[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]





 
   ASSESSING THE ADEQUACY OF DHS EFFORTS TO PREVENT CHILD DEATHS IN 
                                CUSTODY

=======================================================================

                                HEARING

                               before the

                            SUBCOMMITTEE ON
                     BORDER SECURITY, FACILITATION,
                             AND OPERATIONS

                                 of the

                     COMMITTEE ON HOMELAND SECURITY
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             SECOND SESSION

                               __________

                            JANUARY 14, 2020

                               __________

                           Serial No. 116-55

                               __________

       Printed for the use of the Committee on Homeland Security
       
       
                                     

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


                                     

        Available via the World Wide Web: http://www.govinfo.gov

                               __________
                               
                               
                               
               U.S. GOVERNMENT PUBLISHING OFFICE 
40-995 PDF              WASHINGTON : 2020              
 
 
 
                               
                               

                     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           Van Taylor, Texas
Elissa Slotkin, Michigan             John Joyce, Pennsylvania
Emanuel Cleaver, Missouri            Dan Crenshaw, Texas
Al Green, Texas                      Michael Guest, Mississippi
Yvette D. Clarke, New York           Dan Bishop, North Carolina
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
                                 ------                                

     SUBCOMMITTEE ON BORDER SECURITY, FACILITATION, AND OPERATIONS

                 Kathleen M. Rice, New York, Chairwoman
Donald M. Payne, Jr., New Jersey     Clay Higgins, Louisiana, Ranking 
J. Luis Correa, California               Member
Xochitl Torres Small, New Mexico     Debbie Lesko, Arizona
Al Green, Texas                      John Joyce, Pennsylvania
Yvette D. Clarke, New York           Michael Guest, Mississippi
Bennie G. Thompson, Mississippi (ex  Mike Rogers, Alabama (ex officio)
    officio)
             Alexandra Carnes, Subcommittee Staff Director
          Emily Trapani, Minority Subcommittee Staff Director
          
                            C O N T E N T S

                              ----------                              
                                                                   Page

                               Statements

The Honorable Kathleen M. Rice, a Representative in Congress From 
  the State of New York, and Chairwoman, Subcommittee on Border 
  Security, Facilitation, and Operations:
  Oral Statement.................................................     1
  Prepared Statement.............................................     3
The Honorable Clay Higgins, a Representative in Congress From the 
  State of Louisiana, and Ranking Member, Subcommittee on Border 
  Security, Facilitation, and Operations:
  Oral Statement.................................................     4
  Prepared Statement.............................................     6
The Honorable Bennie G. Thompson, a Representative in Congress 
  From the State of Mississippi, and Chairman, Committee on 
  Homeland Security:
  Oral Statement.................................................     7
  Prepared Statement.............................................     8

                               Witnesses

Mr. Brian S. Hastings, Chief, Law Enforcement Operations 
  Directorate, U.S. Border Patrol, U.S. Customs and Border 
  Protection, U.S. Department of Homeland Security:
  Oral Statement.................................................     9
  Prepared Statement.............................................    11
Dr. Alexander L. Eastman, M.D., MPh, FACS, FAEMS, Senior Medical 
  Officer--Operations, Countering Weapons of Mass Destruction 
  Office, U.S. Department of Homeland Security:
  Oral Statement.................................................    16
  Prepared Statement.............................................    17

                             For the Record

The Honorable Bennie G. Thompson, a Representative in Congress 
  From the State of Mississippi, and Chairman, Committee on 
  Homeland Security:
  Statement of the American Academy of Pediatrics................    27

                                Appendix

Questions From Chairwoman Kathleen M. Rice for Brian Hastings....    57
Questions From Chairman Bennie G. Thompson for Brian Hastings....    57
Questions From Honorable Sylvia Garcia for Brian Hastings........    58
Questions From Chairwoman Kathleen M. Rice for Alexander L. 
  Eastman........................................................    58
Questions From Honorable Lauren Underwood for Alexander L. 
  Eastman........................................................    58


   ASSESSING THE ADEQUACY OF DHS EFFORTS TO PREVENT CHILD DEATHS IN 
                                CUSTODY

                              ----------                              


                       Tuesday, January 14, 2020

             U.S. House of Representatives,
                    Committee on Homeland Security,
                          Subcommittee on Border Security, 
                              Facilitation, and Operations,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 10:06 a.m., in 
room 310, Cannon House Office Building, Hon. Kathleen M. Rice 
[Chairwoman of the subcommittee] presiding.
    Present: Representatives Rice, Correa, Torres Small, Green, 
Clarke, Thompson, Underwood, Garcia, Higgins, Joyce, and Guest.
    Also present: Representatives Jackson Lee and Garcia.
    Miss Rice. Subcommittee on Border Security, Facilitation, 
and Operations will come to order. The subcommittee is meeting 
today to receive testimony on assessing the adequacy of DHS 
efforts to prevent child deaths in custody.
    Without objection, the Chair is authorized to declare the 
subcommittee in recess at any point.
    The Chair asks unanimous consent that Representative 
Underwood be permitted to sit and question the witnesses.
    The Chair asks unanimous consent that Representative Garcia 
be permitted to sit and question the witnesses.
    Without objection, so ordered.
    Jakelin Caal Maquin, 7 years old. Felipe Gomez Alonzo, 8 
years old. Darlyn Cristabel Cordova-Valle, 10 years old. Juan 
de Leon Gutierrez, 16 years old. Wilmer Josue Ramirez Vasquez, 
2 years old. Carlos Hernandez Vasquez, 16 years old. These 6 
children died in the custody of the U.S. Government just in the 
past 18 months. These children were migrants from Central 
America who died of preventible conditions that went untreated. 
Three of these children spent the last hours of their lives in 
detention facilities on our Southern Border.
    We must never forget their names, their suffering, or the 
terrible losses their families had to endure. So we are here 
this morning to examine the conditions that led to these 
avoidable tragedies. We have seen a dramatic increase in the 
numbers of families and children arriving on the Southern 
Border over the past several years. Most of these families and 
children arrived from Central America, fleeing vicious cartels, 
gang violence, and extreme poverty.
    After surviving long dangerous journeys, these families 
should have been met with safe refuge, but instead they 
encountered this administration's myriad of inhumane border 
policies like family separation, zero tolerance detention, and 
the Remain in Mexico policy. These policies and management 
decisions by the administration have contributed to mass 
overcrowding and wide-spread inhumane conditions at Customs and 
Border Protection facilities across our Southern Border.
    Numerous reports by the DHS Office of Inspector General and 
court observer attorneys confirm these intolerable conditions. 
I have seen the problems with these facilities with my own eyes 
along with several of my Congressional colleagues on this panel 
today on both sides of the aisle. Yet when pressed about these 
conditions, DHS has consistently failed to maintain 
transparency by stymieing Congressional inquiries.
    This raises concerns that they are hiding serious issues 
with management, in addition to the leadership vacancies at the 
top of the Department. One example of this is the Department's 
decision to conceal information on the death of Carlos 
Hernandez Vasquez. Carlos was a teenage boy from Guatemala, who 
died tragically in U.S. custody on the morning of May 20, 2019. 
CBP issued a press release later that day calling the death a 
tragedy and declaring that they consider the health, safety, 
and humane treatment of migrants to be of the highest priority.
    However, despite information requests by this committee, it 
was not until a ProPublica report was released 7 months later 
that Congress and the public learned more about what happened 
to Carlos, that his death may have been caused by the failure 
to provide urgently needed medical care, and the failure to 
follow the most basic procedures to simply check on a sick 
child.
    While I understand that this specific case is still under 
investigation, this lack of transparency by the Department is 
completely unacceptable. The Office of the Inspector General 
must be doing everything in its power to examine the factors 
that led to these tragedies. That is why I am extremely 
disappointed that the current DHS inspector general declined 
our invitation to testify this morning, especially given the 
recent news that his office closed its investigations into the 
first 2 child deaths in Border Patrol custody.
    The publicly-available summaries of these investigations 
are extraordinarily narrow in scope. They focus only on whether 
DHS personnel committed malfeasance and not whether the 
Department's policies and resources could properly protect the 
children in its care.
    For instance, even with these 2 completed reports, we still 
do not know why Felipe Gomez Alonzo and his father were in CBP 
custody for 6 days before Felipe passed away. I, along with 
several other Members of this committee, remain concerned that 
DHS still isn't doing enough to protect the children in its 
custody.
    Reporting over this past weekend indicates that CBP 
continues to detain families with young children in need of 
medical attention well beyond the 72 hours allowed by the 
agency's own protocols. This is a disturbing pattern that needs 
to be remedied immediately, or we risk losing more children to 
preventible deaths in the future. We must act urgently to 
ensure that the policies and decisions that contributed to 
these tragic deaths are addressed.
    I hope the witnesses here today are prepared to explain 
whether the Department's current approach incorporates the 
lessons learned after these tragedies and how they intend to 
safeguard children in DHS custody going forward. As Members of 
Congress, we may disagree about immigration policy, but there 
should be no disagreement that the Federal Government must take 
responsibility for the human beings in its custody, 
particularly young children. We must never forget Jakelin, 
Felipe, Darlyn, Juan, Wilmer, and Carlos, and we must never let 
this happen to another child again.
    I want to thank the witnesses for joining us, and I now 
recognize the Ranking Member for his opening statement.
    [The statement of Chairwoman Rice follows:]
                Statement of Chairwoman Kathleen M. Rice
                            January 14, 2020
    Jakelin Caal Maquin. Seven years old. Felipe Gomez Alonzo. Eight 
years old. Darlyn Cristabel Cordova-Valle. Ten years old. Juan de Leon 
Gutierrez. Sixteen years old. Wilmer Josue Ramirez Vasquez. Two years 
old. Carlos Hernandez Vasquez. Sixteen years old. These 6 children died 
in the custody of the United States Government in the past 18 months. 
These children were migrants from Central America, who died of 
preventable conditions that went untreated. Three of these children 
spent the last hours of their lives in detention facilities on our 
Southern Border. We must never forget their names, their suffering, or 
the terrible losses their families had to endure. So, we are here this 
morning to examine the conditions that led to these avoidable 
tragedies.
    We've seen a dramatic increase in the numbers of families and 
children arriving on the Southern Border over the past several years. 
Most of these families and children arrived from Central America, 
fleeing vicious cartels, gang violence, and extreme poverty. And after 
surviving long, dangerous journeys, these families should have been 
with met with safe refuge. But instead, they encountered this 
administration's myriad of inhumane border policies, like family 
separation, ``zero tolerance'' detention, and the Remain in Mexico 
policy. These policies and management decisions by the administration 
have contributed to mass overcrowding and wide-spread inhumane 
conditions at Customs and Border Protection facilities across our 
Southern Border.
    Numerous reports by the DHS Office of Inspector General and court 
observer attorneys confirm these intolerable conditions. I have seen 
the problems with these facilities with my own eyes, along with several 
of my Congressional colleagues on this panel today. Yet when pressed 
about these conditions, DHS has consistently failed to maintain 
transparency by stymying Congressional inquiries. This raises concerns 
that they are hiding serious issues with management, in addition to the 
leadership vacancies at the top of the Department. One example of this 
is the Department's decision to conceal information on the death of 
Carlos Hernandez Vasquez. Carlos was a teenage boy from Guatemala, who 
died tragically in U.S. custody on the morning of May 20, 2019. CBP 
issued a press release later that day calling the death a tragedy, and 
declaring that they consider the health, safety, and humane treatment 
of migrants to be of the highest priority.
    However, despite information requests by this committee, it was not 
until a ProPublica report was released 7 months later that Congress and 
the public learned the truth about what happened to Carlos. That his 
death may have been caused by the failure to provide urgently-needed 
medical care and the failure to follow the most basic procedures--to 
simply check on a sick child. While I understand that this specific 
case is still under investigation, this lack of transparency by the 
Department is completely unacceptable. The Office of the Inspector 
General must be doing everything in its power to examine the factors 
that led to these tragedies. And that's why I am extremely disappointed 
that the current DHS inspector general declined our invitation to 
testify this morning. Especially given the recent news that his office 
closed its investigations into the first 2 child deaths in Border 
Patrol custody. The publicly available summaries of these 
investigations are extraordinarily narrow in scope. They focus only on 
whether DHS personnel committed malfeasance and NOT whether the 
Department's policies and resources could properly protect the children 
in its care.
    For instance, even with these 2 completed reports, we still do not 
know why Felipe Gomez Alonzo and his father were in CBP custody for 6 
days before Felipe passed away. I, along with several other Members on 
this committee, remain concerned that DHS still isn't doing enough to 
protect the children in its custody. Reporting over this past weekend 
indicates that CBP continues to detain families with young children in 
need of medical attention well beyond the 72 hours allowed by the 
agency's own protocols. This is a disturbing pattern that needs to be 
remedied immediately, or we risk losing more children to preventable 
deaths in the future. We must act urgently to ensure that the policies 
and decisions that contributed to these tragic deaths are addressed. I 
hope the witnesses here today are prepared to explain whether the 
Department's current approach incorporates the lessons learned after 
these tragedies, and how they intend to safeguard children in DHS 
custody going forward. As Members of Congress, we may disagree about 
immigration policy, but there should be no disagreement that the 
Federal Government must take responsibility for the human beings in its 
custody, particularly young children. We must never forget Jakelin, 
Felipe, Darlyn, Juan, Wilmer, and Carlos. And we must never let this 
happen to another child again.

    Mr. Higgins. Thank you, Madam Chair, and I thank our 
professionals for appearing before us today, the panelists. I 
thank Chiefs Hastings and Dr. Eastman for your service at the 
border and for being here today. I look forward to hearing in 
greater detail about the actions DHS has taken to enhance 
Customs and Border Protection's ability to handle migrants 
arriving at our border in deteriorating health and to address 
preventible deaths in custody.
    The crisis that unfolded along our border last year was 
real, was not the fault of the men and women of Customs and 
Border Protection, wasn't the fault of the Executive branch, 
nor the President of the United States. The truth is, this past 
year, we saw record numbers of family units, unaccompanied 
minors, large groups of 100 migrants or more--213 groups to be 
exact--arriving at our border during the height of flu season 
and during months of extreme heat. At the time, the Border 
Patrol was referring 50 cases per day to medical professionals.
    The border crisis was a result of legal loopholes, activist 
judges, propaganda from criminal cartels, killers, who smuggle 
and traffic migrants for profit. In 2014, under the Obama 
administration, the number of unaccompanied minors encountered 
at the border was viewed as crisis level, leading to former DHS 
Secretary Johnson writing an open letter to Central American 
parents, telling them to not send their children.
    It is clear that sufficient, corrective actions were not 
taken at that time. If that was a crisis, then there are no 
words to describe what we experienced at the border during 
fiscal year 2019. Not only were more than 321,000 minors 
encountered by Customs and Border Protection, family unit 
apprehensions were more than 590 percent higher in fiscal year 
2019 as compared to fiscal year 2014.
    Throughout the crisis, most CBP facilities were at or over 
capacity. Customs and Border Protection personnel were working 
overtime for more than a month without pay to process the large 
groups. Resources were depleting at record time as key 
personnel at the Department were furloughed. Yet Customs and 
Border Protection law enforcement officers still scraped 
together enough money out of their own pockets to buy toys and 
bring extra supplies for the migrants in their custody, many of 
them parents themselves, caring for and loving to the best of 
their ability, the children in their custody.
    After a 35-day shutdown that began in the end of 2018, the 
Federal Government reopened in January 2019 and the crisis 
continued. In light of the growing issues related to the mass 
influx of migrants, President Trump made an official request to 
Congress for supplemental funding for the border. Two months 
went by before we sent that money to the field. My colleagues 
across the aisle blocked a vote on supplemental assistance more 
than 15 times. While leaders of the Majority party were 
repeating the message of tweets like ``fake emergency,'' the 
chief of the Border Patrol was testifying in front of Congress 
that without the funding we may, ``lose the border''.
    The bipartisan Homeland Security Advisory Council released 
a report on the crisis stating that the delay in passing a 
supplemental resulted in unaccompanied minors being held in 
Customs and Border Protection facilities for dangerous lengths 
of time. There are Members on this committee who voted against 
the emergency supplemental.
    A ``no'' vote meant a vote to keep unaccompanied minors in 
Customs and Border Protection custody instead of at a 
Department of Health and Human Services facility, suitable for 
children. It meant releasing thousands of migrants on the 
streets of border communities. Border county Sheriff Napier 
testified before this committee that during the crisis, social 
service resources that should address local issues of hunger 
and homelessness are now completely unable to do so.
    While the men and women of CBP were struggling to keep the 
lights on at the border, they were the subject of partisan 
attacks. One Member even claimed that the deaths of children in 
custody were intentional, an ugly statement, an absurdity that 
was completely debunked as the DHS inspector general found no 
misconduct or malfeasance by DHS personnel upon completion of 
their investigations into the heartbreaking deaths of Jakelin 
and Felipe in December 2018.
    Every life is precious and even 1 death in custody is too 
many, which is why I was encouraged to learn about the 
immediate steps CBP took to enhance their ability to diagnose 
the health of migrants in custody and work with the DHS chief 
medical officer to make long-needed, long-term improvements.
    In December 2018, then commissioner Kevin McAleenan ordered 
secondary medical checks on every child in custody and 
initiated an internal evaluation of CBP care policies. Since 
then, CBP established a phased approach to conducting health 
interviews on all migrants during initial processing and a 
subsequent full medical assessment of all unaccompanied minors 
and at-risk adults.
    On top of that, Customs and Border Protection now has over 
700 medical personnel and contractors stationed across the 
Southwest Border to provide medical support to migrants in 
custody.
    Today I look forward to hearing from our witnesses about 
how CBP's in-custody medical capabilities have improved since 
the fall of 2018, the collaboration process between CBP, the 
office of DHS chief medical officer, and other relevant 
stakeholders, to bolster Customs and Border Protection's 
ability to stop preventible deaths in custody and their expert 
opinions on how to prevent another crisis in the future.
    Madam Chair, thank you for your indulgence, and I yield 
back.
    [The statement of Ranking Member Higgins follows:]
                Statement of Ranking Member Clay Higgins
                             Jan. 14, 2020
    Thank you, Madam Chair.
    And thank you Chief Hastings and Doctor Eastman for your service at 
the border and for being here today.
    I look forward to hearing in greater detail about the actions DHS 
has taken to enhance Customs and Border Protection's ability to handle 
migrants arriving at our border in deteriorating health and to address 
preventable deaths in custody
    The crisis that unfolded along our Southwest Border last year was 
not a fake emergency, it is not the fault of the men and women of CBP, 
and it is not the fault of the President of the United States, Donald 
Trump.
    The truth is, this past year we saw record numbers of family units, 
unaccompanied minors, large groups of 100 migrants or more--213 to be 
exact, arriving at our border during the height of flu season and 
during months of extreme heat. At the time, the Border Patrol was 
referring 50 cases per day to medical providers.
    The border crisis was the result of legal loopholes, activist 
judges, and propaganda from criminal killers who smuggle and traffick 
migrants for profit.
    In 2014, under the Obama administration, the number of 
unaccompanied minors encountered at the border was viewed as crisis-
level, leading to former DHS Secretary Jeh Johnson writing an open 
letter to Central American parents telling them not to send their 
children. It is clear corrective actions were not taken back then.
    If that was a crisis, then there are no words for what we 
experienced at the border during fiscal year 2019. Not only were more 
than 321,000 minors encountered by CBP, family unit apprehensions were 
up more than 590 percent in fiscal year 2019 than fiscal year 2014.
    Throughout the crisis most CBP facilities were at or over capacity. 
CBP personnel were working overtime and for more than a month--without 
pay--to process the large groups. Resources were depleting at record 
time as key personnel at the Department were furloughed.
    Yet CBP law enforcement officers still scraped together money out 
of their own pockets to buy toys and bring in extra supplies for the 
migrants in their custody, many of them parents themselves.
    CBP agents and officers, already short-staffed had to refocus their 
mission from stopping gangs, drugs, murderers, rapists, and even known 
or suspected terrorists to instead process and care for the hundreds of 
thousands of people that arrived at our border without the appropriate 
facilities, resources, and medical support staff to do so.
    After a 35-day shutdown that began at the end of 2018, the Federal 
Government reopened in January 2019 and the crisis continued. In light 
of the growing issues related to the mass influx of migrants, President 
Trump made an official request to Congress for supplemental funding for 
the border. Two months went by before we sent that money to the field. 
House Democrats blocked a vote on supplemental assistance more than 15 
times. While House Democrat leaders were tweeting #FakeEmergency, the 
chief of the Border Patrol was testifying in front of Congress that 
without the funding, we may ``lose the border.''
    The bipartisan Homeland Security Advisory Council released a report 
on the crisis stating that the delay in passing the supplemental 
resulted in unaccompanied minors being held in CBP facilities for 
dangerous lengths of time.
    There are Members on this committee who voted against the emergency 
supplemental. A ``no'' vote meant a vote to keep unaccompanied minors 
in CBP custody instead of at Department of Health and Human Services 
facilities suitable for children. It meant releasing thousands of 
migrants on the streets of border communities. Border county Sheriff 
Napier testified before this committee that during the crisis, ``Social 
service resources that should address local issues of hunger and 
homelessness are now completely unable to do so.''
    While the men and women of CBP were struggling to keep the lights 
on at the border, they were the subject of partisan attacks. One Member 
even claimed that the tragic deaths of children in custody were 
intentional, an absurdity that was completely debunked last month as 
the DHS Inspector General found no misconduct or malfeasance by DHS 
personnel upon completion of investigations into the heartbreaking 
deaths of Jakelin and Felipe in December 2018.
    Every life is precious, and even 1 death in custody is 1 too many, 
which is why I was encouraged to learn about the immediate steps CBP 
took to enhance their ability to diagnose the health of migrants in 
custody and work with the DHS chief medical officer to make needed 
long-term improvements.
    In December 2018, then-Commissioner Kevin McAleenan ordered 
secondary medical checks on every child in custody and initiated an 
internal evaluation of CBP care policies. Since then, CBP established a 
phased approach to conducting health interviews of all migrants during 
initial processing and a subsequent full medical assessment of all 
minors and at-risk adults.
    On top of that, CBP now has over 700 medical personnel and 
contractors stationed across the Southwest Border to provide medical 
support to migrants in custody.
    Today, I would like to hear from our witnesses about how CBP's in-
custody medical capabilities have improved since fall of 2018, the 
collaboration process between CBP, the Office of the DHS Chief Medical 
Officer and other relevant stakeholders to bolster CBP's ability to 
stop preventable deaths in custody, and their expert opinions on how to 
prevent another crisis in the future.

