Work in Healthcare? Tell the Global Inequity Story Loudly, Publicly

By Emily Esmaili

Syrian children in a Greek refugee camp play on a slide. Photo by Ben Sagar.

I am a pediatrician who cares for two young boys in my busy community health clinic; both are 5 years old with spastic cerebral palsy, global developmental delay, and complex seizure disorders. One is a registered refugee from El Salvador who quickly had a treatment team assembled that included a neurologist, gastroenterologist, physical therapist, occupational therapist, case manager, and myself as his pediatrician. The other arrived from Honduras without papers and continues to have uncontrolled nightly seizures as his mother cares for him alone, because they lack health insurance, private transportation, and the ability to pay out of pocket for health appointments. His father works at a pork processing plant two hours away and keeps the family’s only phone, making them nearly impossible to reach. They continue to refuse all assistance — except for a list of food pantries on one occasion — believing that accepting help might expose them to persecution and deportation. Besides the disparate health states of these two patients of mine, the only real difference between them is their immigration status.

I also see several Afghan children — some admitted as refugees and, more recently, many admitted as parolees, ie. without healthcare coverage or public benefits. Same backgrounds, different documents, disparate health outcomes.

This level of inequity should not exist in a country as well-resourced as ours. However, COVID-19 has reminded us that diseases and disparities do not stop at lines on a map. This ubiquitous virus has shown us that certain pathologies — both physical and societal — are also ubiquitous and are not only found in faraway places.

Prior to the pandemic, I traveled to remote regions of the world to find the most neglected conditions of the most neglected children: congestive heart failure from advanced Burkitt’s lymphoma in a Congolese refugee child; severe pulmonary tuberculosis and undiagnosed HIV in a malnourished Lao orphan; a 30-week premature Rwandan baby born to a mother too hungry and tired to produce breast milk, in a hospital with no formula or feeding tubes. We used to load up our rucksacks and fly over oceans to treat, research, and teach about these exotic diseases and disparities of children across the globe. We walked through hard-to-reach refugee camps to find undiagnosed conditions hidden in multi-family tents or swept into corners of overcrowded, makeshift wards. Our foreign eyes saw long-neglected wounds, and our stethoscopes heard sounds and stories of untreated health conditions we could not imagine hearing at home. We met the young victims of trauma, trafficking, and inhumane confinement that we could not imagine existing in our own home country.

Then suddenly, we were told to come home, and stay home, because of an emerging global pandemic. With quarantine, children’s worlds were frozen in place. As a pediatrician in a federally qualified health center, I watched children in my community — and in similar communities nationwide — increasingly suffer from hunger, housing insecurity, and all forms of abuse. Many more suffered from missed opportunities in education. Rates of missed vaccinations, adolescent depression, and childhood obesity sky-rocketed. Meanwhile, medical supplies, PPE, and hospital beds became scarce — all reminiscent of prior experiences in refugee, migrant and other disaster-borne situations around the globe. COVID-19 managed to create and exacerbate local disparities, neglected childhood diseases, and public health disasters akin to those that have long existed in less resourced parts of the world.

While the COVID-19 pandemic keeps many movements of our normal lives frozen in place, new wars have blossomed, and newer iterations of old wars have emerged — such as those in Ethiopia, Burma, and Afghanistan. Humanitarian crises across the globe have continued to erupt, pushing even more children and families to seek new homes. Just across our border in Latin America, violence has blazed on and intensified, following closely by worsening poverty, hunger, lack of employment opportunities, the effects of climate change, and the economic impacts of COVID-19. Similarly in Afghanistan, the collective impacts of protracted poverty, decades of escalating conflict, COVID-19, and now the Taliban’s violent victory have forcibly displaced nearly 6 million from their homes. Following suit, the count of families and children fleeing to our borders and military bases continues to rise.

Despite the evidence of increasing need, global humanitarian aid has diminished. Many official and unofficial refugee camps where I once worked have closed, forcing families to find refuge elsewhere. Some camps have remained standing with barebones resources. All the while, the number of children and families seeking refuge continues to swell, globally. Thankfully, our current administration has once again opened doors to larger numbers of asylum seekers. Given this anticipated increase in U.S. refugee admissions, alongside the Afghan Placement and Assistance (APA) program and the mounting crisis at our border, we can expect that many of these migrant, refugee, asylee and parolee children will stumble into our clinics and hospitals. [Many of these children will be arriving without clear immigration status and thus without public benefits or protections. For example, many Afghan evacuees may arrive as parolees, ie. without access to health insurance or legal protections. Alongside the arrival of these young newcomers, then, we may see yet another rise in the health disparities that surfaced among immigrant and refugee populations during the pandemic — unless we take urgent action.

COVID-19 has forced us to see clearly, in our own clinics and communities, child health disparities that so strikingly mirror those seen in our work abroad. Without travelling far at all, we see children facing food scarcity, neglected health conditions, lack of access to healthcare, missed vaccinations, and fear of deportation. At the same time, COVID-19 has also given us an obligatory, pandemic-imposed pause, which could be used to reflect upon and reconsider our duties as global child health providers. Does our professional duty to a child depend upon his or her immigration papers? Why are so many children being forced to flee their homes, and what can we do from our own homes? How might we intervene upstream of the migrant crises and start addressing the problems at their origin?

We cannot quietly allow fear of deportation, lack of access to healthcare, and child hunger in our home communities where resources are abundant. With our new administration, we are starting to see a wave of action against some of these inequities — for example, an executive order establishing an equity agenda and another dismantling inhumane border policies and reuniting separated children with their families in the U.S. The Biden-Harris administration has also increased SNAP benefits and access to WIC and has implemented the APA program through Operation Allies Welcome. Yet, much work remains. In particular, we must continue to publicly discourage those human rights violations that push so many new children to our borders and to similar holding centers abroad, seeking refuge. And for those children that do land within our borders, they must be given the same rights and protections as U.S. born children.

Those of us in healthcare must share our clinical stories of neglected children in unjust situations — like the Honduran boy who could have such better health outcomes — with congressmen, lawyers, and professional partners. We must continue to advocate for those children we once traveled far distances to reach before COVID kept us at home. Now, with more and more immigrant, refugee and parolee children trickling into our home communities from Afghanistan, Honduras, and elsewhere, we have an opportunity to travel to a world where children with any range of nationalities, diseases, and documents are treated as equals — a world that we must first create.

Emily Esmaili, D.O., is a pediatrician in Durham, where she cares for primarily with immigrant and refugee children. She is an adjunct assistant professor with the Duke Global Health Institute and holds a degree in global bioethics and science policy from Duke. She also completed a fellowship in refugee child health from the Duke Center for Global Health