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Family First: On the Struggles of Familial Medical Clearances

The barriers to entry to the Foreign Service start off high and do not taper off. Individuals pass through written exams, oral examinations, security clearances, and medical (or MED) clearances. Even once an officer has joined the Foreign Service, the hurdles to the career do not stop. Restrictions apply to an officer’s family as well.

American Sign Language Alphabet (2004), Darren Stone, WikiMedia Commons
American Sign Language Alphabet (2004), Darren Stone, WikiMedia Commons

Namely, each accompanying family member must have the ability to pass medical clearances ensuring that they can suitably live at an overseas posting to be able to travel officially for the U.S. government.

For Margaret Dean, the bureaucratic hurdles of the requirements for overseas posting came to light with the adoption of her daughter, Andrea. Despite a long-standing career in the Foreign Service and the previous birth of her two boys, Dean faced the stressful task of ensuring medical clearance for her whole family, as Foreign Service Officers may only travel with cleared family members—or face going to post unaccompanied. After a long and difficult bout with meningitis as an infant, Andrea lost her hearing and the worldwide medical clearance that would be needed to live overseas for any posting her mother might receive.

Margaret Dean entered her career in the Foreign Service while posted in Tel Aviv, Israel with her then-husband, an officer himself. After her husband’s death, Dean remained in the Foreign Service, working primarily as an Economic Officer and in human resources. She would later go on to lead the redesign of the Foreign Service entrance examination procedures as Staff Director of the Board of Examiners.

As a result, the Deans stayed stationed in Washington, D.C. as Margaret Dean fought her way around the restrictions to find a way to keep both her family and her career healthy and on track. In this “Moment in U.S. Diplomatic History,” Dean describes the ways in which family and career intersect for those in the Foreign Service as she details the years after the adoption of her daughter.

Margaret Dean’s interview was conducted by Charles Stuart Kennedy on January 15, 2010.

Read Margaret Dean’s full oral history HERE.

Read about Dean’s work with the Board of Examiners HERE.

Drafted by Miranda Allegar

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Excerpts:

“Does this baby feel hot to you?”

A Welcome Addition: What did I want to do and where did I want to go? Well, I had restrictions imposed on me since I had no medical clearance for my daughter.

I have two sons. I had one son with my first husband, one son with my second husband and I wanted a little girl. So we adopted a child from Colombia. That took a while because the agency initially identified a child for us whose mother never came back and signed the final release forms. Since Nelson was four or five, we wanted a little girl around two years old. So after the opportunity to adopt this other child, Marisol, had vanished, the agency looked for another little girl. Then my husband called me up one day and told me ”They have a new child for us”. And I said, “Oh, good. When was she born?” And he said “August 26.” I said “what year?” He said “This year.” This was August, so it was clear to me that she was a baby. I said, “We didn’t ask for a baby; I’m not ready to do that.” He said, ”I already told them yes and I will do everything.” I said, “What?” He said, “Yes, I’m going to take paternity leave and I am going to stay home and do the midnight feedings.” He was so excited. That fact that he was off by a month and Andrea had really been born a month earlier was immaterial.

With that, we adopted Andrea. The two of us went to Bogotá and we filled out all the papers, completed all the forms, and saw everybody we needed to see. We spent the week with Ted Cubbison, who was the Consul General in Bogotá; we had the baby in our care for the week. Everything was fine. We took the baby out of the orphanage because they had various contagious diseases, including chicken pox. Since it takes awhile for the papers to go through the various court processes, we boarded Andrea with a family recommended by the orphanage and returned to the U.S. The adoption agency calls you when your baby is ready to be adopted. Only one parent has to go back at that point. Since I spoke Spanish I signed up to do that. Many of the European adopting parents just stay in country with the baby for the six weeks or eight weeks that the processing of the adoption application takes. When the adoption agency called I returned to Bogotá the first week in November. I picked up Andrea first thing and the family told me “She’s had a sore throat with some kind of infection, but she’s okay now.”

