Tuesday, December 17, 2019


Keep In Touch
by Natalie Lima

Lately, I’ve been thinking about relationships. About how fleeting they so often are. Sure, there are the short-lived affairs with the mediocre men I regularly fall for (Please tell me I’m not the only one who does this!), but there are also the more meaningful encounters. Friends from college. Work colleagues. Friends from your first recovery group. Relationships that, when we are young, seem as though they’ll last forever. You assume, like student loan debt, once you’re in, you’re in it for the long haul. 

I have a massive pile of postcards, and birthday cards, and thank you cards that I keep stuffed in a box in my closet. I’m not an organized person, or an especially sentimental one. I’m not really sure why I keep these cards around, why I’ve dragged them from Chicago to New Jersey, to Las Vegas, to Los Angeles, to Alabama, to Ft. Lauderdale, and now to Arizona. Maybe because they are handwritten, and therefore physical talismans of love? Maybe because handwriting feels like a dying artform? Maybe because I, myself, am terrible about letter writing and when I hear of someone who does this regularly, my respect for them instantly swells?  

Each time I moved over the last decade, I packed sparingly. Nothing beyond what fits into my car. But I always take the cards. And just recently, because I’m working on a memoir,  I decided to dig. To shove my hand deep into the abyss, hoping not to discover mold or a colony of bugs, and read these notes. Many from people I don’t speak with anymore but who, at one time, I would have taken a bullet for (or, at the very least, a broken arm or something).

I don’t know what to call the feelings this brings up, the sort of melancholy that comes with aging and knowing that many relationships do only come to fruition for a specific reason and, often, last only a season. How when we scribble Keep in touch on a tacky postcard from Vegas, we know that we may never hear back. 

A birthday card from my friend Vicky. In it, she wishes me a happy birthday. Although there is no date on it, I know it’s from 2014 because she closes it with, Let’s run soon! I miss you.

I can’t remember the last time I ran. I think once, in 2015, before I left for grad school. I fractured my ankle in my first year of grad school and life got sedentary really quickly after that. 

I read the card and I wonder if I’ll ever get back to running again. Was I ever really a runner, or was it a dream? 

A postcard from David. I don’t remember a David. The card is from Monument Valley in Arizona. It’s wintertime, just like it is now, and he tells me we should visit the southwest after we visit Cuba. 

I never planned a trip to Cuba with a man. And I drank and dated so much in my early and mid twenties, I know this could have been anyone. If I’d come across this postcard a few years ago, I might feel embarrassed by the fact that I don’t know who this dude is. 

But now it only makes me laugh. It makes me miss the recklessness of being very young. 

There are more. One from a teacher when I was living in Alabama. He sends me a postcard every month and each month, I mentally beat myself up for not sending one back, ever. Why I never do, I'm not sure. 

And there are several from friends I no longer speak with, friends I assumed would be tethered to me for a long time. And now I rarely think of them. We lost touch. Or I had to push them away because a relationship got too toxic. Or I can’t even say, because I don’t remember.


Thursday, December 5, 2019





MS: A kneecap is a tiny teacup floating on a table setting which disregards the pestering of gravity and moves, fully moored, through space and time. Bone white is the swatchiness of the patella, millions of lengths of baseboard and crown molding can thank it for their soothing, yet stain-resistant, tone. A patella can detach from its motherboard, spaceship rising shifty, slinking like clot, deep knee thrombosis, reduce to the size of a grain of pastini, weave through tendon and ligament, dodge between greater bones like small zippy engines, weary, weavy, jagging into capsular voids, stretching into the voidyness of the iliac bursa, growing fatter and wider: a floating knee

LK: Questions about the body manifest as questions about other things, things that demand answers in a more urgent way. What will I eat? What will I wear? What will I buy? How will I move? Will I move? Will I go to the gym? 


MS: The Alps of the hips jut up and out, one palm-shaped handle for each of two large calloused hands, peaks driving away from the body’s hotwet core and pushing out against skinwrap, against the dermal sky, studded with twinkly capillaries, pressing into a place where matter meets sky. On Everest that interstice is called the Death Zone, where cloud and earth become confused about their roles, where air is so thin it is not really air any longer, just that which is wearing its jacket. Atop the iliac crest there are no clouds but there are chips, plinked off shell layers flaking musselly into pearl glazed shards.

