It was two in the morning when Paul Wise got the call: An 8-year-old girl from Panama had died in U.S. Border Patrol custody in Harlingen, Texas. Wise was on vacation in Portugal when his extra cell phone rang, the one he always keeps with him in case of emergencies concerning the care and treatment of migrant children detained at the U.S. border. This was the type of call he most feared.
“I was on the next plane to the Rio Grande Valley,” says Wise, a Stanford professor of pediatrics and of health policy who was serving as the juvenile care monitor for the Border Patrol facilities there. He arrived 48 hours later to participate in the investigation of the death of Anadith Danay Reyes Alvarez on May 17, 2023, her ninth day in custody.
Wise is soft-spoken, a good listener, perhaps from more than 50 years of leaning in to hear the voices of sick children. But on the U.S. border with Mexico—a subject of constant policy debate, where the major-party candidates for president made dueling visits on the same day in February—his voice has broken through. For more than four years, he has served as a court-appointed medical expert in two Border Patrol sectors in Texas, where he has monitored conditions, written reports, and made recommendations to ensure appropriate care and safety for migrant children in U.S. custody. “He has probably saved more children’s lives at the southern border than anybody,” says Nancy Ewen Wang, a Stanford professor of emergency medicine and the medical adviser to the new juvenile care monitor. (Wise, who is on sabbatical, has stepped down as monitor and returned to an advisory role.)
When Wise issued a report about two months after Anadith’s death, he wrote that it was a preventable tragedy. That the system failed. That he’d already explained, in his previous report, how that could happen. “When he issued his report that her death was clearly preventable, it made a difference,” says Neha Desai, a lawyer with the National Center for Youth Law. The media reported his findings, quoted his reports, and no one disputed them. Not the courts, not the human rights advocates, not the Border Patrol. “We will do better to ensure that this does not happen again,” said Troy Miller, the acting head of Customs and Border Protection (CBP).
“It’s complicated because of the political polarization that’s taken place around immigration policy,” Wise says. “There are groups that dehumanize migrants. I’ll fight that. There are groups that dehumanize Border Patrol agents. I’ll fight that too. I try to be fair and pragmatic. But I’m an advocate for the kids and their families. And the Border Patrol knows that. They chose to see me as a court-appointed consultant that can help them improve and reform their systems so that no kid ever dies again in custody.”
‘It was the system that was broken’
Wise first began working to improve the health of vulnerable children in Guatemala, where, on a summer break from Cornell in 1970, he traveled to volunteer in a children’s hospital during a civil war. “I was on a ward with kids dying of malnutrition,” he says. “I was 18 years old. It was a very quick, profound education.” He majored in Latin American studies, then earned his MD at Cornell and MPH at Harvard before beginning his career in Boston. Since 2004, he’s been on the faculty at Stanford, where he bridges the fields of child health equity, public policy, and international security studies. His research and humanitarian efforts, often hands-on, have taken him back to Guatemala many times to work on community and child health programs, to Iraq to evaluate systems of treating injured civilians during the Battle of Mosul, and to the Poland-Ukraine border to advise on the evacuation of children with cancer from Ukraine in the wake of the Russian invasion.
So, it’s not surprising that when news reports about the children at the U.S.-Mexico border—including a series of deaths as well as kids being separated from their families and kept in cages—propelled public outrage to new heights, Wise began outreach to lawyers and visits to the border to offer his assistance. Since 2019, he’s worked to monitor and ensure compliance with the landmark 1997 Flores agreement, a class action settlement between migrant children in custody and the U.S. government that, with input from Wise, reached a further settlement in 2022.
When I first got to the border, people in Kevlar vests were holding the hands of 7-year-olds.’
The current crisis concerning the care of children at the U.S. border traces its roots back to 2013–14, when the Border Patrol apprehended or expelled nearly 70,000 unaccompanied children—a 77 percent increase compared with the prior federal fiscal year. Children and families, many from Honduras, Guatemala, and El Salvador, poured in, seeking relief from violence and devastating economic conditions. Those numbers surged again in 2018–19 and then again in fiscal year 2021, when the number of unaccompanied children reached a new annual high: 144,834.
“When I first got to the border, people in Kevlar vests were holding the hands of 7-year-olds,” Wise says. “The focus of attention was on individual failures of the Border Patrol at that point. And there may have been individual failures, but to me it was the system that was broken. The system was incapable of caring for children in custody. I thought I could help.”
Wang, who also began traveling to the border at that time, agrees. “The pediatric community and society in general were upset about the child separation policy,” she says. “There was huge overcrowding, too many deaths, huge delays in processing. Kids not meant to be detained for more than 72 hours were kept for weeks. We needed some kind of system to keep unaccompanied children—and all the children—safe, and adhere to the fact that they’re kids. That was clear.”
Attorneys for the children went back to court to request enforcement of the Flores agreement, which remains under judicial supervision. The judge appointed attorney Andrea Ordin as the special master in the case. With Wise as her medical adviser, she would work for nearly three years to mediate the next, more detailed settlement.
