Hi, everyone. Thank you so much for being with us in the last day of the conference, and at this time. We're thinking if we should give like one or two minutes, or just to start right away? What do you think? Okay. Okay. So thank you so much, and welcome to our session called Back to the Future, a Dynamic Structural Framework of Migration and Mental Health. My name is Pamela Montana-Arteaga. We don't have disclosures, and this is us. So I'm starting. So I'm an assistant clinical professor at New York University, and I also work for the New York Public Health System, where I work as the director of a Latino bicultural clinic. And I have been working for several years, not as much, because I'm not that old, but with immigrants and vulnerable populations. And we were inspired to do this, because we think all comes on a cycle, and we have to honor the history, and how that all affects us when we are considering these factors. And I'm so glad that I'm sharing this panel with Nathan and Olivia, and I'm going to let each one, because they wanted to do it that way, to present themselves. So I'm Nathan Vega-Potler, PGY3 in the Child and Adolescent Psychiatry Research track at NYU, also a postdoctoral research fellow there, doing work on migrant children and mental health. Hi, everyone. So glad that you came to this session. You're such troopers, the final session of the APA. I'm Olivia Shadid. I'm a PGY4 Child and Adolescent Psychiatry Fellow at the University of New Mexico. And Nathan and I are also both APA Foundation and SAMHSA Minority Fellows this year. Really glad to be with you all today, thank you. So given that it is a relatively small audience that we have, we hope that this can also be interactive and engaged throughout, not just in our sort of more formal interactive part. If folks have questions or comments, we would invite you and encourage you to please engage, raise your hand, and we can converse in real time. So to start us off, migration is as longstanding as humanity has been, dating back tens of thousands of years. But in the contemporary... Is this sound okay to you? Maybe it's just echoing for me, but that's fine if it's just me. In the contemporary context, migration is often discussed in the popular discourse in a way of these overwhelming events. Most recently, that sort of depends on people's partisan or ideological orientations, whether people will use words like wave or even more derogatory like an invasion. These kinds of reports or description are quite commonplace now. You'll see headlines that have descriptive numbers or exclamations about the number of migrants that are apprehended, for example, here at the US-Mexico border, the number of migrants who have died in transit in the process of migration. As you see in the second headline. And every so often, sometimes, there will be something about the drivers of migration, so as in the bottom headline that cites natural disasters, famines, or community violence. And then also some of the mental health sequelae of the process of migration, as in the other headline. In the recent few years in particular, there's been a lot of news coverage of the ways in which migration has been reduced to a spectacle and migrants have been used as pawn in a lot of partisan arguments. Things like Texas Governor Greg Abbott discussing and boasting of busing migrants to various sanctuary cities, including New York City, Chicago, or even to the home of Vice President Kamala Harris. And then in that same period, we're also seeing responses that have a lot of echoes of those same kinds of processes of moving migrants. You know, NYC Mayor Eric Adams talked about the influx of migrants being something that is going to be a pull on public resources, impacting cleanliness of streets, impacting public safety, which picks up on some of these notes of migrants as somehow increasing the level of dangerousness in the places where they resettle. And in fact, New York City, although it was not publicized in the way that Governor Greg Abbott did, has also been sending migrants actually themselves, but to Canada, in this case. So taking a little look at the number of the migrant encounters at the US-Mexico border, they are actually quite high compared to the last couple decades. You can see that while there was a spike in 2019, since 2020 it's been a steady increase in the number of migrants who are coming to the United States. And when considering the relationship between mental health or psychiatry and migration, you first want to think about what the typical framing within a psychiatric encounter usually is, particularly in the United States. And within psychiatry, as it's most commonly discussed here in the United States, the diet is most often the focus, you know, a very individualistic sense of analysis. So thinking about lifestyle factors that individuals are able to address or change, things like non-adherence, non-compliance, you know, why did the individual not take their medication? Or even in things that are perhaps a little bit more meant to consider differences and similarities across cultures, like cultural competence, or even bias, is often reduced to interpersonal implicit bias, with some level of ignoring of the more structural context in which these relationships are actually playing out. And you know, often in thinking about these diets as being these two individual relationships, we often lose some of the structural underpinnings that are very much affecting the relationship. So in thinking about structural frameworks that have been implemented within clinical medicine and discussed more broadly, the first one that we'll just briefly introduce is structural violence, which was popularized by Dr. Paul, the late Dr. Paul Farmer, among others within the realm of clinical medicine. I'll just read this definition, which is, in its general usage, the word violence often conveys a physical image. However, it is the avoidable impairment of fundamental human needs or the impairment of human life which lowers the actual degree to which someone is able to meet their needs below that which would otherwise be possible. Structural violence is often embedded in longstanding ubiquitous social structures, normalized by stable institutions and regular experience. Because they seem so ordinary in our ways of understanding the world, they appear almost invisible. This is highlighting a few concepts, one which is that we're talking about functional impairment in someone's basic ability to survive within the world, something that is also avoidable. And then also something that appears so commonplace that it almost isn't even acknowledged or recognized. And although, as I said, Paul Farmer, among others, popularized the concept within clinical medicine, it's actually an analytical tool that has its roots in liberation theology movement in Latin America and has also been used by social movements across the globe who have centered health within their organizing. Within the U.S. context, the use of structural violence as an analytical tool has actually been used by the Black Panther Party and the Young Lords. This is one of the tenets of the Young Lords, which is we are opposed to violence, the violence of hungry children, illiterate adults, diseased old people, and the violence of poverty and profit. Dr. Mary Bassett, who is the former commissioner of the Department of Health and Mental Hygiene in New York City and the Department of