You are the head of the Department of Public Health Sciences, The University of Texas at El Paso and have been “volunteered” to develop a Rapid Response “shadow” licensing program for the Tornillo, Texas detention camp housing 2300 teens.

INTRODUCTION
Statement from the American Public Health Association and Trust for America’s Health
“As public health professionals we know that children living without their parents face immediate and long-term health consequences. Risks include the acute mental trauma of separation, the loss of critical health information that only parents would know about their children’s health status, and in the case of breastfeeding children, the significant loss of maternal child bonding essential for normal development. Parents’ health would also be affected by this unjust separation.
“More alarming is the interruption of these children’s chance at achieving a stable childhood. Decades of public health research have shown that family structure, stability and environment are key social determinants of a child’s and a community’s health.
“Furthermore, this practice places children at heightened risk of experiencing adverse childhood events and trauma, which research has definitively linked to poorer long-term health. Negative outcomes associated with adverse childhood events include some of society’s most intractable health issues: alcoholism, substance misuse, depression, suicide, poor physical health and obesity.” (A)

“Our field recognizes the importance of avoiding Adverse Childhood Experiences for the healthy growth and development of children. Trauma early in life contributes to a broad range of serious health outcomes, including social impairment, disease and disability, and early death. The harsh treatment of children at the border will affect their health and their lives for many years to come. The trauma to their parents is also devastating, and the lasting consequences to thousands of families will be profound.” (B)

“We also know that as each hour of separation goes by, children’s bodies continue to be flooded with stress hormones, thus creating long-term, disastrous injury and trauma for both the children and families who are separated.
Decades of research tells us that traumatic and forced parent-child separation immediately and permanently affects children’s brain development, educational attainment, mental health functioning, and long-term health outcomes – detailed in this Washington Post story. We also know that families seeking asylum are already traumatized from the circumstances that led to the migration and are exhausted by the journey to reach our borders…” (C)

“There is a significant body of evidence-based research detailing the vast public health implications of adverse childhood experiences. According to the Centers for Disease Control and Prevention, children exposed to adverse childhood experiences suffer from disrupted neurodevelopment; social, emotional, and cognitive impairment; are more likely to adopt health-risk behaviors; are at greater risk of developing chronic diseases, disabilities and social problems; and are susceptible to early death. Family stability is a key social determinant of health, and it’s imperative that we not disrupt these children’s chance at a healthy life.” (D)

“After the United States Department of Justice announced the “Zero Tolerance Policy for Criminal Illegal Entry,” Immigration and Custom Enforcement (ICE — an arm of the Department of Homeland Security) separated approximately 2,000 children from their parents in April and May 2018 as they approached the U.S. border. Children and parents were placed in separate facilities as they were being processed and were not told when or how they would be reunited. This policy and its consequences have raised significant concerns among researchers, child welfare advocates, policy makers, and the public, given the overwhelming scientific evidence that separation between children and parents, except in cases where there is evidence of maltreatment, is harmful to the development of children, families, and communities. Family separations occurring in the presence of other stressors, such as detention or natural disaster, only adds to their negative effects.” (E)

“The policy may have changed, but there’s still a concern over detention. Under the most recent policy change, the administration can still hold children in a confined space with their parents, and there’s a sense that they’re planning large-scale detention. We’ve ended for the moment, family separation, but now we have large-scale detention” (F)

“Reports from the National Academies of Sciences, Engineering, and Medicine contain an extensive body of evidence on the factors that affect the welfare of children – evidence that points to the danger of current immigration enforcement actions that separate children from their parents. Research indicates that these family separations jeopardize the short- and long-term health and well-being of the children involved.” (G)

“Detention, for even brief periods, has short- and long-term negative effects on the health of parents and children. Studies show high levels of psychiatric distress, including depression and post-traumatic stress, among detained asylum seekers, even after short detention periods, and that symptoms worsen over time. Global studies also show significant effects for children held in detention, including depression, post-traumatic stress, suicidal thoughts and behaviors, developmental delays, and behavioral issues. In a policy statement, the AAP notes that research documents negative physical and emotional symptoms among detained children and adults and also shows negative impacts on the parent-child relationship.
In the short term, toxic stress can increase the risk and frequency of infections in children as high levels of stress hormones suppress the body’s immune system. It can also result in developmental issues due to reduced neural connections to important areas of the brain. Toxic stress is associated with damage to areas of the brain responsible for learning and memory.
Over the long term, toxic stress may manifest as poor coping skills and stress management, unhealthy lifestyles, adoption of risky health behaviors, and mental health issues, such as depression. Toxic stress is also associated with increased rates of physical conditions into adulthood, including chronic obstructive pulmonary disease, obesity, ischemic heart disease, diabetes, asthma, cancer, and post-traumatic stress disorder.” (H)

BACKGROUND
“A top Health and Human Services official told Congress on Tuesday that he and others repeatedly warned the Trump administration that its policy of separating immigrant families apprehended at the U.S.-Mexico border would not be in “the best interest of the child.”
“During the deliberative process over the previous year, we raised a number of concerns in the (Office of Refugee Resettlement) program about any policy which would result in family separation due to concerns we had about the best interest of the child as well as about whether that would be operationally supportable with the bed capacity that we have,” Jonathan White, with the Public Health Service Commissioned Corps, told lawmakers at a Senate Judiciary Committee hearing”.… (I)

“The Department of Homeland Security was not ready to carry out the Trump administration’s family separation policy, and some of the government’s practices made the problem worse, according to a report issued Tuesday by the department’s inspector general…
“DHS was not fully prepared to implement the administration’s zero-tolerance policy or to deal with some of its after-effects,” said John Kelly, the acting inspector general.
Tuesday’s report said Customs and Border Protection held children for long periods in facilities intended to be used for only short terms, lacked the ability to reliably track children separated from their parents, and in some cases failed to adequately inform parents about the separation policy…
Computer systems used by CBP and Immigration and Customs Enforcement lacked the ability to share data about parents whose children were separated from them. And those systems were not integrated with the resettlement agency…
In a separate DHS inspector general report dated September 27, the Adelanto ICE Processing Center, a detention center housing up to 1,940 ICE detainees in California, was cited for serious violations including nooses found hanging in detainee cells, “improper and overly restrictive segregation,” and “untimely and inadequate medical care.” “ (J)

DISCUSSION
“In shelters from Kansas to New York, hundreds of migrant children have been roused in the middle of the night in recent weeks and loaded onto buses with backpacks and snacks for a cross-country journey to their new home: a barren tent city on a sprawling patch of desert in West Texas.
Until now, most undocumented children being held by federal immigration authorities had been housed in private foster homes or shelters, sleeping two or three to a room. They received formal schooling and regular visits with legal representatives assigned to their immigration cases…
But in the rows of sand-colored tents in Tornillo, Tex., children in groups of 20, separated by gender, sleep lined up in bunks. There is no school: The children are given workbooks that they have no obligation to complete. Access to legal services is limited…
The camp in Tornillo operates like a small, pop-up city, about 35 miles southeast of El Paso on the Mexico border, complete with portable toilets. Air-conditioned tents that vary in size are used for housing, recreation and medical care. Originally opened in June for 30 days with a capacity of 400, it expanded in September to be able to house 3,800, and is now expected to remain open at least through the end of the year.” …
The roughly 100 shelters that have, until now, been the main location for housing detained migrant children are licensed and monitored by state child welfare authorities, who impose requirements on safety and education as well as staff hiring and training.
The tent city in Tornillo, on the other hand, is unregulated, except for guidelines created by the Department of Health and Human Services. For example, schooling is not required there, as it is in regular migrant children shelters…” (K)

“Thousands of foster children may be getting powerful psychiatric drugs prescribed to them without basic safeguards, says a federal watchdog agency that found a failure to care for youngsters whose lives have already been disrupted.
A report released Monday by the Health and Human Services inspector general’s office found that about 1 in 3 foster kids from a sample of states were prescribed psychiatric drugs without treatment plans or follow-up, standard steps in sound medical care.
Kids getting mood-altering drugs they don’t need is only part of the problem. Investigators also said children who need medication to help them function at school or get along in social settings may be going untreated.
The drugs include medications for attention deficit disorder, anxiety, PTSD, depression, bipolar disorder and schizophrenia. Foster kids are much more likely to get psychiatric drugs than children overall.
“We are worried about the gap in compliance because it has an immediate, real-world impact on children’s lives,” said Ann Maxwell, an assistant inspector general.” (L)

“Traditionally, most sponsors have been undocumented themselves, and therefore are wary of risking deportation by stepping forward to claim sponsorship of a child. Even those who are willing to become sponsors have had to wait months to be fingerprinted and otherwise reviewed.
Federal officials say their vetting procedures are designed to safeguard the children in their care.
“Children who enter the country illegally are at high risk for exploitation by traffickers and smugglers,” Ms. Stauffer said in her statement.
But the longer children are detained, the more anxious and depressed they are likely to become, according to Mr. Greenberg, who oversaw the program under Mr. Obama. When that happens, children may try to harm themselves or escape, and can become violent with the staff and with one another, he said.
Stories of such behavior have emerged through reporting in recent months as the shelter system has faced intense criticism by members of Congress and the public…
The separated children injected a new degree of chaos into the facilities, according to several shelter operators, who spoke anonymously because they are barred by the government from speaking to the news media. The children were younger and more traumatized than those the shelters were used to dealing with, and they arrived without a plan for when they could be released or to whom.” (M)

“Deep within the fine print of a newly proposed federal rule change is an admission of its disastrous health consequences. The Department of Homeland Security’s plan would deny legal immigrants permanent residency status if they accept government assistance to which they are entitled, allegedly an effort to “promote immigrant self-sufficiency” and ensure “they are not likely to become burdens on American taxpayers” or “public charges.”
But the certain collateral damage of this misguided policy, which greatly expands an existing principle to make its application downright punitive, reveals it’s not about promoting self-sufficiency at all.
In describing the impact of this effort, the Department of Homeland Security states, “Disenrollment or foregoing enrollment…by aliens otherwise eligible for these programs could lead to:
“Worse health outcomes, including prevalence of obesity and malnutrition, especially for pregnant or breastfeeding women, infants or children…
“Increased use of emergency rooms and emergency care as a method of primary health care due to delayed treatment
“Increased prevalence of communicable diseases, including among members of the U.S. citizen population who are not vaccinated.”..
The rule change, if implemented, will cause legal immigrants, their spouses and children, including U.S. citizens, to withdraw from government assistance programs out of fear that it would endanger the chances for a family member to obtain a green card and become a legal permanent resident. Washington will, in effect, force individuals to choose between their welfare and a family member’s legal residency status…
Some children will not receive necessary vaccines, making them susceptible to preventable diseases, such as measles, mumps, Hepatitis A and B, and polio. Illnesses will not be addressed when they are easily treatable. Without proper prenatal and perinatal care, there will be an increase in birth complications.” (N)

“Complicating matters, the administration has decreed that reunifications must take place in the family’s country of origin. Which means that, once contacted, parents face an excruciating choice: give up their children’s asylum claims and have them returned home, or leave the children in the United States to try to navigate the asylum process on their own.” (O)

“The Trump administration wants to change how the government defines who is or is likely to become a “public charge.” The Department of Homeland Security released a draft regulation on Sept. 22, in which it proposed that any immigrant who is likely to use or who has already used Medicaid, public housing or a rent voucher, cash assistance or food stamps could be barred from the country or kept from getting permanent resident status.
“….The administration would remake the idea of self-sufficiency, admitting only those who never need to turn to the public safety net, but instead rely solely on “their own capabilities” or the resources of their families and private charity. It even asserts that people who use public programs “in a relatively small amount or for a relatively short duration” are still considered dependent on the welfare state.
This redefinition of self-sufficiency ignores the way that most people use these programs. Even people with jobs often cycle on and off assistance as work comes and goes, or to plug the gaps when it just doesn’t pay enough. These programs allow people to remain healthy and solvent — supporting their independence. This rule therefore hurts everyone, not just immigrants, by stigmatizing the safety net funded by all of us to help people survive when they fall on hard times.” (P)

