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Care of Refugee & (Im)migrant Populations

SEMINAL STUDY

14.1

13.1 // Homelessness

14.2 // ACCOMMODATIONS

14 APPROACH TO SPECIAL & VULNERABLE POPULATIONS

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Care of Refugee & (Im)migrant Populations

Contributors:

Colleen Laurence, MD, MPH

Rebecca Leff, MD

Shama Patel, MD, MPH

Amy Zeidan, MD

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Disclosures

No conflicts of interests to declare

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Objectives

Define displaced and (im)migrant populations
Describe factors that contribute to increased social, structural risk
Discuss population-specific barriers to health care
Share considerations in caring for these populations
Outline additional avenues for education and advocacy

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Why do we care?

In the US

Globally

33% college education

46% with LPOE

44.9 million immigrants

20% in SSA

2/3

from 5 countries

100 million displaced persons

Before we dive into the nuances of caring for this population, let’s discuss why we should care as EM physicians.
(A) To start, 44.9 million individuals or just under 14% of the US population, identified as immigrants and lived in the US in 2019
It is a very heterogeneous population. Many have very unique assets, and many experience significant barriers navigating the US healthcare system.
(A) One major barrier is language. 46% (20.7 million) of immigrants self identify as individuals who have a language preference other than English (or LPOE), which could limit their ability to effectively communicate with clinicians and staff.
(A) And while 33% (12.9 million/39/5 million) of immigrants ages 25 and up have a bachelors degree or higher, which is similar to US born population, education level does vary depending on country of origin, which can impact employment opportunities and ability to adapt to life in a new country.
For those who work internationally with immigrant and displaced populations
(A) In the first months of 2022, more than 100 million individuals were displaced worldwide as a result of persecution, conflict, violence or human rights violations, which was an increase of 10.7 million people compared to 2021.
(A) An estimated 2/3 of displaced persons are from five countries: Syria, Venezuela, Afghanistan, South Sudan and Myanmar.
(A) And the SSA region hosts an estimated 20% of the global refugee population.

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Esterline C and Batalova J. Frequently requested statistics on immigrants and immigration in the United States. Migration Policy Institute, Washington, DC. March 17, 2022. https://www.migrationpolicy.org/article/frequently-requested-statistics-immigrants-and-immigration-united-states
UNHCR. Refugee Statistics. https://www.unrefugees.org/refugee-facts/statistics/. Accessed on August 8, 2022.

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Why do we care?

‘Mirror of humanity’

Joseph Kangi, South Sudan, 2019

“The painting is about unity. People from different countries, different religions and different tribes need to accept each other. We need to put our hands together to build a better world… We should see others as we see ourselves in the mirror, as human beings. Humanity should take precedence over everything.”

Beyond the statistics, it is important to educate ourselves and improve our care for immigrants and displaced persons because we have a moral and legal responsibility to care for these individuals.
This is fundamental to our roles as emergency physicians – we take care of anyone, anything, anytime.
(A) This is a painting called “Mirror of Humanity” by Joseph Kangi, a refugee from South Sudan who resided in the Moria refugee camp in Greece.
His description of it captures the humanity that is essential to our work as emergency physicians
He states, ”The painting is about unity. People from different countries, different religions and different tribes need to accept each other. We need to put our hands together to build a better world [one that does not see colour or differences, only what unites us]. We should see others as we see ourselves in the mirror, as human beings. Humanity should take precedence over everything.”

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’We never chose this’: refugees use art to image a better world – in pictures. The Guardian. https://www.theguardian.com/global-development/gallery/2019/dec/25/we-never-chose-this-refugees-use-art-to-imagine-a-better-world-in-pictures. December 25 2019. Accessed August 8, 2022.

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What’s the difference?

(Im)migrant

Person who chooses to move from their country of origin for varying reasons and with different degrees of protection. Includes citizens, permanent residents, temporary visitors, and undocumented residents

Refugee

Internally displaced person

Asylum seeker

Terminology

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What’s the difference?

(Im)migrant

Person who chooses to move from their country of origin for varying reasons and with different degrees of protection. Includes citizens, permanent residents, temporary visitors, and undocumented residents

Refugee

Person who has fled their country of origin for fear of persecution, human rights violations, war, violence. Recognized right to protection prior to arrival at destination.

Terminology

A refugee is a person who has fled their country of origin and is unable or unwilling to return because of a well-founded fear of war, violence, or being persecuted because of their race, religion, nationality, or membership in a particular social or political group.
Once a refugee flees their home, they must apply for refugee status with an official entity, such as a government or the United Nations Refugee Agency.
This process can take years – on average, 18 to 24 months - and while waiting, many applicants reside in refugee camps where they may be exposed to other risks.
Refugees are not permitted to enter their destination country until their application has been accepted and they have been cleared for travel based on both security and medical screening.

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https://www.internal-displacement.org/global-report/grid2021/#:~:text=People%20living%20in%20displacement,-There%20were%2055&text=A%20record%2048%20million%20people,is%20the%20highest%20ever%20recorded.
“What Is a Refugee? Definition and Meaning | USA for UNHCR.” Definition and Meaning | USA for UNHCR�

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What’s the difference?

(Im)migrant

Person who chooses to move from their country of origin for varying reasons and with different degrees of protection. Includes citizens, permanent residents, temporary visitors, and undocumented residents

Refugee

Person who has fled their country of origin for fear of persecution, human rights violations, war, violence. Recognized right to protection prior to arrival at destination.

Terminology

Asylum seeker

Person who has fled their country of origin for fear of persecution, human rights violations, war, violence. Apply for asylum after arrival or at port of entry.

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What’s the difference?

(Im)migrant

Person who chooses to move from their country of origin for varying reasons and with different degrees of protection. Includes citizens, permanent residents, temporary visitors, and undocumented residents

Refugee

Person who has fled their country of origin for fear of persecution, human rights violations, war, violence. Recognized right to protection prior to arrival at destination.

Terminology

Internally displaced person

Person who has fled or left their home, but has not had to cross an internationally recognized border

Asylum seeker

Person who has fled their country of origin for fear of persecution, human rights violations, war, violence. Apply for asylum after arrival or at port of entry.

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Brief US Immigration & Humanitarian Law Timeline

Citizenship only possible for free white persons if not born in the US

Naturalization Act of 1790

1790

Established a ”barred zone” from which no persons allowed to enter, country quotas

Immigration and Quota Acts

1917-1924

Abolished quota system; allowed family reunification, employment, refugees

Immigration and Nationality Act

1965

Established definitions, R+P program, and annual adjustments

Refugee Act of 1980

1980

> 60,000 asylum seekers returned to Mexico to await hearings

Migrant Protection Protocol

2018

2002

Homeland Security Act

Lead to creation of US Immigration and Customs Enforcement (ICE)

2012

DACA

Renewable temporary protection from deportation for people who arrived as children

While these definitions are pretty basic, they have evolved throughout time.
If we look at immigration and humanitarian law in the US, for example, we can see that the ability to immigrate, apply for citizenship, and qualify for certain rights often reflects political and social undercurrents of the time.
I’ll review a few key moments in US immigration and humanitarian law history and encourage you to check out the notes section below for more information highlighted in yellow.

