 been in a few seconds. All right, well, it is 12.30, and we have a full agenda for today, so I think we're gonna get started on our health policy and bioethics consortium. Thank you, everybody who is joining us via Zoom. Thank you as well to the people who are live streaming this on Facebook and YouTube. We're pleased to have a great panel of experts today, and hundreds of people who have signed up for this, so I'm sure that people will be jumping on and off at various points, but we should get started to try to maximize the time that we have. My name is Aaron Kesselheim. I'm a professor of medicine at Harvard Medical School, and I run the program on regulation, therapeutics, and law, and in concert with the HMS Center for Bioethics. We're pleased to bring you this health policy and bioethics consortium in which we bring in some experts from around the country to talk about some of the key policy and bioethics topics of the day. If anybody wants to tweet about anything that is being said or going on, the hashtag that we use is hashtag policy ethics. Just to remind people who might not have joined us for one of these consortia before, the goal of these consortia are to articulate key issues in the healthcare system and public health that involve ethically challenging policies or practices, bring together experts with different perspectives or experiences to consider and propose solutions, and to stimulate conversation and further academic study of the topic to help advance the field. This is the last of our sessions for the year, and it's been quite a year. Hang on a second. So it's been a great year. We had a conversation in September about the drug pricing games that pharmaceutical companies play to extend their monopolies. We talked about tobacco regulation. We talked about gun violence and issues relating to sugar sweetened beverages and addiction treatment policy last time. And so this is the final one of the year. It's been really pleased to have so many great experts come and talk to us. I just wanted to point out that we are also setting up already for next year. Leah Rand is gonna be helping organize this, and we're already setting up the topics for the next academic year. This policy series takes the summer off, but in September we're gonna talk about COVID-19 response with special guest, Mark Lipsitch, drug shortages and what's next in healthcare reform. And so if you're interested in these topics, please go to our portalresearch.org website. You can sign up for alerts about these. You can also sign up at the HMS Center for Bioethics website. You can also reach out to me or someone else to make sure that we have you on our mailing list. And then finally, we are taking the summer off, but I just wanted to point you to other online learning that you can do. The portal group has developed an online course on drug policy and the law that's been seen by over 60,000 people around the world. And we cover a lot of different issues relating to prescription drug regulation costs and access. And you can access this course for free on the edX or HarvardX platforms. So I want to start our session off today, which is going to be focusing on addressing the public health crisis at border detention centers. And I want to start by introducing our moderator, Wes Boyd, who's an associate professor of psychiatry at Harvard Medical School and a faculty member at the HMS Center for Bioethics as well. He's a staff psychiatrist at the Cambridge Health Alliance where he co-directs the clinician health committee and is a co-founder and director of the human rights and asylum clinic there. He teaches bioethics, human rights and psychiatry at HMS as well as a freshman seminar on the psychology of religion at Harvard College. He writes for lay and academic audiences on issues of health care, justice, addiction, medical education and human rights. And he's here today to moderate the panel, tell us a little bit about the topic and introduce our expert speakers. So thank you very much, Wes, for being with us. Thank you so much, Erin, for that nice introduction. And thank you also for hosting a panel on this very important topic. What is happening on our southern border is absolutely a crisis, a crisis that has life or death implications for asylum seekers and for those who survive, one that is going to leave lifelong scars in multiple ways. I'll have more to say after our speakers have concluded with their opening remarks, but just want to say a little bit about how I got introduced into the issues firsthand of immigration and asylum. I've been at Cambridge Health Alliance since 1992. We treat immigrants all of the time, so I've seen immigrants as patients for the last 28 years. But I only really got into thinking mostly about immigration and asylum about 15 years ago at the urging of one of my medical students. And at that point, I started doing evaluations of asylum seekers. I had not had any training whatsoever. I just got my hand on a template for how to write these evaluations up and submit them to courts to assist lawyers. At first it was really a trickle, but about 10 years ago I teamed up with an internist at Cambridge Health Alliance who was doing medical evaluations of asylum seekers and a psychologist who was running our Victims of Violence program, the Cambridge Health Alliance. Together we formed the asylum clinic at Cambridge Health Alliance. That led to a lot more exposure in the area, doing a lot more evaluations. And later teaming up with Katie Peeler, one of our speakers today to help start the HMS Asylum Clinic. And so it's really become a large part of my identity that is working with immigration, working with asylum seekers, working closely with immigration attorneys and something I care passionately about. The topic today is the crisis at the border. I just wanna say a couple of things before I hand it off to our speakers about what asylum seekers face before they even get to the border. Overwhelmingly asylum seekers in their countries of origin are facing death if they do not flee. I have seen firsthand children who are being recruited to gangs. If it's boys, they're being recruited as drug mules. If it's girls, they're being recruited as sex slaves. And if they consistently say no to gangs, they're going to be killed. I have seen parents whose children have been killed in front of them in the most horrific of ways because the parents would not allow their children to go with gangs. I've seen people who've been victims of domestic violence and that is an easy way to say, a shorthand way of saying some of the real horrors that people have faced. And overwhelmingly individuals in Central America, if they're victims of gang violence or intra-family violence, do not have recourse by going to the police. The police simply say, if it's gangs, we have no say in the matter and if it's a domestic issue, that's a household issue, we don't want to get involved. So that's what they faced in their countries of origin. Compound that with the fact that when they're traveling through Mexico, on routes to the United States, many, many people, especially women, are subjected to physical and sexual violence on route while crossing through Mexico. And then to have what is happening on our Southern border, await them. Once they've left their countries of origin and once they've made it through such a horrific trip often from their country of origin to the Southern border, that's what we're here to discuss today. We have amazing panel put together by Aaron. I'm so grateful to Aaron for doing this. Each panel member is highly distinguished to put it mildly and I'm very humbled to be here presenting alongside them. I'm gonna introduce them in the order that they're going to present. After they've presented, I'll say a few more things to hopefully amplify some of their remarks and then we'll open it up for discussion. And for those watching, please submit questions. There's a chat bar. Feel free to submit as many questions or comments as you wish. Our first speaker is George Annas, the Warren Distinguished Professor at Boston University. He's director of the Center for Health Law, Ethics and Human Rights at Boston University School of Public Health and professor in the Boston University School of Medicine and School of Law. He's the author or editor of 20 books on health law and bioethics. I'm just gonna pause here and say right over there is one of the books that he edited which is the foundational book for a course I teach and the Center for Bioethics in the master's degree program. Back to George. George is the author or editor of 20 books on health law and bioethics. And for 25 years wrote a regular feature in the New England Journal of Medicine on health law, ethics and human rights. He is a fellow of the American Association for the Advancement of Science, a member of the National Academy of Medicine and a former member of the National Academy's Human Rights Committee. Our second speaker today is going to be Katie Peeler. She is a pediatric critical care position at Boston Children's Hospital, medical director of the Harvard Medical School Asylum Clinic, faculty member of Harvard Medical Schools Department of Global Health and Social Medicine and pro bono medical expert for physicians for human rights. Dr. Peeler has performed dozens of forensic evaluations of child and adult asylum seekers to document evidence of their past persecution for their asylum cases. She has written widely about the health and health rights of asylum seekers, teaches medical students and other clinicians how to perform forensic evaluations and has testified as an expert in individual asylum cases and in federal class action lawsuits on behalf of detained immigrants. Most recently, she has written expert declarations and been part of several amicus briefs related to litigation aimed at releasing adults and child immigrants from detention centers in the setting of COVID-19. Our final speaker is Catherine Kate McKenzie. She is a faculty member at Yale School of Medicine and the director of the Yale Center for Asylum Medicine. She has practiced medicine at Yale for over 20 years and teaches undergraduates, students, and residents