The men had health insurance from jobs at one of the nation's largest pork producers. But neither had legal permission to live in the U.S., nor was it clear whether their insurance would pay for the long-term rehabilitation they needed.
So Iowa Methodist Medical Center in Des Moines took matters into its own hands: After consulting with the patients' families, it quietly loaded the two comatose men onto a private jet that flew them back to Mexico, effectively deporting them without consulting any court or federal agency.
When the men awoke, they were more than 1,800 miles away in a hospital in Veracruz, on the Mexican Gulf Coast.
Hundreds of immigrants who are in the U.S. illegally have taken similar journeys through a little-known removal system run not by the federal government trying to enforce laws but by hospitals seeking to curb high costs. A recent report compiled by immigrant advocacy groups made a rare attempt to determine how many people are sent home, concluding that at least 600 immigrants were removed over a five-year period, though there were likely many more.
In interviews with immigrants, their families, attorneys and advocates, The Associated Press reviewed the obscure process known formally as "medical repatriation," which allows hospitals to put patients on chartered international flights, often while they are still unconscious. Hospitals typically pay for the flights.
"The problem is it's all taking place in this unregulated sort of a black hole ... and there is no tracking," said law professor Lori Nessel, director of the Center for Social Justice at Seton Hall Law School, which offers free legal representation to immigrants.
Now advocates for immigrants are concerned that hospitals could soon begin expanding the practice after full implementation of federal health care reform, which will make deep cuts to the payments hospitals receive for taking care of the uninsured.
Health care executives say they are caught between a requirement to accept all patients and a political battle over immigration.
"It really is a Catch-22 for us," said Dr. Mark Purtle, vice president of Medical Affairs for Iowa Health System, which includes Iowa Methodist Medical Center. "This is the area that the federal government, the state, everybody says we're not paying for the undocumented."
Hospitals are legally mandated to care for all patients who need emergency treatment, regardless of citizenship status or ability to pay. But once a patient is stabilized, that funding ceases, along with the requirement to provide care. Many immigrant workers without citizenship are ineligible for Medicaid, the government's insurance program for the poor and elderly.
That's why hospitals often try to send those patients to rehabilitation centers and nursing homes back in their home countries.
Civil rights groups say the practice violates U.S. and international laws and unfairly targets one of the nation's most defenseless populations.
"They don't have advocates, and they don't have people who will speak on their behalf," said Miami attorney John De Leon, who has been arguing such cases for a decade.
Estimating the number of cases is difficult since no government agency or organization keeps track.
The Center for Social Justice and New York Lawyers for the Public Interest have documented at least 600 immigrants who were involuntarily removed in the past five years for medical reasons. The figure is based on data from hospitals, humanitarian organizations, news reports and immigrant advocates who cited specific cases. But the actual number is believed to be significantly higher because many more cases almost certainly go unreported.
Some patients who were sent home subsequently died in hospitals that weren't equipped to meet their needs. Others suffered lingering medical problems because they never received adequate rehabilitation, the report said.
Gail Montenegro, a spokeswoman for U.S. Immigration and Customs Enforcement, said the agency "plays no role in a health care provider's private transfer of a patient to his or her country of origin."
Such transfers "are not the result of federal authority or action," she said in an email, nor are they considered "removals, deportations or voluntary departures" as defined by the Immigration and Nationality Act.
The two Mexican workers in Iowa came to the U.S. in search of better jobs and found work at Iowa Select Farms, which provided them with medical insurance even though they had no visas or other immigration documents.
Cruz had been here for about six months, Rodriguez-Saldana for a little over a year. The men were returning home from a fishing trip in May 2008 when their car was struck by a semitrailer truck. Both were thrown from the vehicle and suffered serious head injuries.
Insurance paid more than $100,000 for the two men's emergency treatment. But it was unclear whether the policies would pay for long-term rehabilitation. Two rehabilitation centers refused to take them.
Eleven days after the car crash, the two men were still comatose as they were carried aboard a jet bound for Veracruz, where a hospital had agreed to take them.
Rodriguez-Saldana, now 39, said the Des Moines hospital told his family that he was unlikely to survive and should be sent home.
The hospital "doesn't really want Mexicans," he said in a telephone interview with the AP. "They wanted to disconnect me so I could die. They said I couldn't survive, that I wouldn't live."
