Two recent deaths have renewed questions about whether or not the government can adequately care for minors in its custody.

A family of three from Honduras crosses the border wall on the beach in Tijuana, Mexico, before surrendering to Border Patrol on the other side on December 13th, 2018. (Photo: Jack Herrera)

The last time Juan de León Gutierrez, the 16-year-old Guatemalan migrant who died in government custody at the end of April, talked to his mother on the phone, he told her that he hoped God would send their family corn, salt, or beans. Climate change-fueled drought in the Guatemalan highlands had forced the teenager's family to eat just one meal a day, and, at the beginning of April, de León Gutierrez began the journey north alone. As the Washington Post reports, the boy called his mother from a smuggler's cell phone in Mexico just before he crossed the border into the United States on April 19th. During that conversation, de León Gutierrez told his mother he had a headache. Less than two weeks later, he was dead from a brain infection.

De León Gutierrez was the third Guatemalan child to die in U.S. custody since the beginning of December, a month in which a seven-year-old girl and eight-year-old boy both died while detained by Customs and Border Protection. (He was under the custody of a different federal agency: the Office of Refugee Resettlement, which is in charge of sheltering unaccompanied minors who arrive in the U.S.)

Then, on Wednesday, May 15th, the Washington Post reported that a fourth child had died after being in government custody. The two-year old, another Guatemalan, had been taken to the hospital after being apprehended by CBP, then formally "released" with his mother while there. He died in the Texas hospital on Tuesday night, several weeks after he was first apprehended.

These deaths have renewed questions about whether or not the government can adequately care for minors in its custody.

Can Authorities Recognize When a Child's Life Is in Danger?

When Jakelin Amei Rosmery Caal Maquin, a seven-year-old Guatemalan girl, was taken into Border Patrol custody with her father in December, none of the agents on the scene noticed any indications that she was unwell. Her father, who did not speak English, signed an English-language form saying she had no current health issues.

It was only after the two were put on a bus to another detention facility that Caal Maquin began vomiting. By the time the bus reached its destination, the girl had stopped breathing. Border Patrol agents resuscitated her and called emergency medical technicians, who—less than eight hours after she was initially apprehended—measured the girl's temperature at 105.7 degrees. Caal Maquin was airlifted to a hospital in El Paso, Texas, where she died less than 24 hours later.

According to Dr. Colleen Kraft, who was the president of the American Academy of Pediatrics at the time of Caal Maquin's death, the critical period in the girl's medical care came long before she entered the hospital, and even before she began vomiting: Medical care needed to begin at the moment Caal Maquin was apprehended.

One of the primary challenges facing CBP and other agencies, according to Kraft, is one of triage: recognizing when a child needs immediate medical attention. It's important to recognize the difference between sick adults and sick kids, Kraft said in an interview with Pacific Standard in January: "When adults get sick, we slow down, we're less active, we rest—but children are so different. A lot of kids will just keep on going."

Kraft explained that young children in the early stages of a life-threatening medical emergency might continue to "play and run around." A child might not mention that she's experiencing any symptoms (consider whether a first-grader would notice that her own heart rate or breathing is getting dangerously fast, and tell an adult). "If you don't know what the differences are between a mildly ill child and an evolving, severely ill child, you're going to miss it," Kraft said.

Kraft explained that the AAP had a list of recommendations for CBP, which included a "developmentally appropriate pediatric health screening"—in other words, the group recommended that each child taken into custody be given a competent pediatric screening to ensure they weren't experiencing any dangerous symptoms. Kraft also said the AAP "recommend[s] training for non-medical or non-pediatric providers on basic standards of care for children."

"Kids are robust: They hang on to the last minute. And then ... they just fall off a cliff. They can look pretty OK, and then suddenly they're not," says Katherine Peeler, a pediatrician who works with the human rights watchdog group Physicians for Human Rights. "So you need to have clinical expertise and experience to be able to recognize when someone is in impending danger. But there's no way that a CBP agent, who has not had that training, is going to be able to do that—and not really through any fault of their own. It's just not actually part of their job right now."

Is the Government Changing Its Practices Fast Enough?

After the second child died in CBP custody in late December, then-commissioner of CBP Kevin McAleenan called Kraft (in her capacity as president of the AAP) to talk about what could be done. Kraft said in January that she was glad to get on the phone with the commissioner—even though, in the last year, the AAP (and Kraft herself) had consistently warned the government that any form of detention was not safe for children.

At the end of January, CBP released a new plan to ensure the medical well-being of people in its custody. The plan, called the Interim Medical Directive, is meant to "enhance [CBP]'s protection of individuals in its custody, with a special emphasis on juvenile (under the age of 18) aliens," according the document, which has been released to the public.

The new plan has a clear emphasis on triage and medical screening: Under the directive, Border Patrol officers "will conduct a health interview and medical assessment for all aliens in [Border Patrol] custody under the age of 18."

Peeler says medical screenings and health interviews are a good and necessary step, but calls such practices "basic": "Taking someone's vital signs, maybe doing a little bit more of an exam: If that's 'enhanced,' I can't imagine what we were possibly doing before, because you can't do any less than that."

The plan calls for CBP's own medical professionals or other licensed health-care providers to perform the assessments, with CBP emergency medical technicians only performing the screenings under "exigent circumstances." After the assessment, if either the supervising Border Patrol agent on scene or health-care professional determines a person needs medical attention, that person will be referred to the necessary level of care.

How Can We Evaluate the Government's Care for Children in Its Custody?

Kraft and Peeler both emphasize that, even with the highest level of training and care, detention facilities are never safe places for children. In 2017, the AAP—the most reputable association of pediatricians in the country—released a policy statement recommending that no child be placed in detention, warning that "even short periods of detention can cause psychological trauma and long-term mental health risks."

In past years, very few children have died in government custody. Before Caal Maquin's death, it had been over a decade since someone under 18 died in CBP custody. Doctors warn, however, that "not dead" is a low bar for evaluating how the government is caring for children in its custody.

Altaf Saadi, a neurologist at the University of California–Los Angeles who has performed evaluations of detained immigrants with Physicians for Human Rights, says that children and other detainees are constantly facing medical harm in detention. "So many individuals are negatively impacted by the conditions of detention on a daily basis," Saadi says. "But they are not captured in media stories or these headlines."

In an op-ed for the Los Angeles Times in February, Saadi wrote about some of the ways she's seen detainees suffer, including being denied access to their medications or timely medical care. She noted that some of the government's own internal reports have found that some immigration detention facilities failed to provide adequate health care.

"It's not just mortality, but morbidity," Saadi says. "Even in a hospital or clinic, we have a lot of other metrics with which we judge the quality of our system other than whether a patient dies. There are so many other things that can harm a patient, and we take those seriously, and we act on them."