and is a former member of Yale, and is a member of Yale Refugee Health Program. Sorry about that. She is a physician advocate for social justice and human rights. Since 2007, Dr. McKenzie has been the director of the Yale Center for Asylum Medicine where she has performed forensic evaluations of asylum seekers at Yale and in detention facilities and has testified as an expert witness in immigration court for individuals referred by law schools, human rights organizations, and immigration attorneys. She leads the Asylum Medicine Teaching Program for trainees and faculty at Yale, mentors, peers across the U.S. and lectures extensively nationally and internationally on topics of asylum, detention, and physician advocacy. At Yale, she received the Leonard B. Toe Award for Humanism in Medicine and the Faculty Award for Achievement in Clinical Care. She has written reviews, clinical cases, and opinion pieces on asylum medicine and publications including the New England Journal of Medicine, the British Medical Journal, Time Magazine, and CNN, among others. With that, I happily give the floor to Georgiana Annas. Thank you, Wes. I'm a little sad by my colleague, Dr. Sander Crosby can't be with us today, but hopefully she's gonna be able to join us for the questions and answers. Most of my, obviously I'm a lawyer, I'm not a physician, so I work with physicians the two I work with the most are Dr. Crosby and Michael Groden, both of whom have long distinguished careers in torture and in asylum work. What I've been asked to do, and I'm happy to do it, is to introduce the topic that we're talking about today in a theoretical legal setting, because that's why we're here. I probably don't have to remind any of you that for the president, immigration is the number one issue. It's not COVID, it's not even the economy, it's immigration. And he and his associate, Stephen Miller, spend a lot of their time trying to figure out different ways to keep people out of the country, especially on the Southern border. And they're very, very, very, very good at it. And it makes the lives of my two co-panelists drives them crazy. I have absolutely no doubt because most of the harm that's visited on asylum seekers and refugees at the border is unnecessary. And it's really a tragedy. But let me just spend a few minutes giving the background of what we've all lived through in the last four years of what the law is that people who come to this country, especially from the Southern border, but from anywhere, have to endure. And it started almost the first day of the administration with the so-called Muslim ban, which I have no doubt you'll remember. And it was a ban of people coming to the United States from seven predominantly Muslim countries. And it was done by a presidential declaration. And it was immediately challenged and ultimately thrown out of court, rewritten, challenged again, ultimately thrown out of court. And then the third time, it actually made it up to the U.S. Supreme Court. And the question was whether the president had the authority to exclude whole categories of people, people from specific countries, from coming to the United States. And the answer, five to four from this Supreme Court, actually the Supreme Court's gotten worse since then, Justice Kennedy was still on the court then, was that this is an exercise of the president's national security authority. And that's where he is the strongest and the court is not gonna second guess him as long as he has a rational basis for picking these countries and for finding that the people from those countries are more dangerous or could be seen as more dangerous than people from other countries. Very low standard, okay? And if the court continues to take that standard, the sad part is virtually every declaration the president makes, anti-immigrant declaration will be upheld as constitutional. Justice Sotomayor writing the dissent said she basically couldn't believe it. She said even though the court did overturn Korematsu, the Japanese internment camp case the same day, they essentially ruled a similarly way in the Muslim ban. The only way they could call it not a Muslim ban was to say, well, there's no mention of religion in the actual proclamation. And we're gonna disregard all the tweets and everything the president has said in public because that's not part of the record and the story. And as I'm sure you know, in January, the president added seven more countries to his list from people who are either extremely difficult for them to travel here now. The other big series of lawsuits is called the Flores lawsuits. And it started way back in the Clinton administration and was based on litigation that involved the that what was then the INS who had detained a undocumented 15 year old girl. And her mother was afraid to go get her from custody. So her employer who was an unnamed but apparently famous movie actor hired a lawyer to go get her. And they wouldn't release her to her cousin. They'd only released it to her mother and her mother was just afraid to go there. That litigation in the end, besides getting her out of jail, fostered a whole decades long litigation about what conditions under which you should be able to hold a minor in jail or prison or detention as we call it. And the original Flores agreement which was a negotiated settlement was that you could only hold them as long as necessary and they had to be held in safe and sanitary settings. Over the years, well, of course, after 9-11 the jurisdiction changed. We had a new department of Homeland Security and they took over jurisdiction for immigration. And the rules changed, the Flores rules kept changing until they applied not just to children but to children and their mothers and the job of taking care of the children was given over to Health and Human Services, a separate agency, which has made things a little confusing too. And the limit has gone down from as long as necessary to 20 days to three days in which you could hold children. And what the Trump administration reaction to that was, well, we'll let the kids go and keep the mothers or we'll separate them at the border. And that's where the separation stuff started from which was when there was a limit to how long you could hold the children but no limit to how long you could hold their parents. Historically, before the Trump administration, although the Obama administration had its problems too, the parents, the mother and the child was released and permitted to stay in the United States until their asylum hearing came up. Trump administration didn't like that. They call it catch and release, I'm sure you've heard that term. And instead they decided to try to do a whole new program that was called the Remain in Mexico program instead of being released to wait for your trial in the United States for your hearing in the United States. The rule was you had to go back to Mexico, go back where you came from even though most people didn't come from Mexico, they came from Central America and stay there until your hearing was called and then come back to the United States there but for your hearing. That policy, I think everyone would agree, it's been a disaster. It's wound up creating a number of basically refugee camps on the border where people waited in very small conditions for their hearings. That has of course been appealed. The Ninth Circuit struck that down so that is totally lawless. It goes against all asylum rules on U.S. asylum rules let alone international asylum rules. And they were ready to affect the closed out of the Remain in Mexico program immediately just last month at the beginning of March but the U.S. Supreme Court issued an injunction and said, no, no, we're gonna hear this case. And so that this case will be heard in the fall. I have some outside feeling that even this U.S. Supreme Court might think that it's just the goal just directly against basic asylum rules, the way the administration is done without amending the law, simply can't be done but we'll have to wait and see. Maybe I'm way too optimistic there. The third thing just to talk about briefly is of course the wall. It's the president's number one thing. He's gonna build a wall, he's gonna and he is building a wall and he's taken money from accounts which Congress did not authorize to use and doing it anyway. And that case is also gonna be in front of the Supreme Court in the fall and how far the president can go to use money allocated by Congress for other purposes for his own project. And it's not just the wall. He's also on at least three occasions called out the U.S. military to go to the border and even General Mattis did it. He was very embarrassed to do it. He shouldn't have done it but he did because there's really no, the only authorization to use troops is that there's some kind of a war going on or a threatened war or we're being invaded. And of course the president did say that, right? He said that Mexican gangs are coming to our country and are gonna do horrible things because they're drug dealers and horrible people. And so the border is a lot of very weird stuff going on at the border but while it's going on, people had to find a place to put families, children. And that's where our next two speakers come in a lot more than I do. So anyway, that's just the introduction. You've all lived it, you all know it but it's not just about the law and it's certainly not about medicine. It's about politics and I'll leave it at that. But we'll be back for questions later. Thank you very much, George. And just to reiterate what Wes had said at the beginning for people who are watching, please do put your questions in the chat and when we go around to addressing audience questions we're gonna be pulling them from there. All right, thank you. Let me just share my screen here. So thank you again for having me. I'm a K.P. Heeler, I'm a pediatric intensivist at Boston Children's Hospital and I work a lot with Wes over at HMS and also with Kate through Physicians for Human Rights which is a nonprofit that does a lot of human rights investigatory work. And so my experiences kind of draw on all of those hats that I have. So I know this talk is not solely about