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Story Publication logo February 1, 2021

They Called for Help. They’d Always Regret It.

An armed guard surveys the grounds from the railing of a prison watchtower. Image by RealWindowCreative/shutterstock. Undated.

A five-article investigative series looks into the longstanding epidemic of preventable deaths in U...

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Diana Zuñiga holds up a family photo taken at Terminal Island federal prison the day Carlos's dad was released after nearly 10 years in custody, and shortly before he was arrested and taken to Twin Towers Jail. Image by Arlene Mejorado/The Atlantic. United States, undated.
Diana Zuñiga holds up a family photo taken at Terminal Island federal prison the day Carlos's dad was released after nearly 10 years in custody, and shortly before he was arrested and taken to Twin Towers Jail. Image by Arlene Mejorado/The Atlantic. United States.

When Antonietta Zuñiga woke up to smoke pouring through her bedroom window, everything she had learned about how to care for her grandson completely left her mind. It was November 2019, in the Los Angeles County city of Pico Rivera. Antonietta’s grandson, Carlos Zuñiga Jr., is schizophrenic; she had the number for ACCESS, L.A. County’s mental-health hotline, taped to her fridge for moments precisely like these. But she knew they were vastly underfunded, and it might take days for them to respond.

Frightened and half-asleep, Antonietta picked up her cell phone and dialed 911. About 10 police cars showed up, she says. When they arrived, she recalls, she told the police that Carlos had been off his medication for weeks and refusing to come inside. He’d been collecting trash in the backyard and had set some on fire to warm himself. “He doesn’t do anything because he wants to do it,” she remembers telling them. “He’s doing that because he’s sick.” Even so, Carlos was taken to jail.

Five months earlier and about 400 miles northwest, a similar scene had played out in the Bay Area city of Fremont. Police officers arrived at the door of Jose Jaime and Gabby Covarrubias, responding to a 911 call for help with their 20-year-old son, Christian Madrigal. “He needs to go back to the clinic,” Jose, Christian’s stepfather, says he told the police. “Something bad has happened in his mind.” Two weeks earlier, Christian had tried hallucinogenic mushrooms for the first time, and he hadn’t been normal since. “When you looked him in the eyes, he was not our boy,” Jose told me. “His eyes were different. His face was different. Everything was different.”

Jose said when the Fremont police arrived, they called for backup and ordered that Christian be brought outside. There, they arrested him for being under the influence of a controlled substance, although his parents maintain that he hadn’t used any drugs since he ingested the mushrooms. When they led him outside the house, Christian began crying out to his mother for help. She and Jose stood by in shock, not knowing what to do.

Carlos and Christian weren’t just unlucky. They’re representative of a decades-long pattern of filling up jails with mentally ill people. When policy makers began closing state-run psychiatric hospitals in the 1950s, they promised to replace them with localized mental-health care—but in most places the funding and political will required to make this happen never materialized, leaving large swaths of the U.S. without any options for those seeking treatment. A conservative estimate says 900,000 people with mental illness end up in our jails every year. “These are people who are not necessarily intending to perform criminal acts,” Christine Montross, a psychiatrist and author of Waiting for an Echo: The Madness of American Incarceration, told me.

The moment their family members called 911, both Carlos and Christian became unwitting players in a system that is massive, complicated, and, according to many experts, manifestly broken. Both families would come to regret the decision to call the police for help, and Christian would not survive. “We were blind to the fact that something could happen to our son in that jail,” Jose told me. “Completely blind.”

Christian Madrigal was shy and disciplined, and he cared about the world’s problems. At 16, he stopped eating meat out of concern for the climate crisis. When his family ate at restaurants, he would order extra food and give it to homeless people on his way out. When Christian wasn’t playing sports or working out, he liked to snuggle up next to his mom on the couch, taking selfies they would decorate with puppy ears and post on Instagram.

But since he’d taken mushrooms, his bad reaction seemed to grow worse each day. He would stare blankly and say nothing for hours, then he would begin weeping, destroying his belongings, and begging to visit his extended family in Mexico. Finally, Gabby relented and bought Christian a plane ticket, but when they arrived at the airport, he broke away from her, charging through the security checkpoint. In the ensuing scuffle with TSA officers, Christian was tased and then taken by ambulance to the emergency room. He was briefly taken to Santa Clara County Jail before being readmitted to the hospital.

A day later, the psychiatric emergency room at Santa Clara Valley Medical Center discharged Christian. If he gets worse, Jose remembers the nurse saying, call 911. Ask the police to 5150 him, they’ll bring him back. (Section 5150 of California’s Welfare and Institutions Code allows the police to commit someone to a psychiatric hospital involuntarily if they present a danger to themselves or others.)

