Impact of COVID-19 on Unaccompanied Immigrant Minors and Families: Perspectives from Clinical Experts and Providers.

The number of unaccompanied immigrant minors (UIMs) and families from Central America seeking asylum in the U.S. continues to rise. This growth, combined with restrictive government policies, led to crowded and suboptimal conditions in Customs and Border Patrol and non-governmental organization facilities. COVID-19 further taxed facilities and exacerbated uncertainty surrounding length of detention, basic human rights, and family reunification. The current project features testimonies from the authors who work as clinical experts and providers in Texas - a top destination for Central American immigrants. In collaboration with a deputy director of a not-for-profit human rights organization, volunteer psychologists, and the director of a humanitarian respite center, we describe challenges faced by administrators and clinical staff in addressing the mental health needs of immigrant children and families during the COVID-19 pandemic. The primary themes identified were anti-immigrant policies that occurred concurrently with COVID-19; difficulty implementing COVID-19 protocols alongside scarcity of supplies and volunteers; increased mental health needs among UIMs and immigrant families; and challenges in UIM placement upon release from custody. Strategies for addressing clinical challenges in the near- and long-term and opportunities for improvement in care systems to immigrant youth, including correcting anti-immigrant policies, addressing ongoing COVID-19 protocols and challenges, meeting mental and physical health needs, facilitating release and reunification for unaccompanied immigrant minors, and maximizing youth resilience through trauma-informed interventions, are presented.

What constitutes a high-quality, comprehensive medico-legal asylum affidavit in the United States immigration context? A multi-sectoral consensus-building modified Delphi.

In the United States, clinicians are often called upon to provide their expertise to generate expert evidence in cases of individuals seeking asylum or other forms of international protection. Due to a lack of validated guidelines specific to the U.S. immigration context, clinical evaluations produced for immigration proceedings in the United States vary in their format, structure, and content, which can be confusing for practitioners and for adjudicators assessing the weight these evaluations should be afforded in asylum proceedings. We sought to review critical components of a medico-legal asylum evaluation from an interdisciplinary perspective of key stakeholders, by collecting and synthesizing expert opinions to reach consensus on what constitutes a high-quality, comprehensive medical or psychological affidavit for U.S. immigration cases. The consensus process incorporated a three-step modified Delphi method, which took place between September and December 2021 and consisted of two rounds of online questionnaires and a synchronous video conference meeting. The areas most experts agreed on included, by order of highest agreement (combining answers of "strongly agree" and "agree"): A narrative form or checklist is preferable to a predetermined template (95%); Primary care physicians should describe their qualifications to diagnose mental health conditions (81%); Use of citation is helpful, with caveats (77%); Clinicians should include an assessment of malingering (72%); Clinicians should include an executive summary/summary of conclusions at the top of the affidavit (72%); Clinicians should reference the Istanbul Protocol and explain its relevance (66%); It may be beneficial for clinicians to describe the anticipated process of healing (57%); Clinicians may include treatment recommendations (52%). Results of this and future consensus-building efforts and resulting guidance should be used to enhance overall quality of medico-legal reports and incorporated in training programs developed for clinicians, attorneys and adjudicators.

Individuals' experiences in U.S. immigration detention during the early period of the COVID-19 pandemic: major challenges and public health implications.

BACKGROUND: Individuals held in carceral settings were significantly impacted by the COVID-19 pandemic. However, limited research exists of the direct experiences of individuals detained by the United States (U.S.) Immigration and Customs Enforcement (ICE). This study illustrates the major challenges described by individuals held in ICE's immigration detention centers during the initial spread of COVID-19. METHODS: We interviewed 50 individuals who were released from ICE detention between March 15, 2020 until August 31, 2020. Participants were recruited through immigration attorneys. Responses to a semi-structured interview were documented. Quotes from these interviews were thematically analyzed. RESULTS: Study participants were detained in 22 different ICE detention centers, which were located across 12 states, in both county (41%) and privately-contracted facilities (59%). The major themes that emerged from interviews included inadequate protections against COVID-19, denial of physical and mental healthcare, and experiences of retaliation in response to self-advocacy. These issues perpetuated emotions of fear, distrust, and helplessness in individuals in immigration detention centers. CONCLUSIONS: This study represents the largest analysis of experiences of ICE-detained immigrants during the early months of the COVID-19 pandemic. To ensure the rights to health and wellbeing for this population, further actions should include improving public health conditions, protecting against human rights violations, addressing barriers to healthcare access, ensuring transparency about conditions in detention centers, and moving toward decarceration.

Clinicians' perceptions of the health status of formerly detained immigrants.

