Doctors on the Border--March 2019

  

Cite Soleil–July 4, 2016 (Photo by John Carroll)

The most stressful part of my Haitian trips during the past 25 years have not been working in Cite Soleil or taking care of very sick Haitian kids. The most stressful part has been applying for non-immigrant visas from the US State Department for kids who need to travel from Haiti to the States for medical care not available in Haiti.

I have been an unwilling physician working on the border of scads of red tape and intimidating bureaucracy. And I have been a witness to the stark reality that succeeding or failing to obtain visas for sick Haitian children often determines whether these kids will live or die.

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The New England Journal of Medicine had an article this week entitled —Physicians as Border Guards — The Troubling Exam for Immigrants. The article is written by Khmer Kidia who is both a physician and a recent immigrant to the United States.

Dr. Kidia’s article describes what he needed to do to obtain his medical exams during his application to receive his green card.

“Today’s exam is burdensome and expensive for prospective immigrants. Only a government-appointed “civil surgeon” can conduct the exam,” writes Dr. Kidia. “There were only 50 civil surgeons in my state. Many did not answer my phone calls, and most of those who did had stopped offering the service. Doctors quoted me fees between $600 and $2,000 and required me to take two afternoons off work for appointments.”

He stated that the US physician he saw did not do a physical exam on him but did order and charge for vaccinations that Kidia already had.

“Clearly, our relationship was not therapeutic. It was transactional.” Dr. Kidia said his doctor rarely looked up from his desk.

Dr. Khidia writes–

“Rules proposed by the Trump administration depend on physicians performing these exams to spot immigrants who are sick enough to become reliant on the government for living costs — so-called public charges. According to a statement from U.S. Citizenship and Immigration Services, these rules would simply implement a rarely used but century-old immigration law. But the impact will be devastating for immigrants who are denied visas.

“Though illness would not be the sole grounds for denying approval to an applicant, and some immigrants would receive medical waivers, the government would view less favorably those who seem unlikely to be able to afford future medical costs. For immigrants who are both sick and poor, a health condition discovered during the medical exam would be a “heavily weighted negative factor” in the application for a green-card.”

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Over 20 years ago I traveled to Haiti with two young American women. Both women were friends of mine. One was a registered nurse and the other was a pre-med student. We worked in Haiti’s countryside and in Port-au-Prince. It was a great trip and we had five kids “bundled-up” to bring back to the States for surgery.

Marie (childrens’ names all changed) was 12 years old and the oldest of the group. She was tall and skinny and was born in Haiti’s rural south. Marie lived with her parents and brothers and sisters in a fairly sturdy house on the side of a steep mountain. She had had rheumatic heart disease and was in congestive heart failure. Marie had been hospitalized several times in Haiti but she needed heart surgery to repair her mitral valve. And this surgery could not be done in Haiti.

Joseph was 18-months-old and had been abandoned on a sidewalk in Port-au-Prince. Joseph was blind from a congenital ophthalmologic disease known as Peters Anomaly. Both of his eyes had corneal opacities due to malformation during his fetal development. From his place on the sidewalk, Joseph sang, “Why have you left me here all alone? Can’t you see the pain I am in?” Joseph was placed in an abandoned children’s home with sixty other kids, but he was hard to ignore. He had continual eye pain and would constantly rub his eyes with his little fists. If picked up, he would attempt to bury his face and eyes into the shoulder of the holder as he sought temporary relief. Joseph’s treatment would involve corneal transplants which could be complicated due to his young age.

Jean-Paul was a two-year-old toddler with hydrocephalus. He was found alone in a street market in a three-hundred-year-old city on Haiti’s southern coast named Jacmel. He needed a surgical shunt placed which would travel from a cavity in his brain to his abdomen. The idea was to decrease the amount of cerebral spinal fluid collecting in his head which was mercilessly squeezing Jean-Paul’s developing brain.

Schneider was a 3-year-old boy. He had a simple congenital heart defect which, for a skilled pediatric heart surgeon, is reasonably easy to perform. Schneider needed to travel too because this surgery was not safely done in Haiti two decades ago.