But Christian’s distress continued. His family tried everything they could think of to calm him, but after two sleepless nights decided to call 911. Christian was not a danger, Jose reassured the officers, but he was worried that the mushrooms had triggered a mental-health issue. But the officers didn’t take Christian back to the clinic. First, they took him to Fremont Jail. After only a few hours there, he was transferred to Alameda County’s Santa Rita Jail.

Santa Rita is a mega-jail, the fifth largest in the nation and bigger than most of California’s state prisons. Many of the prisons and jails I’ve visited are loud, with shouting and the clanging of cell doors, but when I went to Santa Rita last October, it was eerily quiet. Long, windowless corridors seemed designed to disorient. A robotic cart system made even the food service impersonal.

COVID-19 has drawn increased attention to overcrowding and unsafe conditions in jails nationwide, but there’s no evidence that anything has changed in response. At full capacity, Santa Rita can house roughly 3,500 people. Early in the pandemic, the Alameda County Superior Court ordered the sheriff, Gregory J. Ahern, to release as many incarcerated people as he safely could in order to protect those inside from the virus. The jail’s population dropped by about a third—but since then, it’s been steadily rising again. While on average two-thirds of people in the state’s local jails have not been tried or convicted, and are therefore legally innocent, in late 2019 Santa Rita’s number was 84 percent—among the highest in the state. With courts clogged during the pandemic, it’s gone up to 94 percent.

“Our jail was designed to do incarceration,” said Ray Kelly, the public-information officer at the Alameda County Sheriff’s Office, after he had welcomed me to Santa Rita and handed me my PPE. “It was never designed to be a mental-health facility.” Yet a conservative estimate says that half of Santa Rita’s prisoners have mental illnesses, with an even higher number suffering from substance-use issues.

Ahern has his own vision of Santa Rita’s purpose. In a phone interview two weeks before our tour, he described his role as that of a sheepdog, tasked with watching over the community. “The sheepdog has to look after the sheep, to protect the sheep,” he said. “A sheepdog is very much aware that there are wolves out in the community. The sheepdog is responsible to apprehend those wolves and to see that they’re treated as wolves, and not as sheep.”

But legally, those “wolves” are entitled to a certain standard of treatment. Dozens of people currently and formerly incarcerated at Santa Rita have sued the jail, claiming that the people incarcerated there are hungry; that the food is so overcooked it’s inedible; that the cell walls are stained with body fluids, hair, and feces; that arbitrary, long-term isolation is routine; that preventable deaths are rampant. Lisa Fernandez, a reporter at the Bay Area’s Fox affiliate, KTVU, has been tracking every autopsy report: In the past seven years, at least 48 people have died in Santa Rita—a higher death rate than at any other jail in the San Francisco Bay Area. (The death rate in California jails is significantly higher than in the rest of the country.) Seventeen of those deaths were suicides. In 2019 alone, 10 deaths occurred, the most since 2014. Several wrongful-death suits have been filed, claiming excessive force.  

Another long corridor leads us to the Intake, Transfer, and Release lobby, which I immediately recognize from body-cam footage I’ve now watched numerous times. In the video, two officers carry Christian into the building like you would carry a bench or a slab of wood. His face is obscured by a spit mask made of nylon mesh. His hands are cuffed and chained, and his legs are wrapped together tightly with a restraining device. They place him on the floor, and eight or nine more deputies enter and form a circle around him, chatting among themselves. “He’s not answering questions,” one of the officers had said earlier. “He’s playing the game. He’s been here before, eh?”

He hadn’t. Until recently, he’d never had an interaction with the police, good or bad. Jose knew that as Latino men, he and his sons could be targets, so he advised them to always play it safe. “If the cop says dance, you dance,” he told them. “And if the cop says don’t breathe, you just don’t breathe. You do whatever the cop tells you to do.”

In the body-cam footage, Christian is unresponsive to the deputies’ questions, but he doesn’t resist or defy orders. Did he know where he was? Was he hearing voices? “When people are what we call ‘internally preoccupied,’ they’re not going to be able to follow instructions,” Christine Montross said. But in a jail, not responding can be interpreted as disrespect.

At Santa Rita, I asked Kelly to take me to cell R-1. The cramped, windowless space contained a steel sink and toilet and a concrete bench. I immediately scanned the cell door for the food slot, which played a large part in Christian’s death.

In the video, a few deputies stand in front of cell R-1, casually debating how to get Christian out of his restraints. Christian lets out an anguished cry. “He’s probably seeing music,” one officer jokes a few minutes later. “Or tasting colors,” adds another. They’ve been told about the mushrooms.

Christian remains limp as deputies prop him against the cell door and remove the device wrapping his legs. Next, they nudge him into the cell, with his spit mask, handcuffs, and chain still attached. The lieutenant in charge, Craig Cedergren—who, through his attorney, declined to comment—instructs his deputies to leave Christian’s cuffs on, feed the chain through the food slot, fasten it outside the cell, and close the door. The deputies are visibly uncomfortable with the order.

