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Hospitals as places of sanctuary

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... The aggregation of available data on mortality in migrant populations is crucial for comprehensively and rigorously summarising the knowledge base, providing insight with regard to the association between migration and mortality to inform health services, and countering discriminatory or hostile policies. 36,37 Contrary to the negative representation of migrants in the media as a burden to health systems, 38 our research provides substantial evidence in support of the mortality advantage of migrants compared with the general population in high-income countries. These results therefore challenge misconceptions and policies that do injustice to migrants, representing them as a risk and burden to health systems and society, and instead highlight positive contributions of migration in these countries. ...
... Our review provides evidence of the mortality advantage of migrants, but this must not be used as a justification for further restricting access to health care for migrant groups, which is an increasing issue in many countries. 36,37 Health-care needs in migrants vary sub stantially, as shown by the heterogeneity in our estimates. Morbidity in migrants was not assessed by our study and might be higher in migrant groups, particularly in those who are more marginalised or of lower socioeconomic status. ...
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Background 258 million people reside outside their country of birth; however, to date no global systematic reviews or meta-analyses of mortality data for these international migrants have been done. We aimed to review and synthesise available mortality data on international migrants. Methods In this systematic review and meta-analysis, we searched MEDLINE, Embase, the Cochrane Library, and Google Scholar databases for observational studies, systematic reviews, and randomised controlled trials published between Jan 1, 2001, and March 31, 2017, without language restrictions. We included studies reporting mortality outcomes for international migrants of any age residing outside their country of birth. Studies that recruited participants exclusively from intensive care or high dependency hospital units, with an existing health condition or status, or a particular health exposure were excluded. We also excluded studies limited to maternal or perinatal outcomes. We screened studies using systematic review software and extracted data from published reports. The main outcomes were all-cause and International Classification of Diseases, tenth revision (ICD-10) cause-specific standardised mortality ratios (SMRs) and absolute mortality rates. We calculated summary estimates using random-effects models. This study is registered with PROSPERO, number CRD42017073608. Findings Of the 12 480 articles identified by our search, 96 studies were eligible for inclusion. The studies were geographically diverse and included data from all global regions and for 92 countries. 5464 mortality estimates for more than 15·2 million migrants were included, of which 5327 (97%) were from high-income countries, 115 (2%) were from middle-income countries, and 22 (<1%) were from low-income countries. Few studies included mortality estimates for refugees (110 estimates), asylum seekers (144 estimates), or labour migrants (six estimates). The summary estimate of all-cause SMR for international migrants was lower than one when compared with the general population in destination countries (0·70 [95% CI 0·65–0·76]; I²=99·8%). All-cause SMR was lower in both male migrants (0·72 [0·63–0·81]; I²=99·8%) and female migrants (0·75 [0·67–0·84]; I²=99·8%) compared with the general population. A mortality advantage was evident for refugees (SMR 0·50 [0·46–0·54]; I²=89·8%), but not for asylum seekers (1·05 [0·89–1·24]; I²=54·4%), although limited data was available on these groups. SMRs for all causes of death were lower in migrants compared with the general populations in the destination country across all 13 ICD-10 categories analysed, with the exception of infectious diseases and external causes. Heterogeneity was high across the majority of analyses. Point estimates of all-cause age-standardised mortality in migrants ranged from 420 to 874 per 100 000 population. Interpretation Our study showed that international migrants have a mortality advantage compared with general populations, and that this advantage persisted across the majority of ICD-10 disease categories. The mortality advantage identified will be representative of international migrants in high-income countries who are studying, working, or have joined family members in these countries. However, our results might not reflect the health outcomes of more marginalised groups in low-income and middle-income countries because little data were available for these groups, highlighting an important gap in existing research. Our results present an opportunity to reframe the public discourse on international migration and health in high-income countries. Funding Wellcome Trust, National Institute for Health Research, Medical Research Council, Alliance for Health Policy and Systems Research, Department for International Development, Fogarty International Center, Grand Challenges Canada, International Development Research Centre Canada, Inter-American Institute for Global Change Research, National Cancer Institute, National Heart, Lung and Blood Institute, National Institute of Mental Health, Swiss National Science Foundation, World Diabetes Foundation, UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, and European Society for Clinical Microbiology and Infectious Diseases (ESCMID) Study Group Research Funding for the ESCMID Study Group for Infections in Travellers and Migrants.
