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


                 CHILDREN IN CBP CUSTODY: EXAMINING DEATHS, 
                   MEDICAL CARE PROCEDURES, AND IMPROPER 
                   SPENDING

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


                                HEARING

                               BEFORE THE

                     COMMITTEE ON HOMELAND SECURITY
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             SECOND SESSION

                               __________

                             JULY 15, 2020

                               __________

                           Serial No. 116-77

                               __________

       Printed for the use of the Committee on Homeland Security
                                     

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT] 
                                     

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

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
43-865 PDF                  WASHINGTON : 2021                     
          
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                     COMMITTEE ON HOMELAND SECURITY

               Bennie G. Thompson, Mississippi, Chairman
Sheila Jackson Lee, Texas            Mike Rogers, Alabama
James R. Langevin, Rhode Island      Peter T. King, New York
Cedric L. Richmond, Louisiana        Michael T. McCaul, Texas
Donald M. Payne, Jr., New Jersey     John Katko, New York
Kathleen M. Rice, New York           Mark Walker, North Carolina
J. Luis Correa, California           Clay Higgins, Louisiana
Xochitl Torres Small, New Mexico     Debbie Lesko, Arizona
Max Rose, New York                   Mark Green, Tennessee
Lauren Underwood, Illinois           John Joyce, Pennsylvania
Elissa Slotkin, Michigan             Dan Crenshaw, Texas
Emanuel Cleaver, Missouri            Michael Guest, Mississippi
Al Green, Texas                      Dan Bishop, North Carolina
Yvette D. Clarke, New York           Jefferson Van Drew, New Jersey
Dina Titus, Nevada
Bonnie Watson Coleman, New Jersey
Nanette Diaz Barragan, California
Val Butler Demings, Florida
                       Hope Goins, Staff Director
                 Chris Vieson, Minority Staff Director
                           
                           
                           C O N T E N T S

                              ----------                              
                                                                   Page

                               Statements

The Honorable Bennie G. Thompson, a Representative in Congress 
  From the State of Mississippi, and Chairman, Committee on 
  Homeland Security:
  Oral Statement.................................................     1
  Prepared Statement.............................................     4
The Honorable Mike Rogers, a Representative in Congress From the 
  State of Alabama, and Ranking Member, Committee on Homeland 
  Security:
  Oral Statement.................................................     5
  Prepared Statement.............................................     8
The Honorable Sheila Jackson Lee, a Representative in Congress 
  From the State of Texas:
  Prepared Statement.............................................     9

                               Witnesses

Dr. Fiona S. Danaher, M.D., M.P.H., Pediatrician, Chelsea 
  Pediatrics, Child Protection Team, Massachusetts General 
  Hospital, Instructor in Pediatrics at Harvard Medical School:
  Oral Statement.................................................    12
  Prepared Statement.............................................    13
Dr. Roger A. Mitchell, Jr., M.D., Chief Medical Examiner, Office 
  of the Chief Medical Examiner, Washington, DC, Clinical 
  Professor of Pathology at the George Washington University, 
  Associate Professor of Surgery at Howard University:
  Oral Statement.................................................    19
  Prepared Statement.............................................    21
Mr. Joseph V. Cuffari, Inspector General, U.S. Department of 
  Homeland Security:
  Oral Statement.................................................    26
  Prepared Statement.............................................    27
Ms. Rebecca Gambler, Director, Homeland Security and Justice, 
  U.S. Government Accountability Office:
  Oral Statement.................................................    36
  Prepared Statement.............................................    38

                             For the Record

The Honorable Bennie G. Thompson, a Representative in Congress 
  From the State of Mississippi, and Chairman, Committee on 
  Homeland Security:
  Letter, July 14, 2020..........................................     3
  Letter, July 15, 2020..........................................     4
  Letter, June 12, 2020..........................................    74
The Honorable Mike Rogers, a Representative in Congress From the 
  State of Alabama, and Ranking Member, Committee on Homeland 
  Security:
  Letter, July 8, 2020...........................................     6

                                Appendix

Questions From Congressman Emmanuel Cleaver for Fiona S. Danaher.    77
Questions From Congressman Emmanuel Cleaver for Joseph V. Cuffari    80

 
CHILDREN IN CBP CUSTODY: EXAMINING DEATHS, MEDICAL CARE PROCEDURES, AND 
                           IMPROPER SPENDING

                              ----------                              


                        Wednesday, July 15, 2020

                     U.S. House of Representatives,
                            Committee on Homeland Security,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 12:05 p.m., via 
Webex, Hon. Bennie G. Thompson (Chairman of the committee) 
presiding.
    Present: Representatives Thompson, Jackson Lee, Richmond, 
Payne, Rice, Correa, Torres Small, Rose, Underwood, Slotkin, 
Cleaver, Green of Texas, Titus, Barragan, Rogers, Katko, 
Higgins, Lesko, Green of Tennessee, Joyce, Crenshaw, Guest, and 
Bishop.
    Chairman Thompson. The Committee on Homeland Security will 
come to order. The committee is meeting today to receive 
testimony on ``Children in CBP Custody: Examining Deaths, 
Medical Care Procedures, and Improper Spending.'' Without 
objection, the Chair is authorized to declare the committee in 
recess at any point.
    The committee is convening today to examine 3 critical 
related and deeply troubling issues: The terrible death of 
young children in the custody of Customs and Border Protection; 
CBP's failure to consistently implement the revised medical 
screening procedures it adopted after children died in its 
custody; and CBP's improper expenditure of the emergency funds 
appropriated by Congress for the care of migrants.
    In December 2018, 2 children died in CBP custody. A 7-year-
old girl named Jakelin, and an 8-year-old boy named Felipe. 
Last year, another 3 children died in CBP custody, or shortly 
after being released. On January 4, 2019, I sent a letter to 
the Department of Homeland Security requesting documents 
related to the deaths in 2018, after the Department failed to 
produce all documents responsive to the committee's request. In 
November 2019, the committee issued a narrowly tailored 
subpoena by voice vote for many of the documents originally 
requested in my letter 10 months prior.
    In December 2019, the DHS inspector general's office 
publicly issued 2 1-page summaries into the investigations into 
the death that had occurred a year earlier. Unfortunately, the 
inspector general's investigations left us with more questions 
than answers.
    Earlier this year, I sent a letter to Inspector General 
Cuffari detailing the concerns we identified with the report. 
My entire letter is available on the committee's website. Among 
the concerns I raised were the following: Inspector general's 
report and public summaries proclaim that there was no 
malfeasance or misconduct by DHS personnel. It is unclear why 
that standard was used, because there do not appear to have 
been any allegations of malfeasance or misconduct on the part 
of the agents.
    In fact, all available evidence indicates that Border 
Patrol agents showed great compassion for both children. 
However, the inspector general's report appeared to presume 
that since its investigation found no malfeasance or 
misconduct, that is the end of the story. The report fails to 
examine the many troubling questions that these deaths raise 
regarding CBP's ability to care for children in custody, 
including questions about the adequacy of the agency's 
policies, procedures, and training.
    Further, while the inspector general's office certainly 
conducted many interviews, it appeared that key documents and 
evidence were not collected and reviewed. My letter also 
identified omissions in the public summary of one of the 
inspector general's report that was so severe as to render the 
summary inaccurate and potentially misleading. The inspector 
general revised a public summary after receiving my letter.
    Over the past 6 months, DHS has produced some documents in 
response to the committee's subpoena, but these productions are 
clearly incomplete. For example, the inspector general's report 
referenced documents that have never been provided to the 
committee. DHS has also made extensive and improper redactions 
in the documents it has produced.
    Through its refusal to comply fully with the committee's 
subpoena, and through its many redactions, the Department is 
intentionally impeding the committee's investigation. Despite 
these hurdles, the committee has worked to advance our 
investigation. To help with that effort, we asked a 
pediatrician and a medical examiner to conduct independent 
examinations of the 2 deaths that occurred in December 2018. We 
will receive that testimony today. Today, the Government 
Accountability Office is also releasing a report we requested. 
It examines both CBP's use of emergency funding appropriated to 
care for migrants, as well as the agency's implementation of 
new medical screening procedures it announced after the deaths 
in 2018. GAO's report finds that after CBP claimed it urgently 
needed emergency funding to provide care for migrants taken 
into custody, the agency misspent money it received. The Border 
Patrol agents who cared for Felipe, while he was in custody, 
had to pay for medicine for him out of their own pockets, but 
CBP used some of the emergency funding that Congress 
appropriated for the specific purpose of paying for medical 
care, to instead buy jet skis, and dirt bikes, and even dog 
food.
    There is something seriously wrong with this picture, just 
as there is something seriously wrong with the administration's 
approach to caring for migrants, including children.
    I note that GAO's report also finds that although CBP 
adopted new policies governing medical assessments for children 
following the tragic deaths of the 2 children in late 2018, CBP 
did not consistently implement these policies.
    We welcome Dr. Fiona Danaher and Dr. Roger Mitchell before 
the committee, as well as Rebecca Gambler from GAO. I am glad 
that after initially refusing to do so, inspector general has 
agreed to testify before the committee, so that we can explore 
the many questions regarding the work of the inspector 
general's office. We also invited CBP's acting commissioner, 
Mark Morgan to testify.
    In a letter to the committee, he stated that because of the 
White House baseless rules prohibiting administration witnesses 
from attending virtual hearings, he could not appear.
    As I close, let me say that I fully recognize the 
sensitivities of the issues we are discussing. I encourage all 
Members to be very careful and thoughtful in how we approach 
this subject. With that said, it is clear that this 
administration will do everything it can to avoid oversight. 
Therefore, we must continue to do everything we can to hold 
this administration accountable. Given the 18 months of 
obstruction we have endured and have sought documents and 
information about the death of children in custody, as well as 
issues like the administration's child separation policy, I see 
no other way to advance our investigation and to identify 
changes needed in CBP's policies and procedures than to convene 
today's hearing.
    Before I recognize the Ranking Member, I am going to read 
statements from the fathers of the 2 children who died in CBP 
custody in 2018.
    Mr. Caal Cruz, the father of Jakelin, provided the 
following statement: ``I would like to say what I have always 
believed, it is better to check on all children when they are 
sick, and even if they are not sick, to speak up and say 
something even if you are afraid. The most important thing is 
to check on the children so the thing that happened to my 
daughter doesn't happen to anyone ever again. I offer my thanks 
to the committee for taking the time to look into my daughter's 
case and I am very grateful to you all.''
    The father of Felipe, Mr. Gomez Perez stated: ``I want 
justice. I want to know why my son didn't receive medical care 
in time. I don't want other children to go through the same 
thing. This is painful for me today, and it will be painful for 
the rest of my life. Every night I ask myself why my son didn't 
receive medical attention in time. Felipe's treatment was 
inhumane.''
    I ask unanimous consent to submit their letters into the 
record.
    Without objection, so admitted.
    [The information referred to follows:]
                                     July 14, 2020.
Representative Bennie G. Thompson,
Chairman, Committee on Homeland Security, H2-176 Ford House Office 
        Building, Washington, DC 20515.
Statement of Mr. Caal Cruz Regarding the Committee's Investigation into 
the Death of Jakelin Caal Maquin, age 7

    Dear Chairman Thompson: We are providing this statement on behalf 
of our client, Mr. Nery Caal Cruz, to whom we provide pro bono legal 
and social services. Please find below Mr. Caal Cruz's statement in 
response to the Committee on Homeland Security's current investigation 
into the death of his daughter, Jakelin Caal Maquin, then age 7, in CBP 
custody.
    ``I would like to say what I have always believed. It is better to 
check on all children when they are sick and even if they are not sick. 
To speak up and say something even if you are afraid. The most 
important thing is to check on the children. So the thing that happened 
to my daughter doesn't happen to anyone ever again. I offer my thanks 
to the Committee for taking the time to look into my daughter's case 
and I am very grateful to you all.''
    Thank you for your attention and consideration to this important 
issue.
                                                         Sincerely,
                                  Bridget Cambria, Esq. [.]
                                 ______
                                 
                                   July 15th, 2020.

    To whom it may concern, The Tennessee Immigrant and Refugee Rights 
Coalition (TIRRC) is a State-wide member-led advocacy organization 
dedicated to empowering immigrants and refugees to defend their rights. 
In the Spring of 2019, the Guatemalan consulate put us in touch with 
Agustin Gomez Perez after the death of Mr. Gomez Perez's son in CBP 
custody. Over the past year, we have developed a close relationship 
with Mr. Gomez Perez and assisted him through connecting him with 
community resources and getting him settled into his home. We have also 
helped him collect necessary documents for the legal proceedings and 
facilitated the communication between Mr. Gomez Perez and various 
attorneys. For his part, Mr. Gomez Perez has become an active TIRRC 
member through attending our community meetings. Mr. Gomez Perez would 
like for his statement to be read aloud.
    Agustin Gomez Perez's statement:

``I want justice. I want to know why my son didn't receive medical care 
in time. I don't want other children to go through the same thing. This 
is painful for me today, and will be painful for the rest of my life. 
Every night I ask myself why my son didn't receive medical attention in 
time. Felipe's treatment was inhumane.''

    We are proud to support Mr. Gomez Perez in his fight for justice 
for his son and the improved treatment of immigrants. All people 
deserve to be treated with basic human dignity and respect.
            Sincerely,
                                     Lisa Sherman-Nikolaus,
                                                Executive Director.

    [The statement of Chairman Thompson follows:]
                Statement of Chairman Bennie G. Thompson
                             July 15, 2020
    The committee is convening today to examine 3 critical, related, 
and deeply troubling issues: The terrible deaths of young children in 
the custody of Customs and Border Protection (CBP); CBP's failure to 
consistently implement the revised medical screening procedures it 
adopted after children died in its custody; and CBP's improper 
expenditure of emergency funding appropriated by Congress for the care 
of migrants.
    In December 2018, 2 children died in CBP custody--a 7-year-old girl 
named Jakelin and an 8-year-old boy named Felipe. Last year, another 3 
children died in CBP custody or shortly after being released.
    On January 4, 2019, I sent a letter to the Department of Homeland 
Security requesting documents related to the deaths in 2018. After the 
Department failed to produce all documents responsive to the 
committee's request, in November 2019, the committee issued a narrowly-
tailored subpoena by voice vote for many of the documents originally 
requested in my letter 10 months prior.
    In December 2019, the DHS inspector general's office publicly 
issued 2 1-page summaries of its investigations into the deaths that 
had occurred a year earlier. Unfortunately, the inspector general's 
investigations left us with more questions than answers.
    Earlier this year, I sent a letter to Inspector General Cuffari 
detailing the concerns we identified with the reports. My entire letter 
is available on the committee's website. Among the concerns I raised 
were the following: The inspector general's reports and public 
summaries proclaim that there was no malfeasance or misconduct by DHS 
personnel.
    It is unclear why that standard was used, because there do not 
appear to have been any allegations of malfeasance or misconduct on the 
part of agents. In fact, all available evidence indicates that Border 
Patrol agents showed great compassion for both children. However, the 
inspector general's reports appear to presume that since its 
investigations found no malfeasance or misconduct, that's the end of 
the story.
    The reports fail to examine the many troubling questions that these 
deaths raise regarding CBP's ability to care for children in custody, 
including questions about the adequacy of the agency's policies, 
procedures, and training. Further, while the inspector general's office 
certainly conducted many interviews, it appears that key documents and 
evidence were not collected and reviewed.
    My letter also identified omissions in the public summary of one of 
the inspector general's reports that were so severe as to render the 
summary inaccurate and potentially misleading. The inspector general 
revised the public summary after receiving my letter. Over the past 6 
months, DHS has produced some documents in response to the committee's 
subpoena--but these productions are clearly incomplete. For example, 
the inspector general's reports reference documents that have never 
been provided to the committee. DHS has also made extensive and 
improper redactions in the documents it has produced. Through its 
refusal to comply fully with the committee's subpoena--and through its 
many redactions--the Department is intentionally impeding the 
committee's investigation. Despite these hurdles, the committee has 
worked to advance our investigation.
    To help with that effort, we asked a pediatrician and a medical 
examiner to conduct independent examinations of the 2 deaths that 
occurred in December 2018. We will receive their testimony today.
    Today, the Government Accountability Office is also releasing a 
report we requested. It examines both CBP's use of emergency funding 
appropriated to care for migrants as well as its implementation of the 
new medical screening procedures it announced after the deaths in 2018. 
GAO's report finds that after CBP claimed it urgently needed emergency 
funding to provide care for migrants taken into custody, the agency 
mis-spent money it received.
    The Border Patrol agents who cared for Felipe while he was in 
custody had to pay for medicine for him out of their own pockets. But 
CBP used some of the emergency funding that Congress appropriated for 
the specific purpose of paying for medical care to instead buy jet skis 
and dirt bikes, and even dog food. There is something seriously wrong 
with this picture--just as there is something seriously wrong with this 
administration's approach to caring for migrants, including children.
    I note that GAO's report also finds that although CBP adopted new 
policies governing medical assessments for children following the 
tragic deaths of the 2 children in late 2018, CBP did not consistently 
implement these policies. We welcome Dr. Fiona Danaher and Dr. Roger 
Mitchell before the committee, as well as Rebecca Gambler from GAO. I 
am glad that after initially refusing to do so, the inspector general 
has agreed to testify before the committee, so that we can explore the 
many questions we have regarding the work of the inspector general's 
office.
    We also invited CBP's acting director, Mark Morgan, to testify. In 
a letter to the committee, he stated that because of the White House's 
baseless rules prohibiting administration witnesses from attending 
virtual hearings, he could not appear.
    As I close, let me say I fully recognize the sensitivities of the 
issues we are discussing. I encourage all Members to be very careful 
and thoughtful in how we approach this subject. That said, it is clear 
that this administration will do everything it can to avoid oversight. 
Therefore, we must continue to do everything we can to hold this 
administration accountable.
    Given the 18 months of obstruction we have endured as we have 
sought documents and information about the deaths of children in 
custody--as well as issues like the administration's child separation 
policy--I see no other way to advance our investigation and to identify 
changes needed in CBP's policies and procedures than to convene today's 
hearing.

    Chairman Thompson. The Chair now recognizes the Ranking 
Member of the full committee, the gentleman from Alabama, Mr. 
Rogers, for an opening statement.
    Mr. Rogers. Thank you, Mr. Chairman. Can you hear me?
    Chairman Thompson. Yes.
    Mr. Rogers. Great.
    I appreciate you holding this hearing and thank you, again, 
for granting our request to use the committee room. I am, too, 
saddened by the loss of Felipe and Jakelin. Both children and a 
teenager died while in the custody of CBP, or shortly after 
entering custody, which is totally unacceptable. The Department 
has taken measurable steps to improve migrant care, but it is 
up to us in Congress to address the root cause of the problem. 
That can only happen in a bipartisan manner. It means that we 
must fix immigration loopholes. We must provide real and 
adequate resources to both CBP and ICE. We must not encourage 
illegal immigration to our border. We must disrupt the cartels 
and their human smuggling partners, and I hope we never have to 
hear of another tragedy at the borders like what happened with 
these 3 minors.
    Mr. Chairman, I am disappointed at some of the events 
leading up to this hearing, Acting Commissioner Morgan should 
be at this hearing so this committee can directly hear from 
him. It is important we understand what happened and what CBP 
has done since those 2 deaths. The Majority did invite Acting 
Commissioner Morgan, but they also knew he couldn't participate 
in a remote hearing. OMB as provided guidance to senior 
administration officials forbidding them from participating in 
remote hearings. They are permitted to appear in person, Acting 
Commissioner Morgan did before the Senate committee on June 25. 
I ask unanimous consent to insert into the record Acting 
Commissioner Morgan's response to the Chairman's invitation.
    [The information follows:]
                                      July 8, 2020.
The Honorable Bennie G. Thompson,
Chairman, Committee on Homeland Security, U.S. House of 
        Representatives, Washington, DC 20515.
    Dear Chairman Thompson: Thank you for the invitation to testify 
before the House Committee on Homeland Security on July 15, 2020, via 
Cisco Webex regarding ``Children in CBP Custody: Examining Deaths, 
Medical Care Procedures, and Improper Spending.'' However, based on 
guidelines established by the Office of Management and Budget (OMB) and 
the White House Office of Legislative Affairs (WHOLA), I must decline 
this invitation.
    As previously outlined by OMB, Federal officials are required to 
appear in person before a committee to testify, with the Chairman also 
appearing in person. OMB also requires that the Committee adhere to 
normal procedures regarding hearing notice, quorum, and question-and-
answer periods. In light of these requirements and the Committee's 
notice that this hearing will be held via Cisco Webex, I will not be 
able to participate in this hearing in this format.
    Additionally, on July 15, 2020, the Departments of Homeland 
Security (DHS) and Treasury will be holding the quarterly Commercial 
Customs Operations Advisory Committee (COAC) meeting. As you are aware, 
the COAC is a Federal Advisory Committee Act (FACA) committee that 
advises the Secretaries of the Treasury and DHS on all matters 
involving the commercial operations of CBP. The CBP Commissioner is the 
co-chair of the COAC, and I will be co-chairing the quarterly COAC 
meeting on July 15, 2020.
    The CBP Office of Congressional Affairs notified your staff of 
these requirements and my prior commitment. Additionally, my staff 
indicated my willingness to work with the Committee to identify a 
mutually agreeable date so that I can participate in a hearing that 
complies with OMB and the WHOLA guidelines. Unfortunately, we have not 
heard back from your staff to identify a different date for the 
hearing. So I must reiterate that I will not be able to participate in 
the hearing on July 15, 2020.
    I look forward to finding a mutually agreeable date and format that 
complies with the requirements outlined by OMB to testify before your 
Committee on this important topic.
            Sincerely,
                                            Mark A. Morgan,
 Chief Operating Officer and Senior Official Performing the Duties 
                                               of the Commissioner.

    Mr. Rogers. In that letter, Morgan requests to appear 
before the committee in person in accordance with OMB guidance. 
If we want productive hearings, I would suggest to the Majority 
that we find time to hear from him in the next 2 weeks when we 
are in the District of Columbia.
    Further, getting to the bottom of those 2 deaths is 
something that this committee has worked together on. We voted 
unanimously last November to subpoena the Department on 
information related to the deaths of Felipe and Jakelin. Our 
filing the subpoena, it appears the Majority requested and 
received additional information from the University of Mexico, 
Office of Medical Investigations.
    It appears the Majority didn't share this information with 
witnesses here today, and who knows who else, avoid informing 
the Minority of its existence. One witness claims to have 
received the information on June 30. The Minority got it on 
July 12. It is very disappointing to partner with you on things 
like this, just have them turn out to be partisan in less than 
a week before the hearing.
    I am also alarmed by the autopsy information the Majority 
requested. I don't see any legitimate reason why this 
committee, or any committee of Congress, would need human 
tissue samples from a deceased 8-year-old boy. I am concerned 
the Majority's motive of requesting and then sharing with their 
witnesses these autopsy specimens is to try and place blame for 
those deaths on the men and women of Border Patrol. If that is 
true, it is deplorable.
    The IG found that there was no misconduct or malfeasance in 
any of the actions of DHS or its employees surrounding these 
unfortunate deaths. I understand that answer doesn't provide 
any political satisfaction, but those are the facts.
    If the Majority requested and shared human tissue samples 
of a deceased child just to advance political narrative, it 
would mark an appalling new low for this committee. I hope that 
is not the case. We must remember that for months, Congress 
refused to address the border crisis that precipitated these 
deaths. Record numbers of families and children crossed our 
border last year. Groups of hundreds to thousands of migrants 
came across it at once. Migrants traveled over 2,000 miles at 
the whims of cartels and human smugglers to get to our border. 
Many told of abuse, assaults, and worse, on the journey to our 
border. Food, nutrition, access to medicine was not adequate if 
at all provided.
    As a result, many, like Jakelin, arrived in extremely poor 
health. At the height of the crisis, Border Patrol agents spent 
over half their time transporting migrants to hospitals. But 
for months last year, the Majority refused to acknowledge the 
problem, going as far as to call it a manufactured crisis. Even 
after the children died, the Majority insisted there was no 
crisis at our border. At one point last year, the Majority's 
response to the border crisis was to send 316 tweets, 11 press 
releases, and hold 6 hearings. None of that solved anything.
    Finally, after months of denying it, the Majority finally 
admitted there was a crisis. A supplemental appropriations bill 
was brought forward to the House, yet that bill had so many 
poison pills attached to it, the Senate had to strip them out 
before it can head to the border.
    Unfortunately, that bill was, at best, a stopgap measure. 
The Homeland Security Advisory Committee recently concluded 
that until Congress takes action to address the root cause of 
last year's crisis, it is only a matter of time before another 
one occurs. I hope, at some point, we can get off the political 
messaging game and work together to fix the immigration 
loophole that encourage parents to send their children on a 
dangerous, and, oftentimes, deadly trek to our border.
    Thank you, Mr. Chairman. I yield back.
    [The statement of Ranking Member Rogers follows:]
                Statement of Ranking Member Mike Rogers
    Thank you, Mr. Chairman, for holding this hearing today.
    And thank you again for granting our request to use the committee 
room.
    I'm saddened by the loss of both Felipe and Jakelin.
    Both children and a teenager died while in the custody of CBP or 
shortly after entering custody--which is unacceptable.
    The Department has taken measurable steps to improve migrant care, 
but up to us in Congress to address the root cause of the problem.
    That can only happen in a bipartisan manner.
    It means that we must fix immigration loopholes.
    We must provide real and adequate resources to both CBP and ICE.
    We must not encourage illegal immigration to our border.
    We must disrupt the cartels and their human smuggling partners.
    I hope we never have to hear of another tragedy at the border like 
what happened to these 3 minors.
    Mr. Chairman, I am disappointed at some of the events leading up to 
this hearing today.
    Acting Commissioner Morgan should be here so this committee can 
hear directly from him.
    It's important that we understand what happened and what CBP has 
done since these 2 deaths.
    The Majority did invite Acting Commissioner Morgan, but they also 
knew that he couldn't participate in a remote hearing.
    OMB has provided guidance to senior administration officials 
forbidding them from participating in remote hearings.
    They are permitted to appear in person, as Acting Commissioner 
Morgan did before a Senate Committee on June 25.
    I ask Unanimous Consent to insert into the record Acting 
Commissioner Morgan's response to the Chairman's invitation.
    In that letter, Morgan requests to appear before the committee in 
person in accordance with the OMB guidance.
    If we want a productive hearing, I would suggest to the Majority 
that we find time to hear from him in the next 2 weeks when we are in 
the District of Columbia.
    Further, getting to the bottom of these 2 deaths is something this 
committee has worked on together.
    We voted unanimously last November to subpoena the Department on 
information related to the deaths of Felipe and Jakelin.
    However, following that subpoena, it appears the Majority requested 
and received additional information from the University of New Mexico 
Office of the Medical Investigator.
    It appears the Majority then shared this information with the 
witnesses here today, and who knows who else, before informing the 
Minority of its existence.
    Mr. Chairman, can you tell me when this information regarding 
Felipe's autopsy was provided to the committee?
    I yield to the Chairman.
    Thank you, Mr. Chairman.
    One witness claims to have received the information on June 30.
    We got it on July 12.
    It's very disappointing to partner with you on this only to have it 
be made partisan less than a week before the hearing.
    I am also alarmed by the autopsy information the Majority 
requested.
    I don't see any legitimate reason why this committee or any 
committee of Congress would need the human tissue samples from a 
deceased 8-year-old boy.
    I am concerned the Majority's motive in requesting, and then 
sharing with their witnesses, these autopsy specimens is to try to 
place the blame for these deaths on the men and women of the Border 
Patrol.
    If true, I think that's deplorable.
    The IG found that there was no misconduct or malfeasance in any of 
the actions of DHS or its employees surrounding these unfortunate 
deaths.
    I understand that answer doesn't provide any political satisfaction 
to the Majority, but those are the facts.
    If the Majority requested and then shared the human tissue samples 
of a deceased child just to advance a political narrative, it would 
mark an appalling new low for this committee.
    I hope that's not the case.
    We must remember that for months, Congress refused to address the 
border crisis that precipitated these deaths.
    Record numbers of families and children crossed our border last 
year.
    Groups of hundreds to thousands of migrants came across at once.
    Migrants traveled over 2,000 miles, at the whims of the cartels and 
human smugglers, to get to the border.
    Many told of abuse, assaults, and worse on the journey to our 
border.
    Food, nutrition, access to medicine was not adequate, if provided 
at all.
    As a result, many, like Jakelin, arrived in extremely poor health.
    At the height of the crisis, Border Patrol agents spent over half 
of their time transporting migrants to hospitals.
    But for months last year, the Majority refused to acknowledge the 
problem, going so far as to call it a ``manufactured crisis.''
    Even after these children died, the Majority insisted there was 
``no crisis'' at our border.
    At one-point last year, the Majority's response to the border 
crisis was to send out 316 tweets, 11 press releases, and hold 6 
hearings.
    None of that solved anything.
    Finally, after months of denying it, the Majority finally admitted 
there was a crisis.
    A supplemental appropriations bill was brought forward to the 
House.
    Yet that bill had so many poison pills attached to it, that the 
Senate had to strip them out before relief could head to the border.
    Unfortunately, that bill was at best a stop-gap measure.
    The Homeland Security Advisory Committee recently concluded that 
until Congress takes action to address the root cause of last year's 
crisis, it's only a matter of time before another one occurs.
    I hope at some point we can get off the political messaging game 
and work together to fix the immigration loopholes that encourage 
parents to send their children on a dangerous and, often times, deadly 
trek to our border.
    I yield back.

    Chairman Thompson. Thank you very much, Mr. Ranking Member.
    Other Members of the committee are reminded that under 
committee rules, opening statements may be submitted for the 
record. Members are also reminded that the committee will 
operate according to the guidelines laid out by myself and the 
Ranking Member in our July 8 colloquy.
    [The statement of Honorable Jackson Lee follows:]
               Statement of Honorable Sheila Jackson Lee
                             July 15, 2020
    Thank you, Chairman Thompson for convening this opportunity for the 
Homeland Security Committee to provide oversight of ``Children in CBP 
Custody: Examining Deaths, Medical Care Procedures, and Improper 
Spending.''
    I thank today's witnesses and look forward to their testimony:
   Fiona S. Danaher, M.D., MPH, a pediatrician with 
        Massachusetts General Hospital--Chelsea Pediatrics and 
        Massachusetts General Hospital Child Protection Team and an 
        instructor in Pediatrics, Harvard Medical School;
   Roger A. Mitchell, Jr., M.D., chief medical examiner, D.C. 
        Office of the Chief Medical Examiner, clinical professor of 
        pathology, the George Washington University and associate 
        professor of surgery, Howard University;
   The Honorable Joseph V. Cuffari, inspector general, U.S. 
        Department of Homeland Security;
   Ms. Rebecca Gambler, director, Homeland Security and Justice 
        Team, U.S. Government Accountability Office.
    As a senior Member of this committee I have learned a great deal 
about the capacity and strength of the men and women who work at the 
Department of Homeland Security.
    I hold them in the highest regard for their dedication and service 
to our country.
    This Nation depends on the men and women of the Department of 
Homeland Security (DHS) to protect citizens from those who wish to do 
them harm.
    Because of the dedication of DHS professionals, we are better 
prepared to face these challenges as one Nation united against a common 
foe.
    The Department of Homeland Security was not created to protect the 
Nation from desperate people escaping violence and poverty, seeking 
asylum in our country.
    The saddest, most tragic situation is the plight of tens of 
thousands of unaccompanied children or those who were taken from their 
parents or removed from the care of responsible adults.
    My primary domestic security concerns are:
   Making sure that our immigration policies in word and deed 
        reflect the best of our Nation's values and institutions;
   Separating fact from fiction in the debate over U.S. 
        immigration and border policy;
   Controlling access to firearms for those who are deemed to 
        be too dangerous to fly;
   Countering international and home-grown violent extremism;
   Preserving Constitutional rights and due process for all 
        persons;
   Protecting critical infrastructure from physical and cyber 
        attacks, including technology used in public elections;
   Creating equity and fairness in our Nation's immigration 
        policies by addressing fairness for TPS and DACA recipients; 
        and
   Strengthening the capacity of the Department of Homeland 
        Security to meet the challenges posed by natural disasters--
        including pandemics.
    As a former Chair and Ranking Member of the Homeland Security's 
Subcommittee on Border Security, my commitment to securing our Nation's 
borders and protecting the homeland from terrorist attacks remains 
unwavering.
    The United States has a Federal policy supported by laws that 
govern how non-citizens are to be treated, and the rights and well-
being of the most vulnerable are to be met when in U.S. custody.
    I visited CBP facilities when tens of thousands of unaccompanied 
children were arriving at the border weekly during the previous 
administration and observed how DHS met the challenge of receiving 
them, feeding them, and placing them safely in the custody of the 
Department of Health and Human Services was routinely met.
    I was shocked to learn in December 2018, that 2 children died in 
separate incidents while in the custody of the U.S. Border Patrol, 
which were the first deaths of children in Border Patrol custody in 
more than a decade.
    Following the deaths of the 2 children in 2018, U.S. Customs and 
Border Protection, the Border Patrol's parent agency, issued an interim 
directive in January 2019 establishing new medical screening and 
assessment procedures for children taken into custody.
    CBP issued a final directive regarding enhanced medical screening 
procedures in December 2019. At the committee's request, the Government 
Accountability Office (GAO) reviewed CBP's compliance with its new 
procedures. GAO will issue its findings in a report to be released to 
the public the day of the committee's hearing.
    In January 2019, this committee requested documents related to 
these deaths.
    After the Department of Homeland Security (DHS) failed to produce 
all requested documents, the committee issued a subpoena for the 
documents in November 2019.
    DHS has still not produced all the documents demanded by the 
subpoena, and documents that have been produced have had extensive and 
improper redactions.
    The DHS inspector general conducted reviews of the 2 children's 
deaths and issued public summaries of its reviews a year after the 
children's deaths.
    The committee has identified significant deficiencies with both 
reviews.
    The committee also found that the inspector general omitted key 
information from the public summary of one of its reviews, rendering 
the summary inaccurate and potentially misleading.
    Because of the deficiencies of the inspector general's 
investigations of the children's deaths and the on-going failure of DHS 
to comply with committee document requests, we lack full and complete 
information regarding the circumstances in which these deaths occurred.
    In addition, many questions regarding the adequacy of CBP medical 
procedures remain unanswered.
    It is important that those within the Department of Homeland 
Security, including its component agencies, comply with the law and 
respond to the oversight authority of Congressional and Senate 
Oversight Committees.
                            border security
    Real border security cannot be achieved by building a wall on the 
Southern Border, blocking asylum seekers, or separating children from 
their parents.
    These things are in fact making border security more difficult, 
creating unnecessary tensions with our neighbors in Mexico, Central, 
and South America while here at home these policies appeal to anti-
American nativist views.
    Our Nation must and should look at all threats, from those who seek 
to cross our borders by air, who may try to exploit our maritime 
borders, or who cross either of our land borders with intent to smuggle 
or do harm, and develop a strategy to implement thoughtful, proven, and 
fair solutions to keep America secure.
    To further strengthen security along our border, the practice of 
impeding persons outside of our borders in Mexico undermines the 
enforcement of immigration law, treaties, and proper application of 
Federal regulations intended to assure safety and security.
    This practice is called ``metering'', and it is creating 
unnecessary hardship for people seeking entry and fermenting a toxic 
environment where men, women, and children are being held under 
conditions that can easily lead to deteriorating health and safety 
conditions.
                temporary protected status and dreamers
    I strongly advocate for a crucial legislative fix for debate and 
vote that will provide permanent legal residence and a path to 
citizenship to the more than 800,000 Dreamers, including the 124,000 
who live in Texas, whose lives have been turned upside down because of 
this administration's cruel, unwise, and reckless termination of DACA, 
the Deferred Action for Childhood Arrivals program.
    And in connection with legislation to protect Dreamers, I will 
insist that the administration rescind the revocation of Temporary 
Protected Status (TPS) for Haiti, El Salvador, and Honduras, or failing 
that, TPS for those countries be extended by Congressional legislation.
    There are 44,800 residents of Texas who are TPS holders from El 
Salvador (36,300), Honduras (8,400), and Haiti, who combined are 
parents of 53,800 U.S.-born children in Texas and 14,000 of whom have 
home mortgages.
    These TPS holders are integral members of the Texas's social 
fabric, having lived in Texas an average of 20 years, and contribute an 
aggregate $2.2 billion to the Texas economy.
    I look forward to today's hearing and learning more from our 
witnesses.
    Thank you. I yield back the balance of my time.