The Trump administration has put the safety of thousands of teens at a migrant detention camp at risk by waiving FBI fingerprint checks for their caregivers and short-staffing mental health workers, according to an Associated Press investigation and a new federal watchdog report.
None of the 2,100 staffers at a tent city holding more than 2,300 teens in the remote Texas desert are going through rigorous FBI fingerprint background checks, according to a Health and Human Services inspector general memo published Tuesday.
“Instead, Tornillo is using checks conducted by a private contractor that has access to less comprehensive data, thereby heightening the risk that an individual with a criminal history could have direct access to children,” the memo says.
In addition, the federal government is allowing the nonprofit running the facility — BCFS Health and Human Services — to sidestep mental health care requirements. Under federal policy, migrant youth shelters generally must have one mental health clinician for every 12 kids, but the federal agency’s contract with BCFS allows it to staff Tornillo with just one clinician for every 100 children. That’s not enough to provide adequate mental health care, the inspector general office said in the memo…
Because the detention camp is on federal property — part of a large U.S. Customs and Border facility — it is not subject to state licensing requirements…
Federal officials have said repeatedly that only children without special needs were being sent to Tornillo. But facility administrators recently acknowledged that the Tornillo detainees included children with serious mental health issues who needed to be transferred out to facilities in El Paso, according to a person with knowledge of the discussion…(Q)

“The deportation and forced separation of immigrants has negative effects that extend beyond individuals and families to entire communities in the United States, according to a division of the American Psychological Association, which has issued a policy statement calling for changes to U.S. policy.
Based on a review of the effects of three decades of U.S. immigration policy, the policy statement details the psychosocial and economic impacts of deportation on children and families, as well as broader community consequences that unfold as immigrants fearful of being targeted withdraw from civic engagement…
Studies reveal that children who lose a parent to sudden, forced deportation experience anxiety, anger, aggression, withdrawal, a heightened sense of fear, eating and sleeping disturbances, isolation, trauma, and depression.
Children also experience housing instability, academic withdrawal, and family dissolution; older children often need to take on jobs to help support the family.
Ten percent of U.S. families with children have at least one family member who lacks citizenship.
5.9 million children have at least one caregiver who lacks authorization to live in the country.” (R)

“Children tend to respond to separation from their caregiver in three fluid phases. First, children enter an acute phase of protest characterized by fear, distress, crying and urgent seeking of their caregiver that may last from a few hours to days. As the length of separation continues, children enter a phase of despair during which crying weakens, movement lessens and children reject the approach of alternative adults. With prolonged parental absence, children may become passively compliant with care staff, giving the appearance of having ‘settled in’ to their new environment. Disturbingly, this can signify that the child has detached from the parents and is now living in a perceived state of ‘fear without resolution’. Children reunited while they are in the early separation protest phase usually fare well. Children in despair may respond to the reappearance of their parent with hostility or ambivalence, taking many weeks to rebuild their bond. Children who have detached from their parents may reject their approaches or treat them as strangers. Additionally, when children interpret themselves as ‘abandoned’ by parents, they may develop a profound sense that they have done something wrong to cause their caregiver to leave, igniting shame and complex emotions that can damage the lifelong relationships with themselves and others.”(S)

“When children are reunited with parents, the reintegration process is sometimes difficult. Widespread videos of families being reunified have shown emotionless children, some even avoiding their parent’s embrace. A number of children do not even recognize their parents upon return, which speaks to the intense trauma that these children have experienced. “We think that we’ve made the family whole again by simply bringing them back together and letting them go on with their lives, when the reality is that there’s a lot of work that still needs to be done,” said Vivek Sankaran, a clinical professor of law at the University of Michigan Law School. After becoming reunited, the families affected by separation need continuing support in order to reestablish their relationships and routines.” (T)

“It is clear, then, that the families affected by the current administration’s separation policy need services to help them cope with the trauma that has occurred. It is possible for the individuals and the family units to find some healing, given the opportunity, resources, and tools to do so.
Griffith says that a key to working through such a trauma is bringing the families back together as quickly as possible. “If the core family unit can stay intact, that accomplishes a lot. [There’s a feeling of] ‘As long as we’re together, we can be okay, regardless of how harsh the circumstances,'” he says. However, the reunification process thus far has been plodding and uncoordinated. It appears that far too many families will remain separated long term.
In addition to reunification and in the face of indefinite separation, family members should have access to psychosocial services to help them cope. Unfortunately, it is unclear what services are currently available to the children still separated from their parents. “We don’t have access to those facilities,” Lusk says.” (U)

“The Trump administration did not tell key government agencies about its “zero tolerance” immigration policy before publicly announcing it in April, leaving the officials responsible for carrying it out unprepared to handle the resulting separations of thousands of children from their families, according to a government report released on Wednesday.
The Department of Homeland Security, which apprehends border crossers, and the Department of Health and Human Services, which cares for separated migrant children, were both caught off guard when Attorney General Jeff Sessions announced plans to criminally prosecute anyone who crossed the border illegally, the report said…
Because they did not know about the “zero tolerance” policy in advance, officials at the Department of Homeland Security said, they did not take steps to prepare for the resulting family separations. Staff members at the Department of Health and Human Services said their leaders told them not to prepare for an increase in children separated from their families because homeland security officials claimed that they did not have an official policy of separating parents and children, according to the report, which was prepared by the Government Accountability Office, Congress’s nonpartisan investigative arm.” (V)

In just six months, the Trump administration has built a detention camp for migrant kids in the Texas desert that is larger than 203 of the 204 U.S. federal prisons.
Driving the news: The Tornillo camp now holds 2,324 boys and girls, most from Central America, between the ages of 13-17, the AP reports.
Why it matters: “Confining and caring for so many children is a challenge. By day, minders walk the teen detainees to their meals, showers and recreation on the arid plot of land guarded by multiple levels of security. At night the area around the camp, that’s grown from a few dozen to more than 150 tents, is secured and lit up by flood lights.”
Between the lines: Among the list of issues at Tornillo discovered by an AP investigation:
1. Security: The 2,100 staffers haven’t done FBI fingerprint background checks.
2. Costs: “What began as an emergency, 30-day shelter has transformed into a vast tent city that could cost taxpayers more than $430 million.”
3. Rules: “Under federal policy, migrant youth shelters generally must have one mental health clinician for every 12 kids, but shelter officials have indicated that Tornillo can staff just one clinician for every 100 children…”..
The bottom line: There are more than 14,000 migrant children in U.S. detention, most from central America. Figuring out what to do with these kids is a challenge that doesn’t seem to be going away.” (W)

“”Aid workers and humanitarian organizations [are sounding the alarm on] unsanitary conditions at the sports complex in Tijuana where more than 6,000 Central American migrants are packed into a space adequate for half that many people,” AP reports.
Lice infestations and respiratory infections are rampant, and Mexico’s National Human Rights Commission reports four cases of chicken pox.” (X)

“The founder of Southwest Key made millions from housing migrant children..
Southwest Key has collected $1.7 billion in federal grants in the past decade, including $626 million in the past year alone. But as it has grown, tripling its revenue in three years, the organization has left a record of sloppy management and possible financial improprieties, according to dozens of interviews and an examination of documents. It has stockpiled tens of millions of taxpayer dollars with little government oversight and possibly engaged in self-dealing with top executives…
Shortly after, the federal government temporarily shuttered a third Arizona shelter, in Youngtown, after Southwest Key staff members were accused of physically abusing three children. In a recent agreement with Arizona officials, Southwest Key was fined $73,000 and agreed to close that facility and another troubled shelter in Phoenix. Mr. Weber, the government spokesman, said there were “numerous red flags and licensure problems” with the two shelters.” (Y)

(A) BUSSW Dean Statement on Migrant Family Separation Crisis, , Jorge Delva, https://www.bu.edu/ssw/bussw-dean-statement-on-migrant-family-separation-crisis/
(B) Sign-on letter: Public health implications of family separation at the border, http://www.phi.org/news-events/1452/sign-on-letter-public-health-implications-of-family-separation-at-the-border
(C) The Science is Clear: Separating Families has Long-term Damaging Psychological and Health Consequences for Children, Families, and Communities, https://www.srcd.org/policy-media/statements-evidence/separating-families
(D) Jacqueline Bhabha speaks to the human rights of children detained at the U.S.-Mexico border., Professor of the Practice of Health and Human Rights at the Harvard T.H. Chan School of Public Health https://www.hks.harvard.edu/research-insights/policy-topics/human-rights-justice/human-rights-impact-family-separation
(E) Statement on Harmful Consequences of Separating Families at the U.S. Border, http://www.publicnow.com/view/01C73956A92A17674EA5913A13F14F325310FFE6
(F) Separating parents and children at US border is inhumane and sets the stage for a public health crisis, https://www.apha.org/news-and-media/news-releases/apha-news-releases/2018/parent-child-separation
(G) Key Health Implications of Separation of Families at the Border (as of June 27, 2018), https://www.kff.org/disparities-policy/fact-sheet/key-health-implications-of-separation-of-families-at-the-border/
(H) Top HHS official warned Trump administration against separating immigrant families, by Eliza Collins, Alan Gomez, https://www.usatoday.com/story/news/politics/2018/07/31/trump-administration-official-warned-family-separations/874963002/
(I) DHS not prepared for family separations under Trump zero tolerance policy, watchdog finds, by Pete Williams and Jacob Soboroff, https://www.nbcnews.com/politics/politics-news/dhs-not-prepared-family-separations-under-trump-zero-tolerance-policy-n915916(
(J) Migrant Children Moved Under Cover of Darkness to a Texas Tent City, by Caitlin Dickerson, https://www.nytimes.com/2018/09/30/us/migrant-children-tent-city-texas.html
(K) Thousands of foster children may be getting psychiatric drugs without safeguards, watchdog agency says, by Ricardo Alonso-Zaldivar, https://www.statnews.com/2018/09/17/thousands-of-foster-children-may-be-getting-psychiatric-drugs-without-safeguards-watchdog-agency-says/?utm_source=STAT+Newsletters&utm_campaign=fab0f6340f-MR_COPY_12&utm_medium=email&utm_term=0_8cab1d7961-fab0f6340f-149527969
(L) Detention of Migrant Children Has Skyrocketed to Highest Levels Ever, by Mike Blake, https://www.nytimes.com/2018/09/12/us/migrant-children-detention.html?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosam&stream=top
(M) One sick immigration rule: The ‘public charge’ regulation will make America less healthy, by KENNETH L. DAVIS, http://www.nydailynews.com/opinion/ny-oped-one-sick-immigration-rule-20181009-story.html
(N) The Continuing Tragedy of the Separated Children, https://www.nytimes.com/2018/08/30/opinion/family-separation-trump-zero-tolerance.html
(O) Trump Wants to Turn the Safety Net Into a Trap, by By Bryce Covert, https://www.nytimes.com/2018/10/01/opinion/trump-wants-to-turn-the-safety-net-into-a-trap.html
(P) Separating Families at U.S. Borders is a Public Health Issue, Ellen J. MacKenzie, https://www.jhsph.edu/about/dean-mackenzie/news/separating-families-at-us-borders-is-a-public-health-issue.html
(Q) US waived FBI checks on staff at growing teen migrant camp, by GARANCE BURKE AND MARTHA MENDOZA, https://www.apnews.com/0c62b088c27147b0a6055d1e8394a3af?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiospm&stream=top
(R) Deportation and family separation impact entire communities, researchers say, by Jennifer McNulty, https://www.sciencedaily.com/releases/2018/08/180801131554.htm
(S) Impact of punitive immigration policies, parent-child separation and child detention on the mental health and development of children, by Laura C N Wood, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6173255/
(T) The Impact of Parent-Child Separation at the Border, by Hurley Riley, https://sph.umich.edu/pursuit/2018posts/family-separation-US-border.html
(U) Children and Families Forum: The Impact of Immigrant Family Separation, by Sue Coyle, https://www.socialworktoday.com/archive/SO18p8.shtml
(V) ‘Zero Tolerance’ Immigration Policy Surprised Agencies, Report Finds, by Ron Nixon, https://www.nytimes.com/2018/10/24/us/politics/immigration-family-separation-zero-tolerance.html
(W) Axios PM: Trump’s detention camp for migrant teens; November 27, 2018
(X) Axios AM, November 30, 2018
(Y) He’s Built an Empire, With Detained Migrant Children as the Bricks, Tamir Kalifa for The New York Times, by Kim Barker, Nicholas Kulish and Rebecca R. Ruiz, https://www.nytimes.com/2018/12/02/us/southwest-key-migrant-children.html
(Z)

Prequels
..The HHS needs to review thousands of case files by hand for clues to which children were taken from their parents…

“Most immigrants facing deportation wouldn’t climb onto a table during their court hearings. But then again, most 3-year-olds don’t go to court without parents or lawyers.