... Prior research on similar sanctuary practices include using HIPPA protections to withhold personal health information from ICE agents, designating waiting rooms as private spaces, and expanding access to drivers' licenses to prevent lack of care in clinics that still require IDs for treatment (Cleek, 2018). There are also increased calls for hospitals to operate as sanctuary spaces more broadly (Saadi et al., 2017;Saadi and McKee, 2018). Moreover, some studies document additional sanctuary practices such as accepting utility bills or municipal ID cards in lieu of federal or state documents not yet identified by participants in our study (Bauder and Gonzalez, 2018). ...
Article
As the United States (U.S.) continues to prioritize federal immigration enforcement, subnational localities increasingly enact their own immigration policies. Cities limiting cooperation with federal immigration enforcement are commonly referred to as sanctuary cities, which aim to improve immigrant safety and wellbeing. Yet, little is known about how these cities accomplish this beyond immigration enforcement non-cooperation. We draw from qualitative interviews with 54 organizational workers in Seattle, Washington and Boston, Massachusetts. Our findings illuminate lingering challenges immigrants face within sanctuary cities and demonstrate how organizational workers mitigate the shortcomings of sanctuary policies to addressing broad definitions of safety and health by enacting their own sanctuary practices.
... Health professionals and policymakers could also push hospitals and health systems to avoid collaborating with migration policing, as in the recent successful case in the UK. 31 Without these policy-level changes, clinicians may experience significant limits on their ability to provide effective healthcare for migrants. ► Fourth, health professionals, health policymakers and health systems can lend support to migrant communities organising against portrayals of undeservingness and unequal policies. ...
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This article brings the social science concept of ‘deservingness’ to bear on clinical cases of transnational migrant patients. Based on the authors’ medical social science research, health delivery practice and clinical work from multiple locations in Africa. Europe and the Americas, the article describes three clinical cases in which assumptions of deservingness have significant implications for the morbidity and mortality of migrant patients. The concept of deservingness allows us to maintain a critical awareness of the often unspoken presumptions of which categories of patients are more or less deserving of access to and quality of care, regardless of their formal legal eligibility. Many transnational migrants with ambiguous legal status who rely on public healthcare experience exclusion from care or poor treatment based on notions of deservingness held by health clinic staff, clinicians and health system planners. The article proposes several implications for clinicians, health professional education, policymaking and advocacy. A critical lens on deservingness can help global health professionals, systems and policymakers confront and change entrenched patterns of unequal access to and differential quality of care for migrant patients. In this way, health professionals can work more effectively for global health equity.
... The deontology that underpins the practice of most medical professions has in many contexts proved to offer significant resistance to the mingling of migration control with healthcare services (Saadi and McKee 2018). Hospital premises in France are usually deemed safe spaces and healthcare personnel, including medical and nursing staff, do not report undocumented patients. ...
Article
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Drawing on Foucauldian biopolitics, Max Weber's and Hannah Arendt's understandings of bureaucracy, and Achille Mbembe's theoretical insights into necropolitical power, I propose the notion of humanitarian bureaucracy to account for the involvement of medical personnel in the summary deportations of pregnant Comorian women in Mayotte, a French overseas department in the Indian Ocean. In addition to their usual consultations, hospital midwives are asked to assess the health of pregnant women arrested at sea in order to state whether they can be lawfully detained, while deportations happen within hours owing to the specificities of this postcolonial migration regime. The notion of humanitarian bureaucracy traces how a series of bureaucratic acts, duly sanctioned by qualified professionals, performs a minimal and fragmented biopolitical surveillance that neutralizes the question of responsibility and rejects the racialized Other into a liminal space between failing to “make live” and avoiding to “let die.” The article argues that humanitarian bureaucracy represents an ambivalent power, stemming from biopolitics yet producing necropolitics through processes of racialization. The article draws on three months of fieldwork conducted in Mayotte in 2017 and analyzes midwives’ discourses and bureaucratic practices as materialized by the medical certificates they deliver in the context of these assessments.
... However, the "sensitive locations" policy is not applied evenly in the U.S [34]. Since health care facilities are now more likely to have encounters with ICE, staff should take steps to establish location-specific policies that protect their undocumented populations [35]. Health care settings should train all staff about patient legal rights and have visibly clear policies and procedures regarding encounters with immigration authorities including training a designated staff to speak to immigration agents and request warrants from agents to assess its validity [34,36]. ...
