Why many patients are afraid to come to the clinic

The young woman sat in the corner of my exam room, facing away from me as I asked her questions. Her answers were short. “I’m from El Salvador.” Why did she come? “Because of the violence.” Her voice was flat. Her hands trembled. I knew she had suffered terribly and I needed to ask her how.

Slowly, quietly, she recounted the gang violence she had fled in El Salvador. The assault she’d been too afraid to tell her family about lest they be targeted. The death threats to her children that finally led her to seek asylum in the United States.

“They can do what they want to me,” she said. “But they are not going to hurt my children.” She gradually met my eyes as hers filled with tears.

As my patient unburdened herself, I was grateful for her trust. I knew that there were hundreds more young women like her who were afraid to set foot in the clinic.

I wanted to reassure her that she would be safe in the clinic. I wanted to tell her that she would be safe when she went back to her home in Everett, Massachusetts. But as awareness of the world outside filled the space between us, I wasn’t sure I could.

On January 25 President Trump signed an executive order that calls, among other things, for a 50 percent increase in the number of Immigration and Customs Enforcement (ICE) officers; the expanded use of detention centers; and the use of local law enforcement officers to enforce immigration policy. Officers will be allowed to deport immigrants who have been charged with any crime, even if they haven’t been convicted.

In the shadow of the first travel ban, this order did not initially receive much attention. But on February 21, the Trump administration published new Department of Homeland Security rules clarifying that this order greatly expands the classes of people who will be targeted for deportation.

For those who have worked with immigrants for years, it is difficult to explain how the current situation differs from the last 20 years. Both President George W. Bush and President Obama massively increased deportations — sending home 2 million and 2.5 million people, respectively, a huge increase over previous years. They created an efficient system for removals which our current president has inherited.

But under the Obama administration, “deportations were typically done under a Priority Enforcement Program,” said Liza Ryan of the Massachusetts Immigrant and Refugee Advocacy Coalition. Priority was given to those who had committed serious crimes, had recently entered the country, or were deemed a threat to national security. Now, under the executive order currently in force, “they basically don’t have priorities. It’s so extremely broad that it basically encapsulates everyone,” she told me.

My medical school in Atlanta didn’t offer a class on immigration policy. We discussed politics between classes. Taking care of a diverse population in Georgia, our first concern was always not to offend with our personal political beliefs, damaging in some way the patient-physician relationship.

In my third year of medical school, however, I had a crash course in immigration policy while taking care of migrant laborers in rural Georgia. We set up tents in the fields and treated hundreds of patients under the hot Georgia sun.

While we were there, the state of Georgia passed a law allowing local police to demand immigration papers from anyone they stopped. Overnight, before the law was even enforced, thousands of immigrants fled the state, leaving $140 million in crops rotting on the ground. Some mornings, we would pitch our tents only to find the camps had become ghost towns.

Now, with ongoing changes in federal immigration policy, many patients are afraid to even come to clinic. Once again, I sometimes feel like I’m pitching a tent in an empty field.

Dr. Rob Marlin, a primary care physician in Cambridge who directs the Refugee Health Assessment Program, recently provided training for physicians who take care of immigrant patients. He told us we must “individually and institutionally have greater knowledge of immigration policy to take care of our patients.”

Knowing a patient’s immigration status and the reasons they came to this country can affect the services they are eligible for, the relative costs of medications, the fears that may keep them from returning for needed services, and even the diagnosis of unexplained symptoms.

Immigration policy, Marlin told us, “is no longer a spectator sport” for us or for our patients.

But it is not simple to practice medicine under these new and uncertain circumstances. The fear that young woman from El Salvador felt in clinic was partly a fear of me — an authority figure she did not know if she could trust. While we like to think our clinics and hospitals are safe for everyone, that’s not always the case.

woman who showed up to her gynecologist’s office in Houston two years ago presented a fake ID. Staff reported her to ICE officers, who waited for her in the clinic room. Instead of having a pap smear, she was deported, leaving her 8-year-old daughter in the waiting room.

In my current practice, I need to know why my patients might be afraid of the police and of me. However, I do not directly ask about their immigration status because I don’t want them to be fearful of how that information will be used.

I’m also careful what I document in the medical chart because we can never assume any data are secure. Though federal medical privacy law is commonly understood to protect our clinic notes from immigration and law enforcement officers who don’t have a warrant or patients’ permission to disclose, it’s not clear that will always be the case.

The renewed focus on deportation, and shifting rules for who will be targeted, has created a climate of fear that overshadows our care. One of our primary roles as doctors is to relieve our patients’ anxieties. If you have a lump, I know what tests to order to determine if it’s cancerous or benign. We can never be 100 percent sure of anything, but our knowledge, exams and systematic ways of approaching problems give us road maps to help our patients through uncertainty.

Unclear and changing immigration rules make it impossible for me to assure my immigrant patients that their fears are unwarranted.

Nonetheless, there are many things we caregivers can do to improve our current situation. We can refer patients to local agencies that can help. We can get trained in asylum evaluations. We can leave the hospital and go into the community to let patients know we provide a safe space for them.

We can advocate for bills like the Safe Communities Act in Massachusetts, which prevents local law enforcement in our state from acting as immigration officers. Bills like these do not prevent deportations. But they do mean that I, as a physician, can confidently tell women who are being abused or young men who are assaulted that it is safe to call the police before checking their zip code.

We can also seek to understand the existential threat that our patients face and the ways it is changing. Only then can we avoid false reassurance.

Meanwhile, executive orders continue to be signed and shift the ground beneath us. A narrower travel ban, replacing the currently court-suspended order, was signed on March 6. It will cut the number of refugees admitted by half, preventing families from reuniting and exacerbating the worst refugee crisis since World War II.

There may be more executive orders coming. A leaked draft of one order reveals it might become possible to deport immigrants who are legally here simply because they access federal aid, including federally funded health insurance programs.

Few immigrants qualify for Medicaid, but for legal permanent residents who do, such an order could threaten their ability to stay if they enroll in the insurance program.

In the room that day with my patient, I wanted to tell her that she was going to be fine. I wanted to assure her that her children wouldn’t be sent back to El Salvador, perhaps to be killed. But I couldn’t. All I could do was say, “I am here for you. Right now, you are safe.”

Elisabeth Poorman is an internal medicine physician.  She can be reached on Twitter @DrPoorman. This article originally appeared in WBUR’s CommonHealth.

Image credit: Shutterstock.com

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