Global Health at Home: Caring for Migrant Families on their U.S. Arrival

The American Academy of Family Physicians (AAFP) sponsors an annual Global Health Summit. This year’s conference, in Albuquerque, NM, was the largest so far. The conference started primarily as a venue for family physicians who volunteer their time abroad, providing health care and teaching in generally less developed countries. These were for both long (a year or more) or short trips, often sponsored by religious organizations. They also can include work done through government (eg, Peace Corps) or non-governmental but non-religious organizations (eg, Partners in Health, Doctors without Borders, Doctors for Global Health), but the religious root of much of this work is still apparent in the use of the term “mission trip” for most short-term such activities, especially involving medical students or residents. Overall, most such organizations, including those largely or partially sponsored by churches or religiously-affiliated organizations, no longer make religious proselytizing or efforts to “convert the natives” a significant part of these trips, and focus instead on health care and health system development (although there are certainly exceptions). Many of the leaders in this field are also involved in development of health systems in countries across the globe and in international health organizations and efforts including WONCA (the World Organization of Family Doctors), the World Health Organization (WHO) and its sub-groups such as the Pan-American Health Organization (PAHO), and The Network-Towards Unity for Health.

While such international work remains the mainstay of global health activity, there is also increasing interest in addressing needs in the US. To some degree, this reflects a long-standing discussion regarding the degree to which many doctors and students are more interested in going abroad on such trips than providing care to the needy at home. Of course, this need not be a contradiction, and many of the most active physicians in global health also spend the bulk of their time in the US working with underserved communities. But there are also those, including many students, who are attracted to such trips for other reasons. These include “medical tourism” – using the trip as an excuse for an exotic vacation, particularly if the place they are going is near beaches or mountains. They also include what might be called “medical opportunism”, where students go because they will get to do things to people on these trips that would be forbidden for them to do in the US, especially procedures. On the positive side, they can, provided the physicians or students are open to it and do not just talk to each other and can go beyond the “we are here to help you” mentality, allow learning and increase intercultural understanding, as well as increase knowledge of conditions that are more prevalent in the developing world. In addition, some of these conditions, as a result of the climate crisis and other factors, are moving north into our own country, so we see Chikungunya and dengue and other formerly tropical diseases. The key distinction is in how these trips are approached; they should be of benefit to you, but are not, ultimately, about you, but about collaboration with people, and health care providers, in other countries.

One increasing area of interest that tends to bridge this US/international divide involves the care of migrants coming to the US, an issue that has becoming increasingly front and center over the last few years. While the care is done in the US, the people are coming from other countries; in the case of our southern border primarily Central America and Mexico, but people come from all over the world. Several presentations at the Global Health Summit addressed different aspects of “Border Health”, each of which is important and each of which creates the need for linkages with other aspects of the health system. One is the care of people who permanently live along the US/Mexico border. The border, of course, is artificial, and many families live on both sides including Native Americans, such as the Tohono O’odham of Arizona, whose reservation crosses the border. This is a special case of care for the poor and underserved. Another is the care of people who are migrant workers, who may “live” in the border area for much of the year, but move to other regions of the US to follow the harvest. This creates the need for linkages with migrant health providers across the country. A third is the care of just-arrived migrant families who present at our southern border and may spend just a few days in our border communities before moving on to other parts of the US where they have sponsors. This creates the need for communication with appropriate health facilities in those areas, both for general health care and “warm hand offs” for individuals with particular needs. Such needs include those with ongoing chronic diseases often made worse by the journey, acute but severe issues such as injuries (including traumatic amputation by trains) and acute renal failure from dehydration crossing the desert, pregnancies (especially those that are high risk), and newborn but small or premature infants, etc.

“Global Health at Home: Caring for Migrant Families on their U.S. Arrival” was the title of a presentation by three Tucsonans who volunteer at the Casa Alitas migrant shelter, Anna Landau, MD MPH, Patricia J. Kelly, PhD MPH FNP, and myself. Originally accepted as a seminar, it was “upgraded” to a plenary presentation when the originally scheduled Ostegaard Speaker, Michael Kidd of Australia, was unable to attend due to family issues. While it was an honor to be selected, it was also gratifying to note the level of interest among the participants, from those doing similar work in cities on the border such as San Diego, El Paso, and Yuma, AZ, to those across the US who see these people as patients in their home communities, from big US cities to small towns in SW Georgia.

