In a dorm-style health center that serves homeless people in San Francisco’s Mission District, a middle-aged woman named Raquel Escatel lay on a twin bed in early 2018.
Escatel, an undocumented immigrant, had become alarmingly thin as her body tried to battle the cancerous growths inside her. But even as she stoically followed the advice of medical staff working to restore her health, she wrestled with regrets about leaving her family in Mexico and about whether she had failed as a mother.
If only doctors could heal her, Escatel made clear to those around her, she might be able to restore her torn relationship with her faraway children. But first, she needed to overcome a potentially deadly, but usually treatable disease: cancer of the cervix.
Common Pap smears can detect cancerous or precancerous growths, enabling surgeons to cut them out, when necessary. Their use has led to plunging mortality rates for what was formerly one of the most lethal cancers. The key to survival — as with an array of other health threats — involves diagnosing the disease early and taking action.
For undocumented immigrants like Escatel, that isn’t easy — especially in the Trump era. The president and his anti-immigration allies in government often seem to go out of their way to add to a climate of fear in which undocumented people feel vulnerable when they engage with public systems — judicial, social and medical — that help the state and the nation to function.
And that, says Castulo de la Rocha, president of Los Angeles-based AltaMed Health Services, has consequences.
It boosts immigrants’ pre-existing fears of being detained almost anywhere outside their homes and getting sucked into the immigration detention system. So people often carefully assess before they tap into a health care system designed to provide care to poor residents, regardless of their legal status. Their decisions can affect not only their own well-being, but also the health of the general public. Infectious diseases can harm citizens, residents and undocumented people.
Many immigrants ultimately hold off on going to the doctor until they can’t wait anymore, report health care advocates. “They go to the emergency room for things that could have been managed on an outpatient basis,” says de la Rocha. “It is due to fear.”
Medical establishments are supposed to be safe havens where Immigration and Customs Enforcement (ICE) agents cannot venture beyond lobbies without a warrant or other special permissions. That said, they sometimes detain people outside of, or on the way to, such facilities.
Louise McCarthy, president and CEO of the Community Clinic Association of Los Angeles County, which sees about 1.5 million patients annually, says that the arrests of undocumented parents during school drop-offs highlights the breadth of risks for them. “There is no reason for people to feel safe and secure as they walk down the street.”
This climate forces people without papers, when responding to injuries and other medical problems, to weigh competing dangers: ICE or the future threat from diabetes, chlamydia, AIDS, tuberculosis or — in the case of Escatel — cervical cancer.
Typical symptoms of cervical cancer include bleeding between periods or after sex, as well as fatigue, weight loss and leg and back pain. Escatel suffered many of those symptoms but didn’t risk seeking out medical help.
Only when it became clear that her body was seriously malfunctioning — she could no longer urinate — did Escatel rush to a hospital emergency room. Advanced urinary obstruction can be the result of tumors pressing against the ureters.
What could likely have been resolved with a simple Pap test had grown into a full-blown health emergency.
Some stories of human pain can present difficulties for journalists to report. Undocumented people often don’t want to give their names, and medical information about patients is tightly protected on privacy grounds — even after people die.
That is why a San Francisco Department of Public Health worker who had regular contact with Escatel, fearing professional repercussions, recounted the immigrant’s story on condition of anonymity. “These untold stories are really important,” the health worker notes.
Amid a wave of rising violence by the Sinaloa cartel more than a decade ago, Escatel fled Mexico for California, eventually reaching the city of Modesto in the Central Valley.
She cobbled together an underground livelihood, eking out a life as she developed an attachment to stray dogs she took in. For about a decade, she avoided detection by immigration enforcement, in part by cobbling together a mishmash of found and donated clothing into an urban-chic fashion that few people associate with middle-aged undocumented immigrants. It was, in a sense, her camouflage.
Still, her life wasn’t easy. According to the health department worker who knew her, Escatel’s under-the-table work put her in interpersonal danger, and she also wrestled with drug addiction. Then, in her forties, she began to suffer from intense fatigue. It was just the beginning.
At a hospital in Modesto, doctors discovered a large tumor and channeled her into San Francisco’s health ecosystem for impoverished patients. It was far too late to remove her tumor.
Around 2016, Escatel stood at the nurse’s station of Medical Respite, a center that cares for homeless people too sick for a standard homeless shelter.
She was remembered there for her striking streak of white hair and for her sassy humor. Escatel, who was being transferred from a hospital, needed shoes. When a health care worker brought her a pair of sneakers, the incoming patient joked that the shoes weren’t up to snuff: “Oh no, that won’t work. I’m too short — I need heels!”
After some months, while waiting for another round of cancer treatments at Respite, Escatel was feeling trapped in her cubicle decorated with a snow globe and other whimsical kitsch. She also fretted over her dogs and other loose ends from her life in Modesto. One day, some friends from out of town showed up to visit. Soon after, Respite staff realized that Escatel had disappeared; she had left with her friends.
Months later, she reached out to the center again: “I’m really ill,” Escatel told staff. Efforts to restore her health proved futile. Once hope was gone, she was placed into housing where, in 2018, she died.
Raquel Escatel was one of the 4,000-plus women who succumb to a particularly treatable cancer in the United States each year. Latinas, including those who are undocumented, are more likely to suffer from cervical cancer than any other ethnic or racial group, according to the American Cancer Society.
“She did not seek any care because she was living a very underground life in the United States because of her legal status,” the health care worker explains. “Raquel died of a completely avoidable condition.”
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