    Miss Rice. Thank you, Mr. Higgins. The Chair now recognizes 
the Chairman of the overall Homeland Security Committee, the 
gentleman from Mississippi, Mr. Thompson for an opening 
statement.
    Mr. Thompson. Thank you very much, Madam Chair. Good 
morning to those of you who are here on the committee. Today's 
hearing topic is sobering as it centers on the death of 
innocent children. In our current hectic and rapidly-changing 
political environment, it can be easy to move on quickly from 
past disasters and tragedies. The Trump administration 
contributes to this situation by piling scandal on scandal, 
exhausting the public, the media, and the oversight 
organizations.
    It is our oversight responsibility, as Members of Congress, 
to refuse to allow the most disturbing and upsetting events 
fade into the past and help ensure that they are not repeated. 
We are here today to examine the treatment of migrant children 
in the custody of the Department of Homeland Security in 2018 
and 2019, and look at what changes may still be necessary.
    Certainly detention of migrants did not begin with the 
current administration, but in earlier administrations, both 
Democratic and Republican, officials took steps to avoid 
risking the health and safety of the most vulnerable people in 
custody.
    Under the Trump administration, we now find the elderly, 
the infirm, and children in detention facilities such as Border 
Patrol stations, not designed or equipped to hold people for 
extended periods of time. When arrivals at our Southern Border 
began to rise sharply in 2018, the decision to detain everyone 
led to severe overcrowding. The DHS Office of Inspector 
General, attorneys, and Members of Congress, including me, 
observed and reported on the conditions inside these facilities 
for months.
    CBP argued throughout this crisis that they faced severe 
resource constraints, despite Congress providing billions in 
humanitarian funding in early 2019. Standing-room-only cells, 
inadequate hygiene products, and families kept outside in 
extremely variable temperatures were commonplace at CBP 
facilities during the height of migrant arrivals last year.
    In such an environment, the spread of illnesses such as the 
flu are inevitable. Whether individual deaths can be directly 
attributed to specific conditions in a given facility or not, 
we need to understand whether the policies and resource 
management decisions made by the administration put lives in 
jeopardy.
    Congress cannot allow DHS and CBP leaders to make poor 
decisions or ignore existing policies and law for purely 
messaging reasons. Secure borders are a priority for our 
country and for all of us on this panel and have been for 
decades. Part of our responsibility as Members of Congress is 
to check actions by the Executive branch that are misguided. 
Hearings such as this are a critical part of that effort. I 
have strong objections to the policies the Trump administration 
has in place along our border that continue to endanger the 
safety of migrant children such as Remain in Mexico.
    I hope to hear from our DHS witnesses this morning that the 
Department will take its responsibility toward people in its 
custody more seriously going forward. One child death was one 
too many. I am eager to know what the Department plans to do 
differently in order to safeguard children's safety while in 
DHS's custody.
    I thank the Chairwoman and Ranking Member for holding 
today's important hearing, and I yield back.
    [The statement of Chairman Thompson follows:]
                Statement of Chairman Bennie G. Thompson
                            January 14, 2020
    Today's hearing topic is sobering, as it centers on the deaths of 
innocent children. In our current hectic and rapidly-changing political 
environment, it can be easy to move on quickly from past disasters and 
tragedies. The Trump administration contributes to this situation by 
piling scandal on scandal--exhausting the public, the media, and 
oversight organizations. It is part of our oversight responsibility as 
Members of Congress to refuse to allow the most disturbing and 
upsetting events fade into the past and help ensure they are not 
repeated. We are here today to examine the treatment of migrant 
children in the custody of the Department of Homeland Security in 2018 
and 2019, and look at what changes may still be necessary.
    Certainly, detention of migrants did not begin with the current 
administration. But in earlier administrations, both Democratic and 
Republican officials took steps to avoid risking the health and safety 
of the most vulnerable people in custody. Under the Trump 
administration, we now find the elderly, the infirm, and children in 
detention facilities, such as Border Patrol stations, not designed or 
equipped to hold people for extended periods of time. When arrivals at 
our Southern Border began to rise sharply in 2018, the decision to 
detain everyone led to severe overcrowding. The DHS Office of Inspector 
General, attorneys, and Members of Congress--including me--observed and 
reported on the conditions inside these facilities for months. CBP 
argued throughout this crisis that they faced severe resource 
constraints, despite Congress providing billions in humanitarian 
funding in early 2019. Standing-room-only cells, inadequate hygiene 
products, and families kept outside in extremely variable temperatures 
were all commonplace at CBP facilities during the height of migrant 
arrivals last year. In such an environment, the spread of illnesses, 
such as the flu, are inevitable.
    Whether individual deaths can be directly attributed to specific 
conditions in a given facility or not, we need to understand whether 
the policies and resource management decisions made by the 
administration put lives in jeopardy. Congress cannot allow DHS and CBP 
leaders to make poor decisions or ignore existing policies and law for 
purely messaging reasons. Secure borders are a priority for our 
country--and for all of us on this panel--and have been for decades. 
Part of our responsibility as Members of Congress is to check actions 
by the Executive branch that are misguided. Hearings such as this are a 
crucial part of that effort. I have strong objections to the policies 
the Trump administration has put in place along our border that 
continue to endanger the safety of migrant children--such as ``Remain 
in Mexico.''
    I hope to hear from our DHS witnesses this morning that the 
Department will take its responsibility toward people in its custody 
more seriously going forward. One child death was one too many. I am 
eager to know what the Department plans to do differently in order to 
safeguard children's safety while in DHS custody.

    Miss Rice. Thank you, Mr. Chairman.
    Other Members of the subcommittee are reminded that under 
the committee rules, opening statements may be submitted for 
the record.
    I welcome the panel of witnesses. Our first witness, Mr. 
Brian S. Hastings, is chief law enforcement operations, U.S. 
Border Patrol, U.S. Customs and Border Protection, Department 
of Homeland Security. Brian S. Hastings is the chief of the Law 
Enforcement Operations Directorate at U.S. Border Patrol 
headquarters in Washington, DC. He is responsible for oversight 
of the day-to-day law enforcement operations at Border Patrol 
sectors throughout the United States and a principal adviser to 
the chief of the Border Patrol on enforcement operations. Chief 
Hastings began his service with the Border Patrol in 1995 and 
has been stationed in various sectors across all U.S. borders 
and was promoted to the senior executive service in 2018.
    Our second witness, Dr. Alexander L. Eastman, is the senior 
medical officer for operations within the United States 
Department of Homeland Security's Countering Weapons of Mass 
Destruction Office. In this role, he is responsible for 
operational medicine across DHS in addition to countering 
threats to the United States world-wide.
    Previously Dr. Eastman served as the chief of the Rees-
Jones Trauma Center at Parkland Memorial Hospital and as an 
assistant professor and trauma surgeon in the division of 
burns, trauma, and critical care at the University of Texas 
Southwestern Medical Center. Dr. Eastman is also a decorated 
police officer within the Dallas Police Department.
    Without objection, the witnesses' full statements will be 
inserted in the record. I now ask each witness to summarize his 
statement for 5 minutes beginning with Mr. Hastings.

    STATEMENT OF BRIAN S. HASTINGS, CHIEF, LAW ENFORCEMENT 
 OPERATIONS DIRECTORATE, U.S. BORDER PATROL, U.S. CUSTOMS AND 
    BORDER PROTECTION, U.S. DEPARTMENT OF HOMELAND SECURITY

    Mr. Hastings. Good morning, Chairman Rice, Ranking Member 
Higgins, and Members of the subcommittee. As part of CBP's 
mission to safeguard America's borders, we complete initial 
processing of individuals in our custody before transferring 
them on our partners. While our holding facilities were 
designed for only short-term custody, we take seriously our 
responsibility to protect and care for individuals until they 
can be transferred.
    During fiscal year 2019 CBP apprehended or found 
inadmissible more than 1.1 million people. In December 2018, we 
began alerting Congress, the media, and the public that an 
unprecedented spike in Central American families and children 
was creating a crisis on our Southern Border. For months, our 
requests for immediate legal and emergency funding went 
unanswered, and we began diverting resources from our border 
security mission to address the crisis.
    As I prepared to testify before you today, I reflected on 
the numerous actions CBP has taken and continues to take in 
response to this crisis. I could not be more proud of the 
extraordinary efforts undertaken by the men and women of CBP. I 
would like to share with you many examples today of the 
challenges we face and our rapid actions to address them.
    First, as the apprehensions skyrocketed, we had more people 
in our custody than we could quickly process. We continued to 
prioritize processing of the UACs first, followed by families, 
and then single adults. CBP surged more than 1,050 officers and 
agents to the busiest sectors. As many as 40 to 60 percent of 
our agents were diverted from securing the border to caring for 
those in our custody.
    Over 700 DHS personnel provided support at our facilities. 
We expanded our transportation contract and purchased more than 
200 buses and vans to expedite transportation of large groups 
of migrants. We chartered planes and drove busloads of more 
than 43,000 people from overwhelmed locations to facilities 
with more processing capacity.
    Second, even when processing was complete, ICE and HHS had 
limited capacity to accept aliens, which contributed to further 
overcrowding in Border Patrol facilities. In March 2019, Border 
Patrol began releasing noncriminal family units directly into 
the United States rather than transferring them to ICE. During 
fiscal year 2019 a total of 145,000 family members were 
released. CBP rapidly constructed 6 soft-sided facilities that 
provided capacity for an additional 6,500 families and adults.
    By June, Secretary Azar stated HHS shelters were full and 
they could not accept UACs from Border Patrol custody. When HHS 
received supplemental funding in July, the number of UACs in 
our custody quickly dropped from a peak of 2,700, down to 300.
    Third, we addressed the need for amenities that our short-
term holding facilities were not designed to provide. We 
outfitted the new soft-sided facilities and our highest-volume 
stations with portable showers, toilets, sinks, laundry, 
climate control system, and kitchen equipment. We expanded our 
food service contract to provide millions of meals and stock 
countless snacks, water bottles, clothing, and hygiene items.
    Finally, we accelerated the expansion of our medical 
support program. CBP issued interim medical directive in 
January 2019, which was superceded by an enhanced medical 
directive in December. This directive sets forth foundational 
levels of medical support for CBP.
    It utilizes a phased approach through initial observations, 
medical interviews with a standardized health questionnaire, 
and medical assessments to identify potential medical issues 
and low acuity treatment.
    In the last year, CBP has dramatically increased the number 
of contract medical professionals to more than 700. Where we 
built this capacity, U.S. Coast Guard and Public Health 
Services medical personnel were dispatched to many of our 
facilities. Now on any given day, approximately 300 contract 
medical personnel are engaged at more than 40 facilities along 
our Southwest Border, providing 24/7 on-site medical support.
    Our medical support follows a family practitioner model 
which has been observed and validated by medical experts. This 
model ensures our medical providers are trained, licensed, and 
credentialed to care for all populations in our custody, 
including children and pregnant women.
    Physicians, to include pediatricians, provide oversight in 
training, consultation for medical direction, and medical 
quality management. On-site medical personnel may provide care, 
write prescriptions, or recommend advanced care in the local 
health care system.
    In the last year, nearly 250,000 juveniles and more than 
296,000 adults have received medical interviews. Nearly 60,000 
juveniles and more than 95,000 adults have received medical 
assessments. During fiscal year 2019, Border Patrol took a 
total of 26,000 people to a hospital or a medical facility when 
advanced care was needed or requested. Agents spent more than 
319,000 hours providing transportation to and from medical 
facilities and on hospital watch.
    Today with the help of our interagency partners and our 
governmental partners in the hemisphere, we have effectively 
ended catch-and-release at the border. The flow of aliens has 
dropped by 72 percent. However, these initiatives, like the 
supplemental funding, are only temporary fixes. As we have said 
many times before, Congress must close the loopholes in our 
Immigration Service system that serve as pull factors. Or we 
risk returning to or exceeding peak levels and overwhelming our 
immigration system yet again.
    Thank you and I look forward to your questions.
    [The prepared statement of Mr. Hastings follows:]
                Prepared Statement of Brian S. Hastings
                            January 14, 2020
    Chairwoman Rice, Ranking Member Higgins, and Members of the 
subcommittee, I appear before you today to discuss the actions that the 
Department of Homeland Security (DHS) and U.S. Customs and Border 
Protection (CBP) have taken to ensure all people in our custody--
especially children--receive the care they need for the short time they 
are in our custody before entering the U.S. immigration system.
                     cbp's law enforcement mission
    CBP is a Federal law enforcement agency, yet it has a unique role. 
CBP bears the responsibility of serving as the front-line defense along 
the Nation's borders. CBP is responsible for protecting the public from 
dangerous people and materials, while simultaneously facilitating 
legitimate international travel and trade.
    The men and women of U.S. Border Patrol (USBP), Office of Field 
Operations (OFO), and Air and Marine Operations (AMO) go to work each 
day not knowing who the next person they encounter will be: An armed 
criminal, a narcotics smuggler, an individual with ties to terrorism, 
an adult seeking a better life, or--as has increasingly been the case 
over the past year--an innocent child. In our unique law enforcement 
role, CBP must be ready to respond to any situation at any time.
    Every day, our law enforcement personnel arrest individuals for a 
wide variety of criminal and immigration law violations. When we arrest 
an individual, he or she is booked into our systems; the appropriate 
biometrics are collected and record checks are run; then agents and 
officers begin to process the individual through the appropriate 
pathways in the U.S. criminal justice and immigration systems, 
depending on the individual circumstances.
    As is the case for nearly every police station across the country, 
CBP's facilities along the border and at ports of entry (POEs) are 
designed to serve as short-term holding areas for those in our custody 
to undergo this initial processing. At the earliest opportunity, we 
notify and arrange a transfer of custody to the appropriate Federal 
agency.
              the humanitarian crisis of fiscal year 2019
    During fiscal year 2019, CBP apprehended or found inadmissible more 
than 1.14 million individuals. Eighty-five percent of those 
encounters--more than 977,500--occurred on the Southwest Border, an 
average of nearly 2 apprehensions or findings of inadmissibility every 
minute of every day for the entire year.
    Because the majority of illegal entries occur between the ports of 
entry, USBP apprehensions account for the majority of the people 
illegally crossing the 2,000-mile border with Mexico. During fiscal 
year 2019, USBP Southwest Border apprehensions exceeded 851,000--the 
highest level since fiscal year 2017. Nearly 65 percent of USBP 
apprehensions were families and children--more than 473,000 
individuals--the highest number of family units in any year on record 
and an increase of 342 percent over the previous record. Unaccompanied 
alien children (UAC) apprehensions also increased by 52 percent 
compared to the previous year. In total, USBP processed more than 
321,000 alien children on the Southwest Border during fiscal year 2019.
    At the peak of the crisis in May 2019, USBP apprehended nearly 
133,000 people in a single month. Between January and May, both single 
adult and UAC apprehensions doubled while family unit apprehensions 
more than tripled. On a single day in May 2019, USBP apprehended more 
than 5,500 people on the Southwest Border, including more than 1,000 
who illegally entered the United States as a single group. This influx 
led to CBP facilities operating at unprecedented and unsustainable 
occupancy levels.
    CBP's ability to transfer people out of its custody depends on the 
capacity of our partners at U.S. Immigration and Customs Enforcement 
(ICE) and the U.S. Department of Health and Human Services (HHS). These 
and other agencies are able to determine when they accept custody of 
individuals from CBP; as such, they have a level of flexibility that 
CBP does not. CBP must process individuals as they are apprehended and 
maintain custody until our partners can accept custody of them.
    In areas of high rates of illegal entry, many Border Patrol 
stations were unable to efficiently process individuals due to 
exceedingly high volume. To address this shortfall, CBP temporarily 
detailed more than 730 CBP officers and more than 320 USBP agents from 
around the country to augment its operations in these locations. In 
addition, DHS surged more than 700 personnel from other components to 
serve in general support and medical support functions, including U.S. 
Coast Guard, Federal Protective Service, and the Federal Air Marshals 
Service. These volunteers assisted with functions such as personal 
property management, meal service, welfare checks, and transportation 
support.
    CBP continued its long-standing practice of prioritizing the 
processing of UACs, followed by families, then single adults. In 
addition, CBP partnered with ICE to transport family units by plane or 
bus to other parts of the border to expedite processing. However, as 
processing times decreased, ICE and HHS began struggling to keep pace 
with USBP apprehensions, and the backlog of family units and UACs in 
USBP custody continued to swell.
    Beginning in March 2019, Border Patrol stations released family 
units directly into the United States to reduce overcrowding. Rather 
than being transferred to ICE's limited bed space at family residential 
facilities, more than 145,000 individuals in family units were released 
on their own recognizance for a later appearance in immigration court. 
Non-governmental organizations that provided post-release support in 
border communities soon began experiencing their own overcrowding 
issues. In contrast to family units, UACs could not be released into 
communities. Under the Trafficking Victims Protection Reauthorization 
Act of 2008 (TVPRA), CBP generally must transfer custody of UACs to HHS 
within 72 hours.
    Border Patrol stations were not designed to hold large volumes of 
apprehended aliens or for their long-term custody after processing is 
complete. Beginning in February 2019, to accommodate the growing number 
of people in custody, USBP diverted operating funds to rapidly 
construct 6 soft-sided facilities in the Rio Grande Valley, El Paso, 
and Yuma Sectors. The temporary structures are weatherproof, climate-
controlled, and provide areas for eating, sleeping, recreation, and 
personal hygiene. They include shower trailers, chemical toilets and 
sinks, laundry trailers, sleeping mats, personal property storage 
boxes, lockers, power, kitchen equipment, food/snacks/water, clothing 
and hygiene kits, and space for medical assessment and treatment. 
Additionally, since the beginning of the crisis, USBP invested over 
$230 million in humanitarian support, to include consumables such as 
meals, snacks, baby formula, shampoo, diapers, and other hygiene items; 
enhanced medical support; and increased transportation services.
           emergency humanitarian supplemental appropriation
    On May 1, 2019, the administration submitted a request to Congress 
for emergency supplemental funding for CBP, ICE, and HHS to address the 
crisis. The Emergency Supplemental Appropriations for Humanitarian 
Assistance and Security at the Southern Border Act, 2019 was signed 
into law on July 1, 2019, providing $4.6 billion in supplemental 
funding.
    This bill provided CBP with $1.1 billion for humanitarian support, 
border operations, and mission support. To enhance humanitarian support 
efforts, CBP purchased food, water, sanitary items, blankets, medical 
support, and other consumables with these funds; in addition, 462 
additional shower stalls, 79 additional portable toilets, 6 additional 
laundry trailers, 51 commercial washer-dryer sets, 90 refrigerators and 
freezers, and 200 climate control systems were procured. CBP also 
purchased additional transportation assets including buses, vans, and 
Emergency Medical Technician (EMT) vehicles.
    Border operations funding was utilized for overtime and temporary 
duty assignments for USBP agents and CBP officers as well as costs 
associated with the DHS volunteer surge force. These supplemental funds 
enabled the replenishment of operational funds previously expended on 
soft-sided facilities and humanitarian investments. Without the 
supplemental appropriation, the funding for our humanitarian efforts 
would have been exhausted before the end of the fiscal year. Funds were 
also provided for modernized data systems to better integrate 
immigration processing and reporting by the DHS, HHS, and the 
Department of Justice.
    Our partners at HHS received $2.9 billion in the supplemental 
appropriation, which funded additional HHS shelters and beds, allowing 
for more expeditious processing and transport of UACs from CBP custody 
to facilities designed for the long-term care of children. As a result, 
the number of UACs in USBP custody at any one time dropped from the 
peak of nearly 2,700 in early June 2019 to around 300 in July 2019.
    ICE bed capacity shortfalls limited CBP's ability to transfer 
single adults to facilities designed for long-term custody. As a 
result, USBP experienced a higher volume of single adults in custody 
for longer periods of time. From May through July 2019, USBP 
continually averaged more than 6,550 single adults in custody at any 
given time. While DHS requested $108 million for beds at ICE detention 
facilities, this provision was not funded.
                         enhanced medical care
    The recent humanitarian and security crisis along the Southwest 
Border created a significant challenge for CBP. The agency was charged 
with addressing medical support requirements for the increased number 
of people in custody, including children and family units. CBP 
recognized the operational and medical importance of prioritizing the 
expansion of medical support along the Southwest Border and remains 
committed to ensuring that people in CBP custody receive appropriate 
medical support. CBP has taken steps to significantly enhance our 
medical support program, consistent with our core law enforcement 
mission.
    Following the surge in UAC encounters during 2014, CBP established 
a contract for on-site medical support in the busiest sector, Rio 
Grande Valley. In the summer of 2018--prior to the tragic deaths of 2 
Guatemalan children in December 2018--CBP expanded the medical support 
contract to additional priority locations in the Laredo, El Paso, and 
Yuma sectors. CBP continued to enhance and expand medical support 
throughout 2019, dramatically increasing the number of contracted 
medical professionals from approximately 20 in January 2019 to more 
than 700 today. Currently, each day, there are approximately 300 
contracted medical professionals engaged at more than 40 facilities 
along the Southwest Border, providing 24/7 on-site medical support. 
Support is now available at all 9 Southwest Border USBP sectors and all 
4 Southwest Border OFO field offices.
    CBP recognizes the unique challenges of providing medical support 
to children in custody, and has extensively consulted with internal and 
external pediatric subject-matter experts, including multiple HHS 
pediatricians and other senior U.S. Government pediatric care experts. 
CBP has also collaborated with court-appointed pediatric consultants to 
inform CBP's approach to care for children in custody, and contracted 
regional pediatric advisors to provide advice, training, review, 
coordination, and quality management of CBP pediatric care efforts.
    CBP's medical services contract employs medical teams, consisting 
of Advanced Practice Providers and medical technicians, to provide 
round-the-clock medical support at priority locations. These medical 
providers are licensed and credentialed to provide assessment and care 
for our population in custody, to include children and pregnant women.
    This model, a family practitioner model that pairs advanced 
practice providers such as Physician Assistants or Nurse Practitioners 
with medical support personnel at CBP facilities, has a layer of 
supervisory physician-level oversight both regionally and nationally 
for medical direction and records review. This model has been observed 
and validated by medical experts including top pediatricians within 
HHS, who have indicated it provides the appropriate care and scope of 
practice for CBP facilities. It also directs development of appropriate 
medical quality-management efforts, in consultation with the CBP chief 
medical officer, Office of Chief Human Capital Officer, and the DHS 
chief medical officer, as well as accountability through the Management 
Inspection Division and the Juvenile Coordinator.
    As noted in the above, CBP utilizes a layered approach to medical 
support for people in custody. CBP relies heavily on local health 
systems and local standards of care, referring and transporting people 
with complex, urgent, or emergent health issues to local hospitals or 
medical facilities. CBP often operates in remote and austere areas 
where there are limited medical facilities. In these areas, USBP agents 
and CBP officers are often the first responders to a person in need of 
medical attention. More than 1,200 USBP agents and 275 CBP officers 
have voluntarily taken on the additional responsibilities and training 
required to maintain EMT or paramedic certifications as a collateral 
duty. In fiscal year 2019 alone, USBP agents rescued more than 4,900 
migrants in distress along the border after they were placed in 
dangerous situations by smugglers. In addition, USBP referred more than 
26,000 people to hospitals or medical facilities.
    Additionally, CBP relies upon our partners at ICE and HHS who have 
more robust medical capabilities in alignment with their respective 
missions. Medical services, such as vaccinations and convalescence 
centers, are better provided in shelter care environments such as those 
provided by HHS and long-term detention environments provided by ICE.
    CBP is proud of the great strides we have made in providing 
critical and life-saving medical support to those in need while 
remaining cognizant that we are a frontline law enforcement element 
within a broader network of immigration agencies.
Enhanced Medical Support Directive
    In January 2019, CBP issued an Interim Enhanced Medical Directive, 
which established initial priority approaches to enhancing CBP medical 
care for people in custody. On December 30, 2019, CBP issued an 
Enhanced Medical Support Directive as part of an overarching medical 
support construct involving a dynamic process of constant review and 
improvement. This directive was developed using operational and medical 
lessons learned, and with significant stakeholder and medical expert 
input.
    The Enhanced Medical Support Directive outlines the 
responsibilities and procedures for both USBP and OFO in how they will 
deploy enhanced medical support efforts to mitigate health risks to 
those in custody. This effort aligns USBP and OFO medical support 
efforts, but is subject to resource availability and operational 
requirements. The Directive provides top-level guidance and is 
intentionally flexible, to facilitate modifications in alignment with 
changing conditions. Furthermore, it establishes foundational levels of 
medical support, although in many cases, CBP already exceeds these 
levels. It enhances processes established last year and provides clear 
direction for USBP and OFO for establishing an on-going contract 
mechanism to support enhanced medical support along the Southwest 
Border.
    The Enhanced Medical Directive ensures that CBP will sustain 
enhanced medical support capabilities with an emphasis on children less 
than 18 years old. These include a health interview upon initial 
arrival at a CBP facility. The interviews will be conducted by 
contracted medical personnel or by CBP agents/officers using a 
standardized health form. Subject to resource availability, USBP and 
OFO will ensure a more detailed medical assessment is conducted on all 
tender-age (12 and under) children, any person with a positive response 
to mandatory referral questions on the health interview form, or any 
other person with a known or reported medical concern. The medical 
assessments will be conducted by CBP contracted health providers where 
available, or, when appropriate, the individual will be referred to the 
local health care system/providers. CBP EMT-certified agents and 
officers will conduct medical assessments only in exigent circumstances 
and when operationally available.
Infectious Disease
    CBP works closely with State, local, and Federal public health 
officials regarding public health and infectious disease issues. CBP 
continues to engage in extensive dialog and consultation with numerous 
stakeholders who have provided subject-matter expert consultation, 
including DHS, U.S. Coast Guard medical leadership, HHS, and the 
Centers for Disease Control and Prevention.
    CBP-contracted medical personnel are trained to provide early 
identification, treatment, isolation, infection control, and public 
health support for infectious diseases in CBP facilities. For example, 
CBP's on-site contracted medical teams provide early identification and 
diagnosis via rapid flu testing; they can also provide antiviral 
treatment and prophylaxis on-site. Furthermore, they have the ability 
to enact enhanced prevention and control measures, and referrals to 
hospitals and emergency rooms if necessary.
    CBP's medical capabilities are part of a larger system of care for 
migrants in Government custody. CBP ensures that individuals in our 
custody receive the appropriate medical care during the short time they 
are in our custody; however, longer-term facilities at ICE and HHS have 
the resources and facilities to provide necessary comprehensive medical 
care, including vaccinations.
                      the crisis is far from over
    As a result of multiple whole-of-Government initiatives to expedite 
immigration hearings, repatriate individuals ordered for removal, and 
effectively end the release of migrants directly from the border, 
Southwest Border apprehensions have dropped by 75 percent since May 
2019. Word of mouth, including the use of social media and other 
internet-based applications, which had been used to encourage, 
organize, plan, and initiate mass immigration from Central America, is 
now informing prospective migrants that they can no longer rely on 
being released once they get here.
    The reduced migration flows have begun to alleviate the stress on 
our system that the crisis created. Many of the improvements made to 
address the crisis relied on the influx of emergency supplemental funds 
that do not last forever. Similarly, these new initiatives rely heavily 
on partnerships with Mexico and Central American nations. Neither 
address the fundamental flaws in our immigration system. For more than 
a year now, CBP has pleaded with Congress to address the layers of 
existing law and judicial decisions that adversely impact our ability 
to effectively manage our immigration system. There are 3 key gaps in 
our legal framework that Congress has yet to address.
    First, the 1997 Flores Settlement Agreement requires the Government 
to transfer alien minors to non-secure, licensed programs ``as 
expeditiously as possible'' and, if detention is not required, release 
alien minors from detention without unnecessary delay. Soon after the 
2014 surge in UACs along the Southwest Border, the U.S. District Court 
for the Central District of California reinterpreted the Flores 
Settlement Agreement as applying not only to minors who arrive in the 
United States unaccompanied, but also to those children who arrive with 
their parents or legal guardians. In other words, the U.S. District 
Court for the Central District of California applied the Flores 
Settlement Agreement to all children in our custody. The court also 
determined that ICE's family detention facilities are not licensed and 
are secure facilities. As a result of this case and others like it, 
DHS's ability to detain family units for the duration of their 
immigration proceedings is limited, in that DHS rarely detains 
accompanied children and their parents or legal guardians for longer 
than 20 days.
    Second, the TVPRA requires that the U.S. Government extend certain 
protections to UACs. Specifically, the TVPRA requires that, once a 
child is determined to be a UAC, the child must be transferred to HHS 
custody within 72 hours, absent exceptional circumstances, unless the 
child is a National or habitual resident of a contiguous country and is 
determined to be eligible to withdraw his or her application for 
admission voluntarily (i.e., not a trafficking victim, does not have a 
fear of return, and is able to make an independent decision to 
withdraw). UACs from countries other than Canada and Mexico are not 
permitted to withdraw their application for admission and thus, cannot 
be quickly returned to their country of origin. During fiscal year 
2019, 79 percent of the UACs apprehended by USBP on the Southwest 
Border originated in Guatemala, Honduras, and El Salvador.
    Third, CBP has seen a significant increase in the number and 
percentage of people who seek admission without proper documentation or 
unlawfully enter the United States then assert an intent to apply for 
asylum or claim a fear of persecution on account of race, religion, 
nationality, membership in a particular social group, or political 
opinion. This dramatic increase is due in part to the systemic 
deficiencies created by the ineffective legal standards--again, further 
straining border security resources, immigration enforcement and 
courts, and other Federal resources.
                               conclusion
    DHS and CBP remain committed to ensuring that individuals in CBP 
custody receive appropriate care, including medical support, but these 
efforts do not address the on-going challenges we face. Once again, we 
urge Congress to take a comprehensive look at the immigration laws and 
the implications from those court decisions that shaped immigration 
laws. Real change requires real reform.
    Thank you for the opportunity to testify before you today. I look 
forward to your questions.

