One of the last things Francisco Castaneda did before he died in February 2008 was testify before Congress about how the Immigration and Customs Enforcement agency repeatedly prevented him from receiving a biopsy of a festering lesion on his penis that doctors feared might be cancer.
Castaneda, 35, who fled El Salvador for the United States at age 10 with his mother, was convicted on a drug charge in 2006, and in 2007 was sent to a San Diego immigration detention center for deportation. During 10 months in custody there, his health declined. Multiple doctors called for a biopsy of his lesion, but Immigration and Customs Enforcement (ICE) refused.
Finally, in late 2007 when Castaneda was seriously ill, ICE released him.
He went immediately to a private doctor. It was too late. Cancer had spread to lymph nodes and probably his stomach, he told a House subcommittee on immigration in October 2007. Four months later Castaneda was dead.
"I am not the only one who didn't get the medical care I needed," Castaneda told lawmakers. "It was routine for detainees to have to wait weeks or months to get basic care."
The Castaneda case and many others rocked Immigration and Customs Enforcement in 2008 as horror stories about detainees being denied medical care exploded on television, in major newspapers and finally in congressional hearing rooms. Slowly, ICE has begun to take steps to reform.
In late July"two and a half years after Castaneda's death" the agency issued a "request for proposals" to technology vendors for an electronic health records system. The agency says it wants a system that will "increase efficiency, enhance reporting capabilities and improve quality of detainee health care."
That's a start, say ICE critics. "One of the problems we identified was that people in ICE facilities are transferred numerous times, but the medical records are not always moved with the patient," said Ann Baddour, a senior policy analyst at Texas Appleseed, an organization of volunteer lawyers who take on social and economic justice issues.
Often, "people are moved across the country to detention facilities in Texas, and if they are prescribed medication, the records may not catch up with them," she said.
"Inadequate recordkeeping leads to misdiagnosis and inappropriate treatment, increasing the inefficiency of the health care delivery system in detention," Texas Appleseed said in a March 2010 report on the immigration detention system.
In 2009, both ICE's inspector general and a special advisor called in to investigate ICE called for an electronic health records system as one of many steps to improve the abysmal state of health care in ICE detention facilities.
ICE is swamped
Meanwhile, congressional hearings painted an acid picture of detainee treatment denied.
ICE blames the problem on the huge surge in its detainee population in recent years as the U.S. government has cracked down on illegal immigration. On a typical day, ICE has 35,000 people in custody"almost a five-fold increase since 2005.
As a result, ICE now operates "the largest detention and supervised release program in the country," said Dora Schriro, the special advisor brought in by Homeland Security Secretary Janet Napolitano to review ICE detention practices. The immigration agency is part of the Department of Homeland Security.
Some ICE detainees are lodged in 21 federal detention centers, others are kept in 40 privately-run prisons, still others are housed in more than 300 local jails and state prisons scattered across the country.
Over the course of a year, ICE takes into custody nearly 380,000 aliens from more than 200 countries. Of those, it deports about 300,000.
ICE is swamped, and providing adequate medical care for ICE detainees has become a particular challenge. One in four of its detainees arrives in custody with a chronic illness"hypertension, diabetes, tuberculosis, asthma, AIDS, seizure disorders and others.
ICE defenders say it's easy to make the agency look bad, when, in fact, many detainees receive better medical care in custody"at U.S. taxpayers' expense" than they ever received in their countries of origin.
Health IT void
But senior ICE officials acknowledge that the agency can and must do better. "I believe there is some room for improvement," particularly "in the information technology area," Julie Myers, ICE chief in 2008, told the immigration subcommittee.
In October 2009, Schriro stated point blank, "ICE needs an improved system of record-keeping." ICE doesn't just lack electronic records, she said, it lacks any coherent medical recordkeeping system at all.
"There is no policy on the maintenance, retention and centralized storage of medical records," Schriro said. "Instead, a new medical record is opened each time a detainee is transferred to another detention facility." Each holding facility must start from scratch, duplicating examinations, re-issuing prescriptions, wasting time and money.
Homeland Security Inspector General Richard Skinner, who conducted a separate investigation, concluded that the paper records ICE creates are pretty much useless.
"Based on our review, hard-copy medical records can be unreliable," he said. Of the medical records he examined, Skinner said dates were often crossed out or changed. It was impossible to tell if or when required medical screenings had been performed.
Pockets of success
But Skinner discovered some successes in the ICE system, too. Miami's Krome Detention Center has an electronic case management system that "significantly" cut delays in treatment and improved internal controls, Skinner said. The system even reminded medical staff when patient examinations were due.
"Instituting an electronic case management system at detention facilities could improve internal controls, decrease medical care timeliness issues, and offer a more accessible and effective method of record keeping nationwide," Skinner said.
It took ICE more than a year to act, but on July 29, the agency issued a "request for information" inviting e-records vendors to tell the agency how their electronic health record systems could improve the beleaguered ICE detention system.
ICE officials refused repeated requests for an interview about the system. They pointed, instead, to the RFI, which calls for an e-records system that "must improve the availability of information available to providers, support the standardization of the medical services provided to detainees, and ensure the accountability of medical services."
The e-records system is intended for use at 21 ICE detention centers and 40 contract holding facilities, the RFI says.
Some ICE critics are encouraged. There seems to be a genuine desire at ICE to reform, said Baddour at Texas Appleseed, who has battled the agency. But the pace is slow.
Government records show that ICE has asked for $7 million in its 2011 budget "to begin the design and development" of an electronic health records system. But for now, the budget is stalled in Congress and ICE medical care remains chaotic.
Texas Appleseed, too, recommended last March that "ICE needs to establish an electronic [health] records system that not only allows its medical staff to access information necessary to treat immigrants in ICE custody, but also provides timely access for immigrants and their advocates."
ICE's current paper-based system is "archaic," the organization said.
Stung by criticism and assailed by lawsuits, in August 2009 ICE announced major reforms. Among them, ICE pledged "to ensure the timely provision of medical, dental and mental health assessment and services."
But a year later, the ACLU, which has sued ICE seve