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How Far Can Integration Go?

Posted By Joan Fleishman, Tuesday, March 19, 2019


I walk through an empty cobblestone plaza, once bustling with vendors,  the infectious smell of al pastor tacos, and fresh leather sandals. This plaza has been vacant since the period of time in the early 2000s when Tijuana became violent, even dangerous, and Americans didn’t visit.

I climb the snaking stairwells and tunnels leading me across the border, splashed with worn graffiti in two languages. It was as if these walls themselves were pleading for salvation and cursing the division of these two worlds. As I walk, I join the 90,000 people crossing this land border each day, making it one of the busiest in the world.

I don’t know what to expect from today. I’m joining Boarder Dreamers, a grassroots group of medical providers, to provide a mobile medical clinic to migrants at the shelters. Current US policies restrict access to asylum and slow migration, which leaves many people trapped in uncertainty in border towns like Tijuana.


First Stop: Enclave Carocol

We gather in the back of the soup kitchen turned clinic. We are a motley crew of medical providers and students, behavioral health providers, nurses, and legal advocates. Our mission today: Assess and address the biopsychosocial needs of migrants from Central and South America at the shelters and camps we will visit. They are awaiting their number to be called to begin the asylum process.

The clinic in Enclave is sparse. Light shines down from an exposed bulb hanging from the ceiling.  There are two corners of the large open room where colorful, old bed sheets are hung to create exam rooms. There is a 1970s exam table and shelves full of medical equipment. A bowl of shiny red apples and a 5-gallon water jug sit on a bare table. Hanging crookedly on the water jug a sign reads, “potable”.

We step back outside into the sun and brisk January air. We organize into small teams.  The behavioral health team, made up of myself, another psychologist, and two social workers, are going with the physician assistants and their students. They are equipped with a large duffle bag of medications and supplies. The students are in scrubs and around their necks hang polished stethoscopes. Their eyes are bright and wide.


 Second Stop: El Templo aka Little Haiti

Our Uber driver doesn’t actually take us to the Templo. The road is completely washed out and we walk the last ¼ mile on foot. The “road” looks more like a landfill, and what is later explained to us is that the residents throw their trash where the road used to be to help when the road washes out. Ah…yes, of course! Why didn’t I know that?! We walk up this “road”, flanked by horses, chickens, and the largest pigs I have ever seen (which is saying A LOT because I grew up on a farm).  There is wood smoke and Ranchera music in the air.  We are definitely in Mexico.

We see 63 patients at the Templo. Old and young. Haitians who left Haiti by boat after the earthquake and have spent the last few years living in Venezuela and Chile. They tell us they started their journey 5 weeks ago, on foot, to Tijuana. They have only been there a few days.

The medical providers treat scabies and lice, foot sores, and abscesses. They do pregnancy tests and hand out calamine lotion. But what is clear, is that they cannot treat everything our patients are struggling with. Hanging in the air, there is a weariness, an exhaustion, and a vigilance. We see it in their eyes. And we feel it in our hearts.

The statistics of immigration into North America are astonishing.  It is estimated that 500,000 people make the journey to Mexico every year. Many don’t make it. There is a high incidence of violence and sexual assault.  We listen as a mother and her 10-year-old son recount a night on their journey where they witnessed a horrifying event. The exposure to trauma is a given on this journey.

The behavioral health professionals gather. What can we do for these people, these families who have traveled so far, and have experienced unspeakable things? How can we help?  Their journey is not yet over. We ask ourselves, “What does mental health first aid in a migrant shelter look like?”

A few of us lead an art project for the children who are eager to use the colored pencils we brought and learn a few words in English. They are happy to draw and talk and laugh. They ask us questions and draw pictures of worlds in their imagination. We offer any child who wants to talk with one of us about their picture a few minutes of undivided attention.

The rest of us, with the help of our Haitian-Creole translator, facilitate a “charla” (a chat) for the men at the shelter. We discuss anxiety and depression. We normalize the anger and powerlessness.  We discuss the fear they have about the asylum process. For some they fear being separated from their wives and children. Those who don’t have a wife or children they fear they will not be granted a number, which would allow them to be called for a Credible Fear interview, the first step in seeking asylum in the US. The men agree, all they want is to work, to provide for their families, and keep their children safe. Lastly, we talk about resiliency, which of all the people I have met in my humanitarian work, these men truly embody.


 Third Stop: YMCA Youth Shelter

We arrive at the shelter housing unaccompanied minors. There are roughly 25 teens here. Some have been here for months. There is no formal asylum process for unaccompanied minors and they are often at the border for many months before they can cross. Today they are eager to be seen by the doctors.

I am setting up the table for the mental health consults and I start to realize that the way this clinic has been functioning behavioral health and physical health have been viewed as separate. We are asked to set up in separate spaces and do separate things. But I want to do something different. I suggest that the physician, who came with us to the youth shelter, and I see patients together. She is agreeable. So, as the nurse triages the patients, the physician and I set up three chairs in a triangle.

At first, it’s clunky. Who interviews the patient first? When does the physical exam happen? With our limited time and attention to urgent needs, what is most important to ask about or address? The teens have various physical complaints; stomach aches, tooth aches, swollen glands. A 15-year-old is 3 months pregnant. She has had no prenatal care, no prenatal vitamins. No one is sleeping well, a few are having panic attacks, one expresses passive suicidal ideation.

It becomes clear that most of what they are experiencing are reactions to stress, trauma, separation; the psychological toll of migration. We can only offer a kernel of what they truly need, but what we can offer is an opportunity to be heard, to be cared for, to have someone to talk to, tell their story to, and acknowledge their journey.

The sun is beginning to get lower in the sky and I know we need to speed things up. Instead of me seeing all the patients I suggest we try using a Warm Hand Off when the physician thinks the patient would benefit from talking to a behavioral health provider. This works well and is more efficient. She comes and gets one of us on the BH team, introduces us and explains why she thinks it would be a good idea if the patient chatted with us for a bit and then she moves on to her next patient.

In that moment, as we lose daylight and the chill returns to the air, the team gains something, a game changer. They discover how even in a mobile clinic in Tijuana, at a shelter for unaccompanied minors, integration of behavioral and physical health makes sense, saves time, and better meets the patients’ needs.


 As I walk back over the border on the worn sidewalks, through the metal detectors, and past the empty plaza, my teammates are a buzz with how we worked together today at the YMCA Youth Shelter and this new model of care. They are excited to try out integrating physical and behavioral health services at other shelters next weekend. They are eager to use Warm Hand Offs to introduce behavioral health to patients they know would benefit from talking with one of us.

Tonight I realize that integration has no borders.  The utility and value of an integrated model of healthcare is not confined inside the clinic walls, but can be deployed anywhere that multidisciplinary teams exist.

So, I really only have one question for you. Where will you take integration next?

Dr. Fleishman is the Behavioral Health Clinical and Research Director for OHSU’s Department of Family Medicine leading the expansion of the behavioral health services across 6 primary care clinics. She has worked closely with other clinical leaders on strategic planning, program development, clinician training, and workflow implementation. Dr. Fleishman has focused her work on practice transformation, population reach, alternative payment methodology, and team-based care. She is currently involved in several projects including a program evaluation of primary care-based Medication Assisted Treatment (MAT) Program, an implementation study of a screening approach to intimate partner violence in primary care, and implementing Trauma Informed Care standards in a Family Practice clinic.

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