    Chairman Thompson. I now welcome our panel of witnesses. 
Our first witness is Dr. Fiona--I hope I get it right, Danaher 
a pediatrician at Massachusetts General Hospital, Chelsea 
Healthcare Center, and a member of the hospital's child 
protection team. She's also an instructor in pediatrics at 
Harvard Medical School. Dr. Danaher is a graduate of Mount 
Sinai School of Medicine.
    Our second witness is Dr. Roger A. Mitchell, Jr., the chief 
medical examiner for Washington, DC. Dr. Mitchell, Jr. is 
board-certified in anatomic and forensic pathology by the 
American Board of Pathology and a fellow in the National 
Association of Medical Examiners. He began the study of 
forensic science as a forensic biologist for the Federal Bureau 
of Investigation in 1997. Dr. Mitchell is a graduate of the New 
Jersey Medical School.
    Our third witness is the Honorable Joseph V. Cuffari. He 
was confirmed as the Department of Homeland Security's 
inspector general on July 25, 2019. Dr. Cuffari previously 
served as a policy adviser for Military and Veteran Affairs for 
the Governors of Arizona. He also served more than 40 years in 
the United States Air Force. Dr. Cuffari earned a Ph.D. in 
management in 2002.
    Our final witness is Ms. Rebecca Gambler, a director in the 
Government Accountability Office, Homeland Security and Justice 
team. Ms. Gambler joined GAO in 2002, and currently leads the 
agency's work on border security immigration and election 
issues.
    Without objection, the witnesses' full statements will be 
inserted in the record. I now ask each witness to summarize his 
or her statement for 5 minutes, beginning with Dr. Danaher.

  STATEMENT OF FIONA S. DANAHER, M.D., M.P.H., PEDIATRICIAN, 
   CHELSEA PEDIATRICS, CHILD PROTECTION TEAM, MASSACHUSETTS 
 GENERAL HOSPITAL, INSTRUCTOR IN PEDIATRICS AT HARVARD MEDICAL 
                             SCHOOL

    Dr. Danaher. Good morning, Chairman Thompson, Ranking 
Member Rogers, and Members of the committee. Thank you for the 
opportunity to testify before you today.
    I am Dr. Fiona Danaher, a pediatrician at Massachusetts 
General Hospital for Children, where much of my clinical work 
focuses on the care of children in immigrant families. It is a 
privilege to participate in this committee's efforts to improve 
the care of children in U.S. Customs and Border Protection 
custody.
    As you know, in December 2018, 2 young children fleeing 
entrenched poverty in their rural Guatemalan villages became 
the first migrant children without underlying medical 
conditions to die in U.S. custody in a decade. Jakelin Caal 
Maquin, age 7, died from septic shock, which, because it went 
untreated over many hours, cascaded into multiple organ 
failure. Felipe Gomez-Alonso, age 8, died from untreated 
influenza complicated by pulmonary hemorrhage in the context of 
bacterial pneumonia and sepsis.
    Their deaths as well as those of 4 other children in 
Government custody between September 2018 and May 2019 
underscore the deficiencies in an immigration system poorly 
designed to protect the well-being of vulnerable children.
    Review of available records makes clear that Jakelin and 
Felipe both suffered terrifying and painful deaths that could 
potentially have been prevented by timely access to pediatric 
medical care.
    In both cases, medical examiners determined the children 
had died of natural causes and the OIG concluded there was no 
misconduct or malfeasance by DHS personnel. However, death by 
natural causes does not mean that death was inevitable. Lack of 
misconduct or malfeasance or even the great efforts several 
agents went to in assisting the children does not absolve CBP 
as an agency of perpetuating systems that placed children at 
risk for medical neglect.
    CBP responded to Jakelin and Felipe's deaths by issuing an 
interim enhanced medical efforts directive in January 2019 to 
ensure that all children under the age of 18 received health 
interviews and medical screenings while in CBP custody. 
However, the final enhanced medical support efforts directive 
issued by CBP in December 2019 removed many of the safeguards 
instituted under the interim guidance, weakening it so much 
that, had it been in place at the time of Jakelin and Felipe's 
presentations, it is unlikely its provisions would have 
prevented their deaths.
    Children are not little adults. Their remarkable 
physiological resilience can mask severe disease from those 
untrained to recognize it. Any period of detention is 
inherently unhealthy for children's long-term physical and 
emotional development, but detention in substandard conditions 
places children's very lives at risk.
    If children are to be detained in CBP facilities, it is 
incumbent upon the agency to strengthen its medical 
infrastructure. Jakelin and Felipe's deaths illustrate the need 
for CBP to eliminate bureaucratic hurdles that unnecessarily 
prolong detention and delay access to medical care. They also 
highlight the urgency of addressing detention conditions that 
promote illness and its spread.
    Children in detention need timely access to comprehensive 
medical screenings in their native language conducted by 
clinicians with pediatric expertise, followed by referral, as 
appropriate, to pediatric medical centers.
    Those diagnosed with illnesses or underlying medical 
conditions should not return to detention facilities, which are 
fundamentally unequipped to provide safe observation or promote 
children's recuperation.
    Teams of agents working in remote areas must include EMTs 
with enhanced pediatric training. And all forward operating 
bases and Border Patrol stations must be stocked with basic 
pediatric medical equipment and with staff trained in its use. 
CBP must implement the Centers for Disease Control and 
Prevention's recommendations for the prevention of influenza 
and COVID-19 at its facilities.
    Independent oversight of the quality of medical care 
provided to detainees needs to occur regularly, as the OIG 
indicated in its own capping report that it does not possess 
the necessary medical expertise for the task.
    Given the current COVID-19 epidemic and the impending 
arrival of another influenza season, time is of the essence. 
Action must be taken now to apply the lessons learned from 
Jakelin and Felipe's tragic deaths so that other children do 
not meet similarly painful and preventable fates while in 
custody of the U.S. Government.
    Thank you, and I look forward to taking your questions.
    [The prepared statement of Dr. Danaher follows:]
                 Prepared Statement of Fiona S. Danaher
                             July 15, 2020
                              introduction
    In December 2018, 2 young children fleeing entrenched poverty in 
their rural Guatemalan villages became the first migrant children 
without underlying medical conditions to die in U.S. custody in a 
decade. Jakelin Caal Maquin, age 7, died from septic shock which, 
because it went untreated over many hours, cascaded into multiple organ 
failure. Felipe Gomez-Alonso, age 8, died from untreated influenza 
complicated by pulmonary hemorrhage in the context of bacterial 
pneumonia and sepsis. Both children suffered terrifying and painful 
deaths that could potentially have been prevented by timely access to 
pediatric medical care. Their deaths, as well as those of 4 other 
children in Government custody between September 2018 and May 2019, 
underscore the deficiencies in an immigration system poorly designed to 
protect the well-being of vulnerable children.
                         systemic inadequacies
    Review of the circumstances surrounding Jakelin and Felipe's deaths 
suggests that multiple systemic inadequacies in CBP's management of 
child detainees align to place them at risk for grave harm.
   Inadequate screening.--Initial medical screening for Jakelin 
        consisted of one agent shouting to the large group of migrants 
        with whom she was apprehended that those who were sick should 
        come forward. This cursory process assumed that all the 
        migrants would hear the agent, understand Spanish, and feel 
        comfortable disclosing their medical concerns in front of many 
        other people. Not surprisingly, Jakelin was not the only sick 
        child in the group who went unidentified as a result. 
        Completing any further health screening at the forward 
        operating base where she was apprehended was not standard 
        operating procedure at the time. Additional screening did not 
        occur until after the first bus, which was supposedly reserved 
        for medically vulnerable migrants, had already left the remote 
        base for the Border Patrol station. The screening form used for 
        the health interview did not ask about specific symptoms of 
        illness like fever or vomiting, nor did it ask about chronic 
        medical conditions. The CBP agents who completed Jakelin's 
        health interview while she waited for the second bus did not 
        have appropriate qualifications to do so, did not base their 
        finding that Jakelin was ``mentally alert'' on the child's 
        current presentation (she was asleep), and did not conduct the 
        interview in the family's native language.
    It is unclear from available records whether Felipe received any 
        medical screening during the 6 days in CBP custody before he 
        began to show signs of illness.
   Inadequate training.--In both Jakelin and Felipe's cases, 
        CBP agents' lack of basic understanding of pediatric disease 
        processes led to deadly delays in accessing medical care. 
        Jakelin was suffering from sepsis, an overwhelming, systemic 
        infection that can rapidly progress to multiple organ failure. 
        Early signs of sepsis can be subtle and particularly 
        challenging to identify in children, who compensate well for 
        the ensuing cascade of organ dysfunction until their bodies 
        have exhausted all metabolic reserves. It is well-established 
        in emergency and critical care medicine that every hour of 
        delay in accessing treatment for sepsis dramatically increases 
        mortality risk, such that it is standard of care for patients 
        to receive antibiotics within 1 hour of presentation. The 
        remote forward operating base where Jakelin was apprehended was 
        not staffed with any EMTs, and standard operating procedure at 
        the time was to defer health interviews until detainees could 
        be transferred to a Border Patrol station nearly 100 miles 
        away. Given the poor screening Jakelin received at the base, it 
        is impossible to know at what point she became critically ill 
        in the approximately 7 hours that elapsed between her 
        apprehension and her father's request for medical assistance, 
        but because the agents did not recognize the urgency of the 
        situation or call an ambulance to meet them en route to the 
        Border Patrol station, an additional 2 hours elapsed before she 
        received any medical attention. By the time she finally 
        received antibiotics--which appears not to have happened until 
        she reached the hospital nearly 12 hours after apprehension and 
        more than 4 hours after her father sought help--she was too 
        sick to be saved.
    The agents at the highway checkpoint where Felipe was detained also 
        seem not to have recognized the severity of his illness. He was 
        observed having abdominal pain and difficulty breathing hours 
        before he became critically ill, yet agents did not push for 
        Felipe to return to the hospital at that time. As he grew 
        sicker, Felipe undoubtedly experienced significant respiratory 
        distress and excruciating pain. Both he and his father stated 
        they thought he was going to die, yet the agents still 
        interpreted no urgency to the situation, allowing 73 minutes to 
        elapse from his father's request for medical care until arrival 
        of transport. Felipe became unconscious as he was loaded into 
        the CBP cruiser and was pulseless by the time he reached the 
        hospital.
   Inadequate equipment and supplies.--The medical room at the 
        Border Patrol station where Jakelin first received treatment 
        was not stocked with basic medical equipment like oxygen, 
        airway kits, trauma kits, or defibrillators, forcing EMT agents 
        to leave her side to find them. The station lacked pediatric-
        sized equipment like a pulse oximeter or blood pressure cuff to 
        assess Jakelin's vital signs. The highway checkpoint where 
        Felipe stayed was not stocked with basic medications like 
        acetaminophen or ibuprofen, and MedPAR would not cover them, 
        forcing CBP agents to pay out of pocket for medications to 
        manage Felipe's fever and pain.
   Inadequate access to pediatric expertise.--Before receiving 
        medical attention, Jakelin was transferred almost 100 miles out 
        of the way to a Border Patrol station that was another 160 
        miles from the nearest children's hospital. Weeks after 
        Jakelin's death, the Hidalgo County Manager sent an urgent 
        request for assistance to the New Mexico congressional 
        delegation and Governor-elect, noting, ``Our Hidalgo County 
        Emergency Medical Services team consists of 7 full-time 
        employees and 5 volunteers'' to cover 5,000 square miles.\1\ 
        About 10 percent of an EMT's training hours in New Mexico are 
        dedicated to pediatrics, amounting to just 4 hours for an EMT 
        Basic or 6 hours for a paramedic.\2\ The Hidalgo County 
        Emergency Medical Services director stated, ``Border Patrol 
        needs more than EMTs. They need . . . someone of a higher 
        level, so people get proper screenings. But they are not set up 
        for it. They were never set up for families coming across.''\1\
---------------------------------------------------------------------------
    \1\ Villagran L. Southern New Mexico medical facilities strained to 
meet the needs of migrants. Las Cruces Sun News. https://www.lcsun-
news.com/story/news/local/2019/02/05/nm-hospital-health-care-clinic-
migrants-asylum-seekers-ice/2743352002/. Published February 5, 2019. 
Accessed July 11, 2020.
    \2\ New Mexico EMS Bureau. Continuing Education and Renewal Guide 
for EMT Licensure. https://www.nmhealth.org/publication/view/guide/
1894/. Published 2019. Accessed July 12, 2020.
---------------------------------------------------------------------------
    Gerald Champion Regional Medical Center, the local hospital where 
        Felipe received care, does not have a dedicated pediatric 
        emergency department, inpatient unit or ICU. This lack of 
        pediatric expertise is reflected in the management he received 
        during his first emergency room visit, including failure to 
        recognize troubling vital signs, failure to reassess him prior 
        to discharge, prescription of an antibiotic for a viral 
        infection at a dose that would be subtherapeutic for a child 
        even if treating a bacterial infection, failure to prescribe 
        antiviral medication for influenza, and failure to notify CBP 
        of the child's diagnosis despite knowing he was returning to a 
        congregate setting where other detainees might be placed at 
        risk for contracting the disease.\3\
---------------------------------------------------------------------------
    \3\ Gerald Champion Regional Medical Center. Association of Health 
Care Journalists website. http://www.hospitalinspections.org/report/
26235. Accessed July 11, 2020.
---------------------------------------------------------------------------
   Prolonged detention in conditions that promote illness.--
        Felipe was detained in CBP facilities for 6 days, twice as long 
        as the 72-hour maximum generally permitted under CBP's National 
        Standards on Transport, Escort, Detention, and Search 
        (TEDS).\4\ The maximum incubation period for influenza is 4 
        days, so Felipe unquestionably contracted influenza while he 
        was in CBP detention. Felipe passed through multiple crowded 
        CBP facilities, and records suggest that he was cold and sleep-
        deprived, all of which likely contributed to development of his 
        illness. Multiple published reports indicate that conditions 
        which promote vulnerability to infection are common in CBP 
        facilities: Overcrowding, abnormally cold temperatures, 
        inadequate access to shower facilities and basic hygiene 
        products (e.g., soap, toothbrushes, sanitary napkins), open 
        toilets, poor sleep conditions (sleeping on mats, cement 
        benches or floors under mylar blankets with 24 hour artificial 
        light exposure, in some cases without adequate space to lie 
        down), inadequate nutrition, inadequate access to clean 
        drinking water, and confiscation of needed medications without 
        supplying replacements.\5\ \6\ \7\ \8\ \9\ Such conditions not 
        only promote disease, but also inhibit recovery. As the 
        American Academy of Pediatrics has stated, children like Felipe 
        who are diagnosed with illness or special health care needs 
        should not be returned to CBP facilities, as ``the conditions 
        in the centers themselves exacerbate children's suffering'' and 
        are not conducive to recuperation.\10\
---------------------------------------------------------------------------
    \4\ U.S. Customs and Border Protection. National Standards on 
Transport, Escort, Detention, and Search. October 2015.
    \5\ Linton JM, Griffin M, Shapiro AJ, AAP COUNCIL ON COMMUNITY 
PEDIATRICS. Detention of Immigrant Children. Pediatrics. 
2017;139(5):e20170483. doi: 10.1542/peds.2017-0483.
    \6\ ACLU and University of Chicago Law School. Neglect and Abuse of 
Unaccompanied Immigrant Children by U.S. Customs and Border Protection. 
https://www.aclusandiego.org/civil-rights-civil-liberties/. Published 
May 2018. Accessed July 11, 2020.
    \7\ Cuffari JV. Office of Inspector General, Department of Homeland 
Security. Capping Report: CBP Struggled to Provide Adequate Detention 
Conditions During 2019 Migrant Surge. https://www.oig.dhs.gov/sites/
default/files/assets/2020-06/OIG-20-38-Jun20.pdf. Published June 12, 
2020. Accessed July 11, 2020.
    \8\ Halevy-Mizrahi NR, Harwayne-Gidansky I. Medication 
Confiscation: How Migrant Children Are Placed in Medically Vulnerable 
Conditions. Pediatrics. 2020; 145(1):e20192524. doi: 10.1542/peds. 
2019-2524.
    \9\ Peeler KR, Hampton K, Lucero J, Ijadi-Maghsoodi R. Sleep 
deprivation of detained children: Another reason to end child 
detention. Health and Human Rights. 2020;22(1):317-320. https://
www.hhrjournal.org/2020/01/sleep-deprivation-of-detained-children-
another-reason-to-end-child-detention/. Accessed July 11, 2020.
    \10\ Testimony for the Record on Behalf of the American Academy of 
Pediatrics Before the U.S. House of Representatives Committee on 
Homeland Security, Subcommittee on Border Security, Facilitation, & 
Operations. Assessing the Adequacy of DHS Efforts to Prevent Child 
Deaths in Custody. https://downloads.aap.org/DOFA/
Jan%202020%20Hearing%20Statement%20for%20- the%20Record%20%20AAP.pdf. 
Published January 14, 2020. Accessed July 11, 2020.
---------------------------------------------------------------------------
   Inability to appropriately isolate and monitor ill 
        detainees.--The agents responsible for monitoring Felipe when 
        he returned from his first trip to the hospital had limited 
        options for doing so safely: They could either observe him 
        closely in the ``bubble'' processing area, where he potentially 
        exposed staff and other detainees to infection, or place him in 
        a rear cell where observation was more challenging. It seems 
        that once he was back in his cell, agents only checked on him 
        through the door, even after they were made aware that his 
        condition was declining. (Publicly-released video footage of 
        the influenza-related death of Carlos Gregorio Hernandez 
        Vasquez, another child in CBP custody who was placed in a cell 
        to convalesce, suggests that documented wellness checks may not 
        always in fact occur.)\11\
---------------------------------------------------------------------------
    \11\ Moore R. Six Children Died in Border Patrol Care. Democrats in 
Congress Want to Know Why. Pro Publica. https://www.propublica.org/
article/six-children-died-in-border-patrol-care-democrats-in-congress-
want-to-know-why. Published January 13, 2020. Accessed July 6, 2020.
---------------------------------------------------------------------------
   Frequent transfers between crowded facilities promote 
        disease spread.--Felipe passed through 4 overcrowded facilities 
        in 6 days. Studies have demonstrated that ``frequent 
        interfacility transfers, influence disease transmission 
        dynamics. Rapid turnover creates an inflow of people in rapidly 
        consecutive cohorts (a `revolving doors' effect). An inflow of 
        susceptible people within a closed or semi-open community 
        experiencing an outbreak, has been shown to slow the creation 
        of herd immunity and can act as a transmission amplifier, while 
        interfacility transfers can facilitate disease spread.''\12\ 
        The infection control challenges posed by overcrowding and 
        frequent transfers are underscored by the fact that Felipe's 
        young cellmate developed influenza symptoms the day after 
        Felipe's death.
---------------------------------------------------------------------------
    \12\ Riccardo F, Suk JE, Espinosa L, et al. Key Dimensions for the 
Prevention and Control of Communicable Diseases in Institutional 
Settings: A Scoping Review to Guide the Development of a Tool to 
Strengthen Preparedness at Migrant Holding Centres in the EU/EEA. Int J 
Environ Res Public Health. 2018;15(6):1120. doi:10.3390/ijerph15061120.
---------------------------------------------------------------------------
   Bureaucratic barriers to care and release.--Paperwork seems 
        to have delayed medical evaluation in both Jakelin and Felipe's 
        cases. When Jakelin's group was apprehended, agents at the 
        forward operating base decided to complete the I-779 health 
        interview forms but had to wait for them to be delivered from 
        the Border Patrol station 2 hours away, so the first bus of 
        migrants was already loaded by the time the forms arrived. When 
        an agent first attempted to take Felipe to the hospital, agents 
        had to make multiple phone calls to determine how to find the 
        appropriate paperwork, which was being kept at a station 15 
        miles away. His second presentation to the emergency room was 
        also delayed because agents collected paperwork before checking 
        in on him.
    Equally troubling are the bureaucratic and technological barriers 
        leading to Felipe's prolonged detention in the first place. Had 
        he been released sooner, his exposure to influenza--which 
        occurred at least 2 days into his detention--might have been 
        prevented.
   Inadequate language capabilities.--All verbal communication 
        between CBP agents and Felipe and Jakelin's fathers occurred in 
        Spanish, despite the fact that neither are native Spanish 
        speakers. CBP does not systematically utilize effective tools 
        for identifying speakers of indigenous languages, who often 
        understand limited Spanish but feel pressured to communicate in 
        the language.\13\ Felipe's medical providers utilized a CBP 
        agent rather than their own certified medical interpretation 
        service to communicate information in Spanish regarding 
        Felipe's care, significantly increasing the risk of medical 
        errors.\14\ All consents and discharge paperwork were provided 
        in English and verbally translated by the CBP agent, which 
        raises the question of how much Felipe's father understood 
        about reasons to seek additional medical care. (Despite 
        documenting in the medical record that Felipe's father 
        verbalized understanding of the discharge instructions, 
        Felipe's nurse later acknowledged to CMS investigators that he 
        could not confirm if the father actually comprehended.)\3\ 
        Jakelin's health interview was similarly conducted in Spanish, 
        which likely contributed to delays in identifying her illness.
---------------------------------------------------------------------------
    \13\ Gentry B. Indigenous Language Speaking Immigrants (ILSI) in 
the U.S. Immigration System, a technical review. http://
www.amaconsultants.org/uploads/Exclusion_of_Indigenous- 
%20Languages_in_US_Immigration_System_19_June2015version_i.pdf. 
Published May 26, 2015. Accessed July 6, 2020.
    \14\ Flores G, Laws MB, Mayo SJ, et al. Errors in medical 
interpretation and their potential clinical consequences in pediatric 
encounters. Pediatrics. 2003;111(1):6-14. doi:10.1542/peds.111.1.6.
---------------------------------------------------------------------------
   Lack of privacy.--Expecting detainees to disclose 
        potentially sensitive medical information in front of large 
        groups of other migrants upon apprehension at the border is 
        unrealistic. Despite an agent shouting to the group of migrants 
        with whom Jakelin traveled for those who were ill to come 
        forward, none did, and at least 2 sick children were missed as 
        a result. A recent OIG report includes photographs which 
        suggest that medical screenings in Border Patrol stations also 
        occur in large groups, affording detainees no privacy.\7\ Some 
        may hesitate to disclose their medical conditions in front of 
        other migrants with whom they share close quarters, for fear of 
        being stigmatized or receiving blame when other migrants fall 
        ill.
   Lack of autonomy.--When Jakelin's father sought assistance 
        for his sick daughter from multiple agents at the forward 
        operating base, he was repeatedly told he would have to wait 
        until they reached the Border Patrol station, so he ceased to 
        advocate during transit even as she began to experience trouble 
        breathing. Detaining families robs parents of the autonomy to 
        make independent decisions about accessing medical care for 
        their children. Families in detention depend upon CBP agents 
        for all necessities and for timely processing; they may even 
        think that their familial integrity depends upon CBP agents' 
        good graces, given CBP's recent history of separating thousands 
        of families under the previous Zero Tolerance Policy. This 
        power dynamic engenders fear and poses a significant barrier to 
        requesting and accessing help.
               cbp response: enhanced medical directives
    In January 2019, CBP responded to Jakelin and Felipe's deaths by 
issuing an Interim Enhanced Medical Efforts Directive to ensure that 
all children under the age of 18 received health interviews and medical 
screenings while in CBP custody.\15\ However, the final Enhanced 
Medical Support Efforts Directive issued by CBP in December 2019 
removed many of the safeguards instituted under the interim 
guidance.\16\ The final directive:
---------------------------------------------------------------------------
    \15\ U.S. Department of Homeland Security, U.S. Customs and Border 
Protection. CBP DIRECTIVE NO. 2210-003: CBP Interim Enhanced Medical 
Efforts. https://www.cbp.gov/sites/default/files/assets/documents/2019-
Mar/CBP-Interim-Medical-Directive-28-January-2019.pdf. Published 
January 28, 2019. Accessed July 12, 2020.
    \16\ U.S. Department of Homeland Security, U.S. Customs and Border 
Protection. CBP DIRECTIVE NO. 2210-004: Enhanced Medical Support 
Efforts. https://www.cbp.gov/sites/default/files/assets/documents/2019-
Dec/CBP_Final_Medical_Directive_123019.pdf. Published December 30, 
2019. Accessed July 12, 2020.
---------------------------------------------------------------------------
   Does not explicitly require the health interview to occur 
        upon initial processing unless a detainee volunteers a medical 
        concern;
   Narrows the scope of a basic medical screening to no longer 
        specify inclusion of vital signs;
   Mandates medical screenings only for children under 12 or 
        those with identified medical issues ``subject to availability 
        of resources and operational requirements,'' instead of for all 
        children under 18--despite the fact that 2 of the children who 
        died in CBP custody in 2019 were 16 years old;
   Seems to reduce the qualifications required for performing 
        medical screenings, stating they will be conducted by health 
        care providers ``where available,'' and that CBP EMS personnel 
        may conduct them ``in exigent circumstances and based on 
        operational requirements'';
   Permits ``basic, acute medical care, referral, and follow 
        up'' to occur on-site, which would further limit access to 
        health care providers with pediatric expertise. (CBP has 
        contracted with a small number of pediatric advisors to offer 
        consultation and training along the Southwest Border, but the 
        advisors generally do not provide direct patient care to 
        detainees.)\10\
    Neither directive specifies the time frame within which children 
must receive medical screening, and the final directive again places 
the onus on parents to advocate to CBP agents for their children to 
receive timely medical attention.
                             imminent risks
    The limited scope of the protocols vaguely outlined in CBP's final 
Enhanced Medical Support Efforts Directive will do little to protect 
children in its custody from the threats posed by the upcoming 
influenza season, the current COVID-19 outbreak, and other medical 
emergencies that children will undoubtedly experience.
    Half of the recent deaths of migrant children in Government custody 
have been attributed to complications from influenza. Multiple 
evidence-based strategies exist for preventing such deaths, including 
offering the influenza vaccine to detainees, mandating vaccination for 
staff working with detained populations, instituting comprehensive 
screening and triage protocols, ensuring that those with potential 
cases of influenza receive antiviral therapy like oseltamivir as soon 
as possible and no more than 48 hours after onset of symptoms, offering 
antiviral chemoprophylaxis to vulnerable detainees who may have been 
exposed to index cases, minimizing overcrowding, providing appropriate 
space for isolation and convalescence, and ensuring adequate access to 
basic hygiene supplies like soap, hand sanitizer, and face masks. Teams 
from the Centers for Disease Control and Prevention (CDC) visited CBP 
facilities shortly after Jakelin and Felipe's deaths and made similar 
recommendations.\17\ Yet CBP has explicitly stated it will not offer 
influenza vaccination to detainees in its custody, and just 6 months 
after Jakelin and Felipe's deaths, the Government argued in court that 
maintaining ``safe and sanitary'' conditions in CBP detention did not 
even require providing children with soap.\18\
---------------------------------------------------------------------------
    \17\ Letter from Director of the Centers for Disease Control and 
Prevention Dr. Robert Redfield to the Honorable Rosa DeLauro at 10-11. 
https://www.warren.senate.gov/imo/media/doc/
CDC%20Response%20%20migrant%20vaccination.pdf. Published November 7, 
2019. Accessed July 6, 2020.
    \18\ Flynn M. Detained migrant children got no toothbrush, no soap, 
no sleep. It's no problem, government argues. Washington Post. https://
www.washingtonpost.com/nation/2019/06/21/detained-migrant-children-no-
toothbrush-soap-sleep/. Published June 21, 2019. Accessed July 6, 2020.
---------------------------------------------------------------------------
    The present COVID-19 epidemic lends even more urgency to improving 
detention conditions and medical screening protocols. COVID-19 is more 
contagious than influenza, and can cause extremely rapid and 
unpredictable deterioration even in previously healthy individuals. 
While children generally seem less vulnerable to the immediate effects 
of COVID-19 infection (with notable exceptions among infants and those 
with chronic medical conditions), some do become seriously ill with 
COVID-19 symptoms, and others go on to develop the recently recognized 
Multisystem Inflammatory Syndrome in Children (MIS-C) weeks after 
primary infection. MIS-C is a poorly understood, dangerous condition 
that can develop in children who may never have shown previous symptoms 
of COVID-19. Its symptoms are vague--fever and any of a broad array of 
cardiopulmonary, gastrointestinal, neurologic, mucocutaneous, and other 
systemic manifestations--and identifying the condition and its 
potentially life-threatening complications requires nuanced, pediatric-
specific clinical acumen along with extensive laboratory testing. In a 
recent study of MIS-C cases across the United States--most of which (73 
percent) occurred among previously healthy children--80 percent of 
children required intensive care, 48 percent required medications to 
maintain adequate blood pressure, 20 percent required mechanical 
ventilation, 8 percent developed coronary artery aneurysms, and 2 
percent died.\19\ Children detained in remote settings without adequate 
medical screening and rapid access to pediatric expertise will be at 
particular risk for poor outcomes from COVID-19 and MIS-C, including 
long-term disability and death. The CDC has issued interim guidance on 
management of COVID-19 in detention facilities--including social 
distancing, provision of personal protective equipment, and enhanced 
hygiene recommendations, along with other measures similar to those 
recommended for influenza prevention--to which CBP should adhere.\20\
---------------------------------------------------------------------------
    \19\ Feldstein LR, Rose EB, Horwitz SM, et al. Multisystem 
inflammatory syndrome in U.S. children and adolescents. N Engl J Med. 
June 29, 2020. doi: 10.1056/NEJMoa2021680.
    \20\ Interim Guidance on Management of Coronavirus Disease 2019 
(COVID-19) in Correctional and Detention Facilities. Centers for 
Disease Control and Prevention website. https://www.cdc.gov/
coronavirus/2019-ncov/community/correction-detention/guidance-
correctional-detention.html. Updated May 7, 2020. Accessed July 6, 
2020.
---------------------------------------------------------------------------
                              conclusions
    Jakelin and Felipe's deaths could potentially have been prevented 
had CBP established better systems to ensure adequate medical screening 
and prompt access to pediatric medical care. The missed opportunities 
preceding their deaths highlight that:
   Children are not little adults. Their remarkable 
        physiological resilience can mask severe disease from those 
        untrained to recognize it.
   Any period of detention is inherently unhealthy for 
        children's long-term physical and emotional development, as the 
        American Academy of Pediatrics has repeatedly stated, but 
        detention in substandard conditions places children's very 
        lives at risk.
   If children are to be detained in CBP facilities, it is 
        incumbent upon the agency to strengthen its medical 
        infrastructure. CBP must eliminate bureaucratic hurdles that 
        unnecessarily prolong detention and delay access to medical 
        care; address detention conditions that promote illness and its 
        spread; and provide timely access to comprehensive medical 
        screenings in a detainee's native language, conducted by 
        clinicians with pediatric expertise, followed by referral as 
        appropriate to pediatric medical centers. Children diagnosed 
        with illnesses or underlying medical conditions should not be 
        returned to detention facilities, which are fundamentally 
        unequipped to provide safe observation or promote children's 
        recuperation.
   Teams of agents working in remote areas must include EMTs 
        with enhanced pediatric training, and all forward operating 
        bases and Border Patrol stations must be stocked with basic 
        pediatric medical equipment and staff trained in its use.
   CBP must implement CDC's recommendations for the prevention 
        of influenza and COVID-19 in its facilities.
   Independent oversight of the quality of medical care 
        provided to detainees must occur regularly, as the OIG has 
        indicated it does not possess the necessary medical expertise 
        for the task.\7\
    While CBP has increased the number of medical providers it employs 
at the border, few have specific pediatric training, and most screening 
continues to be performed by CBP agents.\7\ CBP has yet to demonstrate 
any real commitment to improving the care it provides, as underscored 
both by the weakening of its Enhanced Medical Support Efforts 
Directive, and by recent revelations that the agency utilized line item 
appropriations for ``consumables and medical care'' to fund its canine 
program and purchase dirt bikes and riot helmets.\21\ Action must be 
taken now to apply the lessons learned from Jakelin and Felipe's 
untimely deaths, so that other children do not meet similarly painful 
and preventable fates while in custody of the U.S. Government.
---------------------------------------------------------------------------
    \21\ Armstrong TH. U.S. Government Accountability Office. Matter 
of: U.S. Customs and Border Protection--Obligations of Amounts 
Appropriated in the 2019 Emergency Supplemental. File B-331888. 
Published June 11, 2020.

