Immigrants Say They Were Pressured Into Unneeded Surgeries
By Caitlin Dickerson, Seth Freed Wessler and Miriam Jordan
NY Times, Sept. 29, 2020
Wendy Dowe was startled awake early one morning in January 2019, when
guards called her out of her cellblock in the Irwin County immigration
detention center in rural Georgia, where she had been held for four
months. She would be having surgery that day, they said.
Still groggy, the 48-year-old immigrant from Jamaica, who had been
living without legal status in the United States for two decades before
she was picked up by immigration authorities, felt a swell of dread come
over her. An outside gynecologist who saw patients in immigration
custody told her that the menstrual cramping she had was caused by large
cysts and masses that needed to be removed, but she was skeptical. The
doctor insisted, she said, and as a detainee — brought to the hospital
in handcuffs and shackles — she felt pressured to consent.
It was only after she was deported to Jamaica and had her medical files
reviewed by several other doctors that she knew she had been right to
raise questions.
A radiologist’s report, based on images of her internal organs from her
time at Irwin, described her uterus as being a healthy size, not swollen
with enlarged masses and cysts, as the doctor had written in his notes.
The cysts she had were small, and the kind that occur naturally and do
not usually require surgical intervention.
“I didn’t have to do any of it,” Ms. Dowe said.
The Irwin County Detention Center in Ocilla, Ga., drew national
attention this month after a nurse, Dawn Wooten, filed a whistle-blower
complaint claiming that detainees had told her they had had their
uteruses removed without their full understanding or consent.
Since then, both ICE and the hospital in Irwin County have released data
that show that two full hysterectomies have been performed on women
detained at Irwin in the past three years. But firsthand accounts are
now emerging from detainees, including Ms. Dowe, who underwent other
invasive gynecological procedures that they did not fully understand
and, in some cases, may not have been medically necessary.
At least one lawyer brought the complaints about gynecological care to
the attention of the center’s top officials in 2018, according to emails
obtained by The New York Times, but the outside referrals continued.
The Times interviewed 16 women who were concerned about the
gynecological care they received while at the center, and conducted a
detailed review of the medical files of seven women who were able to
obtain their records. All 16 were treated by Dr. Mahendra Amin, who
practices gynecology in the nearby town of Douglas and has been
described by ICE officials as the detention center’s “primary gynecologist.”
The cases were reviewed by five gynecologists — four of them
board-certified and all with medical school affiliations — who found
that Dr. Amin consistently overstated the size or risks associated with
cysts or masses attached to his patients’ reproductive organs. Small or
benign cysts do not typically call for surgical intervention, where
large or otherwise troubling ones sometimes do, the experts said.
The doctors stressed that in some cases the medical files might not have
been complete and that additional information could potentially shift
their analyses. But they noted that Dr. Amin seemed to consistently
recommend surgical intervention, even when it did not seem medically
necessary at the time and nonsurgical treatment options were available.
In almost every woman’s chart, Dr. Amin listed symptoms such as heavy
bleeding with clots and chronic pelvic pain, which could justify
surgery. But some of the women said they never experienced or reported
those symptoms to him.
Both the reviewing doctors and all of the women interviewed by The Times
raised concerns about whether Dr. Amin had adequately explained the
procedures he performed or provided his patients with less invasive
alternatives. Spanish-speaking women said a nurse who spoke Spanish was
only sporadically present during their exams.
The diagnoses and procedures are “poorly supported” and “not well
documented,” said Dr. Sara Imershein, a clinical professor at George
Washington University and the Washington, D.C., chair of the American
College of Obstetricians and Gynecologists.
Even if the patients had reported the symptoms recorded by Dr. Amin,
“there would have been many avenues to pursue before rushing to
surgery,” she said. “Advil for one.”
“He is overly aggressive in his treatment and does not explore
appropriate medical management before turning to procedures or surgical
intervention,” said Dr. Deborah Ottenheimer, a forensic evaluator and
instructor at the Weill Cornell Medical School Human Rights Clinic.
But the doctors who reviewed the cases noted that aggressive
overtreatment is all too common among doctors — especially with patients
who do not have the resources to seek a second opinion.
Dr. Ada Rivera, medical director of the ICE Health Service Corps, said
in a statement that the whistle-blower’s allegations “raise some very
serious concerns that deserve to be investigated quickly and
thoroughly.” She added, “If there is any truth to these allegations, it
is my commitment to make the corrections necessary to ensure we continue
to prioritize the health, welfare and safety of ICE detainees.”