LK: Some questions are the kinds of questions that leave you sweating and panting and muscles aching for days. I lift and run then stretch to try and ease the pain. I do the circuit. I end up in the same place I started. The control of numbers and weights. One hundred pounds, one hundred and five, one hundred and fifteen. GET UNDER IT! Capacity and potential feel like an illusion, because they are infinite but infinitely unachievable, and the gym is the place where there are no answers, only questions and control. 


MS: To string a ham is a quick process for a deft hand but a flailing mess for a first timer. Cross the ankles, as if they were skirting under an evening gown, bind them together like a lash of kindling. Run, next, your rope around itself three times at the place where it crosses over itself between the two ankles. You have made an eight, or infinity, or a mistake. Now throw your hank over a beam or a solid pipe or the branch of a very certain tree, catch it on the other side, pull down hard with the motion of stabbing a ski pole into the snowbound earth if a downward grade suddenly pulled up level like a lame horse. Pull pull pull, and when your pig that is not yet a ham points its toes high enough, half hitch the tail of your rope to the eight, or the infinity, or the mistake. If you can’t tie a knot, tie a lot. Now you will feel, if you grasp the thighbacks of your not-yet-a-ham, the coiled power of the butt and the legs meeting in this long pushy cable of meat, how it is a string and yet not a string, a rope and yet not a rope. You can watch, if you are patient enough and have practiced with plenty of boily pots, the striated ribbons of becoming-ham pull out and away from themselves, become longer and stringer and crampy, and when you rise quickly from a kneel to a stand, pushing the ground away with your own thighs, I dare you to say hamstring ever again without feeling a deep pully yank, without feeling your knees and your butt connected with some of god’s own bondage. 

LK: Will I go to the gym? 


MS: The remarkable engineering of a convex hood, thin as a potato chip and sometimes as seethrough, that can windshield wiper the eyeball in all manner of windstorm and salt spray and highway grit extravaganza, should receive more press, more attention at the national, international, global, planetary, interstellar level. We should be talking louder and more often about this delicate bowl of squish and squeegee. There is plenty more to say, and more to learn.

LK: My body changes shape in the mirror, but so do my eyes, my head, the shape of my thoughts about my body. 


MS: A spine is a tired snake, and also an ambitious tree; a slack rope, and also a length of rebar. Depending on the day and the mood and other factors (like: latitude, longitude, willingness to swallow gummy capsules of ocean oil with hot gulps of black coffee, the ergonomics of your work, how squarely you have faced the truths of your own fearfulness) a particular spine might enter the world like a wrigglebacked caterpillar, each piece operating with cheerful independence, or like straight bendy conifer, defined by root and tip but open to discussion in between, or like a splintery and furious length of driftwood, ready to break altogether before allowing any movement. 

LK: I have a purple half-moon scar circling the left side of my belly-button, through which a surgeon directed a thin metal endoscope, equipped with a video camera and miniature surgical instruments, to cut out and remove my appendix. The idea that the appendix is a vestigial organ, and no longer useful to the body, is being slowly disproven as it shows that the appendix contains a store of gut bacteria unique to each person. When the microflora within the gut is wiped out by an infection, a virus, antibiotics, etc. the stored bacteria within the appendix repopulates the gastrointestinal system. Is the microbiome the seat of the soul? Highly unlikely said the slick looking surgeon, during his pre-surgery brief. He looks like a serial killer, American psycho. We talk some more, and I tell him my friend is doing her PhD in religious studies and she wouldn’t be happy that I’m getting my appendix taken out. He smirks: Religious studies? And as he leaves, over his shoulder: Don’t worry, I won’t take out your soul. 


MS: Sometimes it is not possible to say all the things one wishes to say in one sitting or session or speech or tome. Often, l’esprit d’escalier strikes, and we have a note of thanks or explanation or followup to tack on. When this happens north of the pelvis and south of the gullet it is an awkward need to manage, because square footage has been doled out already, and there are not lots sitting empty or undeveloped. Take, now, a small pouch, craft it of deerskin or polymer or coconut husk. Fill it with your left-unsaids, your don’t-forgets, your also-these. Fill it so full it lives in perpetual anxiety of overfilling, churn and swirl it so it remembers it is alive. Do not give it any busywork like the others, and trust in its delicacy: if its seawalls crumble or its innards roil, thank it for its service, retire it with flag and bouquet, trust that it has performed its duties, and move along.