    Miss Rice. Thank you for your testimony. I now recognize 
Dr. Eastman to summarize his statement for 5 minutes.

  STATEMENT OF ALEXANDER L. EASTMAN, M.D., MPH, FACS, FAEMS, 
SENIOR MEDICAL OFFICER--OPERATIONS, COUNTERING WEAPONS OF MASS 
    DESTRUCTION OFFICE, U.S. DEPARTMENT OF HOMELAND SECURITY

    Dr. Eastman. Good morning, Chairwoman Rice, Ranking Member 
Higgins, Chairman Thompson, distinguished Members of the 
subcommittee and guests. It is an honor to be here today to 
discuss the Department of Homeland Security's efforts to 
prevent child deaths in custody through our provision and 
expansion of medical care during the recent migration crisis.
    I am Dr. Alex Eastman, the senior medical officer for 
operations at DHS. I have been a practicing physician for 
nearly 20 years, and in addition to my role here at DHS, 
continue to be a practicing trauma surgeon and surgical 
intensivist.
    Immediately prior to coming to DHS, I was the chief at the 
Rees-Jones Trauma Center at Parkland Memorial Hospital in 
Dallas, Texas. At Parkland, we cared for human beings from all 
backgrounds in their most desperate time. You care for everyone 
without regards to race, color, creed, means, religion. Quickly 
it becomes apparent that when life and death are on the line, 
none of these things matter. Providing care for patients, no 
matter the challenges, was my goal then and is our goal now.
    From all your visits to the border--and it is nice to see 
you all again this morning--I know you are aware that we 
continue to improve the care for all people in our custody, 
especially children.
    From the medical perspective, the crux of this humanitarian 
crisis was a massive increase in the potential demand for care, 
at times nearly 400 percent, a number that would gridlock any 
conventional health care system.
    Additionally, while correctional facilities have embedded 
detainee health care systems, law enforcement agencies do not. 
CBP is primarily a law enforcement organization, never designed 
to have a health care system within its walls. Doing so would 
be akin to building a minute clinic in every police station in 
America.
    Yet our challenge in the midst of this crushing demand, was 
an unconventional problem that required an unconventional 
solution--to help CBP and our other DHS components rise to the 
task of providing care to an overwhelming number of people, 
including children, in our custody.
    The expansion to where we are today, the system currently 
in place, and the direction we are headed, represents a 
Herculean effort in response to an unprecedented challenge. In 
December 2018, the DHS Secretary directed the provision of 
immediate assistance with the rising humanitarian demands of 
the migration crisis.
    We immediately deployed, and for the last 13 months, have 
been working on the border, alongside colleagues from CBP, ICE, 
Federal agencies like HHS and CDC, as well as State and local 
public health, medical experts and professionals to improve the 
care of migrants in custody, with particular attention to the 
children and the most vulnerable adults the law directs us to 
hold.
    Our first priority was to rapidly and urgently expand our 
medical capabilities along the Southwest Border, particularly 
at CBP which had the biggest need. In support of this mission, 
the United States Coast Guard deployed more than 30 teams to 
the Southwest Border providing more than 3,450 medical officer 
days and more than 8,275 health service technician days of care 
in the rapid response to this crisis.
    The Coast Guard served as our lifeline, our immediate 
response force from a medical standpoint. America should be 
grateful for the truly life-saving and timely work of the Coast 
Guard during this crisis as well as so many others.
    DHS also received critical assistance from the United 
States Public Health Service. Our Nation's Assistant Secretary 
for Health, Admiral Brett Giroir, himself, a pediatrician and 
intensivist, was a critical partner as we facilitated the 
targeted deployment of Public Health Service officers to 
critical areas along the Southwest Border.
    There were more than 475 Public Health Service officers 
deployed to the border, totaling more than 6,750 days of care 
provided to migrants. No mission was too difficult, including 
even loading into helicopters and going to our most remote 
border regions to immediately begin assessing migrants and 
providing any care necessary as early as possible.
    When large groups overwhelmed us in areas without Public 
Health Service or Coast Guard assistance, we moved them there. 
These two organizations gave so freely of their time and 
expertise. The officers, and physicians, and nurses who came 
down saved lives directly and continue to do so with the legacy 
they have left along the Southwest Border.
    As the interagency was countering the crushing surge, CBP 
was diligently working to build the system that would assume 
care from the emergency responders. As mentioned, that system 
now includes, among other aspects, more than 700 contracted 
providers, enhanced countermeasures for influenza and other 
infectious disease, and a medical directive that begins to lay 
out the path forward to continue the iterative process that 
allows the system to evolve as required.
    Our approach to improve care has been collaborative, not 
just by coordinating with Federal interagency partners but also 
by building and continuing critical State and local 
partnerships, collaborating with the Mexican government, and 
calling upon non-Government experts to assist when needed. 
Several systematic reviews of this developing system have been 
undertaken in the last year, all agreeing that the approach is 
sound.
    We have a legal, moral, and ethical duty to care for those 
in our custody. The challenge was unprecedented, required an 
unconventional solution, and we responded.
    At DHS and across the Government, we remain committed to 
ensuring that individuals, especially our children, receive 
appropriate medical care.
    Thank you very much, and I look forward to answering your 
questions.
    [The prepared statement of Dr. Eastman follows:]
               Prepared Staement of Alexander L. Eastman
                            January 14, 2020
    Chairwoman Rice, Ranking Member Higgins, and Members of the 
subcommittee: Thank you for the opportunity to appear before you today 
to discuss DHS's medical care of children during the recent migration 
crisis. As you are aware from this committee's many visits to the 
United States Southwest Border (SWB), the medical care of children in 
DHS custody does not occur in a vacuum. It is a system that is 
complicated, involves many other U.S. Government departments, and is 
evolving as we speak. Additionally, while the focus of this hearing is 
on the care of children, we have one system that cares for both adult 
and children in our custody and hence, at times, we'll discuss both. 
From a global ``strategic'' standpoint, our approach is to ensure that 
all persons in DHS custody, whether children or adults, receive the 
right medical care, at the right time, at the right place in this 
complicated, custodial health care system. On behalf of Chief Medical 
Officer Duane C. Caneva and the Countering Weapons of Mass Destruction 
Office (CWMD), where the Office of the Chief Medical Officer resides, 
we are committed to not only implementing this strategy but making sure 
the system improves daily.
       cwmd/cmo support to the southwest border migration crisis
    In late December 2018, Secretary Nielsen asked for immediate 
assistance with the developing crisis along the SWB. Our full attention 
turned to the border crisis, and we deployed experts to assist both 
U.S. Customs and Border Protection (CBP) and U.S. Immigration and 
Customs Enforcement (ICE) with health/medical/public health issues. As 
directed by the Secretary, our priorities were:
    (1) Eliminate preventable deaths related to the migration crisis 
along the SWB;
    (2) Ensure the integrity of our bio-surveillance system with 
regards to protecting the United States from an intentional attack or 
the unintentional risk from an infectious or communicable disease; and
    (3) Provide the best possible, humanitarian medical care to those 
in U.S. Government custody along the SWB.
    During the past 13 months, CWMD has prioritized its limited 
resources, personnel, and time to accomplish each of these goals.
                     cwmd direct support to the swb
    Faced with the rising humanitarian demands of the migration crisis, 
and particularly the increasing numbers of children being brought to 
the United States as part of this crisis, members of CWMD staff 
deployed immediately to the SWB to assist with coordination of health 
care and public health response to meet the goals set by the Secretary. 
CBP provides critical law enforcement functions at our Nation's 
borders. Migrants taken into CBP custody generally are held in CBP 
custody for the short period of time required for processing, and then 
generally transferred to other components of the Department or 
interagency systems that have the appropriate facilities and carry out 
more robust health care functions. However, as the numbers of migrants, 
particularly family units and children, were overwhelming the system's 
capacity and increasing medical and public health risk, core staff were 
deployed to the SWB to assist with development and coordination of the 
medical response to this humanitarian crisis.
    During the winter of 2018 and into the spring of 2019, we spent 
significant time focused on coordinating an interagency medical surge 
response, first with providers from the United States Coast Guard 
(USCG), and then with critical assistance from the United States Public 
Health Service (PHS), all while ensuring close coordination with State 
and local Public Health Offices and private-sector health care systems. 
CWMD medical and public health staff assisted with the response 
coordination, helped the U.S. Border Patrol determine critical needs 
and coordinated interagency efforts to respond to remote areas where 
large numbers of migrants were apprehended outside of the developing 
CBP network of contracted medical support. During the first 6 months of 
the SWB migration crisis, the USCG deployed 34 independent teams to the 
SWB. These teams, consisting of one medical officer and two corpsmen, 
provided 3,468 medical officer days and 8,296 Health Service Technician 
days of care at the most vital time in this response to this crisis.
    Our Nation's Assistant Secretary for Health, ADM Brett Giroir, a 
pediatric intensivist, was a critical partner as we deployed and placed 
PHS Officers in Border Patrol Stations along the SWB. As CBP determined 
its needs and which of its facilities were in critical need of medical 
support, we facilitated the targeted deployment of PHS officers to 
those critical areas. At times, in response to critical and emergent 
operational needs, PHS Officers were flown to remote areas of the SWB 
aboard CBP aircraft to begin triage and treatment of large migrant 
groups immediately after apprehension. From December 30, 2018 through 
October 2, 2019, there were 483 United States PHS officers deployed to 
the SWB, totaling 6,759 days of care provided to migrants.
 unaccompanied alien children and family units: a unique challenge to 
  the swb healthcare ``system'' and the overall 2019 migration crisis
    As described in the CBP testimony submitted for this hearing, the 
preponderance of unaccompanied alien children (UACs) and family unit 
aliens (FMUAs) presented us with unique challenges that the existing 
SWB health care infrastructure was unequipped and unprepared to deal 
with. Relatively early in the crisis, at the request of the CBP acting 
commissioner, CWMD employed the services of an experienced, senior 
pediatrician from Columbia University to serve as our Senior Medical 
Advisor for Pediatrics. In addition, we consulted and engaged with a 
variety of other pediatric and health care experts, who made 
recommendations and helped us shape our on-going efforts with regards 
to the medical care of children caught in this crisis. Many of these 
experts came to the SWB to directly observe the conditions and 
subsequently used these visits and information to provide us with their 
advice on how to best continue to shape and improve the care of 
children in custody.
            specialized expertise: available 24/7, every day
    High-quality EMS medical direction and highly functioning EMS 
systems provide the ability for EMTs and paramedics to reach physician 
expertise. Early in the SWB migration crisis, focused on DHS EMTs and 
paramedics but available to any of our medical providers, we recognized 
the need for a provider involved to have the capacity to be in contact 
with medical experts especially in the provision of care in austere 
environments. Established in early 2017, and enhanced for this crisis, 
we ensured that all DHS EMS and medical providers had the ability to 
reach the DHS medical officer on-call. Originally requiring a phone 
call, we expanded this capability to include the ability to reach out 
via nearly any communication method utilized by DHS LEO EMTs and 
paramedics. Integrated with the National Law Enforcement Communications 
Center (NLECC, aka ``Sector''), from nearly anywhere in the world, our 
providers are now available to contact 1 of our DHS EMS physicians at 
all times.
  consultation, coordination, and integration of an interagency effort
    In addition to the direct operational medical support and pediatric 
guidance described above, we coordinated and consulted with a variety 
of medical experts to ensure that our practices met the most 
appropriate tenets of quality medical care given the operational 
constraints. The following individuals or organizations, inside and 
outside of DHS, were consulted, formally visited the border, or were 
hired to give their recommendations/evaluations of our practices during 
the crisis:
    (1) Centers for Disease Control and Prevention
      a. Influenza Division
      b. Division of Global Migration and Quarantine
    (2) Chief Medical Officer, USCG
    (3) Assistant Secretary for Preparedness and Response, U.S. 
        Department of Health and Human Services (HHS)
    (4) Assistant Secretary for Health, HHS
    (5) Senior Medical Advisor for Pediatrics, DHS.
    As the response effort grew and encompassed the Federal 
interagency, coordination structures for these efforts leveraged a 
Unified Coordination Group structure, which included representatives 
from the appropriate interagency members, established data collection 
and analysis requirements, and refined thresholds for further action. 
In addition to the above, CBP's Senior Medical Advisor has continuously 
engaged with the court-appointed pediatric consultant to inform CBP's 
approach to care for children in custody.
 integration into local swb communities: critical linkages with health 
                     care systems and public health
    While the response to this unprecedented humanitarian migration 
crisis is clearly Federal, much of the health and public health efforts 
lie at the feet of our State and local health department and private-
sector health care partners. Hence, efforts for more deliberate State 
and local public health engagement were reinstituted in the spring of 
2018 and included regular conference calls, presentations at National 
conferences, and face-to-face meetings. Regular coordination calls and 
synchronization meetings with the 4 SWB States were started in October 
2018 and covered DHS operational component updates, disease 
surveillance updates, and feedback. At the peak of the crisis in the 
spring of 2019, these conference calls had more than 250 invited, 
regular participants from along the SWB. The calls continue today, 
though are now held monthly or as necessary. Topics covered include 
coordination on preparedness and response to disease outbreaks or 
public health emergencies, investigation of potential infectious 
disease outbreaks and those migrants that may have been effected, 
discussions with operational components on issues related to detainee 
transfer and release, consultation on Non-Government Organization 
shelters in their States, and on-going public health engagement to 
address specific public health issues including disease surveillance, 
disease outbreak preparedness and response coordination, information 
sharing, and general health care issues of concern locally. In addition 
to these critical coordination calls, members of CWMD staff held, and 
continue to hold, in-person visits and coordination meetings with State 
and local public health officials from the State to the individual 
community level in Texas, New Mexico, Arizona, and California.
   improved coordination and integration of a swb health care system
    After nearly 6 months of responding to the humanitarian crisis 
response at the SWB, it was clear that this unconventional health care 
infrastructure developing in CBP to urgently to meet unprecedented 
demand required better integration and coordination. CBP is distinctly 
different than ICE and HHS that have developed and embedded health care 
systems. The CBP health care infrastructure is complicated by vast 
geography, an international nexus, and the varying roles of multiple 
departments and agencies of the U.S. Government. Recognizing this, CWMD 
and CBP have identified the need to develop systems of coordination 
jointly. This work is on-going at present. From an overall DHS SWB 
health care architecture, close coordination of health care systems 
along the SWB, including ICE Health Service Corps, CBP contract 
services, HHS Office of Refugee Resettlement Agency for Children and 
Families (ORR ACF), and local health care systems continues to 
represent a significant challenge that we work to address daily.
                        international engagement
    International engagement with the Government of Mexico's Ministry 
of Health began informally with a meet-and-greet visit. Regular updates 
of conditions across the border were provided from Department of State 
partners from U.S. consulates near the border and through HHS 
international offices. As result of these initial meetings, and 
concerns expressed along both sides of the SWB, we organized a multi-
agency delegation that visited Mexico in May and outlined a path 
forward to identify U.S. Government leads and partners for on-going 
engagement. The delegation identified issues and outlined solutions to 
ensuring migrant access to medical care, sharing information on disease 
surveillance, options for medical records, and vaccination strategy 
options. The visit also included meetings with international NGO's 
operating to assist the migrant population in Mexico and hearing their 
observations and concerns. The binational engagement occurs through 
three international agreements already in place. The Binational 
Technical Working Group (CDC leads) shares epidemiology trends along 
the SWB at the local and State level, coordinating disease surveillance 
and outbreak investigations. The North American Plan for Animal and 
Pandemic Influenza (NAPAPI) Health Security Working Group (ASPR leads) 
is a tripartite agreement including Canada focusing on coordination for 
animal and human influenza outbreaks. Ultimately, continued binational 
integration efforts continue through the HHS-led Border Health 
Commission, which provides international leadership to improve health 
and quality of life along the SWB.
                           future directions
    We are working diligently to meet the requirements enumerated in 
the fiscal year 2020 Homeland Security (DHS) Appropriations Act and the 
Joint Explanatory Statement. In addition, we continue to address the 
integration of health care along the SWB to include, to the degree 
possible, integrated health record systems, disease surveillance, 
access to and continuity of quality health care for those in our 
Department's care and custody. We are also working to update the Land 
Mass Migration Plan for surges and mass migration along the SWB that 
will include a Medical Annex. The effort includes developing solutions 
that prevent the back-up of migrants in custody occurring in Border 
Patrol Stations. Like, and in conjunction with the update to the 
Maritime Mass Migration Plan and Medical Annex, this will address 
interagency, State, local, and private-sector roles, responsibilities, 
and authorities, thresholds for phased implementation of the responses, 
and requirements identified for further resourcing.
    At DHS, we remain committed to ensuring that individuals in custody 
receive appropriate care, including medical support, but these efforts 
do not address the on-going challenges we face due to continued migrant 
flows and changing demographics. Once again, we urge Congress to take a 
comprehensive look at the immigration laws and the implications from 
those court decisions that shaped immigration laws. Real change 
requires real reform.
    Thank you for the opportunity to testify before you today. I look 
forward to your questions.

