International and Domestic Health Equity and Leadership (IDHEAL) UCLA Emergency Medicine

Social Emergency Medicine Teaching Modules
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Module 11
Todd Schneberk, MD
Shamsher Samra, MD, MPhil


1. Understand the ways in which immigration affects health.

2. Delineate the different barriers to health that immigrants face.

3. Identify methods of mitigating these barriers from the emergency department.


A 38-year-old female presented to the ED after a fall from a ladder. She could not ambulate at the
scene and did nothing but scream when providers attempted to examine her and so she was "pan- scanned", i.e. received multiple CT scans in attempt to identify her injuries. The CT scans were negative. She is signed out to you, the on-coming ED attending, pending the radiology reading of her MRI of the spine. You enter the room to find a patient with a vacant stare. You attempt to engage her and she screams, "¡No me toca!" Her sister-in-law is at bedside and you decide to engage her in conversation.

She reveals the patient’s unfortunate but common backstory. She is originally from El Salvador where she was being extorted for exceeding amounts of money by the "Maras" (MS13, a predominant gang). She feared for her life and, in attempt to escape their extortion and threats, she paid a coyote to smuggle her and her children into the United States. Midway through the journey, the coyote sold her to the Zetas (a Mexican drug cartel) who held her in captivity for 10 months. She was repeatedly sexually and physically assaulted until her family in the U.S. collected enough money to pay ransom. She was then freed and brought to Los Angeles. She has significant residual mental health issues from the experience, including intermittent episodes similar to today's presentation that resemble flashbacks. These episodes are increasingly affecting the patient's
ability to function and especially to parent, so her children are often watched by other family members. The family has been trying to convince her to seek medical help and especially mental health care, but she is too afraid of deportation and the thought of returning to the nightmare she escaped.

She works cleaning houses to help support her family. Today's fall happened at work. She was asked by her employer to clean the windows on the outside of the house. Despite pleading that she didn’t know how to use a ladder, the boss insisted. She complied for fear of losing her job, as work is difficult to find without documentation. Furthermore, if she lost her job, she was afraid that her new husband, a U.S. citizen, would beat her as he had in the past. She married him because he had promised her a green card but since their marriage, he had lost interest in helping her with immigration forms.

The MRI and complete trauma workup was negative. But since you spent the time to engage the sister-in-law, you were able to refer her for treatment of her psychiatric disease for which she now receives medication and therapy. She was referred to legal services and, with their help, submit a VAWA application.

Discussion Questions

1. How has this patient's experiences contributed to her current presentation?

2. What is VAWA?

3. What is a green card and who can get one?

4. What are the different forms of immigration relief available for refugees, asylees, victims
of domestic violence, trafficking, and other crimes?

Teaching Points

1. Immigrants, especially those who emigrated within the last 10 years, are more likely to have experienced traumatic events in their country of origin, making them more likely
refugees rather than economic migrants. (A Refugee is a person who has fled his/her home country and cannot return because of a well-founded fear of persecution due to race, religion, nationality or membership of a particular social group.)

2. Continued subjugation and mistreatment often continues to occur after arrival in the U.S. due to reduced status in society and lack of agency to fight back due to fear of deportation or other negative ramifications, often manifesting as fear of going to the police, or accessing social services or the healthcare system.

3. The ED is a pivotal touch-point for these populations so we need to equip our EDs to provide immigration-informed care, which includes explicit signage welcoming people of all backgrounds and documentation status to the ED, providing appropriate language services, training our providers in specific risks and reticence to fully disclose circumstances within this population, and create medico-legal partnerships from the ED to refer these patients to immigration legal advocates (more below).

4. Patients who are victims of a trafficking, domestic violence, any crime in the U.S. or who are fleeing their home country due to fear may be eligible for status adjustment and legal permanent residence; these, among other options, not only bring stability and security into their life but also provide eligibility for Medicaid and other social services. Asylum status is a form of protection for people who 1. meet the definition of refugee and 2. are already in the U.S. or are at a point of entry to the U.S.

5. Outside of these methods, there are very limited ways for someone to become a legal permanent resident or a U.S. citizen.

Practical Questions

1. What are the immigrant demographics in your local population?

2. What resources are available for these patients locally?

3. What is the sanctuary status of your city and hospital?

Recommended Screening Question(s)

None: Given the current political environment, the LA County Health Agency SBDOH Workgroup has decided to not screen for immigration directly to minimize the risk to patients. It recommends instead that immigration be listed as an example of a potential legal need during the legal needs screener. In this way, the patient can say yes to “I have a legal need,” and receive a referral with no further specifics recorded.

Paired Reading

Saadi A, Ahmed S, Katz MH. Making a Case for Sanctuary Hospitals. JAMA 2017;318:2079-80.

Discussion Points from the Reading

1. One of the ideals of medicine is that all patients should feel secure in seeking medical care, particularly the most vulnerable of our society.

2. The term "sanctuary" has been applied to cities and institutions that have established practices to protect their undocumented populations. Hospitals already adhere to HIPAA and state privacy laws to protect their patients. There are additional, specfic things that hospitals can do to further protect their undocumented patients. Hospitals can create clear policies regarding immigration officers who enter the institution. No hospital employee should provide information to ICE agents without a court-ordered warrant or subpoena. Hospitals can educate employees and patients about the policy so that patients know that their personal information will not be shared with ICE.

Additional Readings

1. Social Determinants of Migrant Health: health

2. Castaneda H, Holmes SM, Madrigal DS, Young ME, Beyeler N, Quesada J. Immigration as a social determinant of health. Annu Rev Public Health 2015;36:375-92.

3. Holmes SM. An ethnographic study of the social context of migrant health in the United States. PLoS Med 2006;3:e448.