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U.S. Diplomats Stuck in Medical Limbo

State Department officials with special needs children face a byzantine bureaucracy that often denies them critical care.

By Robbie Gramer
Illustrations by Melissa McFeeters for Foreign Policy

April 2, 2018

Christie Peterson’s life changed when her youngest daughter attempted suicide. Based in Europe, where her husband is a U.S. diplomat, she and her daughter were medically evacuated to the United States, while her husband and oldest daughter stayed behind.

She thought it was temporary. After weeks of intensive therapy, she and her daughter’s doctors sent formal notice to the State Department’s Bureau of Medical Services saying her daughter had recovered and they were ready to return home.

But the medical bureau had other ideas.

What followed, Peterson says, was a yearlong battle with a dense thicket of bureaucracy, deceit, and apathy, all centered on an obscure State Department office that wields significant power over employees’ careers and families.

The bureau revoked her daughter’s medical clearance, overriding the recommendations of her doctors, and denied multiple appeal requests. Throughout the process, the bureau refused to meet her daughter.

Peterson, who asked that her husband’s and daughter’s names not be used, isn’t alone.

Foreign Policy spoke to two dozen State Department officials and family members who described battles with the State Department’s Bureau of Medical Services all concerning children with mental health issues and special needs.

The State Department and its top medical officials say the bureau is a dedicated, albeit understaffed, group of professionals working to keep officials and their families safe as they deploy around the world. For the two dozen officials and their family members who spoke to FP, however, the medical bureau is a small office nested in a thicket of confusing regulations and hiding behind a screen of medical privacy that is wreaking havoc on their lives.

They describe an office that arbitrarily cuts funding to support children with autism, Down syndrome, attention deficit hyperactivity disorder (ADHD), or other special needs; splits families apart by revoking medical clearances for these children while they’re posted abroad; and ultimately forces some diplomats out of their jobs.

Nearly everyone who spoke to FP for this story asked that their names not be used, fearing retaliation by what they describe as vindictive employees who staff the medical bureau. Seven say they are mulling a class-action lawsuit against the State Department. Most say their careers — and their families — are suffering because of how the department treats children with special needs.

For those working inside the department to address the issues, the matter is one of ensuring a functioning diplomatic corps and also basic fairness.

“Let’s not forget these are people serving our country and trying to represent us abroad,” says one State Department official, who does not have an affected family member but is pushing for reform. “And they are getting screwed.”

The Bureau of Medical Services, known as MED, lives mostly in obscurity within the State Department’s bureaucracy, but the power it wields over the U.S diplomatic corps is critical.

With 168 positions in Washington, MED is tasked with evaluating the health of all employees and their family members, determining whether they can be posted abroad, and doling out support and funding for employees posted abroad.

Diplomats need a medical clearance before they can go to a new country, and the same goes for family members in tow. Their ability to be posted anywhere abroad, the notion of “worldwide availability,” is fundamental to the State Department. Each year, the office has to medically clear more than 29,000 U.S. officials and their families from the State Department, U.S. Agency for International Development, and 28 other federal agencies before they go to embassies and consulates around the world.

Up until a few years ago, diplomats say the office worked with parents and largely deferred to their decisions and those of their family’s doctors on what was appropriate for children with special needs and mental health issues. Diplomats with minor children get an education allowance so their children can attend schools on par with the U.S. education system, and those with special needs get an extra allowance to defray the cost of paying for additional help, such as teacher’s aides.

Around 2015, under new leadership, the bureau started scrutinizing special needs allowances more to help cut back on excesses and education programs considered frivolous. (The Washington Post first reported in October 2017 that the State Department was quietly paring back funding for diplomats with special needs children.)

One current and one former official from MED say the office is now understaffed, overworked, and plagued by a toxic work environment. They describe leaders who scream at employees, mislead diplomats and superiors, and potentially breach federal disability laws in the process — all charges the State Department sharply denies.

The current and former officials requested anonymity out of concerns of professional retaliation.

They say they became alarmed at how the new leadership treated diplomats and their families. The former employee, a doctor, says the bureau went overboard in slashing special needs funding for some families without just cause and pressuring families to curtail their assignments abroad.

“They did not want complicated children overseas where they would have to be responsible for them,” the doctor says. He recalls that one senior medical official “used to complain all the time about kids [going to post] who had complex needs.”

