Damian Reynolds says he saw what the staff at the Etowah County Detention Center had missed—that his fellow prisoner and Jamaican immigrant Miguel Williamson could die in his cell if he didn’t get immediate medical attention.

Williamson was a healthy 45-year-old man when he and Reynolds, held by U.S. Immigration and Customs Enforcement (ICE) pending deportation, arrived at the county-run Alabama jail after a snow-delayed, double-shackled trip from Massachusetts on Jan. 26, 2014.

Reynolds said that months later, he brought food to the listless Williamson, propped him up so he could walk to the shower, contacted his ICE deportation officer, made entreaties to sheriff’s deputies and submitted written requests for medical care in his behalf.

“IT’S THREE DAYS SINCE I HAVE ASK TO SEE THE DOCTOR,” Reynolds wrote on a request form sent in Williamson’s name on May 21, 2014. “. . . AND I’M PEEING BLOOD. CAN YOU PLEASE HELP ME.”

The in-house medical staff eventually gave Williamson a strong antibiotic, but six days later it rejected his complaint that he “is unable to walk and feels funny all over” as “subjective,” according to medical records.

Reynolds says a correction officer put it to him another way: “Medical is saying that, he’s—you know, he’s faking it. There ain’t nothing wrong with him.”

“ That place in Alabama, oh my God. That’s the worst place, that’s the worst place ever. ”

Reynolds reached out to a captain in the sheriff’s office for help—“I had to literally beg,” he says—and Williamson was held overnight in the jail’s clinic, then sent to a hospital in the morning for “general weakness.” Doctors there found that his urinary tract infection had spread throughout his body: It very nearly killed him.

Within the hour he arrived in the emergency room, he suffered a heart attack due to septic shock, according to medical records. “Locked down my kidneys. It locked down my heart, and then it locked down my brain,” Williamson said in a recent telephone interview from Jamaica, where he was deported the week before Christmas last year. He continues to suffer the medical consequences of his time at Etowah, but without the access to health care he’d have in the United States.

“That place in Alabama, oh my God. That’s the worst place, that’s the worst place ever,” he said.

‘Not a Bed and Breakfast’

He’s not the only one saying that. Advocates for immigrants have launched a campaign called Shut Down Etowah, calling for the federal government to end a contract begun some two decades ago. Significantly, a high-level Department of Homeland Security office—created by Congress to ensure that the agency upholds the public’s civil liberties—also urged ICE leaders to stop using the Etowah jail because of a long pattern of uncorrected civil rights violations.

Located in Gadsden in northeastern Alabama, next to the courthouse where Judge Roy Moore began his judicial career by posting the Ten Commandments in his courtroom, the Etowah County facility is emblematic of much of what’s wrong with the world’s largest immigration detention system. The detainees are isolated from their families and from legal help, 500 miles from the immigration court. They’re held, longer than almost anywhere else in the system, in the wrong kind of facility. Like other jails, Etowah is meant for short-timers who are either awaiting trial or serving minor sentences, and not for civil detention—which is supposed to be non-punitive. So there is no outdoor recreation space. Nor is there space for visitors to meet detainees; that’s done through video from an adjacent building. And pay for a sheriff’s detention deputy is $11.99 an hour, leading to turnover and an inexperienced staff.

Now, the Trump administration is poised to ease the 18-year-old standards that county jails like Etowah must agree to maintain—rules that experts say are already weak and outdated. Meanwhile, a federal advisory council led by former FBI Director William Webster has urged ICE to do the opposite: Stop holding detainees in county jails for anything more than 72 hours.

“ IT’S THREE DAYS SINCE I HAVE ASK TO SEE THE DOCTOR… AND I’M PEEING BLOOD. CAN YOU PLEASE HELP ME. ”

“I think the Etowah facility should be closed,” Megan H. Mack, who headed Homeland Security’s Office of Civil Rights and Civil Liberties in the last two years of the Obama administration, told The Daily Beast. “It is not appropriate for housing immigration detainees and may be not for regular inmates either. The facility is inadequate.”