“President Trump has moved on from caring about the migrant children in cages

“Only a dead heart is unstirred by the intentional infliction of suffering on children and babies as a weapon of deterrence.”

“In 6 Days, Trump Admin Reunited Only 6 Immigrant Children With Their Families”, https://doctordidyouwashyourhands.com/2018/06/in-6-days-trump-admin-reunited-only-6-immigrant-children-with-their-families/

“…the only way parents can quickly be reunited with their children is to drop their claims for asylum… and agree to be deported.”

White House Press Secretary Sarah Huckabee Sanders said the government was starting to
“run out of space” to house people apprehended crossing the border

Trump’s policy “could be creating thousands of immigrant orphans in the U.S.”, https://doctordidyouwashyourhands.com/2018/06/trumps-policy-could-be-creating-thousands-of-immigrant-orphans-in-the-u-s/

Tender-Age Immigrant Children. “They need bilingual workers. Some kids speak indigenous languages, so that’s an issue as well. https://doctordidyouwashyourhands.com/2018/06/tender-age-immigrant-children-they-need-bilingual-workers-some-kids-speak-indigenous-languages-so-thats-an-issue-as-well/

“The idea of pulling a child out of a parent’s arms, or identifying a parent but still keeping them separate—it isn’t right.”

“The business of housing, transporting and watching over migrant children detained along the southwest border is not a multimillion-dollar business. It’s a billion-dollar one…

“If it could happen to them…why can’t it happen to us?”…separating children from their parents,

“…Trump’s (family separation) policy amounts to “government-sanctioned child abuse.””,

“The Trump administration’s policy of separating parents and children at the U.S.-Mexico border will have a dire impact on their health, both now and into the future.” (C)

“Subdued and on-script, President Donald Trump struck a bipartisan tone as he signed sweeping legislation Wednesday to combat the opioid epidemic, an issue that has animated his effort to support Republican midterm candidates.
Discussing a crisis affecting urban centers as well as rural communities that supported his election, Trump touted the measure as a bipartisan response to a problem rarely cited as a top issue for voters that nevertheless touches millions of them personally.
“We are going to end it or we are going to at least make an extremely big dent in this terrible, terrible problem.” Trump said during an East Room event that drew members of both parties. “We have mobilized the entire federal government to address this crisis.”..
Speaking at a rally in Nevada this past weekend, Trump touted the “bold action” and “historic effort” he said his administration embarked on to address the problem. His administration’s response has fallen into two categories, he has said: Stepped up enforcement and more funding for states to expand treatment.
“We obtained $6 billion to fight the opioid epidemic,” Trump said during his most recent stop in Houston this week, referencing a funding bill approved by Congress in March.
The new legislation that Congress approved Oct. 3, makes it easier to intercept drugs being shipped into the country, authorizes new funding for more comprehensive treatment, speeds up research on non-addictive painkillers and clears Medicare and Medicaid regulations that advocates have said can stand in the way of treatment. “ (A)

“Addiction treatment advocates say two provisions — one that would allow Medicaid, the federal-state health insurance plan for the poor, to pay for residential treatment in large facilities and another that would allow Medicare, the federal health plan for people 65 and older, to pay for methadone treatment — will substantially improve access to treatment.
The legislation, approved last month by the House and Wednesday by the Senate, also would pay for research into opioid alternatives, support greater use of non-opioid pain management and invest in new law enforcement efforts to curb illicit drugs.
Some critics say the legislation, which calls for roughly $8 billion in federal investment over five years, doesn’t go far enough given the magnitude of the drug overdose crisis.
In an epidemic that killed more than 72,000 people in 2017, the federal government should commit to spending far more money on treatment, prevention and access to the life-saving drug naloxone, advocacy groups have argued. The groups, including the Harm Reduction Coalition, recommended $100 billion more in federal spending, similar to the Ryan White HIV/AIDS Program.
Still, treatment advocates say that Medicaid coverage of residential treatment and Medicare coverage of methadone would go a long way to boosting treatment quality and capacity, as well as people’s ability to pay.
The residential treatment provision would lift a 53-year-old ban in the federal Medicaid statute that prohibits coverage of mental health and addiction treatment services in facilities with more than 16 beds. Called the “institutions for mental disease” or IMD exclusion, the rule was intended to prevent states from using federal dollars to warehouse people with addiction and mental disorders.” (B)

“While very broad in scope, the final legislation contains a number of provisions related to Medicaid’s role in helping states provide coverage and services to people who need substance use disorder (SUD) treatment, particularly those needing opioid use disorder (OUD) treatment.
Services. The most controversial measure in the bill amends the long-standing prohibition against the use of federal Medicaid funds for services in “institutions for mental disease” (IMDs) for nonelderly adults by creating a state option from 10/1/19 to 9/30/23 to cover those services up to 30 days in a year for individuals with a substance use disorder. To be eligible to receive federal matching funds, states must meet maintenance of effort and other requirements..
The SUPPORT Act also requires state Medicaid programs to cover medication-assisted treatment (MAT), including all FDA-approved drugs, counseling services, and behavioral therapy, from October 2020 through September 2025, unless a state certifies to the Secretary’s satisfaction that statewide implementation is infeasible due to provider shortages…
Demonstrations. Prescription Drug Oversight. The SUPPORT Act requires states to have drug utilization review safety edits in place for opioid refills, monitor concurrent prescribing of opioids and other drugs, and monitor antipsychotic prescribing for children” (C)

“Together,” the president told grieving mothers and fathers, cabinet members, lawmakers, and representatives of local law enforcement, “we will end the scourge of drug addiction in America. We’re going to end it or at least make an extremely big dent in this terrible, terrible problem.”
Almost no one who’s studied the legislation and understands the magnitude of an epidemic in which an estimated 72,000 people died from drug overdoses in 2017 thinks it will do any such thing. The bill’s provisions to expand addiction treatment, speed up research on alternative drugs, and provide Medicaid funding to treatment centers with more than 16 inpatient beds will certainly help, as will $6 billion in funding to fight opioids, “the most money ever received in history,” Trump said. But many public-health experts, and some of Trump’s Democratic opponents in Congress, say something closer to $100 billion is needed over 10 years to end or “make an extremely big dent” in opioid addiction. Senator Elizabeth Warren cites “broken promises” by an administration that still does not have a confirmed director of its Office of National Drug Control Policy (ONDCP) after nearly two years in office.
Formed in 1988 through the Anti-Drug Abuse Act, the ONDCP is supposed to coordinate drug-control policy and funding between 16 federal departments and agencies. The director of the office is intended to be the U.S. president’s “principal advisor” on drug-control issues. The Senate has to confirm whomever the president appoints…
The office has yet to release the annual National Drug Control Strategy, which spells out how the administration will tackle drugs and how it will develop a drug-control budget. Three months after taking office, Trump chose an unorthodox approach to drug policy, establishing the President’s Commission on Combating Drug Addiction and the Opioid Crisis, appointing Governor Chris Christie, a Trump political ally, as chair. The commission, staffed and funded by ONDCP, released a report that recommended nearly 60 ways to address the crisis. The recommendations cover prevention, treatment, recovery, and more. “ (D)

“The legislation takes wide aim at the problem, including increasing scrutiny of arriving international mail that may include illegal drugs. It makes it easier for the National Institutes of Health to approve research on non-addictive painkillers and for pharmaceutical companies to conduct that research.
The Food and Drug Administration would be allowed to require drugmakers to package smaller quantities of drugs such as opioids. And there would be new federal grants for treatment centers, training emergency workers and research on prevention methods.
Karen Yost, CEO of Prestera Center, said in a statement the 70 pieces of this bill is a good start, though there is no “magic bullet” to solving the opioid crisis.
“How this legislation is implemented will be key as even good legislation implemented poorly will not be helpful,” Yost said.
“This bill is a start in the right direction, even though it does not address significant underlying issues in this epidemic, including adverse childhood experiences, extreme poverty, gainful employment, safe affordable housing, related chronic health problems and co-occurring mental health problems.”
That’s a long list, and it helps explain how this problem became so big and is so difficult to overcome.” (E)

“Yet many public health advocates and experts say it doesn’t offer the one thing truly needed: The massive amount of funding needed to fully combat a crisis that deeply affects rural and urban communities across America.
Sarah Wakeman,the medical director for Mass General Hospital’s Substance Use Disorders Initiative, said really targeting the depth of the opioid epidemic would require an infusion of federal dollars on par with the more than $20 billion a year spent on HIV/AIDs.
“We have historically not thought of addiction as a medical issue and so our health care and public health system are woefully unprepared to respond in a robust way,” she said.”..
“I hope Congress doesn’t think they can put this behind them because they passed these bills,” said Patrick Kennedy, a former Democratic congressman of Rhode Island and a mental health advocate . “It takes an urgency like we had during HIV-AIDS. That will call to mind what it takes to address a crisis, it takes political will.” (F)

“”Without real money, it’s just lip service,” said John Rosenthal, co-founder and chairman of the Police Assisted Addiction and Recovery Initiative, to CNHI’s Christian M. Wade. “This disease has been raging for more than a decade without any serious federal response. Now they’re playing catch-up.”
Sarah Wakeman, the medical director for Mass General Hospital’s Substance Use Disorders Initiative, told the Washington Post that really targeting the depth of the opioid epidemic would require an infusion of federal dollars on par with the more than $20 billion a year spent on HIV/AIDs.
Rosenthal agreed and said there are “good things” in the bill, but it needs “billions” of dollars in money — similar to the federal response to cancer and HIV/AIDS prevention and treatment.” (G)

“Governments around the globe and their citizens routinely respond to ecological disasters. Think Exxon Valdez or Love Canal in the U.S.; Chernobyl in the Soviet Union; Bhopal in India; and far too many others. The responses, though not always immediate or thorough, at least tend to be multifaceted. We are currently in the midst of a human-made ecological disaster, the opioid crisis, that isn’t recognized as such, but that can benefit from the same sorts of responses made to ecological disasters…
Treating the opioid epidemic as an ecological disaster could set important precedents for cleanup and prevention that can be particularly useful in areas where effective responses have been lagging. Such efforts are relatively easy to visualize when the disaster is a pollutant like mercury. But what does a cleanup look like when the offending substance is, for some people, a medically essential resource?..
The opioid disaster is occurring simultaneously on so many levels and affecting so many lives in ways that other disasters may not. It can be viewed through many different lenses. I see the opioid disaster as an individual living with chronic pain who depends on opioid medications to manage each day. But I also acknowledge and suffer with members of my community who are experiencing substance abuse themselves, or are in recovery from it, or who have lost family members or friends to opioid overdoses.
Even now, nearly 30 years after the Exxon Valdez struck a reef and spilled nearly 11 million gallons of crude oil into Prince William Sound, some of that oil persists in Alaskan soil and water, breaking down minutely year by year. The opioid disaster will continue to saturate our environment for the near future, but it should not need to take three decades for us to break it down.” (H)

