1/oe/ze0@ 10:se r2essesiant vuaversrry pisteict Pace 02 Declaration of Meredith Fort 1. Meredith Fort, declare under the penalty of perjury that the following fs true and correct othe best of my knowledge: A. INTRODUCTION 1. Lave reviewed thefts! recordin the asylum application of Mr, Rene Velasquez ‘Based on my work experience and extensive knowledge ofthe scope and characteristics of heath care services in Guatemala I believe that if Mr. Velasquez is returned to Guatemala, he wil Ikely be unable to receive eppropite medical treatment a an insulin dependent diabetic. This will primarily be due to the Government of Guatemale’s flare to guarantee its citizens thi ights to heal care and necessary medications. 2. _Asaresult of Guaterale’s fires to provide adequate health care and medication ‘equred for his condition, Mr. Velasquez if, heslth, and longevity willbe severely and negatively impacted: be wil likely die more quickly, and more wopleasantly then if he is allowed to rein in the United States, 3. My assessment is based on the structure and management of Guatemale’s healthcare system, the resources and services available tothe client, and the client's extremely low Jncome stu, Which places necessary eal servers and medications out of his reach, B. CREDENTIALS OF MEREDITH FORT 4. Edueation: I received a Bachelor of Ant from Yale Univesity in Biology and Stadies ‘inthe Environment and a Master in Public Health fom the Sehool of Public Health and Community Medicin:, Department of Heath Services, University of Washington in Seattle, am curently a PAD candidate atthe School of Public Health and Community Medicine at the Universiy of Washington. 5. Relevant Bxperienc: Ihave extensive knowledge of Gostemala’'s health care system through my academic and medical professional work have over five years* experience ‘working in Guntemals on health and health reform issues. rom My 2003 to June 2006 1 was the Evaluation axd Supervision Coordinator at Clinica MaxeRa/Instancia Nacional de Salud in Suchitepequez, Guatemala, where | designed and implemented a pan for ‘evaluation and supervision for «4-year pilot primary healthcare project in two rural. health districts in Guatemala. In 2001, eared out e pubic health practicum in ‘Guatemala City with he Instancia Nocional de Sal (National Hesith Advocacy Coalition to establish sytem to monitor the goverament' national health sector reform. From 1997 to 1999 I worked in Pete, Guatemala to help launch a pilot ‘community health program, “Remedies” fr local conservation organization. My VELASQUEZ ASYLUM MEARING EXHIBITO2A2oivec/2eee 1e:se 12eesesct waverstty prsteict Pace 08 ‘Masters in Public Hetth Thesis was tiled “Analysis ofthe Guatemalan Health Sector Reform at the Primary Ceve Level” Relevant Publications and Conference Presentation én, Alejandro and Meredith Fort, “Heal Sector Reform and Community Organizing in Gustemala” in The Practice of Iniernational Health Daniel Periman and Anaoya Roy (editrs) (working ‘chapter and book tthe), Oxford University Pres (forthcoming in 2008); Fort, Meredith, Mary Anne Mercer and Osear Gish eters), Sickness and Wealth (Boston, MA: Southend Press). 2004; Morsls, Lidia and Meredith Fort. Una Imagen Objetivo para Guoiemala: El Sista Piblico de Salud Inchyente (A. Vision for Guatemale: en Inclusive Pubic Heath System), Instancia Nacional de Sal, Guetemala, 2004; {Geuster, Susana, Frarisco Cabrera, Meredith For, Lesly Ramirez, and Lidia Moraes ‘Edueacl, solid, fra: hacia soluciones vieblesenelepiritw de los Acuerdos de Paz (Education health, land: working toward viable solutions in the spit ofthe Peace (Records), PRODESSA, insancia Nacional de Salud, CONGCOOP, Gatemal, 2004; For, Meredith and Alejandro Cerdn, “Analysis ofthe Health Sector Reform in ‘Guatemala a the prinary care level end presentation ofan alternative mode?” American Public Hesth Assocition conference presentation, November 2006; For, Meredith Tiled speaker, Intemational Women’s Day conference ofthe Berkshire chapter of UNIFEM, Massactviets, March 2005; Fort, Meredith “El Dereto 9-2000 y el deecto In sal (Decree 9-2003 and th right o heath)” University of San Carlos Law School, {Gustemal, Human Fights lecture series, November 2003; Derenancourt, Herby, “Meredith For, James Love, and Mary Anne Merce. “Global Wealth, Global Health: Whot Does alesis Economy Mean for te Health uf dhe World's Poor?” American Public Health Assocation conferene presentation, October 