Buenos Dias. Good morning. I'm so excited and honored to introduce today's speaker, two great experts on immigrant child health. Uh First, we have Doctor Ra Ra Rodriguez. He is an associate clinical professor at UCFF with over 10 years of experience working with immigrant Children. He is a co-founder and co-director of the Bridges Clinic, a multidisciplinary team committed to a holistic and community support approach to wellness among recently immigrant Children and their families located within Children's Health Center at Zuckerberg, San Francisco General. Doctor Gutierrez, developed guidelines for intentional and thoughtful health care for immigrant students with an open school based clinic. He serves as a pediatric co-director of the U CS F Health and Human Rights Initiative as well as the Center of Excellence for Immigrant Child Health and well-being with many of Children's Hospital. He is also the Vice Chair of the American Academy of Pediatric Council on Immigrant Child and Family Health. Our second speaker, doctors nor is a pediatrician at UCFF Childrens Hospital. O our own primary care clinic. Her experience as a refugee from Afghanistan led her to an educational and career path focused on caring for immigrant families. She is the Director of International Clinic within primary care, which focused on the medical care of immigrant and refugee pediatric patients. She teaches and mentors resident and medical students, doctor nor has a US Civil Sergeant defination and provides medical exam for immigration purposes. He is a co-director of the U CS S Children's Hospital Center of Excellence for immigrant child health and well-being, an institutional and community hub to support interventions that contribute to equitable health care and healthy Children, regardless of immigration status, doctor, nor also served as a pediatric co-director of the U CS F Health and Human Rights initiative. Due to her enormous commitment in contribution to immigration health. She recently got invited to the White House without any further delay. Here is here are doctor and doctor nor two fabulous colleagues of mine. Thank you, Lourdes. Thank you so much for that introduction. Um I will get started as uh Doctor Guti is gonna uh jump on in a minute. Um So we are gonna talk a little bit today about immigrant health updates and um our role as pediatrician, pediatric care providers um in the care of immigrant Children. Um We uh and we have no disclosures um uh to note here. And before we get started, we just like to do a land recognition um knowing that uh we are on um uh on sacred land of the Rama Olo people. Um And we want to just pay respect to our um uh indigenous uh groups who and uh who have past, present and future, call this place. Um this land that we sit upon their home. So, um today we're gonna talk a little bit um about some of the factors that are contributing to the recent increases in child migration, um especially across the southern US border. Um We'll also uh talk a little bit about some barriers immigrant Children may face while they're accessing health care and then finish up with um talking about ways that medical providers can support um uh immigrant and migrant Children um in, in our practice and um as well as um other opportunities that uh you might be interested in, in, in supporting um this group. So um migration, um what is it? So um an I A migrant is any person who is moving or has moved across an international border or within a state away from his or her or their, their habitual place of residence, regardless of the person's legal status, whether the movement is voluntary and in or involuntary, what the cause for the movements are and what the length of say is. So, um we'll go a little bit more into, into this as well. Um Currently in or in 2020 about a couple of years ago, the numbers of migrants were um had reached up to 281 million migrants um uh across the um world and this is um it's actually a small percentage but it's a, it's a big number but a small percentage of the total u uh world population, the number of displaced people has been increasing steadily. Um, and we have seen this, um especially in the last uh few years. Um It has rose um, up to 89 million in 2020. Um And you can see here that there are, um, you can see the number of what's called refugees. These are designated uh uh folks who are fleeing due to persecution, war, um violence in their home. Um And it has increased steadily, is increasing um as well as well as these internally displaced people. These are people who are being displaced um not across the border but within their own homes, but by May 2022 we've seen this in so that number of 89 here I have hopping on. Hi. Hi, I'll let you get started. I just went over this slide over here and I'll let you take, I think you're muted. Hi, everyone. I'm so sorry. Um that I literally had to introduce a different grand rounds, but I am here now. Um and I will um continue this first half of the talk. Thank you so much um for having um for having us. Um So I think we just talked a little bit about um the number of migrants um in the world. Um and we had seen a record, I think in 2000 um 20 in terms of the numbers. Um And by um yes, uh 89.4 million and by May of 2020 there were more than 100 million people who were forcibly displaced worldwide by persecution, conflict, violence, human rights violations or events seriously disturbing public order. You can do the next little slide there. Um And here's the kind of the trends um at a glance and we can see that um at least for the past 10 years, um we've seen um quite an increase, globally enforceable displaced people with, again, the majority of people being displaced internally at 62.5 million people. Um Only a small fraction of those people are asylum seekers and about a quarter um continue to be um refugees um recognized internationally next side. And if we look down at the ages uh of those who have been forcibly displaced, um We see that about um 40% of, of folks forcibly displaced are actually Children um under the age of 18. Um although they only account for 30% of the world's population. Um So we certainly see, I think an overrepresentation of Children um uh more recently in terms of people who are forcibly um displaced, which I think brings um quite a bit of a new lens um onto migration. Um and the health effects of migration um in the world of pediatrics next side. So certainly a lot of people might be asking well, why are people leaving. Um And there are different ways in which