Transcripts For CSPAN3 House Hearing On Children In CBP Custody 20240712

Implement the revised medical screening proceediers, and the improper expenditure of emergency funds appropriated by congress for the care of migrants. In december, two children died in custody. A sevenyearold girl named jacqueline and an 8yearold boy named felipe. Last year another three children died in custody or shortly after being released. On january 4th, 2019, i sent a letter to the department of Homeland Security requesting documents relating to the deaths in 2018. After they failed to produce all documents responsive and in november and they keep my of the communicating requested in my letter ten months prior. The expecter Generals Office issued two one page sum mum rars. But the questions were left with more questions than answers. Earlier this year i sent a l letter to the expecter general. My entire letter is available on the committees wps. Among the concerns i raised were the following. They say there was no malfeasance or misconduct by dhs personnel. It was unclear why that was used because there did not appear to have been any mal fee sals. Border control agents showed great passion for children. However it appeared to people that because they found no malfeasance that was the end of the story. The report fails to examine the many troubling questions that these deaths raised regarding the ability to care for children in custody including questions about the adequacy of the policies, procedures, and training. Further, while the expecter Generals Office conducted many interviews, it appears that key documents and evidence were not collected and reviewed. My letter also vooifed omissions in the public summary of one of the expecter generals report that was so severe it rendered it inadequate and possibly misleading. They refiezed a public summary. In the past six months they produced some documents in response to the committees subpoena, but these are clearly incomplete. For example, they referred documents that had never been provided to the committee. Dhs also made extensive redakotass in the documents it produced. Though its refusal to comply fully with the committees subpoena and through its many redakotass the department is intentionally impeding the committees investigation. Despite these hurdles, the committee has worked to advance the investigation. We asked a people transcription and a medical examiner to conduct independent examinations of the two kets thdeaths that o. Today the Government Accountability also is also releasing a report that we requested. It includes use of emergency funding appropriated and t agencies implications. They claimed they urgently needed emergency funding to provide care for migrants take into custody, the Border Patrol agents that cared for phillippe had to pay for medicine out of their own pockets, but they appropriated funding to pay for medical care to buy jet skis, dirt bikes, and dog food. There is something seriously wrong with this picture. Just as there is seriously wrong with the administrations approach to caring for migrants, including children. A note that the gao report found that all of the cdp adopted policies governing medical assessmen assessments, they did not consistently implement these policies. We welcome dr. Anna anher and dr. Mitchell before the committee and im glad that after initially refusing to do so, the Inspector General has agreed to testify before the whee so that we can exemployee the questions and we also invited mark morgan to testify. In a letter to the committee he stated that because of the white house baseless rules, prohibiting witnesses from attending virtual hearings that he could not appear. I fully recognize the sensitivities of the issues that we are adiscussioning. I ask all of the members to be thoughtful in how we approach the subject. It is clear this administration will do everything it can to avoid oversight. We need to do everything we can to hold this administration accountable. 18 months of obstruction we have endured and have sought documents and information about the death of children in custody and issues like the administrations child separation policy. And to be able to identify changes needed and the immediatiers needed than to continue on todays hearing. Im going to read daytimes from the fathers of the two children that died in custody in 2018. Mr. Cal cruise said i would 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. To speak up and Say Something even if youre afraid. The most important thing is to check on the children so the thing that happened to my daurn will not happen to anyone ever again. I offer my thanks to the committee for taking the time to check into my daughters case. The father of felipe says i want justice, i want to know why my child did not get care in time. This is painful for me me today and painful for the rest of my life. Ski myself why my son did not get medical attention in time. His stream was inhumane. I ask for their record to be put into the order. Now we recognize mr. Rodgers for an hoping statement. Thank you again for granting our request to use the committee room. Im too saddened by the loss of the children. The department is taking steps to improve migrant care but it is up to us to address the root cause of the problem. It mean thats we must fix immigration loopholes, we must provide resources to cdp and i. C. E. We must not encourage immigration to our border. And i hope that we will never have to hear of another tragedy at the border like what happened with these three minors. Im disappointed that some of the events leading up to the hearing. The commissioner should be here so we can hear directly from him. majority did invite the commissioner but we knew he could not participate. We have provided guidance and they have been forbid ton participate. They asked me to appear in personal before the Senate Committee on june 25th. I ask consent to insert commissioner morgans response to the chairmans invitation. In that letter morgan requested to appear before the committee in person. If we want productive hearings, i would urgent to the majority that we find time to hear from him in the next two weeks when were in dc. Further, getting to the bottom of those two deaths is something that this committee has worked together on. We voted unanimously to. The department for information on the deaths of felipe and it seems we got Additional Information from mexico. It appears they did not share the information with witnesses here today and who knows who else before ninforming the minority of its existence. The minority got it on july 12th. It is disappointing to partner with things like this and have them opportunity out to be partisan and less than a week before the hearing. Im also alarmed by the always information. Why would anyone need human tissue samples from a 8yearold little boy. I hope they shait is not true, if it is it is deplorable. There is no misconduct or man feasance in any of the actions of dhs or its employees surrounding their deaths. I understand that doesnt provide any political satisfaction, but that is the fact. If they shared human issues, it would mark an appalling new low for this committee and i hope that is not the case. We must remember that for months song refused to address the border crisis that precipitated these deaths. Record numbers of families and children crossed our border last year. Hundreds of thousands of migrants came across the once at the whims of the cartels and the human smugglers. Many some of abuse, assaults, and worse. Food and medicine was not provided. Many arrived in extremely poor health. But for months last year the majority refused to even acknowledge the problem going as far as calling it a manufacturing crisis. En after t even after the children died they said there was no crisis. Finally after months, the maj majority admitted that there was a hand it will. Unfortunately that was a stopgap measure. The Homeland Security advisory said until they take action, it is only a matter of time before another one occurs. I hope at some point that we can get off of the political messaging game to fix the loopholes that encourage parents to send their children on a dangerous and dead ly trek to or border. Thank you, i yield back. Thank you very much. Other members are reminded that Opening Statements may be submitted for the record. Always we will operate according to the giant lines laid out in our july 8th colloquy. Now we welcome our panel of witnesses. Our first witness is dr. F danaher. He is member of the hospitals Child Protection team. Also mediate tricks at harvard medical school. Second witness is dr. Roger a mitchell junior. A chief medical examiner. He is Board Certified in anatomic and pathology. He started the study of Forensic Science for the federal bureau of investigation. Dr. Mitchell is a graduate of the new Jersey Medical school. Our third witness is the honorable joseph. He was confirmed as the department of Homeland Securitys Inspector General. He previously served as a policy advisor for military and veteran affairs for the governors of arizona. He earned a ph. D in management. Finally, we have mr. Rebecca gambler. She joined in 2002 and currently leads work in Border Security and election issues. Without objection their full statements will be inserted into the record. Here is her full statement, she has five minutes. Good morning. Chairman thompson, Ranking Member rog jers and members of e committee. Im dr. Fiona dannaher. It is a privilege to be part of the u. S. Customs and Border Protections. As you know in december of 2018, they became the first Migrant Children without underlying medical conditions to die in u. S. Custody. One child died of septic shock which went into multiple organ failure. Another died from untreated influenza. Their deaths, as well as those of four other children in government custody between september 2018 and may 2019 underscore the deficiencies in a system poorly designed to protect the wellbeing of vulnerable children. Review of records makes clear that jacqueline and felipe both suffered painful deaths that could have been prevented by timely access to pediatric medical care. The children died of Natural Causes in both cases and there was no misconduct conclude id to be done by personnel. Death by Natural Causes does not mean death was inevitable. The great efforts that several agents went to to help the children does not about solve them for perpetuating systems for placing children at medical neglect. Cvp released a new directive in an of 2019 to ensure that all children got Health Interviews and medical screenings when in custody. However, many of the safeguards instituted under the guidance were stopped, and it is unlike they the provisions would have prevented their deaths. Children are not little adults. Their remarkable resilience can mask disease from those not trained to see it. But detention in substandard conditions places childrens very lives at risk. If children are to be detained in cvp facilities, it is incumbent on them to strengthen their medical infrastructure. Their deaths illustrate the need for democratic hurdles to be addressed. They also highlight the urgency of addressing conditions that spread. They need comprehensive medical screenings in their native language with pediatric experts and referral as appreciate to mediate trick centers. Those with underlying medical conditions should not be returned to the centers unequ unequipped to provide safe operation. Teams of agents working in remote areas must include the Pediatric Community and Border Patrol stations should be stocked with basic pediatric illness treatments. Independent oversight of the quality of medical provided to the detainees needs to occur regularly. The oig recapped they dont have the necessary medical expertise for the task. Given the under epidemic and the impending arrival of another influenza season, action must be taken now. So that other children do not meet similarly painful and preventable fates by in custody of the United States government. Thank you for your testimony. Now i recognize dr. Mitchell to summarize his statement. Good afternoon for chairman thompson. Im dr. Roger missional junior and i serve as the chief medical examiner of washington dc. It brings me no pleasure to review the cases. I have been asked to review the cases from the medical examiner perspective specifically from the postmortal findings, the cause, and manner of death. I have been studying deaths in custody for over 20 years. And were reminded of deaths like george floyd and rashard brooks. They are under a continuum that is like arrest related, prearrest related, and in custody and incarceration which is shortterm and longterm jail d detention. This committee had been tasked to ru view infant and child deaths for system centered recommendations. This is the lengs a child that was a preended on tapprehe a 105 degree fever. The initial laboratory and aupts fi autopsy findings are consistent with sepsis. Early treatment is critical. Based on the materials that i had to review, the cause and manner of death, and it is my opinion that the death was preventable. The