Article
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Toughened immigration policies exacerbate barriers to public benefits and health care for immigrants. The objective of this study is to examine the impact of the immigration climate on the utilization of pediatric emergency and ambulatory care services and elucidate ways to best support Latino immigrant families. This is a cross-sectional study involving surveys and interviews with Latino parents (≥ 18 years) in the pediatric emergency department. Forty-five parents completed surveys and 40 were interviewed. We identified two themes on health care utilization: fear of detention and deportation in health care settings, and barriers to pediatric primary care; and two themes on how pediatric providers can best support Latinos: information and guidance on immigration policies, and reassurance and safety during visits. Despite immigration fears, Latino parents continue to seek health care for their children. This highlights the unique access that pediatric providers have to this vulnerable population to address immigration fears and establish trust in the health care system. Health care providers are also perceived as trusted figures from whom Latino families want more information on the latest immigration policies, immigration resources, and education on legal rights during medical visits.
... [24][25][26] Studies globally, including the USA, have demonstrated that perceived fear of deportation may act as a barrier to migrants accessing health services and has been associated with poor health outcomes including mental health. [27][28][29][30][31] To date, most studies exploring healthcare registration, access or utilisation of services by migrants focus on specific subgroups, populations and areas within a country and are either qualitative 32 or observational studies (including cross-sectional or a retrospective cohort). 23 33 34 Their limitations include, findings not being generalisable to other settings, or not reflecting the transient nature of migration as they only provide a 'snapshot' in time or being influenced by attrition bias. ...
Article
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Aim To explore healthcare providers’ perceptions and experiences of the implications of a patient data-sharing agreement between National Health Service (NHS) Digital and the Home Office on access to NHS services and quality of care received by migrant patients in England. Design A qualitative study using semi-structured interviews, thematic analysis and constant-comparison approach. Participants Eleven healthcare providers and one non-clinical volunteer working in community or hospital-based settings who had experience of migrants accessing NHS England services. Interviews were carried out in 2018. Setting England. Results Awareness and understanding of the patient data-sharing agreement varied among participants, who associated this with a perceived lack of transparency by the government. Participants provided insight into how they thought the data-sharing agreement was negatively influencing migrants’ health-seeking behaviour, their relationship with clinicians and the safety and quality of their care. They referred to the policy as a challenge to their core ethical principles, explicitly patient confidentiality and trust, which varied depending on their clinical specialty. Conclusions A perceived lack of transparency during the policy development process can result in suspicion or mistrust towards government among the health workforce, patients and public, which is underpinned by a notion of power or control. The patient data-sharing agreement was considered a threat to some of the core principles of the NHS and its implementation as adversely affecting healthcare access and patient safety. Future policy development should involve a range of stakeholders including civil society, healthcare professionals and ethicists, and include more meaningful assessments of the impact on healthcare and public health.
... Various forms of local-level resistance have undermined this national hostility including collective noncompliance among doctors, teachers and social work-ers (Kmietowicz, 2018;Skinner & Salhab, 2019). The Safe Surgeries campaign backed by #peoplenotpassports asks General Practitioners to stop sharing patient data with the Home Office (Saadi & McKee, 2018). Following successful campaigning by Migrant Rights Network, the Memorandum of Understanding between NHS Digital and the Home Office has been scrapped during the time of writing this article. ...
Article
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This article addresses the tense relationship between national and municipal approaches to the inclusion and exclusion of irregular immigrant ‘non-citizens.’ While national policies in the UK have created hostility for irregular migrants, municipallevel cities of sanctuary offer a ‘warm welcome’ which has been extolled as immanently progressive in the face of hostility. This article assesses the extent to which city-based sanctuary movements in the UK provide effective resistance to the national policies of hostility. Building on critiques of the City of Sanctuary (CoS) movement, effective resistance is redefined using a Foucauldian counter-conduct approach. Through applying a counter-conduct lens to a document analysis of the CoS newsletter archive and online resources, the article shows it is not easy to dismiss sanctuary as ineffective resistance, as some earlier critiques have argued. Rather, CoS is demonstrated as both effective and ineffective counter-conduct due to its uneven approach to the various discourses within the hostile environment.
