[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]
CHILDREN IN CBP CUSTODY: EXAMINING DEATHS,
MEDICAL CARE PROCEDURES, AND IMPROPER
SPENDING
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON HOMELAND SECURITY
HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTEENTH CONGRESS
SECOND SESSION
__________
JULY 15, 2020
__________
Serial No. 116-77
__________
Printed for the use of the Committee on Homeland Security
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
43-865 PDF WASHINGTON : 2021
--------------------------------------------------------------------------------------
COMMITTEE ON HOMELAND SECURITY
Bennie G. Thompson, Mississippi, Chairman
Sheila Jackson Lee, Texas Mike Rogers, Alabama
James R. Langevin, Rhode Island Peter T. King, New York
Cedric L. Richmond, Louisiana Michael T. McCaul, Texas
Donald M. Payne, Jr., New Jersey John Katko, New York
Kathleen M. Rice, New York Mark Walker, North Carolina
J. Luis Correa, California Clay Higgins, Louisiana
Xochitl Torres Small, New Mexico Debbie Lesko, Arizona
Max Rose, New York Mark Green, Tennessee
Lauren Underwood, Illinois John Joyce, Pennsylvania
Elissa Slotkin, Michigan Dan Crenshaw, Texas
Emanuel Cleaver, Missouri Michael Guest, Mississippi
Al Green, Texas Dan Bishop, North Carolina
Yvette D. Clarke, New York Jefferson Van Drew, New Jersey
Dina Titus, Nevada
Bonnie Watson Coleman, New Jersey
Nanette Diaz Barragan, California
Val Butler Demings, Florida
Hope Goins, Staff Director
Chris Vieson, Minority Staff Director
C O N T E N T S
----------
Page
Statements
The Honorable Bennie G. Thompson, a Representative in Congress
From the State of Mississippi, and Chairman, Committee on
Homeland Security:
Oral Statement................................................. 1
Prepared Statement............................................. 4
The Honorable Mike Rogers, a Representative in Congress From the
State of Alabama, and Ranking Member, Committee on Homeland
Security:
Oral Statement................................................. 5
Prepared Statement............................................. 8
The Honorable Sheila Jackson Lee, a Representative in Congress
From the State of Texas:
Prepared Statement............................................. 9
Witnesses
Dr. Fiona S. Danaher, M.D., M.P.H., Pediatrician, Chelsea
Pediatrics, Child Protection Team, Massachusetts General
Hospital, Instructor in Pediatrics at Harvard Medical School:
Oral Statement................................................. 12
Prepared Statement............................................. 13
Dr. Roger A. Mitchell, Jr., M.D., Chief Medical Examiner, Office
of the Chief Medical Examiner, Washington, DC, Clinical
Professor of Pathology at the George Washington University,
Associate Professor of Surgery at Howard University:
Oral Statement................................................. 19
Prepared Statement............................................. 21
Mr. Joseph V. Cuffari, Inspector General, U.S. Department of
Homeland Security:
Oral Statement................................................. 26
Prepared Statement............................................. 27
Ms. Rebecca Gambler, Director, Homeland Security and Justice,
U.S. Government Accountability Office:
Oral Statement................................................. 36
Prepared Statement............................................. 38
For the Record
The Honorable Bennie G. Thompson, a Representative in Congress
From the State of Mississippi, and Chairman, Committee on
Homeland Security:
Letter, July 14, 2020.......................................... 3
Letter, July 15, 2020.......................................... 4
Letter, June 12, 2020.......................................... 74
The Honorable Mike Rogers, a Representative in Congress From the
State of Alabama, and Ranking Member, Committee on Homeland
Security:
Letter, July 8, 2020........................................... 6
Appendix
Questions From Congressman Emmanuel Cleaver for Fiona S. Danaher. 77
Questions From Congressman Emmanuel Cleaver for Joseph V. Cuffari 80
CHILDREN IN CBP CUSTODY: EXAMINING DEATHS, MEDICAL CARE PROCEDURES, AND
IMPROPER SPENDING
----------
Wednesday, July 15, 2020
U.S. House of Representatives,
Committee on Homeland Security,
Washington, DC.
The committee met, pursuant to notice, at 12:05 p.m., via
Webex, Hon. Bennie G. Thompson (Chairman of the committee)
presiding.
Present: Representatives Thompson, Jackson Lee, Richmond,
Payne, Rice, Correa, Torres Small, Rose, Underwood, Slotkin,
Cleaver, Green of Texas, Titus, Barragan, Rogers, Katko,
Higgins, Lesko, Green of Tennessee, Joyce, Crenshaw, Guest, and
Bishop.
Chairman Thompson. The Committee on Homeland Security will
come to order. The committee is meeting today to receive
testimony on ``Children in CBP Custody: Examining Deaths,
Medical Care Procedures, and Improper Spending.'' Without
objection, the Chair is authorized to declare the committee in
recess at any point.
The committee is convening today to examine 3 critical
related and deeply troubling issues: The terrible death of
young children in the custody of Customs and Border Protection;
CBP's failure to consistently implement the revised medical
screening procedures it adopted after children died in its
custody; and CBP's improper expenditure of the emergency funds
appropriated by Congress for the care of migrants.
In December 2018, 2 children died in CBP custody. A 7-year-
old girl named Jakelin, and an 8-year-old boy named Felipe.
Last year, another 3 children died in CBP custody, or shortly
after being released. On January 4, 2019, I sent a letter to
the Department of Homeland Security requesting documents
related to the deaths in 2018, after the Department failed to
produce all documents responsive to the committee's request. In
November 2019, the committee issued a narrowly tailored
subpoena by voice vote for many of the documents originally
requested in my letter 10 months prior.
In December 2019, the DHS inspector general's office
publicly issued 2 1-page summaries into the investigations into
the death that had occurred a year earlier. Unfortunately, the
inspector general's investigations left us with more questions
than answers.
Earlier this year, I sent a letter to Inspector General
Cuffari detailing the concerns we identified with the report.
My entire letter is available on the committee's website. Among
the concerns I raised were the following: Inspector general's
report and public summaries proclaim that there was no
malfeasance or misconduct by DHS personnel. It is unclear why
that standard was used, because there do not appear to have
been any allegations of malfeasance or misconduct on the part
of the agents.
In fact, all available evidence indicates that Border
Patrol agents showed great compassion for both children.
However, the inspector general's report appeared to presume
that since its investigation found no malfeasance or
misconduct, that is the end of the story. The report fails to
examine the many troubling questions that these deaths raise
regarding CBP's ability to care for children in custody,
including questions about the adequacy of the agency's
policies, procedures, and training.
Further, while the inspector general's office certainly
conducted many interviews, it appeared that key documents and
evidence were not collected and reviewed. My letter also
identified omissions in the public summary of one of the
inspector general's report that was so severe as to render the
summary inaccurate and potentially misleading. The inspector
general revised a public summary after receiving my letter.
Over the past 6 months, DHS has produced some documents in
response to the committee's subpoena, but these productions are
clearly incomplete. For example, the inspector general's report
referenced documents that have never been provided to the
committee. DHS has also made extensive and improper redactions
in the documents it has produced.
Through its refusal to comply fully with the committee's
subpoena, and through its many redactions, the Department is
intentionally impeding the committee's investigation. Despite
these hurdles, the committee has worked to advance our
investigation. To help with that effort, we asked a
pediatrician and a medical examiner to conduct independent
examinations of the 2 deaths that occurred in December 2018. We
will receive that testimony today. Today, the Government
Accountability Office is also releasing a report we requested.
It examines both CBP's use of emergency funding appropriated to
care for migrants, as well as the agency's implementation of
new medical screening procedures it announced after the deaths
in 2018. GAO's report finds that after CBP claimed it urgently
needed emergency funding to provide care for migrants taken
into custody, the agency misspent money it received. The Border
Patrol agents who cared for Felipe, while he was in custody,
had to pay for medicine for him out of their own pockets, but
CBP used some of the emergency funding that Congress
appropriated for the specific purpose of paying for medical
care, to instead buy jet skis, and dirt bikes, and even dog
food.
There is something seriously wrong with this picture, just
as there is something seriously wrong with the administration's
approach to caring for migrants, including children.
I note that GAO's report also finds that although CBP
adopted new policies governing medical assessments for children
following the tragic deaths of the 2 children in late 2018, CBP
did not consistently implement these policies.
We welcome Dr. Fiona Danaher and Dr. Roger Mitchell before
the committee, as well as Rebecca Gambler from GAO. I am glad
that after initially refusing to do so, inspector general has
agreed to testify before the committee, so that we can explore
the many questions regarding the work of the inspector
general's office. We also invited CBP's acting commissioner,
Mark Morgan to testify.
In a letter to the committee, he stated that because of the
White House baseless rules prohibiting administration witnesses
from attending virtual hearings, he could not appear.
As I close, let me say that I fully recognize the
sensitivities of the issues we are discussing. I encourage all
Members to be very careful and thoughtful in how we approach
this subject. With that said, it is clear that this
administration will do everything it can to avoid oversight.
Therefore, we must continue to do everything we can to hold
this administration accountable. Given the 18 months of
obstruction we have endured and have sought documents and
information about the death of children in custody, as well as
issues like the administration's child separation policy, I see
no other way to advance our investigation and to identify
changes needed in CBP's policies and procedures than to convene
today's hearing.
Before I recognize the Ranking Member, I am going to read
statements from the fathers of the 2 children who died in CBP
custody in 2018.
Mr. Caal Cruz, the father of Jakelin, provided the
following statement: ``I would like to say what I have always
believed, it is better to check on all children when they are
sick, and even if they are not sick, to speak up and say
something even if you are afraid. The most important thing is
to check on the children so the thing that happened to my
daughter doesn't happen to anyone ever again. I offer my thanks
to the committee for taking the time to look into my daughter's
case and I am very grateful to you all.''
The father of Felipe, Mr. Gomez Perez stated: ``I want
justice. I want to know why my son didn't receive medical care
in time. I don't want other children to go through the same
thing. This is painful for me today, and it will be painful for
the rest of my life. Every night I ask myself why my son didn't
receive medical attention in time. Felipe's treatment was
inhumane.''
I ask unanimous consent to submit their letters into the
record.
Without objection, so admitted.
[The information referred to follows:]
July 14, 2020.
Representative Bennie G. Thompson,
Chairman, Committee on Homeland Security, H2-176 Ford House Office
Building, Washington, DC 20515.
Statement of Mr. Caal Cruz Regarding the Committee's Investigation into
the Death of Jakelin Caal Maquin, age 7
Dear Chairman Thompson: We are providing this statement on behalf
of our client, Mr. Nery Caal Cruz, to whom we provide pro bono legal
and social services. Please find below Mr. Caal Cruz's statement in
response to the Committee on Homeland Security's current investigation
into the death of his daughter, Jakelin Caal Maquin, then age 7, in CBP
custody.
``I would like to say what I have always believed. It is better to
check on all children when they are sick and even if they are not sick.
To speak up and say something even if you are afraid. The most
important thing is to check on the children. So the thing that happened
to my daughter doesn't happen to anyone ever again. I offer my thanks
to the Committee for taking the time to look into my daughter's case
and I am very grateful to you all.''
Thank you for your attention and consideration to this important
issue.
Sincerely,
Bridget Cambria, Esq. [.]
______
July 15th, 2020.
To whom it may concern, The Tennessee Immigrant and Refugee Rights
Coalition (TIRRC) is a State-wide member-led advocacy organization
dedicated to empowering immigrants and refugees to defend their rights.
In the Spring of 2019, the Guatemalan consulate put us in touch with
Agustin Gomez Perez after the death of Mr. Gomez Perez's son in CBP
custody. Over the past year, we have developed a close relationship
with Mr. Gomez Perez and assisted him through connecting him with
community resources and getting him settled into his home. We have also
helped him collect necessary documents for the legal proceedings and
facilitated the communication between Mr. Gomez Perez and various
attorneys. For his part, Mr. Gomez Perez has become an active TIRRC
member through attending our community meetings. Mr. Gomez Perez would
like for his statement to be read aloud.
Agustin Gomez Perez's statement:
``I want justice. I want to know why my son didn't receive medical care
in time. I don't want other children to go through the same thing. This
is painful for me today, and will be painful for the rest of my life.
Every night I ask myself why my son didn't receive medical attention in
time. Felipe's treatment was inhumane.''
We are proud to support Mr. Gomez Perez in his fight for justice
for his son and the improved treatment of immigrants. All people
deserve to be treated with basic human dignity and respect.
Sincerely,
Lisa Sherman-Nikolaus,
Executive Director.
[The statement of Chairman Thompson follows:]
Statement of Chairman Bennie G. Thompson
July 15, 2020
The committee is convening today to examine 3 critical, related,
and deeply troubling issues: The terrible deaths of young children in
the custody of Customs and Border Protection (CBP); CBP's failure to
consistently implement the revised medical screening procedures it
adopted after children died in its custody; and CBP's improper
expenditure of emergency funding appropriated by Congress for the care
of migrants.
In December 2018, 2 children died in CBP custody--a 7-year-old girl
named Jakelin and an 8-year-old boy named Felipe. Last year, another 3
children died in CBP custody or shortly after being released.
On January 4, 2019, I sent a letter to the Department of Homeland
Security requesting documents related to the deaths in 2018. After the
Department failed to produce all documents responsive to the
committee's request, in November 2019, the committee issued a narrowly-
tailored subpoena by voice vote for many of the documents originally
requested in my letter 10 months prior.
In December 2019, the DHS inspector general's office publicly
issued 2 1-page summaries of its investigations into the deaths that
had occurred a year earlier. Unfortunately, the inspector general's
investigations left us with more questions than answers.
Earlier this year, I sent a letter to Inspector General Cuffari
detailing the concerns we identified with the reports. My entire letter
is available on the committee's website. Among the concerns I raised
were the following: The inspector general's reports and public
summaries proclaim that there was no malfeasance or misconduct by DHS
personnel.
It is unclear why that standard was used, because there do not
appear to have been any allegations of malfeasance or misconduct on the
part of agents. In fact, all available evidence indicates that Border
Patrol agents showed great compassion for both children. However, the
inspector general's reports appear to presume that since its
investigations found no malfeasance or misconduct, that's the end of
the story.
The reports fail to examine the many troubling questions that these
deaths raise regarding CBP's ability to care for children in custody,
including questions about the adequacy of the agency's policies,
procedures, and training. Further, while the inspector general's office
certainly conducted many interviews, it appears that key documents and
evidence were not collected and reviewed.
My letter also identified omissions in the public summary of one of
the inspector general's reports that were so severe as to render the
summary inaccurate and potentially misleading. The inspector general
revised the public summary after receiving my letter. Over the past 6
months, DHS has produced some documents in response to the committee's
subpoena--but these productions are clearly incomplete. For example,
the inspector general's reports reference documents that have never
been provided to the committee. DHS has also made extensive and
improper redactions in the documents it has produced. Through its
refusal to comply fully with the committee's subpoena--and through its
many redactions--the Department is intentionally impeding the
committee's investigation. Despite these hurdles, the committee has
worked to advance our investigation.
To help with that effort, we asked a pediatrician and a medical
examiner to conduct independent examinations of the 2 deaths that
occurred in December 2018. We will receive their testimony today.
Today, the Government Accountability Office is also releasing a
report we requested. It examines both CBP's use of emergency funding
appropriated to care for migrants as well as its implementation of the
new medical screening procedures it announced after the deaths in 2018.
GAO's report finds that after CBP claimed it urgently needed emergency
funding to provide care for migrants taken into custody, the agency
mis-spent money it received.
The Border Patrol agents who cared for Felipe while he was in
custody had to pay for medicine for him out of their own pockets. But
CBP used some of the emergency funding that Congress appropriated for
the specific purpose of paying for medical care to instead buy jet skis
and dirt bikes, and even dog food. There is something seriously wrong
with this picture--just as there is something seriously wrong with this
administration's approach to caring for migrants, including children.
I note that GAO's report also finds that although CBP adopted new
policies governing medical assessments for children following the
tragic deaths of the 2 children in late 2018, CBP did not consistently
implement these policies. We welcome Dr. Fiona Danaher and Dr. Roger
Mitchell before the committee, as well as Rebecca Gambler from GAO. I
am glad that after initially refusing to do so, the inspector general
has agreed to testify before the committee, so that we can explore the
many questions we have regarding the work of the inspector general's
office.
We also invited CBP's acting director, Mark Morgan, to testify. In
a letter to the committee, he stated that because of the White House's
baseless rules prohibiting administration witnesses from attending
virtual hearings, he could not appear.
As I close, let me say I fully recognize the sensitivities of the
issues we are discussing. I encourage all Members to be very careful
and thoughtful in how we approach this subject. That said, it is clear
that this administration will do everything it can to avoid oversight.
Therefore, we must continue to do everything we can to hold this
administration accountable.
Given the 18 months of obstruction we have endured as we have
sought documents and information about the deaths of children in
custody--as well as issues like the administration's child separation
policy--I see no other way to advance our investigation and to identify
changes needed in CBP's policies and procedures than to convene today's
hearing.
Chairman Thompson. The Chair now recognizes the Ranking
Member of the full committee, the gentleman from Alabama, Mr.
Rogers, for an opening statement.
Mr. Rogers. Thank you, Mr. Chairman. Can you hear me?
Chairman Thompson. Yes.
Mr. Rogers. Great.
I appreciate you holding this hearing and thank you, again,
for granting our request to use the committee room. I am, too,
saddened by the loss of Felipe and Jakelin. Both children and a
teenager died while in the custody of CBP, or shortly after
entering custody, which is totally unacceptable. The Department
has taken measurable steps to improve migrant care, but it is
up to us in Congress to address the root cause of the problem.
That can only happen in a bipartisan manner. It means that we
must fix immigration loopholes. We must provide real and
adequate resources to both CBP and ICE. We must not encourage
illegal immigration to our border. We must disrupt the cartels
and their human smuggling partners, and I hope we never have to
hear of another tragedy at the borders like what happened with
these 3 minors.
Mr. Chairman, I am disappointed at some of the events
leading up to this hearing, Acting Commissioner Morgan should
be at this hearing so this committee can directly hear from
him. It is important we understand what happened and what CBP
has done since those 2 deaths. The Majority did invite Acting
Commissioner Morgan, but they also knew he couldn't participate
in a remote hearing. OMB as provided guidance to senior
administration officials forbidding them from participating in
remote hearings. They are permitted to appear in person, Acting
Commissioner Morgan did before the Senate committee on June 25.
I ask unanimous consent to insert into the record Acting
Commissioner Morgan's response to the Chairman's invitation.
[The information follows:]
July 8, 2020.
The Honorable Bennie G. Thompson,
Chairman, Committee on Homeland Security, U.S. House of
Representatives, Washington, DC 20515.
Dear Chairman Thompson: Thank you for the invitation to testify
before the House Committee on Homeland Security on July 15, 2020, via
Cisco Webex regarding ``Children in CBP Custody: Examining Deaths,
Medical Care Procedures, and Improper Spending.'' However, based on
guidelines established by the Office of Management and Budget (OMB) and
the White House Office of Legislative Affairs (WHOLA), I must decline
this invitation.
As previously outlined by OMB, Federal officials are required to
appear in person before a committee to testify, with the Chairman also
appearing in person. OMB also requires that the Committee adhere to
normal procedures regarding hearing notice, quorum, and question-and-
answer periods. In light of these requirements and the Committee's
notice that this hearing will be held via Cisco Webex, I will not be
able to participate in this hearing in this format.
Additionally, on July 15, 2020, the Departments of Homeland
Security (DHS) and Treasury will be holding the quarterly Commercial
Customs Operations Advisory Committee (COAC) meeting. As you are aware,
the COAC is a Federal Advisory Committee Act (FACA) committee that
advises the Secretaries of the Treasury and DHS on all matters
involving the commercial operations of CBP. The CBP Commissioner is the
co-chair of the COAC, and I will be co-chairing the quarterly COAC
meeting on July 15, 2020.
The CBP Office of Congressional Affairs notified your staff of
these requirements and my prior commitment. Additionally, my staff
indicated my willingness to work with the Committee to identify a
mutually agreeable date so that I can participate in a hearing that
complies with OMB and the WHOLA guidelines. Unfortunately, we have not
heard back from your staff to identify a different date for the
hearing. So I must reiterate that I will not be able to participate in
the hearing on July 15, 2020.
I look forward to finding a mutually agreeable date and format that
complies with the requirements outlined by OMB to testify before your
Committee on this important topic.
Sincerely,
Mark A. Morgan,
Chief Operating Officer and Senior Official Performing the Duties
of the Commissioner.
Mr. Rogers. In that letter, Morgan requests to appear
before the committee in person in accordance with OMB guidance.
If we want productive hearings, I would suggest to the Majority
that we find time to hear from him in the next 2 weeks when we
are in the District of Columbia.
Further, getting to the bottom of those 2 deaths is
something that this committee has worked together on. We voted
unanimously last November to subpoena the Department on
information related to the deaths of Felipe and Jakelin. Our
filing the subpoena, it appears the Majority requested and
received additional information from the University of Mexico,
Office of Medical Investigations.
It appears the Majority didn't share this information with
witnesses here today, and who knows who else, avoid informing
the Minority of its existence. One witness claims to have
received the information on June 30. The Minority got it on
July 12. It is very disappointing to partner with you on things
like this, just have them turn out to be partisan in less than
a week before the hearing.
I am also alarmed by the autopsy information the Majority
requested. I don't see any legitimate reason why this
committee, or any committee of Congress, would need human
tissue samples from a deceased 8-year-old boy. I am concerned
the Majority's motive of requesting and then sharing with their
witnesses these autopsy specimens is to try and place blame for
those deaths on the men and women of Border Patrol. If that is
true, it is deplorable.
The IG found that there was no misconduct or malfeasance in
any of the actions of DHS or its employees surrounding these
unfortunate deaths. I understand that answer doesn't provide
any political satisfaction, but those are the facts.
If the Majority requested and shared human tissue samples
of a deceased child just to advance political narrative, it
would mark an appalling new low for this committee. I hope that
is not the case. We must remember that for months, Congress
refused to address the border crisis that precipitated these
deaths. Record numbers of families and children crossed our
border last year. Groups of hundreds to thousands of migrants
came across it at once. Migrants traveled over 2,000 miles at
the whims of cartels and human smugglers to get to our border.
Many told of abuse, assaults, and worse, on the journey to our
border. Food, nutrition, access to medicine was not adequate if
at all provided.
As a result, many, like Jakelin, arrived in extremely poor
health. At the height of the crisis, Border Patrol agents spent
over half their time transporting migrants to hospitals. But
for months last year, the Majority refused to acknowledge the
problem, going as far as to call it a manufactured crisis. Even
after the children died, the Majority insisted there was no
crisis at our border. At one point last year, the Majority's
response to the border crisis was to send 316 tweets, 11 press
releases, and hold 6 hearings. None of that solved anything.
Finally, after months of denying it, the Majority finally
admitted there was a crisis. A supplemental appropriations bill
was brought forward to the House, yet that bill had so many
poison pills attached to it, the Senate had to strip them out
before it can head to the border.
Unfortunately, that bill was, at best, a stopgap measure.
The Homeland Security Advisory Committee recently concluded
that until Congress takes action to address the root cause of
last year's crisis, it is only a matter of time before another
one occurs. I hope, at some point, we can get off the political
messaging game and work together to fix the immigration
loophole that encourage parents to send their children on a
dangerous, and, oftentimes, deadly trek to our border.
Thank you, Mr. Chairman. I yield back.
[The statement of Ranking Member Rogers follows:]
Statement of Ranking Member Mike Rogers
Thank you, Mr. Chairman, for holding this hearing today.
And thank you again for granting our request to use the committee
room.
I'm saddened by the loss of both Felipe and Jakelin.
Both children and a teenager died while in the custody of CBP or
shortly after entering custody--which is unacceptable.
The Department has taken measurable steps to improve migrant care,
but up to us in Congress to address the root cause of the problem.
That can only happen in a bipartisan manner.
It means that we must fix immigration loopholes.
We must provide real and adequate resources to both CBP and ICE.
We must not encourage illegal immigration to our border.
We must disrupt the cartels and their human smuggling partners.
I hope we never have to hear of another tragedy at the border like
what happened to these 3 minors.
Mr. Chairman, I am disappointed at some of the events leading up to
this hearing today.
Acting Commissioner Morgan should be here so this committee can
hear directly from him.
It's important that we understand what happened and what CBP has
done since these 2 deaths.
The Majority did invite Acting Commissioner Morgan, but they also
knew that he couldn't participate in a remote hearing.
OMB has provided guidance to senior administration officials
forbidding them from participating in remote hearings.
They are permitted to appear in person, as Acting Commissioner
Morgan did before a Senate Committee on June 25.
I ask Unanimous Consent to insert into the record Acting
Commissioner Morgan's response to the Chairman's invitation.
In that letter, Morgan requests to appear before the committee in
person in accordance with the OMB guidance.
If we want a productive hearing, I would suggest to the Majority
that we find time to hear from him in the next 2 weeks when we are in
the District of Columbia.
Further, getting to the bottom of these 2 deaths is something this
committee has worked on together.
We voted unanimously last November to subpoena the Department on
information related to the deaths of Felipe and Jakelin.
However, following that subpoena, it appears the Majority requested
and received additional information from the University of New Mexico
Office of the Medical Investigator.
It appears the Majority then shared this information with the
witnesses here today, and who knows who else, before informing the
Minority of its existence.
Mr. Chairman, can you tell me when this information regarding
Felipe's autopsy was provided to the committee?
I yield to the Chairman.
Thank you, Mr. Chairman.
One witness claims to have received the information on June 30.
We got it on July 12.
It's very disappointing to partner with you on this only to have it
be made partisan less than a week before the hearing.
I am also alarmed by the autopsy information the Majority
requested.
I don't see any legitimate reason why this committee or any
committee of Congress would need the human tissue samples from a
deceased 8-year-old boy.
I am concerned the Majority's motive in requesting, and then
sharing with their witnesses, these autopsy specimens is to try to
place the blame for these deaths on the men and women of the Border
Patrol.
If true, I think that's deplorable.
The IG found that there was no misconduct or malfeasance in any of
the actions of DHS or its employees surrounding these unfortunate
deaths.
I understand that answer doesn't provide any political satisfaction
to the Majority, but those are the facts.
If the Majority requested and then shared the human tissue samples
of a deceased child just to advance a political narrative, it would
mark an appalling new low for this committee.
I hope that's not the case.
We must remember that for months, Congress refused to address the
border crisis that precipitated these deaths.
Record numbers of families and children crossed our border last
year.
Groups of hundreds to thousands of migrants came across at once.
Migrants traveled over 2,000 miles, at the whims of the cartels and
human smugglers, to get to the border.
Many told of abuse, assaults, and worse on the journey to our
border.
Food, nutrition, access to medicine was not adequate, if provided
at all.
As a result, many, like Jakelin, arrived in extremely poor health.
At the height of the crisis, Border Patrol agents spent over half
of their time transporting migrants to hospitals.
But for months last year, the Majority refused to acknowledge the
problem, going so far as to call it a ``manufactured crisis.''
Even after these children died, the Majority insisted there was
``no crisis'' at our border.
At one-point last year, the Majority's response to the border
crisis was to send out 316 tweets, 11 press releases, and hold 6
hearings.
None of that solved anything.
Finally, after months of denying it, the Majority finally admitted
there was a crisis.
A supplemental appropriations bill was brought forward to the
House.
Yet that bill had so many poison pills attached to it, that the
Senate had to strip them out before relief could head to the border.
Unfortunately, that bill was at best a stop-gap measure.
The Homeland Security Advisory Committee recently concluded that
until Congress takes action to address the root cause of last year's
crisis, it's only a matter of time before another one occurs.
I hope at some point we can get off the political messaging game
and work together to fix the immigration loopholes that encourage
parents to send their children on a dangerous and, often times, deadly
trek to our border.
I yield back.
Chairman Thompson. Thank you very much, Mr. Ranking Member.
Other Members of the committee are reminded that under
committee rules, opening statements may be submitted for the
record. Members are also reminded that the committee will
operate according to the guidelines laid out by myself and the
Ranking Member in our July 8 colloquy.
[The statement of Honorable Jackson Lee follows:]
Statement of Honorable Sheila Jackson Lee
July 15, 2020
Thank you, Chairman Thompson for convening this opportunity for the
Homeland Security Committee to provide oversight of ``Children in CBP
Custody: Examining Deaths, Medical Care Procedures, and Improper
Spending.''
I thank today's witnesses and look forward to their testimony:
Fiona S. Danaher, M.D., MPH, a pediatrician with
Massachusetts General Hospital--Chelsea Pediatrics and
Massachusetts General Hospital Child Protection Team and an
instructor in Pediatrics, Harvard Medical School;
Roger A. Mitchell, Jr., M.D., chief medical examiner, D.C.
Office of the Chief Medical Examiner, clinical professor of
pathology, the George Washington University and associate
professor of surgery, Howard University;
The Honorable Joseph V. Cuffari, inspector general, U.S.
Department of Homeland Security;
Ms. Rebecca Gambler, director, Homeland Security and Justice
Team, U.S. Government Accountability Office.
As a senior Member of this committee I have learned a great deal
about the capacity and strength of the men and women who work at the
Department of Homeland Security.
I hold them in the highest regard for their dedication and service
to our country.
This Nation depends on the men and women of the Department of
Homeland Security (DHS) to protect citizens from those who wish to do
them harm.
Because of the dedication of DHS professionals, we are better
prepared to face these challenges as one Nation united against a common
foe.
The Department of Homeland Security was not created to protect the
Nation from desperate people escaping violence and poverty, seeking
asylum in our country.
The saddest, most tragic situation is the plight of tens of
thousands of unaccompanied children or those who were taken from their
parents or removed from the care of responsible adults.
My primary domestic security concerns are:
Making sure that our immigration policies in word and deed
reflect the best of our Nation's values and institutions;
Separating fact from fiction in the debate over U.S.
immigration and border policy;
Controlling access to firearms for those who are deemed to
be too dangerous to fly;
Countering international and home-grown violent extremism;
Preserving Constitutional rights and due process for all
persons;
Protecting critical infrastructure from physical and cyber
attacks, including technology used in public elections;
Creating equity and fairness in our Nation's immigration
policies by addressing fairness for TPS and DACA recipients;
and
Strengthening the capacity of the Department of Homeland
Security to meet the challenges posed by natural disasters--
including pandemics.
As a former Chair and Ranking Member of the Homeland Security's
Subcommittee on Border Security, my commitment to securing our Nation's
borders and protecting the homeland from terrorist attacks remains
unwavering.
The United States has a Federal policy supported by laws that
govern how non-citizens are to be treated, and the rights and well-
being of the most vulnerable are to be met when in U.S. custody.
I visited CBP facilities when tens of thousands of unaccompanied
children were arriving at the border weekly during the previous
administration and observed how DHS met the challenge of receiving
them, feeding them, and placing them safely in the custody of the
Department of Health and Human Services was routinely met.
I was shocked to learn in December 2018, that 2 children died in
separate incidents while in the custody of the U.S. Border Patrol,
which were the first deaths of children in Border Patrol custody in
more than a decade.
Following the deaths of the 2 children in 2018, U.S. Customs and
Border Protection, the Border Patrol's parent agency, issued an interim
directive in January 2019 establishing new medical screening and
assessment procedures for children taken into custody.