    Chairman Thompson. Thank you very much for your testimony. 
I now recognize Dr. Mitchell to summarize his statement for 5 
minutes.

   STATEMENT OF ROGER A. MITCHELL, JR., M.D., CHIEF MEDICAL 
EXAMINER, OFFICE OF THE CHIEF MEDICAL EXAMINER, WASHINGTON, DC, 
   CLINICAL PROFESSOR OF PATHOLOGY AT THE GEORGE WASHINGTON 
UNIVERSITY, ASSOCIATE PROFESSOR OF SURGERY AT HOWARD UNIVERSITY

    Dr. Mitchell. Good afternoon, Chairman Thompson, Ranking 
Member Rogers, and Members of the Committee on Homeland 
Security. I am Dr. Roger Mitchell, Jr., and I currently serve 
as the chief medical examiner of Washington, DC.
    It brings me no pleasure to testify today on these deaths 
in custody, but I appreciate the confidence of the committee in 
asking me to do so. I have been asked to review the cases of 
Jakelin Caal Maquin and Felipe Gomez-Alonso from the medical 
examiner's perspective, specifically postmortem findings, the 
autopsy report cause, and manner of death.
    I have been studying deaths in custody for over 20 years. 
Although when we think about deaths in custody, we are reminded 
of deaths like George Floyd and Rayshard Brooks. Deaths in 
custody occur under a continuum, a continuum that moves through 
phases like arrest-related, pre-arrest-related, and more 
importantly, for this case, in custody and incarceration, which 
is short-term and long-term jail detention.
    In addition, I have served as the chair of the Child and 
Infant Fatality Review Committee for the District of Columbia 
from 2014 to 2019. This committee had been tasked to review 
infant and child deaths for the purposes of creating system-
centered recommendations intended to improve outcomes. This is 
the lens in which I reviewed these following cases.
    We know that Jakelin Caal Maquin was a 7-year-old female 
child who was apprehended with her father on the U.S. border 
and found to have a temperature of 105 and then subsequently 
airlifted to a hospital where she was pronounced dead over 24 
hours later. Jakelin suffered from septic complications from a 
bacterial infection. The initial laboratory and autopsy 
findings are consistent with bacterial sepsis. It is important 
to note that sepsis can progress to organ failure and shock 
rapidly. Therefore, early recognition and treatment are 
critical.
    So based upon the materials I had to review, and it is my 
opinion that the cause and manner of death established by those 
medical examiners is sufficient.
    It is also my opinion that this death was preventable. 
Although the actions taken by individual Border Patrol agents 
seemed to be appropriate and timely, the larger Border Patrol 
system lacks adequate human resources and physical 
infrastructure to respond to medically fragile detainees, 
especially children.
    If the administration of the initial health assessment 
questionnaire had been performed by a licensed medical 
professional, the elevated body temperature would have been 
detected and maybe have saved a life.
    The next case, Felipe Gomez-Alonso, we know is an 8-year-
old male child who was apprehended with his father at the U.S. 
border. They were detained at 3 different Border Patrol 
stations before it was known that he was sick. He was found to 
have a temperature of 103. Now, he was transported to a local 
hospital, diagnosed with an upper respiratory infection, 
prescribed medication and released, but then had to come back 
because of a worsening condition and was pronounced shortly 
after.
    Felipe suffered complications of a flu viral infection 
associated with a superimposed bacterial disease, a bacterial 
infection again. The bacteria isolated were associated with an 
aggressive exotoxin in a very highly contagious bacteria that 
is particularly contagious in close quarters and conditions of 
overcrowding. This exotoxin leads to severe rapidly progressing 
hemorrhagic pneumonia, or necrotizing pneumonia. Based upon the 
review of the materials available, it is my opinion that there 
should have been highlighting of this necrotizing pneumonia in 
the diagnosis, but nonetheless, a bacterial infection that led 
to the death of this young child. The manner of death is 
natural.
    It is my opinion that this death also was preventable. 
Overcrowding is a known condition of the Border Patrol 
stations, and I believe that the overcrowding conditions may 
have played a significant role in the infections that led to 
Felipe's death. There are many missed opportunities to provide 
life-saving care to this child, namely, the hospital's 
mismanagement of this initial presentation.
    However, again, if there was a licensed medical 
professional who would have cared for this patient while at the 
Border Patrol station during this initial assessment, then 
there may have been a more informed assessment prior to his 
initial presentation at the hospital, and may have led to 
better outcomes.
    So what are my recommendations? Well, enforcing control of 
the population of the U.S. Border Patrol station to protect 
against overcrowding; utilize medical personnel for the initial 
health assessment of detainees, especially children; accompany 
this initial assessment with a brief health screening 
assessment, like touchless temperature checks and blood 
pressure, glucose finger sticks or even a COVID nasal swab in 
this environment; and develop an on-site clinical system for 
the U.S. Border Patrol that has the ability to triage pediatric 
patients. Maybe even electronic health records seeing that 
these patients move from Border Patrol station to Border Patrol 
station, and then retraining of our agents.
    In conclusion, immediate and timely access to health care 
assessment by a licensed trained medical professional could 
have prevented the death of both Jakelin and Felipe. The death 
of both these 2 children are symptoms of a more extensive 
system that requires much improvement. No system is perfect, 
but any system that is established by our Government must have, 
at its core, the health and safety of all who come into contact 
with it.
    The cases of these 2 children must remind us that deaths in 
custody are not merely a criminal justice issue, but a public 
health warning. We must provide timely, accurate, and reliable 
care, not only in the detention centers of our borders, but, 
also, the streets of our cities, the jails of our counties, and 
the prisons of our States.
    I appreciate the work that this committee is doing to solve 
this problem. I pray that this hearing does not only provide an 
appearance of addressing the issue that I have outlined, but a 
true call to action with resolutions. This may require your 
dedication to this Nation beyond what is comfortable for some, 
but I believe it is attainable.
    Thank you, Chairman Thompson, and Members of the committee. 
I am now available for any questions that you may have.
    [The prepared statement of Dr. Mitchell follows:]
              Prepared Statement of Roger A. Mitchell, Jr.
                              introduction
    Good afternoon, Chairman Thompson, Ranking Member Rogers, and the 
Members of the Committee on Homeland Security, my name is Dr. Roger A. 
Mitchell, Jr., and I currently serve as the chief medical examiner for 
Washington, DC. It brings me no pleasure to testify today on these 
deaths in custody, but I appreciate the confidence of the committee in 
asking me to do so. I take seriously the task that has been set before 
me. I have been asked to review the cases of Jakelin Caal Maquin and 
Felipe Gomez-Alonso from the medical examiner's perspective; 
specifically the post-mortem findings, the autopsy report, the cause of 
death, and the manner of death.
    Before we get into the specifics of the cases, I would like to 
provide some foundational elements related to the role the medical 
examiner in the investigation, examination, certification, and 
reporting of deaths in custody.
    The medicolegal death investigation (MLDI) system in the United 
States (U.S.) comprises both coroners and medical examiners. The 
difference between these 2 types of systems varies based upon the 
jurisdiction, as there is a lack of uniformity of how the MLDI system 
is implemented across the Nation. In general, coroners are elected 
officials who do not possess a medical education. In contrast, medical 
examiners are board-certified forensic pathologists and are appointed 
by governmental leadership. Both systems require that sudden and 
unexpected deaths be reported to ensure proper investigation, 
examination, and certification. Types of cases include homicides, 
suicides, accidents, undetermined deaths, and even natural causes of 
death. Also, most jurisdictions require the reporting of the sudden 
deaths among children and those who die in the justice system's 
custody. We see both criteria in the cases that we will discuss today.
    I have been studying deaths in custody for over 20 years. Deaths of 
men such as Amidou Diallo (NY) and Earl Faison (NJ) forced me to think 
about deaths in custody as a public health issue. Although much of what 
we think about when we hear the term ``deaths in custody'' are the 
recent, prominent cases like the deaths of George Floyd and Rayshard 
Brooks, we must remember that deaths in custody occur on a continuum. 
The continuum moves through four (4) distinct phases with the overlap 
of each period. The deaths in custody phases include: (1) Pre-arrest 
related (during pursuit); (2) arrest-related (apprehension and 
transport); (3) in-custody (in short-term holding, detention, and 
jail); and (4) incarcerated (long-term jail, detention, or prison).\1\ 
\2\ Additional deaths in custody can occur during judicial executions 
and post-custody (death within 1 year of release from jail or prison). 
Most of the Deaths in Custody occur from natural causes within the 
correctional system (jail, detention, or prison).\3\
---------------------------------------------------------------------------
    \1\ Mitchell RA Jr, Diaz F, Goldfogel GA, et al. National 
Association of Medical Examiners Position Paper: Recommendations for 
the Definition, Investigation, Postmortem Examination, and Reporting of 
Deaths in Custody. Acad Forensic Pathol. 2017;7(4):604-618. 
doi:10.23907/2017.051
    \2\ Frazer E, Mitchell RA Jr, Nesbitt LS, et al. The Violence 
Epidemic in the African American Community: A Call by the National 
Medical Association for Comprehensive Reform. J Natl Med Assoc. 
2018;110(1):4-15. doi:10.1016/j.jnma.2017.08.009
    \3\ Russo, Joe, Dulani Woods, John S. Shaffer, and Brian A. 
Jackson, Caring for Those in Custody: Identifying High-Priority Needs 
to Reduce Mortality in Correctional Facilities. Santa Monica, CA: RAND 
Corporation, 2017. https://www.rand.org/pubs/research_reports/
RR1967.html.
---------------------------------------------------------------------------
    In addition, I served as the chair of the Child and Infant Fatality 
Review Committee for Washington, DC from 2014-2019. The committee is 
tasked with the review of infant and child deaths for the purpose of 
creating system-centered recommendations intended to improve outcomes 
and prevent future deaths. During my tenure the committee reviewed 
nearly 700 deaths.
    It is with this lens that I review the following cases:
                          jakelin caal-maquin
    Materials Reviewed.--Department of Homeland Security--Office of the 
Inspector General, Report of Investigation (I19-BP-ELP-05501).
Brief History/Timeline
    On December 6, 2018, Jakelin Caal-Maquin (Caal-Maquin), a 7-year-
old female child, and her father were apprehended by U.S. Customs and 
Border Patrol (US-CBP) attempting entrance into the United States. 
During the transportation from the location of apprehension to the US 
Border Patrol (USBP) station (93 miles/2 hours away), US-CBP agents 
were informed that Caal-Maquin complained of fever and vomiting. US-CBP 
agents called ahead of their arrival to the USBP station, informing 
them of a sick child on the bus. Caal-Maquin was found to have a 
temperature of 105.7 degrees upon arrival at the USBP station were 
Emergency Medical Technicians (EMT) tended to her, providing oxygen and 
cold compress. Caal-Maquin was witnessed to have a ``seizure.'' She was 
subsequently air-lifted to an area hospital from the USBP station. 
Caal-Maquin was pronounced dead on December 8, 2018.
   December 6, 2018
     2115--Caal-Maquin encountered entering the U.S. Border.
   December 7, 2018
     0500--Caal-Maquin identified and communicated as sick and 
            vomiting
     0630--Caal-Maquin arrives at USBP station; met by EMT
     0640--County Emergency Management Services (EMS) arrives 
            at USBP station
     0650--Emergency air ambulance service identified and 
            contacted
     0730--Emergency air ambulance service arrives at USBP 
            station
     0745--Emergency air ambulance service departs USBP station 
            with Caal-Maquin for hospital
     0850--Emergency air ambulance service arrives with Caal-
            Maquin at hospital
     1100--Caal-Maquin goes into cardiac arrest and is revived.
   December 8, 2018
     0035--Caal-Maquin pronounced dead at the hospital.
Autopsy and Post-Mortem Findings
    Cause of Death.--Sequelae of Streptococcal Sepsis.
    Manner of Death.--Natural.
Pathological Findings:
    I. Sequelae of Streptococcal Sepsis
    a. Clinical Evidence of Disease
      i. Increased Temperature--105.7 degrees
      ii. Disseminated Intravascular Coagulation (DIC)
      iii. Metabolic Acidosis
    b. Required Fluid Resuscitation
      i. Bilateral Pleural Effusions
        1. 160 milliliters--Right
        2. 180 milliliters--Left
      ii. Peritoneal fluid retention
        1. 210 milliliters
    c. Patchy Bronchopneumonia, bilateral, base
      i. Pulmonary Congestion
      ii. Histological evidence of acute inflammation and gram-positive 
            cocci
        1. Immunohistochemistry staining positive for Streptococcus 
            species
        2. Real-time polymerase chain reaction (RT-PCR) positive for 
            Streptococcus species
    d. Splenic Involvement
      i. Histological evidence of reactive changes
      ii. Immunohistochemistry staining positive for Streptococcus 
            species
    e. Hepatic Involvement
      i. Immunohistochemistry staining positive for Streptococcus 
            species
    f. Adrenal Gland
      i. Hemorrhage and necrosis consistent with Waterhouse-
            Friderichsen Syndrome
      ii. Immunohistochemistry staining positive for Streptococcus 
            species
      iii. Real-time polymerase chain reaction (RT-PCR) positive for 
            Streptococcus species
    II. Ascaris Lumbricoides Infection
    a. 2-3 dozen nematodes of different sizes in the small bowel
      i. Duodenum, proximal jejunum, near the ileocecal valve
        1. No bowel obstruction.
                            summary opinion
    The decedent is a 7-year-old female child who suffered septic 
complications from a bacterial infection. The subspecies of 
Streptococcus were unable to be determined; therefore, it is unclear 
the specific bacterial cause of the child's infection. Nonetheless, the 
clinical, laboratory, and autopsy findings are consistent with 
bacterial sepsis. According to the literature, sepsis is defined as a 
clinical syndrome resulting from a dysregulated systemic inflammatory 
response to infection. It is the leading cause of morbidity and 
mortality in children world-wide.\4\ It is important to note that 
sepsis can progress to organ failure and shock rapidly. Therefore, 
early recognition and treatment are critical. Initial treatment 
includes immediate fluid resuscitation. The report also describes the 
presence of Waterhouse-Friderichsen Syndrome (WFS). WFS is 
characterized by hemorrhagic necrosis of the adrenal glands 
accompanying vague symptoms of fever, fatigue, and weakness. According 
to an article in the Pediatric Infectious Disease Journal, WFS can be 
linked to streptococcal infections.\5\
---------------------------------------------------------------------------
    \4\ Plunkett A, Tong J. Sepsis in children [published correction 
appears in BMJ. 2015;350:h3704]. BMJ. 2015;350:h3017. Published 2015 
Jun 9. doi:10.1136/bmj.h3017
    \5\ Gertner M, Rodriguez L, Barnett SH, Shah K. Group A beta-
hemolytic Streptococcus and Waterhouse-Friderichsen syndrome. Pediatr 
Infect Dis J. 1992;11(7):595-596. doi:10.1097/00006454-199207000-00019
---------------------------------------------------------------------------
    Based on the review of the material available to this forensic 
pathologist, it is my opinion that the cause and manner of death 
established by the medical examiner are sufficient. It is also my 
opinion is that this death was preventable. Although the actions taken 
by individual US-CBP agents seem to be appropriate and timely, the 
larger US-CBP system lacks adequate human resources and physical 
infrastructure resources to respond to medically fragile detainees, 
especially children. If the administration of the initial health 
assessment questionnaire (I-779) had been performed by a licensed 
medical professional (nurse practitioner, physician assistant, or 
nurse), the elevated body temperature would have been detected.
    The above opinion is established within a reasonable degree of 
medical certainty.
Recommendations
   Utilize medical personnel (physician, physician assistant, 
        nurse practitioner, or nurse) for the initial health assessment 
        of detainees, especially children.
     Update the initial medical assessment form (I-779) to be 
            administered by licensed health care providers.
       Accompanied by brief initial health screening including 
            touchless temperature check, blood pressure, glucose finger 
            stick, and COVID nasal swab.
   Develop an on-site clinic system for US-CBP that has the 
        ability to triage pediatric patients (i.e. pediatric blood 
        pressure cuffs).
   Establish electronic health record (EHR) for US-CBP.
   Assess and reevaluate training for US-CBP.
   Develop or improve emergency and acute care access standard 
        operating procedure.
                          felipe gomez-alonso
    Materials Reviewed.--Department of Homeland Security-Office of the 
Inspector General, Report of Investigation (I19-BP-ELP-06106), Autopsy 
Report, Autopsy Photographs, Case Notes, Microbiology Report, 
Toxicology Report, and Histology Slides.
    Brief History/Timeline.--On December 18, 2018, Filipe Gomez-Alonso 
(Gomez-Alonso), an 8-year-old male child, and his father were 
apprehended by U.S. Customs and Border Patrol (US-CBP) attempting 
entrance into the United States. They were detained at the first US-
Border Patrol (USBP) station until December 20, 2018. They were 
transferred to a second USBP station because of limited space. Gomez-
Alonso and his father were finally moved to a third USBP station on 
December 23, 2018. On December 24, 2018, Gomez-Alonso was found to have 
``a loud, hoarse cough,'' complaining of a sore throat, upset stomach, 
and a fever.
    Alonso-Gomez was subsequently transported to the local hospital 
emergency room. Clinicians at the hospital saw him. He was, found to 
have a temperature of 103 F. A pharyngeal swab was positive for 
influenza, and he was diagnosed with an upper respiratory infection 
(URI). Alonso-Gomez was prescribed acetaminophen and an antibiotic and 
released from the hospital.
    Alonso-Gomez was transported back to the USBP station by US-CBP 
agents. Reportedly, he seemed to improve over the next several hours 
before an acute decline in his health status. He complained of severe 
stomach pain and vomiting, which required urgent transportation back to 
the hospital. Upon arrival at the hospital, Gomez-Alonso was found to 
be in cardiopulmonary arrest. He was pronounced dead on December 24, 
2018.
   December 18, 2018
     1525--Gomez-Alonso encountered entering the U.S. Border 
            and transported to the first USBP station
   December 20, 2018
     1200--Gomez-Alonso transported to second USBP station due 
            to overcrowding
     Remained at second USBP station
   December 23, 2018
     2317--Gomez-Alonso transported to the third USBP station
   December 24, 2018
     0100-0557--Gomez-Alonso arrival and intake process 
            complete at the third USBP station
     0900--Gomez-Alonso requires medical attention
     0930--Gomez-Alonso arrives at hospital
     1345--Gomez-Alonso diagnosed with Influenza B, provided 
            with prescriptions for acetaminophen and amoxicillin and 
            released from the hospital
     1700--Gomez-Alonso given medications back at the USBP 
            station
     1800--Wellness check of Gomez-Alonso by USBP agents
     1930--Wellness check of Gomez-Alonso by USBP agents
     2100--Wellness check of Gomez-Alonso by USBP agents
     2145--Gomez-Alonso requests to return the hospital
     2200--USBP assigned transportation
     2258--Gomez-Alonso transported to the hospital
     2315--Gomez-Alonso arrives at hospital and receives 
            emergency treatment
     2348--Gomez-Alonso is pronounced dead.
Autopsy and Post-Mortem Findings
    Cause of Death.--Complications of Influenza B infection with 
Staphylococcus aureus superinfection and sepsis.
    Manner of Death.--Natural.
Pathological Findings
    I. Complications of Influenza B infection with Staphylococcus 
aureus superinfection and sepsis.
    a. Clinical Findings at the Initial Hospital Visit
      i. Temperature--103.46F
      ii. Peripheral Pulse--146 bpm
      iii. Oxygen Saturation (SpO2)--91 percent
      iv. Influenza B--Test positive (12/24/2018)
    b. Necrotizing Pneumonia (Pulmonary Hemorrhage and Edema)
      i. Bronchopneumonia, marked
        1. Diffuse alveolar damage
        2. Bacterial blood and lung cultures positive for Methicillin 
            Sensitive Staphylococcus aureus (MSSA)
          a. Immunohistochemical and Real-Time Polymerase Chain 
            Reaction (RT-PCR)--Positive
          b. Panton-Valentine leucocidin (PVL)--Positive
        3. Influenza B virus positive by Real-Time Polymerase Chain 
            Reaction (RT-PCR).
Summary Opinion
    The decedent is an 8-year-old male child who suffered complications 
of influenza viral infection associated with a superimposed bacterial 
disease. According to the Infectious Disease Pathology Branch (IDPB) of 
the Centers for Disease Control (CDC), the bacteria isolated were 
methicillin-sensitive Staphylococcus aureus (MSSA) with associated 
Panton-Valentine leucocidin (PVL) exotoxin. It is a significant factor 
that led to the death. MSSA is highly contagious, particularly in close 
quarters or conditions of overcrowding. PVL-positive MSSA is a severe 
infection, often associated with influenza disease, that leads to 
rapidly progressing necrotizing pneumonia.\6\
---------------------------------------------------------------------------
    \6\ Karli A, Yanik K, Paksu MS, et al. Disseminated Panton-
Valentine Leukocidin-Positive Staphylococcus aureus infection in a 
child. Arch Argent Pediatr. 2016;114(2):e75-e77. doi:10.5546/
aap.2016.eng.e75
---------------------------------------------------------------------------
    Based upon the review of material available to this forensic 
pathologist, it is my opinion that the cause of death should read 
Necrotizing pneumonia due to methicillin-sensitive Staphylococcus 
aureus complicating Influenza B viral infection. The manner of death is 
natural.
    It is also my opinion that this death was preventable. Overcrowding 
is a known condition of the USBP stations. I believe the overcrowded 
conditions played a significant role in the decedent developing the 
infections that led to his death. Although the actions taken by 
individual US-CBP agents seem to be appropriate and timely, the larger 
US-CBP system lacks adequate human resources and physical 
infrastructure to respond to medically fragile detainees, especially 
children. There were many missed opportunities to provide life-saving 
care to this child, namely the hospital's mismanagement of his initial 
presentation. However, if a licensed medical professional (nurse 
practitioner, nurse, or physician assistant) would have cared for this 
patient throughout his stay within the detention station, the patient 
would have had a more informed assessment before presenting to the 
hospital during his initial visit and beyond.
    The above opinion is established within a reasonable degree of 
medical certainty.
Recommendations
   Enforce and control the population in USBP stations to 
        protect against overcrowding.
   Utilize medical personnel (physician, physician assistant, 
        nurse practitioner, or nurse) for initial health assessment of 
        detainees, especially children.
     Update the initial medical assessment form (I-779) to be 
            administered by licensed health care providers.
         Accompanied by brief initial health screening 
            including touchless temperature check, blood pressure, 
            glucose finger stick, and COVID nasal swab.
   Develop an on-site clinic system for US-CBP that has the 
        ability to triage pediatric patients (i.e. pediatric blood 
        pressure cuffs).
   Establish electronic health record (EHR) for US-CBP.
   Assess and reevaluate training for US-CBP agents.
   Develop or improve emergency and acute care access standard 
        operating procedure.
                               conclusion
    In conclusion, immediate and timely access to a health care 
assessment by licensed and trained medical professionals could have 
prevented the deaths of both Jakelin Caal Maquin and Felipe Gomez-
Alonso. The deaths of these 2 children are a symptom of a more 
extensive system that requires much improvement. No system is perfect, 
but any system established by our Government must have at its core the 
health and safety of all who come into contact with it. There is an 
excellent opportunity to make the necessary investment to ensure life-
saving medical care to sick men, women, and children. The cases of 
these 2 children remind us that deaths in custody are not merely a 
criminal justice issue, but a public health issue. We must treat those 
who die in the custody of our detention system as preventable, 
revealing a system that is able to improve.
    In 2017, the National Institute of Justice (NIJ) in collaboration 
with the RAND Justice Policy Program hosted an expert panel of prison 
and jail administrators, researchers and health care professionals 
entitled, Caring for Those in Custody: Identifying High-Priority Needs 
to Reduce Mortality in Correctional Facilities.\3\ I had the pleasure 
of serving on this panel, and what we realized is that those who find 
themselves incarcerated, for whatever the reason, either arrive with or 
acquire health conditions that become the responsibility of the 
institution. We have an obligation to make sure that all who come into 
our custody receive timely, accurate, and reliable care. We must 
provide reliable care in the detention centers of our borders, but also 
on the streets of our cities, the jails of our counties, and the 
prisons of our States.
    I appreciate the work that this committee is doing to solve this 
problem. I pray that this hearing does not only provide an 
``appearance'' of addressing the issues that I have outlined, but is a 
true ``call to action'' with resolutions. This may require your 
dedication to this Nation beyond what is comfortable, but I believe it 
is attainable. Thank you, Chairman Thompson and Members of the 
committee. I am now available to answer any questions that you may 
have.

    Chairman Thompson. Thank you, Doctor, for your testimony.
    I now recognize Inspector General Cuffari to summarize his 
statement for 5 minutes.

