- Email: [email protected]
The pharmacist’s role in advocating for the health care of immigrants in detention centers
SCIENCE AND PRACTICE Journal of the American Pharmacists Association xxx (2020) 1e6
Contents lists available at ScienceDirect
Journal of the American Pharmacists Association journal homepage: www.japha.org
COMMENTARY
The pharmacist’s role in advocating for the health care of immigrants in detention centers E. Michael Murphy*, Jennifer L. Rodis a r t i c l e i n f o
a b s t r a c t
Article history: Received 24 October 2019 Accepted 11 January 2020
Objectives: The primary objectives of this commentary are to (1) summarize the role of pharmacists as an advocate for the health care and appropriate use of medications of migrants in immigration detention centers and (2) describe methods to advocate for this vulnerable population. Summary: There is a current humanitarian crisis occurring within the United States that violates the responsibilities and values held by members of the profession of pharmacy. Reports by reputable news organizations and members of U.S. Congress have shared that there have been inappropriate distribution and use of medications in migrant detention centers along the southern border. Specific instances have been described, including lack of access to vaccinations and vital medications to control chronic conditions and treat acute conditions. The role of the pharmacist is to ensure safe and effective use of medications. This role is not being fulfilled at migrant detention centers in the United States. By advocating to elected leaders, the Department of Homeland Security, and Customs Border and Protection for legislation that ensures the appropriate use and access of medications for migrants in immigration detention centers, pharmacists can push for the appropriate care for this vulnerable patient population. Conclusion: The professional values of a pharmacist should not be hindered by a border or the citizenship of a patient. As is stated in the Oath of a Pharmacist, pharmacists must “consider the welfare of humanity and relief of suffering [their] primary concern.” Through advocacy, pharmacists and student pharmacists can uphold their professional ethics and roles on the health care team by advocating for the care of a patient population that needs the profession’s help. Published by Elsevier Inc. on behalf of the American Pharmacists Association.
Immigration detention in the United States is the largest and oldest detention system in the world.1 For the past 25 years, there has been an increase in the number of individuals held in immigration detention centers.2 Immigrants are placed in detention centers for unlawfully entering the United States, if they submit a claim for asylum, or if they are being deported.3 Beginning in the early 2000s, reports began to surface by numerous news organizations that there were instances of human rights abuses and inappropriate medical care being provided to migrants in immigration detention centers.4,5 An attempt was made to improve the health care of these individuals in May 2008 when the Detainee Basic Medical Care Act of 2008 was introduced to Congress; however, the bill was not enacted.6
Disclosure: The authors declare no relevant conflicts of interest or financial relationships. * Correspondence: E. Michael Murphy, PharmD, Pharmacy Advancement Fellow, 500 W 12th Ave., Room 129F, Columbus, OH 43210. E-mail address: [email protected] (E.M. Murphy).
In June 2018, several news organizations began reporting inappropriate prescribing and administration of antipsychotic medications to control agitation in children without the consent of the parent or guardian.7,8 When a physician advocate was asked by the Los Angeles Times about the prescribing of antipsychotic medications to children in detention centers, she stated, “These children tend to be overmedicated with combinations of meds that are really not indicated for children with PTSD [post-traumatic stress disorder], particularly small children. The purpose of that medication is not really to treat an illness, but to tranquilize them. It’s not a tool of therapy, it’s a tool of control.”7 By August 2018, a federal judge in California had ruled “that the government may not administer psychotropic medications to migrant children in residential centers without first obtaining a court order or consent from a parent or guardian.”9 In the spring and summer of 2019, the number of reports relating to inadequate conditions and inappropriate medical care for migrants in immigration detention centers increased and began making national headlines. Specific instances of
https://doi.org/10.1016/j.japh.2020.01.005 1544-3191/Published by Elsevier Inc. on behalf of the American Pharmacists Association.
SCIENCE AND PRACTICE E.M. Murphy, J.L. Rodis / Journal of the American Pharmacists Association xxx (2020) 1e6
Key Points Background: Reports by reputable news organizations and members of U.S. Congress have shared that there has been inappropriate distribution and use of medications in migrant detention centers along the southern border. Specific instances have been described, including lack of access to vaccinations and vital medications to control chronic conditions and treat acute conditions. The American Pharmacists Association, American Medical Association, and American Academy of Pediatrics have published statements and policy around the care of migrants in immigration detention centers. By empowering the pharmacist to advocate for the appropriate prescribing and administration of medications to migrants in immigration detention centers, the profession of pharmacy can join other health care team members in taking action and calling for the appropriate access of medications for this patient population. Findings: The role of the pharmacist is to ensure safe and effective use of medications. This role is not being fulfilled at migrant detention centers in the United States. This is not a political issue; this is a pharmacy issue, and it is the responsibility of members of the profession to speak up and take action. Through advocating to elected leaders, the Department of Homeland Security, and Customs Border and Protection for legislation that ensures the appropriate use and access of medications for migrants in immigration detention centers, pharmacists can push for the appropriate care for this vulnerable patient population.
