[Intro]: Welcome to 'COVID's Lasting Impact: Caring for Immigrant, Migrant, and Asylee Patients', a 10-episode mini-series within Migrant Clinician Network's 'On The Move' podcast, a podcast dedicated to providers who work with vulnerable populations, specifically migrant populations. In this mini-series MCN provides clinical teams, including community health care workers and Primary Care clinicians, with up-to-date information, expert guidance, resources, and relatable case stories for identifying, treating, and managing COVID and long covid among US-based immigrant, migrant, asylee, and limited English proficient patients in the outpatient setting. MCN is a national non-profit with extensive experience providing timely, practical solutions, at the intersection of vulnerability, migration, and health. Each episode provides clinicians with impactful tools and information for improving the quality of COVID care for vulnerable populations. if you want to hear future conversations on the topic of Health Justice be sure to subscribe to the 'On the Move' podcast. For resources mentioned in today's podcast be sure to click on the link in our episode notes to go to our podcast page at migrantclination.org/podcasts.
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[Garcia]: Welcome to today's podcast 'COVID across a lifespan'. I'm Deliana Garcia, Chief Program Officer of International and Emerging Issues for Migrant Clinicians Network. With MCN I work in the areas of reproductive health, sexual and intimate partner violence, access to primary care, and infectious disease control and prevention.
Today we have with us Dr. Chanelle Diaz, MD, MPH. She's an Assistant Professor of Medicine at Columbia University Medical Center and the Internal Medicine Medical Director at the Charles Rangel Community Health Center. We'll be discussing how COVID treatment can vary across populations, particularly from underserved immigrant and migrant populations, and how care plans can be tailored to best serve these populations while taking into account potentially pre-existing health conditions, occupational hazards, and other factors, to ensure the continuum of care across all ages and stages, from childhood to adulthood.
Dr Diaz I'm going to talk about you just a little bit. Dr. Diaz grew up in Miami, Florida, where she was raised by her immigrant grandparents. She attended Williams College, received her MD/MPH from the University of Miami Miller School of Medicine, and completed her residency training in Primary Care and Social Internal Medicine at Montefiore Medical Center/Albert Einstein College of Medicine. Dr. Diaz’s work focuses on community-engaged approaches to address immigrant health inequities resulting from immigration enforcement policies. As a resident, Dr. Diaz joined a network of volunteer clinicians visiting immigration prisons to evaluate detained immigrants with serious medical conditions to document unmet medical needs. Bearing witness to the many harms detained immigrants experienced influenced her in pursuing research collaborations to document the health harms of immigration imprisonment and publishing several opinion pieces in the lay media on the public health hazards of immigration detention. She has collaborated with other medical and legal experts to develop best practices in the medical evaluation of individuals in immigration detention, and has trained dozens of residents and medical students. Dr. Diaz is committed to using her voice as a physician advocate to uplift human rights, health justice, and equity. Welcome Dr Diaz!
[Diaz]: Thank you, it's so nice to be here with you today.
[Garcia]: It's a pleasure to have you. So, before we get started, it's easiest if we can get you to sort of paint a picture for our listeners in terms of what one of your regular work days might be as it relates to COVID.
[Garcia]: Rather than starting with where I am with taking care of patients with COVID-19 today, I do want to take like a setback and state that in March of 2022 I was on the front line caring for patients hospitalized when the COVID-19 pandemic first hit New York City. And so my colleagues and I found ourselves at the epicenter of the pandemic in the US in the beginning, when we really didn't have the resources that we have now to really treat and prevent COVID-19. So at that time, you know, we really witnessed unprecedented loss and suffering like many in the network and across the globe did. Right?
My day-to-day now is very different from the start of the pandemic. As a primary care doctor, I generally care for patients with COVID-19 in the clinic setting and most of my efforts, are really, are focused on educating patients on prevention of COVID-19 with vaccinations, on treatment options for COVID-19. But I still do rotate on the hospital service a certain number of weeks a year with teaching the residents. And recently, in January, I found myself really surprised by how many patients were hospitalized with COVID-19 that I was caring for. It almost gave me flashbacks to 2020.
[Garcia]: And so, you know, your work now is informed by that sort of historical experience with COVID, but going even further back, when you think about the patients with whom you're working, do you believe having had immigrant parents in some way impacted the way you assess the health or social and cultural needs of your patients?
[Diaz]: Yes, you know, I think now we have a term for it that I didn't realize we did when I was in medical school, which is structural competency. And so, it's really taking into account all the social and structural determinants of health that really shape a patient experience. And so, I didn't have that vocabulary when I was a kid, but I certainly experienced it. I grew up with my immigrant grandparents and really navigated them through so many parts of their health care that involved navigating, you know, my grandfather at the end of his life through the medical care system. So, I was often their advocate and their interpreter. And, you know, I think that really shaped for me the role that I saw that physicians really have in caring for a patient. And, I think in particular the need around education and really empowering patients and their families with the information that they need to make the best decisions for themselves. That was a very formative experience for me.