LK: The doctor cannot tell me if it was completely necessary to take out my appendix in the follow-up appointment. Could I have taken a course of antibiotics? Maybe. Would it have worked? Maybe. Would I still have had to get it taken out after the antibiotics? Maybe. No exercise for four weeks. No lifting, no yoga. You’re young and will heal quickly so after two weeks you can do some cardio. I do a handstand against my kitchen wall that evening, and feel a gentle pain in my abdomen as I try to fall asleep. I cannot tell if it was imagined or real, but I spend the whole night waiting to start vomiting with pain, with the contents of my gut leaking out into my abdominal cavity through burst stitches. This did not happen, but I woke up tired. 


MS: Slaughter a lamb once and a rib will never again be just a rib. The shallow sheet of rainbowsheen fiber that runs over and under the ribcage, laminating the pokiness of the whole bone collection into a single sleek suit of armor is strong, very strong, unlikely to tear unless presented with thin sharp (knitting needle, chopstick, flagpole, drill, boning knife) or with simultaneous wrenching and tear, the thinnest parts stretching even thinner, some light pixelating through, a tissue spread over the lip of a glass with steam rising from hot liquid, suddenly sheet becomes pulp and between the ribs your neat coat of arms fissures into a sad covering that holds too much whippy draft to protect against any of the elements. It is very cold to wait for a winter train wearing such a garment. 

LK: Sometimes in the gym there are those moments where control loses its grip and I am crying and the salt from my tears runs down my face with the rivers of salty sweat and perhaps I am choking -- it feels like I am choking. As soon as someone comes over to see if I am alive I snap straight, wipe my face with my shirt: I’m fine. And try again. 


MS: If you are very slim this will jut like a small mountain range too tall to receive much ground cover, or like bones covered in a very thin layer of skin. Sometimes an object is not a metaphor. The clavicle searches up, reaching skyward, pressing out from the hot core of you towards starry cloud of sky. The clavicle is vulnerable to steering columns and fore-headbutts and makes a perfect tidepool for tiny lakes of seawater, rainwater, bathwater. Stand perfectly still if you wish these pools to heat or cool to the temperature of the rest of you, stand perfectly still and feel for swimmy amoeba making tentative eye contact with each other, brushing their bellies against the tiny fluffs coming off the surface of your skin, waving at the floor of the depths like seagrass and anemones. They will seek the belly of this trench the way all things seek to plumb depths and touch skies. The middle of a thing is a dull and dreary place. The middle of a thing is where beige dangers creep up unsuspected. The middle of a thing can drown you despite all the warning in the world. 

LK: The questions that come up in the gym are ones of movement, how to move efficiently and effectively. Waste no extra energy. Or do? It is good to feel depleted, to feel tired, to feel that work has been done. The work that is done is then, hopefully, manifest in a product: the body, which can be infinitely improved. 


MS: String a guitar too tight and it plays springy tinny bongo bounce, string a foot too tight and it plays high pitch high key soprano squeak, every step a further tightening of what should be free and a slackening of what should be taut. The invisible pain of a furious sole is louder than the visible pain of a blackened eye, but no one worries over it, not even you, who teeters on this poorly strung platform of distress and smiles with your teeth pressed into your softmeat cheeks. 

LK: Will I go to the gym? Or will I run?


MS: We learn of these from Ken dolls, and what we learn is that they should be pronounced but flat, broadly visible, as if the heels of two wide square loaves of firm bread had been placed carefully northeast and northwest of the heart. From the ruined bodies of men who hate themselves we learn that they can be nearly absent, a sheety flatness under a tattered nipple, white like chicken breast and littered with embarrassed looking hair. A man can appear strong in some clothing if he has girthy arms, but in the gazey brightness of daytime nudity, he can never look strong without the cresty curve between his throat and his belly, his unashamed nipples perched overtop low sloping hills. A strong pectoral shelf is useful if you find yourself drowning or on fire in a shallow pit, and if for these or other reasons you must be bench pressed to safety. In such moments a man with a chest is invaluable.

