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2/23/2017 1 An Approach to the Immigrant Patient Margaret Wheeler MD and Devora Keller MD Disclosures We have benefitted directly and indirectly from having recent immigrants in our community Indirectly through taxation, cultural vibrancy, research, agriculture, construction, restaurant work etc. Directly through adoption, friendships, colleagues, personal health care; health care for family members; child care; home repair and cleaning; laundry and the list goes on…. Objectives Review recent trends in US immigration Introduce an approach to immigrant health Review legal issues important caring for undocumented patients World Wide Era of Unprecedented Migration Growing numbers of migrants world-wide More refugees now than at end of WWII US country with highest # of immigrants California state with highest # immigrants/ and highest # undocumented immigrants

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2/23/2017

1

An Approach to the Immigrant Patient

Margaret Wheeler MD and Devora Keller MD

Disclosures

• We have benefitted directly and indirectly from having recent immigrants in our community– Indirectly through taxation, cultural vibrancy,

research, agriculture, construction, restaurant work etc.

– Directly through adoption, friendships, colleagues, personal health care; health care for family members; child care; home repair and cleaning; laundry and the list goes on….

Objectives

• Review recent trends in US immigration

• Introduce an approach to immigrant health

• Review legal issues important caring for undocumented patients

World Wide Era of Unprecedented Migration

• Growing numbers of migrants world-wide

• More refugees now than at end of WWII

• US country with highest # of immigrants– California state with highest # immigrants/

and highest # undocumented immigrants

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Fewer Refugees Admitted to US

• 21.3 M refugees in world

• Only 6% hosted in the Americas

• # of refugees accepted into US set by President + Congress2014-15: 70,000 2016 85,00+ Syrian

2017?• http://www.unhcr.org/en-us/figures-at-a-

glance.htmhttps://www.state.gov/documents/organization/247982.pdf

It’s US History. It’s All Political….

• Immensely diverse groups at different timesHistory shaped by– politics, economics,

culture – stimuli and barriers to

immigration

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US Immigration Over Time

Immigration Since 1860• Today 13.3% (42.4 million) of US population foreign born (FB) • ½ citizens

• ¼ here legally; ¼ without documentation

» Pew, 2016

• 26% FB or children of FB• ¼ US children have at

least 1 FB parent

Shift from Europe to LA and Asia

The Immigrant SES Hourglass

• 20% of low wage workers are immigrants– 70% farmworkers– 75% home-healthcare aides

• 25% of physicians are FB• 22% of STEM workers FB

• More FB with advanced degrees than NB• More FB with low education

– Pew, 2013

American Community Survey

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Undocumented Immigration• Decrease since 2008• Half Mexico; Asia/LA

• Net benefit to economy$12 billion in payroll/SSA taxes

» Goss, 2013 https://www.ssa.gov

State and local taxes–$10.5 billion in 2010

Institute on Taxation and Economic policy, 2013 http://www.itep.org

Mixed Status Families

• Nearly 2/3 of undocumented in US for over decade

• 4 million US born children have one UD parent

• 6-10% of K-12 students have at least one UD parent

An Approach to Immigrant Patients:Three Considerations

• Health risks of native country

• Health risks of travel– both initial and recurrent

• Health risks of adopted country

Risks of Native Country

• Epidemiology of diseases– Higher risk exposure to infectious diseases, environmental

exposures, geography of genetic disorders

– High rate of chronic disease in developing world

• Epidemiology of stressors – Politics/economics/natural disasters– Keeping up current events as important as med updates

• Health care access and practices - Vaccinations, chronic disease care, medication use

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An Approach to Immigrant Health

• Health risks of native country

• Health Risks of Travel–Initial and Recurrent

• Health risks of adopted country

Risks of Initial Travel

• When—age, health, who left behind

• Travel itself—refugee camp, border crossing, debt, jet lag?

• Recurrent travel vs permanent break with home

Migration is Stressful• forced separation • dangers of the migratory

journey, • social isolation, difficulty

communicating • absence/gain opportunities • possible failure of the

migratory goals • drop/gain in social status• remittances/family

expectations • attitudes in the receiving

country.

Migratory GriefSupport/goodConditions-SIMPLE GRIEF

Poor ConditonsCOMPLICATED GRIEF

Ulysses SyndromeDepression/anxiety/ somatic sx

Individual factors

Pre-migration Stress—work,war…

Post-migration factors Migratory Grief

VALERO-GARCES,2014

Ulysses Syndrome• “Ulysses spent his days sitting on

the rocks by the sea, being consumed by tears, sighs and sadness...”

• Odyssey, Song V.

• “… mere mortals have to behave like heroes in order to survive. ....”