A report released in June 2016 disclosed that that the civil rights office of the Department of Homeland Security (DHS), which includes ICE, had called on the agency to stop holding detainees at Etowah. The office emphasized the gravity of the situation by issuing what it called its first “super-recommendation memorandum.”

Mack had sent a May 28, 2015, memo to ICE leadership criticizing the agency for failing to respond to the changes her DHS office called for after on-site inspections of Etowah in 2006, 2008, and 2012. In the three years since the last inspection, her office said, 50 new complaints were under investigation.

“We therefore conclude that serious problems persist,” the memo said. Given the findings of previous investigations, which were conducted by experts of national standing, the civil rights office concluded it “has strong reason to believe that many of these complaints identify real and continuing problems at the facility.” (DHS released a highly redacted version of the memo to the Adelante Alabama Worker Center and other non-profit organizations that filed suit for it under the Freedom of Information Act. The suit is continuing at U.S. District Court in Manhattan.)

Among these complaints were charges that spoiled food was served, and multiple reports of ICE officers roughing up handcuffed detainees to put their fingerprint on travel documents.

Bryan Cox, a spokesman for ICE, said the agency “is aware of that report” and that other “inspections have consistently found the Etowah County Detention Center to operate in compliance with ICE’s rigorous national detention standards.”

Even so, the most recent publicly available ICE Office of Detention Oversight compliance report for Etowah, based on a December 2016 inspection, found that the jail met only six of 15 standards surveyed, with deficiencies in food service and telephone access, which was overpriced. The 2016 report listed more more than twice as many deficiencies as the office’s previous report on Etowah, three years earlier.

In recent months, the jail’s notoriety grew following disclosures that Etowah County Sheriff Todd Entrekin pocketed jail funding thanks to an Alabama law that allows sheriffs to keep surplus funds for food—money left over from serving meals that detainees say are so skimpy that they’re often hungry.

Entrekin said that outside agencies frequently inspect his jail. “We have passed those inspections with flying colors each and every time,” he claimed in a March 23 news conference. Entrekin and his spokesperson have not returned numerous messages and calls seeking comment for this article.

At the news conference, Entrekin insisted the food he serves is nutritious and healthy. The sheriff released his tax returns and answered reporters’ questions about his finances to demonstrate his contention that it was legal for him to take $750,000 over three years in “surplus” food money paid by the state and federal governments.

“This is not a bed and breakfast,” he said, scoffing at detainees who said they were revolted by the food.

Entrekin’s protestations did not impress Etowah County voters, who ousted him by a 2-to-1 margin in a June 5 Republican primary. The winner, Rainbow City Police Chief Jonothon Horton, pledged that he would not take any of the jail money for himself.

ICE, however, has not taken a public stand on Entrekin’s use of the jail funds and did not respond to a request for comment .

‘A Step Backwards’

Even setting aside the Etowah County jail’s checkered history, experts say it would still be a poor choice for jailing immigrants long-term.

Kevin Landy, a former ICE assistant director who headed the agency’s Office of Detention Policy and Planning, said county jails like Etowah are intended for short-term detention of people awaiting trial or serving misdemeanor sentences, not for years of incarceration.

“My opinion is the agency’s use of Etowah as a long-term detention facility is inappropriate,” he said. “Due to its remote location and the conditions at the facility, that jail should at most be used for the short-term detention of individuals apprehended nearby and awaiting transfer to a more suitable facility. That policy would result in a substantially reduced population at Etowah.”

While ICE’s use of privately run facilities has drawn much criticism, its deals with county jails have received less attention. But, as an internal advisory council warned DHS in a December 2016 report, many experts and government officials believe that “county jails are, in general, the most problematic facilities for immigration detention.”

The Homeland Security Advisory Council, headed by Webster, recommended that ICE “use county jails only for short-term detention (less than 72 hours) before transfer to larger and higher-quality dedicated facilities”—that is, facilities used only to detain immigrants.