to look at that and analyze that. Um probably the most common is this kind of push pull theory um which really focuses on the optimization strategy of individuals and families who make this kind of cost benefit calculations on whether to leave their country of origin and go to a different destination, their place of origin or uh uh a different destination. And so, um the idea is that they're weighing these positives and negatives and also um in between, there is these kind of intervening obstacles. What is the environment like? What is the um uh uh local and um destination politics look like? And what are these different things that get in the way of people uh immigrating from one place to another? Um Now, certainly this is probably um a bit of a kind of reductionist idea of how to look at this. And sometimes when we look at just refugees, we think about one event, um you know, the conflict, the war, the natural disaster um that despite all the positive negatives is forcibly displacing people. And that is very much true. Um But many people are really thinking about this much bigger. Um So we know that migration always needs to be understood within the specific historical and social context in which they occur. Um And so it's really difficult to capture by any set of formulas or laws or models. But so many other things go into whether a family or a person decides to move. Um And I'm even gonna use the word decides, but it's uh uh but moves from one place to another and most of the time, um as we can see that this is for force forced displacement. Now, here in the United States, uh we might hear narratives about immigrant populations looking for work um or um they're coming um to take jobs um or to take advantage of the public benefits here in the United States. Um But we know that this is not necessarily true. While those subgroup of uh of immigrants do exist, the vast majority are really looking um um into an array of different things that then may push them to move from their place of work. And those things might be political, whether that be conflict or discrimination or persecution, this might be environmental uh which we're seeing more and more um environmental uh or climate change, refugees, but exposure to hazards, food and water insecurity, um energy insecurity, um loss of jobs because of drought and things like that. Um We might look at demographics, population density, population structure, something social um or something um economic. Um And of course, we also have to think about individual characteristics and then those obstacles and facilitators that then um uh facilitate why a person might uh uh be on the move or stay where they are um in a study of unaccompanied Children who are coming from Central America to the United States that was done by the United Nations. Um They did see that it was not, it was usually not just 11 event or one thing um that, that caused people to move from the country of origin. Uh More often it was a, it was a layering of things. Um, you know, there were like three or four things and then there was that one thing that really just kind of um uh uh sway them um in one direction or the other. Um So it's multifaceted, very complex. Um And I think we have to understand that context um to be able to um appreciate um our patients, our immigrant patients when we're in the clinical setting next slide. So these are some of the major migration and displacement events um uh uh that are happening either now or more recently. Um And I put them under these kind of broad categories. Um But certainly some of them might overlap with each other. Um So, uh uh under conflict, um We see um uh the Syrian Arab Republic, Yemen, Central African Republic, the Democratic Republic of Congo, Sudan, Ethiopia um in Ukraine, um extreme violence, uh for example, the Rohingya forced to seek safety in Bangladesh um or the um uh extreme violence um from gangs um in Honduras, El Salvador and Guatemala, um severe economic and political instability that we've seen in Venezuela and Afghanistan. Um and um and you know, the cycles of this that are happening uh in Nicaragua as well. Um and environmental and climate change, particularly in some countries such as Mozambique, Philippines, and China and India. And for, and like I said, for example, these things can go, can overlap. Sometimes we know that um on top of the extreme violence that's happening in Central America. Um um back in like 2020 or 2021 there were also some major hurricanes that went through the area and devastated many places next slide. So there are a lot of these folks moving across the globe um in the United States. Um in terms of absolute numbers, we probably have, we do have the highest amount of international uh migration by absolute numbers. Um And again, as you can see here, um this was in uh highs over in the like um 18 nineties uh and then started to come down into the 19 seventies. Um And then we've been seen in uh uh a gradual or fairly steep, I would say increase um um over the past um uh 4 to 5 decades. Um However, as we see here on the bottom, right, um even though we have a high number of, of absolute numbers, the share of the total population is about um around the 15 15% um which is much lower than some other countries for, for example, the United Arab Emirates. Um their, their total share of the population is 88% in terms of international migrants. Um and some other uh large ones such as Saudi Arabia. Um so even though we do have a large number of total population in terms of uh uh percentage, um it's not as high as some other countries. For example, Canada, there we have a 21% in Australia at 28% next side. So when Zarin and I are talking about the populations that we serve, um who are we talking about? We are usually talking about the broad term immigrants or those people who intend to stay in a new country permanently. Um And this group of people may have a range of different legal statuses that we'll talk about in a in a second. Typically, we're not talking about what the United States terms, non immigrants or those people who remain only temporarily, whether it be for business, whether it be for uh for work such as seasonal work, um or um or students. Now, there are people who tend to these populations and serve these populations. But for the most part, and I are talking about um immigrants as opposed to non immigrants. Next. So from here, I want us to, I want to center us a little bit. Um and think about immigration and immigration status as a social determinant