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Providers, Not Puppets

Editor’s note: Names and details have been changed to protect patient confidentiality.

“It felt like a freezer and all they gave us was a paper-thin blanket, almost like aluminum foil,” Sameera explained. “We gathered all three of our blankets and wrapped them up into one for my daughter. My husband and I waited and prayed instead.” Sameera was an Iraqi refugee who had recently arrived from Tijuana, Mexico. She fled violence from what seemed like every corner of the globe, starting with Iraq, then to Yemen, Brazil, Mexico, and now to a small, bare and cold cell somewhere in southern California.

Sameera was the very first patient that I had the honor of helping through the Medical Students for Immigrant Justice Asylum Clinic at University of California Riverside (UCR) School of Medicine. I sat by, furiously taking notes and holding back my tears, as she told the forensic psychiatrist her story. Any and every point that Sameera mentioned could prove to be helpful in her asylum case, so I made sure to cross every ‘t’ and dot every ‘i.’ For millions of refugees and immigrants, the idea of moving to America seems like a solution, an opportunity to chase the “American Dream.” Instead, I learned from Sameera that the U.S. government greets them with detention centers that separate families and treat detainees as subhuman.

As I started reading through asylum cases, I began to notice the clinical ramifications of detention centers nationwide. Their unethical and undignified treatment of immigrants was obvious, making headlines even. Despite this, detention centers still managed to gild their substandard care beneath the lie that comprehensive health care was their top priority. Private health care companies hired by Immigration and Customs Enforcement (ICE) asserted that they made “the best possible care decisions with the information that was available to them.” However, the indefinite nature of detention along with the toxic stress, lack of food and hygiene, and poor medical expertise available proved to be more than detrimental for many immigrants locked up all over our country. Since 2003, more than 185 people have died within custody, mainly due to substandard medical attention, inadequate mental health care, the misuse of solitary confinement, and delayed emergency services. Considering no changes have been made to the detention centers being utilized today, it becomes clear that regardless of the amount of medical care that ICE claims to provide, real care is simply not possible in such conditions.

For me personally, it is easy to blame structures like ICE and the Department of Homeland Security for their role in detention centers. However, the role of physicians and those recruited to serve within these systems is more complicated. On one hand, it is an obligation for physicians to treat detainees in need of medical and psychological services. On the other, it seems as though their cooperation allows these systems to continue without consequence. Physicians for Human Rights, a non-profit committed to advocating against human rights violations, refer to this concept as “dual loyalty.” It states that physicians hold responsibilities to their patients but also to the agencies that employ them.

In this case, dual loyalty creates an issue within detention centers for physicians who hold no clinical independence. Currently, health care providers are required to sign non-disclosure agreements, preventing them from reporting the true conditions of the facility they work within and the patients they are serving. By abiding by these reporting rules, physicians are providing a service that could help justify expanding and recreating these detention centers in different locations, thereby putting more people at harm. Simultaneously, physicians’ medical contributions are constantly used as a guise beneath which detention centers continue to treat detainees inhumanely and limit the medical resources available to them. This puzzles me. A cycle of providing care to treat the downstream factors while ignoring the upstream determinants — was this all a physician could do?

Fortunately, the American Medical Association (AMA) principles of medical ethics are clear regarding issues like this, particularly in article III: “A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.” Additionally, article IX states, “A physician shall support access to medical care for all people.”

I was reminded of these principles when I read a piece by Dr. Samuel Slavin, an internist at the Massachusetts General Hospital. He engaged with these principles himself when helping a patient who needed urgent chemotherapy but was on the brink of deportation. Throughout his piece, he weaves in the difficulties he faced as her provider, both in caring for her medical needs and in helping to ensure that her visa was extended so she could receive her treatments. Through Dr. Slavin’s piece, I got to see how these two AMA principles can be applied. His commitment to people, and not systems or titles, exemplifies how to practice health care within a system that does not always share similar ethical guidelines. He points out that “my training did not include prevention of death by deportation,” and this reflection perfectly sums up the issues that medicine faces and will continue to face as long as immigrant detention centers are up and running.

Through stories like this, I realize that working within a broken system first requires acknowledgment. That does not mean being complicit or approving of the systemic conditions that created it but, rather, understanding our role and how we continue to perpetuate it. As health care providers, we cannot afford to be blissfully ignorant when so much is at stake. When public health measures have failed to make any real progress on health equity within the past 25 years, it becomes even more crucial that health care providers on the front lines are cognizant of the different public health crises that continue to haunt our communities. We must be constantly aware of the role we play and seek solutions rather than uplift the very systems that create them. From there, we can begin to advocate for changes that will prioritize our patients and our shared principles.

Outside the walls of detention centers, I still think about how I can stay true to the oath I took when I began medical school. Every time I see a patient in clinic, I think about how our current health care policies can limit patient access to quality care. Whether it is a lack of health insurance coverage, limited access to affordable medication, or the compounded effects of unaddressed health disparities, every patient now presents to me as a conundrum of health care at large: how can I truly fulfill my duties as a provider if the system cannot support my patients? How can I expand my role as a physician to encompass sustainable changes for my patients?

As of this moment, I do not have all of the answers. But I will always aim to promote the well being of my patients first and foremost. After all, medicine and advocacy have always been intertwined, and advocacy has given us the power and direction to help others. In Dr. Slavin’s own words, “We are not quite so powerless when armed with the realization that meaningful advocacy can grow from the human connections at the core of our profession.”

Author’s note: This piece was inspired by Dr. Scott A. Allen, who truly exemplifies the meaning of medical advocacy and selflessness. I want to extend my deepest regards to you for all the work you have done and all the health care providers out there fighting for real change. Thank you.

Image credit: Detention Center Fencing (CC BY 2.0) by D-Stanley

Yasmine Suliman (1 Posts)

Contributing Writer

University of California Riverside School of Medicine

Yasmine Suliman is a first-year medical student at the University of California Riverside School of Medicine in Riverside, CA class of 2023. In 2018, she graduated from Brown University with a Bachelor of Arts in health and human biology. She enjoys spending time with family and friends, cooking and reading. After graduating from medical school, Yasmine would like to pursue a career in pediatrics.