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A Piece of My Mind
January 14, 2020

Doctoring and Deportation

Author Affiliations
  • 1Department of Medicine, Massachusetts General Hospital, Boston
JAMA. 2020;323(2):119-120. doi:10.1001/jama.2019.21005

Her cancer was gone. Her visa was approved. Her nephew was born just days before. So, quietly humming songs of praise, Marie flew for the first time from Haiti to Boston to help care for the baby.

A few years back, when Marie was in her early 30s, the breast cancer diagnosis tore her life to pieces. Her husband abandoned her along with their 2 children soon after she told him about the diagnosis. She was placed on leave from her job because she was too ill to work. Without treatment options in Haiti, she traveled to Cuba for surgery, radiation, and chemotherapy. Eventually she returned to Haiti, believing the cancer was gone for good.

Marie returned to work and by the time she turned 39, cancer seemed firmly behind her. Then, with her first steps off the plane in Boston, a deep pain took hold within her right hip. Her joyous humming stopped. When the pain became unbearable, she presented to our hospital where a scan showed metastatic disease invading the bones of her pelvis. That was when her name initially flashed across my inbox: “Resident Primary Care Needed for Very Polite Young Woman from Haiti with Breast Cancer.” Having spent time in Haiti and being fluent in Haitian Creole, I offered to take her on my primary care panel.

Reviewing her chart as I prepared for our first visit, I imagined my role managing her pain, helping her to cope with an incurable cancer, and coordinating with her oncologist. Indeed, this was the focus of our first 2 encounters. But on our third visit, I could see immediately that something had shaken Marie’s whole body. She crumpled over in tears the moment I said hello. After delicately wiping each eye, she told me her visa had expired. She was late to renew it. She was without documents and faced the threat of deportation.

Deportation to Haiti would mean stopping her treatment, likely an accelerated death and minimal if any palliation. With her typical extreme politeness and reserve, Marie asked me not to abandon her to die in pain. Yet when she asked me for help, I froze.

As physicians, we see our fair share of death. We learn to discuss the things we cannot change. But now the more immediate threat to her life was a behemoth system of our society’s own making. Overcome by a sense of powerlessness, I referred her to our clinic’s medical-legal partnership only to learn that everything rested on our being able to provide a reason for why she missed the deadline. Could I write a letter to explain the delay and justify extending her visa? It was going to be a challenge, I was told, because local immigration officers had been instructed to stop granting extensions.

I opened a Word document and stared at the white page. In its blankness, I saw guilt and regret. I saw all the immigrant rights petitions I had not signed, all the social justice interest group meetings I had not attended, all the news about immigration policy I had not followed, in part, because I was consumed with the task of becoming a doctor, supposedly to care for patients like Marie. I was paralyzed by what I thought I should say and by what policies I thought I should know in order to do this well. I left the document blank until near midnight the night before the deadline. Knowing I had to get up by 5 am to prepare for rounds in the intensive care unit, I saw myself struggling to escape from a kind of mental cage, the confines of which were defined by a narrow conception of my expertise as a physician. My training did not include prevention of death by deportation.

Finally, feeling the pressure of the early morning hours, I produced these words as a first attempt to bend the bars of that cage:

Since Marie became my patient in the summer of 2018, I have come to know her well. I understand that in the fall and winter of 2018, Marie was required to apply for an extension of her visa. Unfortunately, her medical situation made it impossible to do this in a timely fashion for the following reasons….[Importantly, among other factors] I believe the existential terror of a terminal cancer diagnosis at the age of 39 made it difficult for Marie to prioritize the visa extension process. Simply put, she could not think about the months left on her visa when she did not know how many months she had left to live.

There was more to the letter, of course, but these lines were the ones that freed me to write honestly. They sprang from the reality that I knew as her physician, not from furious attempts to Google immigration law. They came from my own angry internal questioning of how she could possibly miss the deadline. And from my own internal response that a patient like Marie, so precise that she always knows exactly how many pills remain in each bottle, did not miss a deadline for any reason other than an all-consuming crisis. The words did not come from the kind of technical expertise that I strive for when presenting a patient’s case to a senior attending but rather from the place of a physician-in-training embroiled in fear and uncertainty with a young and seriously ill patient.

It has been several months since that first letter and Marie still comes to see me. Since then, she has had 2 near brushes with deportation and our focus has shifted into a fight for Medical Deferred Action, once a standard option that is now under threat.

While I continue to collaborate closely with Marie’s lawyers and write letters on her behalf, uncertainty still plagues us. Just as every new ache or pain could be a sign of terminal disease out of control, every letter from immigration officials could mean potential deportation.

But at our last visit, Marie greeted me with uncharacteristic enthusiasm. She said she wanted her story to be told to help others, to give others hope. At first, I felt the same doubt and powerlessness for her that I had felt for myself when faced with writing the initial letter. I nearly dismissed the idea. But then I paused.

Marie was still here. Her cancer remained at bay, and her symptoms were controlled. In fact, despite challenges, Medical Deferred Action still remained a possibility.

Perhaps we are not quite so powerless when armed with the realization that meaningful advocacy can grow from the human connection at the core of our profession. Perhaps, on a larger scale, that human core of the patient-physician relationship still has some power to sway how our nation cares for those sick and tempest-tossed and yearning to breathe free.

At the end of Marie’s last visit, I said we would find a way to share her story. I think, just maybe, I heard her humming as she walked out the door.

Section Editor: Preeti Malani, MD, MSJ, Associate Editor.
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Article Information

Corresponding Author: Samuel D. Slavin, MD, Department of Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114 (sslavin@partners.org).

Conflict of Interest Disclosures: None reported.

Additional Contributions: I thank Marie for granting permission to publish her story and Jessica Zeidman, MD, my clinic preceptor at Massachusetts General Hospital, Chelsea HealthCare Center, for her invaluable collaboration in caring for Marie.

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