Illustration by Joe Ciarediello.

On April 16, 2020, Officer Preston Panana walked up to Joleen Nez at the corner of Texas Street and Zuni Avenue in Albuquerque. Nez was living in a nearby encampment in a neighborhood known as the War Zone, along with dozens of other unhoused Native Americans. About six months pregnant with her fifth child, Nez, who is Navajo and Zia Pueblo, was getting her meals at the Albuquerque Indian Center, where she’d known some of the staff for years.

Panana was with four other police officers when he heard Nez and a man arguing. As the two quarreled, the man set a paper cup and bowl down on the sidewalk, and Nez knocked them over. That’s when, as Panana wrote in the incident report, he advised her “to pick up her litter and of the consequences if she did not.”

Nez had just started walking away, but she turned back and grabbed the bowl. Panana told her the cup was still on the ground. “It’s not my trash,” Nez said. “It’s his.” That didn’t matter to Panana, who cited Nez for littering.

That ticket kicked off a series of events that would end less than a year later with Nez’s death. She would become one of the eight people to die in the Bernalillo County Metropolitan Detention Center in a five-month period. The story of her death reveals a system of brutality that extends from the police to the jails to the medical providers and can be especially dangerous for those without stable homes.

Joleen Nez was born in Santa Fe, N.M., in 1982. the eldest of three daughters, she grew up in her grandmother’s home on the west side of Albuquerque. Gordon Joe, a cook at the Albuquerque Indian Center, told me he remembers living on the downtown streets with Nez’s mother in the 1980s. Nez and her youngest sister, Kayleen Medina, used to call him Dad, and he stayed in touch with their mother until her death in 2012.

When she was 21, Nez became the first of the sisters to leave home. Medina said that Nez had always wanted to travel, and so she went “all along the West Coast, from Seattle all the way down.”

In 2003, Nez married a Navajo man named John Kelly and moved with him to Scottsdale, Ariz. They had two daughters, but in 2009, Kelly died from cirrhosis of the liver. Like her husband, Nez had been struggling with alcoholism, and after his death, she and her daughters moved back to Albuquerque. There, she met Jason Howell. The two were friends on the streets for a while and would talk about seeing the world beyond Albuquerque together. But they fell out of touch after Howell enrolled in a rehab program. When he finished, Howell saw Nez’s photo in the newspaper, alongside an article saying she was incarcerated. He began writing letters to her, and when Nez got out, the two started seeing each other and married in 2012. They had a son but were divorced within a year, Howell told me; the two were on different paths with their sobriety. But they remained close and raised their child together. Howell would come to think of two of Nez’s other children as his own—her eldest daughter and the now 1-year-old son, Elias, that she was pregnant with when police stopped her on the corner of Texas and Zuni.

On that spring day when Nez encountered Panana, she gave him the address of the Albuquerque Indian Center because she didn’t have an address of her own. That meant that when the Bernalillo County Metropolitan Court mailed her a summons, it was returned to sender. When Nez didn’t appear at her first court date on May 19 and then at a rescheduled hearing on June 3, the court put out a warrant for her arrest.

That July, Nez gave birth to Elias, her fifth child, and decided to get sober. She’d been scared and hadn’t told many people that she was pregnant, but after she gave birth, she talked to her eldest daughter, who was living with Howell. Nez’s ex-husband stepped up to help take care of Elias, and Nez looked up rehab programs. By September 25, she was 65 days sober and enrolled at the Mountain Center, an outdoors education program with transitional living and counseling services on the Tesuque Pueblo in northern New Mexico. At the facility, Nez posted photographs of herself smiling under the azure sky. “I cannot remember the last time I was really HAPPY and PROUD of myself,” she wrote on Facebook the day she successfully walked the center’s tightrope course. “I’m starting to feel and see things differently…. I’m walking in beauty.”

When she returned to Albuquerque in November, Nez focused on maintaining her sobriety. Howell told me she had done the best recovery work at rehab that he had ever seen from her. “We really had a good feeling that she was really going to make it and change,” he said. “Everybody was very proud of her.” But in late January 2021, she ran into a police officer. Howell and Gordon Joe heard that she was at the scene of a fight that broke out at the Circle K across the street from the Indian Center. The Albuquerque Police Department said it had no available records clarifying what had happened and did not respond to requests for comment. The only document the Metropolitan Court had on file for Nez shows that an officer served her the outstanding warrant and, on January 29, booked her into the Metropolitan Detention Center.