Health of New York State, discussed that the legacy of the Black Panther Party extended its initial commitment to armed self-defense against police violence to mobilization against a more ambitiously framed concept of violence. In this broader view, a lack of adequate housing, education, and jobs were also forms of violence, and the party proclaimed its obligation to act against these injuries as well. Education comes in the form of programs, not guns. And thinking about other ways in which clinical medicine, there have been attempts to incorporate some structural analysis, structural competency also stands out, which was first discussed by two psychiatrists, Jonathan Metzl and Helena Hansen. They defined structural competency as the trained ability to discern how a host of issues defined clinically as symptoms, attitudes, or diseases, for example, depression, hypertension, obesity, smoking, medication noncompliance, trauma, psychosis, also represent the downstream implications of a number of upstream decisions about such matters as health care and food delivery systems, zoning laws, urban and rural infrastructures, medicalization, and even about the very definitions of illness and health. What we're doing here is an interesting example of how we need to take advantage of the different frameworks that we have been used to approach our patient and the community, and of course we are focusing in the structural framework, but we also need to, we have the legacy, of course, of the cultural competency, like SFI, and also what has been learned from this sociology, anthropology, and even psychodynamic therapy. So even though he's talking about structural violence, but why it has been happening for centuries, so it's in part of this like, we are like, I remember like there was a lecture for, from Dr. Eugenio Rowe, and it was interesting, it was saying like, oh, the chimpanzees are not our ancestors, our cousins, and how that has been like a way that we interact with each other, like setting limits, ordering, and also how like for the group in power, or to preserve privilege, dehumanizes the other, so many things are okay. So aggressive behaviors, or also, what is different from us, usually should be avoided, or extremely dangerous. And also, like, we have created all these limits that is always in just in our minds, because that was not the way it was set up, and how racism, colonization, and imperialism has been like also originated from this area of like, because you are not like us, you are not humans, we can conquer you, we can get what you have, and we can dominate you, and unwelcome you. So, and... And so, within the thinking about structural competence in particular, as mentioned was a reaction to cultural competence, interventions that could be considered within this framework include things like medical-legal partnerships, so understanding the stress, for example, of having to undergo legal proceeding, and the impacts on both physical and mental health. In terms of thinking about clinical medicine, or psychiatry, and understanding migration, one way that the process of migration is often framed and understood is in three phases. This idea of pre-migration, peri- or during-migration, and then a post-migration. And most often, that idea is that of a linear trajectory that ends with someone's arrival in a host or receiving country, for example, the United States. And thinking about pre-migration, you know, the three things that are very often cited as being motivators for the process of migration are community violence, number one, two, climate change, and three, economic deprivation, famine. Obviously, there's a lot of interconnections between those three large drivers, and of course, the COVID-19 pandemic exacerbated each of those. Peri-migration is that of after somebody decides that they are going to go to a new country, the actual conditions of travel, whether they're alone or with family members, the risk of interpersonal, physical, sexual violence, extortion, kidnapping, starvation, limited access to shelter. And also, you know, this can include things like apprehension or detention elsewhere along the migration journey. For example, what happens if many Central American migrants or South American migrants end up in Mexico? And then the post-migration period, which is focusing on the process of detention within the what's called the receiving country, the economic deprivation in many neighborhoods in which migrants resettle, difficulty navigating, you know, public or social safety net or what semblance of it exists wherever migrants resettle. And then the threat of family separation or deportation among those who are living with tenuous legal immigration status or have family members who are at risk of deportation. As well as racial profiling and things like the perpetual foreigner stereotype, this idea that no matter how many generations somebody may have been in the United States, there's this idea that because of appearance, they're always going to be a foreigner or be seen as other. So in thinking about that sort of clinical idea of how migration may be defined, we wanted to provide a little bit more political economic context of migration and think about these stages a little bit more dynamically with using Central America as one example. Of course, Central America is not the only place that many migrants come from. And some of these kinds of analytical strategies can be used for appreciating migration from and to many other places. So in mentioning community violence as one of those premigration drive factors, one thing that is often mentioned when thinking about Central America, as often cited rather, are the homicide rates within Honduras, El Salvador, and Guatemala, which is often a reason why people will leave those countries and go to the United States, although they go to other countries as well, including Mexico or neighboring countries like Costa Rica most commonly. And in thinking about the context for that community violence and why people would want to leave, it's important also to contextualize the relationship between the United States and a lot of the countries where many migrants are coming from. This map does not show the totality of U.S.-backed government regime changes throughout Latin America, though it does have a few examples, including like in Nicaragua, the Iran-Contra scandal of 1981. Well, it started in 1981 and continued for several years thereafter, which involved the sale of arms to Iran and then the use of those funds to fund the Contras, which was basically an insurgent group within Nicaragua that was fighting to overthrow the Sandinista government. Include in 1973 in Chile, the overthrow of Salvador Allende was a democratically elected president and the installation of the military dictatorship of Pinochet. It also includes Venezuela. Yeah, so like Venezuela of Colombia. I'm originally from Colombia, but we can say that, we'll not say that it's like exact date, but just as being the relationship that U.S. and other countries have had with the country and how under this of like, okay, we are going to control the drug cartels or drug system, and they have intervened in many times of the history. For example, like Panama, when we are like in a civil war, U.S. came to like, hello, and we will take control. Like there has been places of advantage, but also how there is a lot of money funding, like sometimes what we call like