Cara R. Muñoz Buchanan, Harvard Kennedy School

The 2024 Homeland Security appropriations bill increased funding for U.S. Immigration and Customs Enforcement operations to handle an anticipated daily detainee population of 41,500, up from an average of 34,000 in recent years.

Yet recent studies have exposed cracks that call into question the agency's ability to medically care for the detainees it is entrusted with, including inhumane conditions, high suicide rates, structural problems such as the use of prisons to hold detainees, delayed or interrupted medical care and overcrowded conditions. Research also shows that the pandemic years further exacerbated these inequalities.

One recent report by a trio of nonprofit advocacy groups blames preventable deaths of people detained by ICE on inadequate investigations and flawed systems at the agency. The report, Deadly Failures, released on June 25, 2024, by the American Civil Liberties Union, American Oversight, and Physicians for Human Rights, documents inadequacies in diagnosis, treatment and emergency response. It points to suicides that might have been prevented with appropriate mental health care and properly managed medication. And it details underlying issues – understaffing and a lack of interpretation and translation services.

The Conversation asked Cara Buchanan, an emergency physician and clinical fellow in health policy and social emergency medicine at the Harvard Kennedy School, whose research the report cites, about research in this area by her team and others, ICE's track record on detainee medical care and what needs to be done to improve medical care for people in ICE custody.

What have you and your colleagues found in studying medical care for detainees in U.S. Immigration and Customs Enforcement custody?

Our research shows that preventable deaths of people in ICE detention are often preceded by lapses in a standardized, consistent and competent approach to medical triage, including identification and escalation of the need for emergency care.

What has other recent research uncovered in this area?

Research across many disciplines, including medicine, law, policy, criminal justice, health economics, human rights and public health, correlate structural design features of immigration detention facilities to adverse health outcomes for detainees. This includes the use of solitary confinement, which is linked to an increased risk of self-harm for detainees in ICE custody.

The COVID-19 pandemic highlighted significant health disparities in immigration detention facilities. Many facilities failed to provide adequate basic, preventive and emergency medical care.

Studies also demonstrate a persistent lack of transparent information about conditions in ICE facilities that continues to prompt ongoing calls for increased oversight and accountability to address the systemic sources of poor health outcomes.

The ultimate failure of the immigration detention system to protect the health and safety of detainees is the outcome of preventable death. Publicly available ICE detainee death reports provide basic details about timelines preceding death. However, independent investigations and analyses into the circumstances surrounding these deaths have demonstrated pervasive and systemic negligence.

Billions of dollars of congressional appropriations continue to pour into the expansion of ICE detention facilities, and private prisons contracted to provide services for immigrants in detention report profit margins in the billions of dollars.

How did your work fit with the recently released report?

Deadly Failures expounds on our prior research with a depth and breadth of context.

The report provides clear policy recommendations for major stakeholders – the Department of Homeland Security, the Department of Justice, Congress and local and state governments.

These recommendations range from feasible to ambitious in detailing actions that would eliminate preventable death for those in ICE custody. Proposed interventions include prompt disposition of detainees who have medical and mental health vulnerabilities, limiting the physical and fiscal expansion of detention facilities, investing in community-based services, banning solitary confinement, passing legislation to ensure accountability to standards of care in facility contracts and establishing mechanisms for regular public data reporting. The report also calls for ICE to dismantle the mass immigration detention system at large.

I was particularly heartened to read the second line of the Deadly Failures executive summary, which highlights the most striking finding of our research – the troubling trend of ICE releasing people from custody immediately prior to their deaths.

Why does this happen?

ICE regulations specify that when a detained noncitizen dies in custody, the agency will conduct timely notification, review and publication of the death. But the regulatory language about people who die immediately after release from ICE custody is vague and doesn't include a reporting timeline or proposed mechanism of accountability for such deaths.