BACKGROUND: In the past decade, the U.S. immigration detention system regularly detained more than 30,000 people per day; in 2019 prior to the pandemic, the daily detention population exceeded 52,000 people. Inhumane detention conditions have been documented by internal government watchdogs, and news media and human rights groups who have observed over-crowding, poor hygiene and sanitation and poor and delayed medical care, as well as verbal, physical and sexual abuse. METHODS: This study surveyed health professionals across the United States who had provided care for immigrants who were recently released from immigration detention to assess clinician perceptions about the adverse health impact of immigration detention on migrant populations based on real-life clinical encounters. There were 150 survey responses, of which 85 clinicians observed medical conditions attributed to detention. RESULTS: These 85 clinicians reported seeing a combined estimate of 1300 patients with a medical issue related to their time in detention, including patients with delayed access to medical care or medicine in detention, patients with new or acute health conditions such as infection and injury attributed to detention, and patients with worsened chronic or special needs conditions. Clinicians also provided details regarding sentinel cases, categorized into the following themes: Pregnant women, Children, Mentally Ill, COVID-19, and Other serious health issue. CONCLUSIONS: This is the first survey, to our knowledge, of health care professionals treating individuals upon release from detention. Due to the lack of transparency by federal entities and limited access to detainees, this survey serves as a source of credible information about conditions experienced within immigration detention facilities and is a means of corroborating immigrant testimonials and media reports. These findings can help inform policy discussions regarding systematic changes to the delivery of healthcare in detention, quality assurance and transparent reporting.

Trauma Exposures, Resilience Factors, and Mental Health Outcomes in Persons Granted Asylum in the U.S. for Claims Related to Domestic Violence and Persecution by Organized Gangs.

Survivors of domestic violence (DV) and of violence perpetrated by organized gangs (GV) face barriers to legal protection under U.S. asylum law. We abstracted data from 132 affidavits based on forensic medical evaluations of asylum seekers granted legal protection in the U.S. on the basis of DV and/or GV. We described claimants' trauma exposures and resilience factors and used multiple logistic regression to quantify associations with Diagnostic and Statistical Manual-5 (DSM-5) diagnoses and improvement in mental health. People seeking asylum based on DV and/or GV have endured multiple types of trauma with significant impacts on their mental health. New experiences of trauma following migration to the U.S. were common and associated with DSM-5 diagnoses. Conversely, resilience factors were associated with improved mental health. Policies that aim to reduce ongoing trauma in the U.S. and to bolster resilience factors may promote asylee mental health and well-being.

Impact of forensic medical evaluations on immigration relief grant rates and correlates of outcomes in the United States.

The purpose of this study was to investigate the impact of forensic medical evaluations on grant rates for applicants seeking immigration relief in the United States (U.S.) and to identify significant correlates of grant success. We conducted a retrospective analysis of 2584 cases initiated by Physicians for Human Rights between 2008 and 2018 that included forensic medical evaluations, and found that 81.6% of applicants for various forms of immigration relief were granted relief, as compared to the national asylum grant rate of 42.4%. Among the study's cohort, the majority (73.7%) of positive outcomes were grants of asylum. A multivariable regression analysis revealed that age, continent of origin, history of sexual or gender-based violence, gang violence, LGB sexual orientation, and being detained by the U.S. government at the time of evaluation request were statistically associated with case outcomes. Forensic physical evaluation was more strongly associated with a positive outcome than forensic psychological evaluation. Our findings strengthen and expand prior evidence that forensic medical evaluations can have a substantial positive impact on an applicant's immigration relief claim. Given the growing applicant pool in the U.S., there is an urgent need for more trained clinicians to conduct forensic medical evaluations as well as to educate adjudicators, immigration lawyers, and policy makers about the traumatic nature of the life-altering events that applicants for immigration relief experience.

The psychological effects of forced family separation on asylum-seeking children and parents at the US-Mexico border: A qualitative analysis of medico-legal documents.

The U.S. government forcibly separated more than 5,000 children from their parents between 2017 and 2018 through its "Zero Tolerance" policy. It is unknown how many of the children have since been reunited with their parents. As of August 1, 2021, however, at least 1,841 children are still separated from their parents. This study systematically examined narratives obtained as part of a medico-legal process by trained clinical experts who interviewed and evaluated parents and children who had been forcibly separated. The data analysis demonstrated that 1) parents and children shared similar pre-migration traumas and the event of forced family separation in the U.S.; 2) they reported signs and symptoms of trauma following reunification; 3) almost all individuals met criteria for DSM diagnoses, even after reunification; 4) evaluating clinicians consistently concluded that mental health treatment was indicated for both parents and children; and 5) signs of malingering were absent in all cases.

Clinicians' Perspectives on the Impacts of Post-2016 Immigration Enforcement on Immigrant Health and Health Care Use.