CBP issued a final directive regarding enhanced medical screening
procedures in December 2019. At the committee's request, the Government
Accountability Office (GAO) reviewed CBP's compliance with its new
procedures. GAO will issue its findings in a report to be released to
the public the day of the committee's hearing.
In January 2019, this committee requested documents related to
these deaths.
After the Department of Homeland Security (DHS) failed to produce
all requested documents, the committee issued a subpoena for the
documents in November 2019.
DHS has still not produced all the documents demanded by the
subpoena, and documents that have been produced have had extensive and
improper redactions.
The DHS inspector general conducted reviews of the 2 children's
deaths and issued public summaries of its reviews a year after the
children's deaths.
The committee has identified significant deficiencies with both
reviews.
The committee also found that the inspector general omitted key
information from the public summary of one of its reviews, rendering
the summary inaccurate and potentially misleading.
Because of the deficiencies of the inspector general's
investigations of the children's deaths and the on-going failure of DHS
to comply with committee document requests, we lack full and complete
information regarding the circumstances in which these deaths occurred.
In addition, many questions regarding the adequacy of CBP medical
procedures remain unanswered.
It is important that those within the Department of Homeland
Security, including its component agencies, comply with the law and
respond to the oversight authority of Congressional and Senate
Oversight Committees.
border security
Real border security cannot be achieved by building a wall on the
Southern Border, blocking asylum seekers, or separating children from
their parents.
These things are in fact making border security more difficult,
creating unnecessary tensions with our neighbors in Mexico, Central,
and South America while here at home these policies appeal to anti-
American nativist views.
Our Nation must and should look at all threats, from those who seek
to cross our borders by air, who may try to exploit our maritime
borders, or who cross either of our land borders with intent to smuggle
or do harm, and develop a strategy to implement thoughtful, proven, and
fair solutions to keep America secure.
To further strengthen security along our border, the practice of
impeding persons outside of our borders in Mexico undermines the
enforcement of immigration law, treaties, and proper application of
Federal regulations intended to assure safety and security.
This practice is called ``metering'', and it is creating
unnecessary hardship for people seeking entry and fermenting a toxic
environment where men, women, and children are being held under
conditions that can easily lead to deteriorating health and safety
conditions.
temporary protected status and dreamers
I strongly advocate for a crucial legislative fix for debate and
vote that will provide permanent legal residence and a path to
citizenship to the more than 800,000 Dreamers, including the 124,000
who live in Texas, whose lives have been turned upside down because of
this administration's cruel, unwise, and reckless termination of DACA,
the Deferred Action for Childhood Arrivals program.
And in connection with legislation to protect Dreamers, I will
insist that the administration rescind the revocation of Temporary
Protected Status (TPS) for Haiti, El Salvador, and Honduras, or failing
that, TPS for those countries be extended by Congressional legislation.
There are 44,800 residents of Texas who are TPS holders from El
Salvador (36,300), Honduras (8,400), and Haiti, who combined are
parents of 53,800 U.S.-born children in Texas and 14,000 of whom have
home mortgages.
These TPS holders are integral members of the Texas's social
fabric, having lived in Texas an average of 20 years, and contribute an
aggregate $2.2 billion to the Texas economy.
I look forward to today's hearing and learning more from our
witnesses.
Thank you. I yield back the balance of my time.
Chairman Thompson. I now welcome our panel of witnesses.
Our first witness is Dr. Fiona--I hope I get it right, Danaher
a pediatrician at Massachusetts General Hospital, Chelsea
Healthcare Center, and a member of the hospital's child
protection team. She's also an instructor in pediatrics at
Harvard Medical School. Dr. Danaher is a graduate of Mount
Sinai School of Medicine.
Our second witness is Dr. Roger A. Mitchell, Jr., the chief
medical examiner for Washington, DC. Dr. Mitchell, Jr. is
board-certified in anatomic and forensic pathology by the
American Board of Pathology and a fellow in the National
Association of Medical Examiners. He began the study of
forensic science as a forensic biologist for the Federal Bureau
of Investigation in 1997. Dr. Mitchell is a graduate of the New
Jersey Medical School.
Our third witness is the Honorable Joseph V. Cuffari. He
was confirmed as the Department of Homeland Security's
inspector general on July 25, 2019. Dr. Cuffari previously
served as a policy adviser for Military and Veteran Affairs for
the Governors of Arizona. He also served more than 40 years in
the United States Air Force. Dr. Cuffari earned a Ph.D. in
management in 2002.
Our final witness is Ms. Rebecca Gambler, a director in the
Government Accountability Office, Homeland Security and Justice
team. Ms. Gambler joined GAO in 2002, and currently leads the
agency's work on border security immigration and election
issues.
Without objection, the witnesses' full statements will be
inserted in the record. I now ask each witness to summarize his
or her statement for 5 minutes, beginning with Dr. Danaher.
STATEMENT OF FIONA S. DANAHER, M.D., M.P.H., PEDIATRICIAN,
CHELSEA PEDIATRICS, CHILD PROTECTION TEAM, MASSACHUSETTS
GENERAL HOSPITAL, INSTRUCTOR IN PEDIATRICS AT HARVARD MEDICAL
SCHOOL
Dr. Danaher. Good morning, Chairman Thompson, Ranking
Member Rogers, and Members of the committee. Thank you for the
opportunity to testify before you today.
I am Dr. Fiona Danaher, a pediatrician at Massachusetts
General Hospital for Children, where much of my clinical work
focuses on the care of children in immigrant families. It is a
privilege to participate in this committee's efforts to improve
the care of children in U.S. Customs and Border Protection
custody.
As you know, in December 2018, 2 young children fleeing
entrenched poverty in their rural Guatemalan villages became
the first migrant children without underlying medical
conditions to die in U.S. custody in a decade. Jakelin Caal
Maquin, age 7, died from septic shock, which, because it went
untreated over many hours, cascaded into multiple organ
failure. Felipe Gomez-Alonso, age 8, died from untreated
influenza complicated by pulmonary hemorrhage in the context of
bacterial pneumonia and sepsis.
Their deaths as well as those of 4 other children in
Government custody between September 2018 and May 2019
underscore the deficiencies in an immigration system poorly
designed to protect the well-being of vulnerable children.
Review of available records makes clear that Jakelin and
Felipe both suffered terrifying and painful deaths that could
potentially have been prevented by timely access to pediatric
medical care.
In both cases, medical examiners determined the children
had died of natural causes and the OIG concluded there was no
misconduct or malfeasance by DHS personnel. However, death by
natural causes does not mean that death was inevitable. Lack of
misconduct or malfeasance or even the great efforts several
agents went to in assisting the children does not absolve CBP
as an agency of perpetuating systems that placed children at
risk for medical neglect.
CBP responded to Jakelin and Felipe's deaths by issuing an
interim enhanced medical efforts directive in January 2019 to
ensure that all children under the age of 18 received health
interviews and medical screenings while in CBP custody.
However, the final enhanced medical support efforts directive
issued by CBP in December 2019 removed many of the safeguards
instituted under the interim guidance, weakening it so much
that, had it been in place at the time of Jakelin and Felipe's
presentations, it is unlikely its provisions would have
prevented their deaths.
Children are not little adults. Their remarkable
physiological resilience can mask severe disease from those
untrained to recognize it. Any period of detention is
inherently unhealthy for children's long-term physical and
emotional development, but detention in substandard conditions
places children's very lives at risk.
If children are to be detained in CBP facilities, it is
incumbent upon the agency to strengthen its medical
infrastructure. Jakelin and Felipe's deaths illustrate the need
for CBP to eliminate bureaucratic hurdles that unnecessarily
prolong detention and delay access to medical care. They also
highlight the urgency of addressing detention conditions that
promote illness and its spread.
Children in detention need timely access to comprehensive
medical screenings in their native language conducted by
clinicians with pediatric expertise, followed by referral, as
appropriate, to pediatric medical centers.
Those diagnosed with illnesses or underlying medical
conditions should not return to detention facilities, which are
fundamentally unequipped to provide safe observation or promote
children's recuperation.
Teams of agents working in remote areas must include EMTs
with enhanced pediatric training. And all forward operating
bases and Border Patrol stations must be stocked with basic
pediatric medical equipment and with staff trained in its use.
CBP must implement the Centers for Disease Control and
Prevention's recommendations for the prevention of influenza
and COVID-19 at its facilities.
Independent oversight of the quality of medical care
provided to detainees needs to occur regularly, as the OIG
indicated in its own capping report that it does not possess
the necessary medical expertise for the task.
Given the current COVID-19 epidemic and the impending
arrival of another influenza season, time is of the essence.
Action must be taken now to apply the lessons learned from
Jakelin and Felipe's tragic deaths so that other children do
not meet similarly painful and preventable fates while in
custody of the U.S. Government.
Thank you, and I look forward to taking your questions.
[The prepared statement of Dr. Danaher follows:]
Prepared Statement of Fiona S. Danaher
July 15, 2020
introduction
In December 2018, 2 young children fleeing entrenched poverty in
their rural Guatemalan villages became the first migrant children
without underlying medical conditions to die in U.S. custody in a
decade. Jakelin Caal Maquin, age 7, died from septic shock which,
because it went untreated over many hours, cascaded into multiple organ
failure. Felipe Gomez-Alonso, age 8, died from untreated influenza
complicated by pulmonary hemorrhage in the context of bacterial
pneumonia and sepsis. Both children suffered terrifying and painful
deaths that could potentially have been prevented by timely access to
pediatric medical care. Their deaths, as well as those of 4 other
children in Government custody between September 2018 and May 2019,
underscore the deficiencies in an immigration system poorly designed to
protect the well-being of vulnerable children.
systemic inadequacies
Review of the circumstances surrounding Jakelin and Felipe's deaths
suggests that multiple systemic inadequacies in CBP's management of
child detainees align to place them at risk for grave harm.
Inadequate screening.--Initial medical screening for Jakelin
consisted of one agent shouting to the large group of migrants
with whom she was apprehended that those who were sick should
come forward. This cursory process assumed that all the
migrants would hear the agent, understand Spanish, and feel
comfortable disclosing their medical concerns in front of many
other people. Not surprisingly, Jakelin was not the only sick
child in the group who went unidentified as a result.
Completing any further health screening at the forward
operating base where she was apprehended was not standard
operating procedure at the time. Additional screening did not
occur until after the first bus, which was supposedly reserved
for medically vulnerable migrants, had already left the remote
base for the Border Patrol station. The screening form used for
the health interview did not ask about specific symptoms of
illness like fever or vomiting, nor did it ask about chronic
medical conditions. The CBP agents who completed Jakelin's
health interview while she waited for the second bus did not
have appropriate qualifications to do so, did not base their
finding that Jakelin was ``mentally alert'' on the child's
current presentation (she was asleep), and did not conduct the
interview in the family's native language.
It is unclear from available records whether Felipe received any
medical screening during the 6 days in CBP custody before he
began to show signs of illness.
Inadequate training.--In both Jakelin and Felipe's cases,
CBP agents' lack of basic understanding of pediatric disease
processes led to deadly delays in accessing medical care.
Jakelin was suffering from sepsis, an overwhelming, systemic
infection that can rapidly progress to multiple organ failure.
Early signs of sepsis can be subtle and particularly
challenging to identify in children, who compensate well for
the ensuing cascade of organ dysfunction until their bodies
have exhausted all metabolic reserves. It is well-established
in emergency and critical care medicine that every hour of
delay in accessing treatment for sepsis dramatically increases
mortality risk, such that it is standard of care for patients
to receive antibiotics within 1 hour of presentation. The
remote forward operating base where Jakelin was apprehended was
not staffed with any EMTs, and standard operating procedure at
the time was to defer health interviews until detainees could
be transferred to a Border Patrol station nearly 100 miles
away. Given the poor screening Jakelin received at the base, it
is impossible to know at what point she became critically ill
in the approximately 7 hours that elapsed between her
apprehension and her father's request for medical assistance,
but because the agents did not recognize the urgency of the
situation or call an ambulance to meet them en route to the
Border Patrol station, an additional 2 hours elapsed before she
received any medical attention. By the time she finally
received antibiotics--which appears not to have happened until
she reached the hospital nearly 12 hours after apprehension and
more than 4 hours after her father sought help--she was too
sick to be saved.
The agents at the highway checkpoint where Felipe was detained also
seem not to have recognized the severity of his illness. He was
observed having abdominal pain and difficulty breathing hours
before he became critically ill, yet agents did not push for
Felipe to return to the hospital at that time. As he grew
sicker, Felipe undoubtedly experienced significant respiratory
distress and excruciating pain. Both he and his father stated
they thought he was going to die, yet the agents still
interpreted no urgency to the situation, allowing 73 minutes to
elapse from his father's request for medical care until arrival
of transport. Felipe became unconscious as he was loaded into
the CBP cruiser and was pulseless by the time he reached the
hospital.
Inadequate equipment and supplies.--The medical room at the
Border Patrol station where Jakelin first received treatment
was not stocked with basic medical equipment like oxygen,
airway kits, trauma kits, or defibrillators, forcing EMT agents
to leave her side to find them. The station lacked pediatric-
sized equipment like a pulse oximeter or blood pressure cuff to
assess Jakelin's vital signs. The highway checkpoint where
Felipe stayed was not stocked with basic medications like
acetaminophen or ibuprofen, and MedPAR would not cover them,
forcing CBP agents to pay out of pocket for medications to
manage Felipe's fever and pain.
Inadequate access to pediatric expertise.--Before receiving
medical attention, Jakelin was transferred almost 100 miles out
of the way to a Border Patrol station that was another 160
miles from the nearest children's hospital. Weeks after
Jakelin's death, the Hidalgo County Manager sent an urgent
request for assistance to the New Mexico congressional
delegation and Governor-elect, noting, ``Our Hidalgo County
Emergency Medical Services team consists of 7 full-time
employees and 5 volunteers'' to cover 5,000 square miles.\1\
About 10 percent of an EMT's training hours in New Mexico are
dedicated to pediatrics, amounting to just 4 hours for an EMT
Basic or 6 hours for a paramedic.\2\ The Hidalgo County
Emergency Medical Services director stated, ``Border Patrol
needs more than EMTs. They need . . . someone of a higher
level, so people get proper screenings. But they are not set up
for it. They were never set up for families coming across.''\1\
---------------------------------------------------------------------------
\1\ Villagran L. Southern New Mexico medical facilities strained to
meet the needs of migrants. Las Cruces Sun News. https://www.lcsun-
news.com/story/news/local/2019/02/05/nm-hospital-health-care-clinic-
migrants-asylum-seekers-ice/2743352002/. Published February 5, 2019.
Accessed July 11, 2020.
\2\ New Mexico EMS Bureau. Continuing Education and Renewal Guide
for EMT Licensure. https://www.nmhealth.org/publication/view/guide/
1894/. Published 2019. Accessed July 12, 2020.
---------------------------------------------------------------------------
Gerald Champion Regional Medical Center, the local hospital where
Felipe received care, does not have a dedicated pediatric
emergency department, inpatient unit or ICU. This lack of
pediatric expertise is reflected in the management he received
during his first emergency room visit, including failure to
recognize troubling vital signs, failure to reassess him prior
to discharge, prescription of an antibiotic for a viral
infection at a dose that would be subtherapeutic for a child
even if treating a bacterial infection, failure to prescribe
antiviral medication for influenza, and failure to notify CBP
of the child's diagnosis despite knowing he was returning to a
congregate setting where other detainees might be placed at
risk for contracting the disease.\3\
---------------------------------------------------------------------------
\3\ Gerald Champion Regional Medical Center. Association of Health
Care Journalists website. http://www.hospitalinspections.org/report/
26235. Accessed July 11, 2020.
---------------------------------------------------------------------------
Prolonged detention in conditions that promote illness.--
Felipe was detained in CBP facilities for 6 days, twice as long
as the 72-hour maximum generally permitted under CBP's National
Standards on Transport, Escort, Detention, and Search
(TEDS).\4\ The maximum incubation period for influenza is 4
days, so Felipe unquestionably contracted influenza while he
was in CBP detention. Felipe passed through multiple crowded
CBP facilities, and records suggest that he was cold and sleep-
deprived, all of which likely contributed to development of his
illness. Multiple published reports indicate that conditions
which promote vulnerability to infection are common in CBP
facilities: Overcrowding, abnormally cold temperatures,
inadequate access to shower facilities and basic hygiene
products (e.g., soap, toothbrushes, sanitary napkins), open
toilets, poor sleep conditions (sleeping on mats, cement
benches or floors under mylar blankets with 24 hour artificial
light exposure, in some cases without adequate space to lie
down), inadequate nutrition, inadequate access to clean
drinking water, and confiscation of needed medications without
supplying replacements.\5\ \6\ \7\ \8\ \9\ Such conditions not
only promote disease, but also inhibit recovery. As the
American Academy of Pediatrics has stated, children like Felipe
who are diagnosed with illness or special health care needs
should not be returned to CBP facilities, as ``the conditions
in the centers themselves exacerbate children's suffering'' and
are not conducive to recuperation.\10\
---------------------------------------------------------------------------
\4\ U.S. Customs and Border Protection. National Standards on
Transport, Escort, Detention, and Search. October 2015.
\5\ Linton JM, Griffin M, Shapiro AJ, AAP COUNCIL ON COMMUNITY
PEDIATRICS. Detention of Immigrant Children. Pediatrics.
2017;139(5):e20170483. doi: 10.1542/peds.2017-0483.
\6\ ACLU and University of Chicago Law School. Neglect and Abuse of
Unaccompanied Immigrant Children by U.S. Customs and Border Protection.
https://www.aclusandiego.org/civil-rights-civil-liberties/. Published
May 2018. Accessed July 11, 2020.
\7\ Cuffari JV. Office of Inspector General, Department of Homeland
Security. Capping Report: CBP Struggled to Provide Adequate Detention
Conditions During 2019 Migrant Surge. https://www.oig.dhs.gov/sites/
default/files/assets/2020-06/OIG-20-38-Jun20.pdf. Published June 12,
2020. Accessed July 11, 2020.
\8\ Halevy-Mizrahi NR, Harwayne-Gidansky I. Medication
Confiscation: How Migrant Children Are Placed in Medically Vulnerable
Conditions. Pediatrics. 2020; 145(1):e20192524. doi: 10.1542/peds.
2019-2524.
\9\ Peeler KR, Hampton K, Lucero J, Ijadi-Maghsoodi R. Sleep
deprivation of detained children: Another reason to end child
detention. Health and Human Rights. 2020;22(1):317-320. https://
www.hhrjournal.org/2020/01/sleep-deprivation-of-detained-children-
another-reason-to-end-child-detention/. Accessed July 11, 2020.
\10\ Testimony for the Record on Behalf of the American Academy of
Pediatrics Before the U.S. House of Representatives Committee on
Homeland Security, Subcommittee on Border Security, Facilitation, &
Operations. Assessing the Adequacy of DHS Efforts to Prevent Child
Deaths in Custody. https://downloads.aap.org/DOFA/
Jan%202020%20Hearing%20Statement%20for%20- the%20Record%20%20AAP.pdf.
Published January 14, 2020. Accessed July 11, 2020.
---------------------------------------------------------------------------
Inability to appropriately isolate and monitor ill
detainees.--The agents responsible for monitoring Felipe when
he returned from his first trip to the hospital had limited
options for doing so safely: They could either observe him
closely in the ``bubble'' processing area, where he potentially
exposed staff and other detainees to infection, or place him in
a rear cell where observation was more challenging. It seems
that once he was back in his cell, agents only checked on him
through the door, even after they were made aware that his
condition was declining. (Publicly-released video footage of
the influenza-related death of Carlos Gregorio Hernandez
Vasquez, another child in CBP custody who was placed in a cell
to convalesce, suggests that documented wellness checks may not
always in fact occur.)\11\
---------------------------------------------------------------------------
\11\ Moore R. Six Children Died in Border Patrol Care. Democrats in
Congress Want to Know Why. Pro Publica. https://www.propublica.org/
article/six-children-died-in-border-patrol-care-democrats-in-congress-
want-to-know-why. Published January 13, 2020. Accessed July 6, 2020.
---------------------------------------------------------------------------
Frequent transfers between crowded facilities promote
disease spread.--Felipe passed through 4 overcrowded facilities
in 6 days. Studies have demonstrated that ``frequent
interfacility transfers, influence disease transmission
dynamics. Rapid turnover creates an inflow of people in rapidly
consecutive cohorts (a `revolving doors' effect). An inflow of
susceptible people within a closed or semi-open community
experiencing an outbreak, has been shown to slow the creation
of herd immunity and can act as a transmission amplifier, while
interfacility transfers can facilitate disease spread.''\12\
The infection control challenges posed by overcrowding and
frequent transfers are underscored by the fact that Felipe's
young cellmate developed influenza symptoms the day after
Felipe's death.
---------------------------------------------------------------------------
\12\ Riccardo F, Suk JE, Espinosa L, et al. Key Dimensions for the
Prevention and Control of Communicable Diseases in Institutional
Settings: A Scoping Review to Guide the Development of a Tool to
Strengthen Preparedness at Migrant Holding Centres in the EU/EEA. Int J
Environ Res Public Health. 2018;15(6):1120. doi:10.3390/ijerph15061120.
---------------------------------------------------------------------------
Bureaucratic barriers to care and release.--Paperwork seems
to have delayed medical evaluation in both Jakelin and Felipe's
cases. When Jakelin's group was apprehended, agents at the
forward operating base decided to complete the I-779 health
interview forms but had to wait for them to be delivered from
the Border Patrol station 2 hours away, so the first bus of
migrants was already loaded by the time the forms arrived. When
an agent first attempted to take Felipe to the hospital, agents
had to make multiple phone calls to determine how to find the
appropriate paperwork, which was being kept at a station 15
miles away. His second presentation to the emergency room was
also delayed because agents collected paperwork before checking
in on him.
Equally troubling are the bureaucratic and technological barriers
leading to Felipe's prolonged detention in the first place. Had
he been released sooner, his exposure to influenza--which
occurred at least 2 days into his detention--might have been
prevented.
Inadequate language capabilities.--All verbal communication
between CBP agents and Felipe and Jakelin's fathers occurred in
Spanish, despite the fact that neither are native Spanish
speakers. CBP does not systematically utilize effective tools
for identifying speakers of indigenous languages, who often
understand limited Spanish but feel pressured to communicate in
the language.\13\ Felipe's medical providers utilized a CBP
agent rather than their own certified medical interpretation
service to communicate information in Spanish regarding
Felipe's care, significantly increasing the risk of medical
errors.\14\ All consents and discharge paperwork were provided
in English and verbally translated by the CBP agent, which
raises the question of how much Felipe's father understood
about reasons to seek additional medical care. (Despite
documenting in the medical record that Felipe's father
verbalized understanding of the discharge instructions,
Felipe's nurse later acknowledged to CMS investigators that he
could not confirm if the father actually comprehended.)\3\
Jakelin's health interview was similarly conducted in Spanish,
which likely contributed to delays in identifying her illness.
---------------------------------------------------------------------------
\13\ Gentry B. Indigenous Language Speaking Immigrants (ILSI) in
the U.S. Immigration System, a technical review. http://
www.amaconsultants.org/uploads/Exclusion_of_Indigenous-
%20Languages_in_US_Immigration_System_19_June2015version_i.pdf.
Published May 26, 2015. Accessed July 6, 2020.
\14\ Flores G, Laws MB, Mayo SJ, et al. Errors in medical
interpretation and their potential clinical consequences in pediatric
encounters. Pediatrics. 2003;111(1):6-14. doi:10.1542/peds.111.1.6.
---------------------------------------------------------------------------
Lack of privacy.--Expecting detainees to disclose
potentially sensitive medical information in front of large
groups of other migrants upon apprehension at the border is
unrealistic. Despite an agent shouting to the group of migrants
with whom Jakelin traveled for those who were ill to come
forward, none did, and at least 2 sick children were missed as
a result. A recent OIG report includes photographs which
suggest that medical screenings in Border Patrol stations also
occur in large groups, affording detainees no privacy.\7\ Some
may hesitate to disclose their medical conditions in front of
other migrants with whom they share close quarters, for fear of
being stigmatized or receiving blame when other migrants fall
ill.
Lack of autonomy.--When Jakelin's father sought assistance
for his sick daughter from multiple agents at the forward
operating base, he was repeatedly told he would have to wait
until they reached the Border Patrol station, so he ceased to
advocate during transit even as she began to experience trouble
breathing. Detaining families robs parents of the autonomy to
make independent decisions about accessing medical care for
their children. Families in detention depend upon CBP agents
for all necessities and for timely processing; they may even
think that their familial integrity depends upon CBP agents'
good graces, given CBP's recent history of separating thousands
of families under the previous Zero Tolerance Policy. This
power dynamic engenders fear and poses a significant barrier to
requesting and accessing help.
cbp response: enhanced medical directives
In January 2019, CBP responded to Jakelin and Felipe's deaths by
issuing an Interim Enhanced Medical Efforts Directive to ensure that
all children under the age of 18 received health interviews and medical
screenings while in CBP custody.\15\ However, the final Enhanced
Medical Support Efforts Directive issued by CBP in December 2019
removed many of the safeguards instituted under the interim
guidance.\16\ The final directive:
---------------------------------------------------------------------------
\15\ U.S. Department of Homeland Security, U.S. Customs and Border
Protection. CBP DIRECTIVE NO. 2210-003: CBP Interim Enhanced Medical
Efforts. https://www.cbp.gov/sites/default/files/assets/documents/2019-
Mar/CBP-Interim-Medical-Directive-28-January-2019.pdf. Published
January 28, 2019. Accessed July 12, 2020.
\16\ U.S. Department of Homeland Security, U.S. Customs and Border
Protection. CBP DIRECTIVE NO. 2210-004: Enhanced Medical Support
Efforts. https://www.cbp.gov/sites/default/files/assets/documents/2019-
Dec/CBP_Final_Medical_Directive_123019.pdf. Published December 30,
2019. Accessed July 12, 2020.
---------------------------------------------------------------------------
Does not explicitly require the health interview to occur
upon initial processing unless a detainee volunteers a medical
concern;
Narrows the scope of a basic medical screening to no longer
specify inclusion of vital signs;
Mandates medical screenings only for children under 12 or
those with identified medical issues ``subject to availability
of resources and operational requirements,'' instead of for all
children under 18--despite the fact that 2 of the children who
died in CBP custody in 2019 were 16 years old;
Seems to reduce the qualifications required for performing
medical screenings, stating they will be conducted by health
care providers ``where available,'' and that CBP EMS personnel
may conduct them ``in exigent circumstances and based on
operational requirements'';
Permits ``basic, acute medical care, referral, and follow
up'' to occur on-site, which would further limit access to
health care providers with pediatric expertise. (CBP has
contracted with a small number of pediatric advisors to offer
consultation and training along the Southwest Border, but the
advisors generally do not provide direct patient care to
detainees.)\10\
Neither directive specifies the time frame within which children
must receive medical screening, and the final directive again places
the onus on parents to advocate to CBP agents for their children to
receive timely medical attention.
imminent risks
The limited scope of the protocols vaguely outlined in CBP's final
Enhanced Medical Support Efforts Directive will do little to protect
children in its custody from the threats posed by the upcoming
influenza season, the current COVID-19 outbreak, and other medical
emergencies that children will undoubtedly experience.
Half of the recent deaths of migrant children in Government custody
have been attributed to complications from influenza. Multiple
evidence-based strategies exist for preventing such deaths, including
offering the influenza vaccine to detainees, mandating vaccination for
staff working with detained populations, instituting comprehensive
screening and triage protocols, ensuring that those with potential
cases of influenza receive antiviral therapy like oseltamivir as soon
as possible and no more than 48 hours after onset of symptoms, offering
antiviral chemoprophylaxis to vulnerable detainees who may have been
exposed to index cases, minimizing overcrowding, providing appropriate
space for isolation and convalescence, and ensuring adequate access to
basic hygiene supplies like soap, hand sanitizer, and face masks. Teams
from the Centers for Disease Control and Prevention (CDC) visited CBP
facilities shortly after Jakelin and Felipe's deaths and made similar
recommendations.\17\ Yet CBP has explicitly stated it will not offer
influenza vaccination to detainees in its custody, and just 6 months
after Jakelin and Felipe's deaths, the Government argued in court that
maintaining ``safe and sanitary'' conditions in CBP detention did not
even require providing children with soap.\18\
---------------------------------------------------------------------------
\17\ Letter from Director of the Centers for Disease Control and
Prevention Dr. Robert Redfield to the Honorable Rosa DeLauro at 10-11.
https://www.warren.senate.gov/imo/media/doc/
CDC%20Response%20%20migrant%20vaccination.pdf. Published November 7,
2019. Accessed July 6, 2020.
\18\ Flynn M. Detained migrant children got no toothbrush, no soap,
no sleep. It's no problem, government argues. Washington Post. https://
www.washingtonpost.com/nation/2019/06/21/detained-migrant-children-no-
toothbrush-soap-sleep/. Published June 21, 2019. Accessed July 6, 2020.
---------------------------------------------------------------------------
The present COVID-19 epidemic lends even more urgency to improving
detention conditions and medical screening protocols. COVID-19 is more
contagious than influenza, and can cause extremely rapid and
unpredictable deterioration even in previously healthy individuals.
While children generally seem less vulnerable to the immediate effects
of COVID-19 infection (with notable exceptions among infants and those
with chronic medical conditions), some do become seriously ill with
COVID-19 symptoms, and others go on to develop the recently recognized
Multisystem Inflammatory Syndrome in Children (MIS-C) weeks after
primary infection. MIS-C is a poorly understood, dangerous condition
that can develop in children who may never have shown previous symptoms
of COVID-19. Its symptoms are vague--fever and any of a broad array of
cardiopulmonary, gastrointestinal, neurologic, mucocutaneous, and other
systemic manifestations--and identifying the condition and its
potentially life-threatening complications requires nuanced, pediatric-
specific clinical acumen along with extensive laboratory testing. In a
recent study of MIS-C cases across the United States--most of which (73
percent) occurred among previously healthy children--80 percent of
children required intensive care, 48 percent required medications to
maintain adequate blood pressure, 20 percent required mechanical
ventilation, 8 percent developed coronary artery aneurysms, and 2
percent died.\19\ Children detained in remote settings without adequate
medical screening and rapid access to pediatric expertise will be at
particular risk for poor outcomes from COVID-19 and MIS-C, including
long-term disability and death. The CDC has issued interim guidance on
management of COVID-19 in detention facilities--including social
distancing, provision of personal protective equipment, and enhanced
hygiene recommendations, along with other measures similar to those
recommended for influenza prevention--to which CBP should adhere.\20\
---------------------------------------------------------------------------
\19\ Feldstein LR, Rose EB, Horwitz SM, et al. Multisystem
inflammatory syndrome in U.S. children and adolescents. N Engl J Med.
June 29, 2020. doi: 10.1056/NEJMoa2021680.
\20\ Interim Guidance on Management of Coronavirus Disease 2019
(COVID-19) in Correctional and Detention Facilities. Centers for
Disease Control and Prevention website. https://www.cdc.gov/
coronavirus/2019-ncov/community/correction-detention/guidance-
correctional-detention.html. Updated May 7, 2020. Accessed July 6,
2020.
---------------------------------------------------------------------------
conclusions
Jakelin and Felipe's deaths could potentially have been prevented
had CBP established better systems to ensure adequate medical screening
and prompt access to pediatric medical care. The missed opportunities
preceding their deaths highlight that:
Children are not little adults. Their remarkable
physiological resilience can mask severe disease from those
untrained to recognize it.