inappropriate distribution and use of medications included reports of the lack of access to vital medications to control chronic conditions (e.g., antiepileptics, antihypertensives, anticoagulants, antipsychotics) and lack of access to medications for acute conditions (e.g., antipyretics).10-14 The lack of access to medications has resulted in patient harm. An example of this harm can be seen with a detainee who was not given access to his anticoagulant, which resulted in the formation of a blood clot in his leg.12 In August 2019, a proposal to eliminate the Flores Settlement was reported by major news organizations. The Flores Settlement is a nationwide policy that sets a 20-day limit on children being detained in immigrant detention centers.15 With the proposal to eliminate the Flores Settlement, there is potential for the inappropriate distribution and use of medications to continue indefinitely for children because they may remain in a detention center beyond the current 20-day detention limit. Elimination of the Flores Settlement is additionally concerning because the Department of Homeland Security (DHS) refuses to
2
administer influenza vaccines to detainees regardless of the fact that multiple migrant children have died from influenza in the past year.16 The previous explanation for as to why influenza vaccines will not be administered to detainees is because the time it takes for the vaccine to begin working would not have been within the time frame that migrants were detained.16 Without this 20-day holding period limit of children, this argument is no longer appropriate. The lack of recommended influenza vaccinations may result in an increase in the morbidity and mortality of detained children. Health professionals have taken a stand to advocate for the improvement of health care in this patient population. In 2017, the American Medical Association (AMA) passed a policy statement, Improving Medical Care in Immigrant Detention Centers D-350.983, and in June 2013, the American Academy of Pediatrics (AAP) revised their policy statement, Providing Care for Immigrant, Migrant, and Border Children, to more optimally advocate for the care of children in migrant detention centers.17,18 The American Pharmacists Association (APhA) has joined AMA and AAP in calling for an improvement in the health care of migrants detained in immigration detention centers.19 Although important for professional organizations to lead in calling for action, it is the responsibility of every member of the profession to speak up when the values of pharmacy are being violated. By empowering the pharmacist to advocate for the appropriate prescribing and administration of medications to migrants in immigration detention centers, the profession of pharmacy can join other health care team members in calling for the appropriate access of medications for this patient population. Objectives The purpose of this commentary was to serve as a call for action for members of the profession of pharmacy to advocate for the basic health care rights of migrants held within immigration detention centers in the United States. The primary objectives of this commentary were to (1) summarize the pharmacist’s role as an advocate for the health care and appropriate use of medications of migrants in immigration detention centers and (2) describe methods to advocate for this vulnerable population. Summary The pharmacist’s role The current humanitarian crisis occurring within the United States at migrant detention centers violates the responsibilities and values held by members of the profession of pharmacy. In October 2019, APhA published a press release recognizing the need for pharmacists to advocate for the health of migrants detained in immigrant detention centers.19 APhA is leading this call for action in the profession of pharmacy because the quality of health care and access to medication afforded to these individuals is in direct contradiction with the official policies of professional pharmacy organizations, which are included in Table 1.20-24 The 1994 Code of Ethics for Pharmacists, which was adopted by APhA and endorsed by the American Society of
SCIENCE AND PRACTICE Pharmacist’s role in health care of immigrants in detention centers
Table 1 Relevant policy statements that support the pharmacist’s role in advocating for the health care of detained migrants20-24 Policy Code of Ethics for Pharmacists, 1994
Disparities in Healthcare, 2009 Mission of Pharmacy, 1991 Professional Affairs Committee, 1994
Pharmacy Benefits for the Uninsured, 2016
Pharmacist Conscience Clause, 2004, 1998
Description The Code of Ethics for Pharmacists was adopted by the membership of the APhA (then the American Pharmaceutical Association) on October 27, 1994. Preamble Pharmacists are health professionals who assist individuals in making the best use of medications. This Code, prepared and supported by pharmacists, is intended to state publicly the principles that form the fundamental basis of the roles and responsibilities of pharmacists. These principles, based on moral obligations and virtues, are established to guide pharmacists in relationships with patients, health professionals, and society. I. A pharmacist respects the covenant relationship between the patient and pharmacist. Considering the patient-pharmacist relationship as a covenant means that a pharmacist has moral obligations in response to the gift of trust received from society. In return for this gift, a pharmacist promises to help individuals achieve optimum benefit from their medications, to be committed to their welfare, and to maintain their trust. II. A pharmacist promotes the good of every patient in a caring, compassionate, and confidential manner. A pharmacist places concern for the well-being of the patient at the center of professional practice. In doing so, a pharmacist considers needs stated by the patient as well as those defined by health science. A pharmacist is dedicated to protecting the dignity of the patient. With a caring attitude and a compassionate spirit, a pharmacist focuses on serving the patient in a private and confidential manner. III. A pharmacist respects the autonomy and dignity of each patient. A pharmacist promotes the right of self-determination and recognizes individual self-worth by encouraging patients to participate in decisions about their health. A pharmacist communicates with patients in terms that are understandable. In all cases, a pharmacist respects personal and cultural differences among patients. IV. A pharmacist acts with honesty and integrity in professional relationships. A pharmacist has a duty to tell the truth and to act with conviction of conscience. A pharmacist avoids discriminatory practices, behavior, or work conditions that impair professional judgment, and actions that compromise dedication to the best interests of patients. V. A pharmacist maintains professional competence. A pharmacist has a duty to maintain knowledge and abilities as new medications, devices, and technologies become available and as health information advances. VI. A pharmacist respects the values and abilities of colleagues and other health professionals. When appropriate, a pharmacist asks for the consultation of colleagues or other health professionals or refers the patient. A pharmacist acknowledges that colleagues and other health professionals may differ in the beliefs and values they apply to the care of the patient. VII. A pharmacist serves individual, community, and societal needs. The primary obligation of a pharmacist is to individual patients. However, the obligations of a pharmacist may at times extend beyond the individual to the community and society. In these situations, the pharmacist recognizes the responsibilities that accompany these obligations and acts accordingly. VIII. A pharmacist seeks justice in the distribution of health resources. When health resources are allocated, a pharmacist is fair and equitable, balancing the needs of patients and society. APhA supports elimination of disparities in health care delivery. APhA affirms that the mission of pharmacy is to serve society as the profession responsible for the appropriate use of medications, devices, and services to achieve optimal therapeutic outcomes. AACP supports the elimination of legal, structural, social, and economic barriers to the delivery of primary care health services that prevent competent health professionals from providing necessary health care services. To support the principle that all patients have the right to receive care from pharmacists; to declare that health-system pharmacists should play a leadership role in ensuring access to pharmacists’ services for indigent or low-income patients who lack insurance coverage and for patients who are underinsured; to advocate better collaboration among health systems, community health centers, state and county health departments, and the federal HRSA in identifying and addressing the needs of indigent and low-income patients who lack insurance coverage and of patients who are underinsured. 1. APhA recognizes the individual pharmacist’s right to exercise conscientious refusal and supports the establishment of systems to ensure patient’s access to legally prescribed therapy without compromising the pharmacist’s right of conscientious refusal. 2. APhA shall appoint a council on an as-needed basis to serve as a resource for the profession in addressing and understanding ethical issues.
Abbreviations used: APhA, American Pharmacists Association; AACP, American Association of Colleges of Pharmacy; HRSA, Health Resources and Services Administration.