right groups or like there is, of course, all these underlying. So that, of course, it's not only for U.S., it started with colonization, but have continued to perpetuate these like issues. And for example, like in the recent case of Venezuela, the current crisis have been going on for a long time, and sometimes like, okay, if they are not making an intervention, sometimes placing sanctions to a country in the way to help is making things worse, right? Like it was very interesting. I was talking with a Uber driver, and he was telling me, I'm going back to Venezuela in December because my family is here, is there, my parents, my kids, and the court, the next court will be in 2026. So he's like trying to save all the money, but he was saying me like, oh, yes, I wish like if they're not going to help us, at least remove the sanctions. Of course, there is corruption, and a lot of the money will not get to the community, but at least it will help. And I think have been also sometimes the cases with Cuba and other countries. Yeah, and so again, returning to Central America, even in 2009, there was a US-backed military coup d'etat, which was during the Obama administration, which Hillary Clinton was during her time as Secretary of State that eventually led to privatization of a lot of the public resources, including mining. And so in thinking about this legacy, obviously it did not start in the 1980s, and there's no single answer explaining the violence, although several of the interconnected factors include geopolitical positioning and extraction of natural resources. And certainly in appreciating the legacy of the US relations with Central America of the last half century, the Reagan administration certainly stands out and playing a particularly important role. These two, like the image here, and also Henry Kissinger's led a bipartisan commission kind of discuss some of the rhetorical justification of US involvement as put pretty succinctly on the shirt here, right? Stop communism in Central America, which is the greatest driver. And then also this more geopolitical explanation of the Soviet-Cuban thrust to make Central America part of their geostrategic challenges, what has turned the struggle in Central America into a security and political problem for the United States and for the hemisphere. Similarly, Reagan alluded to this commission and discussing the importance of quote, support of democratic development, and also highlighting the importance of military aid. This was a address that Reagan had to the US public in 1984. And as noted in this US Senate report to the Foreign Relations Committee in 1989, billions of US federal dollars were sent to Central America to combat revolutionary movements. And including some of those funds went to support US-backed dictatorships, as well as military and paramilitary organizations. And so, as I mentioned, billions of US federal dollars were sent. And this was known as the quote, Central American crisis during the 80s and 70s, at which point there began a period of migration from individuals from Central America to the United States began to happen. Within the conflict in Guatemala, about 200,000 people were killed and others were disappeared. There was recruitment of child soldiers and a genocide of the indigenous people, people, descendants of the Maya lived primarily in the rural highlands, many of whom their descendants are actually migrating, continue migrating to the United States. And in thinking about the continued idea of community violence in Central America, one of the things that always comes up is MS-13 or Madre Salvatrucha 13, which actually originated in the United States in the wake of a lot of these civil wars and a violence that was occurring within, excuse me, within Central America, often backed by either US funding or US support. There was exodus of many Central American migrants to the United States. Many ended up in economically deprived communities and ended up forming into these cliques and then gangs to protect other Salvadoran immigrants. And they actually ended up getting, many folks who had been arrested ended up becoming deported in the mid-90s due to changes in US immigration policy. And when those folks ended up back in El Salvador, they didn't necessarily have much connection with the country. And in this political and economic weakened infrastructure that existed after the decades of civil war, MS-13 as well as a couple other gangs also got a lot more power within the country. And thinking about the association of migration and migrants with criminality, particularly those from Latin America, that's often one side of a lot of the vitriolic rhetoric that is heard. And then the other side of migration exploitation is often this reliance on cheap labor as sort of delineated within this cartoon of this conflict between these two different sides. And in the case of labor, it's very often the case that throughout the United States, there are many migrants that are working either under the table or exploited due to immigration status. And as some of you might have read in the expose that came out in the New York Times within the last several months, through interviews with over 100 migrant children across 20 states, Hannah Dreyer showed the ways in which migrant children have been getting exploited by Earthside Food Solutions, which is in Michigan, and they do packaging for companies such as General Mills, Frito-Lay, Quaker Oats, and a number of other common companies. And what essentially came from these interviews, or sorry, from the series of articles is that there are many trafficked and abused migrant children who have been neglected or abused either by the sponsors with whom they were placed after they were apprehended, including reports of kids being forced to work overnight, the sponsors not enrolling them in school, and forcing them to pay off debts. And one call that was mentioned in the article, a child living in Charlotte, North Carolina, said that his sponsor had found him a job in a restaurant and told him, quote, he needs to work to eat. And teachers at school ended up finding children with burns on their hands that had happened from accidents at work. And in appreciating some of the multidisciplinary research that had actually been showing that this was going on, this is one study, ethnographic study of unaccompanied migrant children, many of whom were of indigenous heritage from Guatemala. In a paper published last year that discussed, there were thoughts that came to my mind that I can consciously control, but there are others that I try to control and they creep up on me. And this is Canicelas describing this one child. He felt a deep sense of stress and dread that he was working as much as he was, but he was still not making enough money to make ends meet and not enough to fulfill his promise to care for his mother and siblings in Guatemala. Highlighting this conflict of the idea of migration in order to support some of his family, while also dealing with the emotional distress of working in this environment in which he didn't have any protections and also still wasn't making enough either to really sustain himself or his family. And in terms of, as I had mentioned, there's the exploitation of labor that can often happen. There's also a lot of money to be made in migrant detention, as we have seen. In 1973, the Immigration Naturalization Service detained 2,370 people every day, ended