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Criminal Negligence

Four years ago, a newly-arrived immigrant miscarried in the bathroom stall of St. Raphael’s emergency room. “It came—a big piece of meat with blood—and I was so scared,” she recalls. “And I said, ‘You know what, I think I’m losing my baby right now.’” She spoke little English. Uninsured, she had been made to wait, pregnant and bleeding, for several hours at a New Haven clinic, then for another hour at St. Raphael’s. “Just take Motrin,” she remembers the doctors saying as they sent her home after the miscarriage. “I said, ‘Should I come back?’and they said, ‘Do you have insurance?’ ‘No.’ And they said, ‘Oh, no, don’t come back. If you come back, you need an appointment and some insurance.’”

She would have three more miscarriages before undergoing surgery to remove uterine scar tissue. The procedure restored her fertility but left her with an unexpected five-thousand dollar debt. Though she had, by that time, heard about and qualified for free care at Yale-New Haven Hospital, her surgery was taken over without her knowledge by the Yale Medical Group, private practitioners at Yale-New Haven who do not participate in the free-care program.

On a recent afternoon at Book Trader Cafe, she pulls out a picture of her daughter, now ten months old. “Now I am aware, and when I had my baby I used to stop them and said, ‘No no no! What are you going to do? Tell me, you belong to Yale Medical Group? Yeah? So—I don’t want you to touch me.’” She had learned her lesson: Even in the middle of labor, she had to fight for her own care.

The story has a clear victim, but who is the perpetrator? Not the doctors and nurses, who deal with chaotic, overcrowded emergency rooms. Not the immigrants, legal or illegal, who make up only a part of the uninsured population. The government, maybe, but before policies can change, Americans must resolve the debate over who can and cannot claim government services. One thing is certain: If health care is a human right, as many argue, then the lack of health services is a crime.

The woman puts away her daughter’s picture and grows serious. “Why, in a first class country, the human beings are treated as merchandise?… How is it possible to have this kind of health care system?” Now an immigrant rights activist with a planner and cell phone on the table in front of her, she speaks with conviction. “We are forgetting that we are human beings. We are forgetting that.”

Non-English-speaking immigrants must navigate the strange byways of an opaque health care system. Legal residents who work minimum wage jobs and are not the guardians of children often don’t qualify for health insurance. Undocumented residents are not only denied benefits but are also often too terrified to ask healthcare professionals for help. “All the time you are afraid,” one immigrant explains. “You are asking yourself, oh, when are they going to ask me for my Social Security?”

The few clinics in New Haven that accept the uninsured—either offering free care or charging a special fee—rarely offer translation services. Even those that do often take up to two hours to get an interpreter on the phone. Emergency room care is limited, says Kelly Hebrank, a New Haven social worker. “People come in and say, ‘You know, I need this tooth pulled, it’s causing me a lot of pain.’ And I say, ‘You know, you can go to an emergency clinic but only if your face is swollen. They’ll only see you if your face is swollen—they don’t care if you’re
in pain!’”

“We don’t have access to a specialist,” says an uninsured mother of two, communicating through a translator. “The other thing that is really stressful is medicine, because you don’t have a special rate for that. It is really hard, really expensive.” She knows people who buy medicine from their home countries or make natural cures themselves. The extremely sick often go back to their own nations when they cannot find treatment here. The government should do more, she insists. But when asked what, she pauses. “It’s hard for me to even think about it because of my legal situation. It’s like you don’t even exist here.”

With no central source of health care information, immigrants learn to rely on word of mouth to navigate the decentralized and chaotic U.S. health care system: a patchwork of hospital programs, public school social services, and intricate government regulations, held together by an array of fund-strapped, overworked non-profits.

For these U.S. residents, there is no health care system.

