Hospital staff are on the front lines in
the fight against a growing threat to their patients' health: Fear.
Sept. 14, 2018
As
a nurse, Michelle Camacho-Johnson is trained to ensure her patients feel safe
and comfortable during their hospital stay. But recently, the California nurse
and her team found themselves facing an unfamiliar threat to a patient’s
health.
The
patient, who arrived with a critical condition, was donning a bulky ankle
monitor, the kind used by Immigration and Customs Enforcement to track asylum
seekers awaiting deportation hearings.
"I
was really taken aback," the nurse at a California hospital told
Healthcare Dive. "The first thing I thought of was, who needs a yellow
star when we have modern day technology to replace that?"
Without
training on how to deal with such situations, Camacho-Johnson faced a flurry of
thoughts: How does she communicate to her patient that they’re safe? What if
ICE agents interfere with treatment? Is it against the law to refuse them?
Would she lose her job for doing so — or worse?
"This
is all new territory," Camacho-Johnson said. "It was distracting to
my nursing care. My focus should be completely on symptom management, lab
values, emotional care as far as dealing with a new diagnosis."
Camacho-Johnson
is not alone in her concern.
ICE
agents detaining children needing emergency care, targeting immigrants visiting
sick family members and deporting patients as they exit hospitals are putting
healthcare workers in precarious positions. Some are finding their
professional purpose compromised by federal immigration policies and fear
patient health will suffer.
A
recent survey from the advocacy group Children's Partnership found about 40% of
immigrant patients in California are skipping appointments and scheduling fewer
visits with their providers for fear of confrontation with ICE. One recent study of 545
Mexican women in the United States concluded that fear of deportation could be
a cardiovascular risk factor for the country's ethnic minorities.
By
design, fear of deportation is not only pushing legal status-holding and
undocumented immigrants away from receiving treatment, but away from signing up
for the public benefits they're eligible to receive.
"If
you're in this country illegally and you committed a crime by entering this
country, you should be uncomfortable," former Trump administration
ICE Director Thomas Homan told the House Appropriations Committee's Homeland
Security Subcommittee last year. "You should look over your shoulder, and
you need to be worried."
Hospital
staff, duty-bound to patient safety, aren't turning a blind eye. They have
consulted lawyers about where federal agents can go and when, and trained
employees about how to protect those in their charge while adhering to the
letter of the law. One clinic in Los Angeles even has regular "ICE
drills."
'Sensitive
locations'
According
to ICE's own "sensitive locations" policy, agents are prohibited
from taking "enforcement actions" against persons of interest inside
hospitals and medical facilities. The agency, however, has found ways around
the policy's ambiguity in the interest of national security.
ICE
spokeswoman Danielle Bennett told Healthcare Dive she is "unaware of any
instance in which this policy has been violated."
Jose de Jesus Martinez,
a Mexican national who was visiting his son at North Central Baptist Hospital
in San Antonio last August, begged to differ. Martinez's son, suffering from a
heat-induced coma after being smuggled across the border in a truck, was being
relocated to another hospital room when Martinez said ICE agents entered and
began interrogating the father aggressively.
Under
ICE's own directive, interviews are considered an "enforcement
action" not to be taken inside a sensitive location. But there are ways
around the policy that make it virtually impotent.
In
this case, according to Bennett, ICE agents were "attempting
to talk to a potential witness to a deadly human smuggling event." Agents
entered the hospital room to interview Martinez to investigate an "exigent
circumstance."
There
appear to be no repercussions for agents who go against the policy. Bennett
said it would be "inappropriate ... to even begin to speculate on
potential penalties for something that isn't even alleged to have
occurred."
Lack
of accountability for the agency has led Democrats in the Senate and the House
to introduce the Protecting Sensitive Locations Act,
which would act as an enforcement mechanism for ICE's own guidance, forcing
them to exclude hospitals and medical facilities from enforcement actions. The
bill has been lauded by healthcare groups that have recognized the threat ICE
imposes on immigrant health, including AMA.
But
chances the bill will gain steam are slim, given Republican control over
Washington.
Is
hospital protocol enough?
The
American Hospital Association does not have a specific policy on the removal,
detainment or apprehension of immigrant patients from medical facilities, so
hospitals have largely been navigating their own way through murky immigration
laws.
That
hasn't always worked out well.
In
2013, for example, Iowa Methodist Medical Center in Des Moines put two comatose undocumented
immigrants on a private jet to Mexico without the consult of
any government authority.
Jeff
Sconyers, a senior lecturer in the graduate program in Health Services
Administration at the University of Washington, co-authored an article in AMA Journal of Ethics in 2016 arguing
providers have a moral obligation to respect the confidentiality of
undocumented immigrants as if they were any other patient.