    STATEMENT OF JOSEPH V. CUFFARI, INSPECTOR GENERAL, U.S. 
                DEPARTMENT OF HOMELAND SECURITY

    Mr. Cuffari. Good afternoon, Chairman Thompson, Ranking 
Member Rogers, and Members of the committee. Thank you for 
inviting me to discuss our work related to children in CBP 
custody.
    My testimony today will include a discussion of our 
investigations of the deaths of the 2 migrant children while in 
CBP custody, the findings of our unannounced inspections of CBP 
facilities, and an overview of our data-driven, risk-based 
audits, inspections, and investigations.
    No parent should have to go through the devastation of 
losing a child. My deepest condolences go out to the families 
who suffered this terrible loss. I am a parent and a new 
grandparent myself. I find the deaths of both children 
heartbreaking. Although they died within 18 days of each other 
and less than 100 miles apart, each circumstance was unique and 
our office conducted separate investigations. The scope of both 
investigations was to determine the circumstances of the in-
custody deaths of the children, including any form of 
misconduct by CBP personnel.
    We dedicated several special agents to each investigation, 
along with multiple support staff. We were augmented by CBP, 
OPR in one case. In total, we conducted 44 interviews between 
the 2 investigations, we reviewed voluminous medical records 
and reports. Neither investigation found misconduct or 
malfeasance on the part of CBP personnel. In fact, both 
investigations determined that the CBP employees involved 
exhibited great concern for the children's welfare and obtained 
medical treatment without delay.
    During fiscal year 2019, CBP experienced a surge in 
families and unaccompanied children crossing the Southwest 
Border, and apprehended more than twice the undocumented aliens 
during fiscal year 2019, than in any other previous 4 full 
fiscal years. Our office has, for many years, conducted 
unannounced inspections at CBP facilities to evaluate their 
compliance with CBP's transport, escort, detention, and search 
standards known as your TEDS standards. During our unannounced 
visits, we focus our elements of the TEDS standards that can be 
observed and evaluated by our inspectors without specialized 
law enforcement or medical training.
    We recently issued a capping report summarizing our 2019 
unannounced inspections. Our inspections found medical coverage 
varied by facility. The facilities we did visit generally met 
the TEDS standards for access to medical care. Nevertheless, 
crowded conditions presented health challenges, including 
containing the spread of contagious diseases. Given these 
observations, we have initiated an audit of CBP policies and 
procedures for handling medical intervention and detention. 
With the surge in apprehension in 2019, we observed more and 
severe overcrowding, and recommended that DHS take immediate 
steps to alleviate it. Our capping report supplemented that 
recommendation and made 2 additional recommendations related to 
telephone access to unaccompanied children and proper handling 
of detainee property.
    DHS is on track to implement these recommendations by the 
end of this calendar year. Given our observations of detainees 
being held beyond the 72 hours generally permitted in TEDS 
standards, we also initiated a review which is on-going, to 
identify the key factors contributing to prolonged CBP 
detention.
    We have more than 20 other on-going or planned projects 
reviewing ICE and CBP. We appreciate the committee's continued 
interest in our work and for Congress' robust funding this 
current fiscal year. With your increased funding, we are 
contracting for medical professionals to supplement our 
expertise across audits, inspections, and investigations. I am 
pleased to report this contract will be awarded in the next few 
weeks.
    In October 2019, I personally observed the conditions at 
the Southwest Border when I visited DHS facilities and 
operations in both El Paso and the Tucson areas. Our office 
continues to monitor the situation at the border and recommend 
improvements to DHS programs and operations.
    Mr. Chairman, this concludes my testimony. Thank you for 
the opportunity to discuss our important work here today and I 
am happy to answer your or the Members' questions that you may 
have. Thank you.
    [The prepared statement of Mr. Cuffari follows:]
                Prepared Statement of Joseph V. Cuffari
                             July 15, 2020
    Chairman Thompson and Ranking Member Rogers, thank you for the 
opportunity to testify today about the Department of Homeland Security 
(DHS) Office of Inspector General's (OIG)'s work related to children in 
U.S. Customs and Border Protection (CBP) custody. My testimony today 
will include a discussion of our investigations of the tragic deaths of 
2 migrant children while in CBP custody, our unannounced inspections of 
CBP facilities, and related on-going work.
    OIG is organized into 3 operational elements: The Office of 
Investigations, comprised of special agents who investigate criminal 
and administrative misconduct on the part of DHS personnel, 
contractors, and grantees; the Office of Special Reviews and 
Evaluations, comprised of inspectors, analysts, and attorneys who 
inspect, evaluate, and review DHS programs and operations; and the 
Office of Audits, comprised of auditors and analysts who conduct 
financial, grant, and performance audits.
    My testimony today includes work by all 3 of our organizational 
units; specifically, our special agents who investigated the 
circumstances of 2 children who died in CBP custody in December 2018; 
our inspectors who conduct unannounced inspections of CBP holding 
facilities; and our auditors who have on-going work relevant to the 
committee's interests here today.
    My testimony today includes a discussion of the conditions on the 
Southwest Border in late 2018 and throughout 2019. Prior to my 
confirmation by the Senate in July 2019, I committed to your 
counterparts on the Senate Homeland Security Committee that I would 
visit the Southwest Border and observe these conditions personally if 
confirmed. After my confirmation, I also personally committed to this 
committee to do the same. I was able to do so in October 2019, when I 
visited DHS facilities and operations in both the El Paso and Tucson 
Sectors.
      investigations of the death of children while in cbp custody
    On December 8, 2018, a 7-year-old girl from Guatemala died while in 
CBP custody. Subsequently, on December 25, 2018, an 8-year-old boy 
passed away while in CBP custody. DHS OIG Special Agents from our El 
Paso Field Office conducted 2 separate investigations to determine the 
circumstances of the in-custody deaths of both children, including any 
form of misconduct by CBP personnel, and if misconduct was found, to 
determine if it was criminal or administrative.\1\
---------------------------------------------------------------------------
    \1\ These investigations were not intended to be systemic reviews 
that would evaluate CBP's policies or procedures for caring for 
migrants in custody or from which over-arching conclusions about CBP's 
role could be drawn. While these investigations were not program 
evaluations of CBP procedures, we do have an on-going audit regarding 
CBP's procedures for detained migrants experiencing serious medical 
conditions.
---------------------------------------------------------------------------
    Both of our investigations determined that all CBP employees who 
were involved did everything possible to ensure both children received 
medical treatment. Our investigations did not find misconduct or 
malfeasance on the part of any CBP personnel.
    Although the deaths of these 2 children occurred within 18 days of 
each other and less than 100 miles apart, each circumstance was unique 
and our office conducted separate investigations of each death. I will 
provide the committee a summary of each investigation, beginning with 
the death of the 7-year-old girl.
        investigation concerning the death of a 7-year-old girl
    The 7-year-old girl and her father entered the United States on 
December 6, 2018 and were apprehended by Border Patrol agents with a 
large group of undocumented aliens at Forward Operating Base (FOB) 
Bounds, near the Antelope Wells, New Mexico, Port of Entry. During 
intake processing, Border Patrol agents conducted brief medical 
assessrnents of all detainees in the group and memorialized the 
assessments on the required form (I-779). DHS OIG reviewed the form for 
the girl and found that it was signed by her father and reported that 
both the child and her father were in good health. Border Patrol made 
arrangements to transport the detained migrants by bus from FOB Bounds 
to the Border Patrol station in Lordsburg, New Mexico, 93 miles away, 
for further processing and for short-term detention. Because the group 
was large, the bus would need to make 2 round trips to transport them. 
Prior to transport, the group of undocumented aliens, to include the 
girl and her father, were asked again by Border Patrol agents if anyone 
was sick, pregnant, or was an unaccompanied child. DHS OIG was told 
that if anyone met these conditions, it was CBP's practice that they 
would be assigned to the first bus going to the Lordsburg station for 
processing. According to the interviews we conducted, no one came 
forward with these conditions.
    Our investigation determined that because the Border Patrol was not 
aware of the child's illness, she and her father were assigned to the 
second bus transporting the undocumented aliens to the Lordsburg 
station. While boarding the bus, the child's father reported to one of 
the drivers that she was sick and vomiting. The driver notified his 
supervisor, who called ahead to the Lordsburg station, notifying them 
that there was a sick child on the bus.
    According to our interviews, during transport to the Lordsburg 
station, the girl's father did not report to CBP that she was vomiting. 
However, according to interviews of the other bus passengers, the 
father did approach several other riders to ask for medicine for his 
daughter. When the bus arrived at the Lordsburg station, the child and 
her father were the first ones off the bus and were immediately met by 
the CBP paramedic on duty.
    The girl's father reported to the paramedic that she was not 
breathing. After the paramedic performed a quick assessment, he 
determined that the child was breathing, but was having difficulty, and 
asked someone to call 911. Two additional CBP EMTs joined to assist 
with assessing and providing care to the child. Her father reported to 
the EMTs that she had not eaten and had been throwing up for the last 2 
to 4 days. The paramedics took her temperature and discovered she had a 
fever of 105.7 degrees Fahrenheit. They administered oxygen with a mask 
and applied ice packs and wet towels in an attempt to cool her down. 
They were unable to provide children's Tylenol to the child because she 
could not swallow. Similarly, the paramedics were unable to intubate 
her because a manipulation of her mouth would have caused her to vomit.
    County Emergency Medical Services (EMS) arrived approximately 10 
minutes after the 911 call. The EMS staff performed life support 
measures, including oxygen and intravenous fluids, and recommended that 
the child be transported to the hospital by ground transport, which 
would have taken approximately 2 hours. Due to her worsening condition, 
the Lordsburg station paramedic recommended she be transported by air, 
to get her to the hospital faster. The air support was cleared to f1y 
and arrived at the Lordsburg station approximately 40 minutes after it 
was requested. The child was transported to El Paso Children's 
Hospital--a level I trauma center.
    The child arrived at the Hospital in El Paso, TX on December 7, 
2018 and passed away on December 8, 2018. The medical examiner's report 
concluded that she died from organ dysfunction caused by sepsis, a 
rapidly progressive infection, and systemic bacterial spread.
    DHS OIG received notice of the child's death on December 14, 2018 
from CBP OPR and immediately initiated an investigation. The OIG 
conducted the first interviews on December 15, 2018.
    We dedicated 7 agents and 2 support staff to investigate her death. 
Our investigation included interviews with approximately 23 individuals 
who had direct contact with the child and her father, or may have 
witnessed her condition. These individuals included Border Patrol 
agents and apprehended detainees who had contact with the child and her 
father. We reviewed all audio and video evidence that was available; 
including 8 DVDs of video footage and recorded radio communications. We 
also reviewed the detailed medical examiner's report documenting the 
causes of death. Our investigation did not reveal any evidence of CBP 
employee malfeasance or misconduct.
        investigation concerning the death of an 8-year-old boy
    An 8-year-old boy and his father were apprehended in El Paso, Texa 
on December 18, 2018. They were processed at the Paso Dd Norte Station 
and then transferred to the El Paso Station due to detention space 
limitations. They remained at the El Paso Station until December 23, 
2018, when they were transferred to Alamogordo, New Mexico to complete 
processing and then transferred to Highway 70 Alamogordo Checkpoint to 
await family placement.
    On December 24, 2018, while at the Highway 70 Alamogordo 
Checkpoint, a Border Patrol agent observed the child in need of medical 
attention. The boy and his father were transported to the Gerald 
Champion Regional Medical Center for treatment. According to our 
interviews, while at the hospital, a medical professional administered 
acetaminophen to the child and informed his father that he had an upper 
respiratory infection. The corresponding hospital discharge paperwork 
also stated the child was diagnosed with an upper respiratory infection 
but prescribed ibuprofen. Medical records reviewed by OIG from the 
emergency room visit stated the diagnosis was a suspected acute upper 
respiratory infection and noted ``low suspicion for any serious medical 
infection.''
    Hospital records reviewed by OIG indicated that the child was 
tested for Strep, Influenza A, and Influenza B during his first visit 
to the hospital. According to the records, the test for Influenza B was 
positive and the tests for Strep and Influenza A were negative. 
Hospital personnel did not tell Border Patrol or the child's father 
that he was diagnosed with Influenza B. The hospital discharge 
paperwork also did not include a diagnosis of Influenza B.
    According to our interviews, the hospital called in a prescription 
to a nearby pharmacy for acetaminophen and amoxicillin. The hospital 
discharge paperwork; however, references only a prescription for 
ibuprofen. On their return trip from the hospital, the Border Patrol 
agent stopped at the pharmacy to fill the prescriptions; however, he 
was told that one prescription was not ready and the other would not be 
covered under insurance. The agent, the child, and the child's father 
left the pharmacy with no prescriptions.
    That evening, a second Border Patrol agent went back to the 
pharmacy to pick up both prescriptions. and paid for one of them with 
his personal funds. When he returned, the child was given both 
medications. Approximately an hour after receiving the medications, the 
child's father reported that the child was feeling better and had 
eaten. However, later that night, the child's father requested to 
return to the hospital because his son was feeling ill again. A Border 
Patrol agent drove the child and his father to the Gerald Champion 
Regional Medical Center again.
    Upon arriving at the hospital, the Border Patrol agent found the 
child's father holding him and crying. The agent observed blood on the 
father's hand. The child received immediate attention from the hospital 
staff, but was pronounced dead a short time later.
    The State medical examiner's autopsy report found the cause of the 
child's death was ``complications of influenza B infection with 
Staphylococcus aureus superinfection and sepsis.''
    DHS OIG received notice of the child's death from CBP's Office of 
Professional Responsibility (OPR), on December 25, 2018, and initiated 
an investigation into the circumstances surrounding the death that same 
day. Because this was the second death investigation of a child in CBP 
custody in a short time frame, and because a large number of OIG agents 
were already assigned to the investigation of the death of the 7-year-
old girl, the OIG decided to leverage assistance from CBP OPR with 
conducting specific parts of the investigation, for example interviews.
    Our investigation included interviews with 11 individuals who had 
direct or indirect contact with the child and his father. These 
individuals included Border Patrol agents, apprehended detainees who 
had contact with the child and his father, and the Public Information 
Officer at the Gerald Champion Regional Medical Center. We reviewed 
video footage of the child and his father's initial apprehension, 
footage from their holding cell at Alamogordo, and footage from the 
Gerald Champion Regional Medical Center. We also reviewed the detailed 
medical examiner's report documenting the causes of death. Our 
investigation did not reveal any evidence of CBP employee malfeasance 
or misconduct.
    Upon the conclusion of both investigations, we posted summaries of 
the investigations on our public website. While we are prohibited by 
privacy laws from posting full OIG reports of investigation, in an 
effort to be transparent about OIG's work, we determined in these 
instances that public summaries were appropriate. We provided both 
reports to the committee after receiving a written request from the 
Chairman. We have also provided 2 briefings to committee staff 
regarding the investigations, and exchanged written correspondence with 
the committee regarding several outstanding questions.
   dhs office of inspector general's unannounced inspections of cbp 
                               facilities
    DHS OIG initiated an unannounced inspections program several years 
ago in response to concerns raised by Congress about conditions for 
aliens in CBP and U.S. Immigration and Customs Enforcement (ICE) 
custody.\2\
---------------------------------------------------------------------------
    \2\ Since 2014, DHS OIG has issued the following reports regarding 
unannounced inspections of CBP detention facilities: Capping Report: 
CBP Struggled to Provide Adequate Detention Conditions During 2019 
Migrant Surge (OIG-20-38), Management Alert--DHS Needs to Address 
Dangerous Overcrowding and Prolonged Detention of Children and Adults 
in the Rio Grande Valley (OIG-19-51), Management Alert--DHS Needs to 
Address Dangerous Overcrowding Among Single Adults at El Paso Del Norte 
Processing Center (OIG-19-46), Results of Unannounced Inspections of 
Conditions for Unaccompanied Alien Children in CBP Custody (OIG-18-87), 
Oversight of Unaccompanied Children 3 (Oct. 2, 2014), Oversight of 
Unaccompanied Children 2 (Aug. 28, 2014), Oversight of Unaccompanied 
Children 1 (July 30, 2014).
---------------------------------------------------------------------------
    CBP is responsible for providing short-term detention for aliens 
arriving in the United States without valid travel documents in 
compliance with the National Standards on Transport, Escort, Detention, 
and Search (TEDS).\3\ TEDS standards govern CBP's interactions with 
detained individuals, providing guidance on things like duration of 
detention, access to medical care, access to food and water, and 
hygiene.
---------------------------------------------------------------------------
    \3\ U.S. Customs and Border Protection, National Standards on 
Transport, Escort, Detention, and Search, October 2015.
---------------------------------------------------------------------------
    TEDS standards generally limit detention in CBP facilities to 72 
hours, with the expectation that CBP will transfer unaccompanied alien 
children (UAC) to the Department of Health and Human Services (HHS) 
Office of Refugee Resettlement, and families and single adults to ICE 
long-term detention facilities. As such, CBP's holding facilities are 
intended for short-term custody, which is evident in how they are 
structured and equipped. Although the infrastructure can vary across 
different facilities, most CBP facilities hold detainees in locked 
cinderblock cells that have a metal combined toilet and sink. 
Facilities generally do not have beds, though some have plastic-covered 
foam mattresses, and only some facilities have showers. Further, most 
facilities are not equipped to wash laundry or cook meals; facilities 
generally do not have cloth blankets and rely on Mylar blankets for 
bedding, and staff use microwaves or warming ovens to heat frozen food 
or prepare other food items, such as instant soup or oatmeal.
    OIG's unannounced inspections of CBP holding facilities evaluate 
compliance with TEDS and determine whether CBP provides reasonable care 
to detainees, from apprehension to holding. During our unannounced 
visits to ports of entry and Border Patrol facilities, we focus on 
elements of the TEDS standards that can be observed and evaluated by 
OIG inspectors without specialized law enforcement or medical training. 
These inspections are limited-scope compliance inspections and we 
report solely on observations of compliance or non-compliance with TEDS 
on the day and time of the inspectors' visit. As part of our 
inspections, we also review records and logs and interview a limited 
number of CBP personnel and, when possible, detainees.
    In fiscal year 2019, Congress mandated that OIG continue its 
program of unannounced inspections of immigration detention facilities, 
and directed OIG to ``pay particular attention to the the health needs 
of detainees.''\4\ In response, between April and June 2019, we 
conducted 21 unannounced inspections of Border Patrol facilities and 
CBP ports of entry in Arizona, New Mexico, and Texas. Again, the 
objectives of our unannounced visits were to determine whether CBP 
complied with observable TEDS standards, and whether CBP provided 
reasonable care from apprehension to holding, includjng its ability to 
identify and respond appropriately to medical emergencies. During these 
inspections, we did not evaluate compliance with all provisions of TEDS 
standards, but rather prioritized those that protect children and other 
at-risk detainees, as well as those related to access to medical care.
---------------------------------------------------------------------------
    \4\ Joint Explanatory Statement, Consolidated Appropriations Act, 
2019 (Pub. L. 116-6).
---------------------------------------------------------------------------
    We began our fiscal year 2019 unannounced visits of CBP facilities 
in April 2019. In the summer of 2019, we issued 2 Management Alerts and 
made 1 recommendation about issues we observed requiring DHS's 
immediate attention. We issued these interim reports because the 
conditions we observed posed a serious and imminent threat to the 
health and safety of both DHS personnel and detainees. These issues 
included dangerous overcrowding and prolonged detention of children and 
adults in both the El Paso and Rio Grande Valley sectors.\5\
---------------------------------------------------------------------------
    \5\ Management Alert--DHS Needs to Address Dangerous Overcrowding 
and Prolonged Detention of Children and Adults in the Rio Grande Valley 
(OIG-19-51), Management Alert--DHS Needs to Address Dangerous 
Overcrowding Among Single Adults at El Paso Del Norte Processing Center 
(OIG-19-46).
---------------------------------------------------------------------------
    Building on the body of work we published last summer, we recently 
issued a capping report summarizing and incorporating our observations 
during 2019 unannounced inspections.\6\ The capping report included the 
following findings:
---------------------------------------------------------------------------
    \6\ Capping Report: CBP Struggled to Provide Adequate Detention 
Conditions During 2019 Migrant Surge (OIG-20-38).
---------------------------------------------------------------------------
   Border Patrol stations were overcrowded,
   Border Patrol stations held detainees longer than 72 hours,
   Overcrowding and prolonged detention affected Border 
        Patrol's compliance with other standards for detainee care,
   Provision of medical care at short-term facilities has 
        limits, and
   CBP ports of entry generally met TEDS standards.
Unable to Control the Number of Apprehensions, and with Limited 
        Transfer Options, Border Patrol Stations Were Overcrowded
    During fiscal year 2019, CBP experienced a surge in families and 
UACs crossing the Southwest Border, with these 2 groups representing 
the majority of all Border Patrol apprehensions. These significant 
increases contributed to Border Patrol apprehending more than twice the 
undocumented aliens during fiscal year 2019 than in any of the previous 
4 full fiscal years.
    With the surge in apprehensions in fiscal year 2019, we observed 
overcrowding in 10 of the 14 Border Patrol facilities we visited; in 
some instances the overcrowding was so severe that detainees were in 
standing-room-only conditions for days or weeks. As described in our 
Management Alerts for example, when our team arrived at the El Paso Del 
Norte Processing Center, they found that the facility--which has a 
maximum capacity of 125 detainees--had more than 750 detainees on-site.
    Despite the crowding, our interviews with detainees and 
observations of the facilities indicated that Border Patrol ensured 
detainees had ready access to potable water and toilets. We also 
observed an Border Patrol stations had food, snacks, juice, and infant 
formula available for children. All Border Patrol stations we visited 
also had basic hygiene supplies (e.g., toilet paper, diapers, and baby 
wipes). However, not all facilities had consistently provided children 
access to hot meals as required. Additionally, not all facilities we 
visited had showers or provided showers consistently to detainees 
approaching 72 hours in detention. Border Patrol had arranged temporary 
shower trailers for some, but not all, facilities. Some facilities 
without showers on-site provided ``dry showers'' (i.e., a wet wipe and 
dry wipe) to detainees.
    In response to the fiscal year 2019 surge in Southwest Border 
apprehensions, Border Patrol established temporary holding areas to 
provide additional shelter for the high volume of detainees. These 
included both makeshift arrangements such as parking lots or sally 
ports with access to portable toilets and water, and large soft-sided 
white tents as stand-alone facilities. These tents had air 
conditioning, portable toilets, washstands, showers, and laundry 
facilities. At the time of our site visit, these tents were reserved 
for families, who were being provided sleeping mattresses and hot 
meals.
    Based on our observations, we recommended in one of our Management 
Alerts that DHS take immediate steps to alleviate the overcrowding at 
the El Paso Del Norte Bridge Processing Center.\7\ CBP concurred with 
our recommendation and described its efforts to construct additional 
soft-sided structures to accommodate more detainees, as well as to open 
a Centralized Processing Center within 18 months. That recommendation 
remains resolved and open, meaning that OIG considers CBP's proposed 
corrective actions responsive to the recommendations.
---------------------------------------------------------------------------
    \7\ Management Alert--DHS Needs to Address Dangerous Overcrowding 
Among Single Adults at El Paso Del Norte Processing Center (OIG-19-46).
---------------------------------------------------------------------------
With Limited Transfer Options, Border Patrol Held Detainees for 
        Prolonged Periods
    With limited transfer options, in 12 of the 14 Border Patrol 
stations we visited, we identified detainees held longer than the 72 
hours generally permitted, some of whom had been held for longer than a 
month. At the time of our visits, across the 14 facilities, at least 
3,750 detainees out of approximately 9,400 (nearly 40 percent) had been 
held longer than 72 hours.\8\ With HHS and ICE operating at or above 
their bed space capacity for UACs and single adults during the surge, 
Border Patrol officials said they struggled with prolonged detention 
for these populations.
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    \8\ We derived these numbers from apprehension and custody data 
maintained in Border Patrol's case management database, which stores 
real-time data on detainees currently in Border Patrol's custody. 
However, due in part to system outages at the time of our visit and 
detainee transfers between facilities, the precise numbers may be 
slightly higher or lower than the numbers reflected in the data.
---------------------------------------------------------------------------
    After observing the challenges CBP faced during the surge with 
meeting the 72-hour target for release or transfer from CBP custody, we 
initiated a separate review to identify the key factors contributing to 
prolonged CSP detention during the surge and propose ways for DHS to 
enhance its ability to respond better to these challenges in the 
future. That review is on-going and the results will be published in an 
upcoming OIG report.
Overcrowding and Prolonged Detention Also Affected Border Patrol's 
        Compliance with Other Standards for Detainee Care
    The overcrowding and prolonged detention described above affected 
Border Patrol's compliance with other TEDS standards.
    For example, UACs must be offered use of a telephone to call a 
relative, sponsor, or consulate. We interviewed UACs at several busy 
and overcrowded facilities and were told that, in some facilities, they 
had not been offered telephone access; logs in Border Patrol's data 
system confirmed this. Incomplete records in other facilities indicated 
Border Patrol was either not tracking UAC access to telephones or was 
not offering the telephone calls. In contrast, at another Border Patrol 
facility, we observed UACs making phone calls.
    Additionally, according to TEDS standards, CBP will safeguard 
detainees' personal property unless it is deemed contraband. However, 
we observed Border Patrol agents in the El Paso sector discarding 
detainee property, at times indiscriminately. For instance, while 
property-handling practices varied by station and there did not appear 
to be a sector-wide policy on discarding property, we observed agents 
at the El Paso Del Norte Processing Center collecting detainees' 
valuables (e.g., money and phones), but discarding virtually all other 
detainee personal property--including backpacks, suitcases, handbags, 
and children's toys--in the nearby dumpster. We made similar 
observations in other locations in the El Paso sector. In contrast, in 
other sectors such as the Tucson sector, we observed that all detainee 
personal property was tagged and stored.
    In response to these observations, we made 2 recommendations to 
CBP. First, we recommended that CBP establish procedures for evaluating 
compliance with requirements to provide and document phone calls for 
unaccompanied alien children in custody. Second, we recommended that 
CBP implement consistent guidance on how it handles detainee personal 
property.
    CBP concurred with both of our recommendations and both of them are 
resolved and open. CBP is taking steps to implement each recommendation 
by December 31, 2020.
    In addition to our observations regarding access to phone calls for 
UACs and the safeguarding of detainee personal property, we also 
observed that--with the exception of facilities dedicated to housing 
UACs and families--Border Patrol facilities did not consistently meet 
TEDS standards requiring some special protections for children in 
detention, including additional requirements for food, clothing, and 
conditions of detention. Based on our observations, not all children 
had access to a shower after 48 hours, or a change of clothing, as 
recommended under the standards. Two facilities in the Rio Grande 
Valley had not provided children access to hot meals until the week we 
arrived; management at these facilities told us there were too many 
detainees on-site to microwave hot meals, and it had taken time to 
secure a food contract. Additionally, preventing the spread of 
contagious illnesses resulted in some UACs and families needing 
treatment being held in closed cells, rather than the least restrictive 
setting recommended in TEDS.
    However, overall, in the facilities we visited, we observed CBP 
staff members making an effort to care for the detained children. For 
example, we observed CBP personnel trying to provide the least 
restrictive setting available for children when possible (e.g., by 
leaving holding room doors open or cells unlocked), We also observed in 
most facilities CBP staff had purchased toys or snacks that appealed to 
children.
    We did not make a recommendation with respect to these specific 
issues relating to these special protections for children because we 
believe that overcrowding and prolonged detention affected Border 
Patrol's compliance with standards for children. In normal 
circumstances, CBP has sufficient microwaves or warming ovens to heat 
frozen food and can transfer unaccompanied children to Health and Human 
Services custody before the need for showers or a change of clothing 
arise. Transfer of families to ICE custody, or to CBP facilities that 
offer more amenities, is also easier when facilities are not 
overcrowded. We are conducting a separate review to evaluate the root 
causes of prolonged detention.
Provision of Medical Care at Short-Term Facilities Has Limits
    Under TEDS standards, CBP agents and officers are also tasked with 
observing and reporting physical and mental injuries and illnesses for 
appropriate medical care. In addition, detainees should have access to 
emergency medical care and necessary medications. Although TEDS 
standards do not require CBP to have trained on-site medical staff in 
its holding facilities, in fiscal year 2014, Border Patrol established 
the Centralized Processing Center in the Rio Grande Valley and staffed 
it with contracted medical teams led by a nurse practitioner or 
physician's assistant. The Centralized Processing Center was the first 
CBP facility with an on-site medical team. Between 2014 and the end of 
2018, CBP expanded the Centralized Processing Center's medical contract 
to provide medical staff and services at 5 additional Border Patrol 
stations. The contract included the services of an on-site medical team 
led by a nurse practitioner or physician's assistant, as well as an on-
call physician, to provide basic care, refill prescriptions, and 
determine which detainees required care at a hospital or clinic. All 
other CBP facilities relied on CBP agents and officers to identify 
medical issues.
    At the time of our inspections, medical coverage varied by 
facility, but the facilities we visited generally met the TEDS 
standards for access to medical care even in the crowded conditions.\9\ 
Specifically, upon a detainee's entry into a CBP hold room, detainees 
were asked about, and visually inspected for, any sign of injury, 
illness, or physical or mental health concerns, and asked questions 
about any prescription medications. In addition, although TEDS does not 
require CBP to maintain on-site medical staff, due to initiatives bv 
CBP and the DHS Office of the Chief Medical Officer, 10 CBP facilities 
had on-site medical personnel handling medical assessments and triage. 
In the remaining facilities, CBP officers and agents, some of whom were 
emergency medical technicians (EMT), performed assessments in 
accordance with TEDS standards.
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    \9\ At the time these inspections were completed, we did not have 
medical expertise to evaluate the quality of medical care. With the 
expanded funding received from Congress in fiscal year 2020, I ordered 
a contract for medical services to supplement our expertise across 
audits, inspections, and investigations and I am pleased to report that 
contract will be awarded in the next few weeks.
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    Most Border Patrol facilities we visited took steps to try to 
evaluate and respond to the medical needs of the sizable detainee 
population resulting from the increase in apprehensions. This included 
conducting medical screenings of all detainees before entrance into a 
facility, stocking common over-the-counter medications, and arranging 
dedicated appointment hours at local clinics. At several facilities we 
visited with on-site medical personnel, a medical team consisting of 2 
to 4 staff questioned detainees about their health and conducted a 
physical assessment of each detainee before processing detainees for 
intake into the facility. In facilities without medical staff, CBP 
officers and Border Patrol agents medically assessed detainees by 
asking them about their health concerns, injuries, and medications.
    At the facilities with medical staff, the medical personnel could 
treat detainees who had minor injuries or illnesses using over-the-
counter medication, which the facilities stocked. Also, the medical 
personnel could identify detainees who needed additional medical care, 
and could prescribe medications. If a detainee needed additional 
treatment, the medical personnel would contact CBP, or call the local 
emergency room, for transport to a local medical facility.
    Even though the Border Patrol stations we visited generally met the 
TEDS standard for access to medical care, crowded conditions presented 
health challenges for on-site medical staff in some facilities, 
including containing the spread of contagious illnesses. On-site 
medical staff we interviewed said they were overwhelmed and the crowded 
conditions at the facilities were not conducive to treating contagious 
illnesses. For instance, Border Patrol's short-term detention 
infrastructure generally did not provide sufficient space for 
quarantining or specialized ventilation systems. Border Patrol agents 
also expressed concern that having many detainees with contagious 
illnesses in their facilities represented a health risk to detainees 
and CBP personnel alike. In addition, Public Health Service officials 
working in Border Patrol stations said that with the large number of 
detainees arriving and departing each day, neither medical personnel 
nor CBP staff could observe and monitor the health status of all 
detainees. Crowding at the facilities further lessened the opportunity 
to identify detainees who may require immediate medical care.
    To prevent the spread of contagious illnesses, CBP took measures 
such as conducting medical assessments outside of the facilities and 
providing protective masks to detainees. At times, efforts to contain 
contagious illnesses indirectly contributed to overcrowding in other 
areas of facilities, as Border Patrol had to set aside multiple holding 
cells or repurpose other space to separate detainees with lice, 
scabies, measles, and flu from each other and from healthy detainees.
    Given these observations, as well as the circumstances of the 
deaths of the 2 children in CBP custody, and our on-going dialog with 
the Committee regarding these issues, we have initiated an audit of 
detention facility policies and procedures for handling medical 
intervention. Our planned audit objective is to determine whether CBP: 
(1) Has policies and procedures to address identifying serious medical 
conditions of detained migrants; and (2) is implementing those policies 
and procedures to ensure the detained migrants with serious medical 
conditions are identified and their health needs are properly 
addressed. We look forward to sharing the results of that audit with 
the committee when it is complete.
Ports of Entry Generally Met TEDS Standards
    In contrast to Border Patrol, which could not control the number of 
undocumented aliens apprehended, CBP Office of Field Operations (OFO) 
ports of entry limited the number they processed by implementing 
``Queue Management''\10\ and other practices.\11\ ``Queue Management'' 
allowed the ports of entry to control the volume of detainees entering 
the facilities, and OFO did not accept more detainees than could be 
transferred to ICE custody. As a result, relatively few detainees were 
held longer than 72 hours; of the ports of entry we visited, only 
Nogales and Hidalgo ports of entry held detainees longer than 72 hours.
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    \10\ See June 5, 2018 Memorandum from Secretary Nielsen, 
``Prioritization-Based Queue Management,'' stating OFO may create 
separate lines for migrants with appropriate travel documents and those 
without such documents. When employing ``Queue Management,'' CBP 
officers are stationed at the international boundary with Mexico and 
advise undocumented aliens to add their names to a waiting list and 
stay in Mexico until CBP has space and staffing to process them.
    \11\ Other initiatives to control intake include the Migrant 
Protection Protocol, through which certain undocumented aliens arriving 
from Mexico are issued a Notice to Appear before, an immigration judge, 
placed in removal proceedings, and then transferred to Mexico to await 
further proceedings.
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    Ports of entry generally met other TEDS standards as well. Our 
observations and interviews with detainees confirmed ports of entry 
were generally able to more easily monitor UACs and provide both adults 
and children hot meals and a variety of foods. Although holding cells 
at the ports of entry we visited were comparable to those in Border 
Patrol stations (e.g., locked cinderblock cells and metal combined 
toilets and sinks), some ports of entry had converted other areas into 
space to hold UACs and families, giving the ports more options for 
holding children in the least restrictive setting possible.
    Ports of entry also faced fewer challenges in meeting TEDS 
standards for medical care. Because ports of entry were not 
overcrowded, it was less difficult to separate detainees with 
contagious illnesses. Although most ports of entry we visited did not 
have medical staff or EMTs on-site, all were near communities with 
clinics and hospitals, and therefore, had easier access to local 
medical care. In addition, fewer detainees required transport for 
medical care. At the time of our site visits, some ports of entry sent 
all children and family units to a clinic or hospital for medical 
screening after initial processing.
                         on-going oig oversight
    Using data-driven, risk-based decision making, our office will 
continue to conduct independent and objective audits, inspections, and 
investigations and make recommendations to improve the Department's 
programs and operations. Consistent with our obligations under the 
Inspector General Act of 1978, we will keep Congress fully and 
currently informed of our findings and recommendations.
    We plan to publish several reports this year and next year 
reviewing CBP and ICE, including;
   CBP's Holding of Detainees Beyond 72 Hours.--This 
        evaluation's objective is to determine the causes leading to 
        CBP's inability to comply with the general requirement to hold 
        detainees in its custody for no more than 72 hours.
   CBP's Processing of Asylum Seekers.--We are reviewing CBP's 
        handling of asylum seekers at ports of entry. The objective was 
        to determine if CBP OFO was turning away those who present 
        themselves for asylum at the ports of entry.
   CBP's Use of Fiscal Year 2019 Appropriated Funds for 
        Humanitarian Assistance.--Our objective is to determine whether 
        CBP has adequately planned for deployment, and is deploying, 
        fiscal year 2019 appropriated funds quickly and effectively to 
        address the humanitarian needs on the Southern Border.
   CBP's Procedures for Detained Migrants Experiencing Serious 
        Medical Conditions.--Our objective is to determine whether 
        CBP's policies and procedures safeguard detained migrants 
        experiencing serious medical conditions while in custody.
   Southern Border Detainee Transportation and Support.--The 
        objective is to determine how the migrant surge affected CBP 
        staffing and its ability to secure the Southern Border.
   Implementation of DHS's Streamlined Asylum Review Pilot 
        Programs.--The objective is to determine how DHS, especially 
        CBP and USCIS, have implemented the Prompt Asylum Claim/
        Screening Review and Humanitarian Asylum Review Process (HARP) 
        pilot programs.
   Audit of CBP Border Security Technology and 
        Infrastructure.--We will assess the effectiveness of CBP's 
        current tools and technologies to support Border Patrol's 
        mission operations for preventing the entry of illegal aliens 
        or inadmissible individuals who may pose threats to National 
        security.
   CBP Leadership's Knowledge of and Actions to Address 
        Offensive Content Posted on Facebook by CBP Employees.--The 
        objective is to determine whether complaints were made to CBP 
        leadership regarding the ``I'm 10-15'' or similar private 
        Facebook group(s) prior to recent media reporting; which 
        senior-level officials knew about the ``I'm 10-15'' or similar 
        private Facebook group(s) prior to the July 2019 media 
        reporting, when they became aware, and what they knew about the 
        content; and what actions, if any, were taken to evaluate and 
        address potential employee misconduct in the group.
   U.S. Customs and Border Protection's Use of Canine Teams.--
        The objective is to determine to what extent CBP's canine 
        training approach and execution support the Canine Program 
        mission.
   U.S. Customs and Border Protection's Use of Force Near the 
        San Ysidro, California Port of Entry on November 25, 2018 and 
        January 1, 2019.--Our objective is to review the circumstances 
        surrounding the incidents and determine whether CBP complied 
        with its use of force of policy.
   Review of Removal of Separated Alien Families.--Our work 
        will determine whether ICE removed any parents without first 
        offering them the opportunity to bring their separated children 
        with them.
   ICE's Use of Segregation in Detention Facilities.--To 
        determine whether ICE's use of administrative and disciplinary 
        segregation across all authorized detention facilities complies 
        with Departmental detention standards.
   DHS DNA Collection.--Our objective is to determine whether 
        DHS law enforcement agencies collect DNA samples from arrested 
        or detained persons as required by the Fingerprint DNA Act of 
        2005 and subsequent Department of Justice regulations.
   DHS Management and Oversight of Immigration Hearings in 
        Temporary Courts Along the Southwest Border.--Our objective is 
        to determine the extent to which DHS provides accurate hearing 
        notices and facilitates immigration hearings at temporary 
        courts in accordance with laws and regulations.
   U.S. Immigration and Customs Enforcement Efforts to Combat 
        Human Trafficking.--Our objective is to determine the extent to 
        which ICE identifies and tracks human trafficking crimes to 
        save victims.
   Review of July 2018 Family Reunifications Issues at Port 
        Isabel Detention Center.--Our objective is to determine whether 
        children were held in vans for up to 39 hours, why that 
        occurred, and whether ICE has taken steps to prevent it from 
        happening again.
   Unannounced Inspections of CBP Holding Facilities & ICE 
        Adult Detention Facilities.--Our objective is to continue 
        conducting unannounced inspections of DHS and contract 
        facilities to monitor DHS compliance with health, safety, and 
        civil rights standards outlined in CBP's National Standards on 
        Transport, Escort, Detention, and Search; and ICE's 
        Performance-Based National Detention Standards.
   CBP's Searches of Electronic Devices at Ports of Entry.--Our 
        objective is to determine to what extent CBP conducted searches 
        of electronic devices at U.S. ports of entry in accordance with 
        its standard operating procedures.
   ICE's Efforts to Prevent and Mitigate the Spread of COVID-19 
        in its Facilities.--Our objective is to determine whether ICE 
        Enforcement and Removal Operations effectively managed the 
        pandemic at its detention facilities and adequately safeguarded 
        the health and safety of both detainees in their custody and 
        their staff.
   Early Experiences with COVID-19 at CBP Facilities.--Our 
        objective is to determine how CBP (Office of Field Operations 
        and Border Patrol) is managing the COVID-19 pandemic at their 
        facilities, with respect to both detainees in their custody and 
        to their staff.
   ICE Should Document its Process for Adjudicating 
        Disciplinary Matters Involving Senior Executive Service 
        Employees.--Our objective was to evaluate U.S. Immigration and 
        Customs Enforcement (ICE) policies and procedures regarding 
        Senior Executive Service (SES) employee discipline after 
        complaints were raised that a former ICE SES official received 
        favorable treatment during disciplinary proceedings.
   Assessing the Effectiveness of DHS's Joint Task Forces.--Our 
        objective is to determine whether DHS has effectively managed 
        and coordinated its Joint Task Forces (JTF) resources to 
        accomplish the JTFs' intended mission.
   CBP's Covert Testing Efforts.--Our objective is to determine 
        whether CBP's covert tests identify vulnerabilities at ports of 
        entry and borders and whether CBP uses the test results to 
        address identified vulnerabilities and shares lessons learned 
        throughout the component.
    Thank you for the opportunity to discuss the important work of the 
OIG. This concludes my testimony, and I am happy to answer any 
questions you may have.

