BY: MARK KUCZEWSKI, PhD, and SUNNY NAKAE, MSW, PhD
The Loyola University Chicago Stritch School of Medicine has 28 students enrolled in its 2018-2020 classes who are undocumented immigrants currently in the Deferred Action for Childhood Arrivals (DACA) program. These Stritch students constitute almost half of the matriculants with deferred action at medical schools across the nation and they are among more than 100 such students who have matriculated to the various schools of Loyola University Chicago. Medical students who are DACA recipients bring much needed diversity to the physician workforce and represent an important asset to many underserved communities. But the current political climate has cast uncertainty over the future of these talented students.
DACA DOCTORS AND CATHOLIC HEALTH CARE
President Barack Obama established the Deferred Action for Childhood Arrivals program via an executive memorandum on June 15, 2012. DACA grants a two-year renewable deferral of action on the recipient's immigration status, provides a work permit and enables one to apply for a Social Security number.
DACA opened numerous opportunities for recipients. Recognizing the potential of these students, Stritch became the first medical school in the nation to change its admissions policy to openly welcome applications from DACA recipients. That decision was based upon the school's Catholic and Jesuit values that affirm the dignity of all persons and seek to promote social justice for marginalized people.
These students bring many skills and personal qualities that make them ideal for such a medical school. DACA recipients typically are bilingual and bicultural. They understand not only the language of a recent immigrant population, but also their experiences and needs. DACA recipients are members of our communities by virtue of growing up within them, and they have an insider's knowledge of new arrivals to our country.
Because these medical school applicants have had to navigate their way through significant barriers to securing a college education, they have demonstrated their resilience and determination in the face of unrelenting challenges — highly valued characteristics in the medical profession. Furthermore, being from communities that often are underserved by the health care system, DACA recipients may be more likely to seek to serve such communities in the future.
Stritch School of Medicine believes enabling qualified applicants of DACA status who successfully competed for admission promotes social justice for the applicants and their future patients.1, 2
There also is a sense in which these DACA medical students exemplify the ideals of Catholic health care. The Catholic social justice tradition is committed to the dignity, quite literally the "worth," of each individual and to altering social structures that marginalize people. Providing opportunity for these persons to achieve to their full potential and enter a life of service fulfills a deep aspiration for Catholic institutions.
DACA recipients spent most of their lives undocumented with no protection from possible deportation and usually lacking access to privileges that citizens generally take for granted, e.g., access to a driver's license, availability of a student loan, the right to pay in-state tuition at the local state college if accepted, and the ability to apply for any job or internship for which one is qualified. These obstacles are very difficult to navigate and require the student to have developed effective self-advocacy skills in dealing with administrators and institutions.
Moreover, DACA students who have achieved to this degree often understand the importance of taking a more public advocacy role. They have developed skills of advocating for themselves in order to surmount institutional barriers. In the current environment, some have utilized these skills to advocate for DACA recipients and undocumented immigrants through their professional organizations. They have become spokespersons in the media and with elected representatives regarding justice for immigrants. (See Stritch medical students' sidebars on page 16 and on page 18.) Their experiences are forming them to be the kind of physicians who are not only compassionate presences in the clinic but who are calling forth more compassionate social policy. Their presence and example also has helped their peers to understand the need for the medical profession to advocate for their undocumented peers and patients. This is the embodiment of a Catholic vision of a developing community physician leadership that can help to transform society.
The Stritch School of Medicine was successful at sharing this vision with other key organizations that understood the potential community benefits doctors of DACA status could provide. As DACA recipients remain ineligible for programs such as federal student loans, several key partners, including Trinity Health, teamed with Stritch to develop a loan program that would enable DACA students to finance their educations on terms similar to those available to all other medical students.
Because DACA was established by a presidential memorandum, President Donald J. Trump may rescind it at will. During the 2016 presidential campaign, then-candidate Trump promised to end DACA on Day 1 of his presidency. However, despite issuing several executive orders that direct much more aggressive steps to find and deport undocumented immigrants, DACA has not been rescinded to this point and President Trump has expressed an openness to finding some way to resolve this precarious situation without harm to DACA recipients.3
Nevertheless, several persons of DACA status have been detained for significant periods of time, calling into question the safeguards DACA confers. DACA recipients now live in a kind of limbo in which their futures are entirely uncertain. As a result, universities have been taking measures to support their undocumented students and to keep them safe to the extent possible. Furthermore, Catholic universities and health care institutions are committed to working closely with the students to be advocates for positive social change in regard to their status and those of our immigrant neighbors and patients.
