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In this two-part series, 麻豆传媒 spoke with physicians providing care to migrants in border cities. This article documents the experiences of providers in El Paso, Texas. Another, focusing on San Diego, can be viewed here.

EL PASO -- A 17-year-old girl came into his clinic dizzy, fatigued, and dehydrated, but Carlos Gutierrez, MD, expected that, knowing she'd recently traveled 2,000 miles from Guatemala.

He told her to drink plenty of water to stay hydrated. She had just been released from a detention center and the next part of her journey would begin the following day, traveling east to stay with relatives.

But then she mentioned the diabetes medication she started taking back home, which she stopped before starting her trip.

Alarmed she would go into diabetic ketoacidosis without insulin, Gutierrez checked her blood sugar. It was 700 mg/dL, enough to send her into a coma or worse if she went any longer without treatment.

"It just goes to show that if you had adequate personnel, something like that should have been picked up," Gutierrez told 麻豆传媒. "How can you ignore this condition that is deadly if you don't treat it aggressively?"

Many doctors and healthcare providers have been drawn in by the border crisis, hoping to provide relief to patients in need. Although recent immigration policies have led to dwindling numbers of refugees in the U.S., federal detention center deaths have been reported, and physicians in El Paso contacted by 麻豆传媒 described troubling cases in which medical care was lacking.

The Guatemalan teenager is one of hundreds of patients Gutierrez has seen as a volunteer for , a non-profit organization in El Paso that provides hospitality services to migrants released from detention who are seeking asylum.

There was also the 10-year-old child with congenital adrenal hyperplasia who'd gone without hydrocortisone for a week, and dozens of adults have presented with blood pressure readings upwards of 200/120 mm Hg as a result of not having their hypertension medication, Gutierrez said.

Why Care Goes Awry

When migrants crossing the border are apprehended by Customs and Border Protection (CBP), their belongings -- including belts, shoelaces, and medication -- are confiscated. Migrants are not intended to stay in CBP custody for more than 72 hours, just enough time to allow for initial processing before they are transferred to detention centers run by Immigration and Customs Enforcement (ICE).

All ICE detainees then undergo an initial screening, and those whose medications have been confiscated can be issued new prescriptions, an ICE official told 麻豆传媒. They also get a comprehensive physical exam within two weeks of arrival, and their belongings are returned to them upon release, he said.

But parts of a medical history can be lost in translation if migrants speak less common native languages and are relying on a child as a translator. In other situations, migrants could be released before they get their medication, causing them to go days without it.

Ramon Villaverde, a medical student and Annunciation House volunteer, said migrants may also withhold medical information for fear that revealing health conditions could keep them in detention longer.

"There is this thing looming over their heads, an uncertainty, and because of this uncertainty they might not be comfortable enough to approach these physicians under the facilities," Villaverde told 麻豆传媒. "That's one of the most significant obstacles to providing care."

An ICE official told 麻豆传媒 that their detention centers staff registered nurses, mental health providers, physician assistants, nurse practitioners, and a physician. There are currently about 200 contract medical providers at CBP facilities, a spokesperson said.

One July job posting for an ICE physician got for stating applicants should be "philosophically committed to the objectives of the facility," and required physicians to sign nondisclosure agreements upon hiring.

Challenges to Continuity of Care

ICE is required to keep medical records that can be made available to outside healthcare providers once migrants are released, but physicians treating migrants who have been released from detention say they struggle to communicate with providers operating within facility walls.

As a result, patient handoffs are far from seamless, said José Manuel de la Rosa, MD, who also volunteers with Annunciation House, specifically when providers don't communicate about medications that are needed.

"We're set up to provide medication to migrants, but we don't hear about [the need] until they've been off medication for two or three days and are beginning to get ill," he said. "That kind of access to the centers would really help our process."

As a result, providers are left to gauge what's happening on the inside, by evaluating the conditions the migrants present with, said Roberto "Bert" Johansson, MD, another Annunciation House volunteer.

Lisa Ayoub-Rodriguez, MD, a pediatrician at a local hospital, has cared for 20 to 30 children hospitalized while in immigration custody since January.

In the winter months, many came in with respiratory problems, pneumonia, or influenza, all of which were complicated by a state of dehydration, she said.

Others were admitted for prolonged refractory seizures due to missing doses of medication. One child, for example, required combination therapy and came into the hospital with a new filled prescription of one medication, but was missing the other, she said.

Hardest on Children

It's unclear whether pediatricians are staffed at CBP or ICE facilities, but in the 2019 fiscal year to date -- more than a 300% increase from the same time period in the previous fiscal year.

Because some illnesses present more subtly in children, EMT-trained personnel or even general practitioners may miss certain conditions upon an initial screening, Johansson said.

For example, last year, two children died from sepsis -- one bacterial case and the other stemming from influenza -- both of which could have initially presented with symptoms similar to the common cold, he said.

"When you look at both of these cases, there was a failure to recognize what could happen," Johansson said.

Mark Ward, MD, vice president of the American Academy of Pediatrics Texas Chapter, was permitted to have a planned and supervised visit to two McAllen, Texas, CBP facilities in the Rio Grande Valley in June. He also toured a center that provides care for recently released migrants.

At the non-profit, he came across a 16-month-old girl with congenital heart problems who had recently been released from detention with her mother. But her condition had been missed in the screening, such that by the time she arrived at the shelter, she was having heart failure and had to be taken to the ICU.

In May, a 10-year-old girl from El Salvador who crossed the border alone in March also had congenital heart defects, and ultimately died after being passed from hand to hand and undergoing a series of complications. She was while in U.S. custody.

"The CBP is a policing agency and they're not there to take care of children, so it's not surprising they aren't capable of doing a great job of it," Ward told 麻豆传媒. "Really the focus is, we've got children in U.S. custody who have done nothing wrong, and they should be treated well, in a way that doesn't damage their health."

Becoming a Silent Problem?

CBP apprehensions along the border peaked in May at 144,255, but those numbers have been decreasing in recent months, with just .

In the fall, physician volunteers treated thousands of migrants each day in more than 25 makeshift clinics across El Paso, including rented out rooms in the Sol y Luna hotel. But today, there are two main centers in operation: one known as Casa Oscar Romero and another large, newly converted warehouse called Casa del Refugiado.

Part of the reason there are fewer migrants on this side of the border is the or "Remain in Mexico" policy, which was implemented in January. This policy sends individuals who enter the U.S. illegally, as well as certain asylum seekers, back to Mexico to wait for the duration of their immigration proceedings.

As of Sept. 1, some 42,000 people had been returned to Mexico under the policy, including more than who were sent to Juárez. Moreover, only a certain number of asylum claims can be taken up in the U.S. per day, a process known as "metering."

Taken together, these policies have caused the overflow of migrants traveling into the U.S. to pile up on the Mexican side of the border.

"Right now, we're in the eye of the hurricane," Johansson said. "Remain in Mexico has reduced the number of immigrants in the U.S., but they're still there."

Most recently, the U.S. Supreme Court endorsed another that turns away migrants coming from Central American countries, where the vast majority begin their journey, unless they've already applied for asylum before entering the U.S.

Ayoub-Rodriguez said she's concerned that fewer patients in El Paso means more in Mexico who may not have adequate access to care.

"I'm worried that now it's becoming a silent problem, that people won't pay attention and the kids will still suffer without the voice," Ayoub-Rodriguez told 麻豆传媒. "That's my biggest fear -- that the harm is still happening and we just aren't seeing it."

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