LK: A firefighter I know spends three and a half to four and a half hours working out everyday, as part of his work day. He is a part of a team of firefighters that get sent all across the country during the fire season, the summer, and they haul chainsaws and tools and other heavy things up and down mountains. They go where there are no roads. His body is lean and muscled, each part of his body defined by the work it does. I run my finger up and down his abdomen -- I can feel each of his abdominals as he exhales. 

11. POLLEX (a)

MS: King of the fingers, lord of the hands, hitcher of hikes, uppy or downy with a smile or a frown. Try not to lose these, they are vital to such tasks as gripping the speckled cast iron of a panhandle, grasping the meatiness of a strong thigh, carrying a bundle of celery. Without a thumb you are left with your trunk, your fingers, and pressure, a tiring enterprise if you wish to lift and hold anything greater than small vegetables. A thumb fits easily in a mouth, an ass, an eyesocket, but rarely in an ear. 

LK: Nobody loves pain except for those people who love pain and pursue it because they haven’t had enough of it, or too much, perhaps, or because their brains need it to understand something about reality. This understanding is not real, and completely. The pain is a lens through which things can make sense. Pain pulls you into the body, and the body becomes everything, the body becomes the thing that interacts with the environment. The self/mind is quiet. Striving is something that can be measured by pain. But it is a slippery marker of success because there is no upper limit, except for perhaps death or complete numbness (the same thing). 

12. POLLEX (b)

MS: A thumb is always a finger but a finger is not always a thumb. Put it up and get a ride, put it down and stake a claim. Suck it and stay stuck in some early stage described by a man who, to be gentle, had some of his own stuff going on. The fingerness of a thumb is obvious but it is never, ever eclipsed by its essential thumbness. Things we can do with our thumbs supposedly separate us from The Animals (by which we mean the ungodly ones, by which we should mean just the other animals). But the orangutan. But the gorilla. Thumbs aplenty, but sitting dopelike in a cage or a field, idly thumbing their ass and swiping at their mouths—we don’t do those things. Not in public, at least. An opposable thumb allows for the use of tools, allows for the creation of hand signs, signals, language, allows for writing and typing and sex that makes clear a difference between touch, the verb, as in, he touched me, and touch, also the verb, as in, our bodies touched each other and touch, the nounish, as in, you don’t need a thumb to experience the touch of another body. 

LK: The problem with “fitness” is that in biology it means the quality of being able to survive and reproduce. It is inherently the quality of being able to do the things that enable ongoing existence relative to the environment. But what does it mean to survive in a world where our livelihoods (mine, at least) are not dependent on physically triumphing over others or the environment?. In the gym there is talk of “functional fitness” which translates into a kind of physical fitness that equips us (the gym-goers) to be able to be functional in everyday life. Like, they say, if you were stranded and you had to run a mile (or three or more) or lift another person or lift an object in order to save someone’s life. But can you really prepare for those kinds of things? Somewhat. But what about other things? The day to day. I bike to campus, some days faster and some days slower. I can lift my groceries out of my car, I can walk downtown to the bars. I am lucky to have all the fitness I need, being relatively healthy, even without the gym, based on the physical demands of my lifestyle and environment. I still pay money for sweat. 


MS: The cup of the heel, part of a complex system of levers and rods, part of a complex structure that negotiates with gravity and surface, part of a sack of sticks contained within a small bag of meat. The foot is the thing that moves us around and yet we tend to ignore it until it becomes painful. The calcaneus holds, like a cup, hopes and dreams and intentions: move here, get there. It is very difficult to move without a foot—even in the typical car. Cup your desire to get up and walk across the room to tuck a piece of curled hair behind your lover’s ear. Cup your desire to cross an ocean on an airplane and never return. Cup your desire to run next to a dog, gentle thumps of paws in rhythm: theirs, yours. If your calcaneus cracks you can still run, for a while. Pain will refer up your leg and to the front of your ankle, pain will confuse you. You can shatter this bone, but why would you, if you could instead break it gently, one strike at a time, body against ground on this tiny flatness, this heel?

LK: My oldest friend has left me for the gym. She no longer tolerates my bad behaviour. Truly disgusted, she stares into my eyes and asks earnestly, “How could you?” when she sees me smoking for the first time in years. She talks in terms of “functionality,” “macros,” and “modalities.” I do not care for this. I care only for aesthetics. Tell me how.


