The young woman sat in the corner of my exam room, facing away from me as I asked her questions. Her answers were short. "I’m from El Salvador." Why did she come? "Because of the violence." Her voice was flat. Her hands trembled. I knew she had suffered terribly and I needed to ask her how.
Slowly, quietly, she recounted the gang violence she had fled in El Salvador. The assault she’d been too afraid to tell her family about lest they be targeted. The death threats to her children that finally led her to seek asylum in the United States.
"They can do what they want to me," she said. "But they are not going to hurt my children." She gradually met my eyes as hers filled with tears.
As my patient unburdened herself, I was grateful for her trust. I knew that there were hundreds more young women like her who were afraid to set foot in the clinic.
I wanted to reassure this patient that she would be safe in the clinic with me and safe when she went back to her home in Everett. But as awareness of the world outside filled the space between us, I wasn’t sure I could.
On Jan. 25 President Trump signed an executive order that calls, among other things, for a 50 percent increase in the number of Immigration and Customs Enforcement (ICE) officers; the expanded use of detention centers; and the use of local law enforcement officers to enforce immigration policy. Officers will be allowed to deport immigrants who have been charged with any crime, even if they haven’t been convicted.
Two days later, the president signed another executive order which banned all refugees from any country for three months, and any type of travel from seven predominately Muslim countries. Courts have suspended that second order, but the first remains in place.
Meanwhile, on Tuesday, the Trump administration published new Department of Homeland Security rules that greatly expand the number and classes of people who can be deported.
For those who have worked with immigrants for years, it is difficult to explain how the current situation differs from the last 20 years. Both President George W. Bush and President Obama massively increased deportations — sending home 2 million and 2.5 million people, respectively, a huge increase over previous years. They created an efficient system for removals which our current president has inherited.
But under the Obama administration, "deportations were typically done under a Priority Enforcement Program," said Liza Ryan of the Massachusetts Immigrant and Refugee Advocacy Coalition. Priority was given to those who had committed serious crimes, had recently entered the country, or were deemed a threat to national security. Now, under the executive order currently in force, "they basically don’t have priorities. It’s so extremely broad that it basically encapsulates everyone," she told me.
My medical school in Atlanta didn’t offer a class on immigration policy. We discussed politics between classes. Taking care of a diverse population in Georgia, our first concern was always not to offend with our personal political beliefs, damaging in some way the patient-physician relationship.
In my third year of medical school, however, I had a crash course in immigration policy while taking care of migrant laborers in rural Georgia. We set up tents in the fields and treated hundreds of patients under the hot Georgia sun.
While we were there, the state of Georgia passed a law allowing local police to demand immigration papers from anyone they stopped. Overnight, before the law was even enforced, thousands of immigrants fled the state, leaving $140 million in crops rotting on the ground. Some mornings, we would pitch our tents only to find the camps had become ghost towns.
Now, with ongoing changes in federal immigration policy, many patients are afraid to even come to clinic. Once again, I sometimes feel like I’m pitching a tent in an empty field.
Immigration policy, Dr. Rob Marlin told us, "is no longer a spectator sport" for us or for our patients.
Dr. Rob Marlin, a primary care physician in Cambridge who directs the Refugee Health Assessment Program, recently provided training for physicians who take care of immigrant patients. He told us we must "individually and institutionally have greater knowledge of immigration policy to take care of our patients."
Knowing patients’ immigration status and the reasons they came to this country can affect the services they are eligible for, the relative costs of medications, the fears that may keep them from returning for needed services, and even the diagnosis of unexplained symptoms.
Immigration policy, Marlin told us, "is no longer a spectator sport" for us or for our patients.
But it is not simple to practice medicine under these new and uncertain circumstances. The fear that young woman from El Salvador felt in clinic was partly a fear of me — an authority figure she did not know if she could trust. While we like to think our clinics and hospitals are safe for everyone, that’s not always the case.
A woman who showed up to her gynecologist’s office in Houston two years ago presented a fake ID. Staff reported her to ICE officers, who waited for her in the clinic room. Instead of having a pap smear, she was deported, leaving her 8-year-old daughter in the waiting room.
As a patient, I’ve never received anything but kindness from doctors around the world. From Brazil to Mexico, I have sought care because of accidents and illnesses. Even with my many advantages, I’ve never been so scared as lying ill and helpless in a foreign country.
But never did anyone ask me for immigration papers before they treated me. In most cases, they didn’t even charge me. In Brazil, when I considered overstaying my visa, I thought about the fine and how it might be difficult to return. I never worried that violating my visa would mean that if I became ill, I would not be treated with basic human mercy.
In my current practice, I need to know why my patients might be afraid of the police and of me. However, I do not directly ask about their immigration status because I don’t want them to be fearful of how that information will be used.
I’m also careful what I document in the medical chart because we can never assume any data are secure. Though federal medical privacy law is commonly understood to protect our clinic notes from immigration and law enforcement officers who don’t have a warrant or patients' permission to disclose, it’s not clear that will always be the case.
Colleagues who take care of pediatric patients tell me of the toll recent developments are taking on children, many of whom are citizens but may have immigrant family members.
Sarai Lamothe, a nurse I used to work with, told me she took care of an 8-year-old girl with chest pain whose parents were undocumented. Eventually it became clear that the child’s chest pain was caused by fear that her parents might be deported. "I felt helpless," Lamothe tole me. "By the end of the visit, everyone was crying."
One of our primary roles as doctors is to relieve our patients’ fears. If you have a lump, I know what tests to order to determine if it’s cancerous or benign. We can never be 100 percent sure of anything, but our knowledge, exams and systematic ways of approaching problems give us road maps to help our patients through uncertainty.
Unclear and changing immigration rules make it impossible for me to assure my immigrant patients that their fears are unwarranted.
Nonetheless there are many things we caregivers can do to improve our current situation. We can refer patients to local agencies that can help. We can get trained in asylum evaluations. We can leave the hospital and go into the community to let patients know we provide a safe space for them.
We can also seek to understand the existential threat that our patients face and the ways it is changing. Only then can we avoid false reassurance.
There may be more executive orders coming. A leaked draft of one order reveals it might become possible to deport immigrants who are legally here simply because they access federal aid, including federally funded health insurance programs.
Few immigrants qualify for Medicaid, but for legal permanent residents with green cards who do, such an order could threaten their ability to stay if they enroll in the insurance program.
Shawn Gremminger, director of legislative affairs for America’s Essential Hospitals, worries that if President Trump issues this order, it would not only threaten the status of legal immigrants but the funding of public hospitals across the country who care for them.
Gremminger wrote in an email to me that if this is order is signed, it would be immediately challenged in court. Unfortunately, even the possibility can be enough to scare patients away from applying for programs like Medicaid, or food stamps for their children.
In the room that day with my patient, I wanted to tell her that she was going to be fine. I wanted to assure her that her children wouldn’t be sent back to El Salvador, perhaps to be be killed. But I couldn’t. All I could do was say “I am here for you. Right now, you are safe.”
Dr. Elisabeth Poorman is a primary care physician in Everett.