of health that is informed by political determinants of health. Um And really look at root cause um or, or these structural um agents of discrimination such as racism, uh classism, sexism, nationalism, and those types of things that then inform the tools that are used to shape the way that immigrants move around or live their experience here in the United States. And those are usually done by law. Um Whether that is a political process, whether it's a statute, whether it's a judicial case, um or regulations or the way that things are enforced downstream, we see an effect on different systems, whether that be public health education, economic stability, which then informs health and well-being. So when we see patients in our clinical setting, we are seeing things way downstream in terms of health and uh health and well-being. Um And so it's important for us to look upstream to really understand the context in which people are showing up in our rooms um in our clinical settings and to really understand um the best ways in which we can support these families um while they're waiting for some element or some type of immigration relief. So I really want a ground is there to really understand how things are kind of moving about um that. So if we think about um these things, um then we start to understand a little bit about why the United States has kind of approached immigration reform and law in which they do. Um And so when we talk about immigration um policies and kind of those root causes, inform the way in which we make these generalized categories of uh of, of immigration status. Um And so when we think about immigration, the United States thinks about these kind of broad categories. So naturalized citizens are those who can apply to naturalize and acquire the benefits and responsibilities of actual citizenship. Um A precursor to that is being a permanent resident. Um So you're a resident but not a citizen and this could be acquired through employment, family relationships or other channels um such as having some special type of visa that then qualify you for permanent residency. Then we have this category of refugees and Asy Lees and these folks are fo are forced to flee due to persecution or fear of persecution based on race, religion, ethnicity, political beliefs or membership in a social group. Um Asy are already in the United States versus refugees who are not in the United States. Um And so as you can imagine, there's a lot of policy and politics around who gets to be um who gets to fall under the category of refugee and asylum and there's lots of room for interpretation um around this definition. And then there's this kind of uh thing that folks call kind of the twilight status. So this is um el liminal legal statuses that protect unauthorized immigrants from deportation. And these are things like DACA humanitarian people, humanitarian parole, temporary protected status um that allows folks to be in the United States for a temporary amount of time um until their case or whatever is happening, kind of resolves. And then there's the kind of a broad category of unauthorized um immigration. Some folks call this irregular immigration. Some you will hear it also as undocumented um immigrants, but these folks are quote unquote unlawfully present in the United States or don't have any of the other permissions um Above and if we break that population down in the United States, um we see that um unauthorized immigrants are almost a quarter of the US uh US foreign born population. Um while the rest of them are um either naturalized citizens, uh lawful permanent residents or some other temporary um lawful resident. That's right. So again, um let's uh sorry one more back. So, so let's go back to this framework. Um and revisit that a little bit understanding the root causes um through structural structural discrimination. Um And then the way in which we use law um or political processes that then affect these systems and outcomes inside. So, in the previous administration, there were about, there were more than 100 policy changes that devastated immigrant and asylum seekers and they fall into a very broad categories. Um So prevented entry, for example, um This is, for example, this would be like the Muslim Ban Muslim Ban um or making asylum seekers wait in Mexico through MP P. But essentially this is banning people from entering the country at all. Um And we saw um medicine or health care weaponized um to be to prevent entry through title 42. Um There's also denying status. Um So preventing people from obtain, obtaining lawful status, um This could be through changes in the public charge rule, for example, or asylum denial for victims of domestic violence as a uh as a summary rule. Um are some of the kind of policies that went into place in the past administration um taking away status um people. So this, this, this was done in attempts to terminate DACA and the temporary protected status programs destroying due process or eliminating fairness of due process. Um So arresting immigrants attending court, we saw that for a little bit um or um uh passing policies that expand what it's what is called ex uh expedited removal um and taking away due process in that way, detaining deporting and terrorizing. Um So we saw this as um family separation. Uh We saw this as increased uh raids um in different parts of the United States um and detention of people in army bases and then retaliation. Um uh So retaliating against anyone who stands up for immigration. So this is uh for example, defunding sanctuary cities from federal dollars uh might be a way in which we saw that, that side. Um So what does this mean on the ground? So when you pass all these policies, what does this mean on the ground. So as you can see here. Um So this is the annual refugee resettlement ceiling and number of refugees admitted to the United States. Um So the annual ceiling you can see here for the most part matches the number of admitted uh refugees. Um There are some lulls here but not as dramatic as we've seen um in the past uh five years or so. So you can see the annual ceiling has gone way down from, it was back in the 19 seventies and eighties. Um And um during the past administration, it was increased um during this administration, but as you can see, the number of admitted refugees does not meet um that ceiling at all. Um So that's one way in which we're seeing it on the ground next slide. And then, um again, I mentioned title 42 as a way of weaponizing medicine during the COVID pandemic