ACTIONS BEING TAKEN
Through a variety of collective and individual statements, university and college presidents, including those of the Jesuit universities and many Catholic institutions, have articulated a commitment to protect their students to the fullest extent permitted by law.4, 5 These steps generally include: safeguarding student information and limiting cooperation with the U.S. Department of Immigration and Customs Enforcement (ICE); educating students, faculty and staff regarding the rights of undocumented individuals; providing referrals to appropriate legal and ancillary services; and continuing to advocate for compassionate treatment of immigrants.
Catholic universities have generally committed to not disclosing student information to or cooperating with ICE agents unless specifically directed to do so by a valid judicial warrant. The development of such "front door" policies that determine the validity of a request for information and limit the access of such officials to university property and information systems is a linchpin of keeping the campus environment a welcoming and supportive learning environment. In addition, universities such as Loyola University Chicago are working to offer numerous "know your rights" trainings that provide important information regarding the rights of individuals when confronted by enforcement authorities. Such training helps students and their families to make prudent decisions and to plan for worst-case scenarios, i.e., detention and deportation.
Access to legal services is vital. It is beyond the ability of most universities to make an open-ended commitment to provide access to qualified immigration attorneys, although some have law schools with immigration law clinics that can help. Fortunately, through the generosity of Trinity Health, the DACA students at the Stritch School of Medicine have access to the legal services available at a Chicago community development organization called The Resurrection Project. These services include screening for possible adjustment of immigration status and advice on emergency planning.
And, of course, the student loan programs created for these students are premised on their holding DACA status. As a result, the Stritch School of Medicine has been developing strategies with its partners such as Trinity Health to enable the students to continue their medical education in the event of the demise of the DACA program.
THE FUTURE OF DACA
The medical profession recognizes that the talent and abilities of trainees from a wide variety of backgrounds, including DACA, are essential to providing culturally relevant, excellent care for patients. The Association of American Medical Colleges and the American Medical Association have come out in full support of DACA recipients in medicine.6, 7 The AAMC has added DACA-specific items to its common applications for both medical school and residency and updated its school guide materials. DACA recipients also are eligible for AAMC fee assistance, sponsored pipeline and award programs.
Right now, DACA recipients in medicine have viable pathways to licensure through their work authorizations. Licensing is up to each individual state board, so there are no national restrictions on professional MD licensure related to immigration status. The Veterans Health Administration issued a ruling in support of full access for DACA recipients to train at the VA, which removed previous barriers.8 DACA recipients who are licensed physicians also are eligible for licenses issued by the Drug Enforcement Administration (DEA).
Permissions and professional points of access granted to resident trainees can all be extended to DACA recipients without special provision, thus there are no viable reasons why residency training programs should discriminate against DACA recipients in their selection processes. As long as DACA remains, the training pathway is sound.
If DACA were to be rescinded, the current recipients who are pursuing their MDs may experience setbacks in licensure after graduating from medical school. If work authorization granted through DACA is no longer possible, newly minted physicians will be unable to legally work. This means they would be unable to complete residency training and the final exam for licensure. Medical school graduates at that point would not be able to provide direct patient care, nor for that matter, to work lawfully at all.
Losing providers who are well prepared to care for patients while our nation suffers a doctor shortage makes little sense. Senators Dick Durbin (D-IL) and Lindsey Graham (R-SC) have proposed bipartisan legislation — called the BRIDGE Act — to provide DACA recipients with DACA-equivalent authorizations in the event that DACA is rescinded. While the prospects for this legislation are uncertain, it provides a vehicle for citizens to express their support to their elected representatives for compassionate and rational immigration policy.
WHAT CATHOLIC HEALTH CARE CAN DO
It is important that our Catholic health care institutions throw off the paralysis that is occasioned by the uncertainty surrounding the continuation of DACA protections.
- Catholic health systems should each consider making an investment in the medical education of DACA students. Stritch and other medical schools will be unable to fund most DACA recipients who compete successfully for admission to the entering class for the 2017-2018 school year. The uncertainty over DACA's fate means that new loans are unlikely to be initiated, and scholarship money is desperately needed to offset the lack of new loans. Without such funds, these qualified students will be lost to the physician workforce.