Hospital officials said they could not discuss the case because of litigation. The men and their families filed a lawsuit in 2010 claiming they received minimal rehabilitative care in Veracruz.
A judge dismissed the lawsuit last year ruling that Iowa Methodist was not to blame for the inadequate care in Veracruz. The courts also found that even though the families of the men may not have consented to their transport to Mexico, they also failed to object to it. An appeals court upheld the dismissal.
Patients are frequently told family members want them to come home. In cases where the patient is unconscious or can't communicate, relatives are told their loved one wants to return, De Leon said.
Sometimes they're told the situation is dire, and the patient may die, prompting many grief-stricken relatives to agree to a transfer, he said.
Some hospitals "emotionally extort family members in their home country," De Leon said. "They make family members back home feel guilty so they can simply put them on a plane and drop them off at the airport."
In court documents, Iowa hospital officials said they had received permission from Saldana's parents and Cruz's long-term partner for the flight to Mexico. Family members deny they gave consent.
There's no way to know for sure whether the two men would have recovered faster or better in the United States. But the accident left both of them with life-altering disabilities.
Nearly five years later, the 49-year-old Cruz is paralyzed on his left side, the result of damage to his hip and spine. He has difficulty speaking and can't work.
"I can't even walk," he said in a telephone interview, breaking into tears several times. His long-term partner, Belem, said he's more emotional since the accident.
"He feels bad because he went over there and came back like this," she said. "Now he can't work at all. ... He cries a lot."
She works selling food and cleaning houses. Their oldest son, 22, sometimes contributes to the family income.
Rodriguez-Saldana said he has to pay for intensive therapy for his swollen feet and bad circulation. He also said he walks poorly and has difficulty working. He sells home supplies such as kitchen and bath towels and dishes, a business that requires a lot of walking and visiting houses. He often forgets where he lives, but people recognize him on the street and take him home because he's confused.
The American Hospital Association said it does not have a specific policy governing immigrant removals, and it does not track how many hospitals encounter the issue.
Nessel expects medical removals to increase with implementation of health care reform, which makes many more patients eligible for Medicaid. As a result, the government plans to cut payments to hospitals that care for the uninsured.
Some hospitals call immigration authorities when they receive patients without immigration documentation, but the government rarely responds, Nessel said. Taking custody of the patient would also require the government to assume financial responsibility for care.
Jan Stipe runs the Iowa Methodist department that finds hospitals in patients' native countries that are willing to take them. The hospital's goal, she said, is to "get patients back to where their support systems are, their loved ones who will provide the care and the concern that each patient needs."
The American Medical Association's Council on Ethical and Judicial Affairs issued a strongly worded directive to doctors in 2009, urging them not to "allow hospital administrators to use their significant power and the current lack of regulations" to send patients to other countries.
Doctors cannot expect hospitals to provide costly uncompensated care to patients indefinitely, the statement said. "But neither should physicians allow hospitals to arbitrarily determine the fate of an uninsured noncitizen immigrant patient."
Arturo Morales, a Monterrey, Mexico, lawyer who helps Cruz and Rodriguez-Saldana with legal issues, is convinced the men would have been better off staying in Iowa.
"I have no doubt," he said. "You have a patient who doesn't have money to pay you. You can't let them die."
--- Associated Press Writer Barbara Rodriguez in Des Moines contributed to this report. ---
Boston Bomb Suspect Captured Alive in Backyard Boat
The alleged Boston Marathon bomber who hid from authorities for more than 12 hours was captured tonight by police, sending cheers up through the Watertown neighborhood where he was found.
Dzhokhar Tsarnaev, 19, was found by a homeowner lying in a boat in the man's backyard around 7 p.m.
Gunfire broke out in the immediate aftermath of the discovery, but quickly stopped as police hunkered down for a standoff with Tsarnaev that lasted a little more than an hour and a half.
Around 8:45 p.m., Tsarnaev was taken into custody and transported away from the scene in an ambulance, as law enforcement officials and onlookers clapped and cheered.
Tsarnaev had been shot by police during gunfire nearly 24 hours earlier. Sources said Tsarnaev was bleeding badly.
A senior Justice Department official told ABC News that federal law enforcement officials are invoking the public safety exception to the Miranda rights, so that Tsarnaev will be questioned immediately without having Miranda rights issued to him.