“It won’t be an improvement overall if we phase out private facilities and it results in a greater use of county detention facilities,” said council member David Martin, former deputy general counsel to the Department of Homeland Security and professor emeritus of law at the University of Virginia. But, he added, “this administration, that’s not a priority for them. They’re looking to expand the use of detention and make more detention facilities available.”

A spokeswoman for ICE, Danielle Bennett, said it would be “operationally infeasible” for ICE to limit detention in county jails to no more than 72 hours.

In fact, ICE is planning to make it easier for county-run facilities like Etowah to comply with federal standards for holding detainees long-term.

ICE currently allows Etowah County to operate under what some experts say are vague National Detention Standards created in 2000 in response to a federal court ruling. Broader, more specific standards were created in 2008 and 2011, and ICE has been working to apply them elsewhere.

Budget documents the Trump administration submitted to Congress say that ICE will “streamline” the National Detention Standards for county facilities created in 2000 because “many state and local partners are unable or unwilling to meet ICE’s detention standards.” The change is intended “to achieve an appropriate level of flexibility” to ensure there are enough lockup spaces available to meet President Donald Trump’s directive to toughen enforcement.

“These standards have been adapted to better reflect the strong relationships ICE has with its law enforcement partners, including where detention facility operators successfully manage their own local populations and are willing to assist ICE with housing immigration detainees,” ICE spokeswoman Bennett said via email.

She said there would be an informal comment period before the standards are finalized, adding that ICE “expects that process and all eventual approvals to take a few months.” ICE would not release a copy of the proposed new standards.

“It would be sad because the 2000 standards are super poor,” said Dr. Marc Stern, a correctional health expert at the University of Washington who has evaluated some 30 detention facilities for government and non-profit groups. “Sounds like a step backwards.”

A Checkered Past

In 1989, a federal judge threatened to imprison the Etowah County attorney in her own “appalling” and “grossly understaffed” firetrap of a jail if it wasn’t improved or replaced. The county’s solution was to open the Etowah County Detention Center in 1994.

From day one, the new jail had some of the same underlying problems as the old jail: no space for outdoor recreation and scant operating funds from the county, a mostly rural area of northeast Alabama that suffered economically with the loss of steel and textile manufacturing jobs.

“ In no other detention facility have we received so many complaints of inadequate, inedible and insufficient food. ”

The budgetary solution was for the county to begin accepting immigration detainees from the federal government—and the $30 a day that came with each one (now up to $45, still well below what ICE generally pays using a formula based on local costs). In 2003, the county expanded the jail to hold more immigrant detainees, using $8.4 million in federal money to cover most of the cost, according to the Gadsden Times. The enlarged facility has a capacity of 852, with up to 357 of the beds for ICE detainees.

With advocacy groups filing complaints about poor conditions inside the jail, the DHS civil rights office conducted on-site investigations in 2006, 2008, and 2012, and “made numerous recommendations to ICE for changes at the facility,” according to a DHS memo. A November 2007 ICE inspection flunked the facility on nine of 10 standards, finding deficiencies in medical care, food service and grievance procedures, records show.

In that same month, Entrekin was appointed sheriff, putting him in charge of the troubled jail. According to the Gadsden Times, he had to borrow $150,000, personally, to be able to feed the jail’s population. Under a peculiar Alabama law, sheriffs run the jails’ food operation and pocket any surplus—and there would eventually be a large “surplus.”

Entrekin played a leading role in beating back a December 2010, announcement from ICE officials that they were going to withdraw all immigration detainees from the Etowah County Detention Center. He and other county officials warned that would devastate the county economy, forcing 50 layoffs and cuts in services. (Members of the county commission did not respond to a request for comment.)

Alabama’s congressional delegation pitched in to block the move in Washington. Rep. Robert Alderholt, a Republican who chaired the Homeland Security subcommittee of the House Committee on Appropriations at the time, was especially well situated. With its funding on the line, ICE backed down. (Aderholt did not respond to a request for comment.)