Any period of detention is inherently unhealthy for
children's long-term physical and emotional development, as the
American Academy of Pediatrics has repeatedly stated, but
detention in substandard conditions places children's very
lives at risk.
If children are to be detained in CBP facilities, it is
incumbent upon the agency to strengthen its medical
infrastructure. CBP must eliminate bureaucratic hurdles that
unnecessarily prolong detention and delay access to medical
care; address detention conditions that promote illness and its
spread; and provide timely access to comprehensive medical
screenings in a detainee's native language, conducted by
clinicians with pediatric expertise, followed by referral as
appropriate to pediatric medical centers. Children diagnosed
with illnesses or underlying medical conditions should not be
returned to detention facilities, which are fundamentally
unequipped to provide safe observation or promote children's
recuperation.
Teams of agents working in remote areas must include EMTs
with enhanced pediatric training, and all forward operating
bases and Border Patrol stations must be stocked with basic
pediatric medical equipment and staff trained in its use.
CBP must implement CDC's recommendations for the prevention
of influenza and COVID-19 in its facilities.
Independent oversight of the quality of medical care
provided to detainees must occur regularly, as the OIG has
indicated it does not possess the necessary medical expertise
for the task.\7\
While CBP has increased the number of medical providers it employs
at the border, few have specific pediatric training, and most screening
continues to be performed by CBP agents.\7\ CBP has yet to demonstrate
any real commitment to improving the care it provides, as underscored
both by the weakening of its Enhanced Medical Support Efforts
Directive, and by recent revelations that the agency utilized line item
appropriations for ``consumables and medical care'' to fund its canine
program and purchase dirt bikes and riot helmets.\21\ Action must be
taken now to apply the lessons learned from Jakelin and Felipe's
untimely deaths, so that other children do not meet similarly painful
and preventable fates while in custody of the U.S. Government.
---------------------------------------------------------------------------
\21\ Armstrong TH. U.S. Government Accountability Office. Matter
of: U.S. Customs and Border Protection--Obligations of Amounts
Appropriated in the 2019 Emergency Supplemental. File B-331888.
Published June 11, 2020.
Chairman Thompson. Thank you very much for your testimony.
I now recognize Dr. Mitchell to summarize his statement for 5
minutes.
STATEMENT OF ROGER A. MITCHELL, JR., M.D., CHIEF MEDICAL
EXAMINER, OFFICE OF THE CHIEF MEDICAL EXAMINER, WASHINGTON, DC,
CLINICAL PROFESSOR OF PATHOLOGY AT THE GEORGE WASHINGTON
UNIVERSITY, ASSOCIATE PROFESSOR OF SURGERY AT HOWARD UNIVERSITY
Dr. Mitchell. Good afternoon, Chairman Thompson, Ranking
Member Rogers, and Members of the Committee on Homeland
Security. I am Dr. Roger Mitchell, Jr., and I currently serve
as the chief medical examiner of Washington, DC.
It brings me no pleasure to testify today on these deaths
in custody, but I appreciate the confidence of the committee in
asking me to do so. I have been asked to review the cases of
Jakelin Caal Maquin and Felipe Gomez-Alonso from the medical
examiner's perspective, specifically postmortem findings, the
autopsy report cause, and manner of death.
I have been studying deaths in custody for over 20 years.
Although when we think about deaths in custody, we are reminded
of deaths like George Floyd and Rayshard Brooks. Deaths in
custody occur under a continuum, a continuum that moves through
phases like arrest-related, pre-arrest-related, and more
importantly, for this case, in custody and incarceration, which
is short-term and long-term jail detention.
In addition, I have served as the chair of the Child and
Infant Fatality Review Committee for the District of Columbia
from 2014 to 2019. This committee had been tasked to review
infant and child deaths for the purposes of creating system-
centered recommendations intended to improve outcomes. This is
the lens in which I reviewed these following cases.
We know that Jakelin Caal Maquin was a 7-year-old female
child who was apprehended with her father on the U.S. border
and found to have a temperature of 105 and then subsequently
airlifted to a hospital where she was pronounced dead over 24
hours later. Jakelin suffered from septic complications from a
bacterial infection. The initial laboratory and autopsy
findings are consistent with bacterial sepsis. It is important
to note that sepsis can progress to organ failure and shock
rapidly. Therefore, early recognition and treatment are
critical.
So based upon the materials I had to review, and it is my
opinion that the cause and manner of death established by those
medical examiners is sufficient.
It is also my opinion that this death was preventable.
Although the actions taken by individual Border Patrol agents
seemed to be appropriate and timely, the larger Border Patrol
system lacks adequate human resources and physical
infrastructure to respond to medically fragile detainees,
especially children.
If the administration of the initial health assessment
questionnaire had been performed by a licensed medical
professional, the elevated body temperature would have been
detected and maybe have saved a life.
The next case, Felipe Gomez-Alonso, we know is an 8-year-
old male child who was apprehended with his father at the U.S.
border. They were detained at 3 different Border Patrol
stations before it was known that he was sick. He was found to
have a temperature of 103. Now, he was transported to a local
hospital, diagnosed with an upper respiratory infection,
prescribed medication and released, but then had to come back
because of a worsening condition and was pronounced shortly
after.
Felipe suffered complications of a flu viral infection
associated with a superimposed bacterial disease, a bacterial
infection again. The bacteria isolated were associated with an
aggressive exotoxin in a very highly contagious bacteria that
is particularly contagious in close quarters and conditions of
overcrowding. This exotoxin leads to severe rapidly progressing
hemorrhagic pneumonia, or necrotizing pneumonia. Based upon the
review of the materials available, it is my opinion that there
should have been highlighting of this necrotizing pneumonia in
the diagnosis, but nonetheless, a bacterial infection that led
to the death of this young child. The manner of death is
natural.
It is my opinion that this death also was preventable.
Overcrowding is a known condition of the Border Patrol
stations, and I believe that the overcrowding conditions may
have played a significant role in the infections that led to
Felipe's death. There are many missed opportunities to provide
life-saving care to this child, namely, the hospital's
mismanagement of this initial presentation.
However, again, if there was a licensed medical
professional who would have cared for this patient while at the
Border Patrol station during this initial assessment, then
there may have been a more informed assessment prior to his
initial presentation at the hospital, and may have led to
better outcomes.
So what are my recommendations? Well, enforcing control of
the population of the U.S. Border Patrol station to protect
against overcrowding; utilize medical personnel for the initial
health assessment of detainees, especially children; accompany
this initial assessment with a brief health screening
assessment, like touchless temperature checks and blood
pressure, glucose finger sticks or even a COVID nasal swab in
this environment; and develop an on-site clinical system for
the U.S. Border Patrol that has the ability to triage pediatric
patients. Maybe even electronic health records seeing that
these patients move from Border Patrol station to Border Patrol
station, and then retraining of our agents.
In conclusion, immediate and timely access to health care
assessment by a licensed trained medical professional could
have prevented the death of both Jakelin and Felipe. The death
of both these 2 children are symptoms of a more extensive
system that requires much improvement. No system is perfect,
but any system that is established by our Government must have,
at its core, the health and safety of all who come into contact
with it.
The cases of these 2 children must remind us that deaths in
custody are not merely a criminal justice issue, but a public
health warning. We must provide timely, accurate, and reliable
care, not only in the detention centers of our borders, but,
also, the streets of our cities, the jails of our counties, and
the prisons of our States.
I appreciate the work that this committee is doing to solve
this problem. I pray that this hearing does not only provide an
appearance of addressing the issue that I have outlined, but a
true call to action with resolutions. This may require your
dedication to this Nation beyond what is comfortable for some,
but I believe it is attainable.
Thank you, Chairman Thompson, and Members of the committee.
I am now available for any questions that you may have.
[The prepared statement of Dr. Mitchell follows:]
Prepared Statement of Roger A. Mitchell, Jr.
introduction
Good afternoon, Chairman Thompson, Ranking Member Rogers, and the
Members of the Committee on Homeland Security, my name is Dr. Roger A.
Mitchell, Jr., and I currently serve as the chief medical examiner for
Washington, DC. It brings me no pleasure to testify today on these
deaths in custody, but I appreciate the confidence of the committee in
asking me to do so. I take seriously the task that has been set before
me. I have been asked to review the cases of Jakelin Caal Maquin and
Felipe Gomez-Alonso from the medical examiner's perspective;
specifically the post-mortem findings, the autopsy report, the cause of
death, and the manner of death.
Before we get into the specifics of the cases, I would like to
provide some foundational elements related to the role the medical
examiner in the investigation, examination, certification, and
reporting of deaths in custody.
The medicolegal death investigation (MLDI) system in the United
States (U.S.) comprises both coroners and medical examiners. The
difference between these 2 types of systems varies based upon the
jurisdiction, as there is a lack of uniformity of how the MLDI system
is implemented across the Nation. In general, coroners are elected
officials who do not possess a medical education. In contrast, medical
examiners are board-certified forensic pathologists and are appointed
by governmental leadership. Both systems require that sudden and
unexpected deaths be reported to ensure proper investigation,
examination, and certification. Types of cases include homicides,
suicides, accidents, undetermined deaths, and even natural causes of
death. Also, most jurisdictions require the reporting of the sudden
deaths among children and those who die in the justice system's
custody. We see both criteria in the cases that we will discuss today.
I have been studying deaths in custody for over 20 years. Deaths of
men such as Amidou Diallo (NY) and Earl Faison (NJ) forced me to think
about deaths in custody as a public health issue. Although much of what
we think about when we hear the term ``deaths in custody'' are the
recent, prominent cases like the deaths of George Floyd and Rayshard
Brooks, we must remember that deaths in custody occur on a continuum.
The continuum moves through four (4) distinct phases with the overlap
of each period. The deaths in custody phases include: (1) Pre-arrest
related (during pursuit); (2) arrest-related (apprehension and
transport); (3) in-custody (in short-term holding, detention, and
jail); and (4) incarcerated (long-term jail, detention, or prison).\1\
\2\ Additional deaths in custody can occur during judicial executions
and post-custody (death within 1 year of release from jail or prison).
Most of the Deaths in Custody occur from natural causes within the
correctional system (jail, detention, or prison).\3\
---------------------------------------------------------------------------
\1\ Mitchell RA Jr, Diaz F, Goldfogel GA, et al. National
Association of Medical Examiners Position Paper: Recommendations for
the Definition, Investigation, Postmortem Examination, and Reporting of
Deaths in Custody. Acad Forensic Pathol. 2017;7(4):604-618.
doi:10.23907/2017.051
\2\ Frazer E, Mitchell RA Jr, Nesbitt LS, et al. The Violence
Epidemic in the African American Community: A Call by the National
Medical Association for Comprehensive Reform. J Natl Med Assoc.
2018;110(1):4-15. doi:10.1016/j.jnma.2017.08.009
\3\ Russo, Joe, Dulani Woods, John S. Shaffer, and Brian A.
Jackson, Caring for Those in Custody: Identifying High-Priority Needs
to Reduce Mortality in Correctional Facilities. Santa Monica, CA: RAND
Corporation, 2017. https://www.rand.org/pubs/research_reports/
RR1967.html.
---------------------------------------------------------------------------
In addition, I served as the chair of the Child and Infant Fatality
Review Committee for Washington, DC from 2014-2019. The committee is
tasked with the review of infant and child deaths for the purpose of
creating system-centered recommendations intended to improve outcomes
and prevent future deaths. During my tenure the committee reviewed
nearly 700 deaths.
It is with this lens that I review the following cases:
jakelin caal-maquin
Materials Reviewed.--Department of Homeland Security--Office of the
Inspector General, Report of Investigation (I19-BP-ELP-05501).
Brief History/Timeline
On December 6, 2018, Jakelin Caal-Maquin (Caal-Maquin), a 7-year-
old female child, and her father were apprehended by U.S. Customs and
Border Patrol (US-CBP) attempting entrance into the United States.
During the transportation from the location of apprehension to the US
Border Patrol (USBP) station (93 miles/2 hours away), US-CBP agents
were informed that Caal-Maquin complained of fever and vomiting. US-CBP
agents called ahead of their arrival to the USBP station, informing
them of a sick child on the bus. Caal-Maquin was found to have a
temperature of 105.7 degrees upon arrival at the USBP station were
Emergency Medical Technicians (EMT) tended to her, providing oxygen and
cold compress. Caal-Maquin was witnessed to have a ``seizure.'' She was
subsequently air-lifted to an area hospital from the USBP station.
Caal-Maquin was pronounced dead on December 8, 2018.
December 6, 2018
2115--Caal-Maquin encountered entering the U.S. Border.
December 7, 2018
0500--Caal-Maquin identified and communicated as sick and
vomiting
0630--Caal-Maquin arrives at USBP station; met by EMT
0640--County Emergency Management Services (EMS) arrives
at USBP station
0650--Emergency air ambulance service identified and
contacted
0730--Emergency air ambulance service arrives at USBP
station
0745--Emergency air ambulance service departs USBP station
with Caal-Maquin for hospital
0850--Emergency air ambulance service arrives with Caal-
Maquin at hospital
1100--Caal-Maquin goes into cardiac arrest and is revived.
December 8, 2018
0035--Caal-Maquin pronounced dead at the hospital.
Autopsy and Post-Mortem Findings
Cause of Death.--Sequelae of Streptococcal Sepsis.
Manner of Death.--Natural.
Pathological Findings:
I. Sequelae of Streptococcal Sepsis
a. Clinical Evidence of Disease
i. Increased Temperature--105.7 degrees
ii. Disseminated Intravascular Coagulation (DIC)
iii. Metabolic Acidosis
b. Required Fluid Resuscitation
i. Bilateral Pleural Effusions
1. 160 milliliters--Right
2. 180 milliliters--Left
ii. Peritoneal fluid retention
1. 210 milliliters
c. Patchy Bronchopneumonia, bilateral, base
i. Pulmonary Congestion
ii. Histological evidence of acute inflammation and gram-positive
cocci
1. Immunohistochemistry staining positive for Streptococcus
species
2. Real-time polymerase chain reaction (RT-PCR) positive for
Streptococcus species
d. Splenic Involvement
i. Histological evidence of reactive changes
ii. Immunohistochemistry staining positive for Streptococcus
species
e. Hepatic Involvement
i. Immunohistochemistry staining positive for Streptococcus
species
f. Adrenal Gland
i. Hemorrhage and necrosis consistent with Waterhouse-
Friderichsen Syndrome
ii. Immunohistochemistry staining positive for Streptococcus
species
iii. Real-time polymerase chain reaction (RT-PCR) positive for
Streptococcus species
II. Ascaris Lumbricoides Infection
a. 2-3 dozen nematodes of different sizes in the small bowel
i. Duodenum, proximal jejunum, near the ileocecal valve
1. No bowel obstruction.
summary opinion
The decedent is a 7-year-old female child who suffered septic
complications from a bacterial infection. The subspecies of
Streptococcus were unable to be determined; therefore, it is unclear
the specific bacterial cause of the child's infection. Nonetheless, the
clinical, laboratory, and autopsy findings are consistent with
bacterial sepsis. According to the literature, sepsis is defined as a
clinical syndrome resulting from a dysregulated systemic inflammatory
response to infection. It is the leading cause of morbidity and
mortality in children world-wide.\4\ It is important to note that
sepsis can progress to organ failure and shock rapidly. Therefore,
early recognition and treatment are critical. Initial treatment
includes immediate fluid resuscitation. The report also describes the
presence of Waterhouse-Friderichsen Syndrome (WFS). WFS is
characterized by hemorrhagic necrosis of the adrenal glands
accompanying vague symptoms of fever, fatigue, and weakness. According
to an article in the Pediatric Infectious Disease Journal, WFS can be
linked to streptococcal infections.\5\
---------------------------------------------------------------------------
\4\ Plunkett A, Tong J. Sepsis in children [published correction
appears in BMJ. 2015;350:h3704]. BMJ. 2015;350:h3017. Published 2015
Jun 9. doi:10.1136/bmj.h3017
\5\ Gertner M, Rodriguez L, Barnett SH, Shah K. Group A beta-
hemolytic Streptococcus and Waterhouse-Friderichsen syndrome. Pediatr
Infect Dis J. 1992;11(7):595-596. doi:10.1097/00006454-199207000-00019
---------------------------------------------------------------------------
Based on the review of the material available to this forensic
pathologist, it is my opinion that the cause and manner of death
established by the medical examiner are sufficient. It is also my
opinion is that this death was preventable. Although the actions taken
by individual US-CBP agents seem to be appropriate and timely, the
larger US-CBP system lacks adequate human resources and physical
infrastructure resources to respond to medically fragile detainees,
especially children. If the administration of the initial health
assessment questionnaire (I-779) had been performed by a licensed
medical professional (nurse practitioner, physician assistant, or
nurse), the elevated body temperature would have been detected.
The above opinion is established within a reasonable degree of
medical certainty.
Recommendations
Utilize medical personnel (physician, physician assistant,
nurse practitioner, or nurse) for the initial health assessment
of detainees, especially children.
Update the initial medical assessment form (I-779) to be
administered by licensed health care providers.
Accompanied by brief initial health screening including
touchless temperature check, blood pressure, glucose finger
stick, and COVID nasal swab.
Develop an on-site clinic system for US-CBP that has the
ability to triage pediatric patients (i.e. pediatric blood
pressure cuffs).
Establish electronic health record (EHR) for US-CBP.
Assess and reevaluate training for US-CBP.
Develop or improve emergency and acute care access standard
operating procedure.
felipe gomez-alonso
Materials Reviewed.--Department of Homeland Security-Office of the
Inspector General, Report of Investigation (I19-BP-ELP-06106), Autopsy
Report, Autopsy Photographs, Case Notes, Microbiology Report,
Toxicology Report, and Histology Slides.
Brief History/Timeline.--On December 18, 2018, Filipe Gomez-Alonso
(Gomez-Alonso), an 8-year-old male child, and his father were
apprehended by U.S. Customs and Border Patrol (US-CBP) attempting
entrance into the United States. They were detained at the first US-
Border Patrol (USBP) station until December 20, 2018. They were
transferred to a second USBP station because of limited space. Gomez-
Alonso and his father were finally moved to a third USBP station on
December 23, 2018. On December 24, 2018, Gomez-Alonso was found to have
``a loud, hoarse cough,'' complaining of a sore throat, upset stomach,
and a fever.
Alonso-Gomez was subsequently transported to the local hospital
emergency room. Clinicians at the hospital saw him. He was, found to
have a temperature of 103 F. A pharyngeal swab was positive for
influenza, and he was diagnosed with an upper respiratory infection
(URI). Alonso-Gomez was prescribed acetaminophen and an antibiotic and
released from the hospital.
Alonso-Gomez was transported back to the USBP station by US-CBP
agents. Reportedly, he seemed to improve over the next several hours
before an acute decline in his health status. He complained of severe
stomach pain and vomiting, which required urgent transportation back to
the hospital. Upon arrival at the hospital, Gomez-Alonso was found to
be in cardiopulmonary arrest. He was pronounced dead on December 24,
2018.
December 18, 2018
1525--Gomez-Alonso encountered entering the U.S. Border
and transported to the first USBP station
December 20, 2018
1200--Gomez-Alonso transported to second USBP station due
to overcrowding
Remained at second USBP station
December 23, 2018
2317--Gomez-Alonso transported to the third USBP station
December 24, 2018
0100-0557--Gomez-Alonso arrival and intake process
complete at the third USBP station
0900--Gomez-Alonso requires medical attention
0930--Gomez-Alonso arrives at hospital
1345--Gomez-Alonso diagnosed with Influenza B, provided
with prescriptions for acetaminophen and amoxicillin and
released from the hospital
1700--Gomez-Alonso given medications back at the USBP
station
1800--Wellness check of Gomez-Alonso by USBP agents
1930--Wellness check of Gomez-Alonso by USBP agents
2100--Wellness check of Gomez-Alonso by USBP agents
2145--Gomez-Alonso requests to return the hospital
2200--USBP assigned transportation
2258--Gomez-Alonso transported to the hospital
2315--Gomez-Alonso arrives at hospital and receives
emergency treatment
2348--Gomez-Alonso is pronounced dead.
Autopsy and Post-Mortem Findings
Cause of Death.--Complications of Influenza B infection with
Staphylococcus aureus superinfection and sepsis.
Manner of Death.--Natural.
Pathological Findings
I. Complications of Influenza B infection with Staphylococcus
aureus superinfection and sepsis.
a. Clinical Findings at the Initial Hospital Visit
i. Temperature--103.46F
ii. Peripheral Pulse--146 bpm
iii. Oxygen Saturation (SpO2)--91 percent
iv. Influenza B--Test positive (12/24/2018)
b. Necrotizing Pneumonia (Pulmonary Hemorrhage and Edema)
i. Bronchopneumonia, marked
1. Diffuse alveolar damage
2. Bacterial blood and lung cultures positive for Methicillin
Sensitive Staphylococcus aureus (MSSA)
a. Immunohistochemical and Real-Time Polymerase Chain
Reaction (RT-PCR)--Positive
b. Panton-Valentine leucocidin (PVL)--Positive
3. Influenza B virus positive by Real-Time Polymerase Chain
Reaction (RT-PCR).
Summary Opinion
The decedent is an 8-year-old male child who suffered complications
of influenza viral infection associated with a superimposed bacterial
disease. According to the Infectious Disease Pathology Branch (IDPB) of
the Centers for Disease Control (CDC), the bacteria isolated were
methicillin-sensitive Staphylococcus aureus (MSSA) with associated
Panton-Valentine leucocidin (PVL) exotoxin. It is a significant factor
that led to the death. MSSA is highly contagious, particularly in close
quarters or conditions of overcrowding. PVL-positive MSSA is a severe
infection, often associated with influenza disease, that leads to
rapidly progressing necrotizing pneumonia.\6\
---------------------------------------------------------------------------
\6\ Karli A, Yanik K, Paksu MS, et al. Disseminated Panton-
Valentine Leukocidin-Positive Staphylococcus aureus infection in a
child. Arch Argent Pediatr. 2016;114(2):e75-e77. doi:10.5546/
aap.2016.eng.e75
---------------------------------------------------------------------------
Based upon the review of material available to this forensic
pathologist, it is my opinion that the cause of death should read
Necrotizing pneumonia due to methicillin-sensitive Staphylococcus
aureus complicating Influenza B viral infection. The manner of death is
natural.
It is also my opinion that this death was preventable. Overcrowding
is a known condition of the USBP stations. I believe the overcrowded
conditions played a significant role in the decedent developing the
infections that led to his death. Although the actions taken by
individual US-CBP agents seem to be appropriate and timely, the larger
US-CBP system lacks adequate human resources and physical
infrastructure to respond to medically fragile detainees, especially
children. There were many missed opportunities to provide life-saving
care to this child, namely the hospital's mismanagement of his initial
presentation. However, if a licensed medical professional (nurse
practitioner, nurse, or physician assistant) would have cared for this
patient throughout his stay within the detention station, the patient
would have had a more informed assessment before presenting to the
hospital during his initial visit and beyond.
The above opinion is established within a reasonable degree of
medical certainty.
Recommendations
Enforce and control the population in USBP stations to
protect against overcrowding.
Utilize medical personnel (physician, physician assistant,
nurse practitioner, or nurse) for initial health assessment of
detainees, especially children.
Update the initial medical assessment form (I-779) to be
administered by licensed health care providers.
Accompanied by brief initial health screening
including touchless temperature check, blood pressure,
glucose finger stick, and COVID nasal swab.
Develop an on-site clinic system for US-CBP that has the
ability to triage pediatric patients (i.e. pediatric blood
pressure cuffs).
Establish electronic health record (EHR) for US-CBP.
Assess and reevaluate training for US-CBP agents.
Develop or improve emergency and acute care access standard
operating procedure.
conclusion
In conclusion, immediate and timely access to a health care
assessment by licensed and trained medical professionals could have
prevented the deaths of both Jakelin Caal Maquin and Felipe Gomez-
Alonso. The deaths of these 2 children are a symptom of a more
extensive system that requires much improvement. No system is perfect,
but any system established by our Government must have at its core the
health and safety of all who come into contact with it. There is an
excellent opportunity to make the necessary investment to ensure life-
saving medical care to sick men, women, and children. The cases of
these 2 children remind us that deaths in custody are not merely a
criminal justice issue, but a public health issue. We must treat those
who die in the custody of our detention system as preventable,
revealing a system that is able to improve.
In 2017, the National Institute of Justice (NIJ) in collaboration
with the RAND Justice Policy Program hosted an expert panel of prison
and jail administrators, researchers and health care professionals
entitled, Caring for Those in Custody: Identifying High-Priority Needs
to Reduce Mortality in Correctional Facilities.\3\ I had the pleasure
of serving on this panel, and what we realized is that those who find
themselves incarcerated, for whatever the reason, either arrive with or
acquire health conditions that become the responsibility of the
institution. We have an obligation to make sure that all who come into
our custody receive timely, accurate, and reliable care. We must
provide reliable care in the detention centers of our borders, but also
on the streets of our cities, the jails of our counties, and the
prisons of our States.
I appreciate the work that this committee is doing to solve this
problem. I pray that this hearing does not only provide an
``appearance'' of addressing the issues that I have outlined, but is a
true ``call to action'' with resolutions. This may require your
dedication to this Nation beyond what is comfortable, but I believe it
is attainable. Thank you, Chairman Thompson and Members of the
committee. I am now available to answer any questions that you may
have.
Chairman Thompson. Thank you, Doctor, for your testimony.
I now recognize Inspector General Cuffari to summarize his
statement for 5 minutes.
STATEMENT OF JOSEPH V. CUFFARI, INSPECTOR GENERAL, U.S.
DEPARTMENT OF HOMELAND SECURITY
Mr. Cuffari. Good afternoon, Chairman Thompson, Ranking
Member Rogers, and Members of the committee. Thank you for
inviting me to discuss our work related to children in CBP
custody.
My testimony today will include a discussion of our
investigations of the deaths of the 2 migrant children while in
CBP custody, the findings of our unannounced inspections of CBP
facilities, and an overview of our data-driven, risk-based
audits, inspections, and investigations.
No parent should have to go through the devastation of
losing a child. My deepest condolences go out to the families
who suffered this terrible loss. I am a parent and a new
grandparent myself. I find the deaths of both children
heartbreaking. Although they died within 18 days of each other
and less than 100 miles apart, each circumstance was unique and
our office conducted separate investigations. The scope of both
investigations was to determine the circumstances of the in-
custody deaths of the children, including any form of
misconduct by CBP personnel.
We dedicated several special agents to each investigation,
along with multiple support staff. We were augmented by CBP,
OPR in one case. In total, we conducted 44 interviews between
the 2 investigations, we reviewed voluminous medical records
and reports. Neither investigation found misconduct or
malfeasance on the part of CBP personnel. In fact, both
investigations determined that the CBP employees involved
exhibited great concern for the children's welfare and obtained
medical treatment without delay.
During fiscal year 2019, CBP experienced a surge in
families and unaccompanied children crossing the Southwest
Border, and apprehended more than twice the undocumented aliens
during fiscal year 2019, than in any other previous 4 full
fiscal years. Our office has, for many years, conducted
unannounced inspections at CBP facilities to evaluate their
compliance with CBP's transport, escort, detention, and search
standards known as your TEDS standards. During our unannounced
visits, we focus our elements of the TEDS standards that can be
observed and evaluated by our inspectors without specialized
law enforcement or medical training.
We recently issued a capping report summarizing our 2019
unannounced inspections. Our inspections found medical coverage
varied by facility. The facilities we did visit generally met
the TEDS standards for access to medical care. Nevertheless,
crowded conditions presented health challenges, including
containing the spread of contagious diseases. Given these
observations, we have initiated an audit of CBP policies and
procedures for handling medical intervention and detention.
With the surge in apprehension in 2019, we observed more and
severe overcrowding, and recommended that DHS take immediate
steps to alleviate it. Our capping report supplemented that
recommendation and made 2 additional recommendations related to
telephone access to unaccompanied children and proper handling
of detainee property.
DHS is on track to implement these recommendations by the
end of this calendar year. Given our observations of detainees
being held beyond the 72 hours generally permitted in TEDS
standards, we also initiated a review which is on-going, to
identify the key factors contributing to prolonged CBP
detention.
We have more than 20 other on-going or planned projects
reviewing ICE and CBP. We appreciate the committee's continued
interest in our work and for Congress' robust funding this
current fiscal year. With your increased funding, we are
contracting for medical professionals to supplement our
expertise across audits, inspections, and investigations. I am
pleased to report this contract will be awarded in the next few
weeks.
In October 2019, I personally observed the conditions at
the Southwest Border when I visited DHS facilities and
operations in both El Paso and the Tucson areas. Our office
continues to monitor the situation at the border and recommend
improvements to DHS programs and operations.
Mr. Chairman, this concludes my testimony. Thank you for
the opportunity to discuss our important work here today and I
am happy to answer your or the Members' questions that you may
have. Thank you.
[The prepared statement of Mr. Cuffari follows:]
Prepared Statement of Joseph V. Cuffari
July 15, 2020
Chairman Thompson and Ranking Member Rogers, thank you for the
opportunity to testify today about the Department of Homeland Security
(DHS) Office of Inspector General's (OIG)'s work related to children in
U.S. Customs and Border Protection (CBP) custody. My testimony today
will include a discussion of our investigations of the tragic deaths of
2 migrant children while in CBP custody, our unannounced inspections of
CBP facilities, and related on-going work.
OIG is organized into 3 operational elements: The Office of
Investigations, comprised of special agents who investigate criminal
and administrative misconduct on the part of DHS personnel,
contractors, and grantees; the Office of Special Reviews and
Evaluations, comprised of inspectors, analysts, and attorneys who
inspect, evaluate, and review DHS programs and operations; and the
Office of Audits, comprised of auditors and analysts who conduct
financial, grant, and performance audits.
My testimony today includes work by all 3 of our organizational
units; specifically, our special agents who investigated the
circumstances of 2 children who died in CBP custody in December 2018;
our inspectors who conduct unannounced inspections of CBP holding
facilities; and our auditors who have on-going work relevant to the
committee's interests here today.
My testimony today includes a discussion of the conditions on the
Southwest Border in late 2018 and throughout 2019. Prior to my
confirmation by the Senate in July 2019, I committed to your
counterparts on the Senate Homeland Security Committee that I would
visit the Southwest Border and observe these conditions personally if
confirmed. After my confirmation, I also personally committed to this
committee to do the same. I was able to do so in October 2019, when I
visited DHS facilities and operations in both the El Paso and Tucson
Sectors.
investigations of the death of children while in cbp custody
On December 8, 2018, a 7-year-old girl from Guatemala died while in
CBP custody. Subsequently, on December 25, 2018, an 8-year-old boy
passed away while in CBP custody. DHS OIG Special Agents from our El
Paso Field Office conducted 2 separate investigations to determine the
circumstances of the in-custody deaths of both children, including any
form of misconduct by CBP personnel, and if misconduct was found, to
determine if it was criminal or administrative.\1\
---------------------------------------------------------------------------
\1\ These investigations were not intended to be systemic reviews
that would evaluate CBP's policies or procedures for caring for
migrants in custody or from which over-arching conclusions about CBP's
role could be drawn. While these investigations were not program
evaluations of CBP procedures, we do have an on-going audit regarding
CBP's procedures for detained migrants experiencing serious medical
conditions.
