Passport to Health: Challenges of Caring for Undocumented Children in the Emergency Department

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Introduction

An undocumented immigrant is an individual who enters the United States without inspection by U.S. Citizenship and Immigration Services, or who enters with expired legal status.1 In 2014, there were an estimated 11.1 million undocumented immigrants living in the U.S.; approximately 1 million of those were children. An additional 4 million children were characterized as “citizen children” – those born to undocumented parents while in the United States.2,3

While some states do offer health care coverage to undocumented children, the federal government does not. For many undocumented children, the first visit to an emergency department may represent his or her first encounter with the US healthcare system. It gives emergency providers a unique opportunity to provide more than just “safety net” care.

Challenges for Undocumented Children

Undocumented families comprise a particularly vulnerable population. They face challenges not only in navigating the US healthcare system, but in breaking through cultural and language barriers, dealing with the consequences of undiagnosed chronic disease, and suffering from mental health conditions such as depression or posttraumatic stress disorder.4-6

The greatest concern for the undocumented immigrant is that of deportation, which can negatively impact the doctor-patient relationship due to lack of willingness to disclose a complete medical history, or failure to present to a physician until a true emergency presents.7

While legal immigrants (including naturalized citizens, lawful permanent residents, refugees, and asylees) will have completed at least a requisite screening prior to entrance, illegal immigrants may have received little to no primary care prior to arrival.

Children may additionally suffer from malnourishment due to diet, parasitic infection, or environmental exposure. They may have experienced trauma, torture, or suffering during or prior to their journey. Indeed, in some instances, physicians have played a role in such torture or abuse, further endangering an already fragile doctor-patient relationship.5

Challenges for Providers

It is imperative that emergency medicine providers make every effort to establish trust and rapport with immigrant families, particularly since it is often their only interface with the health care system. Whenever possible, interpreters should be used, which can present its own set of challenges.7 For example, language barriers have been shown to increase length of stay and decrease threshold for imaging within the emergency department.8,9 In addition, certain dialects may not be available for a given interpreter service.

Beyond language barriers, cultural differences can present a challenge to providers because of alternative healing practices, poor health literacy, different interpretation of the provider-patient relationship, and gender roles. Therefore, a provider who is able to build rapport in an initial encounter may better be able ease a family’s transition into a medical home.

Recommendations for Providers

The Centers for Disease Control and Prevention (CDC) makes recommendations for a medical screening exam on all immigrants and refugees.7 Of particular importance for children presenting to the emergency department are questions pertaining to vaccination status, nutrition, environmental exposure, history of trauma, and mental health.4-6

While families from South America, for example, are traditionally very supportive of vaccination, immunization requirements vary widely. A list of standard immunizations by country is available on cdc.gov, but it is important to note that documentation of vaccinations is the only reliable means of ensuring completion.1,10 While vaccination requirements go beyond the purview of most ED encounters, it does provide insight into which communicable diseases a child may be at risk for contracting or transmitting.

Environmental exposures, poor nutrition, and infectious diseases also play an important role in evaluation. Malnourished children may appear younger than stated age due to short stature. Chronic lead or copper exposure may lead to significant anemia or hepatic failure, respectively. Depending on presentation, a differential for infectious disease must include conditions such as tuberculosis, HIV, Hansen’s disease (leprosy), syphilis, malaria, and typhoid. Based on presentation, additional workup as recommended by the CDC may include: a CBC, lead level, tuberculosis screen, stool for O&P and giardia, a newborn metabolic screen, and an HIV test.1

Trauma may also play an important role in presentation. This population is at risk for infected or poorly healed wounds, malunion or nonunion of fractures, or abuse. A provider should be looking for evidence of prior abuse or trauma, such as characteristic scar patterns from whipping, burn patterns, or female genital mutilation.4,6

Mental health is an often-overlooked issue. Both undocumented and documented immigrants are at very high risk of posttraumatic stress disorder (PTSD) and depression.9 Adolescents in particular may turn to their peer groups or run away from home, placing them at an additional risk for substance abuse, behavioral issues, and trauma.1 In children presenting with vague somatic complaints or with histories that don’t quite fit the presentation, abuse should be high on the differential. A provider should also consider sex trafficking and pay careful attention to child–caregiver dynamics. Any suspicion should prompt an assessment without the caregiver present.