actions taken by the Border Control agents seemed to be timely, but they lack adequate Human Resources and physical infrastructure to respond to medically fragile detainees, especially children. The initial medical questionnaire was provided by a licensed medical professor. In the next case, we know felipe was apprehended with his father at the u. S. Border. Say were detained at three different Border Patrol stations before he was known to be sick. He was found to have a temperature of 103. He was trance port today a local hospital, but he had to come back because of a worsening position. He suffered kpli cases of a flew viral infection. This bacteria was isolated and had an aggressive exo doxin. And a highly contagious bacteria that is in close quarters. This toxin leads to severe rapidly progressing pneumonia. Based on the review of the materials available, it is my opinion, but none the less a bacterial infection. The manner of death is natural. It is my opinion that this every crowding is a known condition and i believe they may have played a significant role in the infections there is many opportunities for life saving care. However if there was a licensed medical professional to care for this child, there may have been a more informed assessment for his ichgs at the hospital. So what are my recommendations . Enforce and control the population to protect against overcrowded. Utilize medical personnel. Accompany this initial assessment with a breer brief health screening. And dwon an on sight clinicalment by the ability to triage patients. Maybe seeing these patients move from Border Patrol station to border pa control station. And retraining our agents. In conclusion, immediate and timely action by a licensed, Trained Medical profession could have prevented the deaths of jacqueline and felipe. They are symptoms of a more extensive system that requires more improvement. Any system that is established by our government must have, at its core, the health and safety of all that come into contact with it. The cases of these children must remind us that deaths in custody are not just a criminal justice issue, but we must provide a timely, accurate Reliable Care in the streets of our cities, the jails of our counties and the prisons of our states. I appreciate the work that the committee is doing and i pray this hearing does not just provide an appearance of addressing the issue, but a true call to action with resolutions. It may beyond what is comfortable for some, but i believe it is attainable. Thank you, chairman thompson, im not available for any questions you may have. Thank you, doctor, for your testimony. Good afternoon, chairman thompson. Thank you for your work about children in custody. My testimony to will include a discussion about the investigations of the death of the two mie grandchildren in custody. The findings of our unannounced inspections of cvp fibacilities and a over view of our inspections, audits, and n investigations. No parent should to go through losing a child. Im a parent and a new grandparent myself and i find that that is heartbreaking. They died within 18 days of each and less than 100 miles apart each case was unique. The cope of both investigations was to determine the stances of the inkes i did deaths of the children including any former misconduct by cvp personnel. We dead cased multiple important staff and we were ughments by cvp in one case. We conducted 44 interviews between the two investigations, neither investigation found min conduct or malfeasance. In fact both investigations determined the employees involved exhibited great concern for the childrens welfare and got medical treatment without delay. Cvb had a surge in families and unaccompanied children. And a pry he needsed more thanu fy19 than in any four fiscal years. Our office has conducted unannounce unannounced visits with cbds transport and search standards known as the t. E. D. Standards that can be observed and evaluated by our inspectors without specialized Law Enforcement or medical training. We summarized our 2019 unannounced inspections. Medical coverage varied by facilities. The facilities we did visit generally met the t. E. D. Standards for access to medical care. Containing the spread of contagious diseases. We have initiated an audit of policies and procedures for handling medical intervention and detention. We observe more overcrowding and recommend dhs take steps to alleviate it. There were two additional recommendations made related to telephone access to unaccompanied children. Dhs is on track to holding beyond the 72 hours we also initiated a review which is ongoing to identify the key factors contributing to prolonged cbp prevention. We have than 20 ongoing or planned projects reviewing vice and cbp. We appreciate the committees continued interest in our work and for Congress Robust funding this current fiscal year. With increased funding we are contracting for medical professionals to supplement our expertise across audits, inspections and investigations. And im pleased to report this will be awarded in the next few weeks. In october of 2019 i personally observed the conditions at the southwest border when i visited dhs facilities and operations in el paso and the tucson areas. Our office continues to monitor the situation at the border and recommend improvements to dhs programs and operations. Mr. Chairman, this concludes my testimony and im happy to answer questions that you may have. Thank you for your testimony. I 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 todays hearing to discuss gaos work on cbp efforts to provide medical care to those in its custodies along the southwest border. My remarks are based on a report gao is releasing today and a legal discussion on issues related to cbps use for and efforts to provide medical care. I will be covering three areas from the report and legal decision. First cbps use and oversight of funds used for consumables and medical care under the fiscal year 2019 emergency supplemental appropriations. Second, cbps efforts to enhance medical care and, third, cbps reporting of deaths in its custody. Emergency supplemental appropriations act was enacted to provide humanitarian assistance and security at the southwest border. The act required that cbp use certain funds for specific purposes which are referred to as line items. One of the line items was consumableab consumables and medical care. There were some funds for consumable and medical care, goods and Services Like food and hygiene products, mask and gloves. Cbp obligated some of the funds for other purposes like goods and services for its k9 program, equipment for facility operations like printers and speakers, and facility upgrades and services. We found these om gabligated violated because of funds from the line item for some goods and services that were not consistent with the purpose of that appropriation. We conclude that had cbp should adjust its accounts accordingly. We identified two factors that contributed to cbps violations. One, insufficient guidance to cbp offices and components before obligations were made and a lack of oversight, roles and responsibilities for reviewing obligations once made. We recommended that cbp develop and implement Additional Guidance and establish oversight rules and responsibilities to ensure supplemental funds are consistent with their purposes. Cbp concurred with these recommendations. Second, cbp has taken steps to enhance medical care and services for individuals in its custody. Including use of contracted medical care providers. And requests the cdc assess conditions and make recommendations for the reduction of influenza and cbp facilities among other things. As a more specific efforts, cbp issued interim and updated medical care directives which, among other things, required Health Interviews and medical assessments for certain groups. In march 2020 cbp issued implementation plans for these directives. While these are positive steps we found that cbp has not consistently implemented its enhanced medical care policies and procedures. For example, we found that some cbp locations were not consistently conducting Health Interviews and medical asse assessments as required. 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 its custody to congress. Weve reviewed cbps 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 reports. We recommended that cbp reports to congress and documentation is maintained. Cbp concurred with this recommendation. In closing, while cbp has taken steps to enhance its medical care efforts our work has identified a number of areas requiring additional attention to ensure that cbp is appropriately using supplemental funds it receives, overseeing medical care efforts, and reliably reporting information on deaths in custody to congress. Going forward we will be monitoring cbps actions to address our recommendations. This concludes my prepared staple, and im pleased to answer any questions members may have. Thank you for your testimony. I thank all the witnesses for their testimony. Ill remind each member he or she will have five minutes to question the panel. Ill now recognize myself for questions. To mr. Cuffari, as you know we sent a letter to you asking for a number of things, the committee, and you sent it back. We reviewed it. And after we sent our response back, you revised the public summary. Why did the original public summary include any reference to influenza as a cause of death . Mr. Chairman, you are correct. In the interest of privacy initially we included a highlevel summary of information on our public website regarding the deaths of the two children. Subsequently, at your request, we made an adjustment to the public summary to include a diagnosis of influenza b and to indicate that our investigation did not reveal Border Patrol were aware of that diagnosis. This is the very first time 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 basically err on the side of privacy for the children. Out of deference to you, sir, weve added those and made those minor corrections. Well, thank you. So, have you noted on your website or the summary itself that the summary has been revised . Yes, sir, we did that the same day we made the updates and sent those to your staff. Thank you very much. With respect to your review of the initial death, did you have qualified medical professionals on your review team . No, sir. Just to clarify for the committees consideration, those two reviews were actually investigations conducted by our office of investigation of the two deaths of the children in custody. We didnt have at the time any medical professionals available for staff. As i indicated in my Opening Statement based on the enhanced funding youve provided this past fiscal year, we are contracting out to have a team of Health Care Professionals augment any of our ongoing or projected work in the future. Audits, inspections and investigations. So at the time, based on what you just said, at the time of your review of the deaths, you did not have on staff or contracted any medical personnel . No, sir. Dr. Mitchell, youve heard my question. In your professional opinion, do you think if youre looking at a death of any kind that a medical personnel would be important to the team . Absolutely. I think especially deaths in custody. Deaths in custody require fatality reviews. Most fatality review panels need to be multidisciplinary and that, therefore, youre going to get the recommendations. So it will depend what youre trying to get out of the investigation, but from a fatality review construct, you need to not only have clinicians like pediatricians, if its a child death, internists if its an adult death, but also a forensic pathologist or medical examiner so they can interpret the findings at autopsy. All that have is going to be required in the future if its going to be helpful. Thank you very much. Mr. Cuffari, according to your report, Border Patrol agents stated they were in contact via text message with felipe when felipe was transported to the hospital the first time, the morning of december 24th. Do you have copies of any of those Text Messages in your file . To my knowledge, sir, no, we do not. So you put in a report information that you could not document . We documented, sir, to testimony from the Border Patrol agents and their supervisors, all credible testimony. I understand that but nobody thought to get a copy of the Text Messages or anything like that . Not to my knowledge, sir. Well, did the inspector Generals Office pull or review any emails or other electronic messages involving cbp personnel regarding felipes care or death . Not to my knowledge, sir. Thank you. I now recognize the Ranking Member of the full committee for questions. Thank you, mr. Chairman. I think it would be more productive if i yield my time to our colleague from tennessee. Mr. Chairman the gentleman from tennessee is recognized for five minutes. Chairman, Ranking Members and witnesses, thank you. The hardest part about being a doctor is sometimes you do everything you can for a patient and they still die. Mr. Chairman, i would like to introduce myself. Theres a few things ive never shared, but today its important i do so. I graduated in the top third of my med school class, attended the number one Residency Training in the nation. All three years in residency scored number one in the nation and, yes, we beat those harvard doctors, too. I deployed all over the world in some of the most remote places on the planet, provided medical care to children of afghani villagers and battled Hardened Navy s. E. A. L. S and have never been sued for malpractice. I served as medical director for four major Emergency Departments in states ranging from depressed rural to a level two trauma center. I was ceo of a company of Emergency Physicians and pas and Nurse Practitioners that ran 52 Emergency Departments in 11 states and served as both defense and plaintiff experts on medmal cases doing this, assessing care given n. This case first by cbp and then medical facilities, both of these cases are about pediatric sepsis. First a few facts about pediatric sepsis. A review found that even when a patient goes to a stateoftheart Emergency Department, the mortality rate for sepsis in america was 10. 