    Chairman Thompson. Thank you very much for your testimony. 
I now recognize our next witness for 5 minutes.

 STATEMENT OF REBECCA GAMBLER, DIRECTOR, HOMELAND SECURITY AND 
         JUSTICE, U.S. GOVERNMENT ACCOUNTABILITY OFFICE

    Ms. Gambler. Good afternoon, Chairman Thompson, Ranking 
Member Rogers, and Members of the committee. I appreciate the 
opportunity to participate in today's hearing to discuss GAO's 
work on CBP efforts to provide medical care to those in its 
custody along the Southwest Border. My remarks are based on a 
report GAO is releasing today, and a legal decision we issued 
last month addressing issues related to CBP's use of funds for 
and efforts to provide medical care.
    I will be covering 3 areas from the report and legal 
decision. First, CBP's use and oversight of funds it received 
for consumables and medical care under the fiscal year 2019 
emergency supplemental appropriations. Second, CBP's efforts to 
enhance medical care. Third, CBP's reporting of deaths in its 
custody.
    First, last summer, the Fiscal Year 2019 Emergency 
Supplemental Appropriations Act was enacted to provide for 
humanitarian assistance and security at the Southwest Border. 
The act required that CBP use certain funds for specific 
purposes which are referred to as line items. One of the line 
items in the act was consumables and medical care. We found 
that CBP obligated some funds in the line item for consumable 
and medical care goods and services, like food and hygiene 
products, masks, and gloves.
    However, CBP also obligated some of the funds for other 
purposes like goods and services for its canine program, 
equipment for facility operations, like printers and speakers, 
and facility upgrades and services. We found that these 
obligations violated an appropriation law known as the purpose 
statute, because CBP obligated funds from the consumables and 
medical care line items for some goods and services that were 
not consistent with the purpose of that appropriation. We 
concluded that CBP should adjust its accounts accordingly.
    We identified 2 factors that contributed to CBP's 
violations: No. 1, insufficient guidance to CBP offices and 
components before obligations were made and a lack of oversight 
roles and responsibility for reviewing obligations once made. 
We recommended that CBP develop and implement additional 
guidance and establish oversight roles and responsibilities to 
ensure supplemental funds were obligated consistent with their 
purposes. CBP concurred with these recommendations.
    Second, CBP has taken various steps to enhance medical care 
and services for individuals in its custody. These steps 
include increasing its use of contracted medical care 
providers, issuing new health screening policies, and 
requesting the CDC assess conditions and make recommendations 
for the reduction of influenza in CBP facilities among other 
things.
    As a more specific example of CBP's efforts, in 2019, CBP 
issued interim and updated medical care directives, which, 
among other things, required health interviews and medical 
assessments for certain groups. In March 2020, CBP issued 
implementation plans for these directives.
    While these are positive steps, we found that CBP has not 
consistently implemented its enhanced medical care policies and 
procedures. For example, we found that some CBP locations were 
not consistently conducting health interviews and medical 
assessments as required by the medical directives. CBP also has 
not documented how it made its decision not to offer influenza 
vaccines to those in its custody as recommended by the CDC. We 
recommended that CBP develop and implement oversight mechanisms 
and document what information it is using to assess whether to 
offer the influenza vaccine to individuals in custody. CBP 
concurred with these recommendation.
    Finally, CBP is supposed to report information on deaths of 
individuals in its custody to Congress. We have reviewed CBP's 
documents and reports for fiscal years 2014 through 2019, and 
found that 31 individuals died in custody along the Southwest 
Border during that period. However, CBP only documented 20 
deaths in its Congressional reports. We recommended that CBP 
ensure reliable information on deaths in custody is reported to 
Congress, and appropriate documentation on such reporting is 
maintained. CBP concurred with this recommendation.
    In closing, while CBP has taken steps to enhance its 
medical care efforts, our work has identified a number of areas 
requiring additional attention to ensure that CBP is 
appropriately using supplemental funds it receives, overseeing 
medical care efforts, and reliably reporting information on 
deaths in custody to Congress. Going forward, we will be 
monitoring CBP's actions to address our recommendations.
    This concludes my prepared statement, and I am pleased to 
answer any questions Members may have.
    [The prepared statement of Ms. Gambler follows:]
                 Prepared Statement of Rebecca Gambler
                        Wednesday, July 15, 2020
southwest border.--cbp should improve oversight of funds, medical care, 
                        and reporting of deaths
                              gao-20-680t
    Chairman Thompson, Ranking Member Rogers, and Members of the 
committee: We are pleased to be here today as you examine issues 
related to U.S. Customs and Border Protection's (CBP) care and custody 
of adults and children. Beginning in fall 2018, the Department of 
Homeland Security's (DHS) CBP experienced a significant increase in the 
number of individuals apprehended at or between U.S. ports of entry 
along the Southwest Border, resulting in overcrowding and difficult 
humanitarian conditions in its facilities.\1\ From December 2018 
through May 2019, 3 children--ages 7, 8, and 16--died in CBP custody, 
prompting questions about CBP's medical screening and care of those in 
its custody. In July 2019, an emergency supplemental appropriations act 
(2019 Emergency Supplemental) was enacted, providing additional funds 
to CBP to respond to the significant increase in Southwest Border 
apprehensions, including approximately $112 million for ``consumables 
and medical care.''\2\
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    \1\ See, for example, Department of Homeland Security, Office of 
Inspector General, Management Alert--DHS Needs to Address Dangerous 
Overcrowding and Prolonged Detention of Children and Adults in the Rio 
Grande Valley (Redacted), OIG-19-51 (Washington, DC: July 2, 2019); 
Management Alert--DHS Needs to Address Dangerous Overcrowding Among 
Single Adults at El Paso Del Norte Processing Center (Redacted), OIG-
19-46 (Washington, DC: May 30, 2019); and Acting Secretary McAleenan's 
Prepared Remarks to the Council on Foreign Relations (Washington, DC: 
Sept. 23, 2019).
    \2\ See Pub. L. No. 116-26, title III, 133 Stat 1018, 1019-1020 
(2019). Supplemental appropriations are laws enacted to address needs 
that arise after annual appropriations have been enacted. In the 
context of CBP's appropriation, the term ``consumable'' refers to goods 
that are exhausted by use, and the phrase ``medical care'' includes 
goods and services used to provide assistance related to the diagnosis 
and treatment of disease or injury and maintaining health. B-331888, 
June 11, 2020, at 4.
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    CBP is the lead Federal agency charged with, among other things, 
ensuring the detection and interdiction of persons unlawfully entering 
or exiting the United States.\3\ Within CBP, the U.S. Border Patrol 
(Border Patrol) apprehends individuals between ports of entry, and 
CBP's Office of Field Operations (OFO) encounters inadmissible 
individuals who arrive at ports of entry. Border Patrol and OFO detain 
individuals at short-term holding facilities to complete processing, 
which involves collecting information about the apprehended individual, 
including any potential health concerns. While individuals are held at 
CBP facilities--either by Border Patrol or by OFO--CBP personnel 
typically place individuals in a secure holding cell or room while 
these individuals await transfer of custody to another agency, removal 
from the country, or release into the United States.\4\
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    \3\ See 6 U.S.C.  211(c).
    \4\ CBP policy states that individuals should generally not be held 
for longer than 72 hours in CBP custody. CBP refers individuals to 
DHS's U.S. Immigration and Customs Enforcement (ICE) for long-term 
detention. If CBP apprehends a child that is designated as an 
unaccompanied alien child, that child is transferred to the custody of 
the Office of Refugee Resettlement within the Department of Health and 
Human Services (HHS).
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    Our remarks are based on our report, released today, entitled 
Southwest Border: CBP Needs to Increase Oversight of Funds, Medical 
Care, and Reporting of Deaths.\5\ Specifically, we will summarize the 
report's key findings on: (1) The extent to which CBP obligated and 
conducted oversight of funds for consumables and medical care; (2) 
steps CBP took to enhance medical care; (3) the extent to which CBP 
implemented and oversaw its medical care efforts; and (4) the extent to 
which CBP has reliable information on, and reported, deaths, serious 
injuries, and suicide attempts of individuals in custody. For the 
report, we reviewed CBP documentation, including financial reports; 
directives, policies, and training related to screening individuals for 
medical issues; and directives and policy documentation on reporting 
deaths in custody. We interviewed CBP officials in headquarters and 2 
field locations and observed medical efforts in facilities in field 
locations, selected based on higher volumes of apprehensions. 
Additional information on our scope and methodology is available in our 
report.\6\ The work on which this statement is based was performed in 
accordance with generally accepted Government auditing standards.
---------------------------------------------------------------------------
    \5\ GAO, Southwest Border: CBP Needs to Increase Oversight of 
Funds, Medical Care, and Reporting of Deaths, GAO-20-536 (Washington, 
DC: July 14, 2020).
    \6\ GAO-20-536.
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    cbp obligated some consumables and medical care funds for other 
              purposes in violation of appropriations law
    We found that, as of May 2020, CBP had obligated nearly $87 million 
of the approximately $112 million it received specifically for 
consumables and medical care in the 2019 Emergency Supplemental.\7\ CBP 
obligated some of these funds for consumable goods and services, like 
food and hygiene products, as well as medical care goods and services 
such as defibrillators, masks, and gloves. However, in June 2020, we 
concluded that CBP violated an appropriations law, known as the purpose 
statute, when it obligated funds from the 2019 Emergency Supplemental 
consumables and medical care line item appropriation for some goods and 
services that were not consistent with the purpose of that line 
item.\8\ Specifically, we found that some of the goods and services did 
not clearly fall within the ordinary meaning of the terms 
``consumable'' or ``medical care,'' nor did they bear a reasonable and 
logical relationship to the purpose of the line item. For example, we 
found that CBP violated the purpose statute when it obligated some of 
these funds for goods and services for its canine program; equipment 
for processing individuals apprehended by CBP, like printers and 
speakers; and various upgrades to computer networks used for border 
enforcement activities. CBP also obligated the consumables and medical 
care line item for transportation items. We concluded that obligations 
for certain transportation-related items that were not primarily used 
to provide medical services violated the purpose statute.\9\
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    \7\ In general, an obligation is a commitment by the Government 
that creates a legal liability to pay for goods or services it orders 
or receives.
    \8\ GAO, U.S. Customs and Border Protection--Obligations of Amounts 
Appropriated in the 2019 Emergency Supplemental, B-331888 (Washington, 
DC: June 11, 2020). Under the purpose statute, appropriations are to be 
used only for the purposes for which they are made, except as otherwise 
provided by law.
    \9\ B-331888, June 11, 2020, at 5-6.
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    We identified 2 factors that contributed to CBP's purpose statute 
violations--insufficient guidance to CBP offices and components before 
obligations were made and lack of oversight roles and responsibilities 
for reviewing obligations once made.
   Insufficient guidance on the purpose of the funds.--After 
        the 2019 Emergency Supplemental was enacted, CBP did not 
        provide sufficient guidance explaining how offices and 
        components could obligate funds for consumables and medical 
        care and, as a result, some offices and components may not have 
        understood that there were limitations on how they could use 
        those funds. For example, officials from one CBP component 
        stated they believed they could use the consumables and medical 
        care funds for any goods or services they considered to be in 
        the interest of individuals in custody or that would help 
        ensure the efficient processing of individuals.
   Lack of oversight roles and responsibilities.--CBP offices 
        and components took some steps to conduct oversight of 
        obligations from the 2019 Emergency Supplemental funds, but we 
        identified gaps in CBP's roles and responsibilities for 
        reviewing obligations to ensure they were consistent with the 
        intended purpose of the funds.\10\ For example, officials from 
        CBP's Office of Finance stated that they were not responsible 
        for determining whether obligations were consistent with the 
        purpose of the line item and relied on components to make such 
        determinations. However, of the 5 components that obligated 
        funds from the consumables and medical care line item 
        appropriation, only 1--Border Patrol--reviewed obligations to 
        determine whether they were consistent with the purpose. 
        Further, Border Patrol's review was limited in scope because it 
        did not include all obligations Border Patrol made using this 
        line item. For example, Border Patrol did not request 
        obligation data on goods and services purchased by its canine 
        office.\11\
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    \10\ While CBP officials stated that individual components had 
processes in place to review individual obligations before they were 
made, the agency had not provided guidance regarding the purpose of the 
individual line items, as noted above.
    \11\ CBP's canine program is responsible for terrorist detection 
and apprehension and the detection and seizure of controlled substances 
and other contraband, among other functions.
---------------------------------------------------------------------------
    DHS and CBP officials stated that the agency experienced challenges 
managing some aspects of the funds from the 2019 Emergency Supplemental 
due to a lack of experience with these line items and the large 
increase of apprehensions on the Southwest Border occurring at the 
time. Specifically, officials from DHS's Office of the General Counsel 
and CBP's Office of Chief Counsel noted that CBP typically receives an 
annual lump-sum appropriation, which provides the agency with broader 
discretion in determining the use of funds as compared to the 2019 
Emergency Supplemental, which specified how CBP could use the funds 
through line items. As such, these officials stated that CBP did not 
have systems in place to ensure that the funds were obligated 
consistent with the purpose of the line item. Our report recommended 
that CBP develop and implement additional guidance for ensuring that 
funds appropriated for a specific purpose are obligated consistent with 
their purpose, and establish oversight roles and responsibilities to 
ensure that such funds are obligated consistent with their purpose. DHS 
agreed with these recommendations and said it plans to issue additional 
guidance and outline new oversight roles and responsibilities within 
its standard operating procedures document.
   cbp increased contracted medical providers, issued new screening 
     policies, and engaged entities with medical expertise in 2019
    We found that, throughout 2019, CBP took various steps to enhance 
medical care and services to individuals apprehended and held at its 
facilities. These steps included increasing the number of facilities 
that have on-site contracted medical providers from 6 locations in 
December 2018 to 42 in December 2019 and issuing new health screening 
policies. In particular, in January 2019, CBP issued an interim 
directive which, among other things, required health interviews and 
medical assessments for certain individuals in its custody.\12\ CBP 
updated this directive in December 2019 and issued corresponding 
implementation plans in March 2020.
---------------------------------------------------------------------------
    \12\ A health interview is a standardized medical questionnaire for 
individuals in CBP custody. A medical assessment is an evaluation of an 
individual by a health care provider to assess medical status.
---------------------------------------------------------------------------
    Additionally, CBP engaged with various entities to leverage their 
expertise and coordinate efforts. Two entities with medical expertise--
the Centers for Disease Control and Prevention (CDC) within the 
Department of Health and Human Services (HHS) and the American Academy 
of Pediatrics (AAP)--also provided recommendations or assistance with 
the development of training. At the request of DHS, CDC teams visited 
Border Patrol facilities in December 2018 and January 2019 to assess 
conditions and make recommendations for the collection of data on, and 
to reduce the spread of, infectious diseases, particularly respiratory 
diseases such as influenza. Based on these visits, CDC provided DHS 
with recommendations to address immediate needs for protection and care 
related to respiratory infections and to prepare for future influenza 
seasons.\13\ In addition, CBP requested, and the AAP developed, a short 
training video on recognizing the signs of a child in medical distress. 
CBP issued the training in late September 2019 as part of a 35-minute 
training for CBP emergency medical technicians and paramedics.
---------------------------------------------------------------------------
    \13\ These recommendations are summarized in our report. See GAO-
20-536.
---------------------------------------------------------------------------
  cbp's implementation and oversight of medical care efforts has been 
                              inconsistent
    While CBP has taken steps to enhance medical care for those in its 
custody, we found gaps in CBP's implementation and oversight of its 
efforts. For example, we found the following:
   Inconsistent implementation of enhanced medical care 
        policies and procedures.--Through facility visits and analysis 
        of CBP data, we found that some CBP facilities along the 
        Southwest Border were not consistently conducting health 
        interviews and medical assessments, as required by the medical 
        directives. Our review of Border Patrol records from a 1-week 
        period in February 2020 found that 143 of 373 apprehended 
        children under age 18 who were processed at Border Patrol 
        stations without contracted medical providers did not receive a 
        health interview or medical assessment referral at those 
        stations. This included 116 children under age 13, and 27 
        children ages 13 through 17. When we notified CBP of these 
        issues, CBP officials said that they found that most of the 143 
        children in question had received a health interview or medical 
        assessment elsewhere, though some children had not. CBP 
        officials indicated they were previously unaware of these 
        issues and had not determined why they occurred.
   CBP did not document how it weighed costs and benefits in 
        deciding not to offer the influenza vaccine. CBP decided not to 
        implement a recommendation from CDC to offer influenza vaccines 
        to individuals in custody but did not document how it arrived 
        at this decision. For example, CBP documentation cited 
        operational, medical, legal, and logistical challenges to 
        vaccinating apprehended individuals for influenza. CBP 
        officials told us that they considered these factors with DHS 
        and that the Department overall decided not to offer the 
        vaccine to apprehended individuals. However, CBP did not 
        document how the agency weighed the costs or potential benefits 
        of offering the influenza vaccine. For example, CBP could not 
        provide documentation on how it determined that costs--such as 
        providing cold storage at CBP facilities to support vaccines, 
        hiring additional medical staff, or maintaining additional 
        medical records related to offering influenza vaccination--
        would be significant. CDC officials we spoke with stated that 
        they believed these challenges and costs could be addressed.
    CBP officials also stated that they believed that offering the 
influenza vaccine to individuals in custody would provide little 
benefit to the agency since it is CBP's goal to transfer individuals 
out of its custody within 72 hours, while the influenza vaccine 
requires 14 days to take effect. However, CBP officials also stated 
that they have no control over how long individuals may remain in CBP 
custody when there is a lack of capacity at ICE facilities. In May and 
June 2019, the DHS Office of Inspector General found serious 
overcrowding and prolonged detention in Border Patrol facilities in 
Texas because CBP could not transfer individuals in custody out of its 
facilities in a timely manner, as both ICE and HHS were operating at or 
above capacity.\14\ For example, the DHS Office of Inspector General 
found that some adults were held as long as a month and some children 
held for 2 weeks.
---------------------------------------------------------------------------
    \14\ See OIG-19-46 and OIG-19-51.
---------------------------------------------------------------------------
    CBP made its initial decision not to offer vaccines to those in its 
custody prior to the Coronavirus Disease 2019 (COVID-19) pandemic. 
Since that time, CDC has noted additional benefits of offering the 
influenza vaccine. Additionally, since CBP made its initial decision, 
CBP officials stated that they continue to meet with other DHS 
officials on public health issues, including how to prevent the spread 
of influenza in its facilities. Officials told us that they will use 
this forum to continually reassess whether to offer influenza vaccines 
to individuals in its custody.
   CBP does not provide officers and agents with training to 
        identify medical distress in children.--CBP policies require 
        officers and agents to identify potential medical issues in all 
        individuals, including children, but CBP has not developed and 
        implemented training for agents and officers on identifying 
        medical distress in children. According to AAP representatives, 
        recognizing medical distress in children in a timely fashion is 
        important because children can fall severely ill faster than 
        adults and are less able to communicate about their illness. 
        CBP officers and agents take 2 first aid courses as part of 
        their initial training, but these courses do not include 
        information specifically related to identifying medical 
        distress in children--such as through changes in skin tone or 
        crying patterns.
    CBP and AAP developed a training video on recognizing medical 
        distress in children, which CBP included as part of its 
        training for emergency medical technicians and paramedics as 
        noted above.\15\ CBP officials told us that the agency has not 
        provided the training video to all officers and agents because 
        they believed it was too technical, though it is available to 
        officers and agents as an optional continuing education course. 
        CBP officials stated that they have considered offering 
        training on recognizing medical distress in children to all 
        officers and agents who may come into contact with children in 
        custody, but have not begun to take steps to develop and 
        implement such training.
---------------------------------------------------------------------------
    \15\ As of April 2020, CBP could not provide information on how 
many of its CBP emergency medical technicians and paramedics had taken 
this training. There are approximately 1,200 emergency medical 
technicians and paramedics that work on the Southwest Border.
---------------------------------------------------------------------------
    Our report recommended that CBP develop and implement oversight 
mechanisms for its policies and procedures relating to medical care; 
document what information it uses to assess whether to offer the 
influenza vaccine to individuals in custody; and develop and implement 
training on recognizing medical distress in children for all officers 
and agents who may come in contact with children. DHS agreed with our 
recommendations and said it plans to clarify performance metrics, 
targets, and corrective actions; consider how to best document whether 
to offer the influenza vaccine to individuals in custody; and develop 
and implement training on recognizing medical distress in children.
  cbp has taken steps to clarify responsibilities and procedures for 
         reporting deaths in custody, but reporting gaps remain
    From fiscal year 2015 through fiscal year 2019, CBP was directed to 
report deaths of individuals in its custody to Congress.\16\ We 
reported that while CBP has taken steps to revise its policies and 
procedures for reporting deaths in custody, the agency has not 
consistently reported deaths to Congress, as directed, or maintained 
documentation of such reporting. Our review of CBP documentation and 
reports to Congress showed that 31 individuals died in custody along 
the Southwest Border from fiscal years 2014 through 2019, and CBP 
provided documentation that it reported 20 to Congress. Additionally, 
when CBP reported deaths to Congress, it did not always report them in 
a timely manner. For example, for fiscal years 2016 through 2019, CBP 
was directed to report all deaths in custody within 24 hours. However, 
CBP was unable to substantiate that the agency met the 24-hour 
requirement for fiscal years 2016 and 2017. Further, in December 2018, 
CBP reported to Congress the death of a 7-year-old girl who died in 
Border Patrol custody 4 days after the 24-hour window for notification 
had passed. Moreover, CBP was directed to provide annual information on 
deaths in custody for fiscal year 2017 but did not provide this 
information until March 2019.
---------------------------------------------------------------------------
    \16\ The Congressional reports accompanying annual Department of 
Homeland Security's appropriations acts for fiscal years 2015 through 
2019 direct DHS to report certain information on deaths in custody 
within specific time frames to the appropriations committees. For more 
information, see table 4 of our report, GAO-20-536. Additionally, in 
fiscal year 2014, DHS was directed to provide information on deaths in 
custody in summary statistics to the appropriations committees. See 
House Rep. No. 113-91 (2013).
---------------------------------------------------------------------------
    CBP officials attributed these reporting issues to a lack of 
defined responsibilities and procedures. In December 2018--recognizing 
the need for more consistent and timely reporting--the CBP Commissioner 
issued a memorandum outlining interim policy and procedures for 
notifications of a death in CBP custody. However, we found that field 
personnel have not consistently followed those procedures, which 
resulted in at least one late notification to Congress, and CBP could 
not provide documentation that it had notified Congress of an 
additional 2 deaths that had occurred after the issuance of the 
memorandum.\17\ Officials stated that this may have been due to a lack 
of awareness about the December 2018 memorandum reporting requirements. 
Our report recommended that CBP ensure that reliable information on 
deaths in custody is reported to Congress and that appropriate 
documentation on such reporting is maintained. DHS agreed with this 
recommendation and said it is reviewing and updating procedures to 
ensure deaths in custody are reported to Congress as appropriate.
---------------------------------------------------------------------------
    \17\ CBP officials stated they may have notified Congress by 
telephone.
---------------------------------------------------------------------------
    In summary, CBP has taken some steps to improve its care and 
custody of adults and children, but the agency needs to increase 
oversight of the use of funds, medical care, and reporting of deaths. 
By implementing our report's recommendations, CBP has the opportunity 
to provide additional guidance and oversight of appropriated funds; 
develop and implement oversight mechanisms related to medical care 
policies; document decisions made regarding offering the influenza 
vaccine; and provide guidance to ensure that deaths in custody are 
reported to Congress, as directed.
    Chairman Thompson, Ranking Member Rogers, and Members of the 
committee, this concludes our prepared remarks. We would be pleased to 
respond to any questions that you may have at this time.

