Medical Repatriation and Other Migrant Health Issues

MEDICAL REPATRIATION AND OTHER MIGRANT HEALTH ISSUES

Lost in the ever-evolving diversity of the American populus is what happens when one of our newest or in some case undocumented immigrants becomes extraordinarily ill. Under our current system, hospitals are often left to shoulder logistical and financial burden of care. How are our hospitals coping with this responsibility and how does this impact the care we can provide to these patients and more broadly to all of our patients?

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, can you start us off with some statistics and the frequency of repatriation cases to capture the scope of the issue?

DR. STEVEN LARSON

You know, that is a very challenging question to answer because I do not know that the data is really there. It’s a situation that’s largely gone unnoticed until the recent article by Ms. Sontag in the New York Times.

DR. MARK NOLAN HILL

But what exactly is repatriation?

DR. STEVEN LARSON

Repatriation in terms of medical issues is the movement of an individual from one location to the other, and in this case, it crosses in an international boundary, typically the article in question by Ms. Sontag address the repatriation of an individual, who is injured here in United States and repatriated to highlands of Guatemala. It is essentially the movement of that body, of that person.

DR. MARK NOLAN HILL

So what are the issues here?

DR. STEVEN LARSON

You know, there are many folks. These individuals, these cases, they tend to be very complicated, they tend to many times involve trauma in individuals, who are now invalidate and often times bedridden and they become almost wards of the state in the sense that after the initial trauma care is provided or the lifesaving procedures are enacted, you know, in the dust settles you are left with an individual who is fairly complicated in terms of the manpower they need, the services they need, and there are very scant resources.

DR. MARK NOLAN HILL

When we say wards of the state, which state we are talking about?

DR. STEVEN LARSON

The individual states that those patients are now residing in.

DR. MARK NOLAN HILL

Who owns this patient, meaning who owns the responsibility? Does the country from which this patient came own this patient or do we now own this patient?

DR. STEVEN LARSON

I do not know the answer to that. I think that’s one for the legal folks to sort through. For me as a healthcare provider, it is more the ethical implications that an individual is in need of my service who is in front of me and that is my patient.

DR. MARK NOLAN HILL

If a patient comes in to the emergency room, gets complex surgery, goes to Intensive Care Unit and then is in a stabilized situation, what is the normal process by which any patient gets transferred to a skilled facility or a similar facility?

DR. STEVEN LARSON

There is a newer <_____> more involved on that process, although I have had some patients and who were familiar with social services that become involved, family resources that become explored, and then I think there is generally an attempt to find the best in area for that individual on a case by case basis. That takes into account in a resources and availability of space, degree of needs, it is a pretty complicated equation. I do not really involve myself in that from the emergency department perspective.

DR. MARK NOLAN HILL

What does the hospital do if no facility will accept this patient?

DR. STEVEN LARSON

Well, I have seen patients who have spent very protracted courses in the hospital occupying the bed and that’s both citizen and non-citizen, you know it’s not uncommon.

DR. MARK NOLAN HILL

And how does the hospital feel about this?

DR. STEVEN LARSON

I would have to imagine if you are in an institution that is running a high senses and that bed is tied up, it costs money, it costs resources, and it diminishes, you know, the potential for revenue.

DR. MARK NOLAN HILL

Is this problem most common in border states or is it seen in states that are not the border states?

DR. STEVEN LARSON

You know, it is an excellent question, and if you would ask me that 20 years ago in the late 80s or early 90s, I would accept it’s principally your border state issue, California, New Mexico, Arizona, Florida, and then if you threw in New York, those are areas with high back in the 80s, high flow of undocumented immigrants. By the late 90s, there were just a broad movement of immigrant nationwide no longer confined to the border states and in fact no longer confined to rural areas, but becoming more urbanized movement and that to place in large cities like Philadelphia and small towns like Hazleton, PA.

DR. MARK NOLAN HILL

Dr. Larson, does it make a difference in terms of repatriation whether the patient is a legal immigrant or an illegal immigrant?

DR. STEVEN LARSON

I do not know that there is a distinction and honestly I don’t know that there is legal precident and I think that’s the context of the article by the near times is that that will be decided in Florida where is, you know, the case in progress and I am certainly in other states that were mentioned in the second time’s article. I suspect ultimately this was going to become a very big, you know, legal challenge that will go away to the top.

DR. MARK NOLAN HILL

Well generally speaking, have there been patients who have actually been sent back to their country?

DR. STEVEN LARSON

Absolutely.

DR. MARK NOLAN HILL

And what happens to them?

