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October 16, 2017

Making a Case for Sanctuary Hospitals

Author Affiliations
  • 1National Clinical Scholars Program, University of California Los Angeles
  • 2American Civil Liberties Union of Southern California, Los Angeles
  • 3Los Angeles County Department of Health Services, Los Angeles, California
JAMA. Published online October 16, 2017. doi:10.1001/jama.2017.15714

In July 2017, Jose de Jesus Martinez, an undocumented immigrant, wept at the bedside of his 16-year-old son Brandon, who was comatose in the intensive care unit of a San Antonio, Texas, hospital after being found in a parked unventilated trailer. Several agents from US Immigration and Customs Enforcement (ICE) entered Brandon’s hospital room and aggressively began questioning Jose.1

The incident was just one in a recent trend of disturbing actions by ICE agents at or near hospitals and other health care facilities. In February 2017, Sara Beltran-Hernandez, a 26-year-old undocumented immigrant, was bound by her hands and feet and removed by wheelchair from a Fort Worth, Texas, hospital by ICE agents while she was awaiting emergency brain surgery.2 In June 2017, ICE agents arrested Oscar Millan, a 37-year-old undocumented immigrant, on his way to pick up his newborn son who was recovering from surgery for pyloric stenosis at a Boston, Massachusetts, hospital.3 In recent months, other undocumented workers injured on the job have been arrested at appointments in physicians’ offices and detained by ICE after filing workers’ compensation claims.4

Stories like these have created justifiable concern by many undocumented immigrants who believe they will not be safe when visiting hospitals to receive care for themselves or their families. The way that ICE has operated, in these situations, is in stark contrast to the important principle and one of the highest ideals of medicine—that everyone deserves to feel secure when in need of medical care, particularly the most vulnerable members of communities. Under previous government administrations, even ICE recognized that hospitals, like schools and places of worship, were sensitive locations where enforcement actions should not take place unless “exigent circumstances” existed.5

The government’s newfound approach to immigration enforcement at hospitals has made it even more difficult for undocumented immigrants to access the US health care system.6 Many individuals already face problems obtaining quality health care due to poverty and other social determinants of health. Now increased concerns about discovery and fear of deportation further dissuade them from accessing services. These concerns, compounded by concerns about increased immigration enforcement at US hospitals, could create serious adverse health care consequences. For example, in 2010, the state of Arizona passed the anti-immigrant law SB 1070, which required local police officers to check the immigration status of anyone they “suspected” of being in the country without authorization. After the law was passed, researchers found that Latina mothers, regardless of their immigration status, were less likely to use the health care system even for primary care visits for themselves or their children.7

With increased public knowledge of more aggressive enforcement by ICE agents, there is also increasing anecdotal evidence around the United States that use of health care services among undocumented immigrants is declining due to heightened concerns and anxiety surrounding possible arrest, detention, and deportation. In Texas, there are anecdotal reports of women who are planning home births rather than planning to deliver their infants in hospitals to avoid providing their names and risk deportation. A recent Los Angeles Police Department report comparing year-to-date statistics between 2016 and 2017 found a 25% decline in the reporting of sexual assault among the city’s Latino population (from 164 to 123),8 and there have been multiple reports of immigrants in Los Angeles who are concerned about seeking hospital care. Concerns by immigrants about obtaining preventive care or receiving care when they are ill could lead to poor control of chronic diseases such as hypertension and diabetes, untreated injuries, spread of infectious diseases, and increased emergency department visits, furthering the financial burden of preventable hospitalizations on the health care system.

For these reasons, it is important for health care professionals to support immigrants and advocate for hospitals and health care facilities to be sanctuary spaces that protect community members regardless of their immigration status. Although there is no clear definition for a sanctuary city or sanctuary institution, the term sanctuary has been applied to cities and institutions that have established policies to protect their undocumented populations. In many ways, hospitals and health care institutions already operate as sanctuary facilities. Many hospitals do not ask about patient immigration status during intake for admissions. Patient information is also protected under the Health Insurance Portability and Accountability Act and state privacy laws that prohibit disclosure of medical records and other sensitive information without authorization from patients except in very limited circumstances.

In other ways, however, hospitals and health care professionals can do more to protect the rights of immigrant patients. Hospitals should have clear policies and procedures regarding encounters with immigration officers and train their staff accordingly. If ICE agents come to the hospital, for example, their identification should be verified, and absent an emergency such as to avoid immediate harm or criminal activity, no hospital employee should provide information about any patient to the agents or provide them access to any patient’s room without a court-ordered warrant or subpoena. Hospitals can conduct patient awareness campaigns to inform patients that their personal information will not be shared with ICE.

It is also important for hospitals to take precautions before cooperating with ICE even when the stated objective of the ICE encounter does not involve an investigation or enforcement action against specific patients. For example, Mission Hospital in Mission Viejo, California, recently refused to join ICE’s Critical Infrastructure Outreach Program, which aims to build partnerships with local organizations like hospitals and medical clinics to help the agents “develop potential sources of information.” As Mission Hospital executives recognized, any impression that the hospital was collaborating with ICE would have signaled to their immigrant patients that the hospital was not a safe space “where all are welcome who have a medical need to seek care … without any fear or hesitation.”9

In a time when immigrant communities are under increased scrutiny, health care professionals should also take a public stand and support legislation that would ensure their places of work and their patients are protected from immigration enforcement. In California, for example, the legislature has passed SB 54, which, among other things, would ensure that state and local resources would not be diverted to help ICE carry out deportations, and that hospitals, schools, courthouses, and other public facilities are safe spaces for everyone in our communities.10 Regarding hospitals, SB 54 requires public health care facilities to implement policies “limiting assistance with immigration enforcement to the fullest extent possible,” and encourages private health care facilities to do the same.10 Federally, the Protecting Sensitive Locations Act was recently introduced in Congress and would prohibit immigration enforcement at sensitive locations, including facilities that provide medical and emergency services.

There has always been a sense among many health care professionals that medicine represents a higher calling, with a commitment to serve those who are underserved, protect those who are less fortunate, and provide care, particularly emergency services, regardless of the ability of an individual to pay for those services or their immigration status. These ideals are what attract many to the field of medicine and have garnered the respect of the public for decades. Physicians remain among the most respected of all professionals. These ideals are being challenged in health care settings and other places that should be safe from politics, and it is important that health care professionals speak with a single voice to fulfill their ethical responsibilities.

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Article Information

Corresponding Author: Altaf Saadi, MD, National Clinical Scholars Program, University of California Los Angeles, 10940 Wilshire Blvd, Ste 710, Los Angeles, CA 90024 (asaadi@mednet.ucla.edu).

Published Online: October 16, 2017. doi:10.1001/jama.2017.15714

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Disclaimer: Dr Katz reports membership on the National Academy of Sciences committee that is researching the issue of homelessness and working as health director for a county that houses homeless individuals using a Housing First model but states that this Viewpoint represents his opinion only.

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Demick  B.  Federal agents in Texas move hospitalized Salvadoran woman waiting emergency surgery to a detention facility. Los Angeles Times, February 23, 2017.http://www.latimes.com/nation/la-na-hospital-seizure-20170223-story.html. Accessed August 8, 2017.
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 SB-54 Law enforcement: sharing data. California Legislature. California legislative information, September 11, 2017. https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201720180SB54. Accessed September 20, 2017.