Health-System Pharmacists, calls on pharmacists to serve “individual, community, and societal needs” and seek “justice in the distribution of health resources” by being “fair and equitable, balancing the needs of patients and
society.”21,22 To meet the ethical standards set by the profession, a pharmacist must not discriminate in the care they provide and should call for the safe and appropriate use of medications that serve the greater society. 3
SCIENCE AND PRACTICE E.M. Murphy, J.L. Rodis / Journal of the American Pharmacists Association xxx (2020) 1e6
[Insert Date] The Honorable [Insert Name of legislator] [Insert address of legislator] Dear [Insert Name of legislator], My name is [Insert name] and I am a [pharmacist/student pharmacist] from [Insert city, state] that [works/goes to school at] at [Insert name of business or school/college of pharmacy]. I am writing to you today because of the humanitarian crisis occurring within our country that violates the responsibilities and values held by members of the profession of pharmacy. Reports by reputable news organizations and members of the United Sates Congress have shared that there are inadequate conditions and inappropriate medical care provided to migrants in immigration detention centers. Specific instances have been described, including lack of access to vaccinations and vital medications to control chronic conditions and treat acute conditions. The result of the lack of access to medications has been patient harm. Examples of this harm have been reported on, such as a detainee who was not given access to his anticoagulant which resulted in a blood clot in his leg, and detainees who were not provided the influenza vaccination which has resulted in the death of multiple detained migrant children by influenza. Previously, antipsychotics were inappropriately administered to control agitation in children. Despite a federal judge since ruling this cannot continue without obtaining a court order or consent, there are still significant reports of the inappropriate distribution and utilization of acute and chronic medications and vaccinations. [If you have a relevant personal story share this here] As a health care professional and member of the profession of pharmacy, I have significant concerns about medication access for those detained in migrant detention centers. I am reaching out today to ask [insert your ask here (i.e., for your support of H.R.3239 - Humanitarian Standards for Individuals in Customs and Border Protection Custody Act, for you to work with the Department of Homeland Security and U.S. Customs and Border Protection to ask them to change their internal policy to allow for the ability to volunteer and donate goods, etc.] Thank you for your time, service to our country, and attention to this important issue. If there is anything I can do to be of assistance regarding this or any pharmacy issue I would be happy to speak further by phone [insert phone number here] or e-mail [insert e-mail here]. Sincerely, [Insert signature] [Insert name] Home address: Figure 1. Sample letter advocating for appropriate medication access in migrant detention centers.
The role of the pharmacist is to ensure safe and effective use of medications. This role is being fulfilled across health care settings, including prisoners within the Federal Bureau of Prisons who are provided traditional pharmacy services and medication management services by U.S. Public Health Services
4
Commissioned Corps Pharmacists.25 However, this role is not being fulfilled at migrant detention centers in the United States. This could lead one to ask the question, “If pharmacy services are made accessible to prisoners in the United States, why are pharmacy services inaccessible to those being detained in
SCIENCE AND PRACTICE Pharmacist’s role in health care of immigrants in detention centers
migrant detention centers?” This is not a political issue; this is a pharmacy issue, and it is the responsibility of members of the profession to speak up and take action.
Methods to advocate There are several ways through which pharmacists can advocate for this vulnerable patient population. Because the care of these individuals is being coordinated by DHS and U.S. Customs and Border Protection (CBP), a natural strategy would be to advocate to members of Congress to pass legislation that would improve the care afforded to migrants detained in immigration detention centers and ban the inappropriate distribution and use of medications in this patient population. H.R.3239-Humanitarian Standards for Individuals in CBP Custody Act was introduced into the 116th Congress and states that a “detainee may not be denied the use of necessary and appropriate medication for the management of the detainee’s illness.”26 It is important to note that the current language of this legislation would not address medications being inappropriately administered to detainees, for example antipsychotics administered to sedate children. H.R.3239 was passed in the House of Representatives in July 2019 but no action has been taken by the Senate. Pharmacists can schedule visits with their elected legislators, write them letters, and call their office to advocate for the passage of language that ensures the appropriate use and access of medications for these patients. A resource for advocates to find their congressmen or congresswomen and senators can be found by entering their address on govtrack.us. A sample letter that advocates may be used as a template if they choose to send letters to their elected leaders in included in Figure 1. Immigration detention centers are not limited to 1 geographic area in the United States. Currently, there are detention centers in every state, Washington, DC, and Puerto Rico.27 It would be beneficial for pharmacists or student pharmacists to volunteer their time and expertise at local detention centers. Unfortunately, DHS and CBP do not currently have procedures set in place to accept donations of goods, money, or volunteers and because of this, vital resources are unable to benefit individuals who are detained.28 Advocating to DHS and CBP through letter writing campaigns and through members of Congress for the ability to volunteer and donate goods would allow for individuals in the profession to make a difference in the care of those that are detained. Further efforts to advocate for this patient population can be made within professional organizations through the passage of official policy statements, statements published by pharmacy employers and colleges or schools of pharmacy, education campaigns, and advocacy initiatives that make the care of these individuals a priority. Through these efforts, pharmacists can make an impact intraprofessionally as well as through interprofessional collaborations. Pharmacists should work with other members of the health care team to advocate for the appropriate care of migrants in detention centers. In addition, student pharmacists are important agents of grassroots advocacy, and with initiatives through student organizations, they can help to educate fellow members of the profession and their communities about this issue.
