How to care for immigrant patients in a time of crisis

  | September 6, 2017

As the nation debates the Deferred Action for Childhood Arrivals (DACA) immigration programathenaInsight shares perspective from Esperanza Health Centers, a Chicago-based federally qualified health center serving the largest population of immigrants from Mexico in the Midwest. 

Jessica Boland, LCSW and manager of behavioral health services, speaks below about the impact of current U.S. immigration policy on the population health of Esperanza's patient community, 95 percent of which is Spanish-speaking from Mexico and other Latino Central and South American countries.

In what ways is the national discourse and policies on immigration affecting Esperanza's patient population? What have your providers observed since 2016?

We have seen a change in what patients present with. There have been suicides among people with DACA status, so we have been on high alert, screening patients for suicidal thoughts, depressed thinking, and increased anxiety.

Overall, there has been a severe uptick in fear and anxiety in both adults and children, and among youngest children — very literal fears that people are going knock on their door and take away their parents. Those fears manifest in what we call regressive behavior: not wanting to go to school because they are afraid of being separated from their parents.

Jessica Boland

How have schools in your community responded to children's anxiety?

The public schools issued very direct statements to families saying that immigration officials are not allowed on school property without warrants. Those statements weren't a reaction to actual actions being taken, but the rumor mill has spread panic like wildfire through certain neighborhoods. A lot of families are choosing not to send their children to school, or their children don't want to go. They are hunkering down.

What have you observed among adult patients?

There are just a lot of unknowns for them. When undocumented adults have jobs, for example, they worry about repercussions for their employers. That anxiety manifests as somatic complaints: insomnia, gastrointestinal complaints, and panic attacks. At Esperanza, we have not noticed a decrease in visits or health-seeking behavior, which we see as a positive sign. But we have seen an uptick in patients presenting with mental health issues or stress-related complaints.

So patients feel safe coming to Esperanza for care? Why?

We've been in the community for over a decade, have strong partnerships with community organizations, and have really worked to cultivate trust in with our patients. We've made use of different platforms, like social media, to reiterate Esperanza's mission and our commitment to meeting the needs of our community, especially at this moment in history when they are vulnerable.

We have been explicit that we do not cooperate with immigration authorities and that they're not allowed in our premises without signed warrants. We put “Know Your Rights" handouts in English and Spanish at the front desk with information on who to call if there is a raid.

I have joined forums at different elementary schools in the area to speak about the mental health effects of the current political climate, and how to talk to children about it. We make sure patients know that they can come to us and ask questions if they are dealing with these issues, and we reiterate that we are a safe place whenever we interact with patients.

What should providers expect when caring for immigrant populations over the long term when policies are in flux?

Working with an integrated healthcare approach, we know about the long-term impact on health of trauma and adverse childhood events: mental health affects physical health and vice versa. In children and young people, this kind of event can affect their outlook on their future and how they perceive themselves.

For example, I now see preteens and teenagers feeling like it's not worth it to continue with school. They think, “Why bother? I'm not going to be able to go to college anyway. I'm not going to be able to qualify for DACA, because it's going to go away."

And those feelings of hopelessness or giving up open the door for high-risk behaviors, getting involved with the criminal justice system, and maybe going down a path that they might not have gone down otherwise. A lot of that turns into substance use. Certainly, here at Esperanza we have a substance abuse treatment program. I don't want to make believe that substance abuse is all because of the stress of immigration policy. But we do know that when people have been exposed to adverse events, when they're dealing with a lot of stress and strife and trauma, it can lead to more substance use as a means of coping or self-medicating.

In our adult population, the stress presents somatically: chronic headaches, chronic gastrointestinal distress, or high blood pressure. I talk to both young patients and adults about anxiety disorder – an exaggerated response to a fear – but in this case, their fears are real. The response is not necessarily exaggerated. Patients need help coping with a very real threat while continuing to function day to day.

Are there families among your patients that have been separated by deportation? How has Esperanza provided care for them?

Yes, there certainly have been. Our pediatricians see children who have had a parent deported. We encourage mental health counseling for them, either support for children on an individual level, or family therapy for the caregiver or the parent who has remained to help support that loss, and that separation, and the ramifications of it. We really want to make sure that we're offering as much support and as many resources as we possibly can.

What are the risks when there's a population afraid to seek out healthcare?

There's a domino effect, things like kids missing vaccinations because they're avoiding interacting with the health system. Benign issues that can become a lot more serious, and costly, if they're neglected. 

Has the national conversation about immigration been a stressor for your physicians and other providers?

A lot of our physicians and providers are also immigrants from Latin American countries. They've done their studies here and pursued careers here, so it can affect them. They have a mission to work in this particular community; they are really invested in their patients' lives. I've heard – and I can speak to this personally – that in the current situation, we double down on our mission. The climate has rededicated us to our work. This is an especially vulnerable moment for a community that always been underserved. And now it's at even more risk.

Gale Pryor is senior editor of athenaInsight.

How to care for immigrant patients in a time of crisis