(A) President Trump tries to project image of bipartisan action with opioid bill signing, by David Jackson and John Fritze, https://www.usatoday.com/story/news/politics/2018/10/24/donald-trump-opioids-bill-signed-into-law-weeks-midterm-election/1750400002/
(B) Opioid Bill Expands Treatment Options, by Christine Vestal, https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2018/10/04/opioid-bill-expands-treatment-options
(C) Federal Legislation to Address the Opioid Crisis: Medicaid Provisions in the SUPPORT Act, by MaryBeth Musumeci, https://www.kff.org/medicaid/issue-brief/federal-legislation-to-address-the-opioid-crisis-medicaid-provisions-in-the-support-act/
(D) Trump’s ‘Big Dent’ in the Opioid Crisis, by Lola Fadulu, https://www.theatlantic.com/politics/archive/2018/10/trumps-signs-landmark-law-fight-opioid-addiction/573850/
(E) Federal opioid law moves in right direction, http://www.reflector.com/Editorials/2018/10/02/Federal-opioid-law-moves-in-right-direction.html
(F) Senate easily passes sweeping opioids legislation, sending to President Trump, by Colby Itkowitz, https://www.washingtonpost.com/politics/2018/10/03/senate-is-poised-send-sweeping-opioids-legislation-president-trump/?utm_term=.25aa48506c2b
(G) Where’s the money? Federal opioid bill gets flack for lack of funds, by Jonathan Greene, https://www.richmondregister.com/news/politics/where-s-the-money-federal-opioid-bill-gets-flack-for/article_c7f460c6-8d37-5542-ab4a-a6b219e03cb4.html
(H) Viewing the opioid crisis as an ecological disaster could help with ‘cleanup’, by MAIA DOLPHIN-KRUTE, https://www.statnews.com/2018/11/15/opioid-crisis-ecological-disaster/

Prequels
“The U.S. is about 5% of the world’s population yet consumes about 80% of the world’s oxycodone supply.” https://doctordidyouwashyourhands.com/2018/08/the-u-s-is-about-5-of-the-worlds-population-yet-consumes-about-80-of-the-worlds-oxycodone-supply-i/

US health official reveals fentanyl almost killed his son, https://doctordidyouwashyourhands.com/2018/07/us-health-official-reveals-fentanyl-almost-killed-his-son/

“For at least six months, staffers in the Office of National Drug Control Policy — often political appointees in their 20s — (have) sat through weekly meetings of an “opioids cabinet” chaired by Kellyanne Conway., https://doctordidyouwashyourhands.com/2018/06/for-at-least-six-months-staffers-in-the-office-of-national-drug-control-policy-often-political-appointees-in-their-20s-have-sat-through-weekly-meetings-of-an-o/

“The House on Friday passed bipartisan legislation aimed at fighting the nationwide epidemic of opioid abuse, culminating months of work on the crisis…, https://doctordidyouwashyourhands.com/2018/06/the-house-on-friday-passed-bipartisan-legislation-aimed-at-fighting-the-nationwide-epidemic-of-opioid-abuse-culminating-months-of-work-on-the-crisis/

Why is there a nationwide hospital shortage of injectable opioids? – follow the money. , https://doctordidyouwashyourhands.com/2018/04/why-is-there-a-nationwide-hospital-shortage-of-injectable-opioids-follow-the-money-part-3-of-a-continuing-case-study-on-the-opioid-crisis/

“In 2016, more than 40 percent of opioid overdose deaths in the U.S. involved a prescription opioid.”, https://doctordidyouwashyourhands.com/2018/04/in-2016-more-than-40-percent-of-opioid-overdose-deaths-in-the-u-s-involved-a-prescription-opioid/

CASE STUDY ON THE OPIOID CRISIS. “We still have lacked the insight that this is a crisis, a cataclysmic crisis”, https://doctordidyouwashyourhands.com/2018/03/case-study-on-the-opioid-crisis-we-still-have-lacked-the-insight-that-this-is-a-crisis-a-cataclysmic-crisis/

Opioid commission member: Our work is a ‘sham’, https://doctordidyouwashyourhands.com/2018/01/opioid-commission-member-our-work-is-a-sham/

“White House counselor Kellyanne Conway will be the point person for the Trump administration’s opioid crisis efforts…, https://doctordidyouwashyourhands.com/2017/12/white-house-counselor-kellyanne-conway-will-be-the-point-person-for-the-trump-administrations-opioid-crisis-efforts/

Facebook users can easily find these drugs – Oxycodone, Hydrocodone, and Percocets, https://doctordidyouwashyourhands.com/2017/11/facebook-users-can-easily-find-these-drugs-oxycodone-hydrocodone-and-percocets/

“…the president.. reversed course to instead declare opioids a public health emergency, a move that releases no new funding to contend with a drug crisis….”, https://doctordidyouwashyourhands.com/2017/10/the-president-reversed-course-to-instead-declare-opioids-a-public-health-emergency-a-move-that-releases-no-new-funding-to-contend-with-a-drug-crisis/

“At a time when the United States is in the grip of an opioid epidemic, many insurers are limiting access to pain medications that carry a lower risk of addiction or dependence…..”, https://doctordidyouwashyourhands.com/2017/10/at-a-time-when-the-united-states-is-in-the-grip-of-an-opioid-epidemic-many-insurers-are-limiting-access-to-pain-medications-that-carry-a-lower-risk-of-addiction-or-dependence/

Congress blocked DEA action against drug companies suspected of flooding the country with prescription narcotics, https://doctordidyouwashyourhands.com/2017/10/congress-blocked-dea-action-against-drug-companies-suspected-of-flooding-the-country-with-prescription-narcotics/

The rise of ‘grandfamilies’: Opioid crisis requires more Hoosier grandparents to raise children.., https://doctordidyouwashyourhands.com/2017/09/the-rise-of-grandfamilies-opioid-crisis-requires-more-hoosier-grandparents-to-raise-children/

Opioid Crisis. ““We got here in part because there was a paper done in the 1980s by a well-meaning physician that said opioids are not addictive…., https://doctordidyouwashyourhands.com/2017/09/opioid-crisis-we-got-here-in-part-because-there-was-a-paper-done-in-the-1980s-by-a-well-meaning-physician-that-said-opioids-are-not-addictive/

“To manage and (eventually) reverse the opioid epidemic, state Medicaid programs should now take a deeper look at the role prescribing plays…”, https://doctordidyouwashyourhands.com/2017/08/to-manage-and-eventually-reverse-the-opioid-epidemic-state-medicaid-programs-should-now-take-a-deeper-look-at-the-role-prescribing-plays/

As Washington dawdles, the States step in on the opioid crisis, with initiatives and lawyers, https://doctordidyouwashyourhands.com/2017/08/as-washington-dawdles-the-states-step-in-on-the-opioid-crisis-with-initiatives-and-lawyers/

“We would never tolerate a situation where only one in 10 people with cancer or diabetes gets treatment, and yet we do that with substance-abuse disorders,” (A), https://doctordidyouwashyourhands.com/2017/08/we-would-never-tolerate-a-situation-where-only-one-in-10-people-with-cancer-or-diabetes-gets-treatment-and-yet-we-do-that-with-substance-abuse-disorders-a/

“For most of my surgical career, I gave out opioids like candy….” “With approximately 142 Americans dying every day”….” We need to take away the matches, not put out the fires.”, https://doctordidyouwashyourhands.com/2017/08/8224/

October 28, 2018

FROM: CEO, Northern New Jersey Regional Medical Center
TO: SVPs
SUBJECT: Tomorrow morning’s Preparedness meeting (just scheduled for 8AM)

Over the last few days there has been a convergence of preparedness challenges. We need to set priorities, confirm assignments, allocate resources, initiate communications plan.

1. NOR’EASTER/ FLOODING.
Assessment. Review SuperStorm Sandy rapid response (A) (B) (C)

2. ACTIVE SHOOTER TRAINING
“Hospital active shooter response programs are essential for healthcare facilities to stay prepared for shootings on their campus or in their communities. Hospitals with the ability to receive patients from an active shooter attack have a responsibility to be prepared.
The new National Fire Protection Association Standard, NFPA 3000: Standard for an Active Shooter/Hostile Event Response (ASHER) Program, gives details on what that preparedness should look like.
Specifically, chapter 19 of the NFPA 3000 standard describes different aspects of an effective, scalable hospital active shooter program.
John Montes, an NFPA emergency services specialist who helped write NFPA 3000, believes active shooter response plans should be distinct from hospital officials’ general emergency plans.” (D) (E)

3. DEADLY VIRUS OUTBREAK & BACTERIAL INFECTION
“New Jersey Department of Health officials said this week that in addition to an investigation of an outbreak of adenovirus that has killed seven children at the Wanaque Center for Nursing and Rehabilitation in Passaic County, they are investigating four cases of Acinetobacter baumannii in the neonatal intensive care unit of University Hospital in Newark, following the death of a premature baby.” (F) (G)

4. POLIO-LIKE ILLNESS
“Acute flaccid myelitis, the polio-like syndrome leaving some children partially paralyzed.
The Centers for Disease Control and Prevention says it doesn’t know what’s causing a sudden rise in cases of a frightening, polio-like condition that leaves children paralyzed or with weakened limbs.
The No. 1 suspect had been a virus called enterovirus D68, or EV-D68. In 2014, a wave of cases of acute flaccid myelitis coincided with outbreaks of EV-D68 across the country.” (H)

5. SEASONAL FLU
“New York City on reported its first flu-related death of the season Thursday, and the health department urged everyone over 6 months of age to get a flu shot.” (I)
“Surge” capacity
Mandatory staff vaccinations? (J)

6. SEPSIS
“Scientists have created an artificial intelligence (AI) system that could help treat patients with sepsis by predicting the best treatment strategy.
The system developed by researchers from Imperial College London in the UK analysed the records of about 100,000 hospital patients in intensive care units and every single doctor’s decisions affecting them.
The findings, published in the journal Nature Medicine, showed the AI system made more reliable treatment decisions than human doctors.” (K)

7. EBOLA TRAINING
“Preparedness for emerging infectious diseases threats saw a marked improvement at U.S. hospitals after an Ebola outbreak scare in 2014, according to a new report from a federal watchdog agency.
The challenge now? Keeping that level of preparedness in the midst of competing priorities.
According to the HHS Office of Inspector General, 71% of hospital administrators reported their facilities were unprepared to receive Ebola patients in 2014. But after scrambling to update emergency plans, train staff to care for patients with emerging infectious diseases (EID), purchasing additional supplies and conducting drills, 86% of administrators said their facilities were prepared in 2017.” (L)

8. HALLOWEEN COVERAGE
Halloween Health and Safety Tips (M)

RESOURCES
Emergency Preparedness and Response, CDC. https://emergency.cdc.gov/planning/index.asp
Emergency Management Resources, The Joint Commission, https://www.jointcommission.org/emergency_management.aspx
Is Your Hospital Prepared? CHA. https://www.calhospitalprepare.org/
Hospital Surge Evaluation Tool https://www.phe.gov/Preparedness/planning/hpp/surge/Pages/default.aspx

