BALTIMORE -- On May 31, 2001, in war-torn West Africa, Francess Camara gave birth to a boy while rebel soldiers paraded through the streets of Sierra Leone and gunfire echoed overhead. She named the child Joshua.
A few years later, the family was granted political asylum in America. Along with their three young children, Francess and Yunis Camara left their homeland and moved to California, then Kansas City and finally settled in Baltimore County in 2008. Yunis Camara supported the family by cleaning hotel rooms and working in private security.
Like many immigrant parents, the Camaras wanted to give their children peace and prosperity. But they found new dangers and senseless tragedies in Baltimore, where deadly gunfire has become a near-daily occurrence.
On March 27, Joshua Camara was shot in the head during a daylight attack in South Baltimore.
What followed was a monthslong battle to save his life as the family struggled with two American institutions meant to deliver healing and justice for gun violence victims: a flawed health care system and a beleaguered criminal justice system.
Their odyssey came to a heartbreaking end in July when Joshua Camara died shortly after being transferred to a nursing and rehabilitation center near Silver Spring. The family believes he received inadequate treatment there and they questioned whether gunshot victims often get substandard care because of assumptions based on their race, socioeconomic status or criminal history.
They said Baltimore's homicide rate alone indicates a tragic failure to protect young Black men.
"We left Africa to come here for a better life. You think you're running away from war to peace, but then we come to Baltimore and find another war going on," said Jameselle Dukule, a cousin who immigrated from Liberia in 1997. "As a child, I thought America would be heaven on earth. You don't expect to come here and live in the same fear."
Joshua Camara was shot around 2:15 p.m. that March afternoon in Lakeland, a neighborhood that borders Westport and Cherry Hill.
Two men allegedly assaulted him, then ran behind a house while Camara started walking away, according to Baltimore Police. About a minute later, three people returned with a gun and he was shot, said police, who have arrested three suspects.
Camara was exchanging Instagram messages about meeting someone in the area, records show. Police said Draquan Smith, who faces first-degree murder and other charges, was looking for the victim to get money from him.
Family members said they're grateful police made arrests, but they feel the massive toll of gun violence is overwhelming the criminal justice system in cities like Baltimore, which has reached 300 homicides for the eighth straight year.
"America is the most armed country in the world - and the least secure," Yunis Camara said. "There are so many guns already out there, more guns than people. So how are you gonna change anything?"
Joshua Camara died July 15 - almost four months after the shooting and one week after he was transferred from the Baltimore hospital to Adelphi Nursing and Rehabilitation Center.
His parents believe the quality of his medical care declined after the transfer to Adelphi, which has received low patient care ratings, and they want to know whether his death was preventable.
Joshua Camara had significant brain damage and couldn't speak, but he was breathing without a ventilator and his family remained hopeful he would recover. His parents said he sometimes responded when they talked to him.
A tube inserted into his windpipe helped him breathe, but the tracheostomy required proper care to limit how much mucus was entering his lungs, his parents said.
In the days before his death, nursing staff at Adelphi expressed concern about his condition, including distressed breathing, a fever and pneumonia, according to his parents. But when the staff called for an ambulance, it was too late.
Adelphi Executive Director Alphonson Jones declined to comment, saying company policy and medical privacy laws prevented him from discussing the case.
Joshua Camara's death certificate says he died from complications of multiple gunshot wounds; his death was ruled a homicide.
On May 31, Yunis and Francess Camara celebrated their son's 21st birthday in his hospital room. They sang happy birthday and tied balloons to the IV stand near his bed.
Several weeks later, they were planning his funeral. Yunis Camara visits his grave regularly, often multiple times a day.
Joshua Camara left behind a baby daughter and pregnant girlfriend. He was living in downtown Baltimore and working at a dollar store. Relatives said he embraced fatherhood.
They said their sense of injustice is amplified because they believe better medical care could have saved his life.
After he had been at the University of Maryland Medical Center for about 10 weeks, the family received a letter from the hospital saying Joshua Camara, a Medicaid patient, would "no longer require a stay in an acute care hospital."
His insurance policy would stop covering the cost of his continued stay at the Baltimore hospital after June 7, according to the letter. The estimated cost was $3,103 per day.
"A safe discharge plan has been arranged," the letter read.
Relatives said a Shock Trauma case manager at the hospital presented Adelphi as essentially the only option for ongoing rehabilitation; another possible placement was two hours from Baltimore.
In a recent statement, hospital officials offered their condolences to the family but declined to discuss the case, citing patient privacy.
"However, the discharge process for patients who require care in another facility after their hospital stay involves a team of dedicated professionals who are focused on safe and proper placement," University of Maryland Medical Center spokesperson Tiffani Washington said.
She said the process considers many factors, including clinical needs and capabilities, insurance requirements and family assessment.
