Strengthening Academic Medicine’s Response to Humanitarian Concerns

As we in academic medicine become increasingly aware of humanitarian concerns across the globe, we encounter new opportunities to use our skills, training, and resources to respond in accordance with our professional values and missions.¹ These efforts often require us to expand beyond our usual approaches to training and care delivery.² These efforts also require us to confront tragedy—caused either directly by interpersonal violence or indirectly by consequences of broader decisions in society—experienced at a scale that we may not have previously encountered or imagined. Many of the challenges are practical in nature, such as bringing clinical care to new service settings and populations. Some challenges are less tangible but no less consequential, such as bringing sensitivity to the intersectional narratives and concerns of those who have experienced displacement, trauma, and human rights violations.^3–7

In this issue of the journal, we are pleased to highlight the efforts and experiences of our colleagues in academic medicine that have addressed the humanitarian crisis of unaccompanied children received at the southern border of the United States, as described by Devaskar et al.⁸ As these authors detail, the numbers of children arriving at the border not accompanied by a biological parent reached unprecedented heights in 2021.^8,9 The majority of these children fled their home countries because of extreme poverty, violence, and social conditions that made it impossible to thrive and grow, seeking to join family members already living in the United States. Many children, then and now, arrive with complex and chronic histories of trauma and adversity, and reach the southern border after undertaking arduous journeys where they faced acute health, safety, and psychological risks.^10,11 These children carry with them incredible resilience and capabilities, but often encounter policies and systems that do not adequately meet their needs and pose risks that can undermine their strengths.^2,12 The combined expertise of health professionals in academic medicine bring valuable insight into the long-term individual and public health consequences to unaccompanied immigrant children that stem from their histories, as well as the best-practice approaches, via health care and service, for addressing and mitigating the risks they face.¹¹

The U.S. government agencies responsible for the reception and care of unaccompanied immigrant children were underprepared for the influx of children arriving at the U.S.–Mexico border in 2021. The influx led to the opening of 14 Emergency Intake Sites (EISs) across the nation to provide temporary congregate shelter and care for children as they awaited release to their families or placement in other longer-term care or foster programs.¹³ Due to the nature of the acute crisis, EIS facilities had little oversight and relied heavily on volunteer federal government staff and contractors.¹⁴ The EIS facilities varied greatly in terms of their conditions and availability of services and programs for children.¹⁵ In that moment of crisis, the federal government turned to academic medicine for support in addressing the medical and health needs of unaccompanied children in government custody at EISs.⁸

Devaskar et al⁸ tell the compelling account of a university health care system—in this case, the University of California Health system (UCH)—mobilizing to meet the needs of both individual children and governmental systems in a critical moment in their respective experiences. This story exemplifies the crucial and influential role that academic medicine can play in responding to humanitarian concerns and crises. The experience of the UCH demonstrates that, when issues arise that touch on the universal values and ethics inherent in academic medicine and health service, large groups of individuals operating in and across complex systems can work collaboratively toward achieving shared aims.

Indeed, Devaskar et al document an impressive process within the UCH to organize and coordinate resources across big organizations and systems to address the humanitarian concerns regarding the health and safety of unaccompanied immigrant children.⁸ The authors offer a roadmap for organizational processes within academic medicine that can inform or be replicated in future efforts (1) to pursue academic–governmental partnerships and/or (2) to advance academic medicine’s responses to humanitarian concerns and crises. Inspired by this effort, we call on other academic health centers to look to the UCH experience in considering the ways they can expand traditional boundaries and service efforts consistent with their missions and values.

In their article, Devaskar et al provide an important model for academic medicine, and their efforts, activities, and lessons learned may have lasting impact for the government agencies charged with the reception and care of immigrant children and, clearly, for all children in government care. For example, the new implementation of a centralized electronic health record system within the EISs via the UCH offered important advances to improve continuity of care, including transfer and follow-up as children were released into communities. Other innovations with similar effect were accomplished through the implementation of on-site pharmacies, evaluation, and laboratory facilities. In these examples, the UCH effort resulted in the demonstration of process innovations that can improve federal systems of care for unaccompanied children.

