Transcripts For CSPAN House Hearing On Children In CBP Custody 20240712

Chairman thompson the committee is meeting today to receive testimony on children in cbp custody, examining death, medical care procedures and improper spending. Without objection, the chair is authorized to declare the committee in recess at any point. The committee is convening today to examine three critical, related, and deeply troubling issues. The terrible deaths of Young Children in the custody of customs and Border Protection, cbps failure to consistently implement the revised medical screening procedures it adopted after children died in its custody, and cbps improper expenditure of emergency funding appropriated by congress for the care of migrants. In december 2018, two children died in cbp custody. A sevenyearold girl named jakelin and an 8yearold boy named felipe. Last year, another three children died in cbp custody or shortly after being released. On january 4, 2019, i sent a letter to the department of Homeland Security requesting documents related to the deaths in 2018. After the department failed to produce all documents responsive to the committees request, in november 2019, the committee issued a narrowly tailored subpoena by voice vote for many of the documents originally requested in my letter ten months prior. In december 2019, the dhs Inspector Generals Office publicly issued two onepage summaries of its investigations into the deaths that had occurred a year earlier. Unfortunately, the Inspector Generals investigations left us with more questions than answers. Earlier this year, i sent a letter to Inspector General cuffari detailing the concerns we identified with the reports. My entire letter is available on the committees website. Among the concerns i raised were the following the Inspector Generals reports and public summaries proclaim that there was no malfeasance or misconduct by dhs personnel. It is unclear why that standard was used because there do not appear to have been any allegations of malfeasance or misconduct on the part of agents. In fact, all Available Evidence indicates that Border Patrol agents showed great compassion for both children. However, the Inspector Generals reports appear to presume that since its investigations found no malfeasance or misconduct, thats the end of the story. The reports fail to examine the many troubling questions that these deaths raise regarding cbps ability to care for children in custody, including questions about the adequacy of the agencys policies, procedures, and training. Further, while the Inspector Generals Office certainly conducted many interviews, it appears that key documents and evidence were not collected and reviewed. My letter also identified omissions in the public summary of one of the Inspector Generals reports that were so severe as to render the summary inaccurate and potentially misleading. The Inspector General revised the public summary after receiving my letter. Over the past 6 months, dhs has produced some documents in response to the committees subpoena, but these productions are clearly incomplete. For example, the Inspector Generals reports reference documents that have never been provided to the committee. Dhs has also made extensive and improper redactions in the documents it has produced. Through its refusal to comply fully with the committees subpoena and through its many redactions, the department is intentionally impeding the committees investigation. Despite these hurdles, the committee has worked to advance our investigation. To help with that effort, we asked a pediatrician and a medical examiner to conduct independent examinations of the two deaths that occurred in december 2018. We will receive their testimony today. Today, the Government Accountability office is also releasing a report we requested. It examines both cbps use of emergency funding appropriated to care for migrants as well as its implementation of the new medical screening procedures it announced after the deaths in 2018. Gaos report finds that after cbp claimed it urgently needed emergency funding to provide care for migrants taken into custody, the agency misspent money it received. The Border Patrol agents who cared for felipe while he was in custody had to pay for medicine for him out of their own pockets. But cbp used some of the emergency funding that congress appropriated for the specific purpose of paying for medical care to instead buy jet skis and dirt bikes and even dog food. There is something seriously wrong with this picture, just as there is something seriously wrong with this administrations approach to caring for migrants, including children. I note that gaos report also finds that although cbp adopted new policies governing medical assessments for children following the tragic deaths of the two children in late 2018, cbp did not consistently implement these policies. We welcome dr. Fiona danaher and dr. Roger mitchell before the committee, as well as rebecca gambler from gao. And i am glad that after initially refusing to do so, the Inspector General has agreed to testify before the committee, so that we can explore the many questions we have regarding the work of the Inspector Generals Office. We also invited cbps acting director, mark morgan, to testify. In a letter to the committee, he stated that because of the white houses baseless rules prohibiting administration witnesses from attending virtual hearings, he could not appear. As i close, let me say i fully recognize the sensitivities of the issues we are discussing. I encourage all members to be very careful and thoughtful in how we approach this subject. That said, it is clear that this administration will do everything it can to avoid oversight. Therefore, we must continue to do everything we can to hold this administration accountable. Given the 18 months of obstruction we have endured as we have sought documents and information about the deaths of children in custody, as well as issues like the administrations child separation policy, i see no other way to advance our investigation and to identify changes needed in cbps policies and procedures than to convene todays hearing. Before i recognize the Ranking Member, i will read statements from the fathers of the two children who died in cbp custody in 2018. Mr. Cruz, the father of jakelin, provided the following statement. Id like to say what i have always believed. It is better to check on all children when they are sick and even when they are not sick. Speak up and Say Something even when you are afraid. The most important thing is to check on the children so the thing that happened to my daughter does not happen to anyone ever again. I offer my thanks to the committee for taking the time to look into my daughters case and i am very grateful to you all. The father of felipe stated, i want justice. I want to know why my son did not receive medical care in time. I do not want other children to go through the same thing. This is painful for me today and it will be painful for the rest of my life. Every night i ask myself why my son did not receive medical attention in time. Felipes treatment was inhumane. I ask unanimous consent to submit their letter to the record. The chair recognizes the Ranking Member of the full committee, the gentleman from alabama for an opening statement. Mr. Rogers thank you mr. Chairman, can you hear me . Chairman thompson yes. Mr. Rogers i appreciate you holding this hearing and granting our request. I am saddened by the loss of felipe and jakelin. They died in the custody of cbp or shortly after entering custody which is unacceptable. The department has taken steps to improve migrant care but it is up to congress to address the root cause of the problem. That can only happen in a bipartisan manner. We must fix immigration loopholes and we must provide adequate resources to both cdp and ice. We must not encourage illegal immigration. We must disrupt the cartels and human smuggling partners and i hope we never have to hear of another tragedy at the borders like what happened with these three minors. Mr. Chairman, i am disappointed at the events leading up to this hearing. The acting commissioner should be here so the committee can directly hear from him. It is important we understand what happened and what cbp has done since the deaths. The majority did invite the acting commissioner. Omb has provided guidance to officials forbidding them to participate in remote hearings. They are permitted to appear in person. The acting commissioner did before the senate committee. I asked unanimous consent to insert into that record commissioner morgans response to the invitation. In that letter, morgan request to appear before the committee with omb guidance. If we want productive hearings, i would suggest to the majority that we find time to hear from him in the next two weeks when we are in d. C getting to the bottom of those two deaths is something that this committee has worked together on. We voted unanimously to subpeona the department on information related to the deaths of felipe and jakelin. It appears the majority received information from the university of Mexico Office of medical investigations. It appears the majority did not share this information with witnesses here today and who knows who else but were informing the minority of its existence. One witness claims to have received the information on june 30. The minority got it on july 12. It is disappointing to partner with you on things like this less than a week before the hearing. I am alarmed by the autopsy information the majority requested. I do not see any reason why this committee or any committee of congress would need human tissue samples from a deceased eightyearold boy. Im concerned the majority has been requesting and sharing with witnesses these autopsy specimens to place blame on the men and women of Border Patrol. If that is true, it is deplorable. The ig found no misconduct or nonfeasance in any of the actions of dhs or its employees surrounding these deaths. I understand that answer does not provide political satisfaction, but those are the facts. If the majority requested and shared human tissue samples of a deceased child to advance a political narrative, it would mark an appalling new low for this committee, i hope this is not the case. We have to remember that for Months Congress refused to address the border crisis that precipitated these deaths. Record numbers of families and children crossed our borders last year. Groups of hundreds to thousands of migrants came across at once. Migrants traveled over 2000 miles at the whims of the cartels and human smugglers to get to our border. Many told of abuse, assault and worse of the journey to our border. Food, nutrition, access to medicine was not adequate if at all provided. As a result many arrived in , extremely poor health. At the height of the crisis, Border Patrol spent over half their time transporting migrants to hospitals. For months last year the majority refused to acknowledge the problem, going as far as to call it a manufactured crisis. Even after the children died, the majority insisted there was no crisis. At one point the majority response to the border crisis was to send 316 tweets, 11 press releases, and hearings. None of which solved anything. After denying it, majority admitted there was a crisis, a supplemental approach bill was brought forward to the house. That bill had so many poison pills attached the senate had to strip them out before it could head to the border. That bill was at best a stopgap measure. The committee concluded that until Congress Takes action to address the root cause of the crisis, it is only a matter of time before another occurs. I hope we can get off of the political messaging game and work to fix this immigration loophole that encourages parents to send their children on a dangerous and deadly trek to our border. Thank you, mr. Chairman. I yield back. Chairman thompson thank you very much. Other members of the committee are reminded that Opening Statements may be submitted for the record. Members are reminded that the committee will operate according to the guidelines laid out by myself and the Ranking Member in our july 8 colloquy. I now welcome our witnesses. Our first witness is dr. Fiona danaher, a pediatrician at massachusetts general hospital, Chelsea Healthcare Center and a member of the Child Protection team. She is also an instructor in pediatrics at harvard medical school. She is a graduate of Mount Sinai School of medicine. Our second witness is dr. Roger mitchell junior, a chief medical examiner for washington d. C. Dr. Mitchell junior is boardcertified in forensic pathology by the american board of pathology and a fellow in the National Association of medical examiners. He began the study of Forensic Science as a forensic biologist at the federal bureau of investigation in 1997. Dr. Mitchell is a graduate of the new Jersey Medical school. Our third witness is the honorable joseph cuffari. He was confirmed as the Inspector General of the department of Homeland Security in 2019. He previously served as the policy advisor for military and veteran affairs for the governors of arizona. He also served more than 40 years in the u. S. Air force. He earned a phd in management in 2002. Our final witness is ms. Rebecca gambler, a director in the Government Accountability office Homeland Security injustice team. She joined in 2002 and currently leads the agencys work on border security, immigration and election issues. Without objection, the full statement will be inserted in the record. I asked each witness to summarize his or her statement for five minutes beginning with dr. Danaher. Dr. Danaher good morning. Chairman thompson and members of the committee, thank you for the opportunity to testify today. I am dr. Fiona danaher, a pediatrician at massachusetts general hospital. Much of my work focuses on children. It is a privilege to participate in this committees efforts. As you know in 2018 [indiscernible] jakelin at age seven died from septic shock because it