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ISSUES OF IMMIGRATION AND HEALTHCARE IN THE UNITED STATES

Change and challenge is in the wind as 2008 comes to an end. The same is true when examining this month's ReachMD XM 160 special series - Focus on Global Medicine. We take a look at both the changes and the challenges impacting global medicine.

Over the past several years, immigration and healthcare have been increasingly compounding issues for our nation's lawmakers and policy experts. In many circumstances like those, who are hospital weighs the possibility of surreptitiously transporting a migrant patient back to their country of origin. The two issues overlap and with medical, legal, ethical, and diplomatic ramifications as well, have we seen any progress towards reconciling these two overarching issues in American policy. You are listening to ReachMD, The Channel for Medical Professionals. Welcome to a special segment - Focus on Global Medicine. I am your host, Dr. Mark Nolan Hill, professor of surgery and practicing general surgeon and our guest is Dr. Steven Larson, assistant dean of global health at the University of Pennsylvania School of Medicine. Dr. Larson is also an associate professor of emergency medicine at the Hospital of the University of Pennsylvania and an expert on migrant health.

DR. MARK NOLAN HILL:

Welcome Dr. Larson.

DR. STEVEN LARSON:

Thanks for having me.

DR. MARK NOLAN HILL:

Dr. Larson, do the healthcare needs of these undocumented immigrants, who come to the United States different than let's say the population of the United States as a whole?

DR. STEVEN LARSON:

You know, it is a fantastic question, so, you know, when you look at the data and the history of the immigrant population back in the 80s and 90s, again it was a predominantly male population that were pretty lean, coming out of the highlands, working long hours, hard labor, and there is this presence of what is known as the Hispanic paradox or the Latino paradox, which fuddles a lot of researchers in the sense that the first generation of immigrants arrive here in actually pretty good health, very good health compared to their counterparts that have lived in the United States.

DR. MARK NOLAN HILL:

Aha.

DR. STEVEN LARSON:

And overtime that advantage gets washed out and that is puzzling. Some people think it has to do with stress, some people think it has to do with diet as you abandoned in a very lean beans and tortillas diet to, you know, big gulps, big <_____>, and, but it is an interesting phenomenon. How much that holds true today, I am not sure because now with the most recent wave of immigration, you have men, women, children, all immigrating in mass and not sure that, that advantage is going to be as clear. There are distinct needs with different populations. Back around 2001-2002, the populations that had been predominantly rural-based agricultural industry populations. The funny thing happened with the building boom and food industries, demands for labor in Philadelphia suddenly saw a very urbanized Mexican population arriving, not just in Philadelphia, but in the surrounding larger town and those needs were going to be clearly different than the guy working on a farm in Southern Chester County, and indeed, from our early work, when we started looking at the issues, for instance, with the women, high levels of domestic abuse, high levels of sexual abuse, you know, just crossing the border alone and ending up in Philadelphia took its toll on them from the stress perspective and from, you know, the issues related to violence.

DR. MARK NOLAN HILL:

And what about comprehensive care to those patients' families?

DR. STEVEN LARSON:

Well, it doesn't exist. I mean there is always the safety net of the public health department, which, you know, can take 2 months to get an appointment. Emergency departments by and large provide in low cities across the nation a safety net, an umbrella, but that is not comprehensive long-term care, it's absent.

DR. MARK NOLAN HILL:

Do you ever see situations where the one sick patient is used as an excuse to repatriate the whole family?

DR. STEVEN LARSON:

I had not seen that, but it is an interesting thought, you know, so you read about in the papers, for instance, when ice makes a raid on a meat-packing plant in Iowa and 400 people suddenly become identified, and they will be repatriated, but the challenge comes to the rest of the family members. You may have several children who are born in Mexico, living in the same house with several children, who are born in the United States. They are all siblings, they are in the same family. The siblings in the United States don't get repatriated, so it is a fascinating conflict.

DR. MARK NOLAN HILL:

Are most of the repatriated decisions still in court in terms of appeals?

DR. STEVEN LARSON:

I think that that article touched off a real raw nerve and in the sense that almost immediately the California Medical Society condemned the practice, within the past 2 to 3 weeks, the AMA has sat down and created a task force to address this and I think people haven't been aware of the magnitude of the problem, but when you are dealing with the 11 million people, who are undocumented, you are going to have more than just one incident of the gentleman being repatriated to Guatemala and I think people can step back and say "Oh yeah, there was a case, I remember that" and it probably was silence that just never really rose up and there was no advocacy and it really never registered on people's minds that this was an issue.

DR. MARK NOLAN HILL:

Do patients ever voluntarily leave for their home country?

DR. STEVEN LARSON:

I have actually had several patients, yes. In those situations, where I have identified somebody with a, you know, very catastrophic, you know, I can think of a guy with Eisenmenger syndrome.

DR. MARK NOLAN HILL:

Aha.

DR. STEVEN LARSON:

He arrived here to work, worked about 2 months and then suddenly had a seizure and it turned out he had a cranial abscess from a septic emboli that, you know, went right to left and the long and short of it is sort of a heart and lung transplant, which would have been impossible. It was very clear that he wasn't going to be able to stay. In many of these, there is a sort of an accepted fate that they are going to go back to their countries and that is going to be it.