(A) Five years after Superstorm Sandy, NYC hospitals may be as ready as Houston’s were for Harvey, by Rachel Z. Arndt, https://www.modernhealthcare.com/article/20170909/NEWS/170909889
(B) Hurricane Sandy: A Tale of 2 Hospitals, by Marc Lallanilla, https://www.livescience.com/40734-hurricane-sandy-shorefront-center-coney-island-hospital.html
(C) Bracing for the Worst, https://today.duke.edu/2018/09/bracing-worst
(D) What Hospital Active Shooter Response Programs Should Look Like, https://economictimes.indiatimes.com/magazines/panache/now-an-ai-system-could-help-treat-patients-with-sepsis-by-predicting-best-treatment-strategy/articleshow/66331925.cms
(E) Children’s Medical Center Dallas boosts ER preparedness with active shooter drills, by by Paige Minemyer, https://www.fiercehealthcare.com/hospitals-health-systems/children-s-health-children-s-medical-center-dallas-active-shooter-training
(F) 8th death reported at North Jersey pediatric care facility, by NICOLE LEONARD, https://www.pressofatlanticcity.com/wellness/deadly-viral-and-bacterial-cases-strike-nj-children-at-health/article_0a4912c9-820f-5890-b2ae-6bcfe558f751.html
(G) STATE TO GIVE FAST TRAINING ON INFECTION CONTROL AT THREE OTHER FACILITIES, by LILO H. STAINTON, https://www.njspotlight.com/stories/18/10/25/state-to-give-fast-training-on-infection-control-at-three-other-facilities/
(H) CDC says polio-like disease is puzzling. These doctors disagree, by Maggie Fox, https://www.theatlantic.com/health/archive/2018/10/afm-polio-like-illness-thats-paralyzing-children/573982/
(I) NYC Health Dept. Announces First Child Flu Death Of Season, https://newyork.cbslocal.com/2018/10/25/child-flu-death-nyc-department-of-health/
(J) Menu of State Hospital Influenza Vaccination Laws, https://www.cdc.gov/phlp/docs/menu-shfluvacclaws.pdf
(K) Now, an AI system could help treat patients with sepsis by predicting best treatment strategy, https://economictimes.indiatimes.com/magazines/panache/now-an-ai-system-could-help-treat-patients-with-sepsis-by-predicting-best-treatment-strategy/articleshow/66331925.cms
(L) U.S. hospitals improved infectious disease preparedness in response to Ebola threat, federal watchdog says, by Tina Reed, https://www.fiercehealthcare.com/hospitals-health-systems/u-s-hospitals-performed-well-response-to-ebola-threat-federal-watchdog
(M) https://www.cdc.gov/family/halloween/halloween_tips.pdf

PREQUELS
We don’t know what we don’t know” (1) The challenge to emergency preparedness….., https://doctordidyouwashyourhands.com/2017/08/we-dont-know-what-we-dont-know-1-the-challenge-to-emergency-preparedness/
“..in a severe (flu) pandemic, the U.S. healthcare system could be overwhelmed in just weeks., https://doctordidyouwashyourhands.com/2018/01/let-there-be-no-mistake-in-a-severe-flu-pandemic-the-u-s-healthcare-system-could-be-overwhelmed-in-just-weeks/
The new Jersey City Medical Center (2004) was constructed above the 100 year flood plain – then came Sandy, Harvey & Irma, https://doctordidyouwashyourhands.com/2017/11/the-new-jersey-city-medical-center-2004-was-constructed-above-the-100-year-flood-plain-then-came-sandy-harvey-irma/

PUBLIC HEALTH CRISIS CREATED BY TRUMP ADMINISTRATION FAMILY SEPARATION POLICY

“Even the judge in her black robes breathed a soft “aww” as her latest case perched on the brown leather.
Her feet stuck out from the seat in small gray sneakers, her legs too short to dangle. Her fists were stuffed under her knees. As soon as the caseworker who had sat her there turned to go, she let out a whimper that rose to a thin howl, her crumpled face a bursting dam.
The girl, Fernanda Jacqueline Davila, was 2 years old: brief life, long journey. The caseworker, a big-boned man from the shelter that had been contracted to raise her since she was taken from her grandmother at the border in late July, was the only person in the room she had met before that day.
“How old are you?” the judge asked, after she had motioned for the caseworker to return to Fernanda’s side and the tears had stopped. “Do you speak Spanish?”
… there are more children showing up more often to federal immigration courtrooms like Judge Zagzoug’s, at hearings that could determine whether they will be deported, reunited with their parents, or granted the asylum that their parents desperately want for them. They often sit at counsel tables alone, unaccompanied by any family and sometimes without even a lawyer.” (A)

“ACLU attorney Lee Gelernt said Immigration and Customs Enforcement isn’t always providing advance notice before sending children back to their parents in Central America. That means the children end up stranded in airports, with their parents sometimes days away in distant villages.
Gelernt said ICE flew a five-year-old boy to Guatemala City without notifying the ACLU or the parents, so he would have to “spend the night in a strange shelter.” (B)

“A top Health and Human Services official told Congress on Tuesday that he and others repeatedly warned the Trump administration that its policy of separating immigrant families apprehended at the U.S.-Mexico border would not be in “the best interest of the child.”
“During the deliberative process over the previous year, we raised a number of concerns in the (Office of Refugee Resettlement) program about any policy which would result in family separation due to concerns we had about the best interest of the child as well as about whether that would be operationally supportable with the bed capacity that we have,” Jonathan White, with the Public Health Service Commissioned Corps, told lawmakers at a Senate Judiciary Committee hearing…
The latest number of immigrant children who remain in detention and apart from their parents stands at 711, according to the Department of Homeland Security. The parents of 431 of those kids have already been deported, while the parents of 120 children waived their right to reunify with them. Sixty-seven other children had parents or guardians that raised a ‘red flag’ about their fitness for the child following background checks.” (C)

“The Department of Homeland Security was not ready to carry out the Trump administration’s family separation policy, and some of the government’s practices made the problem worse, according to a report issued Tuesday by the department’s inspector general…
“DHS was not fully prepared to implement the administration’s zero-tolerance policy or to deal with some of its after-effects,” said John Kelly, the acting inspector general.
Tuesday’s report said Customs and Border Protection held children for long periods in facilities intended to be used for only short terms, lacked the ability to reliably track children separated from their parents, and in some cases failed to adequately inform parents about the separation policy…
Computer systems used by CBP and Immigration and Customs Enforcement lacked the ability to share data about parents whose children were separated from them. And those systems were not integrated with the resettlement agency…
In a separate DHS inspector general report dated September 27, the Adelanto ICE Processing Center, a detention center housing up to 1,940 ICE detainees in California, was cited for serious violations including nooses found hanging in detainee cells, “improper and overly restrictive segregation,” and “untimely and inadequate medical care.” “ (D)

“ICE agents detaining children needing emergency care, targeting immigrants visiting sick family members and deporting patients as they exit hospitals are putting healthcare workers in precarious positions. Some are finding their professional purpose compromised by federal immigration policies and fear patient health will suffer.
A recent survey from the advocacy group Children’s Partnership found about 40% of immigrant patients in California are skipping appointments and scheduling fewer visits with their providers for fear of confrontation with ICE. One recent study of 545 Mexican women in the United States concluded that fear of deportation could be a cardiovascular risk factor for the country’s ethnic minorities…
The American Hospital Association does not have a specific policy on the removal, detainment or apprehension of immigrant patients from medical facilities, so hospitals have largely been navigating their own way through murky immigration laws…
As a law enforcement body, ICE must go through a subpoena process to get a patient’s information. But what happens when ICE agents camp on hospital property while a person of interest is being treated, as was the case with a critically ill woman from El Salvador who last year was bound in her wheelchair by federal agents who moved her from the Texas hospital where she was awaiting emergency brain tumor surgery and into a detention center?” (E)

“The U.S. government has deported hundreds of migrant parents without their children in the aftermath of President Trump’s now-defunct family separation policy. But now administration officials are arguing that it’s the responsibility of the American Civil Liberties Union, not the federal government, to find those deported mothers and fathers.
Justice Department lawyers wrote in a court filing Thursday that the ACLU should use its “considerable resources,” its network of advocacy groups, and information from the government to locate parents removed to foreign countries. The Trump administration added, however, that the State Department has made contact with foreign governments to assist in facilitating family reunions…
ACLU lawyers pushed back against the Trump administration’s demands to find the deported parents, saying that they will do “whatever they can” but that the government must bear the ultimate burden.
The government told a federal court judge that non-profit groups, rather than government officials, should take the lead in reunifying immigrant families…
The ACLU wrote that “there is no blueprint for finding deported parents,” who are scattered in various cities across Central America and who, in many cases, left behind minimal address information.” (F)

“In shelters from Kansas to New York, hundreds of migrant children have been roused in the middle of the night in recent weeks and loaded onto buses with backpacks and snacks for a cross-country journey to their new home: a barren tent city on a sprawling patch of desert in West Texas.
Until now, most undocumented children being held by federal immigration authorities had been housed in private foster homes or shelters, sleeping two or three to a room. They received formal schooling and regular visits with legal representatives assigned to their immigration cases…
But in the rows of sand-colored tents in Tornillo, Tex., children in groups of 20, separated by gender, sleep lined up in bunks. There is no school: The children are given workbooks that they have no obligation to complete. Access to legal services is limited…
The camp in Tornillo operates like a small, pop-up city, about 35 miles southeast of El Paso on the Mexico border, complete with portable toilets. Air-conditioned tents that vary in size are used for housing, recreation and medical care. Originally opened in June for 30 days with a capacity of 400, it expanded in September to be able to house 3,800, and is now expected to remain open at least through the end of the year.” …
The roughly 100 shelters that have, until now, been the main location for housing detained migrant children are licensed and monitored by state child welfare authorities, who impose requirements on safety and education as well as staff hiring and training.
The tent city in Tornillo, on the other hand, is unregulated, except for guidelines created by the Department of Health and Human Services. For example, schooling is not required there, as it is in regular migrant children shelters…
The longer that children remain in custody, the more likely they are to become anxious or depressed, which can lead to violent outbursts or escape attempts, according to shelter workers and reports that have emerged from the system in recent months.” (G)

“It doesn’t take a psychologist to understand that ripping children from their beds in the middle of the night, tearing them from anyone they’ve forged a connection with, and thrusting them into uncertainty could damage them…How to best handle the cases of unaccompanied minors has perplexed authorities since the Obama administration. But the current crowding is not a result of some sharp increase in children stealing across the border — the influx is no greater now than it has been for the past two years.
Instead, the Trump administration’s own draconian policies are to blame. Around the same time that it began separating immigrant children from their parents as they crossed into the United States, the Department of Homeland Security also established strict requirements for the relatives and friends who might care for these children while their cases are sorted out. Prospective sponsors are now required to submit fingerprints, and to share their information with federal immigration officers. Because most of them are undocumented immigrants themselves, they have been scared off by these requirements. And with good cause: Dozens of applicants who took the chance of applying to be sponsors have been arrested on immigration charges. As would-be sponsors shrink away, more children are stranded in federal custody”… (H)

“Thousands of foster children may be getting powerful psychiatric drugs prescribed to them without basic safeguards, says a federal watchdog agency that found a failure to care for youngsters whose lives have already been disrupted.
A report released Monday by the Health and Human Services inspector general’s office found that about 1 in 3 foster kids from a sample of states were prescribed psychiatric drugs without treatment plans or follow-up, standard steps in sound medical care.
Kids getting mood-altering drugs they don’t need is only part of the problem. Investigators also said children who need medication to help them function at school or get along in social settings may be going untreated.
The drugs include medications for attention deficit disorder, anxiety, PTSD, depression, bipolar disorder and schizophrenia. Foster kids are much more likely to get psychiatric drugs than children overall.
“We are worried about the gap in compliance because it has an immediate, real-world impact on children’s lives,” said Ann Maxwell, an assistant inspector general.” (I)

