On the dirt-road outskirts of the border town of Ojinaga, Mexico, Carlos Aguirre-Venegas’ family gathered last fall in a small church to remember him. It had been a year since Carlos had died, four days before his 31st birthday in October 2014. In the front pew, his wife, Berenice Venegas, held tightly to their three young children as her tears ran through her makeup. The oldest child, 7-year-old Mia, wanted to know when her father would return from heaven. She slid from her mother’s lap to kiss her father’s photograph, resting on the podium beside a pastor.
In his own childhood, Carlos was a quiet boy with a commanding frame. He longed to follow his aunt, Ana Lujan to her home in Midland, Texas, and as a teenager he began trying to do so without a visa. Not long after he turned 17, US border agents caught him on his first attempt. He tried twice more before finally arriving—exhausted, his feet covered in blisters, but his eyes still gleaming—at Ana Lujan’s door in late 2000. “He had made it, and he was never going back,” Lujan said.
Yet over the next 11 years, Carlos was deported at least five times, and each time he came back to Texas.
On one of his returns to Mexico, Carlos met Berenice. She was two years older than he, confident, and the holder of a green card. They fell in love and as they built their family, he found devotion like none he’d known.
He worked as a roofer in West Texas and drove long distances for jobs, which put him at risk for being picked up. In August 2011, Aguirre-Venegas was jailed for violating parole for a four-year-old arrest for drug possession. Thanks to a program that engages local police departments in immigration enforcement, he was flagged as undocumented and referred to federal prosecutors. A federal judge sentenced him to 13 months years in federal prison for illegal reentry. (See our story FAQ for an explanation of how and when border crossing became a criminal, rather than civil, offense.)
After his time in federal prison, Carlos was deported once again, and he and Berenice considered whether he should remain in Ojinaga this time. They knew another return could mean more time in prison, and that if he remained free in Ojinaga, she’d continue to visit him there regularly, as she’d been doing since his release and deportation. But when Berenice became pregnant, Carlos knew they had to reunite the family. “He was never going to stop crossing, and I was never going to go over” to Ojinaga for good, Berenice said. He crossed successfully, and resumed his life and work in Texas. Then, in September 2013, he was pulled over again, as he drove from a get-together at his aunt’s house to check on Berenice, who was just days from her due date. He’d been drinking and was arrested. Immigration agents in the Midland County jail flagged him again and referred him to a federal judge. Carlos was remanded to federal prison for another 14 months.
The Bureau of Prisons sent Carlos to Eden Detention Center in central Texas. The facility, one of 11 private federal prisons used only to hold noncitizens, is run by the Corrections Corporation of America. Immigrant- and prisoner-rights advocates have long warned that these prisons are in crisis—stripped down, separate, and unequal facilities where inmates frequently suffer without the medical care that they need. But a trove of more than 9,000 pages of medical files I obtained clarify the scope of this neglect. They expose dozens of deeply questionable deaths inside the facilities, including several cases in which care was flagged as inadequate by the contractors’ own mortality reviews.
Berenice drove three hours to visit Carlos at Eden at least once a month. In the late summer of 2014, she noticed that he started to look ill. His hands were swollen, she says, and by August, his eyes and skin looked weirdly yellow.
In Ojinaga, I met a man named Hector who was locked up with Carlos Aguirre-Venegas. Asking that I not use his last name, he told me he and Carlos became friends after learning they shared the same hometown. He also recalled that Carlos’s skin was turning yellow, for a period of at least a month while he and Carlos were incarcerated together. Even before that, Carlos had complained of stomach pain and was unable to eat full meals.
Shortly after he arrived at Eden, records show, Carlos had tested positive for latent tuberculosis. Medical staff prescribed an antibiotic called isoniazid to suppress the disease. Liver failure is a known potential side effect of the drug, and standard practice includes close monitoring of those who are on it. But the medical records from Eden raise serious questions about whether Carlos was properly monitored.
Both Berenice and Hector say that Carlos knew the pills were making him sick, but he feared that if he stopped taking the dose without permission, he’d be disciplined—sent to a segregation unit, and denied phone and visitation rights. He’d lose touch with his family.
After Carlos died of liver failure on October 10, 2014, a Bureau of Prisons monitoring report on Eden flagged his tuberculosis care as an example of a breakdown in medical care at the facility. The review also found that the prison nurses administered 30 excess doses of the isoniazid.
Carlos Aguirre-Venegas died almost invisibly, in the care of a little-known, but deeply troubled corner of the federal prison system. Nearly all of the men held in privatized, immigrant-only facilities like Eden will be deported when their terms end. But some do not make it out alive. Through a Freedom of Information Act request, I obtained the medical records, turned over to the BOP, for 103 men who died inside. In at least 25 of these cases, a panel of independent medical reviewers identified signs of inadequate care that likely contributed to their premature deaths. These are their names. Some surnames have been omitted due to privacy concerns.
CARLOS AGUIRRE-VENEGAS, 30
Died: Oct. 10, 2014
Carlos was deported six times before he was incarcerated for illegal reentry. “Nothing at all could keep him away,” said Berenice Venegas, his wife and the mother of their three children.
NESTOR GARAY, 41
Died: June 28, 2014
Nestor would never have been placed in a private, immigrant-only federal prison if he’d become a US citizen like his brother Enrique. Nestor’s path to citizenship was derailed after his drug arrest.