to restrict um or deny entry into the United States. Um um Again, this was really only enforced along the southern border. There were certainly folks still flying into the United States during title 42. So you can see how policies can be used um in a very pointed way uh particularly for um uh people who are coming from, uh particularly for people of color, who are coming from countries um that maybe the United States government decides is undesirable. Um We also had things like the migrant uh protection protocols uh which is a misnomer. Uh The protection is not protecting migrants, but rather protecting people in the United States um from immigrants coming into the United States. Um And so this caused a huge humanitarian crisis along the border. Um And uh across uh across the, the Mexico um along the US border, there were several um refugee camps, we would go ahead and call them um where there were unsanitary conditions, people not getting uh medical um attention. Um um And as you can see there, people were using water from the Rio Grande, the Rio Grande River which is highly polluted with um toxins and runoffs um from farms and um factories um um uh farther upstream. That's right. So what is happening now with the new administration? We thought that this would get a lot better. Um And it turns out that it's not that much better. Um And so we can see that um the way in which we treat um immigrants, it's very much enshrined in uh American history um and continues to be upheld in uh American politics in a very uh unfair unjust way. Um That's sometimes and well, a lot of times um pushes us towards causing a humanitarian crisis when it comes to people seeking safety. Uh Next, it, so um luckily title 42 did expire um and it did expire because we essentially um decided to say that COVID is no longer a pandemic or a problem. And so title 42 expired and could be used any longer. The current administration then uh passed a different set of rules and laws um term the asylum ban. Um but um includes returning to uh immigration title eight, which uh May, May and has um revived, exited expedited removal uh for immigrants um along the border. Um It also has longer administrative processes which could lead to crowding um at holding facilities. Um The Department of Homeland Security and the Department of Justice in this rule, uh quote, encourages migrants to avail themselves of lawful, safe and orderly pathways into the United States or otherwise to seek asylum or protection in another country through which they travel. Um This means that essentially we poured more money into strengthening um uh enforcement um at the border. Um And it presumes that individuals who cross the border without authorization or a lawful pathway are ineligible for asylum summarily. Um There's also a bar for reentry for at least five years and potential criminal prosecutions. Um And it severely limits access to asylum for most families. Um So this means that folks who are coming, who are coming from Central America or South America if they do not apply for asylum in the countries in which they pass before getting to the United States. Um Essentially the federal government is saying you did not do this the correct way and you're not eligible for asylum in this country, um which does violate many international laws as well as due process. Next slide. Um We've also seen a significant increase since 2019 of Children crossing the border, um, unaccompanied minors. Um, there was about 76 76,000 apprehended around that time and there was about an eightfold increase just between 2008 and 2019. And in 2022 there were more than 100 and 50,000 unaccompanied um, Children who were apprehended at the border. Um And then beginning in 2019, um we've also seen a sharp increase in folks coming from uh different countries including Brazil, Ecuador and Nicaragua. And then more, more recently, um more folks from Venezuela, Cuba, Chile and Haiti. Um and then of course, we also um um had uh refugees coming in from crises in Afghanistan. Um and the Ukraine. So the demographics continues to shift in the United States. But I think what's been constant and what people are not. Um We're not thinking about was the number of Children who are coming along with these families and these different demographics. Um So that's an important thing to look at. I don't think it's gonna change at all and I think we're gonna continue to see this shift and, and um uh push and pull of, of different populations who are coming from different places other than what we traditionally would have. Is there those folks to Mexico? So what does this look like on the ground Um So this looks like um the United States starting a uh an app um that's called CBP One. That CBP One app has come with many uh uh problematic challenges um that has caused a backlog and for folks to um stay in dangerous conditions in Mexico for a prolonged period of time. Um So, for example, parents are sending migrant Children alone across the border into South Texas. Um because the CV P One app was not working correctly and because it was challenging for families to make an appointment for each individual in a large spot. Um um parents were getting desperate and we really, and we're starting to send their Children across the border alone as unaccompanied Children. Um We also heard of a Honduran man who died from injuries sustained after falling from the US Mexican uh uh border wall. And then most recently, um because of the prolonged stay of folks in border patrol in this case, because um somebody tested positive for flu. Um We saw an eight year old um Anna Dare Alvarez from Panama, um who died in, in border patrol custody. Um um despite being uh evaluated by medical staff that clearly was inadequate. This eight year old um girl had a history of congestive heart failure as well as sickle cell disease, um and um presented to medical personnel at CBP several times uh until she finally um succumbed to um seizures and complications of her illness. And died um in custody. Uh We also recently heard of an Afghan evacuee child um with terminal illness who died while in federal custody. Um and also a 17 year old um who from Honduras, um who died in office of refugee resettlement um after a seizure, um that was not reported in his medical history. Um So essentially what we're seeing here are systems um that are built for law enforcement um trying to care for Children um in a setting that was not meant for them um in a setting that they should never be in to begin with. Um And we're