I stayed with Ted Cubbison again. He was a single male as well as the Consul General. He had nothing in his house at all to do with children. I had this baby and, when I felt her head, she felt hot to me. I asked Ted: “Does this baby feel hot to you?” He had no idea whether the baby felt hot or not. I thought she had a little fever so the next day I took her to a doctor. She was a little bit sick with a slight temperature. Every morning I would do the paperwork necessary for the adoption. I was guided by the adoption agency’s facilitator, getting the new birth certificate (in Colombia only the adopting parents’ names show on the birth certificate), picking up the court order, and obtaining a Colombian passport, etc. Then every afternoon I would take Andrea to a doctor. One day we did stool samples. Then the next day we did urine samples. Then we did blood samples; every day we would check something else. Every day Andrea got sicker and sicker and sicker. On Thursday we were scheduled to go to the embassy-recommended doctor for the medical clearance needed for her to get an immigrant visa. The doctor told me that Andrea was fine. I knew she was not fine. Her temperature by Thursday was running 104, 105. I was every night putting her in cold baths; I dosed her with baby aspirin. I had found infant hydrating solution locally, after initially making my own. I was just doing everything I could to keep this child’s temperature down. She was not sleeping. I was not sleeping. And on Friday I thought Andrea had fallen into a coma when she was not having convulsions. I mean she was twitching. So I went back to the same American Embassy-recommended local doctor and I told him that she was really, really sick. And he said no, she’s fine, she’ll be all right.

Now by this time her back was curved in an arch backwards, which I’ve discovered is due to the pressure in the spinal column. Because of the pressure the backward arch is the least painful way for somebody with spinal meningitis to react. The fontanel in her head (remember, she was only three months old) was all swollen. I could see this. I didn’t know what it meant at the time but subsequently I learned it was an indicator of spinal meningitis. Because we had been scheduled to get the immigrant visa to the U.S. on Friday, I asked Ted to help me and Andrea leave the country on Saturday. He arranged through the consular section to change my airline tickets, which in itself was amazing because that week-end was both a Colombian and a U.S. holiday. For the second time in my life I was, thankfully, the recipient of excellent American Citizen Services assistance. I left with Andrea on Saturday. Tom and Nelson had flown down to Tampa, Florida, to my mother’s house and the four of us were supposed to reune and go back to Washington as a new family. Nice plan; poor execution.

“I was sure she was in a coma.”

           
Foreign Service Medical Clearance Form for Children, U.S. Department of State
Foreign Service Medical Clearance Form for Children, U.S. Department of State

Dangerous Travel: I’ve always believed that babies should be carried or swaddled up close to you; you should not be putting them in plastic containers. But I was really, really, really sorry that I didn’t have one of those plastic seats because every time I would touch Andrea it would hurt her. If I did anything, just move her from one place to another, she would scream. She was obviously in a lot of pain. So we landed in Miami, went through immigration and transferred to the flight to Tampa. We arrived at my mother’s house in a perilous state. I told Tom and my mother that Andrea was really sick. My mother thought she was just sleeping. I was sure she was in a coma. She had just been inert for almost two days, except when she was twitching. So my mother said, “You can either take her to the little local medical unit here that’s a couple blocks away or you can go downtown to St. Joseph’s. They have a big pediatric unit.” So off we went to St. Joseph’s. When we walked into this emergency room in Tampa, Florida, it appeared there were 400 people already there. I thought, “This is the medical option of last resort or first resort for any indigent person in Tampa, Florida. We are going to be here forever.”

Well, that was not what happened. You sign in when you first arrive and the assistants triage waiting patients right away. As soon as they had taken Andrea’s vital statistics she was out of there; she went to the head of the line. They put her in a room; they brought in—because this was a Sunday now—they summoned their pediatrician on call; they beeped their pediatric neurologist; they called several doctors in to look at this child. And they’re asking me all these questions: “How long has she had this fever; when was she sick, what’s her medical history?” I had only had her for five days. Because she had been so sick I had not had any sleep for the last four days. I mean even if I had known the answers to their questions I’m not sure I could have responded coherently. They asked me, “Does she have HIV?” I said, “She’s three months old, how would she have HIV?” That shows how much I knew about the transmission of HIV but in any case they said no, no, not HIV, HIB, which is Haemophilus Influenzae Type B. HIB is the primary cause of spinal meningitis in babies and there is now a vaccine for it. In fact there was a vaccine for it about six months after Andrea came to the States. She was just born six months too early. Andrea asked me once. “Why didn’t I get the vaccination?” I said “Because they didn’t have it when you were born.” HIB, before the vaccine, was the primary cause of deafness in children in the United States.