OBJECTIVE: To examine clinicians' perspectives on changes in health and health care utilization of immigrant patients, the presence of immigration enforcement in health facilities, and institutional responses to these changes in the post-2016 period in the United States. METHODS: From a survey of clinician members of the Physicians for Human Rights Asylum Network (March-June 2020), we described responses and identified key themes. RESULTS: Post-2016 anti-immigrant policies and rhetoric negatively affected mental health, physical health, and health care-seeking behaviors among immigrant patients. Although most clinicians reported rarely witnessing immigration enforcement activities, nearly half reported persistent fear among their immigrant patients. A higher percentage of clinicians in U.S. border states reported increased fears associated with adverse physical and mental health effects among immigrant patients than those in non-border states. CONCLUSION: Clinicians' perspectives on the impact of immigration enforcement on patient health is critical to informing multi-level interventions to improve immigrant health.

Conducting remote medical asylum evaluations in the United States during COVID-19: Clinicians' perspectives on acceptability, challenges and opportunities.

BACKGROUND: Due to the COVID-19 pandemic, medical evaluations for asylum are being performed predominantly remotely. We sought to describe these evaluations and identify barriers. METHODOLOGY: This study utilized an online survey to assess clinician perspectives and experiences regarding remote asylum evaluations. RESULTS: Clinicians reported positive experiences regarding remote interpretation (85%, 51/60), history taking (82.4%, 61/74), rapport building (81.3%, 61/75), and conducting the psychiatric exam (65.7%, 44/67). Concerns were more frequently reported with performing remote physical examinations (83.3%, 15/18). Although the majority denied challenges with technology (62.5%, 45/72), internet (60.8%, 45/74) or clients having difficulty acquiring technology (58.6%, 41/70) or finding private spaces (54.2%, 39/72), these aspects did represent barriers. DISCUSSION: Remote evaluations were relatively easy to perform and acceptable to clinicians. This may facilitate easier access for asylum seekers beyond the pandemic.

"Better than having no evaluation done": a pilot project to conduct remote asylum evaluations for clients in a migrant encampment in Mexico.

BACKGROUND: Asylum evaluations are highly specialized medico-legal encounters to collect physical or mental health evidence for use in immigration proceedings. Although the field of asylum medicine is growing, access to these evaluations is still inadequate, particularly for those in United States immigration detention or other forms of custody, such as under the U.S. Migrant Protection Protocols or "Remain in Mexico" policy. Given advances in telehealth in recent years and growing evidence of similar outcomes with in-person management, it seems prudent to examine whether remote modalities may also be effective for conducting mental health asylum evaluations in hard-to-reach populations. METHODS: We analyzed the responses of 12 U.S. clinicians who conducted 25 cross-border remote mental health evaluations with clients in Mexico prior to the COVID-19 pandemic, and completed a post-evaluation survey regarding their impressions and experiences of the remote encounter. Data were coded through a process of thematic analysis. RESULTS: The average evaluation time was 2.3 h, slightly shorter than might be expected from an in-person encounter. Five themes emerged from the coding process: rapport building, achieving overall goal, comparison of in-person vs. remote, technical issues, and coordination. Clinicians encountered a number of challenges including technical difficulties and a decreased ability to establish rapport. Nearly uniformly, however, clinicians noted that despite difficulties, they were able achieve the goals of the evaluation, including rapport building and diagnosis. CONCLUSION: Remote evaluations appear to achieve their intended goal and may be useful in expanding legal options for hard-to-reach asylum seekers.

Associations between memory loss and trauma in US asylum seekers: A retrospective review of medico-legal affidavits.

BACKGROUND: The U.S. immigration system mandates that persons seeking asylum prove their persecution claim is credible and their fear of returning home is well-founded. However, this population represents a highly trauma-exposed group, with neuropsychiatric symptoms consequent to prior torture or maltreatment that may interfere with cognitive function and their ability to recall their trauma. These memory lapses may be incorrectly perceived by asylum adjudicators as indicators of dishonesty and jeopardize the person's credibility and asylum claim. Our retrospective mixed methods study seeks to present associations between trauma and memory loss in a sample of persons seeking asylum to the U.S. and describe how memory impairments manifest in this trauma-exposed population. METHODS: We randomly selected 200 medico-legal affidavits from 1346 affidavits collected in the past 30 years, as part of the Physicians for Human Rights Asylum Network connecting clinicians with legal providers for medical and/or psychiatric affidavits of U.S. asylum seekers and persons seeking other forms of humanitarian relief (hereafter, "asylum seekers"). Data was extracted from these affidavits using a coding manual informed by the Istanbul Protocol, the global standard for torture documentation. Seven affidavits were excluded due to missing age. We used multiple logistic regression to assess the association of memory loss with neuropsychiatric diagnoses: head trauma, post-traumatic stress disorder (PTSD), and depression. We supplemented these findings with a qualitative content analysis of the affidavits documenting memory loss. Memory loss presented among the asylum seekers' affidavits in several ways: memory gaps of the traumatic event; challenges with presenting a clear chronology of the trauma, avoidance of traumatic memories, and persistent short-term memory loss interfering with daily activity. RESULTS: A majority of the sample received a neuropsychiatric diagnosis: 69% (n = 132) of asylum-seekers received a diagnosis of PTSD and 55% (n = 106) of depression. Head trauma was reported among 30% (n = 58) of affidavits. Further, 68% (n = 131) reported being subject to physical violence and 20% (n = 39) were documented as being at risk of suicide. Memory loss was documented among 21% (n = 40) asylum-seekers. In adjusted models, both PTSD and depression, but not head trauma, were associated with memory loss (p<0.05). CONCLUSION: Stakeholders in the asylum process, spanning the medical, legal and immigration enforcement sectors, must be aware of the interplay of trauma and memory loss and how they might impact immigration proceedings for this vulnerable population.

