IMPORTING POVERTY

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Vast, underground network of clinics caters to immigrants

11.14 a.m. ET (1516 GMT) June 19, 1999

SANTA ANA, Calif. (AP) - It's already dusk, the sun casting a pale glow over the low-slung houses of this industrious immigrant enclave, when Silvia Fernandez makes her way to work.

With an air of authority, and giving nods of recognition, she bustles past a small crowd, some waiting in their cars, others already in line for her services.

The woman they know as Dr. Silvia receives them in a somber room tucked behind an inconspicuous storefront, furnished with a few chairs and a desk. The room's dull lighting casts a pallor on the skin of her patient, a Mexican immigrant. The pungent smell of alcohol is the sole suggestion that medicine, underground medicine, is practiced here.

Fernandez doesn't wear a white coat or use a stethoscope, and she has no examination table. But her hands move like a veteran's. She delivers her diagnosis in soft-toned Spanish and prescribes an ointment

Then she leads her patient to the front room. From a black plastic bag under the counter she pulls out two plastic-and-foil strips of Mexican-produced "ampicilina,'' labeled as antibiotics to treat an infection.

"That's $15,'' she says with a smile.

Word among her patients is that Fernandez was trained to practice medicine in Mexico. But she has no certificate to show for it. And her clinic is actually a back room in a tiny store called "Adriana's Gift Shop.''

To a reporter who witnessed the consultation, she insists: "We sell gifts, we wrap gifts, we have gifts.'' She acknowledges that the shop offers cough syrups, "but not injections and not antibiotics.''

Fernandez is one of dozens of underground health providers who have come to fill a growing need for immigrants in a foreign country: Medical care that is familiar, discreet and cheap. The growing network has little supervision and no official recognition. It thrives on word-of-mouth referrals: clerks inside five-and-dime stores peddling pharmaceuticals in backroom offices, reputed doctors making house calls to inject patients with antibiotics, and licensed doctors cutting corners by hiring untrained office workers to diagnose ailments.

Interviews with practitioners, patients, law enforcement and health-care advocates show that as California's immigrant population grows, so does unlicensed health care. Emergency-room workers, doctors and school nurses increasingly report dangerous reactions from faulty diagnoses made in the secretive clinics.

Unlicensed practitioners have been linked to at least four deaths since 1997 in California, which is home to almost 10 million Hispanics, nearly half of them born abroad. All four of the dead were Hispanic, including a 12-month-old boy and an 18-month-old girl, and authorities say the toll from unlicensed medicine may be much higher.

California has struggled to respond, passing laws to increase penalties and, at a local level, forming a task force to crack down on illegal pharmaceuticals. But for the more than one-third of working-age Hispanics who lack health insurance, the clinics are often the only alternative.

From the outside, the mini-mall store fronting Fernandez' clinic looks like dozens of other low-priced novelty shops in this neighborhood reminiscent of Mexico. Vendors hawk bright-colored pinatas and tamales, bridal shops advertise in Spanish, and botanicas sell Virgin Mary statues and a potpourri of medicinal herbs.

And like many storefront farmacias in Mexico, no prescription is needed at stores like "Adriana's Gift Shop,'' cluttered wall-to-wall with clocks, teddy bears, toiletries and costume jewelry.

But immigrants like Teodora Ortiz know where to go and what is offered behind the rows of trinkets, beyond the door marked "Employees Only'' where Dr. Silvia discreetly gives shots, pills and medical advice.

"I know I will feel better soon,'' Ortiz says minutes after being prescribed a shot of penicillin for her cold. "I trust her.''

Ortiz, 42, earns minimum wage as a cashier at a family-owned market. Like many immigrants, she doesn't have insurance, making any illness a potential catastrophe. Her employee benefits tend toward survival: occasional handouts of expired food. The oldest of her three children, 14-year-old Bryana, stocks food shelves at the market a few times a month to help pay the $650 monthly rent for their one-bedroom apartment.

Since she came from Mexico five years ago, Ortiz has relied on backroom medicine. As she sees it, the visits are quick, Spanish is spoken and "our people'' get treated with a respect not always forthcoming in California's anti-immigrant climate.

That faith persists despite her own personal trials.

Her daughter once had an allergic reaction after getting a penicillin injection. A friend drove them to a hospital, where she told emergency-room workers that her daughter had received the injection in Tijuana, Mexico. In fact, she got it at another backroom clinic in Santa Ana, two-thirds of whose 300,000 residents are Hispanic.

The doctor told her Bryana nearly died. Recalling her daughter's close call, Ortiz shakes her head and smiles wanly.

"That was just an isolated incident. It won't happen again,'' she says.

Immigrants and health experts say the unlicensed practitioners are sought out because the conventional U.S. health system is too complex, because the newcomers prefer the services they were accustomed to in their homeland, and because, if they are illegal immigrants, they don't want anyone checking their papers.

Authorities concede they don't know how many unlicensed practitioners are at work.

"It's widespread. The problem is they are illegal and don't register. They don't license. There is no way of going in and finding how many there are,'' says Allen Davidson, chief of the California Department of Health Services' drug safety unit.

Some of the unlicensed businesses sell medicine at heftier prices, making $1,000 a day more than a legitimate doctor or pharmacist does, says Marc Gonzalez, a state Medical Board investigator.

Law enforcement officials say black-market health care persists for a simple reason: The penalties are weak.

The experience of the King family is telling.