    Miss Rice. I thank all the witnesses for their testimony. I 
will remind each Member that he or she will have 5 minutes to 
question the panel. I will now recognize myself for questions.
    Chief Hastings, early last month, ProPublica released video 
footage of Carlos Hernandez Vasquez, who was being held in 
Border Patrol custody in May 2019. The video shows in 
heartbreaking detail the last hours of Carlos' life. He was 16 
years old at the time. He died in his cell just hours after a 
nurse practitioner apparently recommended immediate medical 
care. In fact, his body was first discovered by his cellmate 
who was another child who was being held in detention. 
Understanding that this specific case is still under 
investigation, what can you tell us about the lesson CBP has 
learned from this particular case?
    Mr. Hastings. So ma'am, I would start by saying, dignity 
and care of those are of the utmost importance. I am a father. 
I have a granddaughter as well. I watched the video. I saw the 
same video from the media report, and the video itself was 
troubling. As you know, the case is still under OIG 
investigation. I can't speak to what their findings are. One 
thing I can add is that I know that all of the video has been 
turned over, all of the items that we had. The video of all the 
cells has been turned over to OIG, and they have all the video, 
not just a piece, as I understand, that was pulled from the 
sheriff's department.
    Miss Rice. So are you insinuating that there is more--I am 
not sure what you are insinuating.
    Mr. Hastings. So as I said, all of the video that we had 
throughout the station that day has been turned over to OIG.
    Miss Rice. What did it show?
    Mr. Hastings. I haven't seen it, ma'am. I just know that we 
have turned it over and provided to OIG, who is the independent 
investigator.
    Miss Rice. I was just curious about what you were 
insinuating by saying, we just saw a little snippet but that--
--
    Mr. Hastings. I am just insinuating we have turned over all 
the evidence and all the video.
    Miss Rice. OK. So broadly speaking what do you think could 
have been done differently, without talking about what was 
done, your review of the case, what do you think could have 
been done differently?
    It has been indicated that welfare checks were conducted on 
this young boy, young teen, but the video shows an increasingly 
sick Carlos in pain, vomiting up blood, writhing around in pain 
until he falls unconscious to the floor of his cell, and this 
happened over a course of hours.
    So I am wondering, is there a finding by just your internal 
review that maybe it wasn't understood, the level of medical 
attention that he needed when he was in the cell at that time?
    Mr. Hastings. So again, it is on-going, and certainly any 
lessons learned from any of the investigations, this 
investigation or any others, we will look at to make changes. I 
can tell you that we did put out guidance to the field that any 
of those--and I believe this was July--a memorandum from then-
Commissioner Saunders went out--any subject in our custody were 
receiving welfare checks every 15 minutes and being documented 
in our system of record.
    Miss Rice. You mean person, not subject, in your custody.
    Mr. Hastings. Person, yes, ma'am.
    Miss Rice. Because that is what they are, they are people, 
not subjects.
    Mr. Hastings. People, ma'am.
    Miss Rice. Can you tell us what policies are in place to 
ensure that recommendations that you received from medical 
professionals are actually followed and what measures exist to 
protect health care professionals who refuse to clear patients 
for detention?
    I mean, I am assuming that a CBP officer has to stay with 
any child or human in detention if they go to a health 
facility. Is that correct?
    Mr. Hastings. That is correct.
    Miss Rice. Are you aware of pressure that CBP officers are 
putting on medical professionals to release patients so that 
they can get back to their job at the border or whatever 
facility to which they are assigned?
    Mr. Hastings. No, ma'am, I am not. In fact, in reviewing 
some of the IG investigation material I saw the contrary where 
one of our agents actually asked for additional care and stood 
up for one of the children that was sick until the fever was 
down. So we have seen the opposite of that.
    Miss Rice. Well, that is a good story to hear, but there 
have also been indications that health professionals feel 
intimidated and pressured by CBP personnel to release patients 
to detention even when it is not medically indicated. To me, it 
seems like a doctor should be the ones making these decisions, 
not CBP officers.
    What policies are in place to ensure that recommendations 
of medical professionals are followed? I mean, are there 
policies? I mean----
    Mr. Hastings. So yes, we have multiple policies, and we 
work closely with both CWMD as well as our own office of 
support. We have medical staff at our--that we have hired to 
oversee the contract and to make sure that we are providing the 
best care we can in the family practitioner model.
    Miss Rice. Dr. Eastman, it is good to see you again. As the 
senior medical officer in the Department of Homeland Security, 
when you make recommendations for the medical care of 
individuals in CBP's custody, are they followed by CBP?
    Dr. Eastman. Nice to see you as well, ma'am, and yes, we 
work collaboratively with CBP to advise and help implement the 
recommendations that we offer. In fact, we have our employees, 
CWMD employees, the senior medical adviser at CBP, and this 
team works collaboratively to implement the recommendations 
that are made with a hardy respect to the fact that there are 
operational considerations as well.
    Miss Rice. If you look at some of the cases involved with 
the children that I mentioned, every single one of them was 
very, very sick and should have been hospitalized and never 
released back into CBP custody.
    So there has to be, I would hope, some effort to review 
where these mistakes were made, that these children who were 
very, very sick, one of whom had a temperature of 105.7, when 
they were initially examined, I mean, I just don't understand 
how that could even be possible.
    I mean, are CBP officers trained to--I know they are not 
medical professionals, but it doesn't take--you don't have to 
be a doctor to see that a child has a 105.7 temperature. So 
what----
    Dr. Eastman. Ma'am, we do the absolute best we can to 
provide the best care possible to the children in our custody, 
but there is not a mechanism for us, as the Department of 
Homeland Security, to review the care that is provided outside 
our system in community hospitals all along the border. I 
think----
    Miss Rice. Well, I am talking about that initial--I mean, 
it was a nurse practitioner, I believe, who examined Carlos and 
gave him Tamiflu because that is what he was diagnosed with. 
But have you recommended flu vaccines for detained migrants?
    Dr. Eastman. Ma'am, our approach to the flu vaccine is a 
comprehensive one, that encompasses all of the settings where 
care is delivered along the Southwest Border. In fact----
    Miss Rice. So is everyone given, is every detained migrant 
given a flu shot?
    Dr. Eastman. The Department of Homeland Security's 
vaccination strategy has resulted in more than 60,000 
vaccinations being given, predominantly in the ISL service 
core. Our goal is to give the right vaccine to the right person 
at the right time.
    Miss Rice. Have you spoken with the Acting Secretary about 
ways to ensure that CBP follows your medical recommendations?
    Dr. Eastman. Ma'am, like I said, the direction from 
leadership, from the Secretary to all the Acting Secretaries I 
have worked has been the same, to do the right thing for the 
people in our custody and for all of us to work together to do 
just that.
    Miss Rice. I understand. I am just asking you--and you can 
just say yes or no--have you specifically spoken with the 
Acting Secretary about ways to ensure that CBP follows your 
medical recommendations?
    Dr. Eastman. Yes, ma'am. Prior to his current role as the 
Acting Secretary, we spoke along the border.
    Miss Rice. Do you continue those conversations?
    Dr. Eastman. Yes, ma'am. Absolutely.
    Miss Rice. Thank you. I now recognize the Ranking Member, 
Mr. Higgins.
    Mr. Higgins. Thank you, Madam Chair.
    Chief Hastings, the President requested emergency 
supplemental assistance to address the crisis at the border on 
May 1, 2019. It took 2 months for that money to be approved by 
Congress and to get that money to the field to provide relief.
    Meanwhile, the Department of Health and Human Services ran 
out of money for unaccompanied minor bed space. Please explain 
to the committee, and the Americans watching this hearing, the 
immediate impact that supplemental funding had on Customs and 
Border Protection operations at the border and CBP's ability to 
move unaccompanied minors out of CBP facilities and into ones 
more suitable for children, including professional medical 
care.
    Mr. Hastings. Thank you for the question, sir. So as 
everyone is fully aware, we dealt with 321,000 total children 
last fiscal year. Those were both UACs and in families. We have 
never seen those kind of numbers before. That quickly 
overwhelmed the entire system. Specifically in May and June 
time frame, 144,000 apprehensions in May, or arrests, and the 
inadmissibles as well. The system got backed up.
    We were still processing in about, on average, 25 hours per 
average per UAC, but the UAC couldn't move. HHS was out of 
funding, they were out of money, and they were telling us they 
couldn't move those in our custody. By law, there is nothing 
more we can do with the UAC either, other than turn them over 
to HHS.
    Mr. Higgins. Thank you for that clarification. In the 
interest of perspective for the American citizens viewing this 
hearing and for my colleagues on the committee, let me just say 
that there has been an undercurrent or insinuation that Customs 
and Border Protection has in some way been neglectful of caring 
for children.
    I believe we all accept that the medical facilities of the 
United States of America, the hospitals of America, will 
provide some of the finest care in the world, arguably the 
finest care in the world. We will investigate any death of any 
child that is in the custody of Customs and Border Protection, 
and those deaths should be investigated. Every loss of a child 
is tragic, and we should take a deep breath and look at that.
    But for the sense of perspective, let me say that in 2017 
alone, 28,308 juveniles died in professional medical facilities 
in the United States of America. Many of these children arrive 
at the border, they are very sick. They are struggling, no 
telling what they have been through. CBP does their best to 
take care of them. But tragically sometimes children die, 
including 28,308 children in American hospitals in 2017 alone. 
Those are Government numbers from the CDC.
    In our juvenile detention facilities, it is not uncommon 
historical data from the Government to show an average of about 
10 deaths in a 6-year period. These are juveniles in juvenile 
detention facilities in America, much better designed and 
equipped to care for the children in their custody. The men and 
women that wear badges care about the children that come under 
our care.
    I lost my first-born daughter in a hospital. I lost many 
more on the street, children in my arms, a young teen hit in 
the head by an axe handle over an unpaid drug debt. I sat there 
in that dark street and held that young man's head, whispering 
prayer into his ear as the life light left his life. Infant 
child, unresponsive, hysterical parents, I did my best to 
perform infant CPR to resuscitate that child. She didn't make 
it.
    Dr. Eastman, in my remaining 25 seconds, sir, please 
respond to the spirit with which Customs and Border Protection 
addresses any sick child that comes into our custody.
    Dr. Eastman. In my experiences, sir, CBP officers, Border 
Patrol agents, they are law enforcement officers, most of them 
are parents as well, and they act exactly as you describe, to 
do the best they can under the circumstances they are dealt.
    Mr. Higgins. Thank you, gentlemen, for appearing today.
    This is a painful and necessary hearing, and I thank Madam 
Chair and the Chairman of the whole committee, for allowing us 
to discuss how we can improve the care for the children that 
come through our border.
    Let us not forget that we must operate based upon the 
cornerstones that have defined America as we attempt to care 
for all of our children.
    So I thank you again, Madam Chair, for holding this 
hearing, and I yield.
    Miss Rice. Apropos of that, Mr. Hastings, would you--oh, I 
am sorry. Apropos of what my friend, Mr. Higgins, was asking 
you, would you agree that taking $3.5 billion from the military 
counter-drug program would be problematic? Because there is 
reporting today indicating that the President is planning to 
divert $7.2 billion in Pentagon funding to build his wall. 
Would you find that to be problematic in terms of addressing 
the issues that you testified about?
    Mr. Hastings. So ma'am, I would also add, though, on the 
other hand, we had a very large influx of families and 
children. We also had an influx of single adults. We saw those 
numbers go up. I would also add that we had 147,000 got-aways 
that we know of last year.
    So we had not only asylum seekers turning themselves in, 
but people trying to elude as well. We need--this is a whole-
of-Government approach to many things that we need to protect 
and safeguard our borders.
    Miss Rice. Do you think taking $3.5 billion from a military 
counter-drug program would be a problem to address the issues 
that you are--yes or no?
    Mr. Hastings. We need a border wall, I can tell you that.
    Miss Rice. I didn't ask you that. Can you answer the 
question I asked you?
    Mr. Hastings. Can you ask the question again?
    Miss Rice. Sure. Do you think it is problematic that the 
President wants to take $3.5 billion from military counter-drug 
program?
    Mr. Hastings. I think we--again, I would say----
    Miss Rice. Is there a reason why you can't just say yes or 
no.
    Mr. Hastings. No, I don't.
    Miss Rice. So you don't think--that is not problematic?
    Mr. Hastings. For our needs, there are needs that we have 
on the border as well to secure our border, and wall and 
construction is one of those.
    Miss Rice. I now recognize Chairman Thompson for 5 minutes.
    Mr. Thompson. Thank you very much, Madam Chair. The title 
of our subcommittee hearing today is ``Assessing the Adequacy 
of DHS's Efforts to Prevent Child Deaths in Custody.'' My 
comments talked about one death in custody is too much.
    I understand that since the deaths have occurred, there is 
an interim medical directive that talks about, that we will no 
longer do medical assessments for children under 18. Are you 
familiar with that, Mr. Hastings?
    Mr. Hastings. Sir, our new policy that just went into 
effect says we are doing health interviews for all of those 
less than 18, and we are doing health assessments, which is 
basically like a physical, for all of those 12 and younger, or 
anyone who says that they have a health condition or a medical 
issue.
    Mr. Thompson. So, Dr. Eastman, are you familiar with that 
policy?
    Dr. Eastman. Yes, sir. Yes, sir, I am.
    Mr. Thompson. Explain it a little bit for the committee.
    Dr. Eastman. Yes, sir. CBP uses a phased approach to meet 
the medical needs of the population in our custody.
    The first phase involves recognition of illness and the 
encouragement of migrants to report to us that they have an 
issue.
    The second phase is a health interview that has been 
standardized across Customs and Border Protection, using a 
questionnaire, able to be administered by a law enforcement 
officer but developed in concert with experts at the CDC and 
across the Government, with a two-fold purpose--to identify an 
emergent medical condition, but also to identify the potential 
of an infectious disease that might harm the migrant or 
threaten the United States.
    The third phase of that approach is a medical assessment 
from a qualified provider. That medical assessment in the final 
medical directive is given to anyone with a positive finding on 
the health interview, or to any child under 12, or to anyone 
who requests it.
    Mr. Thompson. So----
    Dr. Eastman. I would also add, sir, just 1 second, the last 
phase of that care plan is for any true world emergencies, you 
know, someone that would need cardiac care, we are obviously 
utilizing the local health care system where the migrants area.
    Mr. Thompson. So why would you determine 12 as the cut-off 
for an assessment?
    Dr. Eastman. Yes. So the way the directive was derived was 
a collaborative approach from all of us involved from DHS and 
CBP and the other experts, and the way the directive was 
approached, was felt that a teenager would be able to seek and 
request medical care when necessary.
    Mr. Thompson. So what outside groups did you talk to when 
you did this assessment?
    Dr. Eastman. Yes, sir. We have incorporated advice from the 
Assistant Secretary for Health, as I mentioned, several members 
of his staff who are seasoned pediatricians. In addition, we 
worked with a number of Public Health Service officers along 
the border who help give us--who are pediatricians themselves, 
with vast experience in everything from disaster response to 
responding to ebola.
    In addition, we hired a senior medical adviser for 
pediatrics, an outside pediatrician with vast disaster 
experience to come assist us. We also--and we continue to 
listen to the groups that are involved in the care, including 
the American Academy of Pediatrics, the family practitioners, 
and other organizations who have given us advice on this topic. 
We continue to utilize that advice to form our policies and 
procedures.
    Mr. Thompson. Well, I am happy that you mentioned the 
American Academy of Pediatrics. Madam Chair, I have a letter 
from the American Academy of Pediatrics that says there is no 
medical justification to only assess children younger than 12.
    So I want you to seriously consider the group you talked 
about, because they are the one dealing with children, and they 
are saying 12 is not a magic number. Some of us are concerned 
that between 18 and 12 is a vast shortage of opportunity for us 
to help children that we are talking about here today.
    So I just want to put that in the record, Madam Chair.
    Miss Rice. So received.
    [The information follows:]
            Statement of the American Academy of Pediatrics
                            January 14, 2020
    Chairwoman Rice and Ranking Member Higgins, thank you for the 
opportunity to provide written testimony about the adequacy of the 
Department of Homeland Security (DHS)'s efforts to prevent child deaths 
in custody. The American Academy of Pediatrics (AAP) is a non-profit 
professional membership organization of over 67,000 primary care 
pediatricians and medical and surgical pediatric subspecialists 
dedicated to health and well-being of all infants, children, 
adolescents, and young adults. The mission of the AAP is to protect the 
health and well-being of all children, no matter where they or their 
parents were born. As pediatricians, our primary responsibility is to 
support families in order to optimize child health. We strive to help 
all children to grow, develop, and reach their full potential to 
contribute to our collective America.
    As we testified to before your subcommittee in March 2019, AAP 
continues to believe that current conditions and protocols in Customs 
and Border Protection (CBP) custody are inconsistent with evidence-
based recommendations for the appropriate care of children. Children 
simply should not be subjected to these facilities. For over a year, we 
have been calling on DHS to implement specific meaningful steps to 
ensure that all children in CBP custody receive appropriate medical and 
mental health screening and necessary follow-up care by trained 
providers. We have also sought to provide expert advice to DHS and CBP 
about how to best care for and treat children in custody and continue 
to offer this expertise to the agencies.
    The deaths of so many children in CBP custody, the horrifying video 
of Carlos Gregorio Hernandez Vasquez's last hours in a CBP jail cell, 
and the observations of the AAP leadership, DHS Office of Inspector 
General, and others should be a call to action for DHS. We once again 
urge CBP and DHS to increase medical staffing with individuals who have 
pediatric training at its facilities so they can monitor, screen and, 
where possible, treat children who are sick. We urge CBP and DHS to 
require that all children under age 18 are medically screened by a 
medical professional with pediatric training, to have plans for 
appropriate space to isolate ill individuals, and to prioritize the 
transfer of unaccompanied children to the Office of Refugee 
Resettlement (ORR) as quickly as possible.We are aware that the Centers 
for Disease Control and Prevention (CDC) issued a report to DHS based 
on findings by 3 CDC teams who visited DHS Border Patrol facilities in 
December 2018 and January 2019. CDC's recommendations are reasonable, 
routed in public health, and, if implemented, would greatly reduce the 
risk of infectious disease transmission and ensure more appropriate 
screening and treatment for children while in CBP custody. We urge the 
subcommittee to conduct oversight on whether any of CDC's 
recommendations have been implemented and continue to conduct robust 
oversight on how the hundreds of millions of dollars that Congress has 
already appropriated to DHS/CBP specifically for medical and 
humanitarian care through the regular and supplemental appropriations 
process have been spent.
                        unique needs of children
    As pediatricians, we know that children are not little adults. 
Children's vital signs (breathing rate, heart rate, blood pressure) 
have different normal parameters than adults, and these parameters vary 
by age. When children begin to get sick, they present with subtle 
findings, and they tend to get sick more quickly. For example, children 
can become dehydrated more quickly than adults. They require greater 
amounts of fluid per pound of body weight than adults, and high fevers 
and fast breathing can cause children to lose fluid quickly. Children 
also need encouragement to drink when they are ill, and this 
encouragement is exceedingly difficult to provide to frightened 
children.
    The flu can be particularly serious for children and can escalate 
quickly. Signs differentiating a child with mild illness from a child 
with severe illness are quite subtle. A child can be happily playing, 
even running around, while her body systems begin to shut down. When a 
child is having difficulty breathing, she may breathe more quickly or 
her ribs may pull in with each breath; these signs would often not be 
easily visible, especially not to an untrained eye. Additionally, 
children are more prone to muscle fatigue, including the breathing 
muscles, and are thus at greater risk for respiratory failure.\1\ Even 
the dosing of common medications is different in children than it is in 
adults; rather than standard dosing, children are dosed based on their 
weight.\2\
---------------------------------------------------------------------------
    \1\ Woollard M, Jewkes F. 5 Assessment and identification of 
paediatric primary survey positive patients. Emergency Medicine 
Journal. 2004;21:511-517.
    \2\ Palchuk MB, Seger DL, Recklet EG, Hanson C, Alexeyev A, Li Q. 
Weight-based pediatric prescribing in ambulatory setting. AMIA Annu 
Symp Proc. 2006;2006:1055.
---------------------------------------------------------------------------
    Sepsis, for example, must be treated early in children. According 
to the Society of Critical Care Medicine (SCCM), sepsis is a 
complicated disease causing the body to be compromised by serious 
systemic infection leading to multiple organ failure.\3\ The importance 
of recognizing and treating sepsis early in children cannot be 
underestimated; each hour of delay in treatment dramatically increases 
mortality. Because sepsis can be so serious and so difficult to 
recognize in children, the SCCM has a separate set of guidelines for 
recognizing and treating sepsis in children that are different than for 
adults.\4\ For these reasons, it is essential that the individuals who 
interact with children apprehended at the border are trained to 
recognize signs and symptoms of distress and know when to urgently 
refer children to additional care.
---------------------------------------------------------------------------
    \3\ Weiss SL. Five Important Things to Know about Pediatric Sepsis. 
Society of Critical Care Medicine. https://www.sccm.org/Communications/
Critical-Connections/Archives/2018/Five-Important-Things-to-Know-About-
Pediatric-Seps. Accessed March 4, 2019.
    \4\ Dellinger RP, Levy MM, Rhodes A, et al: Surviving Sepsis 
Campaign: International guidelines for management of severe sepsis and 
septic shock: 2012. Crit Care Med. 2013; 41:580-637.
---------------------------------------------------------------------------
                           recent cbp actions
    Unfortunately, CBP's recently released Medical 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 dated January 28, 2019. For example, the new 
Directive no longer requires medical assessments of all children under 
18. Although the directive indicates that tender-age children (ages 12 
and under) will receive a medical assessment, that is heavily caveated. 
As medical providers for children, there is no medical justification to 
only assess children younger than 12. All children should be routinely 
screened and treated, as necessary. Further, the directive no longer 
defines a medical assessment as including taking vital signs severely 
weakening what an actual medical assessment is and gives no definition 
to the required qualifications of ``health care providers'' including 
that anyone interacting with a child have any pediatric training.
    We understand that CBP has hired 4 contracted pediatric advisors 
for the entire Southwest Border to provide pediatric expertise and 
consultation, support medical quality management efforts, advise 
pediatric protocols and support training. However, it does not appear 
that the contracted pediatricians will actually be providing care to 
children in CBP custody. In order to ensure proper care of children in 
CBP custody, there must be a robust pediatric medical presence at the 
border.
                          aap recommendations
    1. Because conditions at CBP processing centers are inconsistent 
        with AAP recommendations for appropriate care and treatment of 
        children, children should not be subjected to these 
        facilities.\5\ The processing of children and family units 
        should occur in a child-friendly manner, taking place outside 
        current CBP processing centers and conducted by child welfare 
        professionals, to provide conditions that emphasize the health 
        and well-being of children and families at this critical stage 
        of immigration proceedings.\6\
---------------------------------------------------------------------------
    \5\ Linton JM, Griffin M, Shapiro AJ. Detention of Immigrant 
Children. Pediatrics. 2017;139(5).
    \6\ Ibid.
---------------------------------------------------------------------------
    2. All children, throughout the immigration process, should have 
        access to comprehensive, trauma-informed care, including 
        preventative care, chronic condition management, dental care, 
        and mental health treatment, when indicated. Humanitarian 
        standards should also be implemented to ensure that immigrants 
        receive proper nutrition, hygiene, and sanitation while in CBP 
        custody. Pediatricians stand with the immigrant families we 
        care for and will continue to advocate that their needs are met 
        and prioritized.
    3. CBP agents, including those who are not trained as EMTs or 
        paramedics and those who work in remote areas along the border, 
        should be trained to know how to identify the signs of a child 
        who is in medical distress and needs immediate medical 
        attention. Ideally, such training would be both on-line and in-
        person. While it may not be possible to provide pediatric 
        medical training to all CBP agents, we can work to ensure that 
        they are better prepared to identify a sick child and to get 
        that child into appropriate care. We must also ensure that CBP 
        provides its agents with necessary basic supplies such as oral 
        hydration, food, first-aid kits, and other supplies that could 
        be life-saving should those agents encounter a sick child. The 
        AAP is pleased to support S. 412, the Remote, Emergency, 
        Medical, On-line Training, Telehealth, and EMT (REMOTE) Act, 
        which addresses many of these recommendations.
    4. The Academy is urging CBP to ensure that all children under 18 
        years of age receive evidenced-based medical screening and care 
        from professionals trained in pediatric care. We must have 
        medical professionals who are trained in the care of children 
        screening and treating vulnerable children who are in the 
        custody of our Government.
    5. Children who are identified as needing additional medical care 
        should be immediately referred for evaluation and treatment, at 
        a children's hospital if there is one available. Procedures 
        should be in place to ensure that when children need treatment, 
        they are quickly able to receive appropriate care and have 
        access to professionals trained in the care of critically-ill 
        children during transport.
    6. Screening and treatment should occur in the child or parent's 
        preferred language so as to ensure the family is able to 
        understand what is happening and accurately answer questions. 
        This means that trained medical interpreters should be used in 
        all clinical encounters with children and their families.
    7. Sick children, children who have been hospitalized, or children 
        with special health care needs should not be returned to a CBP 
        processing facility. When a child is diagnosed with an illness 
        in a pediatrician's office or is discharged from an emergency 
        room or a hospital, he or she is sent home to recover with 
        plenty of rest and a parent to care for them. Parents of 
        children being detained in CBP processing centers do not have 
        that luxury; rather, the conditions in the centers themselves 
        exacerbate children's suffering, and without medical 
        professionals who understand the signs and symptoms to look for 
        to assess a child's condition, these children are at further 
        risk. A sick child should recover in the comfort of a home or 
        child-friendly setting under the care of a parent or caregiver, 
        not on a cold, concrete floor in Federal custody.
    8. Independent oversight of locations in which children are 
        temporarily housed, detained, or sheltered is critical. 
        Licensure of those locations is important to ensure appropriate 
        care and oversight. As these locations are selected, we 
        encourage DHS and HHS to consider their remoteness as that can 
        impact proximity and access to trained pediatric providers.
    9. Medications should not be confiscated from a child unless 
        approved by a pediatrician at a CBP facility. Children with 
        chronic or acute medical conditions rely on life-saving or 
        life-sustaining medications. Children whose medications have 
        been confiscated by CBP may go days or weeks without needed 
        medications as these medicines are not always replaced by CBP 
        in a timely manner. Pediatricians throughout the country have 
        reported children needing to be hospitalized, sometimes in the 
        intensive care unit, as a result of the conditions in CBP 
        facilities including the confiscation without replacement of 
        their medications.
    10. The AAP has called for a thorough, independent investigation of 
        the Government's detention practices, including the appointment 
        of an independent team comprised of pediatricians, pediatric 
        mental health providers, child welfare experts, and others to 
        conduct unannounced visits to Federal facilities including CBP 
        processing centers, ICE family detention centers, and ORR 
        shelters to assess their conditions for children, capacity to 
        respond to medical emergencies involving a child, and to ensure 
        that immigrant children receive optimal medical and mental 
        health care. These experts need unfettered access to sites 
        where children are held in Federal custody to ensure that they 
        receive suitable care while there.
    Thank you for the opportunity to provide written testimony. We look 
forward to working with you to ensure that all children who reach our 
border receive appropriate medical and mental health screening and 
treatment.