From outside the cell, a Spanish-speaking deputy tells Christian to bend down and let them unfasten the cuffs though the slot, but Christian just says he wants to go home. Cedergren then tells them to leave him like that, chained to the cell door. According to an internal investigation by the sheriff’s office published a few weeks later, Cedergren told the deputies, “I’ve done this a hundred times before. It’s not a problem.” In an email, Cedergren’s attorney told me that “Lt. Cedergren’s decision making was not unreasonable, was based on both training and past experience, and was not countermanded by the Jail watch commander.”

Alameda County policy states that all other means must be exhausted before the use of “extraordinary restraint.” In cases where it’s deemed necessary, only a restraint chair can be used. At the time, the policy mandated that the restrained person be checked on every 15 minutes. Accounts vary, but Christian wasn’t checked on for between 30 and 40 minutes. Footage from the security camera shows Christian struggling inside his cell. At 5 p.m., all movement stops. He had contorted his body until the chain attached to his cell door was wrapped around his neck, causing asphyxiation. He died five days later at Eden Medical Center.

The policies and practices of Carlos Zuñiga’s county would prove slightly more forgiving. Growing up in Riverside, a few suburbs away from his grandmother’s house in Pico Rivera, he had loved to draw complex geometric shapes and read about space travel. “But ever since [the voices] started,” Carlos told me when we spoke last summer, “I lost my hold on my life. It caused me to not care anymore. Sometimes I just want to die.” At age 13, with his father in prison, Carlos ran away from home—the first of many times. While living on the streets for a few months, he tried meth, which he found calmed the voices. At 19, Carlos was diagnosed with schizophrenia, and he moved in with Antonietta.

The night Carlos was arrested, his family said, police charged him with residential arson—a sentence that can mean up to eight years in prison—and took him to Twin Towers Correctional Facility, one of several specialized facilities that make up Los Angeles County Jail, this one with a population composed almost entirely of men with mental illness.

The next day, Antonietta called her granddaughter—Carlos’s cousin—Diana Zuñiga. Diana works for the county, and she’s a leader in the movement to close jails in Los Angeles and create alternatives. She has advised dozens of families on how to navigate L.A.’s complex systems of jail diversion and mental-health care.

Diana grew up in a community gutted by incarceration, with many people she loved spending time in Twin Towers or in nearby Men’s Central Jail. She told me that most of her male relatives have been held in the L.A. County Jail system. “My family members experienced violence in that place,” she said. Almost a third of L.A. County Jail’s population suffers from mental illness, including nearly all of the inmates at Twin Towers, which is larger than Santa Rita. In 2019, Diana became a co-chair of the Alternatives to Incarceration Work Group, set up by the L.A. County Board of Supervisors to determine how to redirect resources from jails to community services like housing, substance-abuse programs, and mental-health care.

In early 2020, the work group’s plan was adopted by the board of supervisors. When COVID-19 hit, many of their recommendations were rapidly implemented, and 6,000 people were released. Still, with its population lingering around 12,000, L.A. County Jail remains critically overcrowded.

Carlos describes Twin Towers as being like a construction zone: Everything looks the same and smells like dust. For the first two months, he told me, he was given no clothes—just a mat-like garment to cover himself, used for inmates who are considered suicide risks. “We were naked and they had roaches and the toilet didn’t flush,” he said. (The L.A. County Sheriff's Department took issue with that characterization of Twin Towers Jail, and stated in an email that “inmates are only kept inside cells in good working order.”) After COVID-19 hit the jail system and he became terrified of catching it, Carlos tried to keep to himself. “I was having wicked visions of being incarcerated for a long time,” he says. “I would have thoughts about committing suicide.”

By the time Carlos got to Twin Towers, the L.A. County Board of Supervisors had already decided they were in agreement: People shouldn’t have to go to jail to get treatment for mental illness.

In 2015, the county had opened the Office of Diversion and Reentry, with the goal of identifying “appropriate candidates for diversion” and getting them out of jail. Peter Espinoza, a retired judge and ODR’s director, told me that the office has diverted close to 6,000 people into community-based services over the past five years. “That includes their housing, their medication, their treatment, and their therapies and whatever else it takes to stabilize [them] in the community,” he said. ODR makes this commitment, if necessary, for life. The good news, Espinoza said, is that community beds are much cheaper than jail beds, costing approximately $40,000 per year, versus $219,000 to care for a mentally ill person in jail.

Carlos spent five months at Twin Towers before his cousin’s efforts finally paid off. On March 24, he was approved for pre-plea mental-health diversion into SSG Alliance, an in-house facility. He now shares a kitchen and a living room with more than a dozen other people. He’s required to do chores and attend biweekly group-therapy sessions, and staff check on him every hour. It’s boring, Carlos told me, and he wishes more young people lived there. But he’s relieved to be out of jail, and his family is relieved that he’s getting treatment.