In the meantime, the two officials say morale sunk and experts left in droves. The exodus centered on the deputy medical director of mental health programs, Kathy Gallardo. “Dr. Gallardo just made the office atmosphere toxic,” the doctor says. “She didn't really understand disability law. She didn't understand educational law.”

“I felt I was being told to violate the law,” he says. “I even spoke to my malpractice insurance people, and they recommended I leave"

One employee, he recalls, was reprimanded for being “divisive” when he sent an email to other staff in the office that simply stated federal disability laws. “I felt I was being told to violate the law,” he says. “I even spoke to my malpractice insurance people, and they recommended I leave [the State Department] as soon as possible.”

The State Department sharply disputes these assertions, saying it is not blindly slashing benefits to these families and there have been no reductions in special needs education assistance. It also insists no employee has ever been told to violate federal disability laws.

“The Department takes very seriously its obligation to U.S. taxpayers to ensure that it manages its resources in accordance with applicable laws, regulations and policies,” a State Department spokesperson says.

While acknowledging the bureau has a number of unfilled positions, the spokesperson says that “the abundant camaraderie and sense of shared mission amongst current staff has kept morale high.”

In an email statement to FP, Charles Rosenfarb, the bureau’s medical director, says Gallardo “has served with great distinction” and “consistently received excellent performance evaluations.” He highlights her “demonstrated superior leadership, intellect, communication skills, and accomplished clinical abilities” and adds she “has worked tirelessly since her appointment” to improve the office’s work.

Gallardo also denies these claims. “I understand the critical nature of children’s educational and behavioral health needs and am obligated to ensure [special needs education allowance] is administered with integrity, which requires operating within relevant laws and regulations,” she says.

The families’ frustrations over the education allowance are tied to the larger issue of medical clearances. For many families, a medical clearance is just another bureaucratic hoop to jump through, but it can become a nightmare for those who have children with special needs.

The State Department concedes that the process is complicated and is working to improve it but says it works hard to support each family and their needs. “The narrative that the State Department doesn't care about families with special needs children or has changed its regulations so that the caring, supportive approach we took in the past has now changed, that’s simply not true,” says Steven Walker, the deputy assistant secretary of state for human resources.

Some of the issues families face are inherent to the difficulties that parents of special needs children face, combined with the added complexity of addressing those issues while serving overseas. Finding an appropriate school is often the biggest challenge.

One U.S. diplomat based abroad says his 4-year-old son, who has Apert syndrome, a genetic disorder that can affect the shape of the skull, was kicked out of a preschool created by the U.S. consulate’s association of employees. At first, the school said his son’s physical appearance scared other children. Then they said they didn’t have the resources to support his son’s special needs, the diplomat says.

“They violated [my son’s] civil rights,” the diplomat says. “They did it because they didn’t have to say yes. They did it because they could it get away with it. And I can’t afford a lawyer to fight it.”

Gallardo says she couldn’t directly address the specifics of each family’s case due to strict medical privacy regulations but that MED played “no role” in the decision to expel this child.

“These situations underpin the importance of the medical clearance process and why we have to carefully review resources and plans even when a school or provider believe they can meet a child’s needs,” she says.

Yet parents say that, in reality, they are caught in a maddening Catch-22.

Foreign service officers have to reach out to countries on their bid list for their next post to see if schools would commit to accepting their children up to two years in advance to get the medical clearance for their children. But schools often won’t accept a special needs child unless the State Department can guarantee special needs funding for the child. But the medical bureau won’t guarantee funding — and, by extension, a medical clearance for the child — until a school accepts the child.

“It’s a bureaucratic merry-go-round,” says one State Department official familiar with the process.

Even if diplomats do secure a school that meets their child’s needs, the medical bureau has the authority to reject the school. And once the family is posted there, they say the medical bureau may revoke their child’s clearance at a moment’s notice, even when parents believe their needs are being met.

"Medical clearance decisions are not capricious nor malicious. There is always more to the stories"

The State Department counters by saying it carefully analyzes each person’s case and only pulls clearances if it feels their needs can’t be adequately or safely met overseas. “Medical clearance decisions are not capricious nor malicious. There is always more to the stories, which would have included attempts to make things work at post if at all possible,” a State Department spokesperson says.