COVID-19 but that's kind of the era that we're living in right now. So the title of my talk is that COVID-19 is just yet another trauma for detained immigrant children and families. So kind of building a little bit off what Wes said, all of these people have incurred a lot of trauma already and this is just kind of the latest in it. So we'll kind of talk about that a bit in the end. So I just wanna talk kind of briefly dig down a bit and what Wes talked about with background trauma that children face who are seeking, or what they've faced in the past who are now seeking asylum. The actual effects of the family separation policies that George touched upon and then what's kind of going on with COVID-19 for detained children and their families. And then because this is a ethics forum, I'll just very briefly touch about dual loyalty and people who care for or take care of detained immigrant children. So the latest numbers that we have, just to kind of put some figures on it is that there were about a quarter of a million asylum applications filed in 2017. And about 10% were actually granted asylum. And of those 10%, 16,000 of them were granted asylum affirmatively. Meaning they arrived at the border, they either had a VEL visa to come in and said I would like asylum or they arrived at the border, maybe you did not necessarily have a visa but said I am seeking asylum. And then the other 10,000 who were granted asylum, they came in and either overstated visa and then asked for asylum or maybe they came in without any papers and kind of came in the country quote illegally and then were applying for asylum as part of their deportation hearings and were granted asylum. But of the 16,000 who came and said I want asylum kind of from the get go, it's a very young crowd. So 50% of those 16,000 people are under 25 years old. So that's a lot of young people. And actually 30% of the 16,000 are legitimate children. They are 17 years and younger to their kids. And then in terms of kind of what they have suffered in their home countries, they have a PHR, so did a study of around 200 children between 2014 and 2018 and found that almost 80% had suffered direct physical violence themselves. Another 70% and some of these are the same children suffered threats of violence. So, you know, Wes talked about that if they weren't willing to join gangs or be if they were women unwilling to kind of quote be these girlfriends of the gangs they were suffered threats or actually injured. Around 20% had said that they had suffered sexual violence and 60% had witnessed acts of violence. And some of these are really horrific. You know, Wes had spoken about how some parents have seen their kids murdered along the same veins. Some children have seen their parents murdered. And so they've really witnessed a lot of horrific things that kids should just never be privy to in their lives. And then there's, again, as Wes mentioned, there's a lot going on in their home countries even if none of these specific things have happened to them. Some children are growing up without their parents. Their parents may have left ahead of them to go to the United States to seek a kind of better economic future for their family. And so their kids are home with family members but not growing up with their parents. And so there's other kind of anguish that they go through. And then the journey to the U.S. is no picnic. They are forced to often ride these trains in Mexico, these kind of cargo trains, which they fall off of. They injure their limbs. Some kids die that way. Kids are raped along the way. They have their clothes stolen, have all their money stolen. They're exposed to the elements. They're without food. It's really quite a journey. And oftentimes it takes several attempts to successfully get to the Mexico-U.S. border. And then as Wes mentioned, there's all of the things that kind of go on when you're actually in a detention center, which I'll get to in a minute. And so in terms of family separation, as George mentioned, this is not new to the Trump administration although they certainly have really made a name for themselves in doing it successfully. But essentially under Trump, there was this kind of trial family separation that started in El Paso in the summer to fall 2017, which they thought went wonderfully as a deterrent measure, although it didn't really. And so it was rolled out as a kind of formal national policy in May of 2018. And as we all remember from the news, a lot of kids were separated from their families at that time. So in six weeks, over 2,800 kids were forcibly separated from their families. There was a enormous national outcry, not surprisingly. And so then, because he loves executive orders. In June of 2018, Trump issued an executive order to halt family separation, but that it wasn't just let's halt it, this is obviously a bad program. Instead he asked for families to be detained indefinitely. And he had asked Congress at that time to extend the existing federal detention limitations for children, he did not want to be a have to follow the florist settlement agreement, which George had referred to earlier. And he's been fighting it ever since. Around a week later, there had been a lawsuit that had been going on for the prior, probably six months or so. The U.S. District Court of Southern District of California ruled on this lawsuit, Ms. LV Ice, and they granted a preliminary injunction. They kind of truly theoretically halted further separations and they said there needs to be speedy reunification between children and their families and that contact should be allowed and made easy between families and their children until reunification could take place. And as I think we also remember from the news at that time, that was much easier said than done because the government had done a terrible job keeping track of where kids went. So it was very hard to try to actually reunify families and it took quite a long time. And so, PHR decided to study this a little bit more formally. And so, and actually kind of just before coronavirus hit, this report was released entitled, You Will Never See Your Child Again. And we had looked at the persistent psychological effects of family separation. And persistent obviously should be a bit in quotes because it hadn't been that long since this kind of policy occurred, but they looked at the effects that were kind of somewhat long lasting after this policy. And so, it's a small study, but they had looked at 26 evaluations that were performed by PHR commissions, including myself, that were specifically asked by attorneys to be done to look at the effects of family separation on these, mostly these parents as well as their children's legal cases. And so, there were 17 adults and there were nine children whose affidavits were looked at. So these were affidavits that were already written and then we had gone back and looked at them retrospectively. And essentially, what they found is that, kind of before I go into these bullet points is that immigration authorities had forcibly removed children from their parents' arms. They'd often removed them while they're, they removed parents while their children were sleeping. Sometimes their parents would be sent to get a medical evaluation and their kid would just be disappeared and say they'd get back and their kid was gone. This was extremely commonplace. And then, and when we kind of looked at what families said about their experience as to why they'd come to the United States and what they had experienced upon being separated, uniformly everyone was fleeing physical violence and death threats, often from gangs. Parents mostly said that they were leaving for the safety of their children. They felt like they need to come to the United States or their kids were gonna be harmed or killed if they stayed. Kids, when kids were evaluated, they had a very hard time discussing a persecution when they were by themselves. It's a very traumatic thing to do for a child and offline doesn't really make a lot of sense. They don't kind of fully understand what's going on either with the process of the questioning or unnecessarily kind of what had happened at home. There was no due process, they were just separated. Uniformly, people feared they were never gonna see their children again. And I can talk about a few of the families that I saw. They were sent all around the country, hundreds and thousands of miles away and sometimes sent to more than one place. The detention conditions were terrible I suspect that Catherine will talk a little bit more about that. And then what I witnessed is that parents really struggled with their credible fear interview. So, you know, kind of without getting too much into the weeds, essentially when you kind of come into the United States and you aren't here with a visa, you kind of come and say I want asylum then you're sent to a detention center and the first step to even being allowed to ask for asylum to be applied for asylum is you have to pass your credible fear interview essentially kind of proving that if you go back to your home country, you do have a credible fear of something terrible happening to you. And the women that I interviewed, I was at the Dilly Detention Center, they essentially arrived with their kids. Their kids were taken from them, so basically kidnapped. And then two days later, they had to go basically the most important interview of their lives and they just couldn't do it. You read the transcripts of their interview, it will have the immigration officer saying, you know, Ms. Smith, why are you in the United States? And her answer would be, where is Johnny? And he'd say, I'm sorry, that's important, but you know, can you tell me a little bit about why you left El Salvador? Where is my son? Like it just goes on and on because you can't concentrate because your kid is missing. And so they inevitably would fail their credible fear interviews and would be in deportation hearings. And so their attorneys had asked us to evaluate whether or not they might have had some psychological stress that led to them failing their CFI. And so that's kind of what we were doing down there. And as I mentioned before, there