The first national law concerning immigration was the Naturalization Act of 1790, which stated that any free white person who had been in the U.S. for at least two years could apply for citizenship. The requirements were adjusted over the next few years, reflecting biases against certain nationalities or to limit the influence of foreign-born nationals depending on political fervor of the moment, but Black individuals remained ineligible until passage of the 14th Amendment. This demonstrates that immigration laws have the potential to reify racial biases and discrimination.
The Immigration Act of 1917 again demonstrated bias against individuals from certain regions of the world, creating a ”barred zone” that extended from the Middle East to Southeast Asia from which no person could enter the US. It also established a literacy test for immigration. The Quota Acts in 1921 and 1924 also limited people entering the US and functionally preferenced immigrants from European countries and capped immigrants from majority non-white nations.

In the first year of its enactment, the law permitted 51,000 German immigrants, for example, but only 100 from the Arabian Peninsula.

The quotas and restrictions of the 1920s remained in place until President Lyndon Johnson signed the Immigration and Nationality Act of 1965 into law, which eliminated the quota system and established the principles for immigration regulation enforced today. These preference family reunification, employment, and refugees.

Though not listed on this timeline, the UNHCR issued a protocol in 1967 to implement the goals of the 1951 Refugee Convention, which set forth the key principle of refoulement, or that persons in flight from persecution and danger cannot be forced to return to places of danger.

In 1980, the Refugee Act was passed, establishing the legal basis for humanitarian admissions of refugees and asylum seekers to the United States. This act defined a refugee and established a precedent for the President and Congress to determine the number of refugees to be accepted into the US each fiscal year, among other elements.

It also established the Reception and Placement (R&P) program for initial resettlement under the U.S. Department of State and created the Office of Refugee Resettlement (ORR) under the Department of Health and Human Services (HHS).

Since this law was passed, there have been a number of important legislative and social movements related to immigration, including implementation of Temporary Protected Status for Migrants in 1990 that allows migrants from countries with unsafe conditions to reside and legally work in the US with most recent examples being extension of TPS protections to Ukrainian, Afghan, and Haitian migrants.
In 2002, the Homeland Security Act was passed in response to the 9/11 terrorist attacks. This centralized decision making power over immigration policy under one agency, gave greater power to the executive branch to determine who enters and leaves the country, and lead to the creation of the US Immigration and Customs Enforcement Agency (or ICE).

ICE has faced increased scrutiny regarding potential obstruction of fair hearings for asylees, militarization of US borders, and concern for human rights abuses by Customs and Border Patrol.

In 2012, President Obama issued the Deferred Action for Childhood Arrivals (or DACA) executive order which created renewable two-year grants of protection from deportation—plus work permits and identity documents—for the approximately 700,000 undocumented individuals who arrived in the country as children at that time. Notably DACA does not provide a pathway to citizenship and these individuals remain ineligible for certain federal benefits, including health insurance.

As perceptions of immigration have become increasingly politically polarizing, often changing with presidential administrations, DACA recipients have often been caught in the middle, with protection rescinded and regranted depending on the administration.

During the Trump administration, recognition of immigrant rights and international humanitarian law became increasingly precarious. In December 2018, the Migrant Protection Protocols or “Remain in Mexico” policy was implemented by Department of Homeland Security, forcing over 60,000 asylum seekers to return to Mexico for the duration of immigration proceedings and leading to a backlog of cases and the stranding of asylum seekers in Mexico in often unsafe conditions. Then, in March 2020, The Trump administration activated Title 42, which gives the President the right to exclude people from certain countries during public health emergencies. While the Trump administration said that they were using Title 42 to help stop the spread of Covid-19 in immigrant detention centers, many believe it was a pre-meditated measure to keep asylum seekers out of the country.

Title 42 was used over 2 million times to turn individuals, including families and young children, away at the border and disproportionately affected Black, indigenous, and LGBTQ+ individuals.

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Additional historical moments of note:

In 1868, the Fourteenth Amendment to the U.S. Constitution established that “All persons born or naturalized in the United States and subject to the jurisdiction thereof, are citizens of the United States and of the State wherein they reside.” The states could not curtail these privileges of federal citizenship, and the clause set the expectation that anyone born in the U.S. is automatically a citizen.
In 1882, the Chinese Exclusion Act prohibited immigration of Chinese laborers for 10 years, reflecting growing resentment for their presence and economic competition in the Western US. It was the first time that a specific national or ethnic group was prevented from immigrating to the US and was accompanied by other laws restricting the rights and privileges of Chinese immigrants already in the US. It was not until World War II, when China was a military ally of the United States, that the ban on Chinese immigration was lifted.
There have also been significant changes in the refugee population admitted to the US each year. Historically, the U.S. has resettled more refugees than any other country; however, its resettlement program has not kept up with the 50% increase in the global refugee population over the past five years. The Trump administration decreased the ceiling number of refugees each year of its administration to a historic low of 15,000 refugees for fiscal year 2021. Since assuming office, President Biden has increased the ceiling again with a target of 125,000 for fiscal year 2022; however, the actual number of refugees settled in 2022 will likely fall short of this due to a depleted refugee resettlement infrastructure.

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Carruth L, Martinez C, Smith L, et al. Structural vulnerability: migration and health in social context. BMJ Global Health. 2021; 6: e005109. doi:10.1136/ bmjgh-2021-005109
University of Texas at Austin Department of History. https://immigrationhistory.org/timeline/. Accessed August 24, 2022.

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Deeper dive:

How do immigrants arrive in the US?

Documented:

Lawful permanent resident (LPR)
Temporary legal status

Visa holders
Victims of trafficking, domestic violence
Refugees
Temporary protected status (TPS)

Undocumented:

Those who enter without documentation and those whose visa is not valid.

Visa types:

Non-immigrant v. immigrant
Diversity visa
T visa and U visas

The timeline highlights how the ways in which immigrants arrive in the US can be shaped by historical precedent and politics.
Let’s discuss what this process can look like for different types of migrants today.
First, immigrants may arrive in the US either with or without approved documentation.
Those who are documented include those who are granted or become lawful permanent residents colloquially known as “green card holders,” people with visas, recognized victims of trafficking or domestic violence, refugees, and those with temporary protected status
Visas holders can be further delineated into immigrant and non-immigrant visas, diversity visas, and T and U visas which are specific for victims of trafficking and domestic violence.

Non-immigrant visas include those for athletes, au pairs, diplomats, medical treatment visitors, tourists, etc.
Immigrant visas include fiance's, spouses, adopted children or family members of LPRs, employment and religious related, among others.
Diversity visas are for individuals from specific countries.

The term, undocumented, includes those people who enter the US without approved documentation and those whose approved documentation is longer valid. For example, someone might arrive on a tourist visa or medical treatment visa and stay beyond the approval date.
There are routes to citizenship for individuals who are documented and those who are undocumented; however, as we’ll discuss in the next few slides, the process of applying for and being approved for legal status, much less citizenship is complex, politically fraught, and can take a long time - sometimes between 2-10 years.
Lawful permanent residents must wait for four years to apply for citizenship, and after one year, asylees may apply for lawful permanent resident status.