2001; and Fort, Meredith end Lian Grandia. “Using Local Resoures to Establish a Baseline for Materoa) Morality: the Peten Experience” American Public Health Assocation conference presentation, ‘October 2000, ©. BACKGROUND INFORMATION ‘Mr, Rene Velasquez & 17-year-old indigenous male who lived with his family in Chichieastenango, a ity in remote Quiche, Guatemala, prior to entering the United States in March 2006, Mr. Velasquez received three years of education prior to turing 12 years old, at which time he stared working to provide a souree of income to his low-income family, which consisted of himeet his mother, three brothers, two sisters, and hi father. ‘Soon afer entering the United Sates in 2006, Mr. Velasquez was diagnosed with jvenie diabetes, end as insulin dependent, Mr. Velasquez did experience symptoms of diabetes wile in Chhicestenango, bt never Sew a medical professional, though he did ‘dlain some so~alle “hore remedies.” His family had no money for healthcare. As fated in Mf. Velesquer’s statement, "We can ero put fod on te able, and cannot \VELASQUEZ ASYLUM HEARING EXHIBITO243ex/e4/20e0 10:50 129esesena1 UMNERSrTy prstarcT pase, spend money in seirg a doctor.” (Pesonal Affidavit of Rene Quino Velasquez, #99 667 264, submitted 12/5006, pas 12). 10. Since asiving inthe ited States, Mr. Velasquez has ben receiving ruler care and ‘monitoring for his diabetes. He continues to require mediel check-ps every tree fo four months, in additon o medicines for home-based regulation of blood sugar levels and supplies for selfadminisration of inslin. D. HEALTH RISKS FOR INSULIN DEPENDENT DIABETICS IN GUATEMALA 1, Guctemaia is «county of approximately 13 millon people, characterized bya ow level ‘of social investment und inequitable distribution of resources Asa result, many members ‘of Guntemalen society re denied ther right to health ere, and health indlestrs vary widely among different ethnic groups and socio-economic clases. Overall, life expectancy in the country is 67.3 yeas of ape, as compared to an estimated 71.9 yeats of age forall counties i the Lan Americ end the Carbbesn region! 12, The government of Gustemale does not adequitely address its citizens” health care needs nd rights. The 1996 Peece Accords called for a minimum public investment in health of 2% of gross domeste produc, whereas government expenditures on health car have teen continually lover than this tres 12, Gooterala’s heath eae system is significantly under zesourced to provide adequate hoeth eriows 1 lage portion of te country’s popultion, Gencrelly, health tyes in Guatemala are provided by a variety of different yoveramental snd non-governmental centties. The Minisuy of Heath and Social Welfare isthe main oversight egency forthe heath secior and provies care o patents at no cost through a nerwork of hospitals, bath centers, health posts, and rurl primary eare ambulatory teams throughout the ‘county. The Guatemalan Socal Security Inatnte provides health eae services to the formal working secc. Additionally, private physicians working in individual clinics, _roup practices and private hospitals, lo ofler cre to those in nee, requiring a fe for ‘service. Private not-fe-poft provides and religious orgalzations offer medical cae at reduced fees 14, The scope end avsiltiliy ofthese services ae limite. While free-of-charge hospital and beath center visits ae avilable throughout the country, many persons secking such care ‘must pay for travel toand forte flies, and are ually charged for supplies and ‘medications used or prescribed for chronic conditions, Private health services are " Uned Nations Devlogmnt Progam in Gute, 200, Btniscutl ives: cin «pai Sate noble 6 ast deeb an Users PD 7 ‘culslrinencx Tie \VELASQUEZ_ASYLUM_MEARING EXHIBITO2G4o/es/2008 10:52 r206ses4est Uuuversiry orsterct pace, available, expecially in uban areas, bt are fer too expensive for poorer citizens to afford {8 ther regular soueeof care, People from indigenous communities, who are particularly isadvantaped due to ‘heir general poverty typically donot have the resources to ‘regulrly use privat health services and purchase needed medicines end supplies. Health Care for a Pasen in Mr, Velasquey’s position 15, As explained in this scion, Me. Velasquez wil likely not receive adequate healthcare end medication in Getemata to tea is diabetic condition, fe is retumed there. 