---------------------------------------------------------------------------
Both of our investigations determined that all CBP employees who
were involved did everything possible to ensure both children received
medical treatment. Our investigations did not find misconduct or
malfeasance on the part of any CBP personnel.
Although the deaths of these 2 children occurred within 18 days of
each other and less than 100 miles apart, each circumstance was unique
and our office conducted separate investigations of each death. I will
provide the committee a summary of each investigation, beginning with
the death of the 7-year-old girl.
investigation concerning the death of a 7-year-old girl
The 7-year-old girl and her father entered the United States on
December 6, 2018 and were apprehended by Border Patrol agents with a
large group of undocumented aliens at Forward Operating Base (FOB)
Bounds, near the Antelope Wells, New Mexico, Port of Entry. During
intake processing, Border Patrol agents conducted brief medical
assessrnents of all detainees in the group and memorialized the
assessments on the required form (I-779). DHS OIG reviewed the form for
the girl and found that it was signed by her father and reported that
both the child and her father were in good health. Border Patrol made
arrangements to transport the detained migrants by bus from FOB Bounds
to the Border Patrol station in Lordsburg, New Mexico, 93 miles away,
for further processing and for short-term detention. Because the group
was large, the bus would need to make 2 round trips to transport them.
Prior to transport, the group of undocumented aliens, to include the
girl and her father, were asked again by Border Patrol agents if anyone
was sick, pregnant, or was an unaccompanied child. DHS OIG was told
that if anyone met these conditions, it was CBP's practice that they
would be assigned to the first bus going to the Lordsburg station for
processing. According to the interviews we conducted, no one came
forward with these conditions.
Our investigation determined that because the Border Patrol was not
aware of the child's illness, she and her father were assigned to the
second bus transporting the undocumented aliens to the Lordsburg
station. While boarding the bus, the child's father reported to one of
the drivers that she was sick and vomiting. The driver notified his
supervisor, who called ahead to the Lordsburg station, notifying them
that there was a sick child on the bus.
According to our interviews, during transport to the Lordsburg
station, the girl's father did not report to CBP that she was vomiting.
However, according to interviews of the other bus passengers, the
father did approach several other riders to ask for medicine for his
daughter. When the bus arrived at the Lordsburg station, the child and
her father were the first ones off the bus and were immediately met by
the CBP paramedic on duty.
The girl's father reported to the paramedic that she was not
breathing. After the paramedic performed a quick assessment, he
determined that the child was breathing, but was having difficulty, and
asked someone to call 911. Two additional CBP EMTs joined to assist
with assessing and providing care to the child. Her father reported to
the EMTs that she had not eaten and had been throwing up for the last 2
to 4 days. The paramedics took her temperature and discovered she had a
fever of 105.7 degrees Fahrenheit. They administered oxygen with a mask
and applied ice packs and wet towels in an attempt to cool her down.
They were unable to provide children's Tylenol to the child because she
could not swallow. Similarly, the paramedics were unable to intubate
her because a manipulation of her mouth would have caused her to vomit.
County Emergency Medical Services (EMS) arrived approximately 10
minutes after the 911 call. The EMS staff performed life support
measures, including oxygen and intravenous fluids, and recommended that
the child be transported to the hospital by ground transport, which
would have taken approximately 2 hours. Due to her worsening condition,
the Lordsburg station paramedic recommended she be transported by air,
to get her to the hospital faster. The air support was cleared to f1y
and arrived at the Lordsburg station approximately 40 minutes after it
was requested. The child was transported to El Paso Children's
Hospital--a level I trauma center.
The child arrived at the Hospital in El Paso, TX on December 7,
2018 and passed away on December 8, 2018. The medical examiner's report
concluded that she died from organ dysfunction caused by sepsis, a
rapidly progressive infection, and systemic bacterial spread.
DHS OIG received notice of the child's death on December 14, 2018
from CBP OPR and immediately initiated an investigation. The OIG
conducted the first interviews on December 15, 2018.
We dedicated 7 agents and 2 support staff to investigate her death.
Our investigation included interviews with approximately 23 individuals
who had direct contact with the child and her father, or may have
witnessed her condition. These individuals included Border Patrol
agents and apprehended detainees who had contact with the child and her
father. We reviewed all audio and video evidence that was available;
including 8 DVDs of video footage and recorded radio communications. We
also reviewed the detailed medical examiner's report documenting the
causes of death. Our investigation did not reveal any evidence of CBP
employee malfeasance or misconduct.
investigation concerning the death of an 8-year-old boy
An 8-year-old boy and his father were apprehended in El Paso, Texa
on December 18, 2018. They were processed at the Paso Dd Norte Station
and then transferred to the El Paso Station due to detention space
limitations. They remained at the El Paso Station until December 23,
2018, when they were transferred to Alamogordo, New Mexico to complete
processing and then transferred to Highway 70 Alamogordo Checkpoint to
await family placement.
On December 24, 2018, while at the Highway 70 Alamogordo
Checkpoint, a Border Patrol agent observed the child in need of medical
attention. The boy and his father were transported to the Gerald
Champion Regional Medical Center for treatment. According to our
interviews, while at the hospital, a medical professional administered
acetaminophen to the child and informed his father that he had an upper
respiratory infection. The corresponding hospital discharge paperwork
also stated the child was diagnosed with an upper respiratory infection
but prescribed ibuprofen. Medical records reviewed by OIG from the
emergency room visit stated the diagnosis was a suspected acute upper
respiratory infection and noted ``low suspicion for any serious medical
infection.''
Hospital records reviewed by OIG indicated that the child was
tested for Strep, Influenza A, and Influenza B during his first visit
to the hospital. According to the records, the test for Influenza B was
positive and the tests for Strep and Influenza A were negative.
Hospital personnel did not tell Border Patrol or the child's father
that he was diagnosed with Influenza B. The hospital discharge
paperwork also did not include a diagnosis of Influenza B.
According to our interviews, the hospital called in a prescription
to a nearby pharmacy for acetaminophen and amoxicillin. The hospital
discharge paperwork; however, references only a prescription for
ibuprofen. On their return trip from the hospital, the Border Patrol
agent stopped at the pharmacy to fill the prescriptions; however, he
was told that one prescription was not ready and the other would not be
covered under insurance. The agent, the child, and the child's father
left the pharmacy with no prescriptions.
That evening, a second Border Patrol agent went back to the
pharmacy to pick up both prescriptions. and paid for one of them with
his personal funds. When he returned, the child was given both
medications. Approximately an hour after receiving the medications, the
child's father reported that the child was feeling better and had
eaten. However, later that night, the child's father requested to
return to the hospital because his son was feeling ill again. A Border
Patrol agent drove the child and his father to the Gerald Champion
Regional Medical Center again.
Upon arriving at the hospital, the Border Patrol agent found the
child's father holding him and crying. The agent observed blood on the
father's hand. The child received immediate attention from the hospital
staff, but was pronounced dead a short time later.
The State medical examiner's autopsy report found the cause of the
child's death was ``complications of influenza B infection with
Staphylococcus aureus superinfection and sepsis.''
DHS OIG received notice of the child's death from CBP's Office of
Professional Responsibility (OPR), on December 25, 2018, and initiated
an investigation into the circumstances surrounding the death that same
day. Because this was the second death investigation of a child in CBP
custody in a short time frame, and because a large number of OIG agents
were already assigned to the investigation of the death of the 7-year-
old girl, the OIG decided to leverage assistance from CBP OPR with
conducting specific parts of the investigation, for example interviews.
Our investigation included interviews with 11 individuals who had
direct or indirect contact with the child and his father. These
individuals included Border Patrol agents, apprehended detainees who
had contact with the child and his father, and the Public Information
Officer at the Gerald Champion Regional Medical Center. We reviewed
video footage of the child and his father's initial apprehension,
footage from their holding cell at Alamogordo, and footage from the
Gerald Champion Regional Medical Center. We also reviewed the detailed
medical examiner's report documenting the causes of death. Our
investigation did not reveal any evidence of CBP employee malfeasance
or misconduct.
Upon the conclusion of both investigations, we posted summaries of
the investigations on our public website. While we are prohibited by
privacy laws from posting full OIG reports of investigation, in an
effort to be transparent about OIG's work, we determined in these
instances that public summaries were appropriate. We provided both
reports to the committee after receiving a written request from the
Chairman. We have also provided 2 briefings to committee staff
regarding the investigations, and exchanged written correspondence with
the committee regarding several outstanding questions.
dhs office of inspector general's unannounced inspections of cbp
facilities
DHS OIG initiated an unannounced inspections program several years
ago in response to concerns raised by Congress about conditions for
aliens in CBP and U.S. Immigration and Customs Enforcement (ICE)
custody.\2\
---------------------------------------------------------------------------
\2\ Since 2014, DHS OIG has issued the following reports regarding
unannounced inspections of CBP detention facilities: Capping Report:
CBP Struggled to Provide Adequate Detention Conditions During 2019
Migrant Surge (OIG-20-38), Management Alert--DHS Needs to Address
Dangerous Overcrowding and Prolonged Detention of Children and Adults
in the Rio Grande Valley (OIG-19-51), Management Alert--DHS Needs to
Address Dangerous Overcrowding Among Single Adults at El Paso Del Norte
Processing Center (OIG-19-46), Results of Unannounced Inspections of
Conditions for Unaccompanied Alien Children in CBP Custody (OIG-18-87),
Oversight of Unaccompanied Children 3 (Oct. 2, 2014), Oversight of
Unaccompanied Children 2 (Aug. 28, 2014), Oversight of Unaccompanied
Children 1 (July 30, 2014).
---------------------------------------------------------------------------
CBP is responsible for providing short-term detention for aliens
arriving in the United States without valid travel documents in
compliance with the National Standards on Transport, Escort, Detention,
and Search (TEDS).\3\ TEDS standards govern CBP's interactions with
detained individuals, providing guidance on things like duration of
detention, access to medical care, access to food and water, and
hygiene.
---------------------------------------------------------------------------
\3\ U.S. Customs and Border Protection, National Standards on
Transport, Escort, Detention, and Search, October 2015.
---------------------------------------------------------------------------
TEDS standards generally limit detention in CBP facilities to 72
hours, with the expectation that CBP will transfer unaccompanied alien
children (UAC) to the Department of Health and Human Services (HHS)
Office of Refugee Resettlement, and families and single adults to ICE
long-term detention facilities. As such, CBP's holding facilities are
intended for short-term custody, which is evident in how they are
structured and equipped. Although the infrastructure can vary across
different facilities, most CBP facilities hold detainees in locked
cinderblock cells that have a metal combined toilet and sink.
Facilities generally do not have beds, though some have plastic-covered
foam mattresses, and only some facilities have showers. Further, most
facilities are not equipped to wash laundry or cook meals; facilities
generally do not have cloth blankets and rely on Mylar blankets for
bedding, and staff use microwaves or warming ovens to heat frozen food
or prepare other food items, such as instant soup or oatmeal.
OIG's unannounced inspections of CBP holding facilities evaluate
compliance with TEDS and determine whether CBP provides reasonable care
to detainees, from apprehension to holding. During our unannounced
visits to ports of entry and Border Patrol facilities, we focus on
elements of the TEDS standards that can be observed and evaluated by
OIG inspectors without specialized law enforcement or medical training.
These inspections are limited-scope compliance inspections and we
report solely on observations of compliance or non-compliance with TEDS
on the day and time of the inspectors' visit. As part of our
inspections, we also review records and logs and interview a limited
number of CBP personnel and, when possible, detainees.
In fiscal year 2019, Congress mandated that OIG continue its
program of unannounced inspections of immigration detention facilities,
and directed OIG to ``pay particular attention to the the health needs
of detainees.''\4\ In response, between April and June 2019, we
conducted 21 unannounced inspections of Border Patrol facilities and
CBP ports of entry in Arizona, New Mexico, and Texas. Again, the
objectives of our unannounced visits were to determine whether CBP
complied with observable TEDS standards, and whether CBP provided
reasonable care from apprehension to holding, includjng its ability to
identify and respond appropriately to medical emergencies. During these
inspections, we did not evaluate compliance with all provisions of TEDS
standards, but rather prioritized those that protect children and other
at-risk detainees, as well as those related to access to medical care.
---------------------------------------------------------------------------
\4\ Joint Explanatory Statement, Consolidated Appropriations Act,
2019 (Pub. L. 116-6).
---------------------------------------------------------------------------
We began our fiscal year 2019 unannounced visits of CBP facilities
in April 2019. In the summer of 2019, we issued 2 Management Alerts and
made 1 recommendation about issues we observed requiring DHS's
immediate attention. We issued these interim reports because the
conditions we observed posed a serious and imminent threat to the
health and safety of both DHS personnel and detainees. These issues
included dangerous overcrowding and prolonged detention of children and
adults in both the El Paso and Rio Grande Valley sectors.\5\
---------------------------------------------------------------------------
\5\ Management Alert--DHS Needs to Address Dangerous Overcrowding
and Prolonged Detention of Children and Adults in the Rio Grande Valley
(OIG-19-51), Management Alert--DHS Needs to Address Dangerous
Overcrowding Among Single Adults at El Paso Del Norte Processing Center
(OIG-19-46).
---------------------------------------------------------------------------
Building on the body of work we published last summer, we recently
issued a capping report summarizing and incorporating our observations
during 2019 unannounced inspections.\6\ The capping report included the
following findings:
---------------------------------------------------------------------------
\6\ Capping Report: CBP Struggled to Provide Adequate Detention
Conditions During 2019 Migrant Surge (OIG-20-38).
---------------------------------------------------------------------------
Border Patrol stations were overcrowded,
Border Patrol stations held detainees longer than 72 hours,
Overcrowding and prolonged detention affected Border
Patrol's compliance with other standards for detainee care,
Provision of medical care at short-term facilities has
limits, and
CBP ports of entry generally met TEDS standards.
Unable to Control the Number of Apprehensions, and with Limited
Transfer Options, Border Patrol Stations Were Overcrowded
During fiscal year 2019, CBP experienced a surge in families and
UACs crossing the Southwest Border, with these 2 groups representing
the majority of all Border Patrol apprehensions. These significant
increases contributed to Border Patrol apprehending more than twice the
undocumented aliens during fiscal year 2019 than in any of the previous
4 full fiscal years.
With the surge in apprehensions in fiscal year 2019, we observed
overcrowding in 10 of the 14 Border Patrol facilities we visited; in
some instances the overcrowding was so severe that detainees were in
standing-room-only conditions for days or weeks. As described in our
Management Alerts for example, when our team arrived at the El Paso Del
Norte Processing Center, they found that the facility--which has a
maximum capacity of 125 detainees--had more than 750 detainees on-site.
Despite the crowding, our interviews with detainees and
observations of the facilities indicated that Border Patrol ensured
detainees had ready access to potable water and toilets. We also
observed an Border Patrol stations had food, snacks, juice, and infant
formula available for children. All Border Patrol stations we visited
also had basic hygiene supplies (e.g., toilet paper, diapers, and baby
wipes). However, not all facilities had consistently provided children
access to hot meals as required. Additionally, not all facilities we
visited had showers or provided showers consistently to detainees
approaching 72 hours in detention. Border Patrol had arranged temporary
shower trailers for some, but not all, facilities. Some facilities
without showers on-site provided ``dry showers'' (i.e., a wet wipe and
dry wipe) to detainees.
In response to the fiscal year 2019 surge in Southwest Border
apprehensions, Border Patrol established temporary holding areas to
provide additional shelter for the high volume of detainees. These
included both makeshift arrangements such as parking lots or sally
ports with access to portable toilets and water, and large soft-sided
white tents as stand-alone facilities. These tents had air
conditioning, portable toilets, washstands, showers, and laundry
facilities. At the time of our site visit, these tents were reserved
for families, who were being provided sleeping mattresses and hot
meals.
Based on our observations, we recommended in one of our Management
Alerts that DHS take immediate steps to alleviate the overcrowding at
the El Paso Del Norte Bridge Processing Center.\7\ CBP concurred with
our recommendation and described its efforts to construct additional
soft-sided structures to accommodate more detainees, as well as to open
a Centralized Processing Center within 18 months. That recommendation
remains resolved and open, meaning that OIG considers CBP's proposed
corrective actions responsive to the recommendations.
---------------------------------------------------------------------------
\7\ Management Alert--DHS Needs to Address Dangerous Overcrowding
Among Single Adults at El Paso Del Norte Processing Center (OIG-19-46).
---------------------------------------------------------------------------
With Limited Transfer Options, Border Patrol Held Detainees for
Prolonged Periods
With limited transfer options, in 12 of the 14 Border Patrol
stations we visited, we identified detainees held longer than the 72
hours generally permitted, some of whom had been held for longer than a
month. At the time of our visits, across the 14 facilities, at least
3,750 detainees out of approximately 9,400 (nearly 40 percent) had been
held longer than 72 hours.\8\ With HHS and ICE operating at or above
their bed space capacity for UACs and single adults during the surge,
Border Patrol officials said they struggled with prolonged detention
for these populations.
---------------------------------------------------------------------------
\8\ We derived these numbers from apprehension and custody data
maintained in Border Patrol's case management database, which stores
real-time data on detainees currently in Border Patrol's custody.
However, due in part to system outages at the time of our visit and
detainee transfers between facilities, the precise numbers may be
slightly higher or lower than the numbers reflected in the data.
---------------------------------------------------------------------------
After observing the challenges CBP faced during the surge with
meeting the 72-hour target for release or transfer from CBP custody, we
initiated a separate review to identify the key factors contributing to
prolonged CSP detention during the surge and propose ways for DHS to
enhance its ability to respond better to these challenges in the
future. That review is on-going and the results will be published in an
upcoming OIG report.
Overcrowding and Prolonged Detention Also Affected Border Patrol's
Compliance with Other Standards for Detainee Care
The overcrowding and prolonged detention described above affected
Border Patrol's compliance with other TEDS standards.
For example, UACs must be offered use of a telephone to call a
relative, sponsor, or consulate. We interviewed UACs at several busy
and overcrowded facilities and were told that, in some facilities, they
had not been offered telephone access; logs in Border Patrol's data
system confirmed this. Incomplete records in other facilities indicated
Border Patrol was either not tracking UAC access to telephones or was
not offering the telephone calls. In contrast, at another Border Patrol
facility, we observed UACs making phone calls.
Additionally, according to TEDS standards, CBP will safeguard
detainees' personal property unless it is deemed contraband. However,
we observed Border Patrol agents in the El Paso sector discarding
detainee property, at times indiscriminately. For instance, while
property-handling practices varied by station and there did not appear
to be a sector-wide policy on discarding property, we observed agents
at the El Paso Del Norte Processing Center collecting detainees'
valuables (e.g., money and phones), but discarding virtually all other
detainee personal property--including backpacks, suitcases, handbags,
and children's toys--in the nearby dumpster. We made similar
observations in other locations in the El Paso sector. In contrast, in
other sectors such as the Tucson sector, we observed that all detainee
personal property was tagged and stored.
In response to these observations, we made 2 recommendations to
CBP. First, we recommended that CBP establish procedures for evaluating
compliance with requirements to provide and document phone calls for
unaccompanied alien children in custody. Second, we recommended that
CBP implement consistent guidance on how it handles detainee personal
property.
CBP concurred with both of our recommendations and both of them are
resolved and open. CBP is taking steps to implement each recommendation
by December 31, 2020.
In addition to our observations regarding access to phone calls for
UACs and the safeguarding of detainee personal property, we also
observed that--with the exception of facilities dedicated to housing
UACs and families--Border Patrol facilities did not consistently meet
TEDS standards requiring some special protections for children in
detention, including additional requirements for food, clothing, and
conditions of detention. Based on our observations, not all children
had access to a shower after 48 hours, or a change of clothing, as
recommended under the standards. Two facilities in the Rio Grande
Valley had not provided children access to hot meals until the week we
arrived; management at these facilities told us there were too many
detainees on-site to microwave hot meals, and it had taken time to
secure a food contract. Additionally, preventing the spread of
contagious illnesses resulted in some UACs and families needing
treatment being held in closed cells, rather than the least restrictive
setting recommended in TEDS.
However, overall, in the facilities we visited, we observed CBP
staff members making an effort to care for the detained children. For
example, we observed CBP personnel trying to provide the least
restrictive setting available for children when possible (e.g., by
leaving holding room doors open or cells unlocked), We also observed in
most facilities CBP staff had purchased toys or snacks that appealed to
children.
We did not make a recommendation with respect to these specific
issues relating to these special protections for children because we
believe that overcrowding and prolonged detention affected Border
Patrol's compliance with standards for children. In normal
circumstances, CBP has sufficient microwaves or warming ovens to heat
frozen food and can transfer unaccompanied children to Health and Human
Services custody before the need for showers or a change of clothing
arise. Transfer of families to ICE custody, or to CBP facilities that
offer more amenities, is also easier when facilities are not
overcrowded. We are conducting a separate review to evaluate the root
causes of prolonged detention.
Provision of Medical Care at Short-Term Facilities Has Limits
Under TEDS standards, CBP agents and officers are also tasked with
observing and reporting physical and mental injuries and illnesses for
appropriate medical care. In addition, detainees should have access to
emergency medical care and necessary medications. Although TEDS
standards do not require CBP to have trained on-site medical staff in
its holding facilities, in fiscal year 2014, Border Patrol established
the Centralized Processing Center in the Rio Grande Valley and staffed
it with contracted medical teams led by a nurse practitioner or
physician's assistant. The Centralized Processing Center was the first
CBP facility with an on-site medical team. Between 2014 and the end of
2018, CBP expanded the Centralized Processing Center's medical contract
to provide medical staff and services at 5 additional Border Patrol
stations. The contract included the services of an on-site medical team
led by a nurse practitioner or physician's assistant, as well as an on-
call physician, to provide basic care, refill prescriptions, and
determine which detainees required care at a hospital or clinic. All
other CBP facilities relied on CBP agents and officers to identify
medical issues.
At the time of our inspections, medical coverage varied by
facility, but the facilities we visited generally met the TEDS
standards for access to medical care even in the crowded conditions.\9\
Specifically, upon a detainee's entry into a CBP hold room, detainees
were asked about, and visually inspected for, any sign of injury,
illness, or physical or mental health concerns, and asked questions
about any prescription medications. In addition, although TEDS does not
require CBP to maintain on-site medical staff, due to initiatives bv
CBP and the DHS Office of the Chief Medical Officer, 10 CBP facilities
had on-site medical personnel handling medical assessments and triage.
In the remaining facilities, CBP officers and agents, some of whom were
emergency medical technicians (EMT), performed assessments in
accordance with TEDS standards.
---------------------------------------------------------------------------
\9\ At the time these inspections were completed, we did not have
medical expertise to evaluate the quality of medical care. With the
expanded funding received from Congress in fiscal year 2020, I ordered
a contract for medical services to supplement our expertise across
audits, inspections, and investigations and I am pleased to report that
contract will be awarded in the next few weeks.
---------------------------------------------------------------------------
Most Border Patrol facilities we visited took steps to try to
evaluate and respond to the medical needs of the sizable detainee
population resulting from the increase in apprehensions. This included
conducting medical screenings of all detainees before entrance into a
facility, stocking common over-the-counter medications, and arranging
dedicated appointment hours at local clinics. At several facilities we
visited with on-site medical personnel, a medical team consisting of 2
to 4 staff questioned detainees about their health and conducted a
physical assessment of each detainee before processing detainees for
intake into the facility. In facilities without medical staff, CBP
officers and Border Patrol agents medically assessed detainees by
asking them about their health concerns, injuries, and medications.
At the facilities with medical staff, the medical personnel could
treat detainees who had minor injuries or illnesses using over-the-
counter medication, which the facilities stocked. Also, the medical
personnel could identify detainees who needed additional medical care,
and could prescribe medications. If a detainee needed additional
treatment, the medical personnel would contact CBP, or call the local
emergency room, for transport to a local medical facility.
Even though the Border Patrol stations we visited generally met the
TEDS standard for access to medical care, crowded conditions presented
health challenges for on-site medical staff in some facilities,
including containing the spread of contagious illnesses. On-site
medical staff we interviewed said they were overwhelmed and the crowded
conditions at the facilities were not conducive to treating contagious
illnesses. For instance, Border Patrol's short-term detention
infrastructure generally did not provide sufficient space for
quarantining or specialized ventilation systems. Border Patrol agents
also expressed concern that having many detainees with contagious
illnesses in their facilities represented a health risk to detainees
and CBP personnel alike. In addition, Public Health Service officials
working in Border Patrol stations said that with the large number of
detainees arriving and departing each day, neither medical personnel
nor CBP staff could observe and monitor the health status of all
detainees. Crowding at the facilities further lessened the opportunity
to identify detainees who may require immediate medical care.
To prevent the spread of contagious illnesses, CBP took measures
such as conducting medical assessments outside of the facilities and
providing protective masks to detainees. At times, efforts to contain
contagious illnesses indirectly contributed to overcrowding in other
areas of facilities, as Border Patrol had to set aside multiple holding
cells or repurpose other space to separate detainees with lice,
scabies, measles, and flu from each other and from healthy detainees.
Given these observations, as well as the circumstances of the
deaths of the 2 children in CBP custody, and our on-going dialog with
the Committee regarding these issues, we have initiated an audit of
detention facility policies and procedures for handling medical
intervention. Our planned audit objective is to determine whether CBP:
(1) Has policies and procedures to address identifying serious medical
conditions of detained migrants; and (2) is implementing those policies
and procedures to ensure the detained migrants with serious medical
conditions are identified and their health needs are properly
addressed. We look forward to sharing the results of that audit with
the committee when it is complete.
Ports of Entry Generally Met TEDS Standards
In contrast to Border Patrol, which could not control the number of
undocumented aliens apprehended, CBP Office of Field Operations (OFO)
ports of entry limited the number they processed by implementing
``Queue Management''\10\ and other practices.\11\ ``Queue Management''
allowed the ports of entry to control the volume of detainees entering
the facilities, and OFO did not accept more detainees than could be
transferred to ICE custody. As a result, relatively few detainees were
held longer than 72 hours; of the ports of entry we visited, only
Nogales and Hidalgo ports of entry held detainees longer than 72 hours.
---------------------------------------------------------------------------
\10\ See June 5, 2018 Memorandum from Secretary Nielsen,
``Prioritization-Based Queue Management,'' stating OFO may create
separate lines for migrants with appropriate travel documents and those
without such documents. When employing ``Queue Management,'' CBP
officers are stationed at the international boundary with Mexico and
advise undocumented aliens to add their names to a waiting list and
stay in Mexico until CBP has space and staffing to process them.
\11\ Other initiatives to control intake include the Migrant
Protection Protocol, through which certain undocumented aliens arriving
from Mexico are issued a Notice to Appear before, an immigration judge,
placed in removal proceedings, and then transferred to Mexico to await
further proceedings.
---------------------------------------------------------------------------
Ports of entry generally met other TEDS standards as well. Our
observations and interviews with detainees confirmed ports of entry
were generally able to more easily monitor UACs and provide both adults
and children hot meals and a variety of foods. Although holding cells
at the ports of entry we visited were comparable to those in Border
Patrol stations (e.g., locked cinderblock cells and metal combined
toilets and sinks), some ports of entry had converted other areas into
space to hold UACs and families, giving the ports more options for
holding children in the least restrictive setting possible.
Ports of entry also faced fewer challenges in meeting TEDS
standards for medical care. Because ports of entry were not
overcrowded, it was less difficult to separate detainees with
contagious illnesses. Although most ports of entry we visited did not
have medical staff or EMTs on-site, all were near communities with
clinics and hospitals, and therefore, had easier access to local
medical care. In addition, fewer detainees required transport for
medical care. At the time of our site visits, some ports of entry sent
all children and family units to a clinic or hospital for medical
screening after initial processing.
on-going oig oversight
Using data-driven, risk-based decision making, our office will
continue to conduct independent and objective audits, inspections, and
investigations and make recommendations to improve the Department's
programs and operations. Consistent with our obligations under the
Inspector General Act of 1978, we will keep Congress fully and
currently informed of our findings and recommendations.
We plan to publish several reports this year and next year
reviewing CBP and ICE, including;
CBP's Holding of Detainees Beyond 72 Hours.--This
evaluation's objective is to determine the causes leading to
CBP's inability to comply with the general requirement to hold
detainees in its custody for no more than 72 hours.
CBP's Processing of Asylum Seekers.--We are reviewing CBP's
handling of asylum seekers at ports of entry. The objective was
to determine if CBP OFO was turning away those who present
themselves for asylum at the ports of entry.
CBP's Use of Fiscal Year 2019 Appropriated Funds for
Humanitarian Assistance.--Our objective is to determine whether
CBP has adequately planned for deployment, and is deploying,
fiscal year 2019 appropriated funds quickly and effectively to
address the humanitarian needs on the Southern Border.
CBP's Procedures for Detained Migrants Experiencing Serious
Medical Conditions.--Our objective is to determine whether
CBP's policies and procedures safeguard detained migrants
experiencing serious medical conditions while in custody.
Southern Border Detainee Transportation and Support.--The
objective is to determine how the migrant surge affected CBP
staffing and its ability to secure the Southern Border.
Implementation of DHS's Streamlined Asylum Review Pilot
Programs.--The objective is to determine how DHS, especially
CBP and USCIS, have implemented the Prompt Asylum Claim/
Screening Review and Humanitarian Asylum Review Process (HARP)
pilot programs.
Audit of CBP Border Security Technology and
Infrastructure.--We will assess the effectiveness of CBP's
current tools and technologies to support Border Patrol's
mission operations for preventing the entry of illegal aliens
or inadmissible individuals who may pose threats to National
security.
CBP Leadership's Knowledge of and Actions to Address
Offensive Content Posted on Facebook by CBP Employees.--The
objective is to determine whether complaints were made to CBP
leadership regarding the ``I'm 10-15'' or similar private
Facebook group(s) prior to recent media reporting; which
senior-level officials knew about the ``I'm 10-15'' or similar
private Facebook group(s) prior to the July 2019 media
reporting, when they became aware, and what they knew about the
content; and what actions, if any, were taken to evaluate and
address potential employee misconduct in the group.
U.S. Customs and Border Protection's Use of Canine Teams.--
The objective is to determine to what extent CBP's canine
training approach and execution support the Canine Program
mission.
U.S. Customs and Border Protection's Use of Force Near the
San Ysidro, California Port of Entry on November 25, 2018 and
January 1, 2019.--Our objective is to review the circumstances
surrounding the incidents and determine whether CBP complied
with its use of force of policy.
Review of Removal of Separated Alien Families.--Our work
will determine whether ICE removed any parents without first
offering them the opportunity to bring their separated children
with them.
ICE's Use of Segregation in Detention Facilities.--To
determine whether ICE's use of administrative and disciplinary
segregation across all authorized detention facilities complies
with Departmental detention standards.
DHS DNA Collection.--Our objective is to determine whether
DHS law enforcement agencies collect DNA samples from arrested
or detained persons as required by the Fingerprint DNA Act of
2005 and subsequent Department of Justice regulations.
DHS Management and Oversight of Immigration Hearings in
Temporary Courts Along the Southwest Border.--Our objective is
to determine the extent to which DHS provides accurate hearing
notices and facilitates immigration hearings at temporary
courts in accordance with laws and regulations.
U.S. Immigration and Customs Enforcement Efforts to Combat
Human Trafficking.--Our objective is to determine the extent to
which ICE identifies and tracks human trafficking crimes to
save victims.
Review of July 2018 Family Reunifications Issues at Port
Isabel Detention Center.--Our objective is to determine whether
children were held in vans for up to 39 hours, why that
occurred, and whether ICE has taken steps to prevent it from
happening again.
