Helping health care providers navigate social, political, and legal barriers to patient care

(Press-News.org) In November, The Lancet, one of the world’s most esteemed medical journals, launched a new monthly series of case studies that goes beyond clinical diagnoses to illuminate the social and cultural forces that contribute to each patient’s condition. 

Clinical case studies have long been a fixture in medical journals and are a primary way doctors and other health professionals continue learning after their initial training. Typically, case studies are short summaries of a patient’s predicament alongside a clinician’s assessment, diagnosis, and treatment, reviewed exclusively through medical frameworks. But the new series from The Lancet taps experts from the social sciences and humanities to unpack concepts that health care practitioners, leaders, and policymakers can use to address the social and structural causes of global health inequities. 

The second case study in the series, published on Thursday, was led by medical anthropologist Carlos Martinez, an assistant professor of Latin American and Latino Studies and core faculty member in the Global and Community Health Program UC Santa Cruz. Martinez and his coauthors describe the difficulties that asylum seekers face when trying to access health care and argue that health system leaders need to know how and when to call in outside resources and organizations to help overcome social, political, and legal challenges in patient care. 

“Addressing these nonbiological determinants of health is increasingly being recognized as the most significant way to improve patient health outcomes, particularly among marginalized communities,” Martinez explained. “But clinicians are still not being provided with the knowledge base and tools they need to act on these determinants. Our case study encourages clinicians to partner with community-based advocacy and mutual aid organizations that are already doing a lot of the heavy lifting in supporting marginalized communities and to become familiar with and draw from their expertise in order to better serve patients.”

Revealing the health risks of a broken asylum system Martinez’s case study focuses on a 45-year-old man seeking asylum in the U.S. who was suffering from kidney stone complications. A volunteer doctor at a clinic in Tijuana diagnosed the man and explained that he would need treatment with a specialized medical procedure called lithotripsy, which neither the clinic nor the public health system in Mexico could provide. The doctor prescribed medication to temporarily stabilize the condition, and the man then crossed into the U.S., where both he and his doctor assumed he would be able to get prompt medical care. Unfortunately, that’s not what happened. 

The man was placed in an Immigration and Customs Enforcement (ICE) detention facility, where he was held for three weeks without a medical consultation, despite experiencing extreme pain. He then called a hotline telephone number operated by non-profit human rights organization Migrant Advocates. The organization submitted complaints to the facility’s warden, after which ICE offered a medical consultation from a jail physician but still did not provide adequate pain control, medication, or a specialist referral. That’s when the nonprofit reached out to the doctor in Tijuana who had initially diagnosed the man to request his medical records.

The doctor had never worked with an advocacy organization in this manner before and was worried about potentially running afoul of privacy laws by sharing patient medical information. But he also knew that his patient was at risk of infection and permanent kidney damage if the kidney stone was left untreated. The doctor decided to work with Migrant Advocates, contributing to a series of letters and court petitions advocating for the man to receive appropriate specialty care. The process took more than a year. The patient was eventually released from ICE custody and received the procedure he needed 5 months afterward at a hospital in Los Angeles. But treatment delays left him with moderate permanent kidney damage. 

The whole ordeal took place back in 2022, when strict COVID-era public health rules initially implemented by the first Trump Administration were still in effect, reducing entry into the U.S. and allowing for quick expulsion of would-be immigrants, including asylum seekers. The situation has further deteriorated under the second Trump Administration, Martinez says, and migrants with medical needs now face more threats than ever.

“As Amnesty International has documented, all pathways to legally request asylum at the border are now blocked,” he said. “As a result, asylum seekers at the border are now stuck in permanent limbo in highly precarious environments, requiring more long-term support and medical care. This requires more collaborations between medical professionals, social service organizations, and legal groups documenting these experiences who are seeking to challenge the Trump Administration’s policies in court.”

Teaching clinicians how to call for backup Martinez’s case study demonstrates the need for health care providers to develop what he and his coauthors call “structural intercompetency.” The term refers to both having a strong awareness of social, political, legal, and economic impacts on patient health and being ready and able to effectively collaborate with non-clinicians, such as legal and community advocates, to improve patient outcomes. 

The practice is valuable in any setting where health care providers are working with marginalized populations, ranging from asylum seekers to patients who experience negative health impacts associated with racial or gender-based discrimination, political persecution, domestic violence, homelessness, incarceration, or occupational-related harms. Martinez and his coauthors lay out several pathways to supporting structural intercompetency in these cases. 

First, doctors, hospital administrators, and public health officials can focus on developing and funding medical-legal partnerships, in which legal professionals are embedded in health care settings. These types of partnerships can reduce patient stress, readmission rates, and emergency department visits by helping patients access essential services, rights, and benefits. Health care leaders should also seek to expand partnerships to grassroots organizations, which can often provide both immediate material support for patients and lead advocacy efforts to advance long-term policy change.

“Currently, the partnership-building work of structural intercompetency is often being led by clinicians themselves, rather than by hospital administrators,” Martinez said. “Providers across California are currently collaborating with lawyers and community organizations to develop and advocate for the adoption of hospital policies and protocols that better protect undocumented patients and those who are being brought to hospitals by ICE officials.”

Medical schools also have a role to play. The case study argues that medical schools should integrate experts and practitioners beyond the health professions throughout their curricula, so that students build an awareness of the work of these experts, how it impacts patients, and how physicians can collaborate with them to advance health. This type of training could help students understand the limitations of clinical medicine and the need to work constructively with patients, communities, and outside experts to respond to social and political inequalities.

“Despite the benefits, many medical schools are currently rolling back curricula that address the social determinants of health amidst a political crackdown on so-called DEI in higher education,” Martinez said. “Our hope is that this series on global social medicine in The Lancet, considered one of medicine’s most prestigious journals, will encourage medical schools to restore and expand this kind of curriculum. By better preparing providers to engage collaboratively around social issues, medical schools and health systems could have broader impacts in improving patient and community outcomes and reducing strain on health systems.”

Jason Pohl/UC Berkeley contributed to this reporting

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