NPs Respond to Medical Needs of Refugee and Immigrant Patients

By Stephanie Jordan
Managing Editor, Connections

“The world is currently in the midst of the largest refugee crisis since World War II,” stated Doctors of the World, on June 20 during its promotion of World Refugee Day 2019. “An unprecedented 70.8 million people have been forcibly displaced worldwide, and 37,000 people are forced to flee their homes every day due to conflict or persecution,” continued the international human rights organization that provides emergency and long-term medical care to vulnerable people.

In late 2018, approximately 10,000 people from Honduras and El Salvador fled their countries. The vast majorities were escaping endemic violence and extreme poverty, or being forced from their homes by climate-change related disasters such as floods and droughts. Many were seeking asylum in the United States in the hope of building a better future for themselves and their families. After surviving the dangerous journey, many were detained by authorities in Mexico and were forcibly or voluntarily returned to their home countries. However, according to the Mexican government, 7,000 people still remain in makeshift shelters in the north of Mexico in cities such as Tijuana and Mexicali.

CANP Immediate Past President Theresa Ullrich, MSN FNP-C, who works at La Amistad community clinic in Orange and Fullerton College Student Heath Services providing patient care, recently visited two such refugee locations in the Tijuana area. She travelled as a Saturday volunteer with the Refugee Health Alliance (RHA), one of the largest charity health care providers to immigrants and to the shelters in Tijuana. Every Saturday, at overcrowded shelters throughout Tijuana, RHA hosts mobile clinics with clinical teams of 15-35 physicians, nurses, EMTs, nurse practitioners, and other medical volunteers that typically see between 80-160 patients in one day.

RHA’s focus is not exclusive to medical treatment; it also provides mental health services in the form of psychological consultations and group support to vulnerable subsets of the population, including unaccompanied minors and LGBTQ members. It also hosts recreational therapy sessions, which can include activities like art and yoga to promote psychological and physical wellbeing. In addition, it works closely with lawyers to produce documentation for migrants in preparation for their asylum process.

“RHA was organized in 2018 in response to increasing medical need at the U.S.-Mexico Border,” explains Ullrich. “Patients receiving care are often vulnerable and marginalized. They are families, children, pregnant women and LGBTQ individuals. They have been displaced, possibly deported from the US, and politically and socially excluded.”

On that Saturday in August, Ullrich, along with other volunteer nurses, nurse practitioners, doctors, and technicians, assembled in San Diego and then walked across the border. The 25-member team broke into two groups upon arrival in the morning. Ullrich’s group was assigned a shelter. Using makeshift exam rooms, RHA volunteers tend to patients with a variety of aches, pains, illnesses and occasionally a case of chicken pox. Ullrich dispensed meds in envelopes and Ziploc bags.

“It was a pretty rudimentary set up,” recalls Ullrich. “The shelter had concrete floors and a sheet metal roof. Inside the big indoor space stood large family-sized dome tents, lined up side-by-side. There was a communal kitchen in the back.”

Ullrich observed kids running around and playing and had admiration for the adults seeming to handle the uncertainty of their situation with a go-with-the-flow attitude.

“The kids were great,” states Ullrich. “The patients all had asylum numbers, and it was a sober reminder of how long some of them would be waiting for their chance to enter into the U.S. There are so many that are in a holding pattern.”

But once inside the U.S., there is no guarantee for some immigrants. 

Fear and Uncertainty

Barbara Shaw, who has worked as a Family Nurse Practitioner in community health centers in Boston and Chicago, has always attended to those on the margins of society. Although bilingual in Spanish, she realized she needed to learn Portuguese to better communicate with patients at the clinics of Cook County Medical Center, and so she did. Shaw is an assistant professor in the department of Community, Systems, and Mental Health Nursing at Rush University, as well as teaching in their DNP program. She received her MSN as a Family Nurse Practitioner from Yale in 1988, and completed her doctoral studies at the University of Illinois at Chicago. She also has an academic background in medical anthropology.