• Syndrome of prolonged grief with symptoms that include headaches, insomnia, abdominal discomfort and symptoms of depression and anxiety

• Dr. Joseba Achotegui (2010)

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Stress vs. Mental Health

• Rates of mental illness vary with different groups

• High rates of PTSD, anxiety, depression in refugees/immigrants exposed to violence/IPV as reason for immigrating

• For California Latinos– Central Am: high rates of political violence 1980s, 1990s; gangs– Mexico: IPV, gang, political violence

• Don’t ask, don’t tell – .

High Risk Travel Medicine

• ½ of US residents traveling abroad are FB visiting home

• Higher risk of getting sick while traveling

• Riskier behavior – Visit when pregnant, sick or with children– Stay for longer, eat like hosts. – More often sex, rural areas, contact sick relatives– Travel for health care or use health care– dentistry etc

• But less often vaccinated/prophylaxed• Recs for FB travelers same all travelers

Implications for Care• Awareness of migratory stresses

– Mitigate: language/communication/resources/ culturally competent systems/changes legal status

– Encourage English class, library,

• Practice travel medicine!– Ask about healthcare bridge–

treatments/meds from home– Recognize potential for travel/return home for

treatment and severe illness

An Approach to Immigrant

• Health risks of native country

• Health risks of travel–initial and recurrent

• Health risks of adopted country

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Risks of US Life• Epidemiology of Disease

– More chronic illness, lifestyle changes– Environmental risks:

• Latinos highest workplace fatalities; pesticides, sexual harassment

– https://www.bls.gov/news.release/pdf/cfoi.pdf, Loh

• Epidemiology of Stressors Minority StatusLegal statusLanguage marginalizationDiscrimination/FearAbsent family

• Health Care Access and Practices

Immigrant Health: Summary

• Native country• Screen for infectious diseases, mental illness,

violence/torture, missed screening (PAP), vaccinations

• Traveler• Immigrants are diverse, understand the immigration history• Immigrants are high risk travelers• Take repeated travel history

• Health risks of adopted country• Chronic illnesses, exposures• Remember barriers to care– communication and legal issues• Develop culturally competent systems

Legal Issues and Health Care for Undocumented Immigrants

Tanforan Japanese Internment, Executive 0rder, 1 942

Undocumented and Access to Care

• Highly variable by state, county, city policies• Can range from excellent to none• Undocumented children covered in many states• Undocumented adults covered in NYC, SF, LA,

others• Some undocumented adults have private

insurance via employers

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Policies Matter• Undocumented in Sanctuary Cities with good

access do well:– No difference btwn

undocumented/documented/citizens Mexican-Americans in diabetes outcomes

Iten/Fernandez 2014

– Undocumented present with more advanced HIV do equally well once in care

» Poon, 2012

• Expanding coverage to undocumented children results in high enrollments and better outcomes

» Howell, 2010

Policies Matter: ESRD and Undocumented

• Near universal coverage for ESRD with exception of undocumented

• Two strategies depending on state– Emergent dialysis (only when emergent

conditions exist)• more costly; 5x the mortality

– Chronic dialysis– Rodriguez, 2015; Cervantes, 2017;Fernandez 2017

Policies Matter: US Citizen Children

• In 2012 about 150,000 US children had an undocumented parent deported

» http://www.humanimpact.org/

• 75% undocumented parents report their US citizen children have sx of PTSD

• US citizen children of undocumented parents: – fewer health care visits

– worse health – more food insecurity

» http://www.familyunityfamilyhealth.org 2013 Report

Fear as Barrier

• 1/8 undocumented immigrants fear deportation when accessing care

» Maldonado, 2013

• Patients forgo care for fear of ICE

» Hacker, 2012

• Patients forgo care when immigration policies become more stringent

» Rhodes, 2015

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Asking About Legal Status

• Immigrant rights organizations advise against

• Pts may fear– Denial of care or lower standard of care– Immigration service involvement– Risking future legal/citizen standing– Discrimination

• Documenting in chart: Do Not

• If need, to know or remember “can you travel?”

If Patient Reveals Undocumented Status

Reassure

• Confidentiality, especially from ICE

• Current federal policies keep ICE out of hospitals/clinics

• Will not lead to differential care or abandonment/repatriation

• Consider legal referralshttps://www.immigrationlawhelp.org

Advocating for Undocumented Patients

• Know basic immigration policies and processes

• Refer for forensic examinations, legal assistance and rights education

• Support the immigration process with medical documentation

• Establish clinic policies to support undocumented

• Strengthen partnerships with community groups

Achieving ‘Legal Status’ in the U.S.

