Background
Undocumented immigrants in the United States live under constant fear of contact with law enforcement and potential deportation by Immigration and Customs Enforcement (ICE).Reference Hacker, Anies, Folb and Zallman 1 Policies have been in place for decades which facilitate collaboration between ICE and local police departments. Such policies include Section 287(g) of the U.S. Immigration and Nationality Act of 1996, 2 which deputizes police officers to enforce federal immigration laws, and the Secure Communities program, which allows fingerprints from individuals apprehended by police to be cross-referenced with federal immigration enforcement databases. 3 However, in recent years, national anti-immigrant rhetoric has intensified. Former President Trump’s executive order signed on January 25, 2017, broadened ICE’s focus to most undocumented immigrants in the United States, regardless of criminal record. 4 This represented a striking shift in enforcement priorities from the Obama administration, which prioritized the removal of undocumented immigrants with criminal records or those considered a threat to public safety.Reference Domonoske and Rose 5 Following the executive order, arrests by ICE climbed to a four-year high of more than 158,000 in fiscal year 2018. 6 The Trump administration also fought to expand the definition of “public charge,” a policy in which immigrants who legally receive public benefits may be prevented from obtaining legal permanent residence. This expanded “public charge” designation, which newly included the usage of the Supplemental Nutrition Assistance Program (SNAP, formerly known as food stamps) and Medicaid, was instated in February 2020 after a series of legal challenges. 7
The threat of immigration enforcement affects the health of undocumented immigrants as well as naturalized citizens and US-born members of mixed-status families. Worries about deportation have been associated with greater burden of cardiovascular risk factors among Latina women.Reference Torres, Deardoff, Gunier, Harley, Alkon, Kogut and Eskenazi 8 Restrictive immigration policies contribute to fear, anxiety, and healthcare avoidance,Reference Hacker, Chu, Leung, Marra, Pirie, Brahimi, English, Beckmann, Acevedo-Garcia and Marlin 9 and have been associated with worse mental health among citizen and non-citizen Latinos.Reference Hatzenbuehler, Prins, Flake, Philbin, Frazer, Hagen and Hirsch 10 Immigrant communities reported poorer self-rated health and higher rates of low birth weight following immigration raids.Reference Lopez, Kruger, Delva, Llanes, Ledón, Waller, Harner, Martinez, Sanders and Harner 11 Anti-immigrant policies also impact the health of US-born members in mixed-status families; local risk of deportation is associated with a chilling effect including decreased Medicaid and WIC use among citizens in mixed-status families.Reference Vargas 12 The health and psychological wellbeing of citizen children of immigrant parents are negatively impacted by fears of parental deportation.Reference Allen, Cisneros and Tellez 13 Even the lawful presence of federal agents monitoring a detained patient serves to alarm communities and deter immigrant patients from seeking care.Reference Licon 14
This study aims to evaluate the experience of health professionals with workplace immigration enforcement, their knowledge and training regarding relevant policies, and their beliefs regarding which policies institutions should follow. These findings can help in the development of ethically responsible relevant policies, procedures, and trainings.
Although current immigration policies limit enforcement in “sensitive locations” including healthcare facilities, 15 there are reports of enforcement actions in such settings throughout the United States. These enforcement actions within healthcare workplaces will be defined as “arrests, interviews, searches, and surveillance done for the purposes of immigration enforcement only.” 16 Individuals have been detained while en route to a hospital or leaving a clinic.Reference Campbell 17 Others have been questioned or detained at the bedside of their sick children,Reference Burnett 18 or forcibly removed from the hospital.Reference Demick 19
Fears among immigrants about accessing medical care are especially concerning during the global COVID-19 pandemic. In March 2020, ICE announced that it would temporarily limit its enforcement activities to those with criminal charges or who pose a threat to public safety, similar to prior enforcement priorities under the Obama administration.Reference Sacchetti and Hernandez 20 ICE has released individuals and families from detention who may be at high risk of COVID-19 and increased the number of migrants who are turned away at the US-Mexico border, leading to the lowest detained population since 2016.Reference Hsu 21 Despite these efforts, advocates fear that immigrants will continue to avoid healthcare settings.Reference Madan 22
It is essential that the privacy and safety of immigrant residents and their families are protected while accessing health services. Beyond these anecdotal reports, however, it is unclear the extent to which immigration enforcement is occurring in healthcare settings and how prepared healthcare systems and professionals are to address ICE efforts in and around their facilities. While several hospitals and clinics across the country are developing protocols to guide responses to ICE enforcement,Reference Dembosky 23 these efforts are not widespread and it is unknown how well individual providers understand the policies at their institutions.