- Residency programs at Catholic facilities should declare their openness to entertaining applications from graduating DACA recipients as long as DACA exists. They should add a statement to their residency program's website, where they list their requirements, saying that, in addition to citizens and particular visa holders (usually H-1B visas), they accept applications from graduating medical students with DACA. The uncertainty over DACA means that most residency program directors will likely decline to entertain such applicants for fear of losing a resident at some point during his or her residency. This practice threatens to end opportunity for these students even as the government continues their DACA protections.
- Individuals who work in Catholic health care should call their U.S. senators and representatives to ask them to work for compassionate immigration reform.
- Each Catholic health ministry organization should use its government relations and advocacy capacity to ask their federal representatives to support the BRIDGE Act and compassionate immigration reform.
In sum, these are uncertain and difficult times for our undocumented immigrant neighbors, even if they are in medical school. Catholic health care, drawing on its rich tradition of work in support of immigrants, already has begun to increase its support and advocacy for these students and their communities.9 It is essential that we continue to call for a conversion of hearts and minds that lead to better public policy.
MARK KUCZEWSKI is director for the Neiswanger Institute for Bioethics and chair of the department of medical education, Loyola University Chicago Stritch School of Medicine, Chicago.
SUNNY NAKAE is assistant dean for admissions, recruitment and student life, Loyola University Chicago Stritch School of Medicine, Chicago.
- Mark Kuczewski and Linda Brubaker, "Medical Education for Dreamers: Barriers and Opportunities for Undocumented Immigrants," Academic Medicine 89, no. 12 (December 2014): 1593-98.
- Mark Kuczewski and Linda Brubaker, "Equity for 'DREAMers' in Medical School Admissions," AMA Journal of Ethics 17, no. 2 (February 2015): 152-56 http://journalofethics.ama-assn.org/2015/02/pfor1-1502.html.
- Amy Chozick, "Trump Appears to Soften on Deporting Thousands of Young Immigrants," New York Times Dec. 7, 2016. https://www.nytimes.com/2016/12/07/us/immigration-dreamers-trump.html?_r=1 (accessed April 10, 2017).
- Association of Jesuit Colleges and Universities, "Statement of AJCU Presidents on Undocumented Students," Nov. 30, 2016. www.ajcunet.edu/press-releases-blog/2016/11/30/statement-of-ajcu-presidents-november-2016 (accessed April 10, 2017).
- Association of Catholic Colleges and Universities, "A Statement from Leaders in Catholic Higher Education," Nov. 30, 2016. www.accunet.org/files/Press_Media/Statement-on-DACA-11-30-16.pdf (accessed April 10, 2017).
- Association of American Medical Colleges, "AAMC Calls on President-elect Trump Not to Revoke DACA Executive Action Without Permanent Fix: A Diverse Health Care Workforce Promotes Access and Equity," press release, Dec. 9, 2016. https://news.aamc.org/press-releases/article/statement-daca-executive-action/ (accessed April 10, 2017).
- Troy Parks, "Don't Deport Our 'Dreamers': DACA Bill Earns Physician Support," AMA Wire, Feb. 6, 2017. https://wire.ama-assn.org/ama-news/don-t-deport-our-dreamers-daca-bill-earns-physician-support.
- Department of Veterans Affairs, (VA), Federal Advisory Committee, National Academic Affiliations Council (NAAC), Meeting Minutes for May 5-6, 2016. www.va.gov/ADVISORY/docs/AcadAff%20-%202016%20May%20Minutes.pdf.
- ISN Staff, "Catholic Bishops Support Legislation to Sustain DACA Program for Undocumented Young People," Ignatian Solidarity Network blog, Dec. 28, 2016. https://ignatiansolidarity.net/blog/2016/12/28/catholic-daca-legislation-undocumented/ (accessed April 10, 2017).
A STRITCH MEDICAL STUDENT DESCRIBES WHAT DACA MEANS TO HER
Even though I was born in Guatemala, I grew up in the United States, and I consider the U.S. my home. My end goal has always been to become a physician and to serve the underserved populations in the U.S.
I grew up noticing the lack of adequate health care in many communities, especially in the rural areas of the South. My dream is to be able to alleviate that need, to provide for the neediest and to become a positive change in those communities.
There is a shortage of doctors in the U.S., and if DACA is repealed, the American people will lose a valuable set of future physicians who can empathize with a wide array of patients.
When DACA first came out, many undocumented immigrants gave a sigh of relief. DACA meant individuals were finally able to receive a Social Security number, a driver's license and the ability to work in the United States. I think at that point in my life, the good that DACA brought outweighed the potential negatives, such as providing not only my information but also my family's to the government in order to apply for this deferral.
