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Cuban refugees injured themselves to get into the United States

Many Cuban refugees purposefully injured themselves or feigned illness in an attempt to be sent to the United States for treatment, according to doctors who treated them. Examples of the injuries include self inflicted burning, injection of diesel fuel, and ingestion of metal objects (New England Journal of Medicine 1997; 336:1251-3).

Frustrated by deteriorating economic conditions spurred by the collapse of the Soviet Union and dwindling economic support from Russia, thousands of Cubans attempted to sail to the United States aboard crude rafts only to be captured by US military forces and sent to Guantanamo Bay naval base, where they were held indefinitely.

While the US had previously allowed Cubans to immigrate relatively easily, in November 1994, Attorney General Janet Reno issued a policy allowing entry to only those under age 18, pregnant women, or anyone who had a medical condition that could not be treated at the base. The latter provision led to several hundred detained Cubans attempting to gain a "medical parole" by injuring themselves.

The majority occurred when a detainee copied another who had legitimately become ill or injured and who was consequently evacuated to the United States. For example, one young man was granted medical parole after he suffered severe burns on his hands after burning himself with melted plastic while moulding a sculpture. Several other people then burned themselves with melted plastic. After patients with severe prolapsed haemorrhoids were given medical parole, several people produced bleeding from their rectums by deliberately injuring themselves.

In other unique cases the doctors report, a man swallowed a large, metal hog ring, another injected diesel fuel into his scrotum, and five men cut their Achilles' tendons when faced with deportation back to Cuba because of criminal activity. The doctors also report that so many reported having symptoms of angina that a cardiologist was brought to the base for a three month term to conduct tests.

View larger version (102K): [in this window] [in a new window]   Thousands of people tried to flee Cuba on crude rafts. BILL GENTILE/REX FEATURES

While a small hospital is located on the base already, the US military augmented its medical facilities in order to accommodate the influx of refugees; several clinics were brought in as well as two temporary hospitals equipped to perform surgery and to handle inpatients. The doctors write that these facilities were sufficient, and only the most extreme cases were sent to the United States for treatment.

When Ms Reno lifted the immigration ban in May 1995, allowing Cubans to enter the country, the authors report that cases of self-injury and malingering dropped dramatically, eventually vanishing altogether.

The authors from the Lackland Air Force Base, Texas, recommended that future humanitarian efforts conducted by the United States do not use a person's medical condition as a prerequisite for gaining entry into the country, or that a policy be instated that once people are treated in the US, they are returned to their own country.

But the case raises many problematic questions, several of which are raised by Dr Leon Eisenberg from Harvard Medical School in his accompanying editorial. Dr Eisenberg agrees with the authors' conclusion that the majority of the cases of self-mutilation and malingering discovered were not due to underlying psychiatric disorder, as is usually the cause of such behaviour, but were due to indefinite detainment. "But when behaviour that would be considered insane under ordinary circumstances ... is motivated by a 'single-minded interest in an obvious goal', the social context for that behaviour must itself be insane," he writes.

Father Thomas Wenski, who made several visits to Guantanamo Bay to visit Cubans-and previously to visit Haitians-detained there and whose parish in Miami includes a large number of Cuban immigrants, said the Cuban's behaviour "showed somewhat the desperation of the people." He said he has seen immigrants from China and Haiti who are detained indefinitely in a detention facility in Miami act similarly. "In desperate situations, people do desperate things," he said.

"This puts doctors in an untenable situation," said Susannah Sirkin, deputy director of Physicians for Human Rights in Boston. She compared it to the situation doctors face when confronted with hunger strikers. "The Cuban detainees were harming themselves to obviously avoid harm," but for the doctor it creates a paradox of being obligated to treat while knowing that to do so just perpetuates the situation that led to the injury.

The authors, too, point to this conflict. The situation had a "profound" effect on the doctor-patient relationship, which resulted in the trust that usually surrounds that relationship being replaced by "suspicion and deceit, as the patient attempted to 'fool the doctor' into granting medical parole."

Biomedical ethicist Arthur Kaplan, director of the Center for Bioethics at the University of Pennsylvania, said that conflicts of interest are always difficult, but that the doctors "do have an obligation to patient's health" and that the patient is "entitled to a disclosing discussion." The authors also write that the "added disadvantage of language and cultural barriers," as well as not having medical records influenced the determination of "conditions warranting their placement on the medical parole list." Dr Kaplan said, however, that the doctor should "go as far as you can to maximize patient health while minimizing the role of conflict."

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