As
a law enforcement body, ICE must go through a subpoena process to get a
patient's information. But what happens when ICE agents camp on hospital
property while a person of interest is being treated, as was the case with a
critically ill woman from El Salvador who last year was bound in her wheelchair by federal
agents who moved her from the Texas hospital where she was
awaiting emergency brain tumor surgery and into a detention center?
Can
a hospital ask ICE agents to leave? According to Sconyers, yes. But, he added,
hospitals have a need to maintain a good working relationship with law
enforcement.
"Most
organizations would take a pretty lax view of somebody just camping out. Most
emergency rooms are really busy. If you don't present yourself to the nurse, if
you're not wearing an ICE jacket, they might very well assume you're just a
family member waiting for someone to come out," Sconyers said.
Altaf
Saadi, a UCLA National Clinician Scholars Fellow, told Healthcare Dive that one
direct method for protecting immigrant patients is expanding existing policy on
dealing with law enforcement to include immigration enforcement.
"There
are already some guidelines and policies for hospitals about working with law
enforcement," Saadi said, adding that hospitals don't have to proactively
give immigration enforcement information about immigrant patients in the same
way they don't need to give other law enforcement agencies information on patient
drug use. "People just haven't made that connection ... There's no need to
report undocumented immigrants to officials."
In
a JAMA paper published earlier this year,
Saadi advocated making hospitals sanctuaries where ICE agents must present
verified identification. Above that, the authors wrote, "no hospital
employee should provide information about any patient to the agents or provide
them access to any patient's room without a court-ordered warrant or
subpoena," except in the case of an emergency that poses immediate
harm.
The
role of healthcare workers
Employees
at St. John's Well Child & Family Center in Los Angeles instituted similar
protocols to ensure the protection of their immigrant patients.
Since
spring, employees at the Los Angeles clinic have participated in voluntary
"ICE drills" to train them in protecting immigrant patients from
ICE agents. Mario Chavez, director of government affairs at St. John's, told
Healthcare Dive he developed the training after hearing reports of anxiety
among the clinic's immigrant patient population.
"Rather
than just wait and react, we figured we would equip our staff," Chavez
said. "We had to have a game plan, given all the fear in the community. We
couldn't be reactionary."
St.
John's makes sure its front desk staff and clinicians are "made
clear" on the rights granted to them and their patients by the Fourth
Amendment protection against unreasonable search and seizure. Front desk
employees are given a script to prepare them for questions may be asked by ICE
agents. Managers are trained in how to read warrants.
Staff
who have participated have learned how to form a human shield to prevent
apprehension, much like North Central Baptist employees did in the case of
Martinez last year. Worst comes to worse, St. John's staff have a protocol for
keeping ICE agents in place while patients are locked in their rooms.
"We
shouldn't have to compromise our constitutional rights as citizens or residents
in this country in the name of national security when there's clearly a due
process," Chavez said.
Chavez's
program has caught the interest of other facilities as more healthcare workers
express the need to prepare for a possible ICE raid. A training seminar set
for later this month has already reached max registration.
"The
likelihood of something like that happening is very low," Saadi said.
"It's good to prepare for it, but there are so many other aspects that are
important for caring for this population. That could include training providers
on local legal or community resources to provide to patients experiencing
immigration-related legal concerns."
The
Emergency Department of LAC + USC in Los Angeles, a medical-legal partnership
funded by the Robert Wood Johnson Foundation is going a step further by
helping legalize incoming patients'
immigration status — insuring those patients and making sure
they know their rights in the process.
Rebecca
Trotzky-Sirr, a family doctor with the hospital, is one of the founders of that
medical-legal partnership.
"We
have data from the past year that shows many people who come through our doors
are able to legalize their status," Trotzky-Sirr told Healthcare Dive.
The
cost of fear
Chavez
told Healthcare Dive that St. John's has experienced a 10% drop in visits among
undocumented patients and a 30% no-show rate since the Trump administration
ramped up deportations.
That's
not uncommon in geographies with immigrant-heavy populations. A body of
evidence for this predates the current administration, Saadi said, but fear of
deportation and its health impacts have "certainly
increased" over the past two years.
Aubrey
Hill, director of health systems change at the Center for Health Progress in
Colorado, told Healthcare Dive state providers see increases in appointment
cancellations and no-shows by immigrants and refugees, decreases in
appointments made by those populations and an "uptick" in patients
sharing with their providers a fear or concern over sharing their private
information.
A report released by Hill's
organization last year found an increase in immigrant children
coming into ERs with emergency conditions that could have been
prevented had they visited a primary care physician.
"People
who show up to hospitals, court houses and schools, they're trying to be a part
of society. We want to make sure our institutions are working for
them," Hill said. "These are the most essential functions of our
society. When they break down, we've lost a society that can function properly."
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