El Paso — When Carlos Gutierrez, MD, arrives at the Pastoral Center shelter for immigrants, the line to see him forms slowly. At first, only one unhappy-looking 14-year-old girl shows up. She has bags under her eyes and, though it’s warm outside, a winter scarf pulled up tight over the lower part of her face.
The reason quickly becomes clear: The right side of her neck is badly swollen. “Ella tiene paperas,” Dr. Gutierrez tells the girl and her mother, who are both from Guatemala. She has mumps.
Almost as soon as the El Paso pediatrician makes this diagnosis, a small crowd starts to form in the back of the room. Word has gotten around among the people at the shelter, who are almost all from Guatemala or Honduras: A doctor has arrived. They are all seeking asylum in the United States.
Dr. Gutierrez quickly makes two calls. First, he arranges to have the girl isolated at a local hotel that’s doing double-duty as a shelter. Second, he calls his office to have someone there report the mumps case to county health officials. Between calls he explains to the girl and her mother where they are going and how to treat mumps symptoms.
Dr. Gutierrez is part of a small group of El Paso physicians who provide volunteer medical care at the city’s 18 shelters for asylum-seekers entering the United States through the Texas border. What started in October 2018 as a local, ad hoc way to address health care needs among the steady stream of immigrants is gradually turning into a statewide — even national — network of volunteer physicians.
For now, the physicians want to focus on adequately staffing El Paso’s shelters with medical personnel, says Lisa Ayoub-Rodriquez, MD, one of five pediatricians who, like Dr. Gutierrez, volunteers at the centers and helps coordinate care.
“Our focus so far has been on building our army,” she said. “We’re trying to bite off small pieces [of the problem], but we have 19 [pediatricians] so far.”
People continue to flee to the Texas border from Central American countries — especially El Salvador, Guatemala and Honduras — because of widespread corruption and violence. Because most are poor, they often travel for several weeks without adequate food, water, clothing, or medicine, says Ittay Moreno, MD, an El Paso pediatrician. Many of them are children.
Physicians along other parts of the border, especially the Rio Grande Valley, also work at shelters and get help from outside health care workers. (See “On a Charitable Mission,” December 2014 Texas Medicine, or www.texmed.org/OnAMission.)
“There’s definitely a need [for physicians at the shelters], and it doesn’t seem to be slowing down,” Dr. Moreno said. “As pediatricians, we’re trying the best we can to be advocates for these kids. They’ve been through a lot, and we want to make sure that once they’re here, they can be healthy.”
The El Paso physicians began working at the shelters last October after U.S. Immigration and Customs Enforcement (ICE) abruptly left about 100 asylum-seekers at the El Paso Greyhound station. News outlets reported federal detention centers at the time were overwhelmed with families.
Most of the immigrants did not speak English or have anywhere to go in El Paso. The unusual and unexpected event drew attention from El Paso’s city and nonprofit leaders. Because many of the refugees needed medical care, physicians at the El Paso County Medical Society — having done similar volunteer work before — came out to help.
“There were about 20 or 30 of us health care providers who came in about 8 in the evening to see all these people who were sick,” Dr. Gutierrez said. “We ended up hospitalizing about three or four of them, and it was chaotic.”
Asylum-seekers continue to pour into the El Paso area. With rare exceptions, ICE releases them to one of 18 shelters run by Annunciation House, a nonprofit that has helped immigrants for 41 years. Only four of the shelters operate seven days a week. The rest are mostly churches or hotels that can take refugees one or two days a week, says executive director Ruben Garcia.
Each day, either ICE or Customs and Border Protection (CBP) gives Mr. Garcia a sort of weather report for how many asylum-seekers the agency will release to each shelter. He then sends a text message to five area pediatricians: Drs. Gutierrez, Ayoub-Rodriguez, and Moreno, and Bert Johansson, MD, and Blanca Garcia, MD.
Asylum-seekers arrive at the shelters from ICE custody around 2 pm. Volunteers then help them call family members and friends to set up travel plans. The refugees are given a chance to relax, eat, shower, and pick out clothes or toys from items that have been donated.
When work permits, the volunteer El Paso physicians visit their designated shelter — or make sure another doctor shows up. In most cases, they don’t have much time with these patients. By the next day, the immigrants often begin departing for their final destinations in far-flung places like Boston, Nashville, and Seattle. By the second day, all of them are usually gone, Mr. Garcia says.
Though Dr. Moreno and the other physicians on his call list are pediatricians, they frequently end up treating the adults as well.
“As you’re questioning [the parents] and asking if they have any concerns, they’ll bring up that they’ve been coughing for a while, or that they have had fevers, or they’re suffering from foot ulcers or rashes,” he said. “So you basically end up treating the entire family.”
And the physicians do that as best they can without any history of treatment the families may have received in detention. The Texas Department of State Health Services receives information on reportable diseases from physicians at the ICE detention centers, a spokesman says. But the El Paso-area physicians working in the shelters say they get no information from detention center medical staff about instances of disease or patients who need follow-up care. ICE declined to comment directly, but said in a statement that all detainees receive comprehensive medical care during their stay.
The shelters get their fair share of medically serious cases. People with pneumonia, sepsis, and injuries often require hospitalization. Others have undiagnosed illnesses like diabetes, including one teenage girl with a blood sugar at the potentially fatal level of 780, Dr. Gutierrez says.
Yet another patient turned out to have an unusual type of leukemia, says Dr. Johansson, who specializes in pediatric critical care. It was discovered accidentally because a CBP agent, coming up on a group of immigrants, thought it odd that the boy did not run when everyone else did.