3 in one, 8. 9 in another, 14. 4 , and 19 respectively, even when the patients present to eds in the u. S. , many still die. Why is this disease process so hard to treat . Like was said in testimony, children dont look bad until the very end. When i trained residents we called it the pediatric cliff. They look great and then crash in seconds. I appreciate the written testimony of our pathologist who honestly reported that in both cases he felt, and i quote, the actions taken by individual u. S. Cbp agents seemed appropriate and timely, end quote. Dr. Mitchell understands that standard of care depends on where you are and the facilities available. The reality of Rural Health Care is millions of americans arent able to walk into a harvardquality care. The standard of care at mass general on a day will never be comparable to triaging migrants in the dark of the night. Dr. Mitchells testimony is balanced and professional. Its not political hyperbole but suggests the federal government has the ability to Deploy Doctors to remote areas and do a variety of tests which is simply unrealistic. Dr. Danas testimony critiques the conditions of cbp facilities going on about lack of tooth brushes and clean water. I know from my own visits and the facts in these cases those allegations are simply false. She discusses the psychological dynamic of one patient, do not share to agents as if the dynamic is the Law Enforcements fault. He didnt say jakelin was sick even when he asked. If a patient lies about their medical condition, its not the doctors fault. Look, both of your temperatures center around getting more resources. You want more doctors and Electronic Medical records. The u. S. Is short 14,494 doctors. Where in the world will we get doctors to put somebody at every single crossing site . This testimony proposing Building Health care infrastructure for Illegal Immigrants that would dwarf the systems in 77 of Rural Counties in america. Last year House Democrats voted to advance electronic records when veterans dont have it and wont have it for seven years. Finally this side of the aisle spent all of last year highlighting how dangerous the journey to our border is for kids. 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. The chair recognizes other members for questions they may wish to ask witnesses as previously outlined, i will recognize members in the order of seniority alternating between majority and minority. Members are reminded to unmute themselves when recognized for questioning and to leave cameras on so they are visible to the chair. The chair now recognizes for five minutes the gentle lady from texas, ms. Jacksonlee. Mr. Chairman, thank you for holding this very 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 of 2018 two children died in separate incidents while in the custody of u. S. Border patrol, the first deaths in more than a decade. I want to be very clear that when you lead a nation, all that happens, whether you like it or not, falls at your feet. Ive known Border Patrol agents and visited with them in my state of texas for decades. Ive seen their passion. Ive 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 in 2018, u. S. Customs and Border Protection the Border Patrol Parent Agency issued an interim directive in 2019 establishing new medical screening and other procedures. I physically went down to the border and saw the immediate emergency tactics that were used. It was a table and the use of coast guard doctors. They all meant well. Dr. Danaher, thank you for your leadership. As this falls at the feet of the president of the United States and the administration and we have to adhere to protocols, can you elaborate on the differences between pediatric disease processes and adult disease processes so that when you know a child may be sick and why understanding the nuances of each is important especially in these situations. Dr. Danaher . Certainly. So children are different than adults. They can compensate in different ways for infection than adults can, and as dr. Payne mentioned they can look well before they crash. That is all very true. I think its really important for there to be pediatric efforts at the border. That doesnt have to mean pediatricians. It means intense training for emts who are already working. Currently emts in new mexico we get about 10 of treating pediatrics. Which only amounts to a few hours. Its incredibly important to be able to recognize. And you understand Border Patrol agents are not doctors, theyre not emts, not nurses, correct . Correct. And so it would be your view that minimally a nation as powerful, as rich as the United States could recognize the importance of those nuances and have a system in place that would deal with pediatric issues or children who in lifeanddeath situations i didnt hear you, im sorry . Yes. To mr. Cuffari, you did a report. There was some discussion that cbp officers tried to engage with the parent. Do you know what language they spoke to jakelins father . I believe, maam, jakelins father indicated on his inprocessing paper work he was fluid in spanish and they would have spoken to him in spanish. My understanding is that he spoke his indigenous language. Did anyone try to speak to him in that language to make sure he snu understood . Not to my knowledge, maam. What elements of change would you recommend or did you recommend in light of the two deaths of children that had never happened and certainly didnt happen with the mass migration during the Obama Administration . As i mentioned in my Opening Statement we have three ongoing projects to look at the matters that you just asked about. These are 3 of 21 i have in my prepared statement and we will make recommendations based on what our fouindings are and hol dhs accountable for implementing those recommendations. And the recommendations that you are looking to is framed around two deaths and as well no response, kindly enough, to save those lives. Were looking at the circumstances that surrounded the deaths, the medical care and access and the capability of being provided by dhs. To the children this custody as well as other adults. We have 3 million plus covid deaths in the United States. There will be major investigations dealing with the responsibility of this administration in 3 million cases, let me correct myself, 3 million plus cases rising to 140,000 deaths, maybe 137,000 deaths. 3 million plus cases, making sure the record is clear. Many of those cases are in states like texas, new mexico and even mississippi and others. And 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 directions as to how that is remedied. The loss of a child is precious. I give my deepest sympathy to the families and, therefore, we must make sure that we direct it. I thank you, mr. Chairman, and i yield back. Thank you very much. The chair now recognizes the gentleman from new york for five minutes. Thank you, mr. Chairman. Having lived on the border and prosecuted cases in the mid90s the border and the porousness of the border was a problem and attracted more and more people. And tragedy resulted back then and is still happening today. Its a terrible thing to lose a child. I will note its an incredibly complex issue, much more complex than some of the dialogue today. I would like to defer to my colleague, dr. Green, to take my time. I yield to him. We are calling to connect you to our Live Conference call but it appears the chair recognizes the gentleman from tennessee for the balance of the time. Thank you, mr. Chairman. Dr. Mitchell, you mentioned in your testimony resource hurdles prolonged cbp custody and delayed access to medical care. I agree. The efforts led by House Democrats to defund i. C. E. Have had sweeping consequences mainly impacting cbp facilities such as what happened in december of 2018. I. C. E. Family Residential Centers were at capacity forcing cbp to hold immigrants much longer than they should. The bureaucracy exasperated by the border crisis preventing those cbp custody from reaching i. C. E. Facilities built for longterm holding and for more through medical assessments than access to care. My question to you is do you support additional funding for i. C. E. Capacity and medical staff to ensure children dont get stuck in cbp custody like they did last year . Yeah. I think that any funding thats going to go forward to resolve this issue must go forward to decrease any overcrowding burden. Ill leave it up to the house and the politicians to understand where exactly agencies get those resources. I think you and i agree, dr. Green, that overcrowding conditions is a major concern particularly talking about infectious disease. The issue of timeliness and that i wanted better access to health care there at the border, i agree. I think physicians would be a hard burden, a hard bar to reach. I believe theres opportunities as my colleague dr. Danaher described. Higher training of the emts, nurses, Nurse Practitioners that are available there to make sure that the burden is not placed on our agents to try to triage these patients. I really appreciate your comments, and i think, clearly, we, on our side of the aisle, would like to see more funding for i. C. E. There are a lot of people, and especially the detention facilities, a lot of people want to defund i. C. E. I want to follow up one more question, dr. Mitchell, for you before my time expires. You indicated in your testimony you think jakelins death could have been prevented in the initial Health Assessment questionnaire if it had been performed by a licensed medical provider. You may not know this but yesterday dhs not dhs but hhs released the doc shortage. 77 of americas Rural Counties right now are short both doctors and pas, and by 2032 thats going to be 121,000 short. Where do we get these medical providers . Do we take them from American Cities . Im eager to hear your thoughts on that. No, and, again, i think the shortage of medical providers across the nation as you describe. I just dont believe the recommendation of providing Adequate Health screening to whoever we come into contact with stops being a recommendation because the hurdles and barriers are too big. I think our job is to try to create opportunities where we can meet the goal of saving lives wherever it exists. And so, no, not taking away from anyone but attempt to provide it to everyone. Yeah, we just have to be realistic in our solutions and find solutions that work, and your recommendations were a licensed medical person and with the shortage we already have, i dont see how that can happen. I think my time has expired, mr. Chairman. Thank you. The chair recognizes the gentleman from louisiana, mr. Richmond, for five minutes. Thank you, mr. Chairman. And 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, thats what were doing in terms of access to doctors, i just wont entertain it. We are the greatest country in the world. Dr. Mitchell, could you just, for me, in laymans terms explain what felipe died of . Yes. So felipe, he died of he had a bacterial infection that was superimposed on flu. So everybody know what is bacteria is when i say it. Its a small or beganigan its a small or beganigaism tha cause infection. This particular type he had, he had flu and then that flu had a bacterial infection on top of it. It was the type of infection he had was so severe that it caused a rapid disease within his lungs. And so he died from a hemorrhagic pneumonia or sepsis. And so thats functionally what he died from. Dr. Danaher, let me ask you, and i think both you and dr. Green mentioned the uniqueness of treating children and when the symptoms show. Does it require special training to determine how severely ill a child is . Yes, i would say it does. Miss gambler, in your written statement it says that the report youre releasing today has found, and i quote, cbp does not provide offices and agents with training to identify medical distress in children. Is that correct . Yes, that is our finding. And to the Inspector General in reviewing felipes death, did your review show those training him, if so, what