From the Editor
Strengthening Academic Medicine’s Response
to Humanitarian Concerns
As we in academic medicine become
increasingly aware of humanitarian
concerns across the globe, we encounter
new opportunities to use our skills,
training, and resources to respond
in accordance with our professional
values and missions.1 These efforts
often require us to expand beyond our
usual approaches to training and care
delivery.2 These efforts also require us to
confront tragedy—caused either directly
by interpersonal violence or indirectly
by consequences of broader decisions in
society—experienced at a scale that we
may not have previously encountered
or imagined. Many of the challenges
are practical in nature, such as bringing
clinical care to new service settings
and populations. Some challenges are
less tangible but no less consequential,
such as bringing sensitivity to the
intersectional narratives and concerns
of those who have experienced
displacement, trauma, and human rights
violations.3–7
In this issue of the journal, we are pleased
to highlight the efforts and experiences of
our colleagues in academic medicine that
have addressed the humanitarian crisis
of unaccompanied children received
at the southern border of the United
States, as described by Devaskar et al.8
As these authors detail, the numbers
of children arriving at the border not
accompanied by a biological parent
reached unprecedented heights in
2021.8,9 The majority of these children
fled their home countries because of
extreme poverty, violence, and social
conditions that made it impossible to
thrive and grow, seeking to join family
members already living in the United
States. Many children, then and now,
arrive with complex and chronic histories
of trauma and adversity, and reach
the southern border after undertaking
arduous journeys where they faced
acute health, safety, and psychological
risks.10,11 These children carry with them
incredible resilience and capabilities, but
Acad Med. 2023;98:291–293.
doi: 10.1097/ACM.0000000000005124
Academic Medicine, Vol. 98, No. 3 / March 2023
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
often encounter policies and systems
that do not adequately meet their needs
and pose risks that can undermine their
strengths.2,12 The combined expertise
of health professionals in academic
medicine bring valuable insight into
the long-term individual and public
health consequences to unaccompanied
immigrant children that stem from their
histories, as well as the best-practice
approaches, via health care and service,
for addressing and mitigating the risks
they face.11
The U.S. government agencies
responsible for the reception and care of
unaccompanied immigrant children were
underprepared for the influx of children
arriving at the U.S.–Mexico border in
2021. The influx led to the opening
of 14 Emergency Intake Sites (EISs)
across the nation to provide temporary
congregate shelter and care for children
as they awaited release to their families
or placement in other longer-term care
or foster programs.13 Due to the nature
of the acute crisis, EIS facilities had
little oversight and relied heavily on
volunteer federal government staff and
contractors.14 The EIS facilities varied
greatly in terms of their conditions and
availability of services and programs for
children.15 In that moment of crisis, the
federal government turned to academic
medicine for support in addressing
the medical and health needs of
unaccompanied children in government
custody at EISs.8
Devaskar et al8 tell the compelling
account of a university health care
system—in this case, the University
of California Health system (UCH)—
mobilizing to meet the needs of both
individual children and governmental
systems in a critical moment in their
respective experiences. This story
exemplifies the crucial and influential
role that academic medicine can play in
responding to humanitarian concerns
and crises. The experience of the UCH
demonstrates that, when issues arise
that touch on the universal values and
ethics inherent in academic medicine and
health service, large groups of
individuals operating in and across
complex systems can work collaboratively
toward achieving shared aims.
Indeed, Devaskar et al document an
impressive process within the UCH to
organize and coordinate resources across
big organizations and systems to address the
humanitarian concerns regarding the health
and safety of unaccompanied immigrant
children.8 The authors offer a roadmap for
organizational processes within academic
medicine that can inform or be replicated
in future efforts (1) to pursue academic–
governmental partnerships and/or (2) to
advance academic medicine’s responses
to humanitarian concerns and crises.
Inspired by this effort, we call on other
academic health centers to look to the UCH
experience in considering the ways they can
expand traditional boundaries and service
efforts consistent with their missions and
values.
In their article, Devaskar et al provide an
important model for academic medicine,
and their efforts, activities, and lessons
learned may have lasting impact for
the government agencies charged with
the reception and care of immigrant
children and, clearly, for all children
in government care. For example, the
new implementation of a centralized
electronic health record system within
the EISs via the UCH offered important
advances to improve continuity of care,
including transfer and follow-up as
children were released into communities.