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11,840

How Refugees & Asylees Get to the US

We’ll focus now on the process for refugees and asylum seekers in the US using this schematic by Human Rights First.
As we discuss each group, think about how these designations influence the legal, financial, social support, and health care services and protections afforded to people, how their care is paid for, and care considerations.
Starting at the top, (A) individuals are granted refugee status before arriving in the US after they undergo health and legal screening and an application process (facilitated by the US Department of State, Department of Homeland Security, and UNHCR).
Resettlement agencies help refugees to (1) establish a place to live along with basic furnishings, climate appropriate clothing, and food (2) to attend initial health screenings during which time they are evaluated for infectious diseases, nutritional status, vaccinations, lead screening, pregnancy, and mental health concerns and (3) facilitate educational enrollment, employment training, job searches, and other social and language support.
Refugees receive around 8-months of short-term health insurance called Refugee Medical Assistance. After this, they may be eligible for Children’s Health Insurance Program (CHIP) or insurance through their employment or through Medicaid depending on the policies of the state where they live.
Refugees may access healthcare at community-based or hospital-based clinics that provide specialized, comprehensive care for refugees; however, this obviously varies with location. Before refugees establish primary care, they may use the Emergency Department to address health concerns, and it is helpful for ED physicians to consider referral to establish care if the patient is not already connected.
(A) In 2020, 11,840 persons were admitted to the US as refugees, which is far below the ceiling number of 18,000 established by the Trump administration that year, which was already an unprecedented low.

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Additional information:

These agencies receive a one-time payment per refugee to assist with these expenses during the first three months of their stay in the US; however, the Department of Health and Human Services also works in conjunction with these organizations and others to provide limited cash and medical assistance in addition to other services after the three months conclude.
While these services are afforded by the US, refugees are expected to pay back the State Department’s Reception and Placement (R&P) program, which provides refugees with a loan to travel to the U.S.

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Baugh R, on behalf of the Office of Immigration Statistics. Fiscal Year 2020 Refugees and Asylees Annual Flow Report. US Department of Homeland Security. 8 March 2022.

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18%

11,840

How Refugees & Asylees Get to the US

There are a few different asylum processes.
The first that I’ll discuss is an affirmative asylum process in which a person travels to the US with proper documentation such as a visa and then petitions to stay through an asylum application process.
These individuals can remain in the US while their case is undergoing review and are not typically detained by US Immigration and Customs Enforcement (ICE). In certain cases, they may be allowed to work.
(A) In 2020, the US granted asylum affirmatively to 18% of applicants (16,864/93,224)

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Additional information

To apply for affirmative asylum, asylees must be physically in the US and apply within 1 year of arrival regardless of method of entry.
They must submit an application and then undergo an asylum merits interview with the US Citizenship and Immigration Services (USCIS) and subsequent ruling with either asylum being granted or referred for a hearing by an immigration judge. The hearing results in either approval or denial, independent of the USCIS decision.

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Baugh R, on behalf of the Office of Immigration Statistics. Fiscal Year 2020 Refugees and Asylees Annual Flow Report. US Department of Homeland Security. 8 March 2022.

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18%

11,840

How Refugees & Asylees Get to the US

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18%

11,840

How Refugees & Asylees Get to the US

7.7%

Finally, individuals undergo the defensive asylum process when they request asylum as a defense against removal from the US.
These individuals may have been previously denied by USCIS, apprehended without valid documentation, or caught by Customs and Border Control entering the country without documents.
Immigration judges hear defensive asylum cases and determine if individuals are eligible for asylum or not.
(A) In 2020, the US granted asylum defensively to 7.7% of people (14,565/189,838)
The most important takeaway regarding all of these processes is that they are complicated and take a lot of time - on average at least 2 and up to 10 years
And during this time, seekers may not have any legal protection or access to services..
There are also many individuals who do not necessarily fall into these categories of refugees and asylum seekers – for example, stateless persons, seasonal migrants, and some human trafficking victims

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Baugh R, on behalf of the Office of Immigration Statistics. Fiscal Year 2020 Refugees and Asylees Annual Flow Report. US Department of Homeland Security. 8 March 2022.

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How does legal status affect health care coverage? It depends.

	Undocumented immigrants (>18 yo)	DACA recipients, undocumented immigrants (< 18 yo)	Refugees, Asylees, Victims of trafficking, domestic violence	Lawful Permanent Residents	Pregnant immigrants
ACA Subsidies	No	No	Yes	Yes	No
Medicaid	No – Emergency only	Varies by state	Yes	No - State options for children, pregnancy, > 5 years of residency)	Varies by state
CHIP	No	Varies by state	Yes	Varies by state	Varies by state
Workers Compensation	Yes, though variable enforcement

As I mentioned in the preceding slides, legal status can affect individual access to health care coverage.
Typically, refugees and recognized asylees and victims of trafficking and violence are the most likely to have health care coverage.
For others, it depends on a number of factors, including their legal status, age, the state where they currently reside among others
This chart provides a brief summary of the health care insurance coverage available to different groups.
(A) In general, undocumented immigrants over the age of 18 only qualify for emergency care coverage.
And most states do recognize workers compensation, though with variable enforcement.

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https://help.asylumadvocacy.org/health-care/

https://www.healthcare.gov/immigrants/immigration-status/

https://www.healthcare.gov/immigrants/lawfully-present-immigrants/

https://travel.state.gov/content/travel/en/us-visas/visa-information-resources/all-visa-categories.html

https://www.nilc.org/issues/health-care/healthcoveragemaps/

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How does legal status affect health care coverage? It depends.

	Undocumented immigrants (>18 yo)	DACA recipients, undocumented immigrants (< 18 yo)	Refugees, Asylees, Victims of trafficking, domestic violence	Lawful Permanent Residents	Pregnant immigrants
ACA Subsidies	No	No	Yes	Yes	No
Medicaid	No – Emergency only	Varies by state	Yes	No - State options for children, pregnancy, > 5 years of residency)	Varies by state
CHIP	No	Varies by state	Yes	Varies by state	Varies by state
Workers Compensation	Yes, though variable enforcement

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How does legal status affect health care coverage? It depends.

