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Medical Repatriation in America

by JOHN CARROLL, MD

The other day I read an article in the New England Journal of Medicine (NEJM) from February 23, 2014 entitled “Undocumented Injustice? Medical Repatriation and the Ends of Health Care”.

This article made me think of OSF in Peoria and I will explain why.

Medical repatriation is defined as “the transfer of undocumented patients in need of chronic care to their country of origin.”

The NEJM article begins with a story:

“Quelino Jimenez came to the United States at 18 years of age, seeking work to provide financial support to his family of 11 in Mexico. Jimenez found a construction job in Chicago, where he worked without a legal work or residence permit for more than a year until he sustained injuries after a 20-ft fall on the job, which resulted in quadriplegia. He was admitted to a Chicago hospital, where he remained for months. No long-term care facility was willing to accept Jimenez as a patient. One day, he recounted, “They told me, `Today you are going to your home.’ . . . I wanted to say something, but I couldn’t talk. I wanted to ask why.

Jimenez was subsequently discharged, by means of air ambulance, to a hospital in Oaxaca, Mexico. In the Oaxaca hospital, Jimenez had bedsores, two cardiac arrests, pneumonia, and sepsis. “I didn’t want to come back [to Mexico],” he told family and reporters, “because here there’s no medicine. . . . I need therapy, I need a lot of things they don’t have.” On January 3, 2012, Jimenez died at 21 years of age.”

Unfortunately there are many stories out there similar to Mr. Jimenez. Medical repatriation is not a new concept. In 2008 Deborah Sontag of the New York Times wrote these two eye-opening articles here and here.

The NEJM article describes the dilemma and ethics of what to do about undocumented people in the United States who are injured or who become ill, survive their initial problem with acute hospitalization, and then need chronic care in a long-term care facility. Chronic care facilities don’t want these patients because they do not think they will be reimbursed and hospitals don’t want them any longer because they have given them the acute care that they needed. So some hospitals around the United States are sending these unfortunate patients back to their home country. The patients are frequently pressured to return against their will and against their family’s will. Most undocumented immigrants who have been hospitalized here do not have advocates fighting for them as they are being loaded on the plane.

US hospitals are legally mandated to take care of all patients who need emergency care regardless of citizenship status. Medicare reimburses the hospital for some of the charges. However, federal and state aid does not cover long-term care for illegal immigrants. So nursing homes don’t want these long-term patients and the hospital wants to get rid of them. So the hospital hires a charter plane to fly them home. And some are in a coma when they leave and awaken in their country of origin or in their village.

NEJM notes that there is “tension between medical repatriation and the ethical duties of health care providers.” In other words the hospital administration wants to get rid of the undocumented patient, the long-term facility refuses to accept the patient, the patient and his family want the best medical care (which is not usually found in Port-au-Prince or Guatemala City), and the patient’s doctor is caught in between everyone.

The transfer of stabilized, undocumented civilians is unregulated. And often times patients have not given their consent. The mechanism is not transparent and is being done by the hospitals and the hospital administrators. There is not sufficient documentation as to how many patients have been sent home but observational data in the last few years indicate that there have been at least 800 cases of attempted or successful involuntary medical repatriation of undocumented immigrants in the US alone.

The American Hospital Association does not have a policy governing immigrant removals.

And when these unfortunate people arrive at home they are frequently given substandard care at the accepting hospital. Many patients are then transferred to the care of their families in their villages.

So how does medical repatriation have anything to do with Haitian Hearts and OSF in Peoria? My patients were “documented”, OSF was being reimbursed over 1.1 million dollars for their care, and my Haitian patients were not needing long-term placement like the patients described in the NEJM article.

However, I clearly remember the morning over a decade ago at Children’s Hospital of Illinois when we had a cardiac cath conference. This weekly conference was attended by the pediatric cardiologists and surgeons involved in the care of heart patients at Children’s Hospital of Illinois (CHOI).

One of the cases that was reviewed that day was Jackson Jean-Baptiste. Jackson had been operated at OSF for rheumatic heart disease and his post-operative echo was reviewed. One of the cardiologists (who I thought feared being Jackson’s doctor) declared Jackson a success with the implication that his surgical needs were accomplished and that he could go back to Haiti. However after conference I got on an elevator with another physician. And after the door closed he said to me, “I don’t know what “Dr. X” was smoking. Jackson’s valve still needs more work.” Jackson’s echo was NOT ok. And later that same day another pediatric cardiologist took me aside in Pediatric CVICU, we sat down, and he said Jackson definitely needed more surgery. So I of course drug my feet about taking him back to Haiti and Jackson had successful repeat heart surgery at OSF. (Years later, after he returned to Haiti, Jackson would require more heart surgery. However, OSF would not allow him to return. Jackson died in 2006.)

The NEJM article did not talk about DELAYING care of UNDOCUMENTED immigrants either. However, I felt that care of my DOCUMENTED Haitian kids was being slowed by OSF-CHOI. The nurses in the pediatric cardiology clinic at CHOI told me how the Executive Director of CHOI told them to NOT to schedule a cardiac catheterization for one of my young patients. See this post. So I reported the Director to the Pediatric Resource Center at Children’s for neglect. That very afternoon, after the intervention of one of the pediatric cardiologists, the Haitian child was put back on the cath conference schedule immediately and eventually underwent successful heart surgery.

These were dangerous days for my Haitian Hearts patients. And I felt an enormous amount of tension. I was caught between OSF Administration, the child’s biologic family in Haiti, the host family here in Central Illinois, and the Haitian child with heart disease. It was a very bad space to be in. I couldn’t believe that this could be happening at our Catholic hospital in Peoria but it was.

OSF-CHOI was able to construct a brand new $250 million dollar Children’s Hospital in the mid-2000′s, so somehow Haitian children did not break them. However, the ramifications of some of CHOI’s treatment of Haitian children has not been lost on the public. We DO know that OSF does NOT care for everyone the same way.

Doctors and nurses who work for big academic medical centers like UICOMP-OSF in Peoria have to be very careful when doing international work abroad and asking their medical center to take care of a “medical problem” they find in the developing world. They may find out that the academic medical center back home supports them working in Haiti or somewhere, but doesn’t really want the cute little Haitian at their medical center. The physician and nurses paychecks are signed by the medical center, so they have to be very careful and use much discretion.

Conclusions

Health care should be viewed as a right and not a service commodity. There should be required reporting of repatriation (deportation) of any patient back to their country of origin. Pressure should not be put on the patient, family, or physician to push the patient onto the plane.

The American Council on Ethical and Judicial Affairs issued a strongly worded directive to doctors in 2009 urging them to not allow hospital administrators to use their significant power and the current lack of regulations to send patients to other countries especially against their will. The dignity of the person has to be more important than the bottom line.

International patients, be they documented or undocumented, have a soul and are members of the human community. They deserve humane care.

John A. Carroll, M.D. is a physician working in Port-au-Prince.

 

John A. Carroll, M.D. is a physician working in Port-au-Prince.

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