    Mr. Thompson. All right.
    So Mr. Hastings, why did it take the Department as long as 
it did to revise this directive? Are you familiar with that?
    Mr. Hastings. So we did put out an interim directive 
immediately, in December. Then we worked with these various 
components as was mentioned earlier, internally and externally, 
our stakeholders, to make sure that we got this right. But the 
interim policy was in effect since December 2018.
    Additionally we didn't wait to take actions. We were taking 
many other actions, including increasing our contract personnel 
even before that.
    Mr. Thompson. So are you familiar with the clause ``subject 
to availability of resources and operational requirements'' in 
that directive?
    Mr. Hastings. Resources and obligations?
    Mr. Thompson. Resources and operational requirements.
    Mr. Hastings. Am I--I am not sure what you are referring 
to, which part, sir.
    Mr. Thompson. The same directive you talked about that has 
been developed.
    Mr. Hastings. Well, for one thing, sir, we need funding--
and it does mention funding in there--to continue our 
assistance with resources, is funding basically to continue the 
assistance with our contract medical providers.
    Mr. Thompson. So who makes decisions as to whether 
resources are available?
    Mr. Hastings. It is based on budgetary need. The other 
thing----
    Mr. Thompson. So who makes that decision?
    Mr. Hastings. So if we continue to receive funding to 
provide the current services we are, contract services will 
continue to do that.
    Mr. Thompson. Well, do you make the decision or who?
    Mr. Hastings. Sir, we have to be funded to continue for 
one----
    Mr. Thompson. I am not talking about--I am not talking 
about--I am saying, who makes the decision, what individual, in 
the implementation of this directive?
    Mr. Hastings. So, as I said, we have implemented the 
directive. When we would have had difficulty, what you are 
referring to in staying with the directive, would have been 
very difficult when we were backed up and had 7,500 children--
--
    Mr. Thompson. So when you said ``we,'' is that you?
    Mr. Hastings. That is the Border Patrol.
    Mr. Thompson. So who at the Border Patrol makes that 
decision?
    Mr. Hastings. We would make it operationally and provide a 
heads-up to Congressional.
    Mr. Thompson. So there is no individual by name that you 
can give this committee?
    Mr. Hastings. Sir, we constantly brief what we have going 
on on the border, as far as the amount of numbers we are seeing 
and the resources that we are using down there.
    We consistently brief up what we are seeing on the border 
and the situation, and throughout the crisis, we continue to 
brief those numbers. We were overwhelmed is my point.
    Mr. Thompson. Well, but that is--I am talking about the 
directive. I am not talking about the conditions. You put a 
directive in place.
    Mr. Hastings. We have.
    Mr. Thompson. You said ``subject to the availability of 
resources and operational requirements.'' I am asking you, who 
makes that determination, what individual?
    Mr. Hastings. So we will continue to do that. I would 
imagine that would go to the highest levels. It would probably 
go to the chief or the commissioner to stop something as 
important to this, and we would certainly notify their entities 
if we were forced into a situation, overwhelmed or not budgeted 
for this. We would certainly notify----
    Mr. Thompson. I am having real difficulty with you not 
giving us a name. I mean, I am just--it is not a gotcha 
question. You got a requirement that you pushed out. Someone 
has to be responsible for making decisions on that requirement.
    I am just asking, for my sake and I hope for other Members 
of the committee, who that individual is.
    Mr. Hastings. It would be the chief in consultation with 
the commissioner. We would advise, like I said----
    Mr. Thompson. Is that you?
    Mr. Hastings. No. I am not the chief of Border Patrol. I am 
the chief of operations. I oversee all the operations in field.
    Mr. Thompson. So the chief of Border Patrol would interpret 
the policy we are talking about now, in terms of resources and 
other things?
    Mr. Hastings. When we did not have the resources to fulfill 
that obligation, that is what you are referring to, I believe.
    Mr. Thompson. No. I am talking about the new policy that 
was put in place in response to the death of the children, and 
it said that it is subject to the availability of resources and 
operational requirements. I am just trying to get a sense of 
who is in charge of making those determinations?
    Mr. Hastings. So we--again, it would be--we have to be 
properly resourced to be able to carry this out with our 
contract employees. We have to be properly--we have to have the 
proper funding to do that.
    Operationally, it would be the chief and the commissioner 
that would pass this down in close work with the field 
commanders and the chiefs in the field.
    Mr. Thompson. Madam Chair, I think my problem is, we have 
had a problem, and we have had some proposed solutions, but we 
are not--I am not comfortable with who is responsible for 
carrying it out, to the point that we might end up with another 
situation because the directive is unclear and subject to 
anyone's interpretation. I am just trying to make sure these 
problems don't happen again.
    Mr. Higgins. Will the gentleman yield for 10 seconds?
    Mr. Thompson. Be happy to.
    Mr. Higgins. Thank you, Mr. Chairman, Madam Chair. I 
believe that the witness is attempting to answer the question 
to the best of his ability. You asked him for one name, and the 
answer was that there are many names.
    Chain of command is a multitude of men and women that make 
these decisions on an operational basis based upon what they 
are dealing with in the field at that time, and they report up 
chain and down chain. So the answer is not one name.
    Ultimately, the gentleman referred to at the highest level 
is responsible, but the implementation of a new policy would be 
based upon the work done throughout the chain of command. So it 
is many people, it seems to me.
    Mr. Thompson. Well, you didn't help either with the 
response. So I am still, for clarity's sake, if we have come up 
with a new policy, Madam Chair--and we might just have to 
follow up with some subsequent language requests----
    But I think it is not unreasonable, if a policy is put out 
on an issue this critical, for us not to have those individuals 
who are tasked with the responsibility of making sure they are 
carried out.
    So I yield back.
    Miss Rice. Thank you. The gentleman from Pennsylvania, Mr. 
Joyce, is now recognized.
    Mr. Joyce. Thank you, Mr. Chairman, Madam Chair, Mr. 
Ranking Member.
    Dr. Eastman, in the fiscal year 2019, more than 200 large 
groups of 100 people or more, often of various ages, arrived 
along our Southwest Border. Many of these large groups arrived 
during the height of the flu season, and during months of 
intense high heat.
    Can you give an estimate of how many of these migrants 
likely arrived at the border with a preexisting illness or 
infectious disease in fiscal year 2019?
    Dr. Eastman. On an individual basis, most of the migrants 
we saw overwhelmingly were well, but there were notable cases 
that were not. I will take that back for the record to try to 
get you a more exact number, because I think, you know, we have 
got the data. I don't have a specific number.
    But mostly, overwhelmingly, they were well, but your point 
is exactly accurate, that folks are coming to us after a long 
journey, many of them with the flu or another infectious 
disease that needed to be addressed.
    Mr. Joyce. For those who were traveling hundreds of miles 
to our border, what was the likelihood that they had access to 
medical treatment along their journey?
    Dr. Eastman. Sir, I am not the expert on the care that 
occurs from--prior to them reaching, you know, our Southern 
Border. We have worked collaboratively with the government of 
Mexico to try to, you know, help them do everything they can to 
improve conditions on the Mexican side of the border.
    I know the Department has a number of efforts in Central 
and South America to facilitate other parts of this, but I am 
certainly not the expert on what happens prior to the migrants 
reaching our border.
    Mr. Joyce. Thank you. You mentioned that potential 
infectious diseases have been with these migrants as they 
presented to our border. Can you tell us more about that, 
please?
    Dr. Eastman. Yes, sir. Predominantly, what we have seen is 
seasonal influenza. We have also seen sporadic cases of 
tuberculosis, chickenpox, you know, varicella-zoster virus. We 
have seen some mumps. Knock on wood--I am superstitious and 
hesitant to say this--we have not seen a case of the measles. 
But those are predominantly the diseases that we have seen.
    Mr. Joyce. In contrast to children who have presented with 
grave illnesses, can you tell us how many children that you 
estimate have been saved by the medical attention provided 
under the United States Government's custody?
    Dr. Eastman. Sir, that number is a difficult one to pin 
down directly, but from the beginnings of my work along the 
border, we know that about 10 percent of the migrants that come 
across will end up going into the medical assessment process. 
Again, those are rough very early numbers in the crisis.
    How many were saved directly, I can't pin down. It is hard 
to predict. But there are certainly lives that have been saved 
by the response to this crisis.
    Mr. Joyce. Dr. Eastman, continuing, during this crisis, the 
CBP received medical surge assistance from interagency 
partners, like the United States Coast Guard medical teams, and 
personnel from the United States Public Health Service. How 
important is having additional medical staff on-site at CBP 
facilities?
    Dr. Eastman. Sir, it is important to remember that, you 
know, CBP is a law enforcement organization. We think that 
health care is best provided in health care settings. However, 
by virtue of the unprecedented crisis we faced, we had to mount 
an unprecedented solution.
    That care, you know, assessment and care that was initially 
provided by our first responders, the Coast Guard, by our 
intermediate responders, the Public Health Service, and then 
now subsequently that is placed onto the backs of CBP's 
contracted medical providers, that care is vital. It is vital 
because we have got an unprecedented problem in the system, and 
that is a very unconventional solution. I know of no other law 
enforcement agency that I have ever interacted with or heard of 
that has such a developed health care infrastructure inside it.
    Mr. Joyce. So, in face of this unprecedented crisis, you 
have been able to provide vital health care. Is that the 
message that I am hearing from you, sir?
    Dr. Eastman. Well, I wouldn't say I, I would say we. This 
has been a collaborative interagency approach. At the heat of 
the crisis, I spoke to Admiral Jawa and the chief medical 
officers of the Coast Guard, who have changed hats recently, 
but I spoke to them daily.
    We, the Department, received help from them and many other 
entities to provide what is clearly an unconventional solution 
to this unprecedented problem.
    Miss Rice. We thank you for doing that. Thank you both for 
coming here today, for testifying in front of us.
    I yield the remainder of my time.
    The Chairman. Thank you.
    The gentlewoman from New Mexico, Ms. Torres Small, is now 
recognized for 5 minutes.
    Ms. Torres Small. Thank you, Madam Chair. Thank you, Mr. 
Ranking Member, and thank you, Chief Hastings and Dr. Eastman, 
for being here today.
    In December 2018, Jakelin Caal Maquin and Felipe Gomez 
Alonzo died while in CBP custody after being detained in the 
district that I represent. Subsequently, the DHS Office of 
Inspector General opened an investigation into their deaths. 
Three months later, in this committee hearing room, former 
Secretary Nielsen testified that she directed the CBP's Office 
of Professional Responsibility and the inspector general to 
work as quickly as possible to complete these investigations.
    Then in May 2019, my colleagues and I, again, urged the 
Department and the inspector general to complete the 
investigations in a timely manner. The OIG responded to our 
request saying it was working to complete the investigations as 
expeditiously as possible. But it was only last month, nearly a 
year later after these tragic deaths that the investigations 
were completed and provided to Congress. Even more concerning, 
the OIG limited its investigation scope to only determine 
whether there was malfeasance by personnel and did not consider 
whether CBP's policies and procedures are adequate to prevent 
migrant child deaths.
    As I have said from the beginning, the reason for these 
investigations is not to punish people; it is to keep this from 
happening again. It is to make sure that we have the protocols 
in place in case we are faced with this challenge again.
    It is the committee's understanding that the investigations 
did not even interview medical professionals outside of the 
offices of the medical examiner and the Department. This is 
unacceptable, especially given the significant number of family 
units and unaccompanied children that traveled to the Southwest 
Border last year.
    Now, Chief Hastings, I deeply appreciate the work that the 
men and women of Border Patrol do every single day and have 
done in the past year to mitigate the situation we saw at the 
Southern Border, and I want to find out whether the policies 
and procedures of the agency are setting our agents up for 
success to keep migrant children safe.
    So, Chief Hastings, has CBP received the full reports of 
these investigations?
    Mr. Hastings. Ma'am, I have not seen a full report. I have 
seen an abbreviated report from our Office of Professional 
Responsibility.
    Ms. Torres Small. Thank you, Chief Hastings. That is deeply 
concerning. The committee was told by the OIG that CBP has 
received the reports. So that is something we will follow up 
on.
    Mr. Hastings. I have not personally. I have not.
    Ms. Torres Small. From the information that you received, 
have you identified specific lessons learned that CBP took from 
the reports and have recommended protocol changes to enforce 
them?
    Mr. Hastings. So I think one of the lessons learned is we 
needed a standardized health form across the board for all of 
CBP. One of the things that we saw, there were multiple forms 
being used in the field throughout this entire year. That is 
now standardized.
    Ms. Torres Small. And you have the updated form?
    Mr. Hastings. Yes, ma'am.
    Ms. Torres Small. Any other lessons?
    Mr. Hastings. That is one of the bigger ones. You visited 
the location where we lost Jakelin. You are well aware of the 
remoteness and the amount of time it would take to get even our 
own agent out of that area, so I think you are very well-versed 
with the issues of remoteness and rugged terrain that we had 
out there as well as transportation. We have also added a large 
transportation contract, buses and many other things to help 
get folks from the border.
    Ms. Torres Small. Thank you. That is a great lesson 
learned, and it is certainly something I saw, so I am pleased 
that Border Patrol is addressing that. Do you have multiple 
buses now under contract?
    Mr. Hastings. We do, under contract and our own personal 
that we have purchased, vans and buses, as I mentioned earlier.
    Ms. Torres Small. What about pediatric equipment? One of 
the lessons learned for me with Jakelin's passing is not having 
the appropriate cuff to take her blood pressure. Is there 
pediatric equipment across the board along the border that is 
available, if necessary?
    Mr. Hastings. So we dedicated a large portion of the 
supplemental funding to our EMTs. We have over 1,500 EMTs in 
the field, and we have since updated them with equipment and 
made sure that they have everything to meet their daily needs.
    Ms. Torres Small. That is also part of protocol, so it is 
required. If there is a deficiency, an agent has the ability to 
alert, to fill that deficiency?
    Mr. Hastings. That is correct.
    Ms. Torres Small. Thank you. I want to shift now to 
preventing the spread of infectious diseases in CBP stations.
    Chief Hastings, what are the protocols that CBP has in 
place to protect both migrants and CBP personnel from the 
spread of infectious diseases, such as the flu inside Border 
Patrol stations, processing centers, and ports of entry?
    Mr. Hastings. So, with our contract personnel that we have 
in all 9 Southwest Borders, and about 40 locations, put those 
personnel based upon the highest vulnerable populations, 
highest flow that we were seeing, as well as the least amount 
of medical assistance in the general area, that is how we 
decided where to put them. They are fully trained, and are able 
to care and provide any type of antiviral flu and do flu 
testing. They are able to do that. They are able to do acute 
care and other things that aren't referred to secondary care.
    Ms. Torres Small. You have written protocols that support 
that need? Just yes or no, because I am out of time.
    Dr. Eastman. Yes, ma'am, absolutely we do.
    Ms. Torres Small. If you can supply those to supplement the 
record, I would appreciate it.
    Dr. Eastman. We will work to get that to you, yes.
    Ms. Torres Small. Thank you.
    My time is expired. Thank you.
    Miss Rice. Thank you. We now recognize the gentleman from 
Mississippi, Mr. Guest.
    Mr. Guest. Thank you, Ms. Chairman.
    Chief Hastings, I want to speak to you on the overall 
immigration crisis that we have and are currently experiencing 
along our Southwest Border. I note on page 7 of your written 
testimony, you referred to fundamental flaws in the immigration 
system.
    You go on to say: ``CBP has pleaded with Congress to 
address the layers of existing law and judicial systems that 
adversely impact our ability to effectively manage our 
immigration system. There are three key gaps in our legal 
framework that Congress has yet to address.'' And you list 
there the Flores settlement, the TVPRA, and the asylum 
assertion.
    Could you just take a few moments to expand on each of 
these factors that you have listed there in your report and how 
it impacts your Department's ability to secure our border?
    Mr. Hastings. So we need the ability--under Flores, we need 
the ability to be able to hold in a setting that provides fair 
and expeditious immigration proceedings. Flores is a major 
issue for us, completing that under the current 20-day process 
that is required.
    When we released over 149,000 families, when we were 
interviewing these individuals, they literally told us that we 
were told bring a child and we will be released. That is what 
is encouraging this large flow that we continue to see. We 
believe that they should be housed in an FRC together with all 
of the adequate things that have been provided, medical, 
dental, pharmacy, education, all the many other things.
    The double standard for noncontiguous UACs, being able to 
return a UAC to Guatemala, Honduras, other countries like we 
are currently with Mexico and Canada, that would assist with 
the large number of UACs that we are seeing cross our borders 
today, again, a vulnerable population.
    Last, tightening the asylum bar, the low asylum bar for 
credible fear, as we see the massive backlog of over 1 million 
cases right now.
    Mr. Guest. Would you agree, Chief, that if Congress were to 
address these 3 issues that you have set forth in your report, 
that it would help stem the flow of illegal immigration that we 
have recently seen across our Southwest Border?
    Mr. Hastings. Yes, we believe it absolutely would.
    Mr. Guest. Chief, you were asked a question earlier about 
moving, or the shifting of money that was designated for the 
Department of Defense to our Southwest Border for the purpose 
of border wall construction.
    Do you feel like that the construction of the border wall 
system has improved your agency's ability to protect our 
homeland?
    Mr. Hastings. Absolutely. So, again, a border wall system 
is more than just a wall: It comes with technology, it comes 
with roads, gives us situational awareness, gives us impedance 
and denial and time to respond. I have seen it work personally 
in the many areas I have been in the field. I have seen what it 
does for us, and I strongly support it.
    Mr. Guest. Thank you. Just last, Chief, is there any other 
recommendations that you would make to this committee as to how 
we can better help your Department, again, to secure our 
homeland, and then those individuals that are within our 
custody that we can do our best to make sure that they are 
protected and receive the care that they need?
    Mr. Hastings. I just would request if we are not coming to 
an agreement on some of the recommendations we gave that we 
continue to fund HHS, so we can move those UACs through the 
cycle and get them into the proper environment for care.
    I would also request assistance with ICE funding as well 
for single adult bed space, because that is another demographic 
that we see backing up in our facilities at times. ICE needs 
proper funding for single adult bed space.
    Mr. Guest. Chief Hastings, thank you for your service to 
our Nation.
    Madam Chairman, I yield back.
    Miss Rice. Thank you.
    I now recognize the gentlewoman from New York, Ms. Clarke.
    Ms. Clarke. Thank you, Madam Chair, and I thank our 
witnesses for testifying here before us today.
    Chief Hastings, last year, you testified before the 
Judiciary Committee, and my colleague, Congressman Lieu, asked 
you whether a 3-year-old girl could pose a criminal or National 
security threat, and you responded, ``I don't know.'' I think 
attitude goes a long way in addressing the multitude of issues 
that you have before you, but specifically, preventing child 
deaths in custody. I believe that we shouldn't be surprised 
when children don't receive medical attention they need, 
particularly when we don't know whether a 3-year-old can pose a 
criminal or National security threat.
    Having said that, last fall, I introduced H.R. 3777. It is 
the National Commission to Investigate the Treatment of Migrant 
Families and Children Act, which would create an independent 
commission to study issues like family separation, as well as 
the death of children in CBP custody.
    But short of passing my legislation, we have to rely on the 
Inspector General to get to the bottom of these matters. In a 
report recently released by DHS OIG, it states that a Border 
Patrol supervisor had to pay out of their own pocket for an 
over-the-counter medication for 8-year-old Felipe, because 
Border Patrol's insurance did not cover it. In addition, the 
CBP EMT was unable to take a blood pressure of Jakelin, age 7, 
because they lacked a pediatric cuff.
    What steps has CBP taken to ensure access to basic medical 
necessities and equipment across the Southwest Border?
    Mr. Hastings. Ma'am, thank you for the question. So we did, 
indeed, see an issue or a problem with Border Patrol or CBP 
OFO, being able to fund nonprescriptions, over-the-counter 
prescriptions. We have since fixed that. We have a contract 
through ICE to be able to purchase any needed over-the-counter 
remedy that is prescribed. So we have that. Then additionally, 
as I mentioned earlier, thank you for the supplemental funding 
that we were able to provide much-needed equipment for our EMTs 
out in the field. So those have been fixed.
    Ms. Clarke. Wonderful. I appreciate that. But, you know, in 
the decade prior to 2018, there was not one single child death 
in custody. So I am a bit concerned that, you know, there just 
seems to be a callousness taking place.
    I am glad that we are focused on this. However, if we are 
able to shift funding for a border wall, we should be able to 
shift funding to save human lives, particularly the lives of 
children. We need to understand what went wrong in 2018 and 
2019.
    If a CBP official failed to take reasonable steps to 
prevent the death of a child, what kind of disciplinary 
measures do you think would be appropriate?
    Mr. Hastings. Ma'am, I haven't seen anything----
    Ms. Clarke. I am just asking hypothetically.
    Mr. Hastings. I would have to see all the--everything that 
went into the report. I would have to see the specifics. But if 
it was negligible, we would certainly take immediate action.
    Ms. Clarke. That is good to know. Has any CBP official 
faced accountability for the death of children in custody?
    Mr. Hastings. No, ma'am. There has been no negative 
findings of malfeasance.
    Ms. Clarke. OK. Fine, no problem. How does CBP determine 
what expenses qualify as consumables or medical care?
    Mr. Hastings. How do we determine--I am sorry, I didn't 
hear you.
    Ms. Clarke. How does CBP determine what expenses qualify as 
consumables or medical care?
    Dr. Eastman. Ma'am, let me help Chief Hastings with that. 
We use the MedPar system, which is actually administered 
through ICE. It is the DHS system that pays for care for 
migrants in our custody.
    In addition to that----
    Ms. Clarke. Could you hold on 1 second. Could you just 