	Undocumented Immigrants (>18 yo)	DACA recipients, Undocumented Immigrants (< 18 yo)	Refugees, Asylees, Victims of trafficking, domestic violence	Lawful Permanent Residents, Lawfully Present Immigrants	Pregnant Immigrants
ACA Subsidies	No	No	Yes	Yes	No
Medicaid	No – Emergency only	Varies by state	Yes	No - State options for children, pregnancy, > 5 years of residency)	Varies by state
CHIP	No	Varies by state	Yes	Varies by state	Varies by state
Workers Compensation	Yes, though variable enforcement

;

Some immigrants qualify for Marketplace health care coverage such as refugees; asylees over 14 with valid work permits or under 14 who have had applications pending for 180 days; victims of trafficking or domestic violence; those granted withholding or deferred deportation; lawful permanent residents; those with temporary protected status; and non-immigrant visa holders with worker or student visas
Individuals applying for some of these statuses also qualify - specifically those with temporary protected status and employment authorization; victim of trafficking visas; protection under CAT; asylum, though as discussed before asylum applicants are eligible if they’ve been granted employment authorization or are under the age of 14 and have had an application pending for at least 180 days.
(A) Only 29 states ,the District of Columbia have chosen to provide Medicaid coverage to lawfully residing children and pregnant women without the five year waiting period. 21 of these states also cover lawfully residing children or pregnant women in CHIP

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https://help.asylumadvocacy.org/health-care/

https://www.healthcare.gov/immigrants/immigration-status/

https://www.healthcare.gov/immigrants/lawfully-present-immigrants/

https://travel.state.gov/content/travel/en/us-visas/visa-information-resources/all-visa-categories.html

https://www.nilc.org/issues/health-care/healthcoveragemaps/

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Pre-migration

Push/Pull Factors:

Threat of or violation of human rights
Targeted persecution
Violence, armed conflict
Climate change & natural disasters
Poverty
Economic or educational opportunity
Reunification

Health risks:

Psychological and physical effects of exposure to violence, persecution
Psychological effects of forced displacement
Unreliable access to safe water, sanitation
Inconsistent access to healthcare

We’ve discussed some of the structural elements that influence immigrant access to care in the US, but it is also important to consider immigrant’s migration stories - the factors that prompted them to leave their home in the first place, their experiences en route, and how these might affect patient’s health risks.
Some people divide these migration factors into those that “push” people to migrate and those that “pull” people to a new country.
For example, human rights violations, persecution, violence, armed conflict, natural disaster, and poverty are all factors that might push people to migrate.
Conversely, economic and educational opportunity or family reunification may be factors that pull people to migrate.
These different factors might translate to specific health risks for immigrants – for example, patients who experience the psychological and physical sequelae of torture, violence, or persectution or the effects of displacement and unreliable access to safe water and sanitation.

�

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Pre-migration

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Migration is influenced by inequity

“Immigration is fundamentally determined by social, economic, and political inequities.”

Castañeda et al (2015)

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Vulnerabilities accumulate in migration

How might different conditions before and during migration influence a person’s health?

�How can you include these considerations in your care of refugee and immigrant populations?

Returning to our discussion health risks in migration, these vulnerabilities can also accumulate during the migration process - from before migrants leave until after they arrive at their destination.
Think about how different conditions before and during migration could influence a person’s health and how you might include these considerations in your care of refugee and immigrant populations
For example, the extent to which immigrants are vaccinated, screened, diagnosed, and treated for certain medical conditions can have downstream effects on their health during and after migration. Let’s look at this concept through the lens of Ukrainian and Rwandan refugees.
At left is a picture of Ukrainian refugees entering Poland in spring 2022. Most deaths in Ukraine before the Russian invasion (91% of all deaths in 2017) were due to non-communicable diseases like cardiovascular disease, diabetes, and cancer, so this refugee population had chronic disease risk factors contributing to their morbidity and mortality throughout their migration process. There were also relatively high levels of multidrug resistant tuberculosis, HIV, and viral hepatitis and low vaccination rates in Ukraine, which elevated risks for both individuals with these conditions and others migrating with them.
Compare this scenario with the one on the right of Kigeme refugee camp in Rwanda where over 17,000 refugees and internally displaced persons live as they wait out a protracted refugee screening process, sharing 1 health clinic, 1 women’s center, with limited access to adequate safe drinking water each day.
Though these two refugee contexts are different, the risks that these refugees and other immigrants might encounter in the course of their journeys may be similar: They include

Physical duress of journey (ie, crossing by land or sea with heat/sun exposure, dehydration, exposure to dangerous animals, insects, and inconsistent food/water supply with subsequent malnutrition)
Dangers from other individuals in the form of physical or sexual violence, extortion
Inadequate shelter or living conditions (ie, unsanitary, exposed living conditions, inadequate food or water supply, infectious disease exposure 2/2 crowding)
Among many other factors

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In general, migrants experience higher infant mortality and OB complications as well as increased respiratory and skin infections due to inadequate hygiene, crowding, and inadequate or interrupted health care.

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Loffe Y, Abubaker I, Issa R, Siegel P, Kumar BN. Meeting the health challenges of displaced populations from Ukraine. The Lancet. 2022; 399 (10331): 1206-1208.
World Health Organization. Ukraine crisis: Public health situation analysis – refugee-hosting countries. 17 March 2022. https://apps.who.int/iris/bitstream/handle/10665/352494/WHO-EURO-2022-5169-44932-63918-eng.pdf?sequence=3&isAllowed=y
UNHCR. Kigeme Refugee Camp Profile. April 2021. Accessed 8 August 2022. https://data.unhcr.org/en/documents/download/86480

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Vulnerabilities persist after arrival

Structural vulnerabilities

Social vulnerabilities

Individual vulnerabilities

Political/legal
Economic
Social

Discrimination/exclusion
Separation or displacement
Access to education, services
Language barriers

Context- and person-dependent

In the next two slides, I’m going to share different frameworks for how we can systematically and critically think about the vulnerabilities affecting immigrant populations.
This first schematic is an amalgamation of different frameworks, but generally situates structural vulnerabilities as overarching, macro-level forces, which are then reproduced in different forms as social vulnerabilities and individual vulnerabilities.
Structural vulnerability considers how political, economic, and social hierarchies produce and pattern individual and community health and contribute to negative health outcomes. These hierarchies are perpetuated by institutions at the national, regional, and international level.

Political/legal forces include migration policies established by certain administrations or variable recognition of international human rights
Economic institutions include regulations that limit work authorizations or restrict access to curtains types of employment and subsequent protections and commensurate pay
Social forces at this level refers to the persistence of racism, marginalization, discrimination, and neo-colonialism in different institutional priorities, policies

This structural lens decreases the risk of misattributing certain vulnerabilities to individuals or to cultural differences.
At the next level, social vulnerabilities is used to refer to some of the factors mentioned just now like discrimination and exclusion as well as other factors like access to education, language barriers
Finally, individual factors can increase risk or, conversely, exercise a protective effect depending on the context and person. This level includes identifiers like age, gender, perceived or expressed race or ethnicity, sexual orientation, mental health, and access to resources, among others.

For example, a member of a racialized group may be protective in some contexts but marginalized or oppressed in others.
Similarly, advanced age may provide greater sources of connection or elevated standing in certain communities, younger age may afford greater access to educational programs.

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Carruth L, Martinez C, Smith L, et al. Structural vulnerability: migration and health in social context. BMJ Global Health. 2021; 6: e005109. doi:10.1136/ bmjgh-2021-005109
Gilodi A, Albert I, Nienaber B. Vulnerability in the context of migration: a critical overview and a new conceptual model. Human Arenas. 2022. https://doi.org/10.1007/s42087-022-00288-5
International Organization for Migration. Part I: The Determinants of Migrant Vulnerability. IOM Handbook on Protection and Assistance to Migrants Vulnerable to Violence, Exploitation, and Abuse. 5 December 2019. https://publications.iom.int/books/iom-handbook-migrants-vulnerable-violence-exploitation-and-abuse

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Vulnerabilities persist after arrival

This an alternative model proposed by the International Organization for Migration is roughly based on an ecological model of health and, in addition to the structural and individual factors we’ve already discussed, also recognizes that immigrants belong to households/families and communities, which may confer both protective effects or pose additional risks.
Household and family factors include things like family size, structure, socioeconomic status, education, among other elements and are important because households and families are often the first option for individuals who require support, especially young people.
Community specific factors might include availability of educational opportunities, health care and social services, livelihood and income-generating opportunities, natural environment, and social norms and behaviors.

