Freedom of Movement in the Wake of Coronavirus

Freedom of Movement in the Wake of Coronavirus

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In the wake of the COVID-19 pandemic, the coming weeks will test how Americans and global citizens respond to voluntary and involuntary restrictions of their civil liberties. Surges in beach and grocery store visits combined with elevating panic on social media suggest that challenges are ahead.

There are serious questions about whether mass quarantines during pandemics are as effective as other interventions, in part because of inadequate compliance with public health recommendations. If recent history serves as an example, legal tests of mandatory quarantines will not necessarily favor public health mandates. Following the 2014 Ebola outbreak, a civil rights lawsuit filed against New Jersey officials led to new requirements that respect individual privacy during public health emergencies. Since then, the U.S. Centers for Disease Control and Prevention enacted a rule that asserts the right to legal representation during mandatory quarantines, although it still allows for some relatively minor restrictions on freedom of movement, including attendance at public gatherings and certain forms of travel.

More concerning restrictions on freedom of movement are those that affect some of the most vulnerable populations to the pandemic, including asylum seekers held at the southern border and in detention centers across the United States. Countries in Europe, Canada, the United States, and other nations have already tightened or closed their borders to migrants fleeing realities far worse than the novel coronavirus. As a result, migrants are often forced to stay in small camps, where the risk for disease transmission rises with increased crowding. Likewise, an outbreak can spread quickly in detention centers, where detainees have very few liberties and limited access to healthcare.

Paradoxically, it is probable that restrictions on freedom of movement led to this pandemic. The likely source of COVID-19 was animal markets in China, where the 2003 Severe Acute Respiratory Syndrome (SARS) epidemic—also a coronavirus—similarly emerged. In these markets, animals are kept in small cages, piled on top of one another, and bought alive to be killed on the spot. The practice is not unique to China. Nor is the practice of confining mammals, birds, and other animals for food production. In the United States, almost ten billion animals are killed every year after being kept in confined animal feeding operations (CAFOs), often called factory farms. In 2009, the H1N1 virus (the so-called “swine flu”) most probably emerged as a result of pig confinement in the United States and Mexico. Factory farms also inflict significant environmental injustices on neighboring communities, including through air, water, and soil pollution.

Once we get through the current pandemic—and we will—we will have serious occasion to reevaluate how we treat the right to freedom of movement, including that of animals. Seen through a clear lens, the newest coronavirus is a symptom of our global inattention to rights, the biological link between basic liberties and health, and the indisputable connection between the welfare of people, animals, and the planet. We should not miss this opportunity to look more deeply at the roots of “symptoms” such as COVID-19 or H1N1 in order to abate further disease and suffering.

Shortly after Hurricane Katrina in 2006, the federal government passed the Pets Evacuation and Transportation Standards (PETS) Act. Now, in order for states, cities, and counties to receive federal funding for their disaster relief plans, their plans must account for the needs of people with companion animals before, during, and after a major disaster or emergency. Resounding public support for the PETS Act implicitly acknowledged the connection between human and animal rights and wellbeing.

As people across the globe find themselves increasingly unable to travel amid the COVID-19 outbreaks occurring worldwide, now is the time for us to think more broadly about the links between the basic rights and health of people and animals. Medical and public health professionals, historians, and scientists increasingly recognize these relationships, which are borne out in our communities and in our global market. Although we can each make a difference through individual choices, we also need policy change to help shift norms and everyday practice.

International leaders and institutions must be proactive and alter the lens through which health is viewed. National governments, state and local health departments, and international organizations like the World Health Organization can take this chance to fully embrace the importance of rights in their mission—including those that other animals share with us. Some policymakers are already moving in this direction. China banned the sale of wildlife, and Vietnam’s prime minister called for a similar ban. Closer to home, in 2019, U.S. Senator Cory Booker unveiled legislation that would place a moratorium on large factory farms.

All of these measures would lead to health benefits for some of the most vulnerable people and animals, and they should be viewed as important first steps. Without increased attention to the relationship between human and animal rights, health, and wellbeing, one global crisis will continue to follow another.

 

Photo by Ashkan Forouzani on Unsplash.

Who Does—and Who Doesn’t—Qualify as a Refugee?