In November, L.A. County voted to pass Measure J, allocating 10 percent of the county’s $8.8 billion annual budget to diversion initiatives, like alternative crisis-response teams and expanded bed capacity in mental-health treatment centers. “I don’t think we just created a plan,” Diana told me. “I think we created community and shifted culture, in a place that doesn’t normally lift up the voices of people like me and my father and my family that have been impacted by incarceration.”

Nearly 18 months after Christian’s death, I asked Ray Kelly, the public-information officer, whether the Santa Rita Jail had learned anything from its striking rates of suicide and violence. His answer was vague: “Conversations have taken place,” he told me, and deputies are now being told to “question their superiors” when they’re given an order they believe might fall outside jail policy. “The county jails are left holding the bag because our communities don’t have anywhere else to put these people.”

On that point, Kelly is right. Santa Rita, like all jails, is mandated by law to incarcerate whomever they are sent. Alternatives to jail and services for mentally ill people in Alameda County are critically insufficient. Most of the county’s mental-health facilities only house people for a day or two at a time, and are so overpopulated that they regularly turn people away.

Arguably, the onus to fund these services is on the Alameda County Board of Supervisors. But instead of increasing funding for mental-health services in communities, the board is funding them in jail: Last May, it agreed to provide up to $106 million annually to hire more guards and mental-health staff at Santa Rita. John Lindsay-Poland, of the advocacy group Decarcerate Alameda County, told me he questions whether hiring more staff will solve the jail’s problems, pointing out that “nearly a dozen deputies were present when the decision was made to chain Christian to a cell door.” Kelly responded, “When you don’t have enough jail staff and mental-health staff, you will have an increase in suicides, behavior-health issues, and lack of intervention and help for the patient.”   

Ten months after the order to decarcerate, Santa Rita’s population continues to rise. Even if Alameda County did have the beds needed to care for its mentally ill population outside the jail, the current diversion programs wouldn’t be nearly robust enough to fill them. An ACLU study shows that a mere 5 percent of the 36,572 people arrested in Alameda from 2017 to 2018 were referred to diversion.

On June 17, 2020, a full year after Christian died, the Alameda County district attorney, Nancy O’Malley, released a report that found there was insufficient evidence to file criminal charges against Lieutenant Craig Cedergren and the deputies involved in Christian’s death. When asked for comment on why she didn’t recommend that Christian’s case go to trial, O’Malley told me, “The sheriff’s department had serious issues, [but] in our professional opinion and evaluation of the law they did not support criminal charges.” (A few days after Cedergren learned that the department intended to fire him, he retired.)

Christian’s death wasn’t counted as an official “in-custody” death by Santa Rita Jail, because he died at Eden Medical Center. His parents were paid $5 million in the wrongful-death suit they filed, the largest settlement payout in Alameda County since 2015. Jose and Gabby plan to give some of this money to the nurses at Eden, who fought for five days to save Christian’s life.

Christian’s death didn’t spark national protests. His two younger brothers have moved to Mexico, where they feel safer, but Gabby and Jose remain in Fremont. Their family is divided, their faith in the system shattered. “Six months, a year, you’ll be interviewing someone else because their son passed away in that jail,” Jose told me. He still fantasizes about how things could have gone differently: “If I would have manned up and punched that officer, I could have been taken to jail and protected my son,” he told me. “He probably would still be here.”

For Carlos, having a cousin like Diana in his corner meant everything, but he still feels traumatized by his experience in jail. He has been at the facility in Los Angeles for eight months, and he can’t see his grandmother because of the pandemic. He admitted to me that the program is helping him and he’s glad the voices have gone away, but his future is still uncertain.

Meanwhile, death rates—especially suicide rates—in American jails continue to rise. The pandemic could have been used as a chance to rethink how our mentally ill population is cared for, but for now, most people sucked into the system are at the mercy of forces outside their control, and diversion opportunities remain rare. “Things are starting to shift in places like L.A.,” Insha Rahman, the vice president of advocacy and partnerships at the Vera Institute of Justice, told me. “We see one, great outcome for the Zuñiga family, but they are an outlier … That option of finding an alternative to incarceration is still few and far between.”

This article was originally published on the website and is republished here with The Atlantic's permission.

This article is part of the project “The Cycle,” which is supported by a grant from the John D. and Catherine T. MacArthur Foundation’s Safety and Justice Challenge.

Support for this article was provided by the Alicia Patterson Foundation and the Pulitzer Center. Additional reporting was done by Jean Casella, Katie Rose Quandt, and Andrew Stelzer; additional research was done by Carter Deane, Alexandra Gibbons, and Tash Nguyen. Listen to Stelzer’s radio component on Reveal Podcast here.


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