did your offices review find . You need to unmute yourself. Still not able to hear you. Looks like im sorry, mr. Chairman, my computer froze. I had to come back into the meeting. Im very sorry. Let me repeat that question then. In reviewing felipes death, did your office examine whether the agents who were responsible for caring for him receive training in identifying medical distress in children . If so what did your offices review find . My understanding is the Border Patrol is trained in basic first aid, cpr and trauma care. They also have advanced paramedics in several stations. In this case,the case of jakelin, there was a paramedic who happened to be at that station. I didnt find any evidence of pediatric training at all. Well, it was also clear that felipes father asked for him to be returned to the hospital in a sense of urgency. It took about an hour before they left the station. So 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 about cbps policies and practices for dealing with emergencies that should be reviewed . One issue in the time frame is whether anybody is actually entering the time. What i could tell from the records that were available checking through the cell door, but its not clear that anybody took a close look at felipe. If they had [ inaudible ]. And to the Inspector General, if possible, could you either forward to us or articulate any recommendations or policy revisions you have after reviewing felipes death in the file surrounding it . Sir, we have with that, mr. Chairman, i yield back. You can answer the question. Thank you, mr. Chairman. Sir, as i mentioned we have ongoing projects to look at that exact question, and well be happy, very happy, to provide the committee with our recommendations once we finish those reviews. And you said thats the end of december, right . We should have one some time toward the end of this year for you, sir. Thank you. The chair recognizes the gentle lady, ms. Lesko, for five minutes. Thank you, mr. Chairman, and thank you for those testifying. When i read the accounts of the two Young Children dying, i mean, its very sad. Im sure all of us can agree it was sad, and we wish it didnt happen. But if i heard it right, dr. Mitchell said both deaths were preventible and blamed the customs and Border Protection agency. And dr. Danaher said customs and Border Protection agency was at fault. And after reading the igs report of what all happened, i really fail to see how you came to that conclusion. I mean, first of all, you have in the young girls account she entered the u. S. And was apprehended on december 6th after traveling, i assume, thousands of miles. The cbp asked if anyone was sick, because they wanted to get the sick people on the first bus. And they didnt say anything. Then they didnt fill out they said actually on a filled out form that they were not sick, that they were healthy. And then the father didnt say anything to the cbp officers that his daughter had been vomiting, and he told the bus driver that his daughter was vomiting but didnt tell cbp. So then they got off the bus first after they found out from the father, and the emt gave immediate medical care. And it was only then that the father told the emt that his daughter had been vomiting and not eating for two to four days. So 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 didnt write that he had influenza b. Didnt give medication, the aapproxima hospital error instead of cbp error. My question to mr. Cuffari mr. Cuffari, in your investigation, have you determined either one of these parents, the parents seek medical care and the child received medical care before they were apprehended by cbp, especially the girl who had been sick for two to four days . It doesnt sit down as though the investigation found that had been the case. The first medical treatment was once they came into cbp custody in two different instances, one at the facility at the checkpoint. Thank you. And, mr. Cuffari, do you think the cartel would have given them medical care . I mean, the accounts ive heard about the cartel, they could care less about these people. They just make money off of them. Representative lesko, thats beyond the scope of my testimony for today. You know, its my opinion that 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 . They should be partially accountable for childrens death if the parents dont tell the medical people or customs and Border Protection that their child is even sick. Theyve been traveling thousands of miles. I mean, i just think its unrealistic to expect the customs and Border Protection to just know that these things are going to happen. To me it seemed like they went over and beyond trying to help these children. I have a few seconds left to give to dr. Green. The chair recognizes the gentleman from tennessee for the balance of the time. Thank you, mr. Chairman. A very quick question to dr. Danaher. Have you done med mal cases, reviewed cases before . No. You obviously reviewed the records here. What stood out to you about the resuscitation in this case of felipes resuscitation when you reviewed that case . In terms of when he presented to the hospital the second time . The second visit when they tried to resuscitate him, was there anything that jumped out to you as a physician on that resuscitation documentation . I mean, there were definitely some irregularities in terms of what happened when he reached the hospital. But he arrived already pulseless. They had a really difficult time intubating him. There was a significant amount of blood in the airway with failed intubation. If i could just say answer the question i know youve played guess what im trying to ask you before as a physician, but he was incorrectly intubated and they continued the resuscitation for several minutes with the breathing tube down his esophagus. Clearly that you cant resuscitate a patient and hes not getting oxygen for several minutes in resuscitation, thats problematic for saving the childs life. I yield. The chair now recognizes the gentleman from new jersey for five minutes, mr. Payne. Thank you, mr. Chairman. I appreciate the opportunity to be here today. It is very interesting to listen to the gentleman from tennessee who has stated that he has been on the defense side and the prosecution side of these issues. Also when my other colleague mentions that, you know, its the cartels fault, were all responsible. Were the legislative body of the United States government. Were 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 didnt have anything to do with it. No, this is abominable. This is abominable what im listening to. Two children have died. I put my children in that position. All of us need to put our children in a position, and i think we might take there might be a different tenor to this hearing. I only have five minutes. Dr. Mitchell, can you explain how and why video footage is important to understanding all of the circumstances surrounding a death in custody . Yes. I was one of the primary authors on the death in custody and how to report, examine, investigate and report out deaths in custody put out by the National Association of medical examiners. And part of what that organization calls for is, indeed, any information thats available for deaths in custody which includes any video footage, any medical records, anything that is to give an idea of the time leading up to the death is going to be important to categorizing the final findings at autopsy. Thank you. Inspector general, can you discuss the video footage you obtained and reviewed regarding felipes death . My understanding, sir, is the footage was obtained regarding while felipe was in custody, trained criminal investigators reviewed that footage. And they determined that the footage married the testimony of the Border Patrol agents. Okay. Is the footage is there footage of felipe leaving the station to travel to the hospital on that evening on which he died . You know, sir, i will have to get back to you on that specific question. Okay. Did you review any as peck of the cbps collection and retention of the video footage of the individuals in custody as part of the review of felipe or jakelins death . Im not sure i understand the question, sir. We did obtain the video footage concerning the time period in which they were in custody. I dont believe we took any other footage outside of that time frame. Okay. So you didnt review it or any aspects of how it was collected and retained, right . The collection and retention would have been done by our criminal investigators or by cbp opr agents acting on our behalf. So there would be in the report some mention of that, correct . To my knowledge, necessary. Mr. Chairman, how much time do i have . I know im getting close. The gentleman has one minute left. Thank you, sir. Inspector general, how many times did Border Patrol officers conduct wellness checks of felipe on the day he died after he returned from the hospital . The first time and before he left the station for the hospital for the second time. How many times was he checked on . The exact number i couldnt give you, sir. But from the report of the interview felipes father and consistent with Border Patrol testimony, the father said that the Border Patrol agents checked on he and his son five to six sort of every five to six minutes while they were back in the facility after their first visit to the hospital and before their departure the second time. Okay, thank you. Mr. Chairman, i yield back. Thank you, sir. Thank you. The gentleman yields back. The chair recognizes the gentleman from louisiana for five minutes, mr. Higgins. Mr. Higgins is gone. Okay, thank you. The chair recognizes the gentleman from tennessee again for five minutes. Thank you, mr. Chairman. And i just want to say we are responsible. I can tell you i will never forget the first child that i had to pronounce. The child had been hit by a car. And the image of that mother bringing that child in in her arms is forever burned in my brain. The loss of these two children, it is tragic, but what were doing here is a forensic examination of the record to find where fault happened. This is designed to find where there is fault. And so it takes an objective setting that aside and looking at the case. And so i want to ask dr. Danaher again the records are pretty clear the father of Young Jakelin was asking for medication from his fellow travelers before entering into the United States. In fact, since the antibiotic he had on his hands was fragile, not the best for strep infection, they probably didnt get that prescribed by a physician, he knew she was sick and he failed to disclose it. You mentioned in your written testimony about the environment of a person answering questions to Law Enforcement being a barrier for jakelins father telling the truth about his daughter being sick. And i want to ask you, are you suggesting that theres some kind of new standard of care that if a patient lies about their medical condition the physician or that provider is somehow liable . Not at all. What im saying is that the initial screening that occurred when this large group of migrants arrived at the Forward Operating base was, from what i can gather, one agent yelling to more than 100 people that if anybody was sick, they should come forward. They yelled this in spanish. We dont know if the father heard them, if he understood them. On top of that were asking people to come forward in front of a large group of people to talk about their medical issues which, as im sure you appreciate, can be very sensitive for some. Do you have children yourself . I do. Can you imagine having a sick child and not wanting them to know about it . I dont understand that dynamic. Ive taken care of a lot of pediatric patients in the e. R. And those parents are afraid. They come in and they want to tell you. I dont know why a father would specifically lied, and he asked in spanish and he responded in spanish so he clearly understood spanish. So i think that there is a difference between being able to speak a little bit of spanish, for instance, to share sensitive or nuanced medical information in spanish. On top of that the questions on the Health Interview form are very nonspecific. Theres one question about any type of illness. And the rest are about irrelevant to jakelins case. It hinges on whether the father understood that one question. I dont disagree with you that a form review could make that form better. I cant make cbp responsible for a guy who says his children are okay when asked if theyre medically ill. Lets flip to felipes case, and i only have a little bit of time. I will get right to it. You made some very, i think, appropriate comments about his first visit. I want to you tell the committee what you thought about his care when he was first brought to the hospital at gcrmc and whether you think they should have let that patient go home. No, they should not have let him go home. I agree with you the care is very concerning during his first presentation. His vital signs were significantly abnormal, his heart rate was elevated even when he didnt have a fever. His oxygen level went as low as 91 at one point. Its