MS: Things that have apertures wide enough to sail a thing through them: straws, Twizzlers, copper piping, the more robust pastas—your ziti, your rigatoni. Things that are too clogged and narrow to allow passage: New England plumbing on a bad day, carpal tunnels. Once there were tiny boats drifting fore and aft, once there were dinghies, outrigger canoes, elaborate junks. But over time the speakiness of these vessels grew too loud and clamorous. Dams erupted out of nowhere, boats crashed, souls drowned. Blockage became typical and crash sites were no longer cleared, not for tugboats, not for Zodiacs, not for anything. Hot tinglepain can slice under the surface, beneath wreckage and crams, beneath shattered pieces and soggy limbs, and so the carpal tunnel becomes a tunnel for justpain, for hotness stabbiness burniness: one lane only. 

LK: Parts of my body that I love: 
Femur: the strongest bone in the body. 
Ribcage: the thing that protects the heart.


MS: If the core of a body is the selfiest self and the outside environment is other, then the lips are negotiators between. Are you within me or are you without me: lips ask this question incessantly, so steady and low and constant that at times they must be broached only to silence them, a jagged stab of outside-coming-in the only thing wild and fast enough to ensure a moment’s rest. Close the curtains, slam the door, purse the lips. When children are furious they seal their lips closed and refuse to eat. When women are not eager we stay dry and closed. When we hunger—women, children, mouths, cunts—we go wide and balmy, our doors flung open, our consideration of where we end and the world begins temporarily set aside in favor of some terribly dangerous mixing. Bring the outside in, let the inside out, it is okay, we can sort it out later; borders tell us lies like that: lies about future safety. 

LK: Perhaps I will begin to record the time I spend inspecting my body for ingrown hairs. This is my favorite thing to do, but it makes me sad. 


MS: Triplets, here: medius, maximus, minimus. Together are important to make the leg work for such things as walkingrunningstrollingsprinting, also jumping, also running away, also standing still and absorbing the impact of the moment. Ask your hip pain about middle child syndrome. Ask your awkward gait about family dynamics, sibling rivalry, the rule of thirds. If the torso is the self and the legs are its propellants, the glutei are the stagecoaches in between, flexing and going slack many thousands of millions of times in their lives. Start round and puffy, bounced up and springing out, gently fall, sad, rise again like bread dough under the pressure of enough labor, but, eventually, still, fall. 

LK: Questions of my ongoing existence feel more abstract: financial, emotional, logistical. My passport. Emotional survival, which too is survival, is related to fitness, though; endorphins bring a kind of emotional stability that is difficult to find elsewhere. Science will back me up. But there are those moments of movement, few and far between, where the body does what the brain asks it to, and those are beautifully sweet. A handstand. Jumping rope. 


Friday, November 29, 2019


Figure 1: Ligature Marks

It's a Sunday morning, and my friend and I are sitting in a conference room learning about the physical exam findings suggestive of torture.  The lights in the auditorium dim, and an attorney walks to the podium.  She explains the steps of the asylum process, who might be eligible, how long it takes, and how few applications are accepted. How they need doctors like us to provide an objective, scientific voice to contrast those of the bleeding-heart immigration lawyers.  Then a physician takes her place, ostensibly to teach us how to perform the medical screening exam that will be used as evidence in an asylum case. Emotionless, he clicks through slides of the various methods used as torture -- waterboarding, finger crushing, electrocution, rape, etc -- and the markings they leave on the body. All the ways in which to crush a human spirit. The more evidence we find, the stronger the case. The attorney smiles encouragingly. I avert my gaze.

Figure 2: Metacarpal fractures consistent with trauma, my daughter's bow

When I see these photos, all I can think of is my daughter. So helpless at 9 months of age. What I wouldn't do to protect her. 

Figure 3: My family on Halloween, dressed up like giraffes 

While an applicant waits for their case to be evaluated, they are able to stay in the US. Given a permit to work. Granted a small space to breathe. During the slide about how to document scars, my friend leans over to ask me, "but how can I be sure that these skin markings are from torture? What if they are from childhood injuries? If I judge incorrectly, and that person is granted asylum, does that mean it is denied to someone else?" The weight of that decision feels too heavy. I decide I will pretend it doesn't exist. 

