2/10/2020 Era of Unprecedented World Wide Care of Immigrant Patients in 2020…. Migration • Growing numbers of migrants world-wide • More refugees now than at end of WWII Margaret Wheeler MD It’s US History. It’s All Political…. • Immensely diverse groups at different times History shaped by • politics, economics, culture • stimuli and barriers to immigration 1
2/10/2020 US Immigration • 13.3% (42.4 m) US population foreign born Immigration Since 1860 (FB) today • ½ citizens • ¼ here legally • ¼ without documentation • Pew, 2016 • 27% CA are FB • 26% US pop FB or children of FB Undocumented Immigrants • Numbers declining (reverse migration_ • Largest number today NOT from border crossings but visa overstay • Integrated into our communities • Many in mixed status families • 2/3 here over a decade • Own homes; work; pay billions in taxes 2
2/10/2020 An Approach to Immigrant Patients: Risks of Native Country Three Considerations • Epidemiology of diseases • Risk of exposure to infectious diseases, environmental exposures, geography of genetic disorders • Health risks of native country • https://www.cdc.gov/immigrantrefugeehealth/guidelines/refugee-guidelines.html • Epidemiology of stressors/resilience • Health risks of travel– both • Politics/economics/natural disasters/cultural practices initial and recurrent • Keeping up current events as important as med updates You can’t take good care of your patient if • Health risks of adopted you don’t know where they are from…. • Health care access and practices country - Vaccinations, preventative care, chronic disease care, medication use World news as important as medical Have a global differential… journals • Eosinophilia • think parasitic infections strongyloidiasis, filariasis, or schistosomiasis. • Palpitations • Stressors, PTSD, RHD, • Renal failure • Exposures, lead, DM, untreated HTN, congenital disorders, medications, Balkan/Mesoamerican nephropathy • Hematuria, infertility, or chronic pelvic pain • Schistosomiasis; TB; undiagnosed congenital issues • Splenomegaly • Hepatitis, TB, HIV, malaria syndrome; schistosomiasis; leishmaniasis; • Lymphadenopathy • TB,HIV, filariasis • Heart failure • Chagas disease, rheumatic heart disease • Seizures • neurocysticercosis. 3
2/10/2020 An Approach to Immigrant Health Risks of Initial Travel • Health risks of native country • When—age, health, who left behind • Why left? • Health Risks of Travel–Initial and Recurrent • Travel itself—refugee camp, border crossing, debt, jet lag? • Recurrent travel vs permanent break with home • Health risks of adopted country High Risk Travel Medicine An Approach to Immigrant • ½ of US residents traveling abroad are FB visiting home • Health risks of native country • Higher risk of getting sick while traveling • Health risks of travel–initial and recurrent • Riskier behavior • Visit when pregnant, sick or with children • Stay for longer, eat like hosts. • Health risks of adopted country • More often sex, rural areas, contact sick relatives • Travel for health care or use health care– dentistry, specialty care, return with medications from home • But less often vaccinated/prophylaxed • Recs for FB travelers same all travelers 4
2/10/2020 Risks of US Life Community Strengths • Safer neighborhoods • Epidemiology of Disease • More chronic illness, lifestyle changes • Environmental risks: Occupational Risk • Cultural practices • Epidemiology of Stressors/Resilence • Minority Status • Social capital of family • Legal status • Language marginalization • Discrimination/Fear • Absent family • Health Care Access and Practices Legal Issues: Undocumented and Access to Care Policies Matter • Highly variable by state, county, city policies • Undocumented with good access do well: • No difference btwn undocumented/documented/citizens Mexican- Americans in • Can range from excellent to none diabetes outcomes • Undocumented children covered in many states Iten/Fernandez 2014 • Undocumented adults covered in NYC, SF, LA, others • Undocumented present with more advanced HIV do equally well once in care • Poon, 2012 • Some undocumented adults have private insurance via employers • Expanding coverage to undocumented children results in high enrollments and better outcomes • Howell, 2010 5