was no plan to implement failure reunification. So when that order was made through the courts, there was a lot of scrambling to figure out how they actually were gonna do it successfully. And so some of the quotes from this report, a 17-year-old boy had said, I missed my father, I had no idea whether he was alive or not. I mean, can you imagine just not knowing what has happened to your family and not knowing if you're ever going to know? A mother who was from El Salvador said to a PHR psychologist, she asked the official why her daughter was being taken away from her. The official reportedly responded that her daughter was going to be adopted by an American family and she would be deported and never be able to see her daughter again. I mean, these are just atrocious things to imagine. Another mother said, my life had no value, it felt as though my body were gone. And then a six-year-old girl from Guatemala said, every night I would go to bed alone. I was sad and I would cry myself to sleep. And I thought this was a particularly powerful photo from this video or from this report, rather. This is a 10-year-old who had come to the U.S. with his parents, but they were all separated. And as some of you may know, the detention centers are often done by sex. And so he was with one place, his father was one place and his mother was one place. And then they were kind of deported at different times. So he and his father were essentially reunited in Guatemala City. And here you see him talking to his mother who's in the U.S. who was eventually also deported, but just the kind of separation kind of continues at all times. And then of these, of the adults who we evaluated, based on the findings of the psychologist and the rest of us, almost everyone had PTSD. A large number had depression and a large number had anxiety. And it was pretty apparent that a lot of these symptoms were compounded by the separation process and not, certainly a lot of it was attributable to their experiences back home, but there was a compounding effect from their actual separation from their child. And then we're looking at the children, again, it's a small group, but look how young they are. You know, they're six, seven and eight years old for the most part. They all had PTSD, which was definitely compounded by being separated from their parents, especially children, how young those are. Those are considered tender age children. And again, some depression and some anxiety. And I would say that that's also what I saw when I was in the detention center. And so actually as a result of this report, the PHR found that the federal government, that this policy actually meets the criteria, like the international legal definition of torture and enforced disappearance. So torture being the fact that it causes severe mental suffering, obviously that's there. If done intentionally, this was a specific program that we had put into place. And it was for the purpose of, torture should either be for coercion, punishment, intimidation or discrimination or a discriminatory reason. And obviously this was theoretically prevention. It was a deterrent measure. And by state official or with state consent. And obviously we have that. So it meets all criteria. And then enforced disappearance, these kids were kidnapped. So this is when you have any deprivation of liberty by the state, where there's concealment of the fate or the whereabouts of the disappeared person. And oftentimes parents had no idea where their kids were and vice versa. For like months at a time, a really long time. And they'd be moved around between these weeks and months. And so kind of just with my remaining five minutes, I just wanna talk a little bit more about the children. And so kids can either arrive at the border by themselves like they make that journey by themselves or they can be separated. And either way, they end up in the custody of the federal government and they're considered unaccompanied alien children, which is a, I don't really like. So I just call it unaccompanied minors. They're 18 years, they have to be under 18. They have no lawful immigration status. And either there is no parent with them or the United States government has decided their parent is not an appropriate guardian for them. And these children fall under the custody, as George mentioned of the Department of Health and Human Services, which at least is not a security part of our government. And so it is focused somewhat more on health. And they're under the office of the refugee resettlement. And there have been a lot more kids in recent years. So in just this past year, there were 67,000 unaccompanied children who kind of came into the custody of the federal government. At any given time, there's more, so around 2,500 because they tend to stay in the custody of the government for around two to three months and then are released to sponsors. But that's up from 13,000 just seven years ago. Around two thirds of these are boys. Two thirds tend to be 15 to 17 years old. But there's still a lot of these tender age children that I mentioned before. Around 16% of them are zero, 12 years of age. And the majority come from Guatemala, Honduras, and El Salvador with around 5% from Mexico. And then an even smaller percentage from a handful of other countries around the world. And so what about COVID? They've suffered trauma in their home countries. They've suffered trauma along the way. They've suffered trauma being separated from their parents or in these detention centers. And so the ORR centers are a combination of shelters and foster care homes and residential treatment centers. But not surprisingly, they're all congregate settings. And so ORR has crept up. In March, there were three workers in a facility that housed some unaccompanied children that tested positive for coronavirus. And then there were seven in Houston. And then just recently, there were 37 kids at a Chicago shelter who tested positive, some of whom actually were sick and needed medical care. And we talked about this, you know, they just, it's a constant kind of snowballing effect of trauma to these children and to their families. And so there actually has been some, there has actually been some movement in their direction during this pandemic. So kind of continuing the floor as litigation, Judge Dolly G, who's kind of overseen that litigation, essentially found that both ICE and, so ICE, which is where the family detention centers are kind of managed by ORR, were in violation of the settlement agreement and said that these kids need to be released faster. Most of them already have identified sponsors who are safe. Oftentimes it's their parents who are in the country. And so they have sponsors, they need to be released because if they're gonna be in this pandemic, they should be not in congregate facilities. And so that's kind of moving along. And then a similar case, this OMG versus Wolf is essentially the kind of parallel request, but in terms of family residential centers. So making sure that adults are also released. And then with my last minute and 45 seconds here, I just, from the ethics case, I just want to talk about this is, this is hard for everyone who's taking care of children. So you know, I know it's easy to say that everyone in the government is anti-immigrant, but this is not the case. Certainly there are a lot of people who want to help immigrants gain asylum and have better lives. And that's true kind of all along the different ranks of different caregivers. That's true of some of the people who work in or our facilities. That's true of some asylum officers and some judges. It's not true of everyone, but that, you know, it's really hard these caregivers, and I use that term broadly, are really trying to balance the fact that they're, that theoretically they're trying to put children first, but they're also trying to follow the mandates of the government that has policies in place that lead to deportation, loss of medical care, failing separation, things that are not obviously in the best interest of children. And then, you know, a male at George speak a little bit more about this, but you know, it's, you know, immigration judges are supposed to exercise independent judgment, which theoretically is premised on the separation of the judiciary from the legislative and the executive branches. The immigration court is part of the executive branch and the judges report to the U.S. Attorney, and that attorney is the same person who prosecutes and deports undocumented immigrants. So that doesn't make a whole lot of sense. And then, you know, for physicians, there's just, this was a very kind of famous ad that Renit Mishory wrote a nice op-ed about essentially that was in JAMA and it was quickly pulled, where Geo Group asked for, I'm sure you can hear my child in the background, sorry, but Geo Group posted an ad for a $400,000 primary care job, which for those of you who are not doctors should know is not what we're paid, to go work in one of the detention centers. And the ad had said that they sought a physician who can examine and treat protectional facility detainees, et cetera, but should be philosophically committed to the objectives of the facility. And I think that we all can say that the objectives of the facility are probably not in line with our general code of ethics as physicians. I might answer this question later, but I think there are ways out of this crisis. I think it's mainly through alternatives to detention. I think it's to allow people to actually seek asylum. Our Southern border should not be closed. I'm really sorry if you can hear her screaming. And then I think, to me, I know this sounds a little cliche, but I think the most important thing is to teach our children about the common humanity of people and about celebrating people's differences. I think that the next generation is where I am keeping my hope. And I'm gonna mute it so you can stop hearing my screaming child in the background. Katie, that was great. Thank you so much. And I think everyone watching in these quite odd times can sympathize with children in the background and other odd distractions that wouldn't have existed if we were in