Figure 4: The Dermal Markings of Cigarette Burns Over Time

At lunch, we sit at a table with four young strangers, eagerly saying how they want to help. I learn that they are all medical students. Fitting. They haven't yet lost their eager optimism, forgotten the reasons they went into medicine. My friend and I may be the only attendings in the audience. Where are the rest? The ones who arguably have more authority, more experience, more to offer? Where are they? 

I can imagine, as my friend and I are about to sneak out of the conference early in order to join them. They are probably playing baseball with their kids, or out to brunch with friends, the tension from the hospital workplace dramas slowly dissipating from their taut shoulders. It's 75 degrees and sunny out. Now that we have finished the slog of medical school and residency, we no longer have to work eighty hours a week. Finally, we don't have to sacrifice quite so much. Now is the time to make up for all the years lost. The balance the only way to survive the years of practice that stretch ahead. The enjoyment of health the only way to live in the face of never-ending suffering and illness.

Figure 5: Chapter 3, Section 4: Medical Evidence [of torture]

104. In formulating a clinical impression for the purposes of reporting physical and psychological evidence of torture, there are six important questions to ask:

(a): Are the physical and psychological findings consistent with the alleged report of torture?

(b): What physical conditions contribute to the clinical picture?

(c): Are the psychological findings expected or typical reactions to extreme stress within the culture and social context of the individual?

(d): Given the fluctuating course of trauma-related mental disorders over time, what is the time-frame in relation to the torture events? Where in the course of recovery is the individual?

(e): What other stressful factors are affecting the individual (e.g. ongoing persecution, forced migration, exile, loss of family and social role, etc.)? What impact do these issues have on the victim?

(f): Does the clinical picture suggest a false allegation of torture?


Figure 6: The Eloy Detention Center is a private prison located in Eloy, Pinal County, Arizona, owned and operated by CoreCivic, formerly the Corrections Corporation of America, under contract with the U.S. Immigration and Customs Enforcement 

A few weeks later, I am fidgeting outside the 1st locked door at the large ICE detention center in Eloy. Fencing laced with barbed wire stretches out in all directions around me. The air is dry and smells like cow shit. The horizon is the hazy tan color of pollution. Although I can't see the guards, they can see us. We hear a buzz, followed by the mechanical clank of the metal door unlocking. We walk through a corridor to another door. We again wait. The first door locks behind us as the one in front opens. 

The guards are in the khaki green uniforms, and are annoyed that my friend has forgotten our official documents granting us clearance. They check a binder sitting on the counter, but our verification is nowhere to be found. Phones are not allowed past the security checkpoint, so she has to go back out to the car, retrieve her phone, bring it back inside, pull up the email, show it to the guard, and then return it to the car. There is some confusion as to whether or not we are at the right facility, it is possible that our client has been moved to another detention center in the area. There are several out here. After a few calls via her radio, the guard determines that our client is, in fact, here, but nobody knew he was supposed to have been brought from his cell in time for his 9 am appointment. We are filed through the metal detector, our legs are patted down, and then wait some more, this time in an internal waiting room between the security checkpoint and another locked door. 

I scan the waiting room. There are several benches, much like church pews, stacked in horizontal rows. Most of the other visitors are families, everyone wearing nice dresses, polished shoes, and pressed slacks. A young mother feeds a bottle to a baby swaddled in blankets. A small TV is hanging in the corner. It's playing a silly kids' movie featuring colorful, animated snails with exaggerated facial expressions. 

Figure 7:My stethoscope over sample medical documentation of trauma

The door under the TV swings open, and a guard calls our names. We follow him into another room with tables where detainees can meet their guests, and then into a small cell where our client, who we've never met before, is standing. He has a small frame and his eyes remain focused on the floor. He is biting the inside of his lip. Usually we perform these exams in the clinic, my friend tells the guard. Can we be moved there? We have to examine him and this isn't the best location. Also, we brought this gown for him to change into. The guard sighs. 

Well that will take more time. We may not be able to fulfill that request.

We understand, but if you can, we'd appreciate it.