“It had to be like Christmas, New Year’s, the Fourth of July and a whole bunch of birthdays rolled into one when Etowah County officials got ‘the call’ telling them U.S. Immigration and Customs Enforcement had decided to keep more than 300 detainees in the Etowah County Detention Center,” the local newspaper editorialized in April 2011. “They have much to celebrate.”

Not so for the detainees, though. Food, in particular, continued to be a big problem, according to outside monitors—well before disclosures that Entrekin reeled in a small fortune for himself in “surplus” food money.

“In no other detention facility have we received so many complaints of inadequate, inedible and insufficient food,” the Women’s Refugee Commission said in a 2012 report (PDF). “Every detainee reported to us that the quality and quantity of the food was by far the worst at any facility in which they had been detained.”

Meanwhile, Entrekin lived well while his deputies got by on rock-bottom wages. He took in $250,000 a year from the food fund from 2015 to last year, his disclosure records show, and reportedly bought a four-bedroom home with an in-ground swimming pool in Orange Beach, Alabama, a beach community where the water temperature in the Gulf is already in the ’80s. As one headline in the Birmingham News, the state’s largest paper, had it: Etowah sheriff pockets $750k in jail food funds, buys $740k beach house.

Entrekin in recent years pressed the county commission, unsuccessfully, to pay his deputies more. He says he also asked the commission to take over the food operation, as Alabama law allows, but was turned down. He sought county money to bring the jail up to federal standards, which would have required an outdoor recreation space.

Correspondence shows that ICE officials quickly learned that the jail-improvement plan bogged down in finger-pointing between the sheriff and other county officials over the cost, $1.4 million (PDF). Despite that, ICE continued the contract.

Martin said there are steps ICE can take to improve a facility short of closing it down. In Etowah’s case, he added, “If it’s that important to the local economy, they should be able to raise standards.”

‘The Humanity of These People’

The nature of the population ICE has created at Etowah—men jailed indefinitely, usually without a lawyer, far from relatives and friends—heightens the desperation there. ICE doesn’t make enough arrests locally to fill the beds; nearly all are transferred in from other facilities. It can typically be the fifth or sixth immigration jail for a newly arrived detainee. They are often detainees pursuing lengthy appeals, or whose deportation is snagged by regulations in the native country.

After Huntsville, Alabama, resident Katherine Weathers and a friend read about Etowah in a local newspaper, they decided to visit detainees in Gadsden, a 75-mile drive south. As a recently retired civilian employee of the U.S. Army, Weathers was experienced in dealing with bureaucracy. But, she said, “We spent almost a year trying to gain access.” An organization called CIVIC, short for Community Initiatives for Visiting Immigrants in Confinement, and now known as Freedom for Immigrants, finally helped smooth the way.

“Access” didn’t mean Weathers spoke face-to-face with detainees. Rather, there is a small, narrow room, “sometimes cold,” with a bank of phones and monitors that don’t always work well. For 30 minutes, she and a handful of other volunteers could visit by video from an adjacent building.

“It’s life-changing, really. Just the humanity of these people,” Weathers said. “They’re not the caricatures that you hear about when you turn the news on, these awful people that are invading the country… I’ve talked to so many who are fleeing very desperate institutions in their home countries—their family members have been murdered.” Many, she added, had turned themselves in at the border to claim asylum. “We’re criminalizing these people,” she said.

“ The prisoner’s tooth infection spread through his body, paralyzing him. ICE released him from custody while he was hospitalized and in grave condition. So when he died two months later, he was not listed as a death in ICE custody. ”

Sylvester Owino, a Kenyan who spent nine years and four months in immigration detention, was one of the first she met. They spoke about 10 times during Owino’s close to two years in Etowah, and followed up with letters. “Sylvester would send me jokes in the mail. He was just a fun person to talk to. Now his life is taking off,” Weathers said. “He is about to have a baby, married now, working hard on his business,” selling Kenyan food in San Diego.