The federal government's high value detainee interrogation group will be responsible for questioning him.
The Miranda exemption exists to protect the public safety from another attack, according to the official.
"We got him," Boston Mayor Tom Menino tweeted immediately after Tsarnaev was arrested. "I have never loved this city & its people more than I do today. Nothing can defeat the heart of this city .. nothing."
The Boston police department also sent out a tweet in the aftermath trumpeting, "CAPTURED!!! The hunt is over. The search is done. The terror is over. And justice has won. Suspect in custody."
Tsarnaev and his brother, Tamerlan Tsarnaev, 26, are believed to be behind the bombing of the Boston Marathon on Monday that killed three individuals and injured more than 170.
Tamerlan was killed by gunfire Thursday night in a shoot-out with police. Dzhokhar fled the shoot-out on foot into the Watertown neighborhood, which was the subject of an intense manhunt today involving hundreds of law enforcement personnel. The entire city of Boston was placed on lockdown for the dragnet.
At a new conference around 6 p.m., Gov. Deval Patrick lifted the lockdown order, saying they had not found Dzhokhar Tsarnaev in Watertown.
Shortly after the order came down, Watertown homeowner David Henneberry walked into his backyard and saw something amiss with his boat, according to Henneberry's neighbor, George Pizzuto.
"He looked and noticed something was off about his boat, so he got his ladder, and he put his ladder up on the side of the boat and climbed up, and then he saw blood on it, and he thought he saw what was a body laying in the boat," Pizzuto said. "So he got out of the boat fast and called police."
He said that Henneberry was being interviewed by police about what he saw, and that power was cut to the Henneberry's house.
"That boat's his baby. He takes care of it like you wouldn't believe. And they told him it's all shot up," Pizzuto said. "He's going to be heartbroken."
Henneberry notified police, and minutes later gunfire erupted and dozens of law enforcement officers rushed to secure a perimeter around Franklin Street in Watertown, where residents were immediately warned to stay indoors and "shelter in place."
Erik Thompson, who lives across the street from the Henneberry's home, said he heard gunshots and saw law enforcement rush to the scene.
"There was some gunfire earlier which was almost immediately stopped. People were yelling to cease fire, and it seems to be focused on some homes across the street from where I am, which I think is the western side of the street," Thompson said.
"There's still a significant presence of law enforcement there," he said. "It's like D-Day."
The governor lifted an order that kept people in Watertown, Boston and surrounding suburbs inside all day.
The officials had said at the press conference that they thoroughly searched Watertown and had not found any sign of Tsarnaev.
Earlier in the day, police in took three individuals into custody in connection with the search for Tsarnaev.
Lt. Robert Richard of New Bedford, Mass., said three "college age" individuals were taken in for questioning by the FBI. New Bedford is less than 15 miles north of Dartmouth, Mass., where Tsarnaev attends college.
Following a late-night shootout with police that involved more than 200 rounds of ammunition and explosive devices, Dzhokhar Tsarnaev, 19, abandoned his car and slipped away on foot.
His older brother and alleged accomplice in the bombings, Tamerlan Tsarnaev, 26, was killed in the gunfire. The pair are believed to have dropped two bombs near the finish line of the Boston Marathon Monday, killing three and injuring more than 170.
Massachusetts State Police Superintendent Col. Timothy Alben said at a press conference this afternoon that the Tsarnaev brothers opened fire and threw explosives at cops around 10:30 p.m. Thursday as they fled from Cambridge to Watertown. But he said law enforcement were forced to choose between providing first aid to those in need and securing a perimeter to contain the suspect.
"Unfortunately we did not have enough people to provide first aid" to the injured "and establish a perimeter," the colonel said.
Gov. Deval Patrick ordered everyone in Watertown, Boston and surrounding suburbs to stay indoors, shut down public transportation and taxi service for the day as the search for Tsarnaev proceeded.
Heavily armed officers and military-style vehicles conducted a door-to-door search of Watertown, but the search turned up nothing, Alben said.
Police did find evidence of homemade pipe bombs and a pressure cook at the scene of the shootout, they said.
Shortly after 6 p.m. today, the governor lifted the "shelter in place" order and reopened the city's mass transit system. He asked residents to remain vigilant.
"I know this is how people live every day in other countries. But I'm not used to it here," said Greeley, 27, a technician at Tufts Medical Center who was on duty Monday when part of the hospital was briefly evacuated even as victims of the blast were being treated in the emergency room.
