Howard Markel, MD, PhD

Disclosures

October 03, 2005

One of my favorite clinical experiences came about while I was volunteering at a refugee settlement home called Freedom House. It is situated just a stone's throw away from the Ambassador Bridge, which spans the international border between the United States (Detroit, Michigan) and Canada (Windsor, Ontario), on the campus of Detroit's oldest Catholic Church, St. Anne's. Originally a nunnery, today the red brick building, with its 40 bedrooms, 2 bathrooms, a kitchen and a few common areas, serves as a hostel for refugees who come to the United States seeking asylum.

Here, immigrants -- literally from every "hot migration spot" in the world -- somehow make their way from their lands of origin to this somewhat desolate and, at night, threatening neighborhood on Detroit's southwest side. This area is otherwise inhabited primarily by Mexican and Central American newcomers and, as the 1980s progressed and the drug trade swept this portion of Michigan, became littered with crack houses.

The residents of Freedom House stay for varied lengths of times. Some move on immediately and head to Canada; others whose cases are not favorably reviewed linger for months before returning home. There are others who, trapped in some kind of migratory limbo between the nations, literally escaped with their lives and have gotten stuck in the bureaucracy of our country for years. At any given time, 25 to 40 different nations are represented at Freedom House, making mealtime a linguistic as well as culinary challenge. Their modes of travel vary from the most primitive -- walking and hitchhiking -- to rapid jet transportation.

One of the first families I spent time with traveled to the United States from the interior of Mexico about a year and a half before we met: Hector, 31, his wife Maria, 25, and their 2 children, Hilde, 5 and Rudy, 2 1/2. I met them when they first arrived at Freedom House. Their story of migration is a typical one among the illegal immigrants who hail from South and Central America and Mexico.

This family felt increasingly threatened by both the waves of violence in their country and the inability to earn a decent living wage. Along with 2 other families, they pooled their financial resources and began a nomadic trek on foot out of their village, across the southern and then northern provinces of Mexico. Stopping at several points along the way to earn some cash or merely to rest, this leg of the journey took about 8 months. When I asked, somewhat incredulously, how they managed to make such a journey with 2 small children, Hector simply shrugged his shoulders sheepishly and looked at the ground; Maria's eyes opened widely in fear but her mouth was tightly drawn. I know enough to stop asking probing questions.

In Chihuahua, Hector arranged to give the money they saved to 2 unsavory immigration "travel agents" or coyotes who promised to get them to America for the princely sum of $500 -- no questions asked. Somehow, I never was able to get the complete story; they were smuggled across the border, arriving first in Douglas, Arizona, just around Thanksgiving of 1996. Hector and his wife quickly got jobs in the Southwest as farm workers. Within a few months, they began traveling north in pursuit of jobs -- Texas, Kansas, Missouri, Ohio, and, finally, Michigan. Ironically, these 2 illegal immigrant children, Hilde and Rudy, knew far more US geography than the average American schoolchild.

By December 1997, Hector had obtained a job as an assistant to a roofing contractor in the Detroit area who was well known in the migrant circuit for hiring illegals and for paying a daily wage of $35 in cash. Again, no questions asked. But the law caught up with Hector and several of his colleagues when Immigration Naturalization Service (INS) agents made a visit to one of their work sites and arrested the entire crew. Hector was a bit luckier than his coworkers. When it was discovered that he had a wife and family who were living in a cheap motel room on the west side of Detroit far more often rented by prostitutes and crackheads, a kind-hearted INS agent picked up the family and took them all to Freedom House – on the condition that the shelter would put up a bond guaranteeing they would not flee before their court date.

We met a day after their arrival and my research assistant, Christopher, and I spent much of that Friday afternoon talking with Hector and Maria and playing with their children. We communicated using a mixture of Spanish, English, facial expressions, and the help of a Freedom House aide who was far more facile with Spanish than we were. Hilde and Rudy are both beautiful and energetic children, and the absolute joy they exhibited that afternoon almost completely masked the intense hardship they have experienced their entire lives. Hilde was especially proud of her new pink dress and matching shoes she was given earlier by a Freedom House staff member. She was quick to model her new outfit, as well as to display her quick facility for the English language to anyone who would watch or listen.

Only 1 week later, however, Hilde was neither happy nor particularly pleasant to be with. Stricken with a fever of 102°F, achiness, and soggy with snot, this cute little girl was miserable. Her desire to let me examine, poke, and prod her was about as strong as her desire to chew on glass.