DR. MARK NOLAN HILL:

Dr. Larson, let me throw you a curve ball, let's say if there is an uninsured American, who was in another country and they are stuck in that hospital abroad, is there any comparison to our situation that we are discussing now?

DR. STEVEN LARSON:

You know, I am not sure that there is, and for the simple reason that, you know, the same way we don't dump patients, you know, we have to go from a lower to a higher level of care. For the most part, when you are in a different country barring Europe obviously, you know, you are in Mexico and you are on vacation and you get hit by a surfboard and, you know, you are knocked unconscious, you know, you are going to go once you are stabilized to a higher level of care, so I am not sure how that translates honestly, and again, understanding the origins of this labor force of these individuals and the fact that they are invisible anonymous, you know, I heard somebody described them peasants that there is just, there is no face to them and that was a description from the former minister of health in Mexico. You know, that I am not sure that the advocacy, the resources, I am not sure they should go into a higher level of care and moving in from the US to those country.

DR. MARK NOLAN HILL:

What about the consulates and the immigration authorities, do they help out or they factors in this process?

DR. STEVEN LARSON:

It's fascinating, as I mentioned, the situations where it had support has been at the terminal end of it when it is very clear that a patient is going to expire or has expired, and in that case, for instance, the Mexican population, those individuals are assisted in getting back to their countries. Those individuals, who are chronic in bed, I don't know about those situations, but I have certainly gotten assistance from the consulate with cases that are either fatal or death happened and the body is repatriated to occasionally a case where somebody has an illness. It is just, it's very clear that they need to go home.

DR. MARK NOLAN HILL:

In these situations, is there any oversight from a central governmental agency or an advocacy group?

DR. STEVEN LARSON:

No, no, you know, as I talked to <_____> about it, I think that this is the area that we as physicians need to be certain, everybody is on the same page. I mean I have dealt with many, many cases where it is very clear that the trajectory of a patient's condition is going to take them down the road where it's not survivable, you know, we will sit down and we will have a heart to heart. I mean I have had patients cry about not being able to work and provide for their families, but that discussion takes place and everybody is on board in terms of a plan. My hope would be that, you know, what comes out of all of this discussion is that advocacy becomes a part of that decision making as well as the economics, I mean certainly hospitals can't shoulder the burden economically, the degree to which lawyers need to be involved. It's going to be a big grouping of the people that need to sit down at the table and discuss this and it might end up being on a case-by-case basis. Because this is not, you know, certainly not the norm repatriation, it happens, but I don't think the volume is quite there and I think it could be managed on a case-by-case basis, but there needs to be involvement from all the parties that the federal government needs to become involved, for instance because the resources that need to be allocated for this need to come from on high.

DR. MARK NOLAN HILL:

Let's talk about a hypothetically difficult situation. You have got 2 uninsured patients, one is American citizen and the other is an undocumented immigrant and let's say in that situation that you have a skilled facility or some sort of facility that will accept one of the two, what do you do? Flip a coin to determine on medical priority, does citizenship make a difference, where does that role fall into place?

DR. STEVEN LARSON:

Well, I would imagine citizenship would make the difference unless there was a guaranteed payer guarantying the resource allocation for that undocumented person?

DR. MARK NOLAN HILL:

And finally, Dr. Larson, from our personal perspective, what made you go into this area and certainly we need many more like you, what were the reasons that you went into this area?

DR. STEVEN LARSON:

It's a great question. I had begun traveling and working in Central America in the late 80s, early 90s as a student, as a resident, and then as a faculty person just trying to figure out a way to get involved and become active in global health, and when it became apparent that my academic responsibility required me to be centered in Philadelphia, you didn't need to go North, South, you could go anywhere, North, South, East, or West of the city and find an immigrant population that, you know, there was Southeast Asian population or Western Africa, you could find a population where you could practice your language, cultural competency; all these issues and so for me the logical piece of the puzzle was a Latino population and 45 miles from the city there was.

DR. MARK NOLAN HILL:

Do you ever get frustrated by all this?

DR. STEVEN LARSON:

No, no, you know, I will be honest with you. Over the years, you know, the people who are engaged in this, conduct themselves with a certain and the patients by and large contrary to the myth are not here to take advantage of the system. In fact, my experiences have been that they have much rather not be sick, because being sick means diminished work time, work time which provides them with the money to support themselves and their family, so by and large, they will often times neglect their health until they are really sick, and to see that, you know, again these guys are in ways heroes and we tend to overlook that, I just, for me it was a place to, you know, use my skills and get involved.

DR. MARK NOLAN HILL:

I want to thank our guest, Dr. Steven Larson. We have been discussing issues of immigration and healthcare in the United States.

I am Dr. Mark Nolan Hill and you have been listening to a special segment - Focus on Global Medicine on ReachMD, The Channel for Medical Professionals. Be sure to visit our website at reachmd.com featuring on-demand podcasts of our entire library and thank you for listening.

Thank you for listening to our special series - Focus on Global Medicine. As we celebrate this annual holiday season, everyone at ReachMD wishes you and your family a happy holiday and a successful new year.