Anger, crying jags and nightmares are all normal reactions for both survivors of the Boston Marathon bombings and witnesses to the mayhem. While the injured and those closest to the blasts are most prone to psychological aftershocks, even people with no physical injuries and those like Greeley might feel the emotional impact for weeks afterward as they struggle to regain a sense of security. What's not clear is who will suffer lingering anxiety, depression or even post-traumatic stress disorder.
But specialists say that how resilient people are helps determine how quickly they bounce back. The resilient tend to be people who share their emotions before becoming overwhelmed, who know how to copewith stress, and who have the ability to look for a silver lining - such as focusing on bystanders who helped the wounded.
Focusing on the horror, "that's harder on our body and our mind," said Dr. Catherine Mogil, co-director of the family trauma service at the University of California, Los Angeles. "People who tend to be able to make positive meaning out of tough situations are going to fare better."
Among the typical reactions that psychologists say anyone who witnessed the bombings or their aftermath might experience include difficulty sleeping or eating; sweats or stomachaches; anxiety or fear - especially in crowded situations that remind people of the bombing. People may have a hard time focusing on work or other everyday activities. They may feel numb, anger easily, or cry often.
Priscilla Dass-Brailsford, a psychologist at Georgetown University Medical Center, said that if those symptoms don't fade in about a month, of if they are bad enough to impair function, people should seek help.
But for most, "time is a great healer," said Dass-Brailsford, who served on disaster mental health teams that counseled survivors of 9/11 in New York.
Specialists say only a small number of people are expected to be so severely affected that they develop PTSD, a disorder that can include flashbacks, debilitating anxiety, irritability and insomnia months after the trauma. Even among veterans of the Iraq and Afghanistan wars, the best estimate was that just under 20 percent returned with symptoms of PTSD or major depression.
More at risk for lingering psychological effects are people who've previously been exposed to trauma, whether from the battlefield, a car crash or a hurricane.
During two stints in Iraq as a Marine, Eusebio Collazo of Humble, Texas, was gravely wounded and today runs regularly to help deal with PTSD. Running with a veterans group called Team Red, White & Blue, he was at mile 25 of the marathon when the bombs detonated - and adrenaline fueled his frantic race to find his wife, Karla, at the finish line. She was unharmed.
"My wife keeps asking me, `I don't know how I should be feeling. I want to cry but I can't.' And then I want to cry, and I can't cry either. So, there's a lot of weird, different feelings going on," Collazo said Thursday. It's harder, he said, to handle explosions on the home front than in a war zone.
In Boston's hospitals, teams of counselors and social workers are telling patients and their families what to expect in the difficult days and weeks ahead.
"Most people are having a lot of flashbacks," and thoughts of the bombing interrupt their days and nights, said Lisa Allee, who directs the Community Violence Response Team at Boston Medical Center. "These are very typical, normal, expected emotions after any traumatic event or disaster."
Beyond hospitalized patients, part of coping is awareness about how to take care of the psyche - turning off scary TV coverage and reading a book, going out for a quiet dinner, anything to temporarily cut the stress, says Dass-Brailsford, the disaster specialist.
That's especially true for parents who are trying to calm their children, added UCLA's Mogil, because kids take their emotional cues from the adults around them. Younger children especially don't need to see repeated footage of the blasts, because they may think it's happening again.
For a lot of people, psychiatrists say, talking about their experience can be cathartic.
A cashier's routine "how are you?" was enough for Anndee Hochman to tear up in a Philadelphia hardware store Wednesday. Hochman and her 12-year-old daughter had traveled to Boston to watch her partner run the marathon - and all three were in different places when the bombs exploded, Hochman herself just a few blocks from the finish line.
Hochman spent 10 minutes telling the store clerk her family's story of reuniting - and said it helps every time she's told friends, family, even a near-stranger about the experience.
Unknowingly, Hochman echoed the advice to look for a silver lining as she counseled daughter Sasha, who was nervous about returning to school.
"I reminded her, " `Sweetie' - and reminded myself, too - `there may have been a few people who planned those bombs and wanted to hurt people," Hochman said, "but there are so many more people there and in the world who want to help.'"
AP Medical Writer Lauran Neergaard reported from Washington. AP writer Kevin Freking contributed to this report.