Although Christopher was amazed at how vastly different Hilde's behavior was, having transformed from an effervescent and attractive 5-year-old to a crying, angry, uncooperative terror, it was an excellent introduction to the practice of pediatrics. One reason, I think, parents become so concerned -- frantic, really -- about their child when he or she is attacked by a bad cold is that the child acts so vastly differently. A sick child's needs and complaints seem relentless, the index for satisfaction remarkably high, causing even the most devoted of parents to become tired, exasperated, and desperate for a physician who might have some magic that will "make the monster go away." Sadly, with viruses like influenza, we remain as impotent as the physicians of long-past eras and can only suggest a tincture of time.

Despite being fairly certain of the exact outcome of my diagnosis and prognostic advice, my medical training forces me to look anyway. This is always a wise path to follow since we physicians are so frequently wrong. After asking Maria to hold her daughter on her lap, I began by examining Hilde's mouth and ears, figuring I might as well do the toughest parts of the examination first. But, before tackling such an exploration, I attempted to entertain her with one of my most valuable medical tools: a Mickey Mouse watch that features a large Mickey for the hour-hands and a smaller one that moves about a circle for the second-hand. Relying on the international power of Walt Disney, I inquired, "Donde esta grande Mickey?" Hilde's crying and whining temporarily abated while she pointed to the cartoon character. "Donde esta Mickito?" I ask. Again, Hilde points, but this time to the smaller Mickey Mouse. After a few more rounds of this game, she was smiling and opened her mouth widely to laugh.

Recalling that the medical examination of a child is an entirely opportunistic one, I produced a tongue blade and quickly inserted it, pressed down on her tongue, and peered into the back of her throat. It looked fine, a healthy pink without any evidence of a strep infection. Hilde's brief moment of good cheer, however, was short-lived. She presented a huge, loud, and juicy sneeze right on my face and clutched her mother tightly. As she did this, I took out my otoscope with the speed of a gunslinger and quickly peered into both ear canals to rule out an ear infection. There were no signs of infection.

In fact, Hilde's physical examination was entirely consistent with the "flu." With the help of my translator, I explained to Hector and Maria the importance of making sure Hilde drank plenty of fluids and of administering the fever-reducing medication, Tylenol, every 4 hours. I also warned them that they, and more significantly, little Rudy -- a playful and mischievous boy -- were likely to come down with the same illness. Our conversation, with the exception of the surroundings and the help of a translator, was remarkably similar to the ones I have had with American-born mothers and fathers for more than a decade. The experience of illness and parental concern is not one that knows nationality or borders. Before the day is over, I examined 17 other residents in varying states of viral distress and I had little more to offer them than what I provided for Hilde and her family.

As I drove back to Ann Arbor that evening along the long stretch of Interstate-94 that thrusts drivers out of Detroit, circles around the periphery of the Ford Motor Company's mammoth River Rouge Plant in Dearborn, and then heads due west, I could not help but be somewhat shaken by the throngs of ill immigrants I had just left. They looked particularly sad and especially foreign. I could not help feeling some repulsion and distance in the face of the outbreak of influenza that surrounded us.

Pediatricians see an awful lot of colds and viruses each fall and winter, and many of us catch at least 1 or 2 in the line of duty. There is a legend -- a myth, really -- among us that a good pediatrician can always identify with remarkable specificity the exact kid who sneezed, coughed, spit, or otherwise presented us with the infected body fluid of his or her choice and got us sick. When I returned home that evening, soon after dinner, I complained to my wife that I was feeling somewhat tired and congested. The following morning it was clear that I was caught by "the grippe" -- influenza -- accompanied by a sore throat, a head that ached with the slightest of nods, and a nasty cough that produced thick and tenacious phlegm. My bout with flu lasted for 3 days and, not without irony, I was certain that it was Hilde who gave it to me.

As a practitioner of medicine, I knew intellectually that this was utter nonsense. The time of incubation between seeing Hilde and developing symptoms of my own were far too brief to fit in with the actual period of incubation for flu; I had been seeing college students and other patients at my University clinic who were far more likely to have transmitted their viruses to me. Or, I could have just as easily contracted the flu from a colleague or friend or simply by shaking hands with someone and not washing mine before touching my own face or lips. Yes, I knew all of these "facts" intellectually -- but in my aching head and soggy nose, it was Hilde who I contentedly blamed. And while I am not alone in assuming that anything infectious comes from a distant shore or locale, I should have known better. Maybe next time I will.

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