Available Resources for Patients

Once an acutely ill child has been stabilized, or the family of a not so acutely ill child has been reassured, the next step for a family is establishment of a medical home, or a place that can coordinate long-term care. There are approximately 1,200 federally qualified community health centers nationwide. They are funded in part by federal grants and provide care to all comers, regardless of immigration status. In addition, many communities have clinics and health centers that accept undocumented families without pay or with payment on sliding scale. While undocumented families are not able to independently purchase insurance on the current health exchange, they may do so directly through a broker. However, this is an expensive option and often beyond the means of most families.

There are a number of counties that provide insurance at low or no cost to immigrants, regardless of immigration status. This includes certain counties in Texas, Massachusetts, California, Nevada, Illinois, Maryland, Georgia and New York.8 California allows all undocumented children under the age of 19 to receive affordable care under the Medi-Cal program.11 Of course, it is unclear how any or all of this will change with the current political environment.

Referrals for subspecialty care can be equally, if not more, challenging. As with primary care, referrals for undocumented children will vary from state to state. A provider should be aware of the options within his or her community and make use of social work if available. Obtaining a reliable contact number for follow up and provision of resources is very important.

Conclusion

One of the greatest privileges of emergency medicine is the provision of care to all.

Whether by personal ideology or federal mandate, we take pride in our ability to care for all patients who present to the emergency department: anyone, anywhere, anytime. In caring for undocumented immigrants, particularly for their children, we can offer good treatment, safety, and the opportunity for entry into a medical home. While many undocumented immigrants are hesitant to seek medical help, it is our duty to provide compassionate and culturally competent care.

References

  1. Gray M, Chapman J. Guidelines for Pediatric Immigrant Health. Children’s National. 2015.
  2. Krogstad JM, Passel JS, Cohn D. 5 Facts about illegal immigration in the U.S. Pew Research Center. Nov 3, 2016.
  3. The Week. The truth about America’s illegal immigrants. http://theweek.com/articles/650402/truth-about-americas-illegal-immigrants. Sept. 24, 2016.
  4. Centers for Disease Control and Prevention. Medical Examination of Immigrants and Refugees. http://www.cdc.gov/immigrantrefugeehealth/exams/medical-examination.html.
  5. Seery T, Boswell H, Lara A. Caring for Refugee Children. Peds in Rev. 2015;36(8):323.
  6. Centers for Disease Control and Prevention. Evaluating and Updating Immunizations During the Domestic Medical Examination for Newly Arrived Refugees. http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/immunizations-guidelines.html.
  7. Mahmoud I, Hou XY. Immigrants and the utilization of hospital emergency departments. World J Emerg Med. 2012;3(4):245.
  8. Hampers LC, Cha S, Gutglass DJ, Binns HJ, Krug SE. Language barriers and resource utilization in a pediatric emergency department. Pediatrics. 1999;103(6 Pt 1):1253-1256.
  9. Seery T, Boswell H, Lara A. Caring for Refugee Children. Peds in Rev. 2015;36:323.
  10. Meyer MC, Barron DN, Clements RC. Immigrant Medicine – The ED Perspective Part I: Evaluation, Diagnosis and Treatment of Commonly Encountered Diseases. AHC Media. 2003.
  11. Zanni GR, Stavis PF. The effectiveness and ethical justification of psychiatric outpatient commitment. Am J Bioeth. 2007;7(11):31-41.
  12. Swanson J, Swartz M, Van Dorn RA, et al. Racial disparities in involuntary outpatient commitment: are they real? Health Aff (Millwood). 2009;28(3):816-26.
B. Barrie Bostick, MD

B. Barrie Bostick, MD

Emergency Medicine/Pediatrics Residency, University of Maryland Medical Center, Baltimore, MD
Michael Holdsworth, MD

Michael Holdsworth, MD

Emergency Medicine/Pediatrics Residency, University of Maryland Medical Center, Baltimore, MD
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