Conclusion There is a humanitarian crisis affecting individuals detained in migrant detention centers within the United States that contradicts the official policies of professional pharmacy organizations and violates values held by members of the profession of pharmacy. Inappropriate administration of antipsychotics to sedate children has been banned; however, there are still reports of the inappropriate distribution and use of acute and chronic medications and vaccinations, which may contribute to the morbidity and mortality of migrants in immigration detention centers. The professional values of a pharmacist should not be hindered by a border or the citizenship of a patient. As is stated in the Oath of a Pharmacist, pharmacists must “consider the welfare of humanity and relief of suffering [their] primary concern.”29 Through advocating to elected leaders, DHS, and CBP, the pharmacist can uphold their professional ethics and role on the health care team by fighting for the care of a patient population that needs help from the profession of pharmacy. Acknowledgments The authors thank Timothy R. Ulbrich, PharmD, Professor of Clinical Pharmacy and Program Director for the Master of Science in Pharmaceutical ScienceeHealth-System Pharmacy Administration Program, College of Pharmacy, Ohio State University, Columbus, OH. References 1. Freedom for Immigrants. A short history of immigration detention. Available at: https://www.freedomforimmigrants.org/detentiontimeline. Accessed July 17, 2019. 2. Kassie E. How Trump inherited his expanding detention system. Available at: https://www.themarshallproject.org/2019/02/12/how-trumpinherited-his-expanding-detention-system. Accessed July 17, 2019. 3. U.S. Immigration and Customs Enforcement. Fiscal year 2018 ICE enforcement and removal operations report. Available at: https://www. ice.gov/doclib/about/offices/ero/pdf/eroFY2018Report.pdf. Accessed July 17, 2019. 4. Kalhan A. Rethinking immigration detention. Available at: https://ssrn. com/abstract¼1556867. Accessed July 17, 2019. 5. CBS News. Detention in America. 60 Minutes and The Washington Post report on detainee medical care. Available at: https://www.cbsnews. com/news/detention-in-america/. Accessed July 17, 2019. 6. GovTrack. H.R. 5950 (110th): Detainee Basic Medical Care Act of 2008. Available at: https://www.govtrack.us/congress/bills/110/hr5950. Accessed July 17, 2019. 7. Hennessy-Fiske M. Lawsuit alleges improper medication of migrant children in federal shelters. Available at: https://www.latimes.com/ nation/la-na-immigrant-shelters-medicated-20180620-story.html. Accessed July 17, 2019. 8. Smith M, Bogado A. Immigrant children forcibly injected with drugs, lawsuit claims. Available at: https://www.revealnews.org/blog/immigrantchildren-forcibly-injected-with-drugs-lawsuit-claims/. Accessed July 8, 2019. 9. Lartey J. No more psychotropic drugs to migrant children without consent, US judge rules. Available at: https://www.theguardian.com/us-news/2018/ aug/01/judge-california-psychotropic-medication-border. Accessed July 17, 2019. 10. Romero S, Kanno-Youngs Z, Fernandez M, Borunda D, Montes A, Dickerson C. Hungry, scared and sick: inside the migrant detention center in Clint, Tex. Available at: https://www.nytimes.com/interactive/2 019/07/06/us/migrants-border-patrol-clint.html. Accessed July 8, 2019. 11. Nugent C. Democratic lawmakers outraged by ‘dehumanizing’ conditions at migrant detention centers. Available at: https://time.com/5618919/ migrant-detention-border-tour-democrats/. Accessed July 8, 2019. 12. Saadi A. Detention facilities display dangerous trend of delayed and inadequate care. Available at: https://phr.org/our-work/resources/detention-
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13.
14.
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16.
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20.
21.
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facilities-display-dangerous-trend-of-delayed-and-inadequate-care/#top. Accessed July 8, 2019. Saadi A. Op-Ed: immigrants are suffering in detention. They need adequate healthcare now. Available at: https://www.latimes.com/opinion/ op-ed/la-oe-saadi-immigration-health-care-detention-facilities-2019025story.html. Accessed July 8, 2019. Flores A. Medical care for immigrants is only getting worse at an ICE detention center, advocates say. Available at: https://www.buzzfeednews. com/article/adolfoflores/colorado-ice-detention-aurora-medical-care-migr ants. Accessed July 8, 2019. Stracqualursi V, Sands G, Elkin E, Rocha V. What is the Flores settlement that the Trump administration has moved to end?. Available at: https:// www.cnn.com/2019/08/21/politics/what-is-flores-settlement/index.html. Accessed September 16, 2019. Silverstein JUS. won’t give flu vaccines to migrants in border detention centers. Available at: https://www.cbsnews.com/news/us-wont-give-fluvaccines-to-migrants-in-border-detention-centers-near-mexico-border/. Accessed September 16, 2019. American Medical Association. Improving medical care in immigrant detention centers D-350.983. Available at: https://policysearch.ama-assn. org/policyfinder/detail/Improving%20Medical%20Care%20in%20Immigra nt%20Detention%20Centers%20D-350.983?uri¼%2FAMADoc%2Fdirectives. xml-D-350.983.xml. Accessed September 16, 2019. Council on Community Pediatrics. Providing care for immigrant, migrant, and border children. Available at: https://pediatrics.aappublications.org/ content/131/6/e2028. Accessed September 16, 2019. American Pharmacists Association. APhA issues statement on health care in immigrant detention centers. Available at: https://www.pharmacist.com/ press-release/apha-issues-statement-health-care-immigrant-detentioncenters?is_sso_called¼1. Accessed October 21, 2019. American Pharmacists Association. House of delegates policy and procedure manual. Available at: https://media.pharmacist.com/hod/APhA_ Policy_and_Procedures_2018.pdf. Accessed September 16, 2019. American Pharmacists Association. Code of ethics for pharmacists. Available at: https://www.pharmacist.com/code-ethics?is_sso_called¼1. Accessed September 16, 2019.
22. Vottero LD. The code of ethics for pharmacists. Am J Health Syst Pharm. 1995;52(19):2096. 23. American Society of Health-System Pharmacists. Policy positions and guidelines. Available at: https://www.ashp.org/pharmacy-practice/ policy-positions-and-guidelines. Accessed October 22, 2019. 24. American Association of Colleges of Pharmacy House of Delegates. AACP cumulative policies 1980-2019. Available at: https://www.aacp.org/ sites/default/files/2019-08/Cumulative%20Policy%201980-2019%20.pdf. Accessed October 22, 2019. 25. Flowers L, Wick J, Figg Sr WD, et al. U.S. Public Health Service Commissioned Corps pharmacists: making a difference in advancing the nation’s health. J Am Pharm Assoc (2003). 2009;49(3):446e452. 26. Congress.Gov. H.R.3239 - Humanitarian Standards for Individuals in Customs and Border Protection Custody Act. Available at: https:// www.congress.gov/bill/116th-congress/house-bill/3239/text. Accessed September 16, 2019. 27. Garfield L, Gal S. Migrant detention centers in the US are under fire for their ‘horrifying’ conditionsdand there's at least one in every state. This map shows which have the most. Available at: https://www. businessinsider.com/ice-immigrant-families-dhs-detention-centers-2018-6. Accessed September 16, 2019. 28. Arce J. Americans aren't allowed to donate to and volunteer at migrant detention centers. There's no good reason for that policy. Available at: https://time.com/5627056/migrant-detention-centers-donations-policy/. Accessed September 16, 2019. 29. American Pharmacists Association. Oath of a pharmacist. Available at: https://www.pharmacist.com/oath-pharmacist?is_sso_called¼1. Accessed September 16, 2019.