not clear that anyone noted that fact. The physician who saw him later acknowledged that he had not assessed felipe before the child left the facility. Yeah, and i didnt see any assessments for hydration status, tears or moist mucous membranes. All of those things that would be standard of care this is an american physician at an american Emergency Department, and they let this kid go home. My question is, you know, would a normal Law Enforcement officer question a physician like that . Is he trained enough to question the physician . Whats interesting in this case is it appears the Law Enforcement officer did. He advocated for felipe to receive more care before they left and continued to express concern after they left, which says to me that they could recognize that he was quite sick. Yeah, they definitely recognized the care given was pretty shoddy. I think he had to ask to have the temperature taken. Thank you. I yield, mr. Chairman. Thank you very much. The chair recognizes the gentle lady from new york for five minutes, ms. Rice. Thank you, mr. Chairman, and i would just first like to thank the Inspector General for being here today. I only wish that you had been available when we did a hearing on these two terrible deaths back in january. And you would not come to that hearing. Im glad that you are here today. Would it be fair to say, mr. Inspector general, that in the course of reviewing felipes dea death, you clearly dont come to a conclusion that the cbp did anything negligent or inappropriate. Would that be correct . Thats correct, ms. Rice. So would you say its fair to say the Border Patrol agents were not properly trained to be able to comply with the teds standards involving a detainee with difficulty breathing, would you say . I would say that based on the training that the Border Patrol was provided and had at the time that they complied with the standards upon which they were being judged. Let me read from the teds standards, it states, and i quote, Emergency Medical Services will be called immediately in the event of a medical emergency, for example, heart attack, difficulty breathing, and the call will be documented in the appropriate Electronic System of record. Officers, agents must notify the shift supervisor of all medical emergencies as soon as possible after contacting emergency services. Now, according to your review of felipes death on the day he died felipe was observed to have difficulty breathing and complained about pain in his stomach. An agent reported he asked felipe and his father if he wanted to go to the hospital and both declined. Do you think that was appropriate behavior . At the time it was deemed appropriate. What do you know at the time . Do you have any information now that would lead to you come to any different conclusion . Thats why were doing the reviews and evaluations i mentioned at the beginning. Well be looking at those issues. Dr. Danaher and dr. Mitchell, are there issues of informed consent that could come into play in situations in which cbp personnel are asking children and parents if they want to go to the hospital particularly if they have already been to the hospital on that same day . Would you like me to respond first . Sure. Yes. I think there are multiple issues here. 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 they are in detention they are they may perceive themselves as being at the whims of the Border Patrol agents, and they may not want to make themselves a nuisance because we have to remember six months prior to this Border Patrol was separating parents from their children and there is real reason for people to be afraid of what might happen. Im not suggesting that agents did anything to intimidate the family at all. Im just saying the dynamic of being in detention makes it very challenging for parents to advocate for medical care for their children. Let me just also say i think everyone at this hearing would agree there were mistakes made at the hospital. Clearly he never should have been released that first time. Theres no question. I dont know if theres an investigation into the treatment, the medical treatment he got at the hospital or not but there should be for sure. Any attempt to blame the parent in this situation, felipe when he came into custody was a perfectly healthy child. He got sick while 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 that he was they were apprehended and when he died. They could have paroled him. That was well within the discretion of authority, the government, at that time. And let me also say that i was happy to hear dr. Green talk about how important it is to invest in our Health Care System. No better time than now for us to discuss this as were dealing with a pandemic and we are seeing the way our Health Care System works for people of color and people in certain socioeconomic backgrounds. Im glad to hear dr. Green talk about how important it is to invest in this. I think we all have to agree that children present at the border, and our primary responsibility to them is to keep them healthy and not have them die in our custody. And so we have to make the system work better. I am not blaming these cbp officers because theyre not medically Trained Personnel. But then that means we need to have medically Trained Personnel at the border. And my colleague, ms. Underwood, given her background and her repeated trips to the border before this whole pandemic happened, was calling for just that, a more comprehensive health check for every single child who comes into the custody of cbp or i. C. E. So i just want to thank all of the i. C. E. I just want to thank all the witnesses for coming today, and i yield back mr. Chairman, thank you. Thank you very much, chair recognizes the gentleman from texas, mr. Crenshaw. Thank you, mr. Chairman, thank you for holding this hearing. My first question is for ms. Gambler from gao. The line items on medical care you mentioned, those are from the emergency supplemental, correct . Yes, sir. And that all occurred after the deaths in question, correct . The emergency supplemental was enacted last summer, july 2019. Right, but the spending occurred the spending occurred then after enactment so, yes, sir. This is not in the same time frame. The gaos findings dont have a causal relationship to the child custody deaths in question. Just to confirm, there are two completed ig investigations, one continuing ongoing, correct . Concerning deaths in custody, sir . Yes. Yes. Thats correct. And of the two completed investigations, the ig determined that all cbp employees who were involved in Everything Possible to ensure both children receive medical treatment and there was no misconduct or malfeasance, correct . Thats correct. And from your testimony, it sounds like the main issue here is overcrowding, correct . It was an issue in the event we raised during our unannounced site inspections of cbp facilities in 2019. We issued whats called the a Major Management alert, and they implemented procedures to ale alleviate the overcrowding. Im told that they would complete that by the end of this year. It raises the issue weve long raise which hs which is thn its overcrowded, it raises the question of the purpose of the hearing. If theres any evidence of malicious intent by cbp, i think this hearing would be warranted but there is not. This hearing appears to be designed to at worst to drive a false narrative that implies Malicious Behavior by cbp, at best were seeking to falsely imply that these tragic deaths could have been presentvented b better action, even though the childrens parents brought them across our border in extremely poor health. These false narratives they lack context, assuming that the purpose of border stations is to provide hospital level child care. Of course, the truth is the purpose is, in fact, customs and Border Protection. When i went to the Rio Grande Valley sector late last year there was a humanitarian crisis unfolding. January 2019, there were more than 58,000 apprehensions. In february, that climbed to more than 76,000. Total border numbers spiked 144,000 in may. Lets also keep in mind, these were not typical single male economic migrants, they were mainly family units and unaccompanied minors, more than 76,000 in 2019. Migrants are handled differently and completely overwhelmed our Border Control processing sectors. This crisis unfolded in early 2019, we were sounding the alarm. It was ignored. The crisis was, quote, unquote, manufactured. They didnt vote on an emergency supplemental appropriation until late june. By that time there b had more than 750,000 apprehensions or inadmissibilities along the southwest border. Why are we holding this now . I have to wonder is it because demonizing Law Enforcement is popular right now . Our Border Patrol agents havent been targeted enough lately . Each of those children who lost their life is absolutely tragic. It is also shameful to try and put the blame on our cbp officers and Border Patrol agents, and i think we could engage in some intellectual honesty and highlight the fact that in the past 18 months k, 475,000 agent hours have been transporting children to hospitals. As we know, those who make the trek do not make it here in the best condition. 80,000 migrants in distress, whether rescued from the Rio Grande River or found in need due to dehydration, injury or pregnancy complications, have been rescued by Border Patrol. We could also mention the Border Patrol search trauma and rescue teams, which was created in 19 9d 8 to respond to injured Border Patrol agents in remote locations. Now their main mission is rescuing migrants in distress. We could discuss the number of on the front line of keeping drugs and other contraband out of our country. Positions priorities remain clear. To let our officers and Border Patrol agents know we appreciate your service, we appreciate what youre doing utmost difficult of circumstances, we do have your back. Thank you. I yield back. Chair recognizes the gentle lady from michigan, ms. Slotkin for five minutes. Thanks very much, chairman. So id like to pivot to talk about something that actually mr. Crenshaw raised which was the special appropriation, the emergency appropriation that we passed last summer, and you know, this particular im interested in the 112 million we appropriated to provide for detained medical care and necessities. We passed this 4. 5 billion supplemental, i voted for and many folks sitting here watching voted for it. I wrote to the acting secretary about this just to make sure we understood how that 112 million was being spent. Got a response back about eight months later from cbp just in march. So can you help us understand and elaborate on the findings regarding cbps 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 consumables and medical care caroline item for some goods and servic services that fell within the definition and meaning of consumables and medical care. That included hygiene products, clothing, gloves, masks, but we also we also found that cbp obligated funds from that line item for goods and wservices tht did not fall within the definition or the meaning of that line item, the primary purpose of that line item, and that included things like goods and services for cbps canine program, Computer Network upgrades, Facility Services and upgrades, and we concluded that cbp violated the purpose statute under appropriations law and we concluded that cbp should make adjustments to its accounts accordingly. How much do you believe of the 112 was misspent on things that were not intended . At the time of our work for the legal decision, congresswoman, cbp had not completed its review of the obligations it made under that line item. After we provided a copy of our draft report to cbp, they reported to us that they completed that review and they identified 13 million that they planned to adjust among accounts from last years emergency supplemental and at least 3. 