Unannounced Inspections of CBP Holding Facilities & ICE
Adult Detention Facilities.--Our objective is to continue
conducting unannounced inspections of DHS and contract
facilities to monitor DHS compliance with health, safety, and
civil rights standards outlined in CBP's National Standards on
Transport, Escort, Detention, and Search; and ICE's
Performance-Based National Detention Standards.
CBP's Searches of Electronic Devices at Ports of Entry.--Our
objective is to determine to what extent CBP conducted searches
of electronic devices at U.S. ports of entry in accordance with
its standard operating procedures.
ICE's Efforts to Prevent and Mitigate the Spread of COVID-19
in its Facilities.--Our objective is to determine whether ICE
Enforcement and Removal Operations effectively managed the
pandemic at its detention facilities and adequately safeguarded
the health and safety of both detainees in their custody and
their staff.
Early Experiences with COVID-19 at CBP Facilities.--Our
objective is to determine how CBP (Office of Field Operations
and Border Patrol) is managing the COVID-19 pandemic at their
facilities, with respect to both detainees in their custody and
to their staff.
ICE Should Document its Process for Adjudicating
Disciplinary Matters Involving Senior Executive Service
Employees.--Our objective was to evaluate U.S. Immigration and
Customs Enforcement (ICE) policies and procedures regarding
Senior Executive Service (SES) employee discipline after
complaints were raised that a former ICE SES official received
favorable treatment during disciplinary proceedings.
Assessing the Effectiveness of DHS's Joint Task Forces.--Our
objective is to determine whether DHS has effectively managed
and coordinated its Joint Task Forces (JTF) resources to
accomplish the JTFs' intended mission.
CBP's Covert Testing Efforts.--Our objective is to determine
whether CBP's covert tests identify vulnerabilities at ports of
entry and borders and whether CBP uses the test results to
address identified vulnerabilities and shares lessons learned
throughout the component.
Thank you for the opportunity to discuss the important work of the
OIG. This concludes my testimony, and I am happy to answer any
questions you may have.
Chairman Thompson. Thank you very much for your testimony.
I now recognize our next witness for 5 minutes.
STATEMENT OF REBECCA GAMBLER, DIRECTOR, HOMELAND SECURITY AND
JUSTICE, U.S. GOVERNMENT ACCOUNTABILITY OFFICE
Ms. Gambler. Good afternoon, Chairman Thompson, Ranking
Member Rogers, and Members of the committee. I appreciate the
opportunity to participate in today's hearing to discuss GAO's
work on CBP efforts to provide medical care to those in its
custody along the Southwest Border. My remarks are based on a
report GAO is releasing today, and a legal decision we issued
last month addressing issues related to CBP's use of funds for
and efforts to provide medical care.
I will be covering 3 areas from the report and legal
decision. First, CBP's use and oversight of funds it received
for consumables and medical care under the fiscal year 2019
emergency supplemental appropriations. Second, CBP's efforts to
enhance medical care. Third, CBP's reporting of deaths in its
custody.
First, last summer, the Fiscal Year 2019 Emergency
Supplemental Appropriations Act was enacted to provide for
humanitarian assistance and security at the Southwest Border.
The act required that CBP use certain funds for specific
purposes which are referred to as line items. One of the line
items in the act was consumables and medical care. We found
that CBP obligated some funds in the line item for consumable
and medical care goods and services, like food and hygiene
products, masks, and gloves.
However, CBP also obligated some of the funds for other
purposes like goods and services for its canine program,
equipment for facility operations, like printers and speakers,
and facility upgrades and services. We found that these
obligations violated an appropriation law known as the purpose
statute, because CBP obligated funds from the consumables and
medical care line items for some goods and services that were
not consistent with the purpose of that appropriation. We
concluded that CBP should adjust its accounts accordingly.
We identified 2 factors that contributed to CBP's
violations: No. 1, insufficient guidance to CBP offices and
components before obligations were made and a lack of oversight
roles and responsibility for reviewing obligations once made.
We recommended that CBP develop and implement additional
guidance and establish oversight roles and responsibilities to
ensure supplemental funds were obligated consistent with their
purposes. CBP concurred with these recommendations.
Second, CBP has taken various steps to enhance medical care
and services for individuals in its custody. These steps
include increasing its use of contracted medical care
providers, issuing new health screening policies, and
requesting the CDC assess conditions and make recommendations
for the reduction of influenza in CBP facilities among other
things.
As a more specific example of CBP's efforts, in 2019, CBP
issued interim and updated medical care directives, which,
among other things, required health interviews and medical
assessments for certain groups. In March 2020, CBP issued
implementation plans for these directives.
While these are positive steps, we found that CBP has not
consistently implemented its enhanced medical care policies and
procedures. For example, we found that some CBP locations were
not consistently conducting health interviews and medical
assessments as required by the medical directives. CBP also has
not documented how it made its decision not to offer influenza
vaccines to those in its custody as recommended by the CDC. We
recommended that CBP develop and implement oversight mechanisms
and document what information it is using to assess whether to
offer the influenza vaccine to individuals in custody. CBP
concurred with these recommendation.
Finally, CBP is supposed to report information on deaths of
individuals in its custody to Congress. We have reviewed CBP's
documents and reports for fiscal years 2014 through 2019, and
found that 31 individuals died in custody along the Southwest
Border during that period. However, CBP only documented 20
deaths in its Congressional reports. We recommended that CBP
ensure reliable information on deaths in custody is reported to
Congress, and appropriate documentation on such reporting is
maintained. CBP concurred with this recommendation.
In closing, while CBP has taken steps to enhance its
medical care efforts, our work has identified a number of areas
requiring additional attention to ensure that CBP is
appropriately using supplemental funds it receives, overseeing
medical care efforts, and reliably reporting information on
deaths in custody to Congress. Going forward, we will be
monitoring CBP's actions to address our recommendations.
This concludes my prepared statement, and I am pleased to
answer any questions Members may have.
[The prepared statement of Ms. Gambler follows:]
Prepared Statement of Rebecca Gambler
Wednesday, July 15, 2020
southwest border.--cbp should improve oversight of funds, medical care,
and reporting of deaths
gao-20-680t
Chairman Thompson, Ranking Member Rogers, and Members of the
committee: We are pleased to be here today as you examine issues
related to U.S. Customs and Border Protection's (CBP) care and custody
of adults and children. Beginning in fall 2018, the Department of
Homeland Security's (DHS) CBP experienced a significant increase in the
number of individuals apprehended at or between U.S. ports of entry
along the Southwest Border, resulting in overcrowding and difficult
humanitarian conditions in its facilities.\1\ From December 2018
through May 2019, 3 children--ages 7, 8, and 16--died in CBP custody,
prompting questions about CBP's medical screening and care of those in
its custody. In July 2019, an emergency supplemental appropriations act
(2019 Emergency Supplemental) was enacted, providing additional funds
to CBP to respond to the significant increase in Southwest Border
apprehensions, including approximately $112 million for ``consumables
and medical care.''\2\
---------------------------------------------------------------------------
\1\ See, for example, Department of Homeland Security, Office of
Inspector General, Management Alert--DHS Needs to Address Dangerous
Overcrowding and Prolonged Detention of Children and Adults in the Rio
Grande Valley (Redacted), OIG-19-51 (Washington, DC: July 2, 2019);
Management Alert--DHS Needs to Address Dangerous Overcrowding Among
Single Adults at El Paso Del Norte Processing Center (Redacted), OIG-
19-46 (Washington, DC: May 30, 2019); and Acting Secretary McAleenan's
Prepared Remarks to the Council on Foreign Relations (Washington, DC:
Sept. 23, 2019).
\2\ See Pub. L. No. 116-26, title III, 133 Stat 1018, 1019-1020
(2019). Supplemental appropriations are laws enacted to address needs
that arise after annual appropriations have been enacted. In the
context of CBP's appropriation, the term ``consumable'' refers to goods
that are exhausted by use, and the phrase ``medical care'' includes
goods and services used to provide assistance related to the diagnosis
and treatment of disease or injury and maintaining health. B-331888,
June 11, 2020, at 4.
---------------------------------------------------------------------------
CBP is the lead Federal agency charged with, among other things,
ensuring the detection and interdiction of persons unlawfully entering
or exiting the United States.\3\ Within CBP, the U.S. Border Patrol
(Border Patrol) apprehends individuals between ports of entry, and
CBP's Office of Field Operations (OFO) encounters inadmissible
individuals who arrive at ports of entry. Border Patrol and OFO detain
individuals at short-term holding facilities to complete processing,
which involves collecting information about the apprehended individual,
including any potential health concerns. While individuals are held at
CBP facilities--either by Border Patrol or by OFO--CBP personnel
typically place individuals in a secure holding cell or room while
these individuals await transfer of custody to another agency, removal
from the country, or release into the United States.\4\
---------------------------------------------------------------------------
\3\ See 6 U.S.C. 211(c).
\4\ CBP policy states that individuals should generally not be held
for longer than 72 hours in CBP custody. CBP refers individuals to
DHS's U.S. Immigration and Customs Enforcement (ICE) for long-term
detention. If CBP apprehends a child that is designated as an
unaccompanied alien child, that child is transferred to the custody of
the Office of Refugee Resettlement within the Department of Health and
Human Services (HHS).
---------------------------------------------------------------------------
Our remarks are based on our report, released today, entitled
Southwest Border: CBP Needs to Increase Oversight of Funds, Medical
Care, and Reporting of Deaths.\5\ Specifically, we will summarize the
report's key findings on: (1) The extent to which CBP obligated and
conducted oversight of funds for consumables and medical care; (2)
steps CBP took to enhance medical care; (3) the extent to which CBP
implemented and oversaw its medical care efforts; and (4) the extent to
which CBP has reliable information on, and reported, deaths, serious
injuries, and suicide attempts of individuals in custody. For the
report, we reviewed CBP documentation, including financial reports;
directives, policies, and training related to screening individuals for
medical issues; and directives and policy documentation on reporting
deaths in custody. We interviewed CBP officials in headquarters and 2
field locations and observed medical efforts in facilities in field
locations, selected based on higher volumes of apprehensions.
Additional information on our scope and methodology is available in our
report.\6\ The work on which this statement is based was performed in
accordance with generally accepted Government auditing standards.
---------------------------------------------------------------------------
\5\ GAO, Southwest Border: CBP Needs to Increase Oversight of
Funds, Medical Care, and Reporting of Deaths, GAO-20-536 (Washington,
DC: July 14, 2020).
\6\ GAO-20-536.
---------------------------------------------------------------------------
cbp obligated some consumables and medical care funds for other
purposes in violation of appropriations law
We found that, as of May 2020, CBP had obligated nearly $87 million
of the approximately $112 million it received specifically for
consumables and medical care in the 2019 Emergency Supplemental.\7\ CBP
obligated some of these funds for consumable goods and services, like
food and hygiene products, as well as medical care goods and services
such as defibrillators, masks, and gloves. However, in June 2020, we
concluded that CBP violated an appropriations law, known as the purpose
statute, when it obligated funds from the 2019 Emergency Supplemental
consumables and medical care line item appropriation for some goods and
services that were not consistent with the purpose of that line
item.\8\ Specifically, we found that some of the goods and services did
not clearly fall within the ordinary meaning of the terms
``consumable'' or ``medical care,'' nor did they bear a reasonable and
logical relationship to the purpose of the line item. For example, we
found that CBP violated the purpose statute when it obligated some of
these funds for goods and services for its canine program; equipment
for processing individuals apprehended by CBP, like printers and
speakers; and various upgrades to computer networks used for border
enforcement activities. CBP also obligated the consumables and medical
care line item for transportation items. We concluded that obligations
for certain transportation-related items that were not primarily used
to provide medical services violated the purpose statute.\9\
---------------------------------------------------------------------------
\7\ In general, an obligation is a commitment by the Government
that creates a legal liability to pay for goods or services it orders
or receives.
\8\ GAO, U.S. Customs and Border Protection--Obligations of Amounts
Appropriated in the 2019 Emergency Supplemental, B-331888 (Washington,
DC: June 11, 2020). Under the purpose statute, appropriations are to be
used only for the purposes for which they are made, except as otherwise
provided by law.
\9\ B-331888, June 11, 2020, at 5-6.
---------------------------------------------------------------------------
We identified 2 factors that contributed to CBP's purpose statute
violations--insufficient guidance to CBP offices and components before
obligations were made and lack of oversight roles and responsibilities
for reviewing obligations once made.
Insufficient guidance on the purpose of the funds.--After
the 2019 Emergency Supplemental was enacted, CBP did not
provide sufficient guidance explaining how offices and
components could obligate funds for consumables and medical
care and, as a result, some offices and components may not have
understood that there were limitations on how they could use
those funds. For example, officials from one CBP component
stated they believed they could use the consumables and medical
care funds for any goods or services they considered to be in
the interest of individuals in custody or that would help
ensure the efficient processing of individuals.
Lack of oversight roles and responsibilities.--CBP offices
and components took some steps to conduct oversight of
obligations from the 2019 Emergency Supplemental funds, but we
identified gaps in CBP's roles and responsibilities for
reviewing obligations to ensure they were consistent with the
intended purpose of the funds.\10\ For example, officials from
CBP's Office of Finance stated that they were not responsible
for determining whether obligations were consistent with the
purpose of the line item and relied on components to make such
determinations. However, of the 5 components that obligated
funds from the consumables and medical care line item
appropriation, only 1--Border Patrol--reviewed obligations to
determine whether they were consistent with the purpose.
Further, Border Patrol's review was limited in scope because it
did not include all obligations Border Patrol made using this
line item. For example, Border Patrol did not request
obligation data on goods and services purchased by its canine
office.\11\
---------------------------------------------------------------------------
\10\ While CBP officials stated that individual components had
processes in place to review individual obligations before they were
made, the agency had not provided guidance regarding the purpose of the
individual line items, as noted above.
\11\ CBP's canine program is responsible for terrorist detection
and apprehension and the detection and seizure of controlled substances
and other contraband, among other functions.
---------------------------------------------------------------------------
DHS and CBP officials stated that the agency experienced challenges
managing some aspects of the funds from the 2019 Emergency Supplemental
due to a lack of experience with these line items and the large
increase of apprehensions on the Southwest Border occurring at the
time. Specifically, officials from DHS's Office of the General Counsel
and CBP's Office of Chief Counsel noted that CBP typically receives an
annual lump-sum appropriation, which provides the agency with broader
discretion in determining the use of funds as compared to the 2019
Emergency Supplemental, which specified how CBP could use the funds
through line items. As such, these officials stated that CBP did not
have systems in place to ensure that the funds were obligated
consistent with the purpose of the line item. Our report recommended
that CBP develop and implement additional guidance for ensuring that
funds appropriated for a specific purpose are obligated consistent with
their purpose, and establish oversight roles and responsibilities to
ensure that such funds are obligated consistent with their purpose. DHS
agreed with these recommendations and said it plans to issue additional
guidance and outline new oversight roles and responsibilities within
its standard operating procedures document.
cbp increased contracted medical providers, issued new screening
policies, and engaged entities with medical expertise in 2019
We found that, throughout 2019, CBP took various steps to enhance
medical care and services to individuals apprehended and held at its
facilities. These steps included increasing the number of facilities
that have on-site contracted medical providers from 6 locations in
December 2018 to 42 in December 2019 and issuing new health screening
policies. In particular, in January 2019, CBP issued an interim
directive which, among other things, required health interviews and
medical assessments for certain individuals in its custody.\12\ CBP
updated this directive in December 2019 and issued corresponding
implementation plans in March 2020.
---------------------------------------------------------------------------
\12\ A health interview is a standardized medical questionnaire for
individuals in CBP custody. A medical assessment is an evaluation of an
individual by a health care provider to assess medical status.
---------------------------------------------------------------------------
Additionally, CBP engaged with various entities to leverage their
expertise and coordinate efforts. Two entities with medical expertise--
the Centers for Disease Control and Prevention (CDC) within the
Department of Health and Human Services (HHS) and the American Academy
of Pediatrics (AAP)--also provided recommendations or assistance with
the development of training. At the request of DHS, CDC teams visited
Border Patrol facilities in December 2018 and January 2019 to assess
conditions and make recommendations for the collection of data on, and
to reduce the spread of, infectious diseases, particularly respiratory
diseases such as influenza. Based on these visits, CDC provided DHS
with recommendations to address immediate needs for protection and care
related to respiratory infections and to prepare for future influenza
seasons.\13\ In addition, CBP requested, and the AAP developed, a short
training video on recognizing the signs of a child in medical distress.
CBP issued the training in late September 2019 as part of a 35-minute
training for CBP emergency medical technicians and paramedics.
---------------------------------------------------------------------------
\13\ These recommendations are summarized in our report. See GAO-
20-536.
---------------------------------------------------------------------------
cbp's implementation and oversight of medical care efforts has been
inconsistent
While CBP has taken steps to enhance medical care for those in its
custody, we found gaps in CBP's implementation and oversight of its
efforts. For example, we found the following:
Inconsistent implementation of enhanced medical care
policies and procedures.--Through facility visits and analysis
of CBP data, we found that some CBP facilities along the
Southwest Border were not consistently conducting health
interviews and medical assessments, as required by the medical
directives. Our review of Border Patrol records from a 1-week
period in February 2020 found that 143 of 373 apprehended
children under age 18 who were processed at Border Patrol
stations without contracted medical providers did not receive a
health interview or medical assessment referral at those
stations. This included 116 children under age 13, and 27
children ages 13 through 17. When we notified CBP of these
issues, CBP officials said that they found that most of the 143
children in question had received a health interview or medical
assessment elsewhere, though some children had not. CBP
officials indicated they were previously unaware of these
issues and had not determined why they occurred.
CBP did not document how it weighed costs and benefits in
deciding not to offer the influenza vaccine. CBP decided not to
implement a recommendation from CDC to offer influenza vaccines
to individuals in custody but did not document how it arrived
at this decision. For example, CBP documentation cited
operational, medical, legal, and logistical challenges to
vaccinating apprehended individuals for influenza. CBP
officials told us that they considered these factors with DHS
and that the Department overall decided not to offer the
vaccine to apprehended individuals. However, CBP did not
document how the agency weighed the costs or potential benefits
of offering the influenza vaccine. For example, CBP could not
provide documentation on how it determined that costs--such as
providing cold storage at CBP facilities to support vaccines,
hiring additional medical staff, or maintaining additional
medical records related to offering influenza vaccination--
would be significant. CDC officials we spoke with stated that
they believed these challenges and costs could be addressed.
CBP officials also stated that they believed that offering the
influenza vaccine to individuals in custody would provide little
benefit to the agency since it is CBP's goal to transfer individuals
out of its custody within 72 hours, while the influenza vaccine
requires 14 days to take effect. However, CBP officials also stated
that they have no control over how long individuals may remain in CBP
custody when there is a lack of capacity at ICE facilities. In May and
June 2019, the DHS Office of Inspector General found serious
overcrowding and prolonged detention in Border Patrol facilities in
Texas because CBP could not transfer individuals in custody out of its
facilities in a timely manner, as both ICE and HHS were operating at or
above capacity.\14\ For example, the DHS Office of Inspector General
found that some adults were held as long as a month and some children
held for 2 weeks.
---------------------------------------------------------------------------
\14\ See OIG-19-46 and OIG-19-51.
---------------------------------------------------------------------------
CBP made its initial decision not to offer vaccines to those in its
custody prior to the Coronavirus Disease 2019 (COVID-19) pandemic.
Since that time, CDC has noted additional benefits of offering the
influenza vaccine. Additionally, since CBP made its initial decision,
CBP officials stated that they continue to meet with other DHS
officials on public health issues, including how to prevent the spread
of influenza in its facilities. Officials told us that they will use
this forum to continually reassess whether to offer influenza vaccines
to individuals in its custody.
CBP does not provide officers and agents with training to
identify medical distress in children.--CBP policies require
officers and agents to identify potential medical issues in all
individuals, including children, but CBP has not developed and
implemented training for agents and officers on identifying
medical distress in children. According to AAP representatives,
recognizing medical distress in children in a timely fashion is
important because children can fall severely ill faster than
adults and are less able to communicate about their illness.
CBP officers and agents take 2 first aid courses as part of
their initial training, but these courses do not include
information specifically related to identifying medical
distress in children--such as through changes in skin tone or
crying patterns.
CBP and AAP developed a training video on recognizing medical
distress in children, which CBP included as part of its
training for emergency medical technicians and paramedics as
noted above.\15\ CBP officials told us that the agency has not
provided the training video to all officers and agents because
they believed it was too technical, though it is available to
officers and agents as an optional continuing education course.
CBP officials stated that they have considered offering
training on recognizing medical distress in children to all
officers and agents who may come into contact with children in
custody, but have not begun to take steps to develop and
implement such training.
---------------------------------------------------------------------------
\15\ As of April 2020, CBP could not provide information on how
many of its CBP emergency medical technicians and paramedics had taken
this training. There are approximately 1,200 emergency medical
technicians and paramedics that work on the Southwest Border.
---------------------------------------------------------------------------
Our report recommended that CBP develop and implement oversight
mechanisms for its policies and procedures relating to medical care;
document what information it uses to assess whether to offer the
influenza vaccine to individuals in custody; and develop and implement
training on recognizing medical distress in children for all officers
and agents who may come in contact with children. DHS agreed with our
recommendations and said it plans to clarify performance metrics,
targets, and corrective actions; consider how to best document whether
to offer the influenza vaccine to individuals in custody; and develop
and implement training on recognizing medical distress in children.
cbp has taken steps to clarify responsibilities and procedures for
reporting deaths in custody, but reporting gaps remain
From fiscal year 2015 through fiscal year 2019, CBP was directed to
report deaths of individuals in its custody to Congress.\16\ We
reported that while CBP has taken steps to revise its policies and
procedures for reporting deaths in custody, the agency has not
consistently reported deaths to Congress, as directed, or maintained
documentation of such reporting. Our review of CBP documentation and
reports to Congress showed that 31 individuals died in custody along
the Southwest Border from fiscal years 2014 through 2019, and CBP
provided documentation that it reported 20 to Congress. Additionally,
when CBP reported deaths to Congress, it did not always report them in
a timely manner. For example, for fiscal years 2016 through 2019, CBP
was directed to report all deaths in custody within 24 hours. However,
CBP was unable to substantiate that the agency met the 24-hour
requirement for fiscal years 2016 and 2017. Further, in December 2018,
CBP reported to Congress the death of a 7-year-old girl who died in
Border Patrol custody 4 days after the 24-hour window for notification
had passed. Moreover, CBP was directed to provide annual information on
deaths in custody for fiscal year 2017 but did not provide this
information until March 2019.
---------------------------------------------------------------------------
\16\ The Congressional reports accompanying annual Department of
Homeland Security's appropriations acts for fiscal years 2015 through
2019 direct DHS to report certain information on deaths in custody
within specific time frames to the appropriations committees. For more
information, see table 4 of our report, GAO-20-536. Additionally, in
fiscal year 2014, DHS was directed to provide information on deaths in
custody in summary statistics to the appropriations committees. See
House Rep. No. 113-91 (2013).
---------------------------------------------------------------------------
CBP officials attributed these reporting issues to a lack of
defined responsibilities and procedures. In December 2018--recognizing
the need for more consistent and timely reporting--the CBP Commissioner
issued a memorandum outlining interim policy and procedures for
notifications of a death in CBP custody. However, we found that field
personnel have not consistently followed those procedures, which
resulted in at least one late notification to Congress, and CBP could
not provide documentation that it had notified Congress of an
additional 2 deaths that had occurred after the issuance of the
memorandum.\17\ Officials stated that this may have been due to a lack
of awareness about the December 2018 memorandum reporting requirements.
Our report recommended that CBP ensure that reliable information on
deaths in custody is reported to Congress and that appropriate
documentation on such reporting is maintained. DHS agreed with this
recommendation and said it is reviewing and updating procedures to
ensure deaths in custody are reported to Congress as appropriate.
---------------------------------------------------------------------------
\17\ CBP officials stated they may have notified Congress by
telephone.
---------------------------------------------------------------------------
In summary, CBP has taken some steps to improve its care and
custody of adults and children, but the agency needs to increase
oversight of the use of funds, medical care, and reporting of deaths.
By implementing our report's recommendations, CBP has the opportunity
to provide additional guidance and oversight of appropriated funds;
develop and implement oversight mechanisms related to medical care
policies; document decisions made regarding offering the influenza
vaccine; and provide guidance to ensure that deaths in custody are
reported to Congress, as directed.
Chairman Thompson, Ranking Member Rogers, and Members of the
committee, this concludes our prepared remarks. We would be pleased to
respond to any questions that you may have at this time.
Chairman Thompson. Thank you for your testimony. I thank
all the witnesses for their testimony. I remind each Member
that he or she will have 5 minutes to question the panel.
I now recognize myself for questions. To Mr. Cuffari, as
you know, we sent a letter to you asking for a number of
things, the committee. You sent it back, we reviewed it. After
we sent our response back, you revised the public summary. Why
didn't the original public summary include any reference to
influenza as a cause of death?
Mr. Cuffari. Mr. Chairman, you are correct. In the interest
of privacy, initially we included a high-level summary of
information on our public website regarding the deaths of the 2
children. Subsequently at your request, we made an adjustment
to that public summary to include a diagnosis of influenza B,
and to indicate that our investigation did not reveal Border
Patrol were aware of that diagnosis.
I would like to add that this is the very first time that
we have done public summaries in this fashion, and we wanted to
make sure that we got it right the first time. We thought it
was appropriate to basically err on the side of privacy for the
children. Now, out of deference to you, sir, we added and made
those minor corrections.
Chairman Thompson. Well, I thank you. So have you noted on
your website, or the summary itself, that the summary has been
revised?
Mr. Cuffari. Yes, sir. We did that the same day. We made
the updates and sent those to your staff.
Chairman Thompson. Thank you very much. With respect to
your review of the initial death, did you have qualified
medical professionals on your review team?
Mr. Cuffari. No, sir. Just to clarify for the committee's
consideration, those 2 reviews were actually investigations
conducted by our office of investigation of the 2 deaths of the
children in custody. We didn't have, at the time, any medical
professionals available from for staff. But as I indicated in
my opening statement, based on the enhanced funding that you
provided this past fiscal year, we are contracting out to have
a team of health care professionals augment any of our on-going
or projected work in the future, audits, inspections, and
investigations.
Chairman Thompson. So at the time based on what you just
said, and of your review of the deaths, you did not have on
staff or contracted any medical personnel?
Mr. Cuffari. No, sir.
Chairman Thompson. Dr. Mitchell, you have heard my
question. In your professional opinion, do you think, if you
are looking at a death of any kind that a medical personnel
would be important to the team?
Dr. Mitchell. Yes, absolutely. I think that, especially
deaths in custody, deaths in custody require fatality reviews.
Most fatality review panels need to be multidisciplinary.
Therefore, you are going to get the recommendations. So it is
going to really depend upon what you are trying to get out of
investigation. But from a fatality review construct, you need
to not only have clinicians, like pediatricians if it is a
child death, internists if it is an adult death, but also a
forensic pathologist or a medical examiner, so they would be
able to interpret the findings at autopsies. All of that is
going to be required in the future. It is going to be helpful.
Chairman Thompson. Thank you very much. Mr. Cuffari,
according to your report, Border Patrol agents stated they were
in contact via text message when Felipe was transported to the
hospital the first time, the morning of December 24. Do you
have copies of any of those text messages in your file?
Mr. Cuffari. To my knowledge, sir, no, we do not.
Chairman Thompson. So you put in a report information that
you could not document?
Mr. Cuffari. We documented, sir, the testimony from the
Border Patrol agents and their supervisors. All credible
testimony.
Chairman Thompson. I understand that, but nobody thought to
get a copy of the text messages or anything like that?
Mr. Cuffari. Not to my knowledge.
Chairman Thompson. Well, did the inspector general's office
pull or review any emails or other electronic messages
involving CBP personnel regarding Felipe's care or death?
Mr. Cuffari. Not to my knowledge, sir.
Chairman Thompson. Thank you.
I now recognize the Ranking Member of the full committee
for questions.
Mr. Rogers. Thank you, Mr. Chairman. I think it would be
productive if I yield my time to my colleague from Tennessee,
Dr. Mark Green.
Chairman Thompson. The gentleman from Tennessee is
recognized for 5 minutes.
Mr. Green of Tennessee. Chairman, Ranking Member, and
witnesses, thank you. The hardest part about being a doctor is
sometimes you do everything you can for a patient, and they
still die. Mr. Chairman, I would like to introduce myself.
There are a few things I have never shared, but today it is
important I do so.
I graduated in the top third of my med school class,
attended the No. 1 emergency medicine residency training
program in the Nation. All 3 years in residency, we scored No.
1 in the Nation. Yes, we beat those Harvard doctors too. I
deployed all over the world in some of the most remote places
in the planet, provided medical care to children of Afghani
villagers, and battle-hardened Navy SEALs and delta operators.
I have never been sued for malpractice, I have served as
medical director of 4 different emergency departments in 3
States ranging from depressed rural to a level 2 trauma center.
I was CEO of a company of emergency physicians, and PAs,
and nurse practitioners, that ran 52 emergency departments in
11 States. I have served as both defense and plaintiff expert
on tons of med mal cases doing exactly this, forensically
assessing care given.
In this case, first by CBP and then medical facilities.
Both of these cases are about pediatric sepsis. First, a few
facts about ped sepsis, a review of the medical literature on
sepsis recounted 4 studies in the United States that found that
even when a patient goes to a state-of-the-art emergency
department, the mortality rate for sepsis in America was 10.3
percent in one, 8.9 percent in another, 14.4 percent, and 19
percent respectively. Even when these patients present to EDs
in the United States, many still die.
Why is this disease process so hard to treat? Well, like
Dr. Danaher said in her testimony, children don't look bad
until the very end. When I trained EM residents, we called it
the pediatric cliff. They look great and then crash in seconds.
I appreciate the written testimony of our pathologist who
honestly reported that in both cases he felt, ``The actions
taken by individual U.S. CBP agents seem to be appropriate and
timely''. I affirm from this that Dr. Mitchell understands that
standard of care depends on where you are and the facilities
available.
Dr. Danaher's testimony is disconnected from this idea. The
reality of rural health care is millions of Americans aren't
able to walk into a Harvard quality care. The standard of care
at Mass General on a given day will never be comparable to
triaging 160 migrants in the dark of the night in Antelope
Wells.
Dr. Mitchell's testimony is balanced and professional. It
is not political hyperbole, but it does suggest that the
Federal Government has the ability to deploy doctors to remote
areas of the border, interview migrants about their health, and
do a variety of tests which is simply unrealistic.
Dr. Danaher's written testimony is blatantly partisan. She
critiques the conditions of CBP facilities going on about lack
of toothbrushes and clean water. I know from my own visits, the
CBP facilities and the facts in these cases, those allegations
are simply false. She also discusses the psychological dynamic
of the data of one patient to not share information to agents
as if that environment is the law enforcement officer's fault.
That dynamic existed because of crossed the border illegally,
and then didn't tell agents that Jakelin was sick, even when
they repeatedly asked him.
If a patient presents to an ED in the United States and
lies about their medical condition, it is not the doctor's
fault.
Look, both of your testimonies center around getting more
resources. The bottom line, you want more doctors and
electronic medical records. Just published yesterday new
estimates of doctor shortages in the United States. The United
States is short 14,494 doctors. Where in the world are we going
to get doctors to put somebody at every single crossing site?