up reaching 40,000 by the end of the Obama administration. And in fiscal year 2021, there was almost 200,000 people detained annually. The detention budget was upwards of $2.8 billion and 79% of detainees were held in private companies, whose motivation is to their shareholders of maximizing profits. And understanding the process and the policies behind migrant detention, it's important to appreciate this idea of aggravated felony, excuse me, which first emerged in the Anti-Drug Abuse Act of 1988 and has been subsequently expanded in a number of other laws. It's pretty unique in the sense that it's actually a dynamic, not a static definition. It had not existed previously. It included things like murder, trafficking in firearms or drugs, but also has been expanded to include things like tax fraud, shoplifting, and DUIs. It functions retroactively, so even if somebody had had one of these quote, aggravated felonies in the past that was not an aggravated felony when they were convicted, it can be imposed and be used to actually begin a deportation proceeding and not even immigration judges have the discretion to release those who are convicted with these specific felonies. Additionally, in the Homeland Security Appropriations Act of 2009 was when the bed quota was first introduced. The language that was there basically mandated that the Department of Homeland Security quote, maintain a level of not less than 33,400 detention beds was the first time that that first emerged. Additionally, it was when entry and reentry started to become criminalized and as you can see in this graph, unlawful reentry as a federal conviction ended up increasing after that period and you can see that it began increasing such that it was 10 times what it had been only 10 years before by 2012. Additionally, in 1983, that was when private prisons first began receiving federal contracts for housing migrants. The use of private prisons has basically remained pretty stable proportionately across administrations and something that's a bit unique is that the funding comes from federal government unlike with like a county jail or a state prison. Many of these private companies had these quote, voluntary work programs where folks make a dollar a day. Working tens of thousands are kept in detention daily. Additionally, the growth of the annual revenue for prison companies has just increased since 2001 to 2020 and the private prison industry gets about $3 million from ICE daily. This is one of those private companies, Geo Group, their annual revenues are over $2 billion. Related to some of the work, the voluntary work programs, in 2021, a federal judge ruled that Geo Group, one of the largest private companies, had violated state law for minimum wage and had to pay back an owed $17 million. We can swap places. Yeah, yeah, go for it. We'll go for the next little bit. And of course, one of these social economic factors that deeply influences mental health and I don't need to tell you all this as psychiatrists, the detention is very deleterious to both children and families and adults when it comes to their mental health. So this is from a review article that was done by a mentor of mine, Dr. Sean Sidhu, who himself was mentored by Dr. Balkazar Adam, who we're lucky to have with us this afternoon, looking at rates of mental illness reported across different studies of detained migrants and their parents. And I think we would all guess that it would be pretty high rates, but I think it really hits home seeing it in graphical form that 96% of parents who are detained, whether with their child or separated, experience suicidal ideation and one in three self-harm. So if you're treating any patients that have a history of being detained as migrants, there's a very good chance they have a history and their parents, they have a history of suicidal ideation. Are folks here familiar with the concept of the violence of uncertainty, or is that a new phrase? It was posited by Grace et al. in 2018 in the New England Journal of Medicine. And I'll just read it to give you a sense. The violence of uncertainty is a form of violence, sort of as we heard Dr. Paul Farmer conceptualize, a form of violence inflicted on immigrants and refugees enacted through systematic personal, social, and institutional instability that exacerbates inequality and injects fear into the most basic of daily interactions. It is perpetuated by policies of uncertainty that are intended to create systematic insecurity by constantly changing the terms of daily life and targeting what matters most to people. By separating immigrant children from their parents, for instance, or ending reunification of refugee families. And with this term, we can start to think about not just obvious harms that are potentially done via, say, detention, but also that fear that migrants have to live with, even post-migration. Am I going to have my status revoked? Is my workplace going to get raided? What's going to become of me and my family? And that threat of family separation, it can be as clear as in detention itself, but it also can be this, as it's been phrased, administrative violence. When a refugee migrates, but they can't have, say, their mother or their brother migrate with them, the family structure is changed and that ripples throughout the community structure and functioning. We know there's elevated PTSD symptoms with the threat of family separation and increased internalizing symptoms like separation anxiety. So after talking about political and economic factors that contribute to migrant mental health, and we're hoping to paint this picture that it's not linear, right? Is that how getting started in Central America has to do with what was going on in the United States and what the United States was doing in Central America. But we wanna bring it home for you so that you have a sense of, again, when you see these patients in the next week or in the future, you can apply the structurally competent lens to their case. So we're going to walk through a case study that illustrates large-scale influences on health. This case study we're going to go through is adapted from the Structural Competency Workgroup and it's based on interviews by an anthropologist, James Quesada, at San Francisco State University with Latino day laborers right here in California. So we have a 27-year-old Spanish-speaking male is found down with loss of consciousness and evaluated in, say, your emergency department. This is a fairly typical medical history you might see in an emergency room, no, right? But being psychiatrists, perhaps we can characterize it a little more with having a bit more history. So we can recognize this wasn't the first time this patient had used alcohol excessively. And so we have what's maybe a standard HPI in formulation or assessment. Why are they here and what led to that? But in very truncated, focused, temporally terms, like this is what happened and this was immediately what led to it. So we have a relatively smaller group and people can just shout out, what else would you want to know about this young man? What social, political, economic structures could be contributing to his health outcome? You can just shout them. Everything, you know nothing. Yeah, right. And yet such a typical, relatively typical note type. Yeah, anything in particular you'd want to know about this young man? Where he's from, how he's been here, where's his family, what's he