My vulnerability came to the forefront with the results of the 2016 presidential election and the political climate. Suddenly, my safety net was no longer stable. Would the new president get rid of DACA? If so, what would that mean for me? For my family? Would I and my family be deported? What about my education? These questions and many more have been a constant burden since the election.
As a second-year medical student, I spend countless hours learning many physiological pathways and pathological problems that a patient might have. Any medical student will tell you that learning medicine is hard, and, to do well, you often have to forget about outside stressors and focus on school. Unfortunately, I can no longer just worry about school. I'm constantly thinking about my family and the immigrant community as a whole.
That first week after the election was extremely nerve-wracking, waiting for the imminent collapse of my security. My friends saw my worry and fear. They empathized with me and offered their support, but all their support only made me realize how impotent I felt. Decisions are being made — out of my control — that will ultimately affect my future and the future of my family, friends and my future patient population.
Now more than ever, the U.S is in need of compassionate, caring, multicultural physicians who can relate to patients of varying ethnic backgrounds, race and sexuality. Being immigrants gives us a unique perspective on the world, makes us more open-minded, less judgmental and overall more tolerant of different ideals. Rather than believing that differences split us apart, I believe that it is those differences that allow for the wonderful uniqueness of varying cultures. After all, America has always been known to be a melting pot.
Trepidation, uncertainty and fear are the emotions that prevail during these stressful times. Yet, my parents have ingrained in me a sense of determination, hard work and, above all else, hope and faith. It is these morals and ideals that keep me going. I realize that some things are out of my hands, but, while I still can, I will continue to fight for my education and my dream of becoming a physician. Not only because my dreams are at stake, but because if I don't fight, I am letting down my future patients and communities.
— Belsy Garcia Manrique
A STRITCH MEDICAL STUDENT URGES DACA ADVOCACY
I distinctly remember the week after the  election, when the shock was still palpable. Each morning the realization set in anew that the world we lived in was suddenly permeated by fear and divisive hatred. I realized we each had a part in allowing fear of the unknown and fear of the other to drive history. Though I prided myself on being politically and socially aware and engaging in discourse with friends, it seemed trivial now, and cheap.
To combat fear, one must fight armed with truth and in the openness of complete transparency. So, I set my mind to engaging in advocacy and publicly disclosing my status as an undocumented/"DACAmented" person in the hopes of reaching those outside of my bubble. It has only been a few short months since then, and opportunities have fallen into my lap allowing me to fulfill that vision of breaking the silence.
There are so many people out there who cannot advocate for themselves or their family members. I have been fortunate to be at such a supportive school that not only protects us, but fights for us. Thus, when presented with an opportunity to be at the President's Address to the Joint Session of Congress on Feb. 28, 2017, in a room with all of our elected federal representatives, I knew that DACA deserved to be present. The more of us who were there, the more the public might see that we are like any other Americans, contributing to society, wanting to give back and strive for the American Dream.
The real work began the day after President Trump's speech, when we made congressional office visits. It was a surreal experience, speaking with congressmen or their staffers about our stories in such an intimate setting. We found that regardless of political affiliation, everyone we spoke with was empathetic to our cause but varied in what commitments they might make. We walked away knowing that this was not going to be an overnight change, but a longer battle. We told our stories so that they might "plant a seed" and add to the public pressure for these representatives to take action.
We have advocated through professional societies such as the American Medical Association. Not long after the joint address, I again found myself in our nation's capital, walking onto the stage for a DACA student panel at the AMA's annual Medical Advocacy Regional Conference for Medical Students.
I had shared my story with plenty of people, yet I was still as nervous as the first time. I was surrounded by people ranging from those who were only first learning of DACA that weekend, to those who had actively fought to put DACA onto the AMA's legislative agenda for the sake of their classmates and future patients.
Our advocacy with the AMA had us working double time. I was lobbying legislative aides, who had the ears of those who represent us and have the power to do something about it.
Moreover, I spent much time speaking with and educating my peers and friends that I made that weekend. It was their faces of surprise and encouraging words that truly felt like success. I believe that this person-to-person advocacy is the more impactful. I believe that this is how our stories spread -- from one person, to their family, to their classmates, to their superiors.
Now, more than ever, is the time to stand up and fight for ourselves and the more than 750,000 others who may not be able to speak out, for various reasons. The more our stories are heard, the more humanized this issue becomes, and consequently, the more minds are changed.
— Zarna Patel
Copyright © 2017 by the Catholic Health Association of the United States
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