Social EM in the time of COVID: Dr. Todd Schneberk

Dr. Todd Schneberk is an Assistant Professor and Assistant Program Director in the Department of Emergency Medicine at LAC + USC Medical Center.

By: Nicole Blum (MS4) and P. Quincy Moore, MD

What is your specific area of interest within social emergency medicine? 

Specifically, I have a couple of vulnerable populations that I focus on when it comes to research. We work on hospital-based violence intervention programs and crisis intervention work. I also do a lot of opioid research—buprenorphine wavering and the milieu of trying to reframe and shift away from the stigmatizing way we treated our substance-use population in the past. I spent a lot of time working in and around immigrant health in LA, Southern California, as well Tijuana, Mexico because we have ongoing work there. I co-direct a human rights clinic at USC. We focus mainly on asylum care and trying to make sure we provide opportunities for people in Southern California in detention in the community as well as on the other side of the border, making sure those folks have access to medical affidavits that substantiate their claims for asylum.

How has COVID-19 affected the way ED providers should be thinking about undocumented patients in the ED? 

It has already been pretty tough for that population under the current administration. The amount of harmful, antagonizing, fear-inducing rhetoric that has come from this administration has been discouraging. And, on top of that—on top of public charge*, on top of the already disenfranchised way they feel or they may have been treated—they now have this COVID-19 issue to worry about. It creates more of a disconnect and another access barrier and structural impediment for them to seek care and really be able to perform many of the health protective behaviors they need to perform. 

*Author’s note: Public charge is a complex, recently revised term and rule used by the Department of Homeland Security to evaluate whether individuals applying for permanent residence or a visa for admission to the United States appear likely to require and rely on public benefits. The term was redefined as “a non-citizen who receives or is likely to receive one or more of the specified public benefits for more than 12 months in the aggregate within any 36-month period (such that, for instance, receipt of two benefits in one month counts as two months). The benefits considered are cash assistance for income maintenance from any level of government, SNAP (formerly Food Stamps), public housing, Section 8 housing assistance, and Medicaid (with exceptions for persons under age 21, women during pregnancy and for 60 days after the pregnancy ends and emergency services) (Protecting Immigrant Families).” This policy, which excludes refugees and asylees, can deny lawful permanent residence to individuals determined by an officer as likely to become a “public charge” in the future.

More information on public charge can be found here.

How has COVID-19 affected undocumented patients’ interest or ability to seek care in the ED or elsewhere? 

We have looked at this for the population around LA and have had kind of a drop off in cases, but they are higher acuity when they do present. This has been documented multiple times after anti-immigrant rhetoric—we end up with higher acuity visits but less frequent visits. This is something we’ll probably similarly see after COVID-19 as we displace all of these populations and as their health becomes more tenuous because of job loss and their subsistence needs are threatened. LA has some data that says that 50% of lower SES groups have just lost their jobs. We’ll see what happens in terms of ED throughput, but I think the reality is most of those folks have bigger fish to fry.

Are there unique questions that we should consider when making decisions about which undocumented patients to test for COVID-19?

We run into this all the time where we have somebody young and otherwise healthy, but they live in a studio apartment with four other people. There’s always those housing issues and the ability to isolate and socially distance. I think what’s going to be a difficult kind of go-around is if we do try to do this contact tracing. We need to contact trace people in a way that doesn’t make them feel intimidated, watched, or increase the fear around what has been a frustrating dialogue at the presidential level. The real kind of problem is when this kind of rhetoric [forces] our undocumented underground into an informal economy. Job loss will also contribute to pushing people towards an informal economy which makes them more vulnerable to extortion and being taken advantage of which will further threaten their health. We’ll see what happens as this increasing policing happens. We know that will probably push people into the informal economy and out of the spotlight as well. I’m just hoping that people are able to seek healthcare and share when they are sick and do need help rather than hiding out and ignoring issues that need emergency medicine and medicine in general.

Are there unique questions that we should consider when making decisions about how to dispo undocumented patients with COVID-19? 

I think we need to try to reinstill trust in these folks and make sure that they feel like they can come back to you and your provision of care. We need to try to reassure people that return precautions are safe and they shouldn’t just hide out or be afraid of health-seeking behaviors, which is hard. Our community organizations are constantly working on trying to educate, but all of these organizations are not going to make up for the fact that it’s a hostile environment right now.

What do you think are the most important research questions that need to be answered with regard to undocumented patients and COVID-19? 

We know that the structural barriers of care are going to be further exasperated by COVID-19, and, as people are pushed out of their jobs and unable to subsist in their normal way of life, they are going to have to improvise. And, honestly, how that improvisation works and what we can do to interrupt the pattern that may further the vulnerability of these folks, especially the structural vulnerability, is really at the root of this. For example, we know that people who are victims of domestic abuse are more likely to be homeless or without jobs—this makes kind of a cauldron of worsening inequity. I would just hope that we can paint this picture and let people know that there is a real risk of all of our communities being threatened if we don’t take care of some of these populations. If these people are further disadvantaged, it’s going to be tough for us as a society to be able to keep up with the needs of people’s health and social determinants.