been through, experiences of violence. Yes. Yeah, exactly. Yeah, for psychiatrists, you can just be like, what, that is the tip, the ice cube on top of a giant iceberg. Is anyone, is anything percolating for anybody regarding like structural factors that could contribute to his presentation? Either more proximal, recent stuff that happened or more distal, stuff that could have contributed to this. Depends on where he is right now, what city he's in. In the South, where he's been arrested for working in a slaughterhouse. It's a country he didn't come from. Right. And it's been very much structural. Yeah, absolutely. Thank you. So, we're gonna go through some of those social factors that'll give us a hint of then what are the structural factors that contributed to his presentation. And I just want to tag this for you all, what we're gonna go through, these arrow diagrams for all you educators out there. I think it's a really nice way of showing any type of case study you may be presenting and then kind of weaving in structural factors that are sort of invisible but ever present. So, as you can see, there are many elements of this patient's life that were not included in the typical medical note. Let's look at his life trajectory. So, we're gonna start in the bottom right. So, this patient in the case study was born in Oaxaca, Mexico, fourth generation corn farmer. More specifically, from an indigenous Mixtec community. And during the mid-1990s, when there was an influx of cheap corn from the United States and Mexico, he could no longer make a living as a corn farmer as his parents, grandparents, and great-grandparents had done. In order to support his family, he immigrated to the United States to look for work, specifically the Mission District of San Francisco, about two miles south of here, because he knew an adult acquaintance from his hometown who was living there. As an undocumented immigrant adolescent, he could only find work in a factory and did not continue any formal schooling. Eventually, ICE, Immigration and Customs Enforcement, conducted an unannounced enforcement operation, a raid, on the factory, and he was placed in immigrant detention and deported. He gets released back in northern Mexico, but still needs the economic support, and so immigrates again to San Francisco. And here, kind of illustrating that it's, again, often, this is fairly common, it's often not a linear pattern, but interact with immigration system and different structures in many, many ways. So, he gets back to San Francisco, this time as an adult in age, and begins working as a day laborer. But this is work with unreliable income and minimal workplace protections. Works as a day laborer several years, has an on-the-job injury due to unsafe conditions. This injury prevents him from being able to work, and couldn't get workers' compensation from the employer at the site where he was injured. Consequently, not able to pay his portion of rent in the one-bedroom apartment he shares with seven other people, and begins to sleep on the street instead. While he's sleeping on the street, he's assaulted several times. To cope with this trauma and the overall precariousness of his situation, he begins to drink alcohol more heavily, and that eventually leads to him losing consciousness and being brought into that emergency department. So, you could describe all of these factors as social determinants of health, which are taught fairly broadly in American medical schools. From the last data, I was able to see about two in three American medical schools teach social determinants of health early in the curriculum, and up to 80% have required or optional educational offerings in that regard. But, what we're gonna look at now, however, is those upstream social factors that influence these social determinants of health. So first, again, starting bottom right, have to consider the legacy of colonialism and systemic marginalization and violence against indigenous communities in Southern Mexico. These factors contributed to the family, the patient's community in Oaxaca being quite poor. Without these factors contributing to the level of poverty in his hometown, there could have been additional opportunities for local employment when the patient could no longer earn a living as a farmer. Next, we have to examine the factors that led to the patient no longer being able to earn a living as a corn farmer in his home community. The farmer was put out of business by an influx of cheap corn from the US to Mexico under NAFTA. NAFTA, North American Free Trade Agreement, was a bill signed into law by President Clinton in 1993. It prevented Mexico from taxing imported American corn, but didn't prevent the US government from continuing to heavily subsidize American corn farming and agribusiness overall. As a result, you get artificially cheap corn from the US going to Mexico, where it's cheaper to buy American corn than the corn that's being grown locally in Mexico. As a result, one to two million corn farmers in Mexico are put out of business, and many of them immigrate to the United States. When the patient moved to the United States to look for work, in both instances, he was unable to find employment except in dangerous conditions, such as in a factory, as a miner, or as a day laborer. And US immigration policy, racism, racialized low-wage labor markets contributed to his inability to find stable, well-compensated, safe work. US immigration policy itself, restrictions in insurance eligibility, design of the US healthcare system, limited the patient's access to healthcare. He would have at the time been able to access care in San Francisco, but he didn't know that, and so the access wasn't there. As a result, when he was injured during work, he couldn't get the care he needed to recover fully. And city and federal policies we can look at as contributing to gentrification and displacement in San Francisco. The result being very limited availability of affordable housing for low-income earners. This factored into the patient not being able to afford rent and his subsequent homelessness. And you know, each of these large-scale influences mentioned colonialism, gentrification, NAFTA, US immigration policy, racism, could of course be the topic of their own multi-day trainings. And the case study isn't about focusing on one of these factors versus the other, but rather to start the process or continue the process of thinking through how large-scale social structures could be contributing to the health outcomes of the communities and patients that you serve. And how these structures impact your relationship with each of your patients in the exam room itself and beyond. You know, when we're in the room with a patient, these structures influence what can we ask about, what don't we ask about, what don't we feel like we have the time to discuss, what do we document and what not and why, what treatments do we recommend and which do we not recommend, despite perhaps it being aligned with our best clinical judgment. And recognition of these structures can help us as psychiatrists be aware of any counter-transference or tensions we may be having for our patients. For example, when we're back at work tomorrow, and also interesting to note, like, oh, what feelings come up when I think about being back at work and why? When we're back at work tomorrow or next week and we're having a busy day and we check our messages and we