• Citizenship through birth• Citizenship through Naturalization

– Permanent resident > 5 years– Married to citizen >3 years– Served >1 year in armed forces

• Citizenship through acquisition (born to US parent)• Citizenship through Derivation (naturalization of

one’s parents)

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Paths to Permanent Status

• Family Sponsorship Green Card

• Employment Related Green Card (EB1-5)

• Asylum/refugee

• Victims of crime ( U-visa/T-visa/VAWA)

• Lottery (Diversity Green Card)

Refugees Apply for Legal Status in via Specific Process

https://www.theguardian.com/world/2016/aug/18/boy-i n-the-ambulance-image-emerges-syrian-child-aleppo-r ubble

Fear of Persecution

Must have faced persecution or have a well-founded fear of persecution on protected grounds:

• Race• Religion• Nationality• Political Opinion• Membership in a Particular Social Group

Women (FGM, domestic abuse)LGBT

Home government must have been involved in persecution or unable to protect

Refugee vetting process

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Asylum Process in US

Affirmative Asylum Process•Applies for asylum

– After arrival on valid visa– Within one year of the date of their last arrival in the US

Defensive Asylum Process• Requests asylum

– as a defense against removal while undergoing removal proceedings

– after being denied an affirmative asylum application

Factors Improving Asylum Approval Rates

• Having Legal Representation

• Having a medical affidavit from a physician or mental health provider

• Applying Affirmatively

• Country of origin• Location and assignment of immigration

Judge

Forensic Medical Evaluation: Refer

• Completed by specially trained providerworking with lawyers

• History focusing on trauma and torture

• Assessment of sequela of past abuse

• PE and MS exam documenting trauma

• Written documentation (affidavit) of trauma using guidelines from Istanbul Protocol

Often no treatment or therapies are offered

A forensic affidavit helps

• Helps build a case of ‘credible fear of persecution’

• Documents physical or psychological trauma

• In asylum cases: explains why 1 year bar not met (due to depression/PTSD or other medical concerns)

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Visas for victims of crime perpetrated in the US

Created as part of the Victims of Trafficking and Violence Protection Act (October 2000)

U-Visa•Visa for victims of violent crimes

•Limit to 10,000/year.

•Multiple year backlog.

•Applicants eligible for deferred action while application is pending.

VAWA

•Visa for spouse/child/ parent victim of abuse by American citizen/ green card holder

•Available to all genders

T-Visa

•Visa for victims of human trafficking

•Limit to 5,000/year

•Cap rarely if ever met

How do I screen my patient?

• Take an immigration history

• Screen for domestic violence and community violence

• Ask open ended questions

• Screen for victims of trafficking– Do you live and work in the same place– Do you have access to your own documents– Have you been denied access to

care/food/clothes

If You Are Asked for a Letter

• Contact the lawyer to determine the scope/focus needed for letter

• Refer to legal assistance if your patient does not have legal counsel. (Ideally no letter without lawyer).

Refer Your Undocumented Patients for Legal Advice

• Naturalization

• Asylum

• Specialty visas• Deportation issues

• Advice for DACA

• Anticipatory guidance

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Anticipatory Guidance- Legal • 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

Red Cardshttps://www.ilrc.org/red-cards

Clinic Policies

• Staff training on asking demographics

• On documentation of undocumented status

• Pro-active “signal safety” --- posters, cards

• Strengthen partnership with community groups

• Easy access to referral information for immigration services

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Watch for these possible changes

• Threat to sanctuary cities?

• Rescind DACA( Deferred Action on Child-hood Arrivals)?

• New EO:– Shifts emphasis of deportation– Emphasizes issue of “public charge”– May challenge some privacy issues

Approach to Immigrant HealthSummary: Legal

• Stay up to date on basic national and local immigration policies and processes

• Support the immigration process with medical documentation

• Refer for legal assistance and rights education and planning, now more than ever

• Consult a lawyer!

Immigrant Health: Think Globally, Act Locally Legal Referrals SF

www.projectlegallink.org

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More resources• Public Health Actions for Immigrant Rights

(https://docs.google.com/document/d/1MXecn5b_IZPZ5r6LA3U4Ggz2gSMqxMONGBlCngsXHEU)

• National Immigrant Law Center (https://www.nilc.org)

• The Fair Immigration Reform Movement (FIRM; http://fairimmigration.org/)

• United We Dream (http://unitedwedream.org/)• We Belong Together (https://www.domesticworkers.org/we-

belong-together)• National Council of La Raza (NCLR; http://www.nclr.org/)• Check for potential partners on local college campuses,

which may have groups already formed around immigration.• Human Impact Partners

([email protected])• Immigrant Legal Resource Center (https://www.ilrc.org)• ACLU (aclu.org)

More Resources

• Minnesota Department of Public Health: A Call to Action, Immigrant Health

http://www.health.state.mn.us/divs/idepc/refugee/topics/immhealthrpt.pdf

• Examining asylum seekers: A clinician’s guide to physical and psychological evaluations of torture and ill treatment; 2012 Dec [cited 2015 Sept 1]. 191 . Available from: http://physiciansforhumanrights.org/library/reports/examining-asylum-seekers-manual-2012.html

• United Nations. The Manual on Effective Investigation and Documentation of Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment: Istanbul Protocol. Geneva, Switzerland: United Nations, November 1999.

http://www.ohchr.org/Documents/Publications/training8Rev1en.pdf