Health Professionals, Human Rights Violations at the US-Mexico Border, and Holocaust Legacy.

Health professionals caring for asylum seekers face decisions about whether to participate in force-feeding hunger strikers, performing and reviewing unnecessary x-rays to assess detainees' ages, misusing detainees' health information, and discharging patients based on immigration officials' demands rather than patient safety. The latter action is a classic dual-loyalty dilemma reminiscent of some clinicians' actions during the Holocaust. This article investigates how professional organizations can support clinicians targeted by the state for resisting immigration officials' demands for their participation in human rights violations, opposing policies that compromise health professional values, and refusing to engage in unethical detention practices.

Female Genital Mutilation/Cutting as Grounds for Asylum Requests in the US: An Analysis of More than 100 Cases.

Female Genital Mutilation or Cutting (FGM/C) is a human rights violation used to claim asylum in the US. We sought to understand the nature of these asylum requests. Analysis of 121 FGM/C-focused medical affidavits, and 132 legal case reports. Of 119 eligible affidavits analyzed, 84% were reportedly cut: 4.6% Type I, 84.6% Type II, 16.5% Type III. Average age: 9. Reported acute effects: bleeding (76.3%), infection (27.6%), shock (6.7%), broken bones (2.7%), and hospitalization (2.7%). Reported chronic issues: intercourse difficulty (81.7%), pregnancy complications (54.2%), chronic pain (42.4%), scarring (37.3%), urinary difficulty (31.8%). Psychological consequences included PTSD (72.4%), depression (65.9%), anxiety (51.1%), and lack of trust (10.1%). Co-occurring abuses included domestic violence (62.4%), forced marriage (46%), rape (33.3%), torture (33.3%), child marriage (31.3%), assault due to LGBTQ + status (2.9%). Women claiming asylum based on FGM/C report high rates of chronic health issues. Their histories suggest FGM/C co-occurs with other forms of gender-based violence.

The effects of tibial intraosseous versus intravenous amiodarone administration in a hypovolemic cardiac arrest procine model.

OBJECTIVE: This study compared the effects of amiodarone via tibial intraosseous (TIO) and intravenous (IV) routes on return of spontaneous circulation (ROSC), time to ROSC, maximum drug concentration (Cmax), time to maximum concentration (Tmax), and mean concentrations over time in a hypovolemic cardiac arrest model. DESIGN: Prospective, between subjects, randomized experimental design. SETTING: TriService Research Facility. SUBJECTS: Yorkshire-cross swine (n = 28). INTERVENTION: Swine were anesthetized and placed into cardiac arrest. After 2 minutes, cardiopulmonary resuscitation (CPR) was initiated. After an additional 2 minute, 300 mg of amiodarone were administered via the TIO or the IV route. Blood samples were collected over 5 minutes. The plasma concentrations were analyzed using high-performance liquid chromatography tandem mass spectrometry. MAIN OUTCOME MEASUREMENTS: ROSC, time to ROSC, Cmax, Tmax, and mean concentrations over time. RESULTS: A multivariate analysis of variance indicated that there were no significant differences in the TIO and IV groups in ROSC (p = 0.515), time to ROSC (p = 0.300), Cmax (p = 0.291), or Tmax (p = 0.475). The mean Cmax of the TIO group was 56,292 ± 11,504 ng/mL compared to 74,258 ± 11,504 ng/mL for the IV group. The Tmax for TIO and IV groups were 120 ± 25 and 94 ± 25, respectively. A repeated measures analysis of variance indicated that there were no significant differences between the groups relative to concentrations over time (p > 0.05). CONCLUSION: The TIO provides rapid and reliable access to administer lifesaving medications during cardiac arrest.