by Dana Priest & Amy Goldstein, Washington Post, 11 May 2008
As Tighter Immigration Policies Strain Federal Agencies the Detainees in their Care Often Pay a Heavy Cost
Near midnight on a California spring night, armed guards escorted Yusif Osman into an immigration prison ringed by concertina wire at the end of a winding, isolated road.
During the intake screening, a part-time nurse began a computerized medical file on Osman, a routine procedure for any person entering the vast prison network the government has built for foreign detainees across the country. But the nurse pushed a button and mistakenly closed file #077-987-986 and marked it “completed” — even though it had no medical information in it.
Three months later, at 2 in the morning on June 27, 2006, the native of Ghana collapsed in Cell 206 at the Otay Mesa immigrant detention center outside San Diego. His cellmate hit the intercom button, yelling to guards that Osman was on the floor suffering from chest pains. A guard peered through the window into the dim cell and saw the detainee on the ground, but did not go in. Instead, he called a clinic nurse to find out whether Osman had any medical problems.
When the nurse opened the file and found it blank, she decided there was no emergency and said Osman needed to fill out a sick call request. The guard went on a lunch break.
The cellmate yelled again. Another guard came by, looked in and called the nurse. This time she wanted Osman brought to the clinic. Forty minutes passed before guards brought a wheelchair to his cell. By then it was too late: Osman was barely alive when paramedics reached him. He soon died.
His body, clothed only in dark pants and socks, was left on a breezeway for two hours, an airway tube sticking out of his mouth. Osman was 34.
The next day, an autopsy determined that he had died because his heart had suddenly stopped, confidential medical records show. Two physicians who reviewed his case for The Washington Post said he might have lived had he received timely treatment, perhaps as basic as an aspirin.
Privately, Otay Mesa’s medical staff also knew his care was deficient. On Page 3 of an internal review of his death is this question:
Did patient receive appropriate and adequate health care consistent with community standards during his/her detention …?
Otay Mesa’s medical director, Esther Hui, checked “No.”
Osman’s death is a single tragedy in a larger story of life, death and often shabby medical care within an unseen network of special prisons for foreign detainees across the country. Some 33,000 people are crammed into these overcrowded compounds on a given day, waiting to be deported or for a judge to let them stay here.
The medical neglect they endure is part of the hidden human cost of increasingly strict policies in the post-Sept. 11 United States and a lack of preparation for the impact of those policies. The detainees have less access to lawyers than convicted murderers in maximum-security prisons and some have fewer comforts than al-Qaeda terrorism suspects held at Guantanamo Bay, Cuba.
But they are not terrorists. Most are working-class men and women or indigent laborers who made mistakes that seem to pose no threat to national security: a Salvadoran who bought drugs in his 20th year of poverty in Los Angeles; a U.S. legal U.S. resident from Mexico who took $50 for driving two undocumented day laborers into a border city. Or they are waiting for political asylum from danger in their own countries: a Somali without a valid visa trying to prove she would be killed had she remained in her village; a journalist who fled Congo out of fear for his life, worked as a limousine driver and fathered six American children, but never was able to get the asylum he sought.
The most vulnerable detainees, the physically sick and the mentally ill, are sometimes denied the proper treatment to which they are entitled by law and regulation. They are locked in a world of slow care, poor care and no care, with panic and coverups among employees watching it happen, according to a Post investigation.
The investigation found a hidden world of flawed medical judgments, faulty administrative practices, neglectful guards, ill-trained technicians, sloppy record-keeping, lost medical files and dangerous staff shortages. It is also a world increasingly run by high-priced private contractors. There is evidence that infectious diseases, including tuberculosis and chicken pox, are spreading inside the centers.
Federal officials who oversee immigration detention said last week that they are “committed to ensuring the safety and well-being” of everyone in their custody.
Some 83 detainees have died in, or soon after, custody during the past five years. The deaths are the loudest alarms about a system teetering on collapse. Actions taken — or not taken — by medical staff members may have contributed to 30 of those deaths, according to confidential internal reviews and the opinions of medical experts who reviewed some death files for The Post.
According to an analysis by The Post, most of the people who died were young. Thirty-two of the detainees were younger than 40, and only six were 70 or older. The deaths took place at dozens of sites across the country. The most at one location was six at the San Pedro compound near Los Angeles.