“Traditionally, most sponsors have been undocumented themselves, and therefore are wary of risking deportation by stepping forward to claim sponsorship of a child. Even those who are willing to become sponsors have had to wait months to be fingerprinted and otherwise reviewed.
Federal officials say their vetting procedures are designed to safeguard the children in their care.
“Children who enter the country illegally are at high risk for exploitation by traffickers and smugglers,” Ms. Stauffer said in her statement.
But the longer children are detained, the more anxious and depressed they are likely to become, according to Mr. Greenberg, who oversaw the program under Mr. Obama. When that happens, children may try to harm themselves or escape, and can become violent with the staff and with one another, he said.
Stories of such behavior have emerged through reporting in recent months as the shelter system has faced intense criticism by members of Congress and the public…
The separated children injected a new degree of chaos into the facilities, according to several shelter operators, who spoke anonymously because they are barred by the government from speaking to the news media. The children were younger and more traumatized than those the shelters were used to dealing with, and they arrived without a plan for when they could be released or to whom.” (J)

“These are kids who fled some of the most violent countries in the world. Many have experienced trauma … rape, robbery, all kinds of exploitation,” said Bob Carey, who ran the HHS office overseeing child detention at the end of the Obama administration.
“The question I would ask is, are measures legitimately enhancing the security situation?” added Carey, who’s now a leadership and government fellow with the Open Society Foundations. “The ultimate security is not releasing any child to a sponsor, because then nothing would happen to them. But how much harm are you causing by keeping kids in custody indefinitely in settings that were never designed for that?”
In September 2017, then-ICE acting Director Tom Homan said at a public event that his agency would arrest undocumented people who came forward to care for the children.
“You cannot hide in the shadows,” Homan said at a Washington border security event, adding that parents should be “shoulder-to-shoulder” with their children in court. “We’re going to put the parents in proceedings, immigration proceedings, at a minimum. … Is that cruel? I don’t think so.” (K)

“Deep within the fine print of a newly proposed federal rule change is an admission of its disastrous health consequences. The Department of Homeland Security’s plan would deny legal immigrants permanent residency status if they accept government assistance to which they are entitled, allegedly an effort to “promote immigrant self-sufficiency” and ensure “they are not likely to become burdens on American taxpayers” or “public charges.”
But the certain collateral damage of this misguided policy, which greatly expands an existing principle to make its application downright punitive, reveals it’s not about promoting self-sufficiency at all.
In describing the impact of this effort, the Department of Homeland Security states, “Disenrollment or foregoing enrollment…by aliens otherwise eligible for these programs could lead to:
“Worse health outcomes, including prevalence of obesity and malnutrition, especially for pregnant or breastfeeding women, infants or children…
“Increased use of emergency rooms and emergency care as a method of primary health care due to delayed treatment
“Increased prevalence of communicable diseases, including among members of the U.S. citizen population who are not vaccinated.”..
The rule change, if implemented, will cause legal immigrants, their spouses and children, including U.S. citizens, to withdraw from government assistance programs out of fear that it would endanger the chances for a family member to obtain a green card and become a legal permanent resident. Washington will, in effect, force individuals to choose between their welfare and a family member’s legal residency status…
Some children will not receive necessary vaccines, making them susceptible to preventable diseases, such as measles, mumps, Hepatitis A and B, and polio. Illnesses will not be addressed when they are easily treatable. Without proper prenatal and perinatal care, there will be an increase in birth complications.” (L)

“I didn’t like the sight or the feeling of families being separated,” President Trump said on June 20, when he signed an executive order halting his administration’s depraved practice of separating migrant children from parents seeking asylum at the nation’s southern border. “This will solve that problem.”..
With its zero-tolerance barbarism, the Trump administration managed to do an impressive amount of damage in a very short time. In the six weeks the policy was in effect, more than 2,600 children were taken from their parents, with zero thought or planning for how the families might eventually be reunited…
Predictably, the Trump administration has shown less enthusiasm for cleaning up this mess than it did for making it. Earlier this summer, it tried to weasel out of a big chunk of its reunification responsibilities by asserting that it was the A.C.L.U.’s job to locate all of the parents who had been deported by the administration without their children. Once again, Judge Sabraw had to step in and call foul, ordering that the government coordinate with the A.C.L.U.
Complicating matters, the administration has decreed that reunifications must take place in the family’s country of origin. Which means that, once contacted, parents face an excruciating choice: give up their children’s asylum claims and have them returned home, or leave the children in the United States to try to navigate the asylum process on their own.” (M)

“The Trump administration wants to change how the government defines who is or is likely to become a “public charge.” The Department of Homeland Security released a draft regulation on Sept. 22, in which it proposed that any immigrant who is likely to use or who has already used Medicaid, public housing or a rent voucher, cash assistance or food stamps could be barred from the country or kept from getting permanent resident status.
The proposed rule change is part and parcel of the Trump administration’s hostility to immigrants. But it’s also about more than that. The administration would remake the idea of self-sufficiency, admitting only those who never need to turn to the public safety net, but instead rely solely on “their own capabilities” or the resources of their families and private charity. It even asserts that people who use public programs “in a relatively small amount or for a relatively short duration” are still considered dependent on the welfare state.
This redefinition of self-sufficiency ignores the way that most people use these programs. Even people with jobs often cycle on and off assistance as work comes and goes, or to plug the gaps when it just doesn’t pay enough. These programs allow people to remain healthy and solvent — supporting their independence. This rule therefore hurts everyone, not just immigrants, by stigmatizing the safety net funded by all of us to help people survive when they fall on hard times.” (N)

Coda:
“Helen—a smart, cheerful five-year-old girl—is an asylum seeker from Honduras…
Helen had been brought to Baytown, a shelter run by Baptist Child & Family Services, which the federal government had contracted to house unaccompanied minors…
..in early August, an unknown official handed Helen a legal document, a “Request for a Flores Bond Hearing,” which described a set of legal proceedings and rights that would have been difficult for Helen to comprehend. (“In a Flores bond hearing, an immigration judge reviews your case to determine whether you pose a danger to the community,” the document began.) On Helen’s form, which was filled out with assistance from officials, there is a checked box next to a line that says, “I withdraw my previous request for a Flores bond hearing.” Beneath that line, the five-year-old signed her name in wobbly letters.
An uncounted number of separated children in shelters and foster care fall outside the lawsuit’s current purview—including many like Helen, who arrived with a grandparent or other guardian, rather than with a parent. Many such children have been misclassified, in government paperwork, as “unaccompanied minors,” due to a sloppy process that the Department of Homeland Security’s Office of the Inspector General recently critiqued. Chavez believes that, through misclassification, many kids have largely disappeared from public view, and from official statistics, with the federal government showing little urgency to hasten reunifications…. “(O)

Next Episode:
The Trump administration is mulling plans to renew family separations at the U.S.-Mexico border, as the number of migrant families entering the country illegally has skyrocketed in recent months.
One policy under consideration would be to give asylum-seeking parents a “binary choice” after spending 20 days in detention with their families: either stay in a detention center for months or years awaiting an immigration trial, or allow children to be taken to government shelters while other relatives try to seek custody for them. The Washington Post first reported that this option was being considered…
The option to give families a choice about staying together was endorsed by the Justice Department and the American Civil Liberties Union in a court filing in July. The motion stated that if a parent chose to stay with their children, the parent would waive the child’s “rights with regard to placement in the least restrictive setting appropriate to the minor’s age and special needs.” If a parent did not make any decision, the motion said that the government would keep the family detained together.” (P)

(A) Migrant Children in Search of Justice: A 2-Year-Old’s Day in Immigration Court, by Vivian Yee and Miriam Jordan, https://www.nytimes.com/2018/10/08/us/migrant-children-family-separation-court.html
(B) (B) More Than 200 Immigrant Children Remain Separated From Their Parents, by Jean Guerrero, https://www.kpbs.org/news/2018/oct/09/more-200-immigrant-children-remain-separated-their/
(C) (C) Top HHS official warned Trump administration against separating immigrant families, by Eliza Collins, Alan Gomez, https://www.usatoday.com/story/news/politics/2018/07/31/trump-administration-official-warned-family-separations/874963002/
(D) (D) DHS not prepared for family separations under Trump zero tolerance policy, watchdog finds, by Pete Williams and Jacob Soboroff, https://www.nbcnews.com/politics/politics-news/dhs-not-prepared-family-separations-under-trump-zero-tolerance-policy-n915916(
(E) When ICE comes knocking, healthcare workers want to be prepared, by Tony Abraham, https://www.healthcaredive.com/news/when-ice-comes-knocking-healthcare-workers-want-to-be-prepared/531058/
(F) (F) Trump administration puts burden on ACLU to find deported parents separated from children, by Samantha Schmidt, https://www.washingtonpost.com/news/morning-mix/wp/2018/08/03/trump-administration-puts-burden-on-aclu-to-find-deported-parents-separated-from-children/?noredirect=on&utm_term=.d4c8f475919f
(G) Migrant Children Moved Under Cover of Darkness to a Texas Tent City, by Caitlin Dickerson, https://www.nytimes.com/2018/09/30/us/migrant-children-tent-city-texas.html
(H) Hundreds of Children Rot in the Desert. End Trump’s Draconian Policies. https://www.nytimes.com/2018/10/01/opinion/migrant-children-tent-city-texas.html
(I) Thousands of foster children may be getting psychiatric drugs without safeguards, watchdog agency says, by Ricardo Alonso-Zaldivar, https://www.statnews.com/2018/09/17/thousands-of-foster-children-may-be-getting-psychiatric-drugs-without-safeguards-watchdog-agency-says/?utm_source=STAT+Newsletters&utm_campaign=fab0f6340f-MR_COPY_12&utm_medium=email&utm_term=0_8cab1d7961-fab0f6340f-149527969
(J) Detention of Migrant Children Has Skyrocketed to Highest Levels Ever, by Mike Blake, https://www.nytimes.com/2018/09/12/us/migrant-children-detention.html?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosam&stream=top
(K) ICE arrested undocumented immigrants who came forward to take in undocumented children, by Tal Kopan, https://www.cnn.com/2018/09/20/politics/ice-arrested-immigrants-sponsor-children/index.html
(L) One sick immigration rule: The ‘public charge’ regulation will make America less healthy, by KENNETH L. DAVIS, http://www.nydailynews.com/opinion/ny-oped-one-sick-immigration-rule-20181009-story.html
(M) The Continuing Tragedy of the Separated Children, https://www.nytimes.com/2018/08/30/opinion/family-separation-trump-zero-tolerance.html
(N) (N) Trump Wants to Turn the Safety Net Into a Trap, by By Bryce Covert, https://www.nytimes.com/2018/10/01/opinion/trump-wants-to-turn-the-safety-net-into-a-trap.html
(O) The Five-Year-Old Who Was Detained at the Border and Persuaded to Sign Away Her Rights, by Sarah Stillman, https://www.newyorker.com/news/news-desk/the-five-year-old-who-was-detained-at-the-border-and-convinced-to-sign-away-her-rights?mbid=nl_Daily%20101218&CNDID=50144682&utm_source=Silverpop&utm_medium=email&utm_campaign=Daily%20101218&utm_content=&spMailingID=14422852&spUserID=MjAxODUyNTc3Mjk4S0&spJobID=1500966416&spReportId=MTUwMDk2NjQxNgS2
(P) Trump administration considering new family separation policy for undocumented immigrants, by GRACE SEGERS, https://www.cbsnews.com/news/trump-administration-considering-new-family-separation-policy-for-undocumented-immigrants/
(Q)

Prequels
..The HHS needs to review thousands of case files by hand for clues to which children were taken from their parents…

“Most immigrants facing deportation wouldn’t climb onto a table during their court hearings. But then again, most 3-year-olds don’t go to court without parents or lawyers.

“President Trump has moved on from caring about the migrant children in cages

“Only a dead heart is unstirred by the intentional infliction of suffering on children and babies as a weapon of deterrence.”

“In 6 Days, Trump Admin Reunited Only 6 Immigrant Children With Their Families”, https://doctordidyouwashyourhands.com/2018/06/in-6-days-trump-admin-reunited-only-6-immigrant-children-with-their-families/

“…the only way parents can quickly be reunited with their children is to drop their claims for asylum… and agree to be deported.”

