take a look at what are the alternatives to that 
system.
    So we do thank you for your patience with our voting 
schedule, for your important testimony.
    And this hearing is now adjourned.
    [Whereupon, at 6:15 p.m., the Subcommittee was adjourned.]

                            A P P E N D I X

                              ----------                              


               Material Submitted for the Hearing Record

  Prepared Statement of Karen Long, RN, APN,C, CWOCN, Member of First 
 Friends, Elizabeth Detention Center Visitor Project, Board Member of 
              the Interfaith Refugee Action Team-Elizabeth

    I have been a visitor at the Elizabeth Detention Center for the 
past four years with an organization called First Friends. During this 
time I have met many detainees from all over the world in the same dire 
situation.
    During these visits there were often health complaints which were 
usually minor such as a headache, generalized fatigue or stomach upset. 
I would often find myself telling the detainees that I was visiting 
that they should go to the medical clinic to get treatment. I said this 
even though I was sure I knew the answer. I would get a smirk of some 
sort and would be told something to the effect ``Oh what's the use, 
they don't do anything for you anyway.'' Many would mention getting the 
``red pill'' and being sent back to their dorm. Since these complaints 
never seemed emergent I just went on with my visit and wished them 
well.
    The young woman I had visited most recently is from Liberia. She is 
25 years old. She has documented evidence of Female Genital Mutilation 
(FGM), which unfortunately no longer holds weight with asylum cases. 
This young woman kept complaining of abdominal pain. She told me that 
when she went to the clinic at the EDC all they would do is give her 
some pills and send her back. While in her dorm, when she complained of 
continued pain, despite ``treatment'', she would be given an 
appointment for later that week.
    As a nurse I began to be concerned that she could have a bleeding 
ulcer or some other abdominal pathology because she also was quite 
fatigued and was not getting any sleep. At one point when her case was 
being considered for parole I called down to the parole officer with my 
concern that she needed additional health care and if paroled I or a 
friend of hers would get her the care she needed.
    She did eventually receive parole and at a nearby hospital was 
diagnosed with pelvic Inflammatory Disease (PID), a condition that if 
left untreated could cause fertility problems in the future. She 
continues to have gynecologic problems related to the FGM and will most 
likely need continued management.
    Because of the personal nature of this story I choose not to tell 
her name. If the committee seeks further information from this young 
woman please let me know. I keep in touch with her and a family friend 
who continues to fight for her by spending thousands of dollars in 
legal fees attain asylum for her.

                                













                                

















































                                









                                

























                                







                                

   Submissions from Immigration and Customs Enforcement (ICE), U.S. 
                    Department of Homeland Security


























                                 