... Currently, this remains a theoretical possibility rather than a documented occurrence in the United States, but not in the United Kingdom where government sharing of National Health Service data with immigration authorities has raised alarm. 24 Furthermore, immigration enforcement actions and access to law enforcement data have been documented to occur covertly in self-proclaimed "sanctuary" cities in the United States. 25 Immigration enforcement at hospitals is unlikely, particularly given that enforcement agencies' "sensitive locations" policies discourage such actions in clinical settings. ...
Article
The documentation of immigration status in patient records poses a challenge to clinicians. On one hand, recording this social determinant of health can facilitate continuity of care and improved communication among clinicians. On the other, it might expose patients or their family members to immediate and unforeseen risks, such as being stigmatized and discriminated against by nonimmigrant-friendly clinicians or being exposed to immigration enforcement if staff contact immigration officials in violation of patient confidentiality. Patients may raise concerns about the purpose and risks of such documentation alongside fears about potential data sharing and violations of privacy and confidentiality. This commentary explores clinicians' options for documenting immigration status within the context of ethical, legal, and historical considerations in caring for stigmatized populations in changing political landscapes.
... Health information systems that do not collect data for migration are unable to provide useful data to monitor differences in risk factors, morbidity, and mortality between migrant and non-migrant populations, an essential step in monitoring and improving equity of service provision to this group. When health information systems are misused, civil society, academia, and health- care workers-including through the creation of so- called sanctuary hospitals and sanctuary doctoring 213 -can play an important and essential role in standing up against the data misuse. Human rights law can reduce the risk as it requires respect for confidentiality and other protections against misuse of information. ...
Article
With one billion people on the move or having moved in 2018, migration is a global reality, which has also become a political lightning rod. Although estimates indicate that the majority of global migration occurs within low-income and middle-income countries (LMICs), the most prominent dialogue focuses almost exclusively on migration from LMICs to high-income countries (HICs). Nowadays, populist discourse demonises the very same individuals who uphold economies, bolster social services, and contribute to health services in both origin and destination locations. Those in positions of political and economic power continue to restrict or publicly condemn migration to promote their own interests. Meanwhile nationalist movements assert so-called cultural sovereignty by delineating an us versus them rhetoric, creating a moral emergency.
Chapter
This chapter describes how immigration status affects patients and influences care in the emergency department (ED). There are 11.3 million undocumented immigrants within the US, and many more with limited legal status, who are vulnerable to political, legal, and structural factors predisposing them to poor health outcomes. Many of these factors are beyond the control of the emergency provider, but there are ways to mitigate the structural vulnerability of this population by optimizing their care in the ED. Important steps include educating providers regarding health risks, care gaps, and patient experience; creating a system of immigration-informed care that employs sensitive and stabilizing care while in the ED; and integration of the clinical encounter with community resources (legal, case management, accompaniment) to support patients outside the ED.
Article
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The United States is experiencing a renewed period of immigration and immigrant policy activity as well as heightened enforcement of such policies. This intensified activity can affect various aspects of immigrant health, including mental health. We use the Robert Wood Johnson Foundation 2015 Latino National Health and Immigration Survey (n = 1,493) to examine the relationship between immigration and immigrant policy and Latino health and well-being. We estimate a series of categorical regression models and find that there are negative health consequences associated with Latinos' perceptions of living in states with unfavorable anti-immigration laws, including reporting poor health and problems with mental health. This article builds on the work of public health scholars who have found a link between this heightened policy environment and the mental health of immigrants, yet expands on this research by finding that the health consequences associated with immigration policy extend to Latinos broadly, not just immigrants. These findings are relevant to scholars of immigration and health policy as well as policy makers who should consider these negative effects on the immigrant community during their decision-making process.