But there is a New Haven community that has chosen to take up the battle. Fighting against insufficient care is the collective force that connects immigrants in need with the people and groups that can help them. It is a community in which residents show fierce pride. “We’re united,” says Sandra Trevino, the executive director of the Latino-interests organization Junta for Progressive Action. “I think that’s one of the reasons why a lot of people are attracted to New Haven…We welcome our residents.” The solidarity of groups like Junta accompanies the intimate bonds of residents in neighborhoods like Fair Haven, home to a large immigrant population. Junta holds adult health

Classes to teach skills from “how to talk to doctors” to “how to read medicine labels.” For the most part, immigrants say, they rely on friends and neighbors to advise them and to lead them to the best, safest places to find care.

On a recent Saturday morning, the streets of Fair Haven are silent except for the whip of winter wind. But visitors to HAVEN Free Clinic are greeted with a huge smile and a booming, “¡Buenos días! English or Spanish?” Students from the Yale Schools of Medicine, Public Health, and Nursing, along with advising physicians and a few undergraduates, have run the weekly clinic since 2004. Because HAVEN offers both medical and social services, volunteers know their patients’ biographies, from their boyfriends and grandchildren to their jobs and their bills.

Barbara Hirschman MED ’13, a bubbly medical student with shining blond hair, looks through patients’ charts and squeals with excitement. “We have such great patients coming through today!” She holds up a bulging folder. “Ooh, A.R.T. Another one of our epic patients. Last week he brought in 17 bills.” Hirschman’s team of social service volunteers works to make those bills disappear. While the clinic itself offers only basic care, the volunteers negotiate with doctors and hospitals to secure their patients access to the same expensive tests and procedures that insured people receive. Emma Barber MED ’10, an associate director of HAVEN, sees the work as a lesson for medical students used to a well-funded hospital and well-insured patients. “If we weren’t there, they wouldn’t get a lot of these tests. These are things that are pretty readily available four days a week in the hospital. And you just go a few blocks away and they’re not.” HAVEN also copes with limited translation services. Today, the clinic expects thirty or forty patients, and one of two interpreters has canceled at the last minute. A nurse bursts into the lobby and demands of a volunteer, “Do you know Spanish? How do you say colonoscopy?” The girl hesitates. “Um… I don’t know… colonoscopía?”

HAVEN teaches patients to take advantage of soup kitchens, public school systems, and community organizations like Junta. The more experienced volunteers also serve as unofficial authorities on health care services, especially the maze of regulations that limit access to free care. Yale-New Haven is one of the few providers of free care in New Haven. “St. Raphe’s—they cut the bill in half, but it’s still not enough,” Hirschman says. Even at Yale-New Haven, where the HAVEN group has allies, problems with unannounced Yale Medical Group charges are frequent. Applying for free care requires expert maneuvering. To receive free care, patients must have proof that they do not qualify for State Administered General Assistance, which stipulates that its beneficiaries have a social security number. Free-care hopefuls must apply to SAGA, receive a letter of rejection, and use that letter to qualify for complimentary care. But free care programs accept only one specific reason for rejection. When HAVEN volunteers help a patient apply to SAGA, they include a letter asking for the technical category of rejection that serves as a ticket for free care. “We have had 100 percent success getting rejection,” Hirschman says without irony.

This commitment to patient advocacy has given HAVEN a local reputation as an ally of immigrants—even those who lack documentation. HAVEN workers know to broach the subject delicately with patients. Often people give fraudulent Social Security numbers. Hirschman smiles. “I just ask, did you get this Social Security number from a friend, or a cousin?” Meeting before clinic, the HAVEN team discusses the possibility of making cards for patients seeking social services to present to hospital workers. Such a card would be a discreet way of communicating that a patient is uninsured without admitting to being undocumented. Because HAVEN is a health care provider, its records are protected from the INS. This security, workers say, is one of the reasons the community sees HAVEN as a safe place.

HAVEN is located in the Fair Haven Community Health Center, an expanded house on Grand Avenuewith fresh white paint and delicate woodwork. “That location has been there for 35 years and it really is a pillar in the community,” says Barber. The Saturday after this summer’s Immigration and Customs Enforcement (ICE) raids of Fair Haven homes, HAVEN workers worried that patients would be afraid to leave their houses. “But that Saturday we were packed,” Barber recalls. “People come where they feel comfortable and where they feel safe.”