2/10/2020 Policies Matter: ESRD and Fear as Barrier Undocumented • 1/8 undocumented immigrants fear deportation • Near universal coverage for ESRD with exception when accessing care of undocumented • Maldonado, 2013 • Patients forgo care for fear of ICE • Two strategies depending on state • Hacker, 2012 • Emergent dialysis (only when emergent conditions exist) • Patients forgo care when • more costly; 5x-15x the mortality immigration policies become • Chronic dialysis more stringent • Rodriguez, 2015; Cervantes, 2017/2108;Fernandez 2017 • Rhodes, 2015 • Citizens in mixed status families forgo care too Since Trump Election Asking About Legal Status • Immigrant rights organizations advise against • Fewer immigrants obtaining services • More openly hostile comments in waiting rooms toward • Pts may fear immigrants from other patients • Denial of care or lower standard of care • More immigrant parents making DPOA plans for children • Immigration service involvement • Risking future legal/citizen standing • Actions: more home visits; health care worker outreach; ride • Discrimination shares etc • Fleming, 2018 • Documenting in chart: Do Not • If need, to know or remember “can you travel?” 6
2/10/2020 Refer Your Undocumented Patients for If Patient Reveals Undocumented Status Legal Advice Reassure • Naturalization • Confidentiality, especially from ICE • Asylum • Current federal policies keep ICE out of • Specialty visas (Temporary Protection, U visa, T visa, hospitals/clinics VAWA) • Will not lead to differential care or • Deportation issues abandonment/repatriation • Advice for DACA • Consider legal referrals • Anticipatory guidance https://www.immigrationlawhelp.org How do I screen my patient? If You Are Asked for a Letter • Take an immigration history • Contact the lawyer for scope/focus • Screen for domestic violence and community violence • Refer to legal assistance ( No letter without lawyer.) • Screen for victims of trafficking • Asylum: consider referral for forensic specialist • Do you live and work in the same place? • Do you have access to your own documents? • Civil Surgeon PE/vaccinations • Have you been denied access to care/food/clothes? • Have you been threatened with will call police, deportation, physical violence? • Are you getting paid regularly? 7
2/10/2020 Red Cards Anticipatory Guidance- Legal https://www.ilrc.org/red-cards • Rights of Habeus Corpus • Remain silent • Insist on warrant/don’t open the door • Right to legal counsel • Carry a lawyer’s # • Don’t sign anything • Have an emergency plan, especially with children • Backup childcare • Designate POA • Contact consulate https://www.ilrc.org/know-your-rights-and-what- immigrant-families-should-do-now Advocating for Undocumented Clinic Policies Patients • Staff training • Know basic immigration policies and processes • asking demographics • documentation of legal status • Refer for legal assistance and rights education • Pro-active “signal safety” --- posters, cards • Partnership with community • Establish clinic policies to support undocumented groups • Referral information for • Strengthen partnerships with community groups immigration services • ICE plan? 8
2/10/2020 Immigrant Health: Think Globally, Act Locally Legal Referrals SF www.projectlegallink.org More resources More Resources • Public Health Actions for Immigrant Rights ( https://docs.google.com/document/d/1MXecn5b_IZPZ5r6LA3U4Ggz2gSMqxMONGBlCngsX HEU) • Minnesota Department of Public Health: A Call to Action, Immigrant Health • National Immigrant Law Center (https://www.nilc.org) http://www.health.state.mn.us/divs/idepc/refugee/topics/immhealthrpt.pdf • The Fair Immigration Reform Movement (FIRM; http://fairimmigration.org/) • Examining asylum seekers: A clinician’s guide to physical and psychological evaluations of torture • United We Dream (http://unitedwedream.org/) and ill treatment; 2012 Dec [cited 2015 Sept 1]. 191 . Available from: • We Belong Together (https://www.domesticworkers.org/we-belong- http://physiciansforhumanrights.org/library/reports/examining-asylum-seekers-manual-2012.html together) • United Nations. The Manual on Effective Investigation and Documentation of Torture and Other • National Council of La Raza (NCLR; http://www.nclr.org/) Cruel, Inhuman, or Degrading Treatment or Punishment: Istanbul Protocol. Geneva, Switzerland: • Check for potential partners on local college campuses, which may United Nations, November 1999. have groups already formed around immigration. http://www.ohchr.org/Documents/Publications/training8Rev1en.pdf • Human Impact Partners (immigrationguide@humanimpact.org) • Immigrant Legal Resource Center (https://www.ilrc.org) • ACLU (aclu.org) 9
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