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Carruth L, Martinez C, Smith L, et al. Structural vulnerability: migration and health in social context. BMJ Global Health. 2021; 6: e005109. doi:10.1136/ bmjgh-2021-005109
International Organization for Migration. Part I: The Determinants of Migrant Vulnerability. IOM Handbook on Protection and Assistance to Migrants Vulnerable to Violence, Exploitation, and Abuse. 5 December 2019. https://publications.iom.int/books/iom-handbook-migrants-vulnerable-violence-exploitation-and-abuse

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Caution with “vulnerability” label

Concept of “innate vulnerability” can imply inevitable helplessness without acknowledging underlying structural, social elements
Misperceived as less capable, autonomous, competent → disempowerment, paternalism, neo-colonialism
Can contribute to further discrimination, stigmatization

I want to pause here to discuss the language that I’ve used thus far in the presentation - specifically the term, “vulnerability”
Vulnerability is often used in public health and medicine to describe those at heightened risk of negative outcomes or with limited ability to respond to stressors.
But labeling any one person or population as vulnerable risks implying powerlessness, victimhood, or a need for external interventions and also limits consideration of the structural and social factors that might be at play
It can also lead to increased discrimination and stigmatization if people or groups are reduced to one or two elements of their identity.
Assistance and protection policies can sometimes reproduce a neo-colonial mentality of powerful benefactors helping powerless beneficiaries.

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Carruth L, Martinez C, Smith L, et al. Structural vulnerability: migration and health in social context. BMJ Global Health. 2021; 6: e005109. doi:10.1136/ bmjgh-2021-005109
Gilodi A, Albert I, Nienaber B. Vulnerability in the context of migration: a critical overview and a new conceptual model. Human Arenas. 2022. https://doi.org/10.1007/s42087-022-00288-5

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How does this impact access to culturally-responsive health care?

Coverage and anticipated costs
Distance
Transportation
Time
Fear

Before we move onto our case study, I want to discuss the practical realities and challenges of accessing culturally responsive, trauma-informed care by immigrants
(1) We’ve already discussed the variable levels of insurance coverage, which may determine whether people seek care at a free clinic, an emergency room, or other facility. Often, it is difficult to anticipate the costs of uncovered care, which may limit health seeking behavior all together.
(2) Next, they may have difficulty getting to a place where they can receive care – perhaps they live far away or in a health care desert, the trip is burdensome or costly.
(3) or they have to figure out how to navigate a public transport system or arrange private transportation
(4) All of this can take time, which may be difficult if it means stepping away from other family or job responsibilities.
(5) And immigrants may be fearful of care seeking for different reasons - the US healthcare system is intimidating to navigate even for US born citizens, and certain immigrant populations may be reticent to seek care due to recent Public Charge discussions, concerns about registering in a system, or concerns for the care they might receive.
These barriers have a greater impact on non-citizens who are more likely to have no ”medical home” or place for routine, preventative care (19% v. 10% and 9%) compared to citizens. As a result, they may seek out both routine and emergency care in the ED.

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Fuentes L, Desai S, and Dawson R. New analyses on US immigrant health care access underscores the need to eliminate discxriminatory policies. Guttacher Institute, New York. May 2022. https://www.guttmacher.org/report/new-analyses-us-immigrant-health-care-access-underscore-need-eliminate-discriminatory. Accessed on August 20, 2022.

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How does this impact access to culturally-responsive, trauma-informed health care?

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Case study

CC: Hand injury

Setting and collateral information:

Primary language is Spanish
Transported by colleague at work who also speaks Spanish and a little English
No insurance coverage

Okay, we’re going to look at an example of how these different factors influence care for a patient we might see in the ED – prior to their visit, during their ED course, and after discharge
You are working the 7am shift weekend at your level 2 trauma community ED. Around 7:30 am, a new patient is roomed with the chief complaint of (A) hand injury.
(A) On opening the chart, you see that the patient has Spanish listed as his preferred language.
The registration personal confirms this as they pass you exiting the room and adds, “No insurance.”
When you walk into the room, the friend accompanying the patient offers to interpret for you. You thank them, but defer.
It’s a Saturday, so the in-person interpreters who are present most weekdays during the day are not available, and you must use a phone interpreter.
The patient is grimacing as you get the interpreter on the line, so you order an IM shot of Fentanyl 50 mcgs while planning to do likely digital blocks.
Your nurse administers the Fentanyl saying, “Fentanyl…for dolor” in a loud voice.

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Case study

CC: Hand injury

HPI:

Patient is a 27-year-old right-hand dominant male with no known PMH who presents with injuries to his right thumb, index, and middle finger sustained at work this morning.
Currently endorsing pain and tingling

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Case study - Pause

What factors might have influenced this patient’s ability and/or decision to come to the ED for care?
What aspects of our emergency intake process might contribute to patient fear and/or distrust?

Pause for a few seconds and consider the following questions
First, what factors might have influenced this patient’s ability and/or decision to come to the ED for care?

Fear of lost employment or repercussions with respect to payment by employer
Employer intimidation to not report or present for care
Variable accessibility of transportation to hospital
Foreign health care system and lack of knowledge regarding payment structure
Lack of insurance 2/2 undocumented status
Fear of federal repercussions, potential detention 2/2 undocumented status

Second, what aspects of our emergency intake process might contribute to patient fear and/or distrust?

Availability of interpreter services – in-person, video, or audio
Registration process – putting information into computer, variable explanations for reason
Variable administration of interventions without consent or language interpretation throughout ED course

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Case study

Focused Exam:

+2 radial pulse bilaterally
Lacerations to volar aspect of R thumb, index, middle fingers extending from PIP to pulp and dorsally into nailbed for thumb and index
Exposed bone, possible tendon on index
Inability to flex index at PIP, DIP
Dusky discoloration of R thumb, index finger distal to DIP, diminished sensation

Returning to the case
Here are your focused exam findings

+2 radial pulse bilaterally
Lacerations to volar aspect of R thumb, index, middle fingers extending from PIP to pulp and dorsally into nail bed for thumb and index
Exposed bone, possible tendon on index
Inability to flex index at PIP, DIP
Dusky discoloration of R thumb, index finger distal to DIP, diminished sensation

And XR notably demonstrates a highly comminuted fracture of the right index finger extending proximally from the DIP joint with associated soft tissue swelling of the right index finger as well as of the right thumb and middle fingers.
So without diving into the nitty gritty medical management, there is concern for a significant hand injury with likely microvascular and tendon injury that will require specialist hand surgery consultation
While you are a level II trauma center and have orthopedic generalists on call, you do not have a microvascular hand specialist on call at your facility.
You have two options for transfer in the immediate area – a private community hospital with microvascular hand surgery that is 30 minutes away and a tertiary academic center approximately 45-60 minutes away that you learned earlier is on standby earlier.