This study aims to evaluate the experience of health professionals with workplace immigration enforcement, their knowledge and training regarding relevant policies, and their beliefs regarding which policies institutions should follow. These findings can help in the development of ethically responsible and relevant policies, procedures, and trainings.
Methods
The survey (see Appendix) was distributed nationally via an introductory email and three reminder emails sent from October to November 2018, to the up-to-date Society of General Internal Medicine (SGIM) national online member portal. There are approximately 3,000 SGIM members (including physicians, trainees, researchers, and other healthcare professionals). The online portal, free for all members to access, is the chief means of communication between the society and its members. Recipients of the invitation e-mail were encouraged to forward the survey to other healthcare professionals. Inclusion criteria were defined as any U.S. health professional who provides services to promote health, prevent disease, and deliver healthcare services. 24 All participants met inclusion criteria and no recipients of the questionnaire were excluded from participating. No identifying information was obtained to maintain anonymity. A $5 gift card was offered as incentive to participate. Data were collected anonymously through the Qualtrics survey tool (Qualtrics: Provo, Utah). The Johns Hopkins Institutional Review Board approved this study (Protocol IRB00126840).
The survey was developed through a process of iterative discussion and improvement within the research group. This process was based on a collective review of the literature and reports of law enforcement interactions with patients or staff in healthcare settings caring for immigrants. The survey was not piloted. It included 20 questions: 4 regarding demographic information; 4 regarding respondents’ knowledge about their institutions’ relevant policies and training on how to respond to law and immigration enforcement activities in the workplace; 8 regarding respondents’ own experience with immigration-related law enforcement activity at or near their workplaces; 3 regarding respondents’ perception of institutional preparedness; and 1 allowing respondents to provide additional comments.
Forty-two individuals completed the survey. Data were assessed using descriptive statistics in STATA 15.1 (StataCorp: College Station, TX). Narrative responses were analyzed and coded for themes.
Results
Respondent Demographics
Most survey respondents were attending physicians (69.1%), with 21.4% listing additional administrative roles such as program director, dean, or division chief (see Table 1). A vast majority worked at academic medical centers (90.5%) and in outpatient settings (83.3%). Most lived in the Northeast (40%) or the Midwest (21.4%). The primary language spoken by a majority of the professionals’ patients was English (85.7%), with the remaining 14.3% listing primary languages of “English and Spanish,” “Spanish,” or “English, Spanish, and Portuguese.”
Table 1 Demographics
Awareness of Policies and Enforcement
Participants were largely unaware of institutional policies to guide interactions with immigration officials (see Table 2). For instance, 82.5% of respondents were not aware of specific workplace policies regarding immigration-related law enforcement, and 76.2% were unaware of any policies, either general guidance or specific to immigration, that could be referenced in the event of an immigration enforcement action. Professionals who were aware of immigration-specific policies learned about them through working groups, guidance from legal teams, or presentations from external advocacy groups. Known general law enforcement policies included patient confidentiality policies or instructions to contact institutional counsel with any law enforcement activity.
Table 2 Survey Results
a QI7, QI8, & QI9 are free response questions. The narrative responses were analyzed and coded for themes. The n and percent are based on how many participants gave that response out of the total 42 participants that completed the survey.