    Chairman Thompson. Thank you for your testimony. I thank 
all the witnesses for their testimony. I remind each Member 
that he or she will have 5 minutes to question the panel.
    I now recognize myself for questions. To Mr. Cuffari, as 
you know, we sent a letter to you asking for a number of 
things, the committee. You sent it back, we reviewed it. After 
we sent our response back, you revised the public summary. Why 
didn't the original public summary include any reference to 
influenza as a cause of death?
    Mr. Cuffari. Mr. Chairman, you are correct. In the interest 
of privacy, initially we included a high-level summary of 
information on our public website regarding the deaths of the 2 
children. Subsequently at your request, we made an adjustment 
to that public summary to include a diagnosis of influenza B, 
and to indicate that our investigation did not reveal Border 
Patrol were aware of that diagnosis.
    I would like to add that this is the very first time that 
we have done public summaries in this fashion, and we wanted to 
make sure that we got it right the first time. We thought it 
was appropriate to basically err on the side of privacy for the 
children. Now, out of deference to you, sir, we added and made 
those minor corrections.
    Chairman Thompson. Well, I thank you. So have you noted on 
your website, or the summary itself, that the summary has been 
revised?
    Mr. Cuffari. Yes, sir. We did that the same day. We made 
the updates and sent those to your staff.
    Chairman Thompson. Thank you very much. With respect to 
your review of the initial death, did you have qualified 
medical professionals on your review team?
    Mr. Cuffari. No, sir. Just to clarify for the committee's 
consideration, those 2 reviews were actually investigations 
conducted by our office of investigation of the 2 deaths of the 
children in custody. We didn't have, at the time, any medical 
professionals available from for staff. But as I indicated in 
my opening statement, based on the enhanced funding that you 
provided this past fiscal year, we are contracting out to have 
a team of health care professionals augment any of our on-going 
or projected work in the future, audits, inspections, and 
investigations.
    Chairman Thompson. So at the time based on what you just 
said, and of your review of the deaths, you did not have on 
staff or contracted any medical personnel?
    Mr. Cuffari. No, sir.
    Chairman Thompson. Dr. Mitchell, you have heard my 
question. In your professional opinion, do you think, if you 
are looking at a death of any kind that a medical personnel 
would be important to the team?
    Dr. Mitchell. Yes, absolutely. I think that, especially 
deaths in custody, deaths in custody require fatality reviews. 
Most fatality review panels need to be multidisciplinary. 
Therefore, you are going to get the recommendations. So it is 
going to really depend upon what you are trying to get out of 
investigation. But from a fatality review construct, you need 
to not only have clinicians, like pediatricians if it is a 
child death, internists if it is an adult death, but also a 
forensic pathologist or a medical examiner, so they would be 
able to interpret the findings at autopsies. All of that is 
going to be required in the future. It is going to be helpful.
    Chairman Thompson. Thank you very much. Mr. Cuffari, 
according to your report, Border Patrol agents stated they were 
in contact via text message when Felipe was transported to the 
hospital the first time, the morning of December 24. Do you 
have copies of any of those text messages in your file?
    Mr. Cuffari. To my knowledge, sir, no, we do not.
    Chairman Thompson. So you put in a report information that 
you could not document?
    Mr. Cuffari. We documented, sir, the testimony from the 
Border Patrol agents and their supervisors. All credible 
testimony.
    Chairman Thompson. I understand that, but nobody thought to 
get a copy of the text messages or anything like that?
    Mr. Cuffari. Not to my knowledge.
    Chairman Thompson. Well, did the inspector general's office 
pull or review any emails or other electronic messages 
involving CBP personnel regarding Felipe's care or death?
    Mr. Cuffari. Not to my knowledge, sir.
    Chairman Thompson. Thank you.
    I now recognize the Ranking Member of the full committee 
for questions.
    Mr. Rogers. Thank you, Mr. Chairman. I think it would be 
productive if I yield my time to my colleague from Tennessee, 
Dr. Mark Green.
    Chairman Thompson. The gentleman from Tennessee is 
recognized for 5 minutes.
    Mr. Green of Tennessee. Chairman, Ranking Member, and 
witnesses, thank you. The hardest part about being a doctor is 
sometimes you do everything you can for a patient, and they 
still die. Mr. Chairman, I would like to introduce myself. 
There are a few things I have never shared, but today it is 
important I do so.
    I graduated in the top third of my med school class, 
attended the No. 1 emergency medicine residency training 
program in the Nation. All 3 years in residency, we scored No. 
1 in the Nation. Yes, we beat those Harvard doctors too. I 
deployed all over the world in some of the most remote places 
in the planet, provided medical care to children of Afghani 
villagers, and battle-hardened Navy SEALs and delta operators. 
I have never been sued for malpractice, I have served as 
medical director of 4 different emergency departments in 3 
States ranging from depressed rural to a level 2 trauma center.
    I was CEO of a company of emergency physicians, and PAs, 
and nurse practitioners, that ran 52 emergency departments in 
11 States. I have served as both defense and plaintiff expert 
on tons of med mal cases doing exactly this, forensically 
assessing care given.
    In this case, first by CBP and then medical facilities. 
Both of these cases are about pediatric sepsis. First, a few 
facts about ped sepsis, a review of the medical literature on 
sepsis recounted 4 studies in the United States that found that 
even when a patient goes to a state-of-the-art emergency 
department, the mortality rate for sepsis in America was 10.3 
percent in one, 8.9 percent in another, 14.4 percent, and 19 
percent respectively. Even when these patients present to EDs 
in the United States, many still die.
    Why is this disease process so hard to treat? Well, like 
Dr. Danaher said in her testimony, children don't look bad 
until the very end. When I trained EM residents, we called it 
the pediatric cliff. They look great and then crash in seconds. 
I appreciate the written testimony of our pathologist who 
honestly reported that in both cases he felt, ``The actions 
taken by individual U.S. CBP agents seem to be appropriate and 
timely''. I affirm from this that Dr. Mitchell understands that 
standard of care depends on where you are and the facilities 
available.
    Dr. Danaher's testimony is disconnected from this idea. The 
reality of rural health care is millions of Americans aren't 
able to walk into a Harvard quality care. The standard of care 
at Mass General on a given day will never be comparable to 
triaging 160 migrants in the dark of the night in Antelope 
Wells.
    Dr. Mitchell's testimony is balanced and professional. It 
is not political hyperbole, but it does suggest that the 
Federal Government has the ability to deploy doctors to remote 
areas of the border, interview migrants about their health, and 
do a variety of tests which is simply unrealistic.
    Dr. Danaher's written testimony is blatantly partisan. She 
critiques the conditions of CBP facilities going on about lack 
of toothbrushes and clean water. I know from my own visits, the 
CBP facilities and the facts in these cases, those allegations 
are simply false. She also discusses the psychological dynamic 
of the data of one patient to not share information to agents 
as if that environment is the law enforcement officer's fault. 
That dynamic existed because of crossed the border illegally, 
and then didn't tell agents that Jakelin was sick, even when 
they repeatedly asked him.
    If a patient presents to an ED in the United States and 
lies about their medical condition, it is not the doctor's 
fault.
    Look, both of your testimonies center around getting more 
resources. The bottom line, you want more doctors and 
electronic medical records. Just published yesterday new 
estimates of doctor shortages in the United States. The United 
States is short 14,494 doctors. Where in the world are we going 
to get doctors to put somebody at every single crossing site? 
This testimony proposes building health care infrastructure for 
illegal immigrants that would dwarf the health care systems in 
77 percent of rural counties in America.
    Last year, House Democrats voted to advance an electronic 
medical record to illegal immigrants within 90 days when 
veterans in many States still don't have it, and won't have it 
for 7 years.
    Finally, this side of the aisle spent all of last year 
highlighting how dangerous the journey to our border is for 
kids. The answer is not to turn CBP stations into Mass General. 
We have to break the cartels that entice people to come here 
with children and fix our immigration law loopholes. Until we 
do that, smugglers will continue to turn a profit over enticing 
families to come to our border with false promises.
    Mr. Chairman, I yield.
    Chairman Thompson. Thank you very much.
    The Chair now recognizes other Members for questions they 
may wish to ask witnesses. As previously outlined, I will 
recognize Members in the order of seniority, alternating 
between Majority and Minority. Members are reminded to unmute 
themselves when recognized for questioning, and to the extent 
practical, to leave their cameras on so they are visible to the 
Chair.
    The Chair now recognizes, 5 minutes, the gentlelady from 
Texas, Ms. Jackson Lee.
    Ms. Jackson Lee. Mr. Chairman, thank you for holding this 
very important hearing. Thank you to the Members of the--
witnesses who are here as well who have provided very important 
testimony.
    All of us were shocked to learn in December 2018 that 2 
children died in separate incidents while in the custody of 
U.S. Border Patrol, which are the first deaths of children in 
Border Patrol custody in more than a decade. I am going to be 
very clear that when you lead a Nation, all that happens, 
whether you like it or not, falls at your feet. I have known 
Border Patrol agents and visited with them in my State of Texas 
for decades. I have seen their passion. I have seen them buy 
baby food and formula.
    Where this tragedy falls is clearly at the feet of an 
administration that is inattentive and does not recognize that 
we are to comply with the international protocols of human 
rights and human decency.
    Following the deaths of those 2 children in 2018, U.S. 
Customs and Border Protection, the Border Patrol parent agency, 
issued an interim directive in January 2019 establishing new 
medical screening and other procedures. I physically went down 
to the border and saw the immediate emergency tactics that were 
used. It was a table and the use of Coast Guard doctors. They 
all meant well.
    Dr. Danaher, thank you for your leadership. My question: As 
all of this falls at the feet of the President of the United 
States and the administration and we have to adhere to human 
rights protocols, can you please elaborate on the differences 
between pediatric disease processes and adult disease processes 
so you know that a child may be sick and why understanding the 
nuances of each is important, especially in these situations?
    Dr. Danaher.
    Dr. Danaher. So children are physiologically different from 
adults. They can compensate in different ways for infection 
than adults can. As Dr. Green mentioned, when they are sick, 
they can look well for quite a while before they crash. That is 
all very true.
    So I think it is really, really important for there to be 
pediatric expertise at the border. That does not necessarily 
have to mean pediatricians. It means intense training for the 
EMTs who are already working with the vulnerable people. 
Currently, EMTs in New Mexico helping children who are 
apprehended only get about 10 percent of their training 
dedicated to pediatrics, which only amounts to a few hours.
    So it is incredibly important to be able to recognize when 
children get sick. They definitely look different.
    Ms. Jackson Lee. You understand that Border Patrol agents 
are not doctors, they are not EMTs, they are not nurses, 
correct?
    Dr. Danaher. Correct.
    Ms. Jackson Lee. So it would be your view that minimally, a 
Nation as powerful, as rich as the United States, could 
recognize the importance of those nuances and have a system in 
place that would deal with pediatric issues or children who are 
in life-and-death situations?
    Dr. Danaher. Yes, yes.
    Ms. Jackson Lee. I didn't hear you. I'm sorry.
    Dr. Danaher. Yes, yes.
    Ms. Jackson Lee. Thank you.
    To the inspector general, Mr. Cuffari, you did a report 
there was some suggestion that CBP officers try to engage with 
the parent. Do you know what language they spoke to Jakelin's 
father?
    Mr. Cuffari. I believe, ma'am, Jakelin father indicated on 
his in-processing paperwork that he was fluent in the Spanish 
language and the Border Patrol agents spoke to him in Spanish.
    Ms. Jackson Lee. My understanding is that he spoke his 
indigenous language, K'iche'. Did anyone try to speak to him in 
that language to make sure he understood?
    Mr. Cuffari. Not to my knowledge, ma'am.
    Ms. Jackson Lee. So what elements of change would you 
recommend, or did you recommend, in light of the 2 deaths of 
children that had never happened, and it certainly didn't 
happen with the mass migration during the Obama administration.
    Mr. Cuffari. We actually--as I mentioned in my opening 
statement, we have 3 on-going projects to look at the matters 
that you just asked about. These are 3 of 21 that I had in my 
prepared statement. We will make recommendations based on what 
our findings are at the time and hold DHS accountable for 
implementing those recommendations.
    Ms. Jackson Lee. The recommendations that you are looking 
to is framed around 2 deaths, and as well, no response timely 
enough to save those lives?
    Mr. Cuffari. We are looking at the circumstances that 
surrounded the deaths, the medical care, and the access that is 
capability of being provided by DHS to the children who are in 
custody, as well as to other adults, et cetera.
    Ms. Jackson Lee. Well, let me just say that we have 3 
million-plus COVID-19 deaths in the United States. Obviously 
there will be major investigations dealing with the 
responsibility of this administration in--excuse me, 3 million 
cases, let me correct myself, 3 million-plus cases rising to 
140,000 deaths, maybe about 137,000 deaths. Make sure the 
record is clear, 3 million-plus cases. Many of those cases are 
obviously in States like Texas, New Mexico, and even 
Mississippi and others.
    So, I would emphasize that your work is extremely 
important. When the Federal Government fails the Nation, it is 
important for there to be concise, direct, wide-spread 
understanding of why, and directions of how that is remedied. 
The loss of a child is precious. I give my deepest sympathy to 
the families and, therefore, we must make sure that we correct 
it.
    I thank you, Mr. Chairman. I yield back.
    Chairman Thompson. Thank you very much. The Chair now 
recognizes the gentleman from New York, Mr. Katko, for 5 
minutes.
    Mr. Katko. Thank you, Mr. Chair. Having lived on the border 
and prosecuted cases on the border in the mid-1990's, I can 
tell you back then the border and porousness of the border was 
a problem and it attracted more and more people, and tragedy 
often resulted back then. It is still happening today, and it 
is a terrible thing. It is terrible thing to lose anyone at the 
border in custody. It is a terrible thing ever to lose them if 
they are a child. We have to do all we can to make sure of that 
going forward.
    But I will note that it is an incredibly complex issue, 
much more complex than I think some of the dialog today. I 
would like to defer to my colleague, Dr. Green, to take the 
balance of my time. I yield to him.
    Chairman Thompson. The Chair recognizes the gentleman from 
Tennessee for the balance of the time.
    Mr. Katko. Thank you Mr. Chairman.
    Mr. Green of Tennessee. Thank you, Mr. Chairman.
    Dr. Mitchell, you mentioned in your testimony that resource 
hurdles prolonged CBP custody and delayed access to medical 
care. I agree. The efforts led by House Democrats to defund ICE 
have had sweeping consequences, mainly impacting CBP facilities 
such as what happened during December 2018.
    ICE family residential centers were at capacity, forcing 
CBP to hold immigrants much longer than they should. The 
bureaucracy exacerbated by the border crises preventing those 
in CBP custody from reaching ICE facilities built for long-term 
holding and for more thorough medical assessments and access to 
care.
    My question to you is do you support additional funding for 
ICE capacity and medical staff to ensure that children don't 
get stuck in CBP custody like they did last year?
    Dr. Mitchell. Yes. I think that any funding that is going 
to go forward to resolve this issue must go forward to decrease 
any overcrowding burden. I will leave it up to the House and 
the politicians to understand where exactly that goes and what 
agencies get those resources. But I think you and I agree, Dr. 
Green, that overcrowding conditions is a major concern, 
particularly when we are talking about infectious disease.
    Then as far as the issue of timeliness, and I appreciate 
you elucidating the fact that I wanted better access to health 
care there at the border, I agree. I think physicians would be 
a hard burden, a hard bar to reach. But I believe that there is 
opportunities, as my colleague Danaher described, is that 
higher training of the EMT, maybe nurses, nurse practitioners, 
that are available there to make sure that the burden is not 
placed on our agents to try to triage these patients.
    Mr. Green of Tennessee. I really appreciate your comments. 
I think clearly we, on our side of the aisle, would like to see 
more funding for ICE. There are a lot of people, especially for 
those detention facilities, a lot of people on the other side 
of the aisle want to defund ICE, but I want to follow up one 
more question, Dr. Mitchell, for you before my time expires.
    You indicated in your testimony that you believe Jakelin's 
death could have been prevented in the initial health 
assessment questionnaire if it had been performed by a licensed 
medical provider.
    You may not know this, but yesterday DHS--or not DHS but 
HHS released the doc shortage. Seventy-seven percent of 
America's rural counties right now are short both doctors and 
PAs, and by 2032, that is going to be 121,000 short. Where do 
we get these medical providers? I mean, do we take them from 
American cities? I am eager to hear your thoughts on that.
    Dr. Mitchell. Again, I think the shortage of medical 
providers is across the Nation, as you describe. I just don't 
believe that the recommendation of providing adequate health 
screening to whoever we come into contact with, it stops being 
a recommendation because the hurdles and barriers are too big. 
I think our job is to try to create opportunities where we can 
meet the goals of saving lives, wherever it exists. So no, not 
taking away from anyone, but attempt to provide it to everyone.
    Mr. Green of Tennessee. Yes. We just have to be realistic 
in our solutions and find solutions that work, and your 
recommendations were, you know, a licensed medical person. I 
just--with the shortage we already have, I just don't see how 
that can happen.
    I think my time has expired, Mr. Chairman.
    Chairman Thompson. Thank you.
    The Chair recognizes the gentleman from Louisiana, Mr. 
Richmond, for 5 minutes.
    Mr. Richmond. Thank you, Mr. Chairman. As much as I would 
want to go into the shortage issue and the proverbial Trumpism 
of pitting communities against each other, and I guess that is 
what we are doing in terms of access to doctors, I just won't 
entertain it. I mean, we are the greatest country in the world.
    Dr. Mitchell, could you just for me, in laymen's terms, 
explain what Felipe died of?
    Dr. Mitchell. Yes. So Felipe, he died of--he had a 
bacterial infection that was superimposed on flu. So everybody 
knows what bacteria is when I say it. It is a small organism 
that can cause infection. This particular type of organism that 
he had, he had flu, and then that flu had a bacterial infection 
on top of it.
    The type of infection he had was so severe that it caused a 
rapid disease within his lungs, and so he died from, like, a 
hemorrhagic pneumonia or sepsis, and so that is functionally 
what he died from.
    Mr. Richmond. Dr. Danaher, let me ask you, and I think both 
you and Dr. Green mentioned the uniqueness of treating children 
and when their symptoms show. Does it require special training 
to determine how severely ill a child is?
    Dr. Danaher. Yes. I would say it does.
    Mr. Richmond. Ms. Gambler, in your written statement, it 
says that the report you are releasing today has found, ``CBP 
does not provide officers and agents with training to identify 
medical distress in children.''
    Is that correct?
    Dr. Danaher. Yes. That is our finding.
    Mr. Richmond. To the Inspector General, in reviewing 
Felipe's death, did your office examine whether the agents who 
were responsible for caring for him had received training in 
identifying medical distress in children? If so, what did your 
office's review find?
    Chairman Thompson. You need to unmute yourself.
    Still not able to hear you.
    Looks like we are----
    Mr. Cuffari. I am sorry, Mr. Chairman. My computer froze. I 
had to come back into the meeting. I am really sorry.
    Mr. Richmond. Let me repeat that question, then. In 
reviewing Felipe's death, did your office examine whether the 
agents who were responsible for caring for him had received 
training in identifying medical distress in children? If so, 
what did your office's review find?
    Mr. Cuffari. My understanding is the Border Patrol is 
trained in basic first aid, CPR, and trauma care. They also 
have advanced paramedics in several of their stations. In this 
case, in the case of Jakelin, there was a paramedic who 
happened to be at that station. I didn't find any evidence of 
pediatric training, though.
    Mr. Richmond. Well, it was also clear that Felipe's father 
asked for him to be returned to the hospital in a sense of 
urgency. It took about an hour before they left the station, so 
it is unclear if the urgent nature of the situation was 
conveyed to everyone involved in the transportation.
    So Dr. Danaher, given those circumstances, are there any 
questions about CBP's policies and practices for dealing with 
emergencies that should be reviewed?
    Dr. Danaher. One issue that arose for me in reading the 
time frame in which he received care is whether anybody is 
actually entering the cells to examine a child's [inaudible] 
medical assistance is actually requested. From what I could 
tell from the records that were available it would appear that 
we are checking on his cell door. But it is not clear that 
anybody took a close look at something. If they had, it would 
be very, very apparent if he was in distress.
    Mr. Richmond. To the Inspector General, if possible, could 
you either forward to us or articulate any recommendations or 
policy revisions you have after reviewing Felipe's death and 
the file surrounding it?
    Mr. Cuffari. Sir, we have----
    Mr. Richmond. With that, Mr. Chairman, I yield back.
    Chairman Thompson. You can answer the question.
    Mr. Cuffari. Thank you, Mr. Chairman.
    Sir, as I mentioned, we have on-going projects to look at 
that exact question, and we will be happy, very happy to 
provide the committee with our recommendations once we finish 
those reviews.
    Chairman Thompson. You said that is the end of December, 
right?
    Mr. Cuffari. We should have one sometime toward the end of 
this year for you, sir.
    Chairman Thompson. Thank you.
    The Chair recognizes the gentlelady from Arizona, Mrs. 
Lesko, for 5 minutes.
    Mrs. Lesko. Thank you, Mr. Chairman, and thank you for 
those testifying.
    When I read the accounts of the 2 young children dying, I 
mean, it is very sad. I am sure all of us can agree that it was 
sad, and we wish it didn't happen.
    But if I heard it right, Dr. Mitchell said both deaths were 
preventable and blamed the Customs and Border Protection 
agency, and Dr. Danaher said Customs and Border Protection 
agency was at fault. After reading the IG's report of what all 
happened, I really fail to see how you came to that conclusion.
    I mean, first of all, you had in the young woman's--or the 
young girl's account, she entered the United States and was 
apprehended on December 6 after traveling, I assume, thousands 
of miles. The CBP asked if anyone was sick because they wanted 
to get the sick people on the first bus, and they didn't say 
anything. Then they didn't fill out on the form--they said 
actually on a filled-out form that they were not sick, that 
they were healthy. Then the father didn't say anything to the 
CBP officers that his daughter had been vomiting, and he told 
the bus driver that his daughter was vomiting but didn't tell 
CBP.
    So then they got off the bus first after they found out 
from the father, and the EMT gave immediate medical care, and 
it was only then that the father told the EMT that his daughter 
had been vomiting and not eating for 2 to 4 days.
    So I fail to see how that is the agency's fault. Then they 
airlifted her to a hospital, and unfortunately, she died.
    In the case of the boy, it sounds like the CBP transferred 
as soon as they knew there was something wrong. The hospital 
didn't write in there things, that he had influenza B, didn't 
give medication, the amoxicillin, didn't note that, so to me, 
that seems more like a hospital error than a CBP error.
    So my question to Mr. Cuffari is, Mr. Cuffari, in your 
investigation, have you determined that either one of these 
parents, the parents seeking medical care and the child 
receiving medical care before they were apprehended by CBP, 
especially the girl who had been sick for 2 to 4 days?
    Mr. Cuffari. It doesn't sound as though that the 
investigation found that that had been the case. Their first 
medical treatment was once they came into CBP custody in 2 
different instances, one at the Lordsburg station and the other 
at the facility at the checkpoint.
    Mrs. Lesko. Thank you. Mr. Cuffari, do you think the cartel 
would have given them medical care? I mean, the accounts I have 
heard about the cartel, they could care less about these 
people. They just make money off of them.
    Mr. Cuffari. Representative Lesko, that is beyond the scope 
of my testimony here today.
    Mrs. Lesko. Well, you know, it is my opinion that instead 
of blaming the Customs and Border Protection agency for 
everything that happens, to me, it was clear that traveling 
thousands of miles, we should start blaming the cartels, don't 
you think? People should at least be partly accountable for 
children's deaths if the parents don't tell the medical people 
or Customs and Border Protection that their child's even sick. 
They have been traveling thousands of miles.
    I mean, I just think it is unrealistic to expect the 
Customs and Border Protection to just know that these things 
are going to happen. To me, it seemed like they went over and 
beyond trying to help these children.
    I have a few seconds left to give to Dr. Green.
    Chairman Thompson. The Chair recognizes the gentleman from 
Tennessee for the balance of the time.
    Mr. Green of Tennessee. Thank you, Mr. Chairman.
    A very quick question to Dr. Danaher. Have you done med mal 
cases, review cases before?
    Dr. Danaher. No.
    Mr. Green of Tennessee. You obviously reviewed the records 
here. What stood out to you about the resuscitation in this 
case, Felipe's resuscitation, when you reviewed that case?
    Dr. Danaher. In terms of when he presented to the hospital 
the second time?
    Mr. Green of Tennessee. The second visit when they tried to 
resuscitate him, was there anything that jumped out to you as a 
physician on that resuscitation documentation?
    Dr. Danaher. I mean, there were definitely some 
irregularities in terms of what happened when he reached the 
hospital, but he arrived already pulseless. They had a really 
difficult time intubating him. There was a significant amount 
of blood in the airway which contributed to the multiple failed 
intubation attempts [inaudible].
    Mr. Green of Tennessee. If I could just say, answer the 
question, because I know you have played, you know, guess what 
I am trying to ask you before as a physician. We do that a lot 
to one another. But he was incorrectly intubated, and they 
continued the resuscitation for several minutes with the 
breathing tube down his esophagus. Clearly, you can't 
resuscitate a patient, and he is not getting oxygen for several 
minutes in the resuscitation. That is problematic for saving 
the child's life.
    I yield.
    Chairman Thompson. The Chair now recognizes the gentleman 
from New Jersey for 5 minutes, Mr. Payne.
    Mr. Payne. Thank you, Mr. Chairman. I appreciate the 
opportunity to be here today. It is very interesting to listen 
to the gentleman from Tennessee who has stated that he has been 
on the defense side and the prosecution side of these issues. 
You know, also, when my other colleagues mentioned that, you 
know, it is the cartel's fault.
    You know, we are all responsible. We are the legislative 
body of the U.S. Government. We are responsible for making sure 
that nothing happens to these children. But you see, the 
administration went down a road to collect these people and 
lock them up in cages. Then when something happens, oh, well, 
we didn't have anything to do with it.
    No. This is abominable. This is absolutely abominable, what 
I am listening to. Two children have died. I put my children in 
that position. All of us need to put our children in a 
position, and I think we might take--there might be a different 
tenor to this hearing.
    But I only have 5 minutes, so Dr. Mitchell, can you please 
explain how and why video footage is important to understanding 
all of the circumstances surrounding a death in custody?
    Dr. Mitchell. Yes. So I was one of the primary authors on 
the death in custody and how to report, examine, investigate, 
and report out deaths in custody, put out by the National 
Association of Medical Examiners. Part of what that 
organization calls for is, indeed, any information that is 
available for deaths in custody which includes any video 
footage, any medical records. Anything that can give an idea of 
the time leading up to the death is going to be important to 
categorizing the final findings at autopsy.
    Mr. Payne. Thank you.
    Inspector General, can you discuss the video footage 
obtained and reviewed regarding Felipe's death?
    Mr. Cuffari. My understanding, sir, is the video footage 
was obtained regarding--while Felipe was in custody. Our 
trained criminal investigators reviewed that footage, and they 
determined that the footage married the testimony of the Border 
Patrol agents.
    Mr. Payne. OK. Is there footage of Felipe leaving the 
station to travel to the hospital on that evening on which he 
died?
    Mr. Cuffari. You know, sir, I am going to have to get back 
to you on that specific question.
    Mr. Payne. OK. Did you review any aspect of the CBP's 
collection and retention of the video footage of the 
individuals in custody as part of the review of Felipe or 
Jakelin's death?
    Mr. Cuffari. I am not sure I understand the question, sir. 
We did obtain the video footage concerning the time period in 
which Felipe was in custody. But to my knowledge, that was--I 
don't believe they took any other footage outside of that time 
period.
    Mr. Payne. OK. So you didn't review the aspects of how it 
was collected and retained, right?
    Mr. Cuffari. The collection and retention would have been 
done by our criminal investigators or by CBP OPR agents acting 
on our behalf in collecting the evidence.
    Mr. Payne. So there would be in the report some mention of 
that, correct?
    Mr. Cuffari. To my knowledge, yes, sir.
    Mr. Payne. Mr. Chairman, how much time do I have? I know I 
am getting close.
    Chairman Thompson. The gentleman has 1 minute left.
    Mr. Payne. Thank you, sir.
    Inspector General, how many times did Border Patrol 
officers conduct wellness checks of Felipe on the day he died 
after he returned from the hospital the first time and before 
he left the station for the hospital for the second time? How 
many times was he checked on?
    Mr. Cuffari. The exact number, I couldn't give you, sir. 
But from the report of the interview of Felipe's father and 
consistent with Border Patrol testimony, the father said that 
the Border Patrol agents checked on he and his son 5 to 6--
every--sort of every 5 to 6 minutes while they were back in the 
facility after their first visit to the hospital and before the 
[inaudible] second time.
    Mr. Payne. OK. Thank you, Mr. Chairman.
    I yield back. Thank you, sir.
    Chairman Thompson. Thank you. The gentleman yields back.
    The Chair recognizes the gentleman from Louisiana for 5 
minutes, Mr. Higgins.
    Mr. Rogers. Mr. Chairman, Mr. Higgins is gone.
    Chairman Thompson. Thank you. The Chair recognizes the 
gentleman from Tennessee again for 5 minutes.
    Mr. Green of Tennessee. Thank you, Mr. Chairman. I just 
want to say, you know, we are responsible. I can tell you I 
will never forget the first child that I had to pronounce. The 
child had been hit by a car, and the image of that mother 
bringing that child in in her arms is forever burned in my 
brain.
    The loss of these 2 children, it is tragic, but what we are 
doing here is a forensic examination of the record to find 
where fault happened. This is designed to find where there is 
fault, and so it takes an objective setting that aside and 
looking at the case.
    So I want to ask Dr. Danaher again, you know. The records 
are pretty clear that the father of young Jakelin was asking 
for medications from his fellow travelers before entering into 
the United States. In fact, since the antibiotic he had on his 
hands was Flagyl, not the best for strep infection, they 
probably didn't get that prescribed by a physician. He knew she 
was sick, and he failed to disclose it.
    You mentioned in your written testimony about the 
environment of a person answering questions to law enforcement 
being a barrier for Jakelin's father telling the truth about 
his daughter being sick, and I want to ask you. Are you 
suggesting that there is some kind of new standard of care that 
if a patient lies about their medical condition, the physician 
or that provider is somehow liable?
    Dr. Danaher. Not at all. What I am saying is that the 
initial screening that occurred when a large group of migrants 
arrived at the forward operating base. It was, from what I can 
gather, one agent yelling to more than 100 people that if 
anybody was sick, they should come forward. They yelled this in 
Spanish. The father's native language is K'iche', so we don't 
know if he heard them. We don't know if he understood them.
    On top of that, we are asking people to come forward in 
front of a large group of people to talk about their medical 
issues which, as I am sure you appreciate, could be very 
sensitive for some.
    Mr. Green of Tennessee. Do you have children yourself?
    Dr. Danaher. I do.
    Mr. Green of Tennessee. So you can imagine having a sick 
child and not wanting them to know about it? I mean, I don't 
understand that dynamic----
    Dr. Danaher. I am not certain that----
    Mr. Green of Tennessee [continuing]. I have taken care a 
lot of pediatric patients in the ER, and those parents are 
afraid. They come in, and they want to tell you. Why would he--
I don't understand why a father who cares about a child would 
specifically lie when asked. They asked in Spanish and he 
responded in Spanish, so he clearly understood Spanish.
    Dr. Danaher. So I think that there is a difference between 
being able to speak a little bit of Spanish versus to share 
sensitive or nuanced medical information in Spanish.
    On top of that, the questions on the health interview form 
are very non-specific. There is one question about any type of 
illness, and the rest are about things that wouldn't be 
particularly relevant to Jakelin's case. So this all hinges on 
whether the father understood that one question.
    Mr. Green of Tennessee. I don't agree--I don't disagree 
with you that a form review could make that form better. I 
just--I can't make CBP responsible for a guy who says his 
children are OK when asked if they are medically ill.
    Let's flip to Felipe's case and I only have a little bit of 
time so I am going to get right to it. You made some very, I 
think, appropriate comments in your written testimony about his 
first visit when he went in. I mean, it was horrible when I 
looked at it, but I want you to tell the committee what you 
thought about his care when he was first brought to the 
hospital there at GCRMC and whether you think they should have 
let that patient go home.
    Dr. Danaher. No. They absolutely should not have let him go 
home. I agree with you that the care that he received was very 
concerning during his first presentation. His vital signs were 
significantly abnormal. His heart rate was persistently 
evaluated even when he did not have a fever. His oxygen level 
went as low as 91 percent at one point.
    It is not clear that anybody noted that fact. The physician 
who saw him later acknowledged during a CMS review that he had 
not reassessed Felipe before the child left the facility.
    Mr. Green of Tennessee. Yes. I didn't see any assessments 
for hydration status, you know, tears or moist mucus membranes. 
I mean, all things would be standard of care. This is an 
American physician at an American emergency department, and 
they let this kid go home.
    My question is, is you know, would a normal law enforcement 
officer question a physician like that? Is he trained enough to 
question the physician?
    Dr. Danaher. Well, what is interesting in this case is it 
appears that the law enforcement officer did. He actually 
advocated for Felipe to receive more care before they left and 
continued to express concern after they left which says to me 
that they could recognize that he was quite sick.
    Mr. Green of Tennessee. Yes. They definitely recognized 
that the care given was pretty shoddy. I mean, I think he had 
to ask to have the temperature taken.
    So thank you.
    I yield, Mr. Chairman.
    Chairman Thompson. Thank you very much.
    The Chair recognizes the gentlelady from New York for 5 
minutes, Miss Rice.
    Miss Rice. Thank you, Mr. Chairman, and I would just first 
like to thank the Inspector General for being here today. I 
only wish that you had been available when we did a hearing on 
these 2 terrible deaths back in January, and you would not come 
to that hearing, so I am glad that you are here today.
    I think it is--would it be fair to say, Mr. Inspector 
General, that in the course of reviewing Felipe's death, you 
clearly don't come to a conclusion that the CBP did anything 
negligent or inappropriate? Would that be correct?
    Mr. Cuffari. That is correct, Miss Rice.
    Miss Rice. So would you say it is fair to say that the 
Border Patrol agents were not properly trained to be able to 
comply with the TEDS standards for responding to a medical 
emergency involving a detainee with difficulty breathing, would 
you say?
    Mr. Cuffari. I would say that based on the training that 
the Border Patrol was provided and had at the time that they 
complied with the standards upon which they were being judged.
    Miss Rice. So let me just read specifically from the TEDS 
standards addressing medical emergencies. It states, 
``emergency medical services will be called immediately in the 
event of a medical emergency; for example, heart attack, 
difficulty breathing, and the call will be documented in the 
appropriate electronic system of record. Officers, agents must 
notify the shift supervisor of all medical emergencies as soon 
as possible after contacting emergency services.''
    Now, according to your review of Felipe's death at 
approximately 5 p.m. on the day he died, Felipe was observed to 
have difficulty breathing and complained about pain in his 
stomach. An agent reported that he asked Felipe and his father 
if they wanted to go to the hospital and both declined. Do you 
think that that was appropriate behavior?
    Mr. Cuffari. At the time, it appeared to be appropriate. It 
was within the scope of our investigation, and that is what we 
determined.
    Miss Rice. So what do you mean, at the time? Do you have 
any information now that would lead you to come to any 
different conclusion?
    Mr. Cuffari. Ma'am, that is why we are doing the additional 
reviews and evaluations that I briefly mentioned at the 
beginning. We are going to be looking at those issues.
    Miss Rice. Dr. Danaher and Dr. Mitchell, are there issues 
of informed consent that could come into play in situations in 
which CBP personnel are asking parents and children in 
detention if they want to go to the hospital, particularly if 
they have already been to the hospital on that same day?
    Dr. Danaher. Would you like me to respond first?
    Miss Rice. Sure.
    Dr. Danaher. Yes. So I think there are multiple issues 
here. One is that once a child is in custody, the parent is not 
really in a position to be advocating for their child to go 
back to the hospital. The child is in the custody of the 
Government.
    On top of that, we have to remember that when immigrants 
are in detention, they are--they may perceive themselves as 
being at the whims of the Border Patrol agents, and they may 
not want to make themselves a nuisance.
    Because we have to remember 6 months prior to this, Border 
Patrol was separating parents from their children, and there is 
real reason for people to be afraid of what might happen if--
with these agents. I am not suggesting that agents did anything 
to separate this family at all. I am just saying that the 
dynamic of being in detention makes it very challenging for 
parents to advocate for medical care for their children.
    Miss Rice. Let me just say I think that everyone on this 
hearing would agree that there were mistakes that were made at 
the hospital. Clearly, he should not have been released the 
first time. There is no question. I don't know if there is an 
investigation into the treatment, the medical treatment he got 
at that hospital or not, but there should be for sure. But any 
attempt to blame the parent in this situation--Felipe, when he 
came into custody, was a perfectly healthy child. He got sick 
while he was in custody.
    So CBP had it within their discretion to actually not keep 
Felipe and his father in custody for those 6 days between the 
time that they were apprehended and when he died. They could 
have paroled him. That was well within the discretion of 
authorities, the Government, at that time.
    Let me just also say that, you know, I was happy to hear 
Dr. Green talk about how important it is to invest in our 
health care system. No better time than now for us to discuss 
this, especially as we are dealing with the pandemic.
    We are seeing the disparate way that our health care system 
works for people of color and people in certain socioeconomic 
backgrounds.
    So I am glad to hear Dr. Green talk about how important it 
is to invest in this, but I think we all have to agree that 
children present at the border, and our primary responsibility 
to them is to keep them healthy and not have them die in our 
custody, and so we have to make the system work better.
    I am not blaming these CBP officers because they are not 
medically-trained personnel, but then that means that we need 
to have medically-trained personnel at the border.
    My colleague, Ms. Underwood, given her background and her 
repeated trips to the border before this whole pandemic 
happened, was calling for just that, a more comprehensive 
health check for every single child who comes into the custody 
of CBP or ICE.
    So I just want to thank all of the witnesses for coming 
today, and I yield back, Mr. Chairman. Thank you.
    Chairman Thompson. Thank you very much.
    The Chair recognizes the gentleman from Texas, Mr. 
Crenshaw.
    Mr. Crenshaw. Thank you, Mr. Chairman. Thank you for holing 
this hearing.
    My first question is for Ms. Gambler from GAO. I just want 
to clarify something. The line items on medical care you 
mentioned, those are from the emergency supplemental, correct?
    Ms. Gambler. Yes, sir.
    Mr. Crenshaw. That all occurred after the deaths in 
question, correct?
    Ms. Gambler. The emergency supplemental was enacted last 
summer, July 2019.
    Mr. Crenshaw. Right. But the spending occurred----
    Ms. Gambler. The spending occurred then after enactment, so 
yes, sir.
    Mr. Crenshaw. It was not in the same time frame, so I just 
want to highlight for the records the GAO's findings don't have 
a cause-and-effect relationship the child custody does in 
question.
    Mr. Cuffari, and just to confirm, there are 2 completed IG 
investigations, one continuing, on-going, correct?
    Mr. Cuffari. Concerning deaths in custody, sir?
    Mr. Crenshaw. Yes.
    Mr. Cuffari. Yes. That is correct.
    Mr. Crenshaw. Of the 2 completed investigations, the IG 
determined that all CBP employees who were involved did 
everything possible to ensure both children received medical 
treatment, and there was no misconduct or malfeasance, correct?
    Mr. Cuffari. That is correct, sir.
    Mr. Crenshaw. From your testimony, it sounds like the main 
issue here is overcrowding, correct?
    Mr. Cuffari. It was an issue, actually, that we raised 
during our unannounced site inspections of CBP facilities in 
2019. We issued what is called a major management alert to DHS 
headquarters, and they implemented procedures to alleviate the 
overcrowding. I am told that they will complete that by the end 
of this year.
    Mr. Crenshaw. Thank you. I mean, it raises the issue we 
have long raised which is the reason is there is overcrowding 
is many of our policies encourage people to illegally cross the 
border. There is multiple factors.
    The reason I bring all this up, it raises the question of 
the purpose of the hearing. If there is any evidence of 
malicious intent by CBP, I think this hearing would certainly 
be warranted, but there is not. This hearing appears to be 
designed, at worst, to drive a false narrative that implies 
malicious behavior by CBP.
    At best, we are seeking to falsely imply that these tragic 
deaths could have been prevented by better action by CBP 
officers even though the children's parents brought them across 
our border in extremely poor health.
    Furthermore, these false narratives, they lack context, 
falsely assuming that the purpose of border stations is to 
provide hospital-level child care. Of course, the truth is, the 
purpose of CBP is, in fact, customs and border protection.
    When I went to the Rio Grande Valley sector late last year, 
there was a humanitarian crisis unfolding. In January 2019, 
there were more than 58,000 apprehensions. In February, that 
climbed to more than 76,000. Total border numbers spiked to 
144,000 in May.
    Let's also keep in mind these were not typical single male 
economic migrants. They were mainly family units, more than 
473,000 in fiscal year 2019, and unaccompanied minors, more 
than 76,000 in 2019. As migrants are handled differently and 
completely overwhelmed our border control processing centers.
    When this crisis unfolded in early 2019, we were sounding 
the alarm. It was ignored. The crisis was ``manufactured.'' We 
didn't vote on an emergency supplemental appropriation until 
late June. By that time, there had been more than 750,000 
apprehensions or inadmissibilities along the Southwest Border.
    So again, why are we holding this now? I have to wonder is 
it because demonizing law enforcement is popular right now? 
Border Patrol agents haven't been targeted enough lately? Let's 
be clear. Each of those children who lost their life is 
absolutely tragic. It is also shameful to try and put the blame 
on our CBP officers and Border Patrol agents.
    I think we could engage in some intellectual honesty and 
highlight the fact that in the past 18 months, almost 475,000 
agent hours have been spent transporting migrants to hospitals 
and staying on hospital watch with sick migrants. We know those 
who make the trek from the Northern Triangle do not make it 
here in the best condition.
    We can highlight the fact that more than 8,000 migrants in 
distress whether rescued from the Rio Grande River or found in 
need of medical need due to dehydration, injury, or pregnancy 
complications, have been rescued by Border Patrol. 
Approximately 200 of those were directly attributed to CBP air 
and marine operations assistance.
    We could also mention the Border Patrol search trauma and 
rescue teams which was created in 1998 to respond to injured 
Border Patrol agents in remote locations. Now their main 
mission is actually rescuing migrants in distress, we could 
discuss the number of children and women saved from human 
trafficking by CBP.
    We could talk about CPB being on the front line and keeping 
drugs and other contraband out of our country. Unfortunately, 
though, the positions and priorities appear clear.
    So when we hold this hearing, I want to take the 
opportunity to let our CBP officers and Border Patrol agents 
know that we appreciate your service. We appreciate what you 
are doing under the most difficult of circumstances, and we do 
have your back.
    Thank you. I yield back. Thank you, Mr. Chairman.
    Chairman Thompson. The Chair recognizes the gentlelady from 
Michigan, Ms. Slotkin, for 5 minutes.
    Ms. Slotkin. Thank you very much, Chairman. So I would like 
to pivot to talk about something that actually Mr. Crenshaw 
raised which was the special appropriation, the emergency 
appropriation that we passed last summer. You know, in 
particular, I am interested in the $112 million that we 
appropriated to provide for detainee medical care and necessity 
fees.
    So we passed this $4.5 billion supplemental. I voted for 
it. I think many folks sitting here watching voted for it. I 
wrote to the Acting Secretary about this just to make sure we 
understood how that $112 million was being spent. We got a 
response back that about 8 months later from CBP, just in 
March.
    So Ms. Gambler, can you help us understand and elaborate on 
GAO's findings regarding CBP's use of these $112 million 
specifically, please?
    Ms. Gambler. Certainly, Congresswoman. We found through our 
legal decision and audit work that CBP did obligate funds from 
the consumables and medical care line item for some goods and 
services that fell within the definition or the meaning of 
consumables and medical care.
    So that included things like hygiene products, clothing, 
gloves, masks. But we also found that CBP obligated funds from 
that line item for goods and services that did not fall within 
the definition or the meaning of that line item, the primary 
purpose of that line item, and that included things like goods 
and services for CBP's canine programs, computer network 
upgrades, facilities services and upgrades.
    We concluded that CBP violated the purpose statute under 
appropriations law, and we concluded that CBP should make 
adjustments to its accounts accordingly.
    Ms. Slotkin. How much do you believe of the $112 million 
was misspent on things that were not intended?
    Ms. Gambler. At the time of our work for the legal 
decision, Congresswoman, CBP had not completed its review of 
the obligations it made under that line item.
    After we provided a copy of our draft report to CBP, they 
reported to us that they completed that review, and they 
identified $13 million that they planned to adjust among 
accounts from last year's emergency supplemental, and at least 
$3.9 million that they planned to move from the consumables and 
medical care line item to CBP's regular appropriations.
    I would just note that given the time frames for our 
review, we have not reviewed that information that CBP 
reported.
    Ms. Slotkin. OK. I mean, I guess I would hope that we all, 
everyone on the committee cares about how the money that 
Congress appropriates is spent, and that was certainly 
concerning.
    Mr. Cuffari, can you give us your assessment of this $112 
million? Are you formally doing an IG review of the expenditure 
of this money?
    Mr. Cuffari. Yes, Madam Congresswoman. We have an open 
audit that is going to look at the CBP's use of fiscal year 
2019 appropriation funds for humanitarian assistance. We are 
going to check with our colleagues and cousins at the GAO and 
make sure that we get all information that is available. There 
will----
    Ms. Slotkin. What is the time line of your review? When do 
you expect to be complete?
    Mr. Cuffari. We just opened that few weeks ago, ma'am.
    Ms. Slotkin. So a couple months?
    Mr. Cuffari. I can't give you a definitive time line, but 
we are going to do it as quickly as possible.
    Ms. Slotkin. OK. I just think it is important, and I would 
love to hear your commitment to come back and talk to us about 
that. It is just one of those things. It is like our primarily 
responsibility as an oversight committee to make sure we know 
how that money is spent. I literally have no sort-of piece of 
this, you know, special knowledge of it.
    I just think we all are saying from various, you know, 
angles that we want, you know, this issue to be resourced well 
to the best of our ability to support CBP so that they can do 
what they need to do on detainee health.
    So can you commit, Mr. Cuffari, to coming back and 
testifying in front of us about this issue?
    Mr. Cuffari. You have my continued commitment to be 
responsive Congresswoman.
    Ms. Slotkin. Great. Thanks so much.
    I yield back, Mr. Chairman.
    Chairman Thompson. Thank you very much.
    The Chair recognizes the gentleman from Pennsylvania, Mr. 
Joyce, for 5 minutes.
    Mr. Joyce. I want to thank all of the witnesses for 
appearing today. I want to thank you, Mr. Chairman, for making 
the committee room available for this hearing today.
    I would like to yield my time today to my distinguished 
colleague from Tennessee, Dr. Mark Green.
    Chairman Thompson. The Chair recognizes the gentleman from 
Tennessee for the balance of the time.
    Mr. Green of Tennessee. Thank you, Mr. Chairman. I want to 
first thank Congresswoman Slotkin for her questioning. I echo 
everything she said and agree with her 100 percent and look 
forward to hearing back from the Department on those misspent 
funds. That really is one of our primary concerns.
    I also want to appreciate the fact that Congresswoman Rice 
recognized and reiterated the need for America to address this 
physician shortage. We have significant physician shortages 
now, and it is only going to get worse in the coming years.
    My point in bringing it all up is that we had testimony 
from witnesses who said you needed licensed professionals. My 
conclusion from all this is that we can't take those people 
where Americans aren't even getting care and put them on the 
border. What we really need to do is give advanced training to 
our CBP personnel and make sure they are better trained to do 
those kinds of assessments because I just don't think it is 
feasible to put licensed medical personnel down there.
    I also want to say that I agree with Dr. Danaher that the 
pediatric cuff, the pulse ox would have been helpful at those 
border facilities. But as an emergency physician, I can tell 
you that when Jakelin was posturing, it would not have made a 
difference in this case, and to say so would be--is a little 
bit misleading.
    Also, as a doctor, you know, I have provided care from 
Ziway, Ethiopia, to the Himalayas, and a good field medic 
doesn't need a BP cuff to get a decent pressure off of where 
you take the pulses.
    Dr. Mitchell, I wanted to ask you. What areas of the 
hospital--what areas of hospital care and care of a patient do 
you recognize as the highest risk for medical errors?
    Dr. Mitchell. Oh. Well, in my experience, I have seen 
medical errors in the surgical suite. I have seen medical 
errors in the ICU. I have seen medical errors upon 
presentation. We talked about the poor intubation of one of our 
patients.
    So, you know, where medications are prescribed and infused, 
you can see medical errors. So there are several places within 
the system where you can see them.
    Mr. Green of Tennessee. Well, JCAHO has done some pretty 
extensive research in this. Obviously, the Joint Commission on 
Hospital Organizations, they are the folks that accredit our 
hospitals for those who aren't medical providers in the room. 
They have done a lot of research on this, and those transitions 
of care are fraught with risk.
    When one provider hands a patient off to another provider, 
going from the emergency department to the ICU, a shift change 
is an incredibly high-risk time. The gentleman from Louisiana 
mentioned that hiccup time when one of the officers was going 
off shift with Felipe, particularly, and another came on, 
gassed his car up, got there a few minutes late.
    But when he got there, if you will recall from the 
testimony, tell us what that officer did and how he responded 
when he discovered the severity of the situation with Felipe?
    Dr. Mitchell. Well, I think the Border Patrol agents acted 
swiftly to engage the patient and try to get the patient to 
care, and that was evident throughout the record that I 
reviewed.
    Mr. Green of Tennessee. Do you think there was anything 
else they could have done?
    Dr. Mitchell. No. No. I think the agents are acting--you 
know, particularly in Felipe's case and quite frankly, in 
Jakelin's case, these agents when they became aware, they moved 
to make sure that those individual patients got to care.
    So, you know, they I don't think they probably are as 
equipped to recognize the things that they needed to recognize. 
So we talk about that training. We talk about making sure that 
we have adequate personnel that is doing that work and not 
putting it on agents whose job it is to protect in a different 
way the border. But, yes, I think the actions were swift and 
accurate.
    Mr. Green of Tennessee. Thank you, Mr. Chairman. I think my 
time is up.
    Chairman Thompson. Thank you very much.
    The Chair recognizes the gentleman from California, Mr. 
Correa, for 5 minutes.
    Mr. Correa. Thank you, Mr. Chairman, for holding this most 
important hearing. Can you hear me?
    Chairman Thompson. Yes, sir.
    Mr. Correa. Yes. I want to thank the witnesses as well.
    I would like to direct my questions to Dr. Danaher and Dr. 
Mitchell, the topic, CBP Directives on Medical Care for our 
Children.
    In January 2019, following the deaths of 2 children in CBP 
custody in December 2018, CBP expanded the use of contract 
medical personnel. It is a good step forward. CBP also issued a 
directive setting forth interim enhanced medical efforts to 
mitigate risks to and improve care for individuals in CBP 
custody along the Southwest Border.
    The interim directive required the Border Patrol to conduct 
a health review and medical assessment of all migrants under 
the age of 18. December 2019, CBP issued a final medical 
directive, and that final directive appears to be weaker than 
the interim directive. For example, it only required medical 
assessment of children under 12 rather than children under 18.
    Dr. Danaher, if I may ask you a question. Have you had a 
chance to review the interim and final medical directives?
    Dr. Danaher. Yes, I have.
    Mr. Correa. Do you see other deficiencies in the final 
medical directive?
    Dr. Danaher. Yes. There are actually a number of issues 
that I find quite concerning.
    Mr. Correa. Please elaborate.
    Dr. Danaher. Sure. One is the time frame. The initial 
directive, as I recall, is supposed to be stated that these 
health interviews should occur upon initial processing whereas 
the final directive does not state when the health interview 
needs to occur.
    It also narrows the scope of what is considered a basic 
medical screening so that it no longer specifies that vital 
signs must be collected. As we have already discussed in 
Felipe's case, vital signs could have made all the difference 
if somebody had been paying attention.
    As you mentioned, it only mandates medical screenings for 
children under 12 or those with identified medical issues, and 
it includes a caveat. This is subject to availability of 
resources and operational requirements.
    We have to remember that 2 of the children who died in the 
time frame that we are discussing were 16, and so it is unclear 
to me why we are reducing this cut-off to the age of 12.
    It also seems to reduce the qualifications required for 
performing medical screenings, saying that they will be 
conducted by health care providers where available, and it does 
say that basic acute medical care referral and follow-up can 
occur on-site which on the surface is good. We want there to be 
medical services on-site, but we want to make sure that that 
does not mean children won't have access to pediatricians when 
they need them.
    Mr. Correa. Earlier this year, the American Academy of 
Pediatrics submitted a statement for the record to this 
committee which it stated that the final directive, ``is wholly 
inadequate to ensure the proper care of children in custody and 
represents a step in the wrong direction as compared to the 
interim medical directive.''
    Dr. Danaher, would you agree with that assessment?
    Dr. Danaher. Yes, I do.
    Mr. Correa. What changes should be made to the directive, 
the final directive, to ensure that the adequate medical 
assessments are conducted on all children?
    Dr. Danaher. So as these cases that we are discussing 
illustrate, it is extremely important for health interviews to 
occur in a timely fashion on apprehension, and they need to be 
performed by somebody who has at least some basic medical 
training. That could be an EMT. It does not have to mean moving 
physicians to the border for this purpose.
    We also need to make sure that these health interviews ask 
directed questions so that patients understand what they are 
being asked about, and we need to make sure that medical 
screening is offered across the board. We don't want to be 
missing children just because we are saying that the onus is on 
the parents to speak up when they notice something is wrong. 
Once these children are in custody, they are the responsibility 
of CBP, and we need to make sure they are all healthy.
    Mr. Correa. Thank you.
    Mr. Chairman, how much time do I have?
    Chairman Thompson. The gentleman has 40 seconds.
    Mr. Correa. Dr. Mitchell, do you have anything else to add 
to this topic of the final medical directive and its 
deficiencies?
    Dr. Mitchell. No. I think it illustrates that there is a 
need for a level of training and a level of expertise when 
dealing with these patients, particularly children under the 
age of 18.
    I think that if we are talking about systems and developing 
better access to systems, then we would put those resources in 
place to ensure that our children are being initially screened 
by individuals that have the proper level of training to ensure 
that we have better outcomes.
    Mr. Correa. Thank you very much.
    Mr. Chair, time being over, I yield.
    Thank you very much.
    Chairman Thompson. Thank you very much.
    The Chair recognizes the gentlelady from New Mexico, Ms. 
Torres Small, for 5 minutes.
    Ms. Torres Small. Thank you, Mr. Chair. Thank you for 
holding this important hearing, and I am glad that we are all 
here to reckon with these challenges together because it is 
crucial that we make sure that people in our custody are safe. 
I want to begin by offering my condolences to the families of 
Jakelin Caal Maquin and Felipe Gomez-Alonso and other migrant 
children who have died in U.S. custody.
    Since the deaths of Jakelin and Felipe, both of which occur 
in the district I serve, I have called on DHS and the Inspector 
General numerous times to comprehensively investigate what 
happened and specifically what holes in DHS policies need to be 
filled to make sure we aren't putting our Border Patrol agents 
in situations where they don't have what they need to keep kids 
safe in their custody and to stop more migrant deaths from 
dying in our custody.
    This shouldn't be a blame game. This should be looking 
forward and to the future about how we can solve this together.
    I also want to note that these children's deaths occurred 
in the district I serve, and I agree that we must also take 
action to expand health care for rural Americans.
    I invite all of my colleagues to co-sponsor the Resident 
Physician Shortage Reduction Act, legislation Mr. Katko and I 
have championed, to train and keep more rural health care 
providers.
    As well the Training the Next Generation of Primary Care 
Doctors Act, the Conrad State 30, and Physician Access 
Reauthorization Act, the Keep Physicians Serving Patients Act, 
the Maternal Health Quality Improvement Act, the Promoting 
Access to Diabetic Shoes Act, the Nurse Act, the National Nurse 
Act, the Immediate Relief for Rural Facilities and Providers 
Act, the Healthcare Workforce Resilience Act, the Medicare 
Accelerated and Advance Payments and Improvements Act.
    The Save our Rural Healthcare Providers Act, the Border 
Health Security Act, and the Rural Maternal and Obstetric 
Modernization of Services Act, all of legislation I have co-
sponsored or sponsored to help improve health care for rural 
Americans.
    Inspector General, in your testimony, you noted several new 
issues which your office is working on. In your testimony to 
Mr. Crenshaw, you stated you have one on-going investigation of 
a death in CBP custody. Is your office reviewing any other 
deaths in CBP custody?
    Mr. Cuffari. So good to see you again, ma'am. Thank you for 
the question. I believe that is the only additional death in 
custody investigation that we currently have open.
    Ms. Torres Small. Thank you, sir. I appreciate it.
    In your testimony today, you also noted to Miss Rice that 
you did not have a single medical professional on your staff 
during the investigations into Jakelin and Felipe's deaths.
    Will you have--will your on-going investigation into the 
other death be conducted in the same manner, or will any 
changes be made in how you review that death?
    Mr. Cuffari. Based on the increased funding, as I 
mentioned, that the House and Senate gave us this year, we were 
able to seek outside medical contracts. I am happy to report 
that within a few weeks, the contracts should be awarded, and I 
anticipate probably by the end of next month, those individual 
health care providers will be able to augment our inspectors 
and investigators and our auditors.
    Ms. Torres Small. Thank you. How specifically will the on-
going investigation and the use of medical personnel differ 
from the investigations into Jakelin and Felipe's deaths?
    Mr. Cuffari. They won't at this moment because the 
investigation is at the very end of its cycle. We are waiting--
--
    Ms. Torres Small. So you will not supplement that 
investigation with medical information and expertise?
    Mr. Cuffari. No. We will deal with supplemental review of 
scoping of the entire Border Patrol's handling of medical 
health care providers and services to in-custody children.
    Ms. Torres Small. In the last minute, in your testimony, 
you indicated your office is working on a review of ``CBP's use 
of Fiscal Year 2019 appropriated funds for humanitarian 
assistance.''
    What exactly will you be reviewing in that work, and will 
you be looking more closely at the misspending that GAO has 
already identified and that Congresswoman Slotkin discussed in 
her questions?
    Mr. Cuffari. Certainly, and let me just clarify my last 
response. In this particular case, we have engaged the services 
of an outside medical examiner in the very last instance, so we 
will have someone from outside looking at the medical review 
and the autopsy.
    So to your current question, what we are going to be doing 
is looking at the report that the GAO has done regarding the 
expanding on that, looking at whether CBP has adequately 
planned for in the deployment of appropriated funds to quickly 
and effectively address the humanitarian needs at the border.
    Ms. Torres Small. Thank you. I yield the remainder of my 
time.
    Chairman Thompson. Thank you very much. Mr. Inspector 
General, how long have you had the money at GPN to obligate for 
contracts and services [inaudible] personnel? How long have you 
had this money?
    Mr. Cuffari. I believe, sir, the appropriations came in 
January, and we were funded in February or March of this year.
    Chairman Thompson. So you have had the money about 6 
months?
    Mr. Cuffari. Yes, sir.
    Chairman Thompson. Thank you.
    The Chair recognizes the gentlelady from Illinois, Ms. 
Underwood, 5 minutes.
    Ms. Underwood. Well, thank you, Mr. Chairman. Let me be 
blunt. This administration's treatment of migrant children have 
been appalling. Three years ago, the Department of Homeland 
Security implemented a policy of separating families at the 
border. As a nurse and public health expert, I am familiar with 
the data showing that family separation causes trauma that can 
do both immediate and long-term damage to children's health. 
But it doesn't take a nursing degree to understand that. We all 
know it is inhumane, immoral, and just plain wrong.
    Today, we are trying to get to the bottom of deaths of just 
2 of the migrant children who have died in Federal custody 
under this administration. Felipe and Jakelin are among the 6 
children who died, either during or shortly after their time in 
CBP detention on this administration's watch, after a decade 
with zero deaths.
    Mr. Cuffari, the time line included in your office's report 
regarding Felipe's death states that during his first hospital 
visit on the morning of December 24, 2018, he was diagnosed 
with influenza B. However, the written discharge instructions 
included with the medical records from his first hospital visit 
appear to have been for the treatment of ``an upper respiratory 
infection pediatric'' without specifying an influenza 
diagnosis.
    Did your office conduct interviews with any other medical 
personnel who provided care to Felipe?
    Mr. Cuffari. No, ma'am. That was outside the scope of our 
investigation.
    Ms. Underwood. Did you conduct a forensic analysis of 
Felipe's medical records to fully understand what the Border 
Patrol agents were told about the influenza diagnosis and why?
    Mr. Cuffari. We didn't conduct a forensic analysis. We 
conducted a review of the medical records that we obtained from 
the hospital, and noted in the discharge paper for Felipe, 
there was no indication on there that Felipe had tested 
positive for influenza.
    Ms. Underwood. Dr. Danaher, in June, the inspector 
general's office issued a report entitled ``CBP's Struggle to 
Provide Adequate Detention Conditions During 2019 Migrant 
Surge.'' This report stated, ``Crowded conditions presented 
health challenges for on-site medical staff in some facilities, 
including containing the spread of contagious illnesses.'' 
Felipe had been in custody for 6 days when he died, which is 3 
days longer than allowed. Do you believe it is possible that 
Felipe contracted influenza while in CBP custody?
    Dr. Danaher. I believe I can state with certainty that he 
did. Because the longest incubation period for influenza is 4 
days, [inaudible] manifest itself.
    Ms. Underwood. Thank you.
    Ms. Gambler, last fall, I joined my colleagues in writing 
to the Centers for Disease Control and Prevention to request 
information about their recommendation that CBP should 
vaccinate all migrants over the age of 6 months at the earliest 
feasible time. I am certainly disappointed that nobody from CBP 
is here today to answer questions about why they have not 
implemented the CDC recommendation. Ms. Gambler, did your 
office examine CBP's decision to not implement the CDC's full 
recommendation? If so, what did you find?
    Ms. Gambler. Yes. Thank you for the question. We--through 
our work, we did identify that CBP has not fully documented the 
reasons for its decision not to offer the influenza vaccine to 
those in its custody. CBP identified to us a number of 
challenges to offering those vaccines, including things like 
providing cold storage, and the need for increased contracted 
medical care provider. But they didn't document how they 
considered, or weighed those costs, or considered those costs 
versus the benefits that could come from offering influenza 
vaccine. So, our recommendation was really geared toward CBP 
more fully documenting the reasons why they decided not to 
offer the vaccine----
    Ms. Underwood. Right.
    Ms. Gambler [continuing]. Including how they consider costs 
and benefits so that as they continue to have conversations 
about public health issues going forward, they can have a 
record and good documentation of the decisions they are making.
    Ms. Underwood. Thank you. Ms. Gambler, I understand from 
your written statement that CBP claimed that offering flu 
vaccines to people in their custody would, ``provide little 
benefit to the agency,'' because their goal is to transfer 
people out of their custody quickly. However, as we saw with 
Felipe's case, CBP doesn't always transfer people quickly. 
Isn't that right?
    Ms. Gambler. That is right. There are reports, and I think 
the inspector general has reported this as well, that 
individuals can be in CBP's custody for longer than the amount 
of time that CBP is hoping to detain them for that short period 
of time.
    Ms. Underwood. Ultimately, from a medical standpoint, we 
know that there are consequence of CBP's failure to implement 
the CDC's recommendation for vaccinations. Given the on-going 
coronavirus pandemic, we know that individuals who might come 
into custody would be at increased risk as well.
    Thank you so much, Mr. Chairman. Thank you to our panel of 
witnesses. I yield back.
    Chairman Thompson. Thank you very much. The Chair now 
recognizes the gentleman from Missouri, Mr. Cleaver, for 5 
minutes.
    Mr. Cleaver. Thank you, Mr. Chairman.
    Mr. Inspector General, I don't want you to please take this 
as some kind of an insult, but in Washington, candor is 
sometimes silenced, leaving only power as the source of sound. 
I don't think there is any reason for me to question any of 
your integrity, and please understand that is not just a 
statement I am making. I am asking--that is kind-of the issue 
anyway. But my issue is, do you feel comfortable? Am I still 
being heard? Hello? OK.
    Mr. Cuffari. Repeat your question. I am sorry.
    Mr. Cleaver. My question is, based on everything that you 
have seen and heard, I mean, we have a number of IGs who have 
been fired, relieved of duty. So my question is, do you feel 
comfortable in being as candid as possible without fear that 
you would be silenced if you were to say something that was not 
in harmony with the powers that is all around all of us?
    Mr. Cuffari. I take your question, sir. I commit to you 
that if I ever felt any pressure to change my opinion for 
whatever reason, I would come to the Chair, and the Ranking 
Member of this committee, and other oversight bodies, both in 
the House and in the Senate.
    As you know, I have more than 40 years of honorable service 
as a U.S. Air Force officer. I served every President from 
Jimmy Carter to the current, President Trump. I stand committed 
to speaking truth to powers.
    Mr. Cleaver. There has never been anything that you have 
said or done that would cause me to believe otherwise. I am 
just raising a question because of things that I am seeing has 
happened in Washington, things that have happened in Washington 
that are, at least, appear to be unsavory. So thank you.
    You are familiar with the fact that one of the agents who 
had taken care of Felipe had to pay for some of the over-the-
counter medication----
    Mr. Cuffari. Yes, sir.
    Mr. Cleaver [continuing]. Out of his own pocket. Can you 
explain what that might have--what might have precipitated the 
fact that someone would have to go in their own pocket and pay 
for some medicine for some poor kid that obviously appeared to 
be sick?
    Mr. Cuffari. It appeared that the prescription for 
amoxicillin at the hospital that was issued was covered under 
their health care services, but the over-the-counter 
medication, which was for acetaminophen, I believe, or 
ibuprofen, perhaps--I stand corrected--was not covered. It was 
an over-the-counter medicine.
    Mr. Cleaver. Well, my assumption, Mr. IG, is that the agent 
that we found out, that the agent had actually used his or her 
own money because they were reimbursed. Is that how this came 
to our consciousness?
    Mr. Cuffari. Actually, I don't know, sir, if he was 
reimbursed. He did pay for it up front. I don't know whether he 
asked for reimbursement on that.
    Mr. Cleaver. I was just curious about how we found out 
about it. Perhaps he mentioned it to someone, which is not 
unusual for people who are committed and dedicated. My sister 
is a principal of elementary school here in Kansas City. I am 
always telling her she is going to be retire broke because she 
is buying pencils, and colors, and all that out of her 
paycheck. So I just think that is something that, you know, the 
agent should be praised for. He or she is probably not the only 
one.
    Mr. Cuffari. I feel your pain, sir. My wife is a former 
high school principal as well.
    Mr. Cleaver. Well, you are not going to have any retirement 
money, because I have seen that out all my adult life with my 
sister.
    Dr. Danaher, do you have anything that you would recommend 
to us to make corrections that this would not happen again? 
What would you recommend to us? Do we need to put some policies 
in place? Do we need to do anything that would assure us and 
the American people of this is not going to happen anymore? Or 
are we certainly going to reduce the likelihood that it would 
happen again?
    Dr. Danaher. So I appreciate the question. I think it is 
extremely important, as I mentioned before, for health care 
screening to be occurring as soon as possible after we 
encounter children, and that needs to mean that we have people 
with at least basic medical training out in remote areas, like 
the place where Jakelin was apprehended. If she had to wait 
several hours before she could receive medical attention, that 
several hour period may mean life and death. Having people at 
the border who can at least recognize when children are sick 
and begin the process of getting into medical care quickly is 
extremely important.
    I think also having the better protocols in place to screen 
and triage migrants when illness is identified, to make sure 
they have access to the appropriate medical care preferably on-
site if possible, but [inaudible] that they also have access to 
prescriptions on-site. Of course, as Dr. Mitchell mentioned, we 
need to reduce overcrowding and all of the other conditions 
that are promoting infections.
    Mr. Cleaver. Doctor, thank you very much. I really think 
that triage issue should be further developed. I wouldn't mind 
getting a memo on this.
    Thank you, Mr. Chairman. I yield back the balance of my 
time.
    Chairman Thompson. Well, if you give the staff, Mr. 
Cleaver, we will gladly make that request.
    Mr. Cleaver. Thank you. I will do that. Thank you, sir.
    Chairman Thompson. The Chair recognizes the gentleman from 
Texas, Mr. Green, for 5 minutes.
    Mr. Green of Texas. Thank you, Mr. Chairman. I thank the 
Ranking Member as well. I thank the witnesses for appearing.
    Let me start, if I may, with the IG. Sir, how many times 
did you visit the border pursuant to this investigation?
    Mr. Cuffari. Sir, just so you know, set the record 
straight, I was confirmed by the full Senate at the very end of 
July of last year. Within 2 months, I went to the border to 
look at El Paso and the Tucson sectors. The investigations that 
the committee is holding a hearing regarded events that 
happened 7, 8 months before even my confirmation. This would 
have been in December, 2018.
    Mr. Green of Texas. While you were there, did you pursue 
any actions to further your insight into what happened to these 
children?
    Mr. Cuffari. Not to the children in particular, because 
these were events that had already occurred. I was looking at 
overarching conditions at the El Paso and the Tucson sectors.
    Mr. Green of Texas. You actually visited, I take it, the 
facilities where these children were detained?
    Mr. Cuffari. Not these particular facilities--except I 
stand corrected. We went to the El Paso del Norte Port of Entry 
in El Paso, Texas. Yes.
    Mr. Green of Texas. When you were at that port of entry, 
did you notice it was somewhat akin to a large facility that 
allowed vehicles to flow through? Did you notice that, the 
place where the children entered the facility?
    Mr. Cuffari. I don't believe so, sir. No. Again, this is 
October 2019.
    Mr. Green of Texas. I understand. The facility is still the 
same, I assume.
    Mr. Cuffari. [Inaudible] deconstructed whatever they had as 
temporary facilities.
    Mr. Green of Texas. There is a facility there that is 
probably still standing. This is what I would consider a main 
facility. But in any event, did you notice how the children 
were cared for immediately upon entering the country in terms 
of how they are housed, and whether they are given blankets, 
whether they are kept warm? Did you notice?
    Mr. Cuffari. Yes, sir. I noticed that the El Paso Border 
Patrol station where they had soft-sided--not soft-sided tents, 
but they had large structures that were constructed out of some 
material. The families were kept together in open bay sort-of 
barracks. They had medical attention. They had hot meals. They 
had toys that were actually, in some cases, the Border Patrol 
agents were bringing them in for the children. They had 
access----
    Mr. Green of Texas. Do you think that the facilities are 
adequate for the time of year when it is cold and don't have 
blankets? Do you think that this was adequate?
    Mr. Cuffari. From what I observed at the time on that 
particular day, it was about a 2-hour visit, they appeared to 
be adequate. However, I want to add and just emphasize that we 
are doing on-going work to take a look at CBP's holding of the 
detainees beyond the 72 hours. And migrants experiencing 
serious medical conditions.
    Mr. Green of Texas. Well, isn't it true that they have 
upgraded since you were there, and they have better blankets 
and other materials for the children?
    Mr. Cuffari. That is quite possible, sir. But I am sure our 
inspections and evaluations will identify that in real time.
    Mr. Green of Texas. Let's move to the current circumstance. 
Do you believe now that we are prepared at the border to 
receive children who are sick and appropriately care for them?
    Mr. Cuffari. I actually don't know. My intent is to have 
these 20 different audits and inspections answer that question.
    Mr. Green of Texas. Let's just talk for a moment. One of 
the physicians has been adequately questioned about his medical 
thoughts, and in a sense, is somewhat challenged about his 
opinions. So let me just ask you a couple of questions. Is it 
true that there has been some question with reference to your 
Ph.D.?
    Mr. Cuffari. That is correct.
    Mr. Green of Texas. Is it true that you have signed 
documents indicating that you have a Ph.D., but not that it was 
in management and some question about it being in management 
versus philosophy?
    Mr. Cuffari. There was a posting on our official website. 
When it came to our knowledge that there was a typographical 
error indicating that I had a Ph.D. in philosophy, not a Ph.D. 
in management, which is what I do have. We made the 
typographical correction. I also noted, I will add, there were 
one or two commas that we recently noticed that we needed to 
correct as well.
    Mr. Green of Texas. Did you ever visit the University where 
you received your Ph.D.?
    Mr. Cuffari. I did on 2 occasions, sir.
    Mr. Green of Texas. Is it true that there is currently a 
Subway and a 7-Eleven store in that facility?
    Mr. Cuffari. I have no idea. I attended the University from 
1998 through 2002, when I was awarded my degree.
    Mr. Green of Texas. Is it true that there is some concern 
as to whether or not this was a mill process for presenting 
Ph.D.s?
    Mr. Cuffari. To my knowledge, I did all the appropriate 
work. I paid for the schooling out of my money. I worked for 
the Department of Justice inspector general at the time. I did 
this through on-line learning and I was awarded the degree that 
I earned.
    Mr. Green of Texas. I am going to yield back, Mr. Chairman. 
Thank you.
    Chairman Thompson. The gentleman yields back. The Chair 
recognize the gentlewoman from Nevada, Ms. Titus, for 5 
minutes.
    Ms. Titus. Thank you, Mr. Chairman. I would like to go back 
to that capping report that was mentioned earlier that was 
issued last month by the Inspector General's office. That 
report summarizes the results of the office's unannounced 
inspections at 14 Border Patrol stations, and 7 points of entry 
between April and June 2019. Is that right Mr. Inspector 
General?
    Mr. Cuffari. That is correct, ma'am.
    Ms. Titus. As part of these inspections, you reviewed the 
migrants' access to medical care. However, the capping report 
states, ``Because our office does not have medical expertise, 
we did not evaluate the quality of medical care CBP provided 
detainees.''
    So Mr. Cuffari, when your teams were visiting these Border 
Patrol facilities, what kind of field work did you do to assess 
compliance for the TEDS standards? Did they just simply observe 
what was happening while they were there and do spot checks, or 
did they also do some type of systematic review of records?
    Mr. Cuffari. Just for the record, ma'am, the time of those 
unannounced inspections in 2019, we did not have a medical 
health care provider services contract. Due to our increased 
funding that you have provided, we have contract for such 
augmentation.
    The unannounced inspections normally are between 1 to 3 
days in length at a particular facility. They follow 
procedures. They are looking at events that are occurring in 
their presence at that particular point in time. They document 
that information. If they find that there are abnormalities or 
issues of misconduct, they report them immediately. In one 
instance last summer, we issued a major management alert to the 
Department highlighting a condition that our inspectors saw.
    Ms. Titus. So absent anybody with the medical expertise 
previously, and without evaluating medical care, can you really 
confidently assess compliance with the TEDS standards, 
including that requirement for appropriate care?
    Mr. Cuffari. We follow the Council for Inspector General 
for Integrity and Efficiency Standards. Our auditors and 
inspectors are greeted. We have peer reviews. In fact, we are 
going through a peer review in our inspections and in our audit 
divisions actually this summer. We base our evaluations on what 
we observe at the time that we are in facilities.
    Ms. Titus. Well, the results of the inspections section 
states, ``Most Border Patrol facilities took steps to try and 
evaluate and respond to the medical needs of the sizable 
detainee population. This included conducting medical 
screenings of all detainees before entrance into a facility.'' 
When it says it was ``all detainees,'' does that mean literally 
every single detainee received a screening, as you would think 
that is what ``all'' means. If so, how were your teams able to 
assess whether every single person was screened, particularly 
in the crowding that occurred in some of those facilities?
    Mr. Cuffari. I take the word ``all'' to mean ``all.'' I am 
assuming that our inspectors saw and documented what they saw, 
which would be all the individuals at that particular point 
were getting medical evaluations.
    Ms. Titus. Well, it seems to me that there are a lot of 
kind-of assumptions, and we can think, and we can trust, and we 
believe they did in the report. A lot of these kinds of terms 
being thrown around.
    I would like to ask the 2 doctors if they see anything 
about the assertions that is concerning you. What concerns do 
you have if you have had a chance to review that capping 
report? Could you lay that out for us, so we might be able to 
improve on that in the future?
    Dr. Danaher. Yes. So the capping report, as you mentioned, 
seems to acknowledge that there is medical care occurring at 
some of these facilities. But as you stated, it is very 
difficult to assess from the report what the quality, or even 
the extent of that medical care is.
    I was also troubled to see that it appears that medical 
screenings are occurring in large groups of migrants, no 
privacy. It makes me question whether any exams are actually 
accompanying these screenings, or if it is just somebody asking 
questions.
    I was also a little bit troubled that there was basically 
just a photograph of a number of shelves of medications, and 
there was an assumption that those were the right medications 
needed on-site for the detainees. Without a physician reviewing 
that, it is very difficult to know if having those medications 
there is adequate to meet detainees' needs.
    Ms. Titus. It seems it is difficult to assess any of this 
without a medical expert there, just some officer going in and 
taking a look around.
    Dr. Mitchell, do you have anything to add?
    Dr. Mitchell. Yes. I think that was the point I was going 
to make, Representative. I think that having, you know, a 
medical officer that is engaged in the care that is happening 
at the border, a responsible oversight in medicine, but also, 
the review of anything that comes out of this particular set of 
circumstances is extremely important.
    You know, detention centers, once people are in them, they 
really do become, you know, small hospitals. I mean, in 
general, most people are going to be sick in these detention 
centers, or jails, or prisons within this country. So it is so 
important to have sustainable medical professionals that are 
overseeing the care that is happening, whether it is triage or 
original assessment, but overseeing the triage that is 
happening amongst these individuals. So I would just add that 
to what we are discussing.
    Ms. Titus. Thank you very much. I yield back, Mr. Chairman.
    Chairman Thompson. Thank the very much. The Chair 
recognizes the gentlelady from California, Ms. Barragan, for 5 
minutes.
    Ms. Barragan. Thank you, Mr. Chairman, for convening this 
critically important hearing. I serve as the second vice chair 
of the Congressional Hispanic Caucus. Last year, my 
Congressional Hispanic Caucus colleagues and I toured the 
Alamogordo Border Patrol station on highway 70 CBP checkpoint 
in New Mexico. I saw first-hand the cell where Felipe Alonso-
Gomez, an 8-year-old boy from Guatemala, spent his last hours, 
and tragically died on Christmas eve. I witnessed the awful 
condition he was held in. There were no showers. It was an open 
bathroom where everybody could see you. It was complete 
concrete. There was no nutritious foods for people, especially 
for kids that may be sick. There was a lack of medical 
supplies.
    There was only a first aid kit and a small EMT bag, but no 
trained medical personnel. CBP's lack of immediate and 
meaningful care for asylum seekers are putting migrant 
children's lives in jeopardy. We even spoke to the officers 
there who says they are not trained to take care of those who 
are ill. It was unbelievable to me to see the condition in 
which a child who was sick would be sent to to wait, where 
there is no blankets, where there is nothing padded, a complete 
jail cell.
    Dr. Danaher and Dr. Mitchell, I know we have talked about 
this already today, but I think it is very important. Could you 
please, again, explain the challenges associated with 
recognizing medical distress in children, particularly young 
children who may not be able to talk or where there may be 
language barriers?
    Dr. Danaher. Yes. So it can be extremely difficult to get a 
clear medical history from a young child, on top of that, from 
a parent who is in distress about their child's well-being. 
Children look different than adults when they get sick. They 
have much more physiological reserve, meaning they can 
compensate better for longer when they are sick.
    But it also means that when they run out of their metabolic 
reserves, they crash very fast. We run into this all the time 
in pediatrics where kids come in having looked OK, and then 
they decompensate very quickly. If action is not taken quickly 
to help them, then the outcomes can be really terrible, as we 
saw in this case.
    Ms. Barragan. Thank you. Dr. Mitchell.
    Dr. Mitchell. Yes. Again, I would defer to Dr. Danaher. The 
reality of it is, is that it is a matter of time leads. So, 
when we put trained individuals and not rely on the agents that 
are not trained to do this work, but put trained individuals in 
position to get people to care or recognize distress earlier, 
then we have the potential to save lives. So, you know, that is 
all I would add.
    Ms. Barragan. Thank you. Ms. Gambler, you indicated in your 
testimony that CBP has not trained its personnel on recognizing 
medical distress in children. Is that right?
    Ms. Gambler. Yes. That was one of our findings. In fact, we 
made a recommend decision to CBP that she should develop and 
implement such training for all officers and agents who could 
come in contact with children in custody.
    Ms. Barragan. I believe in your testimony you said that CBP 
and the American Academy of Pediatrics have, and I quote, 
obviously will give the quote here: ``developed a training 
video on recognizing medical distress in children, which CBP 
included as part of its training for emergency medical 
technicians and paramedics.'' Is that right?
    Ms. Gambler. Yes. That was part of our report.
    Ms. Barragan. Ms. Gambler, do you know how many CBP 
personnel are trained as EMTs and paramedics?
    Ms. Gambler. We do have that information in the report and 
we would be happy to follow up and provide that particular 
number after the hearing.
    Ms. Barragan. OK. I can tell you that when I went to the 
CBP station there to ask CBP about Felipe in particular, they 
basically said they had one person available for 3 different 
stations, and they had to rotate him through. So there was just 
no way to have anybody there for any extended period of time. 
There was just a shortage.
    Ms. Gambler, has the video on recognizing medical distress 
in children been shown to all CBP personnel, not just those who 
are EMTs and paramedics?
    Ms. Gambler. CBP told us that that video is available as 
optional training to all officers and agents, but that that 
training video is primarily geared toward officers and agents 
who are trained emergency medical technicians. That was one of 
reasons for our recommendation that CBP needed to develop and 
implement training for children in medical distress to be 
provided to all officers and agents who could come in contact 
with children in custody.
    Ms. Barragan. Well, thank you for recognizing that, because 
it is completely unacceptable that not everybody would be 
trained to recognize the distress symptoms amongst children. So 
thank you for doing that. Hopefully, we will have better 
treatment of our migrants at the border.
    With that, Mr. Chairman, I yield back.
    Chairman Thompson. Thank you very much. Let me thank the 
witnesses for their valuable testimony and the Members for 
their questions. As you can tell, if you are not an expert, you 
will get tested before this committee. I thank all of you for 
actually presenting very well and you responded accordingly.
    Before adjourning I would ask unanimous consent to submit 2 
statements for the record. The first is Mr. Morgan's letter 
responding to the committee's invitation to testify at this 
hearing.* The second is former Acting Secretary McAleenan's 
June 2019 letter to Members of Congress seeking emergency 
appropriations to the care for migrant children.
---------------------------------------------------------------------------
    * The information has been submitted in a previous portion of this 
document.
---------------------------------------------------------------------------
    Without objection, so admitted.
    [The information follows:]
                                     June 12, 2019.