went untreated over many hours cascaded into multiple organ failure. Felipe, age eight, died from untreated influenza complicate it by preliminary hemorrhage in the context of bacterial pneumonia and sepsis. Their deaths as well as those of four other children in government custody between september 2018 and may 2019 underscore the deficiencies in an immigration system poorly designed to protect vulnerable children. The available records make clear that they both suffered terrifying and painful deaths that could have been prevented by access to pediatric medical care. In both cases medical examiners determined the children died of Natural Causes and it was concluded that there was no misconduct by dhs personnel. Death by Natural Causes does not mean death was inevitable. Lack of misconduct or even the efforts went to in assisting the children does not absolve cbp as an agency of perpetuating the systems that place children at risk of medical neglect. Cbp responded to the deaths by issuing an enhanced medical directive in 2019 to ensure that all children under 18 would be interviewed while in custody. The final enhanced support effort issued by cbp in december 2019 removed the safeguards instituted under the guidance, weakening it so much that it is unlikely its provisions would have prevented their death. Children are not adults. Their physiological resilience can mask severe disease from those untrained to recognize it. Any period of detention is inherently unhealthy for longterm physical and emotional development. Substandard conditions put childrens lives at risk. If children are to be detained, it is incumbent upon the agency that it strengthen medical infrastructure. Their deaths illustrate the need for cbp to eliminate bureaucratic hurdles that unnecessarily prolong detention and delay access to medical care. They highlight the urgency of addressing dentention conditions that promote distress. Children in detention need timely access to comprehensive medical treatment in their native language conducted by clinicians and pediatric experts followed by referral. Those diagnosed with illness or underlying medical conditions [indiscernible] which are fundamentally unequipped to provide obligations or cooperation. All Foreign Operating bases should be stocked with basic medical equipment and their staff trained in its use. They must implement the recommendations for the prevention of influenza and covid19 in the facilities. Independent oversight of the quality medical care needs to occur regularly. The oig indicated in its report that it does not possess the medical expertise. Given the current epidemic, time is of the essence. Action must be taken so that other children do not meet the painful and preventable fate while in custody of the United States government. Thank you and i look forward to taking your questions. Chairman thompson thank you for your testimony. I recognize dr. Mitchell to summarize his statement for five minutes. Dr. Mitchell good afternoon, chairman thompson and Ranking Member rogers and members of the committee of Homeland Security. I am dr. Roger mitchell junior and i currently serve as the chief medical examiner of washington, d. C. It brings me no pleasure to testify today on these deaths, but i appreciate the confidence of the committee in asking me to do so. I have been asked to review the cases of jakelin and felipe from the medical examiners perspectives specifically postmortem findings, the autopsy report and manner of death. I have been studying deaths in custody for over 20 years and when you think about deaths in custody, we are reminded of deaths like george floyd and rayshard brooks. Deaths in custody occur under a continuum that moves through phases like arrest related, prearrest related and in this case incarceration which is shortterm and longterm jail detention. In addition i served as the chair of child and infant Fatality Review Committee from 2014 to 2019. This committee has been tasked to review infant and child deaths for the purpose of creating system centered recommendations intended to improve outcomes. This is the lens in which i review the following cases. We know that jakelin was a 7yearold female child who was apprehended with her father on the u. S. Border and was found to have a temperature of 105 and airlifted to a hospital where she was pronounced dead over 24 hours later. Jakelin suffered from septic complications of a bacterial infection. The initial autopsy findings are consistent with bacterial sepsis. It is important to note that sepsis can shock rapidly. Early recognition and treatment are critical. Based on the materials i had to review, it is my opinion that the cause and manner of death established by those medical examiners is proficient. The actions taken by individual agents seemed to be appropriate, the larger Border Patrol system lacks adequate Human Resources and physical infrastructure to respond to medically fragile detainees especially children. Had the administration of the initial Health Assessment questionnaire had been performed by a licensed medical professional, the elevated body temperature would have been detected and maybe would have saved the life. In the case of felipe who was an eightyearold male child who was apprehended with his father at the border. They were detained at three different Border Patrol stations before he was known to be sick and was found with a temperature of 103. He was transported to a local hospital and diagnosed with an upper respiratory infection, prescribed medication and released but then had to come back because of a worsening condition and was pronounced shortly after. Felipe suffered complications of a flu viral infection associated with a bacterial disease. This bacteria isolated and was associated with an exotoxin and a highly contagious bacteria that is particularly contagious in close quarters. This exotoxin leads to severe pneumonia. Based on the review of the materials available, there should have been highlighting of this pneumonia in the diagnosis, but nonetheless a bacterial infection that led to the death of this young child. The manner of death is natural. It is my opinion that this death also was preventable. Overcrowding is a known condition Border Patrol stations. I believe those conditions may have played a significant role in the infection that led to felipes death. There are many missed opportunities to provide lifesaving care to this child. Mainly, the hospitals mismanagement of its initial presentation. However, again if there was a , licensed medical professional who would have cared for this patient while at the Border Patrol station, then there may have been a more informed assessment prior to his initial presentation at the hospital and may have led to better outcomes. What are my recommendations . Enforcing control of the population of the u. S. Border patrol stations to protect against overcrowding, utilize medical personnel for the initial Health Assessment of detainees, especially children, accompanied this initial assessment with a brief Health Screening assessment like temperature checks and blood pressure, glucose finger sticks and even a covid nasal swab and develop an onsite clinical system for u. S. Border patrol that has the ability to triage pediatric patients. Maybe even an Electronic Health record as these patients move from Border Patrol station to Border Patrol station and then retraining of our agents. In conclusion, immediate and timely access to healthcare assessment by a licensed Trained Medical professional could have prevented the deaths. The deaths of both of these children are symptoms of a more extensive system that requires improvement. No system is perfect, but any system that is established by our government must have at its core the health and safety of all who come into contact with it. The cases of these children must remind us that deaths are not a criminal justice issue, a Public Health one. We must provide timely care not only in the Detention Centers of our borders but also the streets of our cities, the jails of our counties and the prisons of our states. I appreciate the work the committee is doing to solve this problem. I pray this hearing does not only provide an appearance of addressing the issue that i have outlined, but a true call to action with resolutions. This will require dedication to this nation beyond what is comfortable, what i believe it is attainable. Thank you, chairman thompson and members of the committee. I am available for any questions you may have. Chairman thompson thank you for your testimony. I now recognize Inspector General cuffari to summarize his statement. Mr. Cuffari good afternoon, chairman thompson and Ranking Members. Thank you for inviting me to discuss our work leading to children in custody. My testimony will include a discussion of our investigations of the deaths of the two Migrant Children in cbp custody. The findings of our inspections of cbp facilities and a new review of datadriven audit, inspections and investigations. No parent should have to go through the devastation of losing a child and my condolences go to the families who suffered this terrible loss. I am a parent and a new grandparent myself and i find the deaths of both children heartbreaking. Although they died within 18 days of each other, each circumstance was unique and our Office Conducted separate investigations. The scope of both investigations was determining the circumstances of the deaths of the children including any form of misconduct by cbp personnel. We have dedicated several special agents to each investigation along with multiple support staff. In total, we conducted 44 interviews between the two investigations, reviewed medical records and reports. Neither investigation found misconduct on the part of cbp personnel. Both investigations determined that cbp employees involved exhibited great concern for the childrens welfare and obtained medical treatment without delay. During fiscal year 19 cbp experienced a surge in families and unaccompanied children crossing the southwest border and apprehended more than twice the undocumented aliens during fy 19 than in any of the previous four fiscal years. Our office has conducted unannounced inspections of cbp facilities to evaluate their compliance with cbps transport, escort, detention and search standards. During visits we focus our elements of these standards that can be observed and evaluated by our inspectors without specialized Law Enforcement or medical training. We recently issued a report summarizing our 2019 unannounced inspections. Our inspections found medical coverage varied by facility. The facilities we did visit generally met the standards for access to medical care. Nevertheless, crowded conditions presented Health Challenges including containing the spread of contagious diseases. Given these observations, we have initiated an audit on the cbp policies and procedures for handling medical intervention and detention. With the surge in 2019, we observed more overcrowding and have recommended that dhs take immediate steps to alleviate it. Our report submitted that recommendations and made other recommendations related to telephone access to unaccompanied children and proper handling of detainee property. Dhs will implement the recommendations by the end of the calendar year. Given our observation of detainees being held beyond the 72 hours generally permitted, we also initiated an review that is ongoing to identify key factors contributing to prolonged detention. We have more than 20 other projects reviewing ice and cbp. We appreciate continued interest in our work and for congresss robust funding this current fiscal year. With your increased funding, we are contracting medical professionals to supplement our expertise across audits, inspections and investigations. I am pleased to report this contract will be awarded in the next few weeks. In october 2019, i personally observed the conditions of the southwest border when i visited dhs facilities and operations in el paso and tucson. Our office continues to monitor the situation at the border and recommend improvements to dhs programs and operations. Mr. Chairman, this concludes my testimony. Thank you for the opportunity to discuss today and i am happy for any questions that you may have. Thank you. Chairman thompson thank you very much for your testimony. I now recognize our next witness for five minutes. Good afternoon, chairman thompson, Ranking Member rogers and members of the committee. I appreciate the opportunity to participate in this hearing to provide medical care to those in custody along the southwest border. My remarks are based on a report released today and a legal decision issued last month addressing issues related to cbps use of funds and efforts to provide medical care. I will be covering three areas from the report and legal decision. First, cbps funds for medical care under the fiscal year 2019 emergency supplemental appropriations. Second, cbps efforts to enhance medical care, and cbps reporting of deaths. The 2019 emergency supplemental appropriations act was enacted to provide for humanitarian assistance and security at the southwest border. The act required that cbp use certain funds for specific purposes. One of the items in the act was medical care. We found that cbp obligated some funds for consumable and medical care goods and Services Like hygiene products, masks, and gloves. Cbp obligated some funds for other purposes like Business Services for canine programs, equipment facility operations like printers and speakers and facility upgrades and services. We found that these obligations violated an appropriation law because cbp obligated funds from the medical care line items for goods and services that were not consistent with the purpose of that appropriation. We concluded that cbp should adjust its accounts accordingly. We identified two factors that contributed to cbps violation. Insufficient guidance to offices and components before obligations were made and a lack of oversight. We recommended that cbp