Lady Liberty, Sostén mi Modelo Especial*

Kristi Noem, probably, Trump's Secretary of Homeland Security nominee, via interpreter

Doctors are empathetic, right? Well, mostly. Hear me out, please?

When you complain about all the forms you must fill out for me that aren’t for me (they are for filing for your insurance reimbursement, for your HIPAA release, for your communication preferences, your Advance Directives, your depression/anxiety screens, etc.)? Well at that point my empathy takes a step back and seems rather distant and uninterested.... Maybe not the best way to start our appointment?

And that odd look on my face? No, it’s not gas, that’s a rewind of the daymare of every primary care provider drowning in forms with no life ring in sight.

These days you come into this world with a form, and you leave this world with a form. No exceptions.

“The Dash” between birth and death in U.S. medicine is heavily punctuated by the innumerable school/work excuses, PG&E medical baseline allowance forms, airlines/cruise refund forms, commercial driver’s license forms, DMV placard forms, immigration paperwork, nursing home forms, assisted living forms, disability forms, DMV unsafe driver reports, controlled substance medication contracts, prior authorization forms, travel clearance forms, sports clearance forms, referral forms, beneficiary forms, commercial driver’s license forms, tuberculosis screening forms for food service workers and educators, jury duty excuses, vaccination forms, a doctor’s letter giving permission to SCUBA over the age of 65 in Australia, a doctor’s letter giving permission to drive in Ireland over the age of 75, CPS/APS forms, etc., etc., ad nauseum.

Though I can see the need for many of these forms, I still don’t see the time in my schedule to complete them, and you don’t even have to wait or watch me complete most of them. Just drop them off and POOF! There’s your completed form. It’s like magic! and free!

Though my typing skills are pretty good¹, I’ll be the first to admit they are far beneath those of the secretaries on a comparable salary. I don’t mind typing, it just doesn’t seem like the best use of my time and skillset. I definitely do not recall from med school that anyone conveyed the extent of time and effort we would spend on forms, much less could they have anticipated the invasion of forms into every nook and cranny of medicine. But the view from the ivory towers is spectacular!

• Do not ever ask me for an immunization exception

• Do not ever ask me for a letter to allow you to have an emotional support burro, or burrito, or both.

Of all those forms, I must admit that one form I do not mind is the opportunity to medically certify that a prospective naturalization applicant – legally often working in unskilled, backbreaking labor for years for our local businesses and the American economy – has difficulty as an adult learning to speak, read, and write English.²

https://www.usa.gov/official-language-of-us

Does the U.S. have an official language?

“The United States does not have an official language.”

The vast majority of California’s unskilled laborers are from Mexico. Doing this hard work is likely all they have ever known, and few appear to have had much of a childhood at all. Quite a few have difficulty writing and reading their native Spanish as they never had any opportunity to go to school, so learning disabilities can be difficult to assess without any history of learning.

I should acknowledge that assessing learning disabilities is not an area of usual medical training, and few if any physicians have expertise in that field.

Dunning meets Kruger by proxy, but here we are.

So, I am not against using my congenital white male privilege to offer them some help in this difficult process, which my white ancestor immigrants did not have to navigate not all that long ago.

Though you may not know the title, or the full Petrarchan sonnet from 1883, you will likely recognize a frequently used excerpt from it:

The New Colossus

Not like the brazen giant of Greek fame,
With conquering limbs astride from land to land;
Here at our sea-washed, sunset gates shall stand
A mighty woman with a torch, whose flame
Is the imprisoned lightning, and her name
Mother of Exiles. From her beacon-hand
Glows world-wide welcome; her mild eyes command
The air-bridged harbor that twin cities frame.

"Keep, ancient lands, your storied pomp!" cries she
With silent lips. "Give me your tired, your poor,
Your huddled masses yearning to breathe free,³
The wretched refuse⁴ of your teeming shore.
Send these, the homeless, tempest-tost to me,
I lift my lamp beside the golden door!"