When we investigated the total number of deaths in ICE custody from fiscal years 2021 to 2023, our research team cross-referenced published ICE death reports with news releases issued by investigative journalists and immigration advocacy groups. Our review of public records and available legal documents confirmed four deaths that were not accounted for in the 11 death reports ICE published from those years.

Through this investigation we found a pattern of detainees who, while hospitalized, were released from ICE custody after being deemed critically ill, with death clinically imminent. When we reviewed these detainees' medical records we found deaths that could have been prevented. In one such case, a detainee contracted COVID-19 while in custody and suffered a series of complications, including multiple hospitalizations for recurrent infections. Concerns raised by the facility medical director about the patient's persistently critical condition went unaddressed, and after ultimately suffering a stroke the patient was placed on life support. ICE released the unconscious patient from custody just prior to his death. This technical release from custody allowed ICE to avoid mandatory public reporting of this case and its details.

Officially, ICE has said that it is continuing to evaluate its enforcement of health standards and is looking for ways to improve medical care delivery.

Our research team's key recommendation, also highlighted by the authors of Deadly Failures, is that all deaths of individuals that occur within 30 days of release from ICE custody be included in mandatory public reporting of ICE statistics and death reports. This is a critical measure of transparency and accountability.

What should Immigration and Customs Enforcement be doing to prevent unnecessary deaths on its watch?

Time in ICE custody is related to preventable death. People detained in ICE facilities should be released as quickly as possible so their medical needs can be transitioned to more consistent and long-term care.

Triage should also be standardized. Detainees who show signs and symptoms of serious medical conditions should be rapidly assessed and quickly transferred to local emergency rooms for further evaluation and treatment. Rigorous oversight and accountability should be established for all workers at ICE facilities and for clinical outcomes of detained patients.

Are you still seeking answers to questions you have about detainees? If so, what are you looking for?

ICE's collection, recording and sharing of high-quality data regarding the capacity of ICE facilities, the scope of health services available and metrics of health outcomes for people detained in ICE custody is markedly limited. The dearth of data leaves a barrage of unanswered questions regarding the conditions that contribute to poor health outcomes. In my view, ICE detention facilities should be held to standards of transparency and accountability to federal and public reporting, as are other large systems of medical care.

Is there anything that has surprised you in what you've found over the past few years?

The instances of deficient professional language services, including interpretation and translation, for people detained in ICE custody is surprising. It is at odds with a federal mandate that stipulates a patient's right to receive health information in their preferred language at no cost. This right is exercised daily in U.S. hospitals and clinics across the country for the nondetained with in-person interpreters or readily accessible technology.

Ultimately, it is disheartening but not surprising that extensive research continues to demonstrate a diminished standard of care experienced by people detained in ICE custody.

Cara R. Muñoz Buchanan, Physician and Clinical Fellow in Health Policy and Social Emergency Medicine, Harvard Kennedy School

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Naomi Cahn, University of Virginia and Sonia Suter, George Washington University

On June 27, 2024, the U.S. Supreme Court dismissed a case brought by the federal government regarding whether Idaho's abortion ban conflicts with a federal law called the Emergency Medical Treatment and Labor Act. The law requires emergency rooms to provide stabilizing care for patients experiencing medical emergencies regardless of their ability to pay.

The Conversation asked law professors Naomi Cahn and Sonia Suter to explain how the case ended up in the Supreme Court's hands and why battles between this federal law and state abortion laws will likely be in the news for the foreseeable future.

What is the key disagreement between Idaho and the federal government?

In Moyle v. United States, the Supreme Court faced the question of whether the Emergency Medical Treatment and Labor Act overrides Idaho's strict abortion ban.

Congress passed the law in 1986 to ensure patients' access to emergency care even if they couldn't afford to pay for it. It requires emergency rooms to stabilize patients if failing to do so would result in serious jeopardy to the patient's health. The law does not require patients to be on the brink of death before treatment.

After the Dobbs decision overturned a federal right to an abortion in 2022, Idaho's trigger law went into effect. The state law banned abortions except to save the life of a pregnant person and in some cases of rape and incest. The Biden administration challenged the law in federal court.