Kennedy was the fifth child and was almost two years old. He too had been placed in a home for abandoned and sick children. This little boy was severely malnourished before being placed in the home by his mother who came from an impoverished village one hour north of Port-au-Prince. In the home, he was found to have a loud heart murmur due to an abnormal connection between his aorta and pulmonary artery (patent ductus arteriosus). With each heartbeat, his lungs were being flooded by too much extra blood. Kennedy needed heart surgery to tie off his open duct to allow his heart and lungs to be happier.

During Haiti trips, I frequently knew the parents of the children who were not abandoned. I had been in many of their homes. And I had looked into their mothers’ eyes and knew I was seeing “the universal look ” of mothers who wanted nothing more than to protect the lives of their children. Thus, I had more than the usual physician-patient relationship and it came natural to advocate for these children.

These kids were literally the “weakest of the weak from the poorest of the poor.” Who could possibly give them a hard time as we sought medical care in the States for these children? I quickly found out that many people would stand in the way. I didn’t know it, but two decades ago, my real medical education–education not found in sterile medical school classrooms–was just beginning.

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Several days before the end of our trip, we purchased five airplane tickets for these five kids and we began the visa application process at the American Consulate in Port. (Now, in 2019, the visa application is more complex, more expensive, and much more difficult to accomplish even for people living in the digital age.) We were told by the Consulate official that we would need to take the children to a Haitian physician in Port-au-Prince to obtain his written medical opinion on each child as part of the visa application process.

So the day before we were to leave Haiti, my two friends and I dutifully took the five children to the Haitian physician’s office in Port-au-Prince. I had recognized this prominent physician’s name but had never met him. He was obviously working for the US State Department in screening Haitian kids for non-immigrant (“medical”) visas to allow travel and entry to the States.

The doctor’s secretary ushered us into his office. I introduced our group to the physician and handed him the medical dossiers for each child. The dossiers included written medical information such as my medical history and physical, previous hospitalizations, echocardiograms, and lab tests pertaining to the children.

We huddled around the physican’s desk holding the pathetic children on our laps. Only Marie was standing. We were all hot and sweaty, and covered with Port-au-Prince’s grey car exhaust. Like Dr. Kidia’s doctor, the Haitan physician stayed seated as he studied the childrens’ dossiers.

He started with Marie’s records and noticed that she had been hospitalized in a hospital in the capital where he was medical director. He advised me to go back to HIS hospital and retrieve the complete set of paper records from her hospitalization. I could not understand why he asked me to do this. Marie had a loud murmur on exam. All he needed to do was get up and examine her and combine his exam findings with her written echocardiogram which I had provided. He simply needed to be a physician. But he did not examine Marie and quickly moved on to the next child’s dossier.

Joseph, the blind boy, had obvious abnormalities on inspection of his corneas. And Joseph was visibly in pain as he whimpered, rubbed his eyes, and looked like a mini Stevie Wonder in distress. But the Haitian physician didn’t examine Joseph either. He simply told me that I needed to take the boy to a Haitian ophthalmologist for a complete eye exam.

My two friends and I could see where this was going. I could feel the battle beginning that I definitely did not want. The Haitian physician “on the border” was doing all he could to slow things down for the children who urgently needed his help.

We were then instructed to take Jean-Paul, the child with the big head, to Haiti’s one neurosurgeon located somewhere in Haiti’s capital. Our eyes turned downward and stared at the floor, knowing that for many reasons this would be so hard to do.

As our debacle continued in his office, his black phone on his desk rang. The doctor interrupted his work to speak with his travel agent in French. During this conversation, he pulled a big wad of American currency out of his pants pocket. He was preparing to buy an American Airlines plane ticket for himself to attend the American Medical Association meeting in the States. I thought how ironic this was that he could travel so easily, yet for the sick kids right in front of him, their travel could be so hard.

After this call was concluded, he began to read Schneider’s medical dossier and look at his echocardiogram. I don’t think he even made eye contact with little Schneider who was wondering what was going on.

And Kennedy was the last. Kennedy needed heart surgery due to the fact that his lungs were getting too much blood from his unclosed duct. I asked the doctor to take a listen to Kennedy’s lungs because this toddler had a fever and cough that morning and was looking quite puny. Kids with this congenital heart defect often have pneumonia due to the abnormal blood flow. The Haitian physician did get up and examined Kennedy for about 30 seconds before he returned to his chair. I couldn’t really understand what the physician said to me regarding Kennedy’s exam.