16, Hypothetialy, if Me, Velasquez was a welleduceted non-indigenous man living in [Gurternala City, witha well-paying and stable job anda familial support network, he right beable o obtain reasonably adequate car; he could attend the hospital or diabetes, Clinic and py for needed veatment out af pocket 17. However, Mr. Velasquez is nt the hypothetical person described above. He is an ‘uneducated and jablets man from an indigenous eoramunity who if returned to ‘Gunterala wil liven the remote city of Chichieasteoango in the department of Quiche, 18, Members of indigenes communities in Guatemala often ie in poverty, and most struggle to find employment. Over 50 pereent of Gustemale’s general population fives in poverty, rth 15 percint living in exteme poverty. Notably, of those living in extreme Poverty abou 70 perent are indipenous, while 30 percent are ladino (of mixed. European-indigenousancesty).” 19, Inthe department of Quiche, were the city of Chihicastenango is oeate, 81 percent of the population lvesia povery.* 20, Indigenous or not, meny Gusterslans strugleto get by. Notably, monthly incomes of ‘over 60 percent of Guaterslan household ere tao low to cover the cot ofthe basic food basket, nd are much lower than the basket ofestental goods which includes clothing, education, transport, Sousng, and other vital needs such as medicines.’ While the legal ‘ally minimum wage wes jncreased on December 31, 2007, to Q47 ($6.17) fo non= > ato si of Statics nae 2006, nut Nacional mtr Condoms de ide BNCOV 206 (Gail Seve of Living Conon, 200) Aiba mv in ob guenconay_ neo Ml acres naar 3.2008, is * Pe American Heth OnsianonS Agere or Iesratics! Deepen 204. “Gtenala County Profle” Heath nie Here 2007, Amilo hp ache apace on ener 3, 2008. \VELASQUEZ ASYLUM MEARING EXHIBITO245n/es/zoee 1e:se 1zbescsaan. uavexsrry DrsTeIcT Pace 2 2 25, agrcultwal work and Q48.$0 (86:36) fr agricultural work, thi salary (at most about ‘3140 per morth) fas wel below whats needed to make ends mest Mr, Velasquez, 8 yeung uneducated indigenous man from Chichicastenango, i likely to lave difieaity cbtaning employment, oie sabe, such employment wil not [rovide adequate resources to live on, of spend on bealth car and required medicines, Accordingly. Mr. Velesquez will not have the mone to afford pvate-or-pofit services {ind medicines, He willalo likely not be eligible forte services provided by the ‘Goatemelan Socal Sesrity Insite because of lack of formal employment. “The only realise optins for Mr Velasquez to pursue to access needed health care Terite for five of recved prices, would be fr him to travel to Guatemala City to visit ‘ther te Horpital Rooseve outpatient core department, of visita reduced price non profit peivate clinic However there are sgnfiant cost associnted with these options, as Explained in the next paragraphs. Hospital Roosevelt, ‘Mr. Velasquez could zavel o Hosptel Roosevelt outpatient care department in ‘Gontemele City, sferbeing refered by an ier! medicine doctor at «host ‘center tne the sate eapta orhealth “To getto Guatemal City, Mr. Velosguer would have to ravel approximately four hours fom Chichicesenang, requiring ransportatin and hotel fees. At Hospital Roosevelt's Sutptient care deparment, Mr Velesqbez would, in theory, be seen by a doctor free of Charge However dur tothe fact hat here ia very large demand by patients and a Shortge of physicians able to respond, patents typically heve to Tine up very carly in the ‘oming,stertng at epproximaely 4:00 am, i they bope tobe sen the same dey. This Teauites patients ote ofthe exptl city to trevel to Guatemala City one day prior to betng seen spend the night before, and generally spend the night ater. Patents ‘Hosp! Roosevelt are tiaged and those with immediate emergency needs are seen frst, ‘White visits to Hospital Roosevelt are fee, medications and other supplies for diabetes pallens ae not. Medeations end supplies that are distributed through the bospital ‘hacrcy must be pshesed (In some eases, needed medicines are not aveilble.) + read, Ton, 2008. "Sets od mys fe minin wage” Prensa Libr, Economy and Developmen aston hoary: 208, Avs a haplwore presale canip!200Sene/3/2 132m arene oF amu 3.2008, VELASQUEZ ASYLUM HEARING EXHIBITO246fo1/e4/zane 10:59 assesses: wuversity pisterot PAGE 67 0. 2. » 2. 