Only two respondents received training regarding immigration-related law enforcement (4.8%); these trainings were conducted in person or disseminated by e-mail. One respondent had a “public safety” individual come to their clinic to educate staff. The second was a civil surgeon and received updates from U.S. Citizenship and Immigration Services. The impact of these trainings is unclear. Training about law enforcement activity in general was also limited (9.5%). Available training discussed care for patients under police custody or how institutional security personnel would interact with local law enforcement.
Nearly 1 in 5 respondents reported that they were aware of immigration enforcement activities in or near their workplace (19.1%). Of these respondents, a minority were aware of any related policies (37.5%) or received any law enforcement training (25%). Respondents cited cases of detained individuals brought to their hospital by ICE for medical attention or incidents targeting employees at nearby workplaces. Participants listed both physicians and registration staff as employees involved in incident response, and indicated that neither security personnel nor general counsel were contacted when patients in ICE custody were brought for medical care.
Facility Preparedness
The characteristics of a “prepared facility” were not defined for participants in order to elicit their perceptions of what constitutes facility preparedness. Roughly half of participants (51.3%) indicated that their facility was either unprepared to respond to immigrant-related law enforcement (24.3%) or that they were unsure of the level of preparedness (27%). Cited reasons for unpreparedness included lack of training (35.5%), lack of known policies (35.5%), potential deference by staff to immigration law enforcement (9.5%), or lack of awareness of the issue (6.5%).
This is the first study to our knowledge assessing immigration-related law enforcement activity in or near healthcare facilities and the degree to which healthcare facilities and professionals are prepared for that activity. Nearly 20% of surveyed clinicians were aware of immigration enforcement activities at or near their workplace. Despite this, respondents were largely unaware of workplace policies at their institution regarding responses to immigration-related or general law enforcement activity, and most had not received any relevant training. Overall, respondents considered their facility unprepared, or were unsure of the preparation level, to respond to immigration enforcement activity.
In particular, according to respondents, training was lacking in immigrant rights, identifying and responding to ICE agents, filling out ICE paperwork, reviewing what constitutes public space and the purview of immigration enforcement, and caring for undocumented patients. For example, one respondent answered as follows: “I feel general staff may not know whether the person asking for information is an ICE agent. I also think that people are not familiar with how to best protect rights when someone is detained. I also think public space has not been well defined in the walls of our hospital. Is it possible that ICE could legally be in our waiting rooms? Or just outside the hospital at the door.”
Some respondents also connected a lack of policies with a potential deference by staff to immigration law enforcement. As one participant stated, “there is no existing policy and there are not many persons in the clinic or in the overall institution who have knowledge about what is required in these situations. Therefore, I have some concern that there would be a high degree of deferring to immigration authorities.”
About 1 in 4 participants considered their facility possibly prepared based on general characteristics of their organization (24.3%), including communicated values of diversity and inclusion, commitment to patient privacy, and location within a “sanctuary city.” Another quarter of participants indicated that their workplace was likely prepared for an immigration-specific response (24.3%), citing specific training for security personnel, and access to legal counsel or social services organizations as resources in responding.
Participants recommended several measures to improve immigration enforcement preparedness. Most respondents suggested education and training for staff (70%) and/or development of policies or procedures to guide staff action (56.7%). Other recommendations included leadership engagement (13.3%), development of a response team (6.7%), provision of additional resources (6.7%), communication to patients (6.7%), and state legislation (3.3%). Leadership engagement was not well defined by participants, but included hospital/clinic administration communicating values of inclusion and diversity, hosting inservices for staff, and directing appropriate responses to immigration enforcement.
One respondent outlines how to incorporate several of these measures to improve facility-level preparedness: “1) Developing likely scenarios, 2) Generating executive-level consensus on how the organization would respond to each of the likely scenarios, 3) organize/coordinate departments that would have to respond to each scenario, including establish on-call point person, communicating steps each department would take, and providing resources to carry out operations; 4) communicating policies, expectations, and responses to wider audience (patients and staff).”