E. Michael Murphy, PharmD, Pharmacy Advancement Fellow, College of Pharmacy, Ohio State University, Columbus, OH Jennifer L. Rodis, PharmD, BCPS, FAPhA, Professor of Clinical Pharmacy and Assistant Dean for Outreach and Engagement, College of Pharmacy, Ohio State University, Columbus, OH
Contents lists available at ScienceDirect
Journal of the American Pharmacists Association journal homepage: www.japha.org
COMMENTARY
The pharmacist’s role in advocating for the health care of immigrants in detention centers E. Michael Murphy*, Jennifer L. Rodis a r t i c l e i n f o
a b s t r a c t
Article history: Received 24 October 2019 Accepted 11 January 2020
Objectives: The primary objectives of this commentary are to (1) summarize the role of pharmacists as an advocate for the health care and appropriate use of medications of migrants in immigration detention centers and (2) describe methods to advocate for this vulnerable population. Summary: There is a current humanitarian crisis occurring within the United States that violates the responsibilities and values held by members of the profession of pharmacy. Reports by reputable news organizations and members of U.S. Congress have shared that there have been inappropriate distribution and use of medications in migrant detention centers along the southern border. Specific instances have been described, including lack of access to vaccinations and vital medications to control chronic conditions and treat acute conditions. The role of the pharmacist is to ensure safe and effective use of medications. This role is not being fulfilled at migrant detention centers in the United States. By advocating to elected leaders, the Department of Homeland Security, and Customs Border and Protection for legislation that ensures the appropriate use and access of medications for migrants in immigration detention centers, pharmacists can push for the appropriate care for this vulnerable patient population. Conclusion: The professional values of a pharmacist should not be hindered by a border or the citizenship of a patient. As is stated in the Oath of a Pharmacist, pharmacists must “consider the welfare of humanity and relief of suffering [their] primary concern.” Through advocacy, pharmacists and student pharmacists can uphold their professional ethics and roles on the health care team by advocating for the care of a patient population that needs the profession’s help. Published by Elsevier Inc. on behalf of the American Pharmacists Association.
Immigration detention in the United States is the largest and oldest detention system in the world.1 For the past 25 years, there has been an increase in the number of individuals held in immigration detention centers.2 Immigrants are placed in detention centers for unlawfully entering the United States, if they submit a claim for asylum, or if they are being deported.3 Beginning in the early 2000s, reports began to surface by numerous news organizations that there were instances of human rights abuses and inappropriate medical care being provided to migrants in immigration detention centers.4,5 An attempt was made to improve the health care of these individuals in May 2008 when the Detainee Basic Medical Care Act of 2008 was introduced to Congress; however, the bill was not enacted.6
Disclosure: The authors declare no relevant conflicts of interest or financial relationships. * Correspondence: E. Michael Murphy, PharmD, Pharmacy Advancement Fellow, 500 W 12th Ave., Room 129F, Columbus, OH 43210. E-mail address: [email protected] (E.M. Murphy).
In June 2018, several news organizations began reporting inappropriate prescribing and administration of antipsychotic medications to control agitation in children without the consent of the parent or guardian.7,8 When a physician advocate was asked by the Los Angeles Times about the prescribing of antipsychotic medications to children in detention centers, she stated, “These children tend to be overmedicated with combinations of meds that are really not indicated for children with PTSD [post-traumatic stress disorder], particularly small children. The purpose of that medication is not really to treat an illness, but to tranquilize them. It’s not a tool of therapy, it’s a tool of control.”7 By August 2018, a federal judge in California had ruled “that the government may not administer psychotropic medications to migrant children in residential centers without first obtaining a court order or consent from a parent or guardian.”9 In the spring and summer of 2019, the number of reports relating to inadequate conditions and inappropriate medical care for migrants in immigration detention centers increased and began making national headlines. Specific instances of
https://doi.org/10.1016/j.japh.2020.01.005 1544-3191/Published by Elsevier Inc. on behalf of the American Pharmacists Association.
SCIENCE AND PRACTICE E.M. Murphy, J.L. Rodis / Journal of the American Pharmacists Association xxx (2020) 1e6
Key Points Background: Reports by reputable news organizations and members of U.S. Congress have shared that there has been inappropriate distribution and use of medications in migrant detention centers along the southern border. Specific instances have been described, including lack of access to vaccinations and vital medications to control chronic conditions and treat acute conditions. The American Pharmacists Association, American Medical Association, and American Academy of Pediatrics have published statements and policy around the care of migrants in immigration detention centers. By empowering the pharmacist to advocate for the appropriate prescribing and administration of medications to migrants in immigration detention centers, the profession of pharmacy can join other health care team members in taking action and calling for the appropriate access of medications for this patient population. Findings: The role of the pharmacist is to ensure safe and effective use of medications. This role is not being fulfilled at migrant detention centers in the United States. This is not a political issue; this is a pharmacy issue, and it is the responsibility of members of the profession to speak up and take action. Through advocating to elected leaders, the Department of Homeland Security, and Customs Border and Protection for legislation that ensures the appropriate use and access of medications for migrants in immigration detention centers, pharmacists can push for the appropriate care for this vulnerable patient population.