Immigration officials told congressional staffers in October that the facility at San Pedro was closed to renovate the fire-suppression system and replace the hot-water boiler. But internal documents and interviews reveal unsafe conditions that forced the agency to relocate all 404 detainees that month. An audit found 53 incidents of medication errors. A riot in August pushed federal officials to decrease the dangerously high number of detainees, many of them difficult mental health cases, and caused many health workers to quit. Finally, the facility lost its accreditation.
The full dimensions of the massive crisis in detainee medical care are revealed in thousands of pages of government documents obtained by The Post. They include autopsy and medical records, investigative reports, notes, internal e-mails, and memorandums. These documents, along with interviews with current and former immigration medical officials and staff members, illuminate the underside of the hasty governmental reorganization that took place in response to the attacks of Sept. 11, 2001.
The terrorist strikes catapulted immigration to a national security concern for the first time since World War II, when 120,000 Japanese residents and their American relatives were locked away in desolate internment camps.
After Sept. 11, the Bush administration transferred responsibility for border security and deportation to the new Department of Homeland Security, which gave it to Immigration and Customs Enforcement (ICE) — a reconfiguration of the decades-old Immigration and Naturalization Service — in 2003, the year the Post used as the starting point for counting detainee deaths. Each year since, the number of detainees picked up for deportation or waiting behind bars for political asylum has skyrocketed, increasing by 65 percent since July 2005.
Government professionals provide health care at 23 facilities, which house roughly half of the 33,000 detainees. Seven of those sites are owned by private prison companies. Last year, the government also housed detainees in 279 local and county jails. To handle the influx of detainees, ICE added 6,300 beds in 2006 and an additional 4,200 since then. They too are nearly full.
These way stations between life in and outside the United States are mostly out of sight: in deserts and industrial warehouse districts, in sequestered valleys next to other prisons, or near noisy airports. Some compounds never allow detainees outdoor recreation; others let them out onto tiny dirt patches once or twice a week.
Detainees are not guaranteed free legal representation, and only about one in 10 has an attorney. When lawyers get involved, they often have difficulty prying medical information out of the bureaucracy — or even finding clients, who are routinely moved without notice.
The burden of health care for this crush of human lives falls on an obscure federal agency that lacks the political clout and bureaucratic rigor to do its job well. The Division of Immigration Health Services (DIHS), housed in a private office building at 13th and L streets NW several blocks from ICE headquarters, had a budget last year of $61 million. ICE spent an additional $28 million last year on outside medical care for detainees.
Medical spending has not kept pace with the growth in population. Since 2001, the number of detainees over the course of each year has more than tripled to 311,000, according to ICE and the Government Accountability Office. Meanwhile, spending for the DIHS and outside care has not quite doubled, ICE figures show. ICE’s conflicting population and budget numbers make the trends difficult to determine.
The agency is responsible for managing and monitoring detainee medical care, about half of which is provided by U.S. Public Health Service professionals and the rest by contracted medical staff. When doctors and nurses at the immigration compounds believe that detainees need more than the most basic treatment, they have to fax a request to the Washington office, where four nurses, working 9 to 4, East Coast time, five days a week, make the decisions.
A proud Statue of Liberty replica stands just beyond the glass doors of DIHS headquarters to remind visitors of the Public Health Service’s historical role in screening and treating European immigrants arriving at Ellis Island at the turn of the last century. Its new role is to keep detained immigrants healthy enough to be deported.
The mission is accompanied at times by a sense of panic and complicity. Many documents obtained by The Post make clear that the people in charge know that the system is in trouble and that piecemeal fixes are not enough.
“The onus is on us if it hits the fan,” one official complained during a high-level headquarters meeting about staff shortages late last summer, according to records of the conversation. “We’re going to be responsible if something happens, because it’s well documented that we know there’s a problem, that the problem is severe.”
“We are putting ourselves and our patients at risk,” another official said.
Doctors express concerns about violating medical ethics and fear lawsuits. In July, Esther Hui at Otay Mesa sent a memo to DIHS medical director Timothy T. Shack, saying her colleagues were worried that they might be sued because of the substandard care they were giving detainees. The agency’s mission of “keeping the detainee medically ready for deportation” often conflicts with the standards of care in the wider medical community, Hui wrote. “I know in my gut that I am exposing myself to the US legal standard of care argument. … Do we need to get personal liability insurance?”