a different forum, but it's completely fine. Thank you so much. And I'm really delighted now to have Kate McKenzie with us. And hear what you have to say. Kate, thank you. Unmute yourself, Kate. Thank you so much. Bear with me for just a minute while I share my screen. There we go. It's really a pleasure to be here with all of you and I'm really honored. And as usual, I'm learning so much. So I'm Kate McKenzie. You all can hear me and see my screen now, correct? Okay, great. I'm an internist at Yale. I've been here almost 25 years. And Wes, when you talked about your journey as a clinician and then discovering how you might contribute as a clinician to asylum seekers, it mirrored what I've been through. I've been seeing asylum seekers at Yale for about 15 years. And I stumbled onto this role in a similar way. I evaluated my first asylum seeker and it really turned into a calling for me. It seems like a way that we as clinicians, as physicians can make this unique, experienced contribution using our medical expertise and training in a way that complements so nicely our caregiving roles. So at Yale Center for Asylum Medicine, I'll just give you a little bit of background of how we assist asylum seekers. Our mission at YKAM, Yale Center for Asylum Medicine is to perform clinical evaluations of asylum seekers, to educate people about the work that we do, asylum medicine as we call it, to contribute original scholarship and to be clinician and physician advocates. So at Yale Physicians, at Yale Center for Asylum Medicine, my colleagues and I meet with people who are seeking asylum, people whose human rights have been violated, who have been persecuted or tortured. And many of these people applying for asylum have evidence of scars, physical scars or mental scars related to their persecution, to their torture. And we meet them in a clinical setting to gather objective forensic evidence of the scars. So I'm an internist, I perform physical evaluations. I might meet someone in a clinical setting where I hear about how they were tortured, I hear about how they were persecuted and I hear about actually how they were physically injured and hurt. And then I will, my colleagues and I will perform an exam and document, describe the data that we find, describe the scars. Many times we do this in the community, we might do this in our medical offices, somewhere on campus. And in recent years, however, we've been performing these evaluations, these medical forensic evaluations more frequently in detention centers. After we meet with asylum seekers, perform these evaluations. Usually they're one-time evaluations, sometimes two times, but they are episodic encounters, specific discrete encounters. We will then write a medical legal affidavit. And in that affidavit we, again, use the objective expert evidence that we have gathered to render our an opinion, an opinion. And we provide that opinion to the attorney who is representing the asylum seeker. And again, it describes for not only the attorney, but the immigration judiciary, what we've found. We might say, for an example, a man who was being persecuted because of his political opinion and who was imprisoned in his native country. And while he was imprisoned, he was tortured for five days. Maybe he was cut as part of that torture with a knife. And when he saw me or my colleagues, we examined him, heard about how it happened, I described the scar that we saw on physical exam, take a photograph and render our opinion about whether it is likely that that scar was related to the persecution he described. So we're trying to translate this medical evidence that we find for the judiciary, for the attorneys. That's what we have done in the past for medical forensic evaluations of asylum seekers. Today we're talking about detention, however, so I'll focus a little bit on that. The work that we do, the medical forensic evaluations are similar whether they're in the community, if you will, that is in our medical office or where they're at a detention center. And in recent years, much more of our work has occurred in detention centers. And you can see why that might be the case. And as we've all alluded to for the last 45 minutes or so, there have been many more detainees, individuals, asylum seekers, migrants in detention under the Trump administration and because of their policies. So what we've been doing, I am in New Haven, Connecticut. And so a immigration facility where we work a lot is in New Jersey, it happens to be two hours away. So what we will do is I will travel there or one of my other, one of the other faculty members and we'll often take trainees with us. And it's been really heartening to hear what Katie said just a few minutes ago as we kind of say at the next generation. There's such dedication in medical students and residents, younger clinicians who want to learn this work. And one way that they're able to do so is to travel to a detention center and really viscerally for maybe a few hours experience what it is like to be a migrant in detention. What it is like to be someone who is a victim of persecution of torture. So as a slide aside and again to quote or to say what Katie said as well, the interactions that I have the trainees when we do this, when we go to detention centers, they are heartening in their own way. So we will travel down and this is a photograph of a trainee at the Elizabeth Detention Center, that's in New Jersey. It takes us about two hours to get down there from New Haven. We plan to spend the whole day there. And when we arrive, we walk into the lobby. Sometimes we're with the attorney and sometimes we're on our own. Before we've come to the detention center, we have provided documentation, our identification and license numbers and so on. So the detainee, the detention staff is expecting us. However, the moment you walk in the lobby, it's just jarring. It just feels so much like this bleak institutional setting you know, of course it is in a way. But when you think that the people who are in here we're seeing the detainees and the migrants, they are not criminals. They've come to this country to seek asylum as has been supported by international and US law for many, many years. They're here to try to have safety from persecution and they end up in a detention facility which really feels like a prison. I mean, in many ways it is. But I try to tell you that because I want to give you this sense of what it's like. So we walk into the lobby and the first thing we have to do is to encounter some adversarial bureaucracy and really that's the best way I can describe it. It's interacting with the staff who often pushes back on every element of us entering the facility. We've already gotten permission and we've given the information that is needed for us to enter. And we'll often be met with delays. The staff member will say, well, I can't talk to you now. I'm in the middle of a meeting or you know, some administrative obligation. You can have a seat. So we might sit there for 30 minutes and then she'll say, you can't meet the asylum seeker now. They're doing count, you know, whatever that is you can imagine what it is. So it'll be another half an hour. And then we will say, she'll say, well, I don't know if we got your license number. And so then if the attorney will make a call to the ICE official or the ORR official and saying, well, we sent it, didn't you receive it? Just this sense that we get of this bureaucratic runaround. And we know that the people who are in detention are experiencing that every day. So it's an interesting experience to say the least. And I'm not describing it as a way of complaining. I'm describing it to show you what we as clinicians have to do when we want to perform these detention evaluations. How much more onerous it is to see these asylum seekers in detention than when we just do it in the community. So it's yet another impediment for these asylum seekers, these migrants to get some of the things that they need. So the other thing is equipment when I'm at this, when the detention center, when I am evaluating asylum seekers in my office, I have a tape measure. I have my smartphone to take a photograph. I have a blank body diagram. So I kind of have a lot of the equipment that I need to do this evaluation so I can describe the findings. At a detention center, there's always questions. I had a small tape measure. Well, what is that? Why are you bringing that? You weren't giving permission to bring the tape measure. And of course, there's always discussions about devices. And devices are really important for us to take photographs of scars. Imagine someone an asylum seeker who was tortured and has a six inch scar from a knife on his leg. I mean, showing immigration judiciary, a photo of that is extremely powerful evidence. We try to be able to take photographs in detention. Some days we're able to and some days we're not. Sometimes we can do it with our smartphone. Sometimes we have to bring a device like an iPad or something. So again, to describe what it's like to go there, to try to do this service for these asylum seekers and how challenging it is in a detention center, again, in contrast to in the community. And then once we are actually admitted, the space where we're doing these evaluations, we're talking to these asylum seekers about these very difficult experiences they've had. We really need to do as a sense of evaluation, I'm sorry, as extensive physical exam as possible. And there have been times when the staff has said the medical suite is not available. You're going to have to perform this in the interview room, the attorney interview room. Well, you can imagine, there's very little privacy there. It's surrounded by windows, it's open. Of course, there's no medical equipment. So such limitations. But as all of us who do this sort of human rights work, we certainly make do. And I think especially as physicians, we make things happen, even if the circumstances are not ideal. So that's what it's like to perform medical forensic evaluations in detention centers. I want to just speak for a minute about what we know about how unsafe it is to be a detainee. Human Rights Watch wrote this