The Camaras had been spending as much time as possible with their son, monitoring his care and keeping him company. His father is a certified nursing assistant who's worked in nursing homes, and his mother works in administration at a group home.
At Adelphi, they believe, staff were not checking on Joshua often enough. They said he was supposed to be repositioned regularly to avoid developing bedsores.
When his breathing became more labored, relatives said, they worried fluid was entering his lungs because of the tracheostomy. He tested positive for pneumonia days before he died, his parents said.
About 24 hours before his death, a staff member called Yunis Camara and said his son seemed distressed overnight, the father said. The next morning, a nurse called and said his temperature was 103 degrees, Yunis Camara said.
"Did you call 911?" he remembered asking.
He said the facility finally did request an ambulance later that morning, after Joshua had lost consciousness. He died soon thereafter.
During a recent interview at their Windsor Mill home, his parents pointed to a framed photo of their son - the way he looked before the shooting. Their cellphones hold more recent photos: Joshua lying in his hospital bed, and later in his coffin.
Adelphi Nursing and Rehabilitation Center has a two-star overall rating (out of five stars) from the U.S. Department of Health and Human Services, which conducts annual surveys to evaluate facilities that are Medicare- and Medicaid-certified. The rating is based on health inspections, staffing and quality measures.
Recent inspections found failures to develop and implement adequate care plans for residents, lapses in routine care - such as failing to reposition bedridden patients often enough - and housekeeping and maintenance issues, including water damage and exposed wiring. Inspectors also found staffing levels were well below the national and statewide averages for similar facilities.
Only 55% of patient family members who participated in a 2021 survey of Maryland nursing homes said they would recommend the facility, compared with a 75% statewide average.
The same survey, conducted annually by the Maryland Health Care Commission, rated the facility 5.5 out of 10 for overall care - placing it near the bottom among Maryland nursing homes.
A pending 2021 lawsuit alleges Adelphi staff failed to properly monitor a diabetic patient's blood sugar, which fell to dangerously low levels and ultimately caused his death.
After Joshua Camara died, his relatives read some of the facility's online reviews, which they said paralleled their experiences: accounts of trash and cigarette butts littering the hallways, unanswered calls for assistance and obvious staffing issues.
Adelphi's executive director did not respond to requests for comment about the ratings or answer general questions about whether the facility has taken steps to improve patient experiences.
For patients on Medicaid, finding quality nursing home care can be a monumental challenge, said Darrell Gaskin, director of the Johns Hopkins Center for Health Disparities Solutions. While Maryland hospitals receive the same reimbursement rate regardless of whether a patient has Medicaid, Medicare or private insurance, that rate standardization policy doesn't apply to nursing homes.
Instead, Gaskin said, nursing homes have a financial incentive to take more patients with private insurance or Medicare because Medicaid has the lowest reimbursement rate. That sometimes means Medicaid patients end up at less-desirable facilities, and the stakes are especially high for someone like Joshua Camara, who needed intensive, specialized rehabilitation care.
Most shooting survivors are young Black men with few resources.
In the United States, medical treatment for gunshot victims costs more than $1 billion annually, with Medicaid patients accounting for about half, according to a 2021 congressional watchdog report. That includes about 50,000 emergency room visits and 30,000 inpatient hospital stays. Among the inpatient group, about 20% are discharged to further care, including skilled nursing facilities.
Research also shows that racial bias within the medical system can define patient experiences and impact health outcomes. Gaskin said gunshot victims face yet another layer of potential bias.
"Unfortunately, our health care providers are human too, and they're in this environment that devalues Black lives, that devalues the lives of people who might be associated with crime, the criminal element," he said. "We make decisions that put patients in marginalized populations at risk."
Those same biases also become problematic in interactions with law enforcement.
"You get the health care and criminal justice systems colliding in the trauma center," said Joseph Richardson, a professor of African American studies and anthropology at the University of Maryland, College Park. "We often are reluctant to acknowledge how they interact."
Dr. Katherine Hoops, assistant professor of pediatric critical care medicine and core faculty in the Johns Hopkins Center for Gun Violence Solutions, said clinicians need to receive training on trauma-informed care. She said she's heartened to see that approach gaining traction.
"We know it takes more than good medicine to achieve good health," she said.
For Joshua Camara, an inability to verbally communicate thrust his parents into an intense dual role of caretaking and trying to advocate for their son while navigating myriad challenges despite their own trauma.
The latest bureaucratic hurdle came after the funeral, when relatives found themselves unable to obtain an exact cause of death.
A spokesperson for the state medical examiner said autopsy results, including whether he died of pneumonia or some other complication, will remain confidential while the criminal case is ongoing. Baltimore Police said they don't have that information.
Yunis Camara recently had a heart attack, which his family attributed to the compounding effects of grief and stress. He spent three nights in the hospital, remembering his son's suffering and praying for a quick discharge.