EXECUTIVE SUMMARY
With high-profile travel bans and well-publicized Immigration and Customs Enforcement (ICE) activities, frontline providers have noticed changes in the behavior of immigrant patients. Some emergency providers report there is more fear and a reluctance to share key information. Also, providers are concerned that worries about deportation will cause immigrant patients to refrain from accessing needed care. Investigators note that such concerns are valid, considering how heightened ICE activities previously have affected immigrant health.
- Emergency providers who see a high number of immigrant patients report patients are very guarded about providing identifying information and recent travel history. They are concerned that medical staff will report them to ICE authorities.
- Some emergency providers are wearing “safety pin” symbols to try to let patients know that they are safe in their care. Others are thinking about posting signs in multiple languages to inform immigrant patients that information about travel history only will be used for medical purposes.
- Experts worry that restrictions on foreign-born physicians and medical students only will exacerbate anticipated shortages, particularly in rural areas.
- In a previous period of increased immigration enforcement, researchers found that more than 40% of frontline providers reported that ICE activities produced negative health effects on their immigrant patients, including stress, anxiety, and avoidance of the healthcare system.
Healthcare providers across the country watched in collective horror on Feb. 22 as a 27-year-old asylum seeker from El Salvador was forcibly removed from Texas Health Huguley Hospital in Fort Worth, TX, and taken in handcuffs to the detention center in Alvarado, TX, where she had been residing since she was picked up by Immigration and Customs Enforcement (ICE) upon entering the United States 16 months ago.
The woman, Sara Beltran Hernandez, had been rushed to the hospital on Feb. 11 after collapsing at the detention center, according to reports. Hernandez complained of pain, dizziness, and memory loss. Tests revealed a large tumor in her pituitary gland, according to her lawyers.
Eventually, lawyers managed to arrange for the woman’s release from the detention center, and she has since been reunited with her mother in New York City. However, some frontline healthcare providers have observed that media coverage of this incident, as well as other ICE raids and deportations, has produced a chilling effect on their immigrant patients, making them reluctant to share important information needed to optimize their care, and potentially resistant to seeking care in the first place. Further, providers say the situation poses risks for public health.
Address Heightened Concerns
Alisheba Hurwitz, MD, is an emergency physician at Methodist Hospital, a community hospital on the south side of Philadelphia that serves an increasingly diverse population.
“There is a big center of Southeast Asian refugees [here], and then we have an increasing Hispanic population that is coming from a lot of different countries,” she explains. “We see a large number of immigrants and refugees — both documented and undocumented patients.”
Hurwitz observes that even before the increased immigration enforcement initiated by the Trump administration, many patients presenting to the ED expressed a certain level of fear and anxiety.
“They are frequently concerned that you are somehow going to connect them with authorities who would want to detain them or deport them,” she says.
In the past, it has been easy for Hurwitz to ease these concerns, but the task has become increasingly difficult during well-publicized travel bans from certain countries and high-profile raids by ICE.
“There are more stories about people who have been deported who would not have been deported under the previous administration,” she says. “I have begun to notice that it is becoming much harder to reassure my patients about the fact that we are not immigration officials in any way and that we have no intention of contacting anyone about their immigration status.”
For instance, Hurwitz recalls the case of a patient who didn’t want to provide his name or date of birth.
“He kept dodging the question or changing the answer, and in the ED, that is very important,” she says. “We use that information to tie things together,” she explains, noting that when patients are experiencing emergencies and are under stress, they may not remember what medicines they take, what allergies they have, or their medical problem list.
In such cases, providers often can pull this information from a patient’s electronic medical record, but they need basic identifying information. Hurwitz reports that in this case, the patient did not speak English, but despite the use of a translator, it was very difficult trying to obtain this information from him.
“That was the first red flag to me that my patients might be directly affected by [immigration enforcement] in terms of the way they are going to interact with me as a medical provider,” she says.
In another case, Hurwitz ran into difficulties with a patient who presented to the ED in a lot of physical distress.
“Particularly since the Ebola crisis, as we triage someone there is an automatic question in our chart now at the hospital [asking whether the patient] has traveled outside the United States in the past 21 days,” she says.
“In trying to rapidly triage this patient, I started to inquire about his travel history, and he just sat upright and started yelling [in his native language] ‘I have a passport’ over and over again,” she continues. “And I couldn’t get him to calm down and get back on track with relating medical information. He was just clearly terrified that there was some sort of ulterior motive.”