Owino, who is free on bond, says ICE transferred him and other detainees previously held in San Diego to make it harder for them to be released on bond under a federal court ruling in effect at that time in California, but not Alabama.

While at Etowah, Owino became acquainted with a detainee from Ethiopia, Teka Gulema, who joined him in calling attention to what they saw as abuses. In a Nov. 28, 2013, letter to Christina Mansfield, co-director of CIVIC, Gulema complained that “Even to see a Nurse Practitioner, we have to wait at least two or three weeks. By that time, the condition has worsened or improved, which puts us in a great condition of suffering… the facility’s medical care is the worst we have ever seen.”

Medical care came off relatively well in the DHS civil rights office review done in 2012. “Within the limits of my examination, the health care operation at ECDC is generally well-run,” the outside expert wrote in a memo. But new allegations followed, and Gulema’s complaint is the most haunting.

Gulema later suffered from a tooth infection, according to Owino. It apparently spread through his body, paralyzing him. ICE officially released him from custody in November 2015, while he was hospitalized in grave condition. Gulema died two months later. Because of his prior release, his case was not investigated as a death in ICE custody.

A report last year by Human Rights Watch about indifference to health care needs at detention facilities across the country cited instances in which detainees at Etowah who submitted requests for care “were never seen for that complaint or were seen weeks later.”

In July 2015, Sylvester Owino and Miguel Williamson were the only named complainants in a complaint CIVIC sent to Mack at the DHS civil rights office calling on ICE to immediately terminate its contract with Etowah County due to its “systematic and severe… abuses.” Eighteen other detainees who remained in the facility were referred to only by pseudonyms “because they fear retaliation.”

In the complaint, Owino said that ICE officers at the Etowah County facility handcuffed men and brought them to the basement, where there were no cameras, then proceeded to beat them into signing and fingerprinting travel documents needed to deport them. (Many of the detainees are held long-term because foreign governments won’t issue travel documents to take in people who the U.S. is trying to deport.)

The complaint described Williamson’s medical treatment; chronic understaffing of sheriff’s deputies that exposed detainees to danger; and paltry, substandard food service that left detainees “in an extreme state of hunger.” According to the complaint, food was often spoiled: moldy corn, foul-smelling meat, rotting produce. Those who could afford it were forced to buy expensive food from the commissary operated by the sheriff.

“The food is really nasty, nasty, nasty,” Williamson said in a telephone interview.

“ They said he was in a bed and didn’t want to see me. At this point, my husband was unconscious. He was in septic shock. ”

The complaint also details the nightmarish experience that Williamson’s wife, Sandra Clahar Williamson, says she had when trying to find out about his perilous medical condition. In an interview, she said his cellmate called one night saying, “Your husband is so sick. He peed blood and he’s not responding. I tried to get him some medical attention and no one is responding.” (Williamson’s former cellmate could not be reached for comment.)

Clahar called the sheriff’s office, repeatedly. “Every time I called they told me they know what they were doing,” she said in a telephone interview. Finally, she flew down to Atlanta from the Hartford area, where she works for the state of Connecticut, and drove three hours from the airport to to the Etowah jail to see Miguel.

“They were shocked that I came. They said he was in a bed (and) didn’t want to see me,” she said. “At this point, my husband was unconscious. He was in septic shock.”

As she left the jail, Clahar said, she heard a man call her name from the window—he’d seen her picture posted in Miguel’s cell.

“Mrs. Williamson, don’t leave, don’t leave,” she heard him say. “Go inside, tell them that your husband needs to go to the hospital.”

Clahar said she went back into the jail and insisted that Miguel be hospitalized. Then, when she went back outside to her car, she was surrounded by “50 police with guns,” she said. “They said I was disturbing the peace… All these police said they were going to arrest me, while my husband was dying.”