inappropriate distribution and use of medications included reports of the lack of access to vital medications to control chronic conditions (e.g., antiepileptics, antihypertensives, anticoagulants, antipsychotics) and lack of access to medications for acute conditions (e.g., antipyretics).10-14 The lack of access to medications has resulted in patient harm. An example of this harm can be seen with a detainee who was not given access to his anticoagulant, which resulted in the formation of a blood clot in his leg.12 In August 2019, a proposal to eliminate the Flores Settlement was reported by major news organizations. The Flores Settlement is a nationwide policy that sets a 20-day limit on children being detained in immigrant detention centers.15 With the proposal to eliminate the Flores Settlement, there is potential for the inappropriate distribution and use of medications to continue indefinitely for children because they may remain in a detention center beyond the current 20-day detention limit. Elimination of the Flores Settlement is additionally concerning because the Department of Homeland Security (DHS) refuses to
2
administer influenza vaccines to detainees regardless of the fact that multiple migrant children have died from influenza in the past year.16 The previous explanation for as to why influenza vaccines will not be administered to detainees is because the time it takes for the vaccine to begin working would not have been within the time frame that migrants were detained.16 Without this 20-day holding period limit of children, this argument is no longer appropriate. The lack of recommended influenza vaccinations may result in an increase in the morbidity and mortality of detained children. Health professionals have taken a stand to advocate for the improvement of health care in this patient population. In 2017, the American Medical Association (AMA) passed a policy statement, Improving Medical Care in Immigrant Detention Centers D-350.983, and in June 2013, the American Academy of Pediatrics (AAP) revised their policy statement, Providing Care for Immigrant, Migrant, and Border Children, to more optimally advocate for the care of children in migrant detention centers.17,18 The American Pharmacists Association (APhA) has joined AMA and AAP in calling for an improvement in the health care of migrants detained in immigration detention centers.19 Although important for professional organizations to lead in calling for action, it is the responsibility of every member of the profession to speak up when the values of pharmacy are being violated. By empowering the pharmacist to advocate for the appropriate prescribing and administration of medications to migrants in immigration detention centers, the profession of pharmacy can join other health care team members in calling for the appropriate access of medications for this patient population. Objectives The purpose of this commentary was to serve as a call for action for members of the profession of pharmacy to advocate for the basic health care rights of migrants held within immigration detention centers in the United States. The primary objectives of this commentary were to (1) summarize the pharmacist’s role as an advocate for the health care and appropriate use of medications of migrants in immigration detention centers and (2) describe methods to advocate for this vulnerable population. Summary The pharmacist’s role The current humanitarian crisis occurring within the United States at migrant detention centers violates the responsibilities and values held by members of the profession of pharmacy. In October 2019, APhA published a press release recognizing the need for pharmacists to advocate for the health of migrants detained in immigrant detention centers.19 APhA is leading this call for action in the profession of pharmacy because the quality of health care and access to medication afforded to these individuals is in direct contradiction with the official policies of professional pharmacy organizations, which are included in Table 1.20-24 The 1994 Code of Ethics for Pharmacists, which was adopted by APhA and endorsed by the American Society of
SCIENCE AND PRACTICE Pharmacist’s role in health care of immigrants in detention centers
Table 1 Relevant policy statements that support the pharmacist’s role in advocating for the health care of detained migrants20-24 Policy Code of Ethics for Pharmacists, 1994
Disparities in Healthcare, 2009 Mission of Pharmacy, 1991 Professional Affairs Committee, 1994
Pharmacy Benefits for the Uninsured, 2016
Pharmacist Conscience Clause, 2004, 1998
Description The Code of Ethics for Pharmacists was adopted by the membership of the APhA (then the American Pharmaceutical Association) on October 27, 1994. Preamble Pharmacists are health professionals who assist individuals in making the best use of medications. This Code, prepared and supported by pharmacists, is intended to state publicly the principles that form the fundamental basis of the roles and responsibilities of pharmacists. These principles, based on moral obligations and virtues, are established to guide pharmacists in relationships with patients, health professionals, and society. I. A pharmacist respects the covenant relationship between the patient and pharmacist. Considering the patient-pharmacist relationship as a covenant means that a pharmacist has moral obligations in response to the gift of trust received from society. In return for this gift, a pharmacist promises to help individuals achieve optimum benefit from their medications, to be committed to their welfare, and to maintain their trust. II. A pharmacist promotes the good of every patient in a caring, compassionate, and confidential manner. A pharmacist places concern for the well-being of the patient at the center of professional practice. In doing so, a pharmacist considers needs stated by the patient as well as those defined by health science. A pharmacist is dedicated to protecting the dignity of the patient. With a caring attitude and a compassionate spirit, a pharmacist focuses on serving the patient in a private and confidential manner. III. A pharmacist respects the autonomy and dignity of each patient. A pharmacist promotes the right of self-determination and recognizes individual self-worth by encouraging patients to participate in decisions about their health. A pharmacist communicates with patients in terms that are understandable. In all cases, a pharmacist respects personal and cultural differences among patients. IV. A pharmacist acts with honesty and integrity in professional relationships. A pharmacist has a duty to tell the truth and to act with conviction of conscience. A pharmacist avoids discriminatory practices, behavior, or work conditions that impair professional judgment, and actions that compromise dedication to the best interests of patients. V. A pharmacist maintains professional competence. A pharmacist has a duty to maintain knowledge and abilities as new medications, devices, and technologies become available and as health information advances. VI. A pharmacist respects the values and abilities of colleagues and other health professionals. When appropriate, a pharmacist asks for the consultation of colleagues or other health professionals or refers the patient. A pharmacist acknowledges that colleagues and other health professionals may differ in the beliefs and values they apply to the care of the patient. VII. A pharmacist serves individual, community, and societal needs. The primary obligation of a pharmacist is to individual patients. However, the obligations of a pharmacist may at times extend beyond the individual to the community and society. In these situations, the pharmacist recognizes the responsibilities that accompany these obligations and acts accordingly. VIII. A pharmacist seeks justice in the distribution of health resources. When health resources are allocated, a pharmacist is fair and equitable, balancing the needs of patients and society. APhA supports elimination of disparities in health care delivery. APhA affirms that the mission of pharmacy is to serve society as the profession responsible for the appropriate use of medications, devices, and services to achieve optimal therapeutic outcomes. AACP supports the elimination of legal, structural, social, and economic barriers to the delivery of primary care health services that prevent competent health professionals from providing necessary health care services. To support the principle that all patients have the right to receive care from pharmacists; to declare that health-system pharmacists should play a leadership role in ensuring access to pharmacists’ services for indigent or low-income patients who lack insurance coverage and for patients who are underinsured; to advocate better collaboration among health systems, community health centers, state and county health departments, and the federal HRSA in identifying and addressing the needs of indigent and low-income patients who lack insurance coverage and of patients who are underinsured. 1. APhA recognizes the individual pharmacist’s right to exercise conscientious refusal and supports the establishment of systems to ensure patient’s access to legally prescribed therapy without compromising the pharmacist’s right of conscientious refusal. 2. APhA shall appoint a council on an as-needed basis to serve as a resource for the profession in addressing and understanding ethical issues.
Abbreviations used: APhA, American Pharmacists Association; AACP, American Association of Colleges of Pharmacy; HRSA, Health Resources and Services Administration.