Are there any new policy measures, be they local or national, related to immigration status and COVID-19 that you are excited about? If you could implement one policy measure related to immigration status and COVID-19, what would it be? 

We need to create opportunities to make Medi-Cal (California Medicaid) or insurance available for these populations and find innovative ways to use governmental funding to support their health. We have a couple initiatives here in LA County. My Health LA is a program for insuring the undocumented. It’s not really insurance, but it’s primary care access through a patchwork of programming. They can get their specialty and subspecialty care at county facilities, but I’d like to see a less fragmented version of that come out. 

I’d like to see us expand medical-legal partnerships. That’s one of the ways I’ve found to support all of these populations is by providing or linking them with legal aid and letting them protect their rights through legal measures because many times it is difficult to support them otherwise. I’ve learned a lot and been impressed with how much lawyers can do in order to improve these folks’ social determinants and the issues that are affecting their health and daily living.

Anything else we should be thinking about? 

There’s been all of this talk about whether they’ll have to pay for this healthcare or whether they have to come in and get COVID-19 testing or treatment and pay for that. I would just like to see us expand our ability to provide healthcare for these folks in general and use COVID-19 as an opportunity to push for a more equitable and universal healthcare system, specifically insurance and healthcare access.

Are there any resources that you would recommend if people are interested in learning more about this topic? 

There’s the social EM textbook that’s going to come out, and then there’s a number of papers about this. One of the things I find useful is the National Immigration Law Center (NILC). They have very useful information about medical-legal partnerships and how to support undocumented immigrant communities locally. Dr. Altaf Saadi came up with a toolkit on how to support immigrant communities in healthcare settings, particularly hospital settings, and so she comes up with a lot of signage and practical ways we can support these populations. Much of it is from a study she did where she interviewed stakeholders across the country and tried to develop a best-practice model. 

I think how we’re going to create opportunities for these patients is by listening to them, and we should have patient representative panels. It’s important to have representation from undocumented and immigrant communities on that panel for them to be able to say what they think would be helpful and would expand access to these communities. The only way it’s going to work is by listening, of course. Also, involve immigrant rights and undocumented rights advocacy groups in your community, bring them into the fold, and have them weigh in on the care you’re providing—the way you’re providing, how you’re signing things, and how to approach people about these issues. It has been helpful for us to have the Coalition for Humane Immigrant Rights of Los Angeles (CHIRLA), and they’ve been really useful in terms of trying to institute programming and making sure we’re aligning our messaging about when people should be coming to the hospital and when they shouldn’t. We are very lucky in LA to have the Office of Immigrant Affairs and a couple different county organizations that focus on this. We had a call of over 200 stakeholder organizations that care about immigrant rights, and when I sit in on that, it’s kind of like all these people are talking about the right messaging, how to unify, when should you come in for testing, and when should you seek care in this setting. It’s really useful to have that kind of organization and be able to feedback from the community and from people who are actually trying to get the word out about what’s helpful and making sure everyone’s aligned.

Is there anything else that you would like to add?

COVID-19 and immigration detention centers

I’d like to see people recognize that [immigration] detention centers are not separated from our communities. It’s a myth that they’re separate populations. These centers are basically tinderboxes for COVID-19 and are something that could really increase the spread of COVID-19. We’ve already had several outbreaks in detention centers, and Immigrations and Customs Enforcement (ICE) has refused still to thin the population. This is a vulnerable population. They’re not able to social distance or follow the national guidelines, and we’re just acting like they’re not really in our communities. Guards going in and out of these facilities are exposed and exposing day in and day out. It’s a false pretense that this is at all different from the community because it is a part of the community. It’s disappointing to see the federal intransigence threatening local communities. You think about that community [surrounding the detention centers]—the ERs over there will be overloaded when there is a really bad outbreak. It will overwhelm resources fast. There is not the capacity to quarantine people in these crowded facilities. But, we have these immigration detention centers throughout the country. About 64% of [the detainees] for the most part are not criminally charged, they’re just seeking asylum. Why do we even lock them up in the first place? Why would we not thin them out and let these people go to their communities to quarantine with their families and friends that they’re going to stay with anyways rather than keeping them in a literal tinderbox to be under high risk of COVID-19 outbreaks. This presents an opportunity for us in the immigration advocacy space to call attention to why we are even locking up these people to begin with. If we can thin these detention centers out but still have all of these people who are not criminally charged and are just seeking asylum—which is their legal right under international treaties—being detained, why are we doing that? Why not just stop doing that and allow people to socially distance and be safe? This gives us a chance to say, “Hey, do you guys know that these people have not been criminally charged, and they’ve literally done nothing wrong and have just been detained because maybe we have a financial incentive for all these private prison organizations to be able to make money off these folks from US taxpayer dollars?” You assume people who are in jail or detention did something wrong, but, when you look at it, a significant portion of our local jail is filled because people can’t pay bond or bail, and the vast majority of people who are in immigration detention centers did nothing wrong and are just being detained because that’s the new normal.