In May 2017, the Refugee Immigrant Child Health Initiative (RICHI) was formed as a non-partisan and pro-child intervention to better serve the needs of immigrant and refugee children and their families. The initiative garnered wide support and commitment by the statewide Illinois Chapter, American Academy of Pediatrics (ICAAP) board and members. RICHI began with a handful of dedicated pediatricians in 2017 and has expanded to 130 members in 2020.
The need for the initiative was established based on local demographics of children and families in the state of Illinois with a specific emphasis on how to better serve the needs of children and families who are immigrants. This article focuses on immigrants, defined broadly to include children who are born outside the United States to non-US citizen parents as well as those born in the US who have at least one parent who is foreign born.1 Illinois demographics mirror the demographics of the US overall with 26% of children living in immigrant families and nearly half of these children with parents who are not US citizens.2 As the population of children in immigrant families continues to grow, health care providers will increasingly manage a wide range of complex issues related to immigration as a social determinant of health.1
Although local statistics paralleled national numbers, certain central aspects of Illinois geography also informed the need for a program like RICHI. For instance, Illinois is home to the sixth largest concentration of undocumented residents across the country, and is one of a handful of states that provides Medicaid insurance to children regardless of immigration status.3–6 Currently, 1.09 million people who are foreign born reside in metropolitan Chicago and the surrounding Cook County, representing 60% of the state's foreign-born population.7 It also houses unaccompanied children in shelters throughout the city.8
From the outset, RICHI's foremost priorities were to build capacity by educating pediatricians regarding policy issues impacting their patients and help health care professionals connect patients and their families to legal and other immigration resources (Table 1). RICHI also spearheaded an effort to train physicians and mental health providers to conduct forensic examinations to produce critical evidence in asylum cases for young children housed in shelters throughout Chicago and facilitated numerous advocacy opportunities for its members.
RICHI Outreach, Coalition Building, and Engagement
Under the leadership of RICHI's physician chair and ICAAP's designated initiative director, RICHI began holding regular monthly meetings to coalesce membership and investment in the group. Meetings were structured with the aforementioned objectives in mind, and speakers were invited to build institutional knowledge and apprise participating Chapter members of best practices and community resources to help them better serve their patients who are immigrants.
RICHI leaders also undertook an environmental scan of community-based and statewide organizations, catalogued local and national resources that would be useful for Chapter members, and set up one-to-one meetings with local immigrant-serving organizations. For example, the Illinois Child Trauma Coalition shared information on trauma-related interventions available to children and a representative from the Illinois Coalition for Immigrant and Refugee Rights educated our members about Medicaid eligibility of immigrant families in Illinois. The National Immigrant Justice Center and the Young Center, organizations that represent unaccompanied children, discussed the intricacies of navigating the legal system related to asylum and immigration law.
Members of community-based organizations and the academic community also provided valuable knowledge to the initiative, shedding light on a variety of issues affecting children and families. Proyecto de Acción de los Suburbios Oeste (West Suburban Action Project) and the Council on American-Islamic Relations presented interventions to address the effects of immigration policies while an anthropologist talked about her research on issues facing deportees who seek to reunite with their children in Mexico.9,10
The backgrounds and talents of RICHI members also informed the group's agenda. For instance, a physician writer led a workshop on opinion-editorial writing to build confidence and aptitude in physician advocacy while RICHI's resident bioethicist shared a model for caring for undocumented patients using a Sanctuary Doctoring Pledge.11 The Immunization Program Medical Director of the Chicago Department of Public Health shared data that demonstrated decreased use of services after the initial threat of changes in the public charge rule.
To further increase its capacity, RICHI established reciprocal relationships between its membership and the various community partners who spoke at RICHI meetings, thus enriching advocacy efforts and resources available to both. Every guest speaker was asked to discuss how RICHI could potentially partner with their organization, continuously informing RICHI's direction and action agenda. Doing so allowed RICHI to widen its membership ranks, bringing together a multidisciplinary collaborative that grew to include psychologists, bioethicists, social workers, lawyers, public health experts, and physician writers. Through this process, RICHI also identified and joined several vital coalitions to expand its reach and further involve members in existing state and national efforts around immigrant and refugee health.