have a request for a prior op or we're sitting with a patient and they're sobbing and it's 10 minutes after their appointment was supposed to end and there's two other patients in the waiting room, I think structural competency can help us recognize those feelings of maybe feeling frustrated or annoyed or imposed upon, which is not appropriate to feel towards the patient, but I think many of us feel given the structures as it is, we can recognize that those feelings are there and perhaps allow those feelings to activate us towards advocacy and interventions. I think structural competency can help us aim our efforts at issues that are actually affecting the lives of our patients and our experiences with our patients. And I'll turn it over to Dr. Montano-Arteaga to talk more about interventions. As we are not many in the room, I think we are planning to have a change of plans because I know that the different frameworks and also we will benefit of learning from each other, including the audience. So, because only a few of you, I don't know if you mind to say who you are and where you're coming from because where we are facing all these issues, that is also matter. So, I know, sorry to put you on the spot, but just here, shout your name and where you're located and that's it. Or you can come closer also. Thank you so much. Does this work? Yes. Okay, so my name is Sue Smith and I grew up in North Dakota, but I have been living in California for many years and I work just down the peninsula here in a community called East Palo Alto. And it's a very underserved community, African-American, Latino, Pacific Islanders, and I work for the County Mental Health. So, I have many immigrants in my patient population and one just recently from Ukraine, so. Thank you. Next one? Sorry. I'm making you like, I know it has been a long conference. My name is Heidi Ernst. My accent is German, but I've worked in community mental health for many years and with a lot of Latina patients. And I think I've underestimated what they went through till I listened to this talk. So, I really appreciate what you're talking about, so. Thank you so much. Anyone else? I'm not going to make it. It's voluntary. Hello, wonderful presentation. Thank you so much. My name is Balkuzar Adam. I am a professor emeritus with the University of Missouri, Columbia. I am a child psychiatrist with rural behavior health. I have been working with diverse population and was focusing on that the majority of my career. And I got the experience of working with different refugee and immigrant from different countries. Thank you very much for having this important session today. Thank you. Anyone else? The first man in the row. Okay, just go. Jim, we have read your book. He has written the book. I know. I have. We have read like three reasons. I'm Larry Merkle. I'm a psychiatrist, anthropologist, University of Virginia, trained at Penn. I've been working with refugees and immigrants for 45 years now, but I really appreciate your efforts and the nice summary you've done. Thank you. And that's why we decided to do this because we are early in our careers and you have so much to learn from each other. So, especially in this part where we're like considering this interacting mode of how we can like to brainstorm approaches at the different levels like individual, interpersonal, in the clinic base, in the community, research and policy. It doesn't have to follow these guidelines, but if you like, for example, like at these different levels, one concrete action that anyone could do or also a big picture if you have a magic wand, what kind of like a structural issue would you address? I know this is very broad, but it's just to start the conversation and make it this very enriching process. So do we have any volunteers or also from the presenters? I know it's very broad. Okay, so we can, okay. Oh, oh, great. One bold one is fix the American healthcare system. We have to really work on the American healthcare system that we can change at least some of it. Like if somebody's injured, gets treatment. So, great. Anyone else? If we could allow the uncertainty of the DACA immigrants so that young people that were brought here as children and who really only know the US as their country. I do have a very high functioning patient who is in that situation and the uncertainty of that is always on his mind. And he is very well educated, but this is a fear in the back of his mind and it has not allowed him to travel abroad for his work, which they might have wanted him to, to go to conventions or go to headquarters, but he cannot do that because of the DACA status. So if I could fix that, have the magic wand, I would do that. Thank you. Thank you. Now after the end of Title 42 and the migrant on the border, and recently there is one girl that died about two weeks ago, three weeks ago, and a week earlier, 17 year old boy that died in Florida. So, and we have, we mentioned earlier about this migrant that being bused to different places. And the situation with this political situation is very critical and I don't know if there is anything that can be done, but it's very serious. I want to bring to your attention the article that was done by ProPublica last year and it was, it won the Pulitzer Award from the Atlantic about the separation of the children on the border and how that the Trump era had affected that in a very, very negative way. We are seeing these kids and their family suffering and every day and the situation is not getting better. I wish there was something that could be done to help with the political situation. Thank you. Before going to the next slide, I think if I had a magic wand, being very, very ambitious, with the current context, first I would like, for example, stop working in silos and build partnerships, right? For example, I'm located in New York and even in New York, everyone is working in silos and we don't know what is happening and in the shelters, in the clinic. And there are some more voices in the community that if we can work with them and empower them, then our reach will be stronger. But also, especially in this conference, because people need help all over, right? Across their countries, going different, for example, if they are migrating, in, for example, in the countries in between, because a lot of, like, of course, issues of human rights are happening and we are seeing these patients and it can bring sometimes, like, this system, like, and I say, again, I work for the New York City Public Health System, and I always complain, but I need to acknowledge that there is some of, like, privilege, right, compared to other areas in the country. Yeah? Like, for example, I was talking, like, to Olivia, something about, like, economics, and I was like, oh, how do they get medications, like, in New Mexico, or, like, we have the fortune, like, that patients can go to our hospital and get the medications for free, right? And, but, and everyone has a therapist just in that place. But there are so many things, like, we are, like, how we expand our reach, and, like, and stop just, like, caring about, like, our niche, but, like, coming in a more, like, and expand to interdisciplinary group, like, people who have studied this more for, like, longer, more than psychiatry, that are much more aware, and bring all over. And actually, it's, like, move, of course, research, we need the data, so we can change the policy, but then