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Last week, the United Nations High Commissioner for Refugees (UNHCR), the UN Refugee Agency, released its annual Global Trends report on forced displacement. The bottom line: Every minute in 2018, 25 people were forced to flee their homes due to war, persecution, or conflict.

In total, more than 70 million people were forcibly displaced in 2018—the highest level of forced migration in 70 years. About 3.5 million people were listed as asylum seekers, 25.9 million people qualified as refugees, and 41.3 million people were internally displaced within their own national borders. 

Across the globe, the largest numbers of refugees, asylum seekers, and internally displaced persons live in places with the fewest public resources. In 2018, countries in developed regions of the globe hosted only 16 percent of refugees, whereas nations classified as the least developed hosted one-third of the global refugee population. Refugees and asylum seekers comprise one-half of one percent of the population throughout the continent of Africa, and it’s about half that in North America. In recent years, the United States has dramatically reduced rather than increased the number of refugees admitted into the country—even though many historical and modern wars waged by the United States have contributed to forced migration.

Recently I returned from the North American Refugee Health Conference in Toronto, where I spoke about issues including asylum medicine, physician advocacy, and how to integrate health and human rights into the medical education curriculum. Refugee resettlement is always a hot topic at the conference, and this year was no different. It’s also a subject that’s difficult for many people—even experts—to wrap their heads around.

Many of my patients are refugees who have resettled in the United States, and you might be surprised to learn how many people in your community are refugees or families of refugees. You might also be surprised to discover how many famous people came to the United States as refugees—for example, Albert Einstein, U.S. Secretary of State Madeleine Albright, Nobel Laureate Elie Wiesel, singer and songwriter Gloria Estefan, and Google co-founder Sergey Brin, to name just a few. Most refugees who resettle in the United States contribute significantly to their communities, and, contrary to political rhetoric, the typical American is 29 times more likely to be killed by a regional asteroid strike than by a refugee (the chances of which are nearly nil).

As anyone who is familiar with the refugee resettlement process will tell you, it is long and difficult. In fact, the most demanding way to legally enter the United States is as a refugee.

Under U.S. law, the term “refugee” refers to someone who is located outside the United States, is of “special humanitarian concern to the United States,” and has demonstrated that they were persecuted or has a well-founded fear of persecution because of race, religion, nationality, social group, or political opinion in their nation of origin. Typically, in order to be considered as a refugee, an individual must be referred to the U.S. Refugee Admissions Program for Refugees by the UNHCR, a U.S. Embassy, a nongovernmental organization, or the U.S. Department of State. Some eligible family members living in the United States can also initiate a family reunification case— for example, for a spouse or children under the age of 21. Most people must first flee their country of origin to apply for refugee status—without firmly resettling in another nation.

If an individual is found to be eligible for consideration of refugee status, the vetting process can take years. It includes extensive background investigation, a face-to-face interview with a U.S. Department of Homeland Security Citizenship and Immigration Services Refugee Officer, health screening to identify any contagious diseases (some of which can be disqualifying), “sponsorship assurance” from an established community-based organization, and a course on cultural orientation before entering the United States. The process also includes numerous security checks through multiple federal and international databases. (Think Federal Bureau of Investigation, Department of Defense, and national intelligence agencies.) People who are rejected by the Department of Homeland Security cannot appeal the decision.

In all, less than one percent of all refugees are considered eligible for resettlement. Most live in limbo in refugee camps or shelters for years without steady access to education, employment, healthcare, or security. And more than half of all refugees are children—many of whom handle their legal cases on their own. Imagine, even as an adult, navigating such a complex system—for example: providing all necessary forms of identification after being forced to flee conflict; a composed, often intimidating interview with a professional immigration officer; a clean bill of health after living in unsafe, crowded conditions without clean water; and the fortitude to adapt to a new land after living through the unimaginable.

Self-sufficiency is a key principle promoted by the government and within refugee resettlement agencies in the United States, and it is a value commonly embraced by refugees. Refugees who are fortunate to resettle in the United States are expected to find a job within six months of arrival, and they must apply for a green card after one year, which triggers further security clearances. Many become active citizens who extoll the virtues and obligations of a free society. For example, one study found that refugees paid more in taxes than they ever received in benefits. Despite a history of trauma, language barriers, and discrimination, many refugees demonstrate remarkable resilience and independence. As I’ve written elsewhere, they are like spirited phoenixes that can rise from the ashes of adversity if given the chance.