Discussion
This is the first study to our knowledge assessing immigration-related law enforcement activity in or near healthcare facilities and the degree to which healthcare facilities and professionals are prepared for that activity. Nearly 20% of surveyed clinicians were aware of immigration enforcement activities at or near their workplace. Despite this, respondents were largely unaware of workplace policies at their institution regarding responses to immigration-related or general law enforcement activity, and most had not received any relevant training. Overall, most respondents considered their facility unprepared, or were unsure of the preparation level, to respond to immigration enforcement activity.
The reported extent of immigration enforcement activity in or near healthcare facilities is alarming given that enforcement efforts should be restricted in these “sensitive locations.” However, the findings corroborate reporting of such events in the media. The lack of knowledge of relevant policies and training participation among respondents is also concerning. This is not surprising, given that few protocols addressing this issue are publicly known and national guidelines are lacking. A recent qualitative study highlighted the policies and procedures adopted by 25 healthcare facilities in states with the largest proportion of undocumented immigrants.Reference Saadi, Molina, Franco-Vasquez, Inkelas and Ryan 26 These facilities are promising examples, but many systems are likely to lack formal or informal policies which protect patients or guide staff response to enforcement events.
This study highlights several areas of opportunity for medical institutions to increase their level of preparedness for immigration-related law enforcement activity in their vicinity. Our findings suggest that institutions should engage their leadership and other key stakeholders, including legal experts, immigrant patients, providers, and local organizations, in order to develop a comprehensive preparedness approach appropriate to their care setting and other contextual factors. Participants highlighted education and training as a key unmet need, as well as clear policies which would protect immigrant patients and guide institutional response to potential enforcement actions. These themes are consistent with recent best practice guidance from the American Civil Liberties Union, National Immigration Law Center, and Physicians for Human Rights, which suggest training staff on “sensitive locations” policies, avoiding documenting immigration status in electronic health records, and educating patients on their rights. 27 This document also emphasizes the need for specific systems and protocols which regulate staff interaction with law enforcement officials and designate staff to review search or arrest warrants. Similarly, the analysis of institutional policies by Saadi et al. suggest that healthcare facilities should address the risk of immigration enforcement on site, the potential for immigration status disclosure, and the psychological toll on patients and providers. 28 By undertaking a comprehensive set of preparedness efforts, institutions can better ensure that they are ready to offer an appropriate and ethical response to immigration-related law enforcement in the vicinity of their clinical settings.
While institutional policy is critical for protecting immigrant patients, further advocacy is necessary at the state and federal level to ensure protections for undocumented patients seeking medical care. Congressional legislation, such as the Protecting Sensitive Locations Act, would codify and expand the designation of “sensitive locations.” 29 For the time being, lawmakers have called upon the administration to end all immigration enforcement in medical facilities during the COVID-19 pandemic. 30 Seeking care for COVID-19 is also currently protected from the public charge rule. However, in September 2020, the U.S. Court of Appeals chose to resume implementation of the expanded Public Charge rule for non-COVID related services. 31 Healthcare workers and their professional organizations should join advocacy efforts to ensure that undocumented immigrants and their families are protected while accessing necessary care including after the COVID-19 pandemic ends.
Limitations
The survey used a convenience sample of members of from the Society of General Internal Medicine professional society. While recipients of the email were invited to send the survey to other interested professionals, this distribution approach appeared to concentrate responses among general outpatient academic internists. Therefore, the results may not reflect perspectives among physicians of other specialties and other healthcare workers or be generalizable to other types of healthcare systems. The sample size of 42 also limited our data analysis and ability to perform meaningful comparative statistics. Accordingly, there is high margin for error in the rates reported in this study. However, for the purposes of this study, the small sample size is suitable for demonstrating that providers are concerned about recent immigrationrelated law activity in or near their institutions and feel unprepared to handle this situation.
The survey instrument itself was also limited. Validity testing was restricted to face validity. Respondent socio-demographic features were not obtained. Institutional policies around immigration enforcement were not publicly available so we were not able to compare whether policies were in place but were not known by the respondent, or whether policies were not in place at all.