9 million that they plan to move from the consumables and medical care line item to cbps regular appropriations. I would just note that given the time frames for our review, we have not reviewed that information that cbp reported. Okay. I mean, i guess i would hope this we all everyone on the committee cares about how the money that Congress Appropriates is spent, and that was certainly concerning. Can you give us your assessment of this 112 million . Are you formally doing an ig review of the expenditure on this money . Yes, madame congresswoman. We have an open audit thats going to look at cbps use of fy2019 appropriation funds for humanitarian assistance. Were going to check with our colleagues and cousins at gao and make sure that we get all information thats available and whats the time line of your review . When do you expect to be complete . We just opened that a few weeks ago, maam. So a couple months. I cant give you a definitive time line. I just think its important, and i would love to hear your commitment to come back and talk to us about that. Its just one of those things, its our primary responsibility. I literally have no sort of piece of this, you know, and special knowledge of it. I just think we all are saying from various, you know, angles that we want you know, this issue to be resourced well to the best of our ability to support cbp so that they can do what they need to do on health. So can you commit mr. Cuffari to coming back and testifying in front of us thois issue . You have my continued commitment. Chair recognizes gentleman from pennsylvania, mr. Joyce for five minutes. I want to thank all the witnesses for appearing today, and i want to thank you mr. Chair mab ffor making the commi room available. I would like to yield my time today to my distinguished colleague from tennessee, dr. Mark green. Chair recognizes the gentleman from tennessee for the balance of the time. That you think, mr. Chairman. I want to first thank congresswoman slotkin for her questioning. I thought i echo everything she said and agree with her 100 and look forward to hearing back from the department on those funds. That really is one of our primary concerns. I also want to appreciate the fact that congresswoman rice recognized and reiterated the need for america to address this physician shortage. We have significant physician shortages now, and its only going to get worse in the coming years. My point in bringing it all up is that we had testimony from witnesses who said we needed licensed professionals. My conclusion from all of this is we cant take those people where americans arent even getting care and put them on the border. What we really need to do is give advanced training to our cbp personnel and make sure theyre better trained to do those kinds of assessments because i just dont think its feasible to put licensed medical personnel down there. I also want to say that i agree with dr. Daniher that the pediatric cuff, the pulse ox would have been helpful. But i can tell you when jake lynn was posturing, it would not have made a difference in this case and to say so is a little bit misleading. Also, as a doctor, you know, ive provided care from ooet yo ethiopia dr. Mitchell, i wanted to ask you what areas of the hospital, what areas of hospital care and care of a patient do you recognize as the highest risk for medical errors . Well, in my experience ive seen medical errors in the surgical suite. Ive seen medical errors in the icu. Ive seen medical errors upon presentation, talked about the poor intubation of one of our patients, so you know, where medications are prescribed and infused, you can see medical errors, so theres several places within the system where you can see them. Jacob has done some pretty Extensive Research on this, the joint commission on hospital organizations. Theyre the folks that accredit our hospitals. Theyve done a lot of research on this and those transitions of care are fraught with risk. When one provider hands a patient off to another provider going from the Emergency Department to the icu, a shift change is an incredibly high risk time, and the gentleman from louisiana, i mentioned that pick up time when one of the officers was going off shift with phillippe, particularly and another came on, gassed his car up, got there a few minutes late, but when he got there, if youll recall from the testimony, tell us what that officer did and how he responded when he discovered the severity of the situation with phillipe . Well, i think the Border Patrol agents acted swiftly to engage the patient and try to get the patient to care, and that was that was evident throughout the record. Do you think there was anything else they could have done . No, no. I think the agents are acting, you know, particularly in phillipes case and quite frankly in jacquelines case, these agents when they became aware, they moved to make sure that those individual patients got to care, and so you know, they, i dont think, probably are as equipped to recognize the things that they needed to recognize, and so we talk about that training. We talk about making sure that we have adequate personnel that is doing that work and not putting it on agents whose job it is to protect in a different way the border, but, yeah, i think the actions were swift and accurate. Thank you, mr. Chairman, i think my time is up. Thank you very much, the chair recognizes the gentleman from california, mr. Correa. Thank you, mr. Chairman for holding this most important hearing. Can you hear me . Zb yes, sir. I want to thank the witnesses as well. Id like to direct my question to dr. Daniher and dr. Mitchell. In january 2019 following the deaths of two children in cbp custody of december 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 directive required the Border Patrol to conduct a h Health Review and medical assessment of all migrants under the age of 18. In december of 2019, cbp issued a final medical directive, and that final directive appears to be weaker than the interim directive. For example, it only required medical assessment of children under 12 rather than children under 18, and dr. Daniher if i may ask you a question, have you had a chance to review the interim and final medical directives . Yes, i have. Do you see other deficiencies and a final medical directive . Yes, sir, actually, a number of issues that i find quite concerning. Please elaborate. Sure. One is the time frame. The initial directive, as i recall, explicitly stated that these Health Interviews should occur upon initial processing. Whereas the final directive does not state when it needs to occur. It also narrows the scope of what is considered a basic medical screen. Vital signs could have made all the difference if somebody had been paying attention. As you mentioned in early mandates medical screenings for children under 12 or those who have identified medical issues. It includes a caveat. This is subject to availability of resources and operational requiremen requirements. We have to remember that two of the children who died in the time frame we are discussing were 16, and so its unclear to me why were reducing this cutoff to the age of 12. It also seems to reduce the qualification required for performing medical screenings saying theyll be conducted by Health Care Providers where available, and it does say that acute medical care referral and followup can occur on site, which on the surface is good. We want there to be medical service on site. We want to make sure that does not mean children wont have access to pediatricians when they need them. Earlier this year the American Academy of pediatrics submitted a statement for the record to this committee, which it stated that the final directive, and i quote, open 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, would you agree with that assessment . Yes, i do. And what changes should be made to the final directive to ensure that the adequate medical assessments are conducted on all children . So as these cases zwhooithat discussing illustrate, its extremely important for Health Interviews to occur in a timely fashion, and they need to be performed by somebody who has at least some basic medical training. That could be an emt. We also need to make sure that these Health Interviews ask directed questions so patients understand what theyre being asked about, and we need to make sure that medical screening is offered across the board. We dont want to be missing children just because were saying that its the onus is on the parents to speak up when they know something is wrong. Plus, these children are in custody there, its the responsibility of cbp, and we need to make sure theyre all healthy. Thank you. Mr. Chairman, how much time do we have . The gentleman has 40 seconds. Dr. Mitchell, do you have anything else to add to this topic of the final medical directive and its deficiencies. I think it illustrates theres a need for a level of training and a level of expertise when dealing with these patients, particularly children under the age of 18. And i think that if were talking about systems and developing better access to systems, then we would put those resources in place to ensure that our children are being initially screened by individuals that have the proper level of training to ensure that we have better outcomes. Thank you very much, and mr. Chair, time being over, i yield, thank you very much. Thank you very much, the chair recognizes the gentle lady from new mexico for five minutes. Thank you, mr. Chair. Thank you for holding this important hearing and im glad that were all here to reckon with these challenges together. Its crucial that we make sure that people in our custody are safe and i want to begin by offering my condolences to the families of jacqueline and felife lee. Since the deaths both of which occurred in the district i serve ive called on dhs and the Inspector General to comprehensively investigate what happened and specifically what holes in dhs policy need to be filled to make sure we arent putting our Border Patrol agents in situations where they dont have what they need to keep kids safe in their custody and to stop more migrants deaths from dying in our custody. This shouldnt be a blame game. This should be looking forward into the future about how we can solve this together. I also want to know these childrens deaths occurred in the district i serve and i agree we must also take action to expand health care for rural americans. I invite all of my colleagues to cosponsor the resident physician shortage reduction act, legislation mr. Catcoand i have championed to train more Health Care Providers as well as training the next generation of primary care doctors act, and physician access reauthorization act, the keep physicians serving patients act, the Maternal Health Quality Improvement act, the nurse act, the National Nurse act, the immediate relief for rural facilities and providers act, the Health Care Work force resiliency act, the save our Rural Health Care providers act, the Border Health security act, and the rural maternal and obstetric monetization of services act. All of legislation i have cosponsored or sponsored to help improve health care for rural americans. Inspector general, in your testimony you noted several new issues of which your office is working on. In your testimony to mr. Crenshaw you stated you have one ongoing information of a death in cbp custody. Is your Office Reviewing any other deaths in cbp custody . Good to see you again, maam. Thank you for the question. I believe that is the only additional death in custody investigation that we currently have. Thank you, sir. I appreciate it. In your testimony today you also noted to ms. Rice that you did not have a single medical professional on your staff during the investigations into jacqueli jacqueline and phillipes deaths. Will your Ongoing Investigation be conducted in the same manner or will any changes be made in how you review that death . Based on the increased funding the house and senate gave us this year, we were able to seek outside medical contracts. Im happy to report that within a few weeks that contract should be awarded, and i anticipate probably by the end of next month those individuals Health Care Providers will be able to augment our inspectors and investigators and our auditors. Thank you. And how specifically will the Ongoing Investigation and the use of medical personnel differ from the investigations into jacqueline and phillipes deaths . They wont at this moment because the investigation is at the very end of its cycle . So you will not supplement that investigation with medical information and expertise . No, we will do a supplemental review, scoping of the entire Border Patrols handling of medical Health Care Providers and services to in custody children. In the last minute, in your testimony you indicated your office is working on a review of and i quote, cbps use of fy 2019 appropriated fun for humanitarian assistance. What exactly will you be reviewing in that work, and will you be looking more closely at the misspending that gao has already identified and congresswoman slotkin discussed in her questions . Certainly, let me just clarify my last response. In this particular case, we have engaged the services of an outside medical examiner in the very last instance, so we will have someone from outside looking at the medical review and the autopsy. So to your current question, what were going to be doing is looking at the great work that gao has tondone. Were going to be expanding on that, looking at whether cbp was adequate by appropriated funds put in effect thank you. And i yield the remainder of my time. Thank you very much. Mr. Inspector general, how long have you had the money to obligate for contracts or servicing . How long has you have the money in the budget . I believe, sir, the appropriations came in january, and we were funded in february and march of this year. So youve had the money about six months . Yes, sir. Thank you. Chair recognizes the gentle lady from illinois, ms. Underwood for five minutes. Thank you, mr. Chairman. Let me be blunt. This administrations treatment of Migrant Children has been appalli appalling. Three years ago the department of Homeland Security implemented a policy of separating families at the border. As a nurse and Public Health expert, im familiar with the data showing that family separation