This testimony proposes building health care infrastructure for
illegal immigrants that would dwarf the health care systems in
77 percent of rural counties in America.
Last year, House Democrats voted to advance an electronic
medical record to illegal immigrants within 90 days when
veterans in many States still don't have it, and won't have it
for 7 years.
Finally, this side of the aisle spent all of last year
highlighting how dangerous the journey to our border is for
kids. The answer is not to turn CBP stations into Mass General.
We have to break the cartels that entice people to come here
with children and fix our immigration law loopholes. Until we
do that, smugglers will continue to turn a profit over enticing
families to come to our border with false promises.
Mr. Chairman, I yield.
Chairman Thompson. Thank you very much.
The Chair now recognizes other Members for questions they
may wish to ask witnesses. As previously outlined, I will
recognize Members in the order of seniority, alternating
between Majority and Minority. Members are reminded to unmute
themselves when recognized for questioning, and to the extent
practical, to leave their cameras on so they are visible to the
Chair.
The Chair now recognizes, 5 minutes, the gentlelady from
Texas, Ms. Jackson Lee.
Ms. Jackson Lee. Mr. Chairman, thank you for holding this
very important hearing. Thank you to the Members of the--
witnesses who are here as well who have provided very important
testimony.
All of us were shocked to learn in December 2018 that 2
children died in separate incidents while in the custody of
U.S. Border Patrol, which are the first deaths of children in
Border Patrol custody in more than a decade. I am going to be
very clear that when you lead a Nation, all that happens,
whether you like it or not, falls at your feet. I have known
Border Patrol agents and visited with them in my State of Texas
for decades. I have seen their passion. I have seen them buy
baby food and formula.
Where this tragedy falls is clearly at the feet of an
administration that is inattentive and does not recognize that
we are to comply with the international protocols of human
rights and human decency.
Following the deaths of those 2 children in 2018, U.S.
Customs and Border Protection, the Border Patrol parent agency,
issued an interim directive in January 2019 establishing new
medical screening and other procedures. I physically went down
to the border and saw the immediate emergency tactics that were
used. It was a table and the use of Coast Guard doctors. They
all meant well.
Dr. Danaher, thank you for your leadership. My question: As
all of this falls at the feet of the President of the United
States and the administration and we have to adhere to human
rights protocols, can you please elaborate on the differences
between pediatric disease processes and adult disease processes
so you know that a child may be sick and why understanding the
nuances of each is important, especially in these situations?
Dr. Danaher.
Dr. Danaher. So children are physiologically different from
adults. They can compensate in different ways for infection
than adults can. As Dr. Green mentioned, when they are sick,
they can look well for quite a while before they crash. That is
all very true.
So I think it is really, really important for there to be
pediatric expertise at the border. That does not necessarily
have to mean pediatricians. It means intense training for the
EMTs who are already working with the vulnerable people.
Currently, EMTs in New Mexico helping children who are
apprehended only get about 10 percent of their training
dedicated to pediatrics, which only amounts to a few hours.
So it is incredibly important to be able to recognize when
children get sick. They definitely look different.
Ms. Jackson Lee. You understand that Border Patrol agents
are not doctors, they are not EMTs, they are not nurses,
correct?
Dr. Danaher. Correct.
Ms. Jackson Lee. So it would be your view that minimally, a
Nation as powerful, as rich as the United States, could
recognize the importance of those nuances and have a system in
place that would deal with pediatric issues or children who are
in life-and-death situations?
Dr. Danaher. Yes, yes.
Ms. Jackson Lee. I didn't hear you. I'm sorry.
Dr. Danaher. Yes, yes.
Ms. Jackson Lee. Thank you.
To the inspector general, Mr. Cuffari, you did a report
there was some suggestion that CBP officers try to engage with
the parent. Do you know what language they spoke to Jakelin's
father?
Mr. Cuffari. I believe, ma'am, Jakelin father indicated on
his in-processing paperwork that he was fluent in the Spanish
language and the Border Patrol agents spoke to him in Spanish.
Ms. Jackson Lee. My understanding is that he spoke his
indigenous language, K'iche'. Did anyone try to speak to him in
that language to make sure he understood?
Mr. Cuffari. Not to my knowledge, ma'am.
Ms. Jackson Lee. So what elements of change would you
recommend, or did you recommend, in light of the 2 deaths of
children that had never happened, and it certainly didn't
happen with the mass migration during the Obama administration.
Mr. Cuffari. We actually--as I mentioned in my opening
statement, we have 3 on-going projects to look at the matters
that you just asked about. These are 3 of 21 that I had in my
prepared statement. We will make recommendations based on what
our findings are at the time and hold DHS accountable for
implementing those recommendations.
Ms. Jackson Lee. The recommendations that you are looking
to is framed around 2 deaths, and as well, no response timely
enough to save those lives?
Mr. Cuffari. We are looking at the circumstances that
surrounded the deaths, the medical care, and the access that is
capability of being provided by DHS to the children who are in
custody, as well as to other adults, et cetera.
Ms. Jackson Lee. Well, let me just say that we have 3
million-plus COVID-19 deaths in the United States. Obviously
there will be major investigations dealing with the
responsibility of this administration in--excuse me, 3 million
cases, let me correct myself, 3 million-plus cases rising to
140,000 deaths, maybe about 137,000 deaths. Make sure the
record is clear, 3 million-plus cases. Many of those cases are
obviously in States like Texas, New Mexico, and even
Mississippi and others.
So, I would emphasize that your work is extremely
important. When the Federal Government fails the Nation, it is
important for there to be concise, direct, wide-spread
understanding of why, and directions of how that is remedied.
The loss of a child is precious. I give my deepest sympathy to
the families and, therefore, we must make sure that we correct
it.
I thank you, Mr. Chairman. I yield back.
Chairman Thompson. Thank you very much. The Chair now
recognizes the gentleman from New York, Mr. Katko, for 5
minutes.
Mr. Katko. Thank you, Mr. Chair. Having lived on the border
and prosecuted cases on the border in the mid-1990's, I can
tell you back then the border and porousness of the border was
a problem and it attracted more and more people, and tragedy
often resulted back then. It is still happening today, and it
is a terrible thing. It is terrible thing to lose anyone at the
border in custody. It is a terrible thing ever to lose them if
they are a child. We have to do all we can to make sure of that
going forward.
But I will note that it is an incredibly complex issue,
much more complex than I think some of the dialog today. I
would like to defer to my colleague, Dr. Green, to take the
balance of my time. I yield to him.
Chairman Thompson. The Chair recognizes the gentleman from
Tennessee for the balance of the time.
Mr. Katko. Thank you Mr. Chairman.
Mr. Green of Tennessee. Thank you, Mr. Chairman.
Dr. Mitchell, you mentioned in your testimony that resource
hurdles prolonged CBP custody and delayed access to medical
care. I agree. The efforts led by House Democrats to defund ICE
have had sweeping consequences, mainly impacting CBP facilities
such as what happened during December 2018.
ICE family residential centers were at capacity, forcing
CBP to hold immigrants much longer than they should. The
bureaucracy exacerbated by the border crises preventing those
in CBP custody from reaching ICE facilities built for long-term
holding and for more thorough medical assessments and access to
care.
My question to you is do you support additional funding for
ICE capacity and medical staff to ensure that children don't
get stuck in CBP custody like they did last year?
Dr. Mitchell. Yes. I think that any funding that is going
to go forward to resolve this issue must go forward to decrease
any overcrowding burden. I will leave it up to the House and
the politicians to understand where exactly that goes and what
agencies get those resources. But I think you and I agree, Dr.
Green, that overcrowding conditions is a major concern,
particularly when we are talking about infectious disease.
Then as far as the issue of timeliness, and I appreciate
you elucidating the fact that I wanted better access to health
care there at the border, I agree. I think physicians would be
a hard burden, a hard bar to reach. But I believe that there is
opportunities, as my colleague Danaher described, is that
higher training of the EMT, maybe nurses, nurse practitioners,
that are available there to make sure that the burden is not
placed on our agents to try to triage these patients.
Mr. Green of Tennessee. I really appreciate your comments.
I think clearly we, on our side of the aisle, would like to see
more funding for ICE. There are a lot of people, especially for
those detention facilities, a lot of people on the other side
of the aisle want to defund ICE, but I want to follow up one
more question, Dr. Mitchell, for you before my time expires.
You indicated in your testimony that you believe Jakelin's
death could have been prevented in the initial health
assessment questionnaire if it had been performed by a licensed
medical provider.
You may not know this, but yesterday DHS--or not DHS but
HHS released the doc shortage. Seventy-seven percent of
America's rural counties right now are short both doctors and
PAs, and by 2032, that is going to be 121,000 short. Where do
we get these medical providers? I mean, do we take them from
American cities? I am eager to hear your thoughts on that.
Dr. Mitchell. Again, I think the shortage of medical
providers is across the Nation, as you describe. I just don't
believe that the recommendation of providing adequate health
screening to whoever we come into contact with, it stops being
a recommendation because the hurdles and barriers are too big.
I think our job is to try to create opportunities where we can
meet the goals of saving lives, wherever it exists. So no, not
taking away from anyone, but attempt to provide it to everyone.
Mr. Green of Tennessee. Yes. We just have to be realistic
in our solutions and find solutions that work, and your
recommendations were, you know, a licensed medical person. I
just--with the shortage we already have, I just don't see how
that can happen.
I think my time has expired, Mr. Chairman.
Chairman Thompson. Thank you.
The Chair recognizes the gentleman from Louisiana, Mr.
Richmond, for 5 minutes.
Mr. Richmond. Thank you, Mr. Chairman. As much as I would
want to go into the shortage issue and the proverbial Trumpism
of pitting communities against each other, and I guess that is
what we are doing in terms of access to doctors, I just won't
entertain it. I mean, we are the greatest country in the world.
Dr. Mitchell, could you just for me, in laymen's terms,
explain what Felipe died of?
Dr. Mitchell. Yes. So Felipe, he died of--he had a
bacterial infection that was superimposed on flu. So everybody
knows what bacteria is when I say it. It is a small organism
that can cause infection. This particular type of organism that
he had, he had flu, and then that flu had a bacterial infection
on top of it.
The type of infection he had was so severe that it caused a
rapid disease within his lungs, and so he died from, like, a
hemorrhagic pneumonia or sepsis, and so that is functionally
what he died from.
Mr. Richmond. Dr. Danaher, let me ask you, and I think both
you and Dr. Green mentioned the uniqueness of treating children
and when their symptoms show. Does it require special training
to determine how severely ill a child is?
Dr. Danaher. Yes. I would say it does.
Mr. Richmond. Ms. Gambler, in your written statement, it
says that the report you are releasing today has found, ``CBP
does not provide officers and agents with training to identify
medical distress in children.''
Is that correct?
Dr. Danaher. Yes. That is our finding.
Mr. Richmond. To the Inspector General, in reviewing
Felipe's death, did your office examine whether the agents who
were responsible for caring for him had received training in
identifying medical distress in children? If so, what did your
office's review find?
Chairman Thompson. You need to unmute yourself.
Still not able to hear you.
Looks like we are----
Mr. Cuffari. I am sorry, Mr. Chairman. My computer froze. I
had to come back into the meeting. I am really sorry.
Mr. Richmond. Let me repeat that question, then. In
reviewing Felipe's death, did your office examine whether the
agents who were responsible for caring for him had received
training in identifying medical distress in children? If so,
what did your office's review find?
Mr. Cuffari. My understanding is the Border Patrol is
trained in basic first aid, CPR, and trauma care. They also
have advanced paramedics in several of their stations. In this
case, in the case of Jakelin, there was a paramedic who
happened to be at that station. I didn't find any evidence of
pediatric training, though.
Mr. Richmond. Well, it was also clear that Felipe's father
asked for him to be returned to the hospital in a sense of
urgency. It took about an hour before they left the station, so
it is unclear if the urgent nature of the situation was
conveyed to everyone involved in the transportation.
So Dr. Danaher, given those circumstances, are there any
questions about CBP's policies and practices for dealing with
emergencies that should be reviewed?
Dr. Danaher. One issue that arose for me in reading the
time frame in which he received care is whether anybody is
actually entering the cells to examine a child's [inaudible]
medical assistance is actually requested. From what I could
tell from the records that were available it would appear that
we are checking on his cell door. But it is not clear that
anybody took a close look at something. If they had, it would
be very, very apparent if he was in distress.
Mr. Richmond. To the Inspector General, if possible, could
you either forward to us or articulate any recommendations or
policy revisions you have after reviewing Felipe's death and
the file surrounding it?
Mr. Cuffari. Sir, we have----
Mr. Richmond. With that, Mr. Chairman, I yield back.
Chairman Thompson. You can answer the question.
Mr. Cuffari. Thank you, Mr. Chairman.
Sir, as I mentioned, we have on-going projects to look at
that exact question, and we will be happy, very happy to
provide the committee with our recommendations once we finish
those reviews.
Chairman Thompson. You said that is the end of December,
right?
Mr. Cuffari. We should have one sometime toward the end of
this year for you, sir.
Chairman Thompson. Thank you.
The Chair recognizes the gentlelady from Arizona, Mrs.
Lesko, for 5 minutes.
Mrs. Lesko. Thank you, Mr. Chairman, and thank you for
those testifying.
When I read the accounts of the 2 young children dying, I
mean, it is very sad. I am sure all of us can agree that it was
sad, and we wish it didn't happen.
But if I heard it right, Dr. Mitchell said both deaths were
preventable and blamed the Customs and Border Protection
agency, and Dr. Danaher said Customs and Border Protection
agency was at fault. After reading the IG's report of what all
happened, I really fail to see how you came to that conclusion.
I mean, first of all, you had in the young woman's--or the
young girl's account, she entered the United States and was
apprehended on December 6 after traveling, I assume, thousands
of miles. The CBP asked if anyone was sick because they wanted
to get the sick people on the first bus, and they didn't say
anything. Then they didn't fill out on the form--they said
actually on a filled-out form that they were not sick, that
they were healthy. Then the father didn't say anything to the
CBP officers that his daughter had been vomiting, and he told
the bus driver that his daughter was vomiting but didn't tell
CBP.
So then they got off the bus first after they found out
from the father, and the EMT gave immediate medical care, and
it was only then that the father told the EMT that his daughter
had been vomiting and not eating for 2 to 4 days.
So I fail to see how that is the agency's fault. Then they
airlifted her to a hospital, and unfortunately, she died.
In the case of the boy, it sounds like the CBP transferred
as soon as they knew there was something wrong. The hospital
didn't write in there things, that he had influenza B, didn't
give medication, the amoxicillin, didn't note that, so to me,
that seems more like a hospital error than a CBP error.
So my question to Mr. Cuffari is, Mr. Cuffari, in your
investigation, have you determined that either one of these
parents, the parents seeking medical care and the child
receiving medical care before they were apprehended by CBP,
especially the girl who had been sick for 2 to 4 days?
Mr. Cuffari. It doesn't sound as though that the
investigation found that that had been the case. Their first
medical treatment was once they came into CBP custody in 2
different instances, one at the Lordsburg station and the other
at the facility at the checkpoint.
Mrs. Lesko. Thank you. Mr. Cuffari, do you think the cartel
would have given them medical care? I mean, the accounts I have
heard about the cartel, they could care less about these
people. They just make money off of them.
Mr. Cuffari. Representative Lesko, that is beyond the scope
of my testimony here today.
Mrs. Lesko. Well, you know, it is my opinion that instead
of blaming the Customs and Border Protection agency for
everything that happens, to me, it was clear that traveling
thousands of miles, we should start blaming the cartels, don't
you think? People should at least be partly accountable for
children's deaths if the parents don't tell the medical people
or Customs and Border Protection that their child's even sick.
They have been traveling thousands of miles.
I mean, I just think it is unrealistic to expect the
Customs and Border Protection to just know that these things
are going to happen. To me, it seemed like they went over and
beyond trying to help these children.
I have a few seconds left to give to Dr. Green.
Chairman Thompson. The Chair recognizes the gentleman from
Tennessee for the balance of the time.
Mr. Green of Tennessee. Thank you, Mr. Chairman.
A very quick question to Dr. Danaher. Have you done med mal
cases, review cases before?
Dr. Danaher. No.
Mr. Green of Tennessee. You obviously reviewed the records
here. What stood out to you about the resuscitation in this
case, Felipe's resuscitation, when you reviewed that case?
Dr. Danaher. In terms of when he presented to the hospital
the second time?
Mr. Green of Tennessee. The second visit when they tried to
resuscitate him, was there anything that jumped out to you as a
physician on that resuscitation documentation?
Dr. Danaher. I mean, there were definitely some
irregularities in terms of what happened when he reached the
hospital, but he arrived already pulseless. They had a really
difficult time intubating him. There was a significant amount
of blood in the airway which contributed to the multiple failed
intubation attempts [inaudible].
Mr. Green of Tennessee. If I could just say, answer the
question, because I know you have played, you know, guess what
I am trying to ask you before as a physician. We do that a lot
to one another. But he was incorrectly intubated, and they
continued the resuscitation for several minutes with the
breathing tube down his esophagus. Clearly, you can't
resuscitate a patient, and he is not getting oxygen for several
minutes in the resuscitation. That is problematic for saving
the child's life.
I yield.
Chairman Thompson. The Chair now recognizes the gentleman
from New Jersey for 5 minutes, Mr. Payne.
Mr. Payne. Thank you, Mr. Chairman. I appreciate the
opportunity to be here today. It is very interesting to listen
to the gentleman from Tennessee who has stated that he has been
on the defense side and the prosecution side of these issues.
You know, also, when my other colleagues mentioned that, you
know, it is the cartel's fault.
You know, we are all responsible. We are the legislative
body of the U.S. Government. We are responsible for making sure
that nothing happens to these children. But you see, the
administration went down a road to collect these people and
lock them up in cages. Then when something happens, oh, well,
we didn't have anything to do with it.
No. This is abominable. This is absolutely abominable, what
I am listening to. Two children have died. I put my children in
that position. All of us need to put our children in a
position, and I think we might take--there might be a different
tenor to this hearing.
But I only have 5 minutes, so Dr. Mitchell, can you please
explain how and why video footage is important to understanding
all of the circumstances surrounding a death in custody?
Dr. Mitchell. Yes. So I was one of the primary authors on
the death in custody and how to report, examine, investigate,
and report out deaths in custody, put out by the National
Association of Medical Examiners. Part of what that
organization calls for is, indeed, any information that is
available for deaths in custody which includes any video
footage, any medical records. Anything that can give an idea of
the time leading up to the death is going to be important to
categorizing the final findings at autopsy.
Mr. Payne. Thank you.
Inspector General, can you discuss the video footage
obtained and reviewed regarding Felipe's death?
Mr. Cuffari. My understanding, sir, is the video footage
was obtained regarding--while Felipe was in custody. Our
trained criminal investigators reviewed that footage, and they
determined that the footage married the testimony of the Border
Patrol agents.
Mr. Payne. OK. Is there footage of Felipe leaving the
station to travel to the hospital on that evening on which he
died?
Mr. Cuffari. You know, sir, I am going to have to get back
to you on that specific question.
Mr. Payne. OK. Did you review any aspect of the CBP's
collection and retention of the video footage of the
individuals in custody as part of the review of Felipe or
Jakelin's death?
Mr. Cuffari. I am not sure I understand the question, sir.
We did obtain the video footage concerning the time period in
which Felipe was in custody. But to my knowledge, that was--I
don't believe they took any other footage outside of that time
period.
Mr. Payne. OK. So you didn't review the aspects of how it
was collected and retained, right?
Mr. Cuffari. The collection and retention would have been
done by our criminal investigators or by CBP OPR agents acting
on our behalf in collecting the evidence.
Mr. Payne. So there would be in the report some mention of
that, correct?
Mr. Cuffari. To my knowledge, yes, sir.
Mr. Payne. Mr. Chairman, how much time do I have? I know I
am getting close.
Chairman Thompson. The gentleman has 1 minute left.
Mr. Payne. Thank you, sir.
Inspector General, how many times did Border Patrol
officers conduct wellness checks of Felipe on the day he died
after he returned from the hospital the first time and before
he left the station for the hospital for the second time? How
many times was he checked on?
Mr. Cuffari. The exact number, I couldn't give you, sir.
But from the report of the interview of Felipe's father and
consistent with Border Patrol testimony, the father said that
the Border Patrol agents checked on he and his son 5 to 6--
every--sort of every 5 to 6 minutes while they were back in the
facility after their first visit to the hospital and before the
[inaudible] second time.
Mr. Payne. OK. Thank you, Mr. Chairman.
I yield back. Thank you, sir.
Chairman Thompson. Thank you. The gentleman yields back.
The Chair recognizes the gentleman from Louisiana for 5
minutes, Mr. Higgins.
Mr. Rogers. Mr. Chairman, Mr. Higgins is gone.
Chairman Thompson. Thank you. The Chair recognizes the
gentleman from Tennessee again for 5 minutes.
Mr. Green of Tennessee. Thank you, Mr. Chairman. I just
want to say, you know, we are responsible. I can tell you I
will never forget the first child that I had to pronounce. The
child had been hit by a car, and the image of that mother
bringing that child in in her arms is forever burned in my
brain.
The loss of these 2 children, it is tragic, but what we are
doing here is a forensic examination of the record to find
where fault happened. This is designed to find where there is
fault, and so it takes an objective setting that aside and
looking at the case.
So I want to ask Dr. Danaher again, you know. The records
are pretty clear that the father of young Jakelin was asking
for medications from his fellow travelers before entering into
the United States. In fact, since the antibiotic he had on his
hands was Flagyl, not the best for strep infection, they
probably didn't get that prescribed by a physician. He knew she
was sick, and he failed to disclose it.
You mentioned in your written testimony about the
environment of a person answering questions to law enforcement
being a barrier for Jakelin's father telling the truth about
his daughter being sick, and I want to ask you. Are you
suggesting that there is some kind of new standard of care that
if a patient lies about their medical condition, the physician
or that provider is somehow liable?
Dr. Danaher. Not at all. What I am saying is that the
initial screening that occurred when a large group of migrants
arrived at the forward operating base. It was, from what I can
gather, one agent yelling to more than 100 people that if
anybody was sick, they should come forward. They yelled this in
Spanish. The father's native language is K'iche', so we don't
know if he heard them. We don't know if he understood them.
On top of that, we are asking people to come forward in
front of a large group of people to talk about their medical
issues which, as I am sure you appreciate, could be very
sensitive for some.
Mr. Green of Tennessee. Do you have children yourself?
Dr. Danaher. I do.
Mr. Green of Tennessee. So you can imagine having a sick
child and not wanting them to know about it? I mean, I don't
understand that dynamic----
Dr. Danaher. I am not certain that----
Mr. Green of Tennessee [continuing]. I have taken care a
lot of pediatric patients in the ER, and those parents are
afraid. They come in, and they want to tell you. Why would he--
I don't understand why a father who cares about a child would
specifically lie when asked. They asked in Spanish and he
responded in Spanish, so he clearly understood Spanish.
Dr. Danaher. So I think that there is a difference between
being able to speak a little bit of Spanish versus to share
sensitive or nuanced medical information in Spanish.
On top of that, the questions on the health interview form
are very non-specific. There is one question about any type of
illness, and the rest are about things that wouldn't be
particularly relevant to Jakelin's case. So this all hinges on
whether the father understood that one question.
Mr. Green of Tennessee. I don't agree--I don't disagree
with you that a form review could make that form better. I
just--I can't make CBP responsible for a guy who says his
children are OK when asked if they are medically ill.
Let's flip to Felipe's case and I only have a little bit of
time so I am going to get right to it. You made some very, I
think, appropriate comments in your written testimony about his
first visit when he went in. I mean, it was horrible when I
looked at it, but I want you to tell the committee what you
thought about his care when he was first brought to the
hospital there at GCRMC and whether you think they should have
let that patient go home.
Dr. Danaher. No. They absolutely should not have let him go
home. I agree with you that the care that he received was very
concerning during his first presentation. His vital signs were
significantly abnormal. His heart rate was persistently
evaluated even when he did not have a fever. His oxygen level
went as low as 91 percent at one point.
It is not clear that anybody noted that fact. The physician
who saw him later acknowledged during a CMS review that he had
not reassessed Felipe before the child left the facility.
Mr. Green of Tennessee. Yes. I didn't see any assessments
for hydration status, you know, tears or moist mucus membranes.
I mean, all things would be standard of care. This is an
American physician at an American emergency department, and
they let this kid go home.
My question is, is you know, would a normal law enforcement
officer question a physician like that? Is he trained enough to
question the physician?
Dr. Danaher. Well, what is interesting in this case is it
appears that the law enforcement officer did. He actually
advocated for Felipe to receive more care before they left and
continued to express concern after they left which says to me
that they could recognize that he was quite sick.
Mr. Green of Tennessee. Yes. They definitely recognized
that the care given was pretty shoddy. I mean, I think he had
to ask to have the temperature taken.
So thank you.
I yield, Mr. Chairman.
Chairman Thompson. Thank you very much.
The Chair recognizes the gentlelady from New York for 5
minutes, Miss Rice.
Miss Rice. Thank you, Mr. Chairman, and I would just first
like to thank the Inspector General for being here today. I
only wish that you had been available when we did a hearing on
these 2 terrible deaths back in January, and you would not come
to that hearing, so I am glad that you are here today.
I think it is--would it be fair to say, Mr. Inspector
General, that in the course of reviewing Felipe's death, you
clearly don't come to a conclusion that the CBP did anything
negligent or inappropriate? Would that be correct?
Mr. Cuffari. That is correct, Miss Rice.
Miss Rice. So would you say it is fair to say that the
Border Patrol agents were not properly trained to be able to
comply with the TEDS standards for responding to a medical
emergency involving a detainee with difficulty breathing, would
you say?
Mr. Cuffari. I would say that based on the training that
the Border Patrol was provided and had at the time that they
complied with the standards upon which they were being judged.
Miss Rice. So let me just read specifically from the TEDS
standards addressing medical emergencies. It states,
``emergency medical services will be called immediately in the
event of a medical emergency; for example, heart attack,
difficulty breathing, and the call will be documented in the
appropriate electronic system of record. Officers, agents must
notify the shift supervisor of all medical emergencies as soon
as possible after contacting emergency services.''
Now, according to your review of Felipe's death at
approximately 5 p.m. on the day he died, Felipe was observed to
have difficulty breathing and complained about pain in his
stomach. An agent reported that he asked Felipe and his father
if they wanted to go to the hospital and both declined. Do you
think that that was appropriate behavior?
Mr. Cuffari. At the time, it appeared to be appropriate. It
was within the scope of our investigation, and that is what we
determined.
Miss Rice. So what do you mean, at the time? Do you have
any information now that would lead you to come to any
different conclusion?
Mr. Cuffari. Ma'am, that is why we are doing the additional
reviews and evaluations that I briefly mentioned at the
beginning. We are going to be looking at those issues.
Miss Rice. Dr. Danaher and Dr. Mitchell, are there issues
of informed consent that could come into play in situations in
which CBP personnel are asking parents and children in
detention if they want to go to the hospital, particularly if
they have already been to the hospital on that same day?
Dr. Danaher. Would you like me to respond first?
Miss Rice. Sure.
Dr. Danaher. Yes. So I think there are multiple issues
here. One is that once a child is in custody, the parent is not
really in a position to be advocating for their child to go
back to the hospital. The child is in the custody of the
Government.
On top of that, we have to remember that when immigrants
are in detention, they are--they may perceive themselves as
being at the whims of the Border Patrol agents, and they may
not want to make themselves a nuisance.
Because we have to remember 6 months prior to this, Border
Patrol was separating parents from their children, and there is
real reason for people to be afraid of what might happen if--
with these agents. I am not suggesting that agents did anything
to separate this family at all. I am just saying that the
dynamic of being in detention makes it very challenging for
parents to advocate for medical care for their children.
Miss Rice. Let me just say I think that everyone on this
hearing would agree that there were mistakes that were made at
the hospital. Clearly, he should not have been released the
first time. There is no question. I don't know if there is an
investigation into the treatment, the medical treatment he got
at that hospital or not, but there should be for sure. But any
attempt to blame the parent in this situation--Felipe, when he
came into custody, was a perfectly healthy child. He got sick
while he was in custody.
So CBP had it within their discretion to actually not keep
Felipe and his father in custody for those 6 days between the
time that they were apprehended and when he died. They could
have paroled him. That was well within the discretion of
authorities, the Government, at that time.
Let me just also say that, you know, I was happy to hear
Dr. Green talk about how important it is to invest in our
health care system. No better time than now for us to discuss
this, especially as we are dealing with the pandemic.
We are seeing the disparate way that our health care system
works for people of color and people in certain socioeconomic
backgrounds.
So I am glad to hear Dr. Green talk about how important it
is to invest in this, but I think we all have to agree that
children present at the border, and our primary responsibility
to them is to keep them healthy and not have them die in our
custody, and so we have to make the system work better.
I am not blaming these CBP officers because they are not
medically-trained personnel, but then that means that we need
to have medically-trained personnel at the border.
My colleague, Ms. Underwood, given her background and her
repeated trips to the border before this whole pandemic
happened, was calling for just that, a more comprehensive
health check for every single child who comes into the custody
of CBP or ICE.
So I just want to thank all of the witnesses for coming
today, and I yield back, Mr. Chairman. Thank you.
Chairman Thompson. Thank you very much.
The Chair recognizes the gentleman from Texas, Mr.
Crenshaw.
Mr. Crenshaw. Thank you, Mr. Chairman. Thank you for holing
this hearing.
My first question is for Ms. Gambler from GAO. I just want
to clarify something. The line items on medical care you
mentioned, those are from the emergency supplemental, correct?
Ms. Gambler. Yes, sir.
Mr. Crenshaw. That all occurred after the deaths in
question, correct?
Ms. Gambler. The emergency supplemental was enacted last
summer, July 2019.
Mr. Crenshaw. Right. But the spending occurred----
Ms. Gambler. The spending occurred then after enactment, so
yes, sir.
Mr. Crenshaw. It was not in the same time frame, so I just
want to highlight for the records the GAO's findings don't have
a cause-and-effect relationship the child custody does in
question.
Mr. Cuffari, and just to confirm, there are 2 completed IG
investigations, one continuing, on-going, correct?
Mr. Cuffari. Concerning deaths in custody, sir?
Mr. Crenshaw. Yes.
Mr. Cuffari. Yes. That is correct.
Mr. Crenshaw. Of the 2 completed investigations, the IG
determined that all CBP employees who were involved did
everything possible to ensure both children received medical
treatment, and there was no misconduct or malfeasance, correct?
Mr. Cuffari. That is correct, sir.
Mr. Crenshaw. From your testimony, it sounds like the main
issue here is overcrowding, correct?
Mr. Cuffari. It was an issue, actually, that we raised
during our unannounced site inspections of CBP facilities in
2019. We issued what is called a major management alert to DHS
headquarters, and they implemented procedures to alleviate the
overcrowding. I am told that they will complete that by the end
of this year.
Mr. Crenshaw. Thank you. I mean, it raises the issue we
have long raised which is the reason is there is overcrowding
is many of our policies encourage people to illegally cross the
border. There is multiple factors.
The reason I bring all this up, it raises the question of
the purpose of the hearing. If there is any evidence of
malicious intent by CBP, I think this hearing would certainly
be warranted, but there is not. This hearing appears to be
designed, at worst, to drive a false narrative that implies
malicious behavior by CBP.