develop and implement Additional Guidance and establish oversight rules and responsibilities to ensure supplemental funds are obligated consistent with their purposes. Cbp concurred with these recommendations. Second, cbp has taken steps to enhance medical care for individuals in its custody. These include increasing use of contracted medical care providers, issuing new Health Screening policies and requesting the cdc assess conditions and make recommendations for the reduction of influenza in cbp facilities. As a more specific example, in 2019 cbp issued medical care directives which required Health Interviews and medical assessments for certain groups. In march 2020 cbp issued plans for these directives. We found that cbp has not consistently implemented its enhanced medical policies and procedures. We found that some locations were not consistently conducting Health Interviews and medical assessments as required by the medical directive. Cbp also has not documented how it made its decision not to offer influenza vaccines to those in its custody as recommended by the cdc. We recommended that cbp develop oversight mechanisms and document what information it is using to assess whether to offer the influenza vaccine to individuals in custody. Cbp concurred with these recommendations. Finally cbp is supposed to report information on deaths of individuals in custody to congress. We reviewed documents and reports from fiscal years 2014 through 2019 and found that 31 individuals died in custody along the southwest border during that period. However cbp only documented 20 deaths in its congressional report. We recommended that cbp ensure reliable information on deaths in custody is reported to congress and appropriate documentation is maintained. Cbp concurred with this recommendation. While cbp has taken steps to enhance medical care efforts, our work has identified a number of areas requiring additional attention to ensure that cbp is appropriately using supplemental funds it was receiving, overseeing medical effort and reporting information on deaths in custody to congress. Going forward, we will be monitoring cbps actions. This concludes my prepared statement and i am pleased to answer any questions. Chairman thompson thank you for your testimony. I thank all of the witnesses for their testimony. I will remind each member that he or she will have five minutes to question the panel. I will now recognize myself for questions. To mr. Cuffari, we sent a letter to you asking for a number of things and you sent it back and we reviewed it. After we sent our response back, you revised the public summary. Why didnt the original public summary include reference to influenza as a cause of death . Mr. Cuffari in the interest of privacy initially, we concluded intervention on our website regarding the deaths of the two children. Subsequently at your request, we made an adjustment to the public summary to include the diagnosis of influenza b and to indicate that our investigation did not reveal Border Patrol were aware of that diagnosis. This is the very first time that we have done public summaries in this fashion and we wanted to make sure that we got it right the first time and we thought it was appropriate to err on the side of privacy for the children. Out of deference to you, we have made those minor corrections. Chairman thompson thank you. Have you noted on your website or the summary itself that the summary has been revised . Mr. Cuffari yes, sir. We did that the same day we made the updates. Chairman thompson thank you very much. With respect to your review of the initial death, did you have qualified medical professionals on your review team . Mr. Cuffari no, sir. Just to clarify, those reviews were actually investigations conducted by our office of investigation of the two deaths of the children in custody. We did not have at the time any medical professionals available and as i indicated in my opening statement, based on the enhanced funding that you provided this past fiscal year, we are contracting out to have a team of professionals augment any of our ongoing or projected work in the future on its inspections and investigations. Chairman thompson so at the time, based on what you said, at the time of your review of the death, you did not have on staff or contracted any medical personnel . Mr. Cuffari no, sir. Chairman thompson dr. Mitchell, you have heard my question. In your professional opinion, if you are looking at a death of any kind that a medical personnel would be important to the team . Dr. Mitchell absolutely. Especially deaths in custody. They require fatality reviews. Most fatality review panels need to be multidisciplinary. There for you will get the recommendations. So it will depend on what you are trying to get out of the investigation. From a fatality review construct, you need to not only have clinicians like pediatricians if it is a child death, in turn if it is an adult death, but also a forensic pathologist so they can interpret the finding of the autopsy. All of that will be required in the future. Chairman thompson thank you. Mr. Cuffari, according to your report, Border Patrol agent stated they were in contact via text message with felipe when he was transported to the hospital. The morning of december 24. Do you have copies of any of those Text Messages in your file . Mr. Cuffari to my knowledge, no we do not. Chairman thompson so you put in a report information that you could not document . Mr. Cuffari we documented the testimony from the Border Patrol agents and their supervisors, all credible testimony. Chairman thompson i understand that, but nobody thought to get a copy of the Text Messages . Mr. Cuffari not to my knowledge. Chairman thompson did the Inspector Generals Office review any emails or other electronic messages involving cbp personnel regarding felipes care or death . Mr. Cuffari not to my knowledge, sir. Chairman thompson thank you. I recognize the Ranking Member of the full committee for questions. Thank you, mr. Chairman. It would be productive if i yield my time to our colleague from tennessee. Chairman thompson the gentleman from tennessee is recognized for five minutes. Ranking member and witnesses, thank you. The hardest part about being a doctor is sometimes you do everything you can for a patient and they still die. Id like to introduce myself. There are things i have never shared, but today it is important i do so. I graduated in the top third of my med school class, attending the number one emergency Residency Training program in the nation. All three years in residency we , scored number one in the nation and we beat the harvard doctors too. I have flown all over the world in the most remote places on the planet, provided medical care to children of afghan villagers and delta operators. I have never been sued for malpractice. I have served as a medical director of four different Emergency Departments in three states ranging from depressed rural to level two trauma center. I am the ceo of a company of Emergency Physicians and Nurse Practitioners for 52 Emergency Departments in 11 states. I have served as the defense and plaintiff expert on tons of medicalmal cases, forensically assessing the care given. In this case, both of these cases are about pediatric sepsis. A few facts about sepsis, a review of the medical literature on sepsis recounted four studies in the u. S. That found that when a patient goes to the stateoftheart Emergency Department, the mortality for sepsis in america was 10. 3 in one, 8. 9 in another and 19 respectively. Even when these patients present in the u. S. , many still die. Like the doctor said in her testimony, children do not look bad until the very end. When i train residents, we call it the pediatric cliff. They look great and crash in seconds. I appreciate the testimony of the pathologist who reported in both cases he felt, the actions taken by agents seem to be appropriate and timely. I affirm that dr. Mitchell understands the standard of care that depends on where you are and the facilities available. Dr. Danahers testimony is disconnected from this idea. The reality of rural healthcare is millions of americans are not able to walk into a harvard quality care. The standard care of mass general will never be comparable to triaging 160 migrants in the dark of the night. Dr. Mitchells testimony is balanced and professional. It is not political hyperbole, but it does suggest that the federal government has the ability to Deploy Doctors to remote areas, interview migrants about their health, and do tests which is simply unrealistic. Dr. Danahers testimony is blatantly partisan. She critiques the condition of cbp facilities about the lack of toothbrushes and clean water. I know from the facts in these cases, those allegations are false. She also discusses the psychological dynamic of the data of one patient did not share information as if that environment is the Law Enforcement officers fault. That dynamic existed because he crossed the border illegally and did not tell agents that he was sick even when they repeatedly asked him. If a patient lies about their medical condition, it is not the doctors fault. Both of your testimonies center around getting more resources. The bottom line, you want more doctors and Electronic Medical records. Just published yesterday, new estimates of doctor shortages in the u. S. The u. S. Is a short over 14,000 doctors. Where will we get doctors at every single crossing site . This testimony proposes building Healthcare Infrastructure that would dwarf the Healthcare Systems in 77 of Rural Counties in america. Last year, House Democrats voted to advance an electronic record to Illegal Immigrants within 90 days when veterans in many states still do not have it and wont have it for several years. Finally this side of the aisle spent last year highlighting how dangerous the journey to the border is for kids. The answer is not to turn cbp into mass general. We have to break the cartels that entice people to come here with children and fix our Immigration Law loopholes. Until we do that, smugglers will continue to turn a profit over enticing families to come to our border with false promises. Mr. Chairman, i yield. Chairman thompson thank you very much. The chair recognizes other members for questions they may wish to ask witnesses. I will recognize members in the order of seniority alternating between majority and minority. Members are reminded to unmute themselves and leave their cameras on so they are visible to the chair. The chair now recognizes for five minutes gentlelady from texas, ms. Jackson lee. Rep. Lee thank you for holding this important hearing and thank you to the members of the witnesses who are here as well who have provided very important testimony. All of us were shocked to learn in december 2018 the two children died in separate incidents while in Border Patrol which was the first death of children in Border Patrol custody in more than one decade. When you lead a nation, all that happens, whether you like it or not, falls at your feet. I have known Border Patrol agents in texas for decades. I have seen their passion. I have seen them buy baby food and formula. Where this tragedy falls is clearly at the feet of an administration that is inattentive and does not recognize that we are to comply with the International Protocols of human rights and human decency. Following the deaths of those two children, u. S. Customs and Border Protection issued a directive in january 2019 establishing new medical screening and other procedures. I physically went down to the border and saw the immediate emergency tactic that was used. It was a table and a use of coast guard doctors. They all meant well. Dr. Danaher, thank you for your leadership. My question as all of this falls at the feet of the administration, can you elaborate on the differences between pediatric disease processes and adult disease processes so that when you know that a child may be sick and why understanding the nuances of each is important especially in these situations . Dr. Danaher . Dr. Danaher children are physiologically different from adults. They can compensate in different ways for infection than adults can. When they are sick, they can look well for quite a while. That is all very true. I think it is really important for there to be pediatric expertise at the border and it does not have to mean pediatricians. It means intense training for those already working at the border. Currently emts in new mexico only get 10 of training for pediatrics which only amounts to a few hours. It is incredibly important to recognize that they definitely look different. Rep. Lee you understand that Border Patrol are not doctors, correct . Dr. Danaher correct. Rep. Lee it would be your view that a nation as powerful as the u. S. Could recognize the importance of those nuances and have a system that would deal with pediatrics issues or children in lifeanddeath situations . I did not hear you. Dr. Danaher yes. To the Inspector General, you did a report, there were some suggestion that cdc officers try to engage with the parents. Do you know what language they kelins father . Thatbelieve he indicated he was fluent in the Spanish Language and the Border Patrol agents who spoke to him in spanish. My understanding is that he spoke his indigenous language, did anyone try to speak to him in that language . Not to my knowledge. Of what elements of change would you recommend or did you recommend in light of the two deaths of children that did not happen with the mass i gratian with the Obama Administration . As i mentioned in my opening statement, we have three ongoing projects to look at the numbers you just asked about. These are three of 21 that i had in my prepared statement, and we will make recommendations based on what our findings are and hold dhs accountable for making those reparations. Rep. Lee and the recommendations that you are looking to is framed around two deaths, as well as no response timely enough to save those lives . Mr. Cuffari we are looking at the