Health-System Pharmacists, calls on pharmacists to serve “individual, community, and societal needs” and seek “justice in the distribution of health resources” by being “fair and equitable, balancing the needs of patients and
society.”21,22 To meet the ethical standards set by the profession, a pharmacist must not discriminate in the care they provide and should call for the safe and appropriate use of medications that serve the greater society. 3
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[Insert Date] The Honorable [Insert Name of legislator] [Insert address of legislator] Dear [Insert Name of legislator], My name is [Insert name] and I am a [pharmacist/student pharmacist] from [Insert city, state] that [works/goes to school at] at [Insert name of business or school/college of pharmacy]. I am writing to you today because of the humanitarian crisis occurring within our country that violates the responsibilities and values held by members of the profession of pharmacy. Reports by reputable news organizations and members of the United Sates Congress have shared that there are inadequate conditions and inappropriate medical care provided to migrants in immigration detention centers. Specific instances have been described, including lack of access to vaccinations and vital medications to control chronic conditions and treat acute conditions. The result of the lack of access to medications has been patient harm. Examples of this harm have been reported on, such as a detainee who was not given access to his anticoagulant which resulted in a blood clot in his leg, and detainees who were not provided the influenza vaccination which has resulted in the death of multiple detained migrant children by influenza. Previously, antipsychotics were inappropriately administered to control agitation in children. Despite a federal judge since ruling this cannot continue without obtaining a court order or consent, there are still significant reports of the inappropriate distribution and utilization of acute and chronic medications and vaccinations. [If you have a relevant personal story share this here] As a health care professional and member of the profession of pharmacy, I have significant concerns about medication access for those detained in migrant detention centers. I am reaching out today to ask [insert your ask here (i.e., for your support of H.R.3239 - Humanitarian Standards for Individuals in Customs and Border Protection Custody Act, for you to work with the Department of Homeland Security and U.S. Customs and Border Protection to ask them to change their internal policy to allow for the ability to volunteer and donate goods, etc.] Thank you for your time, service to our country, and attention to this important issue. If there is anything I can do to be of assistance regarding this or any pharmacy issue I would be happy to speak further by phone [insert phone number here] or e-mail [insert e-mail here]. Sincerely, [Insert signature] [Insert name] Home address: Figure 1. Sample letter advocating for appropriate medication access in migrant detention centers.
The role of the pharmacist is to ensure safe and effective use of medications. This role is being fulfilled across health care settings, including prisoners within the Federal Bureau of Prisons who are provided traditional pharmacy services and medication management services by U.S. Public Health Services
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Commissioned Corps Pharmacists.25 However, this role is not being fulfilled at migrant detention centers in the United States. This could lead one to ask the question, “If pharmacy services are made accessible to prisoners in the United States, why are pharmacy services inaccessible to those being detained in
SCIENCE AND PRACTICE Pharmacist’s role in health care of immigrants in detention centers
migrant detention centers?” This is not a political issue; this is a pharmacy issue, and it is the responsibility of members of the profession to speak up and take action.
Methods to advocate There are several ways through which pharmacists can advocate for this vulnerable patient population. Because the care of these individuals is being coordinated by DHS and U.S. Customs and Border Protection (CBP), a natural strategy would be to advocate to members of Congress to pass legislation that would improve the care afforded to migrants detained in immigration detention centers and ban the inappropriate distribution and use of medications in this patient population. H.R.3239-Humanitarian Standards for Individuals in CBP Custody Act was introduced into the 116th Congress and states that a “detainee may not be denied the use of necessary and appropriate medication for the management of the detainee’s illness.”26 It is important to note that the current language of this legislation would not address medications being inappropriately administered to detainees, for example antipsychotics administered to sedate children. H.R.3239 was passed in the House of Representatives in July 2019 but no action has been taken by the Senate. Pharmacists can schedule visits with their elected legislators, write them letters, and call their office to advocate for the passage of language that ensures the appropriate use and access of medications for these patients. A resource for advocates to find their congressmen or congresswomen and senators can be found by entering their address on govtrack.us. A sample letter that advocates may be used as a template if they choose to send letters to their elected leaders in included in Figure 1. Immigration detention centers are not limited to 1 geographic area in the United States. Currently, there are detention centers in every state, Washington, DC, and Puerto Rico.27 It would be beneficial for pharmacists or student pharmacists to volunteer their time and expertise at local detention centers. Unfortunately, DHS and CBP do not currently have procedures set in place to accept donations of goods, money, or volunteers and because of this, vital resources are unable to benefit individuals who are detained.28 Advocating to DHS and CBP through letter writing campaigns and through members of Congress for the ability to volunteer and donate goods would allow for individuals in the profession to make a difference in the care of those that are detained. Further efforts to advocate for this patient population can be made within professional organizations through the passage of official policy statements, statements published by pharmacy employers and colleges or schools of pharmacy, education campaigns, and advocacy initiatives that make the care of these individuals a priority. Through these efforts, pharmacists can make an impact intraprofessionally as well as through interprofessional collaborations. Pharmacists should work with other members of the health care team to advocate for the appropriate care of migrants in detention centers. In addition, student pharmacists are important agents of grassroots advocacy, and with initiatives through student organizations, they can help to educate fellow members of the profession and their communities about this issue.
