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Infinite Patients

Cover 03.30.05Infinite Patients


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For many of the city’s undocumented Mexican residents, there’s just one doctor they can trust. But Jose Castillo, who’s approaching 80, can’t serve his community forever.

The stairs that descend from street level to the basement of this Rittenhouse area row home lead to an underground world far removed from the fine restaurants and high society of Philadelphia’s most upscale neighborhood.

They invite entry instead to a dimly lit room crowded with undocumented Mexican and Latin American immigrants. A Spanish variety show airs on a corner TV while a dozen or more men, women and children-brought here by word of mouth, by the recommendation of a brother, uncle or amigo-wait patiently and silently for a chance to see “El Doctor.”

“This is the craziest office in the city,” says Dr. Jose “Pepe” Castillo, 77, a small but sturdy man with rumpled gray hair who wears jeans, a fleece jacket and black sneakers beneath his doctor’s coat.

Castillo’s patients list many reasons why they come to him: His visits are cheap; he gives out medicine; his examinations are thorough; he diagnoses everything.

He’s a family physician and general practitioner, but he can give advice on matters-including orthopedics, obstetrics and gynecology, and pediatric and psychiatric medicine-usually handled by specialists. His training is extensive. He’s a certified general surgeon, plastic and reconstructive surgeon, laser surgeon and cancer specialist. But not least in importance, he speaks his patients’ language. And he’s Mexican.

Despite the seeming chaos swirling around him, the proud and humble Castillo remains calm and focused. Lunch hours pass without notice. When electricity goes out in half the building, shutting down a refrigerator full of medicine, he shrugs it off, thankful that the visiting rooms are lit and he can keep seeing patients. He never rushes or raises his voice or emits so much as a disheartened sigh.

But right now, looking at the man lying before him, the doctor is furious.

The man winces and groans in pain, his face and fists clenched tight as Castillo’s assistant pulls pieces of gauze from the raw wounds that cover his right leg.

The man fractured his leg a week earlier in a bike accident and was treated in the emergency room at Pennsylvania Hospital. He now has a serious infection that has spread from his knee to his toes.

Severe cellulitis has turned his leg yellow. He’s lost circulation to his foot, which is now purple and brown. If something isn’t done immediately, it might become gangrenous. The smell of infection released by the undressed leg permeates the air.

The man’s wife stands beside him, explaining her husband’s situation in Spanish. She pulls out a business card from Pennsylvania Hospital and a takeout menu from a Thai restaurant on South Street where her husband had been working cutting vegetables, washing dishes and making deliveries.

He was making a delivery on a bike when he had the accident. The restaurant put him in an ambulance and sent him to the hospital, where he waited for hours before being treated. No one at the restaurant has inquired about him since.

Now, in addition to being extremely sick, he owes the hospital thousands of dollars.

Castillo will call the hospital to determine what emergency work was performed before he immobilizes the leg and treats the infection with a strong course of antibiotics. What has Castillo uncharacteristically angry this day is that a hospital would send a man in this condition home regardless of possible complications.

Castillo takes this personally, sees it as a lack of respect for his people, a people with 30 centuries of culture but little experience with modern civilization, a people often exploited for cheap labor and treated as soulless and disposable.

“It’s subhuman, the treatment. They’re treated as second-class citizens,” Castillo says soberly. “And yet they’re an integral part of the economy. You see them-they’re good people. They work hard.

“I love them,” he says, simply, returning to his patient.

Born in Chalco, a poor suburb of Mexico City, Jose Castillo decided to become a doctor at age 16, after keeping vigil at his mother’s bedside as she died of cancer of the cervix.

He attended the University of Mexico City medical school on a scholarship, then worked as a rural doctor specializing in gynecology before enrolling in the Mexican-American Institute of Cultural Relations for further study. Having heard much about the U.S. and wanting desperately to see an American hospital, Castillo learned English quickly so he could participate in the school’s exchange program.