Because of incidents like these, Hurwitz notes that the issue of how to address patient concerns regarding immigration enforcement at the policy level is a hot topic among her emergency medicine colleagues.
“My group is discussing [the option of] making some kind of poster or other sign that we can display in the waiting room in multiple different languages,” she says.
The sign would explain that while clinicians might ask about travel history, this information is used only for medical purposes, and that providers do not inquire about immigration status or have any interest in that line of questioning, Hurwitz explains.
One approach that Hurwitz employs is to display a safety pin symbol on her body somewhere.
“I don’t know if my patients are aware that this is a way of signaling that I don’t judge based on race, gender, or immigration status, but that is one of the symbols that has popped up in the popular media,” she says.
Hurwitz explains that the safety pin idea first gained traction in Great Britain following the Brexit vote there in June 2016.
“There was a lot of concern about [that vote] being motivated by anti-immigrant sentiment, so there is a movement there where people who wear a safety pin prominently on their clothes try to convey: You are safe with me. I am not going to fault you, judge you, or discriminate against you,” she says.
Beyond these hospital-level actions, Hurwitz would like to see more emergency medicine professionals make it clear that there are clear ethical boundaries at stake.
“When a patient is seeking medical care, I think there needs to be a more explicit positive assertion that this is an ethical imperative for our profession,” she says. “This is not about a liberal or a conservative agenda. It is about the fact that we have an ethical obligation to our patients, and anything that discourages a patient from seeking care is in violation of EMTALA [Emergency Medical Treatment and Labor Act], a federal statute that says you are not allowed to discourage people from seeking care.”
Hurwitz emphasizes that immigration enforcement can affect health issues, and not just for immigrant patients. For instance, she points to the importance of gathering information on infectious ailments such as hepatitis or sexually transmitted diseases.
“You want people to give you their correct information regarding their addresses so that you can followup on late-arriving results,” she says. “I think it is important to remember that this is a non-partisan issue. It is about taking care of people and helping to protect our communities.”
Study Effect on Medical Talent
Bradley Shy, MD, an assistant professor in the department of emergency medicine at Mount Sinai School of Medicine in New York City, also is concerned about the effect of immigration enforcement on his practice, patients, and emergency medicine in general, and he published his thoughts on the issue early this year.1
One of his concerns is the growing shortage of physicians in the United States — especially in rural areas, and the crucial role that foreign-born graduates play in easing this shortage. With heightened restrictions on entry to the United States, this supply of new graduates from other countries is threatened, and hostility toward foreign-born individuals does not help the situation either.
For example, Shy points to the recent experience of a Sudanese physician, Suha Abushamma, MD, who was trying to return to her position as a resident at the Cleveland Clinic, and instead was placed in a holding cell at an airport in New York City, and then sent to Saudi Arabia. She was eventually able to return to the United States.
Shy talks about how many talented physicians he works with are foreign-born, and worries physicians from other countries will no longer seek to practice in America.
Already, there is considerable evidence that foreign students are nixing plans to further their education in the United States, opting instead for countries with less threatening immigration policies.
As far as immigrant patients are concerned, there is no question that many who present to the ED are anxious about their encounters with emergency staff.
“At times, patients will comment to me in a nervously, joking manner about their concerns of being deported or forced to leave the country,” Shy explains. “I haven’t seen any proposals where [the Trump administration] has suggested that hospital records would be used to identify immigrants or refugees and make them more prone to deportation, but I think it is in the back of peoples’ minds.”
Although Shy has not collected any data to suggest that immigrants are declining access to needed care, he worries that the fear of deportation could have that effect, affecting their health as well as their rapport with medical providers.
“Many, many physicians train by practicing emergency medicine with immigrant patient groups, and in many ways, they are better patients because they have more pathologies and disease than a homogenous population, and they have been included in many important emergency medicine research studies,” Shy observes. “I truly feel that we owe a lot to these populations, and I think our mission as emergency medicine physicians and nurses is to serve equally any patients who come to our ED, regardless of attributes such as their ethnicity, ability to pay, or nationality.”
While emergency physicians are heterogeneous from an ideological standpoint, they are all affected by these stricter immigration enforcement policies, Shy notes.