Article
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Background: Growing evidence indicates that immigration policy and enforcement adversely affect the well-being of Latino immigrants, but fewer studies examine 'spillover effects' on USA-born Latinos. Immigration enforcement is often diffuse, covert and difficult to measure. By contrast, the federal immigration raid in Postville, Iowa, in 2008 was, at the time, the largest single-site federal immigration raid in US history. Methods: We employed a quasi-experimental design, examining ethnicity-specific patterns in birth outcomes before and after the Postville raid. We analysed Iowa birth-certificate data to compare risk of term and preterm low birthweight (LBW), by ethnicity and nativity, in the 37 weeks following the raid to the same 37-week period the previous year (n = 52 344). We model risk of adverse birth outcomes using modified Poisson regression and model distribution of birthweight using quantile regression. Results: Infants born to Latina mothers had a 24% greater risk of LBW after the raid when compared with the same period 1 year earlier [risk ratio (95% confidence interval) = 1.24 (0.98, 1.57)]. No such change was observed among infants born to non-Latina White mothers. Increased risk of LBW was observed for USA-born and immigrant Latina mothers. The association between raid timing and LBW was stronger among term than preterm births. Changes in birthweight after the raid primarily reflected decreased birthweight below the 5th percentile of the distribution, not a shift in mean birthweight. Conclusions: Our findings highlight the implications of racialized stressors not only for the health of Latino immigrants, but also for USA-born co-ethnics.
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Background: There is a critical need to document the mental health effects of immigration policies and practices on children vulnerable to parental deportation. Few studies capture the differential experiences produced by U.S. citizen-children's encounters with immigration enforcement, much less in ways that analyse mental health outcomes alongside the psychosocial contexts within which those outcomes arise. Methods: We explore the psychosocial dimensions of depression in U.S. citizen-children with undocumented Mexican parents to examine differences between citizen-children affected and not affected by parental deportation. An exploratory mixed-method design was used to integrate a quantitative measure of depression symptoms (CDI-2) within qualitative data collected with 48 citizen-children aged 8 to 15 with and without experiences of parental deportation. Results: Stressors elicited by citizen-children in the qualitative interview included an inability to communicate with friends, negative perceptions of Mexico, financial struggles, loss of supportive school networks, stressed relation with parent(s) and violence. Fifty percent of citizen-children with probable depression - regardless of experiences with parental deportation - cited 'stressed relation with parents,' compared to 9% without depression. In contrast, themes of 'loss of supportive school network' and 'violence' were mentioned almost exclusively by citizen-children with probable depression and affected by parental deportation. Conclusions: While citizen-children who suffer parental deportation experience the most severe consequences associated with immigration enforcement, our findings also suggest that the burden of mental health issues extends to those children concomitantly affected by immigration enforcement policies that target their undocumented parents.
Article
Background U.S. Latinos report high levels of concern about deportation for themselves or others. No previous research has tested the link between worry about deportation and clinical measures of cardiovascular risk. Purpose We estimate the associations between worry about deportation and clinically measured cardiovascular risk factors. Methods Data come from the Center for the Health Assessment of Mothers and Children of Salinas study. The analytic sample includes 545 Mexican-origin women. Results In multivariable models, reporting a lot of worry about deportation was significantly associated with greater body mass index, greater risk of obesity, larger waist circumference, and higher pulse pressure. Reporting moderate deportation worry was significantly associated with greater risk of overweight and higher systolic blood pressure. Significant associations between worry about deportation and greater body mass index, waist circumference, and pulse pressure, respectively, held after correcting for multiple testing at p < .05. Conclusions Worry about deportation may be an important cardiovascular risk factor for ethnic minority populations in the USA.
Article
In July 2017, Jose de Jesus Martinez, an undocumented immigrant, wept at the bedside of his 16-year-old son Brandon, who was comatose in the intensive care unit of a San Antonio, Texas, hospital after being found in a parked unventilated trailer. Several agents from US Immigration and Customs Enforcement (ICE) entered Brandon’s hospital room and aggressively began questioning Jose.
Weaponising paperwork
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Davies W. Weaponising paperwork. Lond Rev Books 2018;40:13-4.
US Immigration and Customs Enforcement-enforcement actions at or focused on sensitive locations. ICE
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Morton J. US Immigration and Customs Enforcement-enforcement actions at or focused on sensitive locations. ICE, 2011. https://www.ice.gov/doclib/ero-outreach/pdf/10029.2-policy.pdf 2 Saadi A, Ahmed S, Katz MH. Making a case for sanctuary hospitals. JAMA 2017;318:2079-80. 10.1001/jama.2017.15714 29049516
Treating fear: sanctuary doctoring. Neiswanger Institute for Bioethics
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  • M Kuczewski
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Mejias-Beck J, Kuczewski M, Blair A. Treating fear: sanctuary doctoring. Neiswanger Institute for Bioethics. https://hsd.luc.edu/bioethics/content/sanctuary-doctor/