Some Link Citizenship, Transplants

The News & Observer Raleigh, NC
Tuesday, March 4, 2003

Christina Headrick and Vicki Cheng
Staff Writers

Jesica Santillan needed a heart and lungs. Orilda Gramajo and Ana Esparza waited for replacement livers. Filemon Martinez hoped for new bone marrow.

All were immigrants who illegally entered the United States, then sought transplants. In doing so, they became intertwined in a long-running debate about whether foreigners, even illegal immigrants, should have the same access as U.S. citizens to the nation's limited pool of donated organs.

Some groups have argued for years that transplant policy should give U.S. citizens priority, especially when more than 80,000 people are on a national waiting list and more than 5,500 people died last year before they could receive transplants.

The case of Jesica, a 17-year-old Mexican girl who died after two heart-lung transplants, is the latest to fuel the debate and to pull Triangle residents into the discussion.

Jackie Mills, 65, of North Raleigh, said she has consented to be an organ donor but might change that after hearing that Jesica and her family paid a smuggler to sneak them into the United States. Mills would prefer that her organs go only to U.S. citizens.

"I definitely would not want them to go to an illegal alien," Mills said. "I don't think they should be able to come in here and take our hospital and take our medicine and turn around and sue us. This girl was likely to die anyway. She took the organs from two different people [that] could have perhaps saved a healthier child."

Ron Woodard, president of a Cary-based group called N.C. Listen that favors restricting immigration, said he thinks the situation is "just truly tragic for the family, the little girl, her friends," even for Duke University Medical Center.

"But if I was a person on the waiting list," he said, "I'm sure the thought would run through my mind: Why were organs given to someone who was here illegally?"

The short answer is that hospitals have the discretion to put foreign citizens, including illegal immigrants, on the national waiting list for transplants. The United Network for Organ Sharing (UNOS), which oversees the distribution of organs nationwide, allows up to 5 percent of recipients to be from other countries.

"Part of the rationale is that it may be hypocritical to accept donors who are not U.S. citizens, but not allow them to be transplant recipients," said Joel Newman, UNOS spokesman.

National data for 2001 show that 124 donors, or 2 percent of the total, were foreigners who died in the United States. Just 1 percent of transplants -- 258 of 23,985 -- went to foreign recipients.

In North Carolina, Latino families are among the most likely groups to say yes to donating a family member's organs, said Jane Corrado of Carolina Donor Services. Latino consent rates ran about 78 percent during the first six months of last year, compared with 62 percent for other groups.

The controversy over organ transplants and noncitizens dates from the 1980s, when reports surfaced that wealthy foreigners were receiving a disproportionate share of transplants at some hospitals. UNOS adopted guidelines in 1987 to begin monitoring transplants performed on foreigners, dubbed "nonresident aliens." Whether someone is here legally or illegally isn't tracked.

Today, when more than 5 percent of any transplant program's recipients are "nonresident aliens," it triggers a review by a UNOS committee, which can recommend sanctions if necessary. But reviews are rare, affecting 10 to 15 programs annually out of 875 for different organs, Newman said.

Duke University Medical Center has never been investigated for exceeding the 5 percent threshold, Duke officials say.

As long as hospitals follow the guidelines, they have discretion whether to accept such patients as Jesica. Some hospitals will help. Some won't.

"All visa issues must be clarified and in order before we'll even start to talk about a transplant," said Dr. Jeffrey Crippin, a surgeon who runs the liver transplant program at Barnes-Jewish Hospital in St. Louis. "We don't want to have issues where you just got a transplant, and then you're being deported tomorrow. We can't deliver good follow-up care if we have to face those sorts of issues."

But immigration status isn't a deal-breaker at Jackson Memorial Hospital in Miami, where doctors gave Ana Esparza a new liver in 2001.

Ana, who was born in Mexico but lived in the United States most of her life, was initially turned away at a Chicago children's hospital, in part because of her status as an illegal immigrant. Dr. Andreas G. Tzakis, co-director of the division of transplantation at Jackson Memorial, said blocking such patients from seeking care would be "terribly unfair and inhumane."

"We are trained to recognize illness and to take care of it," Tzakis said. "My first priority is how sick they are, my second priority is how sick they are, my third priority is how sick they are."

At Duke, all patients are evaluated the same way, regardless of citizenship, said Tracey Koepke, a hospital spokeswoman.

But transplants on foreign citizens are uncommon, Koepke said. Of 2,541 people who received transplants at Duke from Jan. 1, 1988, to Nov. 30, 2002, there were no "nonresident aliens" recorded, although eight people did not specify their citizenship status, according to UNOS data.

Doctors consider many factors in deciding to list someone as a transplant candidate, but one that all hospitals share is how the patient will pay. Costs in the first year alone range from $143,300 for a new kidney to $814,500 for intestine replacement, according to a 2002 report by Milliman USA, a Seattle company that tracks health-care costs. In later years, patients can spend $20,000 to $30,000 on medications annually.

Jesica Santillan was unusual among illegal immigrants in that she had health insurance, provided through her mother's job at Louisburg College. Mack Mahoney, the Louisburg builder who has been the family's benefactor, said that the insurance covered about 80 percent of the transplant cost and that the foundation he established could cover the balance.

For most illegal immigrants, however, the cost poses a huge obstacle. Although the federal government reimburses hospitals for some emergency medical services, it decided a decade ago to stop reimbursing for transplants for illegal immigrants who were unable to pay.

"If you can't pay, you don't get a transplant," Crippin said.

Ability to pay was a factor for Filemon Martinez, 19, a Mexican immigrant with leukemia who needed a bone marrow transplant. He couldn't find an American hospital to handle the surgery. Finally, he asked the Mexican government to fly him from Arizona to die in Mexico City in 2001.

A similar fate befell Orilda Gramajo, 31, a Guatemalan immigrant who had lived in Cleveland, Ohio, for 10 years. Gramajo died last fall, leaving three children, after a Cleveland hospital delayed placing her on the transplant list for a new liver, said Richard Herman, a Cleveland attorney who took up her cause.

"We are all basically of immigrant backgrounds, and immigrants are so important to our country," Herman said. "You can't have it both ways, allowing people to come here and work and contribute but then telling them if they need anything, they have to go."


Jesica Santillan will be interred at 2 p.m. today at Lancaster Memorial Gardens mausoleum in Louisburg. The service is open to the public.


Jesica Santillan was smuggled into U.S. for transplant.