    Dear Member of Congress: We continue to experience a humanitarian 
and security crisis at the southern border of the United States, and 
the situation becomes more dire each day. On May 1, 2019, the 
Administration requested $4.5 billion in emergency appropriations for 
the Department of Health and Human Services (HHS), the Department of 
Homeland Security (DHS), the Department of Defense, and the Department 
of Justice to address the immediate humanitarian crisis at our southern 
border. We write today to ask that you appropriate this funding as soon 
as possible.
    We cannot stress enough the urgency of immediate passage of 
emergency supplemental funding. This funding will provide resources 
that our Departments need to respond to the current crisis, enable us 
to protect the life and safety of unaccompanied alien children (UAC), 
and help us to continue providing the full range of services to the 
children in our custody.
    While Congress has been considering the request, the average daily 
number of UAC in U.S. Customs and Border Protection (CBP) custody has 
grown from nearly 870 on May 1 to more than 2,300 today. This is 
because the number of arriving children greatly exceeds existing HHS 
capacity. As of June 10, 1,900 processed UAC were in CBP custody 
awaiting placement in HHS care. However, HHS had fewer than 700 open 
beds in which to place them. HHS has significantly increased the rates 
at which we are discharging children to sponsors, but UAC are waiting 
too long in CBP facilities that are not designed to care for children.
    This is a direct result of the unprecedented number of arriving 
children. As of June 10, DHS has referred over 52,000 UAC to HHS this 
fiscal year (FY), an increase of over 60 percent from fiscal year 2018. 
Preliminary information shows nearly 10,000 referrals in May--one of 
the highest monthly totals in the history of the program. If these 
numbers continue, this fiscal year HHS will care for the largest number 
of UAC in the program's history. HHS continues to operate near 
capacity, despite placing UAC with sponsors at historically high rates. 
HHS is working diligently to expand its bed capacity to ensure that it 
can keep pace, and based on the anticipated growth, HHS expects its 
need for additional bed capacity to continue.
    On May 17, the Administration notified Congress of an anticipated 
deficiency in HHS's Office of Refugee Resettlement's (ORR) UAC program, 
as required by law. Absent an emergency appropriation, HHS anticipates 
running out of funding as soon as this month. The Anti-Deficiency Act, 
which is a criminal statute, requires HHS to take actions to minimize 
the deficiency and only to fund operations that are essential for the 
safety of human life and protection of property--similar to those 
activities allowed during a government shutdown. In the last few weeks, 
because of rapidly depleting funds caused by the border surge, ORR was 
required by law to scale back or discontinue awards, and had to 
instruct grantees that new awards cannot be used for UAC activities 
that are not directly necessary for the protection of life and 
property, including education services, legal services, and recreation. 
This was done solely to ensure full compliance with the Anti-Deficiency 
Act and stretch existing funds as far as possible for the life and 
safety of children.
    ORR would not have had to take these actions to preserve essential 
operations if requested supplemental funding had been provided. If 
Congress acts quickly to provide the requested supplemental funding to 
address the border surge, ORR will be able to restore these services. 
Until such funding is provided, ORR will only be able to pay for 
essential services to protect life and safety.
    It is unprecedented for a critical child welfare program to run out 
of funding, and ORR is in close contact with grantees about expected 
impacts. Once the UAC program is entirely out of funding, grantees will 
have to care for children with no Federal reimbursement until an 
emergency appropriation is enacted. It is unclear if grantees would be 
operationally able to continue caring for UAC, as many are small 
nonprofit organizations. This funding lapse could also negatively 
impact grantees' willingness to care for UAC over the longer term and 
ORR's immediate ability to add new child care facilities to address the 
overflow of children in DHS border facilities that were not designed 
for children. Our valued Federal employees in ORR who care for children 
and place them with sponsors would be required to work without pay.
    It is not only the UAC program that will be impacted. On May 16, 
HHS notified Congress that the Anti-Deficiency Act requires HHS to 
reallocate up to $167 million from Refugee Support Services (RSS), 
Victims of Trafficking, and Survivors of Torture to the UAC program if 
activities do not meet the criteria in 31 U.S.C.  1515(b)(1)(B). Last 
week, HHS informed the State refugee coordinators and refugee 
resettlement grantees in 49 States and the District of Columbia that 
ORR was withholding third quarter funding for those programs. The RSS 
program addresses barriers to employment for refugees such as: Social 
adjustment, interpretation and translation, day care for children, and 
citizenship and naturalization. Again, this was not a decision that ORR 
wanted to make, or took lightly. HHS's hand was forced by the current 
funding situation and the law. HHS must ensure that it is fully 
compliant with the Anti-Deficiency Act and that HHS stretch its 
existing funds as far as possible to protect the life and safety of 
children who are presently, or should be, in HHS care.
    While the primary concern of both of our Departments is the safety 
of children in our care, DHS faces changing dynamics at the border that 
continue to stress its ability to respond. For example:
   More groups are illegally entering the United States, and 
        they are getting larger.
     On May 29, U.S. Border Patrol (USBP) agents apprehended 
            over 1,000 migrants illegally crossing from Mexico as one 
            group, overtaxing border operations. Over 400 migrants were 
            apprehended within 5 minutes only 2 weeks before.
   The number of migrants has escalated, with more vulnerable 
        populations arriving.
     In May 2019, an average of more than 4,650 people daily 
            illegally crossed into the United States or arrived at 
            ports of entry without proper documentation. In May 2017, 
            the daily average was under 650 illegal crossings per day.
     May 2019 experienced more than 144,000 total enforcements 
            on the southern border, a 32 percent increase over the 
            previous month and the highest monthly total since March 
            2006. This follows 2 months exceeding 100,000--sustained 
            levels not seen in over 12 years.
     As of June 10, 2019, more than 17,000 people are in CBP 
            custody, including over 2,500 UAC.
     The USBP apprehended nearly 85,000 individuals in family 
            units in May 2019 along the Southwest border. An additional 
            4,100 individuals in a family unit were deemed inadmissible 
            at Southwest border ports of entry. The vast majority of 
            these individuals have been released into the country due 
            to a lack of space and authority to detain them. By 
            comparison, in all of fiscal year 2012, USBP apprehended 
            just over 11,000 individuals in a family unit.
   Border Patrol agents are spending more than 50 percent of 
        their time caring for families and children, providing medical 
        assistance, driving buses, and acting as food service workers 
        instead of performing law enforcement duties.
   Border Patrol agents are making on average 70 trips to 
        hospitals every day to urgently get care to these individuals, 
        further diminishing their ability to perform their official 
        duties.
   The Centralized Processing Center in McAllen, Texas, and 
        other CBP facilities have experienced outbreaks of flu which 
        has required standing up separate quarantine facilities to 
        reduce the risk of further exposing children and other 
        vulnerable populations to infectious disease. While agents are 
        providing the best care possible, these groups need more 
        appropriate care, and they need it now.
    If DHS does not receive additional funding, it will be forced to 
take drastic measures in August that will impact other critical 
programs that support DHS missions throughout the country. All DHS 
components, including the Transportation Security Administration, the 
Federal Emergency Management Agency, the Cybersecurity and 
Infrastructure Security Agency, the Coast Guard, and portions of CBP 
supporting legal trade and travel will be required to redirect manpower 
and funding to support measures to address the crisis.
    In addition to the supplemental, it is clear that we need 
bipartisan legislation to address the causes of this crisis. We urge 
Congress to take swift action to provide the necessary funding to 
address the severe humanitarian and operational impacts of this crisis 
and to enact reforms to the root causes of these problems so that they 
do not persist into the future.
    Thank you for your most immediate attention to this matter. A copy 
of this response will also be sent to your State's executive 
leadership.
            Sincerely,
                                          Alex M. Azar, II,
             Secretary, U.S. Department of Health & Human Services.
                                           Kevin McAleenan,
            Acting Secretary, U.S. Department of Homeland Security.