At a time when there is a humanitarian crisis involving historic levels of forced migration, it is critical that we move beyond myths, misunderstandings, and divisive and discriminatory rhetoric. Volunteering, raising awareness, and supporting resettlement within local communities are all ways to get more involved. And—as for everyone—kindness and compassion can go a long way toward helping individuals rise from the ashes.

Photo by Rene Bernal on Unsplash.

 

Asylum Medicine: A Call to Respond

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Over the past year, the subject of migration has rarely left the headlines. But relatively little of the media coverage has had the substance it merits – particularly on the issue of asylum. We’ve been immersed in a political back and forth that too often ignores the lives of those caught in the middle.

I still vividly remember the first asylum seeker I met as a physician. At the time, I was a volunteer for Doctors of the World-USA (now HealthRight International), a program that trains doctors on how to conduct forensic medical and psychiatric examinations of asylum seekers with claims of torture or other forms of persecution. Through the organization, I learned about the man’s background before meeting him. He had been imprisoned and tortured after standing up for the rights of others in his home country. Soon after, he escaped and eventually made it to the United States to apply for asylum. Honestly, I cannot recall if he entered the country legally or illegally. It was irrelevant to my duties.

I was living in Brooklyn, New York, at the time and took the subway to a large hospital in Manhattan, where the man and I were scheduled to meet. We were both a little nervous, not knowing exactly what to expect. Determined to be thorough in my evaluation and documentation, the interview and physical examination took us hours to get through. He had numerous scars, and one scar on his abdomen was virtually diagnostic. The large scar took the shape of an object many of us use every day. His captors had burned him with it. Due to the burn, he had areas of skin where he could not feel the touch of a hand and other areas that were hypersensitive to light touch. Although I took forensic photographs for his attorney and the immigration judge, I would never need a picture to remind me of the burn’s semi-triangular shape and the mangled scar left behind. That scar and the man’s wounded face as he told me about how he was tortured are permanently etched in my memory.

After completing the asylum evaluation and providing a medicolegal report for the man’s attorney, I never saw him again. Much later, I was informed that he legally qualified for asylum, in part because of the report I provided. He would not be forced to return to a place where he would have likely suffered further persecution, including perhaps death. Nonetheless, I knew he would continue to be at risk for suffering from the psychological consequences of torture. What would he think of every time he saw that abdominal scar in the mirror? I hoped he would at least reflect on his courage and the way he rose up after incredible tragedy.

That first asylum evaluation was about 17 years ago. Since then, I’ve performed forensic medical and psychiatric evaluations of many other torture survivors seeking asylum and trained other healthcare professionals on how to do the same. Several years ago, with dear friends and colleagues, I helped launch an asylum medicine clinic in Washington, DC. And recently, two colleagues and I penned a paper on asylum medicine standards and best practices, hoping to stir further dialogue in this area. One of my coauthors, Amy Zeidan, is an emergency medicine physician who has conducted numerous asylum evaluations. Her first experience sitting in on an asylum evaluation took place when she was my medical student. During a recent training for other healthcare professionals, I was touched to hear her cite my words from years before – that practicing asylum medicine is one way a doctor can save a life. Just out of fellowship, she has already emerged as a leader in the field. We need so many more like her – and like my other coauthor, Katherine McKenzie, an internist who heads an asylum medicine clinic at Yale School of Medicine and trains medical students and residents on the forensic evaluation of asylum seekers.

Today, there are even more people seeking asylum in the United States and elsewhere than there were when I first began conducting asylum evaluations. Worldwide conflict and violence have driven global displacement to record numbers. In the United States, applications for political asylum have increased while the number of people granted asylum has decreased. The United States hosts far fewer asylum seekers and refugees than many other countries, including much poorer nations.