White House Press Secretary Sarah Huckabee Sanders said the government was starting to
“run out of space” to house people apprehended crossing the border

Trump’s policy “could be creating thousands of immigrant orphans in the U.S.”, https://doctordidyouwashyourhands.com/2018/06/trumps-policy-could-be-creating-thousands-of-immigrant-orphans-in-the-u-s/

Tender-Age Immigrant Children. “They need bilingual workers. Some kids speak indigenous languages, so that’s an issue as well. https://doctordidyouwashyourhands.com/2018/06/tender-age-immigrant-children-they-need-bilingual-workers-some-kids-speak-indigenous-languages-so-thats-an-issue-as-well/

“The idea of pulling a child out of a parent’s arms, or identifying a parent but still keeping them separate—it isn’t right.”

“The business of housing, transporting and watching over migrant children detained along the southwest border is not a multimillion-dollar business. It’s a billion-dollar one…

“If it could happen to them…why can’t it happen to us?”…separating children from their parents,

“…Trump’s (family separation) policy amounts to “government-sanctioned child abuse.””,

“The Trump administration’s policy of separating parents and children at the U.S.-Mexico border will have a dire impact on their health, both now and into the future.” (C)

“It is fine to celebrate success, but it is more important to heed the lessons of failure.” – Bill Gates

Vignette 1
One summer Friday early afternoon I was in my car heading off for the weekend when the New Jersey Commissioner of Health called and told me he was closing the Jersey City Medical Center Trauma Center for failure to get renewed State approval.
Our new Trauma Service Director had told me that we were at risk for non-approval so we should have an American College of Surgeons consultation visit before the ACS certificationvisit, a prerequisite for State approval. But apparently he did not know that State approval had an absolute re-approval date of three years no matter what preparatory steps we chose to take.
The call was on the re-approval deadline date so the Commissioner shut the TC down but the radio stations said the ER was shut down, making the matter even worse.
To make a long story short, we got approval to reopen the TC on Monday after an early morning compliance visit by the State, and three months to get re-approval. Which we did with no contingencies, conditions or recommendations.
And what would you do about the Trauma Service Director?

“Failure is only the opportunity to begin again, only this time more wisely.” – Henry Ford

Vignette 2
Bariatric Surgery was the rage and our new Chairman of Surgery said we had to be in the game. So he recruited a team of bariatric surgeons to branch out to Jersey City Medical Center, and spent time at their home base training to be an Assistant Bariatric Surgeon (and thus able to bill for this role).
We staffed up, lots of prospective patients came to orientations, but no cases were ever done. Why? The prospective patients were mostly our own employees who “chose”, we were told, to have the surgery at the team’s home base for “privacy concerns.” So we not only paid for the programs fixed costs but also for the insurance impact when our employees had the surgery elsewhere.

“There are no secrets to success. It is the result of preparation, hard work and learning from failure.” – Colin Powell

Vignette 3
Each of our three hospitals had different protocols to avoid “wrong site/ wrong side” surgery (e.g., a wrong kidney removal actually happened). Some surgeons operated at 2 or 3 of our hospitals (as well as at other non-system hospitals) and thus had to navigate the different protocols. We called a meeting to establish one standard protocol for our system, to be approved by each hospital’s medical staff.
Only to find out months later that our two community hospital medical staffs amended the protocol rather than simply adopt it. So as CEO of all three hospitals I mandated the standard protocol, it rose to the level of the Boards of Trustees, but common sense prevailed.

“A person who never made a mistake never tried anything new.” – Albert Einstein

Vignette 4
Three full time Chairmen told me they were in the final stages of building a free-standing surgi-center a half mile away from the hospital, and that the previous President had promised to buy it. Nothing in writing. I demurred. So they partnered with two competing hospitals. One Wednesday morning I went to a Chamber of Commerce showcase event only to find the three Chairman at their surgi-center booth. All three ran residency training programs and Wednesday was Grand Rounds for all three. They told me they were using vacation time. I said that was not appropriate. They said it was none of my business. I told each of them they had a choice, either sell their shares of the surgi-center or be fired. Two sold, one “left” and took his residents with him to one of the competing hospitals.

Vignette 5
The Mystery of the Hospital CLAUSTROPHOBIA CLUSTER
Recently a friend was told by his doctor he needed an MRI and said that he could get it at the hospital on the campus where the doctor’s office was located, or at a private imaging center two blocks away.
This reminded me of the mystery of the Claustrophobia Cluster about twenty-five years ago, in Greenville Hospital, a member hospital of LibertyHealth.
Our Teaching Hospital, Jersey City Medical Center had just acquired a new state-of-the-art MRI, GH was only a little over a mile away, there was an MRI transfer protocol in place, and we ran a robust county-wide EMS transport system.
But almost every insured patient at GH who needed an MRI was referred to a “private” free-standing Imaging Center due to CLAUSTROPHOBIA. Somehow, also mysteriously, Medicaid patients and the uninsured made it to JCMC.
The problem was compounded by the fact that we were under a DRG reimbursement system where we got reimbursed an all-inclusive rate for every diagnosis, and had to pay for “outside” MRIs out of that bundled payment. These very expensive outside MRIs often meant that GH and the system lost money on many of these patients.
Whichever entity provides the service tacks on a Facilities Fee to the professional fee charged, for example, by a radiologist.
This raises the question of whether self-referral is a purely clinical recommendation or might “ownership” and the Facilities Fee be an influence.
We never solved the CLAUSTROPHOBIA CLUSTER mystery, because the outside MRI was buried in a myriad of corporations, although we felt somewhere this was the case of physicians referring patients to a facility they owned.
But it ended as mysteriously as it started when we started tracking referrals.

Vignette 6
The DOH issued a CN “call” for inpatient rehabilitation beds. This was an excellent opportunity for Meadowlands Hospital with all single bedded rooms and flagging admissions.
The Meadowlands medical staff wanted a patient care model where any physician could admit to the rehab unit and the physiatrist was a consultant. The best practice at academic medical centers as well as rehab hospitals in New Jersey was a “closed unit” where the physiatrist managed the patients and other physicians could consult on other medical conditions such as COPD, UTI, and coronary disease.
This was not a battle over best patient care but a battle over money. We adopted the “closed unit” model but the major Meadowlands attending staff members punished Liberty by never referring patients to Jersey City Medical Center, the closest tertiary care hospital, again unless they were uninsured.
Parenthetically two MH urologists covered the Urology Clinic at JCMC. Patients with insurance were transferred to MH for surgery while those without insurance were treated medically at JCMC. When the urologists were fired MH/ JCMC animosity increased.

Vignette 7
Jersey City Medical Center had “free-standing” residency training programs in medicine, obs/gyn, and pediatrics. After JCMC became a teaching affiliate of the Mount Sinai School of Medicine the programs could be either be affiliated, sponsored, or integrated. “Affiliated” was a euphemism for “free-standing”, “sponsored” meant over sight by the Mount Sinai Dean for Graduate Medical Education, and “integrated” was the “gold standard” or one set of residents rotating between Mount Sinai, JCMC and other Mount Sinai affiliated hospitals.
Our chiefs wanted “affiliated” so no one would be looking over their shoulders but I mandated “sponsored” as a step toward “integrated.”

Vignette 8
In the early 1990’s Jersey City Medical Center was the only hospital in Hudson County to have a diagnostic cardiac catheterization lab. Interventional cardiac catheterization was highly regulated with on-site cardiac surgery back-up required, so there were no interventional labs in the County.

When I was a member of the State Health Planning Board, DOH staff were against a hospital in Trenton getting a CN for open heart surgery, and just assumed the Board would agree. Under-the-radar we garnered support for the application and to the amazement of the DOH staff, it was approved – setting the stage for JCMC in the future.

Then the New Jersey Department of Health issued a Certificate of Need “call’ for a demonstration project allowing a handful of community hospitals to have cath labs for primary angioplasty without cardiac back up, but each applicant had to have a transfer agreement for elective angioplasties. Nearby Bayonne Hospital put in an application including an agreement with JCMC for patient transfers, so we provided a letter of support and together we lobbied the DOH. We were trying to position JCMC as a referral center so we could apply for cardiac surgery, anticipating a “call” down the road. Bayonne got its cath lab and then immediately sign a new transfer agreement with a hospital in Newark.

Later the DOH essentially deregulated primary cath labs and in a period of about one year over 20 new cath labs opened across the State, including three in Hudson County, one being at Meadowlands Hospital. I was against the MH lab but the parent Liberty Board supported the MH Board. Most of the new labs closed within a few years, including all three in Hudson County.

In 1999 JCMC had the opportunity to apply for a CN to start a cardiac surgery program. Everyone on the senior staff was against it except for the CMO. The CFO may and end run to the Board, and the Board chairman told me it was my decision but my “job was on the line.”
We were in the process of building a total replacement hospital on a new site. It was impossible to become a Top Tier New Jersey Hospital without cardiac surgery/ interventional cardiology.
The payer mix at the old hospital was 70% Medicaid/ Charity Care/ self-pay.
We opened the cardiac surgery program at the new JCMC just two months before the CN expired.
Several factors helped the program and saved my job. The American College of Cardiology protocol channeled many insured patients to JCMC mostly those candidates for stenting within the one hour “golden” hour (only JCMC did stenting then). The cardiac surgery payer mix eventually becoming 75% insured, 25% Medicaid, uninsured.

Coda
“Cardiac department at Jersey City Medical Center reaches milestone with 503rd open-heart surgery, looks to future expansion.” Saturday, April 09, 2011 By RHEA MAHBUBANI, JOURNAL STAFF WRITER
“Although each surgery costs between $30,000 and $50,000, there has been a constant demand for both elective and emergency operations. On most days, the cardiac surgery team can expect one such four-to-five hour procedure, while some days bring none and others, two or three.
The first 500 operations were representative of the efforts being made to establish a high-quality program, which could serve as a backbone for the Hudson community, they said.
Having reached nearly 550 surgeries by late-March, the team is no longer focused on simply the basic, daily functioning of their department. “Now its time to start expanding,” “

Vignette 9
Three baseball umpires are at a continuing education program on Barbados, the subject “What’s a ball, and what’s a strike?” The rookie umpire says “There are balls, and there are strikes and I call them as they are.” The mid-career umpire says: “There are balls, and there are strikes and I call them as I see them.” The veteran umpire, about to retires, says” “There are balls, and there are strikes and they ain’t nothing ‘til I call them.” (source unknown)

Vignette 10
There are known knowns. These are things we know that we know. There are known unknowns. That is to say, there are things that we know we don’t know. But there are also unknown unknowns. There are things we don’t know we don’t know. (Donald Rumsfeld)

Vignette 11
“Don’t depend on anyone else to bring the coffee! There’s nothing worse than starting the day at a meeting where they don’t provide coffee. It’s better to have two cups than none.”
I started every new course with this “early morning meeting” aphorism. But students took this as something much more “strategic” and started using it in presentations, papers etc. as a metaphor.
What do you think they were thinking?

“I made a lot of mistakes in my time but didn’t waste any time making them.”
(attributed to Gustave Levy, Goldman Sachs)

“TRUST, BUT VERIFY.” (Ronald Reagan)

“If Columbus had an advisory committee he would probably still be at the dock.” (Arthur Goldberg)

“Never, never, never give up.” (Winston Churchill)

ASSIGNMENT: Profile the University of Maryland Medical System COI challenge.

DISCLOSURE. I am a member and Interim Chairman of the IRB* at Stevens Institute of Technology.