that we can have actionable items that are long term. But I think something they, like, following the model was, of course, like, that we need to work, we all have bias, that's impossible, but work on that, in that someone was calling, like, calling the empathy, and also self-awareness, and, and there is so much that we can learn from each other, we just have conversations. I say try to approach the patient without blame or judgment, I say try, because that is impossible to, to remove the part that we have, use interpreters, if you don't have bilingual staff, and bilingual also, like, take into account, for example, Latin America, I know everyone speak Spanish, right, I was hearing, like, someone in the board there, that she was, I think, 17 year old, that everyone thought it was psychotic, but actually, she was speaking of one of the native languages, so be aware of that. Another thing is, like, when we're talking about diverse staff, don't come with the stereotypes, they want to start in my job, I'm, like, a Latina, and because I'm Colombian, doesn't mean that I know everything, right, we are so different, and even within the same country, so, and, and we need to take that into account, like, how, they are the best teacher, how they perceive what is happening to them, and build that from that, that would be more than individual, right, like, in the setting, and, and, yeah, and, like, someone mentioned, like, for example, like, we are trying to, like, measure social determinants, trying to do some, like, cultural assessments, but there's resources, so it would be great to have, like, greater funding, to be able, like, not only do a screening, but also do something appropriate that can help the population, advocate, advocacy, like, we need to move beyond clinical, and, and also, of course, like, if we meet anyone, like, just trying to understand where they're coming from, research, where they're coming from, ask them, and, like, try to understand, like, their context. In this case, yeah, for, okay, for more just housing policy, and empower the community, and I think, yeah, they were saying, like, organize against trade agreements that contribute to the exploitation of foreign labor, and ideally, organize a universal health care. I don't know, do you have any other comments? There are many things that we can do. Yeah, I, I mean, and I think, you know, too, we have so much expertise and wisdom in the room. If other folks have examples, especially as, as people who are leaders in your, in your clinics and practices, about implementations that you've put into place, that you felt like were really beneficial for migrant patients, would be, or research you've done, funding you've obtained for community programming, would be curious to, to hear if anyone wants to share. Come, come. I can take around the mic. Oh, that's true. We should make it easier for them. Anyone? Just, he will give you the microphone. Clinic-level, department-level advocacy work that you've done, or that you, you've witnessed and admired. In Missouri, we have a migration group. It is different people from the community. Pediatricians, psychiatrists, teachers, Spanish community, African community, librarians, anything, any, anybody, everyone who cares about the care of the migrant and refugees. We meet every three months, and in between, we are in contact. And during this time, we bring the issues that we have in our community, that new issues that's happening, and then we, we discuss it. Like, for example, a new migrant, and he does not have health care. How can we help him? Is there any kind of free clinic? And a new migrant, he does not have an interpreter. He does not have a translator. He does not have special education. How the teacher can do to help this person? So, a person from this community, how can we connect them to this community? How can the community be there to support him and support his family? I see this group very helpful, doing grassroot work to support this patient and their family. And it is just an idea that we have started, and we found it to be very helpful in our community. So, there is a clinic, not just our mental health clinic, locally in the community. And we're meeting some to help collaborate with the patients that each of our clinics see, regarding both their physical and psychiatric care. And there's a lot of bilingual staff in both places, you know, in the clinic in which I work, and the physical health care clinic. So, that's been very good. And to try to, you know, improve the communication around improving their health care, and helping them, like, for example, if somebody is diabetic, and how to really get their care more streamlined or honed in, so that, you know, their health itself, in addition to their psychiatric issues, are dealt with. I guess the other thing in our clinic, we have a family support person who helps families who maybe their child or adult, young adult, is now diagnosed with schizophrenia. And she is a Tongan woman, and we have a number of, you know, Pacific Islanders. And so, she's working with another one of the families that I'm treating, their daughter, who is dealing with psychotic symptoms. So, I think just trying to integrate the care that's available to them, and to help educate them also about the fact that we will see people no matter of their immigration status. We don't report people. We treat people. So, I think, and then we also have an African American peer support worker who also goes out, and we do a lot of case management, even delivering food to folks who don't have it, and trying to get them connected with services that are available to them. So, we're trying to do a lot of outreach in that way. Thank you so much for your great work. Yes, and I mean, I only speak un poquito Espanol, but, you know, the little I speak, I try to with the patients, and it helps make a bond. But I don't use my skills in speaking to them. I always use an interpreter, because I'm not that fluent. But, you know, it helps to make a connection. I think it's really great to talk about those, like, clinic level interventions, I think can be fairly, like, concrete and doable for anyone in leadership or any rabble-rousers in the clinic who are not leaders themselves to do things like you're saying where, even putting up signs in the lobby, we're not documenting immigration status. I know in some states, there's some proposed legislation that health care workers would be mandated reporters. But I think letting them know it's a safe space, you don't need to write down your social security number or know that you don't have one is really important. And I love how both of you highlighted, like, working across these silos, which you mentioned are, in and of themselves, you know, how much of it is the way things are, versus they're there for a reason, and make things harder for these vulnerable communities to access. So I'm really grateful for those examples. It's inspiring and emboldening. Like, it can be done. So thank you. Anyone else? I don't want to pick the brain of Dr. Lim. I also want to say, also, the power of media. The same way that the media can portray things in a negative way, it can also help to change the tone. It will raise our voices. And there were, like, some examples. I remember one of the conferences using, like, for example, like, children's books to change, like, teach about certain issues, using, like, telenovelas for intersectionality, LGBTQ communities within the population. So also, like, we can, and also, like, especially when it's coming from the community, because sometimes we are, like, they're the experts at the end. So helping to channel, like, that their voices could be more understood. And the greater the voice, hopefully greater awareness. Of course, there are things that are very difficult to change, but we can, like, increase our numbers and, like, be more, like, sort of, like, united with the same. We have a similar goal. I don't know. Anyone else want anything to say? Nathan? I think in some ways I'm identifying with you because when I was in my child fellowship at Harbor UCLA in Los Angeles, I did have the opportunity to work with Guatemalan refugees. And we ended up, after I finished my fellowship, there was a healthy start program here in California. And we were able to put together a grant in order to establish a child and family center at a local elementary school in San Pedro, California. And subsequent to that, I was asked to serve on the board of a program called LA Trust for Children's Health. And they have subsequently established, well, when I was last on the board, there were 15 in-school programs where they were providing a combination of mental health and dental health and physical health for, and most of the students in the LA Unified are immigrants from immigrant families or families that are below the poverty level. And so I'm impressed in, because when I was involved in this myself, I felt like I was all by myself in terms of other residents or people who were interested in this. And for you folks to have a peer group and to be as aware as you are of all of the factors that are involved, it's really, I think, promising for the future. And I hope that you're able to continue in the efforts that you're doing and to build it into an academic career and into, you know, into changes that are going to make a bigger difference for the people that need these services. Thank you. And one important thing is like, as you said, like, we don't need, like, there's so much to do, but we don't need to reinvent the wheel of things that are already established. So it would be good, like, for example, of this program that still exists or existed, right? Like, to have the information, what we learned from them so that it could help us, like, to be more, like, to focus our efforts better and use, like, the experiences from, like, the ones that are in different front lines or different areas or have worked in this for years. So thank you so much for, like, being here and sharing your experiences. It's also very meaningful for us. Thank you. Thank you. Are you familiar with the work of Thomas Nail? He's a historian and a philosopher. I think he's at the University of Colorado. For looking at the structural level of things, he's got a very eloquent model of looking at centripetal forces and borders, for understanding human migration, and all the things you've been talking about. It's a very powerful model, but it can be applied to all of these sort of situations to understand them. And in the second half of one of his books, he takes that model and applies it to Mexico specifically, and looks at how all these forces have combined to result in the situation that we're in now. He gives a nice framework for understanding much of the things you're talking about. Thank you so much. Great. Thank you. What was his name again? Was it? Thomas. Okay. I just wanted to comment, too. This is great when you bring in the structural factors as far as how this young man ended up down on the street. And throughout my career, which has been quite a few years already now, but I've always thought, not just in the situation of migrants from South and Central America, but how important history is in knowing about that and treating people. For example, currently the war in Ukraine, or I've had a patient who years ago was a survivor of the Holocaust. So just knowing history is so important. And I think that would be wonderful to really support that teaching in medical schools, that you cannot isolate the present situation from the past. So thank you for elucidating that in your presentation. It's a political problem. If the Republicans are in charge, we're in trouble. So you got to vote. Because right now there's a large anti-immigrant sentiment that the Republicans are pushing. So if you don't vote, the Republicans will win. And you got to get people registered and vote and talk to your Congress people. If you want to do structural. At the child council meeting, someone brought up, you know, there was like very high youth turnout at the last election, but very high as 27% of youth voters. And there's an emergency medicine physician, I wrote his name down, but I don't remember off the top of my head, who has a program called Vote ER, like voter, to when people come to the emergency room, free of trying to sway them one way or another, but just giving them the information on how to register to vote. For those of us working with kids, I thought, well, that's a wonderful idea. It's kind of like you're saying, Dr. Lim, you know, if we can put the power in the hands of the future themselves, I feel really hopeful about the upcoming generation. And I think they could, if they took that chance, could help make some positive changes through that avenue in particular. Sure. I mean, it's uncommon to your point. I think it's a great, a great point. And at the same time, I think part of what we also wanted to emphasize is that some of these things, frankly, go beyond partisan politics in the way that, you know, whether the administration is Democrat or Republican, a lot of these things have not changed fundamentally over, you know, decades that we're looking at. And some of these things are so deeply ingrained in the structures because of, you know, there are entire industries that are built around this thing to continue. Society for the Study of Psychiatry and Culture, SSPC, you should come to those meetings, you'll find very common spirits there. For me it's like, it has been my favorite, I miss it like this year, but that was like, I told Nathan, like, my heart, the one that will inspire me. A very good meeting is a small group of people usually, but Dr. Lim, that are famous for all of this kind of work, and you get to meet them and talk to them, and hear people doing all of this kind of stuff. If you aren't a member, I encourage you to join, they have webinars and all sorts of things. Thank you. Find a home there. I see it's becoming stronger and stronger. I'm a polypsychiatry fellow, but every time I go, wow, I'm hopeful for them and also for the younger generation. And one thing you mentioned, Russell, about voting. Before the 2020 election, one of my friends, she's another psychiatrist, and she and I set up a booth to get people to register to vote. Actually non-partisan, but we went to the community in which I work and we went to another community nearby where people might not have known where to go to register to vote. And so we did that. So we were so concerned about the election and wanted to get as many people registered as we could. So we did. Thank you. Thank you so much. Thank you all.

migration

mental health

structural frameworks

historical contexts

political contexts

structural violence

economic deprivations

labor exploitation

geopolitical influences

interdisciplinary collaboration

advocacy