“When Paul came on board, we had thousands of children across nine different facilities in South Texas, from McAllen to the Gulf,” says Ramiro Garza, who served as an assistant chief for Border Patrol in charge of overseeing the Rio Grande Valley sector before he retired. “It was madness. I was teaching my 25-year-old agents how to change diapers. They signed up to be jumping out of airplanes and riding ATVs in the desert, chasing smugglers. These children were arriving often in bad health, traveling for months, already dehydrated. There were no medical personnel. Border Patrol was ill-equipped for this.
“Paul came right after the agency had several children die in our custody. His primary goal was ‘Let’s make sure they are safe,’ ” Garza says. “He was the first person who understood the operational issues. I said, ‘Tell me what to do, and I’ll tell you whether it’s feasible.’ No one wants kids to die.”
The 2022 Flores settlement obligates Customs and Border Protection to make improvements in nutrition, medical care, and housing for children and families in the Rio Grande Valley and El Paso sectors. It also requires the hiring of caregivers focused on children under 5 and prohibits unnecessary separation between children and adult family members. “Paul was absolutely crucial in getting a settlement made because of the seriousness of his advice, the credibility that he developed with the government and the plaintiff and the court,” Ordin says.
Wise. (Photo: Rod Searcey, ’84)
With that settlement came a new role for Wise: that of juvenile care monitor. He made announced and unannounced visits to the detention facilities in the two sectors, monitoring conditions and interviewing everyone from CBP employees and contractors to families and children. Sometimes Ordin joined him.
“We ask the children, ‘How are you? Where is your country?’ ” Ordin says. “Paul loves it when it’s Guatemala. We ask them about the food, and ‘Did you get to see your mom?’ We sit on the floor with them and chat about how things are going. I’m always impressed by the resilience and the openness of the children and the amount of smiles. They’ve made harrowing journeys, especially those who didn’t make them with their families.”
‘The extremes of vulnerability’
The death of Anadith in May 2023 was the first death of a child in Border Patrol custody since 2019.
According to government reports, Anadith and her family were taken into Border Patrol custody near Brownsville, Texas, on May 9 at 9:34 p.m. as part of a larger group of 47 migrants. Early the next morning, during medical intake at a processing facility in Donna, Texas, the family reported that Anadith had chronic conditions: sickle cell anemia and congenital heart disease. Those were documented in the electronic medical record, but there’s no evidence they were shared with the on-call physician or the appropriate Border Patrol agents. On the fifth day at the facility, Anadith complained of abdominal pain, nasal congestion, and a cough. She had a fever of 101.8 and tested positive for influenza, which meant the family was transferred to Harlingen Station.
“She was positive for the flu, which is not uncommon,” Wise says. “It happens. They moved her. At that time, they were holding all the flu and COVID cases in a Border Patrol station about a half-hour away. And that’s basically a jail setup. They keep the doors open, but it’s basically a cell.”
Over the next three days, Anadith was treated for the flu, but “[i]t appears that the medical monitoring of [her] condition was not augmented in response to her elevated medical risk,” Wise wrote in his report. On May 17, her mother repeatedly took her to the medical desk, begging that she be taken to a hospital. Twice, they were sent back to their holding pod. The third time, her mother was carrying Anadith, who appeared to be having seizures. By the time emergency services arrived, the child was unconscious. She was declared dead at the hospital.
‘A child seeking asylum who has sickle cell anemia—you don’t get more vulnerable than that.’
“The mom kept saying, ‘My kid’s sick,’ and the medical people did not respond appropriately,” Wise says. “They should have called the pediatrician on call. They shoud have transferred her to the local children’s hospital, which wasn’t far away. It’s just astoundingly bad medical judgment. But it was the system that ultimately failed, because the pediatricians on call should have known about this case, and they should have said to the nurse practitioner, ‘Call an ambulance, get this kid immediately to a hospital.’ ” A child with sickle cell and a fever is in danger, he says.
“What got people particularly upset was that I had written about these weaknesses in the system in my prior report. It was a terrible tragedy.”
In his next report, Wise recommended “immediate actions that address the systemic failures that could lead to additional instances of significant harm to children in CBP custody,” including consults with pediatricians for high-risk children, “disciplined conveyance” of medical information, and faster transfer of medically fragile children out of custody. In his last report in November, he indicated that CBP had made improvements in some areas but not all.
“Anadith’s death focused the world’s attention on the extremes of vulnerability,” Wise says. “A child seeking asylum who has sickle cell anemia—you don’t get more vulnerable than that. My report said there was horrendously bad judgment by some medical personnel, but how does the system permit that to end in a child’s death?”
When he went on sabbatical, Wise stepped down as juvenile care monitor and returned to an advisory role. He is at the UNICEF Innocenti Research Centre, in Florence, Italy, studying the origins and future of child protection in areas of political instability and conflict, including Gaza and Ukraine. The U.S. border is never far from his mind. At any time, he knows exactly how many children are in detention. He just hopes his phone never rings in the middle of the night again.
Tracie White is a senior writer at Stanford. Email her at traciew@stanford.edu.