- Emma Lazarus (1849-1887)

Ok, back to work.

USCIS Form N-648, Medical Certification for Disability Exceptions, Department of Homeland Security, U.S. Citizenship and Immigration Services.

“In general, applicants for naturalization must demonstrate that they understand the English language, including the ability to read, write and speak words in ordinary usage. They must also demonstrate knowledge and understanding of the fundamentals of the history, principles, and form of government of the United States. These are called the ‘English and civics requirements.’”

In 1994, Congress legislated an exception to the English and civics requirements for naturalization applicants who cannot meet those requirements because of a physical or developmental disability, or mental impairment.

The U.S. Citizenship and Immigration Services (USCIS), Department of Homeland Security, is very clear that “illiteracy and advanced age alone are not valid reasons to seek an exception from the English and/or civics requirement.”

When you are illiterate in your native language, you are at a huge disadvantage to learn any other language, and there is a mountain of evidence that learning a new language after the age of 18 years old is much more difficult. There is also plenty of evidence that proficiency in a new language is much more difficult after age of 10.

So why can’t these applicants just wing their naturalization tests without new language proficiency?

https://blog.usa.gov/why-vote.gov-supports-multiple-languages

Why vote.gov supports multiple languages

“The U.S. is a multilingual country According to a 2019 U.S. Census Bureau survey, nearly 68 million people in the U.S. speak a language other than English at home. And each year the U.S. welcomes more than 800,000 new citizens from all over the world.

Providing voting information in languages that reflect the diversity of U.S. citizens is an important way to help people exercise their right to vote.”

Medical Certification for Disability Exceptions.

After Part 1, the Applicant’s information and Part 2, the Certifying Medical Professional’s information, Part 3 gets into it.

“Part 3, Item 1. Provide the clinical diagnosis and medical code for all physical or developmental disabilities and/or mental impairments that affect the applicant’s ability to meet the English and/or civics requirements. Also, clearly describe how each disability and/or impairment prevents the applicant from learning English and/or civics. Responses should use common terminology, without abbreviations, that a person without medical training can understand (so that lay person can then use this information to make a medical determination of disability?)

“Part 3, Item 2. What clinical or laboratory diagnostic techniques did you use to diagnose the disabilities and/or impairments?

“Part 3, Item 3. Provide the clinical diagnosis and medical code for all physical or developmental disabilities and/or mental impairments that affect the applicant’s ability to meet the English and/or civics requirements. Also, clearly describe how each disability and/or impairment prevents the applicant from learning English and/or civics.

“Part 3, Item 4. Are any of the disabilities and/or impairment(s) listed in Part 3., Item Number 1. the result of the applicant’s illegal use of drugs? If your answer is “Yes” for all of the disabilities or impairments, do not complete this Form because the applicant is not eligible for this exception.

“Part 3, Item 5. If yes, for some disabilities or impairments, identify which disabilities or impairments are the result of the applicant’s illegal use of drugs.”

It certainly appears these applicants commonly have significant problems with illegal use of drugs, which automagically changes their inability to meet the English and/or civics requirements as undeserving of reasonable accommodation.

“Illegal use of drugs”

“Yes, it is illegal to use prescription drugs without a valid prescription.”⁵

Because of the evidence or perception for potential to harm, many medications in the United States are only available by prescription. If the evidence or perception for potential for harm is thought to be great enough, the medication carries added restrictions and labeling as a “controlled substance.”

Many drugs which are only available by prescription in the United States are available over the counter in Mexico, including some we consider controlled substances like the pain medication tramadol.

Incidentally, alcohol is a drug, regulated by the Federal government, and “the Food and Drug Administration (FDA) regulates the manufacturing, marketing, and distribution of tobacco products to protect public health.”

Cigarette smoking kills more than 480,000 Americans each year. Cigarette smoking cost the United States more than $600 billion in 2018, including more than $240 billion in healthcare spending and nearly $372 billion in lost productivity.

Not sure how much more of this protection We The People can stand.