wonderful, very detailed report called Code Red. And it really outlines the fatal consequences of dangerously substandard medical care and immigration detention. And that pretty much says it all. If you enter detention and you're a healthy person, you must hope that you don't become ill in some way because the medical care that you can receive in detention facilities is going to be often very substandard and you're going to be in danger. If you happen to have an underlying medical problem, you're going to be in even more trouble. The facilities are ill-equipped to provide appropriate care. And these sorts of medical care that's available is really going to be very limited. We know this, we've seen many reports, we've seen a lot of data about how dangerous it is from a medical perspective to be in a detention facility. In fact, we can see that, and this is from months ago, there have been 24 immigrants who have died in ice custody during the Trump administration. And this is many more than have died in previous administrations. So we know the circumstances are bad and we have evidence that people have suffered and died unnecessarily while in detention. And again, to go back to who these people are, these are not criminals. These are people who have come to the US for safety from very traumatic experiences and they are even sometimes in even more danger. Want to talk just briefly about preventative health in detention centers and something as basic as in immunization and especially immunization against the flu. Now, this was pre-COVID, but this was a issue that I and some colleagues worked on at length about nine months ago at the very beginning of the flu season. And the resistance of the US government to do something as straightforward and as low risk as immunizing immigrants. There were certainly plenty of medical experts who weighed in and said, just give people the flu shot. It's very easy, it's inexpensive, it's low risk, it's proven to be beneficial. And in the corner of this slide is this group I work with doctors for camp closure. And I know one of the leaders is at the Zoom meeting today. We really worked hard to try to make this small intervention which is please immunize people in detention centers from the flu, something small and straightforward. Let's talk about infectious outbreaks in detention. You know, very dangerous. As Katie said, these are congregate settings and we knew even before COVID how bad it could be when we saw incidents of something like mumps outbreaks at detention centers. So this was before COVID even, excuse me, became an issue. Speaking of COVID being an issue, six weeks ago some of my physician colleagues began to predict what would happen. COVID-19 and the coming epidemic in US immigration detention centers. And this is when we in the medical community decided that we needed to start advocating and start working hard to get some people released from detention. In fact, we wanted to have everyone released from detention, all migrants who are waiting for their immigration hearings. But in the last six weeks, we've been working with our legal colleagues to at least have some of them that are the highest risk. Why are congregate settings such as detention so hazardous? Imagine what we civilians are being told by the CDC to clean hard surfaces, to wash our hands frequently, to socially distance. And if we are ill to socially isolate, to wear masks when we're out in public or around people. So imagine none of that is possible in detention. We know that, we know that from firsthand accounts for detainees. There's very little PPE, PPE. Social isolationation is not possible. Social distancing is not possible. Many of the detainees say they can't even have much soap to wash their hands. We already know, that's for prevention, but we already know when people get sick in medical facilities, in detention facilities, they can become much more ill than they would in the community. We already know about the poor record of medical care. And let's just talk about the staff, the detention staff. Let's talk about the staff's family members in the communities. And we know that many detention facilities are in rural areas. And those health systems can be quickly overwhelmed by an outbreak and people who are ill. Just a terrible setup for these migrant, these migrants who've been seeking asylum in the US. Many of the amicus briefs and declarations that I and colleagues have been working on in the last four to six weeks have involved people, trying to get people who are at higher risk for severe illness released from detention. And we know about some of these people, the elderly, people with chronic lung disease, heart conditions, immunocompromised states, obesity, diabetes, kidney liver disease. There's certainly migrants who have many of those illnesses that once they are likely to become infected in detention are also more likely to become severely ill from COVID. We've worked on these declarations, these COVID-19 medical legal declarations related to emergency litigation. And this is some of what we hear from the detainees. It's very predictable. I am terrified of getting the coronavirus. And again, referring to what Katie had talked about, these are people who've already been through such trauma. And now when they're in this congregate setting and they know they need to socially distance, they need to wear a mask, wash their hands, and they are not able to. They can't socially distance. They're sharing a room three feet away from their roommate. And in the night, he begins to cough. Who would not be terrified? PPE, the guards have masks and we don't. So this is just an example of a legal case that I was involved in. And it was trying to release several immigrants who are in detention who were at higher risk, whose medical conditions put them at higher risk for developing severe COVID. I'll go back to that for a minute. So that is something that again, we've been doing in the last month as the COVID outbreak has happened. Not so much doing medical legal evaluations for immigration court, but trying to be part of legal cases that advocate for having all migrants released from detention for the sake of them as well as surrounding communities, but especially migrants who are at higher risk for developing severe COVID. And in fact, I just saw this today, what could be predicted, people who are in detention beginning to die from coronavirus and even the staff as well, just in the last few days. So I know this gathering we're having today talks a little bit about ethics. And I just want to bring up the physician as advocate, the clinician as advocate, and how my experience working with asylum seekers pre-COVID and especially now within the COVID area has shown to me the importance of physicians being advocates. And I know within our profession, there is some disagreement about that. There are certainly some physicians who say, physicians should not weigh in on political issues and should not speak in public forums, should not be on Twitter, for example. But I certainly would disagree with that strongly. Physician advocacy is not for everyone, but for those of us who are dedicated to giving voice to those who don't have a voice for protecting the vulnerable, I think it's very important. And here's a couple of photographs. The one is a protest where people were protesting to close immigration detention camps. And finally, in the left-hand corner was one about just a couple of weeks ago where we said detainees should be freed in the COVID era. So again, thank you for your attention. It's just been a pleasure and an honor to be with the rest of you talking today. And I'd be open to any questions along with the rest of you. Kate, thank you so much for that presentation. I have several remarks that I want to keep fairly brief so that we have plenty of time for discussion. I mean, each of the speakers, your remarks were compelling. To go back to some of the things Katie said, the fear of never seeing one's kids again, or for children, the fear that they're never going to see their parents again, I have, since Trump has taken office and people who I've seen have crossed the border after he was inaugurated, they have been separated. And that trauma of separation, because I'm doing psychiatric evaluations on these individuals, the separation from family and the lack of knowledge about whether or not they're ever gonna see each other, where the parent is or where the child is, is often as traumatic as what people have faced in their home countries. When I'm doing evaluations of asylum seekers, I have to sort out what was happening in the home country, what the trauma is from the home country, as compared to what happened en route to the United States or what happened once people were being held in immigration detention, because for asylum purposes, the important thing is what was happening in the home country, but make no mistake, what people are suffering here in the United States at the hands of our government, directly as a result of US policies, is nothing short of torture, as Katie said. The fact that one of my lawyer colleagues, a woman I've done a number of cases with who's at BU School of Law, Sarah Sherman Stokes, when she's been to the border, she's actually had to write on the backs of immigrant children in magic marker, in permanent marker, their date of birth and their parents' names and phone numbers, to try to ensure that they would be able to be identified and reunited with their families at some point, really underscores the kinds of horrors that are being perpetrated by the United States entirely in complete agreement with what our administration wants to do. A couple of other things, when people reach out to me, and I'm sure Kate and Katie have had this experience as physicians who do these evaluations, once people know that we do these evaluations, they'll often say, hey, my client is seeking asylum, can you please do an evaluation? My first thing is always they need a lawyer first, and you need a lawyer who is experienced in asylum law because someone trying to make their own case is really facing an uphill battle to put it mildly. And then to respond to a couple of