seeing kids die because um the setting um I is, is not catering to their needs um and is not built um to be able to take care of Children, particularly those Children with special health care needs. Next slide, um Other programs that we've seen um uh uh uh from this administration is a Central American minors program, this reunites Children from El Salvador, Guatemala Honduras with parents in the United States. Um And this is only for Children less than 21 years of age. Um However, the parent needs to have us permanent residence, uh residency or citizen status. Um So again, uh a program that on the face seems to be positive, but then there are these politi, these policies and regulations within these programs um that limit um accessibility um to these types of, of programs. Um Next slide, um there's also something called Humanitarian Parole that has come out of this, these changes in policies. This is particularly for Cubans, Haitians, Nicaraguans, and Venezuelans. Um that grant advanced travel authorization, but it's on a case by case basis. Um And theoretically up to 30,000 people from these countries um per month may be admitted into the United States for a temporary period of up to two years for urgent humanitarian reasons. Um The they must have a supporter in the United States and that supporter must hold lawful status, lawful status in the United States pass a security and background vetting and demonstrate sufficient funds for financial resources. And then again, the applicant must be from any one of those countries or their immediate family members and outside of the United States. Um So again, on the face of very good program, um but again, we don't know much about this case by case basis. Who's doing this vetting? How are they doing this vetting? What are the decisions, what are the decisions that are made to be, get to, to this 30,000 people um each month? And what are the barriers um to people being able to apply to these things? Um and, and um and be able to seek safety next side. Um Again, we did see um uh Afghan arrivals um um uh escaping Talib the Taliban regime. Um many folks did not make it out. Um We saw that this was a very disorderly evacuation and many people did not make it. Um Some of these folks are traveling to places like Central and South America and making the same artist trek that everyone else is doing so. More than 3600 Afghans traveled from South America to the US border in 2022. Um And many are going through a very long and dangerous um uh journeys in order to make it to the United States uh and be able to uh benefit from the particular programs that are set up for Afghan migrants. Um Certainly, um like any other institution, we do see um uh racism um in immigration policy um particularly for black migrants um at the border. Um There's been uh reports of racist and illegal expulsion of Haitian um asylum seekers at the border um compared to Ukrainian migrants where 95% were paro paroled and allowed to enter and temporarily remain in the United States. Um There we see racial bias, bias, um violent and discriminatory mistreatment of black migrants. I'm sure we remember that, right. Um The folks on horses um with um whips and guns and stuff like that um and pushing back um Haitian migrants along the border. Um The US again, going back to the CBP one that US mobile app that you have to use to uh get yourself an appointment to ask for asylum. Um So the technology there uh for facial recognition um shows bias in technology. Uh many um uh community based organizations and Haitians in Mexico waiting for their appointment have been unable to upload their photos because the technology can't recognize um the tone of, of their skin color. Um And we also know that black migrants face longer detention and higher um bail amounts. Um We've also seen this um at the state um at the state level. Um we know that states vary in laws around the treatment of, of uh uh of unauthorized immigrants. Um For example, here in California, we know that um Children can get uh medical regardless of immigration status, but this is not the case in many other uh in most states. Um California also allows things like getting a driver's license um in state tuition um uh and so on. Um And governors have um particularly Governor Abbot Abbott um um started uh programs that bus migrants um to different places in the United States. Um And they call it the migrant uh relocation program. So they started back in April of 2022 where they were sending buses um without the different municipalities um knowledge. Um And many times uh migrants were forced to go into these buses to go to these different places. But they've sent buses to Washington DC, New York, Chicago, Philadelphia, and most recently, Denver. And this month uh we saw uh buses um to Los Angeles for the first time and some flights that flew into Sacramento. Um These folks are told, um sometimes told that there are jobs there and support for them. Um And again, municipalities don't even know they're coming. And then the last thing I wanted to um showcase here is this kind of idea that many of the families that we see are in this kind of legal limbo. Um There is a growing backlog in the immigration court asylum uh um across the nation. And as you can see here, there was about 100,000 in 2012. And then in 2023 we're seeing that to about 800,000 cases um that are backlogged. Um limited resources, insufficient staffing and complex legal processes have um contributed to the growing backlog. Um There are lengthy wait times. Some families have to wait 2 to 3 years before their case comes to the Immigration Court. And so that's 22 to 3 years of being unauthorized of not having access to public benefits and so forth. Um um It's a huge strain on the court system um and it affects a lot of the due process. Um This of course, is stacked on um these expedited removals that are happening um at the border and violating due process. Next I 10. All right. So I've done my job of doing, doing some updates on what's happening and how policy um is affecting the lives of our immigrant populations. Um And why we're seeing what we see downstream. So I'm gonna hand it off to um who's gonna talk to more about what do we do? Thank, thank you. That was really wonderful just to set the um background and kind of uh give us uh you know, a good understanding of what's going on currently in, in the past. So what does this mean for us as pediatricians, as health care providers as uh folks who are taking care of uh immigrant Children. Um There