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Case study - Pause

How would you explain the need to transfer the patient to them?
What questions do you anticipate the patient might have?
What barriers might you encounter in attempting to transfer an undocumented patient without insurance?

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Case resolution

What difficulties do you anticipate for the patient after discharge?
What precautions or additional measures might you or another provider take in light of these?

Case resolution
You elect to transport by BLS ambulance after discussing the process and need to transfer with the patient and his friend. They agree.
The patient is accepted for transfer at the academic facility 60 miles away after calling the private hospital initially.
You perform digital blocks, irrigate. re-bandage, administer antibiotics, and update tetanus.
You follow up on the patient a few days later and learn that he underwent an OR revision amputation at the DIP of his index finger with tendon repair as well as closure of the other lacerations.
He was discharged with plans to follow up in the orthopedic specialist clinic in 1 week and to remain non-weightbearing with his extremity wrapped till re-evaluation. You estimate that this clinic is approximately 80 minutes away from where the patient lives.

Pausing again to consider the following questions (A)
What difficulties do you anticipate for the patient after discharge?

Ability of employment to accommodate non-weight bearing restriction
Security of employment, repercussions
Transportation and/or time off work to attend follow up appointment

What precautions or additional measures might you or another provider take in light of these?

Using an interpreter ALWAYS
Explaining rationale for non-weight bearing and strict return precautions
Getting follow up contact information
Securing collateral support from family, friends
Looking for follow up options closer to place of residence/work

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Additional case study

Click the picture at right to access an additional case study

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Additional considerations in caring for refugee and immigrant patients in the ED

For ED Clinicians:

Always use interpreters
Reinforce confidentiality of conversations
Practice cultural humility and cultural safety
Seek to build trust with all patients, especially if you’re concerned for human trafficking, bodily autonomy, safety at home or at work
You may ask about country of origin, preferred language, migration history, physical/mental trauma, family safety)
Never document status
Educate yourself about available local, national resources, immigrant rights

Rounding out our conversation, I’m going to discuss steps that you might take as an emergency medicine clinician and as a member of a department and institution to facilitate culturally responsive, equitable care for refugee and immigrant patients and options for further education and advocacy.
First, ask about preferred language and use interpreters in all of your interactions - many patients prefer in-person interpreters, though we know that may not always be feasible
In your conversations and actions, reinforce the confidentiality of your relationship. This is especially important for patients who may be fearful or suspicious due to past trauma or concern for government involvement.
Practice cultural humility, create a safe space for discussion, and seek to build trust with patients. This will impact not only your relationship with the patient, but their relationship with future clinicians as well. This is especially important for certain groups like trafficked persons or victims of violence who may have many touch points in the health system before they disclose such concerns.
As you build a relationship and if it is relevant to the patient’s presentation or follow up, you may consider asking about country of origin, migration history, or physical or mental trauma, but you should never document their legal status.
Finally, continue to educate yourself about available local, national resources and immigrant rights.

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Additional considerations in caring for refugee and immigrant patients in the ED

For ED and institutional pperations:

Use affirming signage, social media to combat fear
Ensure protocols are in place to protect immigrant patients
Facilitate easy access to resources (dot phrases) and establish relationships w/ FQHCs to facilitate follow-up
Host in-service training opportunities to educate on culturally-responsive care
Create ED/hospital patient advisory boards, including immigrants and refugees

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Additional considerations in caring for refugee and immigrant patients in the ED

Patient Education:

Support patients to know their rights, locate health centers and local resources, use their voice to advocate for change

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Avenues for learning and advocacy

The suggestions on the previous slides were adapted from SAEM’s Immigration Advocacy Toolkit, which is a really quick read and great way to think about some general steps that you or your institution can take.
In general, taking steps to learn more by reading is a great first step.
There is a wealth of gray literature and academic literature about immigrant health outcomes in the US and globally, often with suggestions for how we can improve our care approach, delivery, and advocacy and allyship.
The Health and Law Immigrant Solidarity Network also has several modules that provide deep dives into different related topics.
We already have momentum and support from our two national advocacy organizations - SAEM and the American College of Emergency Physicians (ACEP) - regarding our care of these special populations. Here is ACEP’s position published in June 2018 here.
Finally, there are a ton of local, national, and international organizations in need of advocacy, social, medical, and legal assistance.
For example, Physicians for Human Rights offers regular training to conduct asylum medical screenings and will teach you how to write bond letters.
If nothing else, strive to be a culturally-responsive and empowering advocate for your own patients and in your EM Department
My references and the post-module assessment and additional case study follow. Thank you for your attention and future care of immigrant and refugee populations.

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American College of Emergency Physicians. Delivery of Care to Undocumented Persons. June 2018. https://www.acep.org/patient-care/policy-statements/delivery-of-care-to-undocumented-persons/. Accessed August 24, 2022.
Zeidan A, Dekker A, Hsieh D, et al. SAEM Immigration Advocacy Toolkit, 2021 Edition. Society for Academic Emergency Medicine. https://issuu.com/saemonline/docs/184922_20saem_20immigration_20advocacy_20toolkit_2. Accessed on August 24, 2022.

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References

American College of Emergency Physicians. Delivery of Care to Undocumented Persons. June 2018. https://www.acep.org/patient-care/policy-statements/delivery-of-care-to-undocumented-persons/. Accessed August 24, 2022.
Baugh R, on behalf of the Office of Immigration Statistics. Fiscal Year 2020 Refugees and Asylees Annual Flow Report. US Department of Homeland Security. 8 March 2022.
Carruth L, Martinez C, Smith L, et al. Structural vulnerability: migration and health in social context. BMJ Global Health. 2021; 6: e005109. doi:10.1136/ bmjgh-2021-005109
Castañeda H, Holmes SM, Madrigal DS, Young MD, Beyler N, Quesada J. Immigration as a social determinant of health. Annual Review of Public Health. 2015; 36: 375-392.
Esterline C and Batalova J. Frequently requested statistics on immigrants and immigration in the United States. Migration Policy Institute, Washington, DC. March 17, 2022. https://www.migrationpolicy.org/article/frequently-requested-statistics-immigrants-and-immigration-united-states
Fuentes L, Desai S, and Dawson R. New analyses on US immigrant health care access underscores the need to eliminate discxriminatory policies. Guttacher Institute, New York. May 2022. https://www.guttmacher.org/report/new-analyses-us-immigrant-health-care-access-underscore-need-eliminate-discriminatory. Accessed on August 20, 2022.
Gilodi A, Albert I, Nienaber B. Vulnerability in the context of migration: a critical overview and a new conceptual model. Human Arenas. 2022. https://doi.org/10.1007/s42087-022-00288-5
International Organization for Migration. Part I: The Determinants of Migrant Vulnerability. IOM Handbook on Protection and Assistance to Migrants Vulnerable to Violence, Exploitation, and Abuse. 5 December 2019. https://publications.iom.int/books/iom-handbook-migrants-vulnerable-violence-exploitation-and-abuse
Loffe Y, Abubaker I, Issa R, Siegel P, Kumar BN. Meeting the health challenges of displaced populations from Ukraine. The Lancet. 2022; 399 (10331): 1206-1208.
UNHCR. Kigeme Refugee Camp Profile. April 2021. Accessed 8 August 2022. https://data.unhcr.org/en/documents/download/86480
UNHCR. Refugee Statistics. https://www.unrefugees.org/refugee-facts/statistics/. Accessed on August 8, 2022.
University of Texas at Austin Department of History. https://immigrationhistory.org/timeline/. Accessed August 24, 2022.’
We never chose this’: refugees use art to image a better world – in pictures. The Guardian. https://www.theguardian.com/global-development/gallery/2019/dec/25/we-never-chose-this-refugees-use-art-to-imagine-a-better-world-in-pictures. December 25 2019. Accessed August 8, 2022.
World Health Organization. Ukraine crisis: Public health situation analysis – refugee-hosting countries. 17 March 2022. https://apps.who.int/iris/bitstream/handle/10665/352494/WHO-EURO-2022-5169-44932-63918-eng.pdf?sequence=3&isAllowed=y
Zeidan A, Dekker A, Hsieh D, et al. SAEM Immigration Advocacy Toolkit, 2021 Edition. Society for Academic Emergency Medicine. https://issuu.com/saemonline/docs/184922_20saem_20immigration_20advocacy_20toolkit_2. Accessed on August 24, 2022.