In 1995, detainees at the jail—then known as the Bernalillo County Detention Center—filed a class-action lawsuit alleging that the conditions there, specifically overcrowding and racial discrimination, violated their constitutional rights. The lawsuit, McClendon v. City of Albuquerque, took its name from one of the detainees, Jimmy Lee McClendon, who’d scratched his eye while unsupervised in the jail’s psychiatric unit and developed an eye infection that spread to and scarred his face. At the time, the county jail, which was then in downtown Albuquerque, sometimes housed more than 900 inmates in a space designed for less than 600.

Peter Cubra, a civil rights lawyer and longtime advocate for people with disabilities in New Mexico, was one of the attorneys representing McClendon. He said that one reason the jail was overcrowded was because, “in the mid-1990s, the city of Albuquerque and the county of Bernalillo had a custom and practice of sweeping the streets of people who were looked at as nuisances or vagrants—and that included people experiencing homelessness and people with psychiatric problems, people with substance abuse problems.”

Cubra and nearly 30 other attorneys claimed that the city and county were violating the Americans With Disabilities Act and the Rehabilitation Act by arresting people because of their developmental and psychiatric disabilities and, “while incarcerated, denying them minimally adequate care,” Cubra said.

McClendon slowly wound its way through the courts over the next two decades, with the county attempting but failing to reduce the jail’s population and eventually constructing the new Metropolitan Detention Center in 2003. The court issued a consent decree ordering experts to inspect the still-overcrowded facility throughout the 2010s.

But in the mid-2010s, Cubra and the other attorneys for the plaintiffs realized that the city was still arresting and incarcerating people experiencing homelessness and people with disabilities. They filed a motion to hold the city and county in contempt, which was eventually denied but laid the groundwork for a settlement agreement concerning the city’s arrest procedures in 2017.

That deal included a “court order that said to the police department and the sheriff’s officials that they shouldn’t be arresting people because of their disability” and that explicitly prohibited “arresting someone solely on the basis that they didn’t have a permanent address,” Cubra said. But after that reform, he continued, the city and the police adopted a new tactic: Instead of arresting people, the cops would write them tickets.

While the policy meant that police weren’t “handcuffing and taking to jail as many people numerically as they had been in the past,” Cubra explained, they “were issuing citations to individuals for things where other citizens would never receive a citation,” such as for jaywalking or littering. In 2020, 34 percent of the citations issued by police were for littering on public property and no other crime, according to reporters at the Daily Lobo, the University of New Mexico’s student newspaper, who reviewed the city’s data.

For people who won’t be able to appear in court—because they lack either an address at which to receive a summons or the developmental or mental health capacity to attend a hearing—“issuing those citations is nothing more than a slow-motion arrest,” Cubra said. Instead of arresting someone on a petty charge, police did so for not showing up in court. Since the 2017 settlement, Cubra said, the Bernalillo County Metropolitan Court has issued “hundreds and thousands of bench warrants” regarding “offenses for which no one would be incarcerated” but that mandate “that the person be arrested, taken to the jail, and kept in the jail until they appear before a judge.”

When Nez was booked into the Metropolitan Detention Center, she disclosed that she had recently consumed alcohol and used heroin, according to an internal investigation by the jail. (A toxicology report performed after her death would list methamphetamines, not heroin, in her system. All of her friends and family that I spoke with maintain that although she was an alcoholic, they’d never seen her use hard drugs.) She was assigned to a detox unit, and by the time she’d gotten settled on her mattress, it was 1:18 am on January 30.

Over the course of the next 10 hours, Nez would vomit 43 times. At 7:42 that morning, medical staff stopped to check on her, speaking to her for only about 30 seconds. Nez talked to medical staff again at 8:26, 8:54, and 9 am, for a total of about five minutes. The people really caring for Nez were a few of the dozen other women in the detox area, who took turns bringing her water and rubbing her back.

One of those women was Autumn Brown, who knew Nez from being incarcerated together in the past. That day, Brown was working as a porter in the cell, distributing trays of food, and had heard that medical staff had given Nez detox medication—but that she had thrown it up.

At 11:25 am, one of the women in the cell brought Nez a cup of water, and Nez curled up in bed under her blanket. When Brown and another porter, Tabitha Grim, began passing out lunch trays around 11:40 am, Grim tried to wake Nez up. When she wouldn’t stir, Grim pulled back her blanket and face mask—and saw that she had gone blue.

Grim immediately called for help. She was quickly joined by another inmate and then a correction officer, Destiny Cacho, who radioed for help. Within a minute, a third inmate began performing CPR. Brown said this wasn’t her first time seeing an inmate perform CPR on another: “There had been a couple other instances where [Grim and I] had found girls unresponsive [and] had to do lifesaving measures.” She recalled feeling grateful that when officers Cacho and Esmerelda Perea took over CPR, Cacho performed rescue breaths. Many of the other correction officers, according to internal reports, had declined to do so, citing the ongoing Covid-19 pandemic.