In addition to teaching and clinical supervision, Shaw provides care to immigrants and refugees at Heartland Health Center and participates in development and implementation of an advanced practice nurse fellowship in immigrant and refugee health. She works twice a week at the community clinic in Chicago’s Uptown neighborhood where 90 percent of her patients are immigrants, mostly Latino, but also from all over Africa.

In recent years, Shaw says she has never seen fear so severe in her 20 years as a nurse.

“The extreme stress of losing documented status and returning to undocumented status has the potential to exacerbate numerous chronic conditions. It can cause an increase in psychological diagnoses, such as anxiety, depression, adjustment disorders and substance abuse.”

Shaw has been such a strong advocate for her immigrant and refugee patients, including writing articles, that she received the State Award of Excellence for the state of Illinois from the American Association of Nurse Practitioners last year.

She has been quoted as sharing stories of immigration insecurity, such as when she sent an older woman with a bad hip injury to Cook County Hospital for some tests, but the woman never went for fear “la migra” – immigration – might be there. Or another patient, a young construction worker with poorly controlled diabetes, told Shaw he could not come in for regular visits because money has gotten tighter as employers have become more stringent in asking for documentation when hiring. Shaw reports a rise in cases of insomnia, anxiety, and reflux problems associated with heightened stress.

The level of concern that people might forgo care is enough that some hospitals have launched campaigns to clarify that the hospital is not an extension of law enforcement and that it will take care of people regardless of their immigration background.

Caring for Immigrant Children

Several years ago, when news reports captured the public’s attention with stories about thousands of Central American immigrant children crossing the Mexican-American border, Cathy Woodward, DNP, RN, PNP-AC, and an associate professor in the department of pediatrics at University of Texas Health Science Center in San Antonio, began volunteering at a portable health clinic in McAllen, at the southern tip of Texas in the Rio Grande Valley.

“When I first began treating these children, there were certain questions I had about immunizations and TB testing, and I had to do research to find the answers,” said Woodward, chairwoman of the Global Health Care Special Interest Group for the National Association of Pediatric Nurse Practitioners. “I thought it would be useful to share this information with other health care providers.”

As a result, Woodward and three other NPs from the Global Health Care Special Interest Group developed guidelines for primary care providers for the care of newly immigrated children. The guidelines were released in the form of a two-page poster that covers TB screening, immunizations, mental health, developmental needs, nutrition, and growth.

The guidelines also cover the specific mental health issues immigrant children may be facing – such as depression, anxiety, isolation, exposure to violence and post-traumatic stress disorder – and provide tools for evaluating and treating behavioral health.

A Full Day Comes to An End

As part of the same volunteer day, Ullrich was driven about 45 minutes to another Refugee Health Alliance clinic at a church. There was a mix of immigrants and refugees, with over 300 displaced people. 

At both locations, Ullrich did not see anyone with significant health care needs. Those patients would be seen at a hospital or other medical facility. The clinics were rudimentary, but serviceable. Ullrich did have a patient with a 102-degree fever, and there was a girl with yellow eyes that she was able to do labs for, although the results remain unknown to Ullrich.

“We weren’t there to handle chronic illnesses,” Ullrich explains. “For the most part, people had to be in decent health to make the journey from wherever they came from. There were a lot of young families with children.”

At the church, there was a man from Honduras that had applied for asylum, but he had already been denied twice. He was trying for a third time. Ullrich saw him because he had high blood pressure.

Both the morning and afternoon clinics had plumbing. At the church, laundry was hanging about, as well as many sheets used to create separate rooms for privacy. Overall, clothes were clean, people appeared bathed, fed, and had overall good hygiene. 

While the medical team was supposed to have had a communal dinner with all 25 volunteers, the work went so late into the day they could not take the time and instead everyone returned to the U.S. border and home.

“I definitely felt hopeful for these people,” concludes Ullrich of her volunteer day. “Although they might be in for a long wait, the refugees that I saw appeared to be fairly well taken care of.”