I have attached the slides in 'Links to Documents', found on the right side of the blog screen. It is important to recognize that medical care, which given the fact that guests are usually present for only 1-3 days, follows a public health model of dealing with acute needs and screening for infectious disease, is only a small part of the Casa Alitas operation. Hundreds of volunteers – and all are volunteers -- work on food preparation and service, contacting sponsors and arranging transportation, collecting and sorting and distributing clothing, doing laundry, driving guests to the bus station, and the multiple other needs that migrants have. I would also like to quote some parts of an email sent out by the Reverend Delle McCormick, a long-time leader in working with migrants in Tucson, after the recent move of Casa Alitas, which she has given general permission to share widely:

Every day is a triumph of small steps toward smoothly operating, warmly encouraging, just and loving spaces for our guests and volunteers. We have fallen for this new place and time. With each move we get more nimble, creative, and courageous in what we do together. Love shines here….Despite new draconian immigration policies at the border, we still have received 2484 men, women, and children at our new Casa Alitas Welcome Center shelter, making a total of 17,418 since October of 2018 when we stepped up our efforts to provide shelter for families seeking asylum.

Our volunteers still provide extra touches to encourage the human dignity and rights of every person who passes through our door. We hear and hold the most harrowing of stories: from 80+ year-old Sra. T. who stayed with us for a month because we couldn’t locate her sponsor, to the young man who had his toes burned off because he couldn’t pay for his release from kidnappers, to the woman who was shot in the head by her husband, to the daughter whose 68 year-old mother, who is blind, was detained, to the teenager kidnapped and prostituted and beaten by the local gang,  to the many, many others, each of whom has harrowing stories that drove them to leave everything behind to seek asylum.

If anyone is interested in learning more about the work in Tucson at Casa Alitas, in coming to volunteer, or in donating, more information is available at the website https://ccs-soaz.org. Donations can be made directly to CCS at  Support Migrant Aid - Tucson and through its GoFundMe page https://www.gofundme.com/casa-alitas-for-migrant-families.

The Challenge of Global Health and Primary Care

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I recently attended the 7th American Academy of Family Physicians (AAFP) sponsored Family Medicine Global Health Workshop. Over a period of 3 days, we heard plenary speakers, attended small-group breakout sessions, reviewed a large number of posters, and had an opportunity to talk and share ideas with each other. As one of those in attendance with the least experience in international health (while I have spent some time in Brazil, including a rather short teaching Fulbright, I have never been part of so much as a “medical mission” trip, not to mention spent protracted or recurrent time in providing health care or developing health systems in other countries, either in disaster relief or ongoing care), I felt I had a great deal to learn and I tried hard to absorb as much as possible. The collective experience represented by the attendees was overwhelming. Senior participants had spent decades working in both direct patient care and the creation of clinics as well as in consulting with governments and Ministries of Health on developing health systems based in primary care and family medicine. Some of the participants had returned for years – or for decades – to the same regions, spending months there each year. Family physicians ran or were part of a number of not-for-profit organizations that provided disaster medicine or primary care in countries in need around the world. Others were still residents, or even medical students, who had spent some time in areas of need (most recently, of course, in Haiti) and were planning on making this a central part of their future careers.

There was a breadth of motivations for this work. While many of the participants, and many who work in international health, were inspired by their religious beliefs (and “medical missions” still, in most places including medical schools, is the de facto term for any trip taken by physicians and students even when not sponsored by a religious organization), there were others whose motivation was not, and in particular was social justice. A poster presented by Joanie Baumer, MD, from Fort Worth’s John Peter Smith Hospital Family Medicine Residency (the largest in the country), which has been involved in programs in many countries, surveyed participants on what their main motivations were – and what they perceived those of others to be. Social justice topped the both lists, with “mission” (religious) about 4th, although it was higher in motivations attributed to others.

