As a doctor in the Bronx—home to nearly half a million immigrants, including an estimated 113,000 who are undocumented—I have followed much of the immigration-related news of the past year with alarm. The media has reported countless stories on the “Muslim ban,” more-aggressive deportation activity by U.S. Immigration and Customs Enforcement (ICE) and the legislative debate on renewing Deferred Action for Childhood Arrivals. While news stories often feel abstract, in my clinic I see the direct impact of the worsening immigration climate on my patients. Some patients have expressed increasing anxiety and stress during these uncertain times, and others have simply stopped showing up to appointments.
The worsening immigration climate in this country appears to be negatively affecting the health of immigrant communities. A recent article in the New York Times described patients too frightened of immigration authorities to pick up insulin refills or go to emergency rooms. Such fears are not without basis. Proposition 187 (adopted by California in 1994, then later repealed) and the Support Our Law Enforcement and Safe Neighborhoods Act (signed into law in Arizona in 2010) both tried explicitly to deny medical care to undocumented immigrants and use the healthcare system to identify and report them to immigration authorities. Subsequent studies concluded that such efforts increased mistrust of healthcare providers among undocumented immigrants and led to a decrease in medical visits.
More recently, the Los Angeles Times reported on a woman awaiting emergency brain surgery who was removed by ICE from a hospital to an immigration detention facility. There is legitimate concern, therefore, that undocumented patients who are sick are forgoing medical care, with negative consequences for individual and community health.
For immigrant patients who do come in through the doors of the healthcare system, substantial barriers may affect their care. These include limited English proficiency, unfamiliarity with the American healthcare system and lack of health insurance, all of which are more common among undocumented immigrants than among other groups. Furthermore, while we as medical providers frequently care for undocumented immigrants, we may feel unequipped to address the many issues that affect this population. Yet I believe that if we are to fully realize our role as healers, we must attempt to do so, both in the clinic and beyond.
So how can doctors be advocates for our immigrant patients? We can first try to create welcoming environments in our clinics and hospitals. Emphasizing confidentiality and offering reassurance that medical information will not be shared with immigration authorities can let patients know that speaking about sensitive topics is okay. Not directly asking about immigration status and not documenting patients’ status in the medical record can also reduce stigma and avoid any possibility that such information would end up in the hands of ICE.
While we should be discreet in discussing immigration status, paying close attention to details of the clinical encounter may help us identify patients who might be eligible to obtain legal immigration status. For example, patients who have experienced domestic violence, who have been victims of serious crimes in the U.S., who are under 21 and have been abused or neglected by one or both parents, who have suffered psychological trauma or who have experienced female genital mutilation may be able to petition for a change in status. Carefully asking about these sensitive issues and referring patients to appropriate service providers is a truly important service we can perform for our patients.
Physicians can and should advocate for immigrant patients outside the walls of the exam room. For example, physicians at Montefiore have partnered with advocacy organizations to conduct forensic evaluations of refugees seeking asylum as well as persons who are detained in immigration detention centers. We can also directly advocate for change within and beyond our institution. Encouraging decision makers at Montefiore and Einstein to adopt clear policies regarding encounters with immigration authorities is an important action we could take to counteract the fear that some of our undocumented patients have about seeking medical care.
Our primary role as physicians is to promote the well-being of the patients and communities we serve, whose health is being directly affected by the current immigration climate. We can take concrete steps at the bedside, in our hospitals and beyond to make sure that our immigrant patients receive the medical care they need.