I asked the Haitian physician if he was going to sign the papers confirming that he agreed with the diagnoses and that all the children needed to go to the States for proper treatment. He politely said no that he would not without the children being checked out by specialists that he had indicated.

I calmly told him that we would not do this—that this was not necessary—that we both were doctors–and that his stall tactics were dangerous to the kids and unappreciated by us. I told him we would get the visas with or without him. I asked the ladies to pick up the kids and we headed for the door of his office. His last words to me as we went out the door were, “You won’t get visas unless I sign off.”

In the street we all piled in a dirty white van and drove a few blocks to the American Consulate. After several hours of waiting, a Consulate official came out into the hallway where the group of us were waiting in total disarray. The official reviewed all the childrens’ dossiers and asked me if we had the Haitian doctor’s papers verifying that all the kids needed visas for medical care in the States. I told the official that we were at the physician’s office earlier in the morning and that the physician was making inappropriate consults for these children that would be very hard for us to do.

The Consulate ended up issuing the visas that morning for all five children. But they told me that in the future, the Haitian physician’s exam and verification would be necessary to obtain visas.

(The next year, the Consulate was using a different Haitian doctor to examine Haitian kids for medical visas. The new doctor, promoted by an American NGO, were charging $900 US per visa application and would take donations, if offered. This of course would rule out the vast majority of poor Haitian children from ever obtaining medical visas.)

Conclusion—

The Haitian doctor was working for money from the US government. He was a “border physician”. And by playing his referral game with our five children, he was putting their lives at risk. He was not their advocate.

Dr. Kidia, the immigrant physician, did jump through the hoops and received his green card. He ended his article regarding physician involvement on the border–

“…I remain concerned about the biased role of physicians in immigration. In this era of discriminatory immigration policies, I believe we should use our training to help, not hurt, vulnerable migrants.”

Denouement–

So what became of these kids during the past 20 years?

My two friends and I, and our five kids, made it to the Haitian airport the next morning. Inside the airport we ran into more official resistance–this time from Haitian Immigration. They attempted to block the kids from exiting the country. I will not explain now other than to say that there was no road map to follow. And unusual circumstances required an unusual response.  But after a significant amount of stress and a few tears, we eventually were allowed to get on our flight with the kids and we left Haiti…no worse for the wear.

By the time we got to Chicago that day, Kennedy was looking pretty sick. His skin color was not good and he was lethargic.  We had to make a quick decision and decided to get on the short flight to Peoria with this sick boy. Upon arriving in Peoria, we proceeded directly from the airport to the hospital. I clearly remember slipping an IV catheter in a vein on his left arm and we admitted him.

Kennedy went on to improve and had his surgery which tied off his abnormal open duct. He did well post-op. Several years later Kennedy was adopted from Haiti by his host parents in the Peoria area. Kennedy is all grown up now and has his own toddler who he loves the same way his Haitian mother (and American mother) love him.

Joseph, the blind boy left alone on the sidewalk, has had multiple corneal transplants over the last two decades. His medical course has not been easy, but his life has been great. He is now a college student and works part-time. He wishes to work in the field of child welfare and safety.

Schneider had successful heart surgery and needed no further operations. I have lost track of Schneider in Haiti.

Jean-Paul, the toddler with hydrocephalus, underwent successful shunt placement by a neurosurgeon in the States. He was adopted and is now a young adult with special needs.

And Marie had successful mitral valve surgery. Her early post-operative course twenty years ago was complicated with a rare neurologic disorder known as Sydenham’s Chorea. This is an autoimmune movement disorder that can be seen with rheumatic heart disease where patients have involuntary movements of the face and extremities. Her chorea lasted a couple of months and resolved completely on its own. Marie and her parents immigrated to the States when she was a teenager. The girl from Haiti’s rural mountains is now a young married woman with her own baby. Marie has an advanced degree and works in the field of public health.

 

John A. Carroll, MD

www.haitianhearts.org