circumstances that surrounded their deaths, and the capability provided to the children who were in custody, as well as to the adults, etc. Rep. Lee let me just say we have 3 million plus covid19 deaths in the United States. Obviously, there will be Major Investigation on the responsibility of this administration excuse me, 3 million plus cases, rising to thousands of deaths. Make sure the record is clear. Many of the cases are in states like texas, new mexico, mississippi, and others. I would emphasize your work is extremely important when the federal government fails the nation, it is important for there to be concise, direct, widespread understanding of why and direction to how that is remedied. The loss of a child is precious. My deepest sympathies to the families. Therefore, we must make sure we correct it. Thank you, mr. Chairman and i yield back. Chairman thompson thank you. The chair recognizes the gentleman from new york, mr. Carico, for five minutes. Rep. Carico having lived on the border and prosecuted cases on the border in the mid1990s, i can tell you that the porous ess of theorousn border was a problem and it attracted more and more people, and tragedy often resulted back then and it still happens today. It is a terrible thing to have to lose anyone at the border in custody or to lose them if they are a child. We have to do all we can to make sure we do everything going forward. I will note that it is an incredibly complex issue, much more complex than the dialogue today. I would like to defer to my colleague dr. Green to take the rest of my time. I yield to him. This is the House Democratic caucus, we are calling to correct you to our Live Conference call chairman thompson the chair recognizes the gentleman from tennessee for the remainder of the time. R. Green thank you. Dr. Mitchell, you mentioned in your testimony that resource hurdles prolonged, custody and delayed access to medical care, i agree. The efforts led by House Democrats to defund ice have had sweeping consequences, mainly impacting cbp facilities, which is what happened in december of 2018, ice Family Residential centers were at capacity, forcing them to hold residents longer than they should. It was exasperated by the border crisis, preventing custody from reaching ice facilities built for a long phone holder longterm holding. My question to you is, do you support additional funding for ice capacity and medical staff to ensure that children do not get stuck in cbp custody like hey did last year . Dr. Mitchell i think any funding that will go forward to resolve this issue must go forward to decrease any overcrowding burden. I will leave it up to the house and politicians to understand where exactly that goes and what the agencies use and which agencies get those resources, but i think you and i agree, dr. Green, that overcrowding conditions is a major concern, particularly when were talking about infectious disease. And then as far as the issue of timeliness, and i appreciate you elucidating the fact that i wanted better access to health care at the border, i agree. Think physicians would be a hard burden, a hard bar to reach, but i believe there are opportunities, as my colleague danaher described, with higher training of the emt, Nurse Practitioners, that are available there to make sure that the burden is not placed on our agents to try and triage these patients. Dr. Green i really appreciate your comments. Clearly, we, on our side of the aisle, would like to see more funding. Especially for those detention facilities. A lot of people on the other side of the aisle want to defund ice. I want to follow up one more question for you, you indicated that you believe jacobs death could have been prevented in the initial Health Assessment questionnaire if it had been performed by a licensed article provider. Ou may not know this, but, yesterday, dhs or hhs released the doc shortage. 7 of americas Rural Counties right now are short, both doctors and p. A. s. And by 2032, that is going to be 121,000 short. Where do we get these medical providers . Do we take them from American Cities . I am eager to hear your thoughts on that. Dr. Mitchell again, i think shortage of medical providers is across the nation, as you describe. I just do not believe that the recommendation that of providing adequate Health Screenings to whoever we come into contact with, it stops being a recommendation because the hurdles and barriers are too big. I think our job is to create opportunities where we can meet the goal of saving lives. Herever it exists. So, no, not taking away from anyone, but to attempt to provide it to everyone. Dr. Green we have to be realistic in our solutions and find solutions that work. Your recommendations were of a licensed medical person, and with the shorning we already have, i dont see how that can happen. I think my time has expired, mr. Chairman. Chm. Thompson thank you. The chair recognizes the gentleman from louisiana, mr. Richmond. Rep. Richmond thank you, mr. Chairman. As much as i would want to go into the shortage issue and the proverbial trumpism of pitting communities against each other, and i guess that is what we are doing an act in terms of access to doctors, i will not entertain it. We are the greatest country in the world. Dr. Mitchell, for me, in aymans terms, could you xplain what philipe died of . Dr. Mitchell felipe died of a bacterial infection that was superimposed on flu. It is a small organism that can cause infection. This particular organism he had, he had flu and then that flu had a bacterial infection on top of it. The infection he had was so severe that it caused a rapid disease within his lungs, so he died from a hemorrhagic pneumonia or sepsis. That is functionally what he died from. Rep. Richmond dr. Danaher, and i think you and dr. Green both mentioned the uniqueness of treating children and when the symptoms show. Does this require special training to determine how severely ill a child is . Dr. Danaher yes, i would say it does. Rep. Richmond miss gambler, in your written statement, it says you have filed cbp does not provide officers with training to identify medical distress in children, is that correct . Yes, that is our finding. Rep. Richmond to the inspector eneral, in felipes death, did your agents receive training in identifying medical distress in children . If so, what did your officers review find . Chm. Thompson you need to unmute yourself. Till not able to hear you. Ooks like mr. Cuffari i am sorry, mr. Chairman. My computer froze and had to ome back into the meeting. Im very sorry. Rep. Richmond let me repeat the question. In reviewing felipes death, did your office examine whether the agents responsible for caring for him had received training in identifying medical disstress n distress in children . If so, what did your officers review find . Mr. Cuffari my understanding is the Border Patrol is trained in cpr, first in my care. They also have advanced training or par medics and in first aid and trauma care. They also have advanced medics in several stations and in the case in jaclyn, there was a paramedic who had the training. I did not find any evidence of pediatric training at all. Rep. Richmond well, it was also clear that felipes father asked him to be returned to the hospital in a sense of urgency. T took about one hour before they left the station so its unclear if the urgent nature of the situation was conveyed to everyone involved in the transportation. So, dr. Danaher, given those circumstances, are there any questions on cbps policies and practices for dealing with emergencies that should be reviewed . Dr. Danaher one issue that bodes for me is whether anybody is actually educating themselves on the medical processes. What i could tell from the records that were available is that [indiscernible] but its not clear [indiscernible] rep. Richmond and to the Inspector General, if possible, could you either articulate any recommendations of policy revisions you have about reviewing felipes death and file surrounding it . Yield back. Chm. Thompson you can answer the question. Mr. Cuffari thank you, mr. Chairman. Sir, we have ongoing projects to look at that exact question, and we will be very happy to provide the committee with the recommendations once we finish those reviews. Chm. Thompson so that is the end of december, right . Mr. Cuffari we should have one sometime towards the end of the year, yes, sir. Chm. Thompson thank you. Chair recognizes the young lady from arizona for five minutes. Representative thank you, mr. Chairman and to those testifying. When i read the accounts of the two Young Children dying, it is very sad. I am sure all of us can agree that it was sad and we wish it id not happen. But if i heard it right, dr. Mitchell, both deaths were preventable and blamed the customs and Border Protection agency, and dr. Danaher said customs and Border Protection agency was at fault. And after reading the report of what all happened, i really fail to see how you came to that onclusion. First of all, you have in the young girls account, she entered the u. S. And was apprehended on december 5. Fter traveling, i assume thousands of miles, the cbp asked if anyone was sick because they wanted to get the sick people on the first bus, and they did not say anything. Then, they did not fill out a form. They said actually on a filled out form that they were not sick but healthy. The father did not say anything to the cbp officers that is daughter had been vomiting, and he told the bus driver that his daughter was vomiting but did not tell cbp. So then they got off the bus first after they found out from the father, and the emt gave immediate medical care. It was only then that the father told the emt that his daughter had been vomiting and not eating for two days to four days. I fail to see how that is the agencys fault. And then they airlifted her to a hospital, and, unfortunately, she died. In the case of the boy, it sounds like the cbp transferred as soon as they knew there was something wrong. The hospital did not write it in there that he had influenza b, did not give medication, the amoxicillin, so, to me, that seems more like a hospital error than a c. B. P. Error. So my question to mr. Cuffari, in your investigation, have you determined that either one of these parents, the parents and child refusing medical care before they were apprehended by cbp, especially the girl who had been sick for two days to four ays . Sound asri it doesnt though the investigation found that had been the case. Their first medical treatment was once they came into cbp custody. In two different instances. One at the first station and the other at the facility at the checkpoint. Rep. Lesko thank you. Do you think ri, have given themd medical care . The accounts i have heard as they could care less and they just make any off of them. Mr. Cuffari i will not speak beyond the scope of my testimony. Rep. Lesko instead of blaming customs and Border Protection agency for everything that happens, to me, it was clear that traveling thousands of miles we should start blaming the cartels, dont you think . People should at least be partially accountable for childrens death if the parents do not tell the medical people or customs and Border Protection that their child is sick and they have been traveling thousands of miles. I just think its unrealistic to expect customs and Border Protection to just know that these things are going to happen. To me, it seems like they went over and beyond trying to help these children. I have a few seconds left to get o dr. Green. Chm. Thompson chair recognizes the gentleman from tennessee. Dr. Green thank you, mr. Chairman. Very quick question to dr. Danaher. Have you done malpractice review cases before . Dr. Danaher no. Dr. Green you reviewed the record here. What stood out to you on the resuscitation in the case of felipe . When you review that case . Reviewed that case . Dr. Danaher in terms of if he was taken to the hospital in ime . Dr. Grown the second visit when they tried to resuscitate him, was there anything that john out to you, as the physician, on that ecitation documentation . Resuscitation documentation . Dr. Danaher there were definitely irregularities in terms of what happened. E arrived and they had a difficult time intubating him. There was a significant amount f blood in the airway. Dr. Green dr. Green if i could just say answer the question. I know you have played guessing what im trying to ask as a question, but he was incorrectly intubated and he had the breathing tube down his esophagus for several minutes. Clearly that you cannot resuscitate a patient and if he is not getting oxygen for several minutes in the resuscitation, that is problem mate problematic for saving the childs life. I yield. Chm. Thompson the chair recognizes the gentleman from new jersey for five minutes. Mr. Paign . Representative thank you, mr. Chairman. I appreciate the opportunity to be here today and it is very interesting to listen to the gentleman from tennessees, who has stated he has an on the defense side and the prosecution side of these issues. Also, one of my other colleagues mentioned that, you know, its the cartels fault. We are all responsible. We are the legislative body of the United States overnment. We are responsible for making sure that nothing happens to these children. The administration went down a road to collect these people and lock them up in cages, and then when something happens, oh, well, we did not have anything to do with it. This is abominable. This is absolutely abombable what im listening to. Two children have died. I put my children in that position all of us need to put our children in that position. I think we might take there to ht be a different tenor this hearing. I only have five minutes, so, dr. Mitchell, can you please explain how and why video footage is important to understanding all of the circumstances surrounding a death in custody . Dr. Mitchell yes. I was one of the primary authors on the death and custody and how to report, examine, investigate and report out