Paulo Peña, a first-year medical student at the University of Arizona (UArizona) College of Medicine – Phoenix, was struck by the living conditions of the people staying in Tijuana, Mexico, while they waited to see if they might be allowed to enter the United States.
He was in Tijuana the weekend after Thanksgiving 2021 as part of a medical service trip that he and several other medical students at his institution had organized to help provide basic medical care and prescription medications to migrants staying in the border town. At one of the shelters Peña’s team visited, families lived in a warehouse with only tents for privacy. Many had gone without medical care and important medications during their migration journey.
“It was a very eye-opening experience,” he says.
As the child of immigrants — his mother from the Philippines and his father from Ecuador — Peña couldn’t help but think about how easily his life might have been different, and more like those of the people he met in the camps, had his father been deported before he became a legal citizen.
In fact, it was his desire to work with immigrants who have difficulty accessing health care that inspired Peña to apply to medical school and join the Migrant Health Interest Group (MHIG) at the UArizona College of Medicine – Phoenix in his first year.
He’s following in the footsteps of two third-year UArizona College of Medicine – Phoenix students, Rebecca Paxton and Matthew Campanella, who started the MHIG in their first year of medical school and have grown its outreach activities to include volunteering at a local free clinic, starting a medical-legal clinic for people seeking asylum — the legal protection granted to someone who cannot return to their home country for fear of persecution — and organizing the annual Tijuana medical service trip.
The MHIG is one example of how people within the academic medicine community — from students to administrators — are working to provide medical services to immigrants who face significant barriers to accessing the traditional health care system in the United States.
“A great many asylum and refugee clinics are affiliated with an academic medical center. These tend to be partnerships between passionate faculty and passionate students to create pro bono clinics.”
Holly G. Atkinson, MD
Affiliate clinical professor at the CUNY School of Medicine
As of 2019, there were 21.3 million noncitizens living in the United States, with 24% of those lawfully present and nearly half of those who are undocumented being uninsured, according to the Kaiser Family Foundation.
In 2014, about 75% of U.S. medical schools had at least one student-run free clinic dedicated to serving the uninsured, according to a study published in the Journal of the American Medical Association.
As the number of people across the globe seeking refuge or asylum reached a record-breaking 84 million last year, the needs of those seeking to enter or who have recently arrived in the United States have grown.
Often, it is medical students and faculty who have stepped up to meet those needs.
“A great many asylum and refugee clinics are affiliated with an academic medical center,” says Holly G. Atkinson, MD, an affiliate clinical professor at the CUNY School of Medicine and a member of Physicians for Human Rights (PHR), an organization that coordinates medical forensic evaluations — which document physical or psychological harms suffered — for asylum-seekers. “These tend to be partnerships between passionate faculty and passionate students to create pro bono clinics.”
While these volunteer services have limits, they can have a powerful impact on the trainees and physicians who can better serve patients when they better understand their experiences.
“The more experience that you have as a physician with working with those populations, the more you’re going to help your patient get a better health outcome and be able to mitigate barriers that prevent a person from thriving,” Campanella says.
Students taking leadership
Before starting at the UArizona College of Medicine – Phoenix, Campanella made documentaries about the immigration experience at the southern U.S. border and volunteered at a community clinic that served recently arrived migrants. He witnessed firsthand the danger, trauma, and difficulties migrants face when seeking refuge in the United States.
He had these issues in mind when he met Paxton in their first weeks at medical school. Both students were passionate about migrant health and set to work forming a student group focused on outreach to three groups of people: those journeying to the United States, those held in detention facilities, and immigrants living in the Phoenix area.
“I thought it was very, very important to expose students and doctors to what [migrants] go through and what health problems they have before they get to the United States,” Campanella says.
To reach the people still journeying, Paxton and Campanella partnered with the Refugee Health Alliance, a nonprofit organization that runs two clinics and provides medical care to 30 shelters in Tijuana, to plan a single-day service trip for interested medical students and faculty. The first trip took place in 2019, but because of the COVID-19 pandemic, the 2020 trip was canceled. With all volunteers vaccinated and providing a negative COVID-19 test, the trip resumed in November 2021.
“It really is a student-driven event,” says Barbara Garcia, MD, an associate professor of family, community, and preventive medicine at the UArizona College of Medicine – Phoenix who accompanied the students on the trip. “[In medical school, students] practice in a controlled environment … with standardized patients, but nothing really cements your learning like putting those skills in real-life situations. Volunteer experiences like this [trip are] what will reinforce all that they have learned so far in our doctoring curriculum.”
The trip, as well as the weekly opportunities to volunteer at the Phoenix Allies for Community Health free clinic, give students a chance to practice their interview and cultural competency skills while also doing something that serves the community.
“It’s been the most meaningful work of my career,” Paxton says of working with immigrants through the MHIG. “It really keeps me going in many ways.”
She adds that medical students are particularly well positioned to lead and participate in this kind of volunteer work.
“Honestly, we just have more time. I do a lot of wrangling of physicians to make these happen. They’re busy,” she says. “Also, medical trainees are not hindered by the baselines of what we should or should not be doing. We have enough gumption and hope still to say we can do something about this.”
But to create systemic change, Paxton says academic medicine institutions have a responsibility to take an active role in using resources and influence to reach out to migrant populations.
