The Dialysis Crisis

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January 1, 2010

The Breaking Point

For Sick Illegal Immigrants, No Relief Back Home

By KEVIN SACK

EJIDO MODELO, Mexico — On the two-hour bus rides from her village on Lake Chapala to a dialysis clinic in Guadalajara; Monica Chavarria’s thoughts would inevitably turn to the husband and son she left behind in Georgia.

A decade after crossing illegally into the United States, Ms. Chavarria returned home in September after learning that Grady Memorial Hospital in Atlanta was closing the clinic that had provided her with dialysis, at taxpayer expense, for more than a year.

Grady, a struggling charity hospital, had been absorbing multimillion-dollar losses for years because the dialysis clinic primarily served illegal immigrants who were not eligible for government insurance programs.

Hospital officials decided the losses were threatening Grady’s broader mission of serving the region’s indigent population. But before closing the clinic on Oct. 4, they offered to pay to relocate patients to their home countries or other states, and to provide dialysis for three transitional months.

Ms. Chavarria, 34, left quickly with her 8-year-old son, Jose Andres, an American citizen who had never been to Mexico. But she has not found a solution there. Her free treatments have run out, and she can now afford dialysis only by poaching the savings her family has set aside for a transplant.

Her husband, Roberto Barajas, 37, and their 14-year-old son, Eduardo, remained in Georgia so Mr. Barajas could keep working and wire money home for her care.

In separate interviews, one in the farming village of Ejido Modelo, the other in the Atlanta suburb of East Point, Ms. Chavarria and Mr. Barajas each wept while describing their separation after 15 years of marriage.

“I think about them all the time,” said Ms. Chavarria, whose raven hair falls past her waist. “It was the hardest thing to leave without them.”

Mr. Barajas, a stocky road paver, shielded his eyes with his hand. “You don’t know if you’ll be able to see each other again,” he said. “We had always been together, the four of us, and then suddenly they had to go.”

Like other patients repatriated by Grady this fall, Ms. Chavarria gambled that her chances would be better at home. The costs of dialysis and a possible kidney transplant would be considerably lower in Mexico, and she had three siblings there willing to donate an organ.

But it has not worked out that way.

On Dec. 22, she exhausted the 30 free dialysis sessions that Grady had provided at a gleaming private clinic in Guadalajara. On her doctor’s advice, she had been stretching out the treatments, which filter toxins from the blood, by going two times a week instead of the recommended three. Going without dialysis can prove fatal in as little as two weeks, and the twice-a-week regimen has at times left her weak.

Now Ms. Chavarria is dipping into money that Mr. Barajas and other relatives have raised in East Point, which has long been a destination for migrants from Ejido Modelo. They have held raffles and charity soccer tournaments, and placed gold-wrapped donation boxes at taquerias and stores.

The fund-raising proceeds — about $11,000, according to Mr. Barajas — had been earmarked to defray the $20,000 cost of a transplant. So it is a setback each time Ms. Chavarria has to withdraw $100 for a dialysis treatment.

Everywhere, it seems, there are roadblocks to affordable care. The dialysis unit at Guadalajara’s public hospital, which offers heavily discounted prices to the uninsured, has a waiting list that extends for months. Ms. Chavarria is not eligible for the insurance plan known here as Social Security, which is limited to salaried workers. The country’s five-year-old health program for the uninsured, Seguro Popular, does not cover end-stage renal disease.

On top of the cost, the preparations for a kidney transplant can take months. Ms. Chavarria’s brother, Roberto, her first volunteer, recently learned that his own kidneys might not be functioning properly, possibly ruling him out.

When Grady officials decided last summer to close the dialysis clinic for budgetary reasons, the board chairman, A. D. Correll, declared that “people are not going to die on the street because of these actions.” But that pledge may ignore the conditions that await patients who return to Latin America.

Two Grady dialysis patients have died in Mexico since the clinic’s closing, along with one exceedingly ill patient in Atlanta, according to the hospital. A Grady spokesman said the deaths resulted from severe kidney disease and not from insufficient dialysis.

But one of the Grady patients who died in Mexico, Adriana Ríos Fernández, was receiving dialysis only twice a week because her family could not afford a third treatment that might have helped clear her lungs of fluid, her father said. And recent research has found that dialysis patients in Ms. Chavarria’s state of Jalisco, where half of the residents are uninsured, are three times more likely to die than Hispanic dialysis patients in the United States.

“To have end-stage renal disease in Mexico is a tragedy,” said Dr. Guillermo Garcia-Garcia, the lead author of the study. “If you don’t have Social Security, if you don’t have private insurance, you are condemned to die.”