Plenary sessions from former HHS Secretary and University of Miami President Donna Shalala and others addressed important issues. Fitzhugh Mullan, MD, of George Washington University raised the issue of “brain drain” (see also Primary Care, IMGs, and the Health of the People in this blog, August 14, 2010), in which physicians trained in developing countries, often at public expense, migrated to wealthy Western countries, where they were often welcomed (as in the US) to fill residency and underserved-area-practice positions. While there was some pushback from the (small number) of attendees who had come to the US from other countries, it is hard to argue with Dr. Mullan’s proposition that “the US ought to be able to train enough physicians to care for its population without having to import them from the developing world” (paraphrased). As in so much of policy, there is often a distinction between the individual stories, needs and aspirations of individuals and the overall effect. Cynthia Haq, MD, of the University of Wisconsin, told her own story; one of increasing involvement in international work, from naïve trips to longer stays, to work with WHO and helping other countries develop their health systems, seamlessly intertwined with the story of her own family (“Stepping Stones: Strategies to enrich your life with Global Family Medicine”, posted like many of the other presentations, to the Family Medicine Digital Resource Library, www.fmdrl.org). Steven Spann, MD, of Baylor, presented a superb discussion of ethical issues in doing international work. In a breakout session (and remember, I can only report on those I attended) Gary Morsch, MD, founder of Heart to Heart International, presented the work of that group, which provides opportunities for health professionals to work abroad for shorter periods, a week or two, in settings such as Haiti, in contrast to larger and more famous organizations such as Medecins sans Frontieres, which requires 6-9 month commitments. Dr. Morsch also described H2H’s affiliated group, “Docs Who Care”, which provides locums tenens opportunities in rural parts of the Midwest, both helping those communities with their health needs and the physicians with the opportunity to earn a living in a manner that allows them to spend much of their time doing international work.

Haiti, where the January 2010 earthquake created incredible needs in a nation already living on the edge, with over 300,000 killed outright and hundreds of thousands more severely injured physically, psychologically, and emotionally as well as having every aspect of their lives disrupted or destroyed, was obviously a major focus. Many of the presenters of posters and breakout sessions, and many more of the attendees, had spent some time working in Haiti, in the initial “disaster” phase or the (still disastrous) “primary care” phase. They discussed the good (the people and their resilience, the commitment of the volunteers, the resources pouring in) and the not so good (the historical background of oppression and de-resourcing of Haiti, the lack of coordination between relief agencies, the volunteers who were on occasion self-centered and more often ignorant of the needs and realities of the situation). One of the best sessions I attended was by André Vulcain and Michèle Dodard of the University of Miami Department of Family Medicine. In 1999, they helped to start a family medicine residency program in Haiti’s second city, Cap Haitien, which had graduated 35 family physicians by the time of the quake and is still functioning. Unlike many of the other collaborations described, which are often with private (usually religious) hospitals, this program is sponsored by the Ministry of Health of Haiti and is based in a government hospital. While Dr. Vulcain’s powerpoints are not yet available on FMDRL, Dr. Dodard’s description of the work of the University of Miami’s “Project MediShare”, Rebuilding Haiti’s Healthcare System, is. Rebuilding that system, working with the Haitian government and people, training Haitian health professionals so that they do not need to depend on “mission trips” has also become a key focus of the work of Partners in Health (PIH) (“Zanmi Lasante” in Haitian Kreyol) and many other groups.

One of PIH’s founders, Paul Farmer MD PhD, and his colleagues Vanessa Bradford Kerry MD and Sara Auld MD propose the creation of an “International Service Corps for Health” in an article in a the September 23, 2010 issue of the New England Journal of Medicine.[1] They talk about the work that has been done, particularly that done by academic medical centers, but also address the limitations, especially financial, of these efforts, and suggest that a government-sponsored program, working in collaboration with other US agencies, might be a very effective way of increasing the international reputation of the US as well as helping to meet the staggering needs that exist in the world, such as in Africa, which “…bears 24% of the global disease burden but hosts only 3% of the global health care workforce and is responsible for less than 1% of world health care expenditures.” They describe the enormous impact that the small country of Cuba has had internationally, “…between 1999 and 2004, Cuban foreign-service workers increased doctor visits in resource-poor communities by 36.7 million, provided health promotion outreach for millions of underserved people, and taught 900,000 medical education courses to local personnel.” If carried out reasonably and equitably, an International Health Service Corps (IHSC) might be a major step forward.

There are still great healthcare needs in the US, and very underserved communities (both rural and urban), as detailed in the recent US Census Bureau report “Income, Poverty and Health Insurance Coverage in the United States, 2009”, and it is sometimes distressing to medical educators to observe that many medical students have much greater enthusiasm for “international work” than they they do for helping to meet those domestic needs. However, as Kerry et. al., and the presenters at the AAFP Conference, among others, document, the international needs are staggering.

The interest and commitment of health professionals and students in working internationally, demonstrated not only in the AAFP Global Health Conference but daily in our schools and residency programs, is a wonderful thing. Developing meaningful, useful, and long-term opportunities to serve, such as the existing programs described above and at the conference, or a new “international health service corps”, are very important goals.

[1] Kerry VB, Auld S, Farmer P, “An international service corps for health – an unconventional prescription for diplomacy”, NEJM 2010Sep23;363(13):1199-1201
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