By 11:45 am, EMTs from Centurion, the jail’s medical provider, had arrived on the scene, and correction officers were beginning to move the other women out to the recreation yard. Brown said that she and the others sat outside for three hours, waiting to find out what had happened.

Inside, the Centurion EMTs were continuing CPR. Forty-six minutes after Grim called for help, they were able to restart Nez’s heart and loaded her into an ambulance bound for the University of New Mexico Hospital. “She was alive, breathing, conscious, and speaking when she was at UNMH,” Metropolitan Detention Center spokesperson Julie Rivera told the Daily Lobo. When I contacted the detention center, it referred me to the hospital, whose only comment was to confirm that Nez’s case had been handled as an in-custody death.

No one had yet noted that a judge had dropped the charges against Nez at 10:54 that morning.

While Bernalillo County was trying to reduce the population at the Metropolitan Detention Center, the jail’s medical provider faced accusations of neglect and concerns about its significant campaign contributions to politicians.

In 2016, a Tennessee woman sued Centurion after nurses and a doctor ignored her labor pains for four hours, resulting in her giving birth in her prison cell without pain medication or a qualified ob-gyn. More recently, between December 2019 and August 2020, at least 53 people died in the Mississippi prisons serviced by Centurion, and 227 people incarcerated at Parchman Prison sued the company. Centurion would terminate its contract with Mississippi early, citing the state’s unwillingness to invest in the prison system. Earlier this year, the Justice Department announced that Centurion had agreed to a $215,000 settlement for violating the Controlled Substances Act while operating in New Mexico. The company had been distributing controlled substances at the Northeast New Mexico Detention Facility after its DEA registration had lapsed, and it had failed to maintain proper records.

Centurion and its parent company, Centene, also have a long history of donating to political campaigns, as documented by the Center for Responsive Politics and Follow the Money. In Florida, Centene donated $125,000 to Governor Rick Scott’s political committee in 2017 and $35,000 in 2014; it took over the state’s prison health care in 2016. In Mississippi, after a $50,000 contribution to Lieutenant Governor Tate Reeves, Centene became “the biggest donor of the highest fundraising Mississippi official in 2017,” according to the Clarion Ledger. And in Tennessee, the state’s Department of Corrections had to rebid its medical contracts after Centene’s competitor Corizon filed a lawsuit claiming that the department’s former chief financial officer sent internal e-mails related to the contract to Centurion. In return, the lawsuit states, the financial officer “got a ‘cushy’ job with a Centurion affiliate in Georgia.”

In New Mexico, the Albuquerque Journal reported in March that eight people had died at the Metropolitan Detention Center between August 31, 2020, and January 31, 2021, when Nez died; half of those deaths, the paper found, were related to drug or alcohol detoxification. Before 2020, there had been only 10 deaths at the center in the previous four years. Spokesperson Rivera acknowledged to the Journal that the detention center was understaffed: The jail’s plan calls for 476 employees, and there are currently 375.

Staffing problems have been a lingering issue for Centurion as well. Between 2016, when the company began operating in Santa Fe, and 2018, the Department of Corrections fined Centurion a total of $2.1 million for staffing shortages. On online job boards, nurses across the country complain of overwork and high turnover. (Centurion blames the understaffing on low state budgets.)

Meanwhile, Joseph Trujeque, the president of the Corrections Officers Association, directly called out Centurion’s policies in New Mexico. Although he did not respond to my requests for comment, Trujeque told the Albuquerque Journal that Centurion was often slow to respond to crises, and “when the medical professionals got there, they weren’t taking over right away. That put the burden on the officers.”

Albuquerque-based attorney Parrish Collins has filed at least 23 lawsuits against Centurion, largely involving medical neglect. He told me he sees many cases involving diabetes or spinal injuries, where inmates face retaliation for filing medical grievance reports and must wait until their health deteriorates to file a lawsuit to get care. “It’s beyond gross negligence,” Collins said. “It’s deliberate denial of basic medical care, and we get calls every day” from people asking for help.

When her ambulance arrived at the University of New Mexico Hospital, Nez was taken to a trauma room where doctors worked to save her life. Although the hospital asked jail staff repeatedly for her next of kin’s contact information, they had no one listed for her. Eventually, doctors got in touch with Howell, who brought Nez’s eldest daughter and son with him to see her at the hospital. On his drive over, Howell also picked up her sister Kayleen Medina, who was pregnant and staying in a shelter at the time. When they arrived at the hospital, Nez’s family was told that her son was too young to go up to her room because of the Covid-19 protocols—so Howell and Medina took shifts sitting with him in the waiting room while the others went to see her.