The health care dichotomy in Mexico is stark. At Guadalajara’s Hospital Civil, the teeming public hospital where Dr. Garcia is chief of nephrology, the dialysis unit runs eight stations around the clock, and meets barely half the demand. Doctors there said they see uninsured patients die every week for lack of dialysis. By contrast, the private clinic for the insured where Ms. Chavarria received her Grady-sponsored treatments is operating at one-fourth of its capacity.

During her journeys for dialysis, and her three-and-a-half hours in the chair, Ms. Chavarria daydreams that her family might some day reunite. “I hope it’s soon, while things are all right,” she said, as the bus rolled past fields of cactus and maize.

But it is difficult to block out the grim realities. She knows that she may never be strong enough to cross the border again and that her continued treatment may depend on her husband’s ability to earn $11 an hour in Georgia, rather than $12 a day here as a farmhand.

There are an estimated seven million illegal immigrants in the United States who have no medical coverage. New research shows there may be 5,500 with end-stage renal disease alone. The health care bills in Congress do not address the problem, leaving public hospitals like Grady to treat the immigrants with an ever-fraying safety net.

Most of the 66 immigrants who were dislodged by the Grady clinic’s closing have stayed in Atlanta to take advantage of the hospital’s offer of three months of treatment. They have signed documents stating that they understand that Grady’s financial assistance will end on Sunday, although the hospital’s contract with a commercial dialysis provider lasts until September.

Ten to 13 of the patients appear to have returned to Mexico, with varying success. Pastor Chavez, 37, said his aunt had managed to buy insurance for him. Patricia Pichardo, 36, a mother of three, said she was borrowing from friends to afford her twice-weekly dialysis.

Antonio Camron, 20, said he did not know what he would do after his Grady-sponsored treatments ended in late December. “I have very little time left,” he said.

The repatriation of most of the patients was carried out by MexCare, a California company hired by Grady. As an additional inducement, MexCare offered many patients a year of health insurance to follow their three months of paid dialysis.

But six patients interviewed in Mexico this month said they knew of no steps being taken to obtain meaningful health insurance. One of MexCare’s principals, George Ochoa, said in a brief interview that the company’s offer was to pay for a year of Seguro Popular. That program does not cover dialysis or kidney transplants, according to its national commissioner, Salomón Chertorivski Woldenberg.

Matt Gove, a senior vice president at Grady, said the hospital had not been aware that MexCare was promising patients’ insurance coverage.

Residents of this farming village on the south shore of Mexico’s largest lake began seeking work in the suburbs near Atlanta’s airport in the mid-1970s. Relatives then summoned relatives until the apartment complexes filled with immigrants. On their days off from construction and landscaping, they reconstituted their social circles and soccer teams as if they had never left home.

During the holidays, when the population of Ejido Modelo swells with homecoming immigrants, the rutted, unpaved streets are dotted with cars bearing Fulton County, Ga., license plates.

Mr. Barajas’s family came in waves. He said he made the first of his three illegal crossings at age 17 in 1989, shortly after meeting Ms. Chavarria at the soccer field in Ejido Modelo. They courted by telephone and mail, and he returned to marry her in the whitewashed village church. After Eduardo was born, she followed him back to East Point.

Their American dream was to save enough to build a three-bedroom house in Ejido Modelo, and then return home. But in February 2008, while working at an auto parts plant near Atlanta, Ms. Chavarria began having trouble breathing. Doctors at Grady diagnosed her kidney failure and placed her on dialysis. She and her husband were astonished there was no charge.

When it came time to leave, the family made the heartbreaking decision that Eduardo would remain in Georgia because he wanted to stay in American schools. Jose Andres, they decided, was too young to leave his mother (and unlike his brother had the advantage of American citizenship). He is struggling in school in Mexico, according to his parents, because he had never learned to write in Spanish.

Mr. Barajas and Ms. Chavarria said their tearful farewells at a McDonald’s restaurant at Grady, where her MexCare escort had suggested they meet. Mr. Barajas’s sister has moved in to their apartment to help care for Eduardo, but the emptiness remains.

“It’s hard to get home from work or some other place and not see her here,” Mr. Barajas said.

Ms. Chavarria is living with her 64-year-old mother, who welcomes each morning by baking tortillas over a wood fire. Other family members live in a compound of small brick houses surrounding a communal courtyard that is planted with citrus and poinsettias. Ms. Chavarria said she was happy to be with her extended family, but was “missing my own.”

She seems fatalistic about the chances for a reunion, in the house they have all but finished.

“I would want good things to happen,” Ms. Chavarria said, “but destiny is not in our hands.”

David Agren in Mexico and Catrin Einhorn in New York contributed reporting.

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