He was sent to the U.S. with two male students and eight females-one of whom, Nelia, became his wife. (Married 48 years, Nelia now runs the administrative side of her husband’s practice.)

He was assigned to a Missouri doctor, who took him to St. Barnes Hospital in St. Louis and helped him with his papers so he could return as an intern. He attended Washington University as a surgical intern and was later licensed as a general, plastic and reconstructive surgeon. He became a medical volunteer in Vietnam, performing reconstructive surgery, and later became a cancer specialist at Memorial Sloan-Kettering Cancer Center at Memorial Hospital in New York City.

In 1970 he came to Jefferson University Hospital, where he was an assistant professor for five years, before opening up his own plastic surgery practice in 1976. Between maintaining his private practice, managing countless charitable projects serving the Latino poor and elderly communities, and setting up mobile clinics for mushroom workers in Kennett Square, Castillo also found time to host a Spanish language health program on cable TV. He even made a brief appearance in the Tom Hanks movie Philadelphia.

But in 1996 Dr. Castillo’s career suffered a major setback when a federal jury found him guilty of obstruction of justice and conspiracy to harbor a fugitive. The charges stemmed from a series of plastic and reconstructive surgeries he performed on convicted local drug kingpin Richard Ramos-including liposuction, facial scar reduction and fingerprint alterations.

Castillo faced losing his medical license and serving a prison sentence. But his lifetime commitment to the poor earned him sympathy with the jury and leniency with the judge. His sentence involved two years of house arrest, 400 hours of community service and a $35,000 fine. Many supporters rallied to his side, convincing the state medical board to allow him to keep his license.

Through it all, Castillo has maintained his innocence.

Patients arrive at Castillo’s Rittenhouse area office as early as 5:30 in the morning, even though the office doesn’t open till 11. They slip their “papelito” with their name through the mail slot to secure a place in line. By the time Castillo returns from a center for the homeless where he volunteers each morning and gives weekly spiritual talks, a line of patients is already waiting.

He sees 40 to 50 patients daily, six days a week, and a few out-of-town patients on Sundays. Most of his patients are from Mexico, although Nicaraguans, Ecuadorans, Hondurans and Salvadorans seek him out as well. Visits cost $30, but only if the patient can pay. A third or more cannot, but are treated just the same.

“I am very much concerned about the future of these people,” he says. “Up to the present there’s been a great deal of despondency from government officials. People take advantage of their cheap labor. Whether it’s cheap labor or not, they’re part of the economy.

“Think of what the city would do if all the dishwashers and cooks would stop for one day. The city would be paralyzed.”

Castillo says he’s interested in both his patients’ integrity as human beings and the integrity of their culture. He devotes his physical energy to their healthcare needs and his mental energy to intensive studies of pre-Columbian cultures.

“The U.S. in 250 years has become very civilized, but the culture is very young,” he says. “Mexico for example has 30 centuries of cultural patterns. It’s like a tsunami is coming to the U.S., and nobody seems to think of it as any more than an immigration issue. Their mere presence here contributes to the cultural mosaic of this country. They have something beautiful to offer.”

Castillo says the cultural contributions his people offer go far beyond the taquerias along Washington Avenue or the proliferation of Mexican restaurants throughout the city.

Many Mexican immigrants who come here don’t speak Spanish. Some, for example, speak the native Aztec language Nahuatl (pronounced NAH-wahtl). But both those who speak Spanish and those who speak the indigenous language are primarily provincial people, rural campesinos who made the hard journey El Norte to work as hard as possible to sustain the families they’ve left behind in Mexico.

“They have culture, but they’re not civilized for the most part,” Castillo says. “They call it ‘culture shock,’ but it should be called ‘civilization shock.'”

One of Castillo’s fears is that while struggling to survive in their new civilization, many Mexican immigrants risk losing cultural awareness. “I’m concerned about the young people,” he says. “They see other ethnic groups that have patterns of rebelliousness. They’re beginning to forget who they are and where they come from and what they’re doing here.”