things that Kate said, I agree going into a detention center is an absolutely bizarre experience with respect to privacy. If you're in immigration detention, you don't speak English, you often have ICE on your prison uniform, it's often a different color, you are singled out, and everyone knows that you're there for reasons other than criminal behavior. And just to amplify what Kate said, overwhelmingly immigrants and asylum seekers are not criminal. In fact, one of the things I have a database of all the people I've seen for asylum evaluations and one of the categories I have is has this person ever committed a crime in the United States because the rhetoric is, oh, these are all criminals and drug dealers and so on, overwhelmingly asylum seekers have never committed crimes either in their home countries or here in the United States. Also a couple of other things Kate was talking about COVID in prisons. As recently as last night, I was speaking with a person who's incarcerated in the New York state prison system. He's not in immigration detention, he's in for criminal matters here in the United States, but in his prison, he said COVID was rampant, he had already been infected himself and everyone he knew had been infected. There is no way of social distancing or doing anything like that in any kind of prison setting, much less immigration detention. In fact, to amplify what Kate said, there are now lots of reports of the fact that ICE is using solitary confinement to separate people who are in immigration detention from others in order to supposedly protect them, either themselves from being infected or if they're suspected of being infected from infecting others. And we all know that solitary confinement is tantamount to torture. I could go into reasons why, but the data and the literature are very clear that solitary is tantamount to torture and the fact that people are being placed in solitary confinement, again, who have not committed crimes, seeking asylum in other countries is not criminal behavior. The fact that those individuals are being placed in the solitary confinement is absolutely horrible. One other thing that has not been touched on yet is there are children and asylum seekers who are adults who are being forced to take psychiatric medications at times. Kids are understandably distraught, probably exhibiting all kinds of dysregulated behaviors because they're separated from their families, completely understandable, and they're being forced to take benzodiazepine tranquilizers in some instances, anti-psychotic medications and mood stabilizers meant for people with bipolar illness or mania. The fact that our country is doing this, forcibly medicating kids without parental consent, often coerced unto the children themselves. They're told, hey, if you don't take the medicine, you're gonna be deprived of privileges or things like that. Again, the fact that our country is flouting every single ethical principle known to humankind in these immigration and detention centers is unconscionable. And George touched upon it earlier, mentioned the Japanese internment camps. I think what's happening on the Southern border currently is going to be ultimately looked at, viewed by historians as bad and if not as bad, probably worse than what we did to Japanese Americans during World War II by placing them in internment camps. And with that, I will open this up to questions. I just wanna reiterate my sincere thanks to Erin for putting this on and Kate, Katie and George for amazing presentations. Thank you so much. Thanks, Wes. So yes, we have a whole bunch of questions in the queue. Two quick questions or maybe not quick to George. First is whether the recent closure of the border due to COVID-related excuses, what you think about the legality of that and how long that can continue. And second, whether there is any chance of reparations for immigrants who might have been harmed in this process. Oh, George, on mute. Probably is legal. President has a tremendous public health authority at the border, not inside the United States. And Stephen Miller's been trying to get him to declare the border closed because of disease. He used the flu before, he used the mumps before and he used one other disease, I can't remember, but even the White House laughed him out of that one. But COVID, that's like a real disease. And yeah, now you should not be able to deny someone the ability to seek asylum, however. But that's got to get in line with a lot of lawsuits that are going on. Are there ever going to be reparations? Gee, I'd like to say yes, but the answer to that's probably no. When writing with my colleague, Sander Crosby, there should be reparations for people who we torture since 9-11 and there's certainly no movement in that direction here. Sad. There's a lot of calmability at the border. It's really a good problem. Another question for the group is what kind of, so there are a couple, a lot of lawyers on the call and what do you think lawyers can do to help and what kind of legal help do you need more of? A couple of people have asked that question. We'll let the doctors answer that one. Well, I'll start. I, as I said in my closing remarks just now, if people are seeking asylum, the starting place actually is to get a lawyer who is knowledgeable about immigration and asylum. And I think more lawyers who are willing to donate their services and work pro bono on behalf of immigrants and asylum seekers would be great. I agree. I want to thank Kate. We certainly can't do this without you. I mean, what we, as physicians are, are expert opinions, medical experts in cases. And we certainly rely on you to present us with cases that you think are appropriate and then to use our information to help the asylum seekers. But just as an aside, every lawyer in every case I ever work on, I learn a lot. So it's always a pleasure to work with the attorneys. And I would say, I think educating positions too. I also learn a lot from all the attorneys that I work with. But I think the more medical legal partnerships there can be with respect to not just asylum, but kind of immigration related matters would be extremely helpful in a sense that, as an example, public charge. If you ask 100 doctors what the deal is with public charge, you'll get 100 different answers because it just, it's very confusing. And so you can imagine how confusing it must be for our patients. And so people, the default answer is I'm just gonna not take any services from the government because that seems the safest, that seems like the safest plan right now because then no one will notice me, but that's actually not the correct thing to do. And so we need attorneys to educate us. And a lot of these are in policy is that the government purposely changes every week so that we stay confused. So the more that you can educate us, the more that we can help our patients get the services that they need. Okay, so another question that has come up is whether or not the panelists think that there's anything that the current administration might be willing to do to try to improve medical care for asylum seekers, and if there is any sort of compromise or if the cruelty that we are seeing is really the point and there is no compromise. I mean, the point is of the administration is to discourage people from coming to the United States. So they want to be as mean as they can be. One of the leaders made a comment about a year ago which I thought was really telling. He said, what do you want us to set up a welcome center? And the answer, yeah, actually, if they're asylum seekers, yeah, I would like that, but no, no, they want things bad. They have a couple of times when they get into trouble with the press, they put out the same press releases. I've seen them four times now. We've just hired 250 new physicians. No, they haven't, but no one really questions them on that. They just say they're doing stuff, but they don't do it. And to amplify what George just said in terms of making it as uncomfortable and bad as possible, I mean, we saw in Kate's presentation refusal to give flu vaccines and other, you know, basic health measures to people in immigration detention. I'll also say, and I've heard this, this actually predates Trump I mean, immigration. It's not responsible for all of that. Sorry, yeah. Yeah, I mean, immigration was bad. I think those of us who've been doing this work know this, immigration was bad under Obama, but it has gone through a vortex in a black hole of evil under Trump. But for a decade, I've heard when people arrive in the United States, cross the border and are picked up by immigration officials, they're put into basically a freezing room and held there for, you know, some extended period of time. And all of the immigrants I've seen have crossed the southern border to a person will say, oh yeah, the room was freezing. And all I can assume is it's an intentionally made as to be as uncomfortable as possible for people. It's true. The hope is that they'll get discouraged to just leave and go back, you know. Well, I mean, even with the example of the, they try to get rid of medical deferred action. I don't know if the audience remembers that last fall. I mean, that's like a, I don't know if it's benign, but like it seems like a pretty obvious policy. People who have really severe medical needs should probably be allowed to continue to receive medical care. And they briefly got rid of it. And there was a huge public outcry. And so they said, oh, I guess we'll reinstate it for now, but I'm sure they're trying to find ways getting rid of it again. But I would say in terms of the answer to the original question, I think, you know, obviously there is the overarching action, which is to try to vote for people that we want to lead our country. Then there's a second action of trying to fight against those who are potentially currently in power and try to influence them to change their opinions, which I think is unfortunately probably less effective. But then I think there's a third but really important part that again, like there are good people who work within these organizations. Like there are good people within ORR. There are good people within