Francisco Castaneda came to the United States from El Salvador during its civil war of the 1980s. Fleeing the violence, his mother crossed the U.S.-Mexico border illegally in 1982 with Francisco, aged 10, and his three siblings. Her husband had died of a heart attack just before they left. For years, she did odd jobs and sewing in and around Los Angeles. But she died of cancer before turning 40 and before she secured legal status for her children.
After her death, Castaneda, by then in his late teens, was on his own. For a time he had a work permit and did construction. But then he got involved in drugs. In 2005, he was convicted of methamphetamine possession with intent to sell, a felony, and was sent to prison for three and a half months. Upon his release, federal authorities immediately detained him as an illegal immigrant. Pending deportation, he was transferred to a detention center in San Diego operated under the auspices of Immigration and Customs Enforcement, an agency newly organized under the Department of Homeland Security.
The agency's acronym, ICE, a rare instance of bureaucratic humor, has stuck. According to its website, ICE "investigates a wide range of domestic and international activities arising from the movement of people and goods that violate immigration and customs laws and threaten national security." Immigration and Customs Enforcement is the largest investigative agency in the Department of Homeland Security. In 300 facilities, both detention centers and jails, the government processes more than 300,000 detainees — men, women, and children — every year. One of the agency’s five divisions, the Office of Detention and Removal Operations, “is responsible for promoting public safety and national security by ensuring the departure of all removable aliens from the United States through the fair enforcement of the nation’s immigration laws.” The agency is required to detain immigrants in humane conditions, their “departure” just and swift.
While in prison, Castaneda had noticed a sore on his penis and pain in his groin. His back and kidneys were also hurting. He filled out the requisite health-care request forms and was examined at the prison’s “wart clinic.” There, a Department of Corrections medical provider, a man believed to be “S. Pasha,” found “a 2 cm x 2 cm raised white and yellow lesion on his foreskin.” He prescribed antibiotics and ordered an “urgent urological referral,” but Castaneda never received either.
Castaneda was taken to the San Diego Correctional Facility on Otay Mesa in March 2006. The minimum-medium–security lockup, whose population was 1000 when Castaneda arrived, holds detainees while their cases are reviewed; some stay for weeks, some for years. The facility is leased from the County of San Diego by the publicly traded Corrections Corporation of America, which owns or operates 66 prisons and detention centers. (In the wake of September 11, the Corrections Corporation of America received a boon in new contracts. In 2000, the company was nearly bankrupt while last year its revenue topped $1.4 billion.) When ICE contracts with private prisons, the agency guarantees “fair enforcement” of immigration laws, including inmate access to health care. In 2002, the Corrections Corporation of America was relieved of its contract to provide health care at the San Diego Correctional Facility; at the time, a federal medical director found the corporation had decreased its services severely. He returned the job to the Public Health Services’ Division of Immigration Health Services, which, in an ironic twist, outsources some of its care, sending detainees to private doctors.
At the Otay Mesa facility, Castaneda complained, according to court records, that “a lesion on his penis was becoming painful, growing in size, and exuding discharge.” He ranked the pain during urination and erection an eight out of ten. The suppurating wound had a “foul odor,” a necrotic smell, the death of living tissue. The lesion was “now draining pus” and was “more macerated at the glans,” or penis head. Lieutenant Anthony Walker, a physician’s assistant employed by the Division of Immigration Health Services, examined him and requested a “urology consult” as soon as possible — and a biopsy, which he termed “a pertinent surgical” follow-up.
Castaneda told Walker that he was worried about the growth because his mother had died of pancreatic cancer at age 39. Walker, who stated later that he was not sure “what the lesion would present, if and when the biopsy was completed,” realized it was best to “rule out penile cancer — the sooner the better.” (A biopsy was the only way to do that.) Walker drained and cleaned the lesion, but within a few days the pus was back.
Castaneda was getting ibuprofen. At times, he would show his bloodied underpants to guards. They said they couldn’t help his medical condition but would bring him clean bedsheets. One guard told Castaneda that he would pray for him because he could see how much he was suffering.
Two and a half months after the initial diagnosis, Castaneda saw Dr. John Wilkinson, an outside oncologist. His recommendation was unequivocal: “I strongly agree that” the lesion “requires urgent urologic assessment of biopsy and definitive treatment.” He wrote that from even “benign lesions” there can be “considerable morbidity.” Castaneda should also have his foreskin circumcised, Wilkinson wrote, adding that everyone understood “the need for urgent…treatment.”
Enter Dr. Esther Yun-Hung Hui, the clinical director at the Otay Mesa facility and the only onsite physician for the facility’s 1000 detainees. After assessing Castaneda’s case, she wrote that the Division of Immigration Health Services rated a biopsy as an “elective outpatient procedure.” Her recommendation was “to pursue outpatient biopsy that would be more cost effective.” The upshot was, Castaneda received nothing except more pills.
Castaneda filed a grievance, citing Wilkinson’s recommendation, but the grievance was denied. A day later, health services personnel documented that Castaneda’s penis was “getting worse, more swelling to the area, foul odor, drainage, more difficult to urinate, bleeding from the foreskin.” The record also expressed the opinion that he did “not have cancer at this time,” as he had not had a biopsy diagnosing cancer. He was advised “to be patient and wait.”