provide us examples of the types of projects or activities for 
which consumables and medical care funds have been obligated or 
expended since the supplemental was enacted?
    Dr. Eastman. Absolutely, ma'am. Again, thank you for the 
supplemental funding. In response to that, at our more than 40 
locations that now have contracted medical support, they have a 
standardized formulary of medications and equipment that is 
used to care for the migrants in custody.
    So that is a clear example of how money has been 
appropriated from the supplemental to help further the care of 
children in our custody.
    Ms. Clarke. How is that replenished? How do the 
subcontractors----
    Dr. Eastman. There is a--the contractor--I am not an expert 
in their supply chain management, ma'am, but they have a system 
that replenishes those. Again, the supplemental pays for that.
    Ms. Clarke. Very well.
    Madam Chair, I yield back the balance of my time.
    Miss Rice. I now recognize the gentleman from California, 
Mr. Correa.
    Mr. Correa. Thank you, Madam Chair. Gentlemen, thank you 
for being here today.
    I am a Member of both this committee as well as the House 
Judiciary Committee, where we have had numerous oversight 
hearings concerning the dangerous detention facilities' 
inadequate standards of care for migrants, including young 
children.
    Like my colleagues here, I am troubled by the multiple 
reports of overcrowded facilities. I have actually toured some 
of those facilities. There is a general agreement that CBP, 
your facilities are not meant to handle the influx of children 
and families that we have seen over the last 2 years.
    So my question is, what contingency plans does the 
Department have in place to ensure the safety of those within 
your custody?
    Mr. Hastings. So, sir, there are a couple things I would 
add. As I mentioned in my opening----
    Mr. Correa. Yes, sir.
    Mr. Hastings [continuing]. We have 6 soft-sided facilities 
with complete wraparound, medical/food services, shower, pretty 
much all amenities. Additionally, we have planned long-term to 
put central processing centers up in our busiest areas, 
primarily the Rio Grande Valley, the El Paso sector, and the 
Yuma sector. Those are modular buildings that are being 
completed now or will be completed and started in the spring 
for Yuma, but they are actually being completed right now for 
El Paso.
    So, in other words, having those facilities and those 
wraparound services is something that we are planning for now, 
and we have a long-term solution.
    Mr. Correa. Mr. Hastings, I know you are chief of 
operations, but if I can pull back a little bit, when General 
Kelly was Secretary of Homeland Security, here in this 
committee, he testified--and I am going to paraphrase him--that 
border security goes beyond our border. I am thinking to 
myself, you don't wake up one morning and say, Oh, my gosh, 
look at all those folks at our doorstep. I have to imagine you 
coordinate with other agencies and Federal Government with 
other governments and begin to see that flow of refugees, that 
flow of migrants moving.
    So, my thought is, how do you prepare, or are you preparing 
for those ensuing waves of refugees that are coming not only 
from south of the border, not only from Central America, but 
other parts of the world? I don't see this as a one instant 
phenomena but, rather, as the world areas of conflict continue 
to escalate, as you have folks in harm's way, this is going to 
continue to be a challenge, migration, refugees from around the 
world. Are you doing anything to anticipate these kinds of 
situations, near future, long-term?
    Mr. Hastings. Yes. So we are embedded with multiple 
different governments, work closely with the Northern Triangle 
and have agents on the ground down there working with them now. 
Also work very strongly with our Mexican law enforcement 
partners as well on a day-to-day basis, the chiefs in the 
field.
    Mr. Correa. Let me ask you----
    Dr. Eastman. Sir, may I just add something?
    Mr. Correa. Yes. Go ahead, Mr. Eastman.
    Dr. Eastman. In addition to what the Border Patrol does, 
the National Biosurveillance Information Center, which is a 
CWMD entity, you know, with the chief medical officer, works 
continuously with our partners, not just Mexico, but our 
partners south of the border and world-wide, to identify and 
begin to recognize and counter, you know, health-based threats 
to the United States. That is part of the package.
    Mr. Correa. So a little while ago, my colleagues talked 
about the flu vaccinations. Essentially, your response, I 
believe--and you can confirm this or not--operational 
challenges have prevented you from really vaccinating a lot of 
those individuals that need it, yes/no?
    Dr. Eastman. No, sir, that is definitely not my response. 
Just to be clear----
    Mr. Correa. What is your response, sir?
    Dr. Eastman. Our approach is comprehensive. There are 
migrants who have come into United States custody that have 
gotten vaccinations, including and up to this entire CDC 
catchup protocol at HHS. We have administered more than 60,000 
independent vaccines, predominantly in the----
    Mr. Correa. So you are moving in that direction. This 
discussion we have had of independent doctors volunteering to 
get you up to speed to get there, that is not a factor? You 
couldn't use them or you are doing fine on your own?
    Dr. Eastman. Medical volunteers is a challenge to medical 
organizations, not just ours. Because of the difficulties in 
utilizing volunteers and the difficulties with licensure and 
administration, we have actually encouraged them to volunteer 
in the local Government shelters. CBP has some--and both CBP 
and our office have done work to try to vector those volunteers 
into places that can utilize them more easily than we can.
    Mr. Correa. I am running out of time, Madam Chair, but I 
would like to follow up on this issue of the challenges of 
having licensed doctors integrated into your system of actually 
being able to vaccinate some of these children and deliver 
medical services that maybe CBP is not able to deliver because 
of, you know, limited capacity.
    Finally, Madam Chair, if I can get 30 seconds. Dr. Eastman, 
you made a statement that Mexico is trying to improve, on their 
side of the Mexican border, some health care. Are we 
coordinating at all with the Mexican authorities, in terms of 
making sure that health care--disease does not respect a border 
but, rather, it addresses both sides. So are we addressing both 
sides of the border?
    Dr. Eastman. Absolutely, sir. We made a visit. The chief 
medical officer made a visit to counterparts in Mexico City 
last year. We continue the dialog and we continue to work 
together to make the situation as good as possible.
    Mr. Correa. Finally, Madam Chair, if I can, I would like to 
have written testimony on that later on for review.
    Dr. Eastman. We will take the questions for the record.
    Mr. Correa. Thank you very much. Thank you, gentlemen, for 
being here today.
    Miss Rice. Thank you, Mr. Correa.
    I now recognize the gentleman from Texas, Mr. Green.
    Mr. Green. Thank you, Madam Chair. I greatly appreciate the 
opportunity. I thank the witnesses for appearing as well.
    To both of you, do you take the President seriously when he 
makes the comments?
    Mr. Hastings. Sir, I don't know what comments you are 
referring to. I generally----
    Mr. Green. He is our President. You hear his comments.
    Mr. Hastings. When we receive--I don't know what you are 
referring to.
    Mr. Green. Well, about the wall.
    Mr. Hastings. Yes, I think the wall works, from my 
experience, from what I have seen it do in the field first-
hand.
    Mr. Green. So you take him seriously then?
    Mr. Hastings. On the wall.
    Mr. Green. On the wall.
    Mr. Hastings. I think the wall works.
    Mr. Green. So you think Mexico should pay for the wall?
    Mr. Hastings. Sir, all I can tell you is the wall works.
    Mr. Green. You take the President seriously, don't you?
    Mr. Hastings. I can just tell you that I know the wall 
works.
    Mr. Green. The President said Mexico should pay for the 
wall.
    Mr. Hastings. I am not involved in funding the wall. I am 
just telling you that the wall works.
    Mr. Green. Well, you take the President seriously. Let's go 
on. How many lives would the wall have saved?
    Mr. Hastings. I don't know the answer to that question, 
sir. That would be speculative.
    Mr. Green. Well, let me ask you this: Are asylees 
criminals?
    Mr. Hastings. Are the what? I am sorry, sir.
    Mr. Green. Are the people who seek asylum criminals?
    Mr. Hastings. People who cross the border illegally----
    Mr. Green. I didn't ask you about people crossing the 
border illegally. You know what an asylee is, do you not?
    Mr. Hastings. We have people----
    Mr. Green. Do you know the definition of asylee?
    Mr. Hastings. I do.
    Mr. Green. Then my question is, are asylees, asylees, 
people who are seeking asylum, asylees, are they criminals?
    Mr. Hastings. We are asking them to go to a port of entry 
to receive----
    Mr. Green. That has little to do with my question, sir. My 
question is, are they criminals? Why are you evading? Why will 
you not state what you know to be the truth? Why are you doing 
this?
    Mr. Hastings. If they cross the border illegally, they have 
committed a crime.
    Mr. Green. Are asylees, people seeking asylum criminals?
    Mr. Hastings. Again, if they cross the border illegally, it 
is a crime.
    Mr. Green. Where do you find this in the law to support 
your position that people who are seeking asylum are criminals? 
Are the babies criminals? This is why you treat them the way 
you treat them, you perceive them as criminals? Babies aren't 
criminals. They have no malice aforethought.
    What would you recommend we do to prevent future deaths?
    Mr. Hastings. As I have discussed, sir, we are taking a lot 
of those actions and have been taking those actions for quite 
some time. I think we are taking the right steps now to prevent 
further deaths. It will be difficult, as we have explained, to 
say we are going to prevent every death.
    The people that we encounter on the border, many of whom 
have traveled over 2,000 miles or more, some have never seen 
health care. Some have never had treatment. Some may not have 
eaten or drink anything. But we are running into them, 
obviously, at many times in their worst condition and worst-
case scenario, and we are doing everything we can to get them 
immediate treatment and aid when that is the case.
    Mr. Green. Again, what can we do, meaning Congress?
    Mr. Hastings. As I mentioned earlier, I think taking some 
of the actions for the double standards for noncontiguous UACs, 
that is one; to quit drawing UACs up to our border because we 
are unable to return them unless it is Mexico or Canada. Then, 
I think, as I mentioned earlier, the Flores fix, being able to 
hold everyone together, the entire family in the proper setting 
while they go through their expeditious hearing.
    Mr. Green. For edification purposes, UAC I find to be a 
pejorative.
    Mr. Hastings. It is in the law in TVPRA.
    Mr. Green. I understand, but I still find it to be a 
pejorative. These are children. UACs.
    Madam Chair, I am going to yield back the balance of my 
time. Thank you.
    The Chairman. Thank you.
    I now recognize the gentlewoman from Illinois, Ms. 
Underwood.
    Ms. Underwood. Thank you, Madam Chair, for holding this 
hearing to continue this committee's important oversight work 
on the humanitarian situation at our Southern Border.
    During my 3 oversight trips to the border last year, I saw 
and heard first-hand about the need for resources to improve 
medical record keeping. As a nurse, I know how important clear 
record keeping is when it comes to both patient outcomes and 
ensuring health care providers can most effectively do their 
jobs.
    In response to what I saw at the border, I am so proud that 
we based bipartisan legislation last year to provide CBP with 
an electronic health record. Just a few days ago, President 
Trump signed an appropriations package that includes $30 
million in dedicated funding for that electronic health record.
    Dr. Eastman, as a physician, can you tell us more about why 
EHRs are so important to your work at the border?
    Dr. Eastman. Yes, ma'am. Thank you very much. Again, thank 
you for passing the funding we need. EHRs serve a very specific 
function. They not only allow us to effectively document the 
care that is provided, but they also allow us easy access to 
the data to do things like quality assurance. It ensures that 
we are able to measure the care that we are providing. It 
ensures that we are able to assess the quality of that care, 
and it ensures we are able to learn lessons from that.
    In addition, another system that we intend to develop will 
improve our ability to conduct disease and health disease 
surveillance, using artificial intelligence techniques that 
will trigger the presence potentially of an infectious disease 
before a human being could pick it up.
    Ms. Underwood. Again, from your perspective as a medical 
provider, how do EHRs help providers better communicate about 
patient care?
    Dr. Eastman. Yes, ma'am. So electronic health records, you 
know, they are a complicated topic, but they allow us to 
describe the care that we have provided from the point of 
apprehension to the point of release from our custody, not only 
internally, they don't only help us communicate internally 
across multiple settings, but they also allow us to communicate 
to external partners.
    One of the things that I think is important in this hearing 
to mention is that the system that is provided not only 
protects migrants, the system that has been put together. It 
also protects the integrity of the health care systems in local 
communities, that were we not absorbing some of the blow, some 
of those local community health care systems would be overrun 
by the amount of care that is required.
    Ms. Underwood. ICE and ORR already have electronic health 
records, and we know that DHS has already begun the process of 
building one for CBP. Along with the dedicated funding, 
Congress directed DHS to come up with an implementation plan 
for this EHR within 90 days.
    So, Dr. Eastman, can you give us an update on where DHS is 
in this process, and what specific actions have been taken so 
far?
    Dr. Eastman. Yes, ma'am, I can. Right now we are in the 
process, sort-of the first phase of this, which is to identify 
some immediate solutions that can integrate the existing 
technology that is out there. That work is on-going 
immediately. We are also working to plan for the long term.
    We have hired a chief medical and informatics officer who 
we think has the talent and the expertise to help us build a 
system that will not only create an effective customized 
solution for us, but will harness our ability to help our 
operators do their job more effectively. Everything we do has 
to take into account the effects that it has on the individual 
operator who is doing the job at the border, at processing 
centers, and in ports of entry along the border.
    Ms. Underwood. So then what is next? What are the next 
phases in the implementation of this EHR?
    Dr. Eastman. The next phase is we work our fingers to the 
bone to try to get this plan together to come back to brief you 
in 90 days as to where we are headed.
    Ms. Underwood. Excellent. So you mentioned you hired this 
informatics officer.
    Dr. Eastman. Yes, ma'am.
    Ms. Underwood. What date were they hired?
    Dr. Eastman. I will have to take the specifics as a 
question, but he has been around 5 or 6 months.
    Ms. Underwood. OK. In your medical opinion, why is it so 
important to ensure CBP's EHR is interoperable with those used 
by ORR and other DHS components?
    Dr. Eastman. Thank you, ma'am. Again, we want to make sure 
that we are able to provide a seamless picture of all the care 
that is provided from the point of apprehension to the point of 
discharge. It is important for a provider at ICE to know what 
happened upstream of that when the person is--for the care that 
is provided under Border Patrol.
    Now, that being said, we are working hand-in-hand with the 
Border Patrol to make sure that the solutions that we craft 
together not only accomplish the goals of the EHR, but also are 
user-friendly and don't add to the load, the processing load, 
the time that the operators have to put forth to take care of 
the migrants in our custody.
    Ms. Underwood. Well, I appreciate those operational 
benefits, but the other benefit of an electronic health record 
is obviously saving lives. We are not missing information. We 
are not losing patients, and we are not missing opportunities 
to identify infectious diseases or changes in current status.
    We are heading into another flu season that is projected to 
be severe. Dr. Eastman, you noted in your testimony that you 
are working with CDC, ASPR, and other public health agencies to 
improve CBP's response. So what specific steps has DHS taken to 
strengthen its ability to respond to flu outbreaks at the 
border during this current flu season, which we know has been 
particularly harmful and deadly for children throughout the 
United States?
    Dr. Eastman. No question, this flu season, according to the 
CDC and other experts, appears that it may be rough. We have 
worked hand-in-hand with CBP to help craft enhanced flu control 
measures that were crafted with input from experts from the CDC 
when they performed a 3-phase assessment along the border, or 
very early on in the crisis.
    In addition, we have helped provide CBP with the ability to 
rapidly diagnose and treat the flu in our facilities at CBP. 
Again, that capability is present now in over 40 facilities 
along the Southwest Border, and I would challenge folks to find 
another law enforcement agency that diagnoses and treats the 
flu on the law enforcement side, not the custodial side.
    Ms. Underwood. Madam Chair, if I may, just one last follow-
up. What date? Was it new for this flu season that that rapid 
capability has been deployed, because it is not our committee's 
understanding that that capability was present last year. So 
can you----
    Dr. Eastman. That has been developing all along through the 
course of 2019. So as the contract support has been developing, 
that flu capability has been put into place, you know, 
continuously over the year.
    Ms. Underwood. Thank you so much, Madam Chair, and to our 
witnesses for appearing today.
    I yield back.
    Miss Rice. Thank you. I ask unanimous consent that 
Representative Jackson Lee be permitted to sit and question the 
witnesses. Without objection.
    I now recognize the gentlelady from Texas, Ms. Jackson Lee, 
for 5 minutes.
    Ms. Jackson Lee. Madam Chair and Ranking Member, thank you 
very much for this important hearing, and let me thank the 
witnesses for being present today. I think it is very 
important.
    Mr. Hastings, let me just be clear that you handle law 
enforcement operations covering both U.S. Border Patrol and 
Customs and Border Protection. Is that----
    Mr. Hastings. No, ma'am, just Border Patrol.
    Ms. Jackson Lee. All right. So this is a light typo. It has 
you in both positions and you are not. I just wanted to clarify 
that for the record.
    Mr. Hastings. Just Border Patrol, ma'am.
    Ms. Jackson Lee. All right. Let me just for the record take 
note of the fact that a number of children had died in 2018, 
that, in fact, no child had died in CBP custody for the entire 
decade before 2018. We lost, in particular, Jakelin, Felipe, 
and a number of children that proceeded to get medical care and 
who were detained and placed in CBP, and, ultimately, 4 migrant 
children passed away while in or shortly after being released 
from Federal custody.
    Both of you, whether you have children or not, or are 
around children or around relatives, acknowledge that the death 
of any child is a crisis and tragic. Mr. Hastings?
    Mr. Hastings. Ma'am, as I have said earlier, I am a father 
and a grandfather, and it is a tragedy.
    Ms. Jackson Lee. Dr. Eastman.
    Dr. Eastman. Ma'am, I am a parent, and the death of any 
child is devastating. But I think it is important to not only 
note that it is not just devastating to the parents, but I was 
in our facility in Lordsburg and I went and sought our 
personnel who tried valiantly to save Jakelin, and, despite 
their best efforts, they weren't successful, that is brutal on 
the caregivers as well.
    Ms. Jackson Lee. Well, you go right to my point, that dying 
in the custody of individuals who are basically law 
enforcement, but seeing when they are basically committed to 
defend and protect alongside of the immigration 
responsibilities, their chief responsibilities, that that is 
both a crisis and tragic for them to have died in Federal 
custody or having just been released. Is that your opinion?
    Dr. Eastman. Ma'am, the death of any child, any person in 
law enforcement custody is tragic. As you know, you know, law 
enforcement officers across this country take very seriously 
their responsibility that when we place our handcuffs on 
someone, we know we have an ethical, moral, and legal duty to 
care for them as well.
    Ms. Jackson Lee. A child is particularly vulnerable. I 
assume, Mr. Hastings, you agree with that as well, that any 
death in Federal custody of a child is tragic and on the brink 
of a crisis?
    Mr. Hastings. It is tragic, and yes.
    Ms. Jackson Lee. The idea of those line officers I call, 
and I have been and seen the efforts that they have made during 
some very difficult times, buying diapers, getting formula. I 
think that should be put on the record.
    But I think the key point--and I appreciate some of the 
many great steps that Congresswoman Underwood has made. We 
traveled together to the border, and several times thereafter. 
But my question would be, is it time now, as you present 
reports pursuant to the legislation passed, to stand up a very 
effective parallel medical system, based on the present 
policies of this administration, meaning that asylum is being 
denied. They are not being able to access asylum in the way 
that they should. There are migrant camps just on the border in 
Mexico where disease is rampant, or to be rampant, and so that 
means that when they come over, they may be sick.
    Do we have an effective medical system that is parallel to 
your law enforcement system that can do additional things 
besides, you know, the records that are being done and some of 
the other aspects of reporting, an effective almost semi-quasi-
health center for these individuals that are coming in?
    Dr. Eastman. You want me to start?
    Ma'am, I think we have to be very cautious that we 
confabulate a health care facility with a law enforcement 
facility. We firmly believe at DHS, and it is my personal 
belief as a physician that health care is best provided in a 
health care setting.
    So what we ought to continue to do is to facilitate the 
movement of people through our system to the best place to care 
for them. For children, that is at HHS. For single adults, that 
is in ICE custody. But we have to continue to harden the system 
for the times that we face unprecedented demand for care, and I 
believe that is exactly what we are doing right now.
    Ms. Jackson Lee. Mr. Hastings--Madam Chair, can I just have 
a quick follow-up?
    Mr. Hastings, your point on this parallel health system?
    Mr. Hastings. No, I would agree completely. We want, the 
Border Patrol and CBP wants to see UACs, vulnerable populations 
out of our custody as quickly as possible, that is what we want 
to see, through the proper places where they can receive the 
needed care.
    Ms. Jackson Lee. Well, let me ask this quick question, 
because it might have been misinterpreted that I wanted a 
hospital established, and that is not the case.
    First of all, the children were not out of your custody as 
soon as possible. We have some challenges now with a system 
that I helped set up, which is the HHS system, so we will put 
that aside.
    My point is, is that there be some process that is more 
substantial than the law enforcement that can do immediate care 
besides putting someone in a police car and trying to rush them 
to the next or the nearest hospital.
    The question is, do we have an effective emergency response 
on-site that can deal with some of these crises, such as one of 
the young men, a 16-year-old was found nonresponsive, and there 
was not much to deal with his nonresponsiveness. So quickly to 
Mr. Hastings and Dr. Eastman.
    Mr. Hastings. To answer your question, we are certainly 
going in the right direction. As I alluded to earlier, we went 
from 3 sectors covered by a medical personnel contract, medical 
support personnel, to now 9. They are in our busiest locations 
where we need them. We are constantly monitoring to make sure 
we have them where we need them, and will continue to do so. On 
top of that, we have got 1,500 EMTs that can provide support 
and do provide support. I believe that we are taking all the 
right steps that we need to.
    Ms. Jackson Lee. Dr. Eastman.
    Dr. Eastman. Likewise, ma'am. Our strategy is to provide 