The federal government argued that the act requires providers to offer an abortion as stabilizing care in some obstetric emergencies, but that Idaho's law would prohibit the abortion if only the patient's health, but not life, was in jeopardy. Therefore, the government argued, the federal act overrides the Idaho law when the two are in conflict.

A federal district court sided with the Biden administration and ruled that Idaho's ban doesn't apply when the federal act would necessitate an abortion. So Idaho appealed to the 9th Circuit.

As a result of various procedural issues, the case was appealed to the Supreme Court before the 9th Circuit Court of Appeals reached a final ruling on the merits. The Supreme Court also blocked the district court's ruling. As a result, doctors in Idaho could no longer perform abortions in emergency situations unless the patient's life was threatened.

The practical impact of the Supreme Court's action was stark. From January through April 2024, when the Idaho law was fully enforceable, St. Luke's – the largest largest private employer in Idaho – medevaced six women to another state to obtain an abortion for health reasons.

In contrast, from late 2022 to the end of 2023, when the federal law governed, only one pregnant patient had to be airlifted out of state.

What did the justices say?

On June 27, the Supreme Court issued an unsigned (per curiam) opinion: At least five of the justices decided that the court was wrong to hear the case at this early stage. Accordingly, the case goes back to the 9th Circuit for further argument.

But there were four concurring and dissenting opinions, which provide insight into the court's deliberations and may explain why it took so long for the court to issue its one-sentence opinion.

Justices Elena Kagan, Sonia Sotomayor, Amy Coney Barrett and Brett Kavanaugh and Chief Justice John Roberts thought the case should go back to the lower courts for further argument.

Justices Ketanji Brown Jackson, Samuel Alito, Clarence Thomas and Neil Gorsuch thought the court should resolve the question of whether the federal law overrides Idaho's law. Their idea of how it should be resolved differed, however. Alito, Thomas and Gorsuch concluded that the federal law does not preempt Idaho's law. Jackson thought there was a clear conflict between the laws and that “under the Supremacy clause, Idaho's law is preempted.”

Jackson went further in excoriating the Supreme Court for not resolving what she saw as a clear and dire issue: “Today's decision is not a victory for pregnant patients in Idaho. It is delay. While this Court dawdles and the country waits, pregnant people experiencing medical conditions remain in a precarious position, as their doctors are kept in the dark about what the law requires.”

What does this decision mean for abortion in Idaho?

The decision means that the Emergency Medical Treatment and Labor Act – at least for now – applies in Idaho. That is, in cases of medical emergencies, abortions must be an option if one is necessary to stabilize a pregnant patient and protect the patient's health, even if their life is not at risk.

As Jackson noted, those scenarios could arise with many health conditions, like “preeclampsia, preterm premature rupture of the membranes, sepsis and placental abruption.”

It is worth emphasizing that in the rare cases when abortion is necessary to stabilize an obstetric emergency, the pregnancy is “often of a non-viable fetus”, Kagan wrote in her concurrence. Thus, if the federal law is followed, rather than wait until the patient is near death to perform the inevitable abortion, the necessary medical care can be provided earlier to prevent health complications.

While this decision now allows the federal law to block the Idaho abortion ban in cases of obstetric emergencies that can only be stabilized with an abortion, it still allows Idaho to prohibit all other abortions. Thus, Idaho's ban of all other abortions except in limited cases of rape or incest still applies. Of course, it remains to be seen what the 9th Circuit will decide about the effect of the federal law on Idaho's abortion ban.

Is this the last word on the Emergency Medical Treatment and Labor Act?

Probably not.

The Supreme Court will likely have another opportunity to consider whether the Emergency Medical Treatment and Labor Act overrides state abortion bans that conflict with it. The case is going back to the 9th Circuit to decide whether there is a conflict between Idaho and federal law. The losing party will probably appeal to the Supreme Court.