A woman who appears much younger than her 34 years sits serenely in Dr. Castillo’s office, her hair pulled back in a tight ponytail. She and her two children-ages 6 and 9-have been in the country just 10 months. Two and a half months ago her husband abandoned her to live with another woman in New Jersey.

Although she and her husband were legally married in Mexico, he’s threatened to kill her if she makes any complaints. She’s living with her brother now, and he’s helping support her children. She’s here today to be treated for shingles. Underneath her shirt a trail of lesions runs from her breast to her back. Despite the debilitating pain, she continues to work as a housecleaner, struggling to put food on the table and shoes on her children’s feet.

“In American society, everything is spoonfed,” Castillo says. “We make people almost irresponsible sometimes. These people are different. They’re given nothing. The spirit or soul is what gives them the strength.”

Castillo writes two prescriptions for the woman. Together they’ll cost more than $300. He calls the pharmaceutical company that makes the capsules she needs, and gets them to give the woman a course of free samples. But she’ll have to pay for the cream to treat the lesions.

Castillo says the treatment should hardly end here.

“This woman needs counseling, she needs protection for her kids, a safe place to stay,” he says.

He’ll try to secure her a place at Lutheran Settlement House, which operates an emergency shelter and domestic violence program, and look for a public defender who’ll make her husband help support their children.

“I care for them en toda,” Castillo says. “To me they are human beings.”

Undocumented Mexican immigrants are hardly the only victims of the healthcare crisis in this country. Health insurance is unaffordable for many working- and middle-class citizens who don’t qualify for Medicaid.

Young adults and low-wage earners in small businesses are also at a disadvantage. Many documented immigrants eligible for medical assistance aren’t enrolled, due to a lack of knowledge about eligibility even among social workers, benefits counselors and healthcare professionals.

Nearly 45 million non-elderly people living in America are uninsured.

Latinos, though, are disproportionately uninsured. (They comprise 15 percent of the non-elderly population, but 29 percent of the uninsured population.) The undocumented status of (and subsequent discrimination against) Mexican and other Latin American immigrants makes them especially vulnerable to being denied even the most basic services.

In September 2003 the city launched Global Philadelphia, an initiative to make essential services accessible to people who don’t speak English. The initiative covers 14 departments, including police, fire, EMS and health services, in which the percent of those with limited English proficiency is highest.

But the city’s overworked bureaucracy makes progress slow and services sluggish. There’s also the added challenge of overcoming the
undocumented Mexican community’s fear that receiving any form of city service-including those to which they’re entitled-will bring attention to their immigration status and result in deportation.

The city’s eight public health centers try to provide free general practitioner care-and prescription coverage-to uninsured and low-income people. Health Care Center No. 2 is located at Broad and Morris streets, right in the heart of Philadelphia’s Mexican community. But none of the physicians speaks Spanish, nor is there an onsite Spanish interpreter.

Global Philadelphia has adopted a telephonic interpretation service, and trained interpreters will arrive at a clinic or any other location within two hours of being called. (Though a patient can schedule an appointment in advance and arrange for an interpreter to be present, the clinic’s voice recordings are solely in English.)

Health Care Center No. 6, located at Third and Girard, services the city’s well-established Puerto Rican community. Oftentimes Spanish speakers who come to Health Center No. 2 in South Philly are sent there instead.

“That’s not supposed to happen,” says Nan Feyler, who’s now executive director of the Nationalities Service Center but worked closely on Global Philadelphia’s healthcare access issues. “Every health center has an obligation to treat people.”

Although Feyler says it’s not ideal to refer patients to another health center, the reality is that bilingual physicians and in-person interpreters are preferable to telephonic interpretation.

Perhaps even more frustrating for Mexican immigrants than language access are documentation issues. Despite the city’s policy that patients need provide only proof of residency, patients report being asked for a Social Security number and then being denied treatment if they don’t provide one.