“There are many varieties of conflicts of interest, and they appear in different settings and across all disciplines. While conflicts of interest apply to a “wide range of behaviors and circumstances,” they all involve the use of a person’s authority for personal and/or financial gain. Conflicts of interest may involve individuals as well as institutions. Furthermore, individuals, in certain circumstances, may have conflicts occurring on both an individual and an institutional level, as may be seen among members of an Institutional Review Board (IRB).
Conflicts of interest are broadly divided into two categories: intangible, i.e., those involving academic activities and scholarship; and tangible, i.e., those involving financial relationships.” (A)

“In an article in the May 2014 issue of Compliance Today, Bill Sacks, Vice President and co-founder of HCCS, a HealthStream company, describes how new NIH regulations are forcing academic medical centers (AMCs) to examine and update their conflict-of-interest policies. He lists the 15 best practices for management of conflicts of interest that have been proposed by the Pew Charitable Trust and discusses how some of these recommendations are enjoying wide acceptance, as others are being met by serious objections. The Pew “Best Practice” recommendations are summarized below.
1. No gifts or meals should be accepted from industry sales representatives…
2. Faculty must disclose all conflicts of interest. All academic medical centers must have a process in place to manage conflict of interest (COI) disclosures.
3. Industry-funded speaking should not be allowed…
4. Industry-funding of continuing medical education (CME) should be severely limited or prohibited…
5. Faculty, students, and trainees should not attend industry-supported promotional or educational events…
6. Limit or prohibit pharmaceutical sales representative access in academic medical centers…
7. Limit medical device representative presence in academic medical centers to what is necessary…
8. Conflict-of-interest education should be required for all clinical staff and students
9. Conflict-of-interest policies should apply to everyone with a relationship to the academic medical center—paid, volunteering, affiliated, etc…
10. Industry-supported clinical fellowships should be available for scientific training only…
11. Ghostwriting and honorary authorship are strictly prohibited…
12. …Consulting arrangements must require written contracts with clear deliverables, to ensure that inappropriate payments are not involved…
13. Consulting relationships for marketing purposes are prohibited.
14. Pharmaceutical samples can be accepted and used only when they don’t become marketing tools.
15. Members of pharmacy and therapeutics committee cannot vote on formulary or treatment changes involving a company or product in which they have a financial interest… (B)

“Open Payments gives the public more information about the financial relationships between physicians and teaching hospitals and applicable manufacturers and GPOs. Specifically, the program:
Encourages transparency about these financial ties
Provides information on the nature and extent of the relationships
Helps to identify relationships that can both lead to the development of beneficial new technologies and wasteful healthcare spending
Helps to prevent inappropriate influence on research, education and clinical decision making. (C)

“Community Catalyst offers this Policy Guide to Academic Medical Centers and Medical Schools to assist leaders, faculty, staff and medical students in successfully adopting and improving policies to address conflicts of interest and interactions with the pharmaceutical and device industries. Policies such as these and their effective implementation are of critical importance to the integrity of medical education and patient care…
Toolkit on Transparency and Disclosure. Toolkit on Relations with Sales Representatives. Toolkit on Promotional Speaking. Toolkit on Continuing Medical Education. Toolkit on Ghostwriting and Name-Lending. Toolkit on Samples. Toolkit on Pharmaceutical and Therapeutics Committees. Toolkit on COI Policy Implementation. Conflict of Interest Curriculum Toolkit (D)

“Papers in medical journals go through rigorous peer review and meticulous data analysis.
Yet many of these articles are missing a key piece of information: the financial ties of the authors.
Nearly two-thirds of the 100 physicians who rake in the most money from 10 device manufacturers failed to disclose a conflict of interest in their academic writing in 2016, according to a study published Wednesday in JAMA Surgery.
The omission can have real-life impact for patients when their doctors rely on such research to make medical decisions, potentially without knowing the authors’ potential conflicts of interest…
They did this by sampling 10 large surgical and medical device manufacturers. This list includes Medtronic, Stryker Corp., Intuitive Surgical, Covidien, Edwards Lifesciences Corp., Ethicon, Olympus Corp., W.L. Gore & Associates, LifeCell Corp. and Baxter Healthcare.
The researchers also pinpointed the 10 physicians who received the highest compensation from each company. They then searched for articles published by these physicians between Jan. 1 and Dec. 31, 2016, and reviewed the full text of each article for COI disclosure.
According to their findings, those 10 companies paid more than $12 million in 2015 to the 100 doctors included in the study. The median payment to these physicians was $95,993.” (E)

“Memorial Sloan Kettering Cancer Center launched a conflict of interest task force in the wake of the resignation of its chief medical officer, Dr. José Baselga, who failed to disclose connections to medical industry…
The Manhattan-based cancer center said the task force will assess its internal policies and processes for reporting and managing outside activities and industry-supported clinical trials.
The task force was announced by President and Chief Executive Officer Dr. Craig Thompson. It will be chaired by Debra Berns, MSK’s Senior Vice President and Chief Risk Officer.
Among its objectives, the task force will: Review MSK’s policies, procedures, and training on conflicts of interest; Identify best practices in COI, including monetary and commitment limits; Assess new or improved processes to support timely and thorough disclosure; Identify medical societies and journals with whom to partner in improving public disclosure at meetings and in publications. (F)

“One of the world’s top breast cancer doctors failed to disclose millions of dollars in payments from drug and health care companies in recent years, omitting his financial ties from dozens of research articles in prestigious publications like The New England Journal of Medicine and the Lancet.
The researcher, Dr. José Baselga, a towering figure in the cancer world, is the chief medical officer at Memorial Sloan Kettering Cancer Center in New York. He has held board memberships or advisory roles with Roche and Bristol-Myers Squibb, among other corporations; has had a stake in start-ups testing cancer therapies; and played a key role in the development of breakthrough drugs that have revolutionized treatments for breast cancer.
According to an analysis by ProPublica and The New York Times, Baselga did not follow financial disclosure rules set by the American Association for Cancer Research when he was president of the group. He also left out payments he received from companies connected to cancer research in his articles published in the group’s journal, Cancer Discovery. At the same time, he has been one of the journal’s two editors in chief.
At a conference this year and before analysts in 2017, he put a positive spin on the results of two Roche-sponsored clinical trials that many others considered disappointments, without disclosing his relationship to the company. Since 2014, he has received more than $3 million from Roche in consulting fees and for his stake in a company it acquired.” (G)

“Dr. José Baselga, the chief medical officer of Memorial Sloan Kettering Cancer Center, resigned on Thursday amid reports that he had failed to disclose millions of dollars in payments from health care companies in dozens of research articles…
Thompson echoed comments he made to the hospital staff on Sunday, saying that the cancer center had “robust programs” in place to manage employees’ relationships to outside companies, but that “we will remain diligent.” He added, “There will be continued discussion and review of these matters in the coming weeks.” (H)

“An artificial intelligence start-up founded by three insiders at Memorial Sloan Kettering Cancer Center debuted with great fanfare in February, with $25 million in venture capital and the promise that it might one day transform how cancer is diagnosed.
The company, Paige.AI, is one in a burgeoning field of start-ups that are applying artificial intelligence to health care, yet it has an advantage over many competitors: The company has an exclusive deal to use the cancer center’s vast archive of 25 million patient tissue slides, along with decades of work by its world-renowned pathologists.
Memorial Sloan Kettering holds an equity stake in Paige.AI, as does a member of the cancer center’s executive board, the chairman of its pathology department and the head of one of its research laboratories. Three other board members are investors…
Hospital pathologists have strongly objected to the Paige.AI deal, saying it is unfair that the founders received equity stakes in a company that relies on the pathologists’ expertise and work amassed over 60 years. They also questioned the use of patients’ data — even if it is anonymous — without their knowledge in a profit-driven venture.” (I)

“…The AAMC is continuing to work with member institutions, other associations and societies, journals, and the continuing education community to develop tools and resources to help institutions and individuals manage the disclosure of conflicts of interest.
Institutions looking for immediate steps to take could:
Remind faculty of the importance of full disclosure, not only to your institution, but in other writing, speaking and teaching situations, as well as grant applications.
Use relevant current events as an opportunity to recommit to the institution’s obligation to facilitate transparency about the ways in which faculty and industry may be collaborating, and the processes that are in place to review and manage those relationships.
Encourage faculty to review the information posted about them publicly on the Open Payments website, and to ensure its accuracy as well as consistency with complete disclosures in all aspects of their professional responsibilities.” (J)

* “Under FDA regulations, an IRB is an appropriately constituted group that has been formally designated to review and monitor biomedical research involving human subjects. In accordance with FDA regulations, an IRB has the authority to approve, require modifications in (to secure approval), or disapprove research. This group review serves an important role in the protection of the rights and welfare of human research subjects.
The purpose of IRB review is to assure, both in advance and by periodic review, that appropriate steps are taken to protect the rights and welfare of humans participating as subjects in the research. To accomplish this purpose, IRBs use a group process to review research protocols and related materials (e.g., informed consent documents and investigator brochures) to ensure protection of the rights and welfare of human subjects of research.” (K)

(A) https://ori.hhs.gov/education/products/columbia_wbt/rcr_conflicts/foundation/#1_1
(B) 15 Conflict-of-Interest Best Practices for Academic Medical Centers, https://www.healthstream.com/resources/blog/blog/2014/06/04/15-conflict-of-interest-best-practices-for-academic-medical-centers
(C) Open Payments Data in Context, https://www.cms.gov/OpenPayments/About/Open-Payments-Data-in-Context.html
(D) Conflict of Interest Policy Guide for Medical Schools and Academic Medical Centers, https://www.communitycatalyst.org/initiatives-and-issues/issues/prescription-drugs/conflict-of-interest-policy-guide
(E) Financial Ties That Bind: Studies Often Fall Short On Conflict-Of-Interest Disclosures, by Rachel Bluth, https://khn.org/news/financial-ties-that-bind-studies-often-fall-short-on-conflict-of-interest-disclosures/
(F) Memorial Sloan Kettering launches conflict of interest task force after CMO’s resignation, by David Robinson, https://www.lohud.com/story/news/health/2018/09/21/memorial-sloan-kettering-conflict-interest-task-force/1381042002/
(G) Top Cancer Researcher Fails to Disclose Corporate Financial Ties in Major Research Journals, by Charles Ornstein and Katie Thomas, https://www.propublica.org/article/doctor-jose-baselga-cancer-researcher-corporate-financial-ties
(H) Top Official at Memorial Sloan Kettering Resigns After Failing to Disclose Industry Ties, by Charles Ornstein, and Katie Thomas, https://www.propublica.org/article/memorial-sloan-kettering-official-jose-baselga-resigns-after-failing-to-disclose-industry-ties
(I) Sloan Kettering’s Cozy Deal With Start-Up Ignites a New Uproar, by Charles Ornstein, and Katie Thomas, https://www.propublica.org/article/sloan-kettering-cozy-deal-with-start-up-paige-ai-ignites-new-uproar
(J) Conflicts of Interest and Transparency Initiatives, https://www.aamc.org/initiatives/research/coi/
(K) Institutional Review Boards Frequently Asked Questions – Information Sheet, https://www.fda.gov/RegulatoryInformation/Guidances/ucm126420.htm
(L) Facing Crisis, Sloan Kettering Tells Exec to Hand Over Profits From Biotech, by Katie Thomas and Charles Ornstein, https://www.propublica.org/article/facing-crisis-sloan-kettering-tells-exec-to-hand-over-profits-from-biotech(M)

Addendum
“A vice president of Memorial Sloan Kettering Cancer Center has to turn over to the hospital nearly $1.4 million of a windfall stake in a biotech company, in light of a series of for-profit deals and industry conflicts at the cancer center that has forced it to re-examine its corporate relationships…
The move to hand over his stake is one of several steps now underway as the cancer center tries to contain a crisis that has already led to the resignation of its chief medical officer and a review of its conflict-of-interest policies. Several board members and some executives of the nonprofit institution have maintained close ties to the health and drug industries at a time when stunning cancer breakthroughs are generating excitement among investors and spawning a flurry of biotech startups.
At other cancer centers and research institutions, employees are barred from accepting personal compensation when they represent their institution on corporate boards. But Memorial Sloan Kettering had no such prohibition until now.” (L)