Nurses who work on the front lines see the problems up close. “Dogs get better care in the dog pound,” said Catherine Rouse, a contract nurse at an Arizona detention center who quit after two months last year because she saw what she regarded as “scary medicine” in the prison: patients taken off medications they needed and nurses doing tasks they were not qualified to do. “You don’t treat people like that. There has to be some kind of moral fiber,” Rouse said.
In a statement responding to questions raised by The Post, Immigration and Customs Enforcement officials pointed out that the federal government spent nearly $100 million in fiscal 2007 on medical care for immigration detainees. About one in four immigrants in the detainee population has a chronic health condition, the statement said.
“Among ICE’s highest priorities is to ensure safe, humane conditions of confinement for those in our custody,” the statement said. “We make every effort to enforce all existing standards and, whenever possible, to improve upon them. When we find standards that are not being met, we take immediate action to correct deficiencies and when we believe that the deficiencies cannot be corrected, we relocate our detainees to other facilities.”
By their calculations, officials said, the mortality rate among detainees has declined since 2004 to a level that is lower than that in U.S. jails and prisons. The deaths, the statement said, “highlight the tremendous responsibility and potential liability the government faces in providing medical care to a population that often did not have access to adequate health care before coming into our custody.”
To this end, the agency recently increased its inspections of facilities and is creating an inspection group at headquarters to review serious incidents, including deaths or allegations that standards are not being met.
ICE declined to comment on specific cases, citing internal policies on patient privacy or pending litigation.
Neil Sampson, who ran the DIHS as interim director most of last year, left that job with serious questions about the government’s commitment. Sampson said in an interview that ICE treated detainee health care “as an afterthought,” reflecting what he called a failure of leadership and management at the Homeland Security Department. “They do not have a clear idea or philosophy of their approach to health care [for detainees],” he said. “It’s a system failure, not a failure of individuals.”
A new director for health services arrived six months ago, following a stretch when the agency was run first by Sampson and then by a second interim director. The new boss is LaMont W. Flanagan, who brought with him the credential of having been fired in 2003 by the state of Maryland for bad management and spending practices supervising detention and pretrial services. An audit found that Flanagan had signed off on payments of $145,000 for employee entertainment and other ill-advised expenditures. His reputation was such that the District of Columbia would not hire him for a juvenile-justice position.
“Another death that needs to be added to the roster,” Diane Aker, the DIHS chief health administrator, tapped out in an e-mail to a records clerk at headquarters on Aug. 14, 2007.
Juan Guevara-Lorano, 21, was dead.
Guevara, an unemployed legal U.S. resident with a young son, was arrested in El Paso for driving illegal border-crossers farther into the city. He was paid $50.
An entry-level emergency medical technician, with barely any training, had done Guevara’s intake screening and physical assessment at the Otero County immigration compound in New Mexico. Under DIHS rules, those tasks are supposed to be done by a nurse.
After two difficult months in detention, Guevara had decided not to appeal his case. He would go back to Mexico with his family. But on Aug. 4, he came down with a splitting headache, what he called a nine on a pain scale of 10, his medical records show. The rookie medical technician prescribed Tylenol and referred Guevara to the compound’s physician “due to severity of headache … and dizziness,” according to medical records.
But Guevara never saw a doctor. Eight days after the first incident, he vomited in his cell. The same junior technician came to help but was unable to insert a nasal airway tube. Guevara was taken to a hospital, where doctors determined an aneurism in his brain had burst.
His wife, pregnant at the time with their second child, recalled that she rushed to the hospital but ICE guards would not let her inside, until the Mexican Consulate interceded. Guevara’s mother waited five hours before they let her in. By then he was brain-dead.
“My son is not coming back,” sobbed Ana Celia Lozano months later, sitting in Guevara’s small mobile home as her grandson played on the floor. “I want to know how he lived and died, nothing more.”
What appears to be the most incriminating document in Guevara’s case has been partially blacked out. Still, what is left shows that he did not receive adequate care. “The detainee was not seen or evaluated by an RN, midlevel or physician. . . . At the time of the incident on 8/12/2007, the detainee was seen and examined by EMTs.”