The city sent out letters to each clinic restating their policy along with a list of acceptable documents that can serve as proof of residency, from a passport or Pennsylvania driver’s license to a Philadelphia library card or a letter from a social service or faith-based organization verifying the person’s address.

Feyler insists the resources and commitment are at least in place and that improvements are underway. “I do think the city’s working on it in good faith,” she says. “They should be getting served now better than they were.”

“Within Philadelphia things are about as good as they get in Pennsylvania,” says Leonardo Cuello, staff attorney for the Pennsylvania Health Law Project. “It gets much worse when you get outside Philadelphia, where there are large
immigrant communities where these services aren’t available.”

One place where members of the undocumented Mexican community report feeling comfortable is the Southeast Health Center (SEHC), one of about two dozen federally funded qualified health centers in Philadelphia that treat uninsured people at low cost. Unlike similar services that cater to Latinos in North Philadelphia, Southeast Health Center is on the corner of Eighth and Washington streets, in the heart of the city’s largest Mexican community. They’ve been dependent on grassroots outreach and ties with local community groups to slowly get the word out to undocumented residents.

“The biggest thing with the Mexican population is they feel we’re a direct link to the Mexican embassy,” says Amy Villanueva, healthcare administrator at SEHC. “Our primary issue is quality of care and outreach and letting the population know it’s a safe place. We’re not a reporting agency. We have nothing to do with immigration status.”

The center has higher accreditation than the city health centers, and has Spanish-speaking providers, case managers, counselors and administrators. Villanueva says the number of Mexican immigrants coming to the center is growing, and that services for them will, she hopes, expand to include ESL classes and mental health support groups.

“The awareness is growing that there’s a great need and a great demand, but still not enough to get the attention of City Council or anyone interested with the power to grant money,” Villanueva says. The Mexican population, she says,
is a market that hasn’t yet been targeted.

For many Mexican immigrant parents, El Norte promises and delivers a better life for their children, including improved health and nutrition. Here they can afford baby formula, milk and cereal. Immunizations are standard. If the children are born here, they’re automatic citizens and eligible for medical assistance.

But many campesinos who arrive as adults have grown used to eating only one meal a day, and the newfound luxury of being able to eat three meals results in frequent gastrointestinal and colonic problems. Upper respiratory problems, high blood pressure and diabetes are all common as well.

And again, their status as uninsured, undocumented and often unwanted immigrants creates additional unique threats to their health and well-being. Men who work long hours in restaurants are frequently attacked on their way home from work and robbed of their hard-earned wages.

They’re seen as easy targets, a vulnerable population that carries cash and fears contact with police. Undocumented Mexican women are regular victims of rape, domestic violence and sexual abuse-most of which goes unreported.

Castillo has seen it all, from the most routine ailments to the most dramatic, from ingrown toenails and back injuries to mental illness and HIV/AIDS. Many of Castillo’s patients were referred to him by friends or families the first time they fell ill in their new country and have been returning ever since. Others have tried clinics and hospitals, but have learned to trust only Castillo.

A 53-year-old woman from Vera Cruz is having stomach problems that include vomiting and diarrhea. She’s here with her daughter and 11-month-old grandchild, who’s also sick. They brought the baby to a clinic first, but the physician said the baby was fine and sent them home.

The woman says the baby’s had diarrhea for a month. She trusts Castillo will find what’s wrong and treat the child.

A woman from New Jersey comes here with her husband for a gynecological exam. They first tried a clinic in Camden. “Pero no es la misma,” the husband explains.

In the clinic, he says, there are interpreters, but the doctors don’t speak Spanish. They rush you through the clinic, he says. It takes more time and is less personal.

He says that when their 13-year-old daughter overdosed on pills, she was transferred to four different hospitals. The couple is now paying off a $48,000 medical bill. The husband works as a dishwasher from 8 a.m. to 11 p.m. six days a week to pay for “rent, luz, comida, zapatos“-and the $200 monthly medical payment.