“We were up there most of the night,” Howell recalled, adding that he later had to drive Medina back to the shelter, so he spent several hours sitting in his car with his son, talking with his daughter by video while she sat by Nez’s bedside.

The next morning, doctors declared Nez dead. Although internal reports show that the jail believed she was detoxing from heroin and alcohol, neither was found in her system in the blood tests that the hospital—and then the coroner—performed. An autopsy report found that Nez had died from “the toxic effects of methamphetamine.” The report also noted that she’d suffered multiple heart attacks and that her brain had herniated, swelling until it shifted out of place—symptoms that Karen Kelly, a forensic pathologist and medical expert with Physicians for Human Rights, told me were likely a result of the attempts to resuscitate her and how long she remained unresponsive.

In an internal investigation, the jail would conclude that “there was no indication of danger to inmate Nez that set her apart from any of the other inmates going through detoxification.”

After the Daily Lobo broke the news of Nez’s death, local organizations, including the Coalition to Stop Violence Against Native Women, began calling for an investigation into the jail and local police. “We know Native women experience all forms of violence, and that unsheltered people experience heightened violence particularly at the hands of the police and state,” the coalition wrote in a press statement. “Native people are [more] likely to be murdered by law enforcement than any other minority group in the United States.”

Meanwhile, after the public defender’s office reported Nez’s death at a monthly meeting of the Criminal Justice Coordinating Council, Cubra told me, the council began reevaluating the city’s use of bench warrants. “Informal rules have been promulgated in the Metropolitan Court that require that when a person fails to appear on a petty offense, [the court] will have [its] staff check and see if the person’s got a history of having these petty charges brought and then have the cases dismissed, because a person’s mental disability renders them incompetent to stand trial,” he said. The hope is that if judges do not issue bench warrants in cases that will likely be dismissed, police will not be able to arrest and incarcerate people on minor charges. But, Cubra added, “police officers continue to issue these citations.” The Albuquerque Police Department did not respond to my requests for comment about this policy.

Cubra told me that he has asked the APD to issue an order to officers “that explicitly says if it appears to you that the individual is homeless and/or psychiatrically impaired, that you absolutely don’t issue citations for them at all for petty misde fmeanors.” He said the chief of police agreed with the idea, but “it’s never been done.”

In the absence of that police order, Cubra said, the Criminal Justice Coordinating Council suggested that in cases of petty misdemeanors, police should refer people to the new Community Safety Department. Formed in the wake of the police brutality protests that followed George Floyd’s killing, the CSD launched this September with teams of civilians trained to respond to mental health, substance abuse, and homelessness issues. The aim, Cubra said, was to hand cases like Nez’s “over to someone who can’t put them in jail.” But Cubra told me that the APD again said, “‘Great idea, we’ll surely do that,’ and it’s not been done.”

At the Metropolitan Detention Center, the Office of Professional Standards conducted an internal investigation into Nez’s death and concluded that “MDC staff who responded to this incident, and were directly involved, responded appropriately and within MDC policy.” Yet one correction officer noted that he wished the jail had additional Narcan on hand for emergencies. (Although Nez was not withdrawing from heroin, that was what jail staff believed at the time.) And two inmates, including Autumn Brown, said that staff had refused to give Nez rescue breaths while performing CPR and weren’t trained to recognize the signs of an overdose. Brown told me that after she raised her concerns with jail staff, they retaliated by placing her in solitary for the next several months as she awaited trial. When she spoke with me, she said that she was doing so “because I feel like Joleen and all the other inmates that have died in there just really do deserve for everybody to know what’s going on.”

In April, just a month after the Albuquerque Journal published its story on the spike in in-custody deaths, Centurion announced that it would be leaving Bernalillo County in October—more than a year before the end of its contract. But the county chose a new medical contractor, Corizon, that Cubra said has “a long, unhappy history of denying adequate care to people in the state prison system.” In fact, in 2016, Centurion replaced Corizon in New Mexico after one of Corizon’s former doctors, Mark E. Walden—nicknamed “Dr. Fingers”—was sued for allegedly sexually assaulting at least 77 prisoners.

Almost a year after Nez’s death, her family, especially her two eldest daughters, still don’t know why the detention center didn’t get her help sooner or implement changes after seven others had died there in the months before she did. The family has hired an attorney to find out more, but Howell told me nothing will bring Nez back to her children. “She loved being with her kids,” he said. “It’s a sad thing she won’t be a part of growing up with them.”