Each immigration facility is allotted a different number of positions, and a shortage of doctors and nurses is not unusual at centers across the country. Records from February show that about 30 percent of all DIHS positions in the field were unfilled. ICE officials said last week that the current vacancy rate is 21 percent. Concern about the vacancies is voiced repeatedly at clinical directors’ meetings. “How do we state our concerns so that we can be heard? . . . this is a CRITICAL condition. . . . We have bitten off more than we can chew,” a physician wrote in the minutes of one meeting last summer.
In some prisons, the staffing shortages are acute. The Willacy County detention center in South Texas — the largest compound, with 2,018 detainees — has no clinical director, no pharmacist and only a part-time psychiatrist. Nearly 50 percent of the nursing positions were unfilled at the 1,500-detainee Eloy, Ariz., prison in February. At the newly opened 744-bed Jena., La., compound, nurses run the place. It has no clinical director, no staff physician, no psychiatrist and no professional dental staff.
Last August, Sampson, who was then DIHS interim director, warned his superiors at ICE that critical personnel shortages were making it impossible to staff the Jena facility adequately. In a vociferous e-mail to Gary Mead, the ICE deputy director in charge of detention centers, he wrote:
“With the Jena request we have been re-examining our capabilities to meet health care needs at a new site when we are facing critical staffing shortages at most every other DIHS site. While we developed, executed and achieved major successes in our recruitment efforts we have been unable to meet the demand.”
The slow ICE security-clearance process forced many job applicants to go elsewhere, Sampson wrote. Of the 312 people who applied for new positions over the past year, 200 withdrew, he wrote, because they found other jobs during the 250 days it took ICE, on average, to conduct the required background investigations. Last week, ICE officials said the average wait had decreased recently to 37 days.
These shortages have burdened the remaining staff. In July 2007, a year after Osman’s death in Otay Mesa, medical director Hui strongly complained to headquarters about workload stress. “The level of burnout . . . is high and rising,” she wrote in an e-mail. “I know that I have been averaging approximately 2-6 hrs of overtime daily for the past 2 months. I will no longer be able to sustain this pace and will be decreasing the number of hours that I work overtime. This being said, more will be left undone because we simply do NOT have the staff.”
The overcrowding has created a petri dish for the spread of diseases. One mission of the Public Health Service is to detect infectious diseases and contain them before they spread, but last summer, the gigantic Willacy center was hit by a chicken pox outbreak.
The illness spread because the facility did not have enough available isolation rooms and its large pods share recycled air, but also because security officers “lack education about the disease and keep moving around detainees from different units without taking into consideration if the unit has been isolated due to heavy exposure,” noted the DIHS’s top specialist on infectious diseases, Carlos Duchesne. The staff was forced to vaccinate the entire population in mid-July.
In one 2007 death, memos and confidential notes show how medical staff missed an infectious disease, meningitis, in their midst. Victor Alfonso Arellano, 23, a transgender Mexican detainee with AIDS, died in custody at the San Pedro center. The first three pages of Duchesne’s internal review of the death leave the impression that Arellano’s care was proper. But the last page, under the heading “Off the record observations and recommendations,” takes a decidedly critical tone: “The clinical staff at all levels fails to recognize early signs and symptoms of meningitis. . . . Pt was evaluated multiple times and an effort to rule out those infections was not even mentioned.”
Arellano was given a “completely useless” antibiotic, Duchesne wrote. Lab work that should have been performed immediately took 22 days because San Pedro’s clinical director had ordered staff members to withhold lab work for new detainees until they had been in detention there “for more than 30 days,” a violation of agency rules.
“I am sure that there must be a reason why this was mandated but that practice is particularly dangerous with chronic care cases and specially is particularly dangerous with . . . HIV/AIDS patients,” Duchesne wrote. “Labs for AIDS patients . . . must be performed ASAP to know their immune status and where you are standing in reference to disease control and meds.”
Given the frequency with which ICE moves people within the detention network, keeping track of detainees is critical to stopping the spread of infectious illnesses. The purchase of an electronic records system named CaseTrakker in 2004 was supposed to help. But according to internal documents and interviews, CaseTrakker is so riddled with problems that facilities often revert to handwritten records.
A study at one site found that it took one-third more time to use CaseTrakker than to use paper. Thousands of patient files are missing. Recorded data often cannot be retrieved. Day-long outages are common.