The guard leaves. The three of us remain standing it the small room. It is freezing, I wish I had brought a jacket. Our client is wearing a worn uniform, it's cotton thinning. It looks the same as what the prisoners wear when they are brought to my hospital. I have to remind myself that our client is not a prisoner, that we are not in a prison -- our client is seeking asylum under international law. 

128. Interviews with people who are still in custody, and possibly even in the hands of the perpetrators of torture obviously will be very different from interviews in the privacy and security of an outside and safe medical facility. The importance of obtaining the person's trust in such situations cannot be stressed enough. However, it is even more important not to, even unwittingly, betray that trust. All precautions should be taken so that detainees do not place themselves in danger. 

Five minutes later, and the guard returns. We follow him down locked hallways until we are brought to the clinic. Immediately, the air feels a little lighter. The nurses and doctor wave at us as we walk past their counter. We are brought to a room that feels just like any other clinic room, with chairs and a medical examining table. No guards are within sight. But still, the chill remains. I cross my legs and wrap my arms around my elbows, trying to conserve warmth.  For the next two hours, we struggle to piece together a cohesive narrative about the man sitting in front of us. He rarely makes eye contact, talks in a hushed voice, and slurs his words. He was tortured when he was a child, and dropped out of school immediately thereafter. His memories about the incident and his life during that time are extremely vague. They also don't move in a linear, chronologic fashion. This is diagnostic of childhood trauma, but how can I convey that to a judge if I don't have the facts to back it up? Will the judge assume that a lack of details is instead diagnostic of a fabricated narrative?

He also shies away from our attempts to label him with diagnoses of illness, such as PTSD, anxiety, and alcohol use disorder. When I rattle off a list of symptoms whose presence are considered diagnostic, he denies all of them. I imagine that he wants to show us that he isa a survivor, not a victim. That he has overcome. That his scars have been erased. Invisible to the probing eye.

Figure 8: Child Dissociative Checklist juxtaposed against a fisher-price cross

Below is a list of behaviors that describe children. For each item that describes your child now or within the past 12 months, please circle 2 if the item is very true of your child. Circle 1 if the item is somewhat or sometimes true of your child. If the item is not true of your child, circle 0.

0 1 2   1. Child does not remember or denies traumatic or painful experiences that are known to have occurred

0 1 2   2. Child goes into a a daze or trance like-state at times or often appears "spaced-out." Teachers may report that he or she "daydreams" frequently in school

0 1 2   3. Child shows rapid changes in personality. He or she may go from being shy to being outgoing, from feminine to masculine, from timid to aggressive.

0 1 2   4. Child is unusually forgetful or confused about things that he or she should know, e.g. may forget the names of friends, teachers, or other important people, loses possessions or gets easily lost.

0 1 2   5. Child has a very poor sense of time. He or she loses track of time, may think that it is morning when it is actually afternoon, gets confused about what day it is, or becomes confused about when something has happened.

0 1 2   6. Child shows marked day-to-day or even hour-to-hour variations in his or her skills, knowledge, food preferences, athletic abilities, e.g. changes in handwriting, memory for previously learned information such as multiplication tables, spelling, use of tools or artistic ability. 

0 1 2   7. Child shows rapid regressions in age-level behavior, e.g. a twelve-year-old starts to use baby-talk, sucks thumb or draws like a four-year old

0 1 2   8. Child has a difficult time learning from experience, e.g. explanations, normal discipline or punishment do not change his or her behavior.

0 1 2   9. Child continues to lie or deny misbehavior even when the evidence is obvious. 

Figure 9: Review of Torture Methods

143. After eliciting a detailed narrative account of events, it is advisable to review other possible torture methods....Questioning about specific forms of torture is helpful with:

(a) Psychological symptoms cloud recollections

(c) in the case of possible organic brain damage

144. The distinction between physical and psychological methods is artificial.... the entire clinical picture produced by torture is much more than the simple sum of lesions produced by methods on a list.

H. Risk of re-traumatization of the interviewee [is very likely]

Figure 10: Vials of influenza vaccine upon my daughter's block

I arrive at Casa Alitas just in time for the arrival of twenty asylees just released from ICE custody.  It's my first time volunteering with this NGO, so I wander over to a man sitting behind a desk with a sign-in sheet. There is another young man also checking in, a medical student here for the first time. The front-desk-man seems unphased by new volunteers just showing up, and gestures towards the opposite end of the large building, "Find Barb, she'll orient you."

She shows us a form that we are to use when conducting our medical interviews."Usually we also offer flu vaccines, but we don't have anyone available to give them today." 

I spend the next hour administering about twenty vaccines to families from Ecuador, Guatemala, and El Salvador.  The atmosphere in the room is jovial, a sharp contrast to the mood when I give injections to kids in my hospital. What have they endured to make this seem like a pleasant experience? One at a time, kids march up to my table, boldly rolling up their sleeve and offering the flesh of their arms. They squeeze their eyes shut as I pierce their skin, and then laugh when it is over, bragging to their siblings how it didn't even hurt. Their parents laugh. Everyone gets candy. We hand them a packet, Bienvenidos a America. 

Although most everyone I meet that day is their with their family members, there are two women who are alone. They appear to be in their second trimester of pregnancy. I remember how vulnerable I felt while pregnant, every day a new opportunity to cause harm to my unborn child or my bloated, unsteady body. 


Things I hear from other volunteers and healthcare providers:

Usually, when they arrive here, they complain that their stomachs hurt because all they are given to eat in custody are tortillas and ritz crackers. They are usually in detention for several days.

Even though they aren't supposed to be separating families anymore, a woman was separated from her 14-year-old brother because she was not his parent. He was classified as an unaccompanied minor.

We responded to a 911 call for a kid with abdominal pain at a detention facility. There were multiple cells full of just children of various ages. Each cell seemed to have an older kid covered with little ones clambering over them. 

When we transfer pediatric patients in an ambulance from our rural hospital to the regional center with pediatric specialists, we often send them without their parents, as CBP will physically remove undocumented parents from ambulances as they pass through the immigration checkpoint. So we have these little kids, scared, undergoing surgeries in a strange place and without the comfort of their families. Can you imagine sending your child alone? [I imagine my baby naked in a cold operating room, hands in blue gloves holding down her flailing arms and legs, a mask pumping anesthetic gases held firm over her face, muffling her cries]

Figure 11: Health Risks of Customs and Border Protection Detention

Recent deaths of children in custody:
  • Jaelin Caal Maquin, age 7
  • Felipe Alonzo-Gomez, age 8
  • Juan de León Gutiérrez, age 16
  • Wilmer Josué Ramírez Vásquez, age 2
  • Carlos Gregorio Hernández Vásquez, age 16

From the Istanbul Protocol:
54. Health professionals also have a duty to support colleagues who speak out against human rights violations. Failure to do so risks not only an infringement of patient rights and a contravention of the declarations listed above but also brings the health professions into disrepute. Tarnishing the honour of the profession is considered to be serious professional misconduct. The World Medical Association's resolution on human rights calls on all national medical associations to review the human rights situations in their own countries and ensure that doctors do not conceal evidence of abuse even where they fear reprisal...It calls upon individual doctors to speak out against maltreatment and urges national and international medical organizations to support doctors who resist such pressure. 


It has been documented that while in immigration detention facilities, pregnant women and adolescents experience poor access to medical care, and are highly vulnerable to sexual assault. Although standards were published by ICE to improve women’s access to reproductive health care, including prenatal care, facility adherence to these standards is unknown. In 2016, the Department of Homeland Security’s (DHS) Advisory Committee on Family Residential Centers recommended that barring extraordinary circumstances, no pregnant woman or her children should be detained in a family residential center.

All pregnant women and adolescents held in federal custody, regardless of immigration status, should have access to adequate, timely, evidence-based, and comprehensive health care. Pregnant immigrant women and adolescents should have access to high levels of care, care that is not available in these facilities. The conditions in DHS facilities are not appropriate for pregnant women or children. A growing body of evidence suggests that maternal psychological state can negatively affect fetal and child development, and practices like shackling during pregnancy, which have been reportedly used at ICE facilities, have serious negative physical and mental health impacts on pregnant women.

Figure 12: Alternatives to U.S. Immigration Detention, trauma shears, and my daughter's fisher-price triangle

Medical Decision Making:

Innocent people are tortured. They seek asylum in the US. We treat them like prisoners and harm them further, inflicting trauma whose effects will persist for generations. It doesn't have to be this way.

Figure 13: The Sum of its Parts