Yet the numbers back up parents’ claims that the medical bureau has been revoking or downgrading medical clearances for higher numbers of children. Between 2011 and 2016, the number of children in the foreign service community given Class 2 medical designations — meaning they are only cleared for limited travel to certain countries stemming from medical issues — rose from 756 to 1048, according to two State Department officials with access to internal department statistics. They say the number of children with other restricted medical classifications, including those not allowed to travel outside the United States, also rose.

The State Department did not respond to a request to see the statistics.

Diplomats who have children with special needs or mental health issues describe the bureau’s decisions as arbitrary. One foreign service officer based in a Southeast Asian country was told that the State Department wouldn’t allow his son with autism to live there, even though he found a school that would accept his son, which another diplomat’s child with autism had attended.

Some even fear pushing for appeals, and getting on the medical bureau’s bad side, which can be a career-ender.

“There’s two secretive bureaus people are scared of here,” says one senior State Department official. “Diplomatic security [which handles security clearances] and MED.” The official says either can “make or break” your career; without security and medical clearances, “you’re out of a job,” the official says.

Two years ago, several State Department officials, after realizing their stories were part of a broader trend, created a more formal structure to fight back: the Foreign Service Families With Disabilities Alliance, which linked up with the American Foreign Service Association (AFSA), the union that represents foreign service officers, to quietly push for internal reforms. It fills a key gap in the small community of foreign service officers with family members with disabilities, special needs, or other health issues. The group now has about 170 members.

The State Department says it has actively engaged with the association and alliance to improve communications with employees and processes for diplomats who have children with disabilities or other health issues. Last year, the department started a working group on special needs education to work with families.

The families, however, say this is not enough. In the past year, the AFSA has sent five letters expressing concern on this issue to the department. One letter, sent in January 2017, didn’t get a response for more than six months.

“Unfortunately, it’s just so easy to be stonewalled. We can spin our wheels and try and provide information, but it will get nowhere”

“Unfortunately, it’s just so easy to be stonewalled. We can spin our wheels and try and provide information, but it will get nowhere,” says one official pushing for reform.

In November 2017, Democratic Sens. Ben Cardin of Maryland and Patty Murray of Washington sent a letter to the State Department inquiring about the issue. Four congressional aides say that in the ensuing months, the State Department dragged its heels in responding to requests for detailed information and statistics, even after several rounds of closed-door meetings with MED staff.

“It feels like pulling teeth,” vents one congressional aide.

Walker, the deputy assistant secretary of state, rejects this characterization. He says they have been in communication with Congress since the initial requests came in and never stonewalled anyone. “The questions Congress asked and the statistical data they requested were incredibly complex in breadth and depth and took a long time to get full, clear answers, which may take longer than people first think,” he says.

Upheaval in Foggy Bottom following the departure of Secretary of State Rex Tillerson also doesn’t bode well for MED problems getting attention from anyone in senior ranks, some officials say. Others say they can’t lay the blame on the current administration, noting that the issues predate President Donald Trump and Tillerson.

But regardless of who is to blame, mismanagement is taking a toll on the foreign service. Five diplomats say they are on the verge of quitting, not because of their job but because of challenges with MED.

“I've lost track of the number of families who've been separated, assignments have been broken, curtailed when they've already been posted overseas,” says one diplomat involved with the family disabilities alliance. “I am convinced that over time it is having a cost, which will be impossible to calculate. It's having a cost in terms of driving a significant segment of the foreign service out of the department because they just can't deal with it anymore.”

Four diplomats say other parents are now hiding their children’s medical issues from the State Department. “They are judge, jury, and executioner, and so people are scared,” one senior foreign service officer says of MED. “They don't want to speak out.”

In the meantime, the saga for Christie Peterson hasn’t ended. More than a year later, her family is still split apart. Her daughter’s medical clearance remains in limbo, while her husband and oldest daughter live nearly 6,000 miles away.

She says the embassy where her husband is posted sent him a veiled threat about the future of his State Department job if he brought his youngest daughter back into the country, months into their appeals fight. She says the embassy later rescinded the threat once her husband fully informed them of their family’s situation.

"There's so much strain and worry that families are going through already, and to then have to battle with MED, to need to defend your decisions as a parent, to have to try to fight for your job, to try to do all of those things and still take care of your family,” Peterson says. “It's more stress that foreign service families just don't need.”

Robbie Gramer is a staff writer at  Foreign Policy.

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