When detainees are transferred from one facility to another, their records, if they follow them, are often misleading. Some show medications with no medical diagnoses, or “lots of diagnoses but no meds,” according to Elizabeth Fleming, a former clinical director at one compound in Arizona.
After Yusif Osman’s death and the discovery of the problem with his computerized records, the DIHS ordered a review of all charts at the Otay Mesa center. During the review, auditors also found that 260 physical exams were never completed as required. The nurse responsible for the error in Osman’s case was reprimanded, but the computer problem was not fixed.
The CaseTrakker system “has failed and must be replaced,” Sampson, the DIHS interim director, wrote to his ICE supervisors in August.
In January 2008, medical director Shack told colleagues that CaseTrakker “is more of a liability than the use of paper medical record system,” according to the minutes of a meeting. It “puts patients at risk.”
ICE officials said last week that they are not satisfied with CaseTrakker and are working to replace it.
Along with being at the mercy of computer glitches, detainees suffer from human errors that deny or delay their care. And with few advocates on the outside, they are left alone to plead their cases in the most desperate ways, in hand-scribbled notes to doctors they rarely see.
“I need medicine for pain. All my bones hurt. Thank you,” wrote Mexico native Roberto Ledesma Guerrero, 72, three weeks before he died inside the Otay Mesa compound.
Delays persist throughout the system. In January, the detention center in Pearsall, Tex., an hour from San Antonio, had a backlog of 2,097 appointments.
Luis Dubegel-Paez, a 60-year-old Cuban, had filled out many sick call requests before he died on March 14. Detained at the Rolling Plains Detention Facility in the West Texas town of Haskell, he wrote on New Year’s Day: “need to see doctor for Heart medication; and having chest pains for the past three days. Can’t stand pain.”
Ten days later he went to the clinic and became upset when he wasn’t seen. He slugged the window, yelled, pointed at his wristwatch. He was escorted back to his cell.
Another of his sick call requests said: “Need to see a doctor. I have a lot of symptoms of sickness … as soon as possible!” The next was more urgent: “I have a emergency to see the doctor about my heart problems … for the last couple days and I been getting dizzy a lot.”
The next day, Dubegel-Paez collapsed and died. His medical records do not show that he ever saw a doctor for his chest pains.
Hanna Boutros, 52, who came to the United States 30 years ago, waited seven months for surgery after receiving a diagnosis of “high-grade” prostate cancer, which his urologist urged be treated immediately. ICE officials sent him to Krome Service Processing Center in Miami because, they said, it could best deal with his condition.
But he was seen by nurses, not a doctor, until he found an outside lawyer to threaten a suit. Boutros finally got surgery just before Christmas, before he was deported to Lebanon, leaving two children and a wife in the United States. “I was miserable. I was very, very scared. It was always burning,” he said.
Juan Guillermo Guerrero, 37, was denied his seizure medication and given an ineffective substitute. Suffering from one or two painful seizures a week, he told his lawyer to drop his case, saying he preferred to be deported than to die inside an immigration prison. A few days after he returned to Mexico, Guerrero died of asphyxiation during a seizure, according to his lawyers.
Sometimes, to save money, the government releases detainees instead of treating them. Martin Hernandez Banderas, a 40-year-old Mexican, was released from custody last year while he was in the hospital following surgery to amputate his leg. An internal review found that the system failed him before the surgery: Nurses and doctors at Otay Mesa did not appreciate the severity of his diabetic foot wounds, did not properly treat them or prescribe the correct course of antibiotics, and did not bring in a qualified surgeon to evaluate the problem.
Simon Reyes-Altimirano, 25, a Honduran, was diagnosed with chicken pox and sent back to his cell with Benadryl, only to be hospitalized a day later and diagnosed with an inoperable brain tumor. He died two weeks later.
Shack, the medical director, found that Reyes-Altimirano’s care at the El Paso detention center had been “appropriate and timely.” But a nurse at the center poured out her remorse in a typed note placed in Reyes-Altimirano’s medical file. “We always have to listen to the patient and the reason I say this is because” when he first reported his problems, “one of the nurses said, ‘I think he is faking his illness’ … this is not just a medical learning experience but also an emotional one.”
Three weeks after Reyes-Altimirano died, a nurse at the Krome Service Processing Center accused the Rev. Joseph Dantica of faking an illness, too. The 81-year-old Baptist minister had fled Haiti in the fall of 2004, fearing for his life after gangs set fire to the church overlooking Port-au-Prince where he ran a school, let people use computers for free and quietly handed out money to needy families.
As a younger man, Dantica listened to tapes to practice English every day, but he never wanted to live in the United States, said a niece, writer Edwidge Danticat, who was raised by him. He visited once a year, to see his brother in Brooklyn and raise money for his church.
But after U.N. peacekeepers and Haitian riot police seized the church to use as a base against gangs, and after the gangs retaliated by burning the altar, Dantica slipped on a woman’s muumuu and wig and headed to the airport. He arrived in Miami with a valid visa but decided to seek asylum because he thought he might have to stay longer than his visa allowed. In an earlier time, Dantica would have been permitted to go on to New York while the government considered his claim. This time, he was detained.
Dantica and an immigration lawyer were sitting before an asylum officer when the minister began to vomit violently. The lawyer, John Pratt, said agents at the detention center had taken away his client’s blood-pressure medicine.
Dantica “turned very cold. His eyes wandered around, and he appeared not to be conscious of his surroundings,” the asylum officer, Miriam Castro, later told investigators, according to confidential documents. “Applicant assumed a rigid position with his legs stretched out and remained in this position.”
Castro called for medical help. No one came for 15 minutes. When the public health nurse and a physician assistant arrived, the nurse said he believed that Dantica “was faking because Applicant kept looking at him randomly,” Castro said. The nurse, Tony Palladino, “then went on to demonstrate that when he moved Applicant’s head up and down, Applicant maintained his head rigid as opposed to limp, thus not allowing his head to fall back. [The nurse] stated that was another way he determined Applicant was faking symptoms.”
Dantica died a day later in Miami’s Jackson Memorial Hospital, shackled to a bed. Pratt had called the hospital repeatedly, trying to get information about the minister’s condition and permission for his family to see him. “They never said anything but they were doing tests,” Pratt said. Security reasons, hospital officials told him, prevented visitors.
The government’s internal medical records say Dantica died of pancreatitis. A one-page death certificate in his file has “VOID” stamped across it. Two outside doctors who reviewed his medical records for The Post said he probably died of heart problems.
Yusif Osman had been living in Los Angeles as a legal resident for five years when he was detained crossing back from Tijuana in 2006 with a passenger, also from Ghana, who had a false ID. Osman was arrested on a smuggling charge, which he denied and was fighting while locked up at Otay Mesa. He seemed healthy to his friends and family who visited him or spoke to him by phone.
His girlfriend, Dorothy Weens, was stunned when she picked up the phone in late June and a stranger broke the news. “Yusif Osman passed away,” the man said.
When Osman’s lawyer called the compound to verify what had happened, he was told only that his client was no longer there. Weens and a cousin of Osman’s called immigration officials several times for answers. They were told that the matter was under investigation. Eventually they stopped calling.
Osman’s belongings from the prison arrived at his cousin’s house one day by mail. Pants. Socks. Scraps of paper with prayer verses written in Arabic. His birth certificate. A letter from Dorothy: “Hey Babe! Hang in there. I’m trying everything I can do, to get you out of there. I love you and God love you. And that all you needs. I’m sending you $100.00. Love, Dot.”
There was also an inventory of the rest of his personal property on the day he died: “4 yellow envelopes. 1 writing pad. 1 religious beads. 1 Chap Stick. 14 Ramen soups. 1 grape jelly. 1 jar peanut butter. 1 hot cocoa mix. 1 box Q tips.”
The mortuary received a preliminary death certificate from the coroner’s office. It noted Osman’s cause of death as “pending,” enough to release the body. His mosque collected money for a burial in a Muslim cemetery in the Mojave Desert. Male friends dug the grave. They laid his corpse, wrapped in white cloth, into the open earth and covered it with rocky dirt.
The final death certificate arrived in the mail sometime later. Under cause of death, it still read “pending.” Osman’s passing remains a mystery to his grieving relatives in Ghana and his adopted African community in Los Angeles.
An uneven, blank concrete headstone marks Grave 26. The truth of Osman’s death is also buried, thousands of miles away, past the Statue of Liberty replica near the front door, inside a cabinet at the Division of Immigration Health Services, in file #077-987-986.
Staff researcher Julie Tate and database editor Sarah Cohen contributed to this report.