American College of Emergency Physicians. Delivery of Care to Undocumented Persons. June 2018. https://www.acep.org/patient-care/policy-statements/delivery-of-care-to-undocumented-persons/. Accessed August 24, 2022.
Baugh R, on behalf of the Office of Immigration Statistics. Fiscal Year 2020 Refugees and Asylees Annual Flow Report. US Department of Homeland Security. 8 March 2022.
Carruth L, Martinez C, Smith L, et al. Structural vulnerability: migration and health in social context. BMJ Global Health. 2021; 6: e005109. doi:10.1136/ bmjgh-2021-005109
Castañeda H, Holmes SM, Madrigal DS, Young MD, Beyler N, Quesada J. Immigration as a social determinant of health. Annual Review of Public Health. 2015; 36: 375-392.
Esterline C and Batalova J. Frequently requested statistics on immigrants and immigration in the United States. Migration Policy Institute, Washington, DC. March 17, 2022. https://www.migrationpolicy.org/article/frequently-requested-statistics-immigrants-and-immigration-united-states
Fuentes L, Desai S, and Dawson R. New analyses on US immigrant health care access underscores the need to eliminate discxriminatory policies. Guttacher Institute, New York. May 2022. https://www.guttmacher.org/report/new-analyses-us-immigrant-health-care-access-underscore-need-eliminate-discriminatory. Accessed on August 20, 2022.
Gilodi A, Albert I, Nienaber B. Vulnerability in the context of migration: a critical overview and a new conceptual model. Human Arenas. 2022. https://doi.org/10.1007/s42087-022-00288-5
International Organization for Migration. Part I: The Determinants of Migrant Vulnerability. IOM Handbook on Protection and Assistance to Migrants Vulnerable to Violence, Exploitation, and Abuse. 5 December 2019. https://publications.iom.int/books/iom-handbook-migrants-vulnerable-violence-exploitation-and-abuse
Loffe Y, Abubaker I, Issa R, Siegel P, Kumar BN. Meeting the health challenges of displaced populations from Ukraine. The Lancet. 2022; 399 (10331): 1206-1208.
UNHCR. Kigeme Refugee Camp Profile. April 2021. Accessed 8 August 2022. https://data.unhcr.org/en/documents/download/86480
UNHCR. Refugee Statistics. https://www.unrefugees.org/refugee-facts/statistics/. Accessed on August 8, 2022.
University of Texas at Austin Department of History. https://immigrationhistory.org/timeline/. Accessed August 24, 2022.’
We never chose this’: refugees use art to image a better world – in pictures. The Guardian. https://www.theguardian.com/global-development/gallery/2019/dec/25/we-never-chose-this-refugees-use-art-to-imagine-a-better-world-in-pictures. December 25 2019. Accessed August 8, 2022.
World Health Organization. Ukraine crisis: Public health situation analysis – refugee-hosting countries. 17 March 2022. https://apps.who.int/iris/bitstream/handle/10665/352494/WHO-EURO-2022-5169-44932-63918-eng.pdf?sequence=3&isAllowed=y
Zeidan A, Dekker A, Hsieh D, et al. SAEM Immigration Advocacy Toolkit, 2021 Edition. Society for Academic Emergency Medicine. https://issuu.com/saemonline/docs/184922_20saem_20immigration_20advocacy_20toolkit_2. Accessed on August 24, 2022.

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Post-Module Assessment

Question 1:

What health screening and services are available for refugees arriving in the US? What about asylum seekers and immigrants?

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Post-Module Assessment

Answer 1:

Refugees undergo at least two medical screening exams – one overseas and one domestic.

The overseas screening exam evaluates for infectious diseases (TB, STI, HIV, leprosy) and mental health concerns.
The domestic exam is performed within 30-90 days of arrival and evaluates for infectious diseases, nutritional status, vaccinations, lead screening, pregnancy, and mental health.

Refugees and individuals granted asylum have access to short-term insurance called Refugee Medical Assistance (RMA) for up to 8 months after arrival. They may be eligible for Children’s Health Insurance Program (CHIP) and/or Medicaid depending on state income eligibility rules.
In most states, immigrants without documentation are not guaranteed federal health coverage or access.
Asylum seekers may have limited access to coverage depending on the state in which they reside and, if they secure work authorization, they may be able to access health insurance through their employment. Federal access or coverage is typically extremely limited.
Free or charitable clinics and some county and/or safety net hospitals may offer additional avenues for cares for both immigrants without documentation and asylum seekers.

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Post-Module Assessment

Question 2:

What health risks are associated with displacement and migration?

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Post-Module Assessment

Answer 2:

Infectious disease related to unreliable access to clean water, sanitation, crowding, regular health care, and poor nutrition are common. Additional health risks include mental health issues, trauma, and abuse. Individuals may have diagnosed chronic conditions for which they have been unable to access medications or continued screening, care.

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Post-Module Assessment

Answer 2:

Communicable:

Often related to unreliable access to clean water, sanitation, crowding, regular health care, and poor nutrition are common.

Example: viral respiratory infections, skin infections, GI infections, etc

Non-communicable:

Additional health risks include mental health issues, trauma, and abuse. Individuals may have chronic conditions for which they have been unable to access medications or continued screening or care.

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Post-Module Assessment

Question 3:

What are some examples of structural, social, and context and person-specific vulnerabilities that (im)migrants might encounter when seeking care in the ED?

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Post-Module Assessment

Answer 3:

Structural:

Legal status → employment protection, insurance

Racism

Suppression, neocolonial policies → need to migrate

Relative exclusion from public resources and public policies

Social:

Discrimination/bias

Potential lack of social support

Language discordant care, access to interpretation

Context and person-specific:

Age

Sexual orientation

Gender identity

Race/ethnicity

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Post-Module Assessment

Question 4:

What barriers might a recently resettled refugee patient encounter when seeking care in the ED?