“I talked to this agent, and the agent said, ‘I figured this kid must be sick [because he didn’t run],’” said Dr. Johansson. The agent made sure a physician looked him over. “And that agent saved his life. That kid is now at [Memorial Sloan Kettering Cancer Center in New York] because of the rarity of his tumor.”
But as with any clinic, most ailments are minor, says Dr. Gutierrez. At the Pastoral Center shelter, for instance, the mumps case turned out to be the most serious among about 15 patients he saw that day. The rest mostly had stomach problems or barking coughs. Dr. Gutierrez treated them all with over-the-counter medicines donated to the shelter.
Scabies, influenza, measles, and chickenpox also come up a lot, Dr. Gutierrez says. And many of the most common ailments — dehydration, fatigue, diarrhea — are souvenirs of the long journey northward.
“They’ve gone through pure hell to get over here to escape from the dangers of where they come from,” Dr. Gutierrez said.
Many of the refugees clearly need behavioral health services because of the traumas they’ve endured, says Dr. Garcia. Ideally, social workers and psychiatrists would be present to help identify and treat these problems. Even so, refugees’ short stay in the shelters makes treatment difficult, she says.
“I have had kids come in, and I’m, like, ‘Where did that kid go?’” Dr. Garcia said. “They’re already on the bus leaving to wherever. I think for us just dealing with the acute issues to make sure nothing bad happens is what we’re focusing on.”
The El Paso physicians say their long-term goal is to build a nationwide network of volunteer physicians and other health care workers who can help. (See “How You Can Help,” page 36.) They’ve already identified many physician volunteers, especially in big cities in Texas.
Volunteer physicians can help in two ways. They can come to El Paso and other border counties to help treat asylum seekers as they enter shelters. They also can be notified when a patient who needs follow-up medical or psychological care moves to their area, says Dr. Ayoub-Rodriguez.
“It’s critical for the doctors where [the asylum-seekers] are going to know what they’ve been through and to address and recognize the effects of the trauma they’ve experienced,” she said. “So it’s really important to educate nationwide in what’s going on [with asylum-seekers].”
Part of that education must include an understanding of adverse childhood experiences (ACEs) and how even simple interventions can reduce their impact, Dr. Johansson says. (See “What You Need to Know About ACEs,” September 2017 Texas Medicine, pages 53-57, www.texmed.org/WhatToKnowAboutACEs.)
Despite their brief encounters with asylum-seekers, physicians have an opportunity to make a lasting impact for those who need care but seldom get it, Dr. Johansson says.
“And it’s what we need to do,” he said. “We need to help people.”
A surge in asylum-seekers
Before their work at the Annunciation House shelters, El Paso-area physicians like Dr. Gutierrez volunteered in 2014 to help CBP give health screenings to migrants in detention centers, says Wanda Helgesen. She is executive director of BorderRAC, a nonprofit that helps coordinate medical response for immigrants.
“We reached out to the [El Paso County Medical Society] and they created teams of people that actually worked [as volunteers] at the border patrol stations along with the agents,” Ms. Helgesen says. “They did exams right at the border patrol stations.”
While overall border crossings have plunged since 2000, the number of asylum-seekers — especially from Central America — has soared, according to CBP data. (See “Asylum-Seekers,” page 35.)
Before 2014, most immigrants crossing the Texas border were single, young men. But asylum-seekers from Central America frequently bring their children, says Mr. Garcia, Annunciation House director. In 2018, his organization saw a record number of families.
Over time, the El Paso physicians’ volunteer work at Border Patrol stations ended. Then in December 2018, two children of asylum seekers from Guatemala — one 8 and one 7 years old — died of illness in CBP custody. Both died in the El Paso Border Patrol sector.
“That highlighted the special need that children have and how quickly they become ill and the lack of resources at the border patrol stations,” Ms. Helgesen said.
Concern over these deaths caused the Department of Homeland Security (DHS) to contract with the Coast Guard to screen asylum-seekers in detention centers for health problems, Ms. Helgesen says. DHS also called on BorderRAC to coordinate screenings with 16 El Paso-area hospitals. Between Christmas and early February, local hospitals saw about 450 asylum-seekers, she says. These medical services are paid for by the federal government.
That’s not the case once federal agents release asylum-seekers from detention to one of the shelters. And that’s where the volunteer El Paso physicians have stepped up to fill the void.
Dr. Gutierrez expressed frustration that hospitals get paid for the work they do for refugees in detention centers when physicians do much of the same work outside for free. Even so, he does not begrudge his volunteer efforts, but says state and federal funding for health care in the shelters would help many more people.
“We make a comfortable living [as physicians], and it’s only right for us to give back and help those who cannot help themselves,” Dr. Gutierrez said.
From the shelters, asylum-seekers typically go on to live with friends or relatives until their court date. The health care they receive at the detention centers and shelters is minimal, but it’s probably better than what they face once they move on, says Dr. Johansson.
“When they leave here, their ability to get follow-up care in the communities they’re going to will be very precarious,” he said. “Part of that is because of the fear — the fear that ‘this will jeopardize me.’ And that’s a big issue.”
How You Can Help
Physicians, advanced practice registered nurses, physician assistants, and nurses are all needed to help staff El Paso County’s 18 shelters for asylum-seekers. Fluency in Spanish and other languages spoken in Central America is helpful but not required.
“It normally takes about an hour a day,” says pediatrician Carlos Gutierrez, MD. “Some days I’m not needed at all.”
Physicians and health workers who cannot come to El Paso can provide follow-up care to asylum-seekers who settle in their area.
To find out more, contact Patsy Slaughter, executive director at the El Paso County Medical Society, at (915) 533-0940 or firstname.lastname@example.org.
Tex Med. 2019;115(4):30-37
April 2019 Texas Medicine Contents
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