are many opportunities for health professionals to really play a role in the health of migrants and immigrants. Um And these are some of them and we'll go over some of these um in detail, but just to know that there are things that we can do internationally, whether it's supporting local humanitarian aid efforts. Um Perhaps uh you are a researcher do or you do research and you can look in things that may inform policy changes and address some of those push factors that is talking about. Um There are things that we can do trans internationally that means working at or across our borders to assist immigrants and asylum seekers. Um And then there are things that we can do here um in in, in our clinics, in our communities to help uh immigrants, whether it's doing forensic evaluation for asylum um asylum seekers, whether it is getting um your civil surgeon designation, so you can provide these really needed uh medical exam for folks who are who are, um, applying for immigration status change. Um, I have a civil surgeon designation. If anybody has interest in wanting to talk about it, that's like a whole, that we can talk a whole another hour on that. But I can, um, you can reach out to me and I can talk to you about kind of what that entails. Um, we're gonna do a little bit about what we're gonna do. You know what we can do as pediatricians, as health care providers in the clinic. Um and talk a little bit about the medical care um for our um uh immigrant patients. So as you know, migration, even as you know, like rules segment, even under the best conditions, it involves a lot of events that can be highly traumatizing for, for our Children and families and it can place um immigrants at risk. Um They can, there are things that we need to consider such as infectious um diseases, whether um there are things that they've um were exposed to during their, their migration. Um malnutrition is, is a big one. You know, whether it is uh due to things that uh you know, food insecurity that they were experiencing um in their home country, um you know, perhaps uh push some of those push factors, right? Um And or the journey to get to, to their destination, um they were um undernourished um or are facing a lot of uh vitamin and mineral deficiencies. There's a lot happening with climate change and a lot of um uh um uh effects of climate change that uh families are experiencing. And, um, so these can be a lot of environmental exposures whether again from their, you know, um from their home countries or during their um migration. Um We've seen a lot of violence and injuries, um, and, and a lot of trauma that has, uh, that has pushed a lot of folks to, to, to seek um safety and seek refuge. Um And then, you know, some of the sometimes the the of that is some of the mental health issues. Um We talk a little bit more about that and then something that just kind of think also about is um doing a really complete medical history um including a complete developmental history because sometimes we catch a lot of delays and, and chronic conditions that have been misdiagnosed or undiagnosed at all, just given the disruptions that um that the migration caused the family. So the uh with the A AP chapter one, a group, the immigrant health task force, we created this one pager um that goes over kind of the clinical guidelines for the first visit and it, it, you know, highlights some of the stuff you would want to get from the history as well as um getting some uh information about their present situation as well as their migration history and then the exam as well as labs. That you can consider doing and uh and treatments. So, um this is available online for you to look at and just a caveat. I know it says a clinical guide for the first visit, but you may not get to all of these things. Um And during that first visit and uh something I always talk to residents about like you, you know, it takes time to build that report and get some of this history, but it gives you on one page. All the things that we kind of want you to think about when you're taking care of um immigrant Children in addition to, to that is um the heads or the shades that um we do with our adolescent teens. And um you know, we wanted to adapt some of those um based off of kind of the things that uh Raul had talked about um for that affect uh immigrants. And so thinking about kind of like the age, the development, developmental stage that they were at migration. Um they're link, you know, talking asking about their language proficiency. Um What are their cultural, personal identities? You know, we've seen a lot of families who are from a certain country but identify from uh a specific indigenous group or have um personal identities that may differ. So it's very important to kind of explore that family structures, right? What are, where are they living? Are they? Um you know, we have seen a lot of families who are kids who are staying with, um, aunts and uncles or distant relatives or cousins in that separation from their, uh, caregiver, um, during that migration. So it's important to talk about that. Um, there's a lot of other things and one thing that I kind of want to talk, talk a little bit more about and something that I are, I consistently asking a lot more of my, uh, um, immigrant adolescents is employment. Um So are they working, where are they working? What are some of the things um that they're working? Uh what are the conditions that they're working in? There was a New York Times article that just came out in February that kind of highlighted um and it put a spotlight on um the exploitation that migrant Children, immigrant Children are, are facing um uh across the state, across the United States. Um And um you know, really looked at, you know, these, these very young Children who are working long hours overnight shifts, you know, uh working in extremely dangerous conditions, working conditions, doing jobs that they should not be doing. Um you know, missing school days um dropping out of school. So I, you know, I have many teens in my uh clinic who end up leaving school or unable to complete school because they have to work in order to help support their family. Um human trafficking is, is, is um the reality for a lot of these um uh immigrant Children who, you know, are, um, have to pay back, um, their, their, um, you know, uh, fees that they, um, that the smuggler, uh, that, uh, charge them to come to the U. So there's a lot, um, here and there's limited legal protection sometimes because there's a lot of fear