Doctors should not declare anyone fit to be held in immigration detention centres

Guest post by Nicola Cocco, Filipa Alves da Costa, Francesca Esposito, Marie Claire Van Hout, Federica de Cordova, Lara Tavoschi, Patrizia Borsellino, Chiara Montaldo, and Camilla Ponti. Nicola Cocco, Infectious Diseases and Prison Health Specialist, Italian Society of Migration Medicine (SIMM), Milan, Italy. Filipa Alves da Costa, Assistant Professor, WHO Regional Office for Europe, Copenhagen, Denmark; Faculty of Pharmacy, University of Lisbon, Portugal*. Francesca Esposito, Lecturer, School of Social Sciences, University of Westminster, London, UK; Research Fellow,  Instituto de Ciências Sociais da Universidade de Lisboa, Lisbon, Portugal; Associated Director, Border Criminologies, University of Oxford, UK. Marie Claire Van Hout, Professor of International Health Policy and Practice, Faculty of Health, Liverpool John Moores University, UK. Federica de Cordova, Assistant Professor, Department of Human Sciences, University of Verona, Verona, Italy. Lara Tavoschi, Senior Researcher, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy. Patrizia Borsellino, Professor, Department of Philosophy of Law and Bioethics, University of Milan-Bicocca, Milan, Italy .Chiara Montaldo, Head of Medical Unit, MSF-Italy Programs Department, Médecins Sans Frontières – Brussels Operational Center. Camilla Ponti, Psychologist, Network “Mai più lager - No ai CPR”, Milan, Italy.

This blog post was originally published on the BMJ on 1 March 2024.

A campaign by Italian doctors aims to raise awareness of the harmful conditions and health risks associated with immigration detention. The campaigners explain why in this open letter.

On 4 February 2024, Ousmane Sylla, a 22 year old Guinean man died by suicide in Ponte Galeria detention centre in Rome, Italy; as reported by Annalisa Camilli, in the previous weeks he had been transferred from another immigration detention centre, despite his poor mental health and the risk of self-harm extensively documented. This case illuminates the urgency of denouncing the inadequate and unsuitable conditions within these facilities, which expose people detained there to serious health risks, or premature death, as discussed in a forthcoming book edited by Michelle Peterie. 

In 2022, the World Health Organization (WHO) Regional Office for Europe published a document describing the health risks for people subject to immigration detention. The WHO confirms that detention sites across Europe constitute a substantive risk for the mental health of detainees,  risk the spread of infectious diseases, and adhere to low-quality standards in managing noncommunicable diseases. In March 2023 a paper by Marie Claire Van Hout highlight how immigration detention erodes people’s health status by exposing them to unsuitable conditions and barriers to access to healthcare. In 2024, the WHO also endorsed a joint-advocacy brief on ending immigration detention for children, calling for the adoption of explicit legal prohibition of detention of children. 

In Italy, despite the administrative nature of immigration detention, these facilities are prison-like environments, but without the basic safeguards usually guaranteed in prison in many European countries, including the right to healthcare access. Immigration detention centers are managed by private for-profit organizations that sign memoranda of understanding with Prefectures (local branches of the Ministry of Interior) and local health authorities, who should guarantee the rights of the detained people. Health management in immigration detention is contracted to healthcare personnel employed by private contractors, without requiring specific qualifications or training for working with migrant people and/or in detention contexts. Numerous independent reports and investigations, including by the Italian National Guarantor of the rights of persons deprived of liberty, have highlighted the degrading hygienic and sanitation conditions of detention sites and suboptimal healthcare provision. Detained individuals often face serious physical and mental health challenges, exacerbated by confinement, as well as by the barriers in accessing care as per standards guaranteed by the Italian national health system. All these conditions has been independently reported by activists, lawyers, and the National Guarantor. Abuse and misuse of psychotropic drugs prescribed by healthcare staff for security purposes have also been largely documented within these custodial sites. 

At an international level, a recent analysis of existing qualitative evidence highlights how, alongside degrading living conditions, people subject to immigration detention endure the burdens of communication barriers which make it difficult to navigate legal systems, or understanding what is happening, the trauma of having their life projects disrupted, and the abuse of psychotropic drugs. 

In Italy, when entering a detention centre, people must undergo a clinical assessment performed by a doctor affiliated to the national health system. Over the years this medical assessment has increasingly taken the form of an administrative nihil obstat to the detention, just excluding the risk of communicable diseases, without a thorough evaluation of the overall person’s health status. 

This procedure raises substantial concerns: 

Firstly, from a public health perspective, multiple reliable sources have demonstrated that immigration detention is pathogenic and a risk to people’s for health, yet doctors are tasked with certifying the health status of individuals during a short consultation, often without sufficient information on their personal backgrounds; the conditions of the detention sites where they will be held; or the availability and quality of healthcare services offered in detention. 

From an ethical perspective, physicians need adequate time and medical settings to thoroughly evaluate a person's health status. Additionally, informed consent to undergo a medical examination is essential according to international norms, but currently not required in Italy for migrants destined for detention. More importantly, there is the deontological duty for medical doctors to protect vulnerable people (such as undocumented migrant people), in particular when they believe the environment in which the person lives is not suitable for protecting their health, dignity, and quality of life. 

From a medical-legal perspective this process is problematic. If detainees develop health conditions, the health assessment issued could be contested and the doctor signing it could become involved in legal proceedings. 

Based on these considerations, and in line with existing WHO guidelines for the protection of the health of people subjected to detention (WHO, 2022), the Italian Society of Migration Medicine (SIMM), the Network “Mai più lager - No ai CPR”, and the Association for Legal Studies on Immigration (ASGI), have jointly released a  call for action for all healthcare personnel to be aware of the harmful conditions and health risks associated with immigration detention. On the bases of the aforementioned public health, ethical, and legal issues, the campaign aims to increase awareness and provide documentary and organisational support to doctors in order to encourage them not to declare any migrant person suitable for administrative detention. 

Immigration detention centres are invisible settings where the right to health and access to healthcare are      systematically neglected. Bearing in mind the fundamental principles and ethics of the medical profession, healthcare practitioners should be firm in saying that no one should ever be considered fit to be “locked up” in pathogenic environments where health is disregarded and fundamental human rights are at risk. Ultimately, as Ousmane Sylla's recent death sadly reminds us, people in these sites are exposed to group-differentiated vulnerability to premature death, as depicted by Ruth Wilson Gilmore in Golden Gulag. 

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