At best, we are seeking to falsely imply that these tragic
deaths could have been prevented by better action by CBP
officers even though the children's parents brought them across
our border in extremely poor health.
Furthermore, these false narratives, they lack context,
falsely assuming that the purpose of border stations is to
provide hospital-level child care. Of course, the truth is, the
purpose of CBP is, in fact, customs and border protection.
When I went to the Rio Grande Valley sector late last year,
there was a humanitarian crisis unfolding. In January 2019,
there were more than 58,000 apprehensions. In February, that
climbed to more than 76,000. Total border numbers spiked to
144,000 in May.
Let's also keep in mind these were not typical single male
economic migrants. They were mainly family units, more than
473,000 in fiscal year 2019, and unaccompanied minors, more
than 76,000 in 2019. As migrants are handled differently and
completely overwhelmed our border control processing centers.
When this crisis unfolded in early 2019, we were sounding
the alarm. It was ignored. The crisis was ``manufactured.'' We
didn't vote on an emergency supplemental appropriation until
late June. By that time, there had been more than 750,000
apprehensions or inadmissibilities along the Southwest Border.
So again, why are we holding this now? I have to wonder is
it because demonizing law enforcement is popular right now?
Border Patrol agents haven't been targeted enough lately? Let's
be clear. Each of those children who lost their life is
absolutely tragic. It is also shameful to try and put the blame
on our CBP officers and Border Patrol agents.
I think we could engage in some intellectual honesty and
highlight the fact that in the past 18 months, almost 475,000
agent hours have been spent transporting migrants to hospitals
and staying on hospital watch with sick migrants. We know those
who make the trek from the Northern Triangle do not make it
here in the best condition.
We can highlight the fact that more than 8,000 migrants in
distress whether rescued from the Rio Grande River or found in
need of medical need due to dehydration, injury, or pregnancy
complications, have been rescued by Border Patrol.
Approximately 200 of those were directly attributed to CBP air
and marine operations assistance.
We could also mention the Border Patrol search trauma and
rescue teams which was created in 1998 to respond to injured
Border Patrol agents in remote locations. Now their main
mission is actually rescuing migrants in distress, we could
discuss the number of children and women saved from human
trafficking by CBP.
We could talk about CPB being on the front line and keeping
drugs and other contraband out of our country. Unfortunately,
though, the positions and priorities appear clear.
So when we hold this hearing, I want to take the
opportunity to let our CBP officers and Border Patrol agents
know that we appreciate your service. We appreciate what you
are doing under the most difficult of circumstances, and we do
have your back.
Thank you. I yield back. Thank you, Mr. Chairman.
Chairman Thompson. The Chair recognizes the gentlelady from
Michigan, Ms. Slotkin, for 5 minutes.
Ms. Slotkin. Thank you very much, Chairman. So I would like
to pivot to talk about something that actually Mr. Crenshaw
raised which was the special appropriation, the emergency
appropriation that we passed last summer. You know, in
particular, I am interested in the $112 million that we
appropriated to provide for detainee medical care and necessity
fees.
So we passed this $4.5 billion supplemental. I voted for
it. I think many folks sitting here watching voted for it. I
wrote to the Acting Secretary about this just to make sure we
understood how that $112 million was being spent. We got a
response back that about 8 months later from CBP, just in
March.
So Ms. Gambler, can you help us understand and elaborate on
GAO's findings regarding CBP's use of these $112 million
specifically, please?
Ms. Gambler. Certainly, Congresswoman. We found through our
legal decision and audit work that CBP did obligate funds from
the consumables and medical care line item for some goods and
services that fell within the definition or the meaning of
consumables and medical care.
So that included things like hygiene products, clothing,
gloves, masks. But we also found that CBP obligated funds from
that line item for goods and services that did not fall within
the definition or the meaning of that line item, the primary
purpose of that line item, and that included things like goods
and services for CBP's canine programs, computer network
upgrades, facilities services and upgrades.
We concluded that CBP violated the purpose statute under
appropriations law, and we concluded that CBP should make
adjustments to its accounts accordingly.
Ms. Slotkin. How much do you believe of the $112 million
was misspent on things that were not intended?
Ms. Gambler. At the time of our work for the legal
decision, Congresswoman, CBP had not completed its review of
the obligations it made under that line item.
After we provided a copy of our draft report to CBP, they
reported to us that they completed that review, and they
identified $13 million that they planned to adjust among
accounts from last year's emergency supplemental, and at least
$3.9 million that they planned to move from the consumables and
medical care line item to CBP's regular appropriations.
I would just note that given the time frames for our
review, we have not reviewed that information that CBP
reported.
Ms. Slotkin. OK. I mean, I guess I would hope that we all,
everyone on the committee cares about how the money that
Congress appropriates is spent, and that was certainly
concerning.
Mr. Cuffari, can you give us your assessment of this $112
million? Are you formally doing an IG review of the expenditure
of this money?
Mr. Cuffari. Yes, Madam Congresswoman. We have an open
audit that is going to look at the CBP's use of fiscal year
2019 appropriation funds for humanitarian assistance. We are
going to check with our colleagues and cousins at the GAO and
make sure that we get all information that is available. There
will----
Ms. Slotkin. What is the time line of your review? When do
you expect to be complete?
Mr. Cuffari. We just opened that few weeks ago, ma'am.
Ms. Slotkin. So a couple months?
Mr. Cuffari. I can't give you a definitive time line, but
we are going to do it as quickly as possible.
Ms. Slotkin. OK. I just think it is important, and I would
love to hear your commitment to come back and talk to us about
that. It is just one of those things. It is like our primarily
responsibility as an oversight committee to make sure we know
how that money is spent. I literally have no sort-of piece of
this, you know, special knowledge of it.
I just think we all are saying from various, you know,
angles that we want, you know, this issue to be resourced well
to the best of our ability to support CBP so that they can do
what they need to do on detainee health.
So can you commit, Mr. Cuffari, to coming back and
testifying in front of us about this issue?
Mr. Cuffari. You have my continued commitment to be
responsive Congresswoman.
Ms. Slotkin. Great. Thanks so much.
I yield back, Mr. Chairman.
Chairman Thompson. Thank you very much.
The Chair recognizes the gentleman from Pennsylvania, Mr.
Joyce, for 5 minutes.
Mr. Joyce. I want to thank all of the witnesses for
appearing today. I want to thank you, Mr. Chairman, for making
the committee room available for this hearing today.
I would like to yield my time today to my distinguished
colleague from Tennessee, Dr. Mark Green.
Chairman Thompson. The Chair recognizes the gentleman from
Tennessee for the balance of the time.
Mr. Green of Tennessee. Thank you, Mr. Chairman. I want to
first thank Congresswoman Slotkin for her questioning. I echo
everything she said and agree with her 100 percent and look
forward to hearing back from the Department on those misspent
funds. That really is one of our primary concerns.
I also want to appreciate the fact that Congresswoman Rice
recognized and reiterated the need for America to address this
physician shortage. We have significant physician shortages
now, and it is only going to get worse in the coming years.
My point in bringing it all up is that we had testimony
from witnesses who said you needed licensed professionals. My
conclusion from all this is that we can't take those people
where Americans aren't even getting care and put them on the
border. What we really need to do is give advanced training to
our CBP personnel and make sure they are better trained to do
those kinds of assessments because I just don't think it is
feasible to put licensed medical personnel down there.
I also want to say that I agree with Dr. Danaher that the
pediatric cuff, the pulse ox would have been helpful at those
border facilities. But as an emergency physician, I can tell
you that when Jakelin was posturing, it would not have made a
difference in this case, and to say so would be--is a little
bit misleading.
Also, as a doctor, you know, I have provided care from
Ziway, Ethiopia, to the Himalayas, and a good field medic
doesn't need a BP cuff to get a decent pressure off of where
you take the pulses.
Dr. Mitchell, I wanted to ask you. What areas of the
hospital--what areas of hospital care and care of a patient do
you recognize as the highest risk for medical errors?
Dr. Mitchell. Oh. Well, in my experience, I have seen
medical errors in the surgical suite. I have seen medical
errors in the ICU. I have seen medical errors upon
presentation. We talked about the poor intubation of one of our
patients.
So, you know, where medications are prescribed and infused,
you can see medical errors. So there are several places within
the system where you can see them.
Mr. Green of Tennessee. Well, JCAHO has done some pretty
extensive research in this. Obviously, the Joint Commission on
Hospital Organizations, they are the folks that accredit our
hospitals for those who aren't medical providers in the room.
They have done a lot of research on this, and those transitions
of care are fraught with risk.
When one provider hands a patient off to another provider,
going from the emergency department to the ICU, a shift change
is an incredibly high-risk time. The gentleman from Louisiana
mentioned that hiccup time when one of the officers was going
off shift with Felipe, particularly, and another came on,
gassed his car up, got there a few minutes late.
But when he got there, if you will recall from the
testimony, tell us what that officer did and how he responded
when he discovered the severity of the situation with Felipe?
Dr. Mitchell. Well, I think the Border Patrol agents acted
swiftly to engage the patient and try to get the patient to
care, and that was evident throughout the record that I
reviewed.
Mr. Green of Tennessee. Do you think there was anything
else they could have done?
Dr. Mitchell. No. No. I think the agents are acting--you
know, particularly in Felipe's case and quite frankly, in
Jakelin's case, these agents when they became aware, they moved
to make sure that those individual patients got to care.
So, you know, they I don't think they probably are as
equipped to recognize the things that they needed to recognize.
So we talk about that training. We talk about making sure that
we have adequate personnel that is doing that work and not
putting it on agents whose job it is to protect in a different
way the border. But, yes, I think the actions were swift and
accurate.
Mr. Green of Tennessee. Thank you, Mr. Chairman. I think my
time is up.
Chairman Thompson. Thank you very much.
The Chair recognizes the gentleman from California, Mr.
Correa, for 5 minutes.
Mr. Correa. Thank you, Mr. Chairman, for holding this most
important hearing. Can you hear me?
Chairman Thompson. Yes, sir.
Mr. Correa. Yes. I want to thank the witnesses as well.
I would like to direct my questions to Dr. Danaher and Dr.
Mitchell, the topic, CBP Directives on Medical Care for our
Children.
In January 2019, following the deaths of 2 children in CBP
custody in December 2018, CBP expanded the use of contract
medical personnel. It is a good step forward. CBP also issued a
directive setting forth interim enhanced medical efforts to
mitigate risks to and improve care for individuals in CBP
custody along the Southwest Border.
The interim directive required the Border Patrol to conduct
a health review and medical assessment of all migrants under
the age of 18. December 2019, CBP issued a final medical
directive, and that final directive appears to be weaker than
the interim directive. For example, it only required medical
assessment of children under 12 rather than children under 18.
Dr. Danaher, if I may ask you a question. Have you had a
chance to review the interim and final medical directives?
Dr. Danaher. Yes, I have.
Mr. Correa. Do you see other deficiencies in the final
medical directive?
Dr. Danaher. Yes. There are actually a number of issues
that I find quite concerning.
Mr. Correa. Please elaborate.
Dr. Danaher. Sure. One is the time frame. The initial
directive, as I recall, is supposed to be stated that these
health interviews should occur upon initial processing whereas
the final directive does not state when the health interview
needs to occur.
It also narrows the scope of what is considered a basic
medical screening so that it no longer specifies that vital
signs must be collected. As we have already discussed in
Felipe's case, vital signs could have made all the difference
if somebody had been paying attention.
As you mentioned, it only mandates medical screenings for
children under 12 or those with identified medical issues, and
it includes a caveat. This is subject to availability of
resources and operational requirements.
We have to remember that 2 of the children who died in the
time frame that we are discussing were 16, and so it is unclear
to me why we are reducing this cut-off to the age of 12.
It also seems to reduce the qualifications required for
performing medical screenings, saying that they will be
conducted by health care providers where available, and it does
say that basic acute medical care referral and follow-up can
occur on-site which on the surface is good. We want there to be
medical services on-site, but we want to make sure that that
does not mean children won't have access to pediatricians when
they need them.
Mr. Correa. Earlier this year, the American Academy of
Pediatrics submitted a statement for the record to this
committee which it stated that the final directive, ``is wholly
inadequate to ensure the proper care of children in custody and
represents a step in the wrong direction as compared to the
interim medical directive.''
Dr. Danaher, would you agree with that assessment?
Dr. Danaher. Yes, I do.
Mr. Correa. What changes should be made to the directive,
the final directive, to ensure that the adequate medical
assessments are conducted on all children?
Dr. Danaher. So as these cases that we are discussing
illustrate, it is extremely important for health interviews to
occur in a timely fashion on apprehension, and they need to be
performed by somebody who has at least some basic medical
training. That could be an EMT. It does not have to mean moving
physicians to the border for this purpose.
We also need to make sure that these health interviews ask
directed questions so that patients understand what they are
being asked about, and we need to make sure that medical
screening is offered across the board. We don't want to be
missing children just because we are saying that the onus is on
the parents to speak up when they notice something is wrong.
Once these children are in custody, they are the responsibility
of CBP, and we need to make sure they are all healthy.
Mr. Correa. Thank you.
Mr. Chairman, how much time do I have?
Chairman Thompson. The gentleman has 40 seconds.
Mr. Correa. Dr. Mitchell, do you have anything else to add
to this topic of the final medical directive and its
deficiencies?
Dr. Mitchell. No. I think it illustrates that there is a
need for a level of training and a level of expertise when
dealing with these patients, particularly children under the
age of 18.
I think that if we are talking about systems and developing
better access to systems, then we would put those resources in
place to ensure that our children are being initially screened
by individuals that have the proper level of training to ensure
that we have better outcomes.
Mr. Correa. Thank you very much.
Mr. Chair, time being over, I yield.
Thank you very much.
Chairman Thompson. Thank you very much.
The Chair recognizes the gentlelady from New Mexico, Ms.
Torres Small, for 5 minutes.
Ms. Torres Small. Thank you, Mr. Chair. Thank you for
holding this important hearing, and I am glad that we are all
here to reckon with these challenges together because it is
crucial that we make sure that people in our custody are safe.
I want to begin by offering my condolences to the families of
Jakelin Caal Maquin and Felipe Gomez-Alonso and other migrant
children who have died in U.S. custody.
Since the deaths of Jakelin and Felipe, both of which occur
in the district I serve, I have called on DHS and the Inspector
General numerous times to comprehensively investigate what
happened and specifically what holes in DHS policies need to be
filled to make sure we aren't putting our Border Patrol agents
in situations where they don't have what they need to keep kids
safe in their custody and to stop more migrant deaths from
dying in our custody.
This shouldn't be a blame game. This should be looking
forward and to the future about how we can solve this together.
I also want to note that these children's deaths occurred
in the district I serve, and I agree that we must also take
action to expand health care for rural Americans.
I invite all of my colleagues to co-sponsor the Resident
Physician Shortage Reduction Act, legislation Mr. Katko and I
have championed, to train and keep more rural health care
providers.
As well the Training the Next Generation of Primary Care
Doctors Act, the Conrad State 30, and Physician Access
Reauthorization Act, the Keep Physicians Serving Patients Act,
the Maternal Health Quality Improvement Act, the Promoting
Access to Diabetic Shoes Act, the Nurse Act, the National Nurse
Act, the Immediate Relief for Rural Facilities and Providers
Act, the Healthcare Workforce Resilience Act, the Medicare
Accelerated and Advance Payments and Improvements Act.
The Save our Rural Healthcare Providers Act, the Border
Health Security Act, and the Rural Maternal and Obstetric
Modernization of Services Act, all of legislation I have co-
sponsored or sponsored to help improve health care for rural
Americans.
Inspector General, in your testimony, you noted several new
issues which your office is working on. In your testimony to
Mr. Crenshaw, you stated you have one on-going investigation of
a death in CBP custody. Is your office reviewing any other
deaths in CBP custody?
Mr. Cuffari. So good to see you again, ma'am. Thank you for
the question. I believe that is the only additional death in
custody investigation that we currently have open.
Ms. Torres Small. Thank you, sir. I appreciate it.
In your testimony today, you also noted to Miss Rice that
you did not have a single medical professional on your staff
during the investigations into Jakelin and Felipe's deaths.
Will you have--will your on-going investigation into the
other death be conducted in the same manner, or will any
changes be made in how you review that death?
Mr. Cuffari. Based on the increased funding, as I
mentioned, that the House and Senate gave us this year, we were
able to seek outside medical contracts. I am happy to report
that within a few weeks, the contracts should be awarded, and I
anticipate probably by the end of next month, those individual
health care providers will be able to augment our inspectors
and investigators and our auditors.
Ms. Torres Small. Thank you. How specifically will the on-
going investigation and the use of medical personnel differ
from the investigations into Jakelin and Felipe's deaths?
Mr. Cuffari. They won't at this moment because the
investigation is at the very end of its cycle. We are waiting--
--
Ms. Torres Small. So you will not supplement that
investigation with medical information and expertise?
Mr. Cuffari. No. We will deal with supplemental review of
scoping of the entire Border Patrol's handling of medical
health care providers and services to in-custody children.
Ms. Torres Small. In the last minute, in your testimony,
you indicated your office is working on a review of ``CBP's use
of Fiscal Year 2019 appropriated funds for humanitarian
assistance.''
What exactly will you be reviewing in that work, and will
you be looking more closely at the misspending that GAO has
already identified and that Congresswoman Slotkin discussed in
her questions?
Mr. Cuffari. Certainly, and let me just clarify my last
response. In this particular case, we have engaged the services
of an outside medical examiner in the very last instance, so we
will have someone from outside looking at the medical review
and the autopsy.
So to your current question, what we are going to be doing
is looking at the report that the GAO has done regarding the
expanding on that, looking at whether CBP has adequately
planned for in the deployment of appropriated funds to quickly
and effectively address the humanitarian needs at the border.
Ms. Torres Small. Thank you. I yield the remainder of my
time.
Chairman Thompson. Thank you very much. Mr. Inspector
General, how long have you had the money at GPN to obligate for
contracts and services [inaudible] personnel? How long have you
had this money?
Mr. Cuffari. I believe, sir, the appropriations came in
January, and we were funded in February or March of this year.
Chairman Thompson. So you have had the money about 6
months?
Mr. Cuffari. Yes, sir.
Chairman Thompson. Thank you.
The Chair recognizes the gentlelady from Illinois, Ms.
Underwood, 5 minutes.
Ms. Underwood. Well, thank you, Mr. Chairman. Let me be
blunt. This administration's treatment of migrant children have
been appalling. Three years ago, the Department of Homeland
Security implemented a policy of separating families at the
border. As a nurse and public health expert, I am familiar with
the data showing that family separation causes trauma that can
do both immediate and long-term damage to children's health.
But it doesn't take a nursing degree to understand that. We all
know it is inhumane, immoral, and just plain wrong.
Today, we are trying to get to the bottom of deaths of just
2 of the migrant children who have died in Federal custody
under this administration. Felipe and Jakelin are among the 6
children who died, either during or shortly after their time in
CBP detention on this administration's watch, after a decade
with zero deaths.
Mr. Cuffari, the time line included in your office's report
regarding Felipe's death states that during his first hospital
visit on the morning of December 24, 2018, he was diagnosed
with influenza B. However, the written discharge instructions
included with the medical records from his first hospital visit
appear to have been for the treatment of ``an upper respiratory
infection pediatric'' without specifying an influenza
diagnosis.
Did your office conduct interviews with any other medical
personnel who provided care to Felipe?
Mr. Cuffari. No, ma'am. That was outside the scope of our
investigation.
Ms. Underwood. Did you conduct a forensic analysis of
Felipe's medical records to fully understand what the Border
Patrol agents were told about the influenza diagnosis and why?
Mr. Cuffari. We didn't conduct a forensic analysis. We
conducted a review of the medical records that we obtained from
the hospital, and noted in the discharge paper for Felipe,
there was no indication on there that Felipe had tested
positive for influenza.
Ms. Underwood. Dr. Danaher, in June, the inspector
general's office issued a report entitled ``CBP's Struggle to
Provide Adequate Detention Conditions During 2019 Migrant
Surge.'' This report stated, ``Crowded conditions presented
health challenges for on-site medical staff in some facilities,
including containing the spread of contagious illnesses.''
Felipe had been in custody for 6 days when he died, which is 3
days longer than allowed. Do you believe it is possible that
Felipe contracted influenza while in CBP custody?
Dr. Danaher. I believe I can state with certainty that he
did. Because the longest incubation period for influenza is 4
days, [inaudible] manifest itself.
Ms. Underwood. Thank you.
Ms. Gambler, last fall, I joined my colleagues in writing
to the Centers for Disease Control and Prevention to request
information about their recommendation that CBP should
vaccinate all migrants over the age of 6 months at the earliest
feasible time. I am certainly disappointed that nobody from CBP
is here today to answer questions about why they have not
implemented the CDC recommendation. Ms. Gambler, did your
office examine CBP's decision to not implement the CDC's full
recommendation? If so, what did you find?
Ms. Gambler. Yes. Thank you for the question. We--through
our work, we did identify that CBP has not fully documented the
reasons for its decision not to offer the influenza vaccine to
those in its custody. CBP identified to us a number of
challenges to offering those vaccines, including things like
providing cold storage, and the need for increased contracted
medical care provider. But they didn't document how they
considered, or weighed those costs, or considered those costs
versus the benefits that could come from offering influenza
vaccine. So, our recommendation was really geared toward CBP
more fully documenting the reasons why they decided not to
offer the vaccine----
Ms. Underwood. Right.
Ms. Gambler [continuing]. Including how they consider costs
and benefits so that as they continue to have conversations
about public health issues going forward, they can have a
record and good documentation of the decisions they are making.
Ms. Underwood. Thank you. Ms. Gambler, I understand from
your written statement that CBP claimed that offering flu
vaccines to people in their custody would, ``provide little
benefit to the agency,'' because their goal is to transfer
people out of their custody quickly. However, as we saw with
Felipe's case, CBP doesn't always transfer people quickly.
Isn't that right?
Ms. Gambler. That is right. There are reports, and I think
the inspector general has reported this as well, that
individuals can be in CBP's custody for longer than the amount
of time that CBP is hoping to detain them for that short period
of time.
Ms. Underwood. Ultimately, from a medical standpoint, we
know that there are consequence of CBP's failure to implement
the CDC's recommendation for vaccinations. Given the on-going
coronavirus pandemic, we know that individuals who might come
into custody would be at increased risk as well.
Thank you so much, Mr. Chairman. Thank you to our panel of
witnesses. I yield back.
Chairman Thompson. Thank you very much. The Chair now
recognizes the gentleman from Missouri, Mr. Cleaver, for 5
minutes.
Mr. Cleaver. Thank you, Mr. Chairman.
Mr. Inspector General, I don't want you to please take this
as some kind of an insult, but in Washington, candor is
sometimes silenced, leaving only power as the source of sound.
I don't think there is any reason for me to question any of
your integrity, and please understand that is not just a
statement I am making. I am asking--that is kind-of the issue
anyway. But my issue is, do you feel comfortable? Am I still
being heard? Hello? OK.
Mr. Cuffari. Repeat your question. I am sorry.
Mr. Cleaver. My question is, based on everything that you
have seen and heard, I mean, we have a number of IGs who have
been fired, relieved of duty. So my question is, do you feel
comfortable in being as candid as possible without fear that
you would be silenced if you were to say something that was not
in harmony with the powers that is all around all of us?
Mr. Cuffari. I take your question, sir. I commit to you
that if I ever felt any pressure to change my opinion for
whatever reason, I would come to the Chair, and the Ranking
Member of this committee, and other oversight bodies, both in
the House and in the Senate.
As you know, I have more than 40 years of honorable service
as a U.S. Air Force officer. I served every President from
Jimmy Carter to the current, President Trump. I stand committed
to speaking truth to powers.
Mr. Cleaver. There has never been anything that you have
said or done that would cause me to believe otherwise. I am
just raising a question because of things that I am seeing has
happened in Washington, things that have happened in Washington
that are, at least, appear to be unsavory. So thank you.
You are familiar with the fact that one of the agents who
had taken care of Felipe had to pay for some of the over-the-
counter medication----
Mr. Cuffari. Yes, sir.
Mr. Cleaver [continuing]. Out of his own pocket. Can you
explain what that might have--what might have precipitated the
fact that someone would have to go in their own pocket and pay
for some medicine for some poor kid that obviously appeared to
be sick?
Mr. Cuffari. It appeared that the prescription for
amoxicillin at the hospital that was issued was covered under
their health care services, but the over-the-counter
medication, which was for acetaminophen, I believe, or
ibuprofen, perhaps--I stand corrected--was not covered. It was
an over-the-counter medicine.
Mr. Cleaver. Well, my assumption, Mr. IG, is that the agent
that we found out, that the agent had actually used his or her
own money because they were reimbursed. Is that how this came
to our consciousness?
Mr. Cuffari. Actually, I don't know, sir, if he was
reimbursed. He did pay for it up front. I don't know whether he
asked for reimbursement on that.
Mr. Cleaver. I was just curious about how we found out
about it. Perhaps he mentioned it to someone, which is not
unusual for people who are committed and dedicated. My sister
is a principal of elementary school here in Kansas City. I am
always telling her she is going to be retire broke because she
is buying pencils, and colors, and all that out of her
paycheck. So I just think that is something that, you know, the
agent should be praised for. He or she is probably not the only
one.
Mr. Cuffari. I feel your pain, sir. My wife is a former
high school principal as well.
Mr. Cleaver. Well, you are not going to have any retirement
money, because I have seen that out all my adult life with my
sister.
Dr. Danaher, do you have anything that you would recommend
to us to make corrections that this would not happen again?
What would you recommend to us? Do we need to put some policies
in place? Do we need to do anything that would assure us and
the American people of this is not going to happen anymore? Or
are we certainly going to reduce the likelihood that it would
happen again?
Dr. Danaher. So I appreciate the question. I think it is
extremely important, as I mentioned before, for health care
screening to be occurring as soon as possible after we
encounter children, and that needs to mean that we have people
with at least basic medical training out in remote areas, like
the place where Jakelin was apprehended. If she had to wait
several hours before she could receive medical attention, that
several hour period may mean life and death. Having people at
the border who can at least recognize when children are sick
and begin the process of getting into medical care quickly is
extremely important.
I think also having the better protocols in place to screen
and triage migrants when illness is identified, to make sure
they have access to the appropriate medical care preferably on-
site if possible, but [inaudible] that they also have access to
prescriptions on-site. Of course, as Dr. Mitchell mentioned, we
need to reduce overcrowding and all of the other conditions
that are promoting infections.
Mr. Cleaver. Doctor, thank you very much. I really think
that triage issue should be further developed. I wouldn't mind
getting a memo on this.
Thank you, Mr. Chairman. I yield back the balance of my
time.
Chairman Thompson. Well, if you give the staff, Mr.
Cleaver, we will gladly make that request.
Mr. Cleaver. Thank you. I will do that. Thank you, sir.
Chairman Thompson. The Chair recognizes the gentleman from
Texas, Mr. Green, for 5 minutes.
Mr. Green of Texas. Thank you, Mr. Chairman. I thank the
Ranking Member as well. I thank the witnesses for appearing.
Let me start, if I may, with the IG. Sir, how many times
did you visit the border pursuant to this investigation?
Mr. Cuffari. Sir, just so you know, set the record
straight, I was confirmed by the full Senate at the very end of
July of last year. Within 2 months, I went to the border to
look at El Paso and the Tucson sectors. The investigations that
the committee is holding a hearing regarded events that
happened 7, 8 months before even my confirmation. This would
have been in December, 2018.
Mr. Green of Texas. While you were there, did you pursue
any actions to further your insight into what happened to these
children?
Mr. Cuffari. Not to the children in particular, because
these were events that had already occurred. I was looking at
overarching conditions at the El Paso and the Tucson sectors.
Mr. Green of Texas. You actually visited, I take it, the
facilities where these children were detained?
Mr. Cuffari. Not these particular facilities--except I
stand corrected. We went to the El Paso del Norte Port of Entry
in El Paso, Texas. Yes.
Mr. Green of Texas. When you were at that port of entry,
did you notice it was somewhat akin to a large facility that
allowed vehicles to flow through? Did you notice that, the
place where the children entered the facility?
Mr. Cuffari. I don't believe so, sir. No. Again, this is
October 2019.
Mr. Green of Texas. I understand. The facility is still the
same, I assume.
Mr. Cuffari. [Inaudible] deconstructed whatever they had as
temporary facilities.
Mr. Green of Texas. There is a facility there that is
probably still standing. This is what I would consider a main
facility. But in any event, did you notice how the children
were cared for immediately upon entering the country in terms
of how they are housed, and whether they are given blankets,
whether they are kept warm? Did you notice?
Mr. Cuffari. Yes, sir. I noticed that the El Paso Border
Patrol station where they had soft-sided--not soft-sided tents,
but they had large structures that were constructed out of some
material. The families were kept together in open bay sort-of
barracks. They had medical attention. They had hot meals. They
had toys that were actually, in some cases, the Border Patrol
agents were bringing them in for the children. They had
access----
Mr. Green of Texas. Do you think that the facilities are
adequate for the time of year when it is cold and don't have
blankets? Do you think that this was adequate?
Mr. Cuffari. From what I observed at the time on that
particular day, it was about a 2-hour visit, they appeared to
be adequate. However, I want to add and just emphasize that we
are doing on-going work to take a look at CBP's holding of the
detainees beyond the 72 hours. And migrants experiencing
serious medical conditions.
Mr. Green of Texas. Well, isn't it true that they have
upgraded since you were there, and they have better blankets
and other materials for the children?
Mr. Cuffari. That is quite possible, sir. But I am sure our
inspections and evaluations will identify that in real time.
Mr. Green of Texas. Let's move to the current circumstance.
Do you believe now that we are prepared at the border to
receive children who are sick and appropriately care for them?
Mr. Cuffari. I actually don't know. My intent is to have
these 20 different audits and inspections answer that question.
Mr. Green of Texas. Let's just talk for a moment. One of
the physicians has been adequately questioned about his medical
thoughts, and in a sense, is somewhat challenged about his
opinions. So let me just ask you a couple of questions. Is it
true that there has been some question with reference to your
Ph.D.?
Mr. Cuffari. That is correct.
Mr. Green of Texas. Is it true that you have signed
documents indicating that you have a Ph.D., but not that it was
in management and some question about it being in management
versus philosophy?
Mr. Cuffari. There was a posting on our official website.
When it came to our knowledge that there was a typographical
error indicating that I had a Ph.D. in philosophy, not a Ph.D.
in management, which is what I do have. We made the
typographical correction. I also noted, I will add, there were
one or two commas that we recently noticed that we needed to
correct as well.
Mr. Green of Texas. Did you ever visit the University where
you received your Ph.D.?
Mr. Cuffari. I did on 2 occasions, sir.
Mr. Green of Texas. Is it true that there is currently a
Subway and a 7-Eleven store in that facility?
Mr. Cuffari. I have no idea. I attended the University from
1998 through 2002, when I was awarded my degree.
Mr. Green of Texas. Is it true that there is some concern
as to whether or not this was a mill process for presenting
Ph.D.s?
Mr. Cuffari. To my knowledge, I did all the appropriate
work. I paid for the schooling out of my money. I worked for
the Department of Justice inspector general at the time. I did
this through on-line learning and I was awarded the degree that
I earned.
Mr. Green of Texas. I am going to yield back, Mr. Chairman.
Thank you.