In another case pending before the Supreme Court, Texas has challenged the Biden administration's assertion that the federal law preempts laws that would ban abortions in cases of obstetric emergencies. Both the lower federal court and the 5th Circuit concluded that the federal act did not override Texas' abortion bans.

The Biden administration asked the Supreme Court to consider the Texas case, but the court has not yet decided whether to do so. If it does, then the questions related to the federal law will be back again in the next Supreme Court term, which begins in October.

By the time the case gets back to the Supreme Court, a different president may have taken office, and their administration may have a different view of what the act requires.

Does the ruling affect abortion in other states?

Because there are two conflicting federal court rulings in the 9th and 5th circuits on whether the federal law overrides state abortion bans, this Supreme Court ruling has no impact in other states.

In dismissing the case rather than addressing its merits, the Supreme Court has not taken a position as to whether the federal law preempts state laws when there is a conflict. This means that health care providers in the many states that have enacted near-total abortion bans still face a dilemma where, as public health professor Sara Rosenbaum put it, pregnant patients have “become radioactive to emergency departments.”

It is also noteworthy that this is the second time in a single month that the court has ducked an abortion-related issue. Earlier in June 2024, it dismissed a challenge to abortion pill access – leaving many unsettled questions about access to abortion in the United States.

Naomi Cahn, Professor of Law, University of Virginia and Sonia Suter, Professor of Law, George Washington University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Hasan Khatib, University of Wisconsin-Madison

As Israel's offensive in Gaza rages on, people across the entire Gaza Strip find themselves in increasingly dire circumstances, with nearly the entire population experiencing high levels of food insecurity, including malnutrition, hunger and starvation. A famine review analysis from the Integrated Food Security Phase Classification reported on June 25, 2024, that “a high risk of Famine persists across the whole Gaza Strip as long as conflict continues and humanitarian access is restricted.”

The Conversation asked Hasan Khatib, an expert in genetics and epigenetics, to explain the growing crisis in the Gaza Strip and what history lessons from earlier famines can teach us about the short- and long-term consequences of starvation, malnutrition and food insecurity.

What is food insecurity and how widespread is it in Gaza?

Food insecurity refers to the lack of regular access to safe and nutritious food necessary for normal growth and development and maintaining an active, healthy life. Severe food insecurity is characterized by running out of food and going a day or more without eating, leading to the experience of hunger.

An initiative called the Integrated Food Security Phase Classification, or IPC, managed by United Nations bodies and major relief agencies, was established in 2004 to enhance analysis and decision-making on food security and nutrition.

The IPC classification system identifies five distinct phases of food security:
1. Minimal/none; 2. Stressed; 3. Crisis; 4. Emergency; 5. Catastrophe/famine.

The IPC estimates that 96% of the population in Gaza – 2.15 million people – are experiencing high levels of acute food insecurity, classified as IPC Phase 3 or higher.

Approximately 50% to 60% of buildings throughout Gaza, and over 70% of those in northern Gaza, have been damaged or destroyed, including more than 90% of schools and 84% of health facilities.

Due to the destruction of food production and distribution infrastructure, all households skip meals daily, with adults reducing their portions. The IPC projects that by July 2024, half of the population will be classified as being in a famine, experiencing acute malnutrition or death.

As of June 6, 2024, the World Health Organization reported that 32 patients had died from malnutrition and 73 had been admitted because of severe acute malnutrition in Gaza. Malnutrition can weaken the immune system, increasing the risk of serious illness and death, primarily due to infectious diseases.

And as of the same date, the WHO reported 865,157 cases of acute respiratory infections, 485,315 cases of diarrhea, 57,887 cases of skin rashes and 8,538 cases of chickenpox, all of which can be exacerbated by malnutrition.

How do stress and trauma add to hunger?

Strikes by the Israeli forces across the Gaza Strip have resulted in civilian casualties, the destruction of homes and the displacement of over 1.7 million people since October 2023, including many families who had already been displaced multiple times.