Dr. Amin’s lawyer, Scott Grubman, said in a statement that the physician
“strongly disputes any allegations that he treated any patient with
anything other than the utmost care and respect.”
“Dr. Amin also strongly disputes that any patient was treated without
full informed consent,” the statement continued. Mr. Grubman said that
patient privacy laws prevented him from discussing any specific
patient’s treatment, but in each case it “was medically necessary,
performed within the standard of care, and done only after obtaining
full informed consent.”
The statement added that Dr. Amin always uses an interpreter when
treating patients who do not speak English and “always attempts to treat
his patients with more conservative treatment, including medicine and
less invasive procedures, before even recommending surgery,” which he
views as a last resort.
Independent doctors that provide treatment for ICE detainees are paid
for the procedures they perform with Department of Homeland Security
funds. Procedures like the ones that Dr. Amin performed are normally
billed at thousands of dollars each.
Dr. Amin’s billings had previously come to the attention of federal
authorities. In 2013, the Justice Department named him in a civil case
alleging that he and several other doctors had overbilled Medicare and
Medicaid by, among other things, performing unnecessary procedures on
terminal patients and leaving the emergency room staffed by nurses while
billing for diagnoses and treatments as if they had been performed by
doctors. The case was settled for $520,000 with no admission of fault on
the part of the defendants.
‘I could not ask any questions’
In many cases, Dr. Amin’s patients said they were confused about why
they ended up being sent to his office in the first place — some after
raising medical issues that had nothing to do with gynecology.
Yuridia, a 36-year-old immigrant from Mexico, sought out a nurse at the
center soon after she arrived because she was having pain in her rib
after a fight with her abusive ex-partner just before she was picked up
by ICE. She asked to be identified by her first name because she feared
for her safety.
She was sent for a medical exam at Dr. Amin’s office, where she said he
began to prepare an ultrasound machine. “I was assuming they were going
to check my rib,” she said. “The next thing I know, he’s doing a vaginal
exam.”
Dr. Amin recorded in his notes that Yuridia had cysts in her ovaries and
scheduled a surgery to remove them. He also wrote that she had
complained of heavy menstruation and pelvic pain. She said that she
never experienced or reported those conditions and that she had not
asked to see a gynecologist.
Weeks later, she underwent surgery. Pathology reports show that she did
not have dangerous cysts, but small ones of the kind that occur
naturally in most women and do not call for surgical intervention.
Yuridia said she had expected only a minor procedure that would be
performed vaginally, but she was surprised when she woke up to find
three incisions on her abdomen and a piece of skin missing from her
genital area.
“I woke up and I was alone, and I was in pain and everyone spoke English
so I could not ask any questions,” Yuridia said. Three days later, still
sore and recovering, she was deported.
Yuridia’s case bears striking similarities to others that the panel of
doctors reviewed. Many of them led to two surgical procedures performed
simultaneously: “dilation and curettage,” often referred to as a “D &
C,” which involves inserting tools into a woman’s vagina and scraping
tissue from the uterus, and laparoscopy, in which three incisions are
made to insert a camera into the abdominal cavity to examine or perform
procedures on the reproductive organs.
The cases suggest a pattern of “excessively aggressive surgical
intervention without adequate trial of medical remedies,” Dr.
Ottenheimer said.
A report reveals longstanding complaints
It was the Irwin County center’s handling of the coronavirus pandemic
that inspired Ms. Wooten, the nurse whose whistle-blower complaint was
first reported by The Intercept, to come forward about another issue
that troubled her: Dr. Amin’s surgeries. She said in an interview that
she had for years noticed that an inordinate number of women were being
referred to Dr. Amin. She said she would hear reports that they had
undergone surgeries but that they had no idea why the surgeries were
performed.
“After they get up from general anesthesia,” Ms. Wooten said, the women
would ask, “Why’d I have this surgery?”
“And I don’t have an answer for why,” she said. “I am just as shocked as
they are. Nobody explained it to them.”
Data from ICE inspection reports show that the center, which is operated
by a private prison company, Lasalle Corrections, refers more than 1,000
detainees a year for outside medical care, far more than most other
immigration detention centers of the same size. It is not clear how many
of these referrals are for gynecological care. Lasalle Corrections did
not respond to requests for comment.
Concerns from women detained at Irwin emerged long before Ms. Wooten
came forward.