of deportation and that perhaps they don't know, they don't know what the, the laws are around child labor laws. So this is something to think about and really can um ask your families, your, your adolescent teens about this. Uh mental health is huge. Um uh you know, the health of a migrant is really shaped by the experiences and situation. Um not only where their place of origin is, but also during transit, during that whole process of migrating. Um and then also it doesn't end at that, it doesn't end once they're at their destination, it can continue. There are a lot of factors that um affect mental health um as well. So things like the pre migration, these are things that perhaps are, you know, we talked a little bit about those push factors. What are the things that are making them? Um you know, or, or contributing to the fact that they are migrating the whole migration pattern as we've seen um can be treacherous, can be very dangerous for them. And so those can all affect um uh a child's mental health. And then once they arrive here in the US there are things here um whether, you know, it's just this discrimination biases, you know, um as well as difficulties um uh adjusting to their new environment. Um This term acculturation um is we use that to kind of discuss the process of adjusting and adapting to a new culture when individuals and groups migrate to different countries. And this can be things from like language acquisition, learning more about the culture, um identity formation, coping with discrimination, prejudices and then, you know, same as like balancing those cultural views. So for, for, for youth, this can be a little bit easier than adults. Um You know, the because of, you know, most of the time they are in school, which helps a lot with that uh acculturation tasks. Um So they learn how to communicate effectively in, in both languages. Um They start developing, having friends um from both their, you know, having uh social um structures within their family, but then also outside of um their family in the, in the new place that they're here that um they end up knowing the values and practices of both cultures and then code switching, being able to, you know, code switch between the language and the cultures as well. And, and oftentimes Children, because they do these tasks really, really well, they often are that bridge um for their parents or their um adult caregivers um to kind of, you know, help them adjust uh um to, to the language and cultures um of their destination. Um So, you know, as we said, the trauma is, is um the trauma that immigrant Children and, and families experience can be um a lot. So how do we, how do we care for them as pediatricians, as care providers? Um It's important to really think about um the, the way that they view mental health and, and well-being. Um because I think it's important to meet them where they're at and um use the tools that um they're familiar with that resonate with them to help them. Um I think it's important, I think oftentimes we revert to um our, our approaches, our, you know, our medical westernized approaches to mental health. But really thinking about how do we decolonize that approach and really how do we center indigenous voices and knowledge and um support community organizations and cultural religious centers that, that do these traditional healing, the things that um perhaps may better serve our, our population. Um So, really thinking outside of the box of traditional kind of mental health um and, and helping families um find the tools that will help them deal with some of the trauma that they may have experienced or experiencing all of this should be within the framework of trauma informed care. And I, and I know um this grand round series has done a great job of bringing these topics. And so I'm not gonna spend too much time because I think you all have gotten received um talks about trauma informed care what that looks like. Um But just to highlight the importance of this when caring for immigrant Children is important, just given that the fact that um the trauma that they may have experienced um and are still perhaps experiencing so making sure that we um adopt these trauma informed approaches um and make sure that um we practice that one like so the practical ways of doing that. Uh There's a great article that I will refer you guys to, to take a look at, it's called the 10 Clinical Pearls of trauma informed care for refugee and immigrant youth. They give you really concrete examples of how, what this looks like in the clinical setting. Um uh And so given time uh constraints, I'm not gonna go through all of them, but just, you know, thinking about how to make these um uh how to use these uh every day in your clinic. So using strength based, you know, approaches. So helping families really build on past successes and continue to build resiliency, um create family, immigrant family health care environment. So like your signage is important, materials in different languages are important, promote trust, trusting relationship, you know, allow the family to drive the agenda. Um ask for permission um to discuss potentially difficult subject, right? Um Everybody will have a different level of comfort. Um And they will let them have control over their own narrative and let them share when they're ready to share uh recognize the impact of trauma, right on the developing brain. This is super important, important. So using screening tools to make sure you're screening for depression anxiety, um post traumatic stress disorders um treat the trauma, right? This is the what we're talking about. Uh making sure that you connect folks to to treatments within the that fit their uh mental health frameworks, utilize a two generational approach to care, right? We talked a little bit about like the parents, the parents are super important, they can help buffer some of that negative impacts of trauma. So it's important to really, you know, check in with the parents and, and help them as well with um with the this whole acculturation and and adjusting um know your local resources, make sure they're trustworthy uh recognize trauma that may not end after migration, right? Continues. Um There's a lot of anti immigrant rhetoric and policies out there that affect Children and then advocate for your patients um inside and outside the clinic. Um So use your privilege, use your power, write, edit, write letters, write, testify, like write editorials. These are things that you can do and there are other tools