The United Nations Children's Fund estimates that at least 17,000 children have been separated from their parents as of February 2024, and nearly all children in Gaza need mental health and psychological support. Symptoms observed among these children include heightened anxiety levels, loss of appetite, sleep disturbances and panic attacks.

Since Oct. 7, 2023, the United Nations Relief and Works Agency has provided critical psychological support, including psychological first aid, fatigue management sessions and individual and group counseling, to over 650,000 displaced persons, including 400,000 children.

UN Women, an organization focused on gender equality and the empowerment of women, reported that from October 2023 to April 2024, 10,000 Palestinian women in Gaza were killed, resulting in 19,000 children being orphaned. Approximately 50,000 pregnant Palestinian women and 20,000 newborn babies face limited access to health care facilities due to the bombardment of hospitals and health clinics.

In addition, more than 180 women per day are giving birth without pain relief, leading to a 300% increase in miscarriages due to the severe conditions. These dire conditions are causing severe stress and trauma among Palestinian children and women. This combination of stress, trauma and hunger can leave a lasting impact on both the women and their offspring.

What might the consequences be for future generations?

Over the past two decades, extensive research has investigated whether environmental factors such as hunger, stress and trauma can affect future generations that are not directly exposed to them. Pioneering studies of the Dutch famine, which occurred in the Netherlands from 1944 to 1945, found that these types of intergenerational effects were indeed happening.

During the Nazi occupation, food supplies were cut off from the western part of the Netherlands between November 1944 and May 1945, leading to widespread starvation. Decades later, researchers discovered that children and grandchildren of pregnant women exposed to the famine had a higher risk of health problems later in life, including cardiovascular disease, diabetes and other metabolic disorders.

Similarly, the Great Chinese Famine from 1959 to 1961, which resulted in an estimated 15 million to 40 million deaths, is one of the deadliest famines in history. It profoundly affected the physical and mental health, cognition and overall well-being of those exposed to it and their offspring.

Interestingly, our recent research into sheep demonstrated that paternal diet can alter traits such as muscle growth and reproductive characteristics, which can be passed down to two subsequent generations of sheep.

This inheritance of traits is mediated by chemical groups known as epigenetic marks. These epigenetic tags – known as DNA methylation or histone modifications – can originate from external sources, such as diet, or from within our cells. Histones are proteins that help organize and compact the DNA inside our cells.

These changes can control which genes are turned on or off. When exposed to hunger or stress, the epigenetic marks instruct our cells to behave differently, leading to altered traits. Remarkably, some of these epigenetic marks are inherited by offspring, influencing their traits as well.

Stress and trauma have been the focus of extensive research, particularly in understanding how extreme trauma can have biological effects that are transmitted to subsequent generations. Rachel Yehuda, an expert in psychiatry and the neuroscience of trauma, found that experiencing captivity or detention during the Holocaust was linked to elevated levels of epigenetic marks in a gene called FKBP5, which is involved in stress regulation. These epigenetic alterations were also observed in the children of Holocaust survivors.

Epigenetic changes can be reversible

Research shows that lifestyle and environmental factors play a significant role in influencing epigenetic marks. So positive changes in these areas can lead to the reversal of some of these epigenetic shifts.

One study showed that stress responses in adult rats that are programmed early in life can be reversed later in life. The researchers supplemented methionine, a methyl group donor that alters DNA methylation, to adult rats and observed that the stress response caused by maternal behavior in early life can be reversed in adult life.

I see an urgent need for the medical and scientific community to investigate the potential long-term impacts of current trauma and hunger on vulnerable populations in Gaza, particularly pregnant women and children. Notably, some of the epigenetic marks responsible for these long-term effects of trauma and hunger are reversible when conditions improve.

Hasan Khatib, Associate Chair and Professor of Genetics and Epigenetics, University of Wisconsin-Madison

This article is republished from The Conversation under a Creative Commons license. Read the original article.