The nurses put her in isolation because HIB is a contagious disease. I did a lot of research on spinal meningitis to discover that it’s just a description of a condition. It can be any infection that crosses the meninges and enters the spinal fluid. The infection creates a lot of swelling, putting pressure on and eventually damaging the nerves in the spinal column. The infection can come from anything. It can come from a social disease; it can come from flu. It can be viral or bacterial. That meant that until the doctors got the results from the spinal tap they did not know what the cause was. To be safe the medical community treats the patient for both viral and bacterial possibilities. They administer antibiotics in case it is bacterial. At the same time they treat all the symptoms; they have to keep the temperature down and they have to keep the child hydrated, administer painkillers, in case the cause is viral. The tests take about four or five days and the source in Andrea’s case turned out to be bacterial and was HIB. Bacterial meningitis generally kills the person because, as the immune system becomes overwhelmed and collapses, all kinds of other infections take over. Andrea had infections in her bones, in her hips; she had thrush; she had all kinds of gastro infections going on at the same time. She lost a third of her body weight. She was quite sick. Your great-grandmother could have had meningitis and survived. If the causative agent was viral and if the doctor treated the symptoms, she might have survived and you would be here today. If it had been bacterial you would not be around.

Andrea remained in the hospital 28 days and then they would not let her leave Tampa for another week or two. St. Patrick’s allows rooming in with sick children. With Tom in Tampa, we traded days in the hospital; he would take one 24-hours shift and I would take the next one. Whichever parent was off took care of Nelson and stayed at my mother’s house. I had time on my ‘free’ days to go to the library and read about what causes spinal meningitis. Now I could look it up on the internet.

But I’m still angry; I’m still very, very angry at the doctor in Bogotá because he should have at least said to me, “It looks like she’s okay and she can go to the States, but when you get there have her checked out.” He said nothing. I mean the man had to have known she was ill. Perhaps he thought I would abandon her. Perhaps he realized that since what she had was contagious that she would not be allowed to enter the U.S., if he told me. Intending immigrants cannot enter the U.S. with a contagious disease. Still he was lucky she did not die. . . .

“MED says you can’t serve in places that don’t provide the specified accommodations but they don’t tell you where those places are.”

Bureaucratic Hang-ups: This is all by the way of telling you that Andrea lost her medical clearance before she ever got one because she’s deaf, mostly. She has some residual hearing in her right ear but she has no hearing in her left ear; she’s profoundly deaf in her left ear. Of course people see the hearing aid in the right ear so they talk to the left ear because they think she can hear with that ear. Unfortunately that ear is totally useless. She did not have the medical clearance necessary to go overseas and that circumscribed my ability to think about different options when I was trying to choose which amazing country I’d like to go to next.

Q: Why would a deaf child be an impediment to go overseas?

DEAN: According to the medical authorities a child who is learning to speak who’s deaf should concentrate on one language. They should not be exposed to multiple languages and multiple sounds that they can’t hear and interpret. I’m just telling you what I was told, not that I believe it.

Q: Okay, the recording is not picking up my skeptical look.

DEAN: Yes. All I can tell you is that’s what we were told. Even when we eventually did get a class two medical clearance for her I still had to find a post that would provide MED’s prescribed accommodations for her. They wanted changes like carpeting in the room, curtains on the wall, to deaden background noise; they wanted a dedicated American Sign Language interpreter. The list MED gave me had about 25 accommodations that they required

Q: Sounds like a bureaucratic nightmare.

DEAN: It was. You have a limited clearance, which means you are restricted in where you can go. MED however does not coordinate with the assignments people in CDA. You have to build your own list of possible assignments and then work with MED to determine if they meet the criteria. MED says you can’t serve in places that don’t provide the specified accommodations but they don’t tell you where those places are. You have to find them yourself. So I ended up negotiating with several overseas schools when we finally were able to obtain a class two medical clearance for Andrea. She was in second grade. What I did was made movies of her in different situations. I have a movie clip of her in religion class and I have another of her making brownies one day out of a mix, where I’m talking to her and she’s talking to me and we’re showing how well she follows instructions. I packaged six or eight vignettes on one DVDs and sent them to various schools. . . . I put them on VCR tape and I sent them to schools where the Embassy had an economic position for me. In talking to the school in Madrid I found that they initially had said yes, we can probably handle this. I sent off the tape, I sent off all the information about Andrea and the school authorities come back and say ‘Oh, we can’t do this.’ And I asked, “Well, did you look at the tape?” They said, “Oh no, we didn’t want to look at the tape because that might influence our decision.” And I’m thinking, “Yes, that’s exactly why I sent the tape, so you could make a considered judgment based on your observations of Andrea.” Meanwhile the international school in Rome had come back initially and said, “Well, we don’t think we can provide the necessary modifications, but send us the material and we’ll take a look at it.” And they came back and said, “Yes, we really loved the video. Yes, we can work with this child; we can do this”. So I was forced to go to Rome instead of Madrid. That’s ahead of my story. . . .