[Garcia]: You know, and you had that lived experience, and you applied it, and you used it well. Which is not always the case with clinicians - that they will have had that experience in their own lives. So what kind of guidance would you offer, or do you offer now, to the interns and medical students with whom you work, on how to tailor care plans so that they can best serve and migrants and those other underserved communities.
[Diaz]: Yes, you know, those of us who already care for immigrant and migrant communities really know that immigration status is this critical and overlooked social determinant of health and that it's driving inequities. And so, I really focus on framing immigration status as this social determinant of health when I'm working with residents, when I'm working with medical students, and even when I'm giving lectures to other clinicians who maybe haven't really incorporated that into their practice yet. And so, the way that I explain it is that we know that our health depends on the quality of environments where people are born, grow up, live, work, and age, and these are the social determinants of health. But if we think about a person's immigration status, that can really influence their employment opportunities, what their living conditions are like, and what their access to health care is - just to name a few things. So it's this inescapable form of everyday inequality. And it really leaves immigrant and migrant communities vulnerable to poor health outcomes. I think that it's helpful to provide a framework for clinicians, and a concept that I like to share was proposed by a colleague Dr Elsa Saavi and and her colleagues in California. And it's called immigration informed care. And it really is building on trauma informed care but with a focus on immigration.
[Garcia]: That's spectacular. And so you take that, and you're looking at COVID - which is something we know more about now, but really so many things we don't know - and then weave into that how you try and help patients with pre-existing conditions, or even complications from their occupation when you're thinking about care plans.
[Diaz]: Yeah, so if we're taking an immigration informed care approach, that really means that we're looking at using appropriate language services at the time of each encounter so that any information we deliver is really in the language that the patient is most comfortable with. You know, we're also thinking of having these clear referral pathways for patients, and especially for patients that may be uninsured or undocumented and may have more challenges with navigating the health system. And then really empowering clinicians to be culturally and structurally competent - especially when discussing topics that could incite fear. And I would say, and I can get into this more, that vaccination is one of them. And then looking at our institutional policies to make sure that they are ensuring the physical and psychological safety of immigrant patients when when they're seeking care. I think it's really important to understand that there's still a lot of fears related to how their information may be shared, specifically with immigration enforcement officials, what the implications are for their health information in terms of their immigration status, but just really being conscious of all of that, its clear, even before taking into account pre-existing conditions.
[Garcia]: And you have all of that you're considering Dr Diaz. So, now talk to us a little bit about - and then what if there's children? - you know, children versus adult patients. That is in and of itself a whole other consideration.
[Diaz]: Well, I guess I wanted to kind of elaborate more on even the, you know, then, what do we do next if there are pre-existing conditions, right? So what we know is that pre-existing conditions like heart disease, diabetes, and lung disease, both in adults and kids, can really increase an individuals' risk for being hospitalized or having severe complications of COVID-19. And what we've seen in the primary care setting since the pandemic is that so many disruptions to care have happened or there's just been an increase in uncontrolled health conditions because people haven't been able to get the care that they need to manage their conditions. Or there's been other stressors, right? That have created those disruptions.
[Garcia]: I think that that's really important to keep in mind. And the only thing that I would do is add my question back in of - and so then what if the patients are children? And if you can speak a little bit to that. Because you may have also been seening very critically ill children who've been exposed to COVID and that brings about yet another layer of issues for families.
[Diaz]: Right. And I think that, especially when we are thinking about children and families, this is where I would say that we have even more need to really practice cultural and clinical humility and really understand what the family's understanding is of their child's conditions, of their child's risk. And just recognizing that there's still a lot of misinformation about COVID-19 and about vaccinations and it continues to cause fear and hesitation.
What I want to emphasize is that being un-vaccinated or under-vaccinated is really considered one of the highest risks for severe COVID-19 at this point. And so, as much as we can become, or be seen as, trustworthy for families, and be seen as a resource for health information, I think that's really the key. Immigrant families have higher rates of intending to be vaccinated for COVID-19 but have lower COVID-19 vaccination rates. And so what that tells me is that there are existing barriers for immigrant families. And so I think that really meeting families where they are, understanding what those barriers are, understanding their context, that's really going to be the key to addressing those inequities that we still see.
[Garcia]: And now you've seen so many, and you know the environment in which you're trying to do your work, and in which they're trying to live, and we talked some about COVID. What else do you see on the horizon - emerging as either a continual but coming back, or new challenges for clinicians - now that COVID is fading a little bit in its visibility.
[Diaz]: Yeah, I would say that there does feel like there is less of a priority for COVID-19. And I think that that's understandable. Like we've all gone through such a traumatic experience with COVID-19, and we all want to put it behind us, right? And so that is my fear, is that there is this complacency around COVID. And so what we know is that this... we know what works at this point. And we have the tools that we didn't have in 2020. But we still know that people are being hospitalized and people - especially high-risk individuals - are still dying from COVID-19. So what what I see as being needed is really reinforcing information around how to access testing, when to test, you know, like when is a rapid test... when could a rapid test be inacurate? What do I do if I think I have COVID, or I've been exposed to COVID and my rapid test is negative.