RICHI's member participation also grew as the national conversation on immigrant and refugee health became prominent. Following the lead of the AAP policy agenda, RICHI was able to contribute locally and nationally in immigration health initiatives.
RICHI joined in national and statewide coalitions as an active member of Protecting Immigrant Families – Illinois, a group that was formed in response to the proposed rules on public charge.12,13 The campaign against these proposed rules ignited chapter volunteers, along with other national organizations, to compose letters to the editor, give speeches at press conferences and rallies garnering media coverage, and submit chapter and member comments opposing the rules.
RICHI played a prominent role at the June 2018 Families Belong Together national campaign rally in Chicago that was attended by an estimated 50,000 people, when ICAAP became part of the rally's organizing team led by the American Civil Liberties Union of Illinois and Indivisible.14 Additionally, a united group of Chapter members, including residents and medical students, represented RICHI at the rally. A testament to its trusted position outside of the medical community, RICHI's chair was selected as the only physician speaker at the event.
RICHI also contributed to other statewide coalitions improving systems of care for children in immigrant families. It was one of the original organizational members of the Illinois Alliance for Welcoming Health Care, which was established to ensure that immigrants receive equitable access to quality, culturally competent services. Although Illinois is generally considered an immigrant-friendly state, many local communities with large immigrant populations do not feel safe under current policy.15–17 In response, RICHI members were empowered to speak up for their neighbors and patients as a voice promoting immigrant and refugee child health and actively improve the environments in which those children receive health care.
Even though individual physicians or hospitals may not have had the skills or institutional mandate necessary to bend the arc of public policy, the collective efforts of RICHI members mobilized organized responses to various policy changes. For example, when the United States Citizenship and Immigration Services (USCIS) revoked nonmilitary Deferred Medical Action requests in August 2019, hundreds of families with children receiving life-saving care at children's hospitals across the country were issued deportation notices.18 RICHI joined 16 other AAP chapters to draft letters of support, which were ultimately presented by AAP President Dr. Kyle Yasuda to a Congressional Oversight Committee. This policy was later reversed by USCIS, allowing these children to remain in the US and receive care.19 RICHI also joined a US Supreme Court amicus curiae brief supporting Deferred Action for Childhood Arrivals (DACA) in 2019, in which ICAAP discussed the potential harm of repeal on Illinois DACA recipient children.
RICHI encouraged physicians in different stages of their careers to become local experts to connect patients, families, and physicians to medical and legal resources related to their immigrant status. As RICHI organized its members to advocate for pro-immigrant and refugee health policies, such as ending family separation at the border and opposing the expansion of the public charge rule, leaders recognized that local and national campaigns, by virtue of their finite nature, were also opportunities for medical student and resident involvement. Thus, RICHI connected with several teaching institutions to include them in its efforts.
Indeed, residents themselves were actively seeking additional training on how to care for immigrant families, and several RICHI members responsible for resident education at their respective institutions used RICHI resources for their program's immigrant health curriculum, fulfilling this demand. To this end, RICHI provided residency programs with qualified speakers for grand rounds and other resources on how to effectively promote culturally competent resident education.20,21
Aside from their formalized education, residents also played a key role in RICHI's public charge activities, soliciting individual comments from their residency programs and medical schools and attending rallies. Thus, RICHI grew its own pipeline of immigrant child health leaders by teaching peers and trainees effective advocacy skills like op-ed writing and public speaking.
One of RICHI's most powerful achievements has been the formation of the Midwest Human Rights Consortium (MHRC). MHRC is a referral network of multi-institutional and interdisciplinary professionals who perform trauma-informed forensic evaluations for asylum seekers in the US. Prior to the creation of MHRC, no formal training organization or systematic legal referral process for forensic medical and psychological evaluations in support of asylum seekers had been established in the Midwest, despite Chicago's place as a major center for unaccompanied children relocated by the Office of Refugee Resettlement in the region.8
Launched in conjunction with RICHI's January 2019 Forensic Asylum Evaluation Training conference (cosponsored by the University of Illinois-Chicago and other partner institutions), MHRC has connected legal organizations representing immigrant children in asylum cases with medical and mental health professionals. It has trained more than 100 professionals to perform these evaluations and continues to offer ongoing workshops and mentorship to members who have received initial training.