deaths in custody put out by the National Association of medical, and what they called for is indeed any Information Available for deaths in custody, including any video footage, any medical records, anything that could give an idea of the time leading up to the death that would be important to categorizing the final findings t autopsy. Rep. Ayne thank you. Inspector general, can you discuss the video footage regarding felipes death . Mr. Cuffari my understanding is the video footage was obtained while he was in custody and trained criminal investigators gave that footage and they determine aged that it read the testimony of the Border Patrol agents. Rep. Payne was there footage of felipe leaving the station to travel to the hospital on that vening of which he died . Mr. Cuffari you know, sir, i will have to get back to you on that specific question. Rep. Payne did you review any aspect of the cbps video footage of the individuals in custody as part of the review of felipe or jakelins death . Mr. Cuffari i am not sure i understand the question, sir. We did obtain the video footage concerning the time period in which they were in custody, but to my knowledge, i do not believe we took any other footage outside of that timeframe. Rep. Payne ok, so you do not review the aspects of how it was collected and obtained, right . Mr. Cuffari collection and retention would have been done by our criminal investigators or cbp opr agents acting on our behalf to collect evidence. Rep. Payne so there would be in the report some mention of that, correct . Mr. Cuffari to my knowledge, yes, sir. Rep. Payne mr. Chairman, how much time do i have . Know im getting close. Chm. Thompson the gentleman has one minute left. Rep. Payne thank you, sir. Inspector general, how many times did Border Patrol officers conduct wellness checks of felipe the day he died after he returned from the hospital . The first time and before he left the station for the hospital for the second time, how many times was he checked on . Mr. Cuffari the exact number i cannot give you, but from the report from the interview of felipes father, consistent with Border Patrol testimony, his ather said that the Border Patrol agents checked on he and his son sort of every five minutes to six minutes while they were back in the facility after their first visit to the hospital before entering a second time. Rep. Payne chairman, i yield back. Thank you. Chm. Thompson thank you. The chair recognizes the gentleman from louisiana for five minutes. Mr. Higgins. Mr. Chair, mr. Higgins is gone. Hm. Thompson thank you. The chair recognizes the gentleman from tennessee again, for five minutes. Dr. Green thank you, mr. Chairman. I just want to say that we are responsible. I can never forget the first hild i had to pronounce. The child had been hit by a car, and the image of that mother bringing that child in, in her arms, is forever burned into my brain. The loss of these two children, it is tragic, but what we are doing here is a forensic examination of the record to find where fault happened. This is designed to find where there is fault, so it takes an objective of sitting that aside and looking at the case. I would like to ask dr. Danaher again, the records are clear that the father of Young Jakelin was asking for medications from fellow travelers before entering into the United States. In fact, since the antibiotic he had on his hands was not the best for strep infection, they probably do not get that prescribed. He knew she was sick and failed to disclose it. You mentioned in your written it will about the environment of testimony about the environment of a person answering questions to Law Enforcement being a barrier for jakelins father telling the truth on his daughter being sick. I want to ask you, are you suggesting there is some kind of new standard of care that if the patient lies about their medical condition, the physician or that provideer is somehow liable . Dr. Danaher not at all. What i am saying is that the initial screening that occurred when they arrived, from what i could gather, one agent was yelling to more than 100 people that if anybody was sick, they should come forward. They yelled this in spanish when that was not their native language, so we dont know if he heard them or understood them. On top of that, we are asking people to come forward in front of larger people to talk about their medical issues, which im sure you can appreciate could be ensitive for some. Dr. Green do you have children yourself . Dr. Danaher i do. Dr. Green can you imagine having Sick Children yourself and not wanting them to know about it . I dont understand that dynamic. Ive seen a lot of parents in the e. R. And those parents are afraid. They want to come in and went to tell you. I do not understand why father who cares about a child would specifically ask. And he asked in spanish and he responded in spanish, so he clearly understood spanish. Dr. Danaher i think there is a difference between being able to speak a little bit of spanish versus trying to share nuanced medical information in spanish. On top of that, the questions on the Health Interview form are nonspecific. There was one question about any type of illness, and the rest are about things that would not be relevant to jakelins case. So this all hindered on whether the father understood the one yes. Question. Dr. Green i do not disagree with you that a form review, the form could be made better, but i just cannot make cbp responsible for a guy who says his children are ok, when asked if they are medically ill. Lets go to felipes case. I only have a little time, so i will get right to it. You made some very, i think, appropriate comments in your written testimony about his first visit when he went in. It was horrible when i locked at it. But i want you to tell the committee what you thought about his care when he was first brought to the hospital and whether you think they should have led that patient go ome. Dr. Danaher no, they absolutely should not have let him go home. I agree with you that the care he received was very concerning during his first consultation. His vital signs were significantly abnormal. His heart rate was persistently elevated, even with no fever. His oxygen went below the normal percent at one point. It is not clear if anyone noticed the fact. The physician who saw him later act normaled during the review had not been assessed correctly. Dr. Green i did not see any assessments for hydration status, tears, mucous membrane all those things that are standard of care. This is an american physician at American Hospital Emergency Department and they let this kid go home. My question is, would a normal lawenforcement officer question a physician like that . Is he trained enough to question a physician . Dr. Danaher it appears in this case, the Law Enforcement did. He did question and expressed concern after they left, which says to me they could recognize he was quite sick. Dr. Green they definitely recognized the care given was pretty shoddy. I think he had to ask to have the temperature taken. So thank you. I yield back. Chm. Thompson thank you very much. The chair recognizes the young lady from new york for five minutes. Ms. Rice. Representative rice thank you, mr. Chairman. I would just first like to thank theInspector General for being here today. I only wish you had been available when we did a hearing on these two terrible deaths back in january, and you would ot come to that hearing. I am glad you are here today. I think it would it be fair too say, mr. Inspector general, that in the course of reviewing felipes death, you clearly do not come to a conclusion that the cbp did anything negligent or inappropriate, would that be correct . Mr. Cuffari that is correct, s. Rice. Rep. Rice so, would you say it is fair to say that the Border Patrol agents were not properly trained to be able to comply with the standards for responding to a medical emergency involving a detainee with difficulty breathing, would you say . Mr. Cuffari i would say that based on the training that the Border Patrol was provided and had at the time, that they complied with the standards which with they were being udged. Rep. Rice let me read specifically from the standards addressing medical emergencies. It states Emergency Medical Services will be called immediately in the event of a medical emergency. For example, heart attack, difficulty breathing, and the call will be documented in the appropriate Electronic System of record. Officers and agents must notice by the shift supervisor of all medical emergencies as after contacting emergency services. According to your review of felipes death at approximately 00 p. M. On the day he died, felipe was observed to have difficulty breathing and complained about pain in his stomach. An agent reported that he asked felipe and his father if they wanted to go to the hospital and both declined. Do you think that that was appropriate behavior . Mr. Cuffari at the time it appeared to be appropriate within the scope of our investigation and what we determined. Rep. Rice what do you mean at the time . Do you have any information now that would lead you to come to a different conclusion . Mr. Cuffari maam, that is why we are doing the additional reviews. And evaluations that i briefly mentioned at the beginning. Were going to be looking at those issues. Rep. Rice dr. Danaher and dr. Mitchell, are there issues of informed consent that could come into play in situations in which cbp personnel ask parents and children in detention if they want to go to the hospital, particularly if they have already been on that same day . Dr. Danaher dr. Danaher yes. I think there are multiple issues. One is that once a child is in custody, the parent is not in a position to be advocating for their child to go back to the hospital. The child is in the custody of the government. On top of that, we have to remember that when inmates are n detention, they perceive themselves as being at the whims of the Border Patrol agent, and hey may not want to be a nuisance because we have to remember six months prior to this, Border Patrol was separating parents from their hildren. And there was real reason for people to be afraid of what might happen. I am not suggesting the agents did anything to intimidate the family at all, im just saying the dynamics of being and attention makes it difficult for parents to advocate for their childrens medical care. Rep. Rice i think everyone on the hearing would agree there were mistakes made at the hospital. Clearly, he should never have been released the first time. Theres no question, and i dont know if theres an investigation into the treatment he got at that hospital or if there should be four sure, but any attempt to blame the parent parents in this situation felipe when he came into custody was a perfectly healthy child and he got sick while he was in custody. Cbp had it within their discretion to actually not keep felipe and his father in custody for those six days between the time they were apprehended and when he died. They could have paroled him. That was well within the discretion of authorities, the government, at that time. And let me just also say, i am happy to hear dr. Green talk about how important it is to invest in our Health Care System. There is no better time than now for us to discuss this, especially as we deal with a pandemic, and we are seeing the disparate way our Health Care System works for people of color and people in certain socioeconomic backgrounds. So i am glad to hear dr. Green talk about how important it is to invest in this. But i think we all have to agree that children present at the border, our primary response ability to responsibility to them is to keep them healthy and not have them die in our custody. And so we have to make this system work better. I am not blaming these cbp officers because they are not medically Trained Personnel, then that means we need to have medically Trained Personnel at he border. My colleague, ms. Underwood, given her background and repeated trips to the border before the pandemic, was calling expensive hat, a more health check for every single child who comes into the custody of cbp or ice. I just want to thank all the witnesses for coming today. I yield back, mr. Chairman. Thank you. Chm. Thompson thank you very much. The chair recognizes the gentleman from texas, mr. Crenshaw. Rep. Crenshaw thank you, mr. Chairman, for holding this hearing. My first question is for clarification. The line items on medical care you mentioned, this is emergency supplemental, correct . Yes, sir. Rep. Crenshaw and that occurred after the death in question, correct . Letal was ency sup enacted last supplemental was 2019. D last summer, this spending occurred after enactsment. So, yes, sir. Rep. Crenshaw i would just like to highlight for the record that there was not a relationship where custody was in question. There were two investigations done and one is considered ongoing, correct . Mr. Cuffari concerning deaths in custody, sir . Rep. Crenshaw yes. Mr. Cuffari yes, that is correct. Rep. Crenshaw and of the two completed investigations, that ag determined that all employees involved did Everything Possible to make sure children received treatment and there was no malfeasance, correct . Mr. Cuffari correct. Rep. Crenshaw from your testimony, it sounds like the main issue here is overcrowding, correct . Mr. Cuffari it was an issue that we raised during our announced inspections of cbp facilities in 2019. We issued what is called a Major Management alert to headquarters, and they implemented procedures to alleviate the overcrowding. I am told that they complete that by the end of this year. Rep. Crenshaw thank you. It raises the issue that the reason there is overcrowding is many of our policies encourage people to illegally cross the border. There are multiple factors and the reason i bring this up is it raises the question of the purpose of the hearing. If there is any evidence of wishes intent by cbp, i think the hearing would be warranted, but there is