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Post-Module Assessment

Answer 4:

Lack of familiarity with US health care system – how and when to seek emergency care, reconciling expectations for care in the ED, insurance coverage (or lack thereof)
Fear of care-seeking
Transportation to/from ED and health care in general, especially if resettlement area is geographically isolated from medical care
Language discordant care
Variable provider and staff familiarity with cultural nuances
Limited time for ED staff and providers to research, learn more about specific cultural nuances
Inconsistent staff, provider training in trauma-informed care
Financial barriers
Limited access to appropriate follow-up care, including specialty, mental health, and dental care among others

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Post-Module Assessment

Question 5:

What are some steps that you can take to better care and advocate for (im)migrant and refugee patients?

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Post-Module Assessment

Answer 5:

Always use interpreters – ideally for all interactions, but at minimum for your initial HPI and reassessment/disposition
Never document status
Build trust – patients experiencing or recovering from trauma may not disclose to you, but you can help establish a foundation of trust for others
Educate yourself about available local, national resources, immigrant rights and then make sure your patients know their rights
Advocate for institutional policies that are welcoming and respectful of (im)mmigrants and refugees

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Additional case study

CC: Abdominal and back pain

Setting and collateral information:

Minor care area at a level 1 academically-affiliated trauma center
Primary language is Lingala; secondary, Kiswahili and some French
Accompanied by small child

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Additional case study

CC: Abdominal and back pain

HPI:

Patient is a 23-year-old female who presents with 5 days of suprapubic, right flank pain, dysuria, subjective fever, nausea, and NBNB emesis x 3.
She is a G2P1001, around 18 weeks EGA by LMP.
Not yet established OB care
PCP note from refugee and immigrant health center 9 months ago

You must wait 15 minutes before an audio Lingala interpreter is available, but eventually you are able to introduce yourself and nurse to the patient.
You learn that the patient is a 23 year old female with no significant PMH who presents with 5 days of abdominal pain localized to her suprapubic region and right flank over the past two days.
She decided to come in because she is pregnant and was worried about the baby.
On review of systems, she endorses dysuria, subjective fever, and two days of nausea with 3 episodes of NBNB emesis earlier today. She also notes some recent vaginal discharge, but is unsure if it is normal or not. She denies leakage of fluids, hematuria, or vaginal bleeding.
She is a G2P1001 and believes she is around 18 weeks EGA by LMP, but isn’t totally sure. She has not yet established OB care or had an US.
On record review, you find a single PCP note from the refugee and immigrant health center 9 months ago, which confirms that she was HIV-negative and had no known TB, parasitic, or STI at time of arrival to the US from the Democratic Republic Congo. She stayed at the Kigeme Refugee Camp in Rwanda for 3 years before she and her 6-year old son were approved to travel to the US.
You order some blood work including a CBC, BMP as well as a beta hcg, UA, and GC/CT, wet prep.

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Additional case study - Pause

How might the principles of t rauma-informed care guide your interactions with this patient?
Patients recovering from trauma such as recently arrived refugees and immigrants may experience a sense of loss of control. What can you do to restore or provide greater control during a clinical encounter?
What factors might have influenced this patient’s ability or desire to establish regular medical care or OB care?

How might the principles of trauma-informed care guide your interactions with this patient?

It is important to be conscious of the potential for past and present trauma among immigrants, refugees, and asylum seekers. As we’ve discussed, trauma may result from a single event, series of events, or circumstances and may be physical and/or emotional in nature. Trauma may affect patient willingness to share certain information, engage with the health system, or undergo certain exams.
Providing trauma-informed care minimizes the possibility of causing additional harm through the use of practices that do not support recovery. Trauma-informed services maximize a person’s choice and control over the course of their recovery and focus on safety, strengths, spiritual and emotional well-being, and the development of trusting relationships.
The core principles of trauma informed care include: (1) safety (2) trustworthiness and transparency (3) peer support (4) collaboration and mutuality (5) empower and choice (6) awareness of cultural, historic, and gender issues
It may be appropriate to ask about past trauma if it pertain to your medical evaluation and care. For example, for female patients and other marginalized populations (such as LGBTQ patients), it may be important to ask about past gynecologic trauma or sexual assault and discuss this in a trauma-informed manner. Some experiences may be central to patients’ migration stories (ie, FGM, sexual violence or exploitation)
If a patient discloses trauma to you, consider how you can adjust your interactions with them to be mindful of it. For example, if a female requires a pelvic exam and has experienced sexual assault or FGM, you might consider downsizing the speculum, doing a bimanual only if necessary, etc.

What can you do to restore or provide greater control during a clinical encounter?

Throughout the encounter, it is important to be conscious of potential perceived power differentials and the need to empower and restore as much control as possible to individuals like this women.
Maintain warm, kind demeanor with eye contact (if culturally appropriate)
Let the patient control how much or how little they share
Ask open-ended questions and allow for conversation
Mirror the patient’s language and don’t make assumptions
Ask yourself: “who benefits from this question?” - Do not ask questions about past trauma unless symptoms are directly related to this and only if necessary. If it is important for your care, ask for permission to discuss.
Thank patients for their bravery and vulnerability if they do share

What factors might have influenced this patient’s ability or desire to establish regular medical care or OB care?

Logistical barriers to accessing care – distance, transportation, cost, health care system navigation
Presence of social support
Question of whether the pregnancy is desired

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Additional case study

CC: Abdominal and back pain

Vitals:

HR 115, BP 110/70, RR 18, Sp O2 99%, Temp 100.9

Focused Exam:

Gravid uterus, suprapubic and right CVA tenderness, no rebound or guarding
Pelvic exam without CMT, adnexal fullness or tenderness, os closed without friability, discharge

Bedside transabdominal US:

IUP without free fluid, FHR 160 bpm

Work up: UA >100 WBCs, +LE, bacteria, ketones

The patient is noted to be mildly tachycardic with a temperature of 100.9, but is otherwise hemodynamically stable.
Your focused exam is notable for a gravid uterus and suprapubic and right flank tenderness to palpation without rebound or guarding.
You do not appreciate any cervical motion tenderness, adnexal tenderness or fullness, and the cervical os is closed without drainage or friability. You collect GC/CT and wet prep swabs.
You do a bedside transabdominal US which confirms an IUP without free fluid and an appropriate FHR.
Laboratory work up is notable for a UA that suggest the patient likely has pyelonephritis and is dehydrated. She has two more episodes of NBNB emesis in the ED.
You would like to admit the patient for IV antibiotics and fluids; however, the hospital policy states that children cannot stay with admitted patients.

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Additional case study - Pause

How would you share your concerns and approach this discussion with the patient?
What resources might you be able to employ?
If the patient is unable to find someone to assist her with childcare, what steps would you take at that time?

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Case resolution

Check-in– How would you feel if this were your patient? Are there any steps you would want to take based on those feelings?

End of case – click picture at right to return to presentation

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SEMINAL STUDY

ACCOMMODATIONS: TIPS FOR TREATING PATIENTS WITH DISABILITIES IN THE ED

14.2

14.3 // CARE of LGBTQIA+ Populations

14.4 // Care of Incarcerated Populations

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