Here is a thought experiment: Imagine that Thomas Duncan, the unfortunate Texas Ebola patient, had been undocumented in addition to uninsured when he presented to a private hospital in Dallas.
Be sure to consider the impact on his decision making in seeking health care. Now, imagine the media response. Imagine the impact on policy makers.
Hold those thoughts.
Mr. Duncan was legally in the US. But that did not stop the immediate cry from many to “seal the Mexican Border, Ebola will get in.” Some might think that only strange internet extremists would ever say such a thing. But CNN reports differently. Scott Brown, former governor of Massachusetts (Massachusetts!) and current candidate for New Hampshire governor was quoted as saying so. So was the Republican candidate for senator in North Carolina. So did Rand Paul, sitting senator in Kentucky. And so did a physician-Congressman from Georgia who in July apparently wrote the CDC that undocumented children coming from Honduras and El Salvador presented a serious public health menace: "Reports of illegal migrants carrying deadly diseases such as swine flu, dengue fever, Ebola virus and tuberculosis are particularly concerning," (CNN, 10/10/2014, "Ebola fears spark backlash against Latino immigrants").
Undocumented patients are common in our hospital and clinics. When I meet them on the inpatient side, they often present with advanced disease or extreme complications of common illnesses such as hyperosmolar coma in a patient with diabetes. In my experience, these are mainly patients who do not know that SFGH will not report undocumented patients to immigration authorities. San Francisco is a “sanctuary city,” where medical providers are prohibited from sharing immigration information with authorities. When undocumented immigrants do seek routine care in the outpatient side, they do surprising well. (Elizabeth Iten, then a UCSF medical student, and my group did a study that found that undocumented Latino patients with diabetes have similar health care outcomes, including glycemic control and trust in physician, as their documented counterparts.) But some San Francisco residents do not know this and present late with their acute illnesses citing deportation fears, despite the long established sanctuary policy. In a 2013 study done by UCSF ED physician Robert Rodriguez in the SFGH ED, 1 in 8 patients (13%), expressed fear of discovery and consequent deportation. I wonder what the comparable number would be in areas with high West African immigration, even those who also maintain sanctuary policies, such as Dallas.
What would a late presentation for an Ebola patient mean? Most likely, a few more days at home with a fever and symptoms, greater potential to transmit the disease, and apparently an even poorer prognosis. This is why physician groups such as Physicians for a National Health Program are circulating petitions that include, among other recommendations, extending emergency Medicaid to uninsured visitors and undocumented immigrants, and establishing all emergency departments as sanctuary zones. This makes public health sense, as strengthening trust between health services and at-risk populations is a cornerstone of epidemic containment policies. But the current national dialogue seems very far away from that reasonable position.
For a myriad of reasons, I hope we see no additional cases of Ebola in the US. But if we should, I expect anti-immigrant—and anti-Latino—voices to get louder. How will the medical and public health communities respond?