Considerations for Further Research
There is significant opportunity to further expand the knowledge base regarding healthcare facility preparedness and response to immigration-related law enforcement activity. The survey respondents were largely physicians coming from academic medical centers. Further research efforts could solicit insight from a broader range of practice settings and professional types and obtain a larger sample size. A qualitative research project would also be useful to probe further into topics such as providers’ experiences with trainings, the features of a prepared facility, and the barriers to implementation of immigrant-centered policies. Studies could also be conducted before and after the implementation of educational programs or protective protocols to assess the impact on provider confidence in addressing immigration enforcement efforts at their facility. Surveys of immigrant patients on the features of a safe and welcoming facility would also critically inform the development of institutional policies. As more healthcare facilities implement preparedness initiatives, best practices should be implemented and evaluated for effectiveness.
Appendix
Your completion of the survey or questionnaire will serve as your consent to be in this research study.
Demographic Questions
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1. What job do you currently hold?
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2. In what state do you currently work?
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3. In what type of facility do you currently work most of the time?
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• Academic/teaching hospital - inpatient
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• Academic/teaching hospital - outpatient
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• Government hospital - inpatient
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• Government hospital - outpatient
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• Religious hospital - inpatient
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• Religious hospital - outpatient
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• For-profit hospital - inpatient
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• For-profit hospital - outpatient
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• Other hospital - inpatient (please describe)
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• Other hospital - outpatient (please describe)
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• Other (please describe)
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4. What language is spoken by a majority of your patients?
Research Questions
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5. Are you aware of any policies or procedures at your place of work specifically designed to guide a response to immigration-related law enforcement activity?
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• No
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• Yes (please describe the policies or procedures and explain how you became aware of them)
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6. Are you aware of any policies or procedures at your place of work that do not explicitly pertain to immigration-related law enforcement activity but that would be used as default guidance to respond to such activity?
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• No
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• Yes (please describe the policies or procedures and explain how you became aware of them)
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7. Have you received any training specifically designed to guide a response to immigration-related law enforcement activity?
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• No
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• Yes (please describe the training)
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8. Have you received any training designed to guide a response to law enforcement activity, but not specifically immigration-related law enforcement activity?
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• No
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• Yes (please describe the training)
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9. Are you aware of immigration-related law enforcement activity within or in the vicinity of a clinical setting at your place of work?
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• Yes
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• No
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10. How many such incidents are you aware of over the last twelve months?
(If answered 1 or more)
We will now ask you several questions about each of these incidents.
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11. Regarding the X incident, to the best of your memory, when did it occur?
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12. Regarding the X incident, who was the focus of the immigration-related law enforcement activity?
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• Employee (please specific employee’s position)
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• Patient
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• Patient’s family member
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• Other (please specify)
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13. In what setting did the X incident occur?
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• Inpatient hospital - emergency department
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• Inpatient hospital - admitted patient floor (please describe inpatient area)
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• Outpatient clinic (please describe outpatient setting)
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• School-based clinic (please describe school-based clinic)
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• Other (please specify)
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14. Which of the following staff members were involved in some capacity in the response to the X incident?
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• Security personnel
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• Registration staff
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• Nursing staff
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• Physicians
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• Legal counsel for the health system
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• Other (please specify)
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15. To the best of your knowledge, had any of the individual staff members other than you received relevant information or training prior to the X incident?
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• No
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• Yes (please specify which staff members and what type of preparation occurred)
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16. Please provide a narrative description of the X incident, including sequential actions taken by various members of hospital faculty and staff in response to the initial event and how these actions did or did not adhere to any policies or procedures you are aware.
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17. In what aspects do you feel your facility is prepared to manage any immigration-related law enforcement activity within or in the vicinity of a clinical setting at your place of work?
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18. In what aspects do you feel your facility is not prepared to manage any immigration-related law enforcement activity within or in the vicinity of a clinical setting at your place of work?
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19. What steps would need to be taken for your facility to be fully prepared for future immigration-related law enforcement activity?
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20. Are there any other comments you would like to provide about incidents you have witnessed or your facility’s preparation for the possibility of immigration-related law enforcement activity?