causes trauma that can do both immediate and longterm damage to childrens health, but it doesnt take a nursing degree to understand that. We all know its inhumane, immoral and just plain wrong. Today were trying to get to the bottom of deaths of just two of the Migrant Children who have died in federal custody under this administration. Phillipe and jacqueline are moer among the six children who died on this administrations watch after a decade with zero deaths. Mr. Cuffari, the time line included in your offices report regarding phillipes death states that during his first hospital visit on the morning of december 24th, 2018 he was diagnosed with influenza b. However, the written discharge instructions included with the medical records from his first hospital visit appear to have been for the treatment of, quote, an upper respiratory infection pediatric without specifying an influenza diagnosis. Did your office conduct interviews with any of the medical personnel who provided care to phillipe . No, maam. That was outside the scope of our investigation. Did you conduct a forensic analysis of phillipes medical records to fully understood what the Border Patrol agents were told about the influenza diagnosis or why . We didnt conduct a forensic analysis. We conducted a review of the medical records that we obtained from the hospital and noted in the discharge paper for phillipe there was no indication on there that phillipe had tested positive for influenza b. Dr. Danaher, this report stated crowded conditions presented Health Challenges for on site medical staff in some facilities including containing the spread of contagious illnesses. Phillipe had been in custody for six days when he died, which is three days longer than allowed. Do you believe its possible that phillipe contracted influenza while in cbp custody. I can believe i can actually state with certainty he did because the longest incubation period for influenza is four days. Thank you. Ms. Gambler last fall i joined my colleagues in writing to the centers for Disease Control and prevention to request information about their recommendation that cbp should vaccinate all migrants over the age of six months at the earliest tame. I am certainly disappointed that nobody from cbp is here today to answer questions about why they have not implemented the cdc recommendation. Did your office examine cbps decision to not implement the recommendation, and if so, what did you find . Yes, thank you for the question. We through our work we did identify that cbp has not fully documented the reasons for its decisions not to offer the influenza vaccine to those in its custody. Cbp identified to us a number of challenges to offering those vaccines including things like providing cold storage and the need for increased contracted medical care provider, but they didnt document how they considered or weighed those costs or concernsidered those c versus the benefits that could come from offering influenza vaccine, and so our rengs recommendati recommendation was really geared towards cbp more fully documenting the reasons why they decided not to offer the vaccine, so that as they continue to have conversations about Public Health issues going forward, they can have a record and good documentation of the decisions theyre making. Thank you. Ms. Gambler, i understand from your written statement that cbp claimed that offering flaw vaccines to people in their custody would provide little benefit to their agency because their goal is to transfer people out quickly. As we saw with phillipes case, cbp doesnt always transfer people quickly, isnt that right . That is right. There are reports and i think the Inspector General has reported this as well that individuals can be in cbps custody for longer than the amount of time that cbp is hoping to detain them for that short period of time. Ultimately, from a medical standpoint, we know that there are consequences of cbps failure to implement the cdcs recommendation of vaccination and given the ongoing coronavirus pandemic, we know that individuals who might come into custody would be at increased risk as well. Thank you so much mr. Chairman, thank you to our panel of witnesses and i yield back. Thank you very much, chair now recognizes the gentleman from missouri, mr. Cleaver for five minutes. Mr. Inspector general, i dont want you to please take this as some kind of insult, but in washington candor is sometimes silenced leaving only power as the source of sound. I dont think theres any reason for anybody for me to question any of your integrity, and please understand thats not just a statement im making, and im after another kind of issue anyway, but my issue is do you feel comfortable hello . Okay. My question is i didnt get your question, im sorry. Yeah, my question is do you based on everything that you have seen and heard, we have a number of igs who have been fired, relieved of duty, and 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 . I take your question, sir, i commit to you that i ever felt any pressure to change my opinion for whatever reason, i would come to the chair and the Ranking Member of this committee and other oversight bodies both in the house and in the senate. As you know, i have more than 40 years of Honorable Service as a u. S. Air force officer, and i served every president from jimmy carter to the current president trump, and i stand committed to speaking truth foufouto power, sir. Theres never been anything youve said or done that would cause me to believe others. Im just raising the question because of things that im seeing has happened in washington, things that have happened in washington that are that at least appear to be unsavory. Now, so thank you. You are familiar with the fact that one of the agents who have taken care of phillipe had to pay for the some of the over the counter medication . Yes, sir. Out of his own pocket. Do you know can you explain w what that might have what might have precipitated the fact that someone would have to, you know, go in their own pocket and pay for some medicine for some poor kid that obviously appeared to be sick . It appeared that the prescription for amoks sillxycis covered under their health care service, but the over the counter medication, which was for aseibuprofen was not covere. It was an over the counter medicine. Well, my assumption, mr. Ig, is the agent, we found out that the agent had actually used his or her own money because they were reimbursed. Is that how this came to our consciousness . Actually, i dont know, sir, if he was reimbursed. He did pay for it upfront. I dont know whether he asked for a reimbursement on the back end. Yeah, i was just curious about how we found out about it. And perhaps he mentioned it to someone, which is not unusual for people who are committed and dedicated. My sister is a principal of an Elementary School here in kansas city, and im always, you know, telling her shes going to retire broke because shes buying pencils and colors and all of that out of her paycheck, so i just think thats something that the, you know, agent should be praised for, and he or she is probably not the only one. I feel your pain, sir, my wife is a former High School Principal as well. All in my adult life with my sister, so dr. Danaher, do you have anything that you would recommend to us, you know, to make corrections that this would not happen again . What would you recommend to us . Do we need to put some policies in place . Do we need to do anything that would assure us and the American People that this is not going to happen anymore . Are we going to dramatically reduce the likelihood that it would happen again . So i appreciate the question. I think it is extremely important, as i mentioned before, for Health Care Screening to be occurring as soon as possible after we encounter children, and that needs to be mean that we have people with at least basic medical training out in remote areas like the place where jacqueline was. You know, she had to wait several hours before she could receive medical attention, and that several hour period may have been the difference between life and death. So having people who could at least recognize when children are sick and begin the process of getting them to medical care quickly is extremely important. I think also having better protocols in place to triage migrants to make sure they have access to appropriate medical care, probably, you know, on site if possible, but offer prescriptions on site, overcrowding and all of the other conditions that are promoting infection. Doctor, thank you very much. And i really think that triage issue should be further developed. Thank you, mr. Chairman, i yield back the balance of my time. Well, if you gave we would gladly make that request. Thank you, i will do that, thank you, sir. The chair recognizes the gentleman from texas. Mr. Green for five minutes. Thank you mr. Chairman, and i thank the Ranking Member as well, thank the witnesses for appearing. Let me start, if i may, with the ig. Sir, how many times did you visit the border pursuant to this investigation . Sir, just so you know, set the record straight, i was confirmed by the full senate at the very end of july of last year. Within two months, i went to the border to look at el paso and the tucson sectors. The investigations that the committee is holding a hearing regarded events that happened seven, eight months before even my confirmation. This would have been in december of 2018. Ask whind while you were thed you pursue any actions to further your insight into what happened to these children . Not to the children in particular because these were event that had already occurred. I was looking at overarching conditions at the el paso and the tucson sectors. You actually visited, i take it, the facilities where these children were detained . Not these particular facilities, but except i stand corrected. We went to El Paso Del Norte port of entry in el paso, texas, yes. And 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 were entered, entered the facility . I dont believe so, sir. No. And this is october of 2019. I understand, but the facility is still the same, i assume . Whatever they had is temporary facilities. Theres a facility there thats 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 theyre housed and whether they are given blankets, whether they are kept warm . Did you notice yes, sir. That i noticed that the el paso the el paso Border Patrol station where they had soft sided not soft sided fence but they had large structures that were constructed out of some material. The families were kept together in open bay sort of barracks. They had medical attention. They had hot meals. They had toys that were actually in some cases the Border Patrol agents were bringing them in for the children. Do you think that the facilities are adequate for the time of year when its cold and you dont have blankets, do you think this was adequate . From what i observed at the time on that particular day, that was about a twohour visit. They appeared to be adequate. However, i want to add, just emphasize that we are doing ongoing work to take a look at cbps holding of detainees beyond the 72 hours, and migrants experiencing serious medical conditions. Isnt it true that they upgraded since you were there and they have better blankets and other materials for the children . Thats quite possible, sir, but im sure our inspections and evaluations will identify that in realtime. Lets move to the current circumstance. Do you believe now that we are prepared at the border to receive children who are sick and appropriately care for them . I actually dont know. My intent is to have these 20 different audits and inspections answer that question. Let me just 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 just ask you a couple of questions. Is it true that there has been some question with reference to your ph. D. . That is correct. And is it true that you have signed documents indicating that you have a ph. D. But not that it was in management, and some question about it being in management versus philosophy . There was a posting on our official website when it came to our knowledge that there was a typographical error including that i had a ph. D. In philosophy, not a ph. D. In management, which is what i do have. We made the typographical correction. I also noted, i will add, that there were one or two commas that we recently noticed that we needed to correct as well. Did you ever visit the university where you received your ph. D. . I did on two occasions, sir. And is it true that theres currently a subway and a 7eleven store in that facility . I have no idea. I attended the university from 1998 through 2002 when i was awarded my degree. And is it true that theres some concern as to whether or not this was a meal process for presenting ph. D. S . To my knowledge i did all the appropriate work. I paid for the schooling out of my money. I worked for the department of justice Inspector General at the time. I did this through online learning, and i was awarded the degree that i earned. Im going to yield back, mr. Chair. Thank you. The chair recognizes