Consider that self-medication for undiagnosed ADHD is nearly 4 times more prevalent among methamphetamine users than comparison subjects.⁶ It is also not uncommon for them to experience severe adverse health consequences of meth use (Even cocaine and tobacco have physiologic effects which may help with ADHD difficulties). While ADHD is not considered a learning disability, it does make learning difficult.

So maybe, “drugs” aren’t so black and white after all? But let’s see if I have this right. If…

• a legal resident brings an over-the-counter medication back from Mexico for their hard labor pains here, which is a controlled substance here, or

• a 20 year-old legal resident consumes alcohol, or

• a legal resident with undiagnosed ADHD self-medicates with methamphetamines

…and as a result they sustain neurologic damage (stroke, seizures, blindness, all of which is also possible with many U.S.-approved medications) which causes learning disabilities as a result of the applicant’s illegal use of drugs, that applicant would not be eligible for this exception?

But something tells me this is not about illegal use of drugs, but use of illegal drugs, well, because implicit biases tend to travel in packs. I don’t think “Justice is blind” means what they think it means.

Lady of Justice, ca. 2025, appearing unable to read a history book

So I’m finding the meat of this form confusing. Are we addressing the illegal use of drugs or the use of illegal drugs, and does English syntax really matter? Not sure who wrote this form, but it may have involved an exception from the English requirement.

And where to even start with the “civics requirements” of “demonstrating knowledge and understanding of the fundamentals of the history, principles, and form of government of the United States?”

In my conversations with these patients, I absolutely encourage them to study but to put them at ease I also occasionally volunteer other bits of United States-Mexico history, such as:

• Mexico outlawed slavery in 1830, while the United States did not outlaw slavery until 1863.

• The United States paid Mexico for the southernmost part of Arizona and part of New Mexico, known as Venta de La Mesilla, or in gringo, the Gadsden Purchase. Yes, America paid for it, not Mexico.

• Mexico’s President is a woman, Claudia Scheinbaum. America has never had a female President.

• Thousands of Chinese workers were brought to build the southern United States railroad, but when construction was completed, Americans drove them out of the country, and those who chose not to return to China migrated to the southern side of our border with Mexico and founded the city of Mexicali, now the Capital of the Mexican state of Baja California.

You would never know from this map that there were once indigenous peoples here

And as my busy mind is wont to do, these USCIS forms give me pause to consider how many of my American patients, whether illegal drug-using, or illegally using drugs, or neither, could ever come close to passing a naturalization test. In English.

Ay, Dios mío.

1. Thank you Mrs. Bryant, 11^th grade typing class - who knew?

2. Back when white folk were just learning to be angry about having to “press 1 for English,” my since radicalized Talibangelical mother famously said, “When they learn to speak, read and write English properly, I’ll consider their complaint about having to press 1 for English.”

3. “In 2019, during Trump administration, Ken Cuccinelli, whom Trump appointed as acting director of U.S. Citizenship and Immigration Services, revised a line from the poem in support of the administration's “public charge rule” to reject applicants for visas or green cards on the basis of income and education. Cuccinelli added the caveat "Give me your tired and your poor who can stand on their own two feet, and who will not become a public charge"; later suggested that the "huddled masses" were European; and downplayed the poem as it was "not actually part of the original Statue of Liberty." Cuccinelli's remark prompted criticism. The Trump administration rule was later blocked by a federal appeals court.”

4. When I read “wretched refuse” this is what comes to my mind:

5. https://www.justice.gov/archive/ndic/pubs5/5140/5140p.pdf

6. https://www.sciencedirect.com/science/article/abs/pii/S0306460313002256

*A closing note on the title: “In June 2023, Modelo Especial overtook Bud Light to become the best selling beer brand in America. Since then, the sales gap between the two brands has widened—and Michelob Ultra has also overtaken Bud Light to become the second-best selling brand in America—continuing a growth trend that started many years ago.”

https://www.forbes.com/sites/dontse/2024/11/01/how-modelo-became-the-no-1-beer-brand-in-america/