ICE. Like I'm not saying that they're, you know, it's an enormous number, but there are. And so I think trying to allow them to do their job, the people who want to do a good job, who want to try to take care of children or families, trying to have them not get entirely demoralized or jaded. I don't know how to do that, but I think trying to support the people who are trying to do good work is incredibly important. And recognizing that they exist, I'm sure a lot of people read the news and think that everyone just shits on them all the time, frankly, and some of them are doing good stuff. When I last fall went with Doctors for Camp closure to do some lobbying in Washington, we went to Joe Manchin's office. And as you know, he's a moderate Republican, I'm sorry, moderate Democrat. And we talked to his staff and said, first of all, can you close the camps? And of course they said no. And then he said, well, can you at least vaccinate people against the influenza? And she said, well, I'm not sure if the people of West Virginia would support that. So I have to say, I was very discouraged, such a small intervention. And that was what, that was our interaction with this moderate Democrat. Discouraging. So you mentioned Doctors for Camp closure. So the co-founder of that is actually on the call and has one of their principles is about independent medical oversight. And whether or not people thought that that was possible or what other things that some of the doctors or medically trained people on the call can do to help. I'll buy to Kate on that one. I think there does need to be independent oversight. You know, this is indirectly answering that question, but like with the floor settlement agreement, for instance, there are independent monitors that the judge assigns who goes to the, or our facilities. And they document all sorts of stuff. Their main job is not to document medical care or medical conditions, they're tasked at documenting a lot of different things. But there are some means of having independent oversight. I don't think, unfortunately, that medicine really falls within that purview quite yet. I don't think that there are a lot of medical independent reviewers, but I certainly think that that would be really welcome. There have been some physicians who have kind of purposely taken jobs within ICE and then left and written about it, which is indirectly a way of doing it kind of along the, more along the whistleblower route. But that's not, I know that that's not exactly what the question was asking, but Kate, I don't know if you have any further thoughts. Well, as I mentioned, I've worked with doctors for Camp Clojure and so glad to see one of the leaders on this conference today. Can we change the framing of these issues and make them more medical issues and try to depoliticize in a way? There might be some progress we can make in that way. And certainly doctors for Camp Clojure as well as a lot of advocacy groups say that we are nonpartisan. When in fact we are, it's not a partisan, these should not be partisan issues. They happen to be in our hyperpartisan political climate at this time. But I would say that we're medical professionals. We are not politicians and we have some credibility in that regard. So try to reframe some of these issues. There might be some value in that. There is a question that came into me. Thank you both, Kate and Katie for that. A question that came into me. Is there anything being done to keep this or put this more in the public eye? I will say that since the COVID pandemic seems to me that any discussion about this has really fallen off dramatically. But I wonder if people have thoughts about what can be done to promote more public awareness about this? Well, we know, I think everyone on the panel knows about physician advocacy and advocacy within the medical field. Opinion pieces within the medical literature as well as in the lay literature, working with broadcast media. Some of that is still done. I mean, there definitely have been some pieces written just in the last four weeks, six weeks of COVID about its relevance to people in detention. So there's still a space for that discussion. Other thoughts? Sorry, my internet cut out there. I hope I didn't miss too much. I don't know. Another question that was on the queue is about the dual loyalty and whether there, you had heard concerning reports about physician complicity in some of these issues as well as physicians working on the other side. Yeah, to me, it's not necessarily about, I mean, there are issues of physician complicity, but it's more about the position that people are put in where we are the only non-signatory to the UN convention on the rights of the child or the only country in the world. You can pick a lot of other terrible countries for child rights and they've signed on to it. But the overarching point of that document is that the interests of the child are put first, basically in all matters. And so, and that's a little bit kind of what floor this settlement agreement is based off of. And that's really hard when you are taking a job as you're even an attorney who's representing a child, you're a care companion in an ORR facility, you're kind of anywhere along the spectrum to take care of children. And at the same time, you're trying to follow a government who is trying to deport people and take away their parents. And none of those things would be in the best interest of the child. It's not the best interest of the child to go back to a country where they're gonna be subjected to gang violence and further injuries. It's certainly not appropriate to not allow people to seek asylum and to be stuck in camps on the Mexico border where they are easy prey for people to injure them, murder them, kidnap them, extort them, et cetera. And so, to me, it's not really about physician complicity, it's about how do you do your job when you have an ethical mandate to put your patient or your client or whoever it is first. And then you have an employer whose directives are in direct opposition to that. And I think that there's a role for state medical boards in those instances to weigh in and hold physicians accountable to, you know, their basic ethical obligations. Yeah, Wes, you could mention a little bit, you know, what happened with Guantanamo and the APA. Right, I mean, back in the day, we had our war on terror. There were some complaints made to state medical boards about physicians who were known to be complicit in torture that was happening. And to my knowledge, no state medical board took any action against physicians who had been complicit with torture happening at Abu Ghraib, Guantanamo and elsewhere. Ultimately, the AMA and the American Psychiatric Association said physicians were not allowed to participate or even be present in, you know, enhanced interrogation sessions, torture sessions. And at that point, physicians were pulled from those sessions. The problem back in the day was that psychologists were able, you know, because of the American Psychological Association, some of the collusion between the upper echelon of the American Psychological Association, Department of Defense and the CIA, psychologists were allowed to continue to participate and that's why interrogations and torture persisted. All right, we are running up against the end of our time. So final statements. So some people have asked about additional data or that might be useful from health services researchers to try to help with this, but any other just concluding thoughts people might have on where do we go from here? My first thought is doing things like this is absolutely key, promoting awareness about what is happening is absolutely key because what is happening at the border, at the hands of the United States for most people in this country, if they actually knew what was happening, they would find it abhorrent. Yeah, there's no question about that. The family separations actually were the one thing that kind of unified the country against the Trump administration. There's never been anything like that. So whatever we can do to keep the issue in front of the public, I think is mandatory. We have to do that. And I would say to meet the balance of kind of immediate advocacy, whether that be physician advocates, journalists, not that they're supposed to be advocates, but kind of writing actually what's going on in the ground, especially right now in the context of the pandemic, balanced with research. You'd asked about data. Like I think that there is a need for data. We're gonna be, one of our groups at HMS is gonna be interviewing recently detained, recently released detainees to find out really what was it like during the pandemic in detention centers. ICE has made a lot of statements about the things that they're providing, but what's the actual reality on the ground? And that will obviously come way too late to do anything for people there now. The hope would be that that would inform future policy for future pandemics, because there certainly will be future pandemics and there will be future congregate facilities. But I think you need both. You need data to inform the future and then you need kind of immediate advocacy right now. I would say leverage our political expertise, the people on this call, on the Zoom conference, depoliticize the issues, as I mentioned, and appeal to the better nature of the majority of the US population. As Wes said, if people really knew what was going on, and as George said, in family separation, more people would be outraged about this. We need to keep it front and center with the US citizens. All right, well, thank you all very much. It's been a wonderful hour and a half. It went by very quickly. But there's so much more to say and I suggest everybody on the call who's interested in this to look up the various works that the moderator and experts on the panel have written about on this topic for further education. And thank you very much for being a part of our Health Policy and Bioethics Consortium series. Everybody stay safe. Thank you, Erin, for hosting this so much. Really appreciate it. Thank you. Thank you, everybody. Thank you all. Thank you, Wes, for moderating.