by Synphen H. Wu, PhD

Mr. C is a 46-year-old Chinese immigrant restaurant worker who came to Bellevue Hospital after two weeks of fatigue, malaise, right upper quandrant (RUQ) abdominal pain, and progressive jaundice.

He was referred from a Chinatown clinic, where his blood tests showed hepatitis B surface antigen, a hepatitis B viral load of 133 million copies, and elevated liver transaminases and bilirubin levels, consistent with acute hepatitis B reactivation and fulminant hepatic failure. When he arrived at the ER, his eyes were yellow, his skin was mustard-colored, and he was in a confused state.

Over his two-and-a-half-week stay at Bellevue, Mr. C’s encephalopathy subsided and his transaminase levels fell. However, his bilirubin levels remained high, and his jaundice did not improve. As his liver failure progressed, his legs became edematous and his abdomen taut and painful. While Mr. C’s condition would normally have qualified him for placement on the liver transplant list, this was impossible due to his lack of official documents. When nothing more could be done at Bellevue to change the course of his disease, Mr. C decided it was in his best interest to go back to China, where he could potentially receive the new liver he needed. He hadn’t gone back since he came to the United States 16 years ago. He hadn’t seen his wife and children in the many years he’d been gone.

Mr. C is from Fuzhou, the capital city of Fujian province, which in recent years has contributed heavily to the vast army of workers who stock the kitchens and dining rooms of the more than 40,000 Chinese restaurants doing business in America. That’s more restaurants than all the McDonald’s, Burger Kings, and Wendy’s combined.

Getting to the U.S. from Fuzhou to find work within this restaurant subculture is no small feat, and people can invest up to $70,000 to be smuggled in. Mr. C is one of these thousands of undocumented workers who come to this country looking for an opportunity to earn a living and to provide for family still back in China. The center of this world, as far as the East Coast and Midwest is concerned, is Chinatown, New York. In Chinatown, it is possible to find work at restaurants through employment agencies clustered under the Manhattan Bridge. At these agencies, bulletin boards post jobs (waitress, chef, delivery man, driver) and include the salary, the area code of the city where the restaurant is located, and the number of hours by bus the city is from New York. For those who don’t read or speak English, the area codes are easy numerical markers that supplant actual geography. Thanks to the system of Chinese-run buses that link the various Chinatowns in cities across the country, traveling to a new-found job is as easy as turning the corner from the agency and boarding a bus marked with the right three digits.

Work is typically 12-14 hours a day, 6 days per week, and owners provide room and board, often in apartments or buildings that function as dorms. In some towns, the workers at a restaurant may be the only Chinese people in town. There may be little chance to integrate into mainstream American society, and restaurant workers can live in the U.S. for many years, moving from job to job, without learning English. They are aliens in a foreign land, able to survive through the strong bonds of Chinese nationalism and common language that connect the overseas Chinese communities spread throughout the country. While these ties can provide undocumented workers with basic needs and shield them from legal difficulties, when serious health problems arise, these workers may have no recourse but to access healthcare institutions beyond their immediate communities.

Before Mr. C came to Bellevue, he was working as a cook in a Chinese restaurant somewhere in Florida in a town he could not name. His symptoms progressed quickly after they started, and within a few days, he was on a bus heading to New York to seek care, first in Chinatown and then at Bellevue. As much as Chinatown is the central hub for Chinese immigrant life, Bellevue stands as a main adjunct healthcare center for those in the Chinese immigrant community who need serious medical attention. Though he is a foreigner in the larger society, a person like Mr. C is no stranger to Bellevue, where an extraordinary confluence of people from all walks of life and different ethnic and economic backgrounds come for care. Since its inception in 1736, Bellevue has served the immigrant poor. For an extremely ill patient like Mr. C, an undocumented worker with little means, no institution compares to Bellevue in its ability to serve his needs.

Under the Emergency Medical Treatment and Active Labor Act instituted in 1986, undocumented immigrants who come to Bellevue are eligible for emergency care through Emergency Medicaid. This program and other public funding provide an estimated $1.1 billion in healthcare for undocumented adults in the United States every year. Emergency Medicaid covers medical conditions, which if not treated, could reasonably be expected to jeopardize the patient’s health, seriously impair bodily function, or cause serious dysfunction to any bodily organ or part. The hospitals are given the task of defining what constitutes an emergency, and procedures and treatments such as surgery, dialysis, and chemotherapy have all been covered under Emergency Medicaid. The one procedure for which Emergency Medicaid specifically excludes reimbursement is organ transplantation.

For all the care that he received at Bellevue, in the end there was no way to circumvent the fact that Mr. C would not be able to obtain a liver transplant in this country. So, after 16 years of working as a migrant restaurant worker and keeping in close contact with his family only by phone, Mr. C made a decision. “Now that I’m sick,” he said, “maybe it’s time to make a trip back to China. I think it’s time to see my family.”

For better or for worse, the limits of Bellevue’s and America’s healthcare provision for undocumented immigrants have sent Mr. C back to his family and to seek care in a country where he is part of the mainstream culture. After all the sacrifices he has made in America, Mr. C is finally returning home.

Commentary by Antonella Surbone, MD PhD, Clinical Correlations’ Ethics Editor

The dramatic events of Mr. C’s illness and his final decision to return home to China for a liver transplant have been narrated by Dr. Wu in an extremely poignant way.

Because of the complexity of immigration’s individual, social and legal implications and of health care’s inevitable limitations, Dr. Wu finds the human and ethical thread that makes the story of Mr. C and of the hospital that took care of him a positive one.

We are so accustomed to analyze all private and public events from a detached critical perspective that very often, we lose sight of their human essence. Making sacrifices for loved ones, suffering physically and emotionally and being cared for with dedication and love are part of the human condition. It is our ethical duty to fight for a more equal society where all burdens do not fall on minorities but are alleviated through the efforts of the entire community, and it is also our ethical duty to see meaning and beauty in the good that we can do each day in our medical practice.

For Plato, ethics and aesthetics, the good and the beautiful, were interconnected, if not the same. There is good and beauty in this story, and that is inextricably connected with our personal commitment and social engagement as physicians.

Synphen H. Wu is a fourth year medical student at NYU School of Medicine who blogs at Clinical Correlations, where this post originally appeared.

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