It is this sense of community, volunteers suggest, that makes HAVEN worthy of its name. Reaching across neighborhoods and organizations, HAVEN makes up for the disunity of the system by strengthening the unity of the city. As Hirschman exclaims, “We are community members and we want to make a healthier community for everyone.”

Still, HAVEN is not a panacea. In facing the effects of the ICE raids on Fair Haven residents, even community clinics fell short. Trevino, the young, elegantly-dressed executive director of Junta, worked with children traumatized by the raids. “These children were woken up by officers screaming and yelling at six o’clock in the morning and slamming through their doors with guns.” Trevino formed a support group for the children, but some whom she referred to therapy waited months for appointments. “There is negligence in the health care system of the city.” She speaks softly but emphatically. “What happens to a child who’s going through a mental health chaos right now?”

As Trevino’s story illustrates, New Haven faces a chronic shortage of bilingual therapists. Patricia Novelo heads the Latino clinic at Clifford Beers, a local mental health center for children and families. She radiates calm as she stops to talk to children in the waiting room, but she describes her job as a scramble to fit in more appointments. “We have about a six-month waiting list at this point… a few months ago we had about a year waiting list.”

Shortages make the system inefficient. If public schools had a large enough bilingual staff, they would not refer so many families to Clifford Beers. If Clifford Beers had a large enough bilingual staff, they could make the most of the resources they already have. “The clinicians end up using their time translating, which is a waste of their time when they should be providing therapy,” Novelo explains. “It is really overwhelming and frustrating.” It’s a chicken-and-egg dilemma: The fewer available bilingual workers, the less effective those workers can be. Meanwhile, monolingual parents are left in the dark, unable to communicate with English-speaking workers. “It is difficult for families and it can be quite scary for them,” says Novelo. “They don’t understand what’s happening with the kids.”

Having learned to navigate the U.S. for themselves, immigrants who stay to build families find a new set of struggles. Undocumented parents struggle to obtain welfare services for their American-born children. Though, as citizens, these children are entitled to health care, undocumented parents don’t know how to sign their children up for care. Others are simply afraid. Trevino describes a similar problem with heating assistance. In December, federal agents raided the Community Action Agency, a local non-profit that uses federal funds to help poor people pay heating bills. The agency had assisted undocumented residents, who don’t qualify for the funds, by making it easy to sign up with a fraudulent Social Security number. By depriving undocumented parents of heat, Trevino points out, the government also leaves young citizens in the cold. “Maybe the children’s parents don’t qualify for this assistance, but the child does. But the child can’t fill out the forms! So where do you draw the line? Will we allow American children to go cold for these winter months?” Trevino sees it as a health care issue. “Imagine a house that has no heat the entire day, entire night—what is that going to do to one’s health?”

Trevino is working with legislators to change the heating assistance policy. But, for now, her story stands as one more example of a system that ignores the existence of a part of the population. Undocumented immigrants in New Haven number an estimated ten to twelve thousand people—just under ten percent of the city’s population. That number excludes their American-born children and the legal immigrant residents who share many of their problems.

Non-profits are hard-pressed to provide services to these numbers. Medical appointments, translators, and funds all come up short. Activists and social workers across the city repeat: There is not enough. But New Haven isn’t giving up. As Trevino says, “The work that has to be done is endless, it seems at times. But one step at a time and we’re going in the right direction. And the great part of it all is that you’re not going alone. You have a whole community that’s going with you.” That community will allow nothing—not the language barrier, not a discouraging scarcity of resources, not the retaliation of the government—to get in its way. It will push through national health care crises, federal raids, and cold winters. It will keep New Haven fighting for the people who have come knocking at its door.

Amy Fish is a junior in Jonathan Edwards College.

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