not. The hearing appears to be designed, at worst, to drive a false narrative that implies Malicious Behavior by c. B. P. At best, we are seeking to falsely imply the tragic deaths could have been prevented by better action by cbp officers, even though the childrens parents walked them across our border in extremely poor health. Furthermore, the false narratives lack context. Falsely presuming that the responsibility of the border stations is to provide childcare. Of course, the truth is, the purpose of cbp is in fact customs and Border Protection. When i went to the Rio Grande Valley late last year, there was a humanitarian practice unfolding. In january 2019, there are more than 58,000 apprehensions. In february, it went to more than 76,000. Total border numbers spiked to 144,000 in may. These are not typical single male units. But they were mainly family units socioeconomic units, but mainly family units and unaccompanied minors. Migrants are handled differently and it overwhelms our Border Patrol processing factors. This unfolded in early 2019 and we were sounding the alarm and largely ignored. It was manufactured. By that time in late june, there had been more than 750,000 apprehensions along the southwest border, so why are we holding this now . Have to wonder, is it because demonizing how enforcement is popular right now . Lets be clear, the children who lost their life is tragic. It is also shameful to try to put the blame on our cbp and Border Patrol agents. I think we could highlight the fact that in the past 18 months, almost 475,000 agent hours have been spent transporting migrants to hospitals, staying on hospital watch with sick igrants. You know those who make the trek do not make it in the best conditions. But to highlight the fact that more than 8000 migrants were rescued from the Rio Grande River or found a need of medical need you to dehydration, or pregnancy complications, have nrescued by Border Patrol. Have been rescued by border atrol. We could also mention the Border Patrol search, trauma and rescue team, created in 1898, and now their main mission is rescuing migrants in distress. The number of women and children saved from getting trafficking by cbp, he could talk about them being on the front line to keep drugs and other contraband out of our country. Fortunately, though, physicians and priorities appear clear. I want to take this opportunity to let our cbp agents know we appreciate your service and what you are doing under the most ifficult of circumstances. And we do have your back. Thank you, i yield back. Chm. Thompson chair recognizes the gentlelady from michigan for five minutes. Representative thank you. I would like to pivot to talk about something mr. Crenshaw raised, which was the special approach ration, the emergency appropriation we passed last summer. In particular, im interested in for 112 million to provide medical care and necessities. We passed this 4. 5 billion supplemental and i voted for it, and i think many folks voted for it. I wrote to the acting secretary about this to make sure we understand how that 112 million was spent. I got a response eight months later from the cbp in march. Miss gambler, can you help us understand the use of these 112 million specifically, please . Certainly, congresswoman. We found through our legal decision and audit work that cbp did obligate funds from the medical care line items for some goods and services that fell within the definition or meaning of consumables and medical care, including hygiene products, clothing, gloves and masks. We also found that cbp obligated funds from that line item for goods and services that did not follow within the definition or meaning of that line item. The primary purpose. That included things Like Services for cbps k9 program, Computer Network of rates, Facility Service upgrades, and we concluded that cbp violated the purpose statute under appropriations law, and we concluded cbp should make adjustments to its account accordingly. Rep. Slotkin how much do you believe of the 112 million was misspent on things that were not intended . Ms. Gambler at the time of our work for the legal decision, congresswoman, cbp had not completed its review of the obligations they made under that line item. After we provided a copy of our draft report to cbp, they reported to us that they completed the review and identified 13 million that they planned to adjust among accounts from last years emergency supplemental and at least 3. 9 million that they planned to move from consumables and medical care line item to cbps regular appropriations. I would note given the time frames for our review, we have not reviewed that information, that cbp reported. Rep. Slotkin i guess i would hope that everyone on the committee cares about how the money that Congress Appropriates is spent. That was certainly concerning. Mr. Cuffari, can you give us your assessment on the 112 million . Are you formally doing a review of the expenditure on the money . Mr. Cuffari yes, congresswoman. We have an audit that is going to look at the cbps use of fy 2019 appropriation funds. For humanitarian assistance. We are going to check with our colleagues and cousins and make sure that we get all the information that is available. Rep. Slotkin what is the timeline of your review . When do you expect it to be omplete . Mr. Cuffari we just opened that a few weeks ago. Rep. Slotkin so a couple of months . Mr. Cuffari i cannot give you a definitive timeline, but we are going to do it as quickly as possible. Rep. Slotkin i just think it is important, and i would love to hear commitment to come back and talk to us about that. This is one of our primary responsibilities as an Oversight Committee to make sure we know how that money is spent. I literally have no sort of piece of it or special knowledge of it. I think we are just all saying from various angles that we want the issue to be resourced well to the best of our ability to support cbp to make sure they can do what they need to do one detainee help. Can you commit to coming back and testifying to in front of us for this issue . Mr. Cuffari you have my continued commitment. Rep. Slotkin thank you. I yield back. Chm. Thompson thank you very much. The chair recognizes the gentleman from pennsylvania, mr. Joyce, for five minutes. Ep. Joyce i would like to thank all the witnesses for appearing today and id like to thank you, mr. Chairman, for making the Committee Room available for the hearing today. I would like to yield my time today to my distinguished colleague from tennessee, dr. Mark green. Chm. Thompson the chair recognizes the gentleman from tennessee for the balance of the time. Dr. Green thank you, mr. Chairman. I want to first thank congresswoman slotkin for her questioning. I echo everything she said and agree with her 100 , and look forward to hearing back from the department on those misspent funds. That really is one of our primary concerns. I also want to appreciate the fact that congresswoman rice recognized and reiterated the need for america to address this physician shortage. We have a significant physician shortage now, and it will only get worse in the coming years. My point in bringing it all up is we have testimony for witnesses who said we needed icensed professionals. My conclusion from all of this is we cannot take those people where americans are not even getting care and put them on the border. What we need to do is give advanced training to cbp personnel and make sure they are better trained to do those kinds of assessments because i just do not think it is feasible to put licensed medical personnel down there. I also wanted to say that i we would dr. Danaher that pediatricians would have been helpful to read as an emergency physician, i can tell you that when jakelin was a top stream, it would not have made a difference in this case, and to say so would be misleading. Also as a doctor, i have provide care from either yomea good hill layas and a medic there doesnt need before you taked the pulses. Dr. Mitchell, what areas of hospital care and care of patient do you recognize as the highest risk for medical errors . Dr. Mitchell oh, well, in my experience, i have seen medical errors from the surgical suite. I have seen them in the icu. I have seen them upon presentations when you talked oneut the poor intubation of of our patients, so where medications are prescribed, you could see medical errors, so there are several places in the system where you can see them. Dr. Green jacob has done some pretty Extensive Research in this. Obviously the joint commission in research hospitalizations, the folks who accredit our hospitals for those who are not medical professionals, they have done a lot of research on his. Those transitions of care are fraught with risk. When one provider hands a patient off to another provider, going from the Emergency Department to the icu, a shift change is an incredibly high risk time, and the gentleman from louisiana mentioned the pickup time when one of the officers was going off shift with felipe particularly, and another came on, gassed his car up and got there a few minutes ate, but when he got there, if ou recall, from the testimony, tell us what that officer did and how he responded when he discovered the severity of the situation with felipe . Dr. Mitchell i think the Border Patrol agents acted swiftly to engage their patient and try to get the patient care. That was evident throughout the ecord that i read. Dr. Green do you think there was anything else they could have done . Dr. Mitchell no. No. I think the agents are acting articularly in felipes case and quite frankly in jakelins case, the agents, when they became aware, they moved to make sure those individual patients got the care. Dont think they are probably are as equipped to recognize the things they needed to recognize, so we talked about their raining and making sure we had adequate personnel that is doing that work and not putting it on agents whose job it is to protect in a different way the border, but, yeah, i think the actions were swift. Dr. Green thank you, mr. Chairman. I think my time is up. Chm. Thompson thank you very much. The chair recognizes the gentleman from california. Thank you, mr. Chairman for holding this most important hearing. Can you hear me . Chm. Thompson yes, sir. Representative i want to thank the witnesses, as well. I would like to direct my uestion to dr. Danaher and dr. Mitchell. The topic, c. B. P. Directive, medical care for our children. 2018, cbp expanded the use of contract medical personnel. It was a good step forward. Cbp also issued a directive setting forth interim enhanced medical efforts to mitigate risks to and improve care for individuals in cbp custody along the southwest border. The interim director required the Border Patrol to conduct a Health Review and radical assessment of all migrants under the age of 18. A mber of 2019, cbp issued final medical directive and that appears to be weaker than the interim directive. For example, it only required medical assessment of children under 12 rather than children nder 18. Dr. Danaher, if i may ask a question, have you had a chance to review the interim and final edical directives . Dr. Danaher yes, i have. Rep. Correa do you see deficiencies in the final medical directive . Dr. Danaher yes, there are a number of issues i find concerning. Rep. Correa please elaborate. Dr. Danaher sure. One is the timeframe. The initial directive, as i recall, it is supposed to be stated that the Health Review should be occurred among initial processing, as where the final is not addressed when it needs to occur. It also narrows the scope of what is considered basic medical training so it no longer specifies and vital signs could ave made all the difference it someone had paid attention if someone had paid attention. Early mandates for medical screenings for children under 12 or those with identified medical issues. And it includes a caveat. It is subject to availability of resources and operational requirements. We have to remember that two of the children who died in the timeframe we are discussing were 6. It is unclear to me why we are reducing the cutoff age to 12. It also seems to reduce the qualifications required for reporting medical screening. They are only assessed by Health Care Providers where available. It doesnt say followup could occur. On the surface, it is good. But we want to make sure that it does not mean children will not have access to pediatricians when they need them. Rep. Correa earlier this year, the American Academy of pediatrics submitted a statement to the record for this committee, which stated that the final directive, and i quote, is wholly inadequate to ensure the proper care of children in custody and represents a step in the wrong direction as compared to the interim medical directive. Dr. Danaher, do you agree . R. Danaher yes, i do. Rep. Correa what changes should be made to the final directive to ensure that the adequate medical assessments are conducted on all children . Dr. Danaher so, as these cases we are discussing illustrate, it is extremely important for Health Interviews to occur upon apprehension, and they need to be performed by somebody who has some medical training. Hat could be an emt. It does not mean there would have to be a physician at the border for this purpose. We also need to make sure that the Health Interviews ask directive questions so patients understand what they are asked about, and we need to make sure that medical screening is offered across the board. We do not want to say it is on the parents to speak up. When the children are in custody, it is the responsibility of cbp to make sure they are all healthy. Rep. Correa mr. Chairman, how much time do i have . Chm. Thompson the gentleman has 40seconds. Rep. Correa dr. Mitchell, do you have anything else to add to the topic of the final medical directive and its deficiencies . Dr. Mitchell i think it illustrates that there is a need for a level of training and a level of expertise when dealing with these patients, particularly