Ms. Dowe, after being told by Dr. Amin that she had a mass the size of a
“cantaloupe” on her uterus, had reached out in early 2019 to Donald
Anthonyson, an immigrant advocate she had met through a fellow detainee.
She was asking for help, Mr. Anthonyson said.
“She expressed real concerns about going to that doctor,” he said. “She
was concerned about what was happening to her and what she was hearing
from other women.”
Unlike some of the women who had no gynecological complaints, Ms. Dowe
was experiencing intense menstrual cramping, which the doctors who
reviewed her case said could sometimes justify the procedure she
underwent — but only if the patient understands the options and elects
to move forward. Even then, the doctors raised questions about several
seemingly healthy and naturally occurring cysts that Dr. Amin might have
removed unnecessarily while he was operating on her.
After the procedure, Dr. Amin wrote in his notes that Ms. Dowe requested
a second surgery — a full abdominal hysterectomy and removal of her ovaries.
But Ms. Dowe insists she never made any such request. A note in her
medical records from the detention center appears to corroborate her
denial. “Detainee is requesting a second opinion to have a
hysterectomy,” it reads, “OB/GYN scheduled hysterectomy and patient
refused.”
Complaints about Dr. Amin had also been raised with senior officials
long before Ms. Dowe’s case.
In November 2018, a woman named Nancy Gonzalez Hidalgo was left shaken
after several visits with the physician, during which she said he
performed rough vaginal ultrasounds and ignored her when she cried out
in pain. Ms. Gonzalez Hidalgo’s lawyers sent an email to the warden of
the center, David Paulk.
In the email, Erin Argueta, a lawyer at the Southern Poverty Law Center,
explained that Ms. Gonzalez Hidalgo’s health was worsening because of
complications she was experiencing from an earlier miscarriage.
“Nancy hesitated to seek medical attention because her last experience
with Dr. Amin was so painful and traumatic that she did not want to be
sent back to him,” Ms. Argueta wrote.
She referred in her email to several previous verbal complaints about
Dr. Amin that lawyers had taken to the center’s inmates services
director, Marteka George. “Ms. George stated that this was not the first
time someone complained about Dr. Amin, and she said that she would look
into whether Nancy could see a different provider,” the lawyer wrote.
The warden responded twice, stating on Nov. 30 that Ms. Gonzalez Hidalgo
had been scheduled for an appointment with an outside provider “that is
unassociated with Dr. Amin.” The other doctor, Warden Paulk said, was
“reportedly well thought of by his patients.”
Warden Paulk did not respond to requests for comment.
Other women who questioned Dr. Amin’s care in the past said they had
also faced challenges when they tried to seek answers.
On the morning of Aug. 14, Mileidy Cardentey Fernandez said, there was
no interpreter present at the Irwin County Hospital when she was
presented with consent forms in English to sign for a procedure she was
undergoing that day.
She asked the technician, “Spanish, please? Little English.” The woman
urged her to sign the forms — and so she did.
Afterward, she said, she filled out a form on numerous occasions at the
detention center requesting her medical records but got no response.
“I wanted to know everything they had done,” she said. “I made requests
for the biopsy, analyses, and they don’t want to give them to me. They
said they don’t have the results. How can they not have the results?”
When she was released from detention on Sept. 21, she called her
daughter in Virginia and then headed straight to Dr. Amin’s clinic with
her lawyer to demand her records, which she received.
Some women said they had managed to avoid surgeries by Dr. Amin but not
without facing resistance.
Enna Perez Santos said she objected when Dr. Amin suggested that she
undergo a procedure similar to the ones that other women had complained
about. Dr. Amin, she said, counseled her that it was a mistake to forgo
the treatment and he wrote in his notes that she had asked to speak to a
mental health care provider.
Back at the detention center on the same day, Ms. Perez Santos was given
a psychiatric evaluation. “I am nervous about my upcoming procedure,”
Ms. Perez Santos told the examiner, according to the practitioner’s
notes. “I am worried because I saw someone else after they had surgery,
and what I saw scared me.”
Ms. Perez Santos was brought three more times to Dr. Amin’s office over
the next several months, she recalled. Each time, she said, Dr. Amin
raised the prospect of a surgery. She felt “pressured” to agree, she
said, but each time she told him she did not consent.
Three board certified gynecologists who reviewed Ms. Perez Santos’s
medical files say that her instincts appear to have been correct. “Based
on what I see here, Amin was inappropriately suggesting a D & C scope,”
Dr. Ottenheimer said. “There is nothing at all there to support the
procedure.”
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