3. x, “The cots of purchasirg necessary medicines and supplies at Hospital Roosevelt would be ‘wall beyond Mf. Velesguer's means, (See section below on costs of medications and ‘supplies in Gustemala) In addition, Mr. Vlesquce would likely nt afford the costs of repeated tips i {Guatemala Cty to vist Hospital Roosevelt. Fr adatetic person in Mr. Velasque’s ‘Stuntion, the recommenced frequency of visits needed to monitor his heelth would be at least once every 2t ? months, ie, 41 6 vis per year to the capital city. The costs tssortated with ech f these visits would include expense relating to wave, lodging, and ‘hage lose ffm time away from work, assuming tat the Mr. Velasquez was abe to find. Job toch, to reiteret, would eel bea very low peying job) and matoesin tht job ‘espite his need to lene work for medical care. Even ihe settled in Gutemal City and somehow ottained employment, he would stil fikely be uneble to aflord needed medicines end supplies, ven the low wage from the typeof job thet he would be eligible for, and the higher cost of living in the capita city. nother words, wheter lated in Quiche or Guatemala City, Mr. Velasquer would likely not be ebe to afford the needed mediation for his condition. Non-Profit Private Clinics Mir Vetenjuez would lao face egnificant expanses at a reduced nan-pefit private ein, “The most well-known private provider ofthis type for diabetics i the Patronato del Dabur, The Peiraat i headquartered in Gantemela City and has clinics in & number fof depertments throughout he county. However, thet is no Paronoro clini in Quiche, where Chichicatenango ls located, thr, for Me Velasguez the Guster City clinic would appear to be the best option, gain rising isves bout costs of travel, similer to those noted with Hospital Roosevelt. “The Pearonato provides ear to patio ata reduced pre ws compared tothe prvate-for roi sector, which ismmoch mote expensive. However, te fes ae ail sigoiicat fore ion with ited cr no income. Te consultation fe forthe frst visit is Q70 epprowimately $9.21) anda te-consltaton fee is Q35 (approximately $4.60). (These Fire ar used on personal communication wih Guisela Cano, an employe tthe Ptronato Be Diabtico, on inary 3.2008) This fee covers the cost of seeing a doctor, basic ests, hd consltion wth a nutitonist Medications and blood sugar regulation supplies ‘rust be purchased fom the pharmacy. As withthe Hospital Roosevelt, the costs of purchasing necessary medicines and supplies a the Parronaro woul likely be beyond J. Velasguen's eins, (See next tio.) VELASQUEZ ASYLUM HEARING EXHIBITO2A7e/e4/2008 20:50 17e68e5<031 WEVERSITY DISTRICT ase. 35, Aswith the above scenario with Hospital Roosevelt, even if Mr. Velasquez settled in Guatemala City and semehow cbiained employment there he would stil likely be unable to afford these needed services, medicines and supplies 36. Insummary the costsastocisted with visting either the Hospital Roosevelt or Patronato ‘would presenta sigifeant expene to Mr, Velasquez and the cost of medicines and supplies would be beyond his reach. Guatemala v2. Quiche 37, Asnoted above, because of his overarching socio-economic station, Mr, Velasquez ‘would likely net be ale wo obsin needed medical care and medicines from either Hospital Roosevelt othe Poronato, because of travel coss and prohibitively high costs of medicines and suprlcs To reteste, even if he seed in Guatemala City and Somehow obtained employment her be woud stil likely be unable to afford needed Services medicines and supplies, In any case, his situation would be especially grave if Toceted in Quiche In be cate of any medical complications or emergency related to diabetes, Mr, Velasquez would need to be wansported to Guatemela City fom CChichicestenango in crder to receive care with his regular physicisn. Significant ‘ditional eosts would be associated wih such trip —coss which would Tikewise be ‘beyond Mr. Velaquez'e means. 38, Accordingly, if Mr. Velasquez were returned 1o Guatemala he would likely suffer fom ‘gnifieanly limited socess to necessary health care services, medications and supplies. 39, Asereslt his bealth would begin o deteriorate more rapidly de to acute and chronic ‘complications fom asvence of adequate restment, thereby increasing his suffering and Tovvering his life expetaney. E, COSTS OF MEDICATIONS AND SUPPLIES IN GUATEMALA 40. Tn preparation for my stszment tothe cour, I reviewed Mr. Velasquez's medical records and contacted medical professionals end pharmacies in Guatemala to determine the most recent costs and avalailies of the medicines and supplies that Mr, Velasquez curently requires land is being administered inthe United States. 