Other innovations with similar effect
were accomplished through the
implementation of on-site pharmacies,
evaluation, and laboratory facilities.
In these examples, the UCH effort
resulted in the demonstration of process
innovations that can improve federal
systems of care for unaccompanied
children.
The UCH effort—given the level of
experience; training; and expertise of
medical faculty, staff, and trainees—
offered children improved access to
best practices in pediatric care. The
291
From the Editor
services, supports, and resources
offered by the UCH at EIS facilities
sought to minimize distress via crisis
management and support, to prevent
illness and outbreak, and to support
child adjustment and engagement in the
developmentally appropriate tasks of
learning and play. The potential long-
term beneficial effects of this effort,
both in terms of prevention and also
intervention for health risks, cannot
be understated, and we hope they do
not go underappreciated by both our
medical and government communities.
One of us (R.B.M.) spent time with
unaccompanied immigrant children in
a different EIS facility on a military base
in Texas, in an effort to understand the
health and psychological functioning
of these children while in government
custody.16 Interviews and observations
revealed deeply concerning experiences:
Children were spending upward of 22
hours per day restricted against their
will in massive tents with thousands
of other children without educational
or recreational activities. Many
children reported extreme boredom,
anxiety, helplessness, and despair as
they languished without receiving
information or notice about the current
status of their sponsorship cases and
placement plans, while also struggling to
access protective supports from adults or
caregivers both within and outside the
facility. Reports of self-harming behavior
amongst the children were particularly
concerning.16
Although there is clear need to provide
for children and youth as they await
placement, congregate care facilities
that lack individualized supports or
developmentally appropriate activities
may be damaging for children and
youth; nonetheless, the month-to-
month average length of stay in EISs
from April 2021 to April 2022 ranged
from 7 to 28 days, with maximum
lengths of placement spanning over
3 months for some children.15 For
the 2 EIS facilities in California
where the UCH was operating, the
strategic availability of supports such
as psychological first aid and child
life services may have mitigated
some concerns and risks associated
with the EIS custody setting. Other
supports included the availability of
age-appropriate activities, such as daily
education, which offer opportunities for
292
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
productive efforts that, when aligned
with children’s goals, can reduce their
anxiety and despair.
In the current example of partnership
between academic medicine and the
federal government, the UCH was able to
provide services for nearly 5,000 children
in 2 EIS sites, effectively maximizing the
impact of the UCH within their scope of
service and authority. Nonetheless, with 14
EISs in operation under the Department
of Health and Human Services in 2021,
there is reason to consider the experience
and outcomes of the thousands of children
who did not benefit from placement at
a facility with access to UCH resources.
Consistent with our own experience, there
has been wide criticism and concern about
the conditions of care and adversities
experienced by children in many of these
sites.15
As health professionals concerned with
the safety and well-being of children
across the nation (and our world),
we might consider taking advantage
of opportunities for advocacy and
additional training. Through advocacy,
how might we leverage these sorts
of service and partnership efforts to
pursue lasting change in systems and
policies that often risk putting children
at harm? Through training, how might
we improve the preparation of health
professionals who feel the strain and
stresses of encountering trauma and
inequities at a scale previously not
experienced or imagined? How do we
prepare for the complex ethical issues
that arise in extreme settings, e.g., how
to honor unaccompanied children’s
rights when implementing treatment, or
how improved information-sharing and
coordination that is possible through an
electronic medical record must also be
balanced with specific considerations
relevant to the population, such as
whether immigrant children or their
parents/caregivers want their personal
health information to be made accessible
to government agencies and partners?2,7
Academic medicine embraces its 5
missions of scientific discovery; health
professions education; clinical care and
services; community engagement and
leadership; and commitment to excellence,
professionalism, diversity, equity,
inclusion, antiracism, and belonging.1
Each of these missions and commitments
is deeply relevant to the experience of
Academic Medicine, Vol. 98, No. 3 / March 2023
unaccompanied immigrant children—and
all require nurturance within the field
of academic medicine and tremendous
advocacy in our broader society. The
UCH activities in support of children at
EIS facilities represent an illustration of
the positive role of academic medicine
in response to an urgent humanitarian
crisis. Dear Reader, how can we use the
knowledge and momentum gained from
this effort and this partnership to better
realize academic medicine’s values?