the right care to the right person at the right time. I believe 
we are taking the right steps currently to do that. We, you 
know, reserve--and certainly I reserve the right to reassess 
this system continuously as conditions change. But it is our 
belief at DHS and it is my belief personally that we are moving 
in the right direction.
    Ms. Jackson Lee. I look forward to that report coming in so 
I can understand how the system is working.
    Dr. Eastman. Yes, ma'am.
    Ms. Jackson Lee. I thank the Chair for her indulgence, and 
I yield back.
    Miss Rice. Thank you.
    The Chair now recognizes the gentlelady from Texas, Ms. 
Garcia.
    Ms. Garcia. Thank you, Madam Chair, and thank you for your 
vote waiving me in to sit on this committee. Thank you to the 
witnesses.
    I have been following this issue for a great number of 
years, beginning with the first influx when I was the chair of 
the Senate Hispanic Caucus in Texas. I visited probably about 
10 facilities, either under the jurisdiction of CBP or ORR. I 
have seen the differences in a lot of the medical protocols, a 
lot of the medical care that is provided in all those different 
facilities.
    I must say that I have never found them to be adequate. I 
have never certainly found them to be a clinic or a hospital. 
To just borrow the words of my colleague to the right, 
Congresswoman Lee, no one is asking for a hospital.
    Dr. Eastman, I know you have made reference to you can't 
put a clinic in every single, I think you used the word 
substation or police department facility. I don't think we are 
asking for that either. But I think what we do want is what 
many of us have been talking about is the right protocols, the 
right screening, to make sure we get on it as quickly as 
possible.
    I was completely stunned at the lack of any kind of 
screening that was done in the New Mexico facility. I know my 
colleague Torres Small talked about the one in her district. 
That is the one I visited when Jakelin died. I mean, they 
literally took a microwave off a table to let her lay there, 
because there was nowhere else to put her. This was where they 
were waiting until they could get the transportation and the 
bus to go on to the facility where perhaps she could get more 
treatment. Then, of course, she ended up going to the hospital.
    Are you telling me that under today's protocols that has 
now changed? I know you said you visited Lordsburg also.
    Dr. Eastman. Congresswoman, I am telling you that we do the 
absolute best we can under the circumstances we are provided. 
In my opening statement, I told this committee and America that 
when we were faced with unprecedented demand for care to large 
groups----
    Ms. Garcia. But, sir, the question is, has that changed in 
that facility now? They won't have to remove the microwave to 
just put her on that table?
    Dr. Eastman. Ma'am, the system----
    Ms. Garcia. I mean, they will have a screening method so 
that they can detect it sooner to get her on some bus or 
somewhere that is----
    Mr. Hastings. Ma'am, if I can take that one. So a lot of 
our areas have changed. The soft-sided facilities that we have 
placed, put in place in many of those areas, including El Paso. 
El Paso has a soft-side, soon to have a modular facility as 
well, that will give some increased capability and some 
increased space that we need. But still, many of our stations 
in many of our different locations, they haven't changed. They 
were built for a completely different demographic. They have 
not changed. We have added as much as we can in those locations 
in the way of food, health care products, those types of 
things, but, I mean, they were not built to house for long 
periods of time at all.
    Ms. Garcia. Well, I appreciate your answering, but I still 
would like Dr. Eastman to.
    Dr. Eastman. Just to be clear, just to be clear, the system 
that is in place today, by virtue of the growth and the hard 
work of a lot of people across the Government and CBP bears 
little resemblance to what it looked like at Christmastime 
2018.
    Ms. Garcia. But I am asking specifically about some of 
these remote stations, because many people are using that since 
a lot of the port of entries that they were used to using. 
They, frankly, aren't even allowed to get even close enough to 
make entry. They are using other more remote areas.
    So the question is, has that one now been improved? If 
someone presented themselves with high fever, you know, chills, 
the typical flu symptoms----
    Dr. Eastman. So I will give you two tangible examples.
    Ms. Garcia [continuing]. Would that person be put on the 
same microwave table?
    Dr. Eastman. I will give 2 tangible answers to answer your 
question. First of all, the expansion of contracted health care 
allows the Border Patrol to use their 1,500 EMTs in the role 
they were designed, which was not to be screening personnel 
inside facilities, but to be outside in the field caring for 
our personnel and anyone else they encountered.
    The second thing----
    Ms. Garcia. So that is a no?
    Dr. Eastman. Ma'am, the second thing is that there is now 
contracted support in multiple locations along the border, and 
we will take for the record to get you back the exact details 
of where that contracted support exists today.
    Ms. Garcia. So along the entire border of Texas now, there 
is some screening protocols to ensure that this would never 
happen again?
    Dr. Eastman. Yes, ma'am. The tiered approach that I 
described earlier in this hearing is in place all along the 
Southwest Border.
    Ms. Garcia. All right. What about the medical assessment, 
or screening, are there any in place for the folks that are 
coming through in the Migration Protection Protocols, the 
Remain in Mexico program? Are they screened at all? Because I 
am hearing that there is a lot of people on the other side of 
the border that have been turned away under this new program 
that are very, very sick.
    Dr. Eastman. The care that occurs south of the United 
States' Southern Border is outside my scope, and I am not sure 
what is being done on the Mexican side of the border.
    Mr. Hastings. But, ma'am, so I would add they will go 
through medical clearance prior to us putting them into MPP and 
returning them. So they will go through this same process prior 
to being returned under MPP.
    Additionally, there is a map up there that kind-of outlines 
where we are today as far as those 40 different locations that 
we have contract medical service. I realize we are looking at a 
bunch of dots on a map, but the fact is over 300 individuals on 
duty at any given time providing that additional medical 
support through our agents in the field. That map, we can't 
see----
    Ms. Garcia. So you are telling me that although they are 
being turned away to go back to Mexico, that you do screen 
them?
    Dr. Eastman. Can I just take that one, sir?
    Mr. Hastings. Go ahead.
    Dr. Eastman. The approach to the health interview and 
medical assessment applies to everyone that is in our custody, 
with the parameters we described earlier.
    Ms. Garcia. Well, these folks are not in custody, sir. You 
are turning them away.
    Dr. Eastman. Ma'am, if they are in our custody, they get 
the assessments and the care that was described. As I said, it 
is outside my scope to know what happens to them south of the 
border.
    Ms. Garcia. Madam Chair, obviously, apparently the witness 
is not understanding the question. I am talking about the folks 
that are being turned away under the Remain in Mexico program.
    Miss Rice. You are going to have an opportunity to ask that 
again.
    Ms. Garcia. Thank you.
    Miss Rice. Mr. Ranking Member, do you have any additional 
questions?
    Mr. Higgins. Yes, Madam Chair.
    Madam Chair, before I ask my second round of questions, I 
ask unanimous consent to submit the Homeland Security Advisory 
Council final report by the CBP Families and Children Care 
Panel, which was published in November 2019. I ask unanimous 
consent to submit it for the record.
    Miss Rice. So received.*
---------------------------------------------------------------------------
    * The information has been retained in committee files and is 
available at https://www.dhs.gov/sites/default/files/publications/
fccp_final_report_1.pdf.
---------------------------------------------------------------------------
    Mr. Higgins. Mr. Hastings, would you like to clarify the 
medical screening that all human beings that cross the border 
and come in our custody, regardless of what program they are 
then subject to, would you clarify for my colleague, Ms. 
Garcia, and for the rest of the committee?
    Mr. Hastings. Thank you for the opportunity, sir. So that 
is correct. Ma'am, anyone that comes into our facility, 
regardless of what program or initiative that they are going 
into, will go through all of that medical assessment, medical 
screening, and interview.
    Mr. Higgins. So are you clarifying that minors, including 
children, all individuals that are returned to Mexico under the 
program prior to being returned receive medical screening?
    Mr. Hastings. Prior to return, we still have to process 
them. So during processing, we go through that.
    Mr. Higgins. What if they are sick? Let me extend my 
colleague's line of questioning here. What if they are sick?
    Mr. Hastings. Then they will go to the hospital or the 
appropriate medical care.
    Mr. Higgins. If the screening determines that they are 
sick, to the extent that they need professional medical 
attention, we are getting them that medical attention before we 
send them back to Mexico?
    Mr. Hastings. Yes, as evident by the 26,000 we took to the 
hospital last----
    Mr. Higgins. That is our policy across the border or only 
at one location?
    Mr. Hastings. That is across the border, sir.
    Mr. Higgins. Thank you, sir, for clarifying that.
    Dr. Eastman, in your testimony you mentioned the close 
working relationship between CBP and the Office of DHS Chief 
Medical Officer. Can you go into a little more detail, sir, 
about the specialized nature of your team's assistance to 
Customs and Border Protection? Also, based upon your 
observations, how committed has CBP leadership been to 
expeditiously address in-custody medical capabilities?
    Dr. Eastman. Sir, with regards to your first question--and 
thank you--the relationship literally is hand-in-hand. Our 
office and the Border Patrol and CBP communicate constantly. In 
fact, the CBP senior medical adviser is an employee from our 
office that is embedded into CBP to help facilitate these 
issues. The relationship is hand-in-hand, and we communicate 
literally at multiple levels probably, it is safe to say, 
daily.
    With regards to your second question, my direction has been 
clear and our direction has been clear from every leader in the 
Department, whether that is at DHS or CBP, that the direction I 
was given and we----
    Mr. Higgins. What about the direction that you have 
received from up chain, all the way to the top?
    Dr. Eastman. Yes, sir. The direction I have received has 
been clear and has been unanimous: Do the right thing.
    Mr. Higgins. Do you feel like the Executive branch and our 
President is committed by their leadership to expeditiously 
address in-custody medical capabilities?
    Dr. Eastman. Sir, I have not spoken to him directly, but my 
directions come from the Secretaries and the commissioners of 
CBP that I have worked with, and it has been clear, loud, and 
unanimous: Do the right thing, break down barriers, and take 
good care of the people in our custody.
    Mr. Higgins. That message has been pushed throughout the 
chain of command?
    Dr. Eastman. Yes, sir. It has been unanimous and loud and 
clear from everyone I have worked with.
    Mr. Higgins. Thank you for your clarification.
    Madam Chair, thank you for the second round of questioning, 
and I yield.
    Miss Rice. Thank you, Mr. Ranking Member.
    I now recognize the gentlewoman from Illinois, Ms. 
Underwood.
    Ms. Underwood. Thank you, Madam Chair.
    I have a couple follow-up questions, based on what we have 
heard today and what was submitted in the written testimony. In 
Mr. Hastings' written testimony on page 6, I am just going to 
read a couple statements. It says: ``The enhanced medical 
directive ensures that CBP will sustain enhanced medical 
support capabilities, with an emphasis on children less than 18 
years old. These include a health interview upon arrival at a 
CBP facility.''
    Mr. Hastings, can you further delineate whether those CBP 
facilities include all Border Patrol stations?
    Mr. Hastings. It does include all Border Patrol stations, 
yes, ma'am.
    Ms. Underwood. OK. So then just to circle back on what was 
just recently discussed by Ms. Garcia and Mr. Higgins, then if 
it includes the Border Patrol stations for individuals that are 
brought into apprehension, with the idea that they will be put 
into this Migrant--the MPP policy, then you consider that under 
U.S. custody, correct? Because they are being----
    Mr. Hastings. That is correct, ma'am.
    Ms. Underwood. So those individuals all get a health 
interview?
    Mr. Hastings. That is correct.
    Ms. Underwood. OK. If those individuals are seen as having 
some kind of medical flag, to use a casual term, then they will 
get a medical assessment?
    Mr. Hastings. That is correct, yes, ma'am.
    Ms. Underwood. Dr. Eastman, can you confirm that that is 
happening in all facilities?
    Dr. Eastman. Absolutely, ma'am. In the locations where we 
don't have contracted medical support, yes----
    Ms. Underwood. Correct.
    Dr. Eastman [continuing]. As that continues to develop, we 
utilize local resources to get that assessment. So if the 
interview occurs and if folks need health care, and we don't 
have it there, they will get it in a local system.
    Ms. Underwood. OK. So just to reiterate, the individuals 
that are coming to the United States that under current policy 
under DHS, you-all want to send them back to remain in Mexico 
or go through the MPP, and they present with a health care 
issue, you are saying that they are getting both an interview 
and a screening, and if at that local facility, they don't have 
the medical staff on-site to do the screening, you-all are 
sending them externally to get that medical assessment 
completed?
    Dr. Eastman. If they have a medical need, we will certainly 
utilize the local health care system, yes, ma'am.
    Ms. Underwood. OK. OK. My follow-up question then is, on 
page 4 of Mr. Hastings' testimony, he says that currently each 
day, there are approximately 300 contracted medical 
professionals engaged at more than 40 facilities along the 
Southwest Border, providing 24/7 on-site medical support, and 
that support is now available at all 9 Southwest Border USBP 
sectors, so U.S. Border Patrol sectors, and all 4 Southwest 
Border OFO field offices.
    So, based on that, would you then consider there to be 100 
percent coverage?
    Mr. Hastings. No, ma'am, I would not. So, as I mentioned 
earlier, we believe we have about 10 more locations that we 
need to cover that we are working rapidly to get coverage now. 
How we determined where this went was where the highest flow of 
vulnerable populations was.
    Ms. Underwood. I understand.
    Mr. Hastings. Where we had the least medical support in our 
nearest areas, and the highest flow rate that we were seeing. 
We have about 10 more locations that we are looking to expand 
to now still.
    Ms. Underwood. Do you have the current funding to support 
that expansion?
    Mr. Hastings. We do have the current funding to support 
that, yes, ma'am.
    Ms. Underwood. OK. So then the numbers that are submitted 
in your testimony are current as of what date? So these 
individuals and locations were staffed as of what date?
    Mr. Hastings. December, end of December 2019.
    Ms. Underwood. OK. Thank you, Madam Chair, I yield back.
    Miss Rice. Thank you. Where are the 10 additional 
locations?
    Mr. Hastings. I would have to look at the chart, ma'am. I 
can get back to you. I don't have the chart in front of me.
    Miss Rice. OK, thank you. I now recognize the gentle woman 
from Texas, Ms. Garcia.
    Ms. Garcia. Thank you, Madam Chair. Just a quick follow-up. 
Mr. Hastings, what is the average stay these days for a child 
in custody?
    Mr. Hastings. So that varies, ma'am, from day to day, hour 
to hour, but on average, the average time in our custody right 
now is approximately 39 hours, the last time I looked.
    Ms. Garcia. Thirty-nine hours?
    Mr. Hastings. The last time I looked, yes, ma'am. Juveniles 
are leaving our custody quickly since HHS is funded.
    Ms. Garcia. OK. Do you remember what month that was? I 
mean, that is obviously not the numbers I am seeing. So----
    Mr. Hastings. It has been a while since I have looked at 
the TIC time, it is one of--the time in custody time, that is 
one of the many variables that we look at, but the point being 
is----
    Ms. Garcia. It is shy of 2 days.
    Mr. Hastings. Pardon me?
    Ms. Garcia. It is shy of 2 days.
    Mr. Hastings. We are doing very well with individuals 
getting----
    Ms. Garcia. Right. Well, let me ask you this. I don't know 
the age of your grandchildren, but would you be comfortable 
with having your grandchild in custody in one of your own 
facilities for 39 hours?
    Mr. Hastings. I wouldn't want--I don't want any child in my 
facilities for that long, ma'am. For----
    Ms. Garcia. But would you be comfortable----
    Mr. Hastings. I am sorry. In the crisis. For right now, for 
39 hours, I trust that our employees are taking good care of 
the detainees that they are charged with oversight.
    Ms. Garcia. So you would be comfortable if your grandchild 
was there?
    Mr. Hastings. I think we are providing--we are doing very 
well providing proper services for all those in our custody 
right now. During the crisis, no, I wouldn't. I don't want them 
in our----
    I wouldn't want my granddaughter in custody anywhere, but I 
think we are doing the best we can with everything we have out 
there on the border right now, with all the improvements that 
we have made and how quickly we are getting these unaccompanied 
alien children out of our custody.
    Ms. Garcia. Right. What about you, Dr. Eastman? I know you 
mentioned--I don't know if you have children or grandchildren 
or little nieces and nephews like I do, but would you feel 
comfortable with a member of your family being in custody in 
your facility?
    Dr. Eastman. With no offense to Chief Hastings, ma'am, I am 
a little young for grandchildren, but I will tell you----
    Ms. Garcia. I never make assumptions, I have learned in 
this business.
    Dr. Eastman. Right, I understand. I understand, ma'am. I 
want to be clear with Chief Hastings, that it would be my 
preference that we don't ever hold children in our custody. 
However--however----
    Ms. Garcia. Well, that certainly is my preference in that a 
child has not committed any crimes, as my colleague from 
Texas----
    Dr. Eastman. Well, again, however--well, let me be clear 
from my perspective as a physician, that we provide our care 
irrespective of circumstances. It does not matter to us what 
they have or have not done. Our care is provided to every human 
being in our custody the same, no matter what the circumstances 
are.
    Ms. Garcia. Right.
    Dr. Eastman. To answer your question, ma'am, I would be 
very comfortable with my children receiving care in this system 
if it were necessary, and I know that we are going to continue 
to do everything we can to improve it every day.
    Ms. Garcia. Right. Let me follow up on my colleague Mr. 
Correa's questions. Like him, I also serve on the subcommittee 
of Judiciary Committee on immigration. He was asking about 
volunteer doctors. I know that--I am from Houston. We have a 
large medical center, which means we have a lot of doctors 
around. Many of them do a lot of good volunteer work in a 
number of areas and been able to do missions abroad.
    They have mentioned to me that, you know, they have tried 
to help and tried to volunteer, tried to even bring especially 
the flu vaccine to some facilities. I mean, what is the real 
beef if they are Texas facilities or Texas doctors and they are 
willing to help, why wouldn't you allow them to help?
    Dr. Eastman. So, just to be clear, ma'am, I am a Texas 
doctor, as well.
    Ms. Garcia. I know that, I saw your resume.
    Dr. Eastman. But the provision of volunteer medical support 
presents challenges not just to the Department of Homeland 
Security but to medical organizations in this country, in every 
State.
    So while we sometimes have difficulty with the licensure 
and administrative requirements, we certainly--and we have done 
this--we have tried to vector volunteers who want to provide 
that help, to some of the other locations that aren't as 
fortunate to have medical support like we are, like the NGO 
shelters along the Southwest Border. So when we have had Texas 
volunteers, we have tried to vector them into the Texas NGO's 
that need help.
    Oftentimes, while that is not my role as the DHS senior 
medical officer, we have been thrust into that, because in many 
ways, we are the intermediary between those medical volunteers. 
For example, you are from Houston. I talk to Dr. Maddox almost 
daily, and we talk routinely about things like this.
    We talk to--and one of the things I think that is really 
important is that during the course of this crisis, we have 
worked with State and local health departments and doctors all 
across the Southwest Border, and it has been a hand-to-hand, 
direct, face-to-face meetings and working together to solve 
problems as they arise.
    We have tried to be the best partner possible to the State 
and local health departments along the Southwest Border, and I 
think some of you saw evidence of that when you came and 
visited the border and saw some of those interactions. We will 
continue to do that, you have got my word. We are going to 
continue to try to the best partner as possible.
    Ms. Garcia. What impediments or challenges are there, and 
would there be anything that we can do in terms of legislation, 
to be able to provide, you know, better access to volunteer 
doctors?
    Dr. Eastman. Yes. My suggestion, ma'am, is that we take 
this off-line and we work together because the provision of 
volunteer services in disasters in this--volunteer medical 
services in disasters in this country is something that we are 
interested in. It is a tiny bit outside of scope of this 
hearing, but I would love to work together with you to try to 
help solve this problem on an actual basis.
    Ms. Garcia. Well, I think it is in the scope not only for 
this hearing that is focused on CBP, but also we have the same 
challenge and even volunteers who want to help children that 
are in our facilities, even something as simple as taking them 
to the movies.
    I mean, some of these facilities won't even allow people to 
come visit the children in any way to try to assist in terms 
of, particularly their mental health, well-being. So, sure, we 
will take it off-line, and Dr. Maddox is a good friend, so we 
will wake it a three-way call.
    Dr. Eastman. He would love that, ma'am.
    Ms. Garcia. Thank you. Thank you. I yield back.
    Miss Rice. Thank you.
    Let me just say that I--and I think I can speak for my good 
friend, Mr. Higgins, the Ranking Member, but I want to thank 
Mr. Hastings and Dr. Eastman for coming today.
    There are people in positions above you who don't show up, 
who don't answer the call, which is their duty. So the fact 
that you two showed up and took some difficult questions, you 
know, I am grateful. I am very grateful because you could have 
done what they did. We are well within our Constitutional 
obligation of having a role in oversight.
    I want to thank the Ranking Member on this subcommittee 
because we have been trying to address this issue. Before 
anyone is a Republican, a Democrat, black, white, male, woman, 
we are all human beings and we are all Americans. I know that I 
think I can speak for everyone in this room and certainly on 
this committee that even one death in custody is a tragedy.
    Dr. Eastman, I remember meeting you before you even got the 
position, because it was one of the issues we tried to address 
is how quickly we can bring qualified people like you in to 
help solve this problem. I want to thank you. I know that you 
have had contact with my colleague, Ms. Underwood, who has a 
medical background, and it is relationships like this that are 
going to help us all address these tragedies and ensure that 
they don't happen again.
    These are children who are being brought here for a better 
life, which is all any of us want for our children.
    Dr. Eastman. Thank you, madam.
    Miss Rice. I thank the witnesses for their valuable 
testimony and the Members for their questions.
    The Members of the subcommittee may have additional 
questions for the witnesses, and we ask that you--some of which 
we spoke about during the questioning, and we ask that you 
respond as expeditiously as possible in writing to those 
questions.
    Without objection, the subcommittee record shall be kept 
open for 10 days.
    Hearing no further business, the subcommittee stands 
adjourned.
    [Whereupon, at 12:12 p.m., the subcommittee was adjourned.]