we'll talk a little bit about what else you can do. I'm gonna skip this if you um have time. Take a look at this, caring for former unaccompanied immigrant minors, they give you really um great ways of framing interview questions when you're talking to um uh immigrant Children. All right. So kind of continuing on. What, what else can we do? So inside your clinic, you can have signage, you can have, you know, things that welcome, welcome, immigrants have handouts in different languages. Um have community resources that you can share to fam share with, with families. People see this and they, they feel welcome um review clinical. So I I'm gonna skip over this because given time, but just make sure that you have policies perhaps in place in case there are things that um you know, in the past, we've and we continue to worry about ice uh raids and, and ice encounters um in the health care settings. So having policies uh looking at your institution making sure you have policies to address that. Um it's very important to look and ask about the needs of your family and this may be things of uh that are related to their immigration. Um So, um and having things that you can information and handouts that you can give to families is super important. And part of that is building a network in partnership with community based organization, learning what is out there, what resources are out there for your families, knowing also a little bit about benefits and what, what benefits uh what benefits um our uh immigrants are eligible for is important to know. And again, this may be state by state and county by county. Um, but for some of the, um, you know, things that a lot of our families, um, uh, uh, want to know is like, can I sign up for wick and yes, immigrants, regardless of your immigration status, you can get, uh, wake services. So any Children under the age of five or if you're a pregnant, um, uh, pregnant person, you can get wake services cal fresh. You can sometimes be eligible. It has to be at least one household member who um uh has a immigration status that can get core. And then here in California, we we do you can get medical for Children, which is great. And um uh and public school is open to anybody here um in California and just as I mentioned, medic come January 2024 everybody in California, regardless of your immigration status can, if you, if you qualify based on your income can receive medic uh full, you know, full scope medic, which is wonderful and it has been currently limited to under the 26th. Um And then uh for over 50 now Governor Newsom is closing that gap and allowing everybody in California to receive medic. Just a great, great, great, great thing. Um medical legal partnership, I can't speak enough about the importance of medical legal partnerships, especially when working with immigrant. Um because like as we have mentioned, your immigration status, can it can have, you know, downstream effects on your on people's health. And so, um and we know that medical legal partnerships do work and they do help um uh improve the health of, of patients. Um So this is a, a partnership that you have with legal uh legal uh groups to, to help provide kind of a more holistic um uh uh approach to, to patient care. Um I'm gonna give in time language access is important. Um making sure that we have you have interpretation in the correct language and dialect, right? So many times we have families, you know who we think like, I have a lot of um Yemeni Arabic pop the patients in my clinic and and sometimes the Arabic interpreters we use, they don't understand the and so getting a specific dialect is specific um language is super important. Um and then training your staff, training um uh yourself on how to use an interpreter is important. School based health centers is a great way to provide care, especially for immigrant population. They, you know, um provide comprehensive care usually with the interp professionals team. So they can do kind of a wrap around services, getting mental health um social work, getting the some of the social needs addressed as well. And then if you are lucky enough to have a medical legal partnership as well, that provides that other uh level of support for family, for uh for uh immigrant youth. Um Given just I think we're running out of time I'm gonna skip the asylum um uh thing, but just knowing that you can, uh, get trained on how to perform what's called forensic medical and psychological evaluation to help folks who are seeking asylum. Um And so if you want more information, you can go to our website and we can, um, happy to discuss more about how to get trained to do these evaluations and how you can work. We started a pediatric asylum clinic here in Oakland and we do it once a month and where we do evaluations to help. Um I uh uh improve the chances of somebody getting uh asylum by kind of corroborating this their story. Um So this is a great um uh thing if you want to get interested and then I'm gonna skip this, this, there's a lot of work um at the border that you can do to help really um support uh immigrants um in a transnational um way in providing solidarity. Um And so there's the a plug for um uh Doctor Josie Marin's uh sidewalk school where um we do telehealth clinics at the at shelters at the border to provide some kind of medical um support for them and to write humanitarian, parole letters for them. Um Yeah, so this is, you know, kind of how we do it challenge the segmentation of migrants provide in person telehealth care and then channel critical resources along the border and this is our team. Um So I wanna thank you. Thank you, Raul. Thank you for um uh letting us speak uh today. And I'm sorry, I'll leave this key resources up if people want to look at some websites. Thank you so much to you both. This is really incredible. We should probably like stretch it to a second hour. There's like a lot of information to cover. Um But thank you, Raul to answering the questions that came through in the comments as well. And I think the audience members can take a look at that since we are out of time. But we would love to have you both back, you know, in coming years and just hear more about it because I think this is changing all the time and we always need to know what the updates are on policies. So thank you both. Um and thank you to our audience and it's been an honor serving you this year in grand rounds and we will see you in two weeks from now because next week is a holiday. So we want the grand rounds next week.