Doctors Without Borders Exhibit Gives Visitors a Personal View of the Global Refugee Crisis

This piece is by Samantha Hsieh, a fellow at our law firm. Samantha recently graduated from The George Washington University Law School with honors. She is interested in practicing asylum law and removal defense. Samantha’s immigration experience includes interning at a law firm and at the Department of Justice, Office of Immigration Litigation. Prior to law school, she worked as a paralegal at an immigration firm.

I recently attended the Doctors Without Borders, or Médecins Sans Frontières (“MSF”), Forced From Home exhibit on the National Mall in Washington, DC. The exhibit, which is touring five East Coast cities this year, allows participants to learn about the experiences of refugees from around the world and raises awareness for their cause.

Participants could choose between clothes, jewelry, children’s toys, a bicycle, a wheelchair, a guitar, footwear, money, fishing equipment, pets, medication, a phone, keys, water, a sewing machine, photos, scarves, a passport, food, and baby formula
Participants could choose between clothes, jewelry, children’s toys, a bicycle, a wheelchair, a guitar, footwear, money, fishing equipment, pets, medication, a phone, keys, water, a sewing machine, photos, scarves, a passport, food, and baby formula

Upon entry, visitors are given an identity as a refugee, internally displaced person, or asylum seeker from Honduras, South Sudan, Burundi, Syria, or Afghanistan. According to MSF, there are currently 65 million people in the world fleeing from conflict or persecution. Our tour guide, Jane, explained the work of MSF, which employs around 35,000 people and provides free medical care in over 60 countries. Jane is a nurse who has worked in dozens of refugee camps.

One of our first tasks was to select five items from 20 to bring on our journey. I chose a cell phone, medication, passport, water, and stove. Refugees fleeing on foot are limited to items that they can easily carry. Oftentimes, decisions about which items to bring must be made in a hurry. I noticed that the only other participants who had also chosen cell phones were two children whose eyes were glued to their iPads the entire time. We were forced to give up our items one by one in order to pay for different parts of the journey.

Jane led our group onto a small inflatable raft in order to simulate crossing the Mediterranean Sea. We sat in the raft with the men on the perimeter and the women and children in the center on the floor.

These rafts were supposed to hold seven people, but as many as 60 refugees and their belongings would squeeze into one raft. Smugglers load refugees onto the rafts and then leave them to their journey, often without enough fuel. Refugees are sometimes given cheap counterfeit life vests, filled with ineffective packaging material. Rafts that stay on course take about eight days to reach Europe. The cost of admission for a seat in one of these rafts? US$2,000.00 to US$3,000.00 per person. Since January 2016, roughly 3,600 refugees and migrants have died or gone missing attempting to cross the Mediterranean into Europe.

Refugee camp bathrooms lack privacy.
Refugee camp bathrooms lack privacy.

Next, we visited a re-creation of a refugee camp. Each person in the camp receives a daily ration of water, grains, beans, oil, and salt. The young women and girls are responsible for filling and delivering water containers holding up to six gallons. Humans need a minimum of four gallons of water a day for drinking and basic hygiene and cooking. For comparison, the average American uses 90 gallons of water each day. Jane also demonstrated how to use a typical bathroom in a refugee camp, which is essentially a box around a hole with a curtain in the front. Notably missing was toilet paper.

Standing in front of an MSF medical tent, Jane told us about several medical issues that refugees face. While relatively easy to treat, cholera–which arises from contaminated food or water–can kill within hours if left untreated. Malaria is also common. MSF staff test patients for malaria by applying a blood sample to a test card. Because of language barriers, the packaging for the malaria medication uses symbols instead of words to convey dosage instructions.