                            A P P E N D I X

                              ----------                              

     Questions From Chairwoman Kathleen M. Rice for Brian Hastings
    Question 1a. On December 30, 2019, CBP issued an Enhanced Medical 
Support Directive, to among other things, mitigate risk to and sustain 
enhanced medical efforts for migrants in custody along the Southern 
Border.
    Has CBP developed training for CBP personnel to identify children 
in distress during initial encounter as required by the Directive? If 
so, please provide documentation of this training and the number of CBP 
personnel by sector and field office that have completed this training 
as of January 14, 2020.
    Answer. Response was not received at the time of publication.
    Question 1b. The Directive states that Border Patrol and OFO will 
ensure a medical assessment is conducted on certain categories of 
detained migrants, subject to availability of resources and operational 
requirements. What is the threshold level of resources needed to ensure 
that medical assessments are provided to the migrant categories 
identified in the Directive?
    Answer. Response was not received at the time of publication.
    Question 1c. What oversight mechanisms does CBP have in place to 
ensure the directive is followed as required and on a consistent basis?
    Answer. Response was not received at the time of publication.
    Question 2. In your oral testimony, you noted that $1.1 billion of 
the Emergency Supplemental Appropriations for Humanitarian Assistance 
and Security at the Southern Border Act of 2019 was allocated for 
humanitarian support, border operations, and mission support. As of 
January 14, 2020, how much of this funding has been allocated and how 
much of these funds remain unspent and available for use by CBP?
    Answer. Response was not received at the time of publication.
    Question 3. You stated in your written testimony that many of the 
improvements made to address the migrant crisis rely on the existence 
of emergency supplemental funds. What funding level is required for CBP 
to implement the Directive's requirement that every migrant under the 
age of 18 will receive a health interview? What funding level is 
required to ensure that resources are available to ensure that a 
medical assessment is conducted on all children under the age of 12 
held in CBP custody and the other categories of migrants noted in the 
Directive?
    Answer. Response was not received at the time of publication.
    Question 4a. In your testimony, you noted that CBP currently has 
medical support professionals engaged at facilities along the Southern 
Border.
    What is the staffing breakdown of CBP's medical contract, including 
the number of contracted professionals, their job titles, and job 
descriptions?
    Answer. Response was not received at the time of publication.
    Question 4b. In what locations on the Southern Border are medical 
support professionals deployed to and what is CBP's rationale for 
staffing the number of medical professionals at these locations?
    Answer. Response was not received at the time of publication.
    Question 4c. What funding levels are required to ensure 
implementation of this contract along the Southern Border?
    Answer. Response was not received at the time of publication.
    Question 4d. How many trained emergency medical technicians and 
Border Patrol agents certified as emergency medical technicians operate 
on the Southern Border?
    Answer. Response was not received at the time of publication.
     Questions From Chairman Bennie G. Thompson for Brian Hastings
    Question 1. In your written testimony, you noted that the Enhanced 
Medical Directive ensures that CBP will provide a health interview for 
all migrants less than 18 years old. What questions will be asked to 
migrants during this interview and will CBP personnel be permitted to 
ask additional questions if the circumstances of a migrants' health 
warrant?
    Answer. Response was not received at the time of publication.
    Question 2. The Directive states that CBP Form 2500 will be used to 
conduct health interviews. Please provide the committee with a copy of 
this form. Does CBP plan to periodically review and amend this form if 
circumstances warrant changes to it?
    Answer. Response was not received at the time of publication.
    Question 3. The Directive states that it applies to both CBP 
steady-state and surge operations. This Directive also appear to apply 
to crisis operations when additional interagency resources and support 
will be required. What is CBP's criteria for determining ``major surge/
crisis-level operations'' and what additional agency resources will CBP 
seek to ensure requirements within the Directive are met?
    Answer. Response was not received at the time of publication.
    Question 4. In your testimony, you stated that CBP would notify 
Congress if they decide not to follow the Directive based upon 
operational requirements. What exact criteria will CBP assess to 
determine whether resources are, or are not, available to abide by the 
Directive? Who within CBP will make the decision that the Directive 
must or must not be followed based upon the previous assessment?
    Answer. Response was not received at the time of publication.
    Question 5. Please provide the committee with the written 
guidelines for notifying Congress when CBP determines that the 
Directive will or will not be followed.
    Answer. Response was not received at the time of publication.
       Questions From Honorable Sylvia Garcia for Brian Hastings
    Question 1. What is CBP's policy for providing medical treatment to 
migrants that CBP agents identify as sick that are subjected to the 
Migrant Protection Protocols?
    Answer. Response was not received at the time of publication.
    Question 2. What are CBP's written protocols in place to protect 
CBP personnel and migrants from the spread of infectious diseases, such 
as the flu, inside processing centers, Border Patrol stations and ports 
of entry? Please provide these documented protocols.
    Answer. Response was not received at the time of publication.
  Questions From Chairwoman Kathleen M. Rice for Alexander L. Eastman
    Question 1. What is DHS policy for providing medical treatment to 
migrants that are subjected to the Migrant Protection Protocols? What 
kind of engagement is done with the Government of Mexico?
    Answer. Response was not received at the time of publication.
    Question 2. What are DHS protocols to protect DHS personnel and 
migrants from the exposure of illnesses, such as the flu, inside 
processing centers, Border Patrol stations and ports of entry? Please 
provide these documented protocols.
    Answer. Response was not received at the time of publication.
   Questions From Honorable Lauren Underwood for Alexander L. Eastman
    Question 1. What is the status of implementing an electronic health 
record (EHR) system for migrants on the Southern Border?
    Answer. Response was not received at the time of publication.
    Question 2. What is the estimated time to complete this EHR system?
    Answer. Response was not received at the time of publication.
    Question 3. What entities, including Federal, State, local, and 
private stakeholders have DHS engaged with on implementing this EHR 
system?
    Answer. Response was not received at the time of publication.