children under the age of 18. I think that if we are talking about systems, then there ought to be better access to systems then we would put those resources in place to ensure our children are initially screened by individuals who have the proper level of training to ensure that we have better outcomes. Rep. Correa thank you. Mr. Chair, i yield. Thank you. Chm. Thompson thank you. The chair recognizes the gentlelady from new mexico, ms. Orres small. For five minutes. Rep. Torres small thank you, mr. Chair. Thank you for holding this important hearing. And im glad that were all here to reckon with these challenges together because it is crucial we make sure people in our custody are safe. I would like to begin by offering my condolences to the families of felipe and jakelin, and other Migrant Children who ave demide u. S. Custody. Since their deaths, both of which sired in the district i serve, i called on the Inspector General, numerous times, to nvestigate what happened and which holes in dhs policy need to be filled and to make sure we do not put our agents in situations where they do not have what they need to keep children safe in the custody and to keep more migrants from dying in our custody. And this should be looking guard into the future about how we can solve this together. I also want to note that these childrens death occurred in the districts i serve and we need to expand health care for rural americans. I invite all of my colleagues to cosponsor the legislations act when we have championed to train and rural Health Care Providers, as well as the training of primary care doctors at, i invite all of my colleagues to support the act. As well, the training of the next generation of primary care doctors act, the physician act to keep physicians serving patients, the diabetic act, the nurse act, the National Nurse ct, the immediate relief for rural facilities act, the Health Care Workforce resilience act, the medicare accelerated and advanced payments and improvements act, the save our rural Health Care Providers act. The rural maternal modernization of services act, all legislation i have cosponsored or sponsored to improve health care for rural americans. Inspector general, in your testimony you noted several new issues of which your office is working on. You stated. Crenshaw, that you have one in custody. Mr. Cuffairi its good to see you again, maam. Thank you for the question. I believe that is the only additional death in custody information we curveball have open. Thank you, sir, i appreciate it. In your testimony you noted that you did not have a single during the rt investigation into the deaths of felipe and jakelin. Will changes be made in how you review other deaths . Mr. Cuffari based on the increased funding the house gave us this year, we were able to eek outside medical contracts. How will those investigations differ from the investigations into the deaths . They wont at this moment because the investigation is at the very end of its cycle. You will not supplement that investigation with medical information and expertise . No, well do a supplemental review to have scoping of the entire Border Patrols handling of medical care providers and services for children in custody. In your testimony you indicated your office is looking on the review of appropriated funds for humanitarian assistance. Will you will looking more closely at the misspending that g. A. O. Has already eached and that congresswoman watkins eached in her questions . Mr. Cuffari d let me yes, let me clarify my last response. In this but the other case, we have engaged the services of an outside medical examiner, in the very last instance. So we will have somebody from outside looking at the medical review. And the autopsy. So to your current question, we will be looking at the investigation the gao has done. We will be looking at what was dequate. Thank you. I yield the remainder of my time. Chm. Thompson thank you. R. Inspector general, how long have you had the funding for Contractual Services how long have you had this money . Mr. Cuffari i believe the appropriations came in january. And we were funded in february or march of this year. Chm. Thompson so you have had the money about six months . Mr. Cuffari yes, sir. Chm. Thompson the chair recognizes the gentlelady from illinois, miss underwood. Rep. Underwood this administrations treatment of Migrant Children has been appalling. Mr. Cuffari yes, sir. Chm. Thompson the chair recognizes the gentlelady from illinois, miss underwood. Rep. Underwood this administrations treatment of Migrant Children has been appalling. Three years ago, the department of Homeland Security implemented a policy of separating families at the border. As a Public Health expert, i am familiar with the data showing family separation causes trauma that can do immediate and longterm damage to childrens health. It is not take a nurses degree to understand that. We all know it is inhumane, immoral and wrong. Today, we are trying to get to the bottom of deaths of two of the Migrant Children that died under this administration in federal custody, felipe and jakelin, who are among the six children that died during or after detention on this administrations watch, after a decade of zero deaths. The timeline included in your report, regarding the death of felipe, states during his first hospital visit on december 24, 2018, he was diagnosed with influenza b. However, the chart instructions included with the medical records from his first hospital visit appear to have been for the treatment of an upper respiratory infection without specifying the influence or diagnosis. Did your office conduct interviews with any other medical personnel who provided care to felipe . Mr. Cuffari no, that was outside the scope of our investigation. Rep. Underwood did you conduct an analysis of his medical records to understand what they were told about the influenza diagnosis and why . Mr. Cuffari we did not conduct a forensic analysis, we conducted a review of the medical records we obtained from the hospital and noted in the discharge paper for felipe there was no indication that he had tested positive for influenza. Rep. Underwood the Inspector Generals Office issued a report about the conditions during the 2019 migrant surge. The report stated the crowded conditions presented Health Challenges for medical staff in some facilities, including containing the spread of illnesses. Felipe was in custody for six days before he died. Do you believe it is possible he contracted influenza while in custody . I can say with certainty that he did, because the longest incubation for influenza is four days. Rep. Underwood thank you. I joined my colleagues in writing to the cdc to request information about the recommendation that cdp should vaccinate all migrants over the age of six months. Im certainly disappointed that nobody from there is here today to answer questions about why they have not implemented the cdc recommendations. Did your office examine this decision to not implement the cdcs full recommendation, and if so what did you find . Ms. Gambler thank you for the question. Through our work we did identify that they have not fully documented the reasons for its decision to not offer the influenza vaccine to those in custody. They identified to us a number of challenges to offering those vaccines, including things like providing cold storage and the need for increased contracted medical care providers, but they did not document how they considered or weighed the costs, or considered the costs versus the benefits that could come from offering influenza vaccines. So our recommendation was really geared toward them more fully documenting the reasons why they decided not to offer the vaccine, including how they consider cost and benefit, so as they continue to have conversations about Public Health issues going forward, they can have a record and good documentation of the decisions. Rep. Underwood i understand that cbp claims that offering flu vaccines to people would provide little benefit because of their goal is to transfer people out of their custody quickly. But they do not always transfer people quickly, isnt that right . I think the Inspector General has reported this, that individuals can be in custody for longer than the amount that they are hoping to detain them for that short amount of time. From a medical standpoint, we know that there are consequences of their failure to implement the cdcs recommendation on vaccinations, and given the ongoing coronavirus pandemic, we know that individuals who might come into custody would be at an increased risk as well. Thank you so much, mr. Chairman. Our Panel Witnesses and i yield back. Chm. Thompson the chair recognizes the gentleman from missouri for five minutes. Hi, mr. Chairman. Mr. Inspector general, i want you to please take this as not an insult, but in washington sometimes candor is silenced. I do not think there is any reason for me to question any of not just the statement i am making. Do you feel comfortable . Hello . My question i did not hear the question, im sorry. Rep. Cleaver based on everything you have heard, i mean, weve had a number of those who have been fired or relieved of duty, so my question is do you feel comfortable in being as candid as possible without fear that you would be silenced if you were to Say Something that was not in harmony with the power of those all around all of us . Mr. Cuffari i take your question. I commit to you that if i ever felt pressure to change my opinion for whatever reason, i would come to the chair and Ranking Members committee, and other oversight bodies in the house and senate. As you know, i have more than 40 years of Honorable Service as a u. S. Air force officer. And i served every president from jimmy carter to the current president , trump. And i stand committed to speaking truth to power, sir. Rep. Cleaver there has never been anything you have said or done that would convince me otherwise. But i am saying that this has happened in washington, things have happened in washington that do appear to be unsavory. Thank you. You are familiar with the fact that one of the agents who was taking care of felipe had to pay for some of the overthecounter medications out of his own pocket. Mr. Cuffari yes. Rep. Cleaver can you explain how somebody would have to go in their own pocket and pay for medicine for some poor kid that obviously appeared to be sick . Mr. Cuffari it appeared the prescription for amoxicillin that the hospital had issued was covered under their health care services, but the overthecounter medication, which was for acetaminophen or ibuprofen, perhaps, was not covered. It was an overthecounter medicine. Rep. Cleaver my assumption is the agent that we found out the agent actually used his or her own money, because they were reimbursed. Is that how this came to our consciousness . Mr. Cuffari i do not know if that person was reimbursed, but he did pay for it upfront. I do not know if he asked for a reimbursement on the back end. Rep. Cleaver i am curious about how we found out about it. Perhaps he mentioned it to someone. This is not unusual for somebody who is dedicated. My sister is principal of an Elementary School here in kansas city, and im always telling her she will retire broke because she is buying pencils, colors, all out of her paycheck. I think that is something that the, you know, agent should be praised for. He is probably not the only one. Mr. Cuffari my wife is a former high school principal. Rep. Cleaver you know. I have seen that all my adult life with my sisters. So, dr. Danaher, do you have anything you would recommend to us, you know, to make a correction that this would not happen again . What would you recommend to us . Do we need to put policies in place . Can we do anything that would assure the American People this would not happen anymore, or is there the likelihood it would happen again . Dr. Danaher i appreciate the question. I think it is extremely important for health care screenings to happen as soon as possible. And that needs to be where we have people with medical training out in those areas, knowing exactly what is happening. It took several hours before jakelin received medical attention. And so having people at the border who could recognize children who are sick and begin the process of getting them care is extremely important. I think that also being able to triage migrants, making sure that they have access to medical care, possibly that they also have access to nutrition onsite. And as the doctor said, the physicians [indiscernible] rep. Cleaver thank you. Should be fully developed. Chm. Thompson we can gladly make that request. The chair recognizes mr. Green from texas for five minutes. Rep. Green thank you. I thank the Ranking Members and witnesses for appearing. How many times did you visit the border pursuant to this . Mr. Cuffari just to set the record straight, i was confirmed by the full senate at the end of july of last year and within two months i went to the border to look at el paso. The investigations that the committee was holding regarded events that happened about seven or eight months before even my confirmation. That wouldve been december of 2018. Rep. Green while you were there, did you pursue actions to further your insight into what happened to these children . Mr. Cuffari not to the children in particular because these were events that had already occurred. I was looking at overarching conditions at the el paso and tucson sectors. Mr. Green you actually visited the facilities where the children were detained . Mr. Cuffari not these particular facilities. I stand corrected, we did go to the el paso port of entry in el paso, texas. Mr. Green at that port of entry, did you notice that it was somewhat akin to a large facility that allowed vehicles to flow through, did you notice that, the place where the children enter the facility . Mr. Cuffari i do not believe so, sir. This was october of 2019. Mr. Green i am assuming the facility is still the same . Mr. Cuffari they have