“Given the unique nature of the types of patients we treat and how we interact with them, I think we are in a good place among specialties to share our concerns,” he says. “I certainly hope that emergency medicine especially acts as a leader in voicing the concerns of our immigrant patients to our government and other decision-makers.”
Reflect on Recent Experiences
Certainly, this is not the first time that frontline providers have observed concerning changes in their rapport with immigrant patients.
Karen Hacker, MD, MPH, now the director of the Allegheny County Health Department in Pittsburgh, was the lead author of research, published in 2012, that gauged the perspectives of primary care and emergency care providers on the effect of ICE activities on immigrant health in the city of Everett, MA. At the time of the investigation, Everett had the fourth largest concentration of immigrants in the state and had experienced a number of highly publicized ICE raids and deportations.2
During this period, Hacker was serving as the executive director of the Institute for Community Health, a community research organization with the Cambridge Health Alliance in Cambridge, MA.
Investigators found more than 40% of the providers who completed anonymous surveys indicated that the ICE activities produced negative health effects on their immigrant patients, including stress, anxiety, and avoidance of the healthcare system.
Primary care providers were far more likely than emergency providers to report negative effects on their patients.
“What we saw in Massachusetts, which has a very large immigrant population and also a very large undocumented population, was that the news spreads very quickly within the [immigrant] community,” Hacker explains. “Then, the anxiety levels go up, and people are very concerned about going places where immigrants might be because they see that as a really big problem.”
As a result, immigrants would stop arriving for healthcare appointments or accessing treatment when they experienced medical problems, Hacker recalls.
“If they saw that ICE was in the area or even if they saw a traffic stop for a totally different reason, they would turn around and go in the other direction rather than come to a doctor’s appointment,” she says.
Hacker recalls when immigrants accessed healthcare, their anxiety level would rise when asked for any type of documentation.
“They perceive that [request] in the same light as having to show a passport or some sort of ID card, and that becomes an obstacle to getting care,” she says.
Further, many immigrant families were comprised of members with different immigration status levels, and changes for one family member would affect the others.
“You would see these situations where one member of the family might be documented and have a green card ... and the spouse was undocumented,” Hacker notes. “The spouse would end up getting picked up and deported, and then it would be just a one-income family.”
Thus, even immigrants who presented with health coverage might drop out of the healthcare system because they no longer could afford the copays or medications; they were in a different financial situation, Hacker explains.
Be Prepared for Decreased Utilization
Stories that Hacker used to think were just urban myths that get passed around by frightened immigrants turned out to have some validity.
“I remember when someone first said that [ICE] would come to the door and ask for ‘John,’ and if John wasn’t there they just turned to the next person, and if that person didn’t have documentation, they would take that person away,” she explains. “I thought that was just a story that people would tell us ... but it was absolutely true, and I think it could be even more true now.”
Hacker suspects that anxiety levels are so high in the immigrant community that people simply will refrain from accessing healthcare, even if they have coverage.
“Immigrants tend to under-utilize the health system in general, and there has been a lot of analysis on that,” she says. “However, remember that a lot of these folks are working three and four jobs, so it is not as if they have a lot of time, and the ED is the place that is open 24/7 if they are absolutely in dire straits.”
Hacker anticipates that a lot of what she saw during the period of heightened immigration enforcement in the early days of the Obama administration will be evident again as ICE raids, travel bans, and other aspects of immigration enforcement become more visible.
“I think what we are going to see is that people will limit their encounters with any system where they fear [their status] will be potentially disclosed,” she says.
REFERENCES
- Shy BD. Immigrants, the emergency physician and the election day. West J Emerg Med 2017;18:329-330.
- Hacker K, Chu J, Arsenault L, Marlin RP. Provider’s perspectives on the impact of Immigration and Customs Enforcement (ICE) activity on immigrant health. J Health Care Poor Underserved 2012;23:651-665.
SOURCES
- Karen Hacker, MD, MPH, Director, Allegheny County Health Department, Pittsburgh. Email: khacker@achd.net.
- Alisheba Hurwitz, MD, Emergency Physician, Methodist Hospital, Philadelphia. Email: ali.hurwitz@gmail.com.
- Bradley Shy, MD, Assistant Professor, Department of Emergency Medicine, Mount Sinai School of Medicine, New York City. Email: brad.shy@email.com.