Castillo says undocumented immigrants live under extreme stress. Financial struggles alone-working 60-, 70-, 80-hour weeks to pay the rent, put food on the table, pay off smugglers and still find enough
to send back to Mexico-can be overwhelming, and is always compounded by discrimination and fears of deportation.

“When they see a police car coming they start shaking,” Castillo says. “They’re all afraid. They live in a continual state of panic, and many go on to become depressed. They develop frequent episodes of anxiety reactions and anxiety neuroses and even psychic neuroses. The mental health issues are very important. An indirect correlation of this is disturbances within their own relations [such as domestic violence and sexual abuse] because of the pressures of their life.”

Earlier in the day Castillo saw a boy diagnosed as paranoid-schizophrenic. In addition to prescribing him medicine, he’s looking into the possibility of enrolling him in an experimental program so he can receive free therapy and treatment.

Later the same day he treated a man with genital herpes and two others who had gonorrhea. All three men work in camps where prostitutes are frequently brought in for the workers, who face long separations from their wives and families. “That they are even in that situation is pathetic,” Castillo says.

The patient with herpes was there for a follow-up visit. At the initial visit Castillo gave him a coupon that would cover the cost of the expensive medication. But the pharmacist refused to accept the coupon, told the man he had only 20 tablets, and said they’d cost $200.

Afraid that he’d be reported to the U.S. Citizenship and Immigration Services if he objected, the man paid. Castillo called the pharmacy and demanded the pharmacist find out who was working the counter at the time and why the man was charged.

“I am continually fighting,” he says.

Carlos, 33, and his brother Juan, 24, drove over from Camden this Saturday morning to see Dr. Castillo. They’re from Puebla, Mexico.

Before their trip El Norte, Carlos drove a taxi in Mexico City, and Juan worked in a factory that produced backpacks. They, like most in the community, crossed la frontera to get here. They came with their 30-year-old brother.

The trip, as expected, was difficult. There were many problems. A coyote (smuggler) charged them $3,000 each (they’re still working to pay him off), and they had to endure long walks through the desert.

When they were thirsty, they had to drink from the lakes where cattle drank. They think the dirty water from those lakes made their brother sick.

Months later his face turned yellow, his body itched and he grew perpetually tired. Despite his illness, he kept his job at a carwash. By the time he finally came in to see Castillo, his blood tests showed he had both hepatitis A and hepatitis B. His brothers put him on a flight back to Mexico so he could be treated at a hospital.

They’re here to pick up the blood test results and fax them to Mexico so the hospital can start treatment immediately, rather than waiting for a new set of results. But they’re also here to get hepatitis immunizations for themselves, because they’re afraid of becoming sick too.

Their brother, they say, will be fine. As soon as he’s better, he’ll cross the border again and return.

According to a Pew Hispanic Center report released earlier this month, the undocumented population in the U.S. has reached nearly 11 million (although statistics on undocumented immigrants are notoriously difficult to verify). More than half (57 percent) come from Mexico, and another quarter (24 percent) come from other Latin American countries. As the human wave of Latino immigrants continues unabated, so do the numbers who fill Castillo’s office each morning.

He accepts them all. But he’s tired.

He wants to hand over his life’s work, but he has yet to find a person or group with sufficient interest in the community’s health needs. “They need professionals that will be clinicians, that will be interested in helping people, that won’t be in it just for the money,” Castillo says.

He dreams of a unitary group for Latin American immigrants in the area that will offer healthcare, education and legal aid-and possibly a casa de cultura (cultural house) as well-all under one roof. He’s even offered to buy the building that would house the group. All he needs is someone to accept his legacy.

“I want to give this to somebody who will take care of all these people.”

Kate Kilpatrick last wrote about hip-hop journalist Jeff Chang.

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