Adriana's Gift Shop where Silvia Fernandez works is owned by her mother, Rosa Maria King. The King family are veterans of the trade: They have dispensed Mexican-made pharmaceuticals for nearly a decade - out of their home, at swap meets or at family-owned gift shops, say police in Santa Ana and nearby Tustin and Orange.

Authorities have arrested Manuel Javier King, the family patriarch, three times - once when authorities raided a makeshift clinic in his garage in Santa Ana as he was about to give an injection to a 6-month-old baby, says Santa Ana police Sgt. Steve Despenas. One of the arrests led to a conviction for violation of state pharmacy regulations and three years' probation.

At least two other King family members have been convicted on charges connected with illegal pharmaceuticals. Their stiffest penalties have been fines and probation.

Two of the four deaths since 1997 occurred after treatment or drugs were dispensed at Orange County shops owned by the family.

The Kings are not facing charges in the deaths, but local officials are scrutinizing their business practices. The family is already under federal investigation for allegedly smuggling illegal pharmaceuticals across the U.S.-Mexico border, says Jud Bohrer, a special agent in charge of the Los Angeles office of the U.S. Food and Drug Administration.

"They've been investigating us, but we don't know anything,'' Fernandez says. "We're all worried.''

Emergency legislation was enacted in California in September to increase penalties to up to $10,000 in fines and a year in jail for selling pharmaceuticals without a license. The law gave added authority to a Los Angeles County task force to shut down illegal operations.

The task force has advertised its campaign with highly visible crackdowns in Los Angeles and surrounding communities.

One such raid this spring targeted a two-story house in a working-class neighborhood of Los Angeles where a woman was suspected of dispensing smuggled pharmaceuticals and dangerous advice.

Police knocked, entered and emerged 15 minutes later with clear plastic garbage bags filled with open syringes, birth control pills, penicillin and intravenous tubing. Medicine and supplies worth $500,000 were stocked in the kitchen, bedrooms and closets, and police found an envelope with $10,000 in cash, says Todd Sample, a task force member.

Neighbors say that on some days, people were lined up outside the house bordered by rose bushes waiting for an appointment. Police say they discovered notebooks recording patient visits to the home since 1995.

Task force members stuffed three bags crammed with drugs into the trunk of a car and declared the raid a success. The woman was charged with dispensing medicine without a license, but no penalties have been imposed. Despite the raid's high profile, the woman probably will only be fined, the typical sentence for a misdemeanor.

Since last May, the task force has arrested 75 people and raided 173 places suspected of illegally dispensing medicine. Offenders, worried about their competition, are actually helping enforcement efforts.

"They start ratting people out,'' says Donald Ashton, a health specialist and chief of the task force's operations.

But eradicating the problem is difficult because only a handful of deaths are actually reported, says Sample.

"The ones that make the headlines are the baby deaths, not how many times have people been admitted to the emergency room for adverse reactions,'' says pharmacologist Gregory Thompson, director of Los Angeles County-USC Medical Center's drug information center.

"I bet today that if an adult rolled into the county hospital and died no one would ever report it. It would just be a death,'' Thompson said.

That was the case with Pedro Cruz-Sanchez, whose death didn't appear unusual to the coroner.

The 32-year-old trucker had recently come back from a trip to Oklahoma. On Aug. 17, 1997, he was coughing blood and couldn't breathe. The father of three was so weak, his brother and sister-in-law had to carry his 281-pound, 5-foot-6-inch body in their arms to Dr. Miguel Castillo-Inzunza's clinic in Escondido, north of San Diego.

Less than two hours after leaving the clinic, Cruz collapsed and died at his brother's house. Paramedics found him slumped back on the sofa, blood trickling from his nose.

The coroner determined that Cruz, who had evidence of heart disease, was dangerously obese and died from bilateral pneumonia - a natural death. He wrote in his autopsy that Castillo told him he had treated Cruz.

State Medical Board investigators suspected otherwise. Already before Cruz died they were investigating the licensed doctor for allegedly allowing the unlicensed practice of medicine. Nearly two years later, on April 12, the Medical Board filed a complaint against Castillo, questioning the care he provided and alleging that he employed unlicensed people who treated patients and forged prescriptions.

The complaint also claimed an unlicensed practitioner injected Cruz with the wrong dosage of the antibiotic Rocephin and two other Mexican drugs illegal for use in the United States.

Castillo has denied any wrongdoing.

In an interview at his Santa Ana office in a run-down strip mall, Castillo said his two clinics and employees operate "with licenses and within the law.''

"He was morbidly obese and really, who knows?'' Castillo said. "We did all we could to help.''

Cruz's family has filed a wrongful death suit. State authorities are reviewing Castillo's medical license, and he and three employees have pleaded innocent to more than a dozen felony charges.

Castillo was ordered to close his two clinics and not to practice medicine until the case is resolved. If convicted, he could spend 11 years in prison, according to prosecutor David Stultz.

Some public health advocates say law enforcement isn't enough.

"Too often in the desperation to do some type of police action, we lose sight of what is the root cause of this,'' says Martha Jimenez, executive director for Latino Coalition for a Healthy California.

The biggest factor, she says, is insurance: An estimated 7 million in California are uninsured, the largest proportion Hispanic. Across the country, 43 million people lack coverage, according to the Center for Health Policy Research at the University of California, Los Angeles.

"The uninsured are going to go onto the black market and continue to do what they are doing because people are that desperate,'' Jimenez says.

As an uninsured immigrant, Teodora Ortiz continues to go to underground clinics. Even after hearing about the deaths. Even after her own daughter nearly died.

For her, it has become routine.

"I wouldn't know where else to go,'' she says.


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