Once Clahar showed her driver’s license and work identification, the officers backed off, realizing she hadn’t been trying to rile the detainees. “All I want you guys to do is to take my husband to the hospital,” she recalls saying.

The next morning, she would learn, her husband had suffered a heart attack that shut down both of his kidneys and left him in a coma. According to medical records, he coded—his heart stopped—three times. Dialysis treatment and a ventilator kept him alive.

“ These police said they were going to arrest me, while my husband was dying. ”

Williamson filed suit in federal court in 2016 against Entrekin and others in charge of his care. His lawyer, David Gespass, charged that detainees had been “systematically abused” in the Etowah jail for years.

Etowah County settled the lawsuit for an undisclosed sum last September, without first making the usual motion to dismiss it on summary judgment. A key moment in the case probably came when Damian Reynolds frantically notified the lawyer that he was about to be deported, which would prevent him from giving testimony. Gespass filed an emergency motion to take his deposition immediately.

One of the issues raised in the deposition was whether Williamson took the antibiotic he was prescribed a week before his hospitalization. Reynolds testified that he made sure Williamson took the medicine, “one every single day… in the afternoon before he eats.” Unfortunately, the prescription called for the patient to take two pills a day and the disoriented Williamson didn’t take the other daily dose. Medical records show that within two hours after Williamson suffered a heart attack in the hospital, a sheriff’s deputy was sent to take an inventory of his belongings. According to medical records, eight doses remained from the 14 pills Williamson had been given a week earlier. (The company that provides health care at the jail did not respond to a request for comment.)

ICE denied responsibility for Williamson’s condition. Cox said that “independent medical professionals” at a local hospital “diagnosed that Mr. Williamson’s failure to take antibiotics provided to him by ICE for a prior infection likely led to the conditions that caused his hospitalization.”

Gespass, who practices law in Birmingham, said Williamson was severely ill for a week before he was sent to the hospital and that neither medical personnel nor jail officers responded to requests for help. “The main problem was the lack of responsiveness as his condition deteriorated and blaming him for that is beneath contempt,” he said.

‘Undeliverable’

For Williamson, the experience is a blur—he said he doesn’t remember much of it. After his release from Riverview Regional Medical Center in Gadsden on June 27, 2014, he was taken two weeks later to LaSalle Detention Center in Louisiana. “That was the next terrible experience,” he said, recalling that he was put in the back of a vehicle, still unable to walk. At LaSalle, which has a medical facility, he began to recover, he says.

But ICE continued to hold him, indefinitely, while it sought permission from Jamaica to deport him there. Williamson then filed suit, representing himself, seeking release. The court rejected it because he didn’t fill out its preferred form. He filed again, and the case was transferred from one Louisiana federal court jurisdiction to another until ICE released him from custody in May 2015. He went home to Sandra in Connecticut to await the outcome of his deportation appeal—and to many more doctors’ appointments.

After Williamson settled his lawsuit over the Etowah County Detention Center, ICE deported him. Last Nov. 28, he acted as his own attorney to petition the federal appeals court in New York to delay his removal for medical reasons, adding a motion for an emergency stay that was denied the next day. (Unlike criminal defendants, immigration detainees, held under civil law, are not entitled to a lawyer if they can’t afford one.)

Williamson is back in Jamaica now. He had already been deported by the time the appeals court issued a Jan. 25 order saying he’d lose the case if he didn’t pay the $500 fee to file a case or submit a form seeking a waiver. On Feb. 26, his petition was dismissed for “failure to pay fee.” Court records show that as of April, the court’s notices to Williamson that he’d lost his case were still being returned, marked “undeliverable.”

Meanwhile, Williamson continues to suffer the medical consequences of his ICE detention but without the better medical care he’d have if ICE had used its discretion to allow him to stay in the United States. “Sometimes I can walk around,” he said, adding that he has trouble urinating, kidney problems that could lead back to dialysis treatment, constant headaches, poor eyesight, and mental lapses.

“I try not to think about the past,” he said. “For right now, it’s terrible.”