Medical school on the border
Richard Lange, MD, can see Mexico from the office where he serves as president of Texas Tech University Health Sciences Center El Paso and dean of the Paul L. Foster School of Medicine (PLFSOM).
As the first four-year medical school located on the U.S.-Mexico border, PLFSOM serves a unique and integral role in the diverse migrant, refugee, and asylum-seeking populations that both live and pass through the city.
“It’s all part of being a central member of the community,” Lange says. “We tell [prospective] students, ‘If you don’t want to be involved in the community, don’t come here. You’re not going to like it, because that’s what we’re all about.’”
Last year, students logged about 19,000 hours of community engagement through the many outreach programs the institution is involved with, says Jose Manuel de la Rosa, MD, vice president for outreach and community engagement at TTUHSC El Paso.
“The pathology we see becomes a very fertile ground for teaching. The focus really is to teach our students about our populations — about our communities. It’s a wonderful opportunity to teach cultural sensitivity and cultural humility.”
Jose Manuel de la Rosa, MD
Vice president for outreach and community engagement at Texas Tech University Health Science Center El Paso
Over the past two years, the activities have included volunteering at the free clinics that provide primary care to migrant farmworkers who cross the border every day and to recently arrived immigrants staying in local shelters, organizing clothing drives for people living at a refugee camp set up for those who fled Afghanistan and were transported to the country through U.S. Army post Fort Bliss, performing welfare checks on people who test positive for COVID-19 and must isolate in “filter hotels” upon arrival, and aiding at a vaccination clinic for thousands of Mexican factory workers who were allowed to cross the border briefly for the shot.
“What’s the role of a medical school in a community? What’s the role of a physician in a community?” says de la Rosa. “We think a physician should set an example [and] be cognizant of all the factors that impact health: nutrition, migration, cultural humility, racism, [etc.].”
Learning to work with patients who experience the distinct health, psychological, and social challenges that come with migration — whether that be the trauma of fleeing a war-torn home country, the physical effects of a dangerous cross-border journey, or the confusion of seeking medical care in a foreign country — is woven into the curriculum at PLFSOM and is integrated into clinical training.
“The pathology we see becomes a very fertile ground for teaching,” says de la Rosa, who helped develop the curriculum, including a proficiency in Spanish required for graduation. “The focus really is to teach our students about our populations — about our communities. It’s a wonderful opportunity to teach cultural sensitivity and cultural humility.”
Research on asylum-seekers and health
In early 2020, just as the COVID-19 pandemic was beginning to sweep across the world, Katherine Peeler, MD, an assistant professor of pediatrics at Harvard Medical School and head of the Peeler Immigration Lab there, was brainstorming with the medical and graduate students she works with about what topic they could focus on that would be most relevant to the health of asylum-seekers. The group landed on investigating how well Immigration and Customs Enforcement (ICE) detention facilities were instituting public health protocols like social distancing and providing masks, soap, and hand sanitizer.
“Detention, to a lot of us, is a black box,” Peeler says. “What are the conditions like? What happens if you get sick? Those of us who work in asylum medicine have been interested in what happens there to inform policy and, ideally, to end detention. The vast majority of persons are there for administrative reasons, not for committing a crime.”
“If academic medicine is going to be on the cutting edge of training physicians and research into health, it’s important to know the context of this patient population: how they came to be here, what health problems they have, and what structural barriers they face in achieving health.”
Katherine Peeler, MD
Assistant professor of pediatrics at Harvard Medical School
Peeler and her students partnered with PHR to connect with 50 people who had recently been released from detention to conduct anonymous interviews with them about their experiences.
“We found that ICE was not following its own protocols,” she says. PHR published the results of the study in a report entitled Praying for Hand Soap and Masks: Health and Human Rights Violations in U.S. Immigration Detention during the COVID-19 Pandemic.
To Peeler, whose immigration lab has focused on different aspects of public health and immigration detention, research into the issues affecting the health of asylum-seekers in the United States is an imperative for academic medicine institutions.
“If academic medicine is going to be on the cutting edge of training physicians and research into health, it’s important to know the context of this patient population: how they came to be here, what health problems they have, and what structural barriers they face in achieving health,” she adds.
A research study led by Atkinson from CUNY in partnership with PHR and published in the Journal of Forensic and Legal Medicine last year found that asylum cases that included a forensic medical evaluation were granted relief 90% of the time, compared with the national average of 42%. PHR organizes a network of trained clinicians who volunteer to conduct physical and psychological exams to include as evidence in an asylum case.
“The basic skills of being a physician — taking a good history and conducting a physical exam — can be absolutely lifesaving,” says Atkinson, who is also an expert advisor and asylum network member of PHR. “Not only for an individual, but for a family as well.”
The study authors recommended conducting additional research into the role forensic evidence plays in the asylum adjudication process — a role that Atkinson says academic medicine institutions can help fill.
She also believes that the study findings show the need for training more clinicians — including future physicians — on how to do trauma-informed forensic evaluations.
“Given where we are in this country — given the number of people seeking asylum and refugees — this kind of health care is central to training,” Atkinson says, adding that it would ideally be included in the core medical school curriculum.
The work is not only a service to the community but also a way to help restore purpose to clinicians, many of whom are facing staggering rates of burnout, she says.
“It’s one of the ways you keep hope alive.”