Differences in Acute Healthcare Needs for Asylum Seekers

The intersection of US immigrant health policy and clinical practice is a complex area of concern as a physician-advocate. As we navigate new challenges with the incoming presidency and fluctuating public opinion about immigrant rights, it is important to highlight the differences in healthcare needs of this population to provide informed and high-quality clinical care when an asylum seeker walks into our clinic or Emergency Department.

At the US-Mexico Border, asylum seekers in Mexico are subjected to violence, extortion, kidnappings, and sexual assault, with minimal access to healthcare. Dehydration & infections are common. For in situ Asylum Seekers & those in immigration detention, compared to resettled refugees, behavioral disorders are nine times more common and infectious diseases/parasitic infections are twice as prevalent. ICE detainees may also have important medications (ex/ anti-epileptics, cardiac meds, HIV meds, or insulin) confiscated by authorities.

As a general approach to interacting with asylum seekers in the ED, make sure to use an appropriate professional language interpreter, and ask about past medical history & last visit to a health care professional. Consider missed routine vaccinations in children, and consider screening for communicable diseases (i.e. TB, HIV, Hep B and C), as the prevalence of these illnesses are higher among asylum seekers. Also be aware that approximately 87% of torture survivors who resettle in other countries suffer from chronic pain, which often goes undiagnosed due to a lack of culturally sensitive diagnostic tools and confounding psychiatric illnesses.

The asylum seeker population has a particularly high rate of mental health disorder burden. In one study, 69% refugees were diagnosed with PTSD and 55% with depression. In regard to those with detention histories, the adverse mental health impacts of ICE detention include higher levels of anxiety, depression and PTSD. Transgender asylum seeker detainees in particular report psychological trauma secondary to abusive treatment by authorities & culture of transphobia, refusal of access to hormone treatment in ICE detention centers. Thus, strongly consider mental health care referral for PTSD symptoms among asylum seekers - the number needed to treat for PTSD symptom mitigation is as low as two to three patients.

Importantly, consider trafficking in unaccompanied minors: 75-80% of newly arriving unauthorized unaccompanied children were brought across the border by coyotes (paid smugglers), who occasionally sell migrants into labor or sex work to recover costs. One study demonstrated that 68% trafficked persons presented to a healthcare professional at least once, and 56% of the time they presented to an ED or Urgent Care. Thus, EPs should maintain a high index of suspicion for trafficking when caring for these patients.

Finally, connect asylum seeker patients to resources. Inform patients of Medicaid eligibility, provide cost-mitigating strategies such as GoodRx, and enlist Social Work consults for connections to social service programs. Consider a referral to an Asylum Seeker Resource Navigation Center to assist new arrivals to obtain free and confidential help accessing health insurance and school enrollment, mental health counseling, child services, and legal services. Asylum seekers are also more likely to be unhoused than US-born persons - connect them to housing resources as needed.

In summary, Emergency Physicians should...

• Use a trauma-informed approached to the interview and examination

• Directly ask about prior threat, harm or persecution and refer survivors of abuse to community resources

• Offer influenza/tetanus vaccines, STI screening and pregnancy screening when appropriate

• Consider restarting chronic medications when clinically appropriate

• Explore engaging in immigration health advocacy via direct US-Mexico border clinical care, or provision of forensic medical evaluations and/or medical parole letters

References

1. Trump admin plans to block asylum seekers from U.S. by citing public health risk of COVID-19

2. Molyneux K, Singer E. Asylum seekers and the role of the acute care physician. J Am Coll Emerg Physicians Open. 2024 Jun 16;5(3):e13196. doi: 10.1002/emp2.13196. PMID: 38887226; PMCID: PMC11180694.