RICHI members also took an active role in outreach to local high schools, social service organizations, and state agencies, recognizing the benefit of sharing the agenda with other organizations. Members presented at their respective institutions and to professional associations, such as the Medical Organization for Latino Advancement and the Latino Health Symposium. Such outreach also boosted physician recruitment for RICHI.
Conclusion and Lessons Learned
The development of RICHI into a multidisciplinary chapter initiative can be achieved by other organizations aiming to launch similar programming. In assembling any advocacy initiative, it is important to consciously shape both activities and the organizational structure of the group itself with the differing capacities of membership in mind. First, the time commitments, schedules, and expertise of residents and attending physicians can differ drastically and projects must be structured accordingly to ensure meaningful engagement rather than adding to additional burnout. Second, taking the time to interface with established voices in the proposed area of involvement may help chapters accelerate their program development and more effectively accomplish their directives. By identifying and connecting with the leaders and organizations already doing similar work, groups can build working relationships for future activities. Third, forming a program to address immigrant and refugee child health, in particular, requires a multidisciplinary approach.22 The complexity underlying the US immigration system calls for partnering with legal and other immigrant-serving agencies to effectively care for immigrant children. Lastly, RICHI's work has illustrated that the pediatrician voice is appreciated across sectors and is seen as an authority in policy discussions poised to impact child health. RICHI has enabled Illinois pediatricians to tell their stories and those of their patients, whether through opinion-editorials, at press conferences, or in public forums. Leveraging physician voices on the individual, community, organizational, and policy levels can be an effective tool in promoting child-friendly policies.23 RICHI's development demonstrates how organizations can empower pediatricians to support immigrant children and families when they need our help the most.
- Linton JM, Green ACouncil on Community Pediatrics. Providing care for children in immigrant families. Pediatrics. 2019;144(3):e2019–e2077. PMID:31427460
- The Annie E. Casey Foundation. Kids Count Data Center. Children in immigrant families in the United States. https://datacenter.kidscount.org/data/tables/115-children-in-immigrant-families?loc=1&loct=1#detailed/2/2-53/false/37,871,870,573,869,36,868,867,133,38/any/445,446. Accessed April 22, 2020.
- Pew Research Center. Hispanic Trends. U.S. unauthorized immigrant population estimate by state, 2016. https://www.pewresearch.org/hispanic/interatives/u-s-unauthorized-immigrants-by-state/. Accessed April 22, 2020.
- Adams R. Undocumented kids get health care in six states, D.C. https://www.center-forhealthjournalism.org/fellowships/projects/undocumented-kids-get-health-care-six-states-dc. Accessed April 22, 2020.
- Get Covered Illinois. Coverage options for immigrant families. https://getcovered.illinois.gov/Fact%20Sheets/16_GCI_Fact_Sheets_Immigrants.pdf. Accessed April 22, 2020.
- National Academy for State Health Policy. Illinois 2019 CHIP fact sheet. https://nashp.org/wp-content/uploads/2019/12/2019CHIPFactSheet_Illinois_Final.pdf. Accessed April 22, 2020.
- Haymes MVD, Avrushin A, Coleman D. Educating unaccompanied immigrant children in Chicago, Illinois: a case study. Child Youth Serv Rev. 2018;92(C):77–88. doi:10.1016/j.childyouth.2018.03.046 [CrossRef]
- Sanchez M, Cohen JS, Eldeib D. Immigrant children sent to Chicago shelters are traumatized and sick, in some instances with chicken pox or tuberculosis. https://www.propublica.org/article/heartland-chicago-shelters-immigrant-children-sick-traumatized. Accessed April 22, 2020.
