Clinically Oppressed

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Eritza Norville answers the phone at the Brooklyn Caribbean Women’s Health Association with only a gentle, inviting hello. She knows better than to ask for a name.

At the four CWHA clinics in Brooklyn and Queens, 50,000 women a year come in for free gynecological and prenatal care. Many are immigrants, and many are in this country illegally. And since the immigration and welfare laws changed two years ago, Norville says, more and more of the women who call are so scared of getting deported that they refuse at first to give their names to the doctors and nurses who treat them.

In New York, all low-income women are entitled to free prenatal care under the state’s Prenatal Care Assistance Program (PCAP) which provides checkups, prescriptions and hospital care during pregnancy. It’s a smart public health measure–prenatal care reduces infant mortality and birth defect rates. It betters the odds for a safe pregnancy and delivery for the mother. And it’s cheap: According to a 1994 study from the California Elected Women’s Association for Education and Research, every dollar spent on prenatal care saves three dollars in health care expenses in a baby’s first year.

“Prenatal care is absolutely critical,” says Francis X. Monck, the administrator for the Ambulatory Surgery Center of Brooklyn, in Sunset Park. His program offers prenatal medical treatment and nutritional counseling as well as planning for the child’s well-being after birth. There are often times when a mother could benefit from government help, he says, but they flatly reject the suggestion. “There’s a tremendous amount of fear that they’ll be sent away.”

Illegal immigrants have always been wary of taking advantage of government services for fear of deportation. But over the last two years, word has spread among undocumented women that simply going to the doctor can get you thrown out of the country. It has frightened many women away from getting the prenatal care they’re entitled to and need. And thanks to a misapplication of the federal rules by the Immigration and Naturalization Service (INS) and the State Department, even legal immigrants are leery of using programs such as Medicaid. They have heard that taking advantage of these benefits may prejudice their citizenship applications.

“Before coming here, many of our patients have previously gone to emergency rooms, but got scared and left,” Norville observes. “We let them know it is not a risk to come in.”

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“If you are going in to get help, they say you’ll get sent back and your kid will stay here and get adopted,” says one CWHA client, recalling the scare stories she heard while pregnant last year. “All the people around me were saying that. I didn’t know if it’s true, but I was afraid.”

The woman, an 18-year-old undocumented immigrant from Trinidad, followed her mother’s advice to ignore the neighborhood rumors. A close friend recommended that she get prenatal care at CWHA, which gives its clients a letter guaranteeing their anonymity. Even so, she was still nervous about going into the clinic. “I was scared that then I wouldn’t get my green card, but you don’t know if it’s true or not. You got to find out for yourself,” she says now.

Since 1996, the realities of health care have changed dramatically for immigrants, making it much harder to differentiate rumor from policy. The changes in eligibility for publicly funded health care are quite clear: Under the new rules, undocumented immigrants can now only get emergency health care and public health-related care like vaccinations. In New York State, thanks to a lawsuit that defined the unborn child of an immigrant as a citizen, pregnant mothers are also eligible for prenatal care.

But reporting policies–the rules that govern when and where a health care worker is supposed to report an illegal immigrant–have yet to be sorted out, thanks to different philosophies at different layers of government. New York City has long told its health care workers not to report a patient to the INS unless the person is a criminal or a danger to the public. But recent interpretations of the 1996 federal immigration law changed that. That law says that no state or city government can prohibit a government employee from reporting, meaning that while federally funded hospitals and clinics can’t force workers to turn over undocumented patients to the feds, they also cannot prevent an employee from doing so.

The new federal policy would apply only to clinics and hospitals run by the city or state government. But because New York State still uses federal money to fund PCAP, undocumented immigrants who use the program are technically at the mercy of their caretakers. On the New York State application for prenatal care, however, there are still no questions about citizen status.

In New York City, the story is even less clear. The Giuliani administration filed a lawsuit to block implementation of the federal law, which is now in appeals. So technically, at least, the old city policy of not reporting to the INS still holds for now. “But we are in a precarious state,” says Margie McHugh of the New York Immigration Coalition, which does legal counseling and lobbying. “If a worker wanted to report someone, the law would be on their side.”

According to McHugh’s organization, so far no woman in New York State has been caught and deported simply for applying for health care. But the fear is still very real. “Every woman wants health care, and they know it’s there,” says CWHA executive director Yvonne Graham. “But when people come to the U.S. and [start] doing better, they will not risk anything. If that means not accessing prenatal care, they won’t do it.”

Graham says that some women will try to scrape together money to see a private doctor, or visit traditional healers. But in general, clinicians report, many undocumented immigrant women do not consult with anyone during their pregnancy until there is an emergency, or they are about to give birth.

Women who do come in are afraid to explain necessary facts–like where they are from, when their baby was conceived, how long they’ve lived in the country–says Roseanne McCauliff, director of migration services for Catholic Charities. “People are not willing to speak. It limits the help we can offer,” she says. “In the last six months it has been almost impossible. Even when you tell them they will remain anonymous, the answer is no. They are just too frightened.”

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Since the early 1990s, infant mortality in New York City has fallen faster than it has in generations. For example, the infant mortality rate for Hispanics in New York City dropped 25 percent between the late 1980s and the early 1990s, according to the city Department of Health. The decline is extraordinary, say pediatricians, since large-scale health trends like infant mortality usually change very slowly.

But according to a study from CWHA, some women and babies in the city may actually be worse off. When Graham looked at city data, she found that infant mortality rates increased in certain communities during the mid-1990s, especially among newly-arrived Spanish- and French-speaking Caribbean immigrants.

Pediatrician Andrew Racine, an expert in New York City infant mortality trends, points out that it’s unwise to use the experience of one or two neighborhoods to make big conclusions about infant mortality. But he readily agrees that prenatal health care is a problem in the immigrant community. “Even if [access] is not statutorily limited,” he says, “the perception is there that it is.”

Even legal immigrants may be afraid to take advantage of government-funded prenatal care, thanks to wrong-headed State Department and INS procedures instituted after the 1996 reform. When immigrants apply for permanent residency or citizenship, they undergo an evaluation that determines whether they are likely to become a “public charge”–a deadbeat. After the new laws were passed, State Department and INS officials started emphasizing Medicaid records in the public charge evaluation, implying that a legal immigrant might get turned down for a green card or citizenship for having used public health services. The State Department even held some legal immigrants at the border who wanted to re-enter the country, trying to make them pay back past Medicaid charges.

Health and Human Services declared that this was a direct violation of Medicaid protocol and after a confrontation within the Clinton Administration, both agencies officially backed off from these practices in December 1997. But the damage was done. Many legal immigrants still fear that using federally-funded services will hurt their chances for citizenship, and there are reports that INS workers still tell immigrants that Medicaid claims may be held against them.

The New York Immigration Coalition’s Mark Lewis complains that as these fears have intensified, immigration officials have done little to set the record straight. “We want the federal government to plainly state that Medicaid cannot be used for public charges,” he says.

And he blames city and state government for failing to make things easier locally. “New York has not reached out to immigrant pregnant women to come in for prenatal care,” Lewis says. He points out that Massachusetts changed its application to be less intimidating to pregnant women. “The New York State Health Department said they’d consider it, but nothing’s been done as of yet.”

Clear government policy is important, but clinics will have to work hard to undo the damage that has already been done. Monck points to his facility’s weekly workshop, where women can talk with each other about their experiences with health care. “I can tell them ’til I’m blue in the face that it’s safe,” he says, “but until they hear it from someone with the experience, they don’t quite believe me.”

Idra Rosenberg is a Manhattan-based freelance writer.