Ryan B. Matlow, PhD
Clinical associate professor, Department of Psychiatry
and Behavioral Sciences, Stanford School of
Medicine
Laura Weiss Roberts, MD, MA
Editor-in-chief, Academic Medicine
Editor’s Note: The opinions expressed in this
editorial do not necessarily reflect the opinions of
the AAMC or its members.
References
1 Roberts LW. Innovation and leadership
across the five missions of academic
medicine. Acad Med. 2021;96:1623–1624.
2 Sirkin S, Hampton K, Mishori R. Health
professionals, human rights violations at the
US-Mexico border, and Holocaust legacy.
AMA J Ethics. 2021;23:E38–E45.
3 Behbahani S, Smith CA, Carvalho M,
Warren CJ, Gregory M, Silva NA. Vulnerable
immigrant populations in the New York
metropolitan area and COVID-19: Lessons
learned in the epicenter of the crisis. Acad
Med. 2020;95:1827–1830.
4 Coverdale J, Balon R, Beresin EV, et al. Climate
change: A call to action for the psychiatric
profession. Acad Psychiatry. 2018;42:317–323.
5 Coverdale JH, Gordon MR, Nguyen PT, eds.
Human Trafficking: A Treatment Guide for
Mental Health Professionals. Washington,
DC: American Psychiatric Association; 2020.
6 Kuczewski MG, Brubaker L. Medical
education for “Dreamers”: Barriers
and opportunities for undocumented
immigrants. Acad Med. 2014;89:1593–1598.
7 Stone LC, Steimel L, Vasquez-Guzman E,
Kaufman A. The potential conflict between
policy and ethics in caring for undocumented
immigrants at academic health centers. Acad
Med. 2014;89:536–539.
8 Devaskar SU, Cunningham CK, Steinhorn
RH, et al. Academic health centers and
humanitarian crises: One health system’s
response to unaccompanied children at the
border. Acad Med. 2023;98:322–328.
9 U.S. Customs and Border Protection.
Southwest Border Encounters, 2021. https://
www.cbp.gov/newsroom/stats/southwest-
land-border-encounters-by-component.
Published November 14, 2022. Accessed
November 28, 2022.
10 Morales FR, Nguyen-Finn KL, Haidar M,
Mercado A. Humanitarian crisis on the
US-Mexico border: Mental health needs
of refugees and asylum seekers. Curr Opin
Psychol. 2022;48:101452.

11 Markkula N, Cabieses B, Lehti V, Uphoff E,
Astorga S, Stutzin F. Use of health services
among international migrant children—
A systemic review. Global Health. 2018;
14:52.
12 Matlow RB, Reicherter D. Reducing
protections for noncitizen children—
Exacerbating harm and trauma. N Engl J Med.
2019;380:5–7.
13 Office of Refugee Resettlement, Administration
for Children and Families. Field Guidance
#13—Emergency Intake Sites (EIS) Instructions
and Standards. https://www.acf.hhs.gov/
sites/default/files/documents/orr/FG-13%20
Academic Medicine, Vol. 98, No. 3 / March 2023
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
EIS%20Instructions%20and%20Standards%20
2021%2004%2030.pdf. Published October 24,
2022. Accessed November 27, 2022.
14 Aleaziz H. The Biden administration is
looking for more federal volunteers to help
overcrowded border stations. Buzzfeed
News. https://www.buzzfeednews.com/
article/hamedaleaziz/biden-federal-
volunteers-border-facilities. Published
March 25, 2021. Accessed November 28,
2022.
15 Desai N, de Gramont D, Miller A.
Unregulated & unsafe: The use of
emergency intake sites to detain immigrant
From the Editor
children. National Center for Youth
Law. https://youthlaw.org/unregulated-
unsafe-emergency-intake-sites. Published
June 2022. Accessed November 28,
2022.
16 Pls’s Mot Enforce Settlement Emer
Intake Sites Ex C, Flores v Garland,
No. CV 85-4544-DMG-AGRx
(CD Cal Aug 9, 2021), ECF
No. 1161-7. https://youthlaw.org/sites/
default/files/wp_attachments/Flores-v.-
Garland-Pls-Motion-to-
Enforce-8.9.2021.pdf. Accessed
November 28, 2022.
293