Conclusion There is a humanitarian crisis affecting individuals detained in migrant detention centers within the United States that contradicts the official policies of professional pharmacy organizations and violates values held by members of the profession of pharmacy. Inappropriate administration of antipsychotics to sedate children has been banned; however, there are still reports of the inappropriate distribution and use of acute and chronic medications and vaccinations, which may contribute to the morbidity and mortality of migrants in immigration detention centers. The professional values of a pharmacist should not be hindered by a border or the citizenship of a patient. As is stated in the Oath of a Pharmacist, pharmacists must “consider the welfare of humanity and relief of suffering [their] primary concern.”29 Through advocating to elected leaders, DHS, and CBP, the pharmacist can uphold their professional ethics and role on the health care team by fighting for the care of a patient population that needs help from the profession of pharmacy. Acknowledgments The authors thank Timothy R. Ulbrich, PharmD, Professor of Clinical Pharmacy and Program Director for the Master of Science in Pharmaceutical ScienceeHealth-System Pharmacy Administration Program, College of Pharmacy, Ohio State University, Columbus, OH. References 1. Freedom for Immigrants. A short history of immigration detention. Available at: https://www.freedomforimmigrants.org/detentiontimeline. Accessed July 17, 2019. 2. Kassie E. How Trump inherited his expanding detention system. Available at: https://www.themarshallproject.org/2019/02/12/how-trumpinherited-his-expanding-detention-system. Accessed July 17, 2019. 3. U.S. Immigration and Customs Enforcement. Fiscal year 2018 ICE enforcement and removal operations report. Available at: https://www. ice.gov/doclib/about/offices/ero/pdf/eroFY2018Report.pdf. Accessed July 17, 2019. 4. Kalhan A. Rethinking immigration detention. Available at: https://ssrn. com/abstract¼1556867. Accessed July 17, 2019. 5. CBS News. Detention in America. 60 Minutes and The Washington Post report on detainee medical care. Available at: https://www.cbsnews. com/news/detention-in-america/. Accessed July 17, 2019. 6. GovTrack. H.R. 5950 (110th): Detainee Basic Medical Care Act of 2008. Available at: https://www.govtrack.us/congress/bills/110/hr5950. Accessed July 17, 2019. 7. Hennessy-Fiske M. Lawsuit alleges improper medication of migrant children in federal shelters. Available at: https://www.latimes.com/ nation/la-na-immigrant-shelters-medicated-20180620-story.html. Accessed July 17, 2019. 8. Smith M, Bogado A. Immigrant children forcibly injected with drugs, lawsuit claims. Available at: https://www.revealnews.org/blog/immigrantchildren-forcibly-injected-with-drugs-lawsuit-claims/. Accessed July 8, 2019. 9. Lartey J. No more psychotropic drugs to migrant children without consent, US judge rules. Available at: https://www.theguardian.com/us-news/2018/ aug/01/judge-california-psychotropic-medication-border. Accessed July 17, 2019. 10. Romero S, Kanno-Youngs Z, Fernandez M, Borunda D, Montes A, Dickerson C. Hungry, scared and sick: inside the migrant detention center in Clint, Tex. Available at: https://www.nytimes.com/interactive/2 019/07/06/us/migrants-border-patrol-clint.html. Accessed July 8, 2019. 11. Nugent C. Democratic lawmakers outraged by ‘dehumanizing’ conditions at migrant detention centers. Available at: https://time.com/5618919/ migrant-detention-border-tour-democrats/. Accessed July 8, 2019. 12. Saadi A. Detention facilities display dangerous trend of delayed and inadequate care. Available at: https://phr.org/our-work/resources/detention-
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facilities-display-dangerous-trend-of-delayed-and-inadequate-care/#top. Accessed July 8, 2019. Saadi A. Op-Ed: immigrants are suffering in detention. They need adequate healthcare now. Available at: https://www.latimes.com/opinion/ op-ed/la-oe-saadi-immigration-health-care-detention-facilities-2019025story.html. Accessed July 8, 2019. Flores A. Medical care for immigrants is only getting worse at an ICE detention center, advocates say. Available at: https://www.buzzfeednews. com/article/adolfoflores/colorado-ice-detention-aurora-medical-care-migr ants. Accessed July 8, 2019. Stracqualursi V, Sands G, Elkin E, Rocha V. What is the Flores settlement that the Trump administration has moved to end?. Available at: https:// www.cnn.com/2019/08/21/politics/what-is-flores-settlement/index.html. Accessed September 16, 2019. Silverstein JUS. won’t give flu vaccines to migrants in border detention centers. Available at: https://www.cbsnews.com/news/us-wont-give-fluvaccines-to-migrants-in-border-detention-centers-near-mexico-border/. Accessed September 16, 2019. American Medical Association. Improving medical care in immigrant detention centers D-350.983. Available at: https://policysearch.ama-assn. org/policyfinder/detail/Improving%20Medical%20Care%20in%20Immigra nt%20Detention%20Centers%20D-350.983?uri¼%2FAMADoc%2Fdirectives. xml-D-350.983.xml. Accessed September 16, 2019. Council on Community Pediatrics. Providing care for immigrant, migrant, and border children. Available at: https://pediatrics.aappublications.org/ content/131/6/e2028. Accessed September 16, 2019. American Pharmacists Association. APhA issues statement on health care in immigrant detention centers. Available at: https://www.pharmacist.com/ press-release/apha-issues-statement-health-care-immigrant-detentioncenters?is_sso_called¼1. Accessed October 21, 2019. American Pharmacists Association. House of delegates policy and procedure manual. Available at: https://media.pharmacist.com/hod/APhA_ Policy_and_Procedures_2018.pdf. Accessed September 16, 2019. American Pharmacists Association. Code of ethics for pharmacists. Available at: https://www.pharmacist.com/code-ethics?is_sso_called¼1. Accessed September 16, 2019.
22. Vottero LD. The code of ethics for pharmacists. Am J Health Syst Pharm. 1995;52(19):2096. 23. American Society of Health-System Pharmacists. Policy positions and guidelines. Available at: https://www.ashp.org/pharmacy-practice/ policy-positions-and-guidelines. Accessed October 22, 2019. 24. American Association of Colleges of Pharmacy House of Delegates. AACP cumulative policies 1980-2019. Available at: https://www.aacp.org/ sites/default/files/2019-08/Cumulative%20Policy%201980-2019%20.pdf. Accessed October 22, 2019. 25. Flowers L, Wick J, Figg Sr WD, et al. U.S. Public Health Service Commissioned Corps pharmacists: making a difference in advancing the nation’s health. J Am Pharm Assoc (2003). 2009;49(3):446e452. 26. Congress.Gov. H.R.3239 - Humanitarian Standards for Individuals in Customs and Border Protection Custody Act. Available at: https:// www.congress.gov/bill/116th-congress/house-bill/3239/text. Accessed September 16, 2019. 27. Garfield L, Gal S. Migrant detention centers in the US are under fire for their ‘horrifying’ conditionsdand there's at least one in every state. This map shows which have the most. Available at: https://www. businessinsider.com/ice-immigrant-families-dhs-detention-centers-2018-6. Accessed September 16, 2019. 28. Arce J. Americans aren't allowed to donate to and volunteer at migrant detention centers. There's no good reason for that policy. Available at: https://time.com/5627056/migrant-detention-centers-donations-policy/. Accessed September 16, 2019. 29. American Pharmacists Association. Oath of a pharmacist. Available at: https://www.pharmacist.com/oath-pharmacist?is_sso_called¼1. Accessed September 16, 2019.
E. Michael Murphy, PharmD, Pharmacy Advancement Fellow, College of Pharmacy, Ohio State University, Columbus, OH Jennifer L. Rodis, PharmD, BCPS, FAPhA, Professor of Clinical Pharmacy and Assistant Dean for Outreach and Engagement, College of Pharmacy, Ohio State University, Columbus, OH