The UCH effort—given the level of experience; training; and expertise of medical faculty, staff, and trainees—offered children improved access to best practices in pediatric care. The services, supports, and resources offered by the UCH at EIS facilities sought to minimize distress via crisis management and support, to prevent illness and outbreak, and to support child adjustment and engagement in the developmentally appropriate tasks of learning and play. The potential long-term beneficial effects of this effort, both in terms of prevention and also intervention for health risks, cannot be understated, and we hope they do not go underappreciated by both our medical and government communities.

One of us (R.B.M.) spent time with unaccompanied immigrant children in a different EIS facility on a military base in Texas, in an effort to understand the health and psychological functioning of these children while in government custody.¹⁶ Interviews and observations revealed deeply concerning experiences: Children were spending upward of 22 hours per day restricted against their will in massive tents with thousands of other children without educational or recreational activities. Many children reported extreme boredom, anxiety, helplessness, and despair as they languished without receiving information or notice about the current status of their sponsorship cases and placement plans, while also struggling to access protective supports from adults or caregivers both within and outside the facility. Reports of self-harming behavior amongst the children were particularly concerning.¹⁶

Although there is clear need to provide for children and youth as they await placement, congregate care facilities that lack individualized supports or developmentally appropriate activities may be damaging for children and youth; nonetheless, the month-to-month average length of stay in EISs from April 2021 to April 2022 ranged from 7 to 28 days, with maximum lengths of placement spanning over 3 months for some children.¹⁵ For the 2 EIS facilities in California where the UCH was operating, the strategic availability of supports such as psychological first aid and child life services may have mitigated some concerns and risks associated with the EIS custody setting. Other supports included the availability of age-appropriate activities, such as daily education, which offer opportunities for productive efforts that, when aligned with children’s goals, can reduce their anxiety and despair.

In the current example of partnership between academic medicine and the federal government, the UCH was able to provide services for nearly 5,000 children in 2 EIS sites, effectively maximizing the impact of the UCH within their scope of service and authority. Nonetheless, with 14 EISs in operation under the Department of Health and Human Services in 2021, there is reason to consider the experience and outcomes of the thousands of children who did not benefit from placement at a facility with access to UCH resources. Consistent with our own experience, there has been wide criticism and concern about the conditions of care and adversities experienced by children in many of these sites.¹⁵

As health professionals concerned with the safety and well-being of children across the nation (and our world), we might consider taking advantage of opportunities for advocacy and additional training. Through advocacy, how might we leverage these sorts of service and partnership efforts to pursue lasting change in systems and policies that often risk putting children at harm? Through training, how might we improve the preparation of health professionals who feel the strain and stresses of encountering trauma and inequities at a scale previously not experienced or imagined? How do we prepare for the complex ethical issues that arise in extreme settings, e.g., how to honor unaccompanied children’s rights when implementing treatment, or how improved information-sharing and coordination that is possible through an electronic medical record must also be balanced with specific considerations relevant to the population, such as whether immigrant children or their parents/caregivers want their personal health information to be made accessible to government agencies and partners?^2,7

Academic medicine embraces its 5 missions of scientific discovery; health professions education; clinical care and services; community engagement and leadership; and commitment to excellence, professionalism, diversity, equity, inclusion, antiracism, and belonging.¹ Each of these missions and commitments is deeply relevant to the experience of unaccompanied immigrant children—and all require nurturance within the field of academic medicine and tremendous advocacy in our broader society. The UCH activities in support of children at EIS facilities represent an illustration of the positive role of academic medicine in response to an urgent humanitarian crisis. Dear Reader, how can we use the knowledge and momentum gained from this effort and this partnership to better realize academic medicine’s values?