Chairman Thompson. The gentleman yields back. The Chair
recognize the gentlewoman from Nevada, Ms. Titus, for 5
minutes.
Ms. Titus. Thank you, Mr. Chairman. I would like to go back
to that capping report that was mentioned earlier that was
issued last month by the Inspector General's office. That
report summarizes the results of the office's unannounced
inspections at 14 Border Patrol stations, and 7 points of entry
between April and June 2019. Is that right Mr. Inspector
General?
Mr. Cuffari. That is correct, ma'am.
Ms. Titus. As part of these inspections, you reviewed the
migrants' access to medical care. However, the capping report
states, ``Because our office does not have medical expertise,
we did not evaluate the quality of medical care CBP provided
detainees.''
So Mr. Cuffari, when your teams were visiting these Border
Patrol facilities, what kind of field work did you do to assess
compliance for the TEDS standards? Did they just simply observe
what was happening while they were there and do spot checks, or
did they also do some type of systematic review of records?
Mr. Cuffari. Just for the record, ma'am, the time of those
unannounced inspections in 2019, we did not have a medical
health care provider services contract. Due to our increased
funding that you have provided, we have contract for such
augmentation.
The unannounced inspections normally are between 1 to 3
days in length at a particular facility. They follow
procedures. They are looking at events that are occurring in
their presence at that particular point in time. They document
that information. If they find that there are abnormalities or
issues of misconduct, they report them immediately. In one
instance last summer, we issued a major management alert to the
Department highlighting a condition that our inspectors saw.
Ms. Titus. So absent anybody with the medical expertise
previously, and without evaluating medical care, can you really
confidently assess compliance with the TEDS standards,
including that requirement for appropriate care?
Mr. Cuffari. We follow the Council for Inspector General
for Integrity and Efficiency Standards. Our auditors and
inspectors are greeted. We have peer reviews. In fact, we are
going through a peer review in our inspections and in our audit
divisions actually this summer. We base our evaluations on what
we observe at the time that we are in facilities.
Ms. Titus. Well, the results of the inspections section
states, ``Most Border Patrol facilities took steps to try and
evaluate and respond to the medical needs of the sizable
detainee population. This included conducting medical
screenings of all detainees before entrance into a facility.''
When it says it was ``all detainees,'' does that mean literally
every single detainee received a screening, as you would think
that is what ``all'' means. If so, how were your teams able to
assess whether every single person was screened, particularly
in the crowding that occurred in some of those facilities?
Mr. Cuffari. I take the word ``all'' to mean ``all.'' I am
assuming that our inspectors saw and documented what they saw,
which would be all the individuals at that particular point
were getting medical evaluations.
Ms. Titus. Well, it seems to me that there are a lot of
kind-of assumptions, and we can think, and we can trust, and we
believe they did in the report. A lot of these kinds of terms
being thrown around.
I would like to ask the 2 doctors if they see anything
about the assertions that is concerning you. What concerns do
you have if you have had a chance to review that capping
report? Could you lay that out for us, so we might be able to
improve on that in the future?
Dr. Danaher. Yes. So the capping report, as you mentioned,
seems to acknowledge that there is medical care occurring at
some of these facilities. But as you stated, it is very
difficult to assess from the report what the quality, or even
the extent of that medical care is.
I was also troubled to see that it appears that medical
screenings are occurring in large groups of migrants, no
privacy. It makes me question whether any exams are actually
accompanying these screenings, or if it is just somebody asking
questions.
I was also a little bit troubled that there was basically
just a photograph of a number of shelves of medications, and
there was an assumption that those were the right medications
needed on-site for the detainees. Without a physician reviewing
that, it is very difficult to know if having those medications
there is adequate to meet detainees' needs.
Ms. Titus. It seems it is difficult to assess any of this
without a medical expert there, just some officer going in and
taking a look around.
Dr. Mitchell, do you have anything to add?
Dr. Mitchell. Yes. I think that was the point I was going
to make, Representative. I think that having, you know, a
medical officer that is engaged in the care that is happening
at the border, a responsible oversight in medicine, but also,
the review of anything that comes out of this particular set of
circumstances is extremely important.
You know, detention centers, once people are in them, they
really do become, you know, small hospitals. I mean, in
general, most people are going to be sick in these detention
centers, or jails, or prisons within this country. So it is so
important to have sustainable medical professionals that are
overseeing the care that is happening, whether it is triage or
original assessment, but overseeing the triage that is
happening amongst these individuals. So I would just add that
to what we are discussing.
Ms. Titus. Thank you very much. I yield back, Mr. Chairman.
Chairman Thompson. Thank the very much. The Chair
recognizes the gentlelady from California, Ms. Barragan, for 5
minutes.
Ms. Barragan. Thank you, Mr. Chairman, for convening this
critically important hearing. I serve as the second vice chair
of the Congressional Hispanic Caucus. Last year, my
Congressional Hispanic Caucus colleagues and I toured the
Alamogordo Border Patrol station on highway 70 CBP checkpoint
in New Mexico. I saw first-hand the cell where Felipe Alonso-
Gomez, an 8-year-old boy from Guatemala, spent his last hours,
and tragically died on Christmas eve. I witnessed the awful
condition he was held in. There were no showers. It was an open
bathroom where everybody could see you. It was complete
concrete. There was no nutritious foods for people, especially
for kids that may be sick. There was a lack of medical
supplies.
There was only a first aid kit and a small EMT bag, but no
trained medical personnel. CBP's lack of immediate and
meaningful care for asylum seekers are putting migrant
children's lives in jeopardy. We even spoke to the officers
there who says they are not trained to take care of those who
are ill. It was unbelievable to me to see the condition in
which a child who was sick would be sent to to wait, where
there is no blankets, where there is nothing padded, a complete
jail cell.
Dr. Danaher and Dr. Mitchell, I know we have talked about
this already today, but I think it is very important. Could you
please, again, explain the challenges associated with
recognizing medical distress in children, particularly young
children who may not be able to talk or where there may be
language barriers?
Dr. Danaher. Yes. So it can be extremely difficult to get a
clear medical history from a young child, on top of that, from
a parent who is in distress about their child's well-being.
Children look different than adults when they get sick. They
have much more physiological reserve, meaning they can
compensate better for longer when they are sick.
But it also means that when they run out of their metabolic
reserves, they crash very fast. We run into this all the time
in pediatrics where kids come in having looked OK, and then
they decompensate very quickly. If action is not taken quickly
to help them, then the outcomes can be really terrible, as we
saw in this case.
Ms. Barragan. Thank you. Dr. Mitchell.
Dr. Mitchell. Yes. Again, I would defer to Dr. Danaher. The
reality of it is, is that it is a matter of time leads. So,
when we put trained individuals and not rely on the agents that
are not trained to do this work, but put trained individuals in
position to get people to care or recognize distress earlier,
then we have the potential to save lives. So, you know, that is
all I would add.
Ms. Barragan. Thank you. Ms. Gambler, you indicated in your
testimony that CBP has not trained its personnel on recognizing
medical distress in children. Is that right?
Ms. Gambler. Yes. That was one of our findings. In fact, we
made a recommend decision to CBP that she should develop and
implement such training for all officers and agents who could
come in contact with children in custody.
Ms. Barragan. I believe in your testimony you said that CBP
and the American Academy of Pediatrics have, and I quote,
obviously will give the quote here: ``developed a training
video on recognizing medical distress in children, which CBP
included as part of its training for emergency medical
technicians and paramedics.'' Is that right?
Ms. Gambler. Yes. That was part of our report.
Ms. Barragan. Ms. Gambler, do you know how many CBP
personnel are trained as EMTs and paramedics?
Ms. Gambler. We do have that information in the report and
we would be happy to follow up and provide that particular
number after the hearing.
Ms. Barragan. OK. I can tell you that when I went to the
CBP station there to ask CBP about Felipe in particular, they
basically said they had one person available for 3 different
stations, and they had to rotate him through. So there was just
no way to have anybody there for any extended period of time.
There was just a shortage.
Ms. Gambler, has the video on recognizing medical distress
in children been shown to all CBP personnel, not just those who
are EMTs and paramedics?
Ms. Gambler. CBP told us that that video is available as
optional training to all officers and agents, but that that
training video is primarily geared toward officers and agents
who are trained emergency medical technicians. That was one of
reasons for our recommendation that CBP needed to develop and
implement training for children in medical distress to be
provided to all officers and agents who could come in contact
with children in custody.
Ms. Barragan. Well, thank you for recognizing that, because
it is completely unacceptable that not everybody would be
trained to recognize the distress symptoms amongst children. So
thank you for doing that. Hopefully, we will have better
treatment of our migrants at the border.
With that, Mr. Chairman, I yield back.
Chairman Thompson. Thank you very much. Let me thank the
witnesses for their valuable testimony and the Members for
their questions. As you can tell, if you are not an expert, you
will get tested before this committee. I thank all of you for
actually presenting very well and you responded accordingly.
Before adjourning I would ask unanimous consent to submit 2
statements for the record. The first is Mr. Morgan's letter
responding to the committee's invitation to testify at this
hearing.* The second is former Acting Secretary McAleenan's
June 2019 letter to Members of Congress seeking emergency
appropriations to the care for migrant children.
---------------------------------------------------------------------------
* The information has been submitted in a previous portion of this
document.
---------------------------------------------------------------------------
Without objection, so admitted.
[The information follows:]
June 12, 2019.
Dear Member of Congress: We continue to experience a humanitarian
and security crisis at the southern border of the United States, and
the situation becomes more dire each day. On May 1, 2019, the
Administration requested $4.5 billion in emergency appropriations for
the Department of Health and Human Services (HHS), the Department of
Homeland Security (DHS), the Department of Defense, and the Department
of Justice to address the immediate humanitarian crisis at our southern
border. We write today to ask that you appropriate this funding as soon
as possible.
We cannot stress enough the urgency of immediate passage of
emergency supplemental funding. This funding will provide resources
that our Departments need to respond to the current crisis, enable us
to protect the life and safety of unaccompanied alien children (UAC),
and help us to continue providing the full range of services to the
children in our custody.
While Congress has been considering the request, the average daily
number of UAC in U.S. Customs and Border Protection (CBP) custody has
grown from nearly 870 on May 1 to more than 2,300 today. This is
because the number of arriving children greatly exceeds existing HHS
capacity. As of June 10, 1,900 processed UAC were in CBP custody
awaiting placement in HHS care. However, HHS had fewer than 700 open
beds in which to place them. HHS has significantly increased the rates
at which we are discharging children to sponsors, but UAC are waiting
too long in CBP facilities that are not designed to care for children.
This is a direct result of the unprecedented number of arriving
children. As of June 10, DHS has referred over 52,000 UAC to HHS this
fiscal year (FY), an increase of over 60 percent from fiscal year 2018.
Preliminary information shows nearly 10,000 referrals in May--one of
the highest monthly totals in the history of the program. If these
numbers continue, this fiscal year HHS will care for the largest number
of UAC in the program's history. HHS continues to operate near
capacity, despite placing UAC with sponsors at historically high rates.
HHS is working diligently to expand its bed capacity to ensure that it
can keep pace, and based on the anticipated growth, HHS expects its
need for additional bed capacity to continue.
On May 17, the Administration notified Congress of an anticipated
deficiency in HHS's Office of Refugee Resettlement's (ORR) UAC program,
as required by law. Absent an emergency appropriation, HHS anticipates
running out of funding as soon as this month. The Anti-Deficiency Act,
which is a criminal statute, requires HHS to take actions to minimize
the deficiency and only to fund operations that are essential for the
safety of human life and protection of property--similar to those
activities allowed during a government shutdown. In the last few weeks,
because of rapidly depleting funds caused by the border surge, ORR was
required by law to scale back or discontinue awards, and had to
instruct grantees that new awards cannot be used for UAC activities
that are not directly necessary for the protection of life and
property, including education services, legal services, and recreation.
This was done solely to ensure full compliance with the Anti-Deficiency
Act and stretch existing funds as far as possible for the life and
safety of children.
ORR would not have had to take these actions to preserve essential
operations if requested supplemental funding had been provided. If
Congress acts quickly to provide the requested supplemental funding to
address the border surge, ORR will be able to restore these services.
Until such funding is provided, ORR will only be able to pay for
essential services to protect life and safety.
It is unprecedented for a critical child welfare program to run out
of funding, and ORR is in close contact with grantees about expected
impacts. Once the UAC program is entirely out of funding, grantees will
have to care for children with no Federal reimbursement until an
emergency appropriation is enacted. It is unclear if grantees would be
operationally able to continue caring for UAC, as many are small
nonprofit organizations. This funding lapse could also negatively
impact grantees' willingness to care for UAC over the longer term and
ORR's immediate ability to add new child care facilities to address the
overflow of children in DHS border facilities that were not designed
for children. Our valued Federal employees in ORR who care for children
and place them with sponsors would be required to work without pay.
It is not only the UAC program that will be impacted. On May 16,
HHS notified Congress that the Anti-Deficiency Act requires HHS to
reallocate up to $167 million from Refugee Support Services (RSS),
Victims of Trafficking, and Survivors of Torture to the UAC program if
activities do not meet the criteria in 31 U.S.C. 1515(b)(1)(B). Last
week, HHS informed the State refugee coordinators and refugee
resettlement grantees in 49 States and the District of Columbia that
ORR was withholding third quarter funding for those programs. The RSS
program addresses barriers to employment for refugees such as: Social
adjustment, interpretation and translation, day care for children, and
citizenship and naturalization. Again, this was not a decision that ORR
wanted to make, or took lightly. HHS's hand was forced by the current
funding situation and the law. HHS must ensure that it is fully
compliant with the Anti-Deficiency Act and that HHS stretch its
existing funds as far as possible to protect the life and safety of
children who are presently, or should be, in HHS care.
While the primary concern of both of our Departments is the safety
of children in our care, DHS faces changing dynamics at the border that
continue to stress its ability to respond. For example:
More groups are illegally entering the United States, and
they are getting larger.
On May 29, U.S. Border Patrol (USBP) agents apprehended
over 1,000 migrants illegally crossing from Mexico as one
group, overtaxing border operations. Over 400 migrants were
apprehended within 5 minutes only 2 weeks before.
The number of migrants has escalated, with more vulnerable
populations arriving.
In May 2019, an average of more than 4,650 people daily
illegally crossed into the United States or arrived at
ports of entry without proper documentation. In May 2017,
the daily average was under 650 illegal crossings per day.
May 2019 experienced more than 144,000 total enforcements
on the southern border, a 32 percent increase over the
previous month and the highest monthly total since March
2006. This follows 2 months exceeding 100,000--sustained
levels not seen in over 12 years.
As of June 10, 2019, more than 17,000 people are in CBP
custody, including over 2,500 UAC.
The USBP apprehended nearly 85,000 individuals in family
units in May 2019 along the Southwest border. An additional
4,100 individuals in a family unit were deemed inadmissible
at Southwest border ports of entry. The vast majority of
these individuals have been released into the country due
to a lack of space and authority to detain them. By
comparison, in all of fiscal year 2012, USBP apprehended
just over 11,000 individuals in a family unit.
Border Patrol agents are spending more than 50 percent of
their time caring for families and children, providing medical
assistance, driving buses, and acting as food service workers
instead of performing law enforcement duties.
Border Patrol agents are making on average 70 trips to
hospitals every day to urgently get care to these individuals,
further diminishing their ability to perform their official
duties.
The Centralized Processing Center in McAllen, Texas, and
other CBP facilities have experienced outbreaks of flu which
has required standing up separate quarantine facilities to
reduce the risk of further exposing children and other
vulnerable populations to infectious disease. While agents are
providing the best care possible, these groups need more
appropriate care, and they need it now.
If DHS does not receive additional funding, it will be forced to
take drastic measures in August that will impact other critical
programs that support DHS missions throughout the country. All DHS
components, including the Transportation Security Administration, the
Federal Emergency Management Agency, the Cybersecurity and
Infrastructure Security Agency, the Coast Guard, and portions of CBP
supporting legal trade and travel will be required to redirect manpower
and funding to support measures to address the crisis.
In addition to the supplemental, it is clear that we need
bipartisan legislation to address the causes of this crisis. We urge
Congress to take swift action to provide the necessary funding to
address the severe humanitarian and operational impacts of this crisis
and to enact reforms to the root causes of these problems so that they
do not persist into the future.
Thank you for your most immediate attention to this matter. A copy
of this response will also be sent to your State's executive
leadership.
Sincerely,
Alex M. Azar, II,
Secretary, U.S. Department of Health & Human Services.
Kevin McAleenan,
Acting Secretary, U.S. Department of Homeland Security.
Chairman Thompson. The Members of the committee may have
additional questions for the witnesses and we ask that you
respond expeditiously in writing to those questions. Without
objection, the committee record shall be kept open for 10 days.
Hearing no further business, the committee stands adjourned.
[Whereupon, at 2:35 p.m., the committee was adjourned.]
A P P E N D I X
----------
Questions From Congressman Emmanuel Cleaver for Fiona S. Danaher
Question 1. Dr. Danaher, what recommendations would you make to
Custom and Border Protection's (CBP's) protocols so that in the future,
children do not die in Federal custody?
Question 2. What policies or staffing changes should CBP or
Congress put in place to dramatically reduce the likelihood of the
child deaths discussed at the hearing today happening ever again?
Answer. Thank you for the opportunity to provide additional written
testimony.
The current COVID-19 epidemic and the upcoming influenza season
pose unprecedented risks for the health of children in CBP custody.
Recent reports of children detained in hotels by subcontractors who may
not have child welfare training, outside of standard CBP and ICE/ORR
facilities and protocols, with the goal of rapid expulsion, raise
additional questions about how carefully the well-being of children in
immigration custody is being monitored.\1\
---------------------------------------------------------------------------
\1\ Rose, J. and Penaloza, M. Shadow Immigration System: Migrant
Children Detained In Hotels By Private Contractors. NPR. https://
www.npr.org/2020/08/20/904027735/shadow-immigration-system-migrant-
children-detained-in-hotels-by-private-contrac. Published August 20,
2020. Accessed August 20, 2020.
---------------------------------------------------------------------------
As previously described by the American Academy of Pediatrics
(AAP)\2\ and the Centers for Disease Control and Prevention (CDC),\3\
CBP can take multiple steps to protect the health and safety of
children in its custody throughout the process of apprehension,
processing, and detention.
---------------------------------------------------------------------------
\2\ Testimony for the Record on Behalf of the American Academy of
Pediatrics Before the U.S. House of Representatives Committee on
Homeland Security, Subcommittee on Border Security, Facilitation, &
Operations. Assessing the Adequacy of DHS Efforts to Prevent Child
Deaths in Custody. https://downloads.aap.org/DOFA/
Jan%202020%20Hearing%20Statement%20for%20- the%20Record%20%20AAP.pdf.
Published January 14, 2020. Accessed July 11, 2020.
\3\ Letter from Director of the Centers for Disease Control and
Prevention Dr. Robert Redfield to the Honorable Rosa DeLauro at 10-11.
https://www.warren.senate.gov/imo/media/doc/
CDC%20Response%20%20migrant%20vaccination.pdf. Published November 7,
2019. Accessed July 6, 2020.
---------------------------------------------------------------------------
In the field
Prior to apprehension, migrants have often traversed
difficult terrain and endured harsh conditions that place them
at increased risk for illness. As such, teams of CBP agents
working in remote areas should include EMTs with enhanced
pediatric training, such as that already offered by the
American Academy of Pediatrics. Agents should carry basic
supplies like oral rehydration, food, and first aid kits in
case they encounter migrants in distress.
When large groups of migrants are apprehended, they should
be temporarily divided into smaller groups of no more than 10
individuals, and each group should be addressed directly by a
Border Patrol agent to advise them of the option to request
urgent medical attention and/or language interpretation.
Assessing need for language interpretation should be performed
using a standardized, validated tool. This will help to ensure
that all detainees hear and understand the presented
information.
Agents should have access to telephonic interpretation in
case a migrant needs to express an urgent medical issue. Agents
should also receive training in basic medical Spanish.
Migrants identified as needing urgent medical attention
should be triaged directly to the nearest health care facility,
rather than first awaiting completion of processing at a Border
Patrol station. In cases of acute illness in a remote area, an
ambulance should be requested to meet CBP en route to the
hospital.
Migrants who volunteer nonacute medical concerns (as
determined by a CBP EMT) should have their vital signs checked
and receive priority transportation to the nearest Border
Patrol station for additional assessment.
Health interviews
Health interviews should be conducted by appropriately-
trained CBP personnel as soon as possible after apprehension,
in the field if possible. This will not only help to ensure
timely attention to urgent medical issues, but will also
facilitate safe cohorting and transportation of any migrants
with potentially contagious illnesses.
At a minimum, health interviews should be performed upon
initial processing for all detainees under age 18, with
particular emphasis placed on ensuring timely interviews for
pregnant detainees and those who volunteer a medical concern
upon apprehension. If health interviews cannot be completed
upon initial processing, they should occur no later than 24
hours after apprehension to ensure that any health issues
requiring prompt attention are addressed.
Health interviews should be conducted individually and out
of earshot of other migrants whenever possible, to prevent
privacy concerns from hindering disclosure of relevant health
information.
All health interviews should be conducted using a
standardized form, developed in consultation with pediatric
medical experts. Health screening forms should be updated to
include at a minimum:
Comprehensive review of potentially concerning symptoms
(e.g., fever, chills, night sweats, cough, sore throat,
congestion/runny nose, difficulty breathing, nausea/
vomiting, diarrhea, abdominal pain, headaches, dizziness,
chest pain, palpitations, joint or muscle pain, rashes,
wounds/injuries);
Chronic medical conditions;
Current medications (either taking or meant to be taking,
prescribed or over the counter);
Allergies;
Pregnancy status;
History of tuberculosis and whether it has been treated;
Whether the detainee had access to adequate food and water
in the several days prior to apprehension.
To protect confidentiality, questions about particularly
sensitive information like sexually transmitted infections and
HIV status should not be included in the initial health
screening and should only be asked later in a private setting
by a trained medical provider.
Medical screenings
Health interviews will not identify all children in need of
medical attention, so medical screenings should occur as soon
as possible and no more than 48 hours after apprehension.
All children under age 18 should receive medical screenings,
including review of any positive responses on the health
interview, a full set of vital signs, and a basic physical
exam. The medical screening should be conducted with as much
privacy as possible.
Medical screenings should be performed by an appropriately
credentialed clinician, which as per the initial standards set
forth in CBP's Interim Enhanced Medical Efforts Directive could
include CBP contracted medical professionals or Federal, State,
or Local credentialed health care providers. CBP EMS personnel
should only be utilized to conduct medical screenings in
exigent circumstances and under the direct supervision of a
clinician with appropriate expertise.
Detention facilities
Basic detention standards must be met to minimize detainees'
vulnerability to illness. For example, CBP facilities should be
clean and maintained at comfortable temperatures. Detainees
should be provided with nutritionally-balanced meals and ample
access to clean drinking water. They must have adequate space
to lie down and conditions in which they can comfortably do so;
lights should be dimmed overnight to facilitate adequate sleep.
Detainees should be provided with timely access to shower
facilities and basic hygiene products (e.g., soap,
toothbrushes, sanitary napkins, diapers).
As the AAP has stated, detention is never healthy for a
child.\2\ However, if children are to be detained during
processing, CBP should work with State and local child welfare
agencies to ensure appropriate conditions and training of staff
caring for children.
Young detainees should be preferentially located in CBP
facilities within proximity to medical centers with pediatric
expertise, in case emergencies arise.
Children who are sick or medically fragile should not be
detained in CBP facilities, which cannot provide conditions
conducive to safe monitoring and recuperation.
Disease prevention
CBP must implement CDC's recommendations for the prevention
of influenza and COVID-19 in its facilities.\3\
Social distancing protocols should be developed.
Technological and administrative barriers that unnecessarily
prolong detention in CBP facilities should be eliminated to
minimize the health risks posed by overcrowding.
Detainees should have unfettered access to sinks with soap
and hand sanitizer (although hand sanitizer must be kept out of
reach of young children who might mistakenly ingest it).
CBP staff should be required to utilize appropriate personal
protective equipment (PPE), including face masks, when in
proximity to detainees. PPE should also be supplied to
detainees and replaced at regular intervals. All staff and
detainees should receive instruction on how to use PPE
correctly.
High touch surfaces should be cleaned frequently, and
adequate ventilation should be ensured.
Influenza vaccine should be mandated for all CBP employees
who interact with detainees. Influenza vaccine should be
offered to all detainees at the time of their medical
screening.
Repeated transfers of detainees between facilities should be
avoided to minimize risk of disease spread.
On-going disease surveillance
CBP must institute comprehensive screening and triage
protocols to promptly identify developing signs of illness
among detainees.
Specific screening protocols for symptoms of Multisystem
Inflammatory Syndrome in Children (MIS-C) must be developed in
consultation with pediatric experts, as this dangerous
complication of COVID-19 is unique to the pediatric population
and can present subtly at first.
Detainees identified as sick must be safely isolated in a
setting appropriate for convalescence, with close monitoring by
trained personnel, while awaiting prompt testing and treatment.
CBP should work with local public health departments and the
CDC to develop an approach to monitoring for and reporting
disease outbreaks within its facilities.
Obtaining medical care
CBP should increase the number of pediatricians it employs
to oversee care of young detainees.
All forward operating bases and Border Patrol stations
should be stocked with basic pediatric medical equipment and
staff trained in its use. Medical equipment and medications at
all CBP facilities should be centrally located and regularly
inventoried. CBP facilities should stock oxygen and adult and
pediatric doses of basic medications that EMTs or on-site
clinicians might routinely administer to treat common medical
problems and emergencies. Agents and detainees should never
have to pay out of pocket for necessary medications. Detainees'
medications should not be confiscated without supplying
adequate replacements under the guidance of an appropriately
credentialed clinician.
If a detainee requests medical attention, an on-site
clinician (if available) or an agent with EMT training should
promptly triage and assess the detainee. Triage should include
a full set of vital signs and a basic physical exam.
If an agent observes a child exhibiting signs of illness,
the child should by default be brought for medical attention,
rather than relying on a parent to advocate for medical care.
Children with identified medical issues should be treated by
a provider with pediatric expertise whenever possible, even if
that means transporting them to a health care facility off-
site.
Paperwork should be streamlined and digitized so that health
interviews and transfers to medical facilities are not
needlessly delayed by challenges in locating or completing
documents.
Interpretation in medical settings must always be performed
by certified medical interpreters to reduce the risk of medical
errors. It is never appropriate for a medical facility to
utilize a CBP agent for interpretation. All consents and
medical paperwork must be provided in parents' native language
to ensure comprehension.
Any detainees suspected of having influenza should receive
antiviral therapy like oseltamivir as soon as possible and no
more than 48 hours after symptom onset. Antiviral
chemoprophylaxis should be offered to vulnerable detainees who
may have been exposed to influenza index cases.
Independent oversight of the quality of medical care
provided to detainees must occur regularly. This should include
medical record review as well as unannounced site visits.
Pediatricians must be included as part of the oversight team to
ensure that issues unique to the care of young patients are
addressed.
conclusion
An unprecedented number of children have died in CBP custody over
the past several years. The current public health crisis posed by the
COVID-19 epidemic only underscores the urgent need to minimize time in
detention, improve detention conditions, and facilitate access to
medical care so as to protect the well-being of migrant children in
custody of the U.S. Government.
Questions From Congressman Emmanuel Cleaver for Joseph V. Cuffari
Question 1a. Inspector general, your office issued a ``Capping
Report'' in June entitled ``CBP Struggled to Provide Adequate Detention
Conditions During 2019 Migrant Surge.'' The report includes pictures
of, ``Stocked over-the-counter medications and medical supplies''
observed in May and June 2019 in each of the El Paso Del Norte, Texas,
and Donna, Texas facilities. Inspector General, are there any standards
regarding the over-the-counter medications that Border Patrol
facilities should have on hand?
Question 1b. If so, what are they, and did the facilities your
teams visited meet these standards?
Answer. CBP's October 2015 National Standards on Transport, Escort,
Detention, and Search (TEDS) do not require that over-the-counter
medications be kept on hand in Border Patrol facilities and we are not
aware of any other Border Patrol standards with this requirement. We
reported on the stocking of over-the-counter medications as an example
of an economy of scale employed by Border Patrol to better manage the
increase in apprehensions in 2019. It was more efficient for facilities
to stock over-the-counter medications on-site, rather than making a
pharmacy run each time a clinic, hospital, or on-site medical staff
prescribed an over-the-counter medication. Not every facility we
visited had over-the-counter medications in stock.
Question 2a. Are there any standards regarding the administration
of over-the-counter medicines?
Question 2b. If so, what are they and did the facilities your teams
visited meet these standards?
Answer. TEDS standards do not provide specific guidance with
respect to the administration of over-the-counter medicines. With
respect to medication generally, TEDS standard 4.10 states:
``Medication: Except for assistance with lifesaving emergency medical
care which they feel comfortable rendering and are trained to render,
officers/agents will not administer medical techniques, medications, or
preparations unless they are qualified emergency medical technicians or
paramedics rendering care. Medication prescribed in the United States,
validated by a medical professional if not U.S.-prescribed, or in the
detainee's possession during general processing in a properly
identified container with the specific dosage indicated, must be self-
administered under the supervision of an officer/agent. If a detainee
is unable to self-administer their medications due to age or
disability, officers/agents may assist the detainee. All detainee
refusals of prescribed medication or medical assistance must be noted
in the appropriate electronic system(s) of record.
``Non U.S.-Prescribed Medication: Any detainee, not in general
processing, with non U.S.-prescribed medication, should have the
medication validated by a medical professional, or should be taken in a
timely manner to a medical practitioner to obtain an equivalent U.S.
prescription. Exceptions to this requirement may only be made by a
supervisor in collaboration with a medical professional and based on
expected duration of detention and/or elective nature of the
medication. If such an exception is made, it must be recorded in the
appropriate electronic system(s) of record.''
TEDS standard 7.5 states:
``All medications will generally be maintained with the detainee's
personal property unless other conditions warrant, such as the
medication needing to be regularly administered due to need, and/or
needing to be properly stored as the prescription requires.''
TEDS standard 2.10 states:
``When transferring a detainee, officers/agents must ensure that all
appropriate documentation accompanies the detainee including all
appropriate medical records and medication as required by the
operational office's policies and procedures.''
Using these standards as criteria, OIG inspectors conducted
interviews with on-site medical staff and CBP staff to determine
whether processes existed for administering emergency medications,
enabling detainees to self-administer prescriptions, validating or
replacing foreign prescriptions, storing prescriptions that required
refrigeration, and transferring medical records and prescriptions with
detainees. We also observed if there were detainee prescriptions on-
site, whether appropriate storage existed, and if times for
administering medications were tracked in data systems or on white
boards.
From our interviews with CBP staff, medical staff, and a limited
number of detainees, at the time of our visits, we did not identify
instances in which CBP staff did not comply with TEDS standards for
medications, including both prescription medications and over-the-
counter medications that were prescribed for detainees. Ten of the CBP
facilities we visited had on-site medical personnel who either had the
necessary qualifications to prescribe medications, including over-the-
counter medications, or could consult with an on-call doctor. In
addition, if a detainee was prescribed a medication, including an over-
the-counter medication, during a visit to a clinic or hospital, it was
appropriate for CBP staff to supervise self-administration of the
medication. Our conclusions were limited to what we observed at the
time of our site visits and information obtained from detainees, on-
site medical staff, and CBP staff.
[all]