- Robles JM, Gomber-Muñoz R. Activism after DACA: lessons from Chicago's immigrant youth justice league. North Am Dialogue. 2016;19(1):46–54. doi:10.1111/nad.12036 [CrossRef]
- Gomberg-Muñoz R. Labor and Legality: An Ethnography of a Mexican Immigrant Network. 10th ed. New York, NY: Oxford University Press; 2011.
- Kuczewski MG, Mejias-Beck J, Blair A. Good sanctuary doctoring for undocumented patients. AMA J Ethics. 2019;21(1):E78–E85. doi:10.1001/amajethics.2019.78 [CrossRef] PMID:30672423
- U.S. Citizenship and Immigration Services. Public charge. https://www.uscis.gov/green-card/public-charge. Accessed April 22, 2020.
- American Immigration Lawyers Association. Featured issue: public charge changes at USCIS, DOJ, and DOS. https://www.aila.org/advo-media/issues/all/public-charge-changes-at-uscis-doj-and-dos. Accessed April 22, 2020.
- NBC Chicago. Police: more than 50,000 marched in #FamiliesBelongTogether rally. https://www.nbcchicago.com/news/local/chicago-police-say-more-than-50000-marched-in-families-belong-together-rally/2061523/. Accessed April 22, 2020.
- New American Economy. Cities index. https://www.newamericaneconomy.org/cities-index/. Accessed April 22, 2020.
- Esparza J. Illinois is officially a ‘sanctuary state’ for immigrants. Chicago Tribune. https://www.chicagotribune.com/hoy/ct-hoy-illinois-is-officially-a-sanctuary-state-for-immigrants-20170828-story.html. Accessed April 22, 2020.
- Artiga S, Ubri P. Living in an immigrant family in America: How fear and toxic stress are affecting daily life, well-being, & health. The Henry J. Kaiser Family Foundation. http://files.kff.org/attachment/Issue-Brief-Living-inan-Immigrant-Family-in-America. Accessed April 22, 2020.
- American Immigration Lawyers Association. Featured issue: USCIS's elimination of nonmilitary deferred action at local USCIS. https://www.aila.org/advo-media/issues/all/featured-issue-usciss-elimination-of-non-military. Accessed April 22, 2020.
- U.S. Citizenship and Immigration Services. USCIS re-opens previously pending deferral requests. https://www.uscis.gov/news/alerts/uscis-re-opens-previously-pending-deferral-requests. Accessed April 22, 2020.
- Alpern JD, Davey CS, Song J. Perceived barriers to success for resident physicians interested in immigrant and refugee health. BMC Med Educ. 2016;16(1):178. doi:10.1186/s12909-016-0696-z [CrossRef] PMID:27421774
- American Academy of Pediatrics. Immigrant child health toolkit. https://www.aap.org/enus/advocacy-and-policy/aap-health-initiatives/Immigrant-Child-Health-Toolkit/Pages/Immigrant-Child-Health-Toolkit.aspx. Accessed April 22, 2020.
- Linton JM, Green ACouncil on Community Pediatrics. Providing care for children in immigrant families. Pediatrics. 2019;144(3):e20192077. doi:10.1542/peds.2019-2077 [CrossRef]. PMID:31427460
- Fried JE, Shipman SA, Sessums LL. Advocacy: achieving physician competency. J Gen Intern Med. 2019;34(11):2297–2298. PMID:31420826
RICHI Outreach, Coalition Building, and Engagement
|Outreach to Local Organizations
|Community-based immigration and citizenship, social services, education, and immigrant communities
Social justice organizations
Departments of public health
Vaccines for children program
Academic medical centers
State court system
Religious and business organizations
||ICAAP's Midwest Human Rights Consortium
Coalition for Immigrant Mental Health
Illinois Alliance for Welcoming Health Care
Protecting Immigrant Families – Illinois
Families belong Together
Governor's Inaugural Forum
AAP legislative Conference
ICAAP state lobby day
Federal administrative rule-making