4 Tables 1 and 2 dirty below provide lists of the most recent treatment regimens recommended by Mr. Velsquer's doctors in Houston for self adminstration of insulin and Fome-based regulation ef blood sugt levels, (Note that the antibiotic Keflex in Teble 1 is presumed to be necessary ony for a short-term toe infection listed in Me, Velazsquen's medical records the fist our medicines ae presumed tobe necesaryon a monthly bass.) VELASQUEZ ASYLUM HEARING EXHIBITO2a8ei/es/eae xe:se tnessesatan Uuverstry orsreact ree 08 ‘Tablets urrent Medicines Soret “rea Sue Ym IECERANE HUMAN Tae pi 15 nie Bai Deere oR enema oun nouun iso cn nee ne ne nt {Thrr 400 brent S00 PNSULN GLARE Toh wot 15 ut ee ‘Rue cesta tscoeaae SUo> Cie noo sure Soestey marcy, PELE one ergs rove saat rae mo ney Poon ash MO on OE EA ‘Toble2: Recommend medicines prior to changsin Tale ove) an supplies ee ee ee comes ep ng aera oo oo manager 7 2 oo ei > Be om ena reno oe oe eniaecier 7 oem politician 7 42, Note tha ination to he cost of medicines currently prescribed (as noted in Table 1), the patient would need to purchase supplies (lancet, strips and syringes) that are recommended fn July 19, 2006 by de patent's physician (Table 2), in order to conduct daily sef- ‘epation between visits where Blood sugar monitoring would be conducted 43 At an ordinary pharmacy in Guatemala, | estimate thatthe costs of purchasing the veeded txuivalent medications and supplies woul beat lest $200 per month, and possibly mere; in other words, bout $2,50) per yer VELASQUEZ ASYLUM HEARING EXHIBITOZ491/4/2008 32:50 anessesenat uuversrty orsterct Pace 44, Reduced price pharmacies like the one athe Parenoto del Diabtico ot Hospital Roosevelt, while lsser than the above price ranges, would also present a significant expense, beyond ‘Mar Velasquez’s means 45. To put theee prices income, it shouldbe noted thatthe minimum wage sslary in Gustemel (ted earlier) is shout $140 per morth, or $1680 per year. The monthly salary of an funiliacy nurse in Gustemsla City—e poston requiring extensive education and experience—-is ony aboxt $260 per month.” With both wages, most ofthe compensation ‘would g0 to housing, fod, clothing, end otber essentials. Thus, the costs of services, ‘medicines and supplies fer weatment of diabetes would be beyond the means of « minimum ‘wage worker end even a elatively well-paid health worker in Guaterala City, 46, Foran unemployed or unferemplayed indigenous person, the costs above, end even reduced Ices evallable at Patronauo del Diabetic and Hospital Roosevelt, would essentially be prohibitive: Le, 8 person n Me, Velasquen’s position could not afford tke. F. CONCLUSION “47, Most indigenous people in Chihicastnsngo lack the financial means to access adequate health care services, dc to the cost of services, medictions and supplies, the cost of ‘rangpon, and the lost income tat results from leaving work to access medical services and ‘medicines, Those who recite repeated and routine medical cae and medicine are in an even ‘sore statin, #0 the exis of services and mesicines are penerlly heyond their reach. For such persons, relocating to” Gustemela City is not a fealiaie option. as employment opportunities are limited and the cost of living is higher. Even if such persons do relocate, they sl face steep costs for health services and medicines. 48, 1s mare ikely than not ht if Mr. Velasquez wore returned to Guatemala, he would suffer fiom limited eare and wectnen. This problem wuld exist whether he lived in Quiche or in Gustemale City. Given thit te cost of care, medicine and supplies are above Mr. ‘Velesquez’s likely camings if he ls retumed to Guatemala, he will potentially go dough periods without proper medical treatmen. At a rect of Iseking proper eaiment, he wil Uikely suffer scute and chronic eomplictions that will severely affect his healt, quality of ie, and longevity. 1 declaze under penalty of pejury and under the laws of the United States of Ameria that the Terepoing iste and conect. Executed on January 7, 2008, ‘Meredith For \VELASQUEZ ASYLUM HEARING EXHIBITO250xzeea 10:89 r29ssencenn uaverstry bistRict Pree a1 ‘Sate f Washingt King County | cenify that | know or have sisicton evidence tht Meredith Fort f the peron who appeared before me, and sperm acknowledged that hehe land ii ingame and ecknowledged it 10 be hisher fe and velurtary ct forthe We nd purpose enone in he insane duet: slanvary 7 200: a. Metlldh. \VELASQUEZ ASYLUM HEARING EXHIBITO2S1