According to United States and international law, people have a legal right to seek asylum. And the bar is fairly high – in order to qualify for asylum, applicants need to show they have suffered or will likely suffer torture or other forms of persecution in their country of origin based on political opinion, race, religion, nationality, or membership in a social group. Since physicians and other healthcare professionals can document physical and mental evidence of torture, we have a critical role to play in the evaluation of people seeking asylum. Unfortunately, the demand for asylum evaluators currently far exceeds the number of doctors and other clinicians prepared to conduct forensic evaluations.

So, in an effort to bolster the number of qualified healthcare professionals who can conduct asylum evaluations, my two colleagues and I summarized standards and best practices in this emerging area of medicine. In press via Harvard’s Health and Human Rights Journal, the paper is open access for anyone who wants to read it or use it as a resource.

Even if you aren’t a healthcare professional, I hope you will take the time to review the paper and share it widely. At a time when more global citizens are at risk for torture and other human rights violations, it is critical that we set the facts straight about asylum law and asylum seekers. Perhaps you could better inform a family member, friend, colleague, or policymaker about the plight of asylum seekers. Or, if you have a doctor, perhaps you could gauge their interest in asylum medicine and point them to the paper to learn more.

With tremendous gratitude to the asylum seekers I have met over the years – including one man I met in New York 17 years ago – I have been humbled by their stories. They have taught me incredible lessons about adversity and what it takes to overcome our collective human history of violence. And they have deepened my sense of justice, patriotism, and compassion through their own.

A New, Objective & Boundless Ethic

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This month marks the fortieth anniversary of the publication of the Belmont Report, a groundbreaking document written to protect children and adults from research abuses. Today, through its emphasis on informed consent and special protections for vulnerable individuals, the report’s reach and influence extends around the globe.

Recently, my colleagues and I penned a paper called “A Belmont Report for Animals?” asking the question of how principles that currently guide human research—such as respect for autonomy, obligations to avoid harm and promote justice, and special protections for vulnerable populations—could be applied to decisions about the treatment of animals. Under the current law, almost anything can be done to an animal in the name of research—primarily because they are seen as something rather than someone. Nonhuman animals of all species can still be subjected to the most severe forms of pain and suffering, without relief. This problem deserves particular reflection during the upcoming World Laboratory Animal Liberation Week beginning on April 22nd.

Although it could be easy to assume that the Belmont Report emerged without controversy, that is simply not the case for most achievements throughout history. One abuse after another—from torture to deceit—prompted the drafting of the Belmont Report. Throughout the twentieth century alone, researchers systematically targeted prisoners in Nazi concentration camps, African-American men living with syphilis in Tuskegee, Alabama, the Havasupai people living with diabetes in a remote part of the Grand Canyon, hospitalized children with cognitive disabilities, and many other individuals and communities. Only when people demanded and fought for change did such atrocities end.

Sadly many similar abuses continue today—and they are one of the many reasons that the time has come for a more honest evaluation of how humans treat other humans as well as how humans treat animals in society.

Our “A Belmont Report for Animals?” paper will be published later this year. But, in the meantime, as so many people and animals suffer around the globe, we are left with a clear mandate: We need a new, objective ethic—one that is principled, consistent, and inclusive. It is no coincidence that next week marks both Animal Cruelty and Human Violence Awareness Week. There are clear links between how we treat people and animals in society—connections that demand our focus and action.

Admittedly, it can be difficult to be mindful of the big picture, particularly when there are so many real and imagined distractions competing for our time and attention. But until we prioritize an objective ethic bound by key principles such as respect, compassion, and justice, we will continue to make ignorant, cruel decisions about the treatment of others. Arbitrary distinctions and values are responsible for the differential treatment of people and animals—whether in research or other areas of society. Bias and arbitrary distinctions also fuel prejudices such as ableism, classism, ethnocentrism, heterosexism, racism, and sexism. Unless we address one problem, we will not fully address the other. As Dr. Albert Schweitzer wrote, “[We] must oppose all cruel customs no matter how deeply rooted in tradition or surrounded by a halo. We need a boundless ethics which will include the animals also.”

With gratitude for the achievements that have been made, there is still so much left to be done. While we need to remain diligent about calling out and stopping abuses within research and other areas of society, we must also be forward thinking. We need to continually ask ourselves how we can ensure that such abuses never occur in the first place. Outside of an objective ethic, I can’t see how. Can you?

 

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