So really getting information out there that families can use to protect themselves and their loved ones in languages that they, you know, that they feel most confident with. And really countering some of the misinformation that continues to be out there. So, and I think that that requires access. You know, what I found is that patients may be more open to discussing their fears when they're seeing me in clinic, but if they can't make it into that clinic to see me, if they don't have access to a trusted health care provider, they're not going to get that information, right? They may go to other sources that are not as accurate or may not be relevant to them. So I see really addressing access to care as being critical to addressing, you know, inequities in COVID right now.
[Garcia]: Inequities in COVID, and what would you say then, also, about addressing other infectious disease care? Is it the same as COVID or do you feel a different overlay?
[Diaz]: I think that the issues will be there no matter what pandemic it is. And I think that now we're seeing a lot in the news on, you know, bird flu, right? Swine flu. There's all kinds of different viruses out there. And, you know, COVID-19 wasn't the first major pandemic and it won't be the last major pandemic. And so if we haven't learned our lesson on how to reach our most vulnerable communities then we're going to find ourselves in the same place that we were in 2020. And so, from the start, immigrants and migrants were disproportionately impacted by COVID-19. And they're still being impacted by, you know, less access to vaccines and less access to the proven antiviral treatments that we have. So, really, I think our health systems need to do much better in terms of, you know, targeted outreach and education campaigns, providing free and accessible vaccinations, leveraging our community health work, and, you know, really getting out into communities to deliver the care where it's needed the most.
[Garcia]: That's fabulous. Thank you! Well, just to let everyone listening know that the resources from this episode, including a recording of the MCN webinar that you presented on the topic, and is available in English and Spanish, can be found in the link in the notes from this episode. And I think that what you've been able to present and what you remind us of about in terms of the focus, and the strategies, and the fact that everybody I had not heard - sort of that immigrant informed piece that you talked about so much - of understanding all of the circumstances. I think we are not all of us even really able to capture an understanding of the trauma that most immigrants and migrants have experienced prior to reaching us. And you reinforcing that I think is so important. And you're right, there's more that we need to know and that we need to keep in mind regardless of what the health care issue is. And infectious disease is really critical, and vaccination is so important, but you as a trusted voice I think cannot be overstated. That is so important.
Is there anything else that you would want to add on this topic or or reinforce and make sure that we keep front and center in this podcast?
[Diaz]: You know, I think that what we know is that we need a more diverse health care workforce, right? And so, so much of my practice has been informed by my personal experience and just understanding, you know, my family's perspective. And I think that we can't understate the importance of, you know, having a healthcare provider that speaks your language, that shares, you know, your culture in so many ways. And so, really, I think more advocacy is needed and more emphasis is needed on really building up that workforce.
[Garcia]: And you talked about your colleagues - I believe you said in California. Is there anything else that you'd like to promote or highlight? Someone's work or a particular resource that you've used?
[Diaz]: So, I would like to, yes I would, thank you for that. So I would like to highlight my colleague Dr [incoherent]. She has a website. So it's DoctorsforImmigrants.com. It has a toolkit on different strategies that institutions can implement to really deliver immigration-informed care. And I think that's an excellent toolkit.
We're going into an election season and what we know from the last one is that a lot of fear within a community and that really impacted people's use of health care, of benefits. And so I really think that as much as we can do as healthcare workers and institutions to target that fear head-on, and really ensure that our patients have access to care when they need it, that's really essential.
[Garcia]: That's fabulous. Thank you. Well, we want to thank all of our listeners for joining us today while we were speaking with you Dr Diaz. And we want to thank you Dr Diaz for taking your time to join us today in this conversation. I think we want to let the listeners know that if they'd like to reach you they can find you on LinkedIn: Chanelle Diaz, and so they can continue to communicate with you that way. Listeners can reach me at dgarcia@migrantclinician.org.
Dr. Diaz, anything as a parting comment?
[Diaz]: No, just thank you so much for this dialogue today, I really appreciate it. Thank you.
[Garcia]: Thank you! And so for our listeners, for more expert guidance and tools to improve the quality of COVID care for vulnerable populations, follow our podcast 'On the Move' with MCN, and come back and listen! Thank you so much.
[Diaz]: Thank you.
[Outro]: To access resources mentioned in today's podcast click on the link in our notes section to go to our podcast page at migrantclinician.org/podcasts. Visit migrantclinician.org/signup to join our email list and subscribe to our blog to get updates on new MCN podcasts, resources, and webinars. Migrant Clinicians Network is a national non-profit dedicated to providing practical solutions at the intersection of vulnerability, migration, and health. We offer technical assistance, health provider capacity building, resource development, research, and data and evaluation support, and virtual case management for mobile populations, and free resources and training. The information in this podcast is for trained healthcare professional education only. Information should only be used in combination with up-to-date national and international guidelines. The information is not to be used as healthcare advice for the general public.