Q: Well, after this, what was your main goal? Was it to get overseas with the handicapped daughter?

DEAN: I kept working on getting an overseas assignment. The first step was to take Andrea to see if she could get a medical clearance. Finally she got a class two medical clearance, which meant any post/school had to meet this list of requirements that Gallaudet said she needed. Andrea had been going to Gallaudet since she was about 18 months old. She signs and we needed a dedicated signer for her. I can’t remember how I did this but I identified four or five American Sign Language (ASL) signers who were interested in going to Rome. I interviewed them at my home, and I hired one who was a CODA, which is a Child of Deaf Adults. A CODA is a hearing person who is the child of deaf adults and for whom ASL is their mother’s tongue. I wanted somebody like this, although I didn’t know they existed before I started the process, because I figured anybody who was going to Rome and be in an Italian speaking society without anybody around who knew American Sign Language had to have ASL in their bones. ASL shouldn’t be something they acquired in college as a career path they learned at 18, 19, 20 and now they’re 24 or 25. Audrey Ruiz was my first and, it turned out, best choice; she is a Mexican-American and both of her parents are deaf. Audrey stayed with us for two years. The tax structure in Italy changes, i.e., increases markedly, for foreigners working more than two years, so Audrey returned to the U.S. I think the first two years are essentially tax free but after two years they start taxing at Italian rates which are very high. Many Italians don’t pay the full rate but almost all the foreigners do. It’s not really economic to stay after two years.

By then the Internet had made such progress I went online and posted the job there. I received 98 applications for this position and read through them all. Again, I was looking for a CODA, somebody for whom Sign is the mother tongue. I winnowed the pile down to a group of about four or five. Because I paid for these people to come to Rome to interview I wanted to make sure that the one I chose was the best qualified. One young woman, whom I had mid-ranked as not having much experience, sent a video. It was absolutely fantastic. Based on the paper credentials I never would have invited this young woman. I saw that video and included her in the list of interviewees. She came to Rome and knocked the socks off of everybody. I’d sent each candidate to the school, where she interviewed with the teachers there. Each went through a day with Andrea. I asked Audrey, who was the first signer, her opinion of each of these applicants’ abilities. Then I was concerned about Andrea’s reaction; it had to be somebody that she essentially liked or at least didn’t dislike anyway. We then had a conference call with Audrey, the teachers, the special ed instructor. And Kizzie won out head and shoulders over everybody else. She was 21 or 22, not very old, absolutely drop dead gorgeous, blonde, a stunning young woman, absolutely beautiful. Her parents were divorced and her mother was concerned that she would come to Rome and marry some deaf Italian. She assured her mother that she was not going to do that. The year after I left Rome I went back to her wedding to a deaf Italian, Nicola. He is just as handsome as she is gorgeous and his family is fairly wealthy. The family makes bathroom and kitchen ceramic equipment, whether it is toilets or sinks. They have a niche in the market and they do very well. Now Kizzie has two little boys, one of whom is deaf.

In some cases deafness is hereditary and in some cases it’s environmental. In Nicola’s case, that is Kizzie’s husband’s case, he fell and hit his head as a child. His family thought his deafness was because of the fall. Genetic testing when their second son was deaf, however, revealed that Nicola’s deafness was genetic and their son inherited genes from both parents for deafness. In Kizzie’s family’s case on her mother’s side it’s hereditary. End of the story: We did get a clearance to go to Rome because Andrea could go to school there and we did have a dedicated Signer for the four years we were there.

TABLE OF CONTENTS HIGHLIGHTS

Education
BA, University of Kentucky 1962–1966
MA in Spanish Literature and Language, American University 1970–1972 
Joined the Foreign Service 1976
Washington, D.C.—Director of Senior Assignments 1996–1998
Rome, Italy—Economic Minister Counselor 1998–2002
Washington, D.C.—Board of Examiners, Staff Director 2004–2007