deconstructed whatever they had as a temporary facility. Mr. Green there is a facility there that is probably still standing. This is what i would consider a main facility. In any event, did you notice how the children were cared for immediately upon entering the country in terms of how they are housed and whether they are given blankets, whether they are kept warm . Did you notice any of this . Mr. Cuffari i did notice that the el paso Border Patrol station where they had soft sided not soft sided tents, but they had larger structures constructed out of some material, that the families were kept together in open bay barracks. They had medical attention and hot meals. They had toys in some cases the Border Patrol agents were bringing toys for their children. Mr. Green do you think the facilities are adequate for the time of year when it is cold and you do not have blankets . Do you think this was adequate . Mr. Cuffari from what i observed at the time on that particular day. I had about a two hour visit. They appeared to be adequate. However, i want to emphasize that we are doing ongoing work to take a look at the holding of detainees beyond the 72 hours. And migrants experiencing serious medical conditions. Mr. Green isnt it true that they upgraded since you were there and they now have better blankets and other materials for the children . Mr. Cuffari that is possible. I am sure there are inspections that will identify that in real time. Mr. Green lets go to the current circumstance. Do you believe now that we are prepared at the border to receive children that are sick and appropriately care for them . Mr. Cuffari i actually do not know. My intent is to have the 20 different audits and inspections answer that question. Mr. Green lets talk for a moment. One of the physicians has been adequately questioned about his medical thoughts. And in a sense, somewhat challenged about his opinions. So let me ask you a couple questions. Is it true that there has been some question with reference to your phd . Mr. Cuffari that is correct. Mr. Green is it true that you have signed a document indicating you have a phd, but not that it was in management, some question about it being in management versus philosophy . Mr. Cuffari there was a posting on our official website when it came to our knowledge that there was a typographical error indicating i had a phd in philosophy, not in management, which i do have. We made the typographical correction. I also noted that there were one or two commas we needed to correct as well. Mr. Green did you visit the university where you earned your phd . Mr. Cuffari i did. Mr. Green is it true that there is currently a subway and a 7eleven store in that facility . Mr. Cuffari i had no idea. I attended the unniversity from 19982002, when i was awarded my degree. Mr. Green is it true that there is concern as to whether or not this was a meal process, presenting the phds . Mr. Cuffari i worked for the department of justice at the time, i paid my money, i did this all through Online Learning and i was awarded the degree that i earned. Rep. Green i yield back. Chm. Thompson the chair recognizes the genreal lady from nevada, ms. Titus, for five minutes. I would like to go back to that report that was mentioned earlier that was issued last month about the Inspector Generals Office. That report summarizes the results of the offices unnanounced inspections at 14 Border Patrol stations and seven points of entry between april and june 2019. Is that right . Mr. Cuffari that is correct. Rep. Titus you reviewed the migrants access to medical care, however the camping report states because our office does not have medical expertise, we did not evaluate the quality of medical care that cbp provided the detainees. When your teams were visiting these facilities, what kind of fieldwork did you do to assess compliance with the standards, and did they simply observe what was happening, or did they also do some type of systematic review of records . Mr. Cuffari just for the record, the time of the unannounced inspections we did not have a medical Health Care Provider services contract, due to our increased funding that you have provided we have contracted for such augmentation. The unannounced inspections, normally, are between 13 days in length at a particular facility. They follow procedures. They are looking at events occurring in their presence at that particular point. They document the information. If they find that there are abnormalities or issues of misconduct, they report them immediately. In one instance last summer, we issued a Major Management alert to the department, highlighting a condition that our inspector saw. Rep. Titus absent anybody with the medical expertise previously, and with that, evaluating the medical care, can you confidently assess compliance with the standards, including that requirement for appropriate care . Mr. Cuffari we follow the counsel for Inspector General for integrity and efficiency standards. Our auditors and inspectors, we have peerreview. We are going through that now. And actually, this summer, and we base our evaluations on what we observe at the time we are at the facilities. Rep. Titus the results of the inspection section states, most Border Patrol facilities took steps to try to evaluate and respond to the medical needs of the detaining population. This included conducting medical screenings of all detainees before entrance into the facility. When it says all detainees, does that mean literally every single detainee received a screening . You would think that is what all means. In if so, how were your teams able to assess whether everything a person was a screened, particularly in the crowding that occurred in those facilities . Mr. Cuffari i take the word all to mean all, as you do. And i am assuming there are inspectors saw and documented what they saw, which would be all of the individuals at that particular point. Rep. Titus it seems to me that there are a lot of assumptions, what we think and do and believe that they did in the report. A lot of these terms are being thrown around. I want to ask the doctors if they see anything about the assertions that concern you. What concerns do you have . Have you had a chance to review that report . And could you lay that out for us so we might be able to think about that in the future . So the report, as you mentioned, seems to acknowledge that there is medical care occurring at some of these facilities, but it is difficult to assess from the report what the quality or extent of that medical care is. I was also troubled to see that medical screenings are happening in large groups, no privacy. It makes me question whether any exams are actually happening with the screenings, or if it is with the screenings, or if it is just asking questions. I am also troubled that there was basically just a photograph of shelves of medications and there was an assumption that that was what was needed for the detainees. Without a physician reviewing that, it is difficult to know if having those medications is adequate to fit their needs. It is difficult to assess any of this without a medical expert there, just some officer going in and looking around. Dr. Mitchell, anything to add . Dr. Mitchell that was the point i was going to make. I think that having a medical officer that is engaged in the care happening at the border, a responsible oversight in medicine, but also the review of anything that comes out of this particular set of circumstances is extremely important. Detention centers, once people are in them they really do become small hospitals. In general, most people are going to be sick in these Detention Centers, or prisons within this country, so it is so important to have sustainable medical professionals that are overseeing the care, whether it is triage or an initial assessment, but overseeing what is happening amongst these individuals. I would just add that to what we are discussing. Rep. Titus thank you. I yield back. Chm. Thompson the chair recognizes the lady from california for five minutes. Thank you for putting together this incredibly important hearing. I serve the second vice chair of the congressional caucus. Last year, my colleagues and i toured the alamogordo Border Patrol station at highway 70 cbp checkpoint in new mexico. I saw firsthand the cell where felipe gomez, an eightyearold boy, spent his last hours and tragically died on christmas eve. I witnessed the awful conditions he was held in. There were no showers, there was an open bathroom where everybody could see you, it was complete concrete. There was no nutritious food for people, especially for kids who may be sick. There was a lack of medical supplies. There was only a firstaid kit and a small emt bag, but no Trained Medical personnel. Cbps lack of meaningful care for asylumseekers are putting Migrant Childrens lives in jeopardy. We even spoke to officers there, who said that they are not trained to take care of those who are ill. It was unbelievable to me to see the condition in which a child who was sick would be sent to, to wait where there are no blankets, nothing padded, but a complete jail cell. Doctors, i know that we have talked about this already, but i think it is very important. Can you please again explain the challenges associated with recognizing medical distress in children, particularly Young Children who may not be able to talk or where there may be language and barriers. It can be difficult to get a medical history from a young child, or a parent who is distressed about their childs wellbeing. Children look different from adults when they get sick. They have much more physiological reserve. They can compensate better for longer when they are sick. But that also means when they run out of their metabolic reserve, they crash very fast. And we run into this all the time in pediatrics, where the kids come in looking ok, then they go down very quickly. And if action is not taken quickly to help them, then the outcomes can be really terrible, as we saw in this case. Rep. Barragan thank you. Dr. Mitchell . Dr. Mitchell the reality of it is, it is a matter of timeliness. So, when we put trained individuals and not rely on the agents that are not trained to do this work, but put trained individuals in position to get people to care, or recognize distressed earlier, then we have the potential to save lives. So that is all i would add. Rep. Barragan miss. Gambler, you indicated in your testimony that they are not training their personnel on recognizing medical distress in children, is that right . Ms. Gambler that was one of our findings. We made a recommendation that they should develop and implement such a training for all officers and agents who could come in contact with children in custody. Rep. Barragan i believe in your testimony you said that cbp and the American Academy of pediatrics i will give the quote, develped a video on recognizing medical distress in children which they included in part of their training for Emergency Medical Technicians and paramedics, is that right . Ms. Gambler yes. Rep. Barragan do you know how many are trained as emts or paramedics . Ms. Gambler we have the information in the report and we could follow up after the hearing. Rep. Barragan when i went into the cbp station to ask them about felipe in particular, they basically said they had one person available for three different stations and they had to rotate that person through, so there was no way to have anybody there for an extended time. And there was just a shortage. Has the video on recognizing medical distress in children been shown to all personnel . Who are e. M. T. s and paramedics . Ms. Gambler they told us that the video is available as optional training to all officers and agents, but that the video is primarily geared toward those officers and agents who are trained Emergency Medical Technicians. That was one of the reasons for our recommendation that they needed to develop and implement training for children and medical distress, to be provided to all officers and agents who could come in contact with children in custody. Rep. Barragan thank you for recognizing that because it is completely unacceptable that not everybody is trained to recognize symptoms among children, so thank you for doing that. And hopefully we will have better treatment of our migrants at the border. I yield back. Chm. Thompson thank you very much. Let me thank the witnesses for their valuable testimony. As you can tell, if you are not an expert, you will get tested before this committee. And i thank all of you for actually presenting very well and you responsed accordingly. I would ask unanimous consent to submit two statements. The first is the letter responding to the invitation to testify at this hearing. The second is former acting lenny, june,ckel 2019 letter seeking emergency appropriations to care for Migrant Children. Without objection, so admitted. Members of the committee may have additional questions for witnesses and we ask you respond expeditiously in writing to those questions. Without objection, the committee record shall be kept open for 10 days. Hearing no further business, the committee stands adjourned. Thank you. [captions Copyright National cable Satellite Corp 2020] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. Visit ncicap. Org] the u. S. House considers the 2021 National Defense authorization act with votes 11 30 a. M. Early as eastern. The senate convenes at 3 00 p. M. Debate on the vought to of russell be officer of management and budget. Debate and imited advanced his nomination on july 4744. Party line vote of at 5 30 p. M. The senate votes on of the vote nomination. Watch live coverage of the house when they return on cspan, live of the senate on cspan 2. President trump traveled to georgia to speak about latest uckture and the move to relax environmental regulations in order to treamline the approval process for new construction projects. The event took place at a u. P. S. Atlantas international airport. Ladies and gentlemen, please c. E. O. Of u. P. S