    Chairman Thompson. The Members of the committee may have 
additional questions for the witnesses and we ask that you 
respond expeditiously in writing to those questions. Without 
objection, the committee record shall be kept open for 10 days. 
Hearing no further business, the committee stands adjourned.
    [Whereupon, at 2:35 p.m., the committee was adjourned.]



                            A P P E N D I X

                              ----------                              

    Questions From Congressman Emmanuel Cleaver for Fiona S. Danaher
    Question 1. Dr. Danaher, what recommendations would you make to 
Custom and Border Protection's (CBP's) protocols so that in the future, 
children do not die in Federal custody?
    Question 2. What policies or staffing changes should CBP or 
Congress put in place to dramatically reduce the likelihood of the 
child deaths discussed at the hearing today happening ever again?
    Answer. Thank you for the opportunity to provide additional written 
testimony.
    The current COVID-19 epidemic and the upcoming influenza season 
pose unprecedented risks for the health of children in CBP custody. 
Recent reports of children detained in hotels by subcontractors who may 
not have child welfare training, outside of standard CBP and ICE/ORR 
facilities and protocols, with the goal of rapid expulsion, raise 
additional questions about how carefully the well-being of children in 
immigration custody is being monitored.\1\
---------------------------------------------------------------------------
    \1\ Rose, J. and Penaloza, M. Shadow Immigration System: Migrant 
Children Detained In Hotels By Private Contractors. NPR. https://
www.npr.org/2020/08/20/904027735/shadow-immigration-system-migrant-
children-detained-in-hotels-by-private-contrac. Published August 20, 
2020. Accessed August 20, 2020.
---------------------------------------------------------------------------
    As previously described by the American Academy of Pediatrics 
(AAP)\2\ and the Centers for Disease Control and Prevention (CDC),\3\ 
CBP can take multiple steps to protect the health and safety of 
children in its custody throughout the process of apprehension, 
processing, and detention.
---------------------------------------------------------------------------
    \2\ Testimony for the Record on Behalf of the American Academy of 
Pediatrics Before the U.S. House of Representatives Committee on 
Homeland Security, Subcommittee on Border Security, Facilitation, & 
Operations. Assessing the Adequacy of DHS Efforts to Prevent Child 
Deaths in Custody. https://downloads.aap.org/DOFA/
Jan%202020%20Hearing%20Statement%20for%20- the%20Record%20%20AAP.pdf. 
Published January 14, 2020. Accessed July 11, 2020.
    \3\ Letter from Director of the Centers for Disease Control and 
Prevention Dr. Robert Redfield to the Honorable Rosa DeLauro at 10-11. 
https://www.warren.senate.gov/imo/media/doc/
CDC%20Response%20%20migrant%20vaccination.pdf. Published November 7, 
2019. Accessed July 6, 2020.
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In the field
   Prior to apprehension, migrants have often traversed 
        difficult terrain and endured harsh conditions that place them 
        at increased risk for illness. As such, teams of CBP agents 
        working in remote areas should include EMTs with enhanced 
        pediatric training, such as that already offered by the 
        American Academy of Pediatrics. Agents should carry basic 
        supplies like oral rehydration, food, and first aid kits in 
        case they encounter migrants in distress.
   When large groups of migrants are apprehended, they should 
        be temporarily divided into smaller groups of no more than 10 
        individuals, and each group should be addressed directly by a 
        Border Patrol agent to advise them of the option to request 
        urgent medical attention and/or language interpretation. 
        Assessing need for language interpretation should be performed 
        using a standardized, validated tool. This will help to ensure 
        that all detainees hear and understand the presented 
        information.
   Agents should have access to telephonic interpretation in 
        case a migrant needs to express an urgent medical issue. Agents 
        should also receive training in basic medical Spanish.
   Migrants identified as needing urgent medical attention 
        should be triaged directly to the nearest health care facility, 
        rather than first awaiting completion of processing at a Border 
        Patrol station. In cases of acute illness in a remote area, an 
        ambulance should be requested to meet CBP en route to the 
        hospital.
   Migrants who volunteer nonacute medical concerns (as 
        determined by a CBP EMT) should have their vital signs checked 
        and receive priority transportation to the nearest Border 
        Patrol station for additional assessment.
Health interviews
   Health interviews should be conducted by appropriately-
        trained CBP personnel as soon as possible after apprehension, 
        in the field if possible. This will not only help to ensure 
        timely attention to urgent medical issues, but will also 
        facilitate safe cohorting and transportation of any migrants 
        with potentially contagious illnesses.
   At a minimum, health interviews should be performed upon 
        initial processing for all detainees under age 18, with 
        particular emphasis placed on ensuring timely interviews for 
        pregnant detainees and those who volunteer a medical concern 
        upon apprehension. If health interviews cannot be completed 
        upon initial processing, they should occur no later than 24 
        hours after apprehension to ensure that any health issues 
        requiring prompt attention are addressed.
   Health interviews should be conducted individually and out 
        of earshot of other migrants whenever possible, to prevent 
        privacy concerns from hindering disclosure of relevant health 
        information.
   All health interviews should be conducted using a 
        standardized form, developed in consultation with pediatric 
        medical experts. Health screening forms should be updated to 
        include at a minimum:
     Comprehensive review of potentially concerning symptoms 
            (e.g., fever, chills, night sweats, cough, sore throat, 
            congestion/runny nose, difficulty breathing, nausea/
            vomiting, diarrhea, abdominal pain, headaches, dizziness, 
            chest pain, palpitations, joint or muscle pain, rashes, 
            wounds/injuries);
     Chronic medical conditions;
     Current medications (either taking or meant to be taking, 
            prescribed or over the counter);
     Allergies;
     Pregnancy status;
     History of tuberculosis and whether it has been treated;
     Whether the detainee had access to adequate food and water 
            in the several days prior to apprehension.
   To protect confidentiality, questions about particularly 
        sensitive information like sexually transmitted infections and 
        HIV status should not be included in the initial health 
        screening and should only be asked later in a private setting 
        by a trained medical provider.
Medical screenings
   Health interviews will not identify all children in need of 
        medical attention, so medical screenings should occur as soon 
        as possible and no more than 48 hours after apprehension.
   All children under age 18 should receive medical screenings, 
        including review of any positive responses on the health 
        interview, a full set of vital signs, and a basic physical 
        exam. The medical screening should be conducted with as much 
        privacy as possible.
   Medical screenings should be performed by an appropriately 
        credentialed clinician, which as per the initial standards set 
        forth in CBP's Interim Enhanced Medical Efforts Directive could 
        include CBP contracted medical professionals or Federal, State, 
        or Local credentialed health care providers. CBP EMS personnel 
        should only be utilized to conduct medical screenings in 
        exigent circumstances and under the direct supervision of a 
        clinician with appropriate expertise.
Detention facilities
   Basic detention standards must be met to minimize detainees' 
        vulnerability to illness. For example, CBP facilities should be 
        clean and maintained at comfortable temperatures. Detainees 
        should be provided with nutritionally-balanced meals and ample 
        access to clean drinking water. They must have adequate space 
        to lie down and conditions in which they can comfortably do so; 
        lights should be dimmed overnight to facilitate adequate sleep. 
        Detainees should be provided with timely access to shower 
        facilities and basic hygiene products (e.g., soap, 
        toothbrushes, sanitary napkins, diapers).
   As the AAP has stated, detention is never healthy for a 
        child.\2\ However, if children are to be detained during 
        processing, CBP should work with State and local child welfare 
        agencies to ensure appropriate conditions and training of staff 
        caring for children.
   Young detainees should be preferentially located in CBP 
        facilities within proximity to medical centers with pediatric 
        expertise, in case emergencies arise.
   Children who are sick or medically fragile should not be 
        detained in CBP facilities, which cannot provide conditions 
        conducive to safe monitoring and recuperation.
Disease prevention
   CBP must implement CDC's recommendations for the prevention 
        of influenza and COVID-19 in its facilities.\3\
   Social distancing protocols should be developed. 
        Technological and administrative barriers that unnecessarily 
        prolong detention in CBP facilities should be eliminated to 
        minimize the health risks posed by overcrowding.
   Detainees should have unfettered access to sinks with soap 
        and hand sanitizer (although hand sanitizer must be kept out of 
        reach of young children who might mistakenly ingest it).
   CBP staff should be required to utilize appropriate personal 
        protective equipment (PPE), including face masks, when in 
        proximity to detainees. PPE should also be supplied to 
        detainees and replaced at regular intervals. All staff and 
        detainees should receive instruction on how to use PPE 
        correctly.
   High touch surfaces should be cleaned frequently, and 
        adequate ventilation should be ensured.
   Influenza vaccine should be mandated for all CBP employees 
        who interact with detainees. Influenza vaccine should be 
        offered to all detainees at the time of their medical 
        screening.
   Repeated transfers of detainees between facilities should be 
        avoided to minimize risk of disease spread.
On-going disease surveillance
   CBP must institute comprehensive screening and triage 
        protocols to promptly identify developing signs of illness 
        among detainees.
   Specific screening protocols for symptoms of Multisystem 
        Inflammatory Syndrome in Children (MIS-C) must be developed in 
        consultation with pediatric experts, as this dangerous 
        complication of COVID-19 is unique to the pediatric population 
        and can present subtly at first.
   Detainees identified as sick must be safely isolated in a 
        setting appropriate for convalescence, with close monitoring by 
        trained personnel, while awaiting prompt testing and treatment.
   CBP should work with local public health departments and the 
        CDC to develop an approach to monitoring for and reporting 
        disease outbreaks within its facilities.
Obtaining medical care
   CBP should increase the number of pediatricians it employs 
        to oversee care of young detainees.
   All forward operating bases and Border Patrol stations 
        should be stocked with basic pediatric medical equipment and 
        staff trained in its use. Medical equipment and medications at 
        all CBP facilities should be centrally located and regularly 
        inventoried. CBP facilities should stock oxygen and adult and 
        pediatric doses of basic medications that EMTs or on-site 
        clinicians might routinely administer to treat common medical 
        problems and emergencies. Agents and detainees should never 
        have to pay out of pocket for necessary medications. Detainees' 
        medications should not be confiscated without supplying 
        adequate replacements under the guidance of an appropriately 
        credentialed clinician.
   If a detainee requests medical attention, an on-site 
        clinician (if available) or an agent with EMT training should 
        promptly triage and assess the detainee. Triage should include 
        a full set of vital signs and a basic physical exam.
   If an agent observes a child exhibiting signs of illness, 
        the child should by default be brought for medical attention, 
        rather than relying on a parent to advocate for medical care.
   Children with identified medical issues should be treated by 
        a provider with pediatric expertise whenever possible, even if 
        that means transporting them to a health care facility off-
        site.
   Paperwork should be streamlined and digitized so that health 
        interviews and transfers to medical facilities are not 
        needlessly delayed by challenges in locating or completing 
        documents.
   Interpretation in medical settings must always be performed 
        by certified medical interpreters to reduce the risk of medical 
        errors. It is never appropriate for a medical facility to 
        utilize a CBP agent for interpretation. All consents and 
        medical paperwork must be provided in parents' native language 
        to ensure comprehension.
   Any detainees suspected of having influenza should receive 
        antiviral therapy like oseltamivir as soon as possible and no 
        more than 48 hours after symptom onset. Antiviral 
        chemoprophylaxis should be offered to vulnerable detainees who 
        may have been exposed to influenza index cases.
   Independent oversight of the quality of medical care 
        provided to detainees must occur regularly. This should include 
        medical record review as well as unannounced site visits. 
        Pediatricians must be included as part of the oversight team to 
        ensure that issues unique to the care of young patients are 
        addressed.
                               conclusion
    An unprecedented number of children have died in CBP custody over 
the past several years. The current public health crisis posed by the 
COVID-19 epidemic only underscores the urgent need to minimize time in 
detention, improve detention conditions, and facilitate access to 
medical care so as to protect the well-being of migrant children in 
custody of the U.S. Government.
   Questions From Congressman Emmanuel Cleaver for Joseph V. Cuffari
    Question 1a. Inspector general, your office issued a ``Capping 
Report'' in June entitled ``CBP Struggled to Provide Adequate Detention 
Conditions During 2019 Migrant Surge.'' The report includes pictures 
of, ``Stocked over-the-counter medications and medical supplies'' 
observed in May and June 2019 in each of the El Paso Del Norte, Texas, 
and Donna, Texas facilities. Inspector General, are there any standards 
regarding the over-the-counter medications that Border Patrol 
facilities should have on hand?
    Question 1b. If so, what are they, and did the facilities your 
teams visited meet these standards?
    Answer. CBP's October 2015 National Standards on Transport, Escort, 
Detention, and Search (TEDS) do not require that over-the-counter 
medications be kept on hand in Border Patrol facilities and we are not 
aware of any other Border Patrol standards with this requirement. We 
reported on the stocking of over-the-counter medications as an example 
of an economy of scale employed by Border Patrol to better manage the 
increase in apprehensions in 2019. It was more efficient for facilities 
to stock over-the-counter medications on-site, rather than making a 
pharmacy run each time a clinic, hospital, or on-site medical staff 
prescribed an over-the-counter medication. Not every facility we 
visited had over-the-counter medications in stock.
    Question 2a. Are there any standards regarding the administration 
of over-the-counter medicines?
    Question 2b. If so, what are they and did the facilities your teams 
visited meet these standards?
    Answer. TEDS standards do not provide specific guidance with 
respect to the administration of over-the-counter medicines. With 
respect to medication generally, TEDS standard 4.10 states:

``Medication: Except for assistance with lifesaving emergency medical 
care which they feel comfortable rendering and are trained to render, 
officers/agents will not administer medical techniques, medications, or 
preparations unless they are qualified emergency medical technicians or 
paramedics rendering care. Medication prescribed in the United States, 
validated by a medical professional if not U.S.-prescribed, or in the 
detainee's possession during general processing in a properly 
identified container with the specific dosage indicated, must be self-
administered under the supervision of an officer/agent. If a detainee 
is unable to self-administer their medications due to age or 
disability, officers/agents may assist the detainee. All detainee 
refusals of prescribed medication or medical assistance must be noted 
in the appropriate electronic system(s) of record.
``Non U.S.-Prescribed Medication: Any detainee, not in general 
processing, with non U.S.-prescribed medication, should have the 
medication validated by a medical professional, or should be taken in a 
timely manner to a medical practitioner to obtain an equivalent U.S. 
prescription. Exceptions to this requirement may only be made by a 
supervisor in collaboration with a medical professional and based on 
expected duration of detention and/or elective nature of the 
medication. If such an exception is made, it must be recorded in the 
appropriate electronic system(s) of record.''

    TEDS standard 7.5 states:

``All medications will generally be maintained with the detainee's 
personal property unless other conditions warrant, such as the 
medication needing to be regularly administered due to need, and/or 
needing to be properly stored as the prescription requires.''

    TEDS standard 2.10 states:

``When transferring a detainee, officers/agents must ensure that all 
appropriate documentation accompanies the detainee including all 
appropriate medical records and medication as required by the 
operational office's policies and procedures.''

    Using these standards as criteria, OIG inspectors conducted 
interviews with on-site medical staff and CBP staff to determine 
whether processes existed for administering emergency medications, 
enabling detainees to self-administer prescriptions, validating or 
replacing foreign prescriptions, storing prescriptions that required 
refrigeration, and transferring medical records and prescriptions with 
detainees. We also observed if there were detainee prescriptions on-
site, whether appropriate storage existed, and if times for 
administering medications were tracked in data systems or on white 
boards.
    From our interviews with CBP staff, medical staff, and a limited 
number of detainees, at the time of our visits, we did not identify 
instances in which CBP staff did not comply with TEDS standards for 
medications, including both prescription medications and over-the-
counter medications that were prescribed for detainees. Ten of the CBP 
facilities we visited had on-site medical personnel who either had the 
necessary qualifications to prescribe medications, including over-the-
counter medications, or could consult with an on-call doctor. In 
addition, if a detainee was prescribed a medication, including an over-
the-counter medication, during a visit to a clinic or hospital, it was 
appropriate for CBP staff to supervise self-administration of the 
medication. Our conclusions were limited to what we observed at the 
time of our site visits and information obtained from detainees, on-
site medical staff, and CBP staff.

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