the gentle lady from nevada, ms. Titus for five minutes. Thank you, mr. Chairman. Id like to go back to that capping report that was mentioned earlier that was issued last month by the inspector Generals Office. That report summarizes the results of the offices unannounced inspections at 14 Border Patrol, is that right mr. Inspector general . That is correct, maam. And as part of these inspections, you reviewed the migrants access to medical care. How far, the capping report states, and i quote, because our office does not have medical expertise, we did not evaluate the quality of medical care cbp provided detainees. So mr. Cuffari, when your teams were visiting these facilities, what kind of field work did you do to assess compliance with the ted standards and did they simply observe what was happening while they were there and do spot checks or did they also do some type of systematic review of records . Just for the record, maam, the time of those unannounced inspections in 2019, we did not have a medical Health Care Provider services contract. Due to our increased funding that you have provided, we have contracted for such augmentation. In their presence at that particular point in time, they documented information. Did 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 the condition that our inspectors saw. And so absent anybody with the medical expertise previously and without evaluating the medical care, can you really confidently assess compliance with the ted standards including that requirement for appropriate care . We follow the council for Inspector General for integrity and efficiency standards. Our auditors and inspector are rated. We have peer reviews. Were going through a peer review, and our inspections and our audit divisions actually this summer, and we base our evaluations on what we observe at the time that were in the facilities. Well, the results of the inspection section states, and i quote, most Border Patrol facilities took steps to try and evaluate and respond to the medical needs of the detainee population. This included conducting medical screenings of all detainees before entrance into a facility. When it says it was all detainees, does that mean literally every single detainee received a screening as you would think thats what all means . And if so, how were your teams able to assess whether every Single Person was screened, particularly in the crowding that occurred in some of those facilities. I take the word all to mean all as you do, maam, and im assuming that what our inspectors saw and documented what they saw, which would be all the individuals at that particular point were getting medical evaluations. It seems to me there are a lot of kind of assumptions and we trust and we believe they did in the report, a lot of these kind of terms being thrown around id like to ask the two doctors if they see anything about the assertions of what concerns do you have, if youve had a chance tree view that capping report, and could you lay that out for us so we might be able to improve on that in the future . Yes, so the capping report as you mentioned seems to acknowledge that there is medical care occurring at some of these facilities. As we stated its very difficult to assess are from the report what the quality or even the extent of that medical care is. Also troubled to see that there it appears that medical screenings are occurring in large groups of migrants, no privacy. It makes me question whether any exams are actually accompanying these screenings or if its just somebody asking the questions. I was also a little bit troubled that there was basically just a photograph of a number of shelves of medications and it was an assumption that those were the right medications that were needed on site for the detainees. Without a physician reviewing that, its very difficult to know if having those medications there is adequate to meet detainees needs. Seems its difficult to assess any of this without a medical expert there, just some officer going in and taking a look around. Dr. Mitchell, do you have anything to add . Yeah, and i think that was the point i was going to make, representative. You know, i think that having, you know, a medical officer thats engaged in the care thats happening at the border, a responsible oversight in medicine but also the review of anything that comes out of this particular, you know, set of circumstances is extremely important. You know, Detention Centers, once people are in them, they really do become, you know, small hospitals. I mean, in general most people are going to be sick in these Detention Centers or jails or prisons within this country, and so its so important to have sustainable medical professionals that are overseeing the care thats happening whether its triage or initial assessment, but overseeing the triage thats happening amongst these individuals. So i would just add that to what were discussing. Thank you very much. I yield back, mr. Chairman. Thank you. Chair recognizes the gentle lady from california for five minutes. Thank you, mr. Chairman for convening this critically important hearing. I service the second vice chair of the congressional hispanic caucus. Last year my colleagues and i toured the Border Patrol station and highway 70 cbp check point in new mexico. I saw firsthand the cell where phillipe alonzo gomez, the 8yearold boy from guatemala spent his last hours and tragically died on christmas 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 foods for people, especially for kids that may be sick. There was a lack of medical supplies. There was only a first aid kit and a small emt bag but no Trained Medical personnel. Cbps lack of immediate and meaningful care for Asylum Seekers are putting Migrant Childrens lives in jeopardy. We even spoke to the officers there who says they are not trained to take care of those who are ill. It was unbelievable to me to see the condition in which a child who was sick would be sent to to wait where theres no blankets, where there is nothing padded but a complete jail cell. Dr. Danaher and dr. Mitchell, i know we have talked about this already today, but i think its very important. Could you please, again, explain the challenges associated with recognizing medical distress in children, particularly Young Children who may not be able to talk or where there may be language barriers . Yes, so it can be extremely difficult to get a clear medical history from a young child, on top of that from a parent who is in distress about their childs wellbeing, and children look different than adults when they get sick. They have much more physiological reserve, meaning that they can compensate better for longer when theyre sick, but it also means that when they run out of their metabolic reserves, they crash very fast. And we run into this all the time in pediatrics where kids come in having looked okay, and then they decompensate very quickly. If action is not taken quickly, then the outcomes can be really terrible as we saw in this case. Thank you, dr. Mitchell. Yeah, you know, again, i would defer to dr. Danaher, the reality of it is that its a matter of timing, and so when we put, you know, trained individuals and not rely on the agents that are not trained to do this work but put trained individuals in position to get people to care or recognize distress earlier, then we have the potential to save lives, and so, you know, thats all with that. Thank you. Ms. Gambler, you indicated in your testimony that cbp is not trained its personnel on recognizing medical distress in children, is that right . Yes, that was one of our findings. We made a recommendation to cbp that they should develop and implement such training for all officers and agents who could come in contact with children in custody. I believe in your testimony it said that cbp and the American Academy of pediatrics have, and i quote, developed a training video on recognizing medical distress in children, which cbp included as part of its training for Emergency Medical Technicians and paramedics, is that right . Yes, that was part of our report. Ms. Gamblers do you know how many cbp personnel are trained as emts and paramedics . We do have that information in the report, and wed be happy to follow up and provide that particular number after the hearing. Okay. I can tell you that when i went to the cbp station there to ask, cbp about phillipe in particular, they basically said they had one person available for three different stations, and they had to rotate him through, so there was just no way to have anybody there for any extended period of time, and you know, there was just a shortage. Ms. Gambler has the video on recognizing medical distress in children been shown to all cbp personnel, not just those who are emts and paramedics . Cbp told us that that video is available as optional training to all officers and agents but that that training video is primarily geared towards offices and agents who are trained Emergency Medical Technicians, and that was one of the reasons for our recommendation that cbp needed to develop and implement training for children in medical distress to be provided to all officers and agents who could come in contact with children in custody. Thank you for recognizing that because its completely unacceptable that not everybody would be trained to recognize the distress symptoms amongst children. So thank you for doing that, and hopefully well have better treatment of our migrants at the border. With that, mr. Chairman, i yield back. Thank you very much. Let me thank the witnesses for their valuable testimony and the members for their questions. As you can tell, if youre not an expert, youll get tested before this committee, and i thank all of you for actually presenting very well, and you responded accordingly. Before adjourning, id ask unanimous consent to submit two statements for the record. The first is mr. Morgans letter responding to the committees invitation to testify at this hearing. The second is former acting secretarys june 2019 letter to members of congress seeking emergency appropriations to care for Migrant Children. Without objection so admitted. The members of the committee may have additional questions for the witnesses, and we ask that you respond expeditiously in writing to those questions. Without objections, the Committee Records shall be kept open for ten days. Hearing no further business, the committee stands adjourned. Thank you, mr. Chairman, have a good weekend. Ruth Bader Ginsburg announced in a statement that she is receiving chemotherapy treatment for recurring cancer. Justice ginsburg who spent time in the hospital this week for a possible infection writes i will continue biweekly chemotherapy to keep my cancer at bay and am able to maintain an active daily routine. Throughout i have kept up with opinion writing and all other court work. I have often said i would remain a member of the court as long as i could do the job full steam. I remain fully able to do that. You can read her full statement at our website, cspan. Org. Tonight on American History tv, our series landmark cases produced in cooperation with the National Constitution center, we explore the issues, people, and places involved in some of the most Significant Supreme Court cases in our nations cases in history. At 8 00 eastern we begin with mapp versus ohio from a 1961 case protecting against unreasonable searches and seizures, holding that evidence is not admissible in court. Then at 9 30 eastern from the 1962 case baker versus carr, establishing that the manner by which the state legislature aportioned seats is a constitutional question, not a political question, and therefore it could be decided by federal courts. Watch landmark cases tonight on cspan3 and any time at cspan. Org. American history tv on cspan3, exploring the people and events that tell the american story every weekend. Coming up this weekend, saturday at 6 00 p. M. Eastern on the civil war historian Harold Holtzer and Valerie Paley talk about artifacts related to the 1863 draft riots in new york city. Featured in their publication the civil war in 50 objects. On sunday, well tour fort monroe museum, the largest stone fort in the United States which sits at the mouth of the Chesapeake Bay near hampton, virginia. Hear about how the fort served as a beacon of freedom for enslaved people and how it held Jefferson Davis as prison for for two years after the war. At 7 00 p. M. , a look at fdr, truman, and the atomic bomb on the heels of the 75th anniversary of the atomic bombings with president trumans grandson, fdr president ial library and Museum Director paul sparrow. And at 8 00 p. M. On the presidency Ronald Reagans 1983 interview with readers digest, both interviews conducted from the oval office with reagan discussing a variety of issues including his hollywood days, the 1983 bombing that killed u. S. Marines in beirut, lebanon, his vision for u. S. Soviet relations and the assassination attempt that left him seriously wounded. Exploring the american story. Watch American History tv this weekend on cspan3. Now the House Appropriations Committee Debates the 2021 transportation and housing