To be a border physician is to be confronted daily with the human consequences of a failed immigration policy.
Among the patients we treat are migrants who have fallen from the border wall, migrant victims of assault - by both security forces and the cartel, often indistinguishable - and migrant patients hit by vehicles while running the gauntlet of highways on the other side of the border wall.
Our migrant patients suffer from the same exacerbations of chronic diseases characteristic of any emergency department (diabetic ketoacidosis, hypertensive urgency, and more) but also from tropical diseases such as malaria and dengue. Sometimes, they are accompanied by border patrol or other law enforcement officers. Other times, they have found their way to our emergency department, seeking help. What unites all of these patients is their preventable suffering. The wall fall patient is the most emblematic of these injuries, but all of the conditions for which they seek help have been caused or exacerbated by restrictive immigration policies that raise the cost for seeking a safe future for yourself and your children.
These patients we treat in El Paso are perhaps the most vulnerable in the country. Often they lack any sort of access to health care. Sometimes, they present to our emergency department without any legal documentation. And when they do, they are often accompanied by law enforcement; the staff of our emergency department may be the first non-law enforcement Americans they encounter.
As a volunteer at many local migrant shelters, I often find myself in the position of referring patients to my own emergency department. The emergency department is unique in that it is perhaps the only health care location where a version of “universal care” in the United States can be guaranteed. The idea that we treat all comers equally, regardless of ability to pay, was something that drew me to this specialty.
What do we owe these patients?
The answer is simple: We owe them everything. Dr. Paul Farmer, founder of Partners in Health, had a profound insight:
“Diseases…make a preferential option for the poor. That is, the poor are sicker than the non-poor. They are at heightened risk of dying prematurely, whether from increased exposure to pathogens or from decreased access to services…”
Partners in Health was founded on this insight: If diseases make a preferential option for the poor, then health care must too. For the migrant patients I send to the ED, this is perhaps the only chance they will get to receive quality health care. In the emergency department, I can order any lab that I want and consult any specialist I want. If there is any patient who deserves a million-dollar workup, it is the migrant patient.
Your patients in the ED - the unhoused, the destitute sick - also deserve this sort of work-up.
If you or I were treated in the department - resident physicians with ample access to health care - we would have countless other opportunities to seek follow-up care if our issues weren’t resolved. Our destitute patients do not have that luxury.
As emergency medicine residents, we are often driven to “move the meat,” to dispose of and discharge patients as quickly as possible. But “efficiency cannot trump equity in the field of health and human rights” (Paul Farmer). So many of our patients are victims of political pathologies. The first step to undoing the damage is treating these patients with dignity and the highest standard of care. This paradigm will undoubtedly be controversial to cash-strapped hospitals and EDs.
Our specialty has long operated as a band-aid for the policy-driven effects we see daily. Instead of being the societal band-aid, we must reframe our role to truly encompass that of the healers we swore to be. That starts by reframing our understanding of these patients not as “meat to move,” but as dignified human lives who deserve nothing less than the best of care, regardless of citizenship status or ability to pay.