A typical MSF medical tent
A typical MSF medical tent

Malnutrition in young children can be difficult to recognize, particularly for local aid workers who lack formal medical training. MSF staff use mid upper-arm circumference (“MUAC”) bracelets to measure the arms of young children as a simple means of detecting malnutrition and determining a treatment plan. Children whose arm circumference is under 116 millimeters (roughly 4.5 inches) suffer from severe acute malnutrition and are immediately hospitalized. Malnourished children are fed Plumpy’nut, a high-calorie peanut paste mixed with vitamins, minerals, and other ingredients for weight gain. One small packet of Plumpy’nut contains 500 calories.

Finally, we viewed several tents similar to those where refugee families live. Conditions in refugee camps range from reprehensible (more common) to fairly good (rare). Regardless of their living conditions, refugees are forced to wrestle with concerns over the safety of family and friends left behind and uncertainty over their own futures.

Plumpy’nut has been called “surprisingly tasty.”
Plumpy’nut has been called “surprisingly tasty.”

The town of Dadaab, Kenya contains some of the oldest and largest refugee camps in the world. The first camps in Dadaab were constructed in 1992. The Dadaab camps are now home to over 300,000 refugees. Some refugees born in Dadaab have grown up and now have children of their own. Jane told us of one resident she spoke to who had expected to stay for only a few weeks. He has not left the camp in over 15 years.

At the end of the exhibit, Jane told us the greatest lessons she learned from serving as a nurse in refugee camps around the world. “Every day,” she said, “I was reminded of the resilience of humanity and that despite the terrible things that had happened to them there, people always miss their home.”

Follow the route of the Forced From Home exhibit, register to attend, and sign up for updates about future locations here.

Doctors, Detention, and Dual Loyalty

A recent report by Physicians for Human Rights (“PHR”) articulates the difficult dilemma faced by physicians who serve detained immigrants.  Such physicians have a “dual loyalty” problem:

Health professionals working in detention facilities run directly under DHS oversight, report to the federal agency charged with managing health care for detainees, the ICE Health Service Corps (HSC).  Like ICE, HSC is a division of DHS, and therefore, has objectives that tend to focus on deportation and security, rather than on providing comprehensive health care to immigrants in detention.  Review of the HSC mission statement clearly demonstrates that its mandate is prone to conflict with health professionals’ obligation to provide their patients with the best possible care.  The HSC website proudly proclaims: “We protect America by providing health care and public health services in support of immigration law enforcement.”

Perhaps Janus, not Asclepius, is an appropriate patron deity for DHS Doctors.

A doctor’s first loyalty should be to her patient.  However, there are many examples of third parties infringing on the doctor-patient relationship: insurance companies and hospital administrators being two of the most common.  In the case of detained immigrants, a doctor’s loyalty to her patient may be compromised by her loyalty to her employer–in this case, the Department of Homeland Security.  The PHR report points out that this should not happen:

While the term “dual loyalty” may imply equivalence between a medical professional’s loyalty to the patient and loyalty to third party interests [such as DHS], no such equivalence exists.  Ethically, with very rare and well-circumscribed exceptions, a health professional is obligated to act in the interest of the patient above all other concerns.

Great in theory, but not always easy to implement in reality.  The report offers several recommendations, including the following:

  • Require that health care professionals working in detention centers report to health organizations, such as the Department of Health and Human Services, so that they may maintain clinical independence.  They should not report to the Department of Homeland Security or to for-profit private contractors.
  • Create an independent oversight organization to monitor provision of health care in all facilities that house immigration detainees.
  • Create an ombudsman office to which detainees may easily report grievances regarding access to medical care.
  • Make the Performance Based National Detentions Standards (PBNDS) legally enforceable in all facilities that house immigration detainees.  Failure to adhere should result in contract cancellation.

DHS detains about 400,000 people each year.  The recommendations in the PHR report would help to improve medical care for these people and would also help to mitigate the “dual loyalty” problem faced by physicians in the system.  Further, PHR’s recommendations do not seem particularly costly.  Indeed, the primary recommendation–that physicians working with detained immigrants report to HHS instead of DHS–should cost next to nothing.  The recommendations are worthy of consideration by DHS.