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Health Care Access & Coverage
Why Are Immigrants in Detention Facilities Hospitalized?
New Data Reveals Infection and Psychiatric Diagnoses Drive the Majority of Hospitalizations
According to reports, the U.S. Immigration and Customs Enforcement (ICE) fails to meet the medical needs of the thousands of people detained in its facilities. However, ICE provides little data to the public regarding health care utilization, quality of care, or health outcomes of its detainees. While we know a little about mortality rates and causes of death from case reports, we understand even less about the illnesses or the health care received by those held within immigration detention facilities.
A recent study by former LDI Associate Fellow Joseph Nwadiuko and coauthors, including LDI Fellows Judith A. Long and Nandita Mitra, provides new evidence about hospitalizations from immigration detention facilities, finding higher rates of intensive care unit (ICU) admissions than expected but lower overall rates of hospitalization. They also examined the percentage of hospitalizations necessitating ICU or intermediate ICU (i.e., “step-down”) admission and the types of surgical and interventional procedures conducted during these hospitalizations. The researchers are the first to investigate and publish the causes of hospitalizations from immigration detention facilities.
Multiple Data Sources Required
The team compiled and analyzed multiple data sets in order to begin to understand the health care experiences of ICE detainees. To identify hospitalizations, they linked 2015-2018 hospitalization data from Texas and Louisiana to ICE’s payor designation in those states. They supplemented this data with two sources of geospatial identifiers from patient-level addresses to identify hospitalizations that originated from immigration detention facilities. They identified and analyzed 887 hospitalizations from detention facilities.
Hospitalizations Caused by Infection and Psychiatric Conditions
Most patients were young, between the ages of 18 and 45 (73%), and male (76%). The most common diagnoses were related to infection (23%), driven by skin infections and abscesses, active tuberculosis, and pneumonia. Psychiatric diseases made up the second most common cause (17%), with hospitalizations primarily related to mood disorders (e.g., anxiety, depression, and post-traumatic stress syndrome), followed by bipolar disease. Given the relatively high rates of suicide within ICE detention facilities, the researchers also determined if suicidality or self-harm was mentioned as a primary or secondary diagnosis, finding 5% of admissions had suicidal ideation or intentional self-harm as a primary or secondary diagnosis.
Among the hospitalized detainees, ICU admission rates approach the national average of 27%, even though the detainees were younger than most hospitalized populations (73% of the hospitalizations in the sample were from patients between 18 and 45 years old, compared to 29% of adult hospitalizations nationally). The most common reason for ICU admission was cardiovascular conditions (29%). The most common surgical procedure was incision and drainage (6%), which suggested detainees often had infections that progressed to severe conditions by the time patients were hospitalized.
While ICU admission rates were high, the overall rate of hospitalization among ICE detainees was low. The hospitalization rate of 39 per 1,000 prisoner-years is lower than the average rate of 54 per 1,000 prisoner-years for non-immigrant incarcerated persons and 67 per 1,000 prisoner-years for undocumented immigrants.
More data are needed to better understand the causes of the higher-than-expected ICU admission rates, lower-than-expected hospitalization rates, and large number of certain diagnoses and procedures. These data do not speak directly to the quality of health care in detention facilities. Nonetheless, they do raise important questions and highlight the need for clear policies governing health care in immigration detention centers. For example:
- Adherence to ICE’s own standards of comprehensive physical and mental health screenings and timely transfer to hospitals might help reduce avoidable morbidity and mortality in detention centers. Patients deserve rapid and thorough triage at illness presentation within facilities.
- Given the frequency of admissions for psychiatric illness, the Department of Homeland Security (DHS) should conduct complete mental health assessments of all detainees, including risk factors for suicidality and self-harm and take these risk factors into consideration when deciding whether to place individuals in detention.
- Some hospitalizations may be related to exacerbations of pre-existing chronic diseases, and thorough surveillance of health risk factors during detention is also critical.
- The federal government should increase the availability of data related to immigration detention hospitalizations, which have a common payor via ICE. Immigrant detainees are the only cohort of patients with federally sponsored health care for which federal health data is not released. Allowing more systematic access to health data, paired with detention characteristics data (e.g., length of detention stay), will help generate evidence-based interventions to prevent morbidity and mortality in these facilities.
This study preceded the first wave of the COVID-19 pandemic, which caused a drop in the number of detainees in ICE facilities and was associated with an increase in mortality rates in the detained population. A study found that COVID-19 rivaled suicide as the primary cause of death among ICE detainees in 2020. Since spring 2021, the number of detainees again started rising, and as of July 17, 2022, there were 22,886 detainees in ICE custody. In the absence of further systemic changes, the hospitalization patterns described here will likely persist in a COVID-19 and post-COVID-19 era. Beyond providing vaccinations, immigration detention should be structurally reformed to sustainably decrease illness and avoid preventable deaths among the people in its custody.
The study, “Adult Hospitalizations from Immigration Detention in Louisiana and Texas, 2015-2018”, was published August 3, 2022 on PLOS Global Public Health by Joseph Nwadiuko, Chanelle Diaz, Katherine Yun, Karla Fredricks, Sarah Polk, Sural Shah, Nandita Mitra, and Judith A. Long.
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