DR. STEVEN LARSON

Well, you know, in the first New York Times article, when I commented on it being a death sentence in certain ways, that individual, who is repatriated to Guatemala is very complicated from a posttraumatic perspective, significant head injuries, I believe, seizure disorder, and when you have somebody, who is no longer functioning at the level that they were walking, talking fully ambulatory now requiring wheelchair as an assistance in a lot of manpower to give complete native point B, you simply need to go to the point of origin, you know, when we are talking about on documented individuals in this country, these were not computer programers high tech individuals, these are fairly unskilled laborers coming from very rural and remote regions of the countries of origin, so throughout Mexico and Central America, these are individuals, who the infrastructure of those towns is already pretty stripped down.

DR. MARK NOLAN HILL

But wouldn’t they be sent to a facility in that country that would be appropriate for their level of care?

DR. STEVEN LARSON

They may be transferred there, but then ultimately those resources are going to run out and they are going to be removed, they will be put to as in the case in Guatemala, they will be returned to the their villages and you know a wheelchair does not really operate well, well in mud and dirt, and unpaid roads, I mean not to be fees to serve.

DR. MARK NOLAN HILL

No, I understand.

DR. STEVEN LARSON

There is just a certain reality. We see individuals, for instance, who show up and suddenly declare themselves as patients with complete renal failure requiring dialysis. Those are very challenging cases, but you know if you return them to the countries or if they go back to their countries of origin, the access to the system is going to allow them to continue with dialysis, is going to be somewhat shoddy, particularly if they are living in a very remote region in the country, they have no income and no resources.

DR. MARK NOLAN HILL

Now in these situations, what role does a patient's physician play in the process as opposed to the administration of the hospital?

DR. STEVEN LARSON

I think the do no harm monitor that we operate under is first and foremost understanding the limitations of those countries and the realities, I think mandates it as a physician, you know, regardless of one’s country of origin, but you ensure the wellness of that patient, for me it is just, you know, unethical kind of standard I hold myself to try to find out exactly what the resources are, what the realities are, when you have a patient that you are contemplating repatriation, and you know, be an advocate and sometimes that will run counter to the administration, but you know, that is our job I think.

DR. MARK NOLAN HILL

Well, the physicians in United States actually directly communicate with the physicians in the receiving country?

DR. STEVEN LARSON

The cases that I have seen haven’t directly involved me, so I can’t comment. I know that at the level of social work to ascertain dialysis treatment, for instance, those discussions have been had whatever a dialysate is being recommended, etc.

DR. MARK NOLAN HILL

As you mentioned, there is such a great number of people coming into our country and certainly our healthcare system is not ideal, how do we solve this problem?

DR. STEVEN LARSON

That’s tremendously a valid question. I think when you work in immigrant health and there are certainly individuals, who have dedicated their careers to this throughout the nation, you try to find the best practice and in many cases, when you look at the demographics of the population that has immigrated. For instance, in the 80s and 90s, when the agricultural industry Mexicanized in the United States, basically two-thirds of the labor force represented Mexican immigrants. Of those individuals who had come here, the ratio of male to female was 3-4:1, predominantly young healthy men. So the issues of chronic illness really warrant that major relatively healthy population to both employee and to provide care for. Beginning in the mid 90s to the late 90s as the immigration patterns accelerated, you suddenly had almost parity male to female and so then issues that move outside of just basic routine healthcare and bracing, for instance, prenatal care, labor and delivery, pediatric cares, whole family units sort of began to develop a presence in states outside of the border states. The cost of care of arises, but by and large, these are still relatively healthy populations and so strategies to meet those needs that you know have been pushed forward are really based on primary care. Over the years as the population has acclimated and issues of now chronic care start to arise, you know obesity, diabetes, hypertension, again those can principally be taking care of in, you know in the front lines. It’s the occasional case that needs to get into an academic medical center, for instance, that will you know generate the sort of situation that we are talking about and much of it’s actually trauma, I mean in the years that I have been doing it and not been working in immigrant health since 1993, and those are the real challenging cases.

DR. MARK NOLAN HILL

Sometimes you hear that the patient's destiny will depend on what emergency room they visit initially. Whether they receive care or repatriated or they are dispositioned and truth to that statement?

DR. STEVEN LARSON

Well, you know again, I do not know the numbers in terms of repatriation, it is not a very frequent encounter that I have seen working in the South Eastern Pennsylvania area, and I get a lot of phone calls from doctor and providers and community folks asking questions and advice. You know those numbers of cases aren’t that large as far as the SafetyMed Emergency Departments across the South Eastern Pennsylvania region all provide access to the system and I don’t think they deny that, so the way at least in terms of trauma in South Eastern Pennsylvania, you know from the community referrals going to a level-1 trauma center and again there is no screening based on immigration status and the patient comes first.

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 web site at www.reachmd.com featuring on-demand podcast of our entire library and thank you for listening.

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