PABLO ORAMA, 62
Died: March 24, 2014
Pablo visited the prison clinic multiple times over an eight-month period, complaining of chest and shoulder pain. He was given Maalox and told to avoid spicy foods. He died of heart disease.
JESUS ENRIQUE ZAVALA MONTES, 28
Died: March 1, 2013
More than two years after Jesus’ death, his sister still had no idea why he’d been locked up. “I thought he’d done something terrible,” she said. He was serving four months for illegal entry.
MARTIN LOPEZ CERVANTES, 45
Died: Jan. 7, 2013
“I have been trying…to get this [patient] the care I think he needs,” a doctor at a nearby hospital wrote, “but the treatment has been denied.” The chemotherapy that Martin finally received three days before his death was too late to save him from an aggressive cancer.
LUIS ALONSO ZAMORA VILLA, 31
Died: Sept. 8, 2012
Luis had been placed in solitary after a fight. The prison’s chief psychologist evaluated him without a translator. He hanged himself in the small room.
LUIS B., 39
Died: Aug. 23, 2012
Luis’s body was already cool when staff found him hanging in his solitary cell. The officers assigned to monitor solitary had neglected to perform the required rounds that night.
JUAN CARLOS SANCHEZ-PEREZ, 33
Died: June 22, 2012
An intake questionnaire noted that he’d considered suicide in the past. There is no indication that Juan received any substantive mental-health service. “I assume that they should have given him treatment if he was depressed,” said his brother.
ALEJANDRO GUEVARA-AMAYA, 51
Died: July 6, 2011
“The people who leave here and go to the US…we lose them,” his brother Eduardo said upon learning that Alejandro died in an American prison. “If I had known he was in jail, I might’ve gone looking for him.”
MARTIN ACOSTA, 43
Died: Jan. 31, 2011
His common-law wife Guillermina had planned to follow Martin back to El Salvador after his release from a 30-month sentence for illegal reentry. Instead, in a handwritten will, Martin left his land in El Salvador to her.
LUCIO GONZALEZ PEREZ, 33
Died: Jan. 18, 2011
“Right now, I weigh 120 pounds, when I used to weigh 145,” Lucio wrote in one of many letters to his sister. He would later die from AIDS-related illness.
CLAUDIO FAGARDO-SAUCEDO, 45
Died: Jan. 4, 2011
Described as a jokester, Claudio spent his whole adult life in the US. His family hoped he’d return to Mexico after serving time for crossing the border. Instead, he died from complications of HIV infection.
VICTOR CARNATE DUGAY, 52
Died: May 28, 2009
Victor was often treated only by members of the nursing staff. Even when he was seen by doctors, they missed his serious signs of illness. The delays in care and failures to recognize and properly treat problems likely contributed to his death.
CECILIO V., 37
Died: March 13, 2009
Cecilio was diagnosed with oral thrush, a common sign of HIV infection. But after he refused an HIV test, there’s no indication that medical staff tried to test him again, even as his condition worsened.
REYES G., 36
Died: Aug. 2, 2008
Reyes told prison counselors that he would kill himself. A doctor determined there was no need to put him on suicide watch. He slit his throat while in solitary confinement.
JESUS MARIA RIVAS-PRIETO, 56
Died: May 6, 2008
Jesus complained of abdominal pain. The prison’s medical director said that such complaints should prompt an EKG to check for heart conditions. But the nurse failed to perform the test. Jesus died less than 24 hours later.
FRANCISCO CANCINO-RODRIGUEZ, 33
Died: Dec. 26, 2007
Francisco had a 104-degree fever and had lost 30 pounds in eight months. But a doctor wondered in notes whether he might be on a “hunger strike.”
LESAGE PETIT FRERE, 47
Died: Sept. 4, 2007
Lesage was often treated by LVNs. A doctor who reviewed his file described him as a high-risk patient with severe hypertension and chest pains who should probably have been sent to a hospital.
ADALBERTO MELERO-GALLEGOS, 56
Died: Nov. 20, 2006
Adalberto died of liver failure. Despite his deteriorating health, there is almost no doctor involvement in his care documented in Adalberto’s medical records.
JAVIER R., 53
Died: Oct. 19, 2006
Javier, a patient with HIV, received what a doctor called “haphazard” care, including a barrage of antibiotics without a clear target and the termination of part of his HIV-drug regimen.
JAVIER MENDOZA-VARELA, 43
Died: Feb. 18, 2006
Javier had been treated for illness and appeared at the clinic reporting that he was dizzy and had vomited blood. He needed immediate attention, but a transfer to a hospital appears to have been delayed.
ALEJANDRO ROJAS, 45
Died: Dec. 26, 2004
After Alejandro collapsed from a heart attack, it took more than an hour to transfer him to a hospital.
JUAN ANGEL ARIZMENDEZ-MARTINEZ, 52
Died: Dec. 15, 2004
Juan Angel showed signs of a previous heart attack, but he was not provided with standard preventive treatment. When he collapsed face-first from an apparent heart attack, officers did not immediately begin CPR.
DANIEL GOMEZ-HERNANDEZ, 23
Died: Oct. 13, 2004
Daniel complained repeatedly of being cold and vomiting. Nurses took his vital signs and found that his heart rate was unusually high. After two days, Daniel was finally transferred to a hospital, where he died of heart failure hours later.
RONALD H., 39
Died: June 19